Open Access Open Access  Restricted Access Subscription or Fee Access

Challenges and solutions: Pandemic 2009 H1N1 influenza A in a pediatric emergency department

James Graham, MD, Steven Shirm, MD, Elizabeth Storm, MD, Kristen Lyle, MD, W. Matthew Linam, MD, José Romero, MD


Objective: The purpose of this study was to describe the impact of the 2009 H1N1 influenza pandemic on a pediatric emergency department (ED) at a freestanding children’s hospital in the summer and fall of 2009.
Design: In July 2009, active prospective surveillance for influenza-like illness (ILI) was performed on a daily basis of patients presenting to the ED of Arkansas Children’s Hospital. The Centers for Disease Control and Prevention definition of ILI was used. Records of daily ILI volume were kept. A retrospective review of admissions from the ED to the inpatient service was done for patients with ILI and non-ILI. In addition, comparisons of monthly patient census for the months involved were compared with historical census data.
Results: When public schools started in mid- August 2009, there was a rapid and dramatic increase in the number of patients with ILI seen in the pediatric ED.Within 3 weeks, as many as 120 patients with ILI per day were being seen in the ED. The month of September 2009 was the highest census month ever recorded in this ED. The admission rate of the patients with ILI was lower than patients with non-ILI between September and November 2009 (10.8 percent vs 14.8 percent).
Conclusions: The 2009 H1N1 influenza pandemic resulted in unprecedented patient volumes in this pediatric ED; however, patient acuity (based on admission rate) for patients with ILI was lower than patients with non-ILI. Pandemic influenza can overwhelm emergency care resources, even when the overall severity of illness is relatively low.


pandemic, influenza, emergency department, pediatrics

Full Text:



Editors of the American Heritage Dictionaries: The American Heritage Dictionary of the English Language. 4th ed. Boston: Houghton Mifflin Harcourt, 2006.

Centers for Disease Control and Prevention: Updated CDC estimates of 2009 H1N1 influenza cases, hospitalizations and deaths in the United States, April 2009-April 10, 2010.Available at Accessed May 19, 2010.

Centers for Disease Control and Prevention: Update: Novel influenza A H1N1 virus infection: Mexico, March-May, 2009. MMWR Morb Mortal Wkly Rep. 2009; 58(21): 585-589.

Dawood FS, Jain S, Finelli L, et al.: Emergence of a novel swineorigin influenza A (H1N1) in humans. N Engl J Med. 2009; 360: 2605-2615.

Thompson WW, Shay DK,Weintraub E, et al.: Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA. 2003; 289: 179-186.

Morton MJ, Kirsch TD, Rothman RE, et al.: Pandemic influenza and major disease outbreak preparedness in U.S. emergency departments: A survey of medical directors and department chairs. Am J Disaster Med. 2009; 4(4): 199-206.

Institute of Medicine of the National Academies: Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press, 2007.

Miroballi Y, Baird JS, Zachai S, et al.: Novel influenza A (H1N1) in a pediatric health care facility in New York City during the first wave of the 2009 pandemic. Arch Pediatr Adolesc Med. 2010; 164(1): 24-30.

Costello B, Simon HK, Massey R, et al.: Pandemic H1N1 influenza in a pediatric emergency department; a comparison with previous seasonal influenza outbreaks. Ann Emerg Med. 2010; 56: 643-648.

Cruz AT, Patel B, DiStefano MC, et al.: Outside the box and into thick air: Implementation of an exterior mobile pediatric emergency response team for North American H1N1 (swine) influenza virus in Houston,Texas. Ann Emerg Med. 2010; 55: 25-31.

Mohsin M, Forero R, Ieraci S, et al.: A population follow-up study of patients who left an emergency department without being seen by a medical officer. Emerg Med J. 2007; 24(3): 175-179.

Silka PA, Geiderman JM, Goldberg JB, et al.: Demand on ED resources during periods of widespread influenza activity. Am J Emerg Med. 2003; 21(7): 534-539.

Shapiro JS, Geres N, Kuperman G, et al.: Health information exchange, biosurveillance efforts, and emergency department crowding during the spring, 2009 H1N1 outbreak in New York City. Ann Emerg Med. 2010; 55: 274-279.

Pines JM, Pollack CV Jr, Diercks DB, et al.: The association between emergency department crowding and adverse cardiovascular outcomes in patients with chest pain. Acad Emerg Med. 2009; 16: 617-625.

Diercks DB, Roe MT, Chen AY, et al.: Prolonged emergency department stays of non-ST-segment-elevation myocardial infarction patients are associated with worse adherence to the American College of Cardiology/American Heart Association guidelines for management and increased adverse events. Ann Emerg Med. 2007; 50: 489-496.

Pines JM, Hollander JE: Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008; 51: 1-5.

Fee C,Weber EJ, Maak CA, et al.: Effect of emergency department crowding on time to antibiotics in patients admitted with community- acquired pneumonia. Ann Emerg Med. 2007; 50: 501-509.

Richardson LD, Asplin BR, Lowe RA: Emergency department crowding as a health policy issue: Past development, future directions. Ann Emerg Med. 2002; 40: 388-393.

Braitberg G: Emergency department overcrowding: Dying to get in? Med J Aust. 2007; 187(11-12): 624-625.

Society for Healthcare Epidemiology of America: SHEA position statement: Interim guidance on infection control precautions for novel swine-origin influenza A H1N1 in healthcare facilities. Available at Accessed June 13, 2010.

Garrett AL, Park YS, Redlener I: Mitigating absenteeism in hospital workers during a pandemic. Disaster Med Public Health Prep. 2009; 3 (Suppl 2): S141-S147.

Barnett DJ, Levine R, Thompson CB, et al.: Gauging U.S. emergency service workers’ willingness to respond to pandemic influenza using a threat- and efficacy-based assessment framework. PLoS ONE. 2010; 5(3): e9856.

Santos CD, Bristow RB,Vorenkamp JV: Which health care workers were most affected during the spring 2009 H1N1 pandemic? Disaster Med Public Health Prep. 2010; 4: 47-54.



  • There are currently no refbacks.