H1N1 Pediatric Fall/Winter Respiratory Rush -

Are you ready?

By: Richard Molteni, MD, Consultant, Joint Commission Resources 
and Francine Westergaard, RN, MSN, Consultant, Joint Commission International

Late fall and winter are always stressful times for hospitals which provide care for children. When emergency department (ED) care is taken into consideration, nearly all hospitals care for kids – and with varying levels of comfort and expertise. The annual explosion of RSV and other viral triggered bronchiolitis infections and exacerbations of asthma symptoms are concerning for ED staff but commonplace in all hospitals, especially in those that care for children. Staffing shortages, ED overcrowding, severe bed shortages and supply challenges for children stress hospitals – and when stressed, the risk of error and safety breeches increases. This year may be particularly challenging to hospitals when the normal winter viral season collides with the expected H1N1 (swine flu) virus pandemic. Pregnant women, children and those with disabilities represent three of the important and probable high-risk populations that hospitals and outpatient facilities must be especially ready to address. While emergency preparedness and surge capacity have received close attention since 9/11 and Hurricane Katrina, most of the attention has been directed to adults’ disaster situations – despite the fact that 25% of our population is below the age of 17 years. Here are a few helpful tips for hospitals facing this rising onslaught of pediatric respiratory illness:

·         Closely monitor the CDC, AHRQ and WHO Web sites, state and local health departments and other appropriate Web sites for continual updates in geographic spread and the number of current cases. Remember there will not be a brief peak and then fall off in cases. There will be a steady rise in cases, followed by a more prolonged peak and then a slow fall off in cases that will likely last for months, not weeks or days. Be prepared for the long haul, not the short-term response.

·         Develop or utilize existing (CDC, AHRQ and WHO) educational resources for intensive and all-encompassing staff education. All hospital staff must understand the signs and symptoms of this flu, the appropriate screening tools to recognize infected or potentially infected patients (including non-communicating children and non-English speaking parents), be aware of appropriate precautions for staff to take to protect themselves and their patients and families, as well as the type and importance of isolation precautions for patients identified and/or admitted with H1N1 flu. Staff is eager for and looks forward to this information and education from the leadership team. 

·         Partner with community resources to disseminate educational messages for businesses, schools, religious organizations, community centers, sports areas/events, malls and other areas where large number of potentially infected individuals will congregate. Remember the very best approach to limiting the pandemic spread is the proper use of personal hygiene (hand hygiene and sneeze/cough protection) and limiting the spread by “isolation” (stay at home or out of school) of patients with flu like symptoms or illness.

·         Immunize your health care workers and consider a hospital sponsored immunization clinic. Isolate appropriate identified patients and immunize patients who arrive for ED, clinic or inpatient care for other conditions who can be safely immunized prior to home discharge.

·         Have  your hospital telephone health advice lines or urgent care/clinic scheduling systems incorporate clear messaging that identifies flu symptoms, provide symptomatic advice and limit the unnecessary ED or hospital clinic visit for infected patients whose symptomatology and disease can be adequately managed at home.  Encourage patients and families to identify and avoid situations that may result in inadvertent exposure.    

·         Develop expanded patient signage at hospital entrances, especially in the ED and lobbies, reminding patients to identify themselves immediately to hospital personnel if they have flu symptoms, to not visit patients if they are symptomatic or have been exposed to patients with the flu, and to seek advice for care from their medical home if they have only mild symptoms.

·         Determine which triage capabilities and skills the ED staff will have which must be enhanced and expedited. Communities without known H1N1 cases must be prepared to recognize and manage patients presenting with a febrile respiratory infection and who (a) were in close contact with a patient who is confirmed, probable or suspected case of novel H1N1 infection within the past 7 days, or (b) travelled to a community in the US or internationally where there were one or more confirmed cases within the past 7 days.

·         Pediatric patients with confirmed, probable or suspected cases of H1N1 should be placed directly into individual isolation rooms and the door should be kept closed. Children who are diagnosed with H1N1 or considered at risk of respiratory failure and/or respiratory arrest when exposed to H1N1 and have much higher potential for respiratory complications than adults must be managed with frequent patient evaluations, parent/caretaker education and effective staff call systems.

·         All personnel who enter the patient’s room should use standard and contact precautions. In addition, eye protection should be utilized for patients being evaluated for, or in isolation for, H1N1. Adherence to hand hygiene by washing with soap and water or using alcohol-based hand sanitizing immediately after removing gloves or other equipment and after contact with respiratory secretions. Nonsterile gloves and gowns along with eye protection should be donned when entering a patient’s room. Staff entering rooms of patients in isolation for known or suspected cases should wear fit-tested disposable N95 respirators. This more conservative approach is recommended by the CDC (as opposed to surgical masks) until more is known of the specific transmission characteristics of this new virus.

·         Institutions that are uncomfortable or unfamiliar with care of children or utilize staff less familiar with children should consider one of the pediatric triage algorithms most commonly employed in mass casualties, such as the JumpSTART Pediatric MCI Triangle.

·         Large volumes of sick children may also stress the hospital’s medication ordering and delivery system. Hospitals not accustomed to providing medications to seriously ill pediatric patients are at higher risk for medication errors, particularly if the pharmacy is not utilized to prepare and check weight-based dosages for children. Whenever possible (non-emergent drug therapy) pharmacy review of all pediatric medications should be utilized. In addition, a consistent recording of the current patient weight (always kilograms) should only be utilized in all locations in the hospital that treat children.

·         Visitors, in particular visiting children, should be limited to only those patients in which it is essential to the patient’s emotional well-being. When children can be separated from the symptomatic patient by another responsible adult they should be asked to remain outside of the hospital, including the urgent care or ED. When it is not possible to contain the pediatric visitor in the ED/urgent care area the children should be contained within the patient’s room and not allowed to move or wander through the unit or hospital.

·         Patients with H1N1 infection should be considered contagious from one day before the symptoms appear to 7 days following the illness. Health care workers exposed to and caring for these patients should themselves be monitored closely and at regular periodic intervals for signs and symptoms of infection. Health care workers with a febrile respiratory illness should be instructed to not report to work.

·         Hospitals should review their supplies and access to isolation equipment including access to personal protective equipment, respiratory therapy supplies, medications, and ventilator equipment. In particular, staff must be certain that pediatric equipment and supplies are reviewed and increased well above pre-epidemic levels. Unlike adult equipment, pediatric equipment (and medications) comes in varying sizes to accommodate a wide range in childhood weight and anatomic configuration.

·         All hospitals should identify pediatric consultative resources, assure rapid and easy access to pediatric specialists (ED, pulmonary, intensive care, transport services) and develop a formal triage and transport agreement (memorandum of understanding) before the pandemic surge in pediatric cases occurs.

 

Pediatric hospitals will be forced to triage admitted patients to make room for those children who require special pediatric facilities, especially critical care resources, which only the children’s hospitals can provide. Plans for early discharge of less ill patients with community follow-up, transfer to less specialized hospitals capable of the management of less ill children requiring lower levels of care, developing more pediatric intensive care capability (PACU, medical surgical floors) and the use of clinic space for lower acuity children who require hospitalization but may progress rapidly to a higher level of need, will all have to be implemented if the pandemic reaches projected proportions. Canceling elective admissions and elective surgeries may be required, placing financial as well as staffing stress on these pediatric facilities. Medical, nursing and ancillary staffing, medical supplies, particularly respiratory supplies, isolation rooms, and areas for procedures will all be severely stretched to meet projected pediatric patient volumes.

 

Now is the time to review your hospital’s surge capacity plans for pediatric care. This is a large and vulnerable population that cannot be managed in the traditional pediatric specialty hospitals. Review your plans and supplies, consult with a local highly regarded pediatric provider and begin or accelerate education of all of your staff and leadership. Fall and winter are rapidly approaching. Are you prepared?

 

http://www.cdc.govh1n1/guidelines