One was credentialing. The credential was rather inflexible and that has … changed so that it won't happen again …. The other was, the electronic medical record system had not been widely distributed in the hospital but it was in use in the emergency department and we had a lot of resistance to having [other] people use it.
Respondents expressed concern that preparations for the H1N1 pandemic may not have been sufficient had it been more virulent. They recognized the importance of planning for and learning from such an event, yet reported varied approaches to institutionalizing knowledge gained during the pandemic.
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Respondents reported learning from the H1N1 experience, but were apprehensive that they still may not be ready for a more virulent pandemic: Unfortunately, I don't think people are interested in thinking about these issues until you actually have the situation at hand, but I think we have better plans now and better coordination. It ties into yearly surge issues that just occur seasonally anyways …. I'm [still] concerned about potentially more virulent strains, and what that would really do to our system and how to provide care in that.
That's our hospitals.
So were we to have these really ill children, it would be … a different issue. Experiencing the pandemic helped respondents recognize the value of planning ahead for such events.
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One respondent reported: It was taxing. We're a small emergency department with a very high acuity level. I learned from it and wished I had been better prepared [by, for instance,] having the surge plan prepped in advanced so there was more automaticity to it. Yet this recognition was not always tied to postpandemic planning changes.
Rather, respondents reported incomplete institutionalization of lessons learned and, in some cases, an anticipated reliance on informal institutional memory to carry the learned lessons forward. The same respondent went on to remark: [Does our chair have the pandemic plan we developed]?
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By contrast, other respondents reported lasting changes in organizational culture as a consequence of the H1N1 experience, and in some cases, application of developed interventions to management of routine ED surge: We learned a lot about how to expand every one of our units. Also, it really has also led to a revamping of our disaster preparedness office. It was just a couple of people and then a whole bunch of identified people who had no [full time equivalent].
It took a year, but we now have an ED physician who is designated to be part of the hospital readiness response and has [full time equivalent] to go along with that. So it made a big difference. The thing is, out of this came [an approach] to improve our flow in the emergency department. So that's one positive that came out of it. Actually, we've improved our length of stay. This qualitative study exploring pediatric EP leaders' experiences with pandemic planning and medical response during the H1N1 influenza pandemic reveals important pandemic preparedness gaps. Despite federal guidance directing hospitals to develop pandemic plans with detailed outlines for what should be included, and despite the fact that nearly all U.
Although respondents described hospital preparations for acute mass casualty events, existing plans were commonly perceived to be inapplicable to a prolonged, infectious event such as the H1N1 pandemic. Respondents reported that strong and especially preexisting relationships with local public health and other health care entities were beneficial to pandemic response including by facilitating communication of institutional needs, enhancing situational awareness, and by allowing for sharing of pediatric expertise.
They were challenged and frustrated by the need to reconcile public health guidance with the reality of ED practice. Although many anticipated obstacles did not materialize, such as staff willingness to work, some respondents experienced unanticipated institutional challenges in responding to the pandemic, both in garnering necessary institutional support and in overcoming administrative barriers necessary for effective response.
Finally, pediatric EP leaders described varied experiences with organizational learning following the H1N1 pandemic experience. Of note, during data collection for this study, respondents reported additional observations related to important pandemic preparedness issues such as public messaging and staffing augmentation. However, related themes did not strongly emerge in the course of this analysis.
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This work builds on an existing literature base demonstrating suboptimal hospital and ED pandemic preparedness. Furthermore, in recognition of the vulnerability of the pediatric population during such an event, 33 , 41 - 45 our study focused specifically on preparedness in pediatric institutions. There are several potential explanations for our findings. The observed lack of pandemic influenza plan penetration to the level of the pediatric EP leader could be related to the clinically mild nature of the H1N1 influenza pandemic; while federal and state guidance was designed to prepare hospitals for pandemics with high virulence and broad hospital impact, the H1N1 pandemic was associated with relatively low virulence in the general population and high ED patient volumes.
Therefore, observed gaps in preparedness may derive as much from perceived inapplicability of existing plans as from true lack of awareness. In light of prior evidence outlining potential barriers to provider willingness to work during a widespread infectious event, 46 , 47 the reported ease associated with staffing EDs was unexpected. This could potentially be explained by rapid provider recognition of the clinically mild nature of the H1N1 influenza virus. The staffing obstacles that did emerge, for instance, reluctance to relax hospital administrative regulations, may be due to a perceived lack of widespread impact; in our studied hospitals, the stress associated with the clinically mild H1N1 pandemic was relatively isolated to EDs.
Given that the substantial, multiyear, federal investment in hospital pandemic preparedness did not appear to result in optimal academic pediatric ED preparedness for the H1N1 pandemic, there are several important policy implications to consider.
First, policy makers seeking to improve hospital preparedness should recognize that many operational, clinical leaders may not be aware of existing preparedness guidance and so may be unprepared to implement best practices. Developing creative dissemination strategies, tailored to clinical providers and distributed through medical directors, should be considered to improve guidance implementation at the hospital level.
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ED leaders were frustrated by what was perceived to be rapidly changing, impractical public health guidance during the H1N1 pandemic. A more inclusive, collaborative, and dynamic process for generation of public health guidance, before and during a public health event, may improve adherence and provider acceptance. Finally, we found hospitals that proactively established relationships with public health and other community entities reported benefiting from them during the H1N1 pandemic response.
Efforts to improve preparedness should also be emphasized at the hospital level. For instance, multidisciplinary institutional pandemic preparedness committees should consider placing more emphasis on informing and engaging relevant clinician leaders. With regard to identified administrative barriers, respondents reported difficulty rapidly credentialing needed providers. Furthermore, hospitals should consider purposefully institutionalizing lessons learned from responding to episodes such as the H1N1 pandemic, so that valuable innovations and interventions can be applied to future events.
Strengths of this study include use of a purposeful sampling strategy that allowed for a heterogeneous distribution of pertinent institutional characteristics in our sample. Although sampled institutions were diverse, respondents' experiences were characterized by recurrent and common themes. We also instituted a number of strategies to ensure a rigorous methodologic approach, 27 , 28 , 48 - 51 including use of a standardized interview guide administered by a single interviewer, audiorecording and professional transcription of interviews, analysis conducted by a multidisciplinary research team, and participant confirmation that elicited respondent feedback on generated themes.
Future research could examine other hospital settings, including nonacademic and community settings. Similarly, it would be useful to explore the pandemic planning process from the perspective of institutional leaders, including hospital administrators or others involved in pandemic preparedness. In addition, while the reported themes strongly emerged from the data, they were not universally held experiences. Some institutions reported robust pandemic preparedness with active organizational learning postpandemic. Additionally, while our findings are not transferable to all hospitals due to the nature of the study design, hypotheses generated in the course of this analysis could be tested using quantitative methods applied to larger, representative populations.
Finally, more research is needed to understand how federal guidance can optimally complement institutional, local, and regional efforts to help hospitals prepare for pandemic and other public health events. It is important to consider the limitations of this analysis. The use of this sampling frame limits the application of our findings to nonacademic, nonpediatric institutions.
It is unknown why those individuals chose not to participate. Finally, because we were interested specifically in the pediatric EP leader's experience with pandemic planning and response, our sample did not include other hospital representatives who may have been more comprehensively involved with pandemic preparedness at the institutional level. Perspectives of hospital administrators or other clinicians may have differed. According to this study, while EP leaders reported substantial hospital preparations for acute and mass casualty events, most were not aware of federal guidance or hospital pandemic plans.
More research is needed to understand why and how hospitals operationalize federal preparedness guidance. Volume 20 , Issue 1. The full text of this article hosted at iucr. If you do not receive an email within 10 minutes, your email address may not be registered, and you may need to create a new Wiley Online Library account. If the address matches an existing account you will receive an email with instructions to retrieve your username. Academic Emergency Medicine. Original Research Contribution.
Clara E. Search for more papers by this author. Federico E. The authors have no relevant financial information or potential conflicts of interest to disclose. Tools Request permission Export citation Add to favorites Track citation.