Summary of Roles and Responsibilities for Healthcare and Public Health Partners and Public Health

Interpandemic and Pandemic Alert Periods

Healthcare facility responsibilities:

• Develop planning and decision-making structures for responding to pandemic influenza.
• Develop written plans that address: disease surveillance, hospital communications, education and training, triage and clinical evaluation, facility access, occupational health, use and administration of vaccines and antiviral drugs, surge capacity, supply chain and access to critical inventory needs, and mortuary issues.
• Participate in pandemic influenza response exercises and drills, and incorporate lessons learned into response plans.

State and local responsibilities:

• Develop statewide and local or regional plans to manage an influenza pandemic.
• Assist healthcare facilities in conducting exercises and drills to test healthcare response issues and build partnerships among healthcare and public health officials, community leaders, and emergency response workers.
• Develop a communications infrastructure to facilitate and ensure the timely dissemination and transfer of information between the healthcare and public health sectors.
• Address legal issues that can affect staffing and patient care.

HHS responsibilities:

• Provide ongoing public health guidance on healthcare preparedness for an influenza pandemic.
• Provide healthcare facilities with model protocols for early detection and treatment of influenza among patients and staff; these protocols can be piloted during routine influenza seasons.

Pandemic Period

If an influenza pandemic begins in another country:

Healthcare facility responsibilities:

• Heighten institutional surveillance for influenza and prepare to activate institutional pandemic influenza plans, as necessary.

State and local responsibilities:

• Work with HHS to provide local physicians and hospital administrators with updated information and guidance as the situation unfolds.

Healthcare facility responsibilities:

• Activate institutional pandemic influenza plans, in accordance with the 揌ospital Pandemic Influenza Triggers?outlined in Table 1.
• Identify and isolate all potential patients with pandemic influenza.
• Implement infection control practices to prevent influenza transmission.
• Ensure rapid and frequent communication within healthcare facilities and between healthcare facilities and health departments.
• Implement surge-capacity plans to sustain healthcare delivery.

State and local health responsibilities:

• Provide healthcare facilities with information on the global, national, and local situation.
• Work with HHS to provide guidance (as needed) on infection control measures for healthcare and non-healthcare settings.
• Work with healthcare facilities to address surge capacity needs.

HHS responsibilities:

• Assist state and local healthcare and public health partners on issues related to hospital infection control, occupational health, antiviral drug use and clinical management, vaccination, and medical surge capacity.
• Provide states with materials from the Strategic National Stockpile for further distribution to healthcare facilities.

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S3-I. Rationale

An influenza pandemic will place a huge burden on the U.S. healthcare system. Published estimates based on extrapolation of the 1957 and 1968 pandemics suggest that there could be 839,000 to 9,625,000 hospitalizations, 18?2 million outpatient visits, and 20?7 million additional illnesses, depending on the attack rate of infection during the pandemic. Estimates based on extrapolation from the more severe 1918 pandemic suggest that substantially more hospitalizations and deaths could occur. The demand for inpatient and intensive-care unit (ICU) beds and assisted ventilation services could increase by more than 25% under the less severe scenario. Pre-pandemic planning by healthcare facilities is therefore essential to provide quality, uninterrupted care to ill persons and to prevent further spread of infection. Effective planning and implementation will depend on close collaboration among state and local health departments, community partners, and neighboring and regional healthcare facilities. Despite planning and preparedness, however, in a severe pandemic it is possible that shortages, for example of mechanical ventilators, will occur and medical care standards may need to be adjusted to most effectively provide care and save as many lives as possible.

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S3-II. Overview

Supplement 3 provides healthcare partners with recommendations for developing plans to respond to an influenza pandemic. The focus is on planning during the Interpandemic Period for: pandemic influenza surveillance, decision-making structures for responding to a pandemic, hospital communications, education and training, patient triage, clinical evaluation and admission, facility access, occupational health, distribution of vaccines and antiviral drugs, surge capacity, and mortuary issues. Planning for the provision of care in non-hospital settings梚ncluding residential care facilities, physicians?offices, private home healthcare services, emergency medical services, federally qualified health centers (FQHCs), rural health clinics, and alternative care sites梚s also addressed.

The recommendations for the Pandemic Period focus on activation of institutional pandemic influenza response plans. The ability to provide detailed guidance on this aspect of the pandemic is limited because of uncertainty about how the pandemic will evolve and variation and uncertainty of local factors that will influence decisions at various stages.

The activities suggested in Supplement 3 are intended to be synergistic with those of other pandemic influenza planning efforts, including state preparedness plans. Links to additional resources that provide the most up-to-date guidance on particular topics are included. A checklist to help facilities assess their current level of readiness to deal locally with an influenza pandemic is provided in Appendix 2.

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S3-III. Recommendations For The Interpandemic and Pandemic Alert Periods

1. Planning for provision of care in hospitals

   U.S. healthcare facilities must be prepared for the rapid pace and dynamic characteristics of pandemic influenza. All hospitals should be equipped and ready to care for: 1) a limited number of patients infected with a pandemic influenza virus, or other novel strains of influenza, as part of normal operations; and 2) a large number of patients in the event of escalating transmission of pandemic influenza.

   Hospital response plans for pandemic influenza should:

   • Outline administrative measures for detecting the introduction of pandemic influenza, preventing its spread, and managing its impact on the facility and the staff.
   • Build on existing preparedness and response plans for bioterrorism events, SARS, and other infectious disease emergencies.
   • Incorporate planning suggestions from state and local health departments and other local and regional healthcare facilities and response partners.
   • Identify criteria and methods for measuring compliance with response measures (e.g., infection control practices, case reporting, patient placement, healthcare worker illness surveillance).
   • Review and update inventories of supplies that will be in high demand during an influenza pandemic.
   • Review procedures for the receipt, storage, and distribution of assets received from federal stockpiles.
   • Include mechanisms for periodic reviews and updates.

   Hospitals that intend to use an 揳ll-hazards?incident command structure for responding to pandemic influenza will need to incorporate the relevant aspects of communicable disease control that are included in this supplement and in Supplement 4. Hospitals should consider using 搕able top?simulations or other exercises to test response capabilities (see Appendix 1).

   1. Planning process
      
      
      • Groups and individuals involved in the hospital planning process should include:
        • An internal, multidisciplinary planning committee with responsibility for pandemic influenza preparedness and response. The committee should include technical experts, persons with decision-making authority, and representatives from a range of response partners (see Box 1). A pre-existing all-hazards preparedness team (e.g., established for bioterrorism or SARS response) might assume this role.
        • A response coordinator/incident commander to direct the facility抯 planning and response efforts
        • A core group from the multidisciplinary planning committee to work with the response coordinator and assist with decision-making during the pandemic
      • The pandemic influenza response team should plan to remain active throughout the pandemic period, which could be several weeks or months.
      • Hospital planning for pandemic influenza should consider concurrent public health, community, and healthcare planning efforts at the local, state, and regional levels. Some possible mechanisms for collaboration and coordination are to:
        • Include a state or local health department representative as an ex officio member on the hospital planning committee (see Box 1).
        • Obtain copies of draft pandemic influenza plans from other local or regional hospitals to use as models.
        • Work with other local hospitals, community organizations (e.g., social service groups), and the state or local health department to coordinate healthcare activities in the community and define responsibilities for each entity during a pandemic.
        • Collaborate with HRSA hospital preparedness programs in the state or region.
        • Include a hospital representative in local or regional planning efforts.
        • Include representatives from safety-net providers in the local community (e.g., FQHCs and rural health clinics).

   2. lanning elements

      The elements of a hospital influenza pandemic preparedness plan discussed below are listed in the Hospital Preparedness Checklist provided in Appendix 2.

      1. Hospital surveillance

         • Hospital surveillance for novel strains of influenza
           During the Interpandemic and Pandemic Alert Periods, healthcare providers and healthcare facilities play an essential role in surveillance for suspected cases of infection with novel strains of influenza and should be on the alert for such cases. Novel strains may include avian or animal influenza strains that can infect humans (like avian influenza A [H5N1]) and new or re-emergent human viruses that cause cases or clusters of human disease. For detection of cases during the Interpandemic and Pandemic Alert Periods, hospitals should have:

           • Procedures in place to facilitate laboratory testing on-site using proper biosafety levels and reporting of unusual influenza isolates through local and state health department channels (see Supplement 1). If appropriate methods or biosafety levels do not exist at the hospital, specimens should be shipped to the state health department.
           • Predetermined thresholds for activating pandemic influenza surveillance plans (see S3-III.A and the Table).

         • Hospital surveillance for pandemic influenza
           During the Pandemic Period, healthcare providers and healthcare facilities will play an essential role in pandemic influenza surveillance (see Supplement 1). For detection of cases during the Pandemic Period, hospitals should have:

           • Mechanisms for conducting surveillance in emergency departments to detect any increases in influenza-like illness (see box below) during the early stages of the pandemic
           • Mechanisms for monitoring employee absenteeism for increases that might indicate early cases of pandemic influenza
           • Mechanisms for tracking emergency department visits and hospital admissions and discharge of suspected or laboratory-confirmed pandemic influenza patients. This information will be needed to: 1) support local public health personnel in monitoring the progress and impact of the pandemic, 2) assess bed capacity and staffing needs, and 3) detect a resurgence in pandemic influenza that might follow the first wave of cases.
           • Updated information on the types of data that should be reported to state or local health departments (e.g., admissions; discharges/deaths; patient characteristics such as age, underlying disease, and secondary complications; illnesses in healthcare personnel) and plans for how these data will be collected during a pandemic. State and local health departments will provide guidance on the scope and mechanism of reporting (see Supplement 1).
           • Criteria for distinguishing pandemic influenza from other respiratory diseases (see Supplement 5).

         Symptoms of influenza include fever, headache, myalgia, prostration, coryza, sore throat, and cough. Nausea and vomiting are also commonly reported among children. Typical influenza (or 揻lu-like? symptoms, such as fever, may not always be present in elderly patients, young children, patients in long-term care facilities, or persons with underlying chronic illnesses (see Supplement 5, Box 2).

      2. Hospital communications

         Each hospital should work with public health officials, other government officials, neighboring healthcare facilities, the lay public, and the press to ensure rapid and ongoing information-sharing during an influenza pandemic.

         • External communications

           • Assign responsibility for external communication about pandemic influenza; identify a person responsible for updating public health reporting (e.g., infection control), a clinical spokesperson (e.g., medical director), and a media spokesperson (e.g., public information officer).
           • Identify points of contact among local media (e.g., newspaper, radio, television) representatives and public officials and community leaders.
           • With guidance from state or local health departments, determine the methods, frequency, and scope of external communications.
           • Determine how communications between local and regional healthcare facilities will be handled.
             • Consult with state or local health departments on plans for coordinating or facilitating communication among healthcare facilities. In the absence of such a plan, consider organizing a meeting of local health facilities to determine an optimal communications strategy.
             • Identify key topics for ongoing communication (e.g., staffing needs, bed capacity, durable and consumable medical equipment and device needs, supplies of influenza vaccine and antiviral drugs).
             • Assign responsibility within the hospital for communications with other healthcare facilities.
           • Consult with local or state public health officials regarding the hospital抯 role in communicating with the media and the public.
           • Determine the type of hospital-specific communications (e.g., press releases, community bulletin board) that might be needed, and develop templates for these materials.
           • Consult with local or state health departments on plans for a pandemic influenza hotline and/or website for public inquiries.
             • Determine how public inquiries will be handled (e.g., refer callers to the health department; provide technical support for handling calls).
             • Identify the types of information that will be provided by the hospital and the types of inquiries that will be referred to state or local health departments.

         • Internal communications

           • Determine how to keep administrators, personnel (including infection control staff and intake and triage staff), patients, and visitors informed of the ongoing impact of pandemic influenza on the facility and on the community.

      3. Education and training

         Each hospital should develop an education and training plan that addresses the needs of staff, patients, family members, and visitors. Hospitals should assign responsibility for coordination of the pandemic influenza education and training program and identify training materials梚n different languages and at different reading levels, as needed梖rom HHS agencies, state and local health departments, and professional associations (see Appendix 1).

         • Staff Education
           • Identify educational resources for clinicians, including federally sponsored teleconferences, state and local health department programs, web-based training materials, and locally prepared presentations.
           • General topics for staff education should include:
           • Prevention and control of influenza
           • Implications of pandemic influenza
           • Benefits of annual influenza vaccination
           • Role of antiviral drugs in preventing disease and reducing rates of severe influenza and its complications
           • Infection control strategies for the control of influenza, including respiratory hygiene/cough etiquette, hand hygiene, standard precautions, droplet precautions, and, as appropriate, airborne precautions (see Supplement 4).
         • Hospital-specific topics for staff education should include:
         • Policies and procedures for the care of pandemic influenza patients, including how and where pandemic influenza patients will be cohorted
         • Pandemic staffing contingency plans, including how the facility will deal with illness in personnel
         • Policies for restricting visitors and mechanisms for enforcing these policies
         • Reporting to the health department suspected cases of infection caused by novel influenza strains during the Interpandemic and Pandemic Alert Periods
         • Measures to protect family and other close contacts from secondary occupational exposure
         • Establish a schedule for training/education of clinical staff and a mechanism for documenting participation. Consider using annual infection control updates/meetings, medical Grand Rounds, and other educational venues as opportunities for training on pandemic influenza.
         • Cross-train clinical personnel, including outpatient healthcare providers, who can provide support for essential patient-care areas (e.g., emergency department, ICU, medical units).
         • Train intake and triage staff to detect patients with influenza symptoms and to implement immediate containment measures to prevent transmission (see also Supplement 5).
         • Supply social workers, psychologists, psychiatrists, and nurses with guidance for providing psychological support to patients and hospital personnel during an influenza pandemic (see Supplement 11). (HHS agencies will identify or develop educational materials on: signs of distress, traumatic grief, stress management and effective coping strategies, building and sustaining personal resilience, and behavioral and psychological support resources.) If feasible, hospitals should also provide psychological-support training to appropriate individuals who are not mental health professionals (e.g., primary-care clinicians, leaders of community and faith-based organizations).
         • Develop a strategy for 搄ust-in-time?training of non-clinical staff who might be asked to assist clinical personnel (e.g., help with triage, distribute food trays, transport patients), students, retired health professionals, and volunteers who might be asked to provide basic nursing care (e.g., bathing, monitoring of vital signs); and other potential in-hospital caregivers (e.g., family members of patients).
           
           
         • Education of patients, family members, and visitors
           Patients and others should know what they can do to prevent disease transmission in the hospital, as well as at home and in community settings.
           • Identify language-specific and reading-level appropriate materials for educating patients, family members, and hospital visitors during an influenza pandemic. If language-specific materials are not available for the population(s) being served, arrange for translations.
           • Develop a plan for distributing information to all persons who enter the hospital. Identify staff to answer questions about procedures for preventing influenza transmission.
         
         

      4. Triage, clinical evaluation, and admission procedures

         During the peak of a pandemic, hospital emergency departments and outpatient offices might be overwhelmed with patients seeking care. Therefore, triage should be conducted to: 1) identify persons who might have pandemic influenza, 2) separate them from others to reduce the risk of disease transmission, and 3) identify the type of care they require (i.e., home care or hospitalization) (see Supplement 5).

         • Develop a strategy for triage, diagnosis, and isolation of possible pandemic influenza patients. Consider the following triage mechanisms:
           • Using phone triage to identify patients who need emergency care and those who can be referred to a medical office or other non-urgent facility
           • Assigning separate waiting areas for persons with respiratory symptoms
           • Assigning a separate triage evaluation area for persons with respiratory symptoms
           • Assigning a 搕riage coordinator?to manage patient flow, including deferring or referring patients who do not require emergency care (see Supplement 4 and Supplement 5).
         • Review procedures for the clinical evaluation of patients in the emergency department and in outpatient medical offices to facilitate efficient and appropriate disposition of patients.
         • Review admission procedures and streamline them as needed to limit the number of patient encounters in the hospital (e.g., direct admission to an inpatient bed).
         • Identify a 搕rigger?point at which screening for signs and symptoms of pandemic influenza in all persons entering the hospital will escalate from passive (e.g., signs at the entrance) to active (e.g., direct questioning). In addition to visual alerts, potential screening measures might include priority triage of persons with respiratory symptoms and telephone screening of patients with appointments.
         
         

      5. Facility access

         Hospitals should determine in advance the criteria and procedures they will use to limit access to the facility if pandemic influenza spreads through the community.

         • Define 揺ssential?and 搉on-essential?visitors with regard to the hospital and the population served. Develop protocols for limiting non-essential visitors.
         • Develop criteria or 搕riggers?for temporary closing of the hospital to new admissions and transfers. The criteria should consider staffing ratios, isolation capacity, and risks to non-influenza patients. As part of this effort, hospital administrators should: 1) determine who will make decisions about temporary closings and how and to whom these decisions will be communicated, and 2) consult with state and local health departments on their roles in determining policies for hospital admissions and transfers.
         • Determine how to involve hospital security services in enforcing access controls. Consider meeting with local law enforcement officials in advance to determine what assistance, if any, they can provide. Note that local law enforcement might be overburdened during a pandemic and have limited ability to assist healthcare facilities with security services.
         
         

      6. Occupational health

         The ability to deliver quality health care is dependent on adequate staffing and optimum health and welfare of staff. During a pandemic, the healthcare workforce will be stressed physically and psychologically. Like others in the community, many healthcare workers will become ill. Healthcare facilities must be prepared to: 1) protect healthy workers from exposures in the healthcare setting through the use of recommended infection control measures; 2) evaluate and manage symptomatic and ill healthcare personnel; 3) distribute and administer antiviral drugs and/or vaccines to healthcare personnel, as recommended by HHS and state health departments; and 4) provide psychosocial services to health care workers and their families to help sustain the workforce.

         • Managing ill workers
           
           • Establish a plan for detecting signs and symptoms of influenza in healthcare personnel before they report for duty.
           • Develop policies for managing healthcare workers with respiratory symptoms that take into account HHS recommendations for healthcare workers with influenza (see www.cdc.gov/ncidod/hip/GUIDE/infectcont98.htm
           • Consider assigning staff who are recovering from influenza to care for influenza patients.
         • Time-off policies
           Ensure that time-off policies and procedures consider staffing needs during periods of clinical crisis.
         • Reassignment of high-risk personnel
           Establish a plan to protect personnel at high risk for complications of influenza (e.g., pregnant women, immunocompromised persons) by reassigning them to low-risk duties (e.g., non-influenza patient care, administrative duties that do not involve patient care) or placing them on furlough.
         • Psychosocial health services (see also Supplement 11)
           • Identify mental health and faith-based resources for counseling of healthcare personnel during a pandemic. Counseling should include measures to maximize professional performance and personal resilience by addressing management of grief, exhaustion, anger, and fear; physical and mental health care for oneself and one抯 loved ones; and resolution of ethical dilemmas.
           • Determine a strategy for supporting healthcare workers?needs for rest and recuperation.
           • Develop a strategy for housing and feeding healthcare personnel who might be needed on-site for prolonged periods.
           • Develop a strategy for accommodating and supporting staff who have child- or elder-care responsibilities.
           
           

         • Influenza vaccination and use of antiviral drugs
           

           • Promote annual influenza vaccination among hospital employees. Increased vaccination coverage during the Interpandemic Period might help increase vaccine acceptance during a pandemic and will limit the spread of seasonal influenza.
           • Ensure that a system is in place for documenting influenza vaccination of healthcare personnel. The hospital might decide to enroll in the National Healthcare Safety Network (NHSN; www.cdc.gov/ncidod/hip/NNIS/members/nhsn.htm) to help track employee vaccination and health status.
           • Establish a strategy for rapidly vaccinating or providing antiviral prophylaxis or treatment to healthcare personnel as recommended by HHS and state health departments. Preliminary recommendations on the use of antiviral drugs and vaccination have been established (see Part 1, Appendix E and Supplement 6 and Supplement 7) but will need to be tailored to fit the epidemiology of the pandemic.
         
         

      7. Use and administration of vaccines and antiviral drugs

         • Pandemic influenza vaccine and 損re-pandemic?influenza vaccine
           Once the characteristics of a new pandemic influenza virus are identified, the development of a pandemic vaccine will begin. Recognizing that there may be benefits to immunization with a vaccine prepared before the pandemic against an influenza virus of the same subtype, efforts are underway to stockpile vaccines for subtypes with pandemic potential. As supplies of these vaccines become available, it is possible that some healthcare personnel and others critical to a pandemic response will be recommended for vaccination to provide partial protection or immunological priming for a pandemic strain. Policies for the use of pre-pandemic vaccine have not been finalized.

         • Interim recommendations on priority groups for vaccination and strategies for vaccine distribution are discussed in Supplement 6. During a pandemic, these recommendations will be updated, taking into account populations which are most at risk. In the interim, healthcare facilities should:

           • Monitor updated HHS information and recommendations on the development, distribution, and use of a pandemic influenza vaccine (http://www.pandemicflu.gov)
           • Work with local and state health departments on plans for distributing pandemic influenza vaccine.
           • Provide estimates of the quantities of vaccine needed for hospital staff and patients, as requested by the state health department.
           • Develop a stratification scheme for prioritizing vaccination of healthcare personnel who are most critical for patient care and essential personnel to maintain the day-to-day operation of the healthcare facility.
           • Develop a pandemic influenza vaccination plan in the hospital.
           
           

         • Antiviral drugs
           Antiviral drugs effective against the circulating pandemic strain can be used for treatment and possibly prophylaxis during an influenza pandemic. Because of the effectiveness of treatment with antiviral drugs such as oseltamivir and zanamivir, and the greater efficiency of treatment in a setting of limited supply, the use of prophylaxis will be restricted to maximize health benefits. Interim recommendations for the use of antiviral drugs are discussed in Supplement 7. Healthcare facilities should consider how antiviral drugs might be used in their patient and healthcare worker populations, taking into account state and national guidelines, and determine if a reserve supply should be stockpiled. (See also HRSA cooperative agreements www.hrsa.gov/grants/preview/guidancespecial/hrsa05001.htm.)

         
         

      8. Surge capacity

         Healthcare facilities should plan ahead to address emergency staffing needs and increased demand for isolation wards, ICUs, assisted ventilation services, and consumable and durable medical supplies (Box 2). Hospital planners can use FluSurge software (http://www.cdc.gov/flu/flusurge.htm) to estimate the potential impact of a pandemic on resources such as staffed beds (both overall and ICU) and ventilators (see also HRSA and AHRQ planning and surge capacity resources listed in Appendix 1.)

         • Staffing
           

           • Assign responsibility for the assessment and coordination of staffing during an emergency.
           • Estimate the minimum number and categories of personnel needed to care for a single patient or a small group of patients with influenza complications on a given day.
           • Determine how the hospital will meet staffing needs as the number of patients with pandemic influenza increases and/or healthcare and support personnel become ill or remain at home to care for ill family members. Consider the following options:
             • Assigning patient-care responsibilities to clinical administrators
             • Recruiting retired healthcare personnel
             • Using trainees (e.g., medical and nursing students)
             • Using patients?family members in an ancillary healthcare capacity
           • Collaborate with local and regional healthcare-planning groups in an attempt to achieve adequate staffing of the hospital during an influenza pandemic (e.g., decide whether and how staff will be shared with other healthcare facilities, determine how salary issues will be addressed for employees shared between facilities, and consider ways to increase the number of home healthcare staff to reduce hospital admissions during the emergency). State and local health departments can help assess the feasibility of recruiting staff from different hospitals and/or regions, working in coordination with federal facilities, including Veterans Administration and Department of Defense hospitals. Healthcare facilities may implement these arrangements through Mutual Aid Agreements (MAAs) or Memoranda of Understanding/Agreement (MOU/As).
           • Increase cross-training of personnel to provide support for essential patient-care areas at times of severe staffing shortages (e.g., in emergency departments, ICUs, or medical units) (see also S3-III.A.2.c).
           • Create a list of essential-support personnel titles (e.g., environmental and engineering services, nutrition and food services, administrative, clerical, medical records, information technology, laboratory) that are needed to maintain hospital operations.
           • Create a list of non-essential positions that can be re-assigned to support critical hospital services or placed on administrative leave to limit the number of persons in the hospital.
           • Consult with the state health department on plans for rapidly credentialing healthcare professionals during a pandemic. This might include defining when an 揺mergency staffing crisis?can be declared and identifying emergency laws that allow employment of healthcare personnel with out-of-state licenses.
           • Identify insurance and liability issues related to the use of non-facility staff.
           • Explore opportunities for recruiting healthcare personnel from other healthcare settings, (e.g., medical offices and day-surgery centers). Consult public health partners about existing state or local plans for recruitment and deployment of local personnel.
           
           

         • Bed capacity
           

           • Review and revise admissions criteria for times when bed capacity is limited (see also S3-III.A.2.e).
           • Develop policies and procedures for expediting the discharge of patients who do not require ongoing inpatient care (e.g., develop plans and policies for transporting discharged patients home or to other facilities; create a patient discharge holding area or discharge lounge to free up bed space).
           • Work with home healthcare agencies to arrange at-home follow-up care for patients who have been discharged early and for those whose admission was deferred because of limited bed space.
           • Develop criteria or 搕riggers?for temporarily canceling elective surgical procedures and determining what and where emergency procedures will be performed during a pandemic. Determine which elective procedures will be temporarily postponed.
           • Determine whether patients who require emergency procedures will be transferred to another hospital.
           • Discuss with local and state health departments how bed availability, including available ICU beds and ventilators, will be tracked during a pandemic.
           • Consult with hospital licensing agencies on plans and processes to expand bed capacity during times of crisis. These efforts should take into account the need to provide staff and medical equipment and supplies to care for the occupant of each additional hospital bed.
           • Discuss with healthcare regulators whether, how, and when an 揂ltered Standards of Care in Mass Casualty Events?will be invoked and applied to pandemic influenza (See http://www.ahrq.gov/research/altstand/).
           • Develop policies and procedures for shifting patients between nursing units to free up bed space in critical-care areas and/or to cohort pandemic influenza patients.
           • Develop Mutual Aid Agreements (MAAs) or Memoranda of Understanding/Agreement (MOU/As) with other local facilities who can accept non-influenza patients who do not need critical care.
           • Identify areas of the facility that could be vacated for use in cohorting influenza patients. Consider developing criteria for shifting use of available space based on ability to support patient-care needs (e.g., access to bathroom and shower facilities). Consider developing cohorting protocols based on a patient抯 stage of recovery and infectivity.
           
           
         • Consumable and durable supplies
           
           • Evaluate the existing system for tracking available medical supplies in the hospital to determine whether it can detect rapid consumption, including items that provide personal protection (e.g., gloves, masks). Improve the system as needed to respond to growing demands for resources during an influenza pandemic (http://www.cdc.gov/flu/flusurge.htm).
           • Consider stockpiling enough consumable resources such as masks (see Box 2) for the duration of a pandemic wave (6-8 weeks).
           • Assess anticipated needs for consumable and durable resources, and determine a trigger point for ordering extra resources. Estimate the need for respiratory care equipment (including mechanical ventilators), and develop a strategy for acquiring additional equipment if needed. Neighboring hospitals might consider developing inventories of equipment and determining whether and how that equipment might be shared during a pandemic.
           • Anticipate needs for antibiotics to treat bacterial complications of influenza, and determine how supplies can be maintained during a pandemic (see Supplement 5).
           • Establish contingency plans for situations in which primary sources of medical supplies become limited. Consult with the local and state health departments about access to the national stockpile during an emergency.
           
           
         • Continuation of essential medical services
           
           • Address how essential medical services will be maintained for persons with chronic medical problems served by the hospital (e.g., hemodialysis patients).
           • Develop a strategy for ensuring uninterrupted provision of medicines to patients who might not be able to (or should not) travel to hospital pharmacies.

      9. Security

         Healthcare facilities should plan for additional security. This may be required given the increased demand for services and possibility of long wait times for care, and because triage or treatment decisions may lead to people not receiving the care they think they require.

      10. Mortuary issues

          To prepare for the possibility of mass fatalities during an influenza pandemic, hospitals should do the following:

          • Assess current capacity for refrigeration of deceased persons.
          • Discuss mass fatality plans with local and state health officials and medical examiners.
          • Work with local health officials and medical examiners to identify temporary morgue sites.
          • Determine the scope and volume of supplies (e.g., body bags) needed to handle an increased number of deceased persons.
          
          

          Resources for addressing these issues are provided in Appendix 1.

2. Planning for provision of care in non-hospital settings

   Planning and effective delivery of care in outpatient settings is critical. Appropriate management of outpatient influenza cases will reduce progression to severe disease and thereby reduce demand for inpatient care. A system of effective outpatient management will have several components. To decrease the burden on providers and to lessen exposure of the 搘orried well?to persons with influenza, telephone hotlines should be established to provide advice on whether to stay home or to seek care. Most persons who seek care can be managed appropriately by outpatient providers. Health care networks may designate specific providers, offices, or clinics for patients with influenza-like illness. Nevertheless, some persons with influenza will likely present to all medical offices and clinics so that planning and preparedness is important at every outpatient care site. In underserved areas, health departments may establish influenza clinics to facilitate access. Hospitals should develop a strategy for triage of potential influenza patients, which may include establishing a site outside of the Emergency Department where persons can be seen initially and identified as needing emergency care or may be referred to an outpatient care site for diagnosis and management. Finally, home health care providers and organizations can provide follow-up for those managed at home, decreasing potential exposure of the public to persons who are ill and may transmit infection

   Effective management of outpatient care in communities will require that health departments, health care organizations, and providers communicate and plan together. Issues to address include:

   • Plan to establish and staff telephone hotlines.
   • Develop training modules, protocols and algorithms for hotline staff.
   • Within health care networks, develop plans on the organization of care for influenza patients and develop materials and strategies to inform patients on care-seeking during a pandemic
   • For clinics and offices, develop plans that include education, staffing, triage, infection control in waiting rooms and other areas, and communication with healthcare partners and public health authorities.
   
   

   1. Non-hospital healthcare facilities

      The hospital planning recommendations (see S3-III.A) can serve as a model for planning in other healthcare settings, including nursing homes and other residential care facilities, and primary care health centers. All healthcare facilities should do the following:

      • Create a planning team and develop a written plan.
      • Establish a decision-making and coordinating structure that can be tested during the Interpandemic Period and will be activated during an influenza pandemic.
      • Determine how to conduct surveillance for pandemic influenza in healthcare personnel and, for residential facilities, in the population served.
      • Develop policies and procedures for managing pandemic influenza in patients and staff.
      • Educate and train healthcare personnel on pandemic influenza and the healthcare facility抯 response plan.
      • Determine how the facility will communicate and coordinate with healthcare partners and public health authorities during a pandemic.
      • Determine how the facility will communicate with patients and help educate the public regarding prevention and control measures.
      • Develop a plan for procuring the supplies (e.g., personal protective equipment [PPE]) needed to manage influenza patients.
      • Determine how the facility will participate in the community plan for distributing either vaccine or antiviral drugs, including possibly serving as a point of distribution and providing staff for alternative community points of distribution.

      Emergency medical services, private homecare services, FQHCs, and rural health clinics may adapt their planning activities from this model. In some parts of the country, FQHCs and rural health clinics may need to rely on volunteers to provide and administer pandemic influenza vaccines.

3. Alternative care sites

   If an influenza pandemic causes severe illness in large numbers of people, hospital capacity might be overwhelmed. In that case, communities will need to provide care in alternative sites (e.g., school gymnasiums, armories, convention centers). (Also see http://www.ahrq.gov/research/altsites.htm.) The selection of alternative care sites for pandemic influenza should specifically address the following infection control and patient care needs:

   • Bed capacity and spatial separation of patients
   • Facilities and supplies for hand hygiene
   • Lavatory and shower capacity for large numbers of patients
   • Food services (refrigeration, food handling, and preparation)
   • Medical services
   • Staffing for patient care and support services
   • PPE supplies
   • Cleaning/disinfection supplies
   • Environmental services (linen, laundry, waste)
   • Safety and Security

S3-IV. Recommendations for The Pandemic Period

1. Activating the facility抯 pandemic influenza response plan

   Following initial detection of pandemic influenza anywhere in the world, the facility抯 pandemic influenza response plan should be activated in accordance with the level of pandemic activity (see Table).

   1. Pandemic influenza reported outside the United States

      If cases of pandemic influenza have been reported outside the United States, the main steps will be to:

      • Establish contact with key public health, healthcare, and community partners.
      • Implement hospital surveillance for pandemic influenza, including detection of patients admitted for other reasons who might be infected with the pandemic strain of influenza virus.
      • Implement a system for early detection and antiviral treatment of healthcare workers who might be infected with the pandemic strain of influenza virus.
      • Reinforce infection control measures to prevent the spread of influenza (see S5-IV.B and Supplement 4).
      • Accelerate the training of staff, in accordance with the facility抯 pandemic influenza education and training plan.
      
      

   2. Pandemic influenza reported in the United States

      If cases of pandemic influenza have been reported in the United States, additional steps will be to:

      • Identify when pandemic influenza cases begin in the community. See also Supplement 1.
      • Identify, isolate, and treat all patients with potential pandemic influenza. See also Supplements 4, 5, and 8.
      • Implement activities to increase capacity, supplement staff shortages, and provide supplies and equipment.
      • Maintain close communication within and among healthcare facilities and with state and local health departments.

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