It's the Flu! What should we do?

Background: On 4/23/09 the Pediatric Emergency Department (PED) received notification of 4 high school students with complaints of influenza like illness (ILI). An influx followed of 12 teenagers from the same school presenting with similar symptoms - was it the Swine Flu? 

Objective: “To know what to do, you need to know the enemy”. The PED staff, unfamiliar with the etiology, transmission and virulence of this new Influenza strain of “Swine Flu” initiated a plan to address high volume, low acuity throughput assuring optimal patient care and safe practice. Methods: Patients were cohorted and infection control measures were maintained (gown, gloves and masks). Rapid influenza testing was performed confirming H1N1 on symptomatic patients. On 4/24/09, 19 teens and family members were waiting for evaluation. Consistent with Team STEPPS training, staff called a “huddle” to communicate this influx. A coordinated plan was executed to evaluate both adult and pediatric patients with ILI.  The New York City Department of Health (NYCDOH) and Center for Disease Control (CDC) were notified. Reports of school closings stirred public fear encouraging families to seek medical care. On 4/25/09 patient volume exceeded the PED physical and human resources. Alternate space was identified with 15 treatment bays and separate waiting area. CDC recommended discontinuation of viral testing and prophylactic administration of antivirals. Surveillance of patient volume and symtomatology continued to be communicated to Emergency Preparedness Leadership.  To foster patient throughput and prevent transmission, the Psychiatric ED was converted to a “flu center” (the design offered isolated examination and waiting rooms.) A dedicated physician greeter evaluated and escorted patients to the “flu center” and the plan remained operational until 5/3/09. On 5/14/09 an unexpected increase in census of ILI patients presenting with high fever, lethargy and abdominal pain was observed. The increase in acuity of symptoms was escalated to Administration. On 5/15/09 volume skyrocketed and the “flu center” reopened. By 5/27/09, with 11 NYC schools closed, hundreds of patients waiting to be evaluated the “flu center” relocated operations to the Atrium where staff provided care under private tents.  The Atrium remained opened until 6/12/09. Results: Between 4/24/09 – 6/17/09 there were 8,265 ED patient encounters; (39%) 3200 were for ILI (average daily census 90). The NYCDOH recommended the “flu center” as the model to handle an influx of flu patients. The Atrium location, however costly, was the most successful plan.

Conclusions: Teamwork, communication and adaptation with the ever changing climate allowed more than 3,000 patients to be safely and expeditiously evaluated, treated and released. The SCH staff rose to the professional expectation ensuring quality care. The daily briefs, huddles and appropriate escalation to Administration improved on existing plans and ensured a trust in the community.