CATCH­ING THE FLU

Hos­pi­tals scram­ble to cope with spread­ing epi­demic

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The fast and fu­ri­ous start of this year’s flu sea­son is strain­ing ca­pac­ity at many hos­pi­tals, re­quir­ing all-hands-on-deck staffing lev­els. Many hospi­tal of­fi­cials say that pa­tients with the flu and flu-like symp­toms are fill­ing their emer­gency rooms and have been for weeks, cre­at­ing stressed staff mem­bers and lead­ing some to en­act emer­gency pro­ce­dures.

“We’re see­ing an on­slaught of pa­tients, to be hon­est,” said Dr. Robert Kelly, pres­i­dent of New York-Pres­by­te­rian Hospi­tal. “We’re see­ing much higher vol­ume than in pre­vi­ous years.”

The rel­a­tively strong flu sea­son, which last week reached epi­demic lev­els as mea­sured by mor­tal­i­ties from in­fluenza and pneu­mo­nia, could boost rev­enue at hos­pi­tals even­tu­ally as a re­sult of in­creased hos­pi­tal­iza­tions. But in the near term, hospi­tal clin­i­cians are strug­gling to keep up with the in­flux of pa­tients, with of­fi­cials at the Cen­ters for Disease Con- trol and Preven­tion un­able to pre­dict whether the sea­son has peaked yet for ar­eas that have been hit hard al­ready. Short­ages of vac­cines, an­tivi­rals and test­ing sup­plies have been re­ported in some ar­eas as well.

As of Jan. 5, the CDC es­ti­mated that 24 states and New York City are re­port­ing high lev­els of in­fluenza-like ill­ness ac­tiv­ity, 16 states are show­ing mod­er­ate lev­els of ac­tiv­ity, five states are re­port­ing low lev­els and five oth­ers are re­port­ing min­i­mal lev­els.

CDC Di­rec­tor Dr. Thomas Frieden said in a me­dia call that while some ar­eas of the coun­try may be over the peak, other re­gions, par­tic­u­larly in the West, may see ris­ing num­bers of cases. “It’s likely that in­fluenza will con­tinue for sev­eral more weeks,” he said.

How­ever, CDC of­fi­cials say there are mea­sures of im­prove­ment in some ar­eas of the coun­try, such as the South and South­east. Across the coun­try, out­pa­tient vis­its to health­care providers for in­fluenza-like ill­ness de­clined week-over-week to 4.3% for the week ended Jan. 5, but still above the base­line level of 2.2%.

What it all means is un­clear. “Trends are hard to pre­dict,” Frieden said. “Only time will tell us how long this will last.”

The in­crease in pa­tients could help hos­pi­tals’ bot­tom lines, says one for-profit in­dus­try an­a­lyst. Frank Mor­gan, an an­a­lyst at RBC Cap­i­tal Mar­kets, noted that a strong flu sea­son would be a pos­i­tive for pa­tient vol­ume as well as cash flow. Yet he cau­tioned that the in­creased flu ac­tiv­ity won’t nec­es­sar­ily trans­late into higher mar­gins, as the flu not only puts a strain on hospi­tal re­sources but also tends to see lower re­im­burse­ment than other con­di­tions.

Hos­pi­tals and physi­cians across the coun­try are tak­ing a va­ri­ety of steps to han­dle the in­flux of pa­tients.

At 2,264-bed New York-Pres­by­te­rian, which op­er­ates the teach­ing hos­pi­tals of Columbia and Cor­nell univer­si­ties, vol­ume in the emer­gency de­part­ment was al­ready strained fol­low­ing su­per­storm Sandy, which se­verely lim­ited the op­er­a­tions of two down­town med­i­cal cen­ters, 806-bed NYU-Lan­gone and 828-bed Belle­vue.

Kelly, pres­i­dent of the hospi­tal sys­tem, said New York-Pres­by­te­rian has seen a 10% to 15% in­crease in emer­gency room vis­its re­lated to the flu out­break and has ad­mit­ted 110 to 120 pa­tients. The hospi­tal has ramped up its staffing lev­els con­sid­er­ably in the ER as well as set up an over­flow area in the lobby for in­creased vol­ume, he said. It is se­ques­ter­ing pa­tients who come in with flu-like symp­toms to pre­vent the spread of the viruses within the hospi­tal. On its in­pa­tient floors, sin­gle rooms are now serv­ing as dou­ble rooms to meet the need for in­creased ca­pac­ity.

Le­high Val­ley Hospi­tal-Cedar Crest in Al­len­town, Pa., set up a tent with six beds out­side its emer­gency room to ac­com­mo­date the in­crease in pa­tients and seg­re­gate the ones who have the flu.

At 547-bed St. John Med­i­cal Cen­ter in Tulsa, Okla., of­fi­cials are con­sid­er­ing im­ple­ment­ing its emer­gency man­age­ment plan af­ter weeks of work­ing es­sen­tially at ca­pac­ity, said Pam Kiser, chief nurse ex­ec­u­tive and vice pres­i­dent of nurs­ing. “Ev­ery­body has a room. It may not be your tra­di­tional room,” Kiser said. St. John has taken ac­tions such as con­vert­ing an ER pa­tient hold­ing room into an in­ten­sive-care unit, she said.

The Tulsa med­i­cal cen­ter has been able to avoid turn­ing pa­tients away by ex­pand­ing its daily bed man­age­ment pro­gram, but ex­ec­u­tives ap­peared likely to im­ple­ment its plan to

try to ease the stress of the pa­tients, Kiser said.

St. John has also been hit with an in­crease in pa­tients with ill­nesses that aren’t the flu, but are caus­ing flu-like res­pi­ra­tory in­fec­tions, she said.

The same is true at other hos­pi­tals. Whoop­ing cough and a gas­troin­testi­nal virus are go­ing around, said Dr. Chris­tine Laine, a prac­tic­ing physi­cian, ed­i­tor-in-chief of the An­nals of In­ter­nal Medicine and se­nior vice pres­i­dent at the Amer­i­can Col­lege of Physi­cians. “A lot of peo­ple are sick, whether it’s the flu or some­thing worse,” Laine said.

At Wel­lS­tar Health Sys­tem, Marietta, Ga., the sys­tem’s own em­ploy­ees are feel­ing the ef­fects of the in­creased flu ac­tiv­ity, spokesman Keith Bow­er­mas­ter said. His own de­part­ment has seen three of 25 staffers fall vic­tim, he said.

The sys­tem saw three times as many flu cases in am­bu­la­tory set­tings in Novem­ber and De­cem­ber as it did dur­ing the same pe­riod the pre­vi­ous year, with higher flu-re­lated ad­mis­sions as well.

He added that the num­ber of cases is al­ready above the num­ber seen dur­ing that pe­riod in 2007-08, which is the worst flu sea­son on record at Wel­lS­tar. That sea­son peaked in Fe­bru­ary, and with this year’s peak still an open ques­tion, the flu sea­son could well be the sys­tem’s worst.

At 580-bed Wel­lS­tar Kenne­stone Hospi­tal, one of the busiest emer­gency de­part­ments in Ge­or­gia, 826 more pa­tients flooded the ER last month than in De­cem­ber 2011—a 28% in­crease—largely driven by flu-like ill­ness. The hospi­tal in Marietta ad­mit­ted 316 more pa­tients than in De­cem­ber 2011, a 27% spike.

As a re­sult, Kenne­stone has seen back­ups in its wait­ing room as pa­tients wait in the ER for a bed to open up on a busy in­pa­tient floor.

Staffing is­sues

Physi­cian staffing also has been an is­sue for some hos­pi­tals. Four-hospi­tal Health­East Care Sys­tem, St. Paul, Minn., has plenty of phys­i­cal re­sources in terms of build­ing ca­pac­ity and tem­po­rary nurses it can pull in, said Dr. Peter Born­stein, med­i­cal epi­demi­ol­o­gist for the sys­tem and man­ag­ing part­ner of the prac­tice St. Paul In­fec­tious Disease As­so­ci­ates. “We can han­dle that as­pect of it,” he said.

The prob­lem is find­ing physi­cians to help with the in­crease in pa­tients, he said. “It’s tough­est of all on the doc­tors.”

Physi­cians’ of­fices are feel­ing the strain as well. “The places that are see­ing it are both the pri­mary-care cen­ters and the ER,” said Dr. Jay Varkey, an in­fec­tious disease ex­pert at Emory Univer­sity School of Medicine, At­lanta. Varkey con­ceded that last year’s mild flu sea­son, which also got off to a rel­a­tively late start, may have cre­ated less ur­gency in the com­mu­nity to get vac­ci­nated in the early fall. “I’m sus­pi­cious that that might be the case, but it’s too early to tell.”

This sea­son’s flu is dom­i­nated by a strain that is harder on pa­tients than the typ­i­cal dom­i­nant sea­sonal flu. Two in­fluenza A strains are cur­rently in cir­cu­la­tion: H3N2, which is ac­count­ing for 98% of those cases, and H1N1, bet­ter known as the virus be­hind 2009’s swine flu pan­demic, which ac­counts for 2%. In ad­di­tion, two in­fluenza B viruses, which tend to be less vir­u­lent than in­fluenza A, are also in cir­cu­la­tion.

The more vir­u­lent in­fluenza A strain is caus­ing most of the in­creased pa­tient vol­ume across the coun­try, par­tic­u­larly in large cities such as New York, Chicago and Bos­ton. Dr. Wil­liam Schaffner, who chairs the de­part­ment of pre­ven­tive medicine at Van­der­bilt Univer­sity Med­i­cal Cen­ter in Nashville, said deaths have been seen even in oth­er­wise healthy young peo­ple. “This is an in­fec­tion that can take a very healthy per­son and make them very ill.”

The CDC re­ported that 7.3% of all deaths re­ported through the Cities Mor­tal­ity Re­port­ing Sys­tem were be­cause of in­fluenza and pneu­mo­nia, above the 7.2% epi­demic thresh­old for the week ended Jan. 5. Since the be­gin­ning of the flu sea­son, there have been 3,710 lab­o­ra­tory-con­firmed flu-as­so­ci­ated hos­pi­tal­iza­tions, a rate of 13.3 per 100,000. Eighty-six per­cent of them were for the more vir­u­lent in­fluenza A strain, while 13% for in­fluenza B. The re­main­ing cases were uniden­ti­fied.

At Park­land Health & Hospi­tal Sys­tem, Dal- las, the epi­demic has led to a short­age of test­ing sup­plies, lead­ing the 784-bed pub­lic hospi­tal to use triage meth­ods in de­ter­min­ing who gets tested, said Dr. Pranavi Sreer­amoju, chief of in­fec­tion preven­tion at the hospi­tal and as­sis­tant pro­fes­sor, medicine-in­fec­tious dis­eases at UT South­west­ern Med­i­cal Cen­ter. Pa­tients who ap­pear well or who ap­pear to have the flu are less likely to get tested, she said.

Spo­radic short­ages for the pe­di­atric ver­sion of the flu vac­cine have been re­ported, ac­cord­ing to of­fi­cials at the CDC, but the adult ver­sion can be com­pounded into the pe­di­atric dose.

Of­fi­cials at the CDC say the de­cline in out­pa­tient vis­its could sig­nal the epi­demic is re­ced­ing in some re­gions, and at least one ma­jor hard-hit hospi­tal sees a sign that that could be hap­pen­ing. Dr. David Hooper, chief of the in­fec­tion con­trol unit at Mas­sachusetts Gen­eral Hospi­tal in Bos­ton, where a pub­lic health emer­gency was de­clared by the mayor, said that last week the hospi­tal saw a de­crease in cases com­pared with the pre­vi­ous one.

Mas­sachusetts Gen­eral had con­firmed more than 500 cases of the flu with 167 ad­mis­sions, as of Jan. 10. “We’ve seen more flu this year than we’ve seen in the past sev­eral years,” Hooper said.

“It’s been an all-hands-on-deck men­tal­ity,” Hooper said. “We hope we’re past the peak.”

Le­high Val­ley Hospi­tal in Al­len­town, Pa., erected tents to treat an in­flux of flu pa­tients.

AP PHOTO

A nurse ad­min­is­ters the flu vac­cine last week to Alexan­der Dy­jak, 4, as his mother, Ellen, holds him at Ledge Light Health District in New Lon­don, Conn.

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