Brennan sept2806
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Health System Preparedness: Health System Preparedness: The Emergency Department and Beyond The Emergency Department and Beyond PJ Brennan, MD PJ Brennan, MD Chief Medical Officer Chief Medical Officer University of Pennsylvania Health University of Pennsylvania Health System System
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Health System Preparedness:HealthSystemPreparedness: The Emergency Department and BeyondTheEmergencyDepartmentandBeyond PJ Brennan, MDPJBrennan,MD Chief Medical OfficerChiefMedicalOfficer University of Pennsylvania Health SystemUniversityofPennsylvaniaHealthSystem
Transcript of Brennan sept2806
Health System Preparedness: Health System Preparedness: The Emergency Department and BeyondThe Emergency Department and Beyond
PJ Brennan, MDPJ Brennan, MDChief Medical OfficerChief Medical Officer
University of Pennsylvania Health SystemUniversity of Pennsylvania Health System
Reality CheckReality Check• Current H5N1 virus initially seen 1997Current H5N1 virus initially seen 1997• Significant mutations necessary for Significant mutations necessary for
pandemicpandemic– PNAS 2006;103:12121-6PNAS 2006;103:12121-6
• Need to be prepared for all possibilitiesNeed to be prepared for all possibilities• Plan requirementsPlan requirements
– Broad-basedBroad-based– FlexibleFlexible– FluidFluid
Influenza Virus TransmissionInfluenza Virus Transmission
• Respiratory routeRespiratory route– Primarily by large Primarily by large
dropletsdroplets– Possibly small particle Possibly small particle
“short distance” “short distance” aerosolsaerosols
• ContactContact– Hand contact with Hand contact with
secretionssecretions
Transmissibility of InfluenzaTransmissibility of Influenza
• Average number of persons infected by each Average number of persons infected by each case (Rcase (R00) calculated in pandemic outbreaks) calculated in pandemic outbreaks– 1918 pandemic - ~1.8 to 2.71918 pandemic - ~1.8 to 2.7– 1957 pandemic - ~1.71957 pandemic - ~1.7
• Average RAverage R00 similar to SARS (~3) but much similar to SARS (~3) but much less than measles (~12) and mumps (~8)less than measles (~12) and mumps (~8)
• Explosive outbreaks are due to short Explosive outbreaks are due to short generation time of 2.6 to 3.5 daysgeneration time of 2.6 to 3.5 days
Public Health Goals of Pandemic Planning Public Health Goals of Pandemic Planning
1. Delay and flatten outbreak peak2. Reduce peak burden on healthcare system3. Reduce number of cases4. Buy time
DailyCases
#1
#2
#3
Days since First Case
No intervention
With interventions
Potential Tools to Reduce TransmissionPotential Tools to Reduce Transmission • Vaccine:Vaccine:
– probably unavailable in first and second pandemic probably unavailable in first and second pandemic waveswaves
• Antiviral treatment:Antiviral treatment: – may improve outcomes but only modest effect on may improve outcomes but only modest effect on
transmissiontransmission– availability uncertainavailability uncertain– efficacy unprovenefficacy unproven
• Antiviral prophylaxis of contacts:Antiviral prophylaxis of contacts: – may have greater effect on reducing transmissionmay have greater effect on reducing transmission
• Social distancing & infection control:Social distancing & infection control: – should reduce transmission, but strategy requires should reduce transmission, but strategy requires
clarificationclarification
Moderate (1957-like) Severe (1918-like)
Illness 90 million (30%) 90 million (30%)
Outpatient medical care 45 million (50%) 45 million (50%)
Hospitalization 865,000 9, 900,000
ICU care 128,750 1,485,000
Mechanical ventilation 64,875 745,500
Deaths 209,000 1,903,000
Estimates of Impact of an Influenza Pandemic
Breaking the Cycle of Breaking the Cycle of TransmissionTransmission
Population-based Containment
Exposure
Latent / Infectious
Symptomatic / Infectious
Susceptible
Influenza
Asymptomatic / Infectious
Quarantine / IsolationSocial DistancingLiberal LeaveSchool ClosureInfection Control
Prophylaxis
Infection Control Social DistancingSchool ClosureTargeted Social Distancing
TreatmentIsolation
Shunting
Value of combining strategies – Longini model
0
10
20
30
40
50
60
70
Clinical attack rate Antiviral stockpile needed
Base case (Ro=1.9)Generic social distancingSchool closureSchool closure + generic social distancing60% Case treatment + 60% household prophylaxis60% Case treatment + 60% household prophylaxis + 60% social prophylaxis (60% TAP)60% TAP + School closure + generic social distancing
Source: German TC. PNAS (online) April 11, 2006
% o
f po
pula
tion
Layered InterventionsLayered Interventions
↓ cases↑ HH & community transmissionClose schools
Household quarantine
↓ cases↑ relative importance of workplace & community
Social distancing ↓ cases
Keep childrenhome
↓ HH & community transmission↑ relative importance of HH & workplace transmission
Evidence for Social Distancing, Especially School Closure
• Children are the main introducers of influenza into households, more susceptible to influenza and more infectious than adults.
• School closure helpful in flu outbreak, Israel– Significant decreases in children’s diagnoses of respiratory
infections (42%), visits to physicians (28%), emergency departments (28%), and medication purchases (35%).
• Influenza immunizaton of schoolchildren associated with lower illness rates in total population– Controlled trial, small towns in Michigan, 1968-69– Immunization of children in Japan, 1962-87
• Lower rates of isolation of influenza and other respiratory viruses in Hong Kong in SARS– Many social distancing measures, public mask use
Reference: WHO Writing Group. Emerg Inf Dis 2006;12:81-7
Combining strategies – Glass model: Targeted Social Distancing
0
5
10
15
20
25
30
Clinical attack rate
Base case (Ro ~ 1.6)School closure aloneSchool closure + targeted social distancing (10% compliance)School closure + targeted social distancing (30% compliance)School closure + targeted social distancing (50% compliance)School closure + targeted social distancing (90% compliance)
% o
f pop
ulat
ion
Weekly mortality data provided by Marc Lipsitch (personal communication)
1918 Weekly Excess Death Rate by City
0
0.002
0.004
0.006
0.008
0.01
0.012
0.014
0.016
0.018
9/14/1
918
9/21/1
918
9/28/1
918
10/5/
1918
10/12
/1918
10/19
/1918
10/26
/1918
11/2/
1918
11/9/
1918
11/16
/1918
11/23
/1918
11/30
/1918
12/7/
1918
12/14
/1918
12/21
/1918
12/28
/1918
Date
Exce
ss D
eath
Rat
e PhiladelphiaBostonMilwaukeeMinneapolisBaltimorePittsburghSt. Louis
Liberty Loan Parade to Promote Sale of War Bonds:
Philadelphia, September 28, 1918
Weekly mortality data provided by Marc Lipsitch (personal communication)
1918 Death Rates: Philadelphia v St. Louis
0
2000
4000
6000
8000
10000
12000
14000
16000
9/14/1
918
9/21/1
918
9/28/1
918
10/5/
1918
10/12
/1918
10/19
/1918
10/26
/1918
11/2/
1918
11/9/
1918
11/16
/1918
11/23
/1918
11/30
/1918
12/7/
1918
12/14
/1918
12/21
/1918
12/28
/1918
Date
Deat
hs R
ates
/ 10
0,00
0 Po
pula
tion
(Ann
ual B
asis
)
PhiladelphiaSt. Louis
PhiladelphiaPhiladelphia
0
2000
4000
6000
8000
10000
12000
14000
9/14/1
8
9/21/1
8
9/28/1
8
10/5/
18
10/12
/18
10/19
/18
10/26
/18
11/2/
18
11/9/
18
11/16
/18
11/23
/18
11/30
/18
12/7/
18
12/14
/18
12/21
/18
12/28
/18
Date
Dea
th R
ate
/ 100
,000
Pop
ulat
ion
(Ann
ual B
asis
)
Churches, schools, theaters, places of public amusement closed
*Estimated attack rate before interventions:
10.8%
*derived from mortality data using 2% CFR
St. LouisSt. Louis
0
2000
4000
6000
8000
10000
12000
14000
9/14/1
8
9/21/1
8
9/28/1
8
10/5/
18
10/12
/18
10/19
/18
10/26
/18
11/2/
18
11/9/
18
11/16
/18
11/23
/18
11/30
/18
12/7/
18
12/14
/18
12/21
/18
12/28
/18
Date
Dea
th R
ate
/ 100
,000
Pop
ulat
ion
(Ann
ual B
asis
)
First death recorded
Mayor closes “theaters, moving picture shows, schools, pool and billiard halls, Sunday schools, cabarets, lodges, societies, public funerals, open air meetings, dance halls and conventions until further notice”
Closing order withdrawn
*Estimated attack rate before interventions:
2.2%
*derived from mortality data using 2% CFR
Importance of Early Intervention*Scenarios Total Attack
Rate (%)Deaths
No intervention 46.8 80,405
Intervention at 12%attack rate
27.7 47,511
Intervention at 8%attack rate
23.9 41,045
Intervention at 2%attack rate
9.7 15,782
Intervention at 1%attack rate
5.3 9,107
Intervention at 1% with Antiviral Rx of cases, Pxof household contacts
2.9 4,889
*Longini model for Chicago pop 8.8M, NPI intervention TLC w 30% compliance HH-Q
UPHS Emergency Management UPHS Emergency Management TriggersTriggers
• Stage 1Stage 1:: Increased human-to-human Increased human-to-human transmission abroadtransmission abroad
• Stage 2Stage 2:: Disease detected in US Disease detected in US• Stage 3Stage 3:: Disease detected locally Disease detected locally
UPHS General Concepts 1UPHS General Concepts 1
• Broad-based, flexible and fluid outlineBroad-based, flexible and fluid outline• May not be able to predict causeMay not be able to predict cause
– SARS, monkeypox, WNV, etc.SARS, monkeypox, WNV, etc.• Specific actions will respond to course, pace and Specific actions will respond to course, pace and
characteristics of diseasecharacteristics of disease– Pandemic Command CommitteePandemic Command Committee
• Baseline assessment completed for each entityBaseline assessment completed for each entity– August, 2006August, 2006
UPHS General Concepts 2UPHS General Concepts 2
• Limit access to each entityLimit access to each entity– Two easily secured entry points recommendedTwo easily secured entry points recommended
• General screening area for employees and visitorsGeneral screening area for employees and visitors• Influenza Evaluation CenterInfluenza Evaluation Center
– Distinct from Emergency DepartmentDistinct from Emergency Department• Home Care Services will assist management of Home Care Services will assist management of
patients from ambulatory practicespatients from ambulatory practices
Employee Health and Safety/Worker RetentionEmployee Health and Safety/Worker Retention
• Chemoprophylaxis as indicatedChemoprophylaxis as indicated• Vaccine when availableVaccine when available• University will likely close when US disease first University will likely close when US disease first
detecteddetected• Dormitories can be used to house essential Dormitories can be used to house essential
employees and their familiesemployees and their families• Communication!Communication!
Planning StrategiesPlanning Strategies• SurveillanceSurveillance• Stockpile necessary equipment, supplies and Stockpile necessary equipment, supplies and
medicationmedication• Novel staffing patternsNovel staffing patterns
– ““Work quarantine” for exposed but well Work quarantine” for exposed but well employeesemployees
• Identify essential employeesIdentify essential employees– Strict “stay-at-home” criteriaStrict “stay-at-home” criteria
• Plans to limit mass gatheringsPlans to limit mass gatherings– Close cafeteriaClose cafeteria– Cancel Grand Rounds, meetings, etcCancel Grand Rounds, meetings, etc– Telecommute when possibleTelecommute when possible
• SecuritySecurity• Communication!Communication!
Tiered Distribution of Antivirals and Tiered Distribution of Antivirals and VaccinesVaccines
1.1. HCWs with prolonged contact with high-risk patientsHCWs with prolonged contact with high-risk patients► Physicians, RN, NP, RT, etc.Physicians, RN, NP, RT, etc.
2.2. HCWs with prolonged contact with moderate-risk patientsHCWs with prolonged contact with moderate-risk patients3.3. HCWs with intermittent contact with high-risk patientsHCWs with intermittent contact with high-risk patients
► Environmental services, MSW, case managers, etc.Environmental services, MSW, case managers, etc.4.4. HCWs with intermittent contact with moderate-risk patientsHCWs with intermittent contact with moderate-risk patients5.5. HCWs with prolonged contact with low-risk patientsHCWs with prolonged contact with low-risk patients6.6. HCWs with intermittent contact with low-risk patientsHCWs with intermittent contact with low-risk patients
**Should be reviewed by Ethics Committee
Required SuppliesRequired Supplies• Antiviral medicationAntiviral medication• Alcohol hand gelsAlcohol hand gels• Protective gownsProtective gowns• GlovesGloves• Face shields and Face shields and
gogglesgoggles• Surgical masksSurgical masks• N-95 respiratorsN-95 respirators
• Disposable BP cuffsDisposable BP cuffs• Disposable Disposable
stethoscopesstethoscopes• Pulse oximetry probesPulse oximetry probes• LinensLinens• Screening Screening
thermometersthermometers• Transport monitorsTransport monitors• VentilatorsVentilators
Screening CriteriaScreening Criteria• Based upon disease activityBased upon disease activity• Disease overseas (sustained human-to-Disease overseas (sustained human-to-
human transmission)human transmission)– Symptoms, fever AND travel to pandemic Symptoms, fever AND travel to pandemic
regionregion• Disease in USDisease in US
– Symptoms and feverSymptoms and fever• Local disease (or widespread in US)Local disease (or widespread in US)
– Just symptomsJust symptoms
Limiting TransmissionLimiting Transmission
• Screen all employees and visitors dailyScreen all employees and visitors daily– Colored wrist bands for each dayColored wrist bands for each day
• Hand hygieneHand hygiene• Masks for all visitorsMasks for all visitors• Respiratory etiquetteRespiratory etiquette• Social distancingSocial distancing• Contact precautionsContact precautions• Airborne vs. “Droplet Plus” precautionsAirborne vs. “Droplet Plus” precautions
– Necessity of negative pressure controversial Necessity of negative pressure controversial
Infection ControlInfection Control•PatientsPatients •Surgical masksSurgical masks
•Employees w/o direct Employees w/o direct contactcontact
•Surgical masksSurgical masks
•Employees w direct Employees w direct contactcontact
•N-95 respiratorN-95 respirator•Contact and droplet Contact and droplet precautionsprecautions•Hand hygieneHand hygiene
•Employees performing Employees performing high-risk procedures high-risk procedures
•N-95 and eye protectionN-95 and eye protection•Contact and droplet Contact and droplet precautionsprecautions•Hand hygieneHand hygiene
Surge ManagementSurge Management• Fill all existing “open” bedsFill all existing “open” beds• Clear all “pending” dischargesClear all “pending” discharges• Forced discharge roundsForced discharge rounds• Identify isolation unitIdentify isolation unit
– Relocate patientsRelocate patients– Rhoads Building at HUPRhoads Building at HUP
• Double occupancy of all roomsDouble occupancy of all rooms• Cancel elective admissions and proceduresCancel elective admissions and procedures• Utilize non-traditional space for patient careUtilize non-traditional space for patient care
– PACUPACU– Clinic exam roomsClinic exam rooms– PT gyms, conference rooms, etc.PT gyms, conference rooms, etc.
Other ConsiderationsOther Considerations• Altered standards of care possibleAltered standards of care possible
– Ventilator use, for exampleVentilator use, for example• Medical, nursing and dental studentsMedical, nursing and dental students
– Penn Care @ HomePenn Care @ Home• Hospital must continue to provide “routine” careHospital must continue to provide “routine” care
– MI, emergency surgery, trauma, etc.MI, emergency surgery, trauma, etc.• Security criticalSecurity critical• Supplies for ambulatory practicesSupplies for ambulatory practices• Coordinate with CHOPCoordinate with CHOP• Coordinate with Philadelphia DOHCoordinate with Philadelphia DOH
Other IssuesOther Issues• Alternate use of dormsAlternate use of dorms
– Essential personnel +/- familiesEssential personnel +/- families– Healthcare workersHealthcare workers– Work quarantineWork quarantine
• Screening of essential personnelScreening of essential personnel– Utilize health system planUtilize health system plan– Limited access pointsLimited access points
• SecuritySecurity• CommunicationCommunication
– InternalInternal– ExternalExternal
• TransportationTransportation
Health System Preparedness: Health System Preparedness: The Emergency Department and BeyondThe Emergency Department and Beyond
PJ Brennan, MDPJ Brennan, MDChief Medical OfficerChief Medical Officer
University of Pennsylvania Health SystemUniversity of Pennsylvania Health System
