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Pandemic Planning

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  1. Pandemic Planning Gerard Doyle, MD MPH UWSMPH 3 October, 2008

  2. Topics for the Day: • What are the potential threats? • Where are we? • Where do we need to be? • How do we get there?

  3. Why Should I Care? • It Could Happen • “Even Paranoids Have Enemies” • It has happened: 1918, SARS, etc? • It Could Happen to You • What’s out there? • Sanctions and other penalties? • JCAHO, ACEP, etc.

  4. What Is A Pandemic? • Pandemic occurs when: • New organism appears • Reassorted influenza genes, for example • Human population has poor immunity • Result is simultaneous epidemics • Enormous death and illness worldwide From WHO

  5. Not so long ago….

  6. Are We Overdue? • Pandemic flu • 10-13 since 1700 • SWAG: 3% annual • Effect of H5N1?

  7. Interpandemic Period Phase 1: No new human virus Phase 2: No new human virus Animal virus Substantial risk Pandemic alert period Phase 3: New subtype No human-to-human Phase 4: Small clusters Limited spread Virus not adapted Phase 5: Larger clusters Virus better adapted Substantial risk Pandemic period Phase 6: Pandemic Sustained transmission WHO Pandemic Flu Phases

  8. How Bad is the Big Bad Wolf? • Mortality rates of prior flu pandemics • 1918: 2.5% case fatality rate • 1957 and 1968 were not as bad as 1918 • Are we different today? • Populations density much higher • Travel much easier and faster • More people are chronically ill • Are current plans’ predictions valid? • What can we learn from the past?

  9. National Pandemic Flu Plan • HHS convened panel in 2005 • State and local health officials • Funding and some guidance, but…. • YOYO for up to a month? • Local/private agencies bear the burden

  10. Disaster Cycle: • Preparedness • Developing/bolstering critical substrates • Response • Activating and implementing the plan • Recovery • Restoring normalcy • Planning • Recognizing risks and vulnerabilities

  11. Planning and Preparedness: • Essential: PPPPPPPP • Failing to plan is planning to fail…. • Be Aware of Possible Events • For community and hospital • “All hazards” approach makes sense • Plan for Most Probable Events • Planning more important than a plan • Also Plan for Rare but Catastrophic

  12. How to Prepare for a Pandemic? • Preparing for a new flu pandemic • Focus on previous modern pandemics • “Evidence based preparedness” • Highlighting some hot-button issues • Not all inclusive, just some things…. • All-hazards preparedness • More “bang for the buck”

  13. Charge: who? Command and Ctrl Communication Coordination Convergence Contamination Capacity and surge Cooperation Chaos/confusion CISD Chronic Problems: “10 C’s”

  14. Charge: who? Command and Ctrl Communication Coordination Convergence Contamination Capacity and surge Cooperation Chaos/confusion CISD Chronic Problems: “10 C’s”

  15. Reality of current situation • Many hospitals are not prepared • Preparedness is contrary to business • Hospitals are not just hospitals • Hospitals depend on other services • Hospitals can be dangerous places

  16. What is “Surge Capacity?” • Pre-planned process to ensure care • Must address routine operations, too • Needed for all services • Staff needed to provide care • Stuff needed to provide care • Structure • Space to provide care (hospital or OST3F) • System of management to direct resources

  17. Surge Issues: Past Lessons • Patient volumes • Geometric growth in volumes • Supply shortages • Run low on common items • Vaccine supply extension • Studies to “stretch” vaccine by dilution • Elective surgery cancellations • Elective admissions, surgeries curtailed

  18. Hospitals are Dependents MJA 185 #10 S71

  19. Surge Capacity • Trend has been away from capacity • Systems are already running all-out • Surge planning: not good business? • JIT stocking of supplies • Casualization of staff • Non-traditional approaches required

  20. Health care system is: Fragmented Competitive Disorganized Broke Private At capacity and shrinking How can we possibly surge? Surge: Doomsayers Say…

  21. Capacity and Surge: • Beds are key hospital “service” • Staffing to care for bed and its patient • What goes into providing beds? • More than just a room with a bed • How do we ensure enough beds? • Need to know how many we need • Need to know how to provide enough

  22. Staff: Personnel Issues • Personnel trends: just-in-time staff • Temporary/agency staffing • Part-time (casual) employees • Multiple gigs • Union Issues? • Work hour restrictions?

  23. Staff: Personnel Issues • Current planning assumptions • 40% absenteeism!!! • Range of estimates worldwide • What is the proof?

  24. Why 40% absenteeism? • Schools: hardest hit • 20-50% of students out • Some kids held out • “Prophylactically” • Leads to some closures • Primary to university • Football, etc cancelled • Teacher absenteeism • 4x typical as well

  25. Why 40% absenteeism? • General Industry in ‘57 and ‘68 • About 2-4x usual rate were out sick • No disruption in industrial productivity • Less margin for this now?

  26. Why 40% absenteeism? • Hospitals: squeeze from both ends • Up to 10x normal ILI-like cases • Harder hit than industry at large • 30-40% staff absent was “nuisance”

  27. Staff: Absenteeism Surveys • General Population: • Range reported 35-50% fits with past data • First Responders: • 80% if no vaccine or PPE • 38% if no protection for immediate family • Medical workers: • 26% to provide care; 10% to avoid exposure • 50% of hospital workers • 28% in one academic medical center • 46% of health department workers

  28. Staff: Past Flu Absenteeism • Health care worker-specific data: • Canada: (1981) 6% (3x baseline) • Canada: (2005) 16% • USA: (2004) 44%

  29. Staff: Vaccine vs. Absenteeism • Shorter duration of sick leave • Lower attack rates if immunized • Not proven “cost effective” • May offer other benefit: reassurance • All of this assumes folks will get shots!!!

  30. Staff: Mitigation & Absenteeism • School closures proposed to slow flu • Many years start with young kids first • Problems with child care • Models predict 30% HCW miss work • Complicates other staffing issues

  31. Stuff: Spending $ for Surge? • HRSA: 500 beds for 1M people • Assume 50% to ICU, 50% acute • 3 days of supplies • Assume oxygen beds, suction available • $5.5M for basics • No 3rd/4th generation antibiotics, etc.

  32. Stuff: the Cost of the ABCs • Ventilators for mass critical care • Focus of lots of planning and discussion • Major potential source of costs • Bare-bones $3K to $15K each • Major potential source of controversy • Who gets them: from SNS? in ICU? • Prior solutions: work on your grip!!! • BVM used in Denmark, after Katrina

  33. Stuff: Blowback of Outsourcing • Many health care supplies from Asia • Estimate: 80% of consumables for HC • Anybody think of a problem here? • “Asian flu” “Hong Kong flu” “China flu” • Competition: empty shelves • Even in the best of times

  34. Stuff: Business Pan-Flu Plans • Many businesses use Just-in-time • Low stocking levels • Problems reverberate up the system • Can we get food, drugs, oxygen, etc?

  35. Space: Alternate Site Surge • New concept in surge capacity • Several possible functions/benefits • Protect the main facility • Provide medical care and shelter • Have been used with some success • 1957 flu in NYC • Houston floods, Katrina evacuees

  36. Systems Issues: Triage • The worried well and walking wounded • Vastly outnumber those really sick • 9:1 during 9/11/2001 • 500:1 during anthrax! • Survey: 1/4 have no one to care for them • High-risk groups even worse • Problems of over-triage • Increased mortality in most critically ill/injured • Over-worked staff at higher risk Anes Clinics 25: 161-777

  37. Systems Issues: Ethics • Disasters Demand Changes • In systems of care • In familiar moral and ethical “codes” • Key Issues for the hospital • Providers: safety vs. responsibility • Triage: equitably giving unequal care • Ethical preparation: policies in place • Preparation ethic: an obligation?

  38. Systems Issues: Ethics • Other dilemmas • Safety • Concerns of providers vs. patient needs • Community mitigation • Quarantine? • Masks, social distancing, hygiene, etc. • International issues • Travel/borders/immigration? • Trade? • Sharing resources with other nations?

  39. Systems Issues: Legal • EMTALA • Altered standard of care? • When? • For whom? • Sanctions for work refusal by HCWs? • Already in place in several states • License revocation, fines, imprisonment! • Does ability equate with obligation? • Do social obligations require risk taking? • Can expectations be enforced?

  40. Systems issues: Communication • Controlling emotions • Outbreak vs. epidemic vs. pandemic • Bring the whole family • The infamous “two-fer” • Keeping kids home • High attack rates in schools • Rest, fluids, antipyretics: education • Huge predominance of outpatient cases

  41. Systems Issues: Recovery • Recovering issues: • What about those who refused to work? • Will patients trust the standard of care? • All plans should address recovery • Transparency may help retain trust • Pre-planning helps

  42. Key Points: • Pandemics Will Happen! • Planning is as important as the plan! • We are expected to be ready!