Washington Post Staff Writer
Sunday, September 13, 2009

BALTIMORE -- It was a slow day for Maryland's hospitals. But one Baltimore emergency room and an intensive care unit were already maxed out. And the computer monitor tracking the ER and ICU at a medical center in nearby Washington was flashing yellow and red -- signaling that they, too, had run out of room. The next car crash victim would have to go elsewhere; the next heart attack patient risked losing precious minutes before getting lifesaving treatment.
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Disaster Plans Being Revised For Swine Flu
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Special Report: Swine Flu

As the second wave of H1N1 infections begins in the United States, scenes like this from the command center of the Maryland Institute for Emergency Medical Services Systems have federal, state and local health authorities nationwide scrambling. Even if swine flu remains a mild infection, the pandemic could be the tipping point for an emergency medical system teetering on the edge.

"The worry is, the health-care delivery system could be overwhelmed by people who are sick or think they are sick," said Kim Elliott of Trust for America's Health, a nonpartisan think tank and advocacy group.

In response, officials across the country are rewriting disaster plans and stocking up on masks, gowns, drugs and other supplies -- and inventing new strategies. One key line of attack will be encouraging people who are not really sick or are suffering only mild symptoms to recover at home. And in a move creating intense debate, experts are searching for ways to help health-care providers quickly screen those who do seek help and separate bad cases from less-severe ones.

The swine flu virus, also known as H1N1, could infect up to half the U.S. population, making as many as 1.8 million sick enough to need hospitalization, including as many as 300,000 who might need intensive care, according to a presidential advisory council estimate. Even though scientists reported Thursday that the vaccine appears to work much better than hoped, the second wave of U.S. infections is expected to peak next month -- well before the shots become widely available.

"There will be millions and millions of people seeking care in a relatively short period of time," said Eric Toner of the University of Pittsburgh's Center for Biosecurity, noting that the nation has only about 85,000 critical-care beds. "Only a small percentage of those people will require hospitalization and a small percentage will require intensive care. But it's still an awful lot of people."

The federal government is sending $350 million to state and local governments, including $90 million to help the nation's 4,897 hospitals and 3,829 emergency rooms prepare. In addition, the Strategic National Stockpile has more than 116 million masks, more than 52 million doses of antiviral drugs and 4,500 ventilators.

Federal officials are asking hospitals to report more current details about how stressed or well-equipped they are so the officials can help coordinate care in a crisis. They have also begun to count available ventilators, which could be crucial in caring for the sickest patients.

After the virus emerged in Mexico this spring and spread to the United States, many hospitals experienced a surge in patients, and some emergency rooms in New York City and elsewhere were overwhelmed. Experts say they expect the virus to linger longer this fall and winter, raising deep concern about whether the stockpiles of supplies, the contingency plans to improvise extra beds and backup plans to call up reserves of doctors, nurses and other health-care workers will be sufficient.

The first line of defense will be to persuade those with mild symptoms to stay home to minimize the spread of the virus and to make sure those who really need care receive it, while still providing treatment for the usual number of heart attack, gunshot and accident victims.

Federal, state and local health officials are planning multimedia campaigns -- including radio and television ads, subway signs, refrigerator magnets and Twitter feeds -- to convince Americans that they do not need to run to a doctor or emergency room at the first sign of cough or fever.

Many states and some cities are creating Web sites and hotlines for people to get information and, in some cases, talk to a nurse to find out what kind of care they need.

The second line of defense will be procedures to enable doctor's offices, clinics and public health centers to help as many patients as quickly as possible.

"What you do is identify patients who are at high risk and do a very focused set of questions that includes things like: 'Are you dehydrated? Are you short of breath?' It's very much a large-scale screening, like a mass vaccination in the schools where you line them up and keep them moving," said James M. Chamberlain of the Children's National Medical Center in Washington.

Chamberlain acknowledged that, although necessary, such procedures have risks: "We're going to be seeing thousands of children who are well, who are doing fine. I don't want to miss the one in a thousand who isn't doing fine. That's always the concern: missing the one sick kid who isn't doing well."

However, the nation's emergency physicians warn that such steps will be inadequate, calling it "imperative" that the Obama administration do more.

The American College of Emergency Physicians is urging the Department of Health and Human Services to endorse a nationwide protocol to help the public decide when to go to an emergency room, see a doctor within 48 hours or stay home. A national diagnostic standard, automated for use via the Internet or telephone call centers, could dramatically reduce unnecessary visits, officials said.

"It was not an easy thing for emergency physicians -- whose culture is, 'We are ready for everything; we can handle anything, anytime' -- to say that we as a group have to make a statement about people not coming to our emergency departments," said Lynne D. Richardson, chairman of ACEP's public health committee. "But it's clear to us we have to do that."

Some federal officials, however, worry about missing people who later become sick and die, creating liability risks. A government-endorsed triage tool could also appear to limit access to emergency care as Congress debates health-care reform.

"This is occurring in, I think, a highly charged environment where people are very concerned right now about denial of access to health care," said Jesse Goodman, chief scientist and deputy commissioner of the Food and Drug Administration, at an Institute of Medicine forum. "We have to do the right thing from the public health point of view, but we also have to consider this in the lens it's going to be viewed in."

In the meantime, many doctor's offices are planning to take steps on their own.

"We're going to be the ground zero of this thing," said Ted Epperly, president of the American Academy of Family Physicians, who runs a large family-medicine practice in Boise, Idaho. His office plans to bring in extra nurses to help diagnose conditions over the phone; put masks on suspected H1N1 patients as soon as they walk into the office and separate them from others; and give exposed workers antiviral drugs to protect them from becoming infected.

Large numbers of health-care workers getting sick would cripple the system. So hospitals, doctor's offices and other medical facilities are stocking up on antiviral drugs, masks and gowns, and are urging employees to get vaccinated against the regular seasonal flu as well as H1N1.

Facilities are also updating contingency plans developed over the past few years to deal with the much more deadly avian flu. Public health departments and hospitals could open flu clinics to divert patients from emergency rooms for treatment.

"Maybe the plan three years ago assumed people would use an abandoned shopping mall. But maybe that mall has been demolished or is back being a mall again and isn't available anymore," said Dora Anne Mills, Maine's public health director. "Or maybe now that it's more younger people being affected, it would be better to use a local college gym so we can be in a part of town where more patients are located."

In a worst-case scenario, some states, such as Iowa and California, have mobile hospitals consisting of a series of connected tents that they could rush to any area and erect, for example, on a football field.

Hospitals also have contingency plans that would enable them to convert other parts of their facilities into intensive care units. The Children's National Medical Center, for example, can convert any room in its new East Wing for critical care.

If hospitals are short of staff or overwhelmed with flu patients, they could also discharge other patients early and postpone non-emergency care, such as elective surgery.

Because H1N1 disproportionately affects children, many experts worry about the system's ability to handle a large number of pediatric patients. Many facilities do not typically stock medical equipment such as breathing tubes and intravenous tubes for children.

"Kids come in all shapes and sizes," said Joseph L. Wright of the American Academy of Pediatrics. "What could be real disaster is if you don't have equipment to fit the kid in front of you."

Staff writer Spencer S. Hsu contributed to this report.