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Other duties suffered but IPs rose to occasion
IPs must make ethical decisions
Though some other infection prevention duties were shunted aside, IPs and the health care system in general rose to the challenge of the first pandemic in four decades.
"You have to borrow from Peter to pay Paul," concedes Neil Fishman, MD, director of the department of Healthcare Epidemiology and Infection Control at University of Pennsylvania Health System in Philadelphia. "I think that's just a reality of the situation, but you have to make those decisions intelligently and with enough forethought to make certain there isn't a significant spike in other disease activity."
As the H1N1 pandemic unfolded, Fishman and infection prevention colleagues decided where the line had to be held at all costs.
"When we were deciding how to allocate resources and time there were certain activities that under no circumstances could be compromised, and those included anything that would impact bloodstream infections," he says. "We didn't want to see a spike in bloodstream infections, multidrug-resistant organisms, or ventilator-associated pneumonias. We didn't back off on those activities, but we did have to back off on others."
For example, infection surveillance was cut back for minor surgical procedures in ambulatory care patients, he says. In addition, the argument can be made that a heavy emphasis on hand hygiene during H1N1 certainly could have prevented some other viral and bacterial infections.
Still, evidence that H1N1 was taking a toll on other infection prevention activities was clear in a survey of members for the Society for Healthcare Epidemiology of America (SHEA). "The time commitment required to respond to this crisis was considerable, with attention to other critical infection prevention activities suffering as a result," the authors noted.1 The demand on resources was also reflected in the fact that 50.9% of respondents reported neglect of other important infection prevention-related activities during the H1N1 crisis, while nearly one-third of respondents spent more than 60% of their time dealing with issues related to H1N1 during the busiest week.
IP decisions become 'ethical' choices
"Clearly, the demand placed on health care epidemiology personnel during this pandemic has been pronounced, and the detrimental effect this has had on routine infection prevention efforts is of concern," an accompanying editorial stated.2 "Similar concerns were raised in the context of severe acute respiratory syndrome (SARS), where investigators reported increases in methicillin-resistant Staphylococcus aureus and other infections in the setting of an event that required intensive infection control resources and diverted attention elsewhere.3,4 . . . The choices these staff make between activities can pose ethical challenges. . . . The lack of support and the relative difficulty in quantifying the time and labor devoted to pandemic response for hospital administration remains one of the ongoing challenges."
Similar reports of dropped or diverted infection prevention activities came in to pandemic response experts at the Center for Biosecurity at the University of Pittsburgh Medical Center.
"Typically, infection control departments in hospitals can be one person or sometimes two," says Eric Toner, MD, senior associate at the center. "If they are doing a lot of work with a pandemic they don't have time to do other things. So, it's not surprising, but I don't know what you can do about it really. I don't think we can say every hospital ought to hire more infection preventionists because sometime in the future there will be another pandemic. That's not realistic."
However, that was exactly what happened at hospitals in Toronto in the aftermath of the 2003 SARS outbreak, which claimed health care workers among its victims and exposed that infection prevention resources in health care were woefully inadequate. In a reversal of the historical situation, hospitals in Ontario now typically have more infection preventionists than their U.S. counterparts. "I have colleagues in the U.S. asking me, now, 'Where did you get all the infection preventionists?'" says Allison McGeer, MD, a microbiologist and infectious disease consultant at Mount Sinai Hospital in Toronto.
In a study she conducted after the SARS outbreak, McGeer found that "inappropriate reuse of gloves and gowns and failure to wash hands between patients may have contributed to transmission of MRSA during the SARS outbreak."3
That said, H1N1 is no SARS in terms of virulence and mortality, so the documentation of overwhelmed infection prevention departments may remain a footnote on the after-action review lists of pandemic response analysts.
"A more virulent virus than the H1N1 turned out to be certainly would have caused many more problems, particularly in intensive care units and emergency departments," Toner says. "Many ICUs were stressed with this pandemic. They would have been overwhelmed in a more severe pandemic."
The primary problem wasn't staffing to their credit, health care workers were on the job, he says.
"The problem was that some of the patients were so desperately sick and required such prolonged periods of mechanical ventilation for much longer periods of time than we had imagined," Toner says. "It was a tremendous strain on the capacity of ICUs in many places not everywhere to be sure but particularly in referral centers that got the sickest patients from a large geographic area. They had periods of time when they were really severely stressed."
Meanwhile, many emergency departments were swamped with the "worried well" and people seeking H1N1 testing.
"A large number of people who were concerned or seeking testing really stressed the emergency departments," Toner says. "There was a very large number of children with relatively mild illness putting a huge strain on many pediatric emergency departments."
On the positive side, after some initial snafus with supplies and reports of hoarding, distribution of antivirals went fairly well, he reports. "There was plenty of Tamiflu available through the national strategic national stockpile and through normal commercial supply chains," Toner says. "There were very brief transient interruptions, but it didn't turn out to be a big problem."
What worked and what didn't
Now that the postmortems are in full swing at the Pittsburgh center, the Centers for Disease Control and Prevention and by other groups and agencies, answers will be forthcoming that could improve the response to the next pandemic or emerging infection.
"There are certainly things we can learn related to trying to take the stress off emergency departments, ICU capacity, the need for alternate sites of care, the potential need for crisis standards of care," he says. "Questions include how we should prioritize our limited amount of vaccine and what sort of public health mitigation measures really worked."
Such after-action reviews also will show what aspects of the health care response to the pandemic worked and why.
"A lot of people worked very hard, put in very long hours," Fishman says. "The local response at the hospital level, at the health department level was superb. We did learn some lessons about vaccine distribution and communication about the pandemic, but a lot of cards fell in place that made this easier to deal with. Everyone was prepared for a pandemic of severe illness, and we had to shift our focus pretty early on to a pandemic of a mild-to-moderate nature. Suddenly, the focus was on emergency departments and ambulatory settings and not as much on the inpatient setting. I think we made that transition well."
Congratulations and celebrations can be expected to be short-lived. With SARS and H1N1 both arising suddenly in the same decade, experts concur that the next emerging infection is now on the clock.
"I hope everybody looked at this as a drill this was Mother Nature's pop quiz," says Ruth Carrico, PhD, RN, CIC, a veteran IP and assistant professor of health promotion and behavioral sciences at the University of Louisville (KY). "We need to learn from this look at it seriously instead of congratulating ourselves for dodging a bullet. What we really need to be doing is looking at what were our problems. How we were able to respond and how are we going to improve?"
As with performance improvement efforts in clinical care, hospitals and individual IPs should look at their pandemic response and focus on problem areas, she noted. "We have to learn from this experience and make changes," Carrico says. "Even something very simple, like, 'Did our communication processes work? Can I get a hold of my staff?' We need to incorporate simple types of drills into our daily activities. It will only help us and we need to embrace it."