Lack of Hospital Surge Capacity Still a Problem - by Anthony L. Kimerly

Report highlights importance of surge capacity for pandemic, mass casualties A new report by Trust for America’s Health (TFAH) concluded “that 15 states could run out of available hospital beds during the peak of the outbreak [of the H1N1 influenza virus now spreading across the nation] if 35 percent of Americans were to get sick" from this flu virus. “Twelve additional states could reach or exceed 75 percent of their hospital bed capacity, based on estimates from the FluSurge model developed by the Centers for Disease Control and Prevention (CDC),” the TFAH report, “H1N1 Challenges Ahead," concluded. Meanwhile, a report released by the American College of Emergency Physicians disclosed that nearly 90 percent of doctors said in response to a survey in September that they were concerned or very concerned about their hospital’s ability to handle a surge of H1N1 patients. This could quickly pose problems for many hospitals as serious H1N1 cases mount. During the last six months, more than a million Americans have been stricken with the H1N1 influenza virus and more than 10,000 have had to be hospitalized. About 1,000 have died, including 76 children. And flu season has just begun. It runs through next spring. Because of the risk that H1N1 seems to pose to young and at-risk children in particular, many more children could die than the 76 who've so far been killed by the virus, which is a number that appears to be a higher rate than pediatric deaths caused by traditional seasonal flu strains. In other words, many more children could die from H1N1 over the next six to seven months than die from seasonal influenza if they are not soon vaccinated. "We've already had 76 children dying from the 2009 H1N1 virus, and it's only the beginning of October," Anne Schuchat, head of CDC’s National Center for Immunization and Respiratory Diseases, told reporters last week. Also at risk are pregnant women. Officials believe at least 28 pregnant women who contracted H1N1 died from the virus or from complications arising from their flu infection. At least 37 states are reporting widespread H1N1 infections, up from 27 just a week ago. While the number of cases appears to be declining in some areas, it is increasing in others, and could continue to rise and fall in these places – as well as across the nation. "It's hard to know how many waves we're going to have into the fall, winter and spring," Schuchat said. "We still think the vast majority of people in a given community are vulnerable or susceptible to this virus ... Unfortunately, we do expect more illness, including more hospitalizations and deaths, to be occurring in the weeks ahead." Given that we’re just beginning to see the ravages of a full blown H1N1 pandemic season, authorities say it’s not a leap to extrapolate the possible numbers of most at-risk people who could be infected over the next six to seven months and to calculate the possible strain that this could put on the nation’s hospitals' ERs and intensive care units. Last April, for example, when H1N1 infections first erupted in the US, adults arriving with flu-like symptoms at New York’s Montefiore Medical Center's ER - one of the nation's busiest emergency rooms - rose 20 percent. Child ER visits jumped 40 percent. Similar situations were experienced by ERs across the nation. According to a study published last week in the New England Journal of Medicine, H1N1 was responsible for a 15-fold increase in intensive care admissions for viral lung inflammation in Australia and New Zealand, especially among pregnant women, people with chronic lung disease, and people who are obese. H1N1 patients filled 8.9 percent to 19 percent of all intensive-care hospital beds in each state in Australia and New Zealand, while nearly 65 percent of intensive-care H1N1 patients required ventilators. Similarly, severely ill patients in Mexico and Canada were in intensive care units on ventilators for nearly two weeks, according to reports published in the Journal of the American Medical Association. About 17 percent of the Canadian patients and 41 percent of the Mexican patients reportedly died and, in both countries, hospitals' ICU capacities were strained. Authorities in the US are bracing for a possible surge in hospital and ER/ICU admissions and a sudden draw down on resources, especially ventilators, if large numbers of H1N1-sickened persons require mechanical ventilation to survive. But studies such as one conducted in 2006 by the Trauma Center Association of America (TCAA) revealed that in the event of a mass casualty event in which many patients require ventilators, the majority of hospitals that responded to the TCAA survey reported that they would quickly run out, with few hospitals having plans in place to acquire additional ventilators. Numerous authorities HSToday.us talked to said it’s possible that the H1N1 pandemic could be the first nationwide test of national hospital surge capacity limits, the importance of which can’t be overstated when it comes to being prepared for mass casualties. For years, Homeland Security Today and HSToday.us have been reporting on the nation’s inadequate hospital surge capacity. In a two-part series a year ago, HSToday.us reported that inadequate surge and mass casualty trauma care capacity remains a problem nationwide. [Editor’s note: Also see the July 2007 report, “Seeking to Surge,” and the May 2004 feature, “The Trauma in America’s Trauma Care”] “Surge capacity … is one of the most serious remaining challenges for emergency health preparedness,” the TFAH report stressed, noting that “health care providers and hospitals could be quickly overrun or overextended during the H1N1 outbreak, even though it is currently a mild strain of flu, and the plans and capacities to deal with this influx are limited.” The report stated that “federal, state, local, and health system officials will have to continue to clearly communicate with the public as to which groups are urged to seek rapid care and who should practice sound selfcare measures and stay home when ill. The TFAH report stated “one of the biggest ongoing challenges health officials face is that preparations are taking place in the context of a public health system that has been chronically underfunded for decades. Many core systems and capabilities are lagging behind where they should be or could be, which leaves the nation unnecessarily vulnerable during times of emergency. The concurrence of lost workforce due to the economic recession, the continuing need to address other pressing public health issues simultaneously with a pandemic, and the diversion of health department employees to the H1N1 response have placed a severe strain on the public health system.” In short, the nation’s public health infrastructure is eroding. The TFAH report “examines the series of challenges the country faces in preparing to deal with the complications that an H1N1 outbreak adds to this flu season related to medical care capacity, antiviral medications, disease surveillance, vaccinations, budget cuts at public health departments, and caring for people in communities, particularly meeting the special needs of at-risk populations, and provides a series of recommendations for how to address preparedness gaps.” The report “estimates that the number of people hospitalized could range from a high of 168,025 in California to a low of 2,485 in Wyoming, and many states may face shortages of beds or may need to reduce the number of non-flu related discretionary hospitalizations due to limited hospital bed availability. The numbers of people who get sick could range from a high of 12.9 million in California to a low of 186,434 in Wyoming, if 35 percent of Americans were to get H1N1.” The TFAH report made the following estimates of hospital bed capacity at five weeks into a pandemic based on CDC’s FluSurge using expert predictions that H1N1 is a relatively mild strain of the flu and that up to 35 percent of Americans could potentially become sick with H1N1: Fifteen states would be at or exceed hospital bed capacity: Arizona (117 percent); California (125 percent); Connecticut (148 percent); Delaware (203 percent); Hawaii (143 percent); Maryland (143 percent); Massachusetts (110 percent); Nevada (137 percent); New Jersey (101 percent); New York (108 percent); Oregon (107 percent); Rhode Island (143 percent); Vermont (108 percent); Virginia (100 percent); and Washington (107 percent). Twelve states would be at 75 to 99 percent of their hospital bed capacity: Colorado (88 percent); Florida (80 percent); Georgia (78 percent); Maine (83 percent); Michigan (79 percent); New Hampshire (84 percent); New Mexico (93 percent); North Carolina (95 percent); Pennsylvania (77 percent); South Carolina (93 percent); Utah (83 percent); and Wisconsin (75 percent). (Analyst's note:  A troubling assessment. We will not likely have to wait long to see how accurate these predictions are.)