Pandemic flu: managing demand and capacity in health care organisations (surge)

Pandemic influenza will be a widespread, rising-tide phenomenon threatening to overwhelm health and social care services in the UK, and necessitating changes to the scope and delivery of health and social care. It is important to remember that it is the sheer numbers of people affected by the pandemic influenza at any one time, which will disrupt the normal provision of services throughout society. As the pandemic develops, it is likely that some treatments will need to be deferred, clinical care standards will be modified and access to some treatments and services will be restricted. The impact on people’s health will be minimised, but when the numbers of people requiring care exceed available capacity, it is inevitable that the health and care of some people will be affected. The challenge will be to provide sufficient or reasonable care to as many people as possible, balancing the need to provide a minimum level of comfort to everyone.

Preparations for dealing with a surge of patients and service users - and how services and patients are prioritised - need to be developed, agreed and in place amongst all caring agencies before a pandemic strikes. It is important that a common set of prioritisation criteria be used across the UK. Clarity and transparency will be essential, as will consistent planning according to the national planning assumptions and principles as set out in Pandemic flu: A national framework for responding to an influenza pandemic1.

This guidance restricts itself primarily to recommending the principles and approaches that should be adopted by health services. Nevertheless, it recognises that the interface with social care (and other sectors) is critical and that, to ensure effective management of patients, a common understanding of how patients should be managed and cared for across health and social care is required. This includes the need for plans to be agreed with social care commissioners and providers before a pandemic occurs.

A large number of stakeholders have been involved in the development and review of this document (please see Appendix 15). This guidance provides a framework and some clinical outcome tools that services will find helpful in their planning for pandemic. It is recognised that, as a pandemic develops, science may change according to what appears to be the emerging evidence. If so, advice to clinicians will need to change to reflect the most up to date knowledge. This will be available on www.dh.gov.uk/pandemicflu

Executive summary

Since the influenza pandemic in 1968/69, changes to health service delivery and the growth of the UK population, particularly in the older age groups, have meant that the excess capacity to accommodate sudden influxes of patients, which historically existed in the healthcare system, no longer exists. It is estimated that given a 50% clinical attack rate, a locality with 100,000 people could expect 11,000 clinical cases of influenza-like illness in the peak week of a pandemic, with 440 of these people requiring hospitalisation. With these projected numbers, it is likely that health services will be overwhelmed rapidly, unless steps to preserve the provision of essential care are taken, as well as measures to control access to such care are taken.

This document provides guidance on managing the managing the demand and the capacity needed to respond to this volume of patients and the ability of the health service to expand beyond normal capacity to meet an increased demand for clinical care

Chapters 1 and 2 provide context for the guidance. Chapter 3 outlines the ethical principles underpinning the development of the guidance with projections of the expected healthcare demand in chapter 4.

Guiding principles for health service planning are listed in chapter 5, and a conceptual model of the response is described. It is recognised that the majority of people who are ill will have to be cared for outside of hospital, and the presumption must be that they will remain at home with such support as relatives/neighbours/friends/volunteers and health and social care can give.

In chapter 6 a concept of operations, consistent with Pandemic flu: A national framework for responding to an influenza pandemic covers the timing and organisation of the healthcare response at a local level. Three suggested stages to the local health service response are described (increasing capacity, prioritising services, and prioritising patients and treatments), along with examples of the types of activity that might take place at each stage.

Chapter 7 deals with service prioritisation in more detail. The identification in the pre-pandemic period of priority services is critical. A Service Priority Assessment Tool and guidance on its usage has been developed to facilitate this prioritisation process. Service strategies and actions based on local triggers are outlined. Checklists are provided which address some of the broad issues relating to preparation that may be faced locally in healthcare facilities.

Chapter 8 introduces a model of stepped levels of care and emphasises the need to understand and mitigate any potential adverse effects of proposed service alterations. In chapter 9 admission and discharge from services is discussed. A system for prioritising patients is proposed, which includes a process for assessing their continuing need for secondary care in the context of the ethical framework for policy and planning in a pandemic.

In chapter 10, a framework for implementation of phased response patterns and triage for the care of critically ill patients is presented.

The remaining chapters of the guidance cover the provision of paediatric care, non-invasive ventilatory support, End of Life care, Ambulance services, communications and security.

Key challenges in implementing guidance for managing the demand and capacity in health care organisations include:

• Helping the public and professionals to understand the need for, and to be involved in, the prioritisation of services, treatments and patients during the pandemic
• ensuring that appropriate frameworks are in place to support clinical decisions on prioritisation made during a pandemic
• developing the infrastructure in local communities to encourage self-care, to avoid admission of those patients for whom only symptomatic or end of life care is deemed appropriate and to support the early discharge of patients from hospital
• defining the geographical and health service footprint of a locality for the purposes of activating demand and capacity responses, for example health board/primary care trust groupings.

1 Scope and purpose

This document contains guidance for primary and secondary care services in England on managing demand and capacity and the prioritisation of services and patients during an influenza pandemic. The Devolved Administrations will have similar guidance.

This guidance should be used to inform current planning during World Health Organisation (WHO) Phase 3 and to assist in the development of pandemic preparedness plans. It is intended for operational use in the UK once WHO declares Phase 6 and the Department of Health in England (as the UK lead agency for pandemic influenza) declares UK alert level 1 (see Appendix 1).

Once an influenza pandemic is declared, if new clinical data on the course and outcome of the illness emerge from experience in the UK or elsewhere, then health services may have to modify their response. Health services should ensure that they refer to the most up-to-date version of this guidance at www.dh.gov.uk/pandemicflu

This guidance should be read in conjunction with the following documents or their country-specific counterparts:

• Responding to pandemic influenza: the ethical framework for policy and planning
• Pandemic influenza: guidance on preparing acute hospitals in England
• An operational and strategic framework: planning for pandemic influenza in adult social care
• Pandemic influenza: guidance for ambulance services and their staff in England
• Guidance for pandemic influenza: infection control in hospitals and primary care settings
• Pandemic influenza: human resources guidance for the NHS
• Pandemic influenza: guidance on preparing mental health services in England
• Pandemic influenza: guidance on the delivery and contract arrangements for primary care dentistry
• Pandemic influenza: guidance for dental practices
• Pandemic influenza: guidance on preparing maternity services in England
• Pandemic influenza: surge capacity and patient prioritisation in health services - provisional UK guidance
• Pandemic influenza: guidance on planning for vulnerable groups
• Possible amendments to medicines and associated legislation during an influenza pandemic
• Pandemic influenza: guidance on the management of death certification and cremation certification
• Planning for a possible influenza pandemic: a framework for planners preparing to manage deaths (Home Office)
• Planning for a possible influenza pandemic: Registrar General’s guidance on death registration services for Registration Service Managers and Practitioners
• Supporting people with long term conditions to self care: a guide to developing local strategies and good practice
• NHS emergency planning guidance 2005
• Strategic command arrangements for the NHS during a major incident

All of the above guidance is available at www.dh.gov.uk/pandemicflu, and other country- specific guidance is available at:

www.scotland.gov.uk/pandemicflu www.dhsspsni.gov.uk/index/phealth/pandemicflu/pandemic-contingency.htm

www.Wales.gov.uk/topics/health/protection/communicabledisease/flu/?lang=en

2 Audience

The guidance is aimed at:

• Pandemic Influenza Coordination Committees (or equivalent committees/forums),
• Chief Executives of, Strategic Health Authorities and Primary and Secondary care Trusts,
• Mental Health services,
• Medical Directors,
• Directors of Public Health,
• Heads of Services,
• Emergency Planners
• Primary and Secondary care clinicians.

It is also of relevance to other stakeholders, such as

• Ambulance services/trusts,
• Local Authorities
• Private and Voluntary sector providers.

3 Ethical issues

In preparing for and responding to an influenza pandemic, people working at all levels, from Government to those on the front line, will face difficult decisions and choices. These will impact on the freedom, health and, in some cases, survival prospects of individuals. Many people are also likely to face individual dilemmas and tensions between their personal, professional and work obligations. Given expected levels of additional demand, capacity limitations, staffing constraints and potential shortages of medical supplies, hard choices and compromises are likely to be necessary in the fields of health and community care.

It is important that any guidance advocating the prioritisation of healthcare resources to certain groups of patients must have a sound and defensible ethical basis. People are more likely to accept the need for and the consequences of difficult decisions if these have been made in an open, transparent and inclusive way. National and local preparations for an influenza pandemic should therefore be based on widely held ethical values. Choices that may become necessary should be discussed openly as plans are developed so that they reflect what most people will accept as proportionate and fair.

• The UK Committee on Ethical Aspects of Pandemic Influenza (CEAPI) was set up to advise on the ethical issues in health and community care and in public health arising from an influenza pandemic, and has developed an ethical framework to inform the development and implementation of health and community care and public health response policy. The systematic use of the principles it contains can act as a checklist to ensure that all the ethical aspects have been considered.

The overarching ethical principle of equal concern and respect (with its eight component principles listed in the guidance document Responding to pandemic influenza: The ethical framework for policy and planning) has been used to help develop this guidance. The way that these principles have been used in this guidance is detailed in Appendix 2.

4 Context and what to expect

4.1 Context

The impact on the UK healthcare system of previous pandemics has been variable. In his annual report for 1957, the then Chief Medical Officer commented that there was ‘considerable pressure on hospitals for the admission of patients with acute chest infections’2. In the report for 1969, the Chief Medical Officer commented: ‘the intensity of the demand may well have been masked by the availability of a large number of beds normally empty at Christmas.’3

Could the NHS in 2009 cope to a similar degree? There are a number of differences between the situation today and that in 1957/58 and 1968/69:

• Over the last 35 years, there have been considerable changes to the way health services are delivered: there have been clinical innovations, changes to practice and the development of community services. The excess bed capacity that was previously in the system to accommodate large numbers of inpatients no longer exists.
• There have been changes to the way in which primary care services are delivered, with a greater emphasis on chronic disease management and health promotion and the development of out-of-hours services. The increasing complexity of the organisation of primary care services presents challenges in gearing the system to respond to a pandemic.
• Since the last pandemic, the UK general population has grown by 8% (from 55.9 million in 1971 to 60.6 million in 2006). The number of people over 65 years of age - the group usually hardest hit by influenza and traditionally high users of healthcare resources - has increased by 31% (from 7.4 million to 9.7 million).4
• The health service in 2008 is already working at or near capacity. For example, in 2005/06 the NHS in England had an average, overall, staffed bed occupancy of 85%,5 leaving little scope to accommodate sudden increases in demand for inpatient healthcare.
• Treatment modalities have changed and critical care has developed and become more widely used than was the case in 1957 and 1968. It is likely that, in a pandemic, the demand for critical care will be high and the current 3,637 adult critical care beds6 and 320 paediatric critical care beds in England could be rapidly overwhelmed

4.2 What to expect

Over the entire period of a pandemic, up to 50% of the population may show clinical symptoms of influenza. This could result in the total healthcare contacts for influenza-like illness increasing from around 1 million during a ‘normal’ season up to 30 million; it will not be possible to refine estimates until a pandemic occurs and person-to-person transmission begins.

Of those developing symptoms, up to 28.5% (including all affected children under one) will require assessment and treatment by a GP or other health professional, and up to 4% may require hospital admission if sufficient capacity is available. Average length of stay for those with complications may be six days (ten days if in intensive care). Of those who become symptomatic, up to 2.5% may die.

Table 1 illustrates the potential impact of a pandemic based on a population of 100,000.

Table 1: Expected healthcare demand over the course of a pandemic
25% attack rate 35% attack rate 50% attack rate

Hospitalisations and deaths are likely to be greatest if the highest attack rates are in elderly people. The lowest burden on healthcare might be associated with higher attack rates in adults aged 15-64.

A temporal profile of a pandemic wave, based on the three pandemics from the last century and current models of disease transmission, has been developed and is illustrated in Figure 1.