Table 6.

Lessons learned during the “herald wave” of the swine influenza (H1N1) pandemic in spring/summer of 2009 at Winthrop-University Hospital

Laboratory Diagnosis: Rapid Influenza and RT-PCR Testing	Clinical Diagnosis: Winthrop-University Hospital Infectious Disease Division's Diagnostic Swine Influenza (H1N1) Triad	Infection Control Considerations
•Rapid influenza A test positivity correlated fairly well with RT-PCR positivity •30% of rapid influenza A tests for swine flu were falsely negative •Some admitted adult patients with influenzalike illnesses (ILIs) with negative rapid influenza A tests were not placed on influenza precautions resulting in extensive contact investigations of patients/visitors by Infection Control and of exposed employees by the Employee Health Service •A laboratory diagnosis of swine influenza was made by RT-PCR but testing was restricted •Another problem with RT-PCR testing was that the results were not quickly available. Causing major Infectious Disease and Infection Control problems •By the end of July, CDC acknowledged definite/probable case definition because of restricted RT-PCR testing	•Rapid influenza testing was often not done in the ED in patients with ILIs because they had “pneumonia.” Educational efforts were done to inform physicians that admitted adults with swine influenza (H1N1) had swine influenza (H1N1) pneumonia •Chest radiographs were critical in identifying bacterial CAPs and mimics of swine influenza (H1N1) in admitted adults with ILIs with fevers >102°F •Because of Infectious Disease and Infection Control problems with admitted adults who had ILIs with negative rapid influenza A testing (RIDTs) in the ED, the Infectious Disease Division developed clinical criteria to clinically diagnose probable swine influenza (H1N1) pneumonia (see Table 4) • In adults admitted with ILIs and negative rapid influenza A tests (RIDTs), the most important findings of swine influenza (H1N1) and predictive of RT-PCR positivity were: • Dry cough • Temperature >39°C/102°F • Severe myalgias • CXR with no focal segmental/lobar infiltrates • Relative lymphopenia • Thrombocytopenia • Elevated CPK • Elevated AST/ALT	•At the peak of the pandemic, sufficient negative pressure rooms were not always available •Lack of adequate negative pressure single rooms delayed the transfer of nonintubated adults with swine influenza in the intensive care unit (ICU) to floors (to decrease mobile ICU congestion to free up beds for additional swine influenza patients) •It was difficult to determine which of the possible/probable swine influenza (H1N1) patients should have influenza precautions discontinued •N95 masks were used for health care personnel obtaining respiratory samples for swine influenza testing and for those involved in intubating possible/probable swine influenza (H1N1) patients •Some of our personnel were not fit tested for N95 masks or failed the fit test. These health care workers could use the PAPR hood •The supply of N95 respirators was quickly exhausted and, of necessity, surgical masks had to be used •There were problems with visitors who did not always observe influenza precautions. Security escorted one visitor at a time to/from swine influenza (H1N1) patient rooms •Bilingual signs advising people to stay out of the hospital, including the coffee shop/lobby, worked well •Hand sanitizing dispensers were used but visitors were frequently observed coughing without covering in the lobby and coffee shop as well as in front of the signs themselves! •Most health care workers and the public did not fully appreciate that swine influenza (H1N1) is primarily transmitted via aerosols/droplets as well as hand/face transmission •EHS furloughed or prophylaxed HCWS exposed to swine influenza (H1N1). This worked well minimizing the loss of medical personnel taking care of patients with and without swine influenza (H1N1)

Abbreviation: ILI, influenzalike illness.