The strain of the influenza epidemic on emergency departments

Influenza has arrived refusing to be ignored or be the ugly step-virus to Ebola any longer. This influenza season is officially an epidemic. The Washington Post’s Wonkblog reported earlier this month that December 2014 was “one of the worst flu months in years.”  In fact, they found that it was “the worst December since the polling organization started tracking flu season in 2008.”

As of January 3rd, the CDC reported widespread influenza activity in 46 states: Yes, pretty much all of them. They also found the proportion of people seeking treatment for influenza-like illness increased to 5.5 percent from the national baseline of 2 percent.  I can conclude one thing from that statement:  For the millions of Americans without a primary care provider, “seeking treatment from a health care provider” essentially equals seeking treatment from the emergency department (ED).

During such an epidemic, EDs are hit hard. Although it may seem unnecessary for patients with mild flu-like symptoms to leave their beds to wait for hours in an ED to be simply advised they need to go home, rest and take acetaminophen, it is the reality of the ED in our current health care culture.

Many EDs across the country were overwhelmed by a tremendous surge of patients in December, a significant portion of which was due to influenza. This year is now worse than the widely publicized 2012 flu epidemic.

When interviewing emergency department directors regarding their experiences with this year’s flu season, I was shocked to hear the numbers.  Some EDs reported volume increases 15 to 25 percent higher in December compared to November or when compared to last December.  One director I interviewed joked that this epidemic was so significant he had colleagues who had coined it “The Flunami.”

Why is this important? Well, increased volumes like this don’t make it easy for an ED to function normally, and puts a strain on resources and staff. You or your loved one may need treatment from an overcrowded ED that is struggling to be efficient amongst this chaos.

The ideal goal of every ED is effective throughput: Get patients checked in, triaged, seen by a health care provider, and either discharged or admitted quickly. A stress at any point in this process can lead to delays. When there is a prolonged patient surge (like this epidemic), eventually ED and hospital rooms fill up. It’s then a domino effect: If hospital rooms upstairs fill, the admitted patients in the ED have nowhere to go. The ED then must board admitted patients, sometimes for hours. This then causes a delay of waiting room patients being brought back and the waiting room swells. If things get bad enough, EDs are forced to utilize “diversion” — meaning they cannot accept ambulances until there is some relief on their stressed system.

Why should you feel empathy towards the ED?  And why does it matter that these overwhelmed EDs are finding ways to continue to function?  They find ways to function because they never close and have no choice but to carry on and power through the overflowing waiting room.  No matter how brutal the waiting room, how sick or not sick the patient, ED staff must try to get everyone who shows up at their door the care they need. This may not be so visually obvious to the understandably frustrated patient who has been waiting hours to be seen. Sometimes the doctors stay late, don’t eat, don’t go to the bathroom or even drink water for hours.  The nurses and technicians are caring for more patients than usual.

Can’t more staff just work during flu season to solve this? Bringing more soldiers to the front lines is easier said than done. It’s a struggle to predict staffing needs, appropriately mobilize finances and find the bodies to help.  Some administrators increased staff resources based on ED patient numbers seen in the 2012 flu epidemic. However, we are far beyond that now. And of course ED staff are not immune to illness, so having workers out sick further impacts resources.  Administrators must constantly be searching for that virtual crystal ball, predicting what changes are needed from week to week.

Although not transparent to patrons, ED staff must work tirelessly for throughput. Administrators acknowledge that staff are burning out from the increased volumes and the measures that need to be taken to get patients seen. They do what they can to ease the burden. But how much can they do? They cannot stop the influx of patients or build new treatment rooms.  They cannot tell well-appearing patients to turn around and go home to rest; they must all be seen along with the sickest.  So what they can do is acknowledge the current state of chaos and commend staff on their hard work.  Some say they delivered food during the worst days or commended staff often on their hard work. However, in the end probably the biggest motivator to work hard is ensuring the sickest are not ignored.

Unfortunately, no matter how many words of encouragement for staff or apologies to patients, until this epidemic slows down the end result is the same: longer wait times, frustrated patients, and exhausted ED staff members.  Sadly, if the CDC is right, things may get worse before they are better.  At least we know it can’t last forever. There will eventually be a reprieve by spring. Until next winter, that is.

Meeta Shah is an emergency physician.

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