ER Docs Will See H1N1 First—Don't Ignore Their Warnings

America's emergency room doctors have been feeling slighted.

For starters, they were left out of an influential White House health reform summit in March, leaving them grumbling that their new President didn't appreciate their crucial role in saving lives.

Second, they have been arguing for more respect from their hospital CEOs, who they say often turn a blind eye to gridlocked emergency rooms with loaded hallway gurneys. Several emergency room doctors this week complained that while the ED "boards" patients with respiratory illness and injuries waiting for an upstairs bed to clear, empty beds sit for hours on the units labeled "reserved," awaiting well-insured patients scheduled for elective surgery.

And third, they say they were insulted by Kathleen Sebelius, who no sooner than assuming the role of U.S. Health and Human Services secretary this spring, suggested most patients who end up in the emergency room don't really need to be there. In doing so, they say, she "perpetuated myths" and trivialized the very dangerous problem of overcrowding, even as hospitals everywhere prepare for a very different influenza season.

She was so mistaken, says Nick Jouriles, MD, president of the American College of Emergency Physicians, who pointed to a Centers for Disease Control and Prevention report that says only 12% of emergency room patients have non-urgent medical needs. More than half of patients who seek emergent care are admitted, so how can their medical needs not be serious?

And fourth, emergency teams are stretched as never before. The number of visits to the emergency room has increased from 90.3 million patient in 1996 to 119.2 million in 2006 just as the number of hospital emergency rooms has decreased, from 4,019 to 3,833. And the percentage of the population that visited an emergency department increased 18%.

With an underlying sense of umbrage, Jouriles and the College this week reemphasized the critical importance of emergency room teams, and turned up the volume in its call for attention.

In a scary 16-page National Strategic Plan for Emergency Department Management of Outbreaks of Novel H1N1 Influenza, they painted a potentially chaotic scenario this fall when and if the next wave of H1N1 influenza strikes, coming down hardest on America's emergency rooms first.

Some of the most thoughtful scientists are suggesting that H1N1 might return with a vengeance, striking younger people, the ones in the hospital system's workforce, first. Yet not all hospitals are doing what they should to get ready, Jouriles says.

The report contained 27 plan topics, underscored with 93 suggested action items, which the College thinks hospitals wishing to make a serious effort at preparedness should be doing now.

Make sure support personnel have enough resources, check that all appropriate hospital staff are properly certified and trained and set aside time to rehearse with disaster drills—not for a flood or an explosion scenario—but a real live H1N1 pandemic.

For even the largest hospitals, it's a daunting "to do" list. And smaller and medium-sized hospitals, might not get around to completing a lot of what might be required, says Stephen Cantrill, MD, a member of ACEP's H1N1 Task Force.

Cantrill says these are three areas where hospitals are most vulnerable in the event of a pandemic attack:

Number one, Cantrill says, "is staffing. In a disaster like Katrina, you had people from around the country willing to come in and help out. But if the next outbreak is broadly population based, you will lose not only many members of your own staff, but the vast majority of your volunteers."

Hospitals need to start now to mobilize teams of nurses and physicians, even if it means recruiting those retired but who kept their licenses active.

Number two is supplies. Far too many hospitals are using "just-in-time" purchasing policies that will leave them scrambling for masks, gloves, gowns and ventilators, not to mention antibiotics and IV equipment, if a 1918-level flu season strikes.

"If you do the numbers of what would be required for a sustained pandemic, it just strikes fear in the heart of anyone who has looked carefully at this problem," say Cantrill, an emergency room physician at Denver Health Medical Center in Colorado.

"There would be a disruption in our supply chain." And hospitals that normally compete with each other will not be willing to help out if they themselves are running short too, he says.

Number three is communication. Hospitals and public health officials must have a routine, constant communication stream, a conduit he says has historically been a weak link. But the involvement of public health officials is essential to reassuring the public and the media, notifying patients when to go to the hospital, and when to stay away.

At his hospital last April, "the number of patients in our emergency department with respiratory complaints increased by a factor of three. It was overwhelming and debilitating and public health officials need to know about that, and do what they can to offload on other facilities," Cantrill explains.

Lastly, he says, is to imagine the worst. Hospital officials at all levels of care need to dust off their protocol books and spend some time thinking about how such a scenario would really play out when resources are stretched thin.

It's tough to think about, he says, but each hospital needs to have a plan, and a chain of command, for deciding how to triage patients for life-saving care. Who gets a ventilator and who doesn't when there aren't enough to go around?

"We only have 105,000 ventilator in the U.S. and we would need six times that if we had a true pandemic," Cantrill says. "Hospitals are going to have to look at way to prioritize when we have limited supplies."

"These are tough ethical questions," no one can dispute, he says. And while some states and regions of the country have "really taken the bull by the horns," others have not.

The emergency room doctors have turned up the volume of their message. Maybe it's time to listen up.