February, 2007

Literature Review

Hospital preparedness for pandemic influenza
Go to full text in PubMed: Toner, et al. E Biosec and Bioterrorism 2006;4:1

The report noted is from a meeting at the Center for Biosecurity of the University of Pittsburgh Medical Center held March 1, 2006 to address the issue of hospital preparedness for pandemic influenza.  The following is a synopsis:

Background

• The current fatality rate of H5N1 is approximately 20 times greater than that of the 1918-19 influenza pandemic (57% vs. 2.5%). 
• It is not known if this strain will acquire the property of human-human transmission with efficiency, but that property could be acquired rapidly through reassortment or gradually with accumulation of mutations.
• Methods to control the epidemic with vaccine or antiretroviral agents are limited: vaccine production capacity is “extremely limited” and the currently available vaccine for H5N1 is not well matched for the dominant circulating strain.  The supply of oseltamivir is also limited and there is the potential for resistance.
• Secretary Michael Leavitt has recommended pandemic planning based on the 1918 pandemic experience.  This pandemic spread through the US in weeks and only two small communities were spared.  At the peak, there were 15,000 deaths per month. 
• Estimates based on the 1918-19 pandemic flu experience indicates that if this were to occur now, there would be a need for 191% of hospital beds, 461% of ICU beds and 198% of ventilators. 
• The economic consequences would be harsh.  At present, 30% of US hospitals are losing money and the operating margins of those that are profitable average only 1.9%.  There are 45 million uninsured Americans, 48% of emergency departments are at or over capacity, there are substantial shortages of health care workers and the number of hospital beds and hospitals is decreasing. 

On the basis of these observations, the following six challenges were reviewed:

Challenge #1: Hospital preparedness is not well defined: DHHS has provided a comprehensive checklist of tasks for hospitals, but review of these indicates lack of specificity, priorities and metrics.  The recommendation is to have this checklist revised on the basis of advice from hospitals, external experts and the JCAHO.  Specifically, the plan needs to address surge capacity, there needs to be specificity of goals and metrics to evaluate outcome of planning. 

Challenge #2: The preparedness task cannot be accomplished by hospitals alone:  The US health care system is highly fragmented, private and competitive, making collaborations awkward.  Most communities have no administrative or legal mechanisms to coordinate functions that naturally require substantial input outside of the hospital such as alternative care sites, the issues of recruiting, training and credentialing of volunteers and the scientific, legal and ethical framework for decisions in the allocation of limited health care resources.  The obvious need is a community-wide approach.

Challenge #3: The demand for health care will exceed capacity:  In a severe pandemic, there will be the necessity to reorganize some services, there will be a need for rationing of care and altered standards.  The recommendation is for a three tiered framework for guidelines at the national, regional and hospital level.  This would deal with deferral of services, criteria for admission and discharge, criteria for the use of resource-intensive care, alteration of practice standards and alternative care sites.

Challenge #4: A critical shortage of hospital workers will occur:   Coupled with the surge of patients will be the anticipated high rate of absenteeism of hospital workers due to illness, family responsibilities and fear of contagion.  The potential solutions are a maximum effort to protect existing health care workers, funding to establish a state-based Emergency System for Advanced Registration Volunteer Health Professionals, credentialing guidelines that are uniform from state-to-state, liability protection and appropriate use of lay volunteers such as the Citizen Corps Council.

Challenge #5: Federal funding levels for hospital preparedness is inadequate:  The original proposal allocated $500 million/year which equates to $100,000/year/hospital in the US.  The Congress appropriation yielded $350 million for local and state health departments, but none for hospitals.  The estimate from the Center is a need for approximately one million dollars/hospital for this planning.  With 5,000 general hospitals in the US, the national cost would be $5 billion.

Challenge #6: A severe pandemic may threaten hospitals’ solvency:  It is noted that hospital revenue flow will be expected to decrease substantially during a pandemic and these institutions are already broke or near broke as summarized above.  According to the AHA, the average hospital has enough cash for 41 days of operation.  The recommendation is for a congressional allocation to reimburse hospitals “for uncompensated care and extraordinary costs which could be done by amending the Stafford Act.”

The recommendations were distilled to the following:

• Congress should: fund hospital pandemic preparedness with $5 million in emergency funding and $1 billion/year thereafter; there needs to be legislation to ensure hospital solvency and there needs to be legislation to support the use of volunteers to maintain essential medical services.
• The Administration should issue a presidential “call to service” for hospital preparedness, revise the pandemic plan with metrics and accountability, and there should be a national expert committee to develop guidelines for the use of limited medical resources. 
• Other considerations should include pandemic simulation exercises, educational conferences for hospital leaders, a media campaign to raise public awareness and targeted appeals to political leaders including governors. 

Literature Review by John C. Bartlett, M.D. Professor, Division of Infectious Diseases