With Limited Data, Hospitals Face H1N1 Decisions
H1N1 Prompts Tough Choices
By Heidi Splete
Elsevier Global Medical News
As hospitals prepare for a potential surge in cases of the pandemic (A)H1N1
influenza virus this fall, physicians must make decisions about protective
measures based on limited evidence about the virus's transmission and severity.
Planning for pandemic H1N1 includes everything from ordering extra surgical
masks to providing family support for hospital staff so they can come to work,
said Dr. Leonard Mermel, professor of medicine at Brown University and medical
director of the department of epidemiology and infection control at Rhode Island
Hospital, both in Providence, R.I.
Dr. Mermel said that during the first wave of pandemic H1N1 last spring, he
had "rather draconian measures" in place, based on early data from Mexico
suggesting a high mortality rate. "I had a triage desk in our [emergency
department], and N95 respirators," he said in an interview.
But conversations with colleagues, resistance from his staff to routine N95
use, and emerging signs that the new virus was behaving like the seasonal flu
virus led to a transition to standard droplet precautions, said Dr. Mermel, who
was part of a panel discussion on infection control measures at an Institute of
Medicine-sponsored workshop on the use of personal protective equipment for
health care workers.
Dr. Mermel meets regularly with a working group at Rhode Island Hospital to
discuss infection control procedures. Their plans for responding to pandemic
H1N1 include "cough etiquette stations" with surgical masks, hand hygiene
products and instructions for their use at hospital points of entry, and a
triage desk where a staff person will remind people to follow the instructions.
As for personal protective equipment, "it's a real hornet's nest," he said.
The Centers for Disease Control and Prevention recommends the use of N95
respirators by health care workers who are treating patients with pandemic H1N1,
but the Society for Healthcare Epidemiology of America (SHEA), the Infectious
Diseases Society of America (IDSA), and other organizations have concluded that
standard droplet precautions are probably sufficient.
"It's of great importance to mitigate transmission from health care worker to
health care worker," he added. A worker could do everything right in terms of
personal protective equipment, and then become infected during a lunch break
with a colleague who is coughing.
Dr. Mermel's working group has been coordinating with the human resources
department to reinforce the message that staff should stay home when ill. But
the working group also has considered how to help healthy health care workers
get to work if they need child care or elder care at home.
One tricky question is whether to reassign health care workers who may be at
high risk for H1N1 infection, such as pregnant women, Dr. Mermel said. The CDC
recommends reassigning high-risk health care workers, but statements from the
SHEA and the IDSA cite problems with that approach.
ACEP's "National Strategic Plan for Emergency Department Management of
Outbreaks of Novel H1N1 Influenza" is available at
Updated H1N1 guidance documents from the CDC are available at