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Pediatric Integrated Delivery System's Experience With Pandemic Influenza A (H1N1)
Evan S. Fieldston, MD, MBA, MSHP; Richard J. Scarfone, MD; Lisa M. Biggs, MD; Joseph J. Zorc, MD, MSCE; and Susan E. Coffin, MD, MPH
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Pediatric Integrated Delivery System's Experience With Pandemic Influenza A (H1N1)

Evan S. Fieldston, MD, MBA, MSHP; Richard J. Scarfone, MD; Lisa M. Biggs, MD; Joseph J. Zorc, MD, MSCE; and Susan E. Coffin, MD, MPH
Experience of a pediatric integrated delivery system with the surge from the 2009 H1N1 pandemic is described, emphasizing scale, scope, and flexibility at multiple locations.
Objective: To describe 1 pediatric integrated delivery system’s experience with the influenza A (H1N1) pandemic in 2009 to illustrate the benefits of coordination, scale, scope, and flexibility in handling large volumes of patients in many locations.


Methods: Through multidisciplinary planning across a large, multisite pediatric delivery system, an effective 3-tier plan was developed to handle anticipated increased volumes associated with the fall 2009 influenza pandemic in the Philadelphia region.


Results: Patient demand for services increased to record-setting levels, particularly for emergency department visits and phone calls. The 3-tier plan of response allowed for graded and appropriate response to volumes that more than doubled in many locations. Measured by wait times and leftwithout- being-seen rates, the system appeared to match capacity to demand effectively. Lessons learned in terms of successes and challenges are useful for future planning.


Conclusions: The experience of 1 pediatric delivery system in handling increased volume due to pandemic influenza may hold lessons for other organizations and for policy makers seeking to improve the preparedness, quality, and value of healthcare. These experiences do not imply the need for vertical integration with ownership, but do support tight coordination, communication, integration, and alignment in any management structure.


(Am J Manag Care. 2012;18(10):635-644)
A 3-tier plan of response was developed by an integrated pediatric delivery system to handle anticipated increased volumes associated with the fall 2009 influenza A (H1N1) pandemic in the Philadelphia region.


  • The 3-tier plan allowed for graded and appropriate response to volumes that more than doubled in many locations.

  • Measured by wait times and left-without-being-seen rates, the system appeared to match capacity to demand effectively.

  • The experiences of this system support tight coordination, communication, integration, and alignment of resources across multiple locations and provider types.
An integrated delivery system (IDS) is a network of physicians and hospitals that provides a continuum of healthcare services.1 Although integration is promoted primarily for general system improvement and accountable care,2,3 its utility may be particularly relevant to managing care delivery during a pandemic, a period when surge capacity is tested.4,5 The Agency for Healthcare Research and Quality defines surge capacity as “A healthcare system’s ability to rapidly expand beyond normal services to meet the increased demand for qualified personnel, medical care and public health in the event of large-scale public health emergencies or disasters.”6 At the 2006 Academic Emergency Medicine Consensus Conference, a special breakout session titled “Science of Surge Capacity” was convened to define the essential components of surge capacity and outline key considerations when planning for large-scale public health emergencies.7 Three essential elements were described in the resulting conceptual model: staff, stuff (equipment, pharmaceuticals, and supplies), and structure (both physical structure and management infrastructure). In situations that exceed available human or physical resources, the latter element—an organization’s ability to effectively match resources to patient care needs—becomes paramount.

Like other institutions, particularly since 2001, The Children’s Hospital of Philadelphia (CHOP), an IDS dedicated to pediatric care, has focused attention on preparedness and surge capacity across its geographic network with particular concern for these 3 elements. CHOP’s experience with the influenza A (H1N1) pandemic of 2009 illustrates the benefits of an IDS in the face of a pandemic. Using the Academic Emergency Medicine Consensus Conference conceptual model of staff, stuff, and structure as a framework for our experience, we detail the planning and execution, operational experiences, and lessons learned. It is our hope that these insights will inform health system leadership, clinicians, and policy makers as they plan for future infectious and noninfectious surges of activity.

SETTING AND PREPARATORY WORK

The Children’s Hospital of Philadelphia has centralized management of primary, specialty, and tertiary pediatric care facilities. For the fiscal year that included fall 2009, CHOP had a 459-bed main hospital, a 70-bed emergency department (ED), 28 primary care centers, and 9 specialty care facilities (Figure 1). Employing more than 9900 personnel, the CHOP network serves approximately 30% of the 1.6 million children in the Delaware Valley region via more than 1.1 million patient visits each year, including 85,690 ED visits and 28,106 hospitalizations. CHOP owns all hospital and practice locations, and employs all staff directly (except 670 faculty physicians employed by affiliated University of Pennsylvania practice plans). CHOP also operates the After Hours Program (AHP), a service designed to have specially trained nurses provide telephone triage, assessment, and advice using computerized, standardized protocols for a parent concerning their ill child. The AHP handles more than 100,000 calls per year.

In February 2009, prior to the influenza A (H1N1) outbreak in Mexico, administrative and clinical leadership from emergency medicine, general pediatrics, and primary care began routine planning for high wintertime nonurgent volume. Soon after this group convened, H1N1 emerged worldwide and spread in spring 2009, ultimately affecting enough children and adults to be classified as a pandemic.8-12 In Philadelphia, the first H1N1-infected patient was identified in April. From April to June, CHOP ED and inpatient areas saw higher volumes than typical for the season, and there was a spike in influenza A–positive respiratory viral tests (eAppendix, available at www.ajmc.com). Based on guidance from CHOP and Centers for Disease Control and Prevention infectious disease experts, as well as on international experiences with H1N1, CHOP clinicians anticipated that a second wave of infection would emerge in the late summer or fall concordant with the return of children to school.13 In response, in May 2009, CHOP’s Strategic Planning office initiated planning activities to prepare CHOP’s multisite network for a second, even larger surge of H1N1-related activity. The office convened a special meeting of representatives from inpatient and outpatient clinical areas, Environmental Services, Facilities, the Patient Access and Revenue Cycle division, and Security. CHOP’s Emergency Preparedness team took a central role in plan development and coordination of effort across the institution. At their direction, key areas, including the main hospital, ED, pediatric intensive care unit (PICU), primary care centers, and AHP developed 3-tier (green-yellow- red zone) plans for handling successive levels of high volume (Figure 2, Table). Such “traffic-light” graded response schemata are commonly used in clinical and operational care to summarize graded responses.14,15

PLAN EXECUTION

During the 3-week period from October 19 to November 10, 2009, the entire CHOP system experienced H1N1-related high volumes, with specific locations experiencing several days of double the typical volumes for visits or calls. This 3-week period (the surge) coincided with Centers for Disease Control and Prevention influenza surveillance reports of high levels of H1N1 activity in region 3, which includes Philadelphia.16

Staff and Structure

Ambulatory Care and Phone Triage:
Patients from CHOP’s 4 urban practices are frequent users of the CHOP ED, often for nonurgent visits. As such, most ambulatory planning focused on these centers and the AHP phone triage system that services them (Figure 2). During the surge, these urban primary care centers operated in the yellow zone, with visit volumes exceeding prior peak winter volumes on a daily basis (Figure 3). Practices met demand by maximizing clinic work time, reducing administrative time, extending office hours, and replacing nonurgent follow-up visits and older child preventive care slots with acute/same-day visits. Additional strategies included expanding office hours through early opening, scheduling of patients during lunch hours, and extending weekend hours. Practices reassigned resident precepting duties, freeing attending physicians to meet real-time demands in the ED on an as-needed basis. Outpatient volume never officially triggered the red zone. Practices canceled nonurgent or preventive care visits sporadically at only 2 sites. The Children’s Hospital of Philadelphia’s suburban primary care practices added appointments as needed but did not utilize a formal 3-tier plan. Urban and suburban specialty clinics did contribute physicians to increase ED functional capacity, but did not have specific plans for increasing office capacity. Only CHOP clinicians provided services.

For the urban practices, numbers of daytime phone calls surpassed prior peak winter call numbers by 50% to 100% (Figure 3). Home access to the electronic medical record allowed part-time nursing and physician staff to respond to many nonurgent patient calls, AHP staff provided additional daytime coverage of incoming phone calls, and residents on primary care rotations were diverted to help answer calls when phone volume outpaced available respondents. Additionally, automated messages directed patients to online educational sites that addressed common influenza-related questions. Suburban practices had limited trunk lines and phone tree capabilities, and so did not have as much flexibility to support messaging, rerouting of calls, or daytime assistance by AHP staff. As a result, some suburban patients faced prolonged wait times and/ or had difficulty getting through to a CHOP provider.

The AHP operated in the yellow zone throughout the surge, handling 12,348 calls in October 2009 and 10,154 calls in November 2009 (vs 8128 in September 2009 and 8930 in December 2009). From October 18 to November 15, the AHP handled an average of 368 calls per day (SD 33.6), whereas in the corresponding 4 weeks before and after the surge, it handled a mean of 236 calls (SD 14; P <.001) and 242 calls (SD 8.7; P <.001) per day, respectively. During the busiest week (October 25-31, 2009), AHP providers handled a mean of 415 calls per day. The AHP met the increased demand by creating on-hold messages to answer common influenza-related and non–influenza-related questions, streamlining call scripts, splitting and staggering shifts to improve staffing during high call volume times, shifting report writing to slower periods, and using physicians to handle some calls. After Hours Program staff members had access to primary care appointment slots within 24 hours.

Main Hospital Emergency Department. In preparation for the pandemic, ED leadership outlined plans to open additional space, ensure adequate staffing, and improve work flow (Figure 2). To increase capacity for low-acuity patients (with and without suspected H1N1), a newly renovated 14-room ambulatory subspecialty clinic space near the ED was staffed on weekends and from 6 to 11 pm on weekdays by paid physicians from general pediatrics, primary care, adolescent medicine, and emergency medicine, as well as by paid ambulatory nurses. In addition, Department of Pediatrics attending physicians (regardless of specialty) were asked to volunteer to provide care to low-acuity patients during 6 newly created 6-hour ED shifts each day. Volunteer physicians signed up for these shifts via a webbased Google document,17 on average covering 5 to 6 extra 6hour shifts each day. These 2 additional options for nonurgent care increased ED peak bed count to 80, a 38% increase over regular peak bed capacity. During the surge, higheracuity ED patients were cared for in the ED’s 10bed extended care unit. In anticipation of staff illness, the ED and residency program created robust sickness relief programs to ensure adequate staffing.18

During the 3-week surge period, ED patient visits rose 48% compared with the previous year, with 7793 children arriving for ED care (Figure 4). In the corresponding fall 2008 calendar period, 2597 fewer patients were seen and mean daily visits were only 225 compared with a mean of 339 during the surge (P <.001). The 2009 surge exceeded all other previous high winter volume periods.

Of the patients seeking care during the surge, 603 (23%) were cared for in the evening and weekend subspecialty clinic space. Most of the increased ED volume was for infl uenzarelated illness or influenza-like symptoms, but few children who did not require hospitalization were tested for influenza (consistent with prior practice patterns at CHOP). Diagnostic testing using the multiplex-PCR assay was performed on the majority of patients requiring hospitalization. Rapid influenza diagnostic testing was not adopted due to poor sensitivity and specificity.19 The ED operated in its red zone for virtually the entire 3week surge period. Details of CHOP’s ED logistics during the pandemic are discussed at length by Scarfone et al.18

 
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