So much of swine flu preparation news has focused on how hospitals will cope with the pandemic that it was nice to see one organization, the American Hospital Association, sympathize with the challenges facing physician practices.
Since the spring H1N1 outbreak, the healthcare safety community has vigorously debated whether to protect healthcare workers with fit-tested N95 respirators or the more easily used surgical/procedure masks. A September 15 letter urging the CDC to quickly reverse the current recommendations favoring N95s placed the AHA firmly on the mask side of the argument, mainly for epidemiological and supply reasons. The AHA also observed that requiring respirators would give non-hospital settings, such as physician offices, which are unfamiliar with using fit-tested N95s, a disincentive to treat patients with flu-like symptoms, "resulting in a further surge of individuals being inappropriately sent to hospital emergency departments for care."
There is sort of a mild versus severe pandemic balancing act going on here. From the perspective of an outpatient facility, a mild case of H1N1 this winter could actually mean a strong surge for outpatient facilities and physician offices, as Paul Biddinger, MD, medical director for emergency preparedness and emergency physician at Massachusetts General Hospital in Boston, explained in the September issue of Medical Environment Update. "If the second wave [fall and winter] of H1N1 causes mostly mild illness, I think outpatient providers will feel the brunt of the surge of patients. If the virus causes more severe illness, it may be more in the emergency department and in the hospital setting."
But what if the CDC doesn't budge on the AHA's epidemiological and logistical reasons? A recent report by Institute of Medicine expressly favors fit-tested N95s, as do most healthcare worker labor unions and other healthcare professional associations.
Yes, physician offices are unfamiliar and confused about N95 fit testing, judging from calls received through the HCPro OSHA Hotline. Some think it is just a matter of showing workers how to put it on, pinch the metal bridge for the nose, and how to take it off. (See "Don't confuse N95 fit testing with user seal checking".
To hospitals, which regularly conduct fit testing, the N95 recommendation for H1N1 protection admittedly requires extra resources and time, but to the small physician practice, fit-testing probably seems like an insurmountable challenge, what with their lack of experience and expertise.
If you logically extend the AHA's argument, it appears that hospitals and physician practices are in this thing together, whether the CDC says yeah or nay to respirators. That's why the AHA might also recommend that its membership lend assistance to fit-testing staff members of physician practices in their community.
David LaHoda, the managing editor of Medical Environment Update and OSHA Watch, has produced healthcare training videos and consulted for medical practices and ambulatory healthcare facilities.
Bad news comes to those without health insurance. Individuals without private medical insurance are more likely to die, according to a new study, "Health Insurance and Mortality in US Adults," published in the September issue of the American Journal of Public Health.
In fact, they have a 40% higher risk of mortality when compared to people who have insurance, said researchers at The University of Washington School of Medicine in Seattle, and the Cambridge Health Alliance/Harvard Medical School in Boston.
Researchers surveyed 9,000 adults between the ages of 17-64, using nationally representative data from the CDC and the National Health and Nutrition Examination Survey. The study results confirmed their initial hypothesis that not having insurance is linked to mortality.
The latest numbers reiterate previous studies that date back to the 1980s, when researchers found the correlation between lack of coverage and death. Despite advances in medicine, those statistics haven't changed much.
Today, the current lack of health insurance is associated with nearly 45,000 deaths in the U.S., according to the study. With 46.3 million Americans lacking health insurance, according to the latest U.S. Census Bureau report, the link between "uninsurance" (as researchers call it) and mortality rates is suggesting there is a nationwide risk.
"What this study implies for those individuals [without insurance] and for our society as a whole, is that these are people who, because of their limited ability to access the healthcare system, have a higher risk of death," said Andrew P. Wilper, MD, MPH, lead study author and internal medicine physician at University of Washington School of Medicine. "They have a higher risk of not living as long as people who do find a way to find coverage."
Who are the underinsured?
The uninsured population are individuals without any type of healthcare cost coverage, as opposed to underinsured individuals who may receive limited care. The uninsured tends to be younger, poorer, and less educated, according to study results. In addition, those without coverage are traditionally minority (non-Caucasian) groups.
Has the economic downturn affected the number of people who can afford care? Unfortunately, it may have. The number of people without insurance rose by 600,000 in the last year, according to the census.
Most people receive health insurance through employment-sponsored coverage, so those who recently lost their jobs could be a greater risk for uninsurance and lack of care.
"People who are less likely to have work are also less likely to have a health policy," he said about his patients who have lost coverage from their work or state-level Medicaid programs. "Individuals without health insurance often delay care to their determinant. I've seen dramatic tragedies occur in people who have delayed care for very treatable illness."
"Individual physicians, hospital administrators—everyone's efforts make a difference. This is a society-wide problem that we have been unable to tackle for the last 100 years," Wilper said. "'How are we going to ensure that people in our society can have access to medical care?' is a political question."
Congress is expected to vote on the bill by year's end.
Karen M. Cheung is associate editor at HCPro, Inc., and blogger for HospitalistLeadership.com. She can be contacted at kcheung@hcpro.com.
A large number of U.S. medical schools say students have posted unprofessional material on Web sites such as MySpace, Facebook, and Twitter, but few schools have adequate policies in place for dealing with such behavior, a study found. Of 78 U.S. medical schools that responded to a survey, 60% reported incidents of students posting unprofessional content online, including material that was classified as profane, discriminatory, sexually suggestive, or violated patient confidentiality, according to the report.
The major obstacle to adopting evidence-based treatment guidelines may be patients, and Newsweek offers the example of a four-year-old with minor head trauma to illustrate the point. Research suggests that a head CT scan will not improve care in 99.9% of these cases, but most parents are concerned enough about the 0.1% chance to push for the test for their child.
During a pandemic, there is a high likelihood that staff members will not report to work for a variety of reasons. Some may contract the virus, others may have children or family members to care for, and others may require time off because of school closures.
Healthcare worker absenteeism can be detrimental to any facility, but for a small facility with few employees, it can be crippling. Unfortunately, absenteeism is also the toughest to plan for, says Terri Rebmann, PhD, RN, CIC, associate director for curricular affairs and assistant professor at the Institute for Biosecurity at Saint Louis University School of Public Health.
"The main thing is they should be talking about it now and trying to make some kind of plan, knowing there are going to be staff shortages," Rebmann says. "We already saw that before it was even deemed a pandemic, there were staffing shortages."
Rebmann suggests hiring contract workers or even retired healthcare professionals or medical students if the pandemic is bad enough.
Keep in mind that during a pandemic, healthcare workers that exhibit symptoms of influenza should remain at home. Rebmann says a big contributor to the SARS outbreak in 2003 was the fact that sick healthcare workers were still coming to work.
"[Healthcare facilities] need to be looking at their occupational health and sick leave policies to really make sure staff are able to call in sick with no repercussions," Rebmann says.
Plan for a surge of patients
Regardless of whether your facility will be hit hard by seasonal influenza or the H1N1 virus, even small medical facilities should have a detailed plan in place to handle a sudden or prolonged surge of patients.
Rebmann conducted a focus group on the H1N1 outbreaks among infection preventionists at the June Association for Professionals in Infection Control conference. Many of the pediatric facilities reported that their 24/7 hotline worked well to triage patients or provide care without bringing them into the facility.
"That at least reduced the number of people that would show up in the ED, because families would call in, talk to a healthcare provider on the phone, and decide 'yes, it's an emergency; I should go in,' or 'no, it's probably not; I can go see my physician or I can just stay home and not even require treatment,' " says Rebmann.
However, establishing this phone system is often cumbersome for smaller facilities with fewer resources. Directing patients to their local or state health department's phone line, which should be in place for providing guidance or answering questions, may be a better alternative. Other facilities that are part of a system may want to consider pooling their resources and placing one or two nurses on call for the entire system.
Screen patients for symptoms at the door
Many experts say the most important part of reducing the transmission of seasonal influenza and H1N1 is separating sick patients from well patients as soon as they enter the facility. To accomplish this requires two things: screening procedures and isolation precautions.
Rebmann notes that isolation precautions, especially those involving negative pressure, are extremely difficult in the limited space of an outpatient facility. Instead, the facility should plan on designating one or two rooms to place patients with influenza as soon as they enter the facility.
But to separate the sick from the well, you need to have screening measures in place. Screening techniques range from passive screening, such as placing a sign at the facility entrance that directs patients according to their symptoms, to active screening, which might include a brief medical exam.
However, actively screening patients requires resources, which is why many facilities are moving toward enlisting volunteers, student workers, or even security guards to perform basic assessments with the help of a simple checklist.
"We aren't talking about a medical evaluation, obviously," Rebmann says. "That's going to be done by the medical providers."
This article was adapted from one that originally appeared in the September 2009 issue of Medical Environment Update, an HCPro publication.
On the second day of work on legislation intended to overhaul the U.S. healthcare system, the Senate Finance Committee wrestled with politically volatile proposals to squeeze money out of Medicare. As they continued work on the bill, Democrats fended off attempts by Republicans to restore proposed reductions to the program and get rid of government restrictions on the ways insurance companies market to seniors.