Planning for pandemic influenza is critical for ensuring a sustainable healthcare response. The Centers for Disease Control and Prevention (CDC), with input from other Federal partners, have developed this checklist to help hospitals assess and improve their preparedness for responding to pandemic influenza. Because of differences among hospitals (e.g., characteristics of the patient population, size of the hospital/community, scope of services), each hospital will need to adapt this checklist to meet its unique needs and circumstances. 1 This checklist should be used as one of several tools for evaluating current plans or in developing a comprehensive pandemic influenza plan. Additional information can be found at www.flu.gov.
An effective plan will incorporate information from state, regional, tribal and local health departments, emergency management agencies/authorities, hospital associations and suppliers of resources. In addition, hospitals should ensure that their pandemic influenza plans comply with applicable state and federal regulations and with standards set by accreditation organizations, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Comprehensive pandemic influenza planning can also help facilities plan for other emergency situations.
Members of the planning committee include (as applicable to each setting) the following: (Check categories below that apply and develop a list of committee members with the name, title, and contact information for each personnel category checked below, and attach to this checklist.)
Legal counsel/risk management
Infection control/hospital epidemiology
Public relations coordinator/public information officer
Medical staff (e.g., internal medicine, pediatrics, hospitalist, infectious disease)
Human resources (personnel, including Equal Employment Opportunities)
Facility personnel representative (e.g., union representative)
Diagnostic imaging (radiology)
Engineering and maintenance
Environmental (housekeeping) services
Central (sterile) services
Dietary (food) services
Purchasing agent /materials management
Expert consultants (e.g., ethicist, mental/behavioral health professionals)
Other member(s) as appropriate (e.g., volunteer services, community representative, clergy, local coroner, medical examiner, morticians)
Points of contact for information on pandemic influenza planning resources have been identified within local, state and tribal health departments and the state hospital association (insert names, titles, and contact information.)
Local, regional or state emergency preparedness groups4 , including bioterrorism/communicable disease coordinators points of contact, have been identified. (Insert name, title and contact information for each)
Copies of relevant sections of other available plans (i.e., state, tribal, regional, or local) have been obtained and reviewed for incorporation into the facility’s plan.
A copy of the facility plan and other relevant materials are available in Administration and Infection Control. (List other locations where information is available, including facility intranet sites.)
The plan includes strategies for collaborating with local and regional planning and response groups and hospitals and other healthcare facilities in order to coordinate response efforts at the community level (e.g., staffing, material and other resources, triage algorithms, etc.).
The facility plan includes the elements listed in #3 below.
The plan identifies the person(s) authorized to implement the plan and the organizational structure that will be used, including the delegation of authority to carry out the plan 24/7.
The plan stratifies implementation of specific actions on the basis of the WHO Pandemic Phases, US Government Pandemic Stages, and the pandemic severity index level worldwide, in the United States and at the local level. (See section IV and Appendix 3 of the “Community Strategy for Pandemic Influenza Mitigation” at www.flu.gov/planning-preparedness/community/commitigation.html.)
Responsibilities of key personnel and departments within the facility related to executing the plan have been described.
Personnel who will serve as back-up (e.g., B team) for key personnel roles have been identified.
A tabletop simulation exercise or other exercises have been developed to test the plan.
Date performed (____________)
Date performed (____________)
A full scale drill/exercise has been developed to test the plan.
Date performed (____________)
The plan is updated regularly and includes current contact information and lessons learned from exercises and drills.
A plan is in place for surveillance and detection of pandemic influenza in hospital patients and staff.
A method for performing and reporting syndromic surveillance for persons with influenza-like illness has been tested and evaluated during the regular influenza season in preparation for using the system for pandemic influenza surveillance. Hospital sites for syndromic surveillance should include the emergency department, hospital clinics, and occupational health. Surveillance reports are sent to hospital epidemiology/infection control personnel and to the local health authority. (The frequency of reporting should be determined by the local health authority and reflect the pandemic severity level, as well as any applicable federal or state recommendations.)
Responsibility has been assigned for monitoring public health advisories (federal and state) and for updating the pandemic response coordinator and members of the pandemic influenza planning committee when pandemic influenza has been reported in the United States and is nearing the geographic area. (For more information see www.cdc.gov/flu/weekly/fluactivity.htm.)
A written protocol has been developed for monitoring and reporting seasonal influenza-like illness among hospitalized patients, volunteers, and staff (e.g., weekly or daily number of patients and staff with influenza-like illness). (Having a system for tracking illness trends during seasonal influenza will ensure that the hospital can detect stressors that may affect operating capacity, including staffing and supply needs, during a pandemic.) Information on the clinical signs and diagnosis of influenza is available at www.cdc.gov/flu/professionals/diagnosis/.)
A protocol has been developed for the evaluation and diagnosis of hospitalized patients and/or staff with symptoms of pandemic influenza. Information on the clinical signs and diagnosis of influenza is available at www.cdc.gov/flu/professionals/diagnosis/.
A protocol has been developed for the management of persons with possible pandemic influenza who are seen in the emergency department, hospital clinics, or are transferred from another facility or referred for hospitalization by an admitting physician. The protocol includes criteria for detecting a possible case, the diagnostic work-up to be performed, infection control measures to be implemented, medical treatment, and directions for notifying infection control.
Protocols include triggers for different levels of action that are based on the Pandemic Severity Index (See www.pandemicflu.gov or www.cdc.gov/flu.)
A system is in place to monitor for and internally review healthcare-associated transmission of seasonal influenza among patients and staff in the facility. Information used from this monitoring system is used to implement prevention interventions (e.g., isolation, cohorting). (This system will be necessary for assessing pandemic influenza transmission.)
Responsibility has been assigned for communications with public health authorities (i.e., case reporting, status updates) during a pandemic. (Insert names, titles and contact information of primary and backup persons.)
Methods of communicating with the public (e.g., public service announcements (PSAs), message mapping) and the subjects that will be addressed have been discussed.
Plans and responsibilities for communicating with hospital staff, volunteers, and private medical staff have been developed. Anticipate employee fear/anxiety and plan communications accordingly.
Plans and responsibilities for communication with patients and their family members have been developed.
Responsibility has been assigned for internal communications with staff regarding the status and impact of pandemic influenza in the hospital. (Insert names, titles and contact information of primary and backup persons.)
The types of communication needs (e.g., staff and community updates) and methods of communication (e.g., intranet, PSAs, and newspaper reports) have been identified and are appropriate for individuals with visual, hearing, or other disabilities, or limited English proficiency.
A list has been created of other healthcare entities, including their points of contact, within the region (e.g., other hospitals, long-term care and residential facilities, local hospital’s emergency medical services, clinics, relevant community organizations [including those involved with disaster preparedness]) with which it will be necessary to maintain communication in real-time and be able to report information in a timely and accurate manner during a pandemic (Insert location of the list of contacts and attach a copy to the pandemic plan:)
___________________________________________________ (location of list)
The facility has been represented in discussions with other hospitals regarding local plans for inter-facility communication during a pandemic.
A plan is in place to provide education and training for personnel and information for patients and visitors to ensure that the implications of and basic prevention and control measures for pandemic influenza are understood. (For more information and resources see www.cdc.gov/flu/professionals/index.htm.)
A person has been designated with responsibility for coordinating education and training on pandemic influenza (e.g., identifies and facilitates access to available programs, maintains a record of personnel attendance). (Insert name, title and contact information.)
Current and potential opportunities for long-distance (e.g., Web-based) and local (e.g., health department- or hospital-sponsored) influenza training programs have been identified. (See www.cdc.gov/flu/professionals/training/.)
Language, format (i.e., prepared for individuals with visual, hearing or other disabilities) and reading-level appropriate materials for clinical and non-clinical personnel have been identified to supplement and support education and training programs (e.g., materials available through state and federal public health agencies and through professional organizations), and a plan is in place for obtaining these materials.
Education and training for hospital personnel includes information on differences in pandemic influenza infection prevention and control measures if necessary and are provided in languages and format (i.e., prepared for individuals with visual, hearing or other disabilities) appropriate for hospital personnel. Regular education and training should include, but not be limited to: training in Standard and Droplet Precautions; use of respiratory protection; social distancing and respiratory hygiene/cough etiquette.
Education and training includes information on the hospital’s pandemic influenza plan, including relevant personnel policies, and operational changes that will occur once the plan is implemented.
A plan has been established for expediting the identification of, credentialing and training of non-facility staff brought in from other locations within the region to provide patient care when the hospital reaches a staffing crisis.
Informational materials (e.g., brochures, posters) on pandemic influenza and relevant hospital policies (e.g., visitation) have been developed or identified for patients and their families. These materials are language format (i.e., prepared for individuals with visual, hearing or other disabilities) and reading-level appropriate and a plan is in place to disseminate these materials to hospital patients and visitors.
A plan has been developed for triage (e.g., initial patient evaluation) and admission of patients during a pandemic that includes the following:
A designated location, separate from other clinical triage and evaluation areas, (utilizing the principles of social distancing) for the triage of patients with possible pandemic influenza.
Assigned responsibility to specifically-trained healthcare personnel overseeing the triage process.
Use of signage to direct and instruct patients with possible pandemic influenza on the triage process that is language, format (i.e., prepared for individuals with visual, hearing or other disabilities) and reading-level appropriate.
A telephone triage system for prioritizing patients who require a medical evaluation (i.e., those patients whose severity of symptoms or risk for complications necessitate being seen by a physician).
Criteria for prioritizing admission of patients to those in most critical need.
Coordination with local emergency medical services and 9-1-1 services for transport of suspected flu patients.
A method to specifically track admissions and discharges of patients with pandemic influenza
A plan has been developed to address the needs of specific patient populations that may be disproportionately affected during a pandemic or that may need services normally not provided by the hospital (e.g., pediatric and adult hospitals may need to extend services to other populations).
Populations to consider
Children and their families
Frail elderly and their caretakers
Patients with chronic diseases (e.g., diabetes, hemodialysis)
Physically or mentally challenged/individuals with disabilities
Need for specialized equipment, medical devices, and medications
Mental health concerns
Need for social services
Translation services/medical interpreters
Cultural issues affecting behavioral response
A plan has been developed for facility access during a pandemic that includes the following:
Criteria and protocols for modifying admission criteria on the basis of current bed capacity.
Criteria and protocols for closing the facility to new admissions and referrals to other facilities.
Criteria and protocols for limiting or restricting visitors to the hospital, including specific plans for communicating with patients’ families about hospital rules for visiting hospitalized family members.
A contingency plan has been developed in the event of hospital quarantine in conjunction with local jurisdictions to ensure quarantine is enforced and necessary supplies, equipment, and basic necessities can be delivered and maintained.
A plan has been developed for facility security during a pandemic that includes the following:
Hospital security personnel input into procedures for enforcing facility access controls.
Plans for facilitating identification (e.g., special badges) of non-facility healthcare personnel and volunteers by security staff and facilitating their access to the facility when deployed.
The identity of key and essential personnel who would have access to the facility during a pandemic.
Recruitment and training of additional security personnel (e.g., local police, national guard) that is coordinated by the local health authority.
Plans for establishing a controlled, orderly, flow of patients within the facility.
An infection control plan that includes the following is in place for managing hospital patients with pandemic influenza: (For the most recent information on pandemic influenza infection control recommendations for staff in a healthcare setting, see www.flu.gov/planning-preparedness/hospital/index.html.)
A communication plan is developed to inform all hospital staff and employees about appropriate need for and use of infection control measures, social distancing practices, and personal protective equipment.
Use of respiratory protection (i.e., N-95 or higher-rated respirator as feasible) by personnel who are performing aerosol-generating procedures (e.g., bronchosocopy, endotrachael intubation, open suctioning of the respiratory tract). Use of N-95 respirators for other direct care activities involving patients with confirmed or suspected pandemic influenza is also prudent. If supplies of N-95 or higher-rated respirators are not available, surgical masks can provide benefits against large droplet exposures. (Additional guidance available at www.flu.gov/planning-preparedness/hospital/maskguidancehc.html.)
A plan for cohorting patients with known or suspected pandemic influenza in designated units or areas of the facility.
Responsibility has been assigned for regularly monitoring www.pandemicflu.gov for updates/revisions of infection control recommendations and implementing recommended changes. Once a pandemic influenza virus is detected and its transmission characteristics are known, HHS/CDC will provide updated guidance on any need to modify infection control recommendations. Any changes to current recommendations will be published on www.pandemicflu.gov.
A plan for monitoring adherence to infection control procedures and for monitoring the effectiveness of the infection control plan.
The facility’s human resource and payment policies should be reviewed to identify and eliminate language that may encourage staff to work when ill or even when they are symptomatic with influenza-like illness and especially when they are within the period of communicability. An occupational health plan for addressing staff absences and other related occupational issues has been developed that includes the following:
A liberal/non-punitive sick leave policy that addresses the needs of ill and symptomatic personnel and facility staffing needs during various levels of a pandemic health crisis. The policy considers the following:
The handling of personnel who develop symptoms while at work.
Allowing and encouraging ill people to stay home until no longer infectious.
When personnel may return to work after having pandemic influenza.
Personnel who need to care for family members who become ill or affected by closed care centers.
Personnel who must stay home to care for children if schools and childcare centers close
A plan to educate staff and volunteers to self-assess and report symptoms of pandemic influenza before reporting for duty; consider a phone triage system similar to that used for patients.
A list of mental/behavioral health, community and faith-based resources that will be available to provide counseling to personnel during a pandemic.
A system to track annual influenza vaccination of personnel. (Having a system in place to track annual vaccination will facilitate documentation and tracking of pandemic influenza vaccine in personnel.)
A plan for managing personnel who at the time of a pandemic are at increased risk for influenza complications7 (e.g., pregnant women, immunocompromised workers, employees 65 yrs of age and over). A plan might include, for example, placing them on administrative leave, altering their work location, or other appropriate alternative.
CDC and state health department websites have been identified for obtaining the most current recommendations and guidance for the use, availability, access, and distribution of vaccines and antiviral medications during a pandemic.
Local and/or state health departments and the hospital have agreed upon the hospital’s role, if any, in a large scale program to distribute vaccine and antivirals to the general population.
A list has been developed of key healthcare and other personnel who are essential for maintaining hospital operations during an influenza pandemic who would be the first priority for influenza vaccination.
A plan is in place for expediting administration of influenza vaccine to patients as recommended by the state health department.
A plan is in place for expediting provision of antiviral prophylaxis/treatment to patients as recommended by the state health department
A plan is in place for expediting administration of influenza vaccine to staff as recommended by the state health department.
A plan is in place for expediting provision of antiviral prophylaxis/treatment to staff as recommended by the state health department.
The vaccine/antiviral plan considers the following:
How decisions on allocation of limited vaccine or antivirals will be made.
How persons who receive antiviral prophylaxis/treatment will be followed for adverse events.
Security issues have been identified and addressed in the influenza vaccine and antivirals use plans.
Issues related to surge capacity during a pandemic have been addressed and discussed with the local and/or State health department and other pandemic influenza planning partners.
Plans include strategies for maintaining the hospital’s core missions and continuing to care for patients with chronic diseases (e.g., hemodialysis and infusion services), women giving birth, emergency services, and other types of required care unrelated to influenza.
Criteria have been developed for determining when to cancel elective admissions and surgeries.
Plans for shifting healthcare services away from the hospital, e.g., to home care or pre-designated alternative care facilities, have been discussed with local, state, tribal, or regional planning contacts.
Ethical issues concerning how decisions will be made in the event healthcare services must be prioritized and allocated (e.g., decisions based on probability of survival) have been discussed.
A procedure has been developed for communicating changes in hospital status to health authorities and the public.
A contingency staffing plan has been developed that identifies the minimum staffing needs and prioritizes critical and non-essential services on the basis of essential facility operations.
The contingency staffing plan considers how health professions students assigned to the facility will be utilized.
A plan has been developed for utilizing non-facility volunteer staff, such as those who may be made available through a State Emergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VHP) to provide patient care when the hospital reaches a staffing crisis.
The contingency staffing plan includes a strategy for training of non-facility volunteers (e.g., retired clinicians, trainees) and includes a procedure for rapid credentialing/privileging (consistent with the JCAHO disaster privileging standard MS.4.110) and badging for easy identification by security and access to the facility when deployed.
The contingency staffing plan includes a strategy for cross-training and reassignment of personnel to support critical services.
The contingency staffing plan considers alternative strategies for scheduling work shifts in order to enable personnel to work longer hours without becoming overtired.
Responsibility has been assigned for conducting a daily assessment of staffing status and needs during an influenza pandemic. (Insert name, title and contact information of primary and backup persons.)
Define criteria for declaring a “staffing crisis” that would enable the use of emergency staffing alternatives.
Strategies have been developed for supporting personnel whose family and/or personal responsibilities or other barriers prevent them from coming to work (e.g., strategies that take into account the principles of social distancing when schools are closed, care of elders, transportation, reasonable accommodation or state governmental mandate).
The staffing plan includes strategies for collaborating with local and regional planning and response groups to address widespread healthcare staffing shortages during a crisis, including the development of memorandums of advanced agreement (MAAs) and memorandums of understanding (MOUs) with regional and tribal healthcare partners.
Consumable and durable medical equipment and supplies
Estimates have been made of the quantities of essential patient care materials and equipment (e.g., intravenous pumps and ventilators, pharmaceuticals, diagnostic testing materials) and personal protective equipment (e.g., masks, respirators, gowns, gloves, and hand hygiene products), that would be needed during an eight-week pandemic with subsequent eight-week pandemic waves.
Estimates have been shared with local, regional, and tribal planning groups to better plan stockpiling agreements.
A strategy has been developed for how priorities would be made in the event there is a need to allocate limited patient equipment (e.g., ventilators), pharmaceuticals (e.g., antiviral and antibacterial therapy), and other resources.
A plan has been developed to address related shortages of supplies (e.g., intravenous fluids, personal protective equipment), including strategies for using normal and alternative channels for procuring needed resources.
A list of alternative vendors for medical devices, pharmaceuticals, and contracted services (e.g., laundry, housekeeping, food services) has been developed.
A plan has been developed for maintaining critical laboratory testing capability in-house and priorities for tests that require shipping; back-up plans are in place for testing services that will remain in-house.
A process is in place to track and report to public health and other response partners, in real-time, information regarding the status of the hospital and resources available that would identify burden on the system.
Surge capacity plans include strategies to help increase hospital bed capacity.
Signed agreements have been established with area hospitals and long-term-care facilities to accept or receive appropriate non-influenza patients who need continued inpatient care to optimize utilization of acute care resources for seriously ill patients.
Facility space has been identified that could be adapted for use as expanded inpatient beds and this information has been provided to local, regional, and tribal planning contacts.
Plans are in place to increase physical bed capacity (staffed beds), including the equipment, personnel and pharmaceuticals needed to treat a patient with influenza (e.g., ventilators, oxygen, antivirals).
Logistical support has been discussed with local, state, tribal and regional planning contacts to determine the hospital’s role in the set-up, staffing, and provision of supplies and in the operation of pre-designated alternate care facilities.
A contingency plan has been developed for managing an increased need for post mortem care and disposition of deceased patients.
An area in the facility that could be used as a temporary morgue has been identified.
Logistical support for the management of the deceased has been discussed with local, state, tribal, or regional planning contacts and local coroners/medical examiners.
Local morticians have been involved in planning discussions.
Mortality estimates have been used to anticipate and supply needed body bags and shroud packs.
Plans for expanding morgue capacity have been discussed with local, State, tribal and regional planning contacts.