Center Articles and Publications

Meeting Report
Hospital Preparedness for Pandemic Influenza
Eric Toner, Richard Waldhorn, Beth Maldin, Luciana Borio, Jennifer B. Nuzzo, Clarence Lam, Crystal Franco, D.A. Henderson, Thomas V. Inglesby, and Tara O’Toole

Biosecurity and Bioterrorism. Volume 4, Number 2, 2006. © Mary Ann Liebert, Inc. Reprinted with permission.

Sections:
- Background Briefing
- Key Challenges and Possible Solutions
- The Path Forward and Next Steps
- References
- Appendix 1: Participant List 

On March 1, 2006, the Center for Biosecurity of the University of Pittsburgh Medical Center convened a meeting of senior government officials, hospital leaders, clinicians, and public health officials on Hospital Preparedness for Pandemic Influenza in Baltimore, Maryland. A list of meeting participants is provided in Appendix 1. Individual comments were not for attribution so as to foster a frank and open discussion.

The purpose of the meeting was to examine ways the U.S. healthcare community, and especially hospitals, can prepare to care for the large number of patients that would be expected during an influenza pandemic. At the meeting, the group was asked to discuss the serious challenges hospitals and communities will confront, to try to reach accord on what high-level solutions should be pursued, and to examine actions and next steps that the group or others might take to bring about such changes. To structure the meeting conversation, the staff of the Center for Biosecurity presented its initial assessment of the issues. The assessment was informed by analyzing pre-meeting discussions with the group and other government and clinical leaders and by reviewing information from a broad range of government and industry reports and peer-reviewed literature. This meeting report synopsizes the presentations given at the meeting and the group’s discussions.

Initially, a vision of success in hospital preparedness was proposed: U.S. hospitals, individually and jointly, will be able to provide medical care for flu victims while maintaining other essential medical services in the community during and after a pandemic.

Background Briefing
The staff of the Center for Biosecurity presented a briefing on the current state of avian influenza, hospital preparedness, and the threat of pandemic influenza.

Key Challenges and Possible Solutions
The Center for Biosecurity staff presented an analysis of key challenges in hospital preparedness and some possible solutions or paths forward, which the group discussed. The key themes of the discussion are summarized below.

Key Challenge #1: Hospital “preparedness” is not clearly defined.

• HHS has promulgated a comprehensive checklist of pandemic preparedness tasks that hospitals should undertake, but implementation of the items on the checklist is hampered by a lack of specificity, priorities, and metrics.
• The HHS checklist is not harmonized with existing HRSA (Health Resources and Services Administration) bioterrorism benchmarks or JCAHO (Joint Commission on Accreditation of Healthcare Organizations) standards.

Proposed Solution #1: A revised, prioritized hospital pandemic preparedness plan

Group Discussion of Challenge #1

• A lack of specific targets and a lack of a generally accepted, defined, and transparent methodology for planning are paramount obstacles at present to hospital preparedness planning. HHS should provide leadership in developing a nationally sanctioned, specific, and prioritized pandemic planning list that includes clear metrics for measuring hospital pandemic preparedness.
• HHS should coordinate efforts and seek endorsement of an acceptable planning framework from major organizations and government bodies such as HRSA, JCAHO, the American College of Emergency Physicians, the Association of Academic Health Centers, etc. This process should be done in coordination with regional hospitals (and associations) and health departments.
• The methodology for developing specificity and priorities needs to be transparent. Pandemic preparedness mandates should be harmonized with existing hospital preparedness requirements (i.e., HRSA, JCAHO) with the goal of creating a synchronized and jointly prioritized list.
• Implementing the list will require a marked increase in the level of federal funding. Funding to meet the objectives of the nationally sanctioned list will need to be distributed in a timely manner (commensurate with the desired rate of progress). The group agreed that, to ensure institutional ownership of hospital preparedness planning, special efforts should be made to capture the attention of hospital leaders.

Key Challenge #2: 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.
• The scientific, ethical, and legal frameworks for decisions regarding the allocation of limited healthcare resources and the need for possible alterations in standards of care under epidemic circumstances must be considered collectively to be deemed legitimate.
• 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 these functions, and there is limited operational coordination among hospitals, public health agencies, and emergency management agencies.

Proposed Solution #2: “Regional” Hospital Planning and Response Groups (RHPRGs)

Group Discussion of Challenge #2

• Regional coordinating groups are critical for hospital preparedness and response, but getting hospitals to accept and join in the effort may be difficult. Therefore, incentives for regionalization need to be created.
• Regional coordinating groups must include medical and nonmedical stakeholders (in all disciplines) and must be organized in coordination with public health and emergency management agencies.
• These groups should function for all hazards. Some group members pointed out that the regional command structure is foreign to hospitals, but they will need to be educated and integrated into the unified command within the region.
• Regional hospital organizations should coordinate information flow, serve as information clearinghouses, coordinate regional alterations in standards of care, and represent hospital operations by integrating into the larger incident command structure as well as serve as a joint decision-making body.
• Some group members pointed out that regional coordinating groups will be essential in providing consistent public messages during a pandemic.
• It will be important to clarify who “owns” the responsibility for organizing regional coordinating groups. One group member pointed out that while public health needs to make sure that there is a plan to respond, this does not mean that public health has to be the one to carry out the response.
• Some group members felt that membership in these regional coordinating groups should be mandatory for hospitals and should include outpatient care facilities.

Key Challenge #3: The demand for health care 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 nonurgent 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 frameworks—even the discussion of them—is potentially politically charged; therefore, transparency, fairness, and consistency are critical to public acceptance.

Proposed Solution #3: A framework for optimal allocation of limited medical resources

Group Discussion of Challenge #3

• There is an urgent need for a decision-making process for altering standards of care, because such complex decisions will need to be made in advance of a crisis.
• It will be important that plans to modify standards of care be developed transparently, with public input.
• Ways of modifying patient care to make it more efficient in times of crisis (e.g., limiting the number of times the pharmacist must check medications) must be evaluated. The group also suggested that crisis conditions may necessitate modifying the types of duties particular professionals are able to perform and providing “just-in-time” training to support these modifications.
• The group discussed the need to establish thresholds for setting up alternative sites of care, to identify the roles and services to be provided at these facilities, and to determine how they will integrate with the hospitals.
• Group members felt that, while HHS’s role is not to dispense clinical advice, it is unclear who does have the responsibility to coordinate decisions regarding degradation of care. In particular, hospitals will need guidance so that local decisions can be made under the security of a national umbrella.
• The group strongly supported development of a communications plan for altering standards of care. In particular, they underscored the importance of education campaigns to inform Americans that usual standards of care may not be possible during a pandemic.
• It will also be important to make sure that all practitioners are involved (including MDs, PAs, RNs, etc.) to ensure that those delivering care fully understand and comply with developed standards.
• The group encouraged more research so that providers have data to support decisions with regard to diminishing or withdrawing care.

Key Challenge #4: 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.

Proposed Solution #4: Volunteers to maintain medical services

• In addition to protecting the existing healthcare workers, every effort should be made to develop efficient and consistent local systems for volunteer enlistment, credentialing, and call-up.
• For licensed healthcare volunteers (e.g., retired healthcare workers, trained clinicians working in other fields, etc.), there should be enhanced funding and development of the state-based Emergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VHP).
• Credentialing guidelines should be uniform from state to state, and liability protection in emergencies should be made national in scope.
• For lay volunteers there is a need to organize the many existing nonintegrated local volunteer systems. The Citizen Corps Council may provide a platform for such state-based registration and coordination.

Group Discussion of Challenge #4

• A national system (such as ESAR-VHP) is needed that can register medical and nonmedical emergency volunteers in advance and verify their licenses and credentials.
• Recruiting volunteers may present challenges. Some members of the group pointed out that healthcare workers may not see themselves as part of public health or emergency response actions, and, therefore, work must be done to encourage active participation in disaster preparedness and response. One member also pointed out that ESAR-VHP is scary to some healthcare professionals because they don’t understand the program requirements; some have wondered whether signing on would mean they could be involuntarily drafted in a health emergency.
• In order to make volunteer programs more functional, there is a need to collect more information regarding individual competencies, to establish more uniformity among states, and to set standard requirements for training. One participant suggested that volunteers should be given some form of identification, such as a SMART card, that could readily verify skills and credentials in an emergency.
• To improve the pool of ready volunteers, it may be necessary to plan for “just-in-time” training for family caregivers and to encourage participation by medical professionals who will not be working because elective procedures are cancelled.
• One participant cautioned that during a crisis it may not always be feasible to provide optimal personal protection for staff members, particularly in light of the expected supply problems.
• It would be useful to determine the immune status of volunteers so that recovered individuals can help out during a pandemic.
• Some working group members urged consideration of “paid volunteers” and targeted incentives to encourage participation of medical staff who will be most in demand, such as respiratory therapists and nurses.

Key Challenge #5: Federal funding levels for hospital preparedness are inadequate.

• The National Bioterrorism Hospital Preparedness Program (under HRSA) has provided funding to hospitals of approximately $500 million per year nationally since 2002, and the FY07 request is $487 million. This comes to about $100,000 per year per hospital. In December 2005, Congress appropriated $350 million for state and local public health departments for pandemic preparedness; however, none of this appropriation is specifically identified for hospitals.
• The Center for Biosecurity’s rough calculation of the minimum costs of realistic readiness for a severe (1918-like) pandemic indicates a need for at least $1 million for the average size hospital (164 beds). The component costs to achieve minimal preparedness include:

• With approximately 5,000 general hospitals in the U.S., the national cost for initial preparedness would be $5 billion. In addition, there would be recurring annual costs to maintain preparedness, estimated to be approximately $200,000 per year per hospital.
• Note that these figures exclude stockpiling antivirals, since there is a separate national plan to acquire these drugs. In addition, no monies are included for purchases of expensive equipment such as mechanical ventilators, since it is not clear that extra ventilators would be useful if there were no trained personnel to operate them. A rough estimate of the cost to double the number of ventilators in the country, using safe but inexpensive equipment, is $1 billion.

Proposed Solution #5: Increase funding for preparedness

• HHS should urgently designate a working group to calculate more precisely the cost of hospital preparedness based on consensus planning assumptions.
• Based on the conclusions of this group, Congress should appropriate the required funds in an emergency supplemental appropriation to be distributed to hospitals using the existing HRSA funding mechanism with some modifications.
• HRSA should limit the amount of money that state health departments can retain for overhead.
• The funding to hospitals should be tied to achievement of clearly defined goals, using metrics built into the pandemic plans for hospitals and with a mechanism for holding hospitals accountable.

Group Discussion of Challenge #5

• Regional planning should be funded through the RHPGs. At this point it is impossible to estimate this cost until these organizations are more clearly defined.
• Federal funding for hospital preparedness must be significantly increased and must be made be sustainable to allow for long-range planning.
• Healthcare should be integrated into homeland security and funded over the time span that hospitals will need to meet these requirements.
• The group emphasized the need for an officially sanctioned analysis of what it will cost to get hospitals prepared.
• The group cited the failure of national leaders to recognize or pay for the full cost to hospitals for training and educating staff and the lack of funding designated for research.

Key Challenge #6: A severe pandemic may threaten hospitals’ solvency.

• Under current healthcare reimbursement schemes, hospitals lose money on nearly every illness-related hospital admission—especially those, like pneumonia, that are likely to result from flu. Normally, hospitals offset these losses with profitable elective procedures, but these elective cases will be among the first services to be cancelled or deferred in an attempt to respond to the demands of flu patient care during an epidemic.
• Hospitals’ revenue flow can be expected to decrease significantly during a pandemic, even though they will be experiencing record-high patient volumes. In addition, hospitals will undoubtedly need to provide care to many more patients who are uninsured and/or unable to pay. At the same time, operating costs in a pandemic will be extraordinarily high. Hospitals will have to pay a premium for staff and materiel that are in short supply. According to the AHA, the average hospital has only 41 days of cash on hand; thus, many hospitals may have insufficient cash reserves to survive a severe pandemic that significantly interrupts operations for weeks.

Proposed Solution #6: Federal emergency financial aid to hospitals severely affected by a pandemic

• HHS should develop, and Congress should fund, a program to reimburse hospitals for uncompensated care and extraordinary costs as a result of a pandemic. This could be done by amending the existing Stafford Act.
• In addition, the government should provide loan guarantees to offset transient negative cash flow due to deferral of profitable elective services (with the presumption that the deferred services will be provided later).
• Whatever the mechanism of financial relief for hospitals, it is essential that they have advance notice of qualifications for reimbursement (e.g., data collection requirements).

Group Discussion of Challenge #6

• Hospitals would become insolvent if they faced a 1918-like flu pandemic. One participant noted that according to a survey of NYC hospitals (pre- and post-9/11), hospitals are spending on average $2.5 million per year on preparedness (not including pandemic preparations).
• Collaborative planning is needed for the best application of funding.
• The group strongly supported the need to take into account the liability of the individual and the institution in calculating the costs of preparedness.
• With respect to possible federal reimbursements, it is critical that hospitals know in advance what information they need to collect to get reimbursed. Data collection reimbursement forms and requirements should be harmonized with activities that hospitals routinely perform (i.e., this data collection should not be an additional burden to hospitals).
• Individual providers will need compensation for lost services.

The Path Forward and Next Steps
The Center for Biosecurity presented a series of considerations and options for next steps and the path forward toward hospital preparedness. Group discussion followed.

What Congress Can Do:

What the Administration Can Do:

• Issue a presidential “call to service” for hospital preparedness.
• Revise the pandemic plan for hospitals with metrics and accountability, including mandatory participation of hospitals in RHPRGs.
• Convene a national expert commission to develop guidelines for allocating limited medical resources.
• Build on ESAR-VHP to include nonmedical volunteers, and integrate it with other existing volunteer programs.

Other Things that Might Be Considered:

• Pandemic simulation exercise
• Educational conferences for hospital leaders and clinicians
• Media campaign to raise public awareness
• Targeted appeals to political leaders (e.g., governors)

Group Discussion:

References

1.  Maldin B, Inglesby TV, Nuzzo JB, et al. Bulls, bears, and birds: preparing the financial industry for an avian influenza pandemic. Biosecur Bioterror 2005;3(4):363–367.
2. OIE [World Organization for Animal Health]. Update on Avian Influenza in Animals (Type H5). Paris: OIE; March 1, 2006. Available at: http://www.oie.int/downld/AVIAN%20INFLUENZA/A_AI-Asia.htm. Accessed March 1, 2006.
3. World Health Organization. Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO. Geneva: World Health Organization;2006. Available at: http://www.who.int/csr/disease/avian_influenza/country/cases_table_2006_04_04 /en/index.html. Accessed March 1, 2006.
4. U.S. Department of Health and Human Services. Pandemic Planning Update. Washington, DC: U.S. Department of Health and Human Services; March 13, 2006. Available at: http://www.pandemicflu.gov/plan/pdf/panflu20060313.pdf. Accessed April 12, 2006.
5. Treanor JJ, Campbell JD, Zangwill KM, Rowe T, Wolff M. Safety and immunogenicity of an inactivated subvirion influenza A (H5N1) vaccine. N Engl J Med 2006 Mar 30;354(13):1343–1351.
6. de Jong MD, Tran TT, Truong HK, et al. Oseltamivir resistance during treatment of influenza A (H5N1) infection. N Engl J Med 2005 Dec 22;353(25):2667–2672.
7. Lazzari S, Stohr K. Avian influenza and influenza pandemics. Bull World Health Organ 2004 Apr;82(4):242.
8. U.S. Department of Health and Human Services/State of Maryland Summit on Influenza Pandemic; Baltimore, Md, February 26, 2006.
9. Crosby AW. America’s Forgotten Pandemic: The Influenza of 1918. New York: Cambridge University Press; 1989.
10. Barry JM. The Great Influenza: The Epic Story of the Deadliest Plague in History. New York: Viking Penguin USA; 2004.
11. U.S. Department of Health and Human Services. Pandemic Influenza Plan. Washington, DC: U.S. Department of Health and Human Services; November 2005. Available at: http://www.hhs.gov/pandemicflu/plan/pdf/HHSPandemicInfluenzaPlan.pdf. Accessed April 12, 2006.
12. U.S. Centers for Disease Control and Prevention. FluSurge 2.0 Software. Available at: http://www.cdc.gov/flu/flusurge.htm. Accessed April 12, 2006.
13. American Hospital Association. Taking the Pulse 2005: The State of America’s Hospitals. Chicago: American Hospital Association; 2005. Available at: http://www.aha.org/ahapolicyforum/resources/content/TakingthePulse.pdf. Accessed April 12, 2006.

Appendix 1: Hospital Preparedness for Pandemic Influenza Participant List

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