Influenza unmasked

Fall 2013

During the months that stretch from November to May, you may hear mention of the ‘flu' season more often, as health organizations across the nation urge the public to sanitize hands, cover sneezes and coughs and get the flu shot.

Not to be confused with the stomach flu (which is an upset in the gastro-intestinal tract), the ‘flu’ actually refers to the influenza virus, which causes a respiratory infection as well as headache, chills, cough, fever, appetite loss, muscle aches and tiredness.

Influenza is a serious matter. Annually, the infection takes between 500 and 1,500 lives in Canada, with young children, individuals over 65 and those with other systemic diseases like diabetes, cancer and respiratory illness, being the most vulnerable.

Dr. Gary Joubert, city-wide chief/chair of the emergency department at LHSC, Laurie Gould, executive vice president of patient-centred care at LHSC, and Dr. Michael John, medical director, infection prevention and control and medical microbiologist at LHSC, are no strangers to the effects that influenza can have on the function of a hospital, as well as the health of patients.

Recently, they joined us for a panel discussion, bringing us behind the scenes to unmask the truth about how health-care professionals at LHSC manage the 'flu' season.

Explain how influenza season impacts the hospital

Dr. Gary Joubert: The impact on emergency services is significant. Normal volumes at our sites are around 180-200 patients a day at Victoria Hospital (VH) and 130 each day at University Hospital (UH). During our peak flu season, volumes at VH increase to about 250-300 adult patients a day, plus another 20-30 per cent increase in paediatric patients and, at (UH), volumes rise to approximately 175 patients a day.

While some patients are very ill and may require the use of emergency services and hospitalization, there are others who are unwell but really don’t need to be using emergency services, so they may have to wait while sicker patients are seen first. Plus, given the high number of patients who are seen in the emergency department every day, patients without the flu, who aren’t immunized, can contract influenza in the emergency waiting room. This is why we ask people to seek other health care services unless they need to use emergency services because of the illness severity.

During influenza season, we still have all of our normal emergency department business and when we add the burden of influenza on top of that, we don’t have capacity within the system to have all influenza patients use emergency services.

Laurie Gould: The biggest impact is that patients fill up our emergency department, but there are a couple of other things that people may not know.

When influenza patients are admitted, it puts pressure on the hospital with the high number of patients who require an inpatient bed. We have to isolate those with influenza in separate rooms and anyone coming in contact with them must be gowned and gloved. 

This concerns me from a patient and family experience because patients who are isolated with influenza may not get many visitors – or if they do, they can only have a minimum number of visitors.  Influenza has an impact on the patient – not just on the hospital. It has a significant impact on the whole patient and family experience when in the hospital.

Dr. Michael John: Certainly in the laboratory, the flu season has a big impact because many more respiratory viral specimens are sent for testing. We also do testing on weekends, which requires us to bring in extra staff and there’s a very significant cost associated with this testing.  Last year, we spent an enormous amount of money doing the requisite testing. There's also a significant increase in workload within infection prevention and control as all these patients have to be followed up and hospital outbreaks, if they occur, dealt with.

It’s been said that last year was a particularly bad year for influenza, why is that?

Dr. Gary Joubert: It was an interesting flu season. Usually we see the peak flu surge towards the end of December through January, and last year it started in September, which was very early. It caught us off-guard in terms of being ready to institute some of our protocols. The vaccine hadn’t been delivered from the manufacturer yet, and the degree of illness was much higher.

The surge came before public health had any chance to intervene. In addition, it seemed to be a very virulent strain and the impact on patients with comorbidities  (i.e. the presence of more than one disorder) seemed to be much greater, so we were seeing much sicker patients coming to the emergency department than in other flu seasons. These patients required more workup and investigation.

Dr. Michael John: I agree with all of that. One of the things I have wondered about was whether the 2009/10 H1N1 pandemic flu played a factor. During the pandemic, we had really good immunization rates, followed by much less illness than was expected. As a result, there were a lot of people the following season who just stopped getting the vaccine. Of course, what they forget is that pandemic may have had less of an impact because immunization rates were so good.

What have we learned from that experience – and what will be different this year?

Dr. Gary Joubert: An important step is that the hospital has gone to a staff-wide immunization policy. Previously, staff members have been asked to voluntarily become immunized, but this year we’ve created and implemented a hospital-wide immunization policy.

Last year, this policy was only in place for physicians and the immunization rate increased from 40-50% to about 83%. Some areas, like emergency medicine, were 100% immunized.

Now, with the policy staff-wide, the immunization does two things: it helps protect the individual, which is important, but more importantly it helps protect all of the patients we deal with.  You can be an asymptomatic carrier of the influenza virus and be spreading that while you’re working. The staff-wide immunization policy will give us what is called ‘herd immunity’ (i.e. the immunized population will help prevent the spread of the virus).

Dr. Michael John: Also, I’ve learned that we will be getting the vaccine earlier this year – and to expand on what Gary was saying, the new policy will be in all the city hospitals.  Once influenza is deemed to be circulating the community, staff will be required to either be immunized or to wear a mask while providing patient care. Unimmunized visitors will also be asked to wear masks.

Laurie Gould:  One of the most important things we learned is to educate staff that immunization is not just about protecting themselves - it’s about protecting every patient that they come into contact with. This is about patient safety.  So, one of the things that we’re highlighting in our education sessions is myth busting around influenza vaccines.

Dr. Gary Joubert:  Internally, our organization has also looked at our response to hospital occupancy.  We’ll now know what steps to take at different levels of occupancy, so that eventually we can occupy every space in the hospital that is able to be safely occupied for clinical care. We’re hoping we never have to get that far, but we do have a strategy.

Laurie Gould: To clarify - by occupancy, we’re talking about how busy the hospital is. Even when we are full, we have to find emergency department stretchers and inpatient beds to put people in because we don’t close the doors or turn people away. So we have strategies now on how to manage patients as they keep coming into the hospital in a flu season.

When does the hospital start preparing for the flu season?

Laurie Gould:  We start advertising and educating people before the flu season, usually in early September. We have a whole communication strategy around awareness that flu season is coming – that you have to be diligent about washing your hands, you have to get your vaccine and if you don’t, our new policy is that you’ll have to wear a mask in patient care areas. We’re also making it easier for staff to get their vaccine. Roving teams will go around to each unit at different times, giving peer vaccines so that all staff can get immunized.

Dr. Gary Joubert:  I can also tell you, that in the medical advisory committee, which is the physician body that is responsible for quality of care, we think about it all year. We’re planning right from the end of the season for the next super bug. We think, “ok, this is what we’ve done this year, what can we do next year to make it a safer and better environment?”

Dr. Michael John: We also have a working group headed up by occupational health, which starts meeting early in the summer to plan the launch of the hospital’s internal influenza campaign.

If a visitor to the hospital sees a staff member with a mask on, is there a legitimate reason why that employee didn’t get their vaccine?

Dr. Gary Joubert:  A past history of a disease called Guillain–Barré syndrome, which is a neuro-muscular disease, or an allergy - either to the media that the vaccine is carried in, and/or the way the vaccine was prepared, are all valid reasons why someone would not get vaccinated.

Are there any other impacts to the staff around flu season?

Laurie Gould: There’s an impact on their workload, for sure. When staff members have to gown, glove and mask to interact with isolated patients, it puts a lot of burden on the nurses. It takes more time and it uses up more resources. The flu season is not business as usual - it’s business as usual ‘plus’.

What happens at the hospital that the public won’t see?

Laurie Gould: We have some experts like Dr. John, who are part of a national network that monitors influenza. If they see something significant, they’ll notify us and we’ll start to implement actions to address it.  For example, if they started to see a new flu strain, then we would be alerted.

Dr. Michael John: Yes, very much so. We’re likely to find out if there’s flu in the community by isolating it in our lab. By the time we’ve got a couple of people with influenza within the hospital, it’s already circulating the community – as they represent the tip of the iceberg.

We send the first couple dozen isolates to the public health lab where they’ll look at the type of influenza strain and see if it is one of the vaccine strains or any other strain.

Health Canada does the same thing country-wide, tracking the strains that are present across Canada and the World Health Organizations does the same thing globally. All of this data is available.  Some of it we have direct access to and some is passed to us by the Middlesex-London Health Unit, so we know what’s going on.

Dr. Gary Joubert: The other piece of information we get is whether or not the vaccine matches the flu strains. We can see how many patients who were immunized actually got infected. There’s a lot of information that goes back and forth, and it’s readily available – our Middlesex-London Health Unit is excellent. I receive regular updates during influenza season. The communication process is excellent across the board.

What would you say to someone in the community who had some flu symptoms that were quite bad – what would your advice be to them?

Dr. Gary Joubert: I think that unless you have significant comorbidities – in other words, other diseases like diabetes, COPD, congestive heart failure - that you probably should seek care with your primary health care provider (e.g. family doctor) first. Because coming to the emergency department, you’re not going to get seen quickly when there are lots of other people, and your primary health care provider has the skills and tools necessary to care for you.

Obviously if you have symptoms you’re extremely concerned about that are outside of the normal influenza illness, then I think it would make sense to go to an emergency department, realizing that you may have to wait. 

What is the one message that you’d want the community to hear?

Dr. Gary Joubert: You need to get vaccinated and if you do get the flu, then you need to seek care at your family doctor first.  There are a lot of unfortunate misrepresentations about immunizations – get the real story from the Middlesex-London Health Unit.

Laurie Gould: Get your flu shot, and also, staff should to encourage each other to get vaccinated.

Dr. Michael John: Get your flu shot and if you’re sick, don’t come and visit patients unless it’s absolutely critical. We’ll be working hard to ensure that we can provide patients with the safe, high-quality care that they require.

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Sarah Stich, infection safety champion, gears up in full personal protective equipment, which must be worn when dealing with patients with influenza
Dr. Gary Joubert, city-wide chief/chair of the emergency department at LHSC
Dr. Michael John, medical director, infection prevention and control and medical microbiologist at LHSC
Laurie Gould, executive vice president of patient -centred care at LHSC
Under a new policy, those who whork in patient care areas who are not immunized must wear a mask - such as the one seen here on Dr. John
For many health care workers, influenza season is not just business as usual, it's business as usual 'plus' as they must take extra time and precautions
Sarah Stich, infection safety champion, takes a moment to sanitize her hands before visiting an influenza patient room