Friday, February 29, 2008

Review of Ontario Health Plan for an Influenza Pandemic

I have reviewed other pandemic planning documents that deal with the shortage of ventilators before and today I will discuss one that has some particular importance for me. It is produced by the Ontario Ministry of Health and Long Term Care (MOHLTC), and is entitled “Ontario Health Plan for an Influenza Pandemic” (OHPIP). It is dated July 5, 2007 and is the fourth edition. This document is available at
http://www.health.gov.on.ca/english/providers/program/emu/pan_flu/pan_flu_plan.html
Ontario has planned extensively and early for a possible flu pandemic. This is most likely because of its direct involvement in the SARS and the fear that it would become a pandemic.

This plan is important to me of course because I live in Ontario Canada. Previous OHPIPs issued by MOHLTC have been referenced by other planning organizations. Ontario has been early to recognize the need for a triage plan to deal with the expected crisis for health care in a pandemic, and particularly the shortage of ventilators and trained health care staff that will arise. As in other review posts I have done, I will concentrate mainly on the ventilator issue using excerpts with my attached comments.

The list of contributors to the document is very long and diverse including hospitals, community groups, and businesses as well as academia.

It first has a quote by John M. Barry:
“Every expert on influenza agrees that the ability of the influenza virus to reassort genes means that another pandemic not only can happen. It almost certainly will happen … influenza is among the most contagious of all diseases … the influenza virus can spread from person to person before any symptoms develop. If a new influenza virus does emerge, given modern travel patterns it will likely spread even more rapidly than it did in 1918.”


The document begins by discussing the need for pandemic planning and why there is a particular concern for an influenza pandemic now. It then discusses the role of the WHO and other governing and regulatory groups in pandemic planning. There is a discussion of the ethical framework required for the plan. It references “Stand on Guard for Thee”. Legislation that is required to implement the alteration of rights and government control required to implement the plan is also discussed. The planning goals are then explained. The plan uses the Meltzer model from the CDC, uses the FluAid 2.0 software, and assumes a pandemic of mild to moderate severity.

They do not mention central purchase of ventilators.
“The MOHLTC will provide centralized purchase and distribution of certain personal protective equipment, vaccines/antiviral drugs and other clinical supplies.”


Section 4 has a very good list of links to Ontario and world organizations and other information documents. I will post a copy of the links at the bottom of this post. There is also a very detailed section on credentialing including checklists. There are also general plans on how to increase the availability of staff levels. There is much more very good general planning information, but I will skip now to the portions relevant to ventilator shortages.


Here is a hospital capacity table.
This is also a “most likely “ scenario. I am not sure why there are no numbers for ventilators for weeks 9 and 10 in the scenario. Click on the image to see a clear copy.




Tables such as these are deceiving. At first glance it looks as if we will only have a real ventilator shortfall in weeks 4, 5 and 6, but this excludes the normal utilization of the ventilators in hospitals. They assume 1096 ventilators in Ontario. Now if we assume a normal inter-pandemic utilization rate of 80%, then we really only have 219 ventilators available from our existing pool.

The ventilator shortfall becomes this:

---------------Zero Extra Vents------------500 Extra Ventilators
Week 1 ------------58
Week 2 -----------368
Week 3 -----------683----------------------------183
Week 4 -----------972----------------------------472
Week 5 ----------1070---------------------------570
Week 6 ----------1035---------------------------535
Week 7 -----------777
Week 8 ----------469
Total ----------5374----------------------------1760

These are the numbers of ventilator triage decisions that will have to be made each week during this calculated scenario. Now remember, there is a very good chance that the real numbers could be much worse. If the number of supported ventilators could be doubled, then no ventilator triage decisions would have to be made. If the number of supported ventilators could be increased by 500 (50%), then the total number of ventilator triage decisions could be reduced from 5374 to 1760.


Here is a method they suggest to increase the ability to care for ventilated patients. In this example it doubles the capacity.

Scaling Back Elective Services
Scaling back elective services and surgeries can free up hospital areas, such as surgical intensive care units, endoscopic units, step-down units and post anaesthetic care units [PACU], that are well equipped to provide critical care for influenza and non-influenza patients. How much critical care capacity can be increased will depend largely on the availability of ventilators, and personnel skilled in managing critically ill patients. Scaling back elective and non-urgent services can also provide additional personnel who may have skills transferable to critical care – particularly when a team care model is used (figure 17.2). In this model, health care providers who lack experience in a specific area can be supervised by those with the relevant experience. Instead of individual health care providers caring for one or two patients, a team that has a complete skill set and relevant experience collectively cares for a group of patients. For example, a team of 2 ICU nurses supervising 3 stepdown nurses working with a respiratory therapist and a physician could care for 8 to 10 patients instead of the usual complement of 4 ICU nurses caring for 5 ventilated patients (i.e., 1:1 or 1:2 ratio). The care team model has proven effective in past emergencies(5;6).


Here is the Protocol for prioritization of Patients

The final component of the triage protocol is the prioritization of patients for potential admission to the ICU and ventilation. For ease of use, the common blue-red-yellow-green colour scheme was used.

• Blue patients are those who fall in to the expectant category and should not receive critical care. Depending on their condition and medical issues the patient may either continue to have curative medical care on a ward or palliative care.

• Red patients are highest priority for ICU admission and a ventilator if required. The aim is to find the balance between those who are sick enough to require the resource and will do poorly if they don’t receive it, but are not so sick that they are unlikely to recover even if they do receive intensive care. Patients with a single organ failure, particularly those with respiratory failure due to influenza and who otherwise have a very low SOFA score are included in the red category -- if they have no exclusion criteria. The goal is to optimize the effectiveness of the triage protocol so that every patient who receives critical care will survive.

• Yellow patients are very sick and may or may not benefit from critical care. They should receive care if the resources are available but not at the expense of denying care to someone in the red category who is more likely to recover. At the re-assessment points, patients who are improving are given high priority (red) for continued care, while those who are not showing signs of improvement or worsening are prioritized as yellow.

• Green patients should be considered for transfer out of the ICU.



So what is my overall impression for the plan for my province?

I have worked in the Ontario health care system for about 20 years, and in my experience I have found that there is a strong commitment to caring for the patients we are entrusted to. This document addresses that commitment many times, even when it acknowledges that there are limits to what can be done. On first glance the plan looks very thorough, and is detailed in many areas. It does however have one glaring shortfall. It recognizes that there will be many possibly avoidable deaths because there will not actually be enough ventilators. It has plans to increase the physical space available, antiviral medications, legal issues, and even the staffing plans that could support more ventilators, but there is no plan to actually increase the stockpile of ventilators to a number that could have a significant impact.

The estimated number of ventilators seems low. It is stated as 1096 and is stated as the number of ventilator supported beds. The typical numbers used by US planning authorities is 105,000. The population of Ontario is about 12 million and the population of the US is about 300 million. This is a 25:1 ratio. (The US seems to have 4200 ventilators per 12 million population. This may include patients on chronic ventilators.) It seems that the issue of the number of ventilators available for use should be looked into more closely and this discrepancy accounted for.

The number of available anesthetic gas machines that could be used as ventilators should be accounted for as well. The plan does not go into how the number of available ventilators can be expanded or what the requirements for any acquired surge capacity ventilators should be.

I am sure that the MOHLTC does not want to make the types of planning errors in the face of an impending flu pandemic that the Canadian Red Cross made in the 1980’s in the face of the impending AIDS pandemic, where they could have done several things to save lives but they did not. The CBC archives has a retrospective on this at http://archives.cbc.ca/IDD-1-70-737/disasters_tragedies/tainted_blood/

If you are a pandemic planner, or you work for the MOHLTC, you may wish to listen to these clips, and while you listen, think of how you would respond to people who have lost loved ones in a pandemic due to a ventilator shortage, asking about whether you ever considered getting an additional supply of ventilators ahead of time.

(See my earlier post ~ Trusting in the Pandemic Plans)


I will end with another quote from John Barry that was used in the document:

To have any chance in alleviating the devastation of the [1918 influenza] epidemic
required organization, coordination, implementation. It required leadership and it
required that institutions follow that leadership.

The Great Influenza, John M. Barry

Links from Chapter 4


General Information Resources for the Public

Ontario Ministry of Health and Long-Term Care Pandemic Planning information web site
http://www.health.gov.on.ca/pandemic

Telehealth Ontario
A free, confidential telephone service you can call to get health advice or general health information from a Registered Nurse. 1-866-797-0000

Ontario Ministry of Health INFOline INFOline would direct callers to the appropriate information source for health information.
1-800-268-1154 (Toll-free in Ontario only)
in Toronto, call 416-314-5518, TTY 1-800-387-5559

Government of Canada Information on the Preparedness and Response to a Flu Pandemic One-stop access to information from Government of Canada departments and agencies on pandemic, avian and seasonal influenza.
http://www.pandemicinfluenza.gc.ca

Government of Canada pandemic influenza information hotline
For answers to specific questions or comments about avian, seasonal, or pandemic flu.
1-800-454-8302

Public Safety Canada Web Site for Pandemic Preparedness
A compilation of pandemic preparedness plans from several organizations and levels of government (federal, provincial and municipal plans are linked from this site when available). http://www.safecanada.ca/pandemic/index_e.asp

U.S. Government Avian and Pandemic Flu Information Managed by the U.S Department of Health and Human Services.
http://www.pandemicflu.gov

World Health Organization Web site for pandemic influenza Planning, technical and surveillance
information for pandemic influenza.
http://www.who.int/csr/disease/influenza/pandemic/en/

What you should know about a flu pandemic
A public information brochure by the Ontario Ministry of Health and Long Term Care, which is available in 24 languages.
http://www.health.gov.on.ca/pandemic

An American Sign Language Video Visually presents the contents of the public information brochure.
http://www.health.gov.on.ca/pandemic








Fact Sheets


Ten fact sheets including “What You Should Know About a Flu Pandemic,” are available in printable formats in 24 languages.
http://www.health.gov.on.ca/english/public/program/emu/pan_flu/pan_flu_materials.html#fs

Centers for Disease Control and Prevention Information on Community disease control and prevention.
http://www/hhs/gov/pandemicflu/plan/pdf/S08.pdf

Canadian Pandemic Influenza Plan
http://www.phacaspc.gc.ca/cpip-pclcpi/

World Health Organization
http://www.who.int/csr/resources/publications/influenza/GIP_2005_5Eweb.pdf

Health and Human Services, USA.
Pandemic Influenza Plan.
http://www.hhs.gov/pandemicflu/plan/

Resources for Health Care Providers
Ontario Ministry of Health and Long-Term Care Pandemic Influenza
Information for Health Care Professionals. Information includes provincial emergency status, the Ontario Health Plan for an Influenza Pandemic, fact sheets about treatment and patient care, and links to other health Web sites.
http://www.health.gov.on.ca/pandemic

MOHLTC Healthcare Providers Hotline
For answers to health care providers’ questions. 1-866-212-2272

Ontario Ministry of Labour (Occupational Health and Safety)
Information on Occupational Heath and Safety regulations and protocols in Ontario.
http://www.labour.gov.on.ca/english/hs/index.html

Government of Canada Pandemic Influenza Information for Health Care Professionals
Provides information kits, technical information and Epidemiological Surveillance reports.
http://www.influenza.gc.ca/hpi_e.html

Public Safety Canada Website for Pandemic Preparedness
A compilation of pandemic preparedness plans from several organizations and levels of government (federal, provincial and municipal plans are linked from this site when available).
http://www.safecanada.ca/pandemic/index_e.asp

World Health Organization Website for Pandemic Influenza
Planning, technical and surveillance information for pandemic influenza.
http://www.who.int/csr/disease/influenza/pandemic/en/

Pandemic Information compiled by The Public Health Agency of Canada (PHAC).
http://www.phacaspc.gc.ca/fluwatch/

The MOHLTC’s Emergency Management Unit Health Care Provider Hotline
Includes information for health care providers, employers and first responders.
Toll-free phone 1-866-212-2272; email emergencymanagement@moh.gov.on.ca
http://www.health.gov.on.ca/english/providers/program/emu/emu_mn.html

Important Health Notices (IHN)
Issued by the MOHLTC in response to abnormal events that require ministry direction. The information is intended primarily for use by health care workers and facilities/organizations providing health care, including pharmacies, hospitals, long-term care facilities, community-based health care service providers, and pre-hospital emergency services. IHNs are distributed by email, daily at midnight, and are posted to MOHLTC web site. www.health.gov.on.ca/english/providers/program/emu/ihn.html








Fact Sheets for Health Care Professionals


Fact sheets for matters regarding protection, treatment, and patient care.
http://www.health.gov.on.ca/english/public/program/emu/pan_flu/pan_flu_materials.html#fs

Centers for Disease Control
and Prevention Information on Community disease control and prevention.
http://www/hhs/gov/pandemicflu/plan/pdf/S08.pdf

Canadian Pandemic Influenza Plan
http://www.phacaspc.gc.ca/cpip-pclcpi/

World Health Organization
http://www.who.int/csr/resources/publications/influenza/GIP_2005_5Eweb.pdf

Health and Human Services, USA.
Pandemic Influenza Plan
http://www.hhs.gov/pandemicflu/plan/

The Role of Health Leaders in Planning for an Influenza Pandemic
a Publication by the Canadian College of Health Service Executives
http://www.cchse.org/PandemicEnglish.pdf




Context and Assumptions

“Fluwatch”
Maintained by the Public Health Agencyof Canada (PHAC).
Includes archives and up-to-date information on influenza in Canada.
http://www.phacaspc.gc.ca/fluwatch/05-06/def05-06_e.html

The Meltzer Model.
Martin I. Meltzer M.I, Cox N.J, and Keiji Fukuda.
The Economic Impact of Pandemic Influenza in the United States: Priorities for Intervention. Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
http://www.cdc.gov/ncidod/eid/vol5no5/meltzer.htm

FluAid 2.0 software
Developed by the U.S. Centers for Disease Control and Prevention
http://www2a.cdc.gov/od/fluaid/

FluSurge program
Developed by the U.S Centers for Disease Control and Prevention
http://www.cdc.gov/flu/flusurge.htm

FluWorkLoss software
developed by the U.S. Centres for Disease Control
estimates the potential number of days lost from work due to an influenza pandemic.
http://www.cdc.gov/flu/tools/fluworkloss/

The Role of Bioethics in an Influenza Pandemic.
Gibson J et al (2005). Ethics in a Pandemic Influenza Crisis. Framework for Decision Making. Joint Centre for Bioethics, University of Toronto. WHO Global Pandemic Alert Phases
http://www.who.int/csr/disease/avian_influenza/phase/en/




Legislation


The Ontario Health System ImprovementsAct (2007)
http://www.ontla.on.ca/web/bills/bills_detail.do?locale=en&BillID=519

The Ontario Health Protection and Promotion Act (2006).
http://www.elaws.gov.on.ca/DBLaws/Regs/English/030166_e.htm

The Ontario Crown Employees Collective Bargaining Act (1993)
Provides information on the duties of “essential employees”
http://www.elaws.gov.on.ca/DBLaws/Statutes/English/93c38_e.htm

The Ontario Emergency Management Act
http://www.elaws.gov.on.ca/DBLaws/Statutes/English/90e09_e.htm

The Ontario Regulated Health Professions Act (RHPA).
http://www.elaws.gov.on.ca/DBLaws/Statutes/English/91r18_e.htm

The Ontario Occupational Health and Safety Act
http://www.elaws.gov.on.ca/DBLaws/Statutes/English/90o01_e.htm

The Ontario Workplace Safety and Insurance Act
http://www.elaws.gov.on.ca/DBLaws/Statutes/English/97w16_e.htm




Surveillance

Public Health Agency of Canada
FluWatch surveillance system provides a national picture of influenza activity.
http://www.phacaspc.gc.ca/fluwatch/index.html

The Canadian Network for Public Health Intelligence
Contains various internet-based applications and resources designed to provide a secure way for public health authorities to share information and manage resources in an outbreak situation.
https://www.cnphircrsp.ca/cnphi/index.jsp?src=CPHLN

Ontario Influenza Bulletin
Includes regularly updated information on influenza in Ontario
http://www.health.gov.on.ca/english/providers/program/pubhealth/flu/flu_05/flubul_mn.html





Infection Control

Preventing Respiratory Illnesses, Protecting Patients and Staff
Document created by the MOHLTC which includes the FRI Case Finding Protocol
(Note: these guidelines have been developed for non-outbreak conditions; however, because influenza is primarily droplet and contact spread, the principlesof infection control in the guidelines can be applied more broadly.
http://www.health.gov.on.ca/english/providers/program/infectious/diseases/ic_fri.html)

Infection Prevention
A reference booklet for health care workers produced by Engender Health.
http://www.engenderhealth.org/res/offc/safety/ip-ref/pdf/ip-ref-eng.pdf

College of Physicians and Surgeons of Ontario – Infection Control in the Physician’s Office.
http://www.cpso.on.ca/Publications/infectioncontrolv2.pdf

Ontario Ministry of Labour (Occupational Health and Safety)
Information about occupational Heath and Safety regulations and protocols in Ontario as well as a reference about people’s rights as employees.
http://www.labour.gov.on.ca/english/hs/index.html

Infection Control Toolkit Strategies for Pandemics and Disasters.
Can be ordered through the Community and Hospital Infection Control Association (CHICA - Canada). Phone 204-897-5990 or 866-999-7111; email chicacda@mb.sympatico.ca
Canadian Pandemic Influenza Plan Annex F

Infection Control and Occupational Health Guidelines during an Influenza Pandemic in Traditional and Non-Traditional Health Care Settings.
http://www.phacaspc.gc.ca/cpip-pclcpi/pdf-cpip-03/cpip-appendix-f.pdf

Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care.
http://www.phacaspc.gc.ca/publicat/ccdrrmtc/99vol25/25s4/index.html

Handwashing Techniques
http://www.health.gov.on.ca/english/public/pub/pubhealth/pdf/handwash_tech.pdf)

Canada Communicable Disease Report Prevention and Control of Occupational Infections in Health Care.
http://www.phacaspc.gc.ca/publicat/ccdrrmtc/02pdf/28s1e.pdf

Canadian Tuberculosis Standards 5th ed.
Produced by the Canadian Lung Association in 2000
http://www.phacaspc.gc.ca/publicat/ctsncla00/pdf/cts00.pdf)

Ontario Best Practice Manual
Contains information on proper cleaning, disinfection, and sterilization.
http://www.health.gov.on.ca/english/providers/program/infectious/diseases/ic_cds.html

Infection Control Guidelines on Handwashing (Health Canada).
http://www.phacaspc.gc.ca/publicat/ccdrrmtc/98pdf/cdr24s8e.pdf

Engineering Controls. CSA Standard CAN/CZA-Z317.2-01
Special requirements for heating, ventilation, and air conditioning (HVAC) systems in health care acilities. Toronto: Canadian Standards Association, 2001.




Occupational Health and Safety


Ontario Ministry of Labour (Occupational Health and Safety)
Information about occupational Health and Safety regulations and protocols in Ontario as well as a reference about people’s rights as employees.
http://www.labour.gov.on.ca/english/hs/index.html

The Occupational Health and Safety Act
Regulation: Health Care and Residential Facilities
http://www.elaws.gov.on.ca/DBLaws/Regs/English/930067_e.htm

The Workplace Safety and Insurance Act
http://www.elaws.gov.on.ca/DBLaws/Statutes/English/97w16_e.htm


Ontario Safety Association for Community and Healthcare (OSACH)
Pandemic Planning Resources
http://www.osach.ca/new/SaftInfo/PanPlan.shtml

For a complete listing of products and services available from all of Ontario's designated Safe Workplace Associations, see:
http://www.preventiondynamics.com/

Canada’s National Centre for Occupational Health and Safety Pandemic Planning Portal
http://www.ccohs.ca/pandemic/

United States Department of Health and Human Services Health and Safety Information
http://www.pandemicflu.gov/health/index.html

Occupational Health and Safety Association (OSHA) Guidance on Preparing Workplaces for an Influenza Pandemic
http://www.osha.gov/Publications/OSHA3327pandemic.pdf

Potential Training Resources for Volunteers
St. John Ambulance Brigade. Brigade Training System (1997).
http://www.sja.ca/english/health_safety_training/index.asp

St. John Ambulance Brigade. Handbook on the Administration of Oxygen (1993)
ISBN 0-919434-77-0.

Yes, You Can Prevent Disease Transmission (1998).
The Canadian Red Cross Society




Immunizations / Vaccines


The Canadian Immunization Guide, 6th Edition
A comprehensive guide produced by Health Canada
http://www.phacaspc.gc.ca/publicat/ciggci/pdf/cdn_immuniz_guide-2002-6.pdf

Vaccine Storage and Handling Guidelines
A set of guidelines produced by Ontario Ministry of Health to ensure that vaccines are stored and transported at ideal temperature in the appropriate containers
http://www.health.gov.on.ca/english/providers/program/pubhealth/flu/flu_03/implementation_package/vac_store_hand.pdf

California Department of Health Services Immunization Branch
Information on Comforting Restraining for Immunization
http://www.dhs.ca.gov/ps/dcdc/izgroup/news.htm

WHO Directions for the Vaccination ofChildren
http://www.who.int/child-adolescenthealth/publications/referral_care/

Further Information on Safe Vaccine Administration, and Healthcare Worker Safety http://www.who.int/vaccinesdocuments
http://www.safety.ed.ac.uk/resources/Bio/Guidance/General/Preventing_injuries.shtm
http://www.seiu.ca




Laboratory Services and Safety

The Laboratory Annex, Canadian Pandemic Influenza Plan
Contains additional information on avian influenza infection in
http://www.phac-aspc.gc.ca/cpippclcpi/

Transportation of Dangerous Goods Regulations
Detailed information on infectious substance (specimen) packaging and transport
World Organization for Animal Health (Office International des Epizooties)
All novel H5 and H7 influenza strains discovered in a laboratory should also be reported here because of possible “crossspecies” transmission and infection.
http://www.oie.int/eng/oie/en_oie.htm

Public Health Agency of Canada Containment Levels
Updated information is available from the Office of Laboratory Security of the PHAC
(Phone) 613-957-1779, or (fax) 613-941-0596
http://www.phac-aspc.gc.ca/olsbsl/index.html

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