Pandemic Planning and Response in Academic Pediatric Emergency Departments During the 2009 H1N1 Influenza Pandemic

Authors


  • Presented at the Robert Wood Johnson Foundation Clinical Scholars Program National Meeting, Crystal City, VA, November 2011; and the Society for Academic Emergency Medicine New England regional meeting, Springfield, MA, March 2012.
  • Funding was provided by the Robert Wood Johnson Foundation Clinical Scholars Program. Dr. Filice completed this work while a fellow in the Yale Robert Wood Johnson Foundation Clinical Scholars Program; she is now employed by the American Academy of Pediatrics Department of Federal Affairs.
  • The authors have no relevant financial information or potential conflicts of interest to disclose.

Abstract

Objectives

The terrorist attacks of September 11, 2001, initiated a shift toward a comprehensive, or “all-hazards,” framework of emergency preparedness in the United States. Since then, the threat of H5N1 avian influenza, the severe acute respiratory syndrome epidemic, and the 2009 H1N1 influenza pandemic have underscored the importance of considering infectious events within such a framework. Pediatric emergency departments (EDs) were disproportionately burdened by the 2009 H1N1 influenza pandemic and therefore serve as a robust context for evaluation of pandemic preparedness. The objective of this study was to explore pediatric ED leaders' experiences with preparedness, response, and postincident actions related to the H1N1 pandemic to inform future pandemic and all-hazards planning and policy for EDs.

Methods

The authors selected a qualitative design, well suited for exploring complex, multifaceted organizational processes such as planning for and responding to a pandemic and learning from institutional experiences. Purposeful sampling was used to recruit medical directors or their designated physician respondents from pediatric emergency medicine training institutions representing a range of geographic regions across the United States, hospital types, and annual ED volumes; snowball sampling identified additional information-rich respondents. Recruitment began in May 2011 and continued until thematic saturation was reached in January 2012 (n = 20). Data were collected through in-depth individual phone interviews that were recorded and professionally transcribed. Using a standard interview guide, respondents were asked open-ended questions about pandemic planning, response, and institutional learning related to the H1N1 pandemic. Data analysis was performed by a multidisciplinary team using a grounded theory approach to generate themes inductively from respondents' expressed perspectives. The constant comparative method was used to identify emerging themes.

Results

Five common themes characterized respondents' experiences with pandemic planning and response: 1) national pandemic influenza preparedness guidance has not fully penetrated to the level of pediatric emergency physician (EP) leaders, leading to variable states of preparedness; 2) pediatric EDs that maintained strong relationships with local public health and other health care entities found those relationships to be beneficial to pandemic response; 3) pediatric EP leaders reported difficulty reconciling public health guidance with the reality of ED practice; 4) although many anticipated obstacles did not materialize, in some cases pediatric EP leaders experienced unexpected institutional challenges; and 5) pediatric EP leaders described varied experiences with organizational learning following the H1N1 pandemic experience.

Conclusions

Despite a decade of investment in hospital preparedness, gaps in pediatric ED pandemic preparedness remain. This work suggests that raising awareness of pandemic planning standards and promoting strategies to overcome barriers to their adoption could enhance ED and hospital preparedness. Helping hospitals better prepare for pandemic events may lead to strengthened all-hazards preparedness.

Resumen

Planificación y Respuesta de los Servicios de Urgencias Pediátricos Universitarios durante la Pandemia de Gripe H1N1 2009

Objetivos

Los ataques terroristas del 11 de Septiembre del 2001 iniciaron un cambio hacia un marco global o “de riesgo total” en la preparación ante una emergencia en Estados Unidos. Desde entonces, la amenaza de la gripe aviar H5N1, la epidemia del síndrome respiratorio agudo grave y la pandemia de gripe H1N1 2009 han enfatizado la importancia de considerar los eventos infecciosos en dicho marco. Los servicios de urgencias pediátricos (SUP) sufrieron grandes saturaciones por la pandemia de gripe H1N1 2009 y por ello se presentaron como un contexto sólido para la evaluación de la preparación ante una pandemia. El objetivo de este estudio fue explorar la experiencia de los responsables de los SUP en la preparación, la respuesta y las acciones tras el incidente en relación con la pandemia H1N1 con el fin de suministrar información para futuras pandemias y planificar todos los peligros y políticas de los servicios de urgencias.

Método

Se realizó un diseño cualitatitivo, apropiado para explorar procesos organizativos complejos y polifacéticos como la planificación y respuesta ante una pandemia y el aprendizaje de las experiencias institucionales. La muestra propuesta se usó para reclutar directores médicos o a sus correspondientes médicos designados por instituciones académicas de medicina de urgencias pediátricas que representaban distintos SUP en función de volúmenes anuales, tipos de hospitales y regiones geográficas de Estados Unidos. La muestra “en bola de nieve” identificó respondedores adicionales con información de utilidad. El reclutamiento empezó el 21 de mayo de 2011 y continuó hasta que se alcanzó la saturación temática en enero de 2012 (n = 20). Se recogieron datos a través de entrevistas individuales telefónicas que fueron grabadas y transcritas profesionalmente. Mediante el uso de una guía de entrevista estandarizada, se preguntó a los encuestados cuestiones abiertas sobre la planificación de la pandemia, la respuesta y el aprendizaje institucional en relación con la pandemia de gripe H1N1. El análisis de los datos se realizó por un equipo multidisciplinar usando una teoría basada en la aproximación de generar temas inducidos desde los puntos de vista expresados por los encuestados. Se utilizó el método comparativo constante para identificar temas emergentes.

Resultados

Cinco temas comunes caracterizaron las experiencias de los encuestados con la planificación y la respuesta a la pandemia: 1) la guía nacional de preparación para la pandemia de gripe no ha alcanzado en su totalidad al nivel de los responsables médicos del SUP, lo que condujo a situaciones diversas de preparación; 2) los SUP que mantuvieron relaciones estrechas con el sistema sanitario público local y otras entidades sanitarias encontraron que dichas relaciones fueron beneficiosas para la respuesta a la pandemia; 3) los responsables médicos de SUP documentaron dificultad en conciliar las guías sanitarias públicas con la realidad de la práctica del SUP; 4) aunque muchos obstáculos esperados no se materializaron, en algunos casos los responsables médicos de SUP experimentaron retos institucionales no esperados; y 5) los responsable médicos de SUP describieron diversas experiencias con el aprendizaje institucional tras la experiencia de la pandemia de gripe H1N1.

Conclusiones

A pesar de una década de inversión en la preparación hospitalaria, en los SUP siguen existiendo lagunas en la preparación ante una pandemia. El presente trabajo sugiere una mayor conciencia de los estándares de planificación de pandemias y que la promoción de estrategias para superar las barreras para su adopción podría mejorar la preparación del SUP y del hospital. Ayudar a los hospitales para preparar mejor los sucesos pandémicos puede conducir a fortalecer la preparación frente a un “riesgo total.”

The terrorist attacks of September 11, 2001, initiated a shift toward a comprehensive, or “all-hazards,” framework of emergency preparedness in the United States. Since then, the threat of H5N1 avian influenza, the severe acute respiratory syndrome epidemic, and the 2009 H1N1 influenza pandemic have underscored the importance of considering infectious events within such a framework.

Substantial federal efforts have supported health care entities, including hospitals, in preparing for infectious mass casualty events including pandemic influenza. The 2005 U.S. Department of Health and Human Services (HHS) pandemic influenza plan[1] is a comprehensive guide for health system preparedness and response related to an influenza pandemic. For each chronological phase of a pandemic, the plan directs health care facilities to address detailed, specific functions including surveillance, development of decision-making structures, communications, education, triage and clinical evaluation, facility access, occupational health, use of vaccines and antiviral drugs, surge capacity and inventory, and mortuary issues. Recommended actions have been linked to funding to incentivize hospitals to address critical emergency capabilities; approximately $400 million annually has been devoted to addressing pandemic influenza and other preparedness objectives through the HHS Hospital Preparedness Program.[2]

Concurrently, increasing attention has been directed towards preparing for emergency department (ED) and inpatient surge[3, 4] or sudden increases in patient volume related to mass casualty events. Studying preparedness in the ED setting is particularly important because many U.S. EDs currently operate at or near capacity and could benefit from tools and plans to capably generate surge capacity.[5] Although most U.S. hospitals have broad pandemic plans,[6-8] pandemic plans specific to EDs are less common,[9, 10] and drills to test such plans are not widely conducted.[8-10]

Given that the recent H1N1 influenza pandemic disproportionately affected children,[11-13] and given that it was largely an ambulatory phenomenon due to its generally low virulence, pediatric EDs were burdened with high patient volumes during the pandemic.[14-22] Therefore, pediatric EDs during the H1N1 pandemic serve as a useful context in which to examine current ED pandemic preparedness. Previous studies of pediatric ED preparedness during the H1N1 pandemic report improvisation of pandemic plans after pandemic onset,[23] and varied surge management strategies,[6, 17, 24] including use of alternate care sites[21] and institution of rapid triage systems.[25] Yet previous work has been limited to single institutions, has not focused on pediatric institutions, or did not employ qualitative methods to examine the in-depth experience of responding pediatric EDs in planning for, responding to, and learning from the H1N1 influenza pandemic experience.

The objective of this study was to explore the experiences of pediatric emergency physician (EP) leaders with preparedness, response, and postincident actions related to the H1N1 pandemic to inform future pandemic and all-hazards planning and policy for EDs.

Methods

Study Design

We selected a qualitative design, well suited for exploring complex, multifaceted organizational processes[26-28] such as planning for and responding to a pandemic and learning from institutional experiences. We conducted in-depth, one-on-one telephone interviews[29] to collect data. The Human Investigation Committee at Yale University determined the research to be exempt from institutional review.

Study Setting and Population

To identify a manageable, finite domain of institutions in which to study the pediatric experience, we drew respondents from “academic” pediatric emergency medicine institutions, defined for the purpose of this study as those institutions participating in the Pediatric Emergency Medicine fellowship match through the National Residency Matching Program. Pediatric academic institutions were chosen because they typically serve solely pediatric, relatively high-acuity patient populations, which we anticipated would yield information-rich contexts for study. A purposeful sampling strategy[27] was used to ensure representation with regard to institutional characteristics thought to be relevant to pandemic planning and response, including geographic distribution (by both HHS region and U.S. state), institutional type (freestanding children's hospital vs. embedded children's hospital within a general hospital), and pediatric ED annual patient volumes (obtained from publicly available institutional or American Hospital Association data). For each institution, the pediatric ED medical director was asked to participate or to designate another respondent with knowledge of the institution's pandemic planning and operational ED responses to the H1N1 pandemic. We used snowball sampling[27] to identify additional information-rich respondents perceived to have had relevant experiences during the H1N1 pandemic. Recruitment of participants began 1 year after the first wave of H1N1-associated illness in the United States, and interviews were completed over the course of the following 9 months.

We continued to recruit participants until we achieved thematic saturation, the point at which no novel themes were emerging from successive interviews.[27] This occurred with 21 interviews; one interview recording was not sufficiently audible for transcription so was excluded from the analysis. One researcher (CF) recruited the sample by contacting a total of 31 physicians by postal mail, e-mail, and/or telephone to invite participation; two declined due to time limitations, and eight did not respond despite multiple contact attempts. All participants verbally consented to study participation.

Study Protocol

One researcher (CF) conducted all interviews. Standard in-depth interviewing techniques were used.[29] Semistructured interviews[29] were opened with a broad question exploring the respondent's role in pandemic planning in the ED. Additional open-ended questions[29] (Table 1) explored development and implementation of the institution's pandemic plan, challenges faced and solutions adopted in managing surge associated with the pandemic, and postpandemic institutional planning adoption and efforts. Probes were used to elicit clarification or elaboration of statements as necessary.[27] Interviews were audiorecorded and professionally transcribed.

Table 1. Interview Guide and Illustrative Probes
  • 1.Describe your role in pandemic preparedness and response in the ED.
  • 2.Did you have a pandemic influenza plan in place prior to the H1N1 pandemic?
    1. Had you ever practiced using your pandemic plan?
    2. If you used it, what triggered implementation of the plan?
    3. Did you have to deviate from the plan or modify it? Why?
  • 3.Describe how your department operated on a day-to-day basis during the pandemic. How was it similar or different from how it usually operates?
  • 4.What issues really challenged your department during the pandemic? Were there any unexpected challenges?
    1. How did you address staffing?
    2. Did you have any problems obtaining beds for patients who needed to be admitted? Did you change any of your criteria for who got admitted or discharged?
    3. Did you have to turn anyone away from the ED?
    4. Did you run out of any necessary supplies?
  • 5.Describe solutions that were employed. Were they successful?
  • 6.How did you communicate with the public? Were there proactive things that your community or your hospital did to discourage well children from coming to the ED?
  • 7.Were you supported by others from your hospital, other hospitals, or other public health organizations?
  • 8.What would you do differently if you were to face another pandemic? Have you made changes to your pandemic plan already?

Data Analysis

Our multidisciplinary data analysis team included a pediatrician (CF), two emergency medicine physicians (SB, FV), and a public health student (SP). Using a grounded theory[30, 31] approach, we generated themes inductively from respondents' expressed perspectives rather than through testing of predetermined hypotheses.[26, 27, 31] All four coding team members independently reviewed three transcripts at a time, applying codes or tags to text segments as concepts became apparent, then met regularly to negotiate consensus over differences in independent coding and to refine the evolving code structure. We used the constant comparative method,[30, 32] iteratively comparing coded transcript segments to previously coded segments to identify novel concepts, ensure consistent identification of emerging themes, and expand or refine codes. Through this process and with regular input from additional content (NL) and qualitative methods (LC) experts, we achieved a comprehensive final code structure. CF then systematically applied the final structure to all transcripts, and this was reviewed and approved by the data analysis team.

Near the conclusion of data analysis, we conducted participant confirmation,[27] in which summary results were distributed to all interviewees to ensure that themes were consistent with their perspectives and experiences. Two participants suggested clarifying that not all noted challenges were directly experienced in their respective hospitals; this feedback was incorporated into the findings. We used qualitative analysis software (ATLAS.ti 5.0, Scientific Software Development, Berlin, Germany) to facilitate data organization and review.

Results

Respondent and Institutional Characteristics

Our final sample consisted of one pediatric EP from each of 20 institutions. All respondents were clinicians in leadership positions in the pediatric ED; 15 medical directors completed the interview themselves, and five designated other EPs in leadership roles in their departments. Sampled institutions were diverse across a range of pertinent characteristics including geography, institutional type, and annual pediatric ED visit volumes. There were institutions from all 10 HHS regions and 18 states; 12 were freestanding children's hospitals, and eight were children's hospitals embedded within general hospitals. Annual pediatric ED visit volumes of sampled institutions ranged from <25,000 to >150,000, with a mean annual volume of 58,418 and median of 47,818. For the purposes of this analysis, the bottom annual volume quartile was designated as “low-volume,” the top volume quartile as “high-volume,” and the middle two quartiles as “medium-volume.”

Themes

Our study explored pediatric EP leaders' experiences with institutional pandemic planning and response. This foundational analysis focuses on five common themes that characterized respondents' experiences with pandemic planning and response: 1) national pandemic influenza preparedness guidance has not fully penetrated to the level of pediatric ED physician leaders, leading to variable states of preparedness; 2) pediatric EDs that maintained strong relationships with local public health and other health care entities found those relationships to be beneficial to pandemic response; 3) pediatric EP leaders reported difficulty reconciling public health guidance with the reality of ED practice; 4) although many anticipated obstacles did not materialize, in some cases pediatric EP leaders experienced unexpected institutional challenges; and 5) pediatric EP leaders described varied experiences with organizational learning following the H1N1 pandemic experience.

National Pandemic Influenza Preparedness Guidance Has Not Fully Penetrated to the Level of Pediatric EP Leaders, Leading to Variable States of Preparedness

Pediatric EP leaders in our study reported wide-ranging processes and states of pandemic planning. Many did not communicate awareness of federal preparedness guidance or of recommended specific triggers and associated actions for hospitals before and during a pandemic. Furthermore, although respondents commonly reported knowledge of institutional efforts to plan for and respond to acute, mass-casualty events, respondents were often unaware of whether their institution had similarly prepared for pandemics.

Some respondents reported insufficient anticipation of the pandemic-associated increase in ED volume led to a lagging response:

People didn't anticipate the volume, and so folks were a little slow in activating the surge capacity processes; for example getting the tests, getting the additional personnel. And once people started thinking, “Oh, we should have a process, [it] -was towards the end of the pandemic.”

—Low-volume, nonfreestanding institution

Participants described institutional preparedness for acute, mass-casualty events, but felt that existing planning was inapplicable or inadequate to address a prolonged, infectious event such as the H1N1 pandemic:

What we hadn't prepared for was this … sustained high census. We're prepared for the mass casualty event. We do a lot of drilling around mass casualty and that's where most of our attention went …. It really was, “How do you prepare for an event that might be weeks long for staffing and for mobilization and for expansion?” And, “How do you do it for respiratory illnesses?”

—Medium-volume, freestanding institution

As a consequence of perceived insufficient institutional planning, ED leaders described independently planning for needed interventions while the pandemic unfolded, attributed in some cases to an underlying departmental culture of self-sufficiency in the face of difficult circumstances:

I think most of it was on the fly initially … the reason we got the plan up and running is because I made the plan. We didn't have one before—that was clear—for this kind of an event. And I think the initial response from emergency departments are [sic] to grin and bear it, and that's what I did.

—Low-volume, nonfreestanding institution

Pediatric EDs That Maintained Strong Relationships With Local Public Health and Other Health Care Entities Found Those Relationships to Be Beneficial to Pandemic Response

Respondents reported that strong, especially preexisting, relationships with local public health departments—relationships established in response to previous events or facilitated by the Hospital Preparedness Program—made communication during the pandemic easier. Specifically, this facilitated identification of key contacts and navigation of the public health bureaucracy:

The good thing for us has been that through the [federal] hospital preparedness grants … managed through the [CITY] Department of Public Health, we had been working with these folks for a number of years on improving disaster planning for children in the city. So we kind of knew who to talk to. It was very helpful I think, that we had those liaisons set up. [For example,] at some point … we could say, “We're running out of [pediatric masks], anybody got 'em, what are we doing about it? …” The health department would start to look into the CDC stockpile … and we got more pediatric masks.

—Medium-volume, freestanding institution

Planning and responding in an interdisciplinary, interinstitutional manner was also beneficial for situational awareness, particularly with regard to understanding and planning for the effects of the H1N1 pandemic on the ambulatory pediatric population:

[The interdisciplinary planning team]… did interact with public health institutions and others … at the coalition level. And yes, we were on daily calls with the Department of Health, CDC, and other entities to address the issues we were facing, both locally and nationally. Masks, treatment plan options, see what's going on with the virus at that time, and that kind of stuff …. It was very helpful in our situation awareness, [to] know what's going on, anticipate other things, and learn from other people's mistakes.

—High-volume, freestanding institution

Respondents saw regional interactions as an opportunity to share pediatric expertise and contribute to the development of common treatment patterns for children:

So that was one of the really nice things about the collaboration on the city level is … [as] the pediatric experts, [we] could tell these other smaller community hospitals, “This is what we're doing with the kids” and therefore you didn't see gallons of Tamiflu being prescribed at one place and none at another.

—Medium-volume, freestanding

Pediatric EP Leaders Reported Difficulty Reconciling Public Health Guidance With the Reality of ED Practice

Respondents relied on local, regional, and federal public health guidance related to responding to the H1N1 pandemic. They reported difficulty reconciling recommendations with perceived realities of feasibility, necessity, or both within their own institutions:

For me, the biggest issues were related to the lack of strong agreements on recommendations … at the national and international level. That related both to testing and treatment, as well as things like infection control. I think the CDC did a pretty darn good job by the time the fall event rolled around, but there was still a fair amount of gray. For all children's hospitals most of the patients who we see with fever are less than five years of age. Depending on how you read the guidance … every one of those kids qualified for treatment. … to me, … the biggest challenge was not our internal resource but really trying to figure out how we would apply the recommendations … to our practice.

—Medium-volume, freestanding institution

Perceived inflexibility of national guidance in the face of emerging epidemiologic information and supply constraints led respondents to feel unsupported and frustrated. Although they were uncomfortable with noncompliance, ultimately, respondents felt forced to adapt:

All the personal protective equipment—that was a big frustration of mine. The reality is we just quit wearing masks, quit doing that stuff. When they create guidelines that are unrealistic and difficult to follow … you feel more unsupported. Because you do what you need to do, and yet you know you're violating what some people in the cubicle believe is the right thing to do …. Boy, if we had to gown up and mask up or especially if we did … N95 masks … [for] every patient who walked in with fever, things would have literally ground to a halt.

—Low-volume, nonfreestanding institution

Although Many Anticipated Obstacles Did Not Materialize, in Some Cases Pediatric EP Leaders Experienced Unexpected Institutional Challenges

Respondents anticipated that responding to the pandemic would require traditional surge interventions—increased staffing, inpatient and critical care beds, ventilators, and other supplies. These were not reported to be significant challenges. However, some respondents were surprised by other, unexpected, institutional challenges associated with the pandemic, including difficulty eliciting needed responses from others in the institution, and overcoming institutional administrative hurdles.

Staffing, in particular, was not found to be challenging; staff illness and absenteeism due to fear of illness were rarely reported. The offer of additional pay for overtime work was helpful in recruiting staff, but individual providers were also motivated by a desire to help EDs cope:

I probably had a harder time getting people to stay home when they were sick than … to volunteer for extra shifts. We had no trouble with slots when we opened up the moonlighting unit … we had plenty of moonlighting available at baseline, so it's not like people needed that income-wise. If they saw how much we were being slammed in the main department, people wanted to step up and help.

– High-volume, freestanding institution

In some cases, others within the institution lacked awareness or investment in the ED's pandemic experience, which led to difficulty implementing needed interventions to manage surge associated with the incident:

It would be nice … to have an off-site space that's set up, designed, or an identified space you would go to automatically if something like this happened in the future …. Because we got pushback … initially we identified the family practice clinic … but the family practice folks were not cooperative, so we had to go to surgery. So we had pushback … during the middle of crisis.

—Low-volume, nonfreestanding institution

Respondents also noted administrative challenges during the pandemic. One respondent described the barriers to preparing practitioners to work in the ED:

If we had a neurologist … who wanted to come and work in the emergency department, there were two barriers. One was credentialing. The credential was rather inflexible and that has … changed so that it won't happen again …. The other was, the electronic medical record system had not been widely distributed in the hospital but it was in use in the emergency department and we had a lot of resistance to having [other] people use it.

—High-volume, freestanding institution

Pediatric EP Leaders Described Varied Experiences With Organizational Learning Following the H1N1 Pandemic Experience

Respondents expressed concern that preparations for the H1N1 pandemic may not have been sufficient had it been more virulent. They recognized the importance of planning for and learning from such an event, yet reported varied approaches to institutionalizing knowledge gained during the pandemic. Respondents reported learning from the H1N1 experience, but were apprehensive that they still may not be ready for a more virulent pandemic:

Unfortunately, I don't think people are interested in thinking about these issues until you actually have the situation at hand, but I think we have better plans now and better coordination. It ties into yearly surge issues that just occur seasonally anyways …. I'm [still] concerned about potentially more virulent strains, and what that would really do to our system and how to provide care in that.

—High-volume, freestanding institution

Additionally, respondents expressed concern that given underlying, routine hospital capacities, it may be difficult to rapidly expand and sustain higher capacities in the event of a serious pandemic requiring more inpatient care:

I don't know hospitals in general, but in [CITY], the hospitals are at 100% to 110% capacity every day. That's our hospitals. So were we to have these really ill children, it would be … a different issue.

—Low-volume, nonfreestanding institution

Experiencing the pandemic helped respondents recognize the value of planning ahead for such events. One respondent reported:

It was taxing. We're a small emergency department with a very high acuity level. So getting that extra volume was tough … getting 80% literally more of what you would normally have … particularly when it was sustained over days to weeks. I learned from it and wished I had been better prepared [by, for instance,] having the surge plan prepped in advanced so there was more automaticity to it.

—Low-volume, nonfreestanding institution

Yet this recognition was not always tied to postpandemic planning changes. Rather, respondents reported incomplete institutionalization of lessons learned and, in some cases, an anticipated reliance on informal institutional memory to carry the learned lessons forward. The same respondent went on to remark:

[Does our chair have the pandemic plan we developed]? I'm going to say “no.” So I'm thinking they'll just call me? [Laughter]. … Our pediatric ED-specific surge/H1N1 pandemic plan— … I can't honestly say it's incorporated into the hospital's plans, but I guess being part of a hospital, maybe the short answer is “yes,” because it's there and it's ready to go.

—Low-volume, nonfreestanding institution

By contrast, other respondents reported lasting changes in organizational culture as a consequence of the H1N1 experience, and in some cases, application of developed interventions to management of routine ED surge:

We learned a lot about how to expand every one of our units. … I know that critical care and in-patient hospital units and the ED have all learned quite a bit and have made their plans much more robust. Also, it really has also led to a revamping of our disaster preparedness office. It was just a couple of people and then a whole bunch of identified people who had no [full time equivalent]. Now we have a vice-president in charge of continual readiness. It took a year, but we now have an ED physician who is designated to be part of the hospital readiness response and has [full time equivalent] to go along with that. So it made a big difference.

—Medium-volume, freestanding institution

The thing is, out of this came [an approach] to improve our flow in the emergency department. So that's one positive that came out of it. […] It's permanent now, so we actually use it for our regular patients. Actually, we've improved our length of stay.

—High-volume, freestanding institution

Discussion

This qualitative study exploring pediatric EP leaders' experiences with pandemic planning and medical response during the 2009 H1N1 influenza pandemic reveals important pandemic preparedness gaps. Despite federal guidance directing hospitals to develop pandemic plans with detailed outlines for what should be included, and despite the fact that nearly all U.S. hospitals reportedly have emergency response plans for epidemics or pandemics in place,[8] pediatric EP leaders in this evaluation did not communicate commensurate awareness of such guidance or hospital plans. Although respondents described hospital preparations for acute mass casualty events, existing plans were commonly perceived to be inapplicable to a prolonged, infectious event such as the 2009 H1N1 pandemic. Consequently, ED leaders felt compelled to develop pandemic responses “on the fly.”

Respondents reported that strong (and especially preexisting) relationships with local public health and other health care entities were beneficial to pandemic response including by facilitating communication of institutional needs, enhancing situational awareness, and by allowing for sharing of pediatric expertise. They were challenged and frustrated by the need to reconcile public health guidance with the reality of ED practice. Although many anticipated obstacles did not materialize, such as staff willingness to work, some respondents experienced unanticipated institutional challenges in responding to the pandemic, both in garnering necessary institutional support and in overcoming administrative barriers necessary for effective response. Finally, pediatric EP leaders described varied experiences with organizational learning following the H1N1 pandemic experience. Of note, during data collection for this study, respondents reported additional observations related to important pandemic preparedness issues such as public messaging and staffing augmentation. However, related themes did not strongly emerge in the course of this analysis.

This work builds on an existing literature base demonstrating suboptimal hospital and ED pandemic preparedness.[33] Prior investigations of academic ED leaders,[6, 10, 34] emergency health professionals,[9] hospital administrators,[35, 36] infection prevention specialists,[37] and epidemiologists[38] document significant gaps, notably related to presence of general pandemic plans,[35] ED-specific plans,[9] pediatric-specific plans,[34] conduction of epidemic or pandemic simulations or drills,[6, 8, 9] plans for staffing and supply augmentation,[9, 35] perceived pandemic readiness,[9, 10, 38] and coordination with public health agencies or other health care institutions.[35-37, 39, 40] Our findings parallel those in the existing literature but expand on prior work by contributing novel characterizations of preparedness from the pediatric EP leaders' perspective. Furthermore, in recognition of the vulnerability of the pediatric population during such an event,[33, 41-45] our study focused specifically on preparedness in pediatric institutions.

There are several potential explanations for our findings. The observed lack of pandemic influenza plan penetration to the level of the pediatric EP leader could be related to the clinically mild nature of the H1N1 influenza pandemic; while federal and state guidance was designed to prepare hospitals for pandemics with high virulence and broad hospital impact, the H1N1 pandemic was associated with relatively low virulence in the general population and high ED patient volumes. Therefore, observed gaps in preparedness may derive as much from perceived inapplicability of existing plans as from true lack of awareness. In light of prior evidence outlining potential barriers to provider willingness to work during a widespread infectious event,[46, 47] the reported ease associated with staffing EDs was unexpected. This could potentially be explained by rapid provider recognition of the clinically mild nature of the H1N1 influenza virus. The staffing obstacles that did emerge, for instance, reluctance to relax hospital administrative regulations, may be due to a perceived lack of widespread impact; in our studied hospitals, the stress associated with the clinically mild H1N1 pandemic was relatively isolated to EDs.

Given that the substantial, multiyear, federal investment in hospital pandemic preparedness did not appear to result in optimal academic pediatric ED preparedness for the H1N1 pandemic, there are several important policy implications to consider. First, policy makers seeking to improve hospital preparedness should recognize that many operational, clinical leaders may not be aware of existing preparedness guidance and so may be unprepared to implement best practices. Developing creative dissemination strategies, tailored to clinical providers and distributed through medical directors, should be considered to improve guidance implementation at the hospital level. ED leaders were frustrated by what was perceived to be rapidly changing, impractical public health guidance during the H1N1 pandemic. A more inclusive, collaborative, and dynamic process for generation of public health guidance, before and during a public health event, may improve adherence and provider acceptance. Finally, we found hospitals that proactively established relationships with public health and other community entities reported benefiting from them during the H1N1 pandemic response. Preparedness policies that promote establishment and maintenance of community-level health care coalitions may lead to a more cohesive, effective response to future infectious events, as well as to other public health emergencies.

Efforts to improve preparedness should also be emphasized at the hospital level. For instance, multidisciplinary institutional pandemic preparedness committees should consider placing more emphasis on informing and engaging relevant clinician leaders. With regard to identified administrative barriers, respondents reported difficulty rapidly credentialing needed providers. Hospitals may benefit from reviewing and expanding on the circumstances under which expedited credentialing and privileging requirements would be acceptable to manage sustained, high-volume, low-acuity events, as well as acute mass casualty incidents. Furthermore, hospitals should consider purposefully institutionalizing lessons learned from responding to episodes such as the H1N1 pandemic, so that valuable innovations and interventions can be applied to future events.

Strengths of this study include use of a purposeful sampling strategy that allowed for a heterogeneous distribution of pertinent institutional characteristics in our sample. Although sampled institutions were diverse, respondents' experiences were characterized by recurrent and common themes. We also instituted a number of strategies to ensure a rigorous methodologic approach,[27, 28, 48-51] including use of a standardized interview guide administered by a single interviewer, audiorecording and professional transcription of interviews, analysis conducted by a multidisciplinary research team, and participant confirmation that elicited respondent feedback on generated themes.

Future research could examine other hospital settings, including nonacademic and community settings. Similarly, it would be useful to explore the pandemic planning process from the perspective of institutional leaders, including hospital administrators or others involved in pandemic preparedness. In addition, while the reported themes strongly emerged from the data, they were not universally held experiences. Some institutions reported robust pandemic preparedness with active organizational learning postpandemic. Further study of these apparently high-performing institutions may reveal important institutional characteristics that could guide future efforts to optimize preparedness. Additionally, while our findings are not transferable to all hospitals due to the nature of the study design, hypotheses generated in the course of this analysis could be tested using quantitative methods applied to larger, representative populations. Finally, more research is needed to understand how federal guidance can optimally complement institutional, local, and regional efforts to help hospitals prepare for pandemic and other public health events.

Limitations

It is important to consider the limitations of this analysis. First, because they were felt to be potentially information-rich contexts with high-acuity, pediatric-specific populations, we included only academic medical institutions with pediatric emergency medicine training programs. The use of this sampling frame limits the application of our findings to nonacademic, nonpediatric institutions. Additionally, one-third of approached ED directors did not respond to requests for participation in this study. It is unknown why those individuals chose not to participate. Finally, because we were interested specifically in the pediatric EP leader's experience with pandemic planning and response, our sample did not include other hospital representatives who may have been more comprehensively involved with pandemic preparedness at the institutional level. Perspectives of hospital administrators or other clinicians may have differed.

Conclusions

Despite a decade of investment in hospital preparedness, gaps in pediatric ED pandemic preparedness remain. According to this study, while EP leaders reported substantial hospital preparations for acute and mass casualty events, most were not aware of federal guidance or hospital pandemic plans. More research is needed to understand why and how hospitals operationalize federal preparedness guidance. However, these findings suggest more effective guidance dissemination, targeted education of clinical providers, dynamic and interactive guidance development, promotion of community-wide cooperative planning coalitions, and augmented hospital-level preparedness efforts may help hospitals achieve readiness for events like the 2009 H1N1 influenza pandemic. Future policies that incorporate these and other complementary strategies may lead to improved pandemic, and by extension all-hazards, hospital preparedness in the United States.

The authors acknowledge Steve Krug, MD.

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