Hospital Capacity during an Influenza Pandemic—Buenos Aires, Argentina, 2009
At a major referral hospital in the Southern Hemisphere, the 2009 influenza A (H1N1) pandemic brought increased critical care demand and more unscheduled nursing absences. Because of careful preparedness planning, including rapid expansion and redistribution of the numbers of available beds and staff, hospital surge capacity was not exceeded.
Healthcare preparedness and surge capacity are key aspects of pandemic planning. Although many pandemic plans were implemented during the 2009 influenza A (H1N1) pandemic, few quantitative data exist regarding whether preparedness efforts were adequate to cope with increases in the number of patients with severe influenza disease.1
In the Southern Hemisphere, Argentina reported the highest number of confirmed 2009 H1N1 influenza–related deaths through August 2009.2 The number of cases peaked during late June, when the Ministry of Health recommended national school closures and furloughs for workers at risk for influenza complications. The capital province of Buenos Aires was the most heavily affected, accounting for more than 30% of 2009 H1N1 influenza–related hospitalizations reported in the country.3 To assess the effectiveness of healthcare preparedness measures during the peak of the pandemic in Argentina, we investigated surge capacity in general and critical care hospital services at the largest national hospital, Hospital Nacional Profesor Alejandro Posadas, a 500‐bed referral center in Buenos Aires.
Hospital Nacional Profesor Alejandro Posadas is a large multispecialty teaching and referral hospital in the capital city, Buenos Aires, with more than 500 beds and a catchment area of roughly 3 million people. Annually, the hospital manages 20,000 discharges and half a million outpatient visits, with a staff of approximately 3,000 people, including 800 licensed nurses. On April 28, 2009, this hospital reported the first suspected 2009 H1N1 influenza infection in Argentina, and it reported the first confirmed 2009 H1N1 influenza–related hospitalization on June 3, 2009.
To assess pandemic preparedness measures, we interviewed hospital leadership, including the director, research chiefs, nursing team leads, epidemiologists, and members of the pandemic planning committee in August 2009 and reviewed their written plans and policies.4 To investigate surge capacity, we reviewed daily administrative hospital records from Argentina’s peak pandemic period of June–August 2009. For comparison, we also collected data from the same months of the previous year (June–August 2008), during Argentina’s usual peak of seasonal influenza transmission. Descriptive data elements included general and critical care bed availability, hospital occupancy by ward (adult or pediatric), and nursing staff absences. Only patients receiving mechanical ventilation on each day were assumed to have respiratory critical care needs. Because adult and pediatric critical care ward occupancy data were not recorded separately in 2008, we also collected stratified data from the prepandemic period of the same year (March–May 2009). We then calculated the numbers of bed‐days occupied during the peak pandemic period that exceeded prepandemic capacity.
Administrative records were available for 179 days (97%) during the 6‐month period of March–August 2009 and 91 days (99%) during the 3‐month period of June–August 2008. Pediatric critical care ward occupancy data were not available for 2008.
On April 26, 2009, in response to reports of severe influenza cases in North America and before any cases were reported in Argentina, Hospital Nacional Profesor Alejandro Posadas implemented their pandemic plan for equipment, services, and staff, including the purchase of 40 new ventilators, with 24 ventilators assigned to adult wards, 9 ventilators assigned to pediatric wards, and 7 additional reserve ventilators. Additional plan components included increasing hospital communication with daily assessments of resource requirements in each ward, expanding laboratory capability to offer on‐site polymerase chain reaction testing for the detection of 2009 H1N1 influenza virus, and identifying designated wards for patients with respiratory symptoms. Other infection control plans included recommending the use of N95 respirators and restricting movement within the hospital. Admission criteria were not altered, and no presenting patients were refused.4
Forty‐six nurses (approximately 6%) accepted 6 weeks of paid leave from work from July 2 through August 11, 2009, in accordance with a national policy to furlough workers with medical conditions who were at risk for developing pandemic influenza. Although overall nursing absences were similar to those during prepandemic periods, unscheduled absences increased, reaching a peak of 38 nurses absent on July 12, 2009, representing 43% of the nurses required to staff the hospital that day. To compensate, 80 temporary nurses were hired, some nurses were shifted to higher acuity care areas, and vacations and other scheduled absences were canceled.
During June–August 2009, the peak pandemic period, fewer hospital beds were occupied, compared with the same months in 2008 (Figure 1). This decrease was attributable to a decrease in the number of hospital admissions and the postponement of some elective surgeries by concerned patients. However, the number of patients with respiratory critical care needs was 16% higher during the peak pandemic period, compared with the previous influenza season (3,837 bed‐days vs 3,306 bed‐days).
The higher critical care demand was most marked in adult wards. The number of patients receiving mechanical ventilation in adult wards was 56% higher during the peak pandemic period, compared with the prepandemic period (2,220 bed‐days vs 1,427 bed‐days). Adult critical care demand, however, did not exceed capacity because of the addition of critical care beds. Without pandemic planning, the hospital would not have been able to meet adult critical care needs for a total of 166 bed‐days on 33 separate days during June–August 2009 (Figure 2A).
There was little increase in pediatric critical care needs during the pandemic. In pediatric wards, the number of patients receiving mechanical ventilation was 0.6% higher during the peak pandemic period, compared with the prepandemic period (1,617 bed‐days vs 1,606 bed‐days). Pediatric critical care demand did not exceed capacity at any time. Without pandemic planning, the hospital would not have been able to meet pediatric critical care needs for a total of 3 bed‐days on 2 separate days during June–August 2009 (Figure 2B).
This study examines surge capacity at a large multispecialty referral hospital during the time of peak transmission of 2009 H1N1 influenza in Buenos Aires, the epicenter of the epidemic in Argentina. We found that although capacity was not exceeded, the need for respiratory critical care beds was substantially higher during the pandemic, compared with the 2008 influenza season, mostly in adult wards. Without pandemic planning, this referral hospital would not have been able to provide 169 bed‐days of needed critical care. These results highlight the importance of prompt implementation of pandemic plans.
2009 H1N1 influenza had a geographically uneven impact on hospital services. In Chile, increased emergency department visits for influenza‐like illness made little impact on hospital bed use.5 However, in Australia there was a sustained demand for intensive care unit beds even after the pandemic peak.6 At this hospital, critical care capacity was challenged, but overall there were fewer hospitalized patients, compared with the previous year. Although this was partly attributable to postponed surgeries, anecdotal evidence suggests that patients with noncritical illnesses chose to stay away from the hospital during the pandemic. The nursing staff absenteeism of 43% during the pandemic may not be unusually high, considering that baseline absenteeism rates before the pandemic ranged from 11% to 46% in other South American hospitals.7,8 Nonetheless, ensuring adequate staffing levels is critical, because it is well established that reduced nursing hours are associated with adverse outcomes and deaths.9
This analysis focused on pandemic impact at the hospital level. One limitation is that, because patient‐level data were not assessed, the mean length of stay and the overall number of affected patients were not determined. Furthermore, because no diagnostic data were collected, observed changes in demand could be attributable to diseases other than influenza. However, the period of increased respiratory critical care needs closely matched that of increased pandemic influenza activity in Buenos Aires, when 2009 H1N1 influenza accounted for 94% of circulating respiratory viruses among people aged more than 5 years.3
Worldwide during the 2009 pandemic, healthcare capacity was challenged with a higher than usual number of severe influenza cases, largely because of a lack of preexisting herd immunity. Severe influenza and death disproportionately affected non‐elderly adults. Healthcare systems should plan to assess needs and capacity promptly and continually, redistributing or acquiring new resources as needed. Because influenza pandemics behave unpredictably, surveillance is vital to inform healthcare systems about how best to prepare and implement effective pandemic control measures and target populations most at risk. Computer modeling tools, such as FluAid or FluSurge, may help in planning and decision making.10
Although Argentina experienced a full‐length influenza season in 2009, some regions may remain susceptible to 2009 H1N1 influenza during the current season. Facilities should continue to prepare and implement pandemic plans. Quickly meeting local demand for critical care beds is especially important.
We thank our colleagues at the Hospital Nacional Profesor Alejandro Posadas, Argentina National Ministry of Health, Centers for Disease Control and Prevention, Pan‐American Health Organization, and World Health Organization for encouraging this collaboration.
Financial support. Centers for Disease Control and Prevention intramural funds.
Potential conflicts of interest. All authors report no conflicts of interest relevant to this article.
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