Friday, January 06, 2006

Boston hospital learns uncomfortable pandemic lessons

A useful way to get ready for an influenza pandemic is to role play it. This is the story of one Boston hospital (Tufts-New England Medical Center) who did a pandemic exercise this fall, as reported in the American Journal of Health-System Pharmacists (issue of January 15, 2006).
Four adults were quickly admitted to the hospital's intensive care units (ICUs), and a dozen more awaited confirmation of their diagnosis. In short order, all of the hospital's ICU beds were filled by patients stricken with avian influenza. The emergency room was soon physically unable to hold additional people, and the decision was made to lock down the hospital.

Elsewhere in the city, other hospitals were likewise inundated with avian influenza victims. The influenza pandemic had arrived.

At Tufts–New England, one of the first things that Clinical Pharmacy Director Edward Decker did was take stock of the hospital's supply of oseltamivir, or Tamiflu, the only drug known to be active against currently circulating H5N1 avian influenza viruses. Decker estimated that the hospital had enough oseltamivir available to treat "maybe 17–20%" of those who should receive the drug, and he immediately set about obtaining more.

"This is a drill," Decker said as he telephoned the hospital's drug wholesalers and the Massachusetts Emergency Management Administration (MEMA), the state organization that handles requests to access the Centers for Disease Control and Prevention's (CDC's) Strategic National Stockpile. "Can you help us?" he asked.

As the hospital's three-hour pandemic influenza drill unfolded, Decker and his colleagues learned that they were essentially on their own in a rapidly worsening situation.

On the drug front, the initial news was not all bad. The wholesalers, Decker said, would each send the hospital "x number of hundreds of doses" of oseltamivir.

But the pharmacy learned that CDC did not know when it would be able to send Tufts–New England any Tamiflu from the federal stockpile.

Faced with that uncertainty, Decker said, pharmacy and infectious disease personnel "decided that we would immediately determine what our supplies of other antiviral drugs—rimantadine, amantadine—were."

"At that point, everyone recognized we were grasping at straws in terms of pharmacotherapy of the avian flu, because there's just nothing that's available to us," Decker said.

Pharmacy was not the only department to be quickly overwhelmed during the drill, Decker said.

"We knew that there was about to become a critical shortage of resources in terms of ICU space, masks, and supplies for the health caregivers to wear," he said, adding that the hospital was working to send home all inpatients who could be safely discharged to make way for flu victims.

Caregivers—in particular, nurses—would soon be in short supply, Decker said.

"It was evident right away that at least 30% of the evening shift was not going to show up," he explained. "So it became nursing's responsibility to figure out what to do in terms of increasing the ratio of nurses to patients."

Early on, Decker said, the decision was made that "the very limited resources of Tamiflu would be used for treatment only, not for prophylaxis." Then, midway through the drill, CDC delivered twin blows to the hospital.

"Strategic National Stockpile [staff] informed us that they were going to be unable to supply us with additional Tamiflu," Decker said, noting that the stockpile was not actually contacted during the drill. "Then we learned that CDC had recommended that the dose of Tamiflu be doubled in order to treat our known sick patients. We just looked at each other and said, 'OK, our limited supplies will last one half the time that we had expected.'"

"At that point the pharmacy's hands were tied," he said. "We did make a decision for certain patients to use rimantadine, [but] we had no idea if it was going to do any good." Instead of actively treating the viral infection, he explained, the pharmacy would soon supply only respiratory drugs and other supportive medications.

But many patients died anyway. By the end of the drill, Decker said, the hospital's morgue capacity had been outstripped, and bodies were being kept in a refrigerated truck parked behind the hospital.