Boston Medical Center Pediatric Emergency Response to H1N1

PEDIATRIC UPDATE

BOSTON MEDICAL CENTER PEDIATRIC EMERGENCY RESPONSE TO H1N1 Authors: Maureen Curtis Cooper, BSN, RN, CPEN, CEN, FAEN, Kathleen Walz, BSN, RN, Mirinda G. Brown, BSN, RN, Kathleen McDonald, BSN, RN, CPEN, Dena Dwyer, BSN, RN, Patricia Dowd, BSN, MSN, RN, Kathleen Byrne, BSN, RN, and Michelle Griffin, BSN, RN, Boston, MA Section Editors: Donna Ojanen Thomas, RN, MSN, Joyce Foresman-Capuzzi, BSN, RN, CEN, CPN, CTRN, and Michelle Tracy, RN, MA, CEN, CPN

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andemic H1N1 is an influenza virus that was first detected in the United States in April 2009. On June 11, 2009, the World Health Organization raised the worldwide pandemic alert level to phase 6, indicating a global pandemic is under way.1 The Centers for Disease Control and Prevention (CDC) reported that Massachusetts had a regional H1N1 outbreak, with 1287 confirmed cases (928 cases in which the patient was younger than 24 years of age) and 4 deaths.1 This article will review the response of Boston Medical Center (BMC) Pediatric Emergency Department (PED) to the rapid increase in patient volume caused by the regional outbreak of H1N1. BMC, located in Boston, Massachusetts, is a universityaffiliated inner-city teaching hospital and New England’s busiest level I trauma center with 129,000 annual patient visits (100,000 adult visits and 29,000 pediatric visits). Maureen Curtis Cooper, Member, Beacon Chapter, is Staff Nurse, Boston Medical Center Pediatric Emergency Department, Boston, MA. Kathleen Walz, Member, Beacon Chapter, is Staff Nurse, Boston Medical Center Pediatric Emergency Department, Boston, MA. Mirinda G. Brown is Staff Nurse, Boston Medical Center Pediatric Emergency Department, Boston, MA. Kathleen McDonald, Member, Beacon Chapter, is Staff Nurse, Boston Medical Center Pediatric Emergency Department, Boston, MA. Dena Dwyer is Staff Nurse, Boston Medical Center Pediatric Emergency Department, Boston, MA. Patricia Dowd is Pediatric Emergency Department Nurse Manager, Boston Medical Center Pediatric Emergency Department, Boston, MA. Kathleen Byrne is Staff Nurse, Boston Medical Center Pediatric Emergency Department, Boston, MA. Michelle Griffin is Staff Nurse, Boston Medical Center Pediatric Emergency Department, Boston, MA. For correspondence, write: Maureen Curtis Cooper, BSN, RN, CPEN, CEN, FAEN, Boston Medical Center Pediatric Emergency Department, 21 John St, Boston, MA 02148; E-mail: [email protected]. J Emerg Nurs 2009;35:580-3. Available online 29 August 2009.

The city of Boston, Massachusetts, responded to the H1N1 flu epidemic by asking its residents to familiarize themselves with factual information about the illness and to take preventative measures such as practicing good hand hygiene and wearing personal protective equipment.2 By June 2009, 20 Boston schools were temporarily closed to prevent and control the spread of the illness.3 At schools that remained open, students who had flu-like symptoms were asked to stay home for 7 days. Many concerned parents arrived in the PED because they feared their child had been exposed, and others requested clearance to return their child to school because they could not afford the economic impact of the 7-day work/school absence. The Boston Public Health Commission worked in conjunction with state and federal agencies to keep a close surveillance on the situation.4 BMC provided a daily update on its internal Web page to keep employees informed about pertinent H1N1 influenza information, including updates on criteria for flu testing as the pandemic evolved. Different guidelines were provided by the CDC and other government Web sites regarding which level of personal protective equipment to utilize, droplet or airborne precautions.5-7 The constant confusion about which level of precautions health care providers should use led to a shortage of the N95 respiratory mask. Background

BMC PED is a 16-bed unit with a triage room, 11 nonacute rooms, a 4-bed acute area, one fast track room, and one trauma room. The PED has a different staff and is geographically separate from the BMC adult emergency department. Ordinarily, there is one triage nurse. If 6 to 8 patients are waiting to be triaged, the triage nurse asks for another nurse to assist with vital signs and physical examination while the triage registered nurse (RN) enters the patient data into the electronic documentation and tracking system. We call this stepped up triage our “tag team” approach to triage.

0099-1767/$36.00 Copyright © 2009 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2009.07.011

The Volume Surge

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The PED’s weekly volume is typically 560 patients. The weekly volume of patients increased significantly for a

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FIGURE 1 The Pediatric Emergency Departments weekly volume is typically 560 patients. As the above chart indicates, the weekly volume of patients increased significantly for a 7 week period during the H1N1 pandemic peaking at 865 patients. This figure can be viewed in color and as a full-page document at www.jenonline.org.

7-week period during the H1N1 pandemic, peaking at 865 patients (Figure 1). The new surge in our census required us to be creative in managing the care of a large volume of patients arriving at triage. In the first weeks of the surge in volume, we established a second fully independent triage location in the fast-track room staffed by an RN from a non-acute area. The 2 independent triage nurses provided a more efficient assessment of waiting children, prioritized patients earlier, and decreased the waiting time for patients to be triaged. Despite the addition of a second triage nurse, the volume of patients waiting to be evaluated by a physician remained seriously high and a concern. After the fifth week, our volume peaked at 865 patients. The medical director of the PED, the pediatric nursing director, the BMC disaster coordinator, and the nurse manager of the PED met to formalize a disaster management strategy. The goals were to provide efficient safe care and to decompress the waiting room. The decision was made to open a Surge Clinic during the busiest time, 10 AM to 10 PM. Specific criteria for the Surge Clinic visits were that the patient must not require a full flu workup or septic pathway level of care and the visit must be completed in 15 minutes. The Challenges/Solutions

FIGURE 2 Surge Clinic desk area. This figure can be viewed in color and as a full-page document at www.jenonline.org.

LOCATION OF THE CLINIC

The department ran out of space and seating for the volume of patients arriving in the PED. An adjacent conference room immediately outside the PED was converted. The conference table was replaced with 3 cots with privacy curtains, a “desk” for documentation with computer access, and a rolling supply shelf (Figures 2 and 3). Some downfalls were that the cots were low to the floor, the privacy blinds provided only visual privacy, and there was no capability for respiratory isolation in the clinic. TRIAGE SYSTEM MODIFICATIONS

A non-PED BMC pediatrician, a PED nurse, and a certified nursing assistant staffed the surge clinic. Each physician of the BMC Department of Pediatrics was asked to staff the clinic for one 4-hour shift. The PED nurses and PED certified nursing assistants volunteered for extra 4-hour paid time slots.

The triage nurse needed to follow new triage guidelines and possess a clear understanding of the logistics of the new “wing” of the emergency department. The triage nurse became responsible for deciding which patients met the criteria, flagging them as Surge Clinic, and moving the flagged patients through the new surge clinic registration process. Each shift, the triage nurse met with the surge clinic team to review lessons learned from prior shifts and the logistics of the clinic.

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nurses and the Department of Pediatric physicians. The majority of the Surge Clinic physicians and the PED nurses had never met or worked together. The physicians only worked once, for a 4-hour shift. The emergency nurses in the PED were very committed and eager to make the Surge Clinic successful for the sake of safe patient care. Lessons Learned

For future surges in volume, we would mobilize the Surge Clinic at an earlier stage and pay more attention to supply par levels, anticipating those needing to be increased, such as respiratory masks, ibuprofen, juice, and laundry. Ergonomically, we would not use cots and would reduce the number of beds in the unit to 2. Additionally, we would create a holding area for patients treated by the surge physicians but who were waiting for test results to free up the bed space. The waiting area was implemented as a result of suggestions made during one of the shift meetings to evaluate our process. Future Implications

FIGURE 3 Surge Clinic note projector in ceiling. This figure can be viewed in color and as a full-page document at www.jenonline.org.

PATIENT DOCUMENTATION

The physicians covering the surge clinic did not have access or training on the ED computer system. It was necessary for the surge clinic patients to be registered on the paper system. When the triage nurse deemed a patient appropriate for the Surge Clinic, their acuity was entered as “express care,” and “Surge Clinic” was noted in the comment section. The registration clerks received in-service sessions each day to be aware of patients with these cues. The PED RN became responsible for entering, documenting, and moving the patient within the computerized system. The physicians documented on paper charts, which are used during our computer downtime protocol, and the charts were later scanned into the database.

We have demonstrated that our department has surge capability. We have tested the ability of other departments to support the PED when volume has overtaxed our system. Infection control experts predict a re-emergence of H1N1 in the fall of 2009. Our department will stand at the ready to meet patient volume demands. Our model is flexible to respond to other events such as natural and human-made disasters, which would increase the need for emergency medical care. This model can be implemented quickly in response to a surge in patient volume. Our department had chosen to swim instead of drown and has arrived stronger and wiser for the challenge with new tools that we can apply to any surge event. REFERENCES

The success of the Surge Clinic was due to the strong collaborative team-building efforts between the PED emergency

1. Centers for Disease Control and Prevention. H1N1 flu (Swine Flu): a pandemic is declared. Available at: http://www.cdc.gov/ H1N1FLU/. Accessed July 2, 2009. 2. Auerbach J. Letter from the Commissioner. Available at: http:// www.mass.gov/Eeohhs2/docs/dph/cdc/flu/swine_letter_20090427. pdf. Accessed June 19, 2009. 3. Boston Public Health Commission Influenza H1N1 (Swine Flu) information for parents and caregivers. Available at: http:// www.bphc.org/programs/infectiousdisease/infectiousdiseasesatoz/ influenza/swineflu/partentscaregivers/Pages/Home.aspx. Accessed June 22, 2009. 4. Boston Public Health Commission. Info for parents and caregivers. Available at: http://www.bphc.org/programs/infectiousdisease/

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Available at: http://publichealth.blog.state.ma.us/h1n1-swine-flu/. Accessed July 2, 2009.

infectiousdiseasesatoz/influenza/swineflu/Pages/Home.aspx. Accessed June 16, 2009. 5. Executive Office of Health and Human Services. Weekly report on novel H1N1 influenza (Swine Flu) as of June 18, 2009. Available at: http://www.mass.gov/?pageID=eohhs2terminal&L= 6&L0=Home&L1=Provider&L2=Guidelines+and+Resources& L3=Guidelines+for+Services+%26+Planning&L4=Diseases+and+ Conditions&L5=Influenza&sid=Eeohhs2&b=terminalcontent& f=dph_cdc_c_flu_swine&csid=Eeohhs2. Accessed June 19, 2009. 6. World Health Organization pandemic H1N1 2009 guidance documents. Available at: http://www.who.int/csr/disease/swineflu/en/ index.html. Accessed July 2, 2009. 7. Massachusetts Department of Public Health H1N1 Swine Flu.

Submissions to this column are encouraged and may be sent to Donna Ojanen Thomas, RN, MSN [email protected] or Joyce Foresman-Capuzzi, BSN, RN, CEN, CPN, CTRN [email protected] or Michelle Tracy, RN, MA, CEN, CPN [email protected]

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