HEALTH SERVICES
Hospital capacity and management preparedness for pandemic influenza in Victoria Ben Dewar,1 Ian Barr,2 Priscilla Robinson1
I
n addition to the threat of high morbidity and mortality, influenza pandemics can overwhelm health systems and cause significant societal and economic disruption.1 Pandemic preparedness planning is vital for ensuring health and other essential systems continue functioning during a pandemic, thereby reducing the economic and social cost.2 Australia’s Chief Medical Officer stated that although Australia’s health system was stressed during the 2009 pandemic, spare capacity in hospital beds was available.3 Also, due to the low rates of admission, ICUs were still able to cope with the increased demand and resource use such as ECMO (extracorporeal membrane oxygenation) of H1N1 patients4 even during the peak in July 2009.5 In short, even though the 2009 H1N1 pandemic may have overwhelmed the Australian health system, it did not – mainly due to the generally mild nature of the virus. However, there is no guarantee that a future pandemic will not be more severe and may indeed swamp the system. One of the lessons highlighted by the 2009 H1N1 influenza pandemic was the need for health services, especially those with critical care facilities such as ICUs and Emergency Departments (EDs), to plan and prepare for the challenges a future pandemic may bring.6 Hospitals face particular challenges during an influenza pandemic. Most important is ensuring that there is sufficient, sustainable frontline workforce available in all essential areas. During any disaster relief effort there are barriers to staff participation including transport problems, responsibilities of staff
Abstract Objective: This study was designed to investigate acute hospital pandemic influenza preparedness in Victoria, Australia, particularly focussing on planning and management efforts. Methods: A prospective study was conducted by questionnaire and semi-structured interview of health managers across the Victorian hospital system from July to October 2011. Participants with responsibility for emergency management, planning and operations were selected from every hospital in Victoria with an emergency department to complete a questionnaire (response rate 22/43 = 51%). Each respondent was invited to participate in a phone-based semi-structured interview (response rate 11/22 = 50%). Results: Rural/regional hospitals demonstrated higher levels of clinical (86%) and non-clinical (86%) staff contingency planning than metropolitan hospitals (60% and 40% respectively). Pandemic plans were not being sufficiently tested in exercises or drills, which is likely to undermine their effectiveness. All respondents reported hand hygiene and standard precautions programs in place, although only one-third (33%) of metropolitan respondents and no rural/regional respondents reported being able to meet patient needs with high levels of staff absenteeism. Almost half Victoria's healthcare workers were unvaccinated against influenza. Conclusions and implications: Hospitals across Victoria demonstrated different levels of influenza pandemic preparedness and planning. If a more severe influenza pandemic than that of 2009 arose, Victorian hospitals would struggle with workforce and infrastructure problems, particularly in rural/regional areas. Staff absenteeism threatens to undermine hospital pandemic responses. Various strategies, including education and communication, should be included with in-service training to provide staff with confidence in their ability to work safely during a future pandemic. Key words: pandemic, hospitals, influenza, Australia, planning as carers, lack of staff knowledge of risks or their role in the response, and staff safety fears for family or themselves through their participation.7 The type of disaster also matters, with workers reportedly less likely to turn up for work during an influenza pandemic than during a weather related disaster.7 Studies have shown that up to half the healthcare workers may not
respond if required to work during a severe influenza pandemic.8,9 The willingness of any particular staff member to respond was strongly linked to the type of worker role and the perceived importance of that role.9,10 During the 2009 H1N1 pandemic, Australian health worker absenteeism was as high as it was in 2007, when Australia experienced its worst influenza season in recent years.11
1. School of Public Health and Human Biosciences, La Trobe University, Victoria 2. WHO Collaborating Centre for Reference and Research on influenza, Victoria Correspondence to: Mr Ben Dewar, School of Public Health and Human Biosciences, La Trobe University, Franklins Street (City) Campus, 215 Franklin Street, Melbourne, Victoria 3000; e-mail: [email protected] Submitted: June 2013; Revision requested: August 2013; Accepted: October 2013 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2014; 38:184-90; doi: 10.1111/1753-6405.12170
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Hospital preparedness for pandemic influenza in Victoria
Strategies exist that may improve worker participation such as staff vaccinations, provision of antiviral therapies and effective education and communication programs.12 Importantly, a study of infection rates after the peak of the 2009 H1N1 pandemic showed that healthcare workers had similar levels of infection to the general community, and that household rather than workplace exposure was more strongly associated with infection.13 The provision and correct use of personal protective equipment (PPE) such as gloves, gowns, masks and face shields may be an effective measure to reduce transmission.13 However, once a pandemic occurs, regular stocks of PPE will be rapidly depleted and it will be the responsibility of each hospital to calculate its requirements and stockpile required amounts of PPE.14 Hence, this is a potential weakness in the current pandemic plans for healthcare workers. Epidemic outbreaks of influenza in healthcare facilities have been associated with low staff vaccination rates.15 Staff vaccinations are therefore essential to prevent or ameliorate virus outbreaks amongst patients and staff in hospitals.15 Increasing healthcare workers’ vaccination rates leads to reduced influenza amongst patients and staff, reduced mortality among patients, a safer workplace and a more productive workplace through reduced sick leave.15 Ethical arguments can be made that the welfare of patients and co-workers outweighs the personal preferences of staff, and that staff vaccinations should be made mandatory.15 Hospitals play an integral role in the public health response to pandemics;16 however, few reviews have been published of Australian hospitals’ performance during the 2009 H1N1 pandemic or how planning has since been modified. This study was designed to investigate pandemic influenza preparedness in acute care hospitals in Victoria, Australia, with a focus on policy, planning and management efforts, and the subsequent changes made to counter future influenza pandemics.
Methods The Australian Institute of Health and Welfare’s My Hospitals website17 was used to identify all Victorian hospitals with an ED. All 43 hospitals identified were contacted by phone to identify the Emergency Management Coordinator or similar person in
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charge of emergency management, planning and operations.
at their hospital during the 2009 H1N1 pandemic.
A questionnaire was prepared based on the hospital requirements described in the Victorian Health Management Plan for Pandemic influenza16 and a 2010 report by Sprung et al.18 The questionnaire covered three main areas: hospital planning information; workforce issues; and infrastructure and surge capacity. The questionnaire was piloted with a small group of colleagues. Staffing levels suggested by Sprung et al. were used to identify and test potential capacity. Questionnaires were mailed to respondents, who were asked to complete it with colleagues if necessary. One response from each hospital was requested. Reminder phone calls were placed two weeks after posting. After completing the questionnaire all participants were invited to take part in a follow-up qualitative semistructured telephone interview covering personal and professional experiences during the pandemic.
Nine participants (41%) indicated that they were the Emergency Management Coordinator or similar title, five respondents (23%) held positions related to infection control, four (18%) were ED Managers and three respondents (14%) identified their role as relating to Nursing or Acute Services. Half of the questionnaire responders consented to an interview.
Data on healthcare worker immunisation was provided by the Victorian Infection Control Nosocomial Infection Surveillance System (known as VICNISS) with permission from the Victorian Department of Health. All identifying details were removed prior to analysis. This work was approved by the La Trobe University Faculty Human Ethics Committee (Reference: FHEC11/095). Descriptive statistics with a 95% confidence interval were calculated for univariate and bivariate analysis. Text responses were analysed using a qualitative approach and grouped into themes.
Results Staff from 22 hospitals provided responses to the questionnaire, a response rate of 51%. Seven responses were received from rural/ regional hospitals (7/16 = 44%) and 15 from metropolitan hospitals (15/27 = 56%) with the latter including one private hospital. Hospital sizes ranged from 35 to 885 hospital inpatient beds (median = 260, metropolitan median = 352, rural/regional median = 101) with 184 to 5,000 full-time equivalent staff (median = 2,370, metropolitan median = 2,485, rural/ regional median = 944) and between 8 and 62 ED and ICU beds combined (median = 44, metropolitan median = 52, rural/regional median = 17). All but two rural services (91%) reported confirmed cases of H1N1 influenza
All respondents surveyed indicated that an incident control system (ICS) was in place and all but three had been internally reviewed within the last two years (86%). The most frequently cited frameworks or practices (multiple could be cited) upon which systems or plans were developed were: Hospital Resilience Code Brown Policy Framework (11 citations: 50%); Victorian Health Management Plan for Pandemic influenza (5 citations: 23%); and the Australian Health Management Plan for Pandemic influenza (4 citations: 18%). Others included the National Australian Standard 4083/1997; WHO Strategic Plan 2007; NSW Health influenza Pandemic Plan 2006; and the New Zealand influenza Pandemic Action Plan 2006 (1 citation each: 5%). Of these, 16 plans (73%) were endorsed at the executive level, four (18%) were endorsed by the CEO and one (5%) was not yet endorsed (and one did not provide a response). Staff cited by respondents as commonly involved in planning worked in infection control, occupational health and safety departments, or were medical staff or hospital executives. Other departments (for example supply, engineering, ICUs and pharmacy) were poorly represented (Table 1). Metropolitan respondents reported higher rates (60%) for testing of plans in a functional exercise or drill than rural/regional respondents, where no testing was reported (Table 2). In the event of another pandemic, respondents indicated that current planning efforts would be effective only to a point, with important variables being the severity of the next virus and workforce availability. None of the rural/regional respondents and almost half the hospitals overall (45%) reported that patient needs could not be met with rates of staff absenteeism expected during a pandemic (Table 2). The results of the survey indicated that compliance with standard precautions training and the presence of hand hygiene programs was
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high. However, in the year following the 2009 pandemic, aggregate Victorian healthcare worker influenza vaccination rates again fell to below 50% (Figure 1) with medical staff (39.6%) and nursing staff (44.3%) demonstrating the lowest rates.
Although anxiety was observed by interviewees to be high among staff during the 2009 pandemic there was no observed refusal to work. Interviewees described a variety of strategies employed by hospitals to reduce infection exposure and staff anxiety, including: creating frontline ‘flu teams’ that dealt exclusively with influenza patients thereby reducing contact for other staff, identifying and removing susceptible healthcare workers such as pregnant staff from exposure, and establishing mandatory daily update meetings for department heads that were also available to other staff. Education both before and during the pandemic to keep staff aware of protocol updates was seen as a key challenge that was necessary to reduce uncertainty.
Table 1: Frequency of involvement of certain hospital groups in the development of hospital emergency and pandemic plans. Group
Frequency
Count
Infection Control
90%
19
Occupational Health & Safety
43%
9
Medical/Clinical Director or Medical Staff
38%
8
Hospital Executive
33%
7
Emergency Management Committee
33%
7
Director of Nursing/ Nursing Staff
24%
5
Emergency Department
24%
5
Quality and Risk
14%
3
Supply
10%
2
Engineering
10%
2
Department of Human Services/ Health
10%
2
Microbiology
10%
2
Chief Operating Officer
5%
1
Medical Administration
5%
1
ICU
5%
1
Bed Coordinators
5%
1
Pharmacy
5%
1
Service Managers
5%
1
Allied Health
5%
1
Environmental Services
5%
1
Theatre
5%
1
Security
5%
1
The respondents’ perceived capacity of hospitals to meet pandemic infrastructure and supply demands was mixed. Even at hospitals with few pandemic-related presentations, infrastructure capacity was identified as a potential weakness if patient numbers had significantly increased. Emergency departments proved the greatest management challenge. Common problems identified by interviewees are shown in Box 1. Interviewees commented that due to the nature of patient presentations during the 2009 pandemic, plans based on the assumption that infectious disease wards would be required to manage large numbers of admissions were found to be redundant. Where possible these plans were adapted by moving departments close to the ED elsewhere and expanding the ED into the newly created space.
Figure 1: Healthcare worker influenza vaccination rates for Victoria. 70%
2007
2008
2009
2011
2010
2012
60% 50% 40% 30% 20% 10% 0% Medical
Nursing
Allied Health
Source: VICNISS. Note: Emergency staff data was not collected in 2007.
186
NonClinical
Laboratory Emergency
Other
Aggregate
Box 1: Problems identified in emergency departments. • Little or no scope to expand capacity • Single entry points so that entry of patients with influenzalike illness (ILI) could not be separated from those without ILI • No waiting room segregation for ILI patients • Inability to clean cubicles effectively or in a timely way between patients
Rural/regional respondents more commonly reported maintaining stockpiles of medical equipment, personal protective equipment, medication and basic supplies adequate to manage a mass casualty event than metropolitan respondents. Despite this, rural/ regional respondents rarely reported access to extra ventilators when needed or capacity to expand patient isolation within ICUs (Table 2). Rural/regional hospital respondents also expressed concern that supply was not available during the pandemic either from private or government suppliers, particularly for P2/N95 masks. Metropolitan respondents reported fewer supply issues. Although mask supplies had to be monitored, stocks were available from both government stockpiles and usual suppliers. Metropolitan hospitals placed greater reliance on the release of government stocks due to financial challenges and a lack of storage capacity limiting the ability to stockpile. The supply of essential equipment and consumables during a pandemic was raised as a concern for the health system as a whole, particularly given the sector’s move towards just-in-time supply chains. The lack of timely patient test results from influenza polymerase chain reaction (PCR) testing was also identified as an issue by some respondents. Pandemic communication processes were felt by one interviewee to be enhanced by ensuring there was a single co-ordinator to receive, co-ordinate and distribute internal and external information. The majority of rural/regional hospital managers interviewed felt that communication and the level of pandemic response by the Victorian Department of Human Services (DHS), now the Victorian Department of Health, was different for rural/regional areas than for metropolitan areas, with responses to regional queries or requests for help perceived as slow and possibly hampered by indirect communication through regional hubs rather than direct communication with a central body. The content of communication was also a source of concern, as case definitions and diagnostic
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2014 vol. 38 no. 2 15 9 6 13 14 10 9
Have incident management positions been determined with clearly defined roles and leadership?
Are clinical staffing levels accounted for in the plan?
Are non-clinical staffing levels accounted for in the plan?
Are equipment contingencies accounted for in the plan?
Are space contingencies accounted for in the plan?
Have incident escalation trigger points for impact on hospital operations been set in the event of a pandemic?
Have plans been tested in a functional exercise or drill?
15 15 10 5
Are all staff trained in standard infection control precautions?
Does the hospital have a hand hygiene program?
Are staffing patterns designed to change at different operating stages?
Can the hospital meet patient needs at the stages identified above with 25-40% of staff absent?
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8 10 7 10 13 7 9 11 8
In a mass casualty event (MCE) does your hospital have stockpiles of equipment?
In a mass casualty event (MCE) does your hospital have stockpiles of PPE?
In a mass casualty event (MCE) does your hospital have stockpiles of medication?
In a mass casualty event (MCE) does your hospital have stockpiles of basic supplies?
Does the hospital have one ventilator per critical care bed?
Are contingency plans in place to obtained more ventilators up to planned limits within 6-12 hours?
Does the hospital have the capacity to expand isolation of patients in the ICU including provision of negative airflow?
Have areas that can be separately ventilated been identified?
Is the hospital able to accommodate a large number of deceased in a respectful way?
6
3
4
7
1
5
5
5
7
9
3
4
3
0
0
0
4
3
1
2
9
6
0
0
N
n M rM P 1 P M M rM nM 1
0
Is there capacity to expand the ICU to 300% of current capacity? *
Y = Yes. N = No, DK = Don’t Know, A = Abstain, PM = “Yes” Proportion Metropolitan, PR = “Yes” Proportion Rural/Regional, CL = Confidence Limit * Hospitals without an ICU were marked as A (Abstain) Confidence Intervals were calculated for the difference between two proportions allowing for the finite population size: CL P R P M 1 . 96 Where nx is the number of hospitals, eg. nM is the number of metropolitan hospitals with emergency departments in Victoria rx is the number of respondents, eg. rR is the number of rural/regional respondents Note: Where values were missing the hospital was removed from that section of the analysis.
11
Are coordination systems and agreements in place with neighbouring health providers?
Infrastructure and Surge Capacity
12
Are staff willing to take antiviral prophylaxis medication?
15
Is there a process of incident management (such as an incident action plan) in place?
Workforce
Y
Hospital Planning
0
1
2
1
1
0
0
0
0
3
0
2
2
0
0
0
1
1
0
0
0
0
0
0
A
4
5
1
4
3
6
5
7
6
1
4
0
4
7
7
4
0
3
6
6
6
6
7
7
Y
n R rR P R 1 P R n 1 rR R
1
0
0
0
0
0
3
0
0
3
1
4
0
0
0
3
1
1
0
0
0
0
0
0
DK
Metropolitan
Table 2: Details of questionnaire results including analysis of differences between metropolitan and rural/regional hospital responses.
3
0
4
3
3
1
2
0
1
5
1
6
1
0
0
0
7
2
1
1
1
1
0
0
N
0
0
0
0
0
0
0
0
0
0
1
0
1
0
0
2
0
1
0
0
0
0
0
0
DK
Rural/Regional
0
2
2
0
1
0
0
0
0
1
1
1
1
0
0
1
0
1
0
0
0
0
0
0
A
4%
-2%
-46%
10%
-44%
19%
25%
33%
32%
14%
-16%
-33%
-10%
0%
0%
-23%
-60%
-24%
-8%
-1%
46%
26%
0%
0%
(PR - PM)
Mean Difference
-28.1%
-30.9%
-70.4%
-21.4%
-73.9%
-5.3%
-5.0%
19.6%
7.6%
-5.8%
-47.4%
-47.1%
-41.1%
0.0%
0.0%
-53.6%
-74.3%
-55.4%
-29.0%
-23.4%
21.1%
1.1%
0.0%
0.0%
95%CL
Lower
35.7%
27.1%
-21.1%
42.4%
-13.7%
43.4%
54.5%
47.1%
57.2%
34.4%
15.0%
-19.6%
22.0%
0.0%
0.0%
7.9%
-45.7%
7.8%
13.7%
21.4%
70.4%
50.4%
0.0%
0.0%
95%CL
Upper
95% Confidence Intervals for Differences: Rural - Metropolitan
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criteria changed. Testing, tracing, treatment and reporting requirements from DHS were cited by interviewees as major issues for hospitals. Although these criteria were later eased, the initial protocols were seen by some interviewees as too strict and impractical to achieve, especially had the number of presentations rapidly increased.
a combination of both (all responses scored 7+ on a scale of 1 to 10).
Interviewees also commented that the autonomy and devolved governance arrangements of Victorian hospitals were challenged by DHS instructions to maintain normal operations during the pandemic, despite their hospital emergency plans calling for a scaling down of regular services at certain trigger points. It was suggested that the combination of rapidly changing and potentially impractical instructions may have contributed to a desire by some hospitals to act more independently in their management of the pandemic.
In addition, the planning frameworks identified by respondents only represent the knowledge of the respondents rather than the practice that might be implemented, the framework that was used to write the hospital plan, or any co-ordinated action that governments might take should a pandemic arise.
Respondents defined a number of changes that occurred as a result of the pandemic. A summary of these is presented in Table 3. Most respondents reported needing to develop or adapt their response to meet changing testing and treatment protocols across the various stages of the pandemic. Those interviewed believed that hospitals managed the pandemic well, either through effective planning, a lack of presentations, or
Limitations The main limitations of this study are the small number of hospitals in Victoria with an ED, and a relatively low response rate.
While complete data on Victorian hospital bed-numbers was not available, survey respondents did represent a broad crosssection of the Victorian hospital system, including small, medium and large hospitals from both metropolitan and rural areas. The study was also strengthened by the addition of qualitative interview data to expand on the quantitative survey results.
Discussion Pandemics can be variable in their disease severity ranging from very mild, as occurred in 2009, to very severe, as happened in the
Table 3: Changes in hospital practice identified following review of the 2009 pandemic. Change area
Summary of suggested revisions
Revision of the existing plans
• Addition of a step-by-step protocol to the existing pandemic plan with practical steps in pandemic management and when they should be done, contact numbers, etc • Development of plans to set up flu houses and clinics for triage, funding permitting • Incorporation/inclusion of the local community in more effective management of the pandemic • More proactive management of the relationship with State Government • Greater involvement consultation and coordination with the local division of general practice – now called a Medicare Local. • Development of a new business continuity plan
Expanded capacity
• Use of in-house validated PCR diagnostic kits for seasonal influenza testing • Definition of areas within the hospital where patients can be decanted for cohorts of pandemic influenza patients, such as outpatient areas for patients who need assessment before going home, and patients who are not very sick but need isolating and hospital management • Expansion of capacity to isolate patients in future hospital designs • Allocation of storage areas for personal protective equipment such as tissues, gloves, handwash, etc, in strategic parts of the hospital
Improved communication
• Embedding of daily meetings as part of operations in a pandemic • Establishment of a single central coordinator as part of the hospital incident management team to coordinate internal and external communication and 'close the information loop' • Formalised documentation that can be released in a timely way during the next pandemic that defines the role of staff (particularly ED staff) at various pandemic stages • Incorporation into plans of factsheets developed by the State Government for providing information to the community
188
'Spanish influenza' of 1918-19 when an estimated 50 million people died globally.16,19 Moderate pandemics were seen with the more recent Asian flu in 1957 (H2N2) and the Hong Kong flu in 1968 (H3N2)1 in which there were an estimated two million and one million deaths worldwide, respectively. When the pandemic arrived in May 2009, Victorian hospitals were in varying stages of preparation and many found their plans to be inadequate to the challenges at hand. The lack of citations for the state or national frameworks as the basis for hospital pandemic plans was surprising, and although the reasons for this were not explored, the lack of a consistent framework on which hospital pandemic plans were based may hamper state and national co-ordination efforts in the future. The Victorian hospitals’ ‘Code Brown’ emergency response framework was the most commonly cited basis for hospital pandemic plans. This framework was designed for external situations likely to challenge a hospital’s capacity to maintain normal services;20 however, Code Brown responses are typically designed and tested for fast-onset, mass casualty incidents (e.g. a train collision) with potentially very different challenges to the demands of a pandemic, which has a relatively slow patient influx that can rapidly escalate.21 During the 2009 pandemic, hospital plans that were particularly designed to respond to an influx of inpatients were found to be inadequate to meet the pressures placed on outpatient services, EDs, ICUs and high dependency units. Without a progressive, scalable, adaptable and specific response to the demands of the pandemic at hand, hospitals risk not being able to adapt and cope in a timely way. Other studies have also called for the relationship between pandemic and disaster planning to be clarified in the wake of the 2009 pandemic.22 Hospitals may benefit from developing specific pandemic plans in addition to their more generic Code Brown response. The Code Brown Framework20 describes the role of Emergency Management Coordinator as “the person who is in overall charge of emergency management, planning and operations.” As no suggested title is provided by the state or national frameworks for this hospital role in a pandemic, it was assumed the role of co-ordinating the organisation’s pandemic response would also rest with the holder of the role established by the Code Brown Framework. Despite the
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Hospital preparedness for pandemic influenza in Victoria
Code Brown framework being the most commonly cited basis for plan development, only three respondents had adopted the suggested title, which made it difficult for the authors of this present study to identify the person(s) carrying out this role in the hospital. In addition to the lack of consistency in role titles that hospitals have adopted, the diversity of knowledge and experience of those who responded in this study identifying themselves as responsible for the hospital’s pandemic response may potentially further hamper co-ordination efforts in an emergency. The challenges experienced by some Victorian hospitals in the 2009 pandemic were exacerbated by the geographic concentration of cases, with the vast majority of confirmed cases being reported from metropolitan Melbourne with particular foci in the outer northern and western suburbs.23 The importance of using surveillance systems to understand geographical distribution and their review during pandemics for public health purposes has been noted before.24 Interestingly, despite the need for intra-organisational and possible inter-organisational commitment to external emergency responses, none of the respondents to this study indicated that pandemic plans had been endorsed at the board level. A common theme emerging from interviews was the lack of knowledge, planning or belief in workforce capacity. These concerns appear justified based on previous studies and evidence.8,9,11 Reviews by others25 of expected absenteeism based on hypothetical scenarios, have shown absenteeism varying from 13% to 85%.The Victorian Health Management Plan for Pandemic influenza3 suggests staff absenteeism levels of 30–50% might be expected during a pandemic. Self-reported absenteeism by emergency medical and nursing staff during the 2009 pandemic was as high as 56.6%.25 The pressures of the pandemic were also reported to have negatively affected the care for non-influenza patients in the ED.22 Our data suggest that even with an anticipated 25–40% of staff absent, less than a quarter of Victorian hospitals (23%) expected to meet their patients’ needs, with none of these being in rural/regional areas. Staff absenteeism in an influenza pandemic is driven by both personal sickness and the staff member’s uncertainty about their ability to work safely for fear of infecting
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family and friends.7 Although the latter has been shown to be relatively unimportant as a motivator for absenteeism,22 rates of observed absenteeism perhaps ought to be higher; it has been shown, for example, that clinicians in particular will continue to attend work despite having influenza-like illness, in breach of clinical guidelines.25 Education is important for reducing absenteeism as frontline staff may not fully appreciate the effectiveness of basic preventative measures10 and interviewees in this study affirmed that other strategies such as vaccination, the provision of influenza antivirals, education and structured staff communication can be effective, as has also been noted elsewhere.10 The role vaccination might have played in reducing absenteeism during the 2009 pandemic was undermined by issues of timing and lack of uptake. A specific vaccine against the pandemic virus was not available until after the first wave of the pandemic had passed, and when it did become available in October 2009 uptake was low, with only an estimated 18.1% of the Australian population vaccinated.26 While the level of protection afforded by the seasonal trivalent vaccine was uncertain at the time27,28 it was later shown to be generally beneficial.29 The National Health and Medical Research Council has recommended that all staff involved in patient contact be vaccinated against influenza.30 While rates of vaccination have improved over the past six years and peaked in 2009, rates among Victorian medical and nursing staff remain low (Figure 1). To improve staff vaccination rates it has been suggested that influenza vaccination should be made mandatory.31 Despite being critical to effective hospital functioning, non-clinical staff tend to view their roles as less essential than clinical staff and have been shown to be less willing to attend during a pandemic than their clinical colleagues.9 Metropolitan hospital plans failed to adequately consider staffing contingencies, particularly for non-clinical staff. Rural/regional hospitals displayed greater diligence in staff planning, which likely reflected workforce shortages and the lack of access to nursing banks and agency staff that are enjoyed by metropolitan hospitals. Once a pandemic occurs, regular stocks of personal protective equipment (PPE) will be rapidly depleted and, in principle, each hospital should take responsibility for stockpile levels.14 The pre-exposure use of
antiviral drugs32 could reasonably be a part of the PPE armoury, as modelling shows that prophylactic use does not impede the ability to contain influenza outbreaks when used post-exposure.32 Aided by their relative geographic proximity, metropolitan hospitals demonstrated greater capacity to co-ordinate efforts among themselves, including supply. In contrast, rural/regional respondents identified stock depletion and communication with government on this issue to be problematic in the 2009 pandemic. As has been noted previously,11 delays in receiving PCR influenza test results made the management of suspected influenza cases difficult, delayed clinical decision-making, and impaired the ability to cohort patients effectively. To reduce result turnaround time, some hospitals purchased and validated influenza PCR kits and developed in-house influenza testing capacity. This was seen as an effective means of improving information flow and building organisational capacity that could be adopted more broadly. The whole-of-Government simulated influenza pandemic exercise “Exercise Cumpston” in 2006 was designed to assess the response capacity of the health system; however, only one hospital in Australia – the Royal Brisbane and Women’s Hospital in Queensland – was involved and the drill did not address hospital surge requirements.33 The Victorian Hospital Resilience Code Brown Framework20 recommends that exercises be conducted annually. Our results suggest that the effectiveness of planning efforts has been undermined in Victoria by a lack of regular testing using exercises and drills. Testing influenza pandemic preparedness is an integral part of effective planning, the value of which cannot be underestimated in evaluating the strengths and weaknesses of current plans.34,35 In addition, the need for adaptable plans to ensure equity in the distribution of resources has been noted36 with a need for national – and, by extension, local – plans to be appropriately flexible for maximum public health effectiveness.
Conclusions Hospitals across Victoria displayed different levels of preparedness for an influenza pandemic. Dedicated hospital pandemic plans need to be developed that are adaptable to the conditions of the pandemic at hand; however, the effectiveness of plans
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is possibly being undermined by a lack of testing and a lack of framework consistency across the state. Hospital managers and policy makers should put processes in place to ensure plans are audited and tested on an annual basis.
McGuigan (Epworth HealthCare, Richmond, Victoria) for advice on statistical analysis of quantitative data; and the three anonymous reviewers for their helpful comments.
References
A number of strategies contribute to hospital preparedness, including education and communication plans for reducing staff absenteeism. Staff contingency planning is a critical area in which Melbourne metropolitan hospitals could improve. The need for the State Government to provide strong leadership, clear practical advice and a means of developing effective capacity was identified. Supply issues were raised as an example of how competing financial and productivity pressures were reducing hospital management’s capacity to plan for pandemics effectively. Even at its peak, the H1N1 pandemic in 2009 did not overwhelm critical care capacity or hospital operations in either the metropolitan or rural/regional areas of Victoria, possibly because of its geographical heterogeneity. If a more severe influenza virus was to become pandemic, such as the A(H7N9) virus that has caused recent human infections and deaths in China,37 it would put much greater pressure on the Victorian health system and hospitals, who would struggle with workforce and infrastructure issues, particularly in rural/ regional areas. Hospital and management preparedness is still an issue and this paper would be a useful reminder for hospital managers and policy developers, at a state and national level throughout Australia and New Zealand, to review and improve their future efforts in managing influenza pandemics.
Acknowledgements The Melbourne WHO Collaborating Centre for Reference and Research on influenza is supported by the Australian Government Department of Health and Ageing. Thank you to Ann Bull from VICNISS for supplying data on hospital staff influenza vaccine records. The VICNISS Coordinating centre is funded by the Victorian Department of Health. Thank you also to Ben Cowie (VIDRL, North Melbourne, Victoria) for advice on study design and submission preparation; Sean
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1. Department of Health and Aging. Australian Health Management Plan for Pandemic influenza. Canberra (AUST): Commonwealth of Australia; 2009. 2. Department of Communicable Disease Surveillance and Response. Informal Consultation on Influenza Pandemic Preparedness in Countries with Limited Resources. Kuala Lumpur (MYS): World Health Organization; 2004. 3. Bishop JF, Murnane MP, Owen R. Australia’s winter with the 2009 pandemic influenza A (H1N1) virus. N Engl J Med. 2009;361(27): 2591-4. 4. The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) influenza Investigators. Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome. JAMA. 2009;302(17):1888-95. 5. Drennan K, Hicks P, Hart G. Impact of pandemic (H1N1) 2009 on Australasian critical care units. Crit Care Resusc. 2010;12 (4):223-9. 6. Baker MG, Kelly H, Wilson N. Pandemic H1N1 influenza lessons from the southern hemisphere. Euro Surveill. 2009;14(42):pii 19370. 7. Hope K, Durrheim D, Barnet D, et al. Willingness of frontline healthcare workers to work during a public health emergency. Aust J Emerg Manag. 2010;25(3): 39-47. 8. Balicer RD, Barnett DJ, Thompson CB, et al. Characterizing hospital workers’ willingness to report to duty in an influenza pandemic through threatand efficacy-based assessment. BMC Public Health. 2010;10:436. 9. Balicer RD, Omer SB, Barnett DJ. Local public health workers’ perceptions toward responding to an influenza pandemic. BMC Public Health. 2006;6:99. 10. Martinese F, Keijzers G, Grant S, Lind J. How would Australian hospital staff react to an avian influenza admission, or an influenza pandemic? Emerg Med Australas. 2009;21:12-24. 11. Collignon PJ. Swine Flu – lessons learnt in Australia. Med J Aust. 2010;192(7):364-5. 12. Cretikos MA, Merritt TO, Main K, et al. Mitigating the health impacts of a natural disaster- the June 2007 long-weekend storm in the Hunter region of New South Wales. Med J Aust. 2007;187(11-12):670-3. 13. Marshall C, Kelso A, McBryde E. Pandemic (H1N1) 2009 risk for frontline health care workers. Emerg Infect Dis. 2011;17(6):1000-6. 14. Hashikura M, Kizu J. Stockpile of personal protective equipment in hospital settings: Preparedness for influenza pandemics. Am J Infect Control. 2009;37:703-7. 15. Tilburt JC, Mueller PS, Ottenberg AL. Facing the challenges of influenza in healthcare settings: The ethical rationale for mandatory seasonal influenza vaccination and its implications for future pandemics. Vaccine. 2008;26 Suppl 4:D27–30. 16. Communicable Disease Control Unit. Victorian Health Management Plan for Pandemic Influenza. Melbourne (AUST): Victorian Department of Human Services; 2007. 17. National Health Performance Authority. My Hospitals Website [Internet]. Canberra (AUST): Commonwealth of Australia; 2011 [cited 2011 Mar 21]. Available from: http://www.myhospitals.gov.au/ 18. Sprung CL, Zimmerman JL, Christian MD, et al. Recommendations for intensive care unit and hospital preparations for an influenza epidemic or mass disaster: Summary report of the European Society of Intensive Care Medicine’s Task Force for intensive care unit triage during an influenza epidemic or mass disaster. J Intensive Care Med. 2010;36:428–43.
19. Morens DM, Taubenberger JK, Harvey HA, Memoli MJ. The 1918 influenza pandemic: Lessons for 2009 and the future. Crit Care Med. 2010;38 Suppl 4:e10-e20. 20. Statewide Quality Branch. Hospital Resilience Code Brown Framework. Victorian Department of Human Services; 2008. 21. McLeod M, Mason K, White P, Read D. The 2005 Wellington influenza outbreak: Syndromic surveillance of Wellington Hospital Emergency Department activity may have provided early warning. Aust N Z J Public Health. 2009;33(3):289–94. 22. FitzGerald G, Aitken P, Shaban RZ, Patrick J, Arbon P, McCarthy S, et al. Pandemic (H1N1) influenza 2009 and Australian emergency departments: Implications for policy, practice and pandemic preparedness. Emerg Med Australas. 2012;24:159-65. 23. Fielding JE, Higgins N, Gregory JE, et al. Pandemic H1N1 influenza surveillance in Victoria, Australia, April – September, 2009. Euro Surveill. 2009;14(42):pii. 19368. 24. Clothier H, Turner J, Hampson A, Kelly H. Geographic representativeness for sentinel influenza surveillance: implications for routine surveillance and pandemic preparedness. Aust N Z J Public Health. 2006;30(4):337– 41. 25. Considine J, Shaban RZ, Patrick J, Holzhauser K, Aitken P, Clark M, et al. Pandemic (H1N1) 2009 influenza in Australia: Absenteeism and redeployment of emergency medicine and nursing staff. Emerg Med Australas. 2011;23:615-23. 26. Australian Institute of Health and Welfare. 2010 Pandemic Vaccination Survey: Summary Results. Catalogue No.: PHE 128. Canberra (AUST): AIHW; 2010. 27. Fielding JE, Grant KA, Garcia K, Kelly HA. Effectiveness of seasonal influenza vaccine against pandemic (H1N1) 2009 virus, Australia, 2010. Emerg Infect Dis. 2011;17(7):1181-7. 28. Janjua NZ, Skowronski DM, Hottes TS, et al. Seasonal influenza vaccine and increased risk of pandemic A/H1N1‐related illness: First detection of the association in British Columbia, Canada. Clin Infect Dis. 2010;51(9):1017-27. 29. Yin JK, Chow MY, Khandaker G, et al., Impacts on influenza A(H1N1)pdm09 infection from crossprotection of seasonal trivalent influenza vaccines and A(H1N1)pdm09 vaccines: Systematic review and meta-analyses. Vaccine. 2012;30(21):3209-22. 30. Department of Health. VICNISS Hospital Acquired Infection Surveillance Annual Report 2009 – 2010. Melbourne (AUST): State Government of Australia; 2013. 31. Maltezou HC, Tsakris A. Vaccination of health-care workers against influenza: Our obligation to protect patients. Influenza Other Respir Viruses. 2011;5:382–8. 32. McVernon J, McCaw JM, Nolan TM. Modelling strategic use of the national antiviral stockpile during the CONTAIN and SUSTAIN phases of an Australian pandemic influenza response. Aust N Z J Public Health. 2010;34(2):113–19. 33. Office of Health Protection. National Pandemic influenza Exercise – Exercise Cumpston 06 Report. Canberra (AUST): Commonwealth Department of Health and Ageing; 2007. 34. Zoutman DE, Ford BD, Melinyshyn M, Schwartz B. The pandemic influenza planning process in Ontario acute care hospitals. Am J Infect Control. 2010;38(1):3-8. 35. McCormick LC, Yeager VA, Rucks AC, et al. Pandemic influenza preparedness: Bridging public health academic and practice. Public Health Rep. 2009;124(2):344-9. 36. Bennett B, Carney T. Law, ethics and pandemic preparedness: The importance of cross-jurisdictional and cross-cultural perspectives. Aust N Z J Public Health. 2010;34(2):106–112. 37. Li Q, Zhou L, Zhou M, Chen Z, Li F, Wu H, et al. Epidemiology of Human Infections with Avian Influenza A(H7N9) Virus in China. N Engl J Med. 2014;370:520-32. DOI: 10.1056/NEJMoa1304617.
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Hospital capacity and management preparedness for pandemic influenza in Victoria Ben Dewar,1 Ian Barr,2 Priscilla Robinson1
I
n addition to the threat of high morbidity and mortality, influenza pandemics can overwhelm health systems and cause significant societal and economic disruption.1 Pandemic preparedness planning is vital for ensuring health and other essential systems continue functioning during a pandemic, thereby reducing the economic and social cost.2 Australia’s Chief Medical Officer stated that although Australia’s health system was stressed during the 2009 pandemic, spare capacity in hospital beds was available.3 Also, due to the low rates of admission, ICUs were still able to cope with the increased demand and resource use such as ECMO (extracorporeal membrane oxygenation) of H1N1 patients4 even during the peak in July 2009.5 In short, even though the 2009 H1N1 pandemic may have overwhelmed the Australian health system, it did not – mainly due to the generally mild nature of the virus. However, there is no guarantee that a future pandemic will not be more severe and may indeed swamp the system. One of the lessons highlighted by the 2009 H1N1 influenza pandemic was the need for health services, especially those with critical care facilities such as ICUs and Emergency Departments (EDs), to plan and prepare for the challenges a future pandemic may bring.6 Hospitals face particular challenges during an influenza pandemic. Most important is ensuring that there is sufficient, sustainable frontline workforce available in all essential areas. During any disaster relief effort there are barriers to staff participation including transport problems, responsibilities of staff
Abstract Objective: This study was designed to investigate acute hospital pandemic influenza preparedness in Victoria, Australia, particularly focussing on planning and management efforts. Methods: A prospective study was conducted by questionnaire and semi-structured interview of health managers across the Victorian hospital system from July to October 2011. Participants with responsibility for emergency management, planning and operations were selected from every hospital in Victoria with an emergency department to complete a questionnaire (response rate 22/43 = 51%). Each respondent was invited to participate in a phone-based semi-structured interview (response rate 11/22 = 50%). Results: Rural/regional hospitals demonstrated higher levels of clinical (86%) and non-clinical (86%) staff contingency planning than metropolitan hospitals (60% and 40% respectively). Pandemic plans were not being sufficiently tested in exercises or drills, which is likely to undermine their effectiveness. All respondents reported hand hygiene and standard precautions programs in place, although only one-third (33%) of metropolitan respondents and no rural/regional respondents reported being able to meet patient needs with high levels of staff absenteeism. Almost half Victoria's healthcare workers were unvaccinated against influenza. Conclusions and implications: Hospitals across Victoria demonstrated different levels of influenza pandemic preparedness and planning. If a more severe influenza pandemic than that of 2009 arose, Victorian hospitals would struggle with workforce and infrastructure problems, particularly in rural/regional areas. Staff absenteeism threatens to undermine hospital pandemic responses. Various strategies, including education and communication, should be included with in-service training to provide staff with confidence in their ability to work safely during a future pandemic. Key words: pandemic, hospitals, influenza, Australia, planning as carers, lack of staff knowledge of risks or their role in the response, and staff safety fears for family or themselves through their participation.7 The type of disaster also matters, with workers reportedly less likely to turn up for work during an influenza pandemic than during a weather related disaster.7 Studies have shown that up to half the healthcare workers may not
respond if required to work during a severe influenza pandemic.8,9 The willingness of any particular staff member to respond was strongly linked to the type of worker role and the perceived importance of that role.9,10 During the 2009 H1N1 pandemic, Australian health worker absenteeism was as high as it was in 2007, when Australia experienced its worst influenza season in recent years.11
1. School of Public Health and Human Biosciences, La Trobe University, Victoria 2. WHO Collaborating Centre for Reference and Research on influenza, Victoria Correspondence to: Mr Ben Dewar, School of Public Health and Human Biosciences, La Trobe University, Franklins Street (City) Campus, 215 Franklin Street, Melbourne, Victoria 3000; e-mail: [email protected] Submitted: June 2013; Revision requested: August 2013; Accepted: October 2013 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2014; 38:184-90; doi: 10.1111/1753-6405.12170
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Health Services
Hospital preparedness for pandemic influenza in Victoria
Strategies exist that may improve worker participation such as staff vaccinations, provision of antiviral therapies and effective education and communication programs.12 Importantly, a study of infection rates after the peak of the 2009 H1N1 pandemic showed that healthcare workers had similar levels of infection to the general community, and that household rather than workplace exposure was more strongly associated with infection.13 The provision and correct use of personal protective equipment (PPE) such as gloves, gowns, masks and face shields may be an effective measure to reduce transmission.13 However, once a pandemic occurs, regular stocks of PPE will be rapidly depleted and it will be the responsibility of each hospital to calculate its requirements and stockpile required amounts of PPE.14 Hence, this is a potential weakness in the current pandemic plans for healthcare workers. Epidemic outbreaks of influenza in healthcare facilities have been associated with low staff vaccination rates.15 Staff vaccinations are therefore essential to prevent or ameliorate virus outbreaks amongst patients and staff in hospitals.15 Increasing healthcare workers’ vaccination rates leads to reduced influenza amongst patients and staff, reduced mortality among patients, a safer workplace and a more productive workplace through reduced sick leave.15 Ethical arguments can be made that the welfare of patients and co-workers outweighs the personal preferences of staff, and that staff vaccinations should be made mandatory.15 Hospitals play an integral role in the public health response to pandemics;16 however, few reviews have been published of Australian hospitals’ performance during the 2009 H1N1 pandemic or how planning has since been modified. This study was designed to investigate pandemic influenza preparedness in acute care hospitals in Victoria, Australia, with a focus on policy, planning and management efforts, and the subsequent changes made to counter future influenza pandemics.
Methods The Australian Institute of Health and Welfare’s My Hospitals website17 was used to identify all Victorian hospitals with an ED. All 43 hospitals identified were contacted by phone to identify the Emergency Management Coordinator or similar person in
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charge of emergency management, planning and operations.
at their hospital during the 2009 H1N1 pandemic.
A questionnaire was prepared based on the hospital requirements described in the Victorian Health Management Plan for Pandemic influenza16 and a 2010 report by Sprung et al.18 The questionnaire covered three main areas: hospital planning information; workforce issues; and infrastructure and surge capacity. The questionnaire was piloted with a small group of colleagues. Staffing levels suggested by Sprung et al. were used to identify and test potential capacity. Questionnaires were mailed to respondents, who were asked to complete it with colleagues if necessary. One response from each hospital was requested. Reminder phone calls were placed two weeks after posting. After completing the questionnaire all participants were invited to take part in a follow-up qualitative semistructured telephone interview covering personal and professional experiences during the pandemic.
Nine participants (41%) indicated that they were the Emergency Management Coordinator or similar title, five respondents (23%) held positions related to infection control, four (18%) were ED Managers and three respondents (14%) identified their role as relating to Nursing or Acute Services. Half of the questionnaire responders consented to an interview.
Data on healthcare worker immunisation was provided by the Victorian Infection Control Nosocomial Infection Surveillance System (known as VICNISS) with permission from the Victorian Department of Health. All identifying details were removed prior to analysis. This work was approved by the La Trobe University Faculty Human Ethics Committee (Reference: FHEC11/095). Descriptive statistics with a 95% confidence interval were calculated for univariate and bivariate analysis. Text responses were analysed using a qualitative approach and grouped into themes.
Results Staff from 22 hospitals provided responses to the questionnaire, a response rate of 51%. Seven responses were received from rural/ regional hospitals (7/16 = 44%) and 15 from metropolitan hospitals (15/27 = 56%) with the latter including one private hospital. Hospital sizes ranged from 35 to 885 hospital inpatient beds (median = 260, metropolitan median = 352, rural/regional median = 101) with 184 to 5,000 full-time equivalent staff (median = 2,370, metropolitan median = 2,485, rural/ regional median = 944) and between 8 and 62 ED and ICU beds combined (median = 44, metropolitan median = 52, rural/regional median = 17). All but two rural services (91%) reported confirmed cases of H1N1 influenza
All respondents surveyed indicated that an incident control system (ICS) was in place and all but three had been internally reviewed within the last two years (86%). The most frequently cited frameworks or practices (multiple could be cited) upon which systems or plans were developed were: Hospital Resilience Code Brown Policy Framework (11 citations: 50%); Victorian Health Management Plan for Pandemic influenza (5 citations: 23%); and the Australian Health Management Plan for Pandemic influenza (4 citations: 18%). Others included the National Australian Standard 4083/1997; WHO Strategic Plan 2007; NSW Health influenza Pandemic Plan 2006; and the New Zealand influenza Pandemic Action Plan 2006 (1 citation each: 5%). Of these, 16 plans (73%) were endorsed at the executive level, four (18%) were endorsed by the CEO and one (5%) was not yet endorsed (and one did not provide a response). Staff cited by respondents as commonly involved in planning worked in infection control, occupational health and safety departments, or were medical staff or hospital executives. Other departments (for example supply, engineering, ICUs and pharmacy) were poorly represented (Table 1). Metropolitan respondents reported higher rates (60%) for testing of plans in a functional exercise or drill than rural/regional respondents, where no testing was reported (Table 2). In the event of another pandemic, respondents indicated that current planning efforts would be effective only to a point, with important variables being the severity of the next virus and workforce availability. None of the rural/regional respondents and almost half the hospitals overall (45%) reported that patient needs could not be met with rates of staff absenteeism expected during a pandemic (Table 2). The results of the survey indicated that compliance with standard precautions training and the presence of hand hygiene programs was
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high. However, in the year following the 2009 pandemic, aggregate Victorian healthcare worker influenza vaccination rates again fell to below 50% (Figure 1) with medical staff (39.6%) and nursing staff (44.3%) demonstrating the lowest rates.
Although anxiety was observed by interviewees to be high among staff during the 2009 pandemic there was no observed refusal to work. Interviewees described a variety of strategies employed by hospitals to reduce infection exposure and staff anxiety, including: creating frontline ‘flu teams’ that dealt exclusively with influenza patients thereby reducing contact for other staff, identifying and removing susceptible healthcare workers such as pregnant staff from exposure, and establishing mandatory daily update meetings for department heads that were also available to other staff. Education both before and during the pandemic to keep staff aware of protocol updates was seen as a key challenge that was necessary to reduce uncertainty.
Table 1: Frequency of involvement of certain hospital groups in the development of hospital emergency and pandemic plans. Group
Frequency
Count
Infection Control
90%
19
Occupational Health & Safety
43%
9
Medical/Clinical Director or Medical Staff
38%
8
Hospital Executive
33%
7
Emergency Management Committee
33%
7
Director of Nursing/ Nursing Staff
24%
5
Emergency Department
24%
5
Quality and Risk
14%
3
Supply
10%
2
Engineering
10%
2
Department of Human Services/ Health
10%
2
Microbiology
10%
2
Chief Operating Officer
5%
1
Medical Administration
5%
1
ICU
5%
1
Bed Coordinators
5%
1
Pharmacy
5%
1
Service Managers
5%
1
Allied Health
5%
1
Environmental Services
5%
1
Theatre
5%
1
Security
5%
1
The respondents’ perceived capacity of hospitals to meet pandemic infrastructure and supply demands was mixed. Even at hospitals with few pandemic-related presentations, infrastructure capacity was identified as a potential weakness if patient numbers had significantly increased. Emergency departments proved the greatest management challenge. Common problems identified by interviewees are shown in Box 1. Interviewees commented that due to the nature of patient presentations during the 2009 pandemic, plans based on the assumption that infectious disease wards would be required to manage large numbers of admissions were found to be redundant. Where possible these plans were adapted by moving departments close to the ED elsewhere and expanding the ED into the newly created space.
Figure 1: Healthcare worker influenza vaccination rates for Victoria. 70%
2007
2008
2009
2011
2010
2012
60% 50% 40% 30% 20% 10% 0% Medical
Nursing
Allied Health
Source: VICNISS. Note: Emergency staff data was not collected in 2007.
186
NonClinical
Laboratory Emergency
Other
Aggregate
Box 1: Problems identified in emergency departments. • Little or no scope to expand capacity • Single entry points so that entry of patients with influenzalike illness (ILI) could not be separated from those without ILI • No waiting room segregation for ILI patients • Inability to clean cubicles effectively or in a timely way between patients
Rural/regional respondents more commonly reported maintaining stockpiles of medical equipment, personal protective equipment, medication and basic supplies adequate to manage a mass casualty event than metropolitan respondents. Despite this, rural/ regional respondents rarely reported access to extra ventilators when needed or capacity to expand patient isolation within ICUs (Table 2). Rural/regional hospital respondents also expressed concern that supply was not available during the pandemic either from private or government suppliers, particularly for P2/N95 masks. Metropolitan respondents reported fewer supply issues. Although mask supplies had to be monitored, stocks were available from both government stockpiles and usual suppliers. Metropolitan hospitals placed greater reliance on the release of government stocks due to financial challenges and a lack of storage capacity limiting the ability to stockpile. The supply of essential equipment and consumables during a pandemic was raised as a concern for the health system as a whole, particularly given the sector’s move towards just-in-time supply chains. The lack of timely patient test results from influenza polymerase chain reaction (PCR) testing was also identified as an issue by some respondents. Pandemic communication processes were felt by one interviewee to be enhanced by ensuring there was a single co-ordinator to receive, co-ordinate and distribute internal and external information. The majority of rural/regional hospital managers interviewed felt that communication and the level of pandemic response by the Victorian Department of Human Services (DHS), now the Victorian Department of Health, was different for rural/regional areas than for metropolitan areas, with responses to regional queries or requests for help perceived as slow and possibly hampered by indirect communication through regional hubs rather than direct communication with a central body. The content of communication was also a source of concern, as case definitions and diagnostic
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2014 vol. 38 no. 2 15 9 6 13 14 10 9
Have incident management positions been determined with clearly defined roles and leadership?
Are clinical staffing levels accounted for in the plan?
Are non-clinical staffing levels accounted for in the plan?
Are equipment contingencies accounted for in the plan?
Are space contingencies accounted for in the plan?
Have incident escalation trigger points for impact on hospital operations been set in the event of a pandemic?
Have plans been tested in a functional exercise or drill?
15 15 10 5
Are all staff trained in standard infection control precautions?
Does the hospital have a hand hygiene program?
Are staffing patterns designed to change at different operating stages?
Can the hospital meet patient needs at the stages identified above with 25-40% of staff absent?
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© 2014 The Authors. ANZJPH © 2014 Public Health Association of Australia
8 10 7 10 13 7 9 11 8
In a mass casualty event (MCE) does your hospital have stockpiles of equipment?
In a mass casualty event (MCE) does your hospital have stockpiles of PPE?
In a mass casualty event (MCE) does your hospital have stockpiles of medication?
In a mass casualty event (MCE) does your hospital have stockpiles of basic supplies?
Does the hospital have one ventilator per critical care bed?
Are contingency plans in place to obtained more ventilators up to planned limits within 6-12 hours?
Does the hospital have the capacity to expand isolation of patients in the ICU including provision of negative airflow?
Have areas that can be separately ventilated been identified?
Is the hospital able to accommodate a large number of deceased in a respectful way?
6
3
4
7
1
5
5
5
7
9
3
4
3
0
0
0
4
3
1
2
9
6
0
0
N
n M rM P 1 P M M rM nM 1
0
Is there capacity to expand the ICU to 300% of current capacity? *
Y = Yes. N = No, DK = Don’t Know, A = Abstain, PM = “Yes” Proportion Metropolitan, PR = “Yes” Proportion Rural/Regional, CL = Confidence Limit * Hospitals without an ICU were marked as A (Abstain) Confidence Intervals were calculated for the difference between two proportions allowing for the finite population size: CL P R P M 1 . 96 Where nx is the number of hospitals, eg. nM is the number of metropolitan hospitals with emergency departments in Victoria rx is the number of respondents, eg. rR is the number of rural/regional respondents Note: Where values were missing the hospital was removed from that section of the analysis.
11
Are coordination systems and agreements in place with neighbouring health providers?
Infrastructure and Surge Capacity
12
Are staff willing to take antiviral prophylaxis medication?
15
Is there a process of incident management (such as an incident action plan) in place?
Workforce
Y
Hospital Planning
0
1
2
1
1
0
0
0
0
3
0
2
2
0
0
0
1
1
0
0
0
0
0
0
A
4
5
1
4
3
6
5
7
6
1
4
0
4
7
7
4
0
3
6
6
6
6
7
7
Y
n R rR P R 1 P R n 1 rR R
1
0
0
0
0
0
3
0
0
3
1
4
0
0
0
3
1
1
0
0
0
0
0
0
DK
Metropolitan
Table 2: Details of questionnaire results including analysis of differences between metropolitan and rural/regional hospital responses.
3
0
4
3
3
1
2
0
1
5
1
6
1
0
0
0
7
2
1
1
1
1
0
0
N
0
0
0
0
0
0
0
0
0
0
1
0
1
0
0
2
0
1
0
0
0
0
0
0
DK
Rural/Regional
0
2
2
0
1
0
0
0
0
1
1
1
1
0
0
1
0
1
0
0
0
0
0
0
A
4%
-2%
-46%
10%
-44%
19%
25%
33%
32%
14%
-16%
-33%
-10%
0%
0%
-23%
-60%
-24%
-8%
-1%
46%
26%
0%
0%
(PR - PM)
Mean Difference
-28.1%
-30.9%
-70.4%
-21.4%
-73.9%
-5.3%
-5.0%
19.6%
7.6%
-5.8%
-47.4%
-47.1%
-41.1%
0.0%
0.0%
-53.6%
-74.3%
-55.4%
-29.0%
-23.4%
21.1%
1.1%
0.0%
0.0%
95%CL
Lower
35.7%
27.1%
-21.1%
42.4%
-13.7%
43.4%
54.5%
47.1%
57.2%
34.4%
15.0%
-19.6%
22.0%
0.0%
0.0%
7.9%
-45.7%
7.8%
13.7%
21.4%
70.4%
50.4%
0.0%
0.0%
95%CL
Upper
95% Confidence Intervals for Differences: Rural - Metropolitan
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criteria changed. Testing, tracing, treatment and reporting requirements from DHS were cited by interviewees as major issues for hospitals. Although these criteria were later eased, the initial protocols were seen by some interviewees as too strict and impractical to achieve, especially had the number of presentations rapidly increased.
a combination of both (all responses scored 7+ on a scale of 1 to 10).
Interviewees also commented that the autonomy and devolved governance arrangements of Victorian hospitals were challenged by DHS instructions to maintain normal operations during the pandemic, despite their hospital emergency plans calling for a scaling down of regular services at certain trigger points. It was suggested that the combination of rapidly changing and potentially impractical instructions may have contributed to a desire by some hospitals to act more independently in their management of the pandemic.
In addition, the planning frameworks identified by respondents only represent the knowledge of the respondents rather than the practice that might be implemented, the framework that was used to write the hospital plan, or any co-ordinated action that governments might take should a pandemic arise.
Respondents defined a number of changes that occurred as a result of the pandemic. A summary of these is presented in Table 3. Most respondents reported needing to develop or adapt their response to meet changing testing and treatment protocols across the various stages of the pandemic. Those interviewed believed that hospitals managed the pandemic well, either through effective planning, a lack of presentations, or
Limitations The main limitations of this study are the small number of hospitals in Victoria with an ED, and a relatively low response rate.
While complete data on Victorian hospital bed-numbers was not available, survey respondents did represent a broad crosssection of the Victorian hospital system, including small, medium and large hospitals from both metropolitan and rural areas. The study was also strengthened by the addition of qualitative interview data to expand on the quantitative survey results.
Discussion Pandemics can be variable in their disease severity ranging from very mild, as occurred in 2009, to very severe, as happened in the
Table 3: Changes in hospital practice identified following review of the 2009 pandemic. Change area
Summary of suggested revisions
Revision of the existing plans
• Addition of a step-by-step protocol to the existing pandemic plan with practical steps in pandemic management and when they should be done, contact numbers, etc • Development of plans to set up flu houses and clinics for triage, funding permitting • Incorporation/inclusion of the local community in more effective management of the pandemic • More proactive management of the relationship with State Government • Greater involvement consultation and coordination with the local division of general practice – now called a Medicare Local. • Development of a new business continuity plan
Expanded capacity
• Use of in-house validated PCR diagnostic kits for seasonal influenza testing • Definition of areas within the hospital where patients can be decanted for cohorts of pandemic influenza patients, such as outpatient areas for patients who need assessment before going home, and patients who are not very sick but need isolating and hospital management • Expansion of capacity to isolate patients in future hospital designs • Allocation of storage areas for personal protective equipment such as tissues, gloves, handwash, etc, in strategic parts of the hospital
Improved communication
• Embedding of daily meetings as part of operations in a pandemic • Establishment of a single central coordinator as part of the hospital incident management team to coordinate internal and external communication and 'close the information loop' • Formalised documentation that can be released in a timely way during the next pandemic that defines the role of staff (particularly ED staff) at various pandemic stages • Incorporation into plans of factsheets developed by the State Government for providing information to the community
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'Spanish influenza' of 1918-19 when an estimated 50 million people died globally.16,19 Moderate pandemics were seen with the more recent Asian flu in 1957 (H2N2) and the Hong Kong flu in 1968 (H3N2)1 in which there were an estimated two million and one million deaths worldwide, respectively. When the pandemic arrived in May 2009, Victorian hospitals were in varying stages of preparation and many found their plans to be inadequate to the challenges at hand. The lack of citations for the state or national frameworks as the basis for hospital pandemic plans was surprising, and although the reasons for this were not explored, the lack of a consistent framework on which hospital pandemic plans were based may hamper state and national co-ordination efforts in the future. The Victorian hospitals’ ‘Code Brown’ emergency response framework was the most commonly cited basis for hospital pandemic plans. This framework was designed for external situations likely to challenge a hospital’s capacity to maintain normal services;20 however, Code Brown responses are typically designed and tested for fast-onset, mass casualty incidents (e.g. a train collision) with potentially very different challenges to the demands of a pandemic, which has a relatively slow patient influx that can rapidly escalate.21 During the 2009 pandemic, hospital plans that were particularly designed to respond to an influx of inpatients were found to be inadequate to meet the pressures placed on outpatient services, EDs, ICUs and high dependency units. Without a progressive, scalable, adaptable and specific response to the demands of the pandemic at hand, hospitals risk not being able to adapt and cope in a timely way. Other studies have also called for the relationship between pandemic and disaster planning to be clarified in the wake of the 2009 pandemic.22 Hospitals may benefit from developing specific pandemic plans in addition to their more generic Code Brown response. The Code Brown Framework20 describes the role of Emergency Management Coordinator as “the person who is in overall charge of emergency management, planning and operations.” As no suggested title is provided by the state or national frameworks for this hospital role in a pandemic, it was assumed the role of co-ordinating the organisation’s pandemic response would also rest with the holder of the role established by the Code Brown Framework. Despite the
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Hospital preparedness for pandemic influenza in Victoria
Code Brown framework being the most commonly cited basis for plan development, only three respondents had adopted the suggested title, which made it difficult for the authors of this present study to identify the person(s) carrying out this role in the hospital. In addition to the lack of consistency in role titles that hospitals have adopted, the diversity of knowledge and experience of those who responded in this study identifying themselves as responsible for the hospital’s pandemic response may potentially further hamper co-ordination efforts in an emergency. The challenges experienced by some Victorian hospitals in the 2009 pandemic were exacerbated by the geographic concentration of cases, with the vast majority of confirmed cases being reported from metropolitan Melbourne with particular foci in the outer northern and western suburbs.23 The importance of using surveillance systems to understand geographical distribution and their review during pandemics for public health purposes has been noted before.24 Interestingly, despite the need for intra-organisational and possible inter-organisational commitment to external emergency responses, none of the respondents to this study indicated that pandemic plans had been endorsed at the board level. A common theme emerging from interviews was the lack of knowledge, planning or belief in workforce capacity. These concerns appear justified based on previous studies and evidence.8,9,11 Reviews by others25 of expected absenteeism based on hypothetical scenarios, have shown absenteeism varying from 13% to 85%.The Victorian Health Management Plan for Pandemic influenza3 suggests staff absenteeism levels of 30–50% might be expected during a pandemic. Self-reported absenteeism by emergency medical and nursing staff during the 2009 pandemic was as high as 56.6%.25 The pressures of the pandemic were also reported to have negatively affected the care for non-influenza patients in the ED.22 Our data suggest that even with an anticipated 25–40% of staff absent, less than a quarter of Victorian hospitals (23%) expected to meet their patients’ needs, with none of these being in rural/regional areas. Staff absenteeism in an influenza pandemic is driven by both personal sickness and the staff member’s uncertainty about their ability to work safely for fear of infecting
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family and friends.7 Although the latter has been shown to be relatively unimportant as a motivator for absenteeism,22 rates of observed absenteeism perhaps ought to be higher; it has been shown, for example, that clinicians in particular will continue to attend work despite having influenza-like illness, in breach of clinical guidelines.25 Education is important for reducing absenteeism as frontline staff may not fully appreciate the effectiveness of basic preventative measures10 and interviewees in this study affirmed that other strategies such as vaccination, the provision of influenza antivirals, education and structured staff communication can be effective, as has also been noted elsewhere.10 The role vaccination might have played in reducing absenteeism during the 2009 pandemic was undermined by issues of timing and lack of uptake. A specific vaccine against the pandemic virus was not available until after the first wave of the pandemic had passed, and when it did become available in October 2009 uptake was low, with only an estimated 18.1% of the Australian population vaccinated.26 While the level of protection afforded by the seasonal trivalent vaccine was uncertain at the time27,28 it was later shown to be generally beneficial.29 The National Health and Medical Research Council has recommended that all staff involved in patient contact be vaccinated against influenza.30 While rates of vaccination have improved over the past six years and peaked in 2009, rates among Victorian medical and nursing staff remain low (Figure 1). To improve staff vaccination rates it has been suggested that influenza vaccination should be made mandatory.31 Despite being critical to effective hospital functioning, non-clinical staff tend to view their roles as less essential than clinical staff and have been shown to be less willing to attend during a pandemic than their clinical colleagues.9 Metropolitan hospital plans failed to adequately consider staffing contingencies, particularly for non-clinical staff. Rural/regional hospitals displayed greater diligence in staff planning, which likely reflected workforce shortages and the lack of access to nursing banks and agency staff that are enjoyed by metropolitan hospitals. Once a pandemic occurs, regular stocks of personal protective equipment (PPE) will be rapidly depleted and, in principle, each hospital should take responsibility for stockpile levels.14 The pre-exposure use of
antiviral drugs32 could reasonably be a part of the PPE armoury, as modelling shows that prophylactic use does not impede the ability to contain influenza outbreaks when used post-exposure.32 Aided by their relative geographic proximity, metropolitan hospitals demonstrated greater capacity to co-ordinate efforts among themselves, including supply. In contrast, rural/regional respondents identified stock depletion and communication with government on this issue to be problematic in the 2009 pandemic. As has been noted previously,11 delays in receiving PCR influenza test results made the management of suspected influenza cases difficult, delayed clinical decision-making, and impaired the ability to cohort patients effectively. To reduce result turnaround time, some hospitals purchased and validated influenza PCR kits and developed in-house influenza testing capacity. This was seen as an effective means of improving information flow and building organisational capacity that could be adopted more broadly. The whole-of-Government simulated influenza pandemic exercise “Exercise Cumpston” in 2006 was designed to assess the response capacity of the health system; however, only one hospital in Australia – the Royal Brisbane and Women’s Hospital in Queensland – was involved and the drill did not address hospital surge requirements.33 The Victorian Hospital Resilience Code Brown Framework20 recommends that exercises be conducted annually. Our results suggest that the effectiveness of planning efforts has been undermined in Victoria by a lack of regular testing using exercises and drills. Testing influenza pandemic preparedness is an integral part of effective planning, the value of which cannot be underestimated in evaluating the strengths and weaknesses of current plans.34,35 In addition, the need for adaptable plans to ensure equity in the distribution of resources has been noted36 with a need for national – and, by extension, local – plans to be appropriately flexible for maximum public health effectiveness.
Conclusions Hospitals across Victoria displayed different levels of preparedness for an influenza pandemic. Dedicated hospital pandemic plans need to be developed that are adaptable to the conditions of the pandemic at hand; however, the effectiveness of plans
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is possibly being undermined by a lack of testing and a lack of framework consistency across the state. Hospital managers and policy makers should put processes in place to ensure plans are audited and tested on an annual basis.
McGuigan (Epworth HealthCare, Richmond, Victoria) for advice on statistical analysis of quantitative data; and the three anonymous reviewers for their helpful comments.
References
A number of strategies contribute to hospital preparedness, including education and communication plans for reducing staff absenteeism. Staff contingency planning is a critical area in which Melbourne metropolitan hospitals could improve. The need for the State Government to provide strong leadership, clear practical advice and a means of developing effective capacity was identified. Supply issues were raised as an example of how competing financial and productivity pressures were reducing hospital management’s capacity to plan for pandemics effectively. Even at its peak, the H1N1 pandemic in 2009 did not overwhelm critical care capacity or hospital operations in either the metropolitan or rural/regional areas of Victoria, possibly because of its geographical heterogeneity. If a more severe influenza virus was to become pandemic, such as the A(H7N9) virus that has caused recent human infections and deaths in China,37 it would put much greater pressure on the Victorian health system and hospitals, who would struggle with workforce and infrastructure issues, particularly in rural/ regional areas. Hospital and management preparedness is still an issue and this paper would be a useful reminder for hospital managers and policy developers, at a state and national level throughout Australia and New Zealand, to review and improve their future efforts in managing influenza pandemics.
Acknowledgements The Melbourne WHO Collaborating Centre for Reference and Research on influenza is supported by the Australian Government Department of Health and Ageing. Thank you to Ann Bull from VICNISS for supplying data on hospital staff influenza vaccine records. The VICNISS Coordinating centre is funded by the Victorian Department of Health. Thank you also to Ben Cowie (VIDRL, North Melbourne, Victoria) for advice on study design and submission preparation; Sean
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