With Limited Data, Hospitals Face H1N1 Decisions

ACEP News
October 2009

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

www.acep.org/WorkArea/DownloadAsset.aspx?id=45781

. Updated H1N1 guidance documents from the CDC are available at

www.cdc.gov/h1n1flu/guidance

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