'Onslaught of patients'

The fast and furious start of this year's flu season is straining capacity at many hospitals, requiring all-hands-on-deck staffing levels.

Many hospital officials say that patients with the flu and flu-like symptoms are filling their emergency rooms and have been for weeks, creating stressed staff members and leading some to enact emergency procedures.

“We're seeing an onslaught of patients, to be honest,” said Dr. Robert Kelly, president of New York-Presbyterian Hospital. “We're seeing much higher volume than in previous years.”

The relatively strong flu season, which last week reached epidemic levels as measured by mortalities from influenza and pneumonia, could boost revenue at hospitals eventually as a result of increased hospitalizations. But in the near term, hospital clinicians are struggling to keep up with the influx of patients, with officials at the Centers for Disease Control and Prevention unable to predict whether the season has peaked yet for areas that have been hit hard already. Shortages of vaccines, antivirals and testing supplies have been reported in some areas as well.

As of Jan. 5, the CDC estimated that 24 states and New York City are reporting high levels of influenza-like illness activity, 16 states are showing moderate levels of activity, five states are reporting low levels and five others are reporting minimal levels.

CDC Director Dr. Thomas Frieden said in a media call that while some areas of the country may be over the peak, other regions, particularly in the West, may see rising numbers of cases. “It's likely that influenza will continue for several more weeks,” he said.

However, CDC officials say there are measures of improvement in some areas of the country, such as the South and Southeast. Across the country, outpatient visits to healthcare providers for influenza-like illness declined week-over-week to 4.3% for the week ended Jan. 5, but still above the baseline level of 2.2%.

What it all means is unclear. “Trends are hard to predict,” Frieden said. “Only time will tell us how long this will last.”

The increase in patients could help hospitals' bottom lines, says one for-profit industry analyst. Frank Morgan, an analyst at RBC Capital Markets, noted that a strong flu season would be a positive for patient volume as well as cash flow. Yet he cautioned that the increased flu activity won't necessarily translate into higher margins, as the flu not only puts a strain on hospital resources but also tends to see lower reimbursement than other conditions.

Hospitals and physicians across the country are taking a variety of steps to handle the influx of patients.

At 2,264-bed New York-Presbyterian, which operates the teaching hospitals of Columbia and Cornell universities, volume in the emergency department was already strained following superstorm Sandy, which severely limited the operations of two downtown medical centers, 806-bed NYU-Langone and 828-bed Bellevue.

Kelly, president of the hospital system, said New York-Presbyterian has seen a 10% to 15% increase in emergency room visits related to the flu outbreak and has admitted 110 to 120 patients. The hospital has ramped up its staffing levels considerably in the ER as well as set up an overflow area in the lobby for increased volume, he said. It is sequestering patients who come in with flu-like symptoms to prevent the spread of the viruses within the hospital. On its inpatient floors, single rooms are now serving as double rooms to meet the need for increased capacity.

Lehigh Valley Hospital-Cedar Crest in Allentown, Pa., set up a tent with six beds outside its emergency room to accommodate the increase in patients and segregate the ones who have the flu.

At 547-bed St. John Medical Center in Tulsa, Okla., officials are considering implementing its emergency management plan after weeks of working essentially at capacity, said Pam Kiser, chief nurse executive and vice president of nursing. “Everybody has a room. It may not be your traditional room,” Kiser said. St. John has taken actions such as converting an ER patient holding room into an intensive-care unit, she said.

The Tulsa medical center has been able to avoid turning patients away by expanding its daily bed management program, but executives appeared likely to implement its plan to try to ease the stress of the patients, Kiser said.

St. John has also been hit with an increase in patients with illnesses that aren't the flu, but are causing flu-like respiratory infections, she said.

The same is true at other hospitals. Whooping cough and a gastrointestinal virus are going around, said Dr. Christine Laine, a practicing physician, editor-in-chief of the Annals of Internal Medicine and senior vice president at the American College of Physicians. “A lot of people are sick, whether it's the flu or something worse,” Laine said.

At WellStar Health System, Marietta, Ga., the system's own employees are feeling the effects of the increased flu activity, spokesman Keith Bowermaster said. His own department has seen three of 25 staffers fall victim, he said.

The system saw three times as many flu cases in ambulatory settings in November and December as it did during the same period the previous year, with higher flu-related admissions as well.

He added that the number of cases is already above the number seen during that period in 2007-08, which is the worst flu season on record at WellStar. That season peaked in February, and with this year's peak still an open question, the flu season could well be the system's worst.

At 580-bed WellStar Kennestone Hospital, one of the busiest emergency departments in Georgia, 826 more patients flooded the ER last month than in December 2011—a 28% increase—largely driven by flu-like illness. The hospital in Marietta admitted 316 more patients than in December 2011, a 27% spike.

As a result, Kennestone has seen backups in its waiting room as patients wait in the ER for a bed to open up on a busy inpatient floor.

Physician staffing also has been an issue for some hospitals. Four-hospital HealthEast Care System, St. Paul, Minn., has plenty of physical resources in terms of building capacity and temporary nurses it can pull in, said Dr. Peter Bornstein, medical epidemiologist for the system and managing partner of the practice St. Paul Infectious Disease Associates. “We can handle that aspect of it,” he said.

The problem is finding physicians to help with the increase in patients, he said. “It's toughest of all on the doctors.”

Physicians' offices are feeling the strain as well. “The places that are seeing it are both the primary-care centers and the ER,” said Dr. Jay Varkey, an infectious disease expert at Emory University School of Medicine, Atlanta. Varkey conceded that last year's mild flu season, which also got off to a relatively late start, may have created less urgency in the community to get vaccinated in the early fall. “I'm suspicious that that might be the case, but it's too early to tell.”

This season's flu is dominated by a strain that is harder on patients than the typical dominant seasonal flu. Two influenza A strains are currently in circulation: H3N2, which is accounting for 98% of those cases, and H1N1, better known as the virus behind 2009's swine flu pandemic, which accounts for 2%. In addition, two influenza B viruses, which tend to be less virulent than influenza A, are also in circulation.

The more virulent influenza A strain is causing most of the increased patient volume across the country, particularly in large cities such as New York, Chicago and Boston. Dr. William Schaffner, who chairs the department of preventive medicine at Vanderbilt University Medical Center in Nashville, said deaths have been seen even in otherwise healthy young people. “This is an infection that can take a very healthy person and make them very ill.”

The CDC reported that 7.3% of all deaths reported through the Cities Mortality Reporting System were because of influenza and pneumonia, above the 7.2% epidemic threshold for the week ended Jan. 5. Since the beginning of the flu season, there have been 3,710 laboratory-confirmed flu-associated hospitalizations, a rate of 13.3 per 100,000. Eighty-six percent of them were for the more virulent influenza A strain, while 13% for influenza B. The remaining cases were unidentified.

At Parkland Health & Hospital System, Dallas, the epidemic has led to a shortage of testing supplies, leading the 784-bed public hospital to use triage methods in determining who gets tested, said Dr. Pranavi Sreeramoju, chief of infection prevention at the hospital and assistant professor, medicine-infectious diseases at UT Southwestern Medical Center. Patients who appear well or who appear to have the flu are less likely to get tested, she said.

Sporadic shortages for the pediatric version of the flu vaccine have been reported, according to officials at the CDC, but the adult version can be compounded into the pediatric dose.

Officials at the CDC say the decline in outpatient visits could signal the epidemic is receding in some regions, and at least one major hard-hit hospital sees a sign that that could be happening. Dr. David Hooper, chief of the infection control unit at Massachusetts General Hospital in Boston, where a public health emergency was declared by the mayor, said that last week the hospital saw a decrease in cases compared with the previous one.

Massachusetts General had confirmed more than 500 cases of the flu with 167 admissions, as of Jan. 10. “We've seen more flu this year than we've seen in the past several years,” Hooper said.

“It's been an all-hands-on-deck mentality,” Hooper said. “We hope we're past the peak.”