6.3.Key Issues and Lessons Identified

One of the key lessons learned was that considerable resources are required to sustain a public health emergency response over several months, even during a less severe pandemic. While there is a general view that the public health workforce was stretched during the 2009 response, it should be taken into consideration that ‘business as usual’ generally continued in both the public and clinical healthcare settings during the 2009 pandemic.

6.3.1 Surveillance reporting

There were high demands on jurisdictional public health units (PHU) and hospital staff to report and communicate data for media and health services purposes. Requirements for hospital staff to report data compounded the stress of an additional workload in emergency departments (EDs).²⁶

6.3.2 Border measures

Many PHUs established clinics at international terminals to triage and assess passengers recently returned from countries affected by pandemic (H1N1) 2009 influenza. These clinics were often staffed by nurses from area health services, with support from PHUs. These health personnel came from a finite pool of skilled workers, and some jurisdictions reported shortages in the workforce for clinical management. The opportunity cost of maintaining healthcare professionals at the border is discussed in Chapter 4: Border Measures.

6.3.3 Contact tracing

Pandemic planning had identified that the burden of contact tracing on the public health workforce would be considerable, and work on establishing surge capacity had been undertaken. However, the capacity of public health staff to undertake extensive contact tracing was quickly exceeded by the demand in 2009. Consideration needs to be given to less specific and more manageable definitions of close contacts, and possibly to only undertaking contact tracing in a severe pandemic.

6.3.4 Laboratories

Laboratory staff surge capacity was limited due to difficulty in identifying appropriately trained staff. The changed policy and revised testing recommendations associated with the CONTAIN phase were not well communicated to the clinical sector, and did not reduce the testing demand as expected. There was an apparent expectation that individuals could continue to be tested to confirm whether they had pandemic (H1N1) 2009 influenza, and extensive testing continued beyond the need to inform public health decision making or to focus clinical attention on vulnerable individuals. This had a substantial impact on laboratory workloads over an extended period of time, and extra administrative staff were required to deal with the ongoing number of inquiries and the manual preparation of reports. Private laboratories provided support in some jurisdictions.

6.3.5 The hospital system

Hospital resources in Australia were managed in line with planned strategies, such as deferral of elective surgery, and more extensive use of some high-dependency units. Some state and territory health departments worked with private hospitals to manage hospital capacity, specifically intensive care unit (ICU) resources, although private capacity was not fully used.

Hospitals reported full capacity and lack of beds. Some of the strain in the early weeks arose from patients being admitted with mild symptoms. This is likely to occur in another pandemic because there will be early efforts to contain the disease until the severity is known. Isolating hospitalised patients with pandemic (H1N1) 2009 influenza was challenging. Isolation rooms are limited and the effort required to isolate those not unwell enough to need hospitalisation was a burden.

It has been suggested that a ‘live’ hospital audit system, similar to that used in the UK where their hospital audit was updated three times a day during the response,²⁷ could enhance the Australian health sector’s capability to assess hospital system capacity in real time during a pandemic.

Staffing arrangements for ‘flu clinics’ differed across jurisdictions. Hospital-based clinics were generally staffed by hospital employees, while other clinics were staffed by personnel engaged on fixed-term contracts. Unfortunately, in a system already stretched, additional staffing for flu clinics was not readily available and staff were often drawn from already busy EDs. Further work is required on flu clinic models to determine the most appropriate setting for such clinics, examining a range of pandemic severity scenarios.

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6.3.6 ICU capacity

Although there is some ICU surge capacity in all states and territories, jurisdictions identified that a major limitation to surge capacity was lack of availability of trained intensive care staff. The UK developed a strategy to double its critical-care capacity²⁸ that included upgrading and conversion of facilities in other clinical areas to critical-care levels, cancellation of all non-urgent surgery, cancellation of leave for medical and nursing staff, deployment of reserve-trained critical-care nursing and medical staff, and changes to the ratios of critical-care–trained nurses to patients if necessary. A similar strategy could be considered in the Australian context (see section 6.3.10).

6.3.7 Specialised intensive care

Extra-corporeal membrane oxygenation (ECMO) had not been considered in the planning phase by Australia or other countries, and Australia’s experience with this response informed planners in the northern hemisphere of the anticipated demand in their subsequent winter. One of the biggest issues with the use of ECMO identified during this response was that ECMO could not be used during medical retrieval of patients. The available ECMO equipment was not designed for out-of-hospital use and therefore did not meet aviation or road transport standards. Rationing the use of ECMO may have been required if the peak of the 2009 pandemic had been higher.

6.3.8 Primary care

The moderate nature of the pandemic resulted in a larger role in public health actions for general practice than had been considered in planning. However, capacity was reported as not being exceeded in 2009.

6.3.8.1 Supporting healthcare professionals

The structures that were in place to liaise with, support and provide information to GPs were not well developed. There are opposing views about the most appropriate channels to communicate with clinicians. Communication with GPs was seen by some as inadequate in volume, content and timeliness. For example, early, consolidated clinical advice was needed about antiviral medications and their use. Some GPs reported that they received information through the general media rather than directly. Others felt that the information provided to clinicians was overwhelming and therefore difficult to prioritise and action.

The CMO wrote to the clinical sector at key points, such as at phase changes and to provide advice on the pandemic vaccination program, and this communication mechanism was welcomed. However, given that similar communications by state and territory CHOs duplicated messages, nationally consistent communication jointly from the CMO and CHOs should be considered. While the GP Roundtable group was a successful initiative to improve communication with the primary healthcare sector, there were still communication issues between governments, peak bodies and GPs on the ground. There is a need to enhance the intersection and integration of the Commonwealth, state and territory governments and local networks of peak bodies.

6.3.9 Other workforce considerations

Remote community settings have a limited trained health workforce, and therefore little surge capacity. Planning needs to ensure the availability of critical-care surge support, including early planning for critical-care remote airlift capacity.

An important area identified where further work is needed is to collaborate with the Aboriginal Community Controlled Health Services (ACCHS) to ensure appropriate planning, communication and training for a pandemic response.

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6.3.10 Future pandemic surge capacity planning

The 2009 pandemic clearly highlighted the need to develop guidance on strategies that could be employed during a pandemic to enhance the finite health sector workforce capacity and to address the need to sustain surge capacity for long periods of time, noting that the hospitals system and health workforce are adept at escalating to surge capacity when needed but that this capacity is difficult to maintain. While such guidance would focus on health workforce issues related to influenza pandemics, it is anticipated that this guidance would have broad application to all events where demand for health care could exceed surge capacity, particularly over an extended period of time. The guidance could cover strategies to maximise critical-care capacity in a pandemic, including flexible use of cross-professional skill sets and finite treatment modalities such as ECMO, as well as maximising the traditional health workforce through return-to-work policies, use of retired staff and appropriate use of volunteers or partially trained staff. Guidance could also address patient assessment and prioritisation in line with an agreed ethical framework, and ensuring that health services are optimised, including considering a range of service delivery models in pandemics of different severities (such as GPs, influenza-specific services, ‘flu clinics’ and telephone consultations).





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²⁶ FitzGerald, GJ et al. (2010), ‘Pandemic (H1N1) 2009 influenza outbreak in Australia: impact on emergency departments’, Queensland University of Technology. Research project funded by the Australian Government National Health and Medical Research Council.
²⁷ Report of the Swine Flu Critical Care Clinical Group and Key Learning Points for Future Surge Planning, on behalf of the clinical group by Dr Judith Hulf CBE.
²⁸ Department of Health, United Kingdom (2009), ‘Critical care strategy: managing the H1N1 flu pandemic September 2009’, available from www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_104973.pdf.