hospital role in facing pandemic situations- 2009 h1n1 swine flu

HOSPITAL ROLE IN FACING PANDEMIC SITUATIONS- 2009 H1N1 SWINE FLU
Authors: Dr. R.K Bhaskar * , Dr. Somu.G ** , Dr. Aaditya Sirohi ***
Affiliations:
* Professor & HOD, Dept. of Hospital Administration, KMC Manipal
** Associate Professor, Dept. of Hospital Administration, KMC Manipal
***
Postgraduate Resident, Dept. of Hospital Administration, KMC Manipal
Presenting Author: Dr. Somu.G
Address for Correspondence:
Dr.Somu.G
Associate Professor
Department of Hospital Administration
KMC Manipal
Manipal-576104
E-mail: somu.g@manipal.edu
Phone: 09448463186
Abstract:
More communities are being affected by 2009 H1N1 influenza virus in the winter months of 2009 than
during the summer months of 2009. Seasonal influenza viruses may also cause illness, possibly at the
same time that swine flu virus outbreaks are occurring. Influenza-A virus was the most common cause of
human influenza (flu) in 2009. In June 2009, the World Health Organization (WHO) declared the new
strain of swine origin H1N1 as pandemic. This novel virus spread worldwide and caused about 17,000
deaths by the start of 2010. Although the severity, amount and timing of illness that H1N1 influenza and
seasonal influenza will cause are uncertain, some people will require medical care as a result of their
influenza virus infections. In view of these and other uncertainties, healthcare facilities will need to be
ready to adjust their pandemic plans as dictated by changing conditions. Detailed standard operating
protocols support the Guiding Principles and address the broad spectrum of operational issues and the
challenges of coordinated international outbreak response.
Preparedness to face pandemic situations by hospitals & healthcare establishments is vital in trying to
control & mitigate the spread of the disease. This paper shares the experience of a tertiary care hospital in
facing the pandemic (H1N1) by making available the necessary infrastructure and implementing
standardized guidelines and protocols thereby helping district health authorities of the state in addressing
the scare Swine flu virus within the district.
The practical difficulties and advantages in facing swine flu scare have also been discussed. People were
educated about the disease to prevent panic and screening of patients was done in camps. Hospital had to
make changes by revising visitors’ policy, using limited access plans and procedures. The results showed
that an estimated 11,000 people with flu like symptoms were screened for the virus during the period of
which 80 patients tested positive for swine flu. 8 patients diagnosed for swine flu expired.
Key words: H1N1 influenza virus; pandemic; preparedness; mitigation

Introduction:
Pandemic situations faced in the past include Plague (third pandemic in the 19 th Century); Cholera (first
pandemic in 1816-1826) and Influenza (first pandemic in 1580) to mention a few. Typhus, small pox,
measles, malaria and tuberculosis have also created epidemic situations during the past years. Different
strains of Influenza virus has been causing pandemic situations every 20- 30 years, the more recent one
being H1N1 swine flu 1 .
More communities are being affected by 2009 H1N1 influenza virus in the winter months of 2009 than
during the summer months of 2009. Seasonal influenza viruses may also cause illness, possibly at the
same time that swine flu virus outbreaks are occurring 2 . Influenza-A virus was the most common cause of
human influenza (flu) in 2009. In June 2009, the World Health Organization (WHO) declared the new
strain of swine origin H1N1 as pandemic 3 . In other words, a lot of people have to fall seriously ill, and a
lot of them have to die. This, of course, did not happen with the H1N1 flu. Although many people caught
the illness, most experienced only mild symptoms. Only a small percentage became seriously ill, and a
smaller percentage died. At the time of the pandemic declaration, nearly 30,000 people in 74 countries
had been infected but only 144 people died. The death rate works out to less than 0.5 percent, which is
very low 4 .
This novel virus spread worldwide and caused about 17,000 deaths by the start of 2010. Although the
severity, amount and timing of illness that H1N1 influenza and seasonal influenza that will cause are
uncertain, some people require medical care as a result of their influenza virus infections. In view of
these and other uncertainties, healthcare facilities will need to be ready to adjust their pandemic plans as
dictated by changing conditions 3 . Detailed standard operating protocols support the Guiding Principles
and address the broad spectrum of operational issues and the challenges of coordinated international
outbreak response 5 .
Preparedness to face pandemic situations by hospitals & healthcare establishments is vital in trying to
control & mitigate the spread of the disease. The role of a tertiary care hospital may be critical in facing a
pandemic like Swine flu (H1N1) in making available the necessary infrastructure and implementing
standardized guidelines and protocols thereby helping district health authorities of the state in addressing
the scare of Swine flu within a district.
Definition:
A pandemic is a worldwide epidemic that, according to the World Health Organization (WHO), has to
meet three conditions 6 :
• The microbe infects and causes serious illness in humans.
• Humans do not have immunity against the virus.
• The virus spreads easily from person-to-person and survives within humans.
- The role of WHO and recommendations for national measures before and during pandemics March 2005
The original pandemic definition had two important words removed shortly before the World Health
Organization (WHO) on 11 June 2009 declared the current H1N1 flu outbreak to be a "pandemic". The
original definition contained two other conditions -- there must be a high morbidity and a high
mortality rate. 7

The steps required in planning a response to the H1N1 pandemic can be outlines as stated below:
H1N1 Influenza Planning and Response Action Steps 8
1. Optimize Internal and External Hospital Incident Management Structures
2. Revise Emergency Operations Plan for H1N1 Influenza
3. Provide Appropriate Human Resource Policies and Personal Protective Equipment for Staff
4. Develop a Plan for Antiviral Prophylaxis and Vaccination for Staff
5. Establish Inpatient Surge Capacity Capabilities
6. Establish Accurate and Coordinated Public Information Dissemination
7. Enhance Coordination of Critical Care within Hospitals and across Hospital Systems
8. Maximize Critical Care Staffing
9. Identify and Take Action to Mitigate Key Supply Chain Gaps for Critical Care Medical Equipment
10. Identify Additional Critical Care Treatment Locations
Aim & Objectives:
The study was carried out with the following aim & objectives
To review the protocols already available & those developed by the hospital in gearing towards
the swine flu scare
To study the infrastructural requirements developed and made available in combating the
pandemic
To highlight on the administrative difficulties (if any) faced by the management during the
period
Methodology and study setting:
The study was conducted at a large tertiary care teaching hospital. Methodology adopted was, review of
protocols; documents etc. Perusal of records and registers pertaining to Swine flu (H1N1) maintained at
the hospital. Informal interviews with the administrative, clinical and other healthcare staff who had been
during the pandemic episode.
Observations & Discussions:
The first cases of Swine flu (H1N1) virus were notified in the month of August 2009 for which the
hospital had been sensitized. The top management of the hospital swung into action and protocols in
handling H1N1 case was being reviewed, responsibilities had been entrusted to all the clinical
departments and hospital infection control committee (HICC) took an active role in reviewing the
protocols and procedures in facing the swine flu scare. Almost during the same period the swine flu cases
had rampant representation across the globe and several parts of the country.

The hospital under study is a teaching hospital providing healthcare facilities to a population of
approximately 12 lakh people within the district of which a floating population of 1% represents students,
staff and employees in the campus. As it is also a referral hospital it caters to an indirect population of
nearly 5 lakh people annually.
With more and more case of swine flu either being suspected or detected, the top management took
immediate measures in controlling the spread of the disease and also curbing the scare of H1N1 among
the population. A press meet was called for and a press release was issued in the wake of the pandemic.
The top management reaffirmed its commitment in taking care of students, faculty, staff and other
employees working for and on behalf of the organization. The release also stated the preparedness in
tackling the current situation of the H1N1 (Swine Flu) by the top management.
The preparatory steps were as follows:
1. Protocol developed for mass screening
Establishing ‘Special Clinics’ for screening of students, faculty & staff close to hostels belonging
to respective the institutions for convenience of the students.
Core team of doctors identified and formed from the departments of Medicine; Community
Medicine and Pediatrics for the purpose of screening.
Functioning of the ‘Special Screening Clinic’ was from 10.00 am to 6.00 pm an all days including
Sundays. After 6.00 pm the faculty and students could avail the screening facility in additional
locations identified close to the hospital premises.
A Dedicated ambulance also made available for transporting students and lab specimens to the
hospital after screening at the special clinics.
The ‘Special Screening Clinics’ at two locations within the hospital was identified for screening
of the general public during the day time from 8.00 am to 5.00 pm
2. Infrastructural arrangement within the hospital
A 20 bedded Isolation ward was created in a specified location within the hospital having less
access to general public, for admitting and quarantining the confirmed cases of Swine Flu.
17 beds in another location identified and kept for receiving H1N1 cases
1 room identified for intensive care
3 ventilators kept on standby & kept as a reserve for Intensive care purposes
A team of doctors (2), nurses (4) and housekeeping (4)personnel identified and trained for care
delivery of suspected cases of H1N1
The hospital had a strict vigil in monitoring any incidence of swine flu in the surroundings. They were
also in touch with the state and central health ministries under Govt. of India, receiving information,
guidelines and directions in facing the H1N1 pandemic. WHO guidelines were also adopted.
3. Swine flu (H1N1) protocol developed for the hospital
1. Patient care
Reporting at Medicine OPD, Casualty or Student Health Clinic
Suspected cases to be quarantined and admitted to the identified ward

Facility for augmenting critical care at intermediate care unit
2. Dedicated team of doctors for the identified wards
Two Residents from General Medicine department nominated
Patients with Swine flu to be treated as per the protocol briefed
3. Dedicated team of nurses for the identified wards
4 senior nurse identified for care delivery in shifts through the day
Nurses to deliver patient care as per the protocol briefed
4. Dedicated team of housekeeping staff for the identified wards
4 General duty workers/cleaners nominated for House Keeping activities, where patients are
admitted with swine flu
The HK staff briefed about the protocol to be followed.
5. Personnel Protective Equipments
Personnel Protective equipments required for healthcare workers identified
The list includes N95 Mask; Disposable Gowns; Head cover; Foot cover; Safety Goggles;
Vyzers; Sterile Gloves
All protective equipments mentioned above to be stocked in the places identified for the
patients with swine flu.
All healthcare worker involved in treating infected patients to be provided with Prophylaxis
6. Sample Collection
Protocol to be followed as per WHO guidelines
A Microbiologist identified and made responsible for collection & processing of samples
7. Waste Management protocol
Protocols to be followed as per WHO guidelines & Biomedical waste management Act
Hospital wastes from all the identified wards to be collected in yellow bags
Collection by a dedicated team of Housekeeping staffs
Collection in closed waste colleting trolley with protective equipments (PPE).
All wastes will be collected and sent to the outsourced agency for disposal as per Govt.
Guidelines.
8. Drugs and Medication
Tami flu tablet to be procured and distributed after the guidelines received from the Govt.
Creating awareness among the students’, staff and general public visiting the hospital:
The top management as a next step took adequate measures in creating awareness about the H1N1 swine
flu virus among the students, staff and the general public visiting the hospitals. The communication was

through press release, newsletters, distribution of pamphlets, posters, counseling and conducting
awareness programs.
1. Press release: As soon as the outbreak of swine flu disease was notified in the hospital, a press
meet was held by the top management. Highlights of the meeting included top management’s
commitment towards students, parents and staff in ensuring protection against the swine flu scare.
Machinery adopted by them in facing the pandemic.
2. Newsletters, pamphlets and posters were distributed amongst the staff and students. The message
to the student community was to clarify and make the management’s strategy clear regarding
issue of tackling the H1N1 threat in the campus. Reassurance was given to the people regarding
the illness which is manifest among young healthy adults with flu like symptoms and is self
limiting. The managements also gave assurance regarding prompt treatment to those affected.
Having facilities for collection of lab samples and recognized Virology labs for testing within the
campus was highlighted. Full cooperation by the district health authorities was very well
acknowledged and highlighted. The dos and don’ts were also communicated in the message. The
posters also highlighted precautionary measures/steps to be taken in minimizing the spread of
Swine flu (H1N1).
3. Awareness programs: Apart from display of posters awareness programs was conducted for all
the staff, students and employees working under the university. Awareness was created by
delivering lectures using power-point presentations in meeting halls; class rooms; seminar halls
etc. in small groups for a period of not more than 15-30 minutes. The target audience were
housekeeping staff; paramedical; nurses and students. Resource persons were doctors, senior
nurses; medical administrators and academicians.
Case definition of H1N1 suspect care
Following was the criteria in labeling a case as a suspect for H1N1 care.
Fever with a temperature of more than 38.5 0 C or 101 0 F
Associated with flu like symptoms like running nose, sore throat, cough and body ache
5-10% develop ARDS
Vulnerable group to develop Swine flu (H1N1)
People in extremes of age groups are most susceptible to contract the swine flu virus
Children below 12 years
Aged population above 60 years
Pregnant women
Patients on immunosuppressant medication
Immuno- compromised patients
Swine flu protocol in practice
The Special H1N1 Clinic for screening students, faculty & Staff was established close to hostels.
Doctors from departments of Medicine, Community Medicine and Pediatrics deputed to the
Special H1N1 clinics for screening of students & faculty after protocol has been briefed.
Special Screening Clinic made functioning from 10.00 am to 6.00 pm an all days including
Sundays.
After 6.00 pm faculty and students to avail screening facility at specified locations in the hospital
premises.

Testing and Admission for H1N1 flu at the discretion of the treating Physician
All admissions under Medicine/Pediatric departments
Suspected cases requiring admission transported to hospital in designated ambulance
Masks provided for both the Driver & the suspected cases while being shifted to Hospital.
Suspected case admitted to the specified location with 20 beds
All suspected cases to be informed to District Surveillance Officer (DSO)
DSO made responsible for providing medication (drugs) to the confirmed cases
Negative cases to be immediately shifted out of the specified ward.
Figure-1: Showing guidelines for dealing with H1N1 Fever

Figure-2: Showing Admission procedure for a case of Swine flu
The number of cases of swine flu has drastically declined over the last few months. However the hospitals
protocol in dealing with swine flu cases is in place. As our tertiary care centre has been identified as one
of the nodal centers for treating cases of swine flu, a dedicated isolation ward with necessary
infrastructure to deal with swine flu case has been created with fifteen beds which include two ICU beds.
Nursing and other manpower necessary in handling cases of H1N1 have been identified and trained. All
personnel protective equipments required in treating swine flu case are adequately stocked and made
available as and when suspected cases may arrive. Protocols are in place and constantly updated as per
WHO and CDC guidelines. All healthcare personnel (doctors, nurses, paramedical and housekeeping
staff) have been vaccinated against H1N1swine flu.
Administrative difficulties faced during the pandemic:
Although the top management was very prompt in taking the action against spread of Swine flu, there
were few hard ships faced during the initial phases of the pandemic.
1. Protocols were well laid down there was implementation difficulties primarily in coordination of
activities and fixing of responsibilities
2. Space identification within the hospital for isolation of patients was difficult and took some time.
3. Identifying manpower and training them in handling swine flu case took time during the initial
phase.
4. Visitors policy & security concerns had to be revisited especially for the isolation wards
5. Routine hospital activities had to continue without compromise on its functioning
6. Lab sample collection & reporting posed a problem initially when people screened in large
numbers
7. Establishing proper communication with external authorities during initial phase

There were a few advantages also for the hospital in handling the cases effectively
1. Availability of manpower, seniors and juniors
2. Tertiary level medical college teaching hospital
3. Availability of level II Virology lab for testing samples
4. People in the organization committed
Results:
The first case of swine flu was detected during the early the first week of August 2009. During the initial
phase a lot number of students and staff have lined up for screening purposes, nearly 1200 people were
screened through the special clinics and in the hospital during the first week. There were apprehensions
among the staff & students during the initial period pronounced by rampant use of face masks among the
hospital staff, students and patients. The outpatient numbers had fallen and students preferred to be at
home. Adequate preparedness and prompt planning and action by the top management helped in
containing the fear of H1N1 scare among the student, staff and the general population at large. Delivery
of awareness programs, handouts, posters and call for press meet helped gain confidence of the general
public. A total of 11000 people (approximately 10% of the population within the district) were screened
for the swine flu (H1N1) virus in a span of one year, more during the initial phase. Nearly 80 cases have
reported positive for throat swab cultures detected at authorized virology labs for testing H1N1 swab
samples. Prompt treatment was given to all during which most case showed completely recovery. During
the period of study nearly 10% of the positive case had reported deaths. The tertiary centre is also
identified as a referral centre for H1N1 cases. A certain number of beds have been identified for treatment
of H1N1 cases with clear cut protocols and tracking of the disease in place.
Conclusion:
In conclusion, facing a Pandemic situation can be attained effectively by keeping update of the protocols
by following guidelines given by WHO and CDC for managing outbreaks. During the situation standard
operative procedures should be followed which need to be flexible, if necessary able to adopt changed
guidelines. Effective communication within the system and external agencies is the key to bring about
coordination which is essential especially in large outbreaks and disaster management situations. Creating
awareness among the people and delivering prompt treatment helps to reduce fear and panic among
people and also mitigate the impact of the prevailing situation. Commitment from the management with
support from all levels is the key to success for facing any pandemic situation.
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http://www.flu.gov/professional/hospital/infectioncontrolguidance.html#a
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http://en.wikipedia.org/wiki/Influenza_A_virus_subtype_H1N1

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