H1N1 on the horizon: Here's how to prepare your practice -- and staff

Physicians are urged to be ready for potential employee and supply shortages, as well as a surge of patients.

By Victoria Stagg Elliott — Posted Sept. 7, 2009

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The exact number of people who will contact A(H1N1)-related illnesses is unpredictable. The disruption around the office when H1N1 hits is certain.

This fall and winter promise lots of patients sick with some kind of flu -- or fearful that they are -- as well as depleted staff levels when employees get sick or have to stay home with someone who is.

That's why experts are advising physicians to plan now for what is expected to be a very unusual, active flu season. Those who don't prepare will quickly be overwhelmed, said John Fontanesi, PhD, professor of medicine at the University of California, San Diego. He is working with the American Medical Association to create tools for physicians to make planning easier.

Beyond managing vaccine schedules, physician practices are advised to consider cross-training employees, having staff work from home, keeping those with H1N1 symptoms away from other patients, and even directing patients elsewhere to minimize disruption and illness spread.

The H1N1 virus is not more virulent than others, but because most people lack immunity to it, it has the potential to sicken large numbers. Most of these patients are likely to seek care at outpatient venues and not be so ill as to need hospitalization.

"We may actually see more of a surge in the number of visits to doctors' offices than hospitals," said Patrick O'Neal, MD, director of the division of emergency preparedness and response for the Georgia Dept. of Community Health.

Plan for regular flu, then go further

Experts say practices should use their usual plans for flu season as merely a baseline for handling the H1N1 season. Public health agencies and medical societies, including the American Medical Association, have numerous resources on this subject.

Plans should include strategies for informing patients -- and everyone working in the practice -- that they may need H1N1 immunization in addition to the usual vaccine for seasonal flu. Because H1N1 began attracting so much media attention with the first wave of illnesses in the spring, some physicians say encouraging vaccination is likely to be the easy part.

"People are running very scared," said Ryan Kauffman, MD, a family physician and partner in Oakhill Medical Associates in West Liberty, Ohio.

Plans need to include strategies for separating symptomatic patients in the office or even stopping them from coming in at all. A patient with respiratory symptoms needs to be at least three feet away from anyone else to reduce the risk of spread.

Dr. Kauffman, who has cared for a couple of patients infected with H1N1, used this approach: Patients were triaged by phone. When the nurse realized the patients possibly had the virus, they were given appointments and told to enter the practice through the back door.

When there are more cases than Dr. Kauffman's practice can handle in this manner, patients suspected of having H1N1 will be directed to the local hospital.

"The goal is to keep them out of the office, where we have many other patients," he said.

Experts also recommend posting signs educating patients about respiratory hygiene and cough etiquette. Alcohol-based hand rub should be widely available to staff and patients. During a pandemic, any items that patients may share but are unnecessary to medical care, such as toys or magazines in the waiting room, should be removed.

Any flu-season plans should address the possibility that a practice will have multiple employees -- including physicians -- out sick at the same time. Staff who have a suspected or diagnosed case of H1N1 should be encouraged to stay home for at least seven days or until they are well, whichever is longer, government guidelines suggest. This time is needed to prevent spread to patients and other staff, which would worsen absenteeism.

Also, with day care centers, schools and employers pushing symptomatic people to stay home, it's possible you will lose staff who have to take care of H1N1-afflicted (or H1N1-suspected) family members.

Preparing for staff outages

To stay operational, experts are advocating cross-training employees so staff can cover for each other as much as possible. Some employees also could be set up to work from their homes, allowing productivity from those who are well enough to work but for various reasons can't come in.

For example, the four coders and 15 other business people at Idaho Emergency Physicians, which staffs the emergency departments of several hospitals in that state, have been trained in each other's jobs and set up to do their work remotely if necessary. This took an investment of a few hundred dollars per employee to ensure data security, install software on personal computers or supply laptop computers.

"It was not that expensive, and this will be an advantage if we get a pandemic," said Tom Peterson, Idaho Emergency Physicians' CEO.

Some practices also are taking additional steps to reduce the chance that staff will have to take sick time this winter. Jason Terk, MD, senior consultant pediatrician at the Cook Children's Physicians Network in Keller, Texas, is giving seasonal flu shots to his staff as well as their spouses and children.

"This will reduce absenteeism during that time, and it's the right thing to do for our staff," said Dr. Terk, who also is a member of the Texas Medical Assn.'s Council on Public Health.

Medical practices also need to prepare for possible disruptions in the supply chains for various infection-control items, such as alcohol-based hand rubs and surgical masks. Distributors may have problems meeting the demand for these items.

"It might be better to have a little extra on hand," said Bruce Cadwallender, director of safety and emergency management at the University of Michigan Health System.

Physicians who are preparing say they have ordered anywhere from 10% to 50% more of these items than usual. Although this involves an initial cash investment, these items either have no expiration date or a rather long one, so physicians do not expect to lose money on them. If the additional supplies are not used to care for influenza patients, they eventually will be used in the course of usual medical practice.

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H1N1 prep checklist

Among the resources at the U.S. government's Web site is a checklist for medical practices. Among the specific tasks suggested:

Prepare to plan

  • Create a planning committee, or designate a responsible person, to specifically address pandemic influenza preparedness and incorporate it into emergency management plans.

Prepare your plan

  • Create a plan for surveillance and detection of pandemic influenza in the population served.
  • Develop a communication plan covering contact of local and state health departments, local and regional pandemic influenza entities, any health care entities with which the practice might have contact, and patients who have regularly scheduled visits that might need to be postponed or held at another point of care.
  • Develop a strategy for triage and management of patients.
  • Have an infection-control plan.
  • Develop strategy for vaccine and antiviral use.
  • Determine sick leave policy for your staff. A liberal/nonpunitive policy is recommended for staff with symptoms or documented illness, and for those who need to care for ill family members. This plan should also include a system for offering vaccines to staff and for evaluating their symptoms before they report for duty. Also include mental health and faith-based resources available to provide counseling as needed.
  • Address issues related to a potential influx of patients and supply shortages.

Prepare to carry out your plan

  • Determine the organizational structure (lines of authority) that will be used to put the plan into effect.
  • Incorporate and complement the community response plan.

Source: U.S. government (link)

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External links

American Medical Association resources on H1N1 (link)

Federal government resources on H1N1, avian and pandemic flu (link)

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