Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness (PHEP) program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
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8. Influenza Pandemic Preparedness
This chapter applies information from the previous chapters to preparing for a specific mass casualty event—an influenza pandemic.
An influenza pandemic is a "developing impact" mass casualty event (MCE). It occurs in many areas simultaneously. Indeed, a pandemic affects a large part of the population across the world and across all age groups, including the health care and emergency response workforce. Large numbers of patients may quickly overwhelm hospitals and emergency departments and necessitate the allocation of scarce resources.
The National Strategy for Pandemic Influenza Implementation Plan puts the bulk of the planning and coordination responsibility on States and localities rather than the Federal Government. Because many communities may be simultaneously affected, State and local health authorities and community planners represent the front lines of pandemic preparedness response planning efforts.
Planners should create their pandemic preparedness plans now, practice and exercise the plans, and revise them when necessary. Effective and coordinated risk communication, domestically and internationally, before and during a pandemic, is essential to help the public understand the rationale for recommended actions and accept the prioritization of scarce resources.
Communications activities include identification of credible spokespersons at all levels of government to communicate informative and timely messages Available communications tools (see box) should be used to develop messages to address the issues, including the uses of scarce resources and caring for the sick at home. Communities should identify which resources will be needed and which processes and systems should be put in place and prepare their plans now.
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All influenza viruses are capable of mutating. When a novel strain of virus gains the capacity to spread in humans, an influenza pandemic may ensue.
We have experience with pandemics. Over the course of the last century, the world witnessed three pandemics: the "Spanish influenza" of 1918, which resulted in a worldwide death toll of more than 50 million; the "Asian influenza" in 1957, which resulted in 1-to-2 million deaths worldwide; and the "Hong Kong influenza" in 1968, with 700,000 deaths worldwide.
With novel viruses, people have little or no immune protection, so most are susceptible. The supply of antiviral drugs may be inadequate and the development of a vaccine may take a long time. Moreover, as with any public health emergency, shortages of supplies, equipment, and hospital beds are possible.
Potential shortages of ventilators could be particularly problematic. Hospitals may not have an adequate supply of reserve ventilators to treat patients suffering from acute respiratory failure. The Centers for Disease Control and Prevention (CDC) has a limited reserve supply of thousands of mechanical ventilators in the Strategic National Stockpile that may deployed at the time of a pandemic to alleviate some of the shortfall. The American Association for Respiratory Care (AARC) has issued a set of guidelines and recommendations on ventilator capacity.
A pandemic may result in school closings and increased worker absenteeism as employees remain at home because of their own illness or that of a family member.
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Concepts, Strategies, and Actions for Planners
The following sections detail concepts, strategies, and actions that planners need to incorporate into their preparedness planning for pre-pandemic, early pandemic response, and widespread pandemic response periods of a hypothetical pandemic. Concepts and actions for prehospital, hospital, alternative care site (ACS), and palliative care sectors are highlighted.
In a flu pandemic, planners should emphasize the importance of the home as a "safe haven" and consider the use of primary care vans to provide services so that people may remain in their homes. At the same time, planners need to recognize the vital role of primary care providers in deciding which patients may remain at home and which patients need to go to the hospital. Primary care providers may be the first medical personnel contacted, and the ambulatory care system will be critical in keeping hospitals from being overwhelmed.
Many concepts provided here will need to be tailored to the resources and systems in each locality, region, or State. This chapter aims to provide community planners with options to consider. Further pandemic influenza planning resources are listed in this and previous chapters.
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Pre-Pandemic Period: General Coordination and Planning Issues
Most advance planning for a pandemic should take place in the pre-pandemic period. An overview of issues and activities that community planners need to consider is listed below.
- Determine the trigger for emergency health powers provision (see discussion of legal issues in Chapter IV of this guide).
- Discuss with hospital associations and local and State public health officials when the trigger would be pulled and who would make that decision.
- Develop continuity of government and leadership protocols in the event that senior leadership becomes incapacitated or dies.
- Conduct regional exercises that are inclusive, use realistic scenarios, involve all responders, and embrace participation from agencies that are often not included.
- Include local and State political representatives, using education and exercises to get them involved, committed, and supportive.
- Consider special needs populations and children in all planning scenarios.
- Begin a public communication campaign. Focus the messaging campaign on managing expectations; and providing updates on the community plan for pandemic response, including community care sites. This communications campaign should be a joint effort by hospitals, hospital partners, and public health departments.
- Emphasize prevention. Inform and educate the public about influenza. Provide advice and information on prevention and interventions to reduce virus transmission so that if and when the virus arrives, the public is knowledgeable about reducing the spread.
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Prehospital: Pre-Pandemic Period
- Maintain standard precautions for every patient encounter.
- Preplan community staging locations—predesignated sites that could be opened in advance for alternative care and EMS staging.
- Locate surge transport assets in advance.
- Arrange mutual aid agreements for acquiring and using specialized assets by meeting with local and regional transportation authorities or businesses and agreeing by memorandum of understanding (MOU) on available assets (e.g., buses and other transport, staff augmentation), deployment, and staging locations. The MOU could be enhanced further by the development of a pre-event contractual agreement between the government and these institutions.
- Evaluate triage models such as JUMPSTART Pediatric Mass Casualty Incident Triage Tool and Sacco Triage Method.
- Develop and publicize call centers to minimize load on hospitals and clinics.
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Prehospital: Early Pandemic Response Period
- Establish an Emergency Operations Center (EOC). The EOC should include, but not be limited to, representatives of the following groups: community health centers, home health care organizations, hospitals, Public Health agencies (local, State, and Federal), Metropolitan Medical Response Systems, long-term care organizations, and other health-related groups.
- The EOC will coordinate all EMS resources including public, private, and volunteer.
- The EOC should encourage the use of area health operation centers to allow the EOC to communicate directly with a larger medical community, for guidance and direction.
- Determine in advance a trigger for opening an EOC.
- Establish a comprehensive public information strategy.
- Use mass media to provide the public information on preventive measures, home care management, and the appropriate time to seek health care services.
- Use community health care call centers to reinforce mass messaging and to provide additional and more tailored information to individuals with questions and concerns. Review these issues for their value as potential mass media messages.
- Use community call centers to assist with outpatient (home care) monitoring and support, thereby helping to extend the reach of public health and healthcare systems into households.
- Use information collected by the call centers for situational awareness and disease outbreak management and control.
- Engage mutual aid partners for sharing assets.
- Consider home care preparations. During a pandemic, it is likely that the home will serve as a major care site. Planners may want to consider the following steps:
- Ensure adequate stock of routine chronic care medications is available to the community.
- Include basic first aid supplies, including bandages, antipyretic medications (acetaminophen, ibuprofen, oral electrolyte solutions), and thermometers.
- Ensure that backup utility support is in place for those patients requiring electricity support for medical devices should the power grid be disrupted by decreased staffing.
- Provide advice on the establishment of a "sick room" in the home for primary management of ill household members.
- In the event of caring for patients with advanced symptoms too sick for hospital care, provide symptom palliation with a home care team coordinated by local public health authorities.
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Prehospital: Widespread Pandemic Response Period
Set Up and Use of Casualty Treatment Areas
- Use formal triage and treatment protocols and complete triage and treatment in nontraditional triage/treatment areas by bringing prehospital personnel to those areas.
- Determine who can be treated on site to include those with moderate (yellow) and minor (green) triage status.
- Determine who should be transported to area hospitals and by what means, with the sickest casualties with a reasonable chance of survival treated and transported first.
- Consider suspension of some medical protocols (e.g., base contact for certain interventions, expansion of scope of practice, appropriate standard of care).
- Consider secondary triage methodologies such as one hospital triaging patients to another.
911 Dispatch Issues
- Arrange for dispatchers to screen response need.
- Provide precaution advice for scene responders.
- Limit the number of responders to the minimal necessary response.
- Provide a nonemergency information and advice line.
Best Use of Available Personnel
- Create modified shifts. Expand number of providers and vehicle types. Call for volunteers from within the hospital system. Assign to clean; transport specimens and patients; deliver oral fluids to patients; support those waiting to be seen with fluids oral fluids; and restock waterless hand cleaner, tissues, mask dispensers.
Maximum Transport Capability
- Staff ambulances with one EMT and one non-EMT driver (such as a firefighter, police officer, etc.)
- Expand the use of paramedic-initiated alternative transport mechanisms (e.g., buses, taxis, privately owned vehicles).
- Load ambulances with more than one patient, e.g., two critical, one critical plus one or more noncritical. (Air transport probably will be of limited use.)
Maximum Personal Protection Available to Personnel
- Distribute vaccine to personnel and consider including family members in the vaccine distribution.
Maximum Destination Choices
- Encourage home care rather than transport, if possible.
- Transport patients not only to hospitals but also to clinics and ACSs.
- Consider "batching" noncritical calls in the same geographic area and transporting all patients to the closest appropriate facility rather than the facility of the patient's choice.
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Hospital: Pre-Pandemic Period
- The Hospital Planning Committee, a multidisciplinary committee including response partners (go to box), should complete all parts of the hospital pandemic influenza preparedness and response plans.
|The potential hospital pandemic influenza planning committee may include representatives from the following departments, among others:
- Administration/senior management
- Legal counsel/risk management (including fiscal official
- Infection control/emergency coordinator
- Hospital disaster/emergency coordinator
- Safety director
- Engineering/physical plant
- Nursing administration
- Medical staff including outpatient
- Intensive care unit
- Laboratory services
- Environmental services (housekeeping, laundry)
- Public relations
- Materials management
- Education/training/staff development
- Occupational health
- Diagnostic imaging
- Information technology
- Adjunct staff (infectious diseases, mental health, union representatives, human resources, director of house staff/fellowship and other training programs, pathology, social work, critical care medicine, pathology)
- State and local health departments (communicable diseases division, laboratory services, medical examiners)
- Community partners (emergency medical technicians, local law enforcement, funeral service personnel, community service agencies, Federally qualified health centers and other health care safety net providers)
Source: HHS Pandemic Influenza Plan at http://www.hhs.gov/pandemicflu/plan/sup3.html#box1.
- Assess surge capacity (beds, ventilators, etc.) to meet expected increased needs.
- Develop plan to expand staff capacity. Determine how the hospital will meet staffing needs.
- Develop contingency plans for staff absences, particularly ED staff.
- Create procedures and policies for use of supplemental providers.
- Consider volunteers, ESAR VHP, CERT, MRC, clinic staff, out-of-State licensed staff, National Guard, retirees, non-health-care staff, among others.
- Ensure policies are in place to test and manage deployment of nonhospital personnel at both the community and hospital levels.
- Ensure that a plan for managing volunteers is in place.
- Initiate discussions of allocation of hospital resources; hospital administrators meet with hospital ethics committee early in planning process:
- Establish hospital process for scarce resource allocation.
- Develop communication process so community understands the rationale behind resource allocation policies.
- Stockpile supplies and equipment including PPE equipment (e.g., gloves, masks).
- Estimate increased need for medical equipment/supplies and develop strategy to acquire additional equipment/supplies if needed. Consult with local and State health departments about access to the Strategic National Stockpile.
- Develop facility access guidelines.
- Define essential and non-essential visitors and develop policies for restricting visitors during a pandemic (and mechanisms for enforcing the policies).
- Plan to limit hospital entry to a few key entrances.
- Plan for increased security needs.
- Develop a health care risk communication message, including criteria for seeking health care, such as postponement of elective procedures or surgeries.
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Hospital: Early Pandemic Response Period
- Activate the Hospital Incident Command System (HICS), open a hospital command post and assign an Incident Commander (IC).
- Hold briefings for administrators and staff members. Review talking points and discuss general action plans to be followed in the event that a flu pandemic should spread across the United States.
- Confirm the hospital process for allocating scarce resources. Activate/test internal hospital committees on standards of care if necessary. Review policies and protocols.
- Conduct just-in-time-training for staff via E-mail, posters, and shift briefings. Include information on transmission, infection control, ventilator management, and hospital plans.
- Conduct personal protective equipment (PPE) training. Perform fit testing, donning and doffing instruction, practice, and competencies for inpatient and outpatient staff.
- Increase hospital supplies from the usual baseline of 3-day supply to 7-day supply if possible (based on an estimated 150 percent occupancy rate). Order, inventory, and increase par levels of IV fluids, medicines, linens, and other consumable medical goods.
- Estimate quantities of essential patient care materials and equipment and personal protective equipment that would be needed during an 8-week pandemic with subsequent 8-week waves.
- Establish lines of communication among Public Health officials, hospitals, EMS and emergency medicine to provide daily updates. Identify personnel/procedures to run the Joint Information Center.
- Designate a public relations person as the hospital Public Information Officer.
- Reinforce the public information messaging begun in the pre-pandemic period.
Drills, Tests, and Reviews
- Test Health Alert Network (HAN) to include off-hours and notification of HAN alerts from the ED to infection control.
- Review plans for security, behavioral health, and general disaster contingencies.
- Review the facilities plan, including heating, ventilation, and air conditioning and other cohorting plans.
Monitoring the Outbreak and Screening Outpatients
- Establish a local public health point of contact. Begin Department of Health monitoring of influenza-like illness (outpatient and inpatient). Screen outpatients per CDC guidance for influenza symptoms based on fever and/or respiratory symptoms and travel history. Begin screening at the Emergency Department and outpatient clinic check-in points.
- Verify referral agreements with local hospitals to ensure that patients will be accepted. Clarify patient movement between hospitals for infectious cases (e.g., EMS protocol for transfer patients) and within a hospital (e.g., protocol for elevator transport of pandemic patients).
- Reinforce infection control and respiratory etiquette for those with respiratory symptoms using posters, staff reminders, educational materials, and patient masks and tissues at triage and clinic registration points and near common points such as elevators and major entrances.
- Plan for Vaccine Distribution. Arrange internal distribution to staff members based on prior planning and in concert with State and regional plan criteria for essential personnel.
- Limit hospital entry to a few key entrances.
- Screen patients for symptoms of influenza and relevant travel history and with rapid diagnostic tests if available.
- Mask patients with suspect symptoms and make sure that providers wear appropriate PPE.
- Notify surgeons that elective surgeries must be suspended due to surge.
- Ramp up outpatient services by increasing clinic hours and personnel to provide nonurgent services. Extra staffing will be needed because outpatient services will be a likely place for screening for flu.
- Cohort to separate those with flu-like symptoms from those with chronic illnesses who could be susceptible to developing more severe illness.
- Ensure that backup utility support is in place should the power grid be disrupted by decreased staffing for those patients requiring electricity support for medical devices.
- Establish a hospital hotline and enable the prerecorded greeting to triage calls for information to nonclinical staff and clinical inquiries to appropriate staff at the department of health.
- Prepare flat space areas in conference rooms, auditoriums, etc., for patient care (organize cots, linens, etc.)
- Open a joint information center (JIC) with the hospital association acting as liaison with all hospitals in the region. The regional coordinating hospital provides updates and solicits baseline availability of ventilators and patient beds.
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Hospital: Widespread Pandemic Response Period
Planning and Information
- Institute action planning. The planning section anticipates resource needs for the next operational period and gathers situational information from within the hospital and from regional/State entities. It also determines staffing and availability.
- Activate the Joint Information Center. The JIC is managed by the hospital association liaison for all hospitals in conjunction with Public Health and EMS. The JIC provides a daily briefing for staff and media, provides daily media messages and holds press conferences.
- Have key representatives from public health, emergency medicine, EMS, and hospital staff monitoring information on the system status from all agencies/hospitals (including liaisons from neighboring States).
- Conduct action planning at the regional level.
- Compare the triage levels at area facilities to assure consistency.
- Request resources (when possible) via jurisdictional Emergency Medicine.
- Use the staffing coordinator to manage public health, emergency medicine, EMS, and hospital requests for staffing and allocates them based on the resources available, including the Medical Reserve Corps and ESAR VHP.
- Communicate with the local Emergency Operations Center or Department of Health about regional resource and policy needs.
- Ensure public health coordination with home care agencies and messaging, hotline, and Internet support for families.
Review of Staffing Plans
- Use families to provide basic patient care. The hospital should engage the patients' families (one person at a time) to provide basic patient care, such as feeding. Nurses (including Medical Reserve Corps, ESAR-VHP, and retirees with appropriate mentorship by current staff nurses) provide medications and assessments and review vital signs.
- Respiratory therapy manages ventilators only; other respiratory care services are to be provided by nurses. Train floor nurses in basic ventilator monitoring, with floor units supervised by a roving ICU nurse to monitor ventilated patients.
- Physicians see patients on an as-needed basis, providing critical interventions and assessment for interventions, transfer, and discharge.
- Consider expanding staff capacity with changes in staff scheduling (e.g., duration of shifts, staffing ratios, changes in staff assignments).
Use of Hospital Space and Supplies
- Set up cohort areas of inpatient and outpatient units for infectious patient care. These areas can be used when volume allows. (The entire facility may be a cohort during peak periods.)
- Discontinue elective surgery scheduling. Only immediate need or emergent surgery is done.
- Select operating room and procedure room space to be used for additional ventilated patient care.
- Use minimal documentation. Use short assessment and plan notes - medication and vital signs documentation, for example.
- Reuse disposable supplies when possible.
Clinical Care Committee
- Institute daily meetings of the clinical care committee to examine new guidance, the situation at the hospital, and the regional situation and to determine appropriate levels of care to be offered based on staffing and other resources.
- The committee adapts State guidance to the hospital level and reviews any updates.
- The committee submits recommendations to the Planning Chief and then to the IC.
- On approval of the IC, any changes to the previous day's triage, treatment, and diagnosis protocols are communicated to the ED, outpatient, and inpatient areas. These may include:
- Guidance on laboratory and x-ray testing (both influenza case testing and clinical lab/x-ray guidance).
- Guidance on outpatient/ED denial of service (e.g., deny care to those
who will not be seen because their injury/illness is too minor).
- Updated information for all patients and family members presenting to the facility to be handed out by a triage nurse and reviewed with the patient's nurse or physician.
- Inpatient care guidelines (staff responsibilities).
- Inpatient triage/resource situation.
- Anticipated events/trends in the next operational period.
- Set up a triage team (may consist of one critical care and one infectious disease physician, among others) to review conflicting resource needs (e.g., two patients needing a single ventilator) on a case-by-case basis.
- Use a decision tool supplied by the State and the clinical care committee to assign resources.
- Physicians are to provide patient care when not performing triage functions.
- Identify a bed czar to monitor the bed and "hard" resources, e.g., ventilators, make assignments based on availability, and implement triage team recommendations. The bed czar receives periodic input from clinical units about patient statuses (improving, deteriorating, etc.)
- Establish alternative care sites in conjunction with other area hospitals as well as in conjunction with Public Health and Emergency Medicine to enable hospital decompression.
- Notify EMS, public health, and others of need to decompress the hospital, as appropriate.
- Transfer patients to and from facilities as needed based on hospital resources; critical care to be concentrated in hospitals.
A Regional Home Death Management Process
- Set up regional hubs for body retrieval and processing with a review by the Medical Examiner, a registration process, and a temporary holding place awaiting definite management. Communicate this plan to affected parties.
- Deploy refrigerated trucks from the hospital for body management, exchanged daily to regional processing sites.
- Arrange for Web-based death certificate processing and secure tracking to the Department of Health.
Hospitals in Rural Areas
- Some issues are more likely to apply to hospitals located in rural areas.
- The triage physician (and/or nurse) implementing decisions at the hospital/ward level.
- Promoting a regional hospital and multiagency coordination system to share staff and resources as possible and help hospitals in the region share information. Coordinate the setup of a regional ACS when needed (under the host city's jurisdictional umbrella).
- Patient referral to regional hospitals (when possible) or supportive care provided to the extent possible at the facility.
- Offsite care (may be a single regional facility). The ACS is the screening and care point for noncritical patients. The ACS may meet the need for additional screening and minor treatment in a rural area. In smaller communities, hospitals and clinics may not have the space and resources for screening that urban areas have, so bottlenecks may occur in outpatient assessment as well as inpatient care.
- Coordination of care with home care/families.
- Hospital coordination with the local public health agency to determine the scope of care in the community and facilitate home and palliative care.
- Transfers from the hospital morgue to a regional processing point or local undertakers with the medical examiner as needed.
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Alternative Care Sites: Pre-Pandemic Period
- Define ownership, command, and control of ACS.
- Perform site selection based on best estimates of need.
- Decide on the scope of care to be provided in the ACS.
- Establish functional requirements based on the level of care to be provided:
- Acquire supplies, equipment (including communications equipment), and pharmaceuticals.
- Plan staffing, taking into account absentee rates from potential staffing sources.
- Develop MOUs for operational support of the ACS, including housing for health care workers.
- Develop policies of operation for the ACS, including:
- Role of incident commander.
- Criteria for admission, discharge, and transfer.
- Infection control.
- Pharmacy and medication control.
- Safety and security.
- Food service.
- Linen services.
- Finances and documentation.
- Engineering (plant operations, electrical, plumbing, etc.).
- Develop criteria for hospital decompression.
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Alternative Care Sites Early Pandemic Response Period
The following measures need to be undertaken to prepare for operation of the ACS:
- Perform resource assessment for standing up an ACS, including acquisition of additional necessary disposable supplies.
- Review and finalize policies of operation for the ACS.
- Exercise the ACS if possible. As early as possible, explore the legal issues around standing up an ACS for full functional exercise with patients.
- Test communications.
- Identify and roster the ACS staff.
- Establish a process of immunization and prophylaxis of potential staff members.
- Establish incident command structure for ACS. Planners should ensure that ACS is integrated with community, regional and State incident command systems.
- Unpack and inventory supplies at the selected site(s).
- Enable the security protection systems of the ACS.
- Develop a patient transport plan for movement of ACS patients to and from area hospitals.
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Alternative Care Sites: Widespread Pandemic Response Period
- Ensure all ACSs are fully operational.
- Investigate the need for the establishment of other functional sites for supplying ambulatory care, inpatient care, quarantine, and/or palliative care.
- Establish criteria for closing the ACSs as the pandemic eventually passes.
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Palliative Care: Pre-Pandemic Period
- Hold planning discussions of treatment options limitations due to scarce resources. Decisions must be made that typically would not be considered under usual circumstances. Standards of care and treatment options will be appropriate to the situation at the time the decision is made. Community planners need to be aware that it may not always be possible to save a life during a pandemic. It is important to have these difficult discussions prior to the occurrence of a pandemic.
- Establish and maintain standards of palliative care. Ensure that the standards are published and available for consideration during planning efforts.
- Provide education and training for palliative care responders for understanding, recognizing and establishing response actions in a pandemic flu situation.
- Include instruction about self-protection and avoidance of the spread of disease.
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Palliative Care: Early Pandemic Response Period
- Discuss goals of care. Complications from the flu may result in the individual becoming too sick to survive. It may be necessary to discuss goals of care and preferences with the patient.
- Provide information on treatment options. Patients and families need to have updated information so they may understand their condition and treatment options.
- Decisionmaking about the patient's care plan must be sensitive both to changes in the patient's condition and to the availability of community resources.
- Address pain and symptom control, psychosocial distress, spiritual issues, and practical needs with patients and their families throughout the continuum of care.
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Palliative Care: Widespread Pandemic Response Period
- Establish patient triage criteria by levels of care.
- Classify patients who are already chronically ill, extremely old, or in long-term care facilities (e.g., by physician prognosis).
- Plan for use of long-term care facilities. Nursing homes can provide a preventive care response to an influenza pandemic (e.g., immunizations, drug management), thus providing relief to hospitals.
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Home Care: Early Pandemic Response Period
- Address the myriad challenges of providing health care services in the home for people with substantial disability and/or illness or without family or other resources to provide care. Consider the following issues:
- Develop alternative ways to provide care to people in the community such as primary care vans that go into neighborhoods to provide care, answer questions, and provide resources.
- Establish telephone hotlines to answer questions regarding the flu, such as "Ask-A-Nurse"-type support services. Also make use of existing hotlines.
- Consider ways to provide incentives for people to work during times of crises. Health care workers may not want to leave their families to care for flu patients. Incentives should be considered (e.g., giving them priority status for vaccines).
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