Musings on transfusion medicine: Hell, no, I won't go? (musings on pandemic flu)

In the 1960s, a famous antiwar mantra about Vietnam was, "Hell, no, I won't go!" This blog's title is a take-off on that phrase as related to who of us will show up for work during a flu pandemic.

Having just participated in a provincial project to develop a contingency plan for blood shortages due to pandemics and other disasters, I got to wondering how many hospital transfusion services (TS) have developed such plans and particularly about contingencies for staff shortages.

For example, what would happen in your TS during a a flu pandemic, if a significant percentage of staff (30-40% or more) were too sick to work, some stayed home to take care of children or other family members who were ill or because schools had closed, and others stayed home out of fear of becoming infected in the hospital?

For interest, in Canada during the SARS crisis of 2003, health care workers (HCW) were at great risk. One small study showed that among 43 nurses who worked in two Toronto critical care units with SARS patients, 8 of 32 nurses who entered a SARS patient's room were infected.

SARS among Critical Care Nurses, Toronto. Emerg Infect Dis [serial online] 2004.

A larger study showed that of 74 SARS cases reported during April 15 -June 9 to Toronto Public Health, 39% occurred among health care workers, 38% occurred as a result of exposure during hospitalization, and 23% occurred among hospital visitors.

Update: Severe Acute Respiratory Syndrome --- Toronto, Canada, 2003. MMWR. June 13, 2003 /52(23);547-50.

Given that much has been learned from the SARS crisis, today, would you put the duty to care for pandemic flu and other patients above potential health risks to yourself and family and above your responsibility to care for your family?

For overviews of these issues, see:

1. Hospital pandemic preparedness: health care workers’ opinions on working during a pandemic. Med J of Australia 2007; 187 (11/12): 676.

Key findings:
67% would work during a pandemic;
26% would stay home to care for dependents;
10% admitted they would stay away because of fear of catching influenza.

2. Will first-responders show up for work during a pandemic? Lessons from a smallpox vaccination survey of paramedics. Disaster Manag Response 2007 Apr-Jun;5(2):45-8.

Key findings:
More than 80% of respondents would not remain on duty if there were no vaccine and protective gear;
Even if protective gear was available but the vaccine was unavailable, only 39% of respondents would remain on duty.

3. Influenza pandemic and professional duty: family or patients first? A survey of hospital employees. BMC Public Health. 2006; 6: 311.

Key findings:
28% agreed that it would be professionally acceptable for HCW to abandon their workplace during a pandemic in order to protect themselves and their families;
77% disagreed with the statement that HCW should be permanently dismissed for not reporting to work during a pandemic;
21% of respondents agreed that HCW without children should primarily care for the influenza patients.

BLOOD CONTINGENCY PLANS
Most of the publicly available plans are designed to offer guidance at a national level, and, as would be expected, tend to focus mostly on the blood suppliers. See Further Reading below.

Blood shortage preparedness for hospitals is built around the twin pillars of
(i) Practicing sound blood management at all times;
(ii) Inventory levels triggering the contingency plan, at which point hospitals are expected to cut back on inventory and begin to triage which patients will be transfused and which will not.

In Canada several provinces are developing blood contingency plans targetted to hospitals. These plans are based in part on the UK integrated blood shortage plan (see Further Reading below) and provide guidelines for TS to use in developing their own plans. Only a few forward-looking hospital regions have begun planning for severe blood shortages that would occur during pandemics. Almost all have plans for short term shortages caused by mass casualties and similar events.

Existing blood contingency plans are mostly designed to cover blood shortages regardless of cause, e.g., pandemic, terrorist attack, natural disaster, mass casualty accident.

Hospital-focused plans tend to assume that associated problems such as power outages, transportation disruption, communication failures, and staff shortages with be covered by hospital emergency preparedness plans and regional emergency planners.

Emergency preparedness planners mainly use the Incident Command System (ICS) model to develop to their plans. Most people in the transfusion medicine community have never heard of ICS. (Also see information on disaster response systems in Canada)

STAFF SHORTAGES
Transfusion services must be prepared for severe staff shortages. In pandemics, the effects of a staff shortage may be lessened because fewer transfusions will occur due to a shortage of blood donors. Laboratories that use manual test methods and procedures that are more labour intensive will be hit hardest.

There are many strategies that TS labs can use to develop contingencies for staff shortages. Most revolve around identifying core services that must be maintained and ensuring an adequate supply of trained staff to perform them.

Bottom line: The results of research into the attitudes of HCW to caring for families and protecting their own health during pandemics suggest that preparedness strategies need to extend beyond the logistics of ensuring adequate staff. Equally important will be

Staff education about pandemics and how the disease is spread, combined with
Equipment and other strategies designed to protect HCW from infection.

QUESTIONS (food for thought)

Does your hospital have a blood shortage contingency plan?
If yes, does it include contingencies for staff shortages?
Have you received education about pandemic flu?
How do you think you will be protected when you come to work during a flu pandemic?
Do you know who will be given priority for available vaccine during a flu pandemic?
Other than being ill, under which circumstances would you not show up for work during a flu pandemic?
As a health professional, would you risk your life for others or is it Hell, no, I won't go?