Pandemic Influenza Exercise Yields Valuable Insights on Facilities States of Readiness

Seasonal influenza causes severe illness and death every winter in North America, attacking the elderly and the debilitated with particular intensity. Outbreaks of influenza have been known to occur for centuries, with three influenza pandemics occurring during this last century the Spanish (1918), Asian (1957) and Hong Kong (1968) pandemics. The Spanish pandemic, in two short years, killed an estimated 20 million people worldwide, with some experts reporting deaths as high as 40 million.

Entire towns were devastated and many families were wiped out as a result of influenza. Physicians tending to soldiers in military camps wrote letters home about young healthy men who came to the infirmary with a cough in the morning and were dead by nightfall. This virus quickly made its way around the globe.

Experts are predicting that another pandemic influenza will occur, although the timing and pattern of the pandemic is unpredictable. When it does, the impact may be devastating. Death estimates from the World Health Organization (WHO) range in the area of 2 million to 7.4 million worldwide. Those seeking medical care would quickly overwhelm most healthcare systems, even the healthiest healthcare systems.

In November 2005, an executive order was issued requesting that healthcare facilities develop, test, and educate healthcare personnel about a pandemic influenza plan. On March 2, 2007, my employer, Metro Health in Grand Rapids, Mich., held a tabletop drill to test our plan. Due to a surprising amount of community interest, we opened our drill to area hospitals, emergency management systems, the Red Cross, fire and police departments, the local homeland security agency, the public health department, vendor representatives, and representatives from the public sector to measure impact of news releases, as well as the local news media. The drill was planned to test all aspects of our pandemic plan and allowed all other participating agencies to do the same. Our objectives included:

• Demonstrate the ability to plan response operations within the capabilities and competencies of available personnel, supplies, and equipment 

• Identify the functions of the agencies participating Identify the importance of pre-incident planning 

• Demonstrate the transfer of command and control 

• Validate current plans and procedures 

• Determine necessary changes needed 

• Make recommended changes 

• Provide an opportunity to exercise responses 

• Evaluate the effectiveness of responses 

Participants were informed that there are no right or wrong answers to the module questions. The tabletop consisted of four sessions, broken down into three modules, with a 45-minutes group and 10-minute group briefings. Group briefings were situational updates, and included a press release. Responses were to be kept brief. The purpose of this tabletop exercise was to offer participants an opportunity to gain an understanding of problems healthcare organizations and emergency management could face in response to a pandemic influenza emergency.

Our scope for this exercise focused on a pandemic influenza emergency affecting the Grand Rapids area and ultimately the rest of the country. Emergency response and decision-making processes emphasizing communications, public information, emergency response coordination, resource integration, and problem identification and resolution were assessed. This provided a unique opportunity to evaluate stakeholder readiness for an emergency that would significantly impact delivery of essential services and programs to the residents of Grand Rapids. The exercise addressed the following areas:

• The decision-making process. Exercise their individual organizations response plans and work through the scenario using available resources. Interact plans with regional, local municipal, and key agencies assisting with decision-making processes and identify areas needing refinement. Identify key actions to be taken and by whom.

• Affected area access/quarantine. Review the organizations' roles and responsibilities when dealing with isolation and quarantine issues. Identify local municipal and regional operations for area access control and possible quarantine issues resulting from a pandemic influenza emergency.

• Town/city and regional agencies and private/public sector interface. Examine the local interface between town/city and regional agencies in the conduct of crisis and consequence management activities. Examine local municipal and regional interactions with the private and public sector during the threat or actual occurrence of a pandemic influenza emergency.

• Public information and media relations. Discuss process to provide timely information and instructions to the community. Review regional and local municipal public information and crisis communications plans to ensure the timely and consistent dissemination of accurate and meaningful information. Discuss how media will be coordinated when local municipal, regional, and federal agencies are involved.

• Medical monitoring/surveillance. Review the local healthcare, emergency medical transport, and public health department capabilities to recognize, identify, monitor and respond to an incident involving pandemic influenza.

• Training and education. To provide an opportunity for the participants to gain a better understanding of their roles and responsibilities and the relationships between the stakeholder plans during a pandemic influenza emergency.

• As in any exercise, a number of assumptions and artificialities may be necessary to complete discussions within the time allotted. During the operation, the following will apply:

• The various scenarios, while fictitious, have been created to reflect what many experts feel will occur and have been tailored to local circumstances.

• All participants will receive information at the same time.

• The exercise will evolve in a compressed time frame even though the scenarios take place over several months.

• Participants should assume that all jurisdictions are implementing their plans, procedures and protocols and utilizing only existing resources.

• A pandemic usually spreads in two or more waves, either in the same year or in successive influenza seasons (i.e., October to April). A second wave may occur within three to nine months of the initial outbreak wave and may cause more serious illnesses and deaths (in the absence of antivirals and vaccine) than the first. In any locality, the length of each wave of illness is approximately eight weeks.

The drill lasted seven hours, and we learned a lot. It was a significant eye-opener to discover that area hospitals were not on the same page, and that one of the larger facilities acknowledged that they would not have picked up the index case. Another area of mixed handling involved what would be done with staff in-satellite sites such as medical centers. One facility would close them to pull available staff to areas of need, and another facility would leave theirs open and funnel all emergency walk in traffic to them. Supply distribution was another area where answers were non-specific, vague, or cavalier; for example, some participants noted, The health department will make sure we will receive vaccine and antivirals that we need, or The health department will allocate resources.

Other vague issues revolved around disruption of contracted services such as trash removal, and it was revealed that no one has a sound plan for handling the deceased. Many participants were looking to the government to make decisions, while the government is looking to the hospitals to develop the plans. The most disturbing areas of non-action involved the ethical decisions regarding ventilator and other limited supplies usage. It appears that there are a lot of guidelines out there, but no one is willing to put down on paper what will be needed in the height of emergency triage and hospital supply distribution.

Mindsets were another concern. Participants ranged from those who felt this would never happen and there were more important issues to spend time and money, to those who felt no matter how prepared we were, If it was that bad, we would be working from Maslows hierarchy of needs.

I am sure that each facility left with a list of action plans. The local health department has hired a person to develop a plan acceptable to all hospitals so that there is no confusion for the public. Issues that specifically need to be resolved include being sent home from one facilitys emergency room (ER) with a diagnosis of the flu, whereas another ER may contact the health department for possible home quarantine based on symptoms and travel history, or an unseasonable spike in influenza-like complaints.

Needless to say, Hurricane Katrinas devastation of New Orleans is truly an event we should examine and learn from, and the Toronto SARS situation is another valuable teaching tool that we should not ignore. In the end, those being tasked with writing the plans are not being given the authority necessary to develop plans of action that can be successfully implemented in the event of a pandemic event.

Deborah Paul-Cheadle RN, CIC, is employed by Metro Health Hospital in Grand Rapids, Mich.