News & Events

Nov 2 2009 Swine flu: Worst-case outbreak could severely strain hospitals–shortage of ECMOs, ICU beds, N95 and surgical masks, gels, staff etc etc all possible

Children’s Memorial Hospital saw supplies dwindle during H1N1 flu surge in May

By William Mullen Tribune reporter
November 2, 2009
For a mere peek into the potential difficulties of managing a worst-case outbreak of swine flu, one need only look back at a few weeks in May at Children’s Memorial Hospital on Chicago‘s North Side.

During the first wave of H1N1 virus that swept through the area last spring, an influx of children with flu symptoms inundated Children’s Memorial, pushing its normal intake of 150 patients per day to nearly 400.

The emergency room staff got hit, too, in one week suffering 16 times as many absences as normal. The hospital briefly ran out of a key antiviral medication, and within a 72-hour period, it used up three-quarters of a 60-day supply of special respirator masks to be worn around highly contagious patients.

The Children’s Memorial staff had prepared for and ultimately weathered the sudden storm, but not until after it harshly tested the hospital’s resources and ability to keep up with a pandemic illness that is now surging again across the country.

"We thought we had a good handle on things for these kinds of situations," said Mary Margaret Crulcich, the hospital’s safety officer, "but it was a bit surprising to see the rate at which our supplies were being depleted."

All 214 Illinois hospitals have been toiling since April to ready themselves in case the H1N1 virus sickens a large percentage of the population. To prepare for a possible rush at emergency rooms and clinics, hospitals are holding drills, refining emergency plans created after Sept. 11, 2001, and making sure they can tap into local, state and national stockpiles of medical provisions.

No Chicago-area hospitals have reported a big influx of flu patients thus far, but federal officials say millions of Americans already have been infected by H1N1 and it is spreading at an increasing rate. Some studies suggest that if 35 percent of the population falls ill from H1N1, the nation’s hospital resources would be severely strained.

On Oct. 24, President Barack Obama declared the H1N1 outbreak a national emergency, an administrative step to help hospitals set up alternative treatment sites and triage systems if overwhelming numbers of flu patients show up at hospital doors.

Hospital administrators also have been studying reports from the winter flu season in the Southern Hemisphere from June to August. In Australia and New Zealand, H1N1 patients clogged emergency rooms and put nearly overwhelming demands on intensive care units.

One lesson was the increased need for a lung-bypass machine known as an ECMO, for extracorporeal membrane oxygenation. The normally little-used devices — to which patients are hooked up for weeks at a time — suddenly became crucial and were credited by New Zealand doctors with saving the lives of many extremely ill H1N1 patients.

Hospital administrators in the U.S. now may wish they had more ECMOs, but they would be expensive purchases at a time when health experts don’t know how severe the new flu wave will be. Large hospitals normally have only a few ECMO machines: Children’s Memorial has four. The Loyola University Health System in Maywood has three.

"In Australia and New Zealand, there were reports of ICUs at maximum capacity and having to triage their ventilators," said Jorge Parada, director of infection control at Loyola. "We’re nowhere near that state in the U.S. at this time, but it is a possibility we might have to face.

"Everybody is waiting to see how this will play out."

Key to hospitals’ emergency response is planning and cooperation.

Every hospital in Illinois belongs to one of 11 regional hospital networks, each overseen by a "pod" hospital. For Region 11, which includes most Chicago hospitals, the pod hospital is Advocate Illinois Masonic Medical Center.

By 10 a.m. each day, each of the regions reports to a statewide hospital database that keeps count of every spare bed and the amount, whereabouts and availability of stockpiled medicines and medical supplies in Illinois, including huge federal emergency stockpiles maintained at undisclosed sites around the state.

Each hospital also prepares rigorously detailed contingency plans for emergencies, keeping updated lists of qualified medical personnel that can be called to sub.

The plans have to be practiced in periodic drills, including worst-case scenarios where the hospital goes into a rigid, military-style stance called "incident command."

Sharon Ward, a registered nurse who is Illinois Masonic’s director of emergency and trauma services, said the morning phone call is crucial to readiness.

"If we had a worst-case scenario in which a lot of kids in emergency departments needed to be hospitalized, we would have an instant bird’s-eye view of which hospitals in the city had available pediatric beds," she said.

Robert Weinstein, interim chairman of the medical department at Stroger Hospital [the former Cook County Hospital], said all hospitals now have to prepare as though they will be inundated.

His hospital has readied plans to keep flu patients away from emergency areas treating gunshot and accident victims, and to turn away visitors, a measure already in force in other hospitals.

"We are thinking through how we can free up space if we have to, by postponing elective surgeries on things like repairing hernias," Weinstein said. "Last spring was important. It was a big wake-up call."

A lot of planning and training turned out to be useful in May at Children’s Memorial. Soon after the big flu surge hit, the hospital went into a 40-day period of incident command, putting all resources, personnel and communications under a single leader.

"The most important thing is that you don’t have different people giving contradictory directions to the staff," said Terry Rearick, Children’s Memorial’s accreditation readiness chief, who was command leader the first two weeks.

She used her power to direct the conversion of clinic rooms to urgent-care rooms dedicated to H1N1 patients to keep from mixing children with flu symptoms from other children. She recruited extra staff and allowed advanced nurse practitioners to see potential flu patients without a physician present.

The hospital’s bed capacity was never threatened because most kids’ symptoms were mild and they were sent home. But it had enough severe cases warranting hospitalization that supplies were stretched. For instance, the hospital ran out of Tamiflu, an antiviral treatment, but was resupplied by other hospitals in the statewide emergency system.

During a "sustainability analysis" of supplies in December, the hospital had created a reserve, 60-day cache of supplies like gowns, goggles, hand gels and masks, both looser-fitting surgical masks and airtight N95 respirator masks.

When May’s swine flu surge quickly depleted the supply of N95 masks, the hospital had to race to replace them with a different brand. Then each staffer had to go through a half-hour custom refitting procedure for the new respirator masks.

Missing staff due to flu also was a complication. In a normal week, the hospital’s emergency room has about 14 staff "absent days" due to illness. In the week of May 24, it had 112 absent days, the following week 224 absent days.

"It was a challenge for a few weeks," said Dr. Steve Krug, head of Children’s Memorial’s emergency medicine division. "But we got through it without any interruption of our normal services.

"The silver lining of what we experienced, it allowed us to plan better going forward. We are better resourced now, if we are faced with a similar situation this winter."