A patient walks into a busy emergency department complaining of body aches, fever, cough, sore throat, headache and lassitude. In the absence of other factors and lab testing, it could be another case of H1N1 flu.

Although information on H1N1 discourages people from going to the ED when it appears flu is the diagnosis, it may be hard to keep them away. Especially those who use the ED as their primary care physician. This patient isn't the first and won't be the last.

In this instance, given his symptoms, he gets an antiviral medication and is told to go home, rest, drink lots of fluids and don't go back to work until he is fever-free for 24 hours.

Leaves Something Behind

Once the man leaves, staff turns to the next patient, not thinking about what the first patient left behind - H1N1 virus.

Because the man tried to suppress a sneeze with his hands, there is now viral evidence of that in the waiting room on the arms of the chair he sat in, on the knob of the bathroom door after he used the restroom and on the countertop of the triage desk where he placed his hands as he was answering questions. According to the CDC, the H1N1 virus can live as long as 2-8 hours on a surface.

"Although EDs are busy 24/7, many do not have dedicated housekeeping, which becomes a major infection control issue when dealing with a pandemic" notes Theresa Tavernero, MHA, MBA, RN, CEN, associate director of patient safety programs for TeamHealth, a provider of physician staffing and management in more than 550 hospitals and physician groups across the country.

A Plan of Action

Just walk into any ED in the U.S. and you'll soon realize they are the first line of medical care for many. According to statistics in the National Strategic Plan for Emergency Department Management of Outbreaks of Novel H1N1 Influenza (shortened to National Strategic Plan in this article), "EDs could see 150 percent of normal volume of respiratory complaints."

Already beleaguered and overtaxed, what can EDs do to prepare for an even greater influx of patients during an influenza pandemic?

Tavernero has been talking to EDs and providing resources and support on this subject since 2003. Recently, people have begun to be keenly interested in her advice.

"The best work I've seen on this is the National Strategic Plan, developed in collaboration with the Office of the Assistant Secretary for Preparedness and Response, the Emergency Care Coordination Center and the American College of Emergency Physicians," Tavernero says. "This plan is based on five pillars, which we've adapted:

1. enhancing or improving situational awareness;

2. protecting ED personnel;

3. preventing disruption of service or care;

4. organizing a surge medical response; and

5. providing support to providers (administrative, legal, etc.) for actions that need to be taken during a disaster." Tavernero points out this is different from the last pillar of the National Strategic Plan, which emphasizes recovery to the previous steady state.

Situational Awareness

Common sense and practical measures are essential to handle an expected surge in EDs, Tavernero believes: "Look at lessons learned from countries that have gone through this already, using regular measures."

Her first advice, hospitals should "dig out that disaster plan and ensure patient care and disaster management procedure is workable and accurate." "H1N1 is a type of biological disaster, under the all-hazards model that many hospitals have adopted. The problem in disasters, including H1N1, is finding a way to discourage patients who are not sick from coming to the ED. It is the 'walking worried' who will overload the ED," Tavernero says.

"Hospitals need to raise awareness and educate the public and staff in strategies to prevent and contain the virus," she says. "People need to stay at home if they suspect they have the flu, which is social distancing and is so important.

"Public health bulletins, newspaper articles, radio spots, signage - use anything that will get the word out that if a person has symptoms like cough, congestion and fever, he shouldn't go to the ED unless the symptoms are severe or he has other comorbidities, and he shouldn't go to school or work."

And, of course, "A disaster fundamental is to take care of your own first."