H1N1 Influenza: a descriptive study of the response of an influenza assessment clinic collaborating with an emergency department in Australia
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The document summarizes a study of an Influenza Assessment Clinic (IAC) that collaborated with an emergency department in Australia during the 2009 H1N1 influenza pandemic. Over 1,100 patients presented to the IAC and ED with influenza-like symptoms between June 3 and July 3, 2009. Most patients presented in the morning. Those presenting to the ED were younger on average than those presenting to the IAC. The IAC had a higher proportion of discharges compared to admissions, with a ratio of admissions to discharges of 1:16 across both facilities. The caseload was shared between the IAC and ED as expected based on the streaming of patients.
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H1N1 Influenza: a descriptive study of the response of an influenza assessment clinic collaborating with an emergency department in Australia
- 1. H1N1 Influenza 2009: A descriptive study of the response of an influenza assessment clinic collaborating with an emergency department in Australia. Mr Jamie Ranse: Clinical Manager, Emergency Department – Calvary Health Care ACT Mr Shane Lenson: Manager of Emergency Department Services– Calvary Health Care ACT Mr Matt Luther : Nurse Practitioner, Emergency Department– Calvary Health Care ACT
- 2. Overview Background Aims Method Results Discussion
- 3. Background In June 2009 the WHO elevated their pandemic index to Phase 6. Worldwide as at February 2010: 213 countries 16,455 deaths Australia as at February 2010: 37,700+ cases 13% hospitalised (M = 31 yrs) 14% of these required ICU (M= 40yrs) 191 deaths (M=48 yrs)
- 4. Background Some lesson from SARS and Avian Influenza Outbreak outside Mexico Victoria
- 5. Background: Emergency Departments 30% increase in patient presentations Change in function Strategies Separate triage areas Surge clinics Influenza Assessment Clinic (IAC)
- 6. Background: Influenza Assessment Clinics Opened based on ED demand / trigger points First day clinic on 26th May 2009 Monday – Friday; 0900 – 1700 Surge outside business hours Collocated
- 7. Background: Influenza Assessment Clinics 1) Entrance
- 8. Background: Influenza Assessment Clinics 2) Registration
- 9. Background: Influenza Assessment Clinics 3) Screening - Initial clinical observations - Possible referral to the ED
- 10. Background: Influenza Assessment Clinics 4) Waiting area - Complete questionnaire whilst waiting
- 11. Background: Influenza Assessment Clinics 5) Assessment area
- 12. Background: Influenza Assessment Clinics 6) H1N1 management
- 13. Aim This study described the profile of patients presenting to the IAC and ED with influenza-like symptoms, and tested the relationships that influenced the collaboration between the IAC and ED. Describe the frequency and demographic characteristics of patients presenting with influenza-like symptoms to the Calvary Hospital IAC and ED during the H1N1 2009 influenza pandemic, Identify the ratio of admissions to discharges in persons presenting with influenza-like symptoms, and Analyse the caseload as shared by the IAC and the ED.
- 14. Method Three hypotheses were developed to guide inferential statistical analysis: 1) There is a significantly higher proportion of patients who were discharged to home from the IAC, when compared with the ED, 2) There are no significant differences of caseload between morning shift and afternoon shift, and 3) There is no significant difference between the expected proportion of cases assigned to ED and the actual proportion of case assigned to ED.
- 15. Method: Design This study was retrospective in nature, utilising a descriptive study design
- 16. Method: Setting Calvary Hospital is a 334 bed community hospital in the city of Canberra, in the Australian Capital Territory The public ED has approximately 45,000 presentations per annum Canberra is an inland city of approximately 350,000 people
- 17. Method: Sample and population Non-probability purposive sampling All patients that presented to the Calvary Hospital IAC and ED during the period of 3 June 2009 to 3 July 2009 Sample included all presentations from the above population that presented with influenza-like symptoms, and included a total of 1106 persons
- 18. Method: Data collection Retrospectively from an existing ED patient information system IAC utilised an existing ED patient information system An independent identifying code, as a data collection and patient tracking tool. Date, time, complaint, disposition and demographic information.
- 19. Method: Data analysis Demographic characteristics for Descriptive statistics t-test for interval data Mann-Whitney U test for ordinal data Chi-square test for nominal data
- 20. Method: Protection of human participants Approval from Calvary Health Care ACT HREC
- 22. Discussion Patients who presented to the ED were younger (M=23) than the IAC (M=30) Both were aged greater than the national median Few of the patients that presented were over the age of 65 (N=24/1106; 2.2%) Need to report nationally
- 23. Discussion Proportionately, the ED admitted more patients to hospital than the IAC An admission to discharge ratio of 1:16 reflects a large number of patient discharges Role of staff in the IAC needs to be explored further Impaired ability to compare to other IAC like models
- 24. Discussion A larger number of discharges from the ED than expected. Streaming of patients
- 25. Discussion A sustainable IAC like model needs to exist Test models during seasonal influenza periods, rather than a reactive composition during a pandemic response. Prospective data collection
- 26. Discussion: Limitations A single Australian IAC and ED Results may differ in differing influenza strains Did not provide epidemiological information about the attack rate of confirmed H1N1 2009
- 27. Conclusion More patients presented during the morning period Patients presenting to the ED were younger than those presenting to the IAC There was a low rate of admissions in comparison to discharges, a ratio of 1:16 ED v IAC caseload A sustainable IAC like could be applied to other situations where increased ED patient presentations are experienced or expected
- 28. Questions? Australasian Emergency Nursing Journal Australian Journal of Emergency Management
Editor's Notes
- In June 2009 the World Health Organisation (WHO) elevated their pandemic index to Phase 6, indicating human-to-human transmission had occurred at a community level across multiple countries and WHO regions. This index relates to incidence of disease rather than morbidity or mortality severity.As of February 2010, over 213 countries and overseas territories or communities had laboratory confirmed cases of H1N1 2009 influenza, and an estimated 16,455 deaths had occurred worldwide.In Australia, there have been over 37,700 laboratory confirmed cases of H1N1 2009 influenza, with 13% (4,992/37,713) requiring hospitalisation, and 14% of these (681/4,992) requiring intensive care management.
- With early reports of H1N1 09 outbreaks occurring in countries outside of Mexico and the continental United Sates, especially Japan and New Zealand, the need for pandemic-scale planning was becoming more evident.
- There was a reported 30% increase in patient presentations to EDs in Victoria in June 2009.This increase in patient presentations resulted in some changes in function within these EDs. This type of change was seen throughout the world with many health facilities and health services implementing strategies to prevent the ongoing transmission of H1N1 2009 influenza. Within the ED, strategies primarily focused on diverting patients with influenza-like symptoms from the general ED patient population to specific streams of care. Such strategies outlined to date in the literature include having a separate triage area,6 establishing surge clinics during busy periods,7 and establishing IACs.5,8
- Many health facilities and health services in Australia established IACs as a strategy to divert high volumes of low acuity patients away from the EDs.5 These IACs were then closed once community demand diminished. Calvary Health Care ACT (Calvary Hospital) established an IAC which operated from 03 June 2009, with sustained operations, Monday to Friday, 0900 – 1700, until 03 July 2009. The IAC was collocated with the ED on the hospital campus; however, it was segregated from the ED and isolated from the general hospital as part of the hospital pandemic infection control management plan. Collocating the IAC and ED was a strategy that enhanced the institutions response capacity.9 The IAC was staffed by nurses from the ED and General Practitioners from the community. Details of this IAC establishment have been outlined by Luther and Lenson,8 who provide an overview in the rapid establishment of an IAC.
- Overflow waiting to be registeredStep 1: is an initial waiting room to accommodate a surge in presentations that the clerical staff are not able to attend to immediately.
- Step 2: consists of registration and generation of medical record paperwork and patient labels.
- Step 3: includes the collection of clinical observations with referral back to the ED if required.
- Step 4: is the IAC waiting room. Whilst waiting, each patient is asked to complete a questionnaire including demographic information that may be required in contact tracing and symptomology of their ILI.
- Stratified against H1N1 case definition, either: Discharged home with URTI advice / medications Referred to stage 6 for swabbing and antiviral medications.Step 5: is where the patient is assessed against the H1N1 09 case definition. If the patient meets the case definition then they are referred to Step 6 for swabbing and or antiviral medications. If the patient doesn’t meet case definition they are assessed against URTI criteria and given the appropriate health advice before being discharged directly from the clinic.
- Step 6: is the final stage prior to discharge where viral swabbing and or dispensing of antiviral medications.
- To ensure efficient and effective future pandemic response capacity, there is a need to describe the differences of IACs and EDs during the H1N1 2009 influenza pandemic. Therefore, this study aims to: Describe the frequency and demographic characteristics of patients presenting with influenza-like symptoms to the Calvary Hospital IAC and ED during the H1N1 2009 influenza pandemic, Identify the ratio of admissions to discharges in persons presenting with influenza-like symptoms, and Analyse the caseload as shared by the IAC and the ED.
- This period was chosen as it was the period in which the IAC was initially established and operational using nurses from the ED to sustain services. The sample included all presentations from the above population that presented with influenza-like symptoms, and included a total of 1106 persons.