Reuters Health has a short note on a survey of 169 nurses, doctors and other health care workers (HCWs in the jargon) about whether they would report for duty during a pandemic. It was done by Dr. Charlene Irvin of St. John Hospital and Medical Center in Detroit, Michigan. I don't know where it was published or what its methods were, so it is hard to say how representative of all HCWs the results are. But it probably isn't very far off. Remember, though, I'm an epidemiologist. We are infamous for blithely acting as if numbers like 84 and 86 are the same. Some of you may remember a sign along the interstate between Boston and New York that said, "86 is now 84." It referred to Interstate highway I-86 being renumbered I-84, but I always took it as official validation of epidemiological method. But where was I? Oh, yes, the survey of HCWs about whether they would come to work during an influenza pandemic.
About 50 percent of the hospital workers said "yes" they would report to work, while 42 percent said "maybe" and 8 percent said "no, even if I would lose my job."Doctors (73 percent) were more likely than nurses (44 percent) or other hospital personnel (33 percent) to indicate that they would report to work in the event of bird flu pandemic.
"I was very surprised that only 44 percent of nurses said they would report to work as usual," Irvin admitted. "Additionally, that only 33 percent of the ancillary support (secretaries, transporters, environmental workers) -- that ironically have less exposure to infection than doctors or nurses -- were planning on reporting to work as usual."
Men were more likely than women to indicate that they would report to work (66 percent versus 42 percent). For the "maybe" responders, the factor making the biggest difference (83 percent) was their level of confidence that the hospital would protect them.
Eighteen percent said a financial incentive to come to work would make no difference, even up to triple pay. (Bloomberg)
Presumably the objective here was to estimate how HCWs would act without taking account they or members of their family might be ill -- in other words, to gauge to what extent fear of becoming sick would keep them from reporting for duty. Clearly illness is a legitimate reason to stay out of work. Indeed it is a mandatory reason. The hospital will be full, but not solely with influenza patients. People will continue to require hospitalization for the usual reasons and being infected by a HCW isn't the best therapy for any of them. This survey suggests that in addition to a possible 40% absenteeism from sickness, half of those remaining will also fail to show up, i.e., staffing could be down 60 - 70%, not 40%.
Surveys like this, done before an actual event, no matter how representative (and there are questions about this one given the tiny sample size and no description of methods) are probably a poor measure of behavior during a pandemic. Behavior will depend on many things, most of which aren't specified in this survey. And people react differently than they think they will ahead of time. Some rise to the occasion. Others find their fear is greater than they imagined. My guess is that HCWs will behave much better than these numbers suggest. Maybe that's wishful thinking. I don't even know how I will act. Honorably, I hope.
However Dr. Irvin drew the conclusion that the projected low compliance was a reflection of lack of confidence in measures the hospital would take to protect their workers.
"Clearly, we have work we need to do to educate healthcare personnel about the realistic risk given the infection control measures we would be using," Irvin said. "The SARS outbreak can be used as a close template for what to expect; once strict infection control measures were followed, the infection rate in healthcare personnel plummeted."
Getting "realistic" information out to the public about the risk of bird flu is also important, Irvin said, noting that "the 50 percent mortality risk reported (in the media) is likely an over-exaggeration. Experts predict the mortality risk will be closer to the influenza pandemic of 1918 at less than 5 percent."
Unfortunately the idea that "the Truth shall set you free" is probably not The Truth, although since we don't know what The Truth is for a possible pandemic its somewhat immaterial. Educating HCWs to an appreciation of the risk is difficult when no one knows what the risk is. The current CFR may or may not sink to "only" the level of the 1918 flu. No one knows and there is no way to predict. To say otherwise is incorrect and doesn't inspire confidence about other claims -- for example, that the hospital's infection control practices would be effective -- especially as most hospitals are not remotely prepared for a pandemic. Even if masks and other measures work, and there is controversy about that, most institutions have only a fraction of what they would need. If whether HCWs show up to work or not depends on their confidence in their employer's ability to protect them, then we are in a lot of trouble. That's not the strong suit of most hospitals, alas. My guess is that people will come anyway and take matters into their own hands when it comes to protecting themselves at work. Somehow.
But there will likely be things hospitals will do, such as dispense antivirals, or if available, vaccines (possibly even a mismatched one). In a related story, researchers at the Division of Outcomes and Effectiveness Research of the Department of Public Health at Weill Cornell Medical College have looked into the best way to provide antivirals, vaccines or other dispensed services to the entire HCW staff in the event of an emergency. This is the kind of non-obvious question that quickly becomes a matter of great urgency when the Shit Hits the Fan. Using techniques from operations research to perform simulations -- a standard and well validated technique in many industrial applications -- the Cornell team wondered how best to dispense something in a day or two to thousands or tens of thousands of workers, say in a large medical center. Allowing each employee to decide on their own resulted in wait times as long as an hour and required many nurses or other employees to give the vaccinations to handle peak load times at the beginning and end of the day. Other strategies were dramatically more efficient:
The method found to be the best, called the "ticket strategy" and inspired by the practice of customers taking numbers at a delicatessen, assigned staff members a specific time of day to receive prophylaxis based on a number such as the last digits of their identification badge. Assuming that 75 percent of staff followed the rules, the expected time in line would be only slightly more than two minutes. Waits were still much less than those of the unmanaged scenario, even if levels of compliance were as low as 25 percent.
Another method, called the "flag strategy," allowed employees to get their inoculation at the time of their choosing -- but only when the line had fewer than a set number of people. With a queue maximum of five, this method resulted in a wait of more than four and a half minutes; with a queue maximum of three, it resulted in a wait of nearly three minutes. One major disadvantage was the many return trips necessitated when the line maximum was met. (Pharma-Lexicon)
This is an example of how a little forethought and preparation can improve efficiency and instill a notion of confidence and credibility in the institution. The impression of a workplace where everyone gets his or her stash of antivirals or a vaccination in an orderly and efficient way would go a long way to bolstering confidence that the institution was also competent in other aspects of protecting the worker. It wouldalso save time and money. Conversely, an otherwise highly competent institution whose delivery of a protective service to the staff is botched, chaotic or disorganized will be seen as incompetent.
Concrete measures properly done will do more to improve HCW turnout during a pandemic than attempts to educate the worker about a realistic appreciation of the risk. That's a loser. We don't know at this point what the risk is and there will be no shortage of credible sources to say it. It will be seen as trying to minimize the danger to serve an institutional purpose.
And given what we know and don't know, that's exactly what it would be.
- Log in to post comments
These numbers come from an abstract published in the Academic Emergency Medicine. Here is the abstract...http://www.aemj.org/cgi/content/full/14/5_Supplement_1/S13-a
Nick: Thanks for the cite.
Similar findings were published a year ago in BioMedCentral Public Health - a self-predicted no-show rate of 46% among surveyed workers in three health departments. Open-access online: www.biomedcentral.com/1471-2458/6/99
There was a presentation about this at last years APHA conference. Apparently, their findings had show/no-show rates differ wildly based on levels of uncertainty and the nature of the disease. It was certainly interesting.
What noone seems to be talking about, and that the entire room of people there couldn't answer is...will everyone else?
I used to work for a company who, among other things, supplied medical grade oxygen to hospitals. Pump operators, truck drivers and someone with a key to the front gate all have to show up for the hospital trucks to get through. Even if all the nurses are there...will their supplies be?
What interests me is that, in the face of maybe not even being able to get to a hospital in a pandemic, more people don't want to volunteer to work in hospitals. After all, if you get sick, there you are, right there with the doctors and equipment, and possibly even more cheerful and responsive treatment in recognition of your hard work.
Many healthcare workers report they will not show up if they do not have confidence in their employer's plan to protect their health (and by extention - their family's health). So how do healthcare employers respond to this information - by taking steps to improve their health and safety programs? No - many continue to resist the possibility of airborne transmission, fight the need for respirator fit testing, confuse masks with respirators and so on. Why should healthcare workers trust such employers?
I think you're right about what should be done, Revere.
Even if they were right and the CFR did drop to to 1918 levels, that's still to my mind a daunting risk. One in twenty is people you know, on your floor, on your shift. It is, unless you have delusions of immortality, possibly you.
Of course, the attack rate would also be a factor. Hospitals might claim that their protective measures would make HCWs safer than the general public, but I suspect that being in close proximity to and caring for many infected people could make the attack rate among HCWs as high as among the general population, if not higher.
Because lets not forget, although people are most averse to dying or infecting their families, they're also averse to agony, which from all accounts is what a bad case of the flu is. Many HCWs may be thinking of the suffering they don't want to go through as well as the end they don't want to meet. (And they may reason that they won't be much good to anyone laid out.)
Which is yet another reason the "it probably won't kill you" is a flawed message, and protective measures must be improved; people don't merely not want to die of a pandemic flu, they don't want to get it at all. Which is a reasonable sentiment.
Anyone got anything on them showing up after the first couple of weeks. I mean this is more of a marketing survey. Out of honor and duty I would think that a Revere would be there until the bitter end. On the other hand, as this is a survey...change the question. Would you show up for work after all supplies for treating the sick were expended, or if there was no food for the patients, or the power/water wasnt on. I think that number would shift dramatically.
Then there are as Caia points out...the facts. If it sank to the 5% level, the total numbers would be horrendous. If it stays where it is now, it would be unfriggin' believable. This doesnt take into account the HCW's that would be sick but recovering either. I think that I read that with a 5% you still get a 30% infected population and sick HCW's are one of the first signs of epidemic.
So whats the fix? Cant say what that is until we see the final problem. I would hope that it would be 5% or none at all. I looked around at all the pandemics in the past and the best that I was able to come up with Revere was about half of the initial case loads and that was with all available resources being throw at it in relation to it. So if you take the 63% WHO number or my rolling 83% annual rate its still going to be 30 to 40% if it pops on in here. You might have better sources on that but crap this is one I wouldnt want to be right on. CFR of 30-40% would mean that nearly everyone had it or has it if I translate that right. .
My own neighbor trains the county EMT's and I handed her the latest from the CDC about mask use and it was news to her. No how can that be? I dont plan on being a casualty but it might happen, but if I do it will happen while I do what I have been geared for by the state EMA. Going down trying to make it work wont be a bad thing. I think that initial response above from those doctors and nurses is duty ridden on one end, and very informed on the other. Its a calculated decision. That calculating will continue once it starts and might produce even worse response than 70%.
All of this may be moot anyway. I don't know what the actual numbers might be, and YMMV, but the idea that any complex system, such as a hospital, let alone an entire health care system, GP's, specialists, referral protocols, supply chain, waste disposal, patient transport, home care, the lot, will continue to have any meaningful function at all with an absentee rate of even 30% is a fantasy.
An army is organisationally non-functioning at 10% loss (which is why decimated means something) a human being dies if they lose 15% of their water, I'd bet that even a much simpler system like a hospital would be totally dysfunctional at 25% so anything beyond that is essentially irrelevant.
I did an informal survey of HCWs in our local area about 14 months ago and the results are very similar. The real question is how realistic these numbers are. Does anyone have an idea of how many HCWs failed to show up for work in the 1918 pandemic?
I don't get the impression that very many health care workers failed to show up in 1918. In looking at our local newspapers from that time, all of the physicians seemed to be working hard and long hours, hiring others to drive their cars or horse carriages for them so they could sleep between home visits.
Of course, communicable disease deaths were much more common then, and the risk of exposure to fatal diseases was a given for a nurse or physician. This perception is less common today.
It does appear to have been difficult to recruit adequate numbers of volunteers to staff the "emergency hospitals," based on pleas for help in the newspaper, and some volunteers dropped out after the first shift, appalled by what they were seeing. But others only worked harder. Toward the end, one of our communities had to pay the "volunteers" as people were burning out.
Listen I have been in hospital work for the last 15 years and NOW I KNOW THEY DO NOT LOOK OUT FOR THEIR OWN!!!!!! YOU MUST LOOK OUT FOR YOURSELF!!!!!! THAT IS THE MOST VALUABLE LESSON I HAVE LEARNED>>>> getting sick while at work and working so SHORT STAFFED THAT THEY TELL YOU TO FIND YOUR OWN COVERAGE SO YOU CAN GO HOME!!!!! After seeing the Louisiana Dr and Nurses go on trial after being left behind with such deplorable conditions to only do a humane euthanasia despite their own personal horror.....no save yourself and don't even go in because someone is always looking to sue you or point the finger at you or not cover you when something happens to you...
Lisa, while i think what you say is true, in a bad pandemic there n't going to be time or the people to conduct witchhunts.
That sounds about right for the hospitals my husband has worked at. He's an RN, and the "what will we do if X disaster happens" is a conversation we had immediately after 9/11, and again when the bird flu started making news. There was never any question about if he would be at the hospital -- just how to manage communication, how to cope with potential "unable to come home/leave the hospital" situations, and how to take care of our family in his absence or potential illness.
It would be interesting to see what the figures for nurses would look like broken down by education -- I know that my husband is in the minority at his hospital in having his BSN. It would also be helpful to see what the percentages look like for RNs vs. LPNs.
It would be nice to hear about more advance planning on the part of the hospitals -- I agree that having clear protocols for taking care of hospital staff in disaster/pandemic conditions would encourage more HCWs to work under such conditions. It's difficult to plan how to respond on a family level when you don't know what will be going on on the professional level.
PB-HCW's that dont show could, if the governor of a state under declaration of emergency or the President at the time does the same force them to go to work. You could sue post of this if he got sick and died and there would be a compensation package of some kind but everyone is making some very flawed assumptions. Most of this relates to the fact that until that declaration they have rights. Once that declaration is in then you have only the right to do what you are told to do. This could entail things from every disaster move Irwin Allen ever made, Stephen King, Gone With the Wind, Nick Bostrom Phd (for those who dont read much http://www.nickbostrom.com/existential/risks.html), Revere and quite a few others such as Webster.
Reasonable people make reasonable decisions based upon reasonable information. If all the supplies for helping people in a pandemic are gone....would you show up? What is a doctor going to do if there are no pharmaceuticals to treat a patient, no bed sheets, no food to feed them when they are in a hospital, no food to feed the doctors who are sequestered there with their nurse and HCW staffs. Sure dedication would and will be a major factor to the outcomes to some patients but if we have a 5% event but how many different outcomes would there be in all reality.
I am also talking about the US response to this. The Grim Reaper wont be running a scythe on this one. He will have a John Deere 355 horsepower mower cutting them down on the other side of this planet as they will be least able to defend and protect themselves. They will though likely recover faster than we will due to our supply scenario. They are closer to their food supply. We are on average removed from it by some 5 tiers, they are only 2. It wont be pretty.
I've been blogging about the total lack of participation by organized professional nursing in national emergency preparedness and disaster planning. I wrote several comments to the NYTimes and WaPo reporters, and at least one of those was forwarded to the CDC. As a result, the president of the American Nurses Association is now a panel member of the HHS Pandemic Planning Leadership Panel. It has instituted a short term five week long action blog.
It will be the presence - or absence of professional nursing care that will directly impact recovery and mortality rates from a pandemic. However, very few nurses have been involved in COOP assessment and planning. Fewer still practice in shared or self-governance employment settings. The ANA is hosting a planning and policy development conference for disaster preparedness in concert with the CDC in June. But at this late date, it's difficult to tell how much impact that will have across the nation.
There are also practice standards questions which have yet to be addressed. To what standard of care will nurses be held in a pandemic? If nurses feel legally intimidated, they most likely will abandon their jobs and stay home, rather than being exposed to legal liability. The case of the NOLA physician and nurses who are being prosecuted for patient malpractice sent a deep ripple of fear through the nation's nurses - who already feel at risk from too high patient case loads.
Pertinent links:
http://universalhealth.wordpress.com/2007/05/26/ana-and-pandemic-planni…
http://blog.pandemicflu.gov/?page_id=2
http://blog.pandemicflu.gov/?page_id=9