In place of JEN Editor-in-Chief Renee Holleran's November editorial, the Journal is featuring a guest editorial by JEN Senior Clinical Editor, Margaret (Peggy) M. McMahon, RN, MN, CEN, FAEN.
The current H1N1 influenza epidemic continues to tax emergency departments worldwide. The first wave in late spring 2009 overwhelmed us with both the ill and the anxious well, subsided as schools closed for the summer, surged again in late summer as schools reopened, and continued into the fall. The second wave was particularly impressive with the number of patients visiting some ED visits doubling in just a few days.1, 2 While the number of deaths associated with 2009 H1N1 is low, children, young adults, pregnant women, and individuals with chronic diseases continue to be most seriously affected. One study found that 82% of the patients hospitalized with 2009 H1N1 were between the ages of 0-44 years, with the largest percent aged 5-17 years.3
Thus far, most flu-related ED patients have been only mildly ill. The onslaught of critically ill children and young adults thankfully has not materialized. The worst fear is that virus mutation will result in a third wave of victims, with massive mortality likened to the 1918 flu epidemic where 50-100 million died and a third of the world population was stricken. The scenario is daunting: large numbers of young people dying, rationing of ventilators, a 30-50% reduction in work force, inadequate supplies due to production and transportation impacts, and widespread economic hardship.
Preparing for a devastating pandemic influenza has been a government and public health priority for a number of years.4, 5 While considerable government and public health planning and drilling has occurred, hospitals are now working at warp speed to hone plans for dealing with such a scenario, bringing to light a number of issues. Keeping current is particularly challenging as information and recommendations regarding the current epidemic change very frequently. The supply of N95 masks (3M Company, St. Paul, MN), the only airborne exposure masks recommended by the Centers for Disease Control and Prevention (CDC) for health care workers, has been depleted due to the spring and fall surges. N-95 fit testing of health care workers who do not normally work in a clinical area in anticipation of their reassignment to clinical roles poses a dilemma as it will further deplete the supply. Some hospitals now restrict N-95 mask use to high-risk airborne exposure situations and direct the use of surgical masks for other situations. Research suggests that standard surgical masks are as effective as the N-95 in preventing influenza-like illness (ILI), but controversy continues.6
2009 H1N1 is highly contagious and can be spread to others for at least a day before 1 becomes symptomatic. Since health care worker ILI poses a risk to patients and co-workers, and because only about 40% of health care workers receive seasonal flu vaccine each year, the Association for Professionals in Infection Control and Epidemiology recommends mandatory influenza immunization for health care workers.7 Some states and health care organizations have already mandated seasonal influenza vaccine for this group and will most likely require the H1N1 vaccine as well.
Mandating health care worker vaccination is a contentious issue. New this year is the CDC recommendation of obtaining signed declination forms for health care workers opting not to receive seasonal influenza vaccination. Consequences vary for those who chose not to be vaccinated and fail to sign a declaration form. Availability of H1N1 vaccine is uncertain, and it is unclear if the recipients will have had sufficient time to generate immunity before a third wave strikes.
While the supply of 2009 H1N1 vaccine may be greater than originally anticipated (because only one dose, rather than two, may be needed), and while health care workers are high on the priority list for receiving the vaccine, availability for their families is uncertain. Personnel policies may require health care workers who have had the flu to stay home for extended periods of time; recommendations for the actual number of days have changed as well. Extended sick leaves pose hardships to those with limited or no sick time and may lead them to return to work prematurely as they cannot afford not to work, especially with our current economic difficulties. Decreasing exposures through school closures and restricted public transportation may add to the reduced workforce, as health care workers stay home with their children or due to lack public transportation to get to work. Limited public transportation may also increase the strain on emergency medical services agencies. Projected workforce reductions of 30-50% may result in delay or unavailability of services such as diagnostic studies and outpatient dialysis, adding to the emergency department and hospital burden. Supplies of oxygen may be limited as well. As many of the patients will be children, clinicians and institutions not normally providing pediatric care may be faced with inadequate equipment, supplies, and expertise.
Perhaps the most difficult issue will be the need to ration care and resources, particularly ventilators. It is not simply who gets put on a ventilator, but also who is taken off because their potential for survival is minimal and someone else needs it more. Many have anguished over this possibility, and tools such as the Sequential Organ Failure Assessment (SOFA) and Modified SOFA scores are proposed to assist clinicians in decision-making.8 Patients may be triaged directly to palliative care and not even make it through the hospital doors. The prospect of providing end-of-life care to countless children and young adults is difficult to comprehend. Real-time, in-department support for staff, patients, and families from behavior health, pastoral care, and ethics professionals will be required, and the emotional toll may be substantial.
Clearly, emergency departments and health care organizations are working hard to identify how care will be delivered if our worst fears are realized. The American College of Emergency Physicians' National Strategic Plan for Emergency Department Management of Outbreaks of Novel H1N1 Influenza, developed in collaboration with the Emergency Nurses Association (ENA) and other organizations, defines assumptions and outlines action steps to deal with a pandemic surge.9 Our challenge is to drill down on the specifics of how our own departments will operate, what activities we will and will not perform, what medications and treatments have priority, and how we will utilize staff who have never worked in an emergency department.
How can we keep the third wave from hitting? Representing ENA on the Institutes of Medicine Forum on Medical and Public Health Preparedness for Catastrophic Events, I am struck with the discussions on resiliency as fundamental to a community or country's ability to respond to any catastrophic event. Resiliency can be defined a number of ways, including quick to recover, hardy and resistant.
Keys to preventing widespread death and disability in this crisis are promoting hardiness through immunization for both seasonal and H1N1 influenza, education, personal responsibility, individual and family preparation, and community engagement. The CDC, public health departments, the media, and many organizations have done an incredible job in educating the public about flu prevention, home management, and when to seek medical care. Despite these efforts, our emergency departments continue to be overwhelmed with people who may have fared just as well at home. Crucial to our ability to provide care to the significantly ill is providing citizens with education on prevention and home care, and user-friendly tools needed to make informed decisions about when and where to seek care. Influenza algorithms, such as the Strategy for Off-Site Rapid Triage for Pandemic Influenza developed by Kellerman and colleagues10, 11 at Emory University, are intended to assist the public in their decision-making. Emergency nurses and health care organizations must seize this opportunity to educate our patients and communities on prevention, preparation, and informed health care choices.
Am I prepared for the third wave? Yes and no. Yes, the supplies are in place and dog care is squared away. But no, I am not prepared for taking children off ventilators or supporting countless parents as they say goodbye. I don't think anyone is. Let us act now so that we never face that challenge.
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