Pediatric Integrated Delivery System’s Experience With Pandemic Influenza A (H1N1) | Page 2

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

The average time patients waited to be seen by an ED physician during the surge was less than that during the prior winter’s period of maximal infl uenza activity (Figure 5). Overall, 400 (5.1%) patients arriving for ED care during the surge left without being seen by a physician; none had been triaged as critical and only 16 had been triaged as acute (n =1761, yielding a leftwithoutbeingseen rate of 0.9%). Although that was twice the 2009 average left-without-being-seen rate, fewer patients left without being seen during the fall 2009 surge than during the high-respiratoryvolume month of February 2009 (eAppendix), when the leftwithoutbeingseen rate was 8%. For admitted patients and those discharged to home, the total ED length of stay was either unaffected or comparable to that of prior high-volume periods. The ED did not go on divert status.