09/09/2008 - 12:54

Health-care realities during a pandemic

Laura H. Kahn

Laura H. Kahn

A general internist who began her career in health care as a registered nurse, Kahn works on the research staff of Princeton University's ...

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Despite the availability of antiviral medications and intensive care units, mortality rates for the 385 humans infected with avian influenza remain high. Virtually all of the victims have been from developing countries, with the case fatality rate in children younger than 15 years of age reaching  almost 90 percent. (See "Avian Influenza A (H5N1) Infection in Humans.")

Whatever the age or locale, patients stricken with avian influenza would most likely require intensive nursing care. Yet, despite the critical role that nurses play in patient outcomes, by 2025, the United States is estimated to have a shortage of as many as 500,000 registered nurses, or RNs--the best trained and educated nurses who often supervise licensed practical nurses and nurses' aides. Already, 14 percent of U.S. hospitals report a severe nursing shortage with more than 20 percent of their positions vacant.

Addressing the U.S. nursing shortage would require more funding for education, training, and higher salaries--never priorities compared to investing in new technologies."

Worse yet, given the country's aging population, the need for nurses is only increasing; the U.S. Bureau of Labor Statistics anticipates that more than 587,000 new nursing positions will be created by 2016.

Contributing factors for the nursing shortage include restricted nursing school enrollment capabilities due to a lack of faculty and a high-stress workload that drives many nurses to leave the profession. Fear of workplace violence, particularly in psychiatric wards, emergency rooms, and nursing homes is cited as another factor. Of course, fewer nurses has meant an increase in patient violence, widening the gap further still--see "Nurses Step Up Efforts to Protect Against Attacks."

There's also a significant gender gap. Ninety-five percent of the nearly 3 million RNs in the United States are women, meaning one-half of the country's population--men--typically don't become nurses. Needless to say, this disparity is alarming, and there should be a major effort to recruit more men into the field.

Unfortunately, given the current state of the U.S. healthcare system, it's unlikely that the nursing shortage will be resolved anytime soon. Addressing it would require more funding for education, training, higher salaries, and lower nurse-to-patient ratios--never priorities compared to investing in new technologies.

The rise of the nursing profession

Before Florence Nightingale and her team of 38 volunteer nurses went to care for sick and wounded soldiers during the Crimean War, nursing wasn't considered a respectable profession for well-to-do ladies.

At first, Nightingale was rebuffed by physicians at a military hospital in Scutari, Turkey, even though the medical staff was severely overstretched and sanitary conditions were appalling. A century before antibiotics, infections such as gangrene, dysentery, and typhus killed more soldiers than war injuries.

Nightingale was a firm proponent of the burgeoning "Sanitation Movement" and believed that clean food and water, hygiene, and comfort would be more beneficial to healing and recuperation than bleeding, mercury, and arsenic--the medical practices of the day. She and her nurses cleaned up the raw sewage on the wards, bathed and fed the soldiers, laundered bed linens, and installed retractable windows. She used her own money to provide soups, teas, cereals, and other easily digestible foods that the sick soldiers could eat rather than the army's meager war rations. Through her meticulous management skills and record keeping, she demonstrated an almost seventeen-fold drop in mortality rate over a one-year period. And her leadership had a profound and lasting impact on nursing, infection control, and hospital epidemiology.

Nursing care during the 1918 influenza pandemic

Because of World War I, there were severe shortages of health-care personnel during the 1918 influenza pandemic, as most nurses and physicians were caring for soldiers overseas. Many of the doctors and nurses who remained stayed away from patients because they feared for their own lives. (See "Hospital's Full-Up: The 1918 Influenza Pandemic.")

Therefore, student nurses and doctors were recruited to help alleviate the shortage. Isaac Starr was just starting his third year at the University of Pennsylvania School of Medicine when he went to work as a nurse on the hospital wards. In a published recollection of his experiences, he wrote, "I soon found myself 'head nurse' on the top floor for the shift starting at 4 p.m. and ending at midnight. . . . Thinking of my function as that of a nurse, I was prepared to carry out the orders given me. But for most patients there were no orders, and many died without having been seen by any medical attendant but me. . . . As their lungs filled with [fluid] the patients became short of breath and increasingly [blue]. After gasping for several hours they became delirious and incontinent, and many died struggling to clear their airways of a blood-tinged froth that sometimes gushed from their nose and mouth."

The estimated mortality rate was somewhere between 2 to 3 percent. Many of those who died were healthy young adults; in 1918, there weren't intensive care units, ventilators, antibiotics, or antiviral medications. In fact, most people were cared for by family members in their homes.

Informal caregivers

Today, about 52 million people in the United States voluntarily provide care to a family member or friend with a chronic illness or disability. Thirty-eight percent of these family caregivers are adult children who provide care to their aging parent(s); 11 percent are spouses who take care of an ill husband or wife. Both men and women provide informal care, and most are middle-aged and employed. Family caregivers' services have been estimated at an economic value of $257 billion (in 2000 dollars).

The National Family Caregivers Association, founded in 1993, provides resources for family caregivers through educational materials, support, and advocacy. In 2002, the organization supported the passage of the National Family Caregivers Support Program --an amendment to the Older Americans Act. The program helps states and local agencies provide family caregivers with information, assistance, support groups, and training. It also provides grant funding for innovations to help family caregivers.

This vast network of unsung heroes shows that people will care for family and friends when the need arises. A similar support system could be developed during an influenza pandemic when overwhelmed and understaffed healthcare facilities turn people away.

In addition to government support, nongovernmental organizations could play a major role in pandemic preparedness. For example, the Red Cross provides information on home preparedness in the event of a disaster and offers courses in babysitting, CPR, and first aid. And although it already provides basic information on influenza, it could go a step further and offer courses in family caregiving to help people learn how to monitor vital signs (temperature, pulse, respiration), food and fluid intake, and output during an influenza pandemic. Along these lines, the Red Cross has begun a new program for family caregivers who provide care to the elderly and disabled.

There should also be a Family Caregiver magazine and website that features news and information for those who informally care for others with acute (e.g. hepatitis A, rubella, pertussis, influenza) and chronic illnesses (e.g. diabetes, HIV/AIDS, Parkinson's disease). The need for such information will only grow as the population ages. In the face of the current and future nursing shortage, the public should be prepared that  their family and friends would likely not  receive professional nursing care during an influenza pandemic. In fact, the responsibility might fall on you and me.