In fact, much of what existed in the planning and preparation repertoire of U.S. hospitals and other healthcare facilities resided on paper and in simulations studies that generated theoretical solutions to anticipated problems.

Although the healthcare industry’s pandemic planning efforts were fueled by a consistent threat of an outbreak and how it would respond to infected patients and maintain operations, those efforts accelerated as a higher-level priority following the 9/11 terrorist attacks in 2001.

Save for the SARS outbreak that alarmed and swept through much of Asia a few years ago and spiked global demand for gloves, masks and respirators, U.S. hospitals and other healthcare facilities thankfully have yet to crack open those thick binders, fully engage the computer programs and implement their pandemic strategies.

But H1N1, something more tepid than the doomsday scenario pandemics explored in myriad simulations and studies, represents a prototypical litmus test for how well the healthcare industry – and the government – planned and is implementing plans to handle something decidedly more serious and lethal.

So here in the middle of flu season after plenty of warnings, what’s the verdict to date?

Healthcare Purchasing News reached out to more than a dozen experts representing hospitals, group purchasing organizations, manufacturers, distributors and consulting firms to recruit them to issue letter grades to a set of 12 related issues and explain their evaluations of industry and government performance during the ongoing H1N1/flu season.

HPN then tallied their scores, calculated an average grade, and then offered its own brief evaluation. Because all of these organizations deal regularly with the government, some were a bit hesitant to reveal harsh letter grades even among critical comments meant to be constructive. Recognizing that hesitation and in the interest of fairness, HPN decided an adequate compromise was to share source comments with readers but not their individual letter grades, opting instead for listing an average grade, coupled with observational commentary shaping its own grading.

HPN developed this report card exercise with the noblest of intentions, hoping it serves either as a wake-up call or a heaving, affirming sigh about industry efforts so far.

By and large, sources were respectfully generous, crediting the Department of Health and Human Services (HHS), the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) for their domestic reactions to a perceived global threat.

"CDC, HHS, WHO gave as much warning as possible once they learned of the Mexico experience and have kept up information flow, sometimes daily, in multiple venues, [including] press conferences, Web site updates, conference calls, publicly available slides, faxes and print updates," acknowledged Gina Pugliese, R.N., vice president, Premier Safety Institute, Premier Inc., Charlotte, NC.

Wava Truscott, director, Scientific Affairs and Clinical Education, Kimberly-Clark Health Care, Roswell, GA, wholeheartedly concurred. "The U.S. government and CDC reacted very rapidly once they learned of the influenza epidemic in Mexico," she said. "The Mexican government definitely hampered U.S. and global warning systems by delaying communication of the emergence and spread of 2009-H1N1 in their country." 

Irving, TX-based Novation’s Stephanne Hale, senior clinical manager – Safety, Business Development, Clinical Contract Services, Marketing and Strategy, credited both the CDC and HHS for doing "an awesome job developing tools and resources to inform the public of the H1N1 situation in advance of the pandemic, especially considering the fact that H1N1 was a novel virus, and there was limited historical information on H1N1."

Richard Jaffe

Richard Jaffe, chairman and CEO, San Diego-based Safe Life Corp., which manufactures antimicrobial-laced N95 respirators, commended the CDC’s commitment and response – specifically for reinforcing interim guidelines on respiratory protection by recommending the use of fit-tested, NIOSH-certified, N95 respirators for healthcare personnel who are in close contact with suspected or confirmed 2009 H1N1.

"This was not an easy decision for the CDC," said Jaffe who formerly held the same position at glove maker Safeskin Corp. prior to its acquisition by Kimberly-Clark Health Care. "It faced considerable pressure from hospital administrators concerned with the cost and lack of availability of N95 respirators. It also faced considerable pressure from special-interest groups pointing to a recent clinical trial suggesting standard surgical masks provide the same level of protection as N95 respirators. Despite these pressures, the CDC never lost sight of what was most important – the best interest of our healthcare workers.

"The government should not, and we’re happy to say, did not compromise the health and safety of those who care for the sick based on insufficient research, concerns over supply availability or financial considerations," he added.

Ranjeet Banerjee, vice president, Medical Surgical Systems, BD, Franklin Lakes, NJ, gave generally favorable marks but discounted scores based on accountability details.

"The general warnings around H1N1 were helpful and clear," Banerjee noted. " Flu.gov, for example, is a credible and informative resource both for the healthcare industry and the general public. However, the specificity on preparedness plans was confusing. Specifically, what role the federal government would take vs. the responsibility of state public health departments and healthcare facilities themselves."

But Mike Bowen, executive vice president of surgical mask and respirator manufacturer Prestige Ameritech, Richland Hills, TX, concluded back in late 2007 that the industry was flirting with a mask and respirator shortage, due in part to outsourcing product manufacturing to international facilities. Bowen based his conclusions on several corporate meetings and presentations with HHS.

"From the HHS presentations and meetings, it became clear to the mask industry that HHS was concerned that America was woefully short of masks and respirator stockpiles, that many companies had outsourced their mask production to foreign countries and that Americans were ultimately reliant on foreign health officials for protection during global emergencies," he said.

Bowen indicated he was concerned that HHS would make product manufacturers stockpile masks and respirators for future pandemics, something he believes the government should handle. "Business, HHS soon learned, cannot afford to take on the responsibilities of government," he said. "Having the mask industry stockpile masks is like asking Campbell’s Soup Co. to stockpile soup.

"Had HHS had the authority to fix the problem instead of just to study it, stockpiling could have been initiated in time to produce meaningful results," Bowen continued. "Since nothing was done, the U.S. is currently having a mask and respirator shortage. Had this been a 1918-type pandemic, things would be much, much worse."

HPN: B+. With a public relations master in the White House, you’d have to be off-planet, below the surface or in such a signal-free satellite dead zone to escape the government’s broad-based and comprehensive awareness campaign. Honestly, H1N1 received more multimedia coverage and exposure in the last year than the government-mandated, deadline-postponed switch to digital television got in the last few. Yet awareness campaigns, coupled with information-laden Web sites may not inspire behavioral changes unless the servers crash from the onslaught of interest. But much to the government’s and healthcare industry’s chagrin, public H1N1 fears have yet to overshadow the more popular online voting for the next "American Idol."

While sources gracefully gave the government the benefit of the doubt they lowered the hammer on their own industry, arguing that despite all of the pandemic planning efforts to date hospitals and other healthcare organizations still have miles to go. In fact, several placed a considerable part of the blame on a particular supply chain strategy lauded for its cost effectiveness during routine demand.

Pugliese was quick to credit healthcare organizations with a rapid response but tempered the compliment due to their having limited supplies, using primarily what was on hand, she noted. "Planning and challenges of a just-in-time inventory are still showing weaknesses even with all the planning for H1N1 that has been underway within each state developing pandemic influenza plans," she said.

Ranjeet Banerjee

Indeed, according to Banerjee, the manufacturing community may have been more ready than the providers. "I believe that the syringe manufacturers, for example, did a good job of ramping up capacity early enough to meet the demand of this unique flu season," he said. "However, the healthcare industry works with just-in-time inventories and limited surge capacities, so early preparations such as stockpiling or increased inventories were very limited."

The healthcare industry may have responded to government warnings in a timely manner, but that’s not nearly enough, according to Jaffe.

"Proper pandemic preparedness means being ready long before any warnings are issued in the first place," he said. "That means maintaining an adequate stockpile of critical supplies at all times, so that when a pandemic occurs, you can immediately begin providing these supplies to workers as needed. The healthcare industry did a poor job of maintaining adequate supplies of N95 respirators. It wasn’t until the pandemic began in earnest that the industry took a hard look at its existing supply of N95s, and only then did many companies realize that they would be facing a significant shortage.

"If there’s one thing the industry should learn from all of this, it’s that pandemic preparedness is not something you can afford to take a ‘wait-and-see’ approach on. This will not be the last pandemic the world faces. But it can be the last one in which the industry is forced to deal with a shortage of critical supplies."

Truscott clearly expressed disappointment, reciting a litany of shortcomings that plague the industry.

"Theoretical strategies and binders containing plans were in place, but minimal actual preparation had taken place at the time H1N1 hit," she noted. "[Healthcare workers] did not know what their specific roles were when absenteeism and huge numbers of patients altered normal assignments. Altered admission criteria had not been scripted. Triage procedures with pre-admission segregation areas were not in place. Expansion capabilities for excess capacity were not an automatic option. Procedures were not in place for HCWs required to perform procedures they did not routinely perform. Supplies had not been stockpiled." 

Bowen focused on mask production moving to international areas, relegating U.S. demand to "the stability of Mexico and the mercy of China." He credited his company’s pre-pandemic predictions of mask and respirator shortages to GPOs like Premier and MedAssets "rethinking where they source pandemic medical countermeasures.

"Hospital systems are becoming more and more uncomfortable with their mask supply chain that begins in poor towns in places like China, Thailand, Colombia and Mexico," he continued. Prestige Ameritech recently acquired a mask and respirator manufacturing facility near Fort Worth, TX, and converted it to a "Global Pandemic Preparedness and Response Center" that Bowen contends will help prepare for future pandemics.

"If heeded, the lessons learned during H1N1 will make America and the world better prepared for future pandemics," he added.

HPN: B-/C+. Ask any supply chain manager about demand forecasting during normal operations and he or she likely will break out in a cold sweat. JIT and stockless distribution and inventory management may be a watershed tactic for budgeting and balance sheet dynamics, but either program can represent a Waterloo during critical demand spikes, particularly unpredictable disease outbreaks and pandemic panic. It’s debatable whether computer calculations, manufacturing plants, distribution trucks or even the repetitive arm motions of syringe-wielding nurses can outpace the spread of germs on an ambivalent public with questionable hygiene habits.

Although Novation’s Hale gave healthcare facilities above-average marks for adequate testing and surveillance of the H1N1 virus early on, as well as reporting confirmed cases to the CDC for tracking, it’s clear that this issue over time, became more complex than it sounds.

Gina Pugliese

From rapid tests to real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) capability, Pugliese rapped the industry’s overall inability to diagnose H1N1 with a qualifier. "Since a negative test provides no information on type of virus present - that is sometimes the nature of rapid tests – this question may not be ‘fair,’" she noted.

But the ability of PCR to confirm the type of flu is spot-on even though it takes 48 hours, according to Pugliese. "When 99 percent of the flu, April to October, was determined to be from H1N1, there was no reason to do any testing outside of research purposes. [This] would be a waste of time and resources, and no difference in prevention or treatment. A goal, of course, would be to have a more effective rapid test that can confirm the infecting virus type." She maintained that it should remain a goal for "more effective logistics."

Truscott tepidly credited industry reaction, which was offset by performance and judgment. "Generally, diagnostics were developed rapidly," she said. "However, false negatives of many of the early rapid diagnostic kits resulted in several cases of avoidable deaths. Had antivirals been prescribed at the time the false negative was declared, it is likely many of those in high risk categories, such as pregnant women, could have been saved."

Truscott also marveled at the "incredible" speed with which the virus spread. "This led to just assuming persons with influenza-like illness (ILI) were 2009-H1N1 positive, and confirmations were often discontinued in many outbreak areas," she continued. "[Advancing] into the regular flu season (circa October), the possibility of other strains of Influenza A and Influenza B increase and may not be identified. Additionally, it may be more difficult to identify antigenic mutations that could alter vaccine or antiviral efficacy if we are not testing all patients for 2009-H1N1 antigen recognition.

HPN: C. Tough for non-clinicians to call, but it’s hard not to agree with the experts. Media coverage of the early – and regrettable – deaths from H1N1 only fanned the flames of vaccine-seeking hysteria and panic. The media scrambled – and sometimes failed – to effectively communicate how to distinguish between flu strains, short of medical assistance, let alone placing many of the H1N1-related deaths into context. Later reporting showed that H1N1 fatalities nearly always surfaced among high-risk patients, specifically those with pre-existing or secondary medical and respiratory ailments.

As the fundamental issue of supply chain management, sources were virtually unanimous in saying providers as well as the government, by and large, dropped the ball. At least one faulted JIT.

"The healthcare industry works with just-in-time inventories and limited surge capacities and therefore does not have the ability to pre-order or stock up on critical supplies," Banerjee said.

Pugliese acknowledged "heroic efforts to locate supplies, but this needs to be viewed within context of even the federal government’s inadequate National Stockpile, which wasn’t close to the predicted supply needed, especially for N95s and masks. Even releases following the Emergency Use Authorization took too long, and some states didn’t even free up existing supplies when healthcare providers were in need," she said.

Hale qualified providers’ ability to preorder as "adequate" but recognized that the initial reaction was to stockpile, which created some supply chain problems.

"Some facilities were ordering more than 10 times their normal purchase histories of necessary supplies which made it difficult to fulfill every request at those amounts," she said. "Because Novation’s internal H1N1 task force worked to educate members on pandemic planning in addition to working with contracted suppliers, we were able to facilitate deliveries of necessary supplies to our members."

Truscott politely warned providers not to be so quick to blame the manufacturers because there’s a domino effect for picking up the slack.

"The assumptions by healthcare provider institutions is often that manufacturers will adjust as the emergency orders come in, eliminating their need to stockpile," Truscott said. "Unfortunately, this is not the case. Machines, along with the land and facilities to accommodate them, the personnel, and supplies for production, as well as the warehousing capacity for storage are all huge financial outlays. If the orders are not coming in from the hospitals, there are no funds for the additional capacity. If a manufacturer is routinely supplying regular orders for, say 2,500 hospitals, there is no way manufacturers can warehouse stockpiles for each facility. Healthcare providers must stockpile critical items."

With the pandemic already well into its second phase, the industry’s ability to order supplies is largely dictated by availability, according to Jaffe. "That said, the healthcare industry should not allow perceived lack of availability to get in the way of making a good faith effort to purchase critical supplies," he added.

Jaffe singled out N95 respirators as a prime example. "There is, without question, a global supply shortage, one exacerbated by the fact that many of the nation’s leading providers are on back-order well into 2010," he noted. "There are, however, companies such as Safe Life that are actively ramping up the production of next-generation N95 respirators in response to the pandemic. We have a substantial supply available for purchase, and have been working with leading healthcare providers during the H1N1 pandemic."

Bowen indicated that the federal government needs to step up because businesses and hospitals "have limited funds with which to prepare for an event that ‘might’ happen.

"It is up to governments to stockpile these items in the good times because the healthcare industry cannot," he said. "The healthcare industry also cannot manufacture and distribute enough of these items during a pandemic to keep up with demand."

HPN: D. They didn’t drop the ball; they misplaced the ball. Unfortunately, at core this is the paramount issue in responding to a serious pandemic. Could a disaster or a pandemic really be JIT’s Achilles’ heel? Even if many healthcare providers were on the ball, recurring images of vaccine waiting lines looping around buildings and snaking through parking lots left indelible impressions of inefficiency – as Washington debates healthcare reform – and haven’t been seen since the releases of the last few Harry Potter books, some of the Star Wars films and Cabbage Patch dolls in the 1980s, as well as the gasoline station lines during the shortage of 1979.

Media warnings about swine flu vaccine production delays due to outdated manufacturing processes as well as complaints about hand sanitizer hoarding that potentially was depleting product availability and the ongoing mask and respirator shortages were prominent in the fall even as H1N1 concerns began to ebb and treatment and prevention measures became routine. But as everyone becomes comfortable with practices and processes, the blame game begins.

Hale dismissed the criticism. "Overall, I believe the manufacturing industry did an outstanding job ramping up production of supplies, especially in light of the unprecedented demands from the healthcare industry," she said matter-of-factly.

Banerjee concurred. "Many of the medical devices critical for flu are very mature product categories and operate with limited excess capacity," he said. "Given enough time, the industry can plan to ramp up capacity and build inventories to supply the necessary excess products, but with short lead time, this is a very challenging task. That the syringe industry specifically was able to provide the excess product needed for the H1N1 vaccination campaign while maintaining close to normal existing customer supplies was a huge accomplishment."

Pugliese highlighted some of the confusion in the supply chain as being troublesome. "Backorders for masks and N95 respirators are the norm six months into the pandemic, and remain in current shortages across the country," she said. "However, other supplies were shipped and managed very well."

But she further noted "the very fact that CDC/NIOSH/OSHA had to develop guidance in light of such major shortages indicates insufficient production, and may reflect more on the federal government’s insufficient planning and ordering for the Strategic National Stockpile during the buildup for pandemic Asian flu. Also, unlike the government purchasing the vaccine, there was not the same support for manufacturers to ramp up production of respiratory protection, coupled with manufacturers unwilling to do this in case of no pandemic or no need for the products."

Charlie Kilfoyle

Charlie Kilfoyle, senior product manager, STERIS Infection Prevention Technologies, STERIS Corp., Mentor, OH, acknowledged that "not all suppliers were prepared" and there has been "some significant shortcomings in the ability to meet demand" for key products.

"Customers have stated that N95 respirators are simply unavailable – and have been for an extended period – and we have heard rumors of mask shortages," Kilfoyle continued. "We also know that many producers of hand sanitizers have been out of stock of key products – some for extended, or uncertain, periods. In some respects, it is difficult to criticize manufacturers because demand jumped significantly in a very short period of time."

Kilfoyle credited STERIS for forecasting demand spikes, ramping up production and inventory for certain products and working with vendors to ensure component availability, as well as helping providers and distributors manage their pandemic plans and ordering. "In spite of demand that led to volumes two to three times the norm, STERIS was able to supply sanitizers for all our dispensers, assuring that no dispensers went empty in this critical time," he added. "In addition, STERIS was able to fill gaps in supply for non-STERIS customers who had difficulty obtaining products from leading vendors who could not keep up with healthcare orders."

Jaffe advised the industry to get real. "Companies cannot ask their factories to make supplies in the hope that they might be ordered," he said. "Though companies can ramp up production in the face of a pandemic as Safe Life has done, the industry as a whole cannot be expected to flip a switch once such an event is in progress and begin mass production of enough supplies to make up for years of lagging orders. The healthcare industry needs to make pandemic preparedness a priority and incorporate sound stockpiling strategies into their ongoing operations. In doing so, medical device manufacturers would follow suit and produce sufficient supplies to keep reserves at appropriate levels."

Carol Zilm, president, Infusion and Respiratory Systems, CareFusion Corp., San Diego, admitted that her company started to plan for a possible pandemic more than 18 months ago – well in advance of government warnings.

"As part of the planning process, CareFusion contacted key suppliers, ordered long-lead items and increased manufacturing capability threefold, in anticipation of future need," she said. "This has enabled CareFusion to greatly increase the number of ventilators manufactured in response to the unprecedented demand from hospitals around the world and commit to an aggressive delivery schedule for the 4,500 ventilators ordered through the VA system for the CDC national stockpile.

"Being prepared and responsive means more than simply supplying consumables and equipment to the industry, it also means educating and supporting those who deliver care to H1N1 patients," she added. "CareFusion also maintains 24-7 clinical support and fields a team of clinical experts to assist hospitals on site."

HPN: C+. This represents a difficult, narrow and winding road to navigate. On the one hand, vendors are beholden to the historical purchasing patterns of their customers because they track them religiously. Hysterical purchasing patterns, however, remain the proverbial X factor. Questionable forecasting by providers, which arguably is understandable, throws a wrench into the production and sales process only because the vendors don’t want to make and stock excess products that eat into their revenue and profitability. This, too, is understandable.

As Safe Life’s Jaffe said, "The healthcare industry needs to make a concerted effort to maintain adequate stockpiles of critical supplies such as N95 respirators at all times. In response, device manufacturers need to be prepared to maintain consistent lines of production to meet the pandemic preparedness needs of the healthcare industry. In that model, there’s no room for opportunistic manufacturers looking to profit from the onset of a pandemic without making a long-term commitment to the industry." While that sounds great on paper, it’s tough to achieve and balance in practice.

By and large, sources gave the manufacturers props for speed but busted the federal government’s chops for putting speed bumps in the way. Despite "hiccups in the process," the industry did an "outstanding" job, according to Hale.

"Overall the manufacturers did an excellent job of producing vaccine in the traditional manner in a short time frame, given their production was already underway for seasonal flu and the late addition of H1N1," Pugliese said. "They all knew the virus was a slow grower and believed the government-industry partnership was too optimistic in production projections, but they all stepped up to the plate in production, especially in needing to switch from seasonal to H1N1 under great pressure."

Wava Truscott

Pugliese dismissed criticism of Big Pharma’s reliance on egg production in the manufacturing process as "no one’s fault" in delaying vaccine availability. In fact, she argued that the government and industry partnership should have "pushed harder over past years to develop seasonal vaccine in non-traditional methods, such as genetically vs. reliance on eggs." 

Truscott concurred. "The speed and accuracy for vaccine production utilizing the current methods was impressive," she admitted. "The challenge for the future is to develop alternate methods of production that will elevate the use of the rate-limiting-requirement for egg inoculation, harvesting and antigen clean-up. Additionally, a means of vaccine production utilizing a pan-influenza A critical stable antigen that would generate antibodies against Influenza A strains, alleviating the seasonal high probability guess-work and the threat of cross-species attack were a huge accomplishment."

HPN: C. While it may be splitting hairs to quibble with the experts, it should be noted that no matter how fast or accurate the industry was in developing and producing a vaccine in the context of an antiquated process, the fact remains that it relies on an antiquated process, which is hardly efficient in a healthcare reform-minded nation. What if this had been a more serious and more lethal pandemic? This should serve as a wake-up call to speed up the development of alternative and more efficient processes. The 2009 H1N1 outbreak offered what the golfing world calls a Mulligan, allowing industry and government to skate by with some degree of relief. But there’s little-to-no excuse for slipping up next time.

Just as Big Pharma were given relatively high marks that were dragged down by the federal government’s performance, sources rewarded the distribution industry with higher marks that were offset by provider system performance and software programming challenges.

Kilfoyle lauded distributors for having "sound pandemic plans" and "executing them well," which was echoed by Banerjee.

But Banerjee questioned communications about the timing of various shipments as syringes and vaccines had to arrive separately because the vaccines required cold storage capabilities. "Public health facilities were not aware of the separate shipments and expected everything to arrive together," he said.

Truscott complained about inefficient ordering systems complicating the process with inaccuracies and lost orders, creating "huge headaches" for providers, distributors and manufacturers. "Even completing simple long standing orders have resulted in extreme aggravation by all parties," she noted. "Although manufacturers and suppliers are receiving the brunt of the criticism, the software programming corporations have got to take the responsibility and correct this problem."  

She also questioned the lackluster "safe-zone delivery" processes where hospitals accept deliveries in such a space and method as to ensure a virus is not transmitted to or from truckers and dockworkers. "Admittedly, 2009 H1N1 has not been the feared virulent strain it could have been, but this is the perfect opportunity to ensure such plans are in place and the bugs, if you will, are worked out," she added.

HPN: B+. Let’s face it. Barring a complete logistical system collapse or failure, or utter industry-wide incompetence, distributors are experts at moving stuff around. It’s what they do best and they’re doing the best they can with what’s available at their own docks from manufacturers, as well as what’s ordered by the providers. Blaming the distributor for late deliveries and shipments or other problems is a lot like blaming the messenger of bad news for the bad news. They’re one component of the larger supply chain. Any problems up and down the line likely will be shared by all. Clearly providers and software companies have more kinks to work out.

Sources offered relatively high marks for the government’s own logistical process, save for some communication mishaps early on.

In fact, Banerjee felt the government should have launched its admirable procurement process earlier to avoid some of the confusion that emerged.

Pugliese and Truscott both commended the feds for its overall performance in this area, but Truscott questioned some aspects of the vaccine priority status, and Pugliese wondered about the risk of developing resistance on a weekly basis.

HPN: B+. While the logistical fundamentals seem to be in place on paper, more practice may be needed to meet real-life crises.

Sources credited the Obama Administration for establishing a clear hierarchy for who should receive the vaccine first – high-risk groups, but marked it down for failing to communicate, explain and justify the plans as clearly as it could to avoid confusion.

Truscott even dinged manufacturers and distributors for packaging nuances. "The next time both a pandemic and seasonal flu vaccine must be manufactured and given, [the products] should look dramatically different in bottle, grouped packaging and case labeling as deliveries and injections have been confused at times," she said. 

HPN: B. Something about those long lines created a visual backwash of healthcare rationing fears.

Sources gave glowing reviews to preventive awareness campaigns, but dimmed the reviews somewhat in the execution of preventive measures.

"Healthcare rose to the demand with tremendous energy and creativity with available supplies, reaching out to patients and the community," Pugliese said. "Physicians and infection preventionists continue to put in 18-hour days to reassure the worried. Organizations developed methods of triage to handle ER and protect the facility."  

Kilfoyle recognized the heightened focus on hand hygiene, illustrated by "record order volumes for sanitizers and soaps over the past few months, which strongly suggests that hand hygiene compliance has increased considerably in the healthcare industry in an attempt to prevent the spread of H1N1."

But Bowen argued that the H1N1 response should serve as a "wake-up call" for the government and industry to improve preparations for future pandemics.

Carol Zilm

Insufficient stockpiling of necessary products has been a problem as much as the lack of "wipe down" practices by all healthcare workers, according to Truscott. "It is expected that housekeeping will take care of surface decontamination," she said. "But with patients constantly coughing and droplets falling on surfaces in a radius around them and carried elsewhere on the hands and gloves of HCWs, a habit of constant surface disinfection by all healthcare personnel needs to become an accepted practice – like picking up your trash at a fast food restaurant or washing your hands between patients."

Zilm noted that technology exists to help providers identify potential infections before they become a problem, which represents a giant leap forward in intervention. "Anytime the healthcare industry is faced with a pandemic or increasing infection rates, it is a challenge," she said, "but every challenge makes the industry smarter. The current H1N1 pandemic is no different. By applying what was learned from previous pandemics and similar viruses, as well as sharing best practices and disseminating actionable information to key stakeholders, we can better prepare for a variety of health issues."

HPN: B. Let’s forget the encouraged practice of sneezing into your shirt sleeve that has all of the etiquette mavens aghast at the acceptability of long-established boorish behavior and remind ourselves that we still have a serious handwashing problem among doctors and nurses, absent a pandemic.

Overall, sources indicated the good news outweighed any not-so-good news.

"Organizations followed the enormous amount of direction and support from the CDC to assess, treat and manage ill patients, assessing primarily on symptoms and not depending on rapid tests with limitations," Pugliese summed.

"Many hospitals struggled to set up triage capabilities that kept patients with ILI separated, staff protected, and all patients assessed in a timely manner," Truscott noted. But she spotlighted several successful methods, including drive-by triage, separate tents for ILI and non-ILI potential patients, use of more improved rapid flu tests and engineering controls, such as portable isolation units, improved air handling, portable HEPA units and other barriers that improved the ability to isolate and control viral spread while confirming ILI patient status.

HPN: B+. Providers are working as best they can with what they have and know. But that shouldn’t be an excuse nor a justification for acceptable vs. optimal practices.

By and large, sources were polarized on this issue with some exalting pandemic planning effectiveness while others bemoaned the mounting pressure from the burgeoning patient base.

"Even when patient load was at its highest, most facilities dealt with the patient crush with energy," Pugliese commented.

But Truscott disagreed. "This has been a wake-up call for how rapidly capacity is overwhelmed in a pandemic scenario and how the alternatives must be ready for patients with only a few days notice and with personnel trained for providing patient care in their alternate surroundings."

HPN: C+. With expert opinions so polarized at opposite ends of the grading spectrum, the only prudent way to offer a fair evaluation is to compromise and slide to the middle. While some may argue that an average-to-a-smidgeon-above-average grade demonstrates nothing more than a cop-out, it can be spun to say the situation is not as bad as it could be but also not as good as it should be.