Flu, coronavirus challenge hospitals' ability to withstand surge of patients

It was late last summer when LCMC Health Children’s Hospital of New Orleans began to see its first flu-infected patients in the current season. By mid-November, the hospital had treated 185 patients for flu in a single week compared with just two instances during the same time a year earlier.

“It was incredibly early for us to see flu cases,” said Dr. Leron Finger, chief quality officer at Children’s Hospital. “I think we recognized in the months of September and October that even though we only had sort of a trickle of cases, it was a leading indicator that it might be a far earlier flu season than we might have anticipated.”

Those indicators prompted meetings of the hospital’s surge capacity team, made up of leaders from the clinical and nonclinical departments typically most affected by a patient surge.

Alerts were sent to various departments, ranging from clinical care to environmental services to labs, explaining that they should expect greater demand for their services than they would normally receive.

The hospital’s early response adhered to LCMC’s process for addressing surge capacity issues, which Finger said relies on clinical and nonclinical personnel being trained to identify a potential emergency and respond accordingly. He said that has helped better prepare the hospital to manage room capacity issues, as well as burdens on supplies and staffing that an unexpected influx of patients can cause.

Yet, the current flu season has highlighted the unpredictable nature of managing patients, even with prudent planning. And the threat of a pandemic-like event has grown sharply with emergence of the 2019 novel coronavirus in Wuhan, China.

“We take the approach of preparing for the worst and hoping for the best,” said Dr. Sarah Nafziger, physician adviser for the Center for Patient Flow and medical director for employee health at the University of Alabama at Birmingham Medicine.

“The reality is that new infectious diseases can emerge at any time and those diseases could have a significant impact,” she said. “Careful preparation combined with a timely and robust health sector response is our best chance to mitigate the threat of emerging diseases.”

Providers in many Southern and Western states have been dealing with the effects of a severe influenza season for months. Virus activity was already widespread by early November in California and Louisiana, according to tracking data from the Centers for Disease Control and Prevention.

By the end of that month 14 more states had reached widespread flu activity, with high levels reported across the South from Texas to South Carolina.

The CDC estimated there were at least 13 million flu-related illnesses, 120,000 hospitalizations and 6,600 deaths from Oct. 1 to Jan. 11.

Health experts attribute the early elevated levels of flu activity across the Southern U.S. to the prevalence of influenza B, a strain that normally occurs later in the season but has already made up more than 67% of the positive flu tests collected by the CDC as of Jan. 11.

Prevalence of the B strain has been a problem in particular for many pediatric hospitals since that virus tends to hit children the hardest.

Of the 39 pediatric flu deaths that have occurred this season, 28 were from the B strain.

Nafziger of the University of Alabama at Birmingham said its first flu patients surfaced in late October with an influx of pediatric patients at the health system’s primary-care clinics and its children’s hospital.

As cases of influenza B started to taper off and adult cases of H1N1 started to surge, Nafziger said the hospital began monitoring local and state public health department data for the influenza-like illness rate within the community. A rate that reaches around 5% usually triggers activation of the hospital’s action plan.

Nafziger said the response plan first calls for the heads of each department discussing how to ameliorate the flu surge by focusing on areas most susceptible to capacity problems. “Each flu season is unique and different,” she said. “Being proactive in your planning is key.”

The emergency department is one key area that can become quickly overwhelmed. UAB Hospital began its preparations by creating an alternate layout to the ED waiting room to better separate patients with flu-like illnesses from other patients.

An additional discharge area was also created for patients waiting to leave in order to free up beds in the ED. At the start of an active flu season, UAB leaders typically first implement their limited-capacity protocol, Nafziger said.

Some of the actions taken as part of the protocol include directing environmental services personnel to focus primarily on cleaning patient rooms rather than cleaning common areas.

But Nafziger said a large component of UAB’s capacity management involves a focus on flu prevention among patients and staff.

In addition to messaging campaigns that encourage using hand cleansers and limiting the number of patient visitors, three years go UAB began mandating all employees get flu vaccinations.

Nafziger credits the overall strategy with a decline in employees calling in sick, as well as its work with the human resources department to make sure there’s no pressure on employees to come into work when they are sick and to offer incentive payments for other employees to work if needed.

Like LCMC’s Finger, Nafziger said closely following the flu outbreak’s progress is key in preparing for capacity challenges. Besides tracking public health officials’ surveillance data during flu season, healthcare professionals should constantly monitor lab-confirmed flu cases within the hospital and ambulatory settings, as well as patients whose condition requires clinicians to wear personal protective equipment.

Such surveillance is necessary to not only stay apprised of known cases being managed within the hospital but to identify a potential outbreak before it can put a burden on capacity and resources.

“When you combine all of the data inputs and put them together, that allows you to paint a picture of just kind of where are we with the flu season right now,” Nafziger said.

While hospitals in the South have had to contend with higher than normal flu activity for the past several months, the heavy outbreaks have just begun throughout the rest of the country.

Michelle Stephenson, chief operating officer at Lurie Children’s Hospital of Chicago, said while flu-related cases haven’t risen in the past month, a spike in viral respiratory illnesses since mid-December has led to a 28% increase in patient volume and an admission rate of about 20%.

Like other hospitals, Lurie has an emergency instant command system in place that responds when a patient surge has the potential to require additional resources across multiple departments.

A logistics chief is responsible for managing needs for additional supplies, security and environmental services personnel, while planning and medical chiefs make sure adequate clinician staffing levels are maintained.

The hospital’s response was driven by its ability to detect early on that the surge in patients was going to be more than a few days.

A typical night in the hospital’s emergency department means treating 160 to 180 patients, while busier nights such as Sunday and Monday can have more than 200 visits.

Stephenson said Lurie’s surge response kicked in once the ED began seeing more than 200 patients every day for over a week.

The hospital relocated a unit that was adjacent to the ED and converted it to accommodate 10 extra beds and additional providers. Stephenson credited that move with driving down wait times closer to those of an average night.

David Kruger, director of emergency services at Lurie, said the hospital has done a lot of work over the past three years looking at trends and data to better adjust staffing models during surges. The hospital has nine staffing models that it can employ to place personnel in areas that can get overwhelmed when a seasonal surge in flu patients begins.

In addition to standard monitoring of local and state public health department data to spot illness trends, Kruger said the hospital tracks patient volume levels on a daily basis.

That kind of tracking allows the hospital to make needed staffing, room and resource adjustments to accommodate a prolonged surge within seven days of first noticing a spike. Smaller, quicker adjustments can also be made in a matter of hours if the hospital gets a sudden huge influx of patients.

Emergency department staff receive bed status alerts three times a day to provide them with bed availability, while hospital inpatient care personnel receive updates on the number of patients in the ED and the number in the waiting room. Kruger views such teamwork and communication between departments as a critical part of creating better patient flow.

Stephenson estimated that many of the changes that have been made to address the surge in respiratory viral patients will stay in place as preparation for the impending influx of flu cases.

“We’re probably not going to see anything worse than what we’ve already responded to,” she said. “We feel like we’re pretty well-prepared.”