Sit for hours amid the sneezing in an emergency room this fall, and if you didn't arrive with swine flu you just might leave with it.
Fearing swamped ERs, the government is working with worried doctors to develop hot lines or interactive Web sites to help the flu-riddled decide when they really need a hospital — and when to stay home.
With flu season rapidly approaching, the plans aren't finished yet, and it's too soon to know how many people could access such programs.
But, "we are working on triage systems so people will have good information about, 'What will I need to do?'" Dr. Anne Schuchat of the Centers for Disease Control and Prevention told state health officials last week.
Every winter, crowded emergency rooms are flooded with hacking sufferers of the regular flu. When swine flu appeared last spring, ERs in New York and other hard-hit areas had a similar surge — and most visits were by the mildly ill, not those in real danger. More ominous, both types of flu are expected to spread widely this fall and winter.
"There's a clear sense that we can't afford a repetition of the spring experience all over the country," says ER specialist Dr. Arthur Kellerman of Atlanta's Emory University, who has pushed the government planning and praises what he calls "an unprecedented partnership" to create the tools in time.
"You can't drop millions, much less tens of millions of Americans, into that system willy-nilly because they want to play it safe and get checked," Kellerman said. "The play-it-safe strategy may be to stay home."
The goal is one-on-one interactions, either with nurses or with sophisticated technology, for a customized assessment of whether someone's symptoms and medical history put them at low or high risk for flu complications.
At low risk? Stay homeAt low risk? The advice is to stay home, rest and stay hydrated. Doctors don't want you sneezing on the guy with chest pain or the kid with the broken arm or the immune-weakened chemotherapy patient while you wait for that message in person.
"You could wait 18 hours to see me and I'll tell you, 'Please go home and go to bed,'" Kellerman warning.
Conversely, call centers could give families the info they need to, in Kellerman's words, "drag Grandpa out of the bed and take him to the emergency room."
Exactly how call centers may work or even how many hasn't been finalized, Schuchat cautions. In the meantime, the CDC has given states and hospitals guidelines on how to open their own — using existing phone-banks like poison-control centers plus the agency's latest information on flu risk and treatment — while exploring whether the government can create a more comprehensive system. Emory and Georgia's health department developed a prototype that Kellerman says is being refined for potential national use.
Call centers put to the testBut there are numerous models. A handful of communities opened swine-flu advice centers during the spring outbreak and found a confused public hungry for guidance:
— People as far away as California telephoned New Jersey's hot line, says Dr. James Pruden, emergency-preparedness director at St. Joseph's Healthcare System in Paterson, N.J. — who called it himself, anonymously, to make sure staffers gave appropriate health advice. It passed his inspection.
— New York's Montefiore Medical Center has one of the nation's busiest ERs. Adult visits rose 20 percent and child ER visits jumped 40 percent in April, so high that children with flulike symptoms were diverted next door to a special flu-exam clinic. Montefiore activated an online service that could e-mail 35,000 patients to discuss ER alternatives, such as a newly opened urgent-care center, and added nurses to a call center that it's planning to expand in the fall.
"We still were extraordinarily busy but I think we were able to manage the crisis better by having these tools," says Montefiore Vice President Stephen Rosenthal.
— Colorado's Rocky Mountain Poison and Drug Center has offered a flu-season call center since 2003, when it handled 20,000 calls in six months. Called the Health Emergency Line for the Public, or CoHELP, it has offered similar, seasonal advice about other outbreaks and been customized for use in Hawaii and Nevada, too. The system automatically logs the most-asked questions, so states can be sure the biggest concerns are addressed.
Recession-spurred budget cuts mean it's not clear if the flu center will operate this fall. But every dollar spent on the poison-control system has been shown to save $7 by avoiding unnecessary doctor and hospital visits. Research director Dr. Gregory Bogdan estimates the disease triage service is equally cost-effective.
— Dallas' health department opened a call center to help doctors decide whether and how to treat sneezy patients, to blunt ER visits, and has begun planning an expanded fall program. The main message, says preparedness chief Dr. Ira Nemeth: Most patients probably won't need the ER.