As hospitals prepare for a potential surge in cases of the pandemic H1N1(A) influenza virus this fall, physicians must make decisions about protective measures based on limited evidence about the virus’s transmission and severity.

Planning for pandemic H1N1 includes everything from ordering extra surgical masks to providing family support for hospital staff so they can come to work, said Leonard Mermel, D.O., professor of medicine at Brown University and medical director of the department of epidemiology and infection control at Rhode Island Hospital, both in Providence, Rhode Island.

Dr. Mermel said that during the first wave of pandemic H1N1 last spring, he had “rather draconian measures” in place, based on early data from Mexico suggesting a high mortality rate. “I had a triage desk in our [emergency department], and N95 respirators,” he said in an interview.

But conversations with colleagues, resistance from his staff to routine N95 use, and emerging signs that the new virus was behaving like the seasonal flu virus led to a transition to standard droplet precautions, said Dr. Mermel, who was part of a panel discussion on infection control measures at an Institute of Medicine–sponsored workshop on the use of personal protective equipment for health care workers.

Dr. Mermel meets regularly with a working group at Rhode Island Hospital to discuss infection control procedures. Their plans for responding to pandemic H1N1 include “cough etiquette stations” with surgical masks, hand hygiene products and instructions for their use at hospital points of entry, and a triage desk where a staff person will remind people to follow the instructions.

Other potential strategies to prevent H1N1 transmission include limiting unnecessary visitors to the hospital, limiting procedures that might increase the risk of virus transmission, and assigning immunized personnel to perform such procedures, Dr. Mermel said.

As for personal protective equipment, “it’s a real hornet’s nest,” he said. The Centers for Disease Control and Prevention recommends the use of N95 respirators by health care workers who are treating patients with pandemic H1N1, but the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and other organizations have concluded that standard droplet precautions are probably sufficient.

“At this moment, we are using droplet precautions for standard care and [N95] respirators for aerosol-generating procedures,” Dr. Mermel said.

“It’s of great importance to mitigate transmission from health care worker to health care worker,” he added. A worker could do everything right in terms of personal protective equipment, and then become infected during a lunch break with a colleague who is coughing.

Dr. Mermel’s working group has been coordinating with the human resources department to reinforce the message that staff should stay home when ill. But the working group also has considered how to help healthy health care workers get to work if they need child care or elder care at home.

One especially tricky question is whether to reassign health care workers who may be at high risk for H1N1 infection, such as pregnant women, Dr. Mermel said. The CDC recommends reassigning high-risk health care workers, but recent statements from the SHEA and the IDSA cite problems with that approach.

The CDC may change its guidance on protective measures after reviewing the IOM panel’s report. If the CDC maintains its recommendations, hospitals will have to decide how far to follow them, Dr. Mermel said.

Copyright (c) 2009 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

在医院为今年秋季可能爆发的甲型H1N1流感做好防备工作的同时，医生必须根据有关该流感传播和严重程度的有限证据，制订有关防护措施的决策。

 

罗得岛普罗维登斯市布朗大学的内科学教授兼罗得岛医院流行病学与感染控制科的医学主任、骨科博士Leonard Mermel指出，甲型H1N1流感防备工作包罗万象，包括订购额外外科口罩以及为医院员工提供家庭支持，以确保他们能够正常上班。

 

Mermel博士表示，在去年春季首波甲型H1N1流感流行期间，他根据来自墨西哥的高病死率早期数据制订了“相当严厉的措施”。 他在接受采访时说道，“我在我们的急诊科设了分诊台，并准备了N95口罩。”

 

在由医学研究院主办的探讨为医护人员配备个人防护装备的专题讨论会上，Mermel博士参与了有关感染控制措施的讨论。Mermel博士通过与同事交谈发现，有同事反对常规应用N95口罩，并且最新证据表明，这种新型病毒的传播特性与季节性流感病毒相似，因此可改为采取预防飞沫传染的标准防护措施。

 

Mermel博士定期与罗得岛医院的一个工作组会面，共同讨论感染控制程序。他们应对甲型H1N1流感的计划包括在医院入口设立“咳嗽检查站”和分诊台。该“咳嗽检查站”提供外科口罩、手部清洁用品及使用说明。分诊台人员将提醒人们按说明使用这些用品。

 

Mermel博士说，其他预防甲型H1N1流感传播的策略包括限制不必要的人员探访医院、限制可能增加病毒传播危险的操作、及指派已接种人员来进行这些操作。

 

他表示，至于个人防护装备方面，“问题确实很棘手。”美国疾病控制与预防中心(Centers for Disease Control and Prevention，CDC)建议医护人员在治疗甲型H1N1流感患者时配戴N95口罩，但美国医疗保健流行病学学会(Society for Healthcare Epidemiology of America，SHEA)、美国感染病学会(Infectious Diseases Society of America，IDSA)和其他组织表示，标准飞沫防护措施可能就足以预防感染。

 

Mermel博士说道，“目前，我们正将飞沫防护措施作为标准防护措施，并通过应用N95口罩防止飞沫的产生。”

 

他补充说道，“减少流感在医护人员之间的传播具有重要意义。”在配戴个人防护装备的情况下，医护人员能够妥善完成每件事，但是却可能在午餐期间因同事咳嗽而被感染。

 

Mermel博士的工作组一直在与人力资源部协调，争取让生病的医护人员呆在家中。但针对家里有小孩或老人要照顾的健康医护人员，工作组会考虑设法帮助他们安心工作。

 

Mermel博士指出，一个特别棘手的问题是，是否应对可能发生甲型H1N1流感的高危医护人员(如孕妇)重新分配工作。CDC建议对高危医护人员重新分配工作，但SHEA和IDSA最近发表的声明中提到这样做会产生一些问题。

 

在审查IOM专家组的报告后，CDC可能会修改其有关防护措施的指导建议。Mermel博士指出，如果CDC维持其建议，那么医院将需要自行定夺应在多大程度上遵循这些建议。

 

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