When the CDC upgraded Kentucky's prevalence of influenza from regional to widespread in the mid-September surveillance report, Cibina Harris, RN, CIC, manager of infection prevention and control at Kentucky Children's Hospital in Lexington, wasn't at all surprised. "That reflects the experience here on our campus, where we're already seeing 10-15 more patients a day with flu-like illness, as well as the worried well," she says.

Joan Kowalczyk, BA, BSN, RN, CIC, infection control practitioner at the Cleveland Clinic in Ohio, shares a pragmatic view of the infection. "We've learned that flu has not really left our area, since we've consistently had positive lab tests for influenza A since spring," she says. "Whether that influenza A is seasonal flu or H1N1, we have to think flu at all patient encounters. We're saying a flu is a flu and treating patients accordingly."

How are health care facilities dealing with H1N1?

Community Planning

As interim lead infection preventionist at TriHealth in Cincinnati, Lyn Plummer, RN, CIC, appreciates the support from colleagues in her area. "Hospitals in the region agreed to collaborate on visitation restrictions as announced by the Greater Cincinnati Health Council," she explains. "As a group, we will be restricting visits from children under the age of 14, and the health council will be providing signs to help us communicate that message."

A community-centered approach makes good sense, says Plummer. "It's good to have regional backing because it simplifies communication to the general public and prevents our hospital from being singled out as we put measures in place to protect our patients and employees," she said.

Harris and her colleagues have also been actively involved in state, city, community and campus planning around H1N1 influenza in Lexington. "We have a large Hispanic population in our community and are fortunate to have a very strong group within the population who are disseminating H1N1 information in their newspapers and other publications," she says.

Communicating

Plummer discussed the importance of clear, consistent and timely communication to dispel myths and rumors around H1N1. "We are a very large organization with two hospitals and multiple off-site locations, and are working fast and furiously to disseminate information about H1N1 flu as it changes," she said. "We've been preparing for the pandemic for several years, and people are hungry for accurate, current information about H1N1. It's important we stay on top of information so we're doing the right thing for our patients and our employees."

Plummer and her colleagues are using a variety of communication channels to meet the demand. "Our medical director for infection prevention and I review all information before it's disseminated to staff, and then we send out targeted e-mails on key changes such as visitor restrictions and testing," she says. "We're using our hospital intranet as a flu resource for employees, and share information in meetings as well."

Many area hospitals are using CDC pamphlets about H1N1 to educate patients and families as they teach about disease prevention and control.

Upfront Prevention

Clinicians at the Cleveland Clinic have been focused on prevention since H1N1 showed its head in their area in early May. "We have an aggressive and organized seasonal flu vaccine campaign for patients, visitors and employees with both a central location for immunizations and rolling carts that have gone out to 100 sites to vaccinate over 17,000 employees," says Kowalczyk. "We have an additional 75 flu vaccine clinics for the public."

A forward-thinking approach to primary care has limited the number of patients coming into Cleveland Clinic's emergency department with flu-like symptoms. "We're seeing the majority of our flu patients in outpatient settings, including our regional medical practices and ambulatory family practices," says Kowalczyk. "Patients who call in to our practices to say they need a physician are routinely offered a same-day appointment."

The Cleveland Clinic boasts a multimedia Web site devoted to both seasonal and H1N1 flu featuring a slideshow about 10 flu-related myths, a video clarifying issues around H1N1 flu, an online chat with a physician expert, fact sheets about flu-related topics, and a schedule of flu shot locations for both employees and the public. There are also links to wellness pages that discuss the importance of hand hygiene and tips for boosting the immune system.

Reducing the Spread of Infection

Kentucky Children's Hospital has already taken a number of precautions to reduce the spread of both seasonal and H1N1 influenza, restricting sibling visits and screening visitors for signs and symptoms of illness. "We have a large number of children with compromised immune systems, including those on our hematology/oncology service, a large group of children with cystic fibrosis, and children we care for pre- and post-transplant," says Harris. "We're talking about ways to install barriers with fire-grade plastic walls to limit traffic in and out of those areas, and about cohorting physicians and nurses caring for those children. If there is a significant outbreak, we'll close our playroom and work with child-life staff on ways to serve children in their own rooms."

It's important to differentiate between the various strains of influenza and other fall and winter respiratory infections such as respiratory syncytial virus (RSV). "We've already seen some influenza B and RSV, but most of the time it's the novel H1N1 strain of influenza A," says Harris. "We've received approval to purchase two more PCR units for the lab so we can run up to 48 tests at a time for the hospital itself, as well as student and university health and outside facilities. Physicians and nurse practitioners can use the results in a timely manner to treat the infection, prescribing Tamiflu when appropriate."

TriHealth has established respiratory etiquette stations in their facilities containing tissues, hand sanitizer and masks when appropriate. ED nurses are triaging quickly and moving patients with respiratory symptoms into segregated areas or private rooms as soon as possible. "Most of the patients who present in our EDs with flu-like symptoms are screened, treated and released; only a few have required admission," says Plummer.

Surge Capacity

If H1N1 grows into epidemic status, infection preventionists at Kentucky Children's Hospital are ready. "We've worked closely with nursing and medical directors in our 12-bed PICU, our 66-bed level III NICU and our 53-bed children's hospital to identify capacity in case of a surge in H1N1 cases," says Harris. "We've determined our PICU can expand to 24 beds if need be, especially if those are smaller children in cribs. It's important to realistically identify what each unit can manage if they end up losing 30-40 percent of their staff to illness at any given time."

Medical equipment and supplies like N95 masks will be at a premium if there's a significant increase in H1N1 cases requiring hospitalization. "We've made an inventory of our ventilators and IV pumps, and are working with neighboring hospitals to make sure children can receive the right level of care," says Harris. "For those hospitals that provide pediatric inpatient care but no PICU, we're talking about how we can transfer less ill children to them so we can provide intensive care for the sickest patients."

The ED already has a rapid triage process in place. "Staff assess for flu-like symptoms, provide masks to reduce the spread of the virus, get the patient out of the waiting room as soon as possible and then either admit or discharge the child quickly," says Harris. "We have plans to expand our capacity if there's a surge in patients, so we're ready!"

Bottom Line

Infection preventionists have their fingers crossed that a concerted effort to protect community residents will prevent H1N1 from turning into a pandemic. (according to WHO, it is already a pandemic)

"We need to encourage people to think flu, use good hand hygiene, employ cough etiquette, get immunized against both seasonal flu and H1N1 flu as the vaccines become available, and stay home if they become ill," Kowalczyk relates.

Sandy Keefe is frequent contributor to ADVANCE.