By ERIC TONER
Baltimore
RATES of infection with H1N1 influenza in the United States are down from their peak in April but still running well ahead of what is normal for this time of year; many summer camps, for instance, are reporting flu outbreaks. And history suggests that we are likely to experience a much bigger, second wave of the pandemic early in the fall, perhaps before a vaccine is widely available. Argentina, Australia, Chile and New Zealand, where the winter flu season has just begun, are all experiencing major outbreaks.
Fortunately, so far, most people infected with the H1N1 virus have had relatively mild symptoms, like those you get with ordinary seasonal flu. Even so, during the spring wave in New York City, hospital emergency departments experienced a flood of patients — most of them children. Some emergency rooms had several times their normal volume of patients for several weeks. Hospitals in Texas and California reported similar experiences.
When this kind of overload happens, all patients, not just those with flu, have to endure delays and reduced quality of care. And this is what we should prevent this fall.
The good news is that only a small percentage of patients have been sick enough to require hospital care beyond the emergency department. Even fewer patients have required intensive care. Nonetheless, stories of young patients who become critically ill with the H1N1 flu, requiring sophisticated and prolonged intensive care, are emerging around the world. There is the real possibility that in the fall some hospitals will be short of ventilators and other life-saving equipment.
Many of our hospitals are already dangerously overburdened, plagued by chronic shortages of personnel, especially of the most highly trained nurses, respiratory therapists and radiology and laboratory technicians — precisely the people we need most in a pandemic.
There are steps that, if taken now, could lessen the stress on our hospitals this fall. First, we must reduce the number of flu patients who go to emergency departments with mild symptoms. This will involve both educating the public on proper responses to the flu and offering good alternatives to emergency department care.
The public needs to be informed that most flu patients can be adequately treated at home with fluids, rest and over-the-counter medications (acetaminophen or ibuprofen for fever, for example). State and local health departments should urge doctors and clinics to extend their hours temporarily and, if necessary, add employees. In some communities, temporary flu clinics may need to be established and manned by volunteers.
For their part, hospitals should plan to maximize the number of workers available for their emergency departments and intensive care units. This may mean canceling or postponing vacations, instituting mandatory overtime and reassigning personnel from other departments. They can also minimize the number of people absent because of illness by ensuring that staff members are inoculated as soon as a vaccine against H1N1 is available and monitoring proper use of masks, gowns and gloves.
Most important, hospitals should cooperate with one another, and with public health agencies, to distribute patient loads, stockpile supplies and share limited resources. Certainly, this will require financial support from federal, state and possibly also local governments. But hospitals, other health care providers and governments must prepare together immediately to cope with the large number of flu patients expected soon.
Eric Toner, a specialist in emergency medicine, is a senior associate with the Center for Biosecurity at the University of Pittsburgh Medical Center.
