BETHESDA, MD 17 September 2009—As the 2009 H1N1 virus continues to infect people in the United States, hospital pharmacies are examining ways to provide essential services while also supporting staff members who become ill or must care for a sick family member.
"You`re certainly worried about your work and your patients, but you`re also worried . . . if you`re going to get sick and bring [the virus] home," said Scott Knoer, director of pharmacy at University of Minnesota Medical Center in Minneapolis.
Brainstorming sessions at the hospital have discussed accommodating employees` needs for child care, elder care—even pet care—if their usual arrangements are disrupted because of widespread influenza.
Influenza Resources For important information about seasonal and pandemic influenza, visit ASHP`s H1N1 Flu Resource Center, the new Stop the flu—it starts with you! resource center, and the ASHP Foundation`s Pandemic Influenza Assessment Tool for Health-System Pharmacy Departments.
"We put a lot of thought into that. I don`t know if we have good answers, Knoer said. "We`re like everyone else, trying to figure this out and plan."
Knoer said that if influenza activity causes his staffing levels to fall drastically, the medical center could temporarily centralize its pharmacy services to focus more on dispensing activities and less on bedside care.
Allowing pharmacists to work off-site is another option under discussion. Knoer said the seven-hospital Fairview Health Services network that includes his medical center has some experience with remote order verification. Specifically, he said, one hospital pharmacy that operates around the clock has verified orders for a smaller hospital with limited pharmacy hours.
"The doctor would write an order, the pharmacists would verify it, and the nurse would get it out of the automated dispensing unit," Knoer said.
In theory, he said, pharmacy staff with remote computer access to the hospital could verify orders from home if schools close and workers need to stay with or near their children.
"We have talked about, in the case where we would have issues with the employees not being able to come to work, we could have employees work from home or another [Fairview] site," Knoer said.
But he cautioned that many issues remain to be discussed before remote order entry can work on a large scale at Fairview.
"I don`t want to overstate where we`re at," he said.
Janet Silvester, director of pharmacy and emergency services at Martha Jefferson Hospital in Charlottesville, Virginia, said hospital administrators recognize that maintaining adequate staffing when employees or their families are ill "might get difficult" this flu season.
"Our staff has always demonstrated the ability to pull together and work extra when things are tight for whatever reason," she said. "I have that expectation now, and I know that they won`t let me down. We will do what we need to do to take care of the patients."
She said the hospital may turn to recently retired, part-time, and staffing-service pharmacists to supplement staff levels if necessary.
The extra staff could be needed if many pharmacy employees become ill and cannot work or if the hospital faces a large influx of patients who need care, she said.
A different type of problem also needs to be dealt with: pharmacy staff who are sick but want to come to work anyway.
"We have asked our staff to stay home if they have flu or flu-like symptoms, especially if they are febrile," Silvester said. "If they come in sick, then we would send them home."
Silvester said none of her pharmacy staff have called in sick with influenza so far during the pandemic.
Knoer said a couple of his staff had influenza this summer, including one person who offered to return to work before recovering completely from the illness. That person was told to stay home to avoid spreading the virus around the hospital.
"A lot of folks have a strong work ethic, and they want to take care of patients," Knoer said. "They will try to come in sick. . . . So we need to communicate proactively so they know that`s not OK."
Kathy Pawlicki, director of pharmacy at Beaumont Hospital in Royal Oak, Michigan, said no changes have been made so far to the staffing policies in the pharmacy. But she said the hospital plans to monitor overall staffing levels and will respond as needed if absenteeism becomes a problem during the pandemic.
Pawlicki said the hospital is stocking up on masks and other protective equipment and supplies that are expected to be needed this flu season. But the biggest preventive activity will be to encourage influenza vaccination as the best way to keep staff healthy and care for patients.
"We will be having a full-blown campaign for our employees related to getting the immunizations, both for the regular flu and for the H1N1," Pawlicki said. "We also will be encouraging employees to get their families immunized."
Pawlicki said the hospital will hold a mass-vaccination drill in October that could serve as a dry run for H1N1 vaccination and also, perhaps, remind the staff about the importance of seasonal influenza vaccination.
Knoer and Silvester said their hospitals are also pushing employees to get vaccinated against influenza.
Fairview has already learned some important lessons about H1N1 influenza since it emerged this past spring.
Early during the outbreak, Knoer said, an undiagnosed H1N1-infected patient was "coughing all over the emergency department" at one of Fairview`s hospitals, inadvertently exposing about 30 employees to the virus.
As a result, he said, the "inpatient pharmacy had a huge number of employees coming down for Tamiflu [prophylaxis], and that was a logistical challenge."
Knoer said the health system is now better prepared for mass prophylaxis needs. In addition, he said, patients who enter the emergency department with flu-like symptoms are given a mask right away to limit exposures.
The Centers for Disease Control and Prevention (CDC) recently revised its recommendations for postexposure prophylaxis and now suggests that hospitals consider monitoring those who were exposed to the virus and giving antivirals only if influenza symptoms develop.
Knoer said watchful waiting is something his hospital has considered to help achieve a balance between limiting illness and making judicious use of costly and potentially scarce antiviral drugs.
CDC has rcommended Tamiflu—Roche`s oseltamivir product—and zanamivir, sold as Relenza by GlaxoSmithKline, for the treatment of influenza caused by the 2009 H1N1 virus as well as seasonal influenza type A viruses.
Recently circulating seasonal H1N1 viruses have been resistant to oseltamivir but susceptible to zanamivir. But these H1N1 influenza viruses have mostly been supplanted by the 2009 H1N1 strain, so either drug is appropriate for treatment unless the resistance profiles of circulating viruses change, according to CDC.
CDC`s most recent epidemiologic data indicate that influenza activity is normal in many states, including Michigan, Minnesota, and Virginia, but elevated overall nationwide. October 4 is the official start of the 2009–10 influenza season.
