The American Journal of Managed Care
October 2012
Volume 18
Issue 10

Pediatric Integrated Delivery System's Experience With Pandemic Influenza A (H1N1)

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.


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.


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.


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.


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.


Figure 1

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 (). 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.


Figure 2


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 (, available 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 (, ). Such “traffic-light” graded response schemata are commonly used in clinical and operational care to summarize graded responses.14,15


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

Figure 3

Staff and StructureAmbulatory 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 (). 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

Figure 4

During the 3-week surge period, ED patient visits rose 48% compared with the previous year, with 7793 children arriving for ED care (). 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

Figure 5

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 (). 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.

Main Hospital Inpatient Occupancy. During the surge, ED admission rates were lower than average, but absolute numbers of admissions and inpatient occupancy were high. The OctoberNovember 2008 average admission rate was 18.0% (SD 2.9%, daily range 12.8%25.3%), reflecting the typical monthly rate of 18% to 21%. In comparison, the average admission rate during the 2009 surge was 14.7% (SD 2.1%, daily range 11%20%; P <.001).

The daily peak inpatient census during the 3-week surge averaged 423 (SD 22.1). That was 12% higher than the census during the same calendar period in fall 2008 (mean daily peak census 374 [SD 22]; P <.001), but only 2.9% higher than the census during February 2009 (mean daily peak census 411 [SD 23.2]; P = .06). During the surge, the main hospital was more than 90% occupied at peak daily census during 83% of weekdays and more than 95% occupied during 33% of weekdays. This additional patient volume was met by the creation and as needed deployment of an additional general pediatrics team; this team was supervised by a volunteer attending physician from the Department of Pediatrics. Pediatric residents on elective rotations were added to these teams as needed. The yellow zone plan for an additional general pediatrics team was needed for 5 days, and the red zone plan was not triggered.

Peak daily occupancy in the 46-bed main hospital PICU exceeded 90% on virtually all days of the surge (94%) and more than 100% occupancy on 15% of days (PICU treatment rooms were used for patients). The yellow zone plan for the PICU, which required increased staffi ng by nurses, fellows, and nurse practitioners, was active from October 21 to November 22, 12 days beyond the 3week networkwide surge period. Additional nursing hours (mean of 80 hours per day, representing a 10%15% increase over baseline nursing hours) for the ED and PICU were created through overtime, canceling educational activities, placing orientees in supervised clinical roles, and reassigning nurses from lowercensus units or nonclinical roles. Census levels alone did not trigger the red zone. Acuity was high enough, however, that PICU leadership decided to increase overnight inhouse critical care attending coverage from 1 to 2 during this period.

Death is a rare outcome in pediatrics. During the surge, there was 1 death recorded for a PICU patient with a primary diagnosis of infl uenza. This patient also had developmental delay and chronic medical conditions. There were 9 other deaths in the hospital during the surge, but infl uenza was not a contributing factor to these deaths.


Supplies and Equipment for Primary Care, Emergency Department, and Inpatient Areas. Ensuring adequate supplies to provide patient care was identifi ed early in planning as a critical challenge. During the planning phase, the emergency preparedness director worked with the director of resource management to secure gowns, gloves, and masks. Factors such as personal protective equipment (PPE) use based on clinical role, work setting, and number of patient encounters per shift, along with expected patient volumes, were used to estimate total PPE needs. In addition, Emergency Preparedness staff projected demand for chairs, screens, and supply carts for the auxiliary waiting area. The hospital procured PPE supplies through regular contact with distributors and weekly status reports. Distributor commitment to shipping PPE within 8 to 24 hours allowed stockpiling of supplies at a local distributor site. Ultimately, PPE use was 300% to 550% above normal. Although CHOP did not exhaust key supplies, estimates for needs were too low.

Infection Prevention and Control. After review of the literature and in consultation with local and national experts, CHOP followed Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, and Association for Professionals in Infection Control and Epidemiology recommendations on transmission-based precautions for H1N1. The network adopted contact and droplet precautions for all patients with influenza-like illness and airborne isolation precautions for patients with known or suspected influenza who were undergoing aerosolgenerating procedures (eg, bronchoscopy, endotracheal intubation and extubation, open suctioning of airways). This strategy offered cost savings, as well as avoidance of supply shortages and unnecessary fit-testing of thousands of healthcare workers for N95 respirators.21

To limit H1N1 transmission between patients, several measures were implemented. In the primary care setting, selfscreening stations were placed at the entrance of each clinic. During yellow zone periods, patients were asked to don a mask and perform hand hygiene if they had both fever and respiratory symptoms. In collaboration with Medicaid managed care insurers, CHOP created and sent letters to families describing vaccination and influenza clinics. When the H1N1 vaccine became available in November 2009, CHOP primary care practices used vaccine stations to administer vaccine to patients with scheduled appointments and highrisk patients. Approximately 33% of CHOP’s primary care network patients received the H1N1 vaccine during the winter of 2009 to 2010. Distribution was limited due to vaccine availability during the peak of the local outbreak; supplies increased only after regional disease decreased.

As vaccine availability was limited, Infection Prevention & Control, Occupational Health, and ambulatory specialties defined “tier 1” staff for H1N1 vaccination using 2 criteria: vulnerability of patients and repeated staff exposure to potential infections. Targeted tier 1 staff included 1307 staff working in the ED, neonatal intensive care units, the PICU, the PICU step-down unit, the cardiac intensive care and cardiac care unit, oncology (inpatient and clinic), the special immunology clinic, and the specialized perinatal unit. When the H1N1 vaccine arrived at CHOP during the last week of October, there was only enough supply to vaccinate approximately half of all direct care providers. Numerous staff saw themselves as direct care providers and wanted vaccine, even if they were not tier 1 staff. Prior to 2009, the Emergency Preparedness Working Group asked the CHOP Ethics Committee to develop a conceptual framework for allocation of scarce resources such as vaccine during a pandemic. After 2 formal presentations and additional informal discussions, Ethics Committee guidance was incorporated into plans for the 2009 H1N1 pandemic. When the initial vaccine supply became available, 1229 of the 1307 tier 1 employees (94%) were vaccinated. Ultimately, a total of 4506 healthcare workers were immunized.

Public Relations and Communications. The Marketing Department collaborated with Infection Prevention & Control on a multifaceted approach to communication materials. Target audiences included employees, patients and families, referring physicians, and members of the community. Documents were approved by Infection Prevention & Control, posted online by the marketing web team, and distributed in print form across the network. Materials and online activities included general frequently asked questions, clinical guidelines for staff, vaccine facts in English and Spanish, and a webinar for community-based primary care physicians, school nurses, and child care workers. In September and October, CHOP’s H1N1 intranet pages (used by internal CHOP staff) had 3213 and 4112 hits, respectively (compared with 1047 in November, 307 in December, and 199 in January 2010). Extranet postings (particularly those detailing vaccine availability) were updated throughout the surge.


During the 2009 H1N1 pandemic, CHOP, as an IDS, met the needs of patients in a variety of settings despite substantial increases in patient volumes. The ability to coordinate and share resources across a centrally owned network mitigated direct effects on single providers or provider types, optimized distribution of scarce resources, and increased functional capacity. Using the surge capacity conceptual framework of staff, stuff, and structure, CHOP implemented flexible deployment of staff, centralized management of supplies and resources, and coordination of physical structure and management activities—all of which were central to the success of this response.


Being an IDS afforded CHOP the ability to deploy staff in real time as patient care needs were identified. It is imporant to point out, however, that much of the success of CHOP’s response to the 2009 H1N1 pandemic was due to that fact that staff members were able and willing to move across traditional roles. This flexibility, in conjunction with the ability to centrally coordinate its workforce via mechanisms like the web-based volunteer sign-up document, allowed the system as a whole to best match capacity to demand when and where it occurred. It is hard to envision how a nonintegrated system or unrelated offices and hospitals could have done the same. Centralized ownership may afford more ability to increase capacity than a coordinated, but not financially linked, organization, as staff temporarily employed in nontypical roles can be compensated through established payroll mechanisms. Large organizations like CHOP are also more likely to have employee resources including online education modules (not utilized during this particular pandemic) and programs to provide emergency child care to further enhance staff flexibility. Additionally, an IDS may uniquely be able to mandate immunization of staff working in multiple locations, as CHOP has done for seasonal influenza vaccine.

Attempts at effectively increasing staff capacity during the 2009 pandemic were limited by several factors. Although staffing and patient care hours were increased at all 4 urban primary care centers, many families bypassed these centers and came directly to the ED. Similarly, even after hearing prerecorded informational messages, the majority of parents remained on the phone to speak to a nurse; there were insufficient nurses to manage this increased volume. Of note, we lack information on phone triage outcomes in terms of potential delays in needed acute care. As the phone triage system was not new, but instead based on validated approaches to phone triage, there was the potential for any increase in phone triage workload to result in adverse outcomes. Suburban practices had limited trunk lines and phone tree capabilities, and so were not as amenable to attempts to increase capacity through 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. Finally, although CHOP is integrated, technology platforms are not uniform. The electronic health record supported many aspects of flexibility, but primary care physicians were not familiar with ED software. These and other technology differences created challenges in sharing personnel across the network (Table).

Certain particulars of CHOP staffing and the 2009 pandemic should be noted when considering generalizability beyond our single hospital and health system experience. For example, the large number of nurses, fellows, and research physicians associated with a large academic instutition with extensive resources created an additional workforce that might not be available in other settings. Second, our reliance on volunteers enabled us to meet acute needs, but would not necessarily be sustainable. Although there was no vocal resistance and all volunteer shifts were easily filled, no formal survey work was done to obtain staff feedback, nor can we know at what point volunteerism would falter. In addition, the H1N1 virus had low virulence and staff was minimally affected; a future pandemic might increase patient acuity and limit staff availability.


Like other institutions, particularly since 2001, CHOP has focused attention on emergency preparedness across its geographic network, including the purchase of supplies such as PPE. Although CHOP’s transmission-based precautions for H1N1 minimized use of personal protective devices and supplies along with their associated costs, supply availability and the ability to centrally control distribution were key to limiting intrainstitutional spread of H1N1. Had the pandemic been of greater severity, this benefit of integration likely would have been of even greater importance. Similarly, CHOP’s ability to dictate vaccine distribution for employees across the network allowed healthcare workers at greatest risk to be vaccinated first. Access to CHOP’s Ethics Committee helped to ensure that vaccine distribution was fair. Vaccine distribution to patients was, however, subject to public health regulations beyond CHOP’s control. As the CHOP network extends over 2 states, requirements for tracking and transferring vaccine between network sites varied. These extrainstitutional requirements limited CHOP’s ability to centralize vaccine distribution. Moreover, given the limited duration and acuity of this pandemic, the demand for pharmaceuticals did not threaten supply, but a more severe or prolonged pandemic could be problematic from the equipment and supply standpoint. Marketing efforts produced many materials that were distributed across the network and to outside sources such as the media.


The majority of CHOP’s pandemic preparedness efforts centered on its main hospital, ED, and 4 urban ambulatory care locations. Although CHOP did not build any new temporary or permanent structures to accommodate pandemic patients, the newly renovated 14-room ambulatory subspecialty care space near the main ED was utilized to increase capacity for low-acuity patients on evenings and weekends. In addition, the existing hospital atrium was equipped with chairs, triage desks, and refrigerators to function as an intake, triage, and waiting location to augment the existing ED waiting area. In the case of the 2009 pandemic, CHOP’s ED, including its preexisting 10- bed extended care unit, was large enough to accommodate the increased number of patients. Had the pandemic been more severe, the capacity of these physical structures might have been exceeded. Similarly, while peak daily occupancy in the 46-bed main hospital PICU exceeded 90% virtually all days of the surge, overflow patients were accommodated in existing PICU treatment rooms. Had the scenario been worse, even with alterations in standards of care,22 staffing flexibility might have been of little value for patients requiring additional critical care beds, ventilators, and equipment.

Overall Impact and Cost

The H1N1 pandemic created challenges for public health authorities23 and individual healthcare organizations, highlighting the need for preparedness planning.24 CHOP’s experience as an IDS emphasizes the benefits of flexibility, scale, and scope. Estimating that between 5% and 20% of the increased volume of primary care visits and phone calls would otherwise have resulted in ED visits, CHOP’s integrated response detailed above may have helped to avoid an estimated 11 to 44 ED visits per day. For those who did seek care at the CHOP ED, wait times and left-without-being-seen rates were maintained below those of previous high-demand periods. It is difficult to calculate the financial cost of CHOP’s response to the 2009 H1N1 pandemic, in part because considerable preparatory work had been done in the years preceding the pandemic. Purchases of supplies and equipment were spread over time, excess volunteer staffing was largely uncompensated, and no construction was undertaken specifically to accommodate patients during the pandemic. As CHOP did not cancel scheduled admissions or procedures, opportunity costs were not encountered to an appreciable degree. Clearly, without prior planning, the ability to utilize volunteer staff, and the capacity to continue scheduled admissions and procedures, a system’s immediate costs could be substantial, particularly for a prolonged event.

Lessons learned during the H1N1 pandemic continue to guide internal planning. First, convincing leaders of potential pandemic severity was challenging. The brevity and relative low acuity of the spring wave of H1N1 infection provided some with a false sense of security concerning the likelihood and potential severity of a second wave. When the pandemic struck, there was reluctance to cancel scheduled admissions, whether medical, surgical, or research related, even at high levels of occupancy. Second, the size and scope of CHOP as an IDS created a paradox. The enterprise was large and well resourced; however, its size, scope, and complexity made it difficult for any individual or small group to fully understand the entire system or nuances of operations in each department. Similarly, the large number of personnel working in diverse roles and locations made it harder to communicate timely information using the right messaging. As noted, education or training was limited as the available online educational system was not used.

There are limitations to CHOP’s experience that affect generalizability, many of which have been noted in the Discussion section. As a single institution, with its own physical footprint, staffing pattern, and culture, CHOP’s planning and execution might have differed from what others experienced. Similarly, the pandemic played out in a particular way in the Philadelphia region and for children. Had its timing or virulence been otherwise, outcomes might have been different. Finally, as noted above, we do not have information about clinical outcomes such as those resulting from guidance provided through the phone triage system or the ED that had high patient volumes.


In conclusion, the fall 2009 H1N1 pandemic caused record volumes of patients to seek care at primary care offices, EDs, inpatient services, and intensive care units. The experience of 1 pediatric delivery system in planning for and executing a plan to handle this surge in activity may hold lessons for other organizations and for policy makers seeking to improve the preparedness, quality, and value of healthcare. These experiences do not necessitate vertical integration with direct ownership as in CHOP’s case, but do support tight coordination, communication, integration, and alignment of clinical and nonclinical resources.Acknowledgments

We acknowledge the contributions of data, experiential descriptions, and suggestions regarding the manuscript from Paula Agosto, MHA, RN, CCRN, Monika Alkhatib, Kristen Behrens, Abby Bronstein, MSW, Brandon Calderon, MHSA, Jonathan Crossette, MPH, Amy Feldman, MD, Trude Haecker, MD, Patricia Hubbs, RN, MBA, CCRN, Talene Metjian, PharmD, Sue Morgan, BSJ, Nicole Murphy, Jacqueline Nolls, RN, BSN, CEN, and Samir Shah, MD, MSCE.

Author Affiliations: From Department of Pediatrics (ESF, RJS, LMB, JJZ, SEC), University of Pennsylvania School of Medicine, Philadelphia, PA; Division of General Pediatrics (ESF, LMB), Division of Emergency Medicine (RJS, JJZ), Division of Infectious Disease (SEC), The Children’s Hospital of Philadelphia, Philadelphia, PA.

Funding Source: None.

Author Disclosures: The authors (ESF, RJS, LMB, JJZ, SEC) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (ESF, RJS, LMB, SEC); acquisition of data (ESF, JJZ); analysis and interpretation of data (ESF, JJZ); drafting of the manuscript (ESF, RJS, LMB, SEC); critical revision of the manuscript for important intellectual content (ESF, RJS, LMB, JJZ, SEC); statistical analysis (ESF); administrative, technical, or logistic support (ESF); and supervision (ESF).

Address correspondence to: Evan S. Fieldston, MD, MBA, MSHP, The Children’s Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA 19104. E-mail: Crosson FJ. 21st-century health care—the case for integrated delivery systems. N Engl J Med. 2009;361(14):1324-1325.

2. Rittenhouse DR, Shortell SM, Fisher ES. Primary care and accountable care—two essential elements of delivery-system reform. N Engl J Med. 2009;361(24):2301-2303.

3. Luft HS. Becoming accountable—opportunities and obstacles for ACOs. N Engl J Med. 2010;363(15):1389-1391.

4. Peleg K, Kellermann AL. Enhancing hospital surge capacity for mass casualty events. JAMA. 2009;302(5):565-567.

5. Kaji AH, Koenig KL, Lewis RJ. Current hospital disaster preparedness. JAMA. 2007;298(18):2188-2190.

6. Agency for Healthcare Research and Quality. Public health preparedness: common definitions and reverse triage can help hospital planners meet surge capacity demands during emergencies. Published August 2009. Accessed September 17, 2012.

7. Kaji A, Koenig KL, Bey T. Surge capacity for healthcare systems: a conceptual framework [published correction appears in Acad Emerg Med. 2007;14(1):22]. Acad Emerg Med. 2006;13(11):1157-1159.

8. Centers for Disease Control and Prevention (CDC). Update: novel influenza A (H1N1) virus infection—Mexico, March-May, 2009. MMWR Morb Mortal Wkly Rep. 2009;58(21):585-589.

9. Centers for Disease Control and Prevention (CDC). Update: swine influenza A (H1N1) infections—California and Texas, April 2009. MMWR Morb Mortal Wkly Rep. 2009;58(16):435-437.

10. Thompson WW, Shay DK, Weintraub E, et al. Influenza-associated hospitalizations in the United States. JAMA. 2004;292(11):1333-1340.

11. Jain S, Kamimoto L, Bramley AM, et al; 2009 Pandemic Influenza A (H1N1) Virus Hospitalizations Investigation Team. Hospitalized patients with 2009 H1N1 influenza in the United States, April-June 2009. N Engl J Med. 2009;361(20):1935-1944.

12. Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1) 2009 Influenza, Bautista E, Chotpitayasunondh T, Gao Z, et al. Clinical aspects of pandemic 2009 influenza A (H1N1) virus infection [published correction appears in N Engl J Med. 2010;362(21):2039]. N Engl J Med. 2010;362(18):1708-1719.

13. World Health Organization. Preparing for the second wave: lessons from current outbreaks: Pandemic (H1N1) 2009 briefing note 9. Published August 28, 2009. Accessed September 15, 2012.

14. Oldfield P, Clarke E, Piruzza S, et al. Red light-green light: from kids’ game to discharge tool. Healthc Q. 2011;14(1):77-81.

15. Oregon Fire Chiefs Association. H1N1 response guidance for EMS providers. Salem, OR: Oregon Fire Chiefs Association; 2009.

16. Centers for Disease Control and Prevention (CDC). Past weekly surveillance reports. Published 2011. Accessed September 15, 2012.

17. Kippenbrock T, Holloway E, Moore DD. Google docs: a better method than a paper clinical schedule. Comput Inform Nurs. 2010;28(3):138-140.

18. Scarfone RJ, Coffin S, Fieldston ES, Falkowski G, Cooney MG, Grenfell S. Hospital-based pandemic influenza preparedness and response: strategies to increase surge capacity. Pediatr Emerg Care. 2011;27(6):565-572.

19. Centers for Disease Control and Prevention (CDC). Interim guidance for the detection of novel influenza A virus using rapid influenza diagnostic tests. Published August 10, 2009. Accessed September 15, 2012.

20. Murphy KA. Pediatric Triage Guidelines. St Louis, MO: Mosby; 1996.

21. Loeb M, Dafoe N, Mahony J, et al. Surgical mask vs N95 respirator for preventing influenza among health care workers: a randomized trial. JAMA. 2009;302(17):1865-1871.

22. Kanter RK, Moran JR. Pediatric hospital and intensive care unit capacity in regional disasters: expanding capacity by altering standards of care. Pediatrics. 2007;119(1):94-100.

23. Trust for America’s Health and the Robert Wood Johnson Foundation. Ready Or Not? Protecting the Public’s Health From Diseases, Disasters, and Bioterrorism. Princeton, NJ: Robert Wood Johnson Foundation; December 2009.

24. Daugherty EL, Carlson AL, Perl TM. Planning for the inevitable: preparing for epidemic and pandemic respiratory illness in the shadow of H1N1 influenza. Clin Infect Dis. 2010;50(8):1145-1154.

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