Summit convened by:

Center for Biosecurity of UPMC

Canadian Policy Research Network

Center for Science Technology and Security Policy at AAAS

National Consortium for the Study of Terrorism and Responsed to Terror

Roundtable II: What If Hospitals Cannot Take Everyone In?
The Problem of Meeting Immense Medical Needs

Issues and participants  |  Purpose and scenario  |  Transcript  |  Summary

Background

1. According to Secretary of Health and Human Services (HHS) Michael Leavitt, pandemic planning should be based on a 1918-like pandemic. [1]
   
   

   Pandemics spread quickly; in both 1918 and 1957, the outbreak spread across the U.S. in a matter of weeks.[2],[3] For example, during a 10-day period in October 1918 in Philadelphia, daily influenza deaths increased from 1 per day to 759 per day. In the peak week of October 1918, 4,597 Philadelphians died of flu, and a total of 15,000 people died during that month.[4] In 1918, there were no antiviral medications, antibiotics, mechanical ventilators, IV fluids, oxygen, or intensive care units.

2. It is unclear how modern medical care would improve chances of survival; however, during a pandemic, people may expect that substantial medical care would be available to them.
   
   

   Many communities are likely to be affected by pandemic at once. The federal government will not be able to provide special medical resources to all or even many of the local communities served by the 5,000 U.S. hospitals. The impact of a 1918-like pandemic on U.S. hospitals may be estimated using the HHS planning assumptions for a severe pandemic [5], CDCs FluSurge 2.0 software [6], and middle of the road epidemiological variables. This modeling projects that at the peak of the outbreak (week 5), the following percentages of available hospital resources would be needed for influenza patients alone: 191% of non-Intensive Care Unit (ICU) beds 461% of ICU beds 198% of ventilators

3. The current operational realities of U.S. hospitals and, by implication, their ability to handle a surge of flu patients can be illustrated by the following:
   
   

   30% of U.S. hospitals are currently losing money; of those that are profitable, the operating margins average 1.9%. 45 million Americans are uninsured; $25 billion per year in uncompensated care is provided by U.S. hospitals. There are shortages of healthcare workers of all kindsfor example, 100,000 additional registered nurses (8% of workforce) are needed. 48% of emergency departments report being at or over capacity. 46% of emergency departments had spent time on diversion (i.e., they needed to divert patients to other hospitals for some period of time) during a calendar year, due primarily to lack of inpatient beds. The numbers of hospitals, hospital beds, and emergency rooms have all decreased in recent years. [7]

4. During a pandemic, there will still be significant non-flu related demands on hospitals:
   
   

   Each day 12,000 babies are delivered In a non-pandemic year (2002) hospitals accommodated >90,000 admissions per day. One proposed way for coping with anticipated surges in medical demands is for hospitals to cancel elective surgeries. It is important to note that what are termed todays elective surgeries include such life-saving procedures as angioplasties, cancer surgeries, aneurysm surgeries. Also, hospitals depend on these procedures for much of their revenues.

5. Key challenges to hospital preparedness for pandemic influenza include the following:
   
   

   The demand for healthcare will exceed capacity-- In a severe pandemic, it will not be possible to provide traditional hospital care to all who need it. There will not be enough beds, supplies, or trained staff to take care of all the sick people, using normal practice standards. Hospital care will have to be reorganized through deferral of some services, rationing, and altered standards of care in order to do the greatest good for the greatest number. Hospitals will need to defer non-urgent services, but few hospitals have any processes in place to decide what services can be delayed and for how long. While many experts recognize the need to ration care in a severe pandemic, there are no nationally sanctioned scientific, ethical, or legal frameworks for the optimal allocation of scarce medical resources. The creation of such frameworkseven the discussion of themis potentially politically charged; therefore, transparency, fairness, and consistency are critical to public acceptance. A critical shortage of hospital workers will occur-- In a pandemic there will be high absenteeism of all hospital staff (not just clinical staff) due to illness, family responsibilities, or fear of contagion. Mutual aid agreements for sharing personnel will be of limited use in a pandemic that affects all hospitals, because there will be no personnel to share. Deployable federal medical assets (such as DMAT teams) and fixed federal assets (such as Veterans Administration and Department of Defense facilities) are unlikely to be available or of much use, since they also will be affected by the pandemic. There will be many demands on the few volunteers who are available. Some key preparedness tasks cannot be accomplished by hospitals individually-- Regional resource allocation, patient redistribution, and use of alternative care sites all require collaboration among hospitals, and among hospitals and public health and emergency management agencies, both in planning and in response. Effective recruitment, training, credentialing, and deployment of volunteer health and hospital workers require cooperation among hospitals, which might otherwise be competing for the same volunteers. There are significant barriers to collaboration among hospitals. The U.S. has a highly fragmented, private, and competitive hospital sector with inherent disincentives for collaboration. In most communities there are no administrative or legal mechanisms to coordinate preparedness functions, and there is limited operational coordination among hospitals, public health agencies, and emergency management agencies.

References

1. Leavitt, M. Secretary Leavitts meeting with states on pandemic influenza preparedness. Maryland. February 24, 2006.
2. Crosby AW. Americas Forgotten Pandemic: The Influenza of 1918, Cambridge University Press, 1989.
3. D.A. Henderson, personal communication. February 2006.
4. Barry JM. The Great Influenza: The Epic Story of the Deadliest Plague in History. Viking Penguin USA, 2004.
5. U.S. Department of Health and Human Services (HHS). Pandemic Influenza Plan. November 2005. Available at http://www.hhs.gov/pandemicflu/plan/pdf/HHSPandemicInfluenzaPlan.pdf. Accessed April 12, 2006.
6. U.S. Centers for Disease Control and Prevention (CDC). FluSurge 2.0 Software. Available at http://www.cdc.gov/flu/flusurge.htm. Accessed April 12, 2006.
7. American Hospital Association (AHA). Taking the Pulse 2005: The state of Americas hospitals. Available at http://www.aha.org/ahapolicyforum/resources/content/TakingthePulse.pdf. Accessed April 12, 2006.