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Pines)] TJ ET 0.271 0.267 0.267 rg BT 341.623 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 347.044 638.299 Td /F1 9.8 Tf [(Jamil D. Bayram)] TJ ET 0.271 0.267 0.267 rg BT 418.551 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 423.972 638.299 Td /F1 9.8 Tf [(Yu-Hsiang Hsieh)] TJ ET 0.271 0.267 0.267 rg BT 497.116 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 502.537 638.299 Td /F1 9.8 Tf [(Gabor Kelen)] TJ ET 0.271 0.267 0.267 rg BT 557.274 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 26.250 626.394 Td /F1 9.8 Tf [(Lori Uscher-Pines)] TJ ET 0.271 0.267 0.267 rg BT 103.724 626.394 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 109.145 626.394 Td /F1 9.8 Tf [(Kevin Jeng)] TJ ET 0.271 0.267 0.267 rg BT 157.378 626.394 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 162.799 626.394 Td /F1 9.8 Tf [(Gai Cole)] TJ ET 0.271 0.267 0.267 rg BT 200.726 626.394 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 206.147 626.394 Td /F1 9.8 Tf [(Richard Rothman)] TJ ET 0.271 0.267 0.267 rg BT 26.250 614.490 Td /F1 9.8 Tf [(Dugas AF, Morton M, Beard R, Pines JM, Bayram JD, Hsieh Y, Kelen G, Uscher-Pines L, Jeng K, Cole G, Rothman R. )] TJ ET BT 26.250 602.585 Td /F1 9.8 Tf [(Interventions to Mitigate Emergency Department and Hospital Crowding During an Infectious Respiratory Disease Outbreak: )] TJ ET BT 26.250 590.680 Td /F1 9.8 Tf [(Results from an Expert Panel. PLOS Currents Disasters. 2013 Apr 17 . Edition 1. doi: )] TJ ET BT 26.250 578.775 Td /F1 9.8 Tf [(10.1371/currents.dis.1f277e0d2bf80f4b2bb1dd5f63a13993.)] TJ ET q 15.000 23.986 577.500 552.408 re W n 0.271 0.267 0.267 rg BT 26.250 549.673 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 529.719 Td /F1 9.8 Tf [(Objective: To identify and prioritize potential Emergency Department \(ED\) and hospital-based interventions which could mitigate )] TJ ET BT 26.250 517.814 Td /F1 9.8 Tf [(the impact of crowding during patient surge from a widespread infectious respiratory disease outbreak and determine potential )] TJ ET BT 26.250 505.909 Td /F1 9.8 Tf [(data sources that may be useful for triggering decisions to implement these high priority interventions.)] TJ ET BT 26.250 486.504 Td /F1 9.8 Tf [(Design: Expert panel utilizing Nominal Group Technique to identify and prioritize interventions, and in addition, determine )] TJ ET BT 26.250 474.600 Td /F1 9.8 Tf [(appropriate triggers for implementation of the high priority interventions in the context of four different infectious respiratory )] TJ ET BT 26.250 462.695 Td /F1 9.8 Tf [(disease scenarios that vary by patient volumes \(high versus low\) and illness severity \(high versus low\).)] TJ ET BT 26.250 443.290 Td /F1 9.8 Tf [(Setting: One day in-person conference held November, 2011.)] TJ ET BT 26.250 423.885 Td /F1 9.8 Tf [(Participants: Regional and national experts representing the fields of public health, disease surveillance, clinical medicine, ED )] TJ ET BT 26.250 411.981 Td /F1 9.8 Tf [(operations, and hospital operations.)] TJ ET BT 26.250 392.576 Td /F1 9.8 Tf [(Main Outcome Measure: Prioritized list of potential interventions to reduce ED and hospital crowding, respectively. In addition, )] TJ ET BT 26.250 380.671 Td /F1 9.8 Tf [(we created a prioritized list of potential data sources which could be useful to trigger interventions.)] TJ ET BT 26.250 361.266 Td /F1 9.8 Tf [(Results: High priority interventions to mitigate ED surge included standardizing admission and discharge criteria and instituting )] TJ ET BT 26.250 349.362 Td /F1 9.8 Tf [(infection control measures. To mitigate hospital crowding, panelists prioritized mandatory vaccination and an algorithm for )] TJ ET BT 26.250 337.457 Td /F1 9.8 Tf [(antiviral use. Data sources identified for triggering implementation of these interventions were most commonly ED and hospital )] TJ ET BT 26.250 325.552 Td /F1 9.8 Tf [(utilization metrics.)] TJ ET BT 26.250 306.147 Td /F1 9.8 Tf [(Conclusions: We developed a prioritized list of potentially useful interventions to mitigate ED and hospital crowding in various )] TJ ET BT 26.250 294.243 Td /F1 9.8 Tf [(outbreak scenarios. The data sources identified to trigger the implementation of these high priority interventions consist mainly )] TJ ET BT 26.250 282.338 Td /F1 9.8 Tf [(of sources available at the local, institutional level.)] TJ ET BT 26.250 245.735 Td /F4 12.0 Tf [(Funding Statement)] TJ ET BT 26.250 225.781 Td /F1 9.8 Tf [(This work was supported by the Department of Homeland Security \(PACER: National Center for Study of Preparedness and )] TJ ET BT 26.250 213.876 Td /F1 9.8 Tf [(Response [2010-ST-061-PA0001]\).)] TJ ET BT 26.250 184.774 Td /F4 12.0 Tf [(Introduction)] TJ ET BT 26.250 164.820 Td /F1 9.8 Tf [(As the safety net of the U.S. healthcare system, emergency departments \(ED\) are responsible for managing the large influx of )] TJ ET BT 26.250 152.915 Td /F1 9.8 Tf [(patients, commonly referred to as a surge, resulting from a disaster or pandemic outbreak. However, EDs are already )] TJ ET BT 26.250 141.010 Td /F1 9.8 Tf [(stretched to near-capacity and are routinely overcrowded.)] TJ ET 0.267 0.267 0.267 rg BT 274.982 142.517 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 279.801 141.010 Td /F1 9.8 Tf [( ED crowding itself, apart from disasters, is associated with )] TJ ET BT 26.250 129.105 Td /F1 9.8 Tf [(decreased quality of care, including delays in critical treatments and increased risks of in-hospital mortality.)] TJ ET 0.267 0.267 0.267 rg BT 486.294 130.613 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 491.113 132.994 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 493.522 130.613 Td /F4 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 498.341 132.994 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 500.750 130.613 Td /F4 8.7 Tf [(4)] TJ ET 0.271 0.267 0.267 rg BT 505.569 132.994 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 507.978 130.613 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 512.797 129.105 Td /F1 9.8 Tf [( This crowding )] TJ ET BT 26.250 117.201 Td /F1 9.8 Tf [(is exacerbated by seasonal influenza, and many hospitals and EDs are unprepared to manage the surge in patient volumes )] TJ ET BT 26.250 105.296 Td /F1 9.8 Tf [(which occur during a large scale infectious respiratory disease outbreak.)] TJ ET 0.267 0.267 0.267 rg BT 337.831 106.803 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 342.649 105.296 Td /F1 9.8 Tf [( Even during the 2009 H1N1 pandemic influenza )] TJ ET BT 26.250 93.391 Td /F1 9.8 Tf [(outbreak, when the majority of patients were not critically ill and did not require intensive ED or hospital services, many EDs and )] TJ ET BT 26.250 81.486 Td /F1 9.8 Tf [(hospitals across the U.S. were overwhelmed and unable to meet patient care demands in a timely manner.)] TJ ET 0.267 0.267 0.267 rg BT 486.323 82.994 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 491.142 85.375 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 493.551 82.994 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 498.370 85.375 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 500.779 82.994 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 505.598 85.375 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 508.007 82.994 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 512.826 85.375 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 515.235 82.994 Td /F4 8.7 Tf [(10)] TJ ET 0.271 0.267 0.267 rg BT 26.250 62.082 Td /F1 9.8 Tf [(To maintain high-quality care and manage the increase in ED volumes during an infectious respiratory disease outbreak, )] TJ ET BT 26.250 50.177 Td /F1 9.8 Tf [(hospitals and EDs must have a response plan with the ability to implement timely and effective interventions designed to )] TJ ET BT 26.250 38.272 Td /F1 9.8 Tf [(increase capacity and diminish the effects of crowding which can directly impact patient safety and quality of care. Although )] TJ ET Q q 15.000 659.406 577.500 78.594 re W n 0.267 0.267 0.267 rg BT 15.000 718.042 Td /F2 21.0 Tf [(Interventions to Mitigate Emergency Department and Hospital )] TJ ET BT 15.000 693.094 Td /F2 21.0 Tf [(Crowding During an Infectious Respiratory Disease Outbreak: )] TJ ET BT 15.000 668.146 Td /F2 21.0 Tf [(Results from an Expert Panel)] TJ ET Q 0.271 0.267 0.267 rg BT 15.000 650.140 Td /F3 9.8 Tf [(April 17, 2013)] TJ ET BT 76.483 650.140 Td /F3 9.8 Tf [()] TJ ET 0.267 0.267 0.267 rg BT 81.358 650.140 Td /F3 9.8 Tf [(Research Article)] TJ ET BT 26.250 638.299 Td /F1 9.8 Tf [(Andrea Freyer Dugas)] TJ ET 0.271 0.267 0.267 rg BT 119.450 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 124.871 638.299 Td /F1 9.8 Tf [(Melinda Morton)] TJ ET 0.271 0.267 0.267 rg BT 192.059 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 197.480 638.299 Td /F1 9.8 Tf [(Raphaelle Beard)] TJ ET 0.271 0.267 0.267 rg BT 270.097 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 275.519 638.299 Td /F1 9.8 Tf [(Jesse M. Pines)] TJ ET 0.271 0.267 0.267 rg BT 341.623 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 347.044 638.299 Td /F1 9.8 Tf [(Jamil D. Bayram)] TJ ET 0.271 0.267 0.267 rg BT 418.551 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 423.972 638.299 Td /F1 9.8 Tf [(Yu-Hsiang Hsieh)] TJ ET 0.271 0.267 0.267 rg BT 497.116 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 502.537 638.299 Td /F1 9.8 Tf [(Gabor Kelen)] TJ ET 0.271 0.267 0.267 rg BT 557.274 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 26.250 626.394 Td /F1 9.8 Tf [(Lori Uscher-Pines)] TJ ET 0.271 0.267 0.267 rg BT 103.724 626.394 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 109.145 626.394 Td /F1 9.8 Tf [(Kevin Jeng)] TJ ET 0.271 0.267 0.267 rg BT 157.378 626.394 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 162.799 626.394 Td /F1 9.8 Tf [(Gai Cole)] TJ ET 0.271 0.267 0.267 rg BT 200.726 626.394 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 206.147 626.394 Td /F1 9.8 Tf [(Richard Rothman)] TJ ET 0.271 0.267 0.267 rg BT 26.250 614.490 Td /F1 9.8 Tf [(Dugas AF, Morton M, Beard R, Pines JM, Bayram JD, Hsieh Y, Kelen G, Uscher-Pines L, Jeng K, Cole G, Rothman R. )] TJ ET BT 26.250 602.585 Td /F1 9.8 Tf [(Interventions to Mitigate Emergency Department and Hospital Crowding During an Infectious Respiratory Disease Outbreak: )] TJ ET BT 26.250 590.680 Td /F1 9.8 Tf [(Results from an Expert Panel. PLOS Currents Disasters. 2013 Apr 17 . Edition 1. doi: )] TJ ET BT 26.250 578.775 Td /F1 9.8 Tf [(10.1371/currents.dis.1f277e0d2bf80f4b2bb1dd5f63a13993.)] TJ ET q 15.000 23.986 577.500 552.408 re W n 0.271 0.267 0.267 rg BT 26.250 549.673 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 529.719 Td /F1 9.8 Tf [(Objective: To identify and prioritize potential Emergency Department \(ED\) and hospital-based interventions which could mitigate )] TJ ET BT 26.250 517.814 Td /F1 9.8 Tf [(the impact of crowding during patient surge from a widespread infectious respiratory disease outbreak and determine potential )] TJ ET BT 26.250 505.909 Td /F1 9.8 Tf [(data sources that may be useful for triggering decisions to implement these high priority interventions.)] TJ ET BT 26.250 486.504 Td /F1 9.8 Tf [(Design: Expert panel utilizing Nominal Group Technique to identify and prioritize interventions, and in addition, determine )] TJ ET BT 26.250 474.600 Td /F1 9.8 Tf [(appropriate triggers for implementation of the high priority interventions in the context of four different infectious respiratory )] TJ ET BT 26.250 462.695 Td /F1 9.8 Tf [(disease scenarios that vary by patient volumes \(high versus low\) and illness severity \(high versus low\).)] TJ ET BT 26.250 443.290 Td /F1 9.8 Tf [(Setting: One day in-person conference held November, 2011.)] TJ ET BT 26.250 423.885 Td /F1 9.8 Tf [(Participants: Regional and national experts representing the fields of public health, disease surveillance, clinical medicine, ED )] TJ ET BT 26.250 411.981 Td /F1 9.8 Tf [(operations, and hospital operations.)] TJ ET BT 26.250 392.576 Td /F1 9.8 Tf [(Main Outcome Measure: Prioritized list of potential interventions to reduce ED and hospital crowding, respectively. In addition, )] TJ ET BT 26.250 380.671 Td /F1 9.8 Tf [(we created a prioritized list of potential data sources which could be useful to trigger interventions.)] TJ ET BT 26.250 361.266 Td /F1 9.8 Tf [(Results: High priority interventions to mitigate ED surge included standardizing admission and discharge criteria and instituting )] TJ ET BT 26.250 349.362 Td /F1 9.8 Tf [(infection control measures. To mitigate hospital crowding, panelists prioritized mandatory vaccination and an algorithm for )] TJ ET BT 26.250 337.457 Td /F1 9.8 Tf [(antiviral use. Data sources identified for triggering implementation of these interventions were most commonly ED and hospital )] TJ ET BT 26.250 325.552 Td /F1 9.8 Tf [(utilization metrics.)] TJ ET BT 26.250 306.147 Td /F1 9.8 Tf [(Conclusions: We developed a prioritized list of potentially useful interventions to mitigate ED and hospital crowding in various )] TJ ET BT 26.250 294.243 Td /F1 9.8 Tf [(outbreak scenarios. The data sources identified to trigger the implementation of these high priority interventions consist mainly )] TJ ET BT 26.250 282.338 Td /F1 9.8 Tf [(of sources available at the local, institutional level.)] TJ ET BT 26.250 245.735 Td /F4 12.0 Tf [(Funding Statement)] TJ ET BT 26.250 225.781 Td /F1 9.8 Tf [(This work was supported by the Department of Homeland Security \(PACER: National Center for Study of Preparedness and )] TJ ET BT 26.250 213.876 Td /F1 9.8 Tf [(Response [2010-ST-061-PA0001]\).)] TJ ET BT 26.250 184.774 Td /F4 12.0 Tf [(Introduction)] TJ ET BT 26.250 164.820 Td /F1 9.8 Tf [(As the safety net of the U.S. healthcare system, emergency departments \(ED\) are responsible for managing the large influx of )] TJ ET BT 26.250 152.915 Td /F1 9.8 Tf [(patients, commonly referred to as a surge, resulting from a disaster or pandemic outbreak. However, EDs are already )] TJ ET BT 26.250 141.010 Td /F1 9.8 Tf [(stretched to near-capacity and are routinely overcrowded.)] TJ ET 0.267 0.267 0.267 rg BT 274.982 142.517 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 279.801 141.010 Td /F1 9.8 Tf [( ED crowding itself, apart from disasters, is associated with )] TJ ET BT 26.250 129.105 Td /F1 9.8 Tf [(decreased quality of care, including delays in critical treatments and increased risks of in-hospital mortality.)] TJ ET 0.267 0.267 0.267 rg BT 486.294 130.613 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 491.113 132.994 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 493.522 130.613 Td /F4 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 498.341 132.994 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 500.750 130.613 Td /F4 8.7 Tf [(4)] TJ ET 0.271 0.267 0.267 rg BT 505.569 132.994 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 507.978 130.613 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 512.797 129.105 Td /F1 9.8 Tf [( This crowding )] TJ ET BT 26.250 117.201 Td /F1 9.8 Tf [(is exacerbated by seasonal influenza, and many hospitals and EDs are unprepared to manage the surge in patient volumes )] TJ ET BT 26.250 105.296 Td /F1 9.8 Tf [(which occur during a large scale infectious respiratory disease outbreak.)] TJ ET 0.267 0.267 0.267 rg BT 337.831 106.803 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 342.649 105.296 Td /F1 9.8 Tf [( Even during the 2009 H1N1 pandemic influenza )] TJ ET BT 26.250 93.391 Td /F1 9.8 Tf [(outbreak, when the majority of patients were not critically ill and did not require intensive ED or hospital services, many EDs and )] TJ ET BT 26.250 81.486 Td /F1 9.8 Tf [(hospitals across the U.S. were overwhelmed and unable to meet patient care demands in a timely manner.)] TJ ET 0.267 0.267 0.267 rg BT 486.323 82.994 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 491.142 85.375 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 493.551 82.994 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 498.370 85.375 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 500.779 82.994 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 505.598 85.375 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 508.007 82.994 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 512.826 85.375 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 515.235 82.994 Td /F4 8.7 Tf [(10)] TJ ET 0.271 0.267 0.267 rg BT 26.250 62.082 Td /F1 9.8 Tf [(To maintain high-quality care and manage the increase in ED volumes during an infectious respiratory disease outbreak, )] TJ ET BT 26.250 50.177 Td /F1 9.8 Tf [(hospitals and EDs must have a response plan with the ability to implement timely and effective interventions designed to )] TJ ET BT 26.250 38.272 Td /F1 9.8 Tf [(increase capacity and diminish the effects of crowding which can directly impact patient safety and quality of care. Although )] TJ ET Q q 15.000 659.406 577.500 78.594 re W n 0.267 0.267 0.267 rg BT 15.000 718.042 Td /F2 21.0 Tf [(Interventions to Mitigate Emergency Department and Hospital )] TJ ET BT 15.000 693.094 Td /F2 21.0 Tf [(Crowding During an Infectious Respiratory Disease Outbreak: )] TJ ET BT 15.000 668.146 Td /F2 21.0 Tf [(Results from an Expert Panel)] TJ ET Q 0.271 0.267 0.267 rg BT 15.000 650.140 Td /F3 9.8 Tf [(April 17, 2013)] TJ ET BT 76.483 650.140 Td /F3 9.8 Tf [()] TJ ET 0.267 0.267 0.267 rg BT 81.358 650.140 Td /F3 9.8 Tf [(Research Article)] TJ ET BT 26.250 638.299 Td /F1 9.8 Tf [(Andrea Freyer Dugas)] TJ ET 0.271 0.267 0.267 rg BT 119.450 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 124.871 638.299 Td /F1 9.8 Tf [(Melinda Morton)] TJ ET 0.271 0.267 0.267 rg BT 192.059 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 197.480 638.299 Td /F1 9.8 Tf [(Raphaelle Beard)] TJ ET 0.271 0.267 0.267 rg BT 270.097 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 275.519 638.299 Td /F1 9.8 Tf [(Jesse M. Pines)] TJ ET 0.271 0.267 0.267 rg BT 341.623 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 347.044 638.299 Td /F1 9.8 Tf [(Jamil D. Bayram)] TJ ET 0.271 0.267 0.267 rg BT 418.551 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 423.972 638.299 Td /F1 9.8 Tf [(Yu-Hsiang Hsieh)] TJ ET 0.271 0.267 0.267 rg BT 497.116 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 502.537 638.299 Td /F1 9.8 Tf [(Gabor Kelen)] TJ ET 0.271 0.267 0.267 rg BT 557.274 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 26.250 626.394 Td /F1 9.8 Tf [(Lori Uscher-Pines)] TJ ET 0.271 0.267 0.267 rg BT 103.724 626.394 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 109.145 626.394 Td /F1 9.8 Tf [(Kevin Jeng)] TJ ET 0.271 0.267 0.267 rg BT 157.378 626.394 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 162.799 626.394 Td /F1 9.8 Tf [(Gai Cole)] TJ ET 0.271 0.267 0.267 rg BT 200.726 626.394 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 206.147 626.394 Td /F1 9.8 Tf [(Richard Rothman)] TJ ET 0.271 0.267 0.267 rg BT 26.250 614.490 Td /F1 9.8 Tf [(Dugas AF, Morton M, Beard R, Pines JM, Bayram JD, Hsieh Y, Kelen G, Uscher-Pines L, Jeng K, Cole G, Rothman R. )] TJ ET BT 26.250 602.585 Td /F1 9.8 Tf [(Interventions to Mitigate Emergency Department and Hospital Crowding During an Infectious Respiratory Disease Outbreak: )] TJ ET BT 26.250 590.680 Td /F1 9.8 Tf [(Results from an Expert Panel. PLOS Currents Disasters. 2013 Apr 17 . Edition 1. doi: )] TJ ET BT 26.250 578.775 Td /F1 9.8 Tf [(10.1371/currents.dis.1f277e0d2bf80f4b2bb1dd5f63a13993.)] TJ ET q 15.000 23.986 577.500 552.408 re W n 0.271 0.267 0.267 rg BT 26.250 549.673 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 529.719 Td /F1 9.8 Tf [(Objective: To identify and prioritize potential Emergency Department \(ED\) and hospital-based interventions which could mitigate )] TJ ET BT 26.250 517.814 Td /F1 9.8 Tf [(the impact of crowding during patient surge from a widespread infectious respiratory disease outbreak and determine potential )] TJ ET BT 26.250 505.909 Td /F1 9.8 Tf [(data sources that may be useful for triggering decisions to implement these high priority interventions.)] TJ ET BT 26.250 486.504 Td /F1 9.8 Tf [(Design: Expert panel utilizing Nominal Group Technique to identify and prioritize interventions, and in addition, determine )] TJ ET BT 26.250 474.600 Td /F1 9.8 Tf [(appropriate triggers for implementation of the high priority interventions in the context of four different infectious respiratory )] TJ ET BT 26.250 462.695 Td /F1 9.8 Tf [(disease scenarios that vary by patient volumes \(high versus low\) and illness severity \(high versus low\).)] TJ ET BT 26.250 443.290 Td /F1 9.8 Tf [(Setting: One day in-person conference held November, 2011.)] TJ ET BT 26.250 423.885 Td /F1 9.8 Tf [(Participants: Regional and national experts representing the fields of public health, disease surveillance, clinical medicine, ED )] TJ ET BT 26.250 411.981 Td /F1 9.8 Tf [(operations, and hospital operations.)] TJ ET BT 26.250 392.576 Td /F1 9.8 Tf [(Main Outcome Measure: Prioritized list of potential interventions to reduce ED and hospital crowding, respectively. In addition, )] TJ ET BT 26.250 380.671 Td /F1 9.8 Tf [(we created a prioritized list of potential data sources which could be useful to trigger interventions.)] TJ ET BT 26.250 361.266 Td /F1 9.8 Tf [(Results: High priority interventions to mitigate ED surge included standardizing admission and discharge criteria and instituting )] TJ ET BT 26.250 349.362 Td /F1 9.8 Tf [(infection control measures. To mitigate hospital crowding, panelists prioritized mandatory vaccination and an algorithm for )] TJ ET BT 26.250 337.457 Td /F1 9.8 Tf [(antiviral use. Data sources identified for triggering implementation of these interventions were most commonly ED and hospital )] TJ ET BT 26.250 325.552 Td /F1 9.8 Tf [(utilization metrics.)] TJ ET BT 26.250 306.147 Td /F1 9.8 Tf [(Conclusions: We developed a prioritized list of potentially useful interventions to mitigate ED and hospital crowding in various )] TJ ET BT 26.250 294.243 Td /F1 9.8 Tf [(outbreak scenarios. The data sources identified to trigger the implementation of these high priority interventions consist mainly )] TJ ET BT 26.250 282.338 Td /F1 9.8 Tf [(of sources available at the local, institutional level.)] TJ ET BT 26.250 245.735 Td /F4 12.0 Tf [(Funding Statement)] TJ ET BT 26.250 225.781 Td /F1 9.8 Tf [(This work was supported by the Department of Homeland Security \(PACER: National Center for Study of Preparedness and )] TJ ET BT 26.250 213.876 Td /F1 9.8 Tf [(Response [2010-ST-061-PA0001]\).)] TJ ET BT 26.250 184.774 Td /F4 12.0 Tf [(Introduction)] TJ ET BT 26.250 164.820 Td /F1 9.8 Tf [(As the safety net of the U.S. healthcare system, emergency departments \(ED\) are responsible for managing the large influx of )] TJ ET BT 26.250 152.915 Td /F1 9.8 Tf [(patients, commonly referred to as a surge, resulting from a disaster or pandemic outbreak. However, EDs are already )] TJ ET BT 26.250 141.010 Td /F1 9.8 Tf [(stretched to near-capacity and are routinely overcrowded.)] TJ ET 0.267 0.267 0.267 rg BT 274.982 142.517 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 279.801 141.010 Td /F1 9.8 Tf [( ED crowding itself, apart from disasters, is associated with )] TJ ET BT 26.250 129.105 Td /F1 9.8 Tf [(decreased quality of care, including delays in critical treatments and increased risks of in-hospital mortality.)] TJ ET 0.267 0.267 0.267 rg BT 486.294 130.613 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 491.113 132.994 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 493.522 130.613 Td /F4 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 498.341 132.994 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 500.750 130.613 Td /F4 8.7 Tf [(4)] TJ ET 0.271 0.267 0.267 rg BT 505.569 132.994 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 507.978 130.613 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 512.797 129.105 Td /F1 9.8 Tf [( This crowding )] TJ ET BT 26.250 117.201 Td /F1 9.8 Tf [(is exacerbated by seasonal influenza, and many hospitals and EDs are unprepared to manage the surge in patient volumes )] TJ ET BT 26.250 105.296 Td /F1 9.8 Tf [(which occur during a large scale infectious respiratory disease outbreak.)] TJ ET 0.267 0.267 0.267 rg BT 337.831 106.803 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 342.649 105.296 Td /F1 9.8 Tf [( Even during the 2009 H1N1 pandemic influenza )] TJ ET BT 26.250 93.391 Td /F1 9.8 Tf [(outbreak, when the majority of patients were not critically ill and did not require intensive ED or hospital services, many EDs and )] TJ ET BT 26.250 81.486 Td /F1 9.8 Tf [(hospitals across the U.S. were overwhelmed and unable to meet patient care demands in a timely manner.)] TJ ET 0.267 0.267 0.267 rg BT 486.323 82.994 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 491.142 85.375 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 493.551 82.994 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 498.370 85.375 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 500.779 82.994 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 505.598 85.375 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 508.007 82.994 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 512.826 85.375 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 515.235 82.994 Td /F4 8.7 Tf [(10)] TJ ET 0.271 0.267 0.267 rg BT 26.250 62.082 Td /F1 9.8 Tf [(To maintain high-quality care and manage the increase in ED volumes during an infectious respiratory disease outbreak, )] TJ ET BT 26.250 50.177 Td /F1 9.8 Tf [(hospitals and EDs must have a response plan with the ability to implement timely and effective interventions designed to )] TJ ET BT 26.250 38.272 Td /F1 9.8 Tf [(increase capacity and diminish the effects of crowding which can directly impact patient safety and quality of care. 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26.250 755.571 Td /F1 9.8 Tf [(to infectious respiratory disease outbreaks, it is difficult to compare the impact of interventions across sites due to lack of )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(standardized outcome measures, as well as variability in medical center structure, patient populations, and the particular )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(characteristics and dynamics of an individual outbreak.)] TJ ET 0.267 0.267 0.267 rg BT 262.512 733.269 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 272.149 735.650 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 274.559 733.269 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 284.196 735.650 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 286.605 733.269 Td /F4 8.7 Tf [(13)] TJ ET 0.271 0.267 0.267 rg BT 296.243 735.650 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 298.652 733.269 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 308.289 731.762 Td /F1 9.8 Tf [( Furthermore, medical centers tend to implement multiple )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(responses during an outbreak to help control both short and long-term patient surges, further complicating attempts to )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(independently and accurately evaluate the impact of any individual intervention on the outcomes of interest, namely maintaining )] TJ ET BT 26.250 696.048 Td /F1 9.8 Tf [(timely care within the ED and hospital.)] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(While many hospitals across the U.S. have preparedness plans and protocols for dealing with emerging infections, not all )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(outbreaks are the same. For example, outbreaks can manifest as high or low severity of illness, and high or low levels of )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(contagion, which ultimately contributes to the volume of patients seeking care. Hence, it is unclear if a single set of )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(preparedness protocols would address varying types of outbreaks with differential volume of patients and severity of illness. )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(Given the inherent difficulty of analyzing the published literature, and lack of differentiation in the operational approach to the )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(various types of major emerging infectious outbreaks, it is necessary to approach this problem through a mixed methods )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(approach.)] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(Utilizing the opinions of an expert panel, we compared and prioritized ED and hospital interventions to mitigate the impact of a )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(surge due to infectious respiratory disease outbreaks with varying patient volume and severity of illness. A secondary objective )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(was to prioritize potential data sources which might trigger the decision to implement ED or hospital-based interventions for )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(each of the outbreak types.)] TJ ET BT 26.250 513.493 Td /F4 12.0 Tf [(Methods)] TJ ET BT 26.250 493.539 Td /F4 9.8 Tf [(Expert Panel Selection)] TJ ET BT 26.250 474.134 Td /F1 9.8 Tf [(We convened an expert panel for a one-day conference on November 4th, 2011 in Baltimore, Maryland. Panelists with direct )] TJ ET BT 26.250 462.229 Td /F1 9.8 Tf [(experience and expertise in fields which contribute to the guidance, decision-making, and implementation of local and national )] TJ ET BT 26.250 450.324 Td /F1 9.8 Tf [(interventions associated with mitigation of ED and/or hospital surge were selected by the advisory panel based upon their )] TJ ET BT 26.250 438.420 Td /F1 9.8 Tf [(expertise in the field as evidenced by their record of publication, speaking engagements at national meetings, impact on )] TJ ET BT 26.250 426.515 Td /F1 9.8 Tf [(national or regional policy, or representation of a directly related governmental organization. Of the 66 panelists invited, 34 )] TJ ET BT 26.250 414.610 Td /F1 9.8 Tf [(\(52%\) attended the one day conference and were offered financial reimbursed for basic travel expenses only. To ensure )] TJ ET BT 26.250 402.705 Td /F1 9.8 Tf [(appropriate representation, participants were selected from all key geographic areas of the U.S., and if a representative of a )] TJ ET BT 26.250 390.801 Td /F1 9.8 Tf [(directly related governmental organization was unable to attend, they were asked to select a replacement to represent that )] TJ ET BT 26.250 378.896 Td /F1 9.8 Tf [(organization. The panelists represented the fields of public health \(8\), disease surveillance \(15\), clinical medicine \(13\), )] TJ ET BT 26.250 366.991 Td /F1 9.8 Tf [(emergency medicine operations \(8\), hospital operations \(6\), and systems experts \(7\), with some panelists representing more )] TJ ET BT 26.250 355.086 Td /F1 9.8 Tf [(than one field. Representatives included those from the federal organizations \(2\), state and city health departments \(6\), )] TJ ET BT 26.250 343.182 Td /F1 9.8 Tf [(corporate and non-profit organizations \(2\), and academic institutions \(24\). This study was reviewed and approved by the )] TJ ET BT 26.250 331.277 Td /F1 9.8 Tf [(Institutional Review Board with a waiver of consent.)] TJ ET BT 26.250 311.872 Td /F4 9.8 Tf [(Initial Survey)] TJ ET BT 26.250 292.467 Td /F1 9.8 Tf [(To accomplish our objectives, we used a mixed-methods design, involving an initial survey instrument followed by in-person )] TJ ET BT 26.250 280.563 Td /F1 9.8 Tf [(discussion utilizing nominal group technique.)] TJ ET 0.267 0.267 0.267 rg BT 219.163 282.070 Td /F4 8.7 Tf [(15)] TJ ET 0.271 0.267 0.267 rg BT 228.801 284.451 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 231.210 282.070 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 240.848 280.563 Td /F1 9.8 Tf [( Prior to the conference, the study team members \(AD, MM, RB, KJ, RR\) )] TJ ET BT 26.250 268.658 Td /F1 9.8 Tf [(performed a review of the existing academic literature to identify potential ED and hospital-based interventions to manage )] TJ ET BT 26.250 256.753 Td /F1 9.8 Tf [(crowding from a respiratory infectious disease outbreak.)] TJ ET BT 26.250 237.348 Td /F1 9.8 Tf [(This initial list of potential interventions was distributed to the 34 invited panelists who committed to attend the conference one )] TJ ET BT 26.250 225.444 Td /F1 9.8 Tf [(month in advance. In addition, study investigators distributed definitions and brief descriptions of four types of infectious )] TJ ET BT 26.250 213.539 Td /F1 9.8 Tf [(respiratory disease outbreaks to allow the panelists the opportunity to express their varied opinions on interventions relative to )] TJ ET BT 26.250 201.634 Td /F1 9.8 Tf [(expected patient volume and severity of illness. These four scenarios were: 1\) low volume/low severity \(e.g. seasonal )] TJ ET BT 26.250 189.729 Td /F1 9.8 Tf [(influenza\), 2\) high volume/low severity \(e.g. 2009 H1N1\), 3\) low volume/high severity \(e.g. Severe Acute Respiratory Syndrome )] TJ ET BT 26.250 177.825 Td /F1 9.8 Tf [([SARS]\), and 4\) high volume/high severity \(e.g. 1918 H1N1\).)] TJ ET BT 26.250 158.420 Td /F1 9.8 Tf [(Panelists were instructed to separately rate each intervention by both ease of implementation and importance for each of the )] TJ ET BT 26.250 146.515 Td /F1 9.8 Tf [(four infectious respiratory disease outbreak scenarios using a 1-5 Likert scale. Ease of implementation included: consideration )] TJ ET BT 26.250 134.610 Td /F1 9.8 Tf [(of factors such as cost, operational complexity, facility \(time\) of setup, and intensity of resource utilization. Importance was )] TJ ET BT 26.250 122.706 Td /F1 9.8 Tf [(defined as the likely effectiveness of the intervention in reducing ED or hospital crowding or augmenting surge. Panelists were )] TJ ET BT 26.250 110.801 Td /F1 9.8 Tf [(encouraged to suggest additional write-in interventions not already listed. Results were tallied in advance of the conference.)] TJ ET BT 26.250 91.396 Td /F4 9.8 Tf [(Conference Proceedings)] TJ ET BT 26.250 71.991 Td /F1 9.8 Tf [(A full 1-day conference was held at the National Center for the Study of Preparedness and Catastrophic Response \(PACER\).)] TJ ET 0.267 0.267 0.267 rg BT 565.454 73.499 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 26.250 60.087 Td /F1 9.8 Tf [(Overview presentations were conducted by selected experts summarizing the current state of emergency department and )] TJ ET BT 26.250 48.182 Td /F1 9.8 Tf [(hospital crowding, existing and novel surveillance mechanisms, and potential interventions to mitigate crowding as published in )] TJ ET BT 26.250 36.277 Td /F1 9.8 Tf [(the peer-reviewed literature. The conference leaders then presented the results of the pre-conference survey and distributed )] TJ ET Q q 15.000 21.991 577.500 755.009 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(there are numerous reports in the literature describing various interventions designed to mitigate ED and hospital crowding due )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(to infectious respiratory disease outbreaks, it is difficult to compare the impact of interventions across sites due to lack of )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(standardized outcome measures, as well as variability in medical center structure, patient populations, and the particular )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(characteristics and dynamics of an individual outbreak.)] TJ ET 0.267 0.267 0.267 rg BT 262.512 733.269 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 272.149 735.650 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 274.559 733.269 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 284.196 735.650 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 286.605 733.269 Td /F4 8.7 Tf [(13)] TJ ET 0.271 0.267 0.267 rg BT 296.243 735.650 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 298.652 733.269 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 308.289 731.762 Td /F1 9.8 Tf [( Furthermore, medical centers tend to implement multiple )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(responses during an outbreak to help control both short and long-term patient surges, further complicating attempts to )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(independently and accurately evaluate the impact of any individual intervention on the outcomes of interest, namely maintaining )] TJ ET BT 26.250 696.048 Td /F1 9.8 Tf [(timely care within the ED and hospital.)] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(While many hospitals across the U.S. have preparedness plans and protocols for dealing with emerging infections, not all )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(outbreaks are the same. For example, outbreaks can manifest as high or low severity of illness, and high or low levels of )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(contagion, which ultimately contributes to the volume of patients seeking care. Hence, it is unclear if a single set of )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(preparedness protocols would address varying types of outbreaks with differential volume of patients and severity of illness. )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(Given the inherent difficulty of analyzing the published literature, and lack of differentiation in the operational approach to the )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(various types of major emerging infectious outbreaks, it is necessary to approach this problem through a mixed methods )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(approach.)] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(Utilizing the opinions of an expert panel, we compared and prioritized ED and hospital interventions to mitigate the impact of a )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(surge due to infectious respiratory disease outbreaks with varying patient volume and severity of illness. A secondary objective )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(was to prioritize potential data sources which might trigger the decision to implement ED or hospital-based interventions for )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(each of the outbreak types.)] TJ ET BT 26.250 513.493 Td /F4 12.0 Tf [(Methods)] TJ ET BT 26.250 493.539 Td /F4 9.8 Tf [(Expert Panel Selection)] TJ ET BT 26.250 474.134 Td /F1 9.8 Tf [(We convened an expert panel for a one-day conference on November 4th, 2011 in Baltimore, Maryland. Panelists with direct )] TJ ET BT 26.250 462.229 Td /F1 9.8 Tf [(experience and expertise in fields which contribute to the guidance, decision-making, and implementation of local and national )] TJ ET BT 26.250 450.324 Td /F1 9.8 Tf [(interventions associated with mitigation of ED and/or hospital surge were selected by the advisory panel based upon their )] TJ ET BT 26.250 438.420 Td /F1 9.8 Tf [(expertise in the field as evidenced by their record of publication, speaking engagements at national meetings, impact on )] TJ ET BT 26.250 426.515 Td /F1 9.8 Tf [(national or regional policy, or representation of a directly related governmental organization. Of the 66 panelists invited, 34 )] TJ ET BT 26.250 414.610 Td /F1 9.8 Tf [(\(52%\) attended the one day conference and were offered financial reimbursed for basic travel expenses only. To ensure )] TJ ET BT 26.250 402.705 Td /F1 9.8 Tf [(appropriate representation, participants were selected from all key geographic areas of the U.S., and if a representative of a )] TJ ET BT 26.250 390.801 Td /F1 9.8 Tf [(directly related governmental organization was unable to attend, they were asked to select a replacement to represent that )] TJ ET BT 26.250 378.896 Td /F1 9.8 Tf [(organization. The panelists represented the fields of public health \(8\), disease surveillance \(15\), clinical medicine \(13\), )] TJ ET BT 26.250 366.991 Td /F1 9.8 Tf [(emergency medicine operations \(8\), hospital operations \(6\), and systems experts \(7\), with some panelists representing more )] TJ ET BT 26.250 355.086 Td /F1 9.8 Tf [(than one field. Representatives included those from the federal organizations \(2\), state and city health departments \(6\), )] TJ ET BT 26.250 343.182 Td /F1 9.8 Tf [(corporate and non-profit organizations \(2\), and academic institutions \(24\). This study was reviewed and approved by the )] TJ ET BT 26.250 331.277 Td /F1 9.8 Tf [(Institutional Review Board with a waiver of consent.)] TJ ET BT 26.250 311.872 Td /F4 9.8 Tf [(Initial Survey)] TJ ET BT 26.250 292.467 Td /F1 9.8 Tf [(To accomplish our objectives, we used a mixed-methods design, involving an initial survey instrument followed by in-person )] TJ ET BT 26.250 280.563 Td /F1 9.8 Tf [(discussion utilizing nominal group technique.)] TJ ET 0.267 0.267 0.267 rg BT 219.163 282.070 Td /F4 8.7 Tf [(15)] TJ ET 0.271 0.267 0.267 rg BT 228.801 284.451 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 231.210 282.070 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 240.848 280.563 Td /F1 9.8 Tf [( Prior to the conference, the study team members \(AD, MM, RB, KJ, RR\) )] TJ ET BT 26.250 268.658 Td /F1 9.8 Tf [(performed a review of the existing academic literature to identify potential ED and hospital-based interventions to manage )] TJ ET BT 26.250 256.753 Td /F1 9.8 Tf [(crowding from a respiratory infectious disease outbreak.)] TJ ET BT 26.250 237.348 Td /F1 9.8 Tf [(This initial list of potential interventions was distributed to the 34 invited panelists who committed to attend the conference one )] TJ ET BT 26.250 225.444 Td /F1 9.8 Tf [(month in advance. In addition, study investigators distributed definitions and brief descriptions of four types of infectious )] TJ ET BT 26.250 213.539 Td /F1 9.8 Tf [(respiratory disease outbreaks to allow the panelists the opportunity to express their varied opinions on interventions relative to )] TJ ET BT 26.250 201.634 Td /F1 9.8 Tf [(expected patient volume and severity of illness. These four scenarios were: 1\) low volume/low severity \(e.g. seasonal )] TJ ET BT 26.250 189.729 Td /F1 9.8 Tf [(influenza\), 2\) high volume/low severity \(e.g. 2009 H1N1\), 3\) low volume/high severity \(e.g. Severe Acute Respiratory Syndrome )] TJ ET BT 26.250 177.825 Td /F1 9.8 Tf [([SARS]\), and 4\) high volume/high severity \(e.g. 1918 H1N1\).)] TJ ET BT 26.250 158.420 Td /F1 9.8 Tf [(Panelists were instructed to separately rate each intervention by both ease of implementation and importance for each of the )] TJ ET BT 26.250 146.515 Td /F1 9.8 Tf [(four infectious respiratory disease outbreak scenarios using a 1-5 Likert scale. Ease of implementation included: consideration )] TJ ET BT 26.250 134.610 Td /F1 9.8 Tf [(of factors such as cost, operational complexity, facility \(time\) of setup, and intensity of resource utilization. Importance was )] TJ ET BT 26.250 122.706 Td /F1 9.8 Tf [(defined as the likely effectiveness of the intervention in reducing ED or hospital crowding or augmenting surge. Panelists were )] TJ ET BT 26.250 110.801 Td /F1 9.8 Tf [(encouraged to suggest additional write-in interventions not already listed. Results were tallied in advance of the conference.)] TJ ET BT 26.250 91.396 Td /F4 9.8 Tf [(Conference Proceedings)] TJ ET BT 26.250 71.991 Td /F1 9.8 Tf [(A full 1-day conference was held at the National Center for the Study of Preparedness and Catastrophic Response \(PACER\).)] TJ ET 0.267 0.267 0.267 rg BT 565.454 73.499 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 26.250 60.087 Td /F1 9.8 Tf [(Overview presentations were conducted by selected experts summarizing the current state of emergency department and )] TJ ET BT 26.250 48.182 Td /F1 9.8 Tf [(hospital crowding, existing and novel surveillance mechanisms, and potential interventions to mitigate crowding as published in )] TJ ET BT 26.250 36.277 Td /F1 9.8 Tf [(the peer-reviewed literature. The conference leaders then presented the results of the pre-conference survey and distributed )] TJ ET Q q 15.000 21.991 577.500 755.009 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(there are numerous reports in the literature describing various interventions designed to mitigate ED and hospital crowding due )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(to infectious respiratory disease outbreaks, it is difficult to compare the impact of interventions across sites due to lack of )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(standardized outcome measures, as well as variability in medical center structure, patient populations, and the particular )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(characteristics and dynamics of an individual outbreak.)] TJ ET 0.267 0.267 0.267 rg BT 262.512 733.269 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 272.149 735.650 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 274.559 733.269 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 284.196 735.650 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 286.605 733.269 Td /F4 8.7 Tf [(13)] TJ ET 0.271 0.267 0.267 rg BT 296.243 735.650 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 298.652 733.269 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 308.289 731.762 Td /F1 9.8 Tf [( Furthermore, medical centers tend to implement multiple )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(responses during an outbreak to help control both short and long-term patient surges, further complicating attempts to )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(independently and accurately evaluate the impact of any individual intervention on the outcomes of interest, namely maintaining )] TJ ET BT 26.250 696.048 Td /F1 9.8 Tf [(timely care within the ED and hospital.)] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(While many hospitals across the U.S. have preparedness plans and protocols for dealing with emerging infections, not all )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(outbreaks are the same. For example, outbreaks can manifest as high or low severity of illness, and high or low levels of )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(contagion, which ultimately contributes to the volume of patients seeking care. Hence, it is unclear if a single set of )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(preparedness protocols would address varying types of outbreaks with differential volume of patients and severity of illness. )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(Given the inherent difficulty of analyzing the published literature, and lack of differentiation in the operational approach to the )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(various types of major emerging infectious outbreaks, it is necessary to approach this problem through a mixed methods )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(approach.)] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(Utilizing the opinions of an expert panel, we compared and prioritized ED and hospital interventions to mitigate the impact of a )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(surge due to infectious respiratory disease outbreaks with varying patient volume and severity of illness. A secondary objective )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(was to prioritize potential data sources which might trigger the decision to implement ED or hospital-based interventions for )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(each of the outbreak types.)] TJ ET BT 26.250 513.493 Td /F4 12.0 Tf [(Methods)] TJ ET BT 26.250 493.539 Td /F4 9.8 Tf [(Expert Panel Selection)] TJ ET BT 26.250 474.134 Td /F1 9.8 Tf [(We convened an expert panel for a one-day conference on November 4th, 2011 in Baltimore, Maryland. Panelists with direct )] TJ ET BT 26.250 462.229 Td /F1 9.8 Tf [(experience and expertise in fields which contribute to the guidance, decision-making, and implementation of local and national )] TJ ET BT 26.250 450.324 Td /F1 9.8 Tf [(interventions associated with mitigation of ED and/or hospital surge were selected by the advisory panel based upon their )] TJ ET BT 26.250 438.420 Td /F1 9.8 Tf [(expertise in the field as evidenced by their record of publication, speaking engagements at national meetings, impact on )] TJ ET BT 26.250 426.515 Td /F1 9.8 Tf [(national or regional policy, or representation of a directly related governmental organization. Of the 66 panelists invited, 34 )] TJ ET BT 26.250 414.610 Td /F1 9.8 Tf [(\(52%\) attended the one day conference and were offered financial reimbursed for basic travel expenses only. To ensure )] TJ ET BT 26.250 402.705 Td /F1 9.8 Tf [(appropriate representation, participants were selected from all key geographic areas of the U.S., and if a representative of a )] TJ ET BT 26.250 390.801 Td /F1 9.8 Tf [(directly related governmental organization was unable to attend, they were asked to select a replacement to represent that )] TJ ET BT 26.250 378.896 Td /F1 9.8 Tf [(organization. The panelists represented the fields of public health \(8\), disease surveillance \(15\), clinical medicine \(13\), )] TJ ET BT 26.250 366.991 Td /F1 9.8 Tf [(emergency medicine operations \(8\), hospital operations \(6\), and systems experts \(7\), with some panelists representing more )] TJ ET BT 26.250 355.086 Td /F1 9.8 Tf [(than one field. Representatives included those from the federal organizations \(2\), state and city health departments \(6\), )] TJ ET BT 26.250 343.182 Td /F1 9.8 Tf [(corporate and non-profit organizations \(2\), and academic institutions \(24\). This study was reviewed and approved by the )] TJ ET BT 26.250 331.277 Td /F1 9.8 Tf [(Institutional Review Board with a waiver of consent.)] TJ ET BT 26.250 311.872 Td /F4 9.8 Tf [(Initial Survey)] TJ ET BT 26.250 292.467 Td /F1 9.8 Tf [(To accomplish our objectives, we used a mixed-methods design, involving an initial survey instrument followed by in-person )] TJ ET BT 26.250 280.563 Td /F1 9.8 Tf [(discussion utilizing nominal group technique.)] TJ ET 0.267 0.267 0.267 rg BT 219.163 282.070 Td /F4 8.7 Tf [(15)] TJ ET 0.271 0.267 0.267 rg BT 228.801 284.451 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 231.210 282.070 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 240.848 280.563 Td /F1 9.8 Tf [( Prior to the conference, the study team members \(AD, MM, RB, KJ, RR\) )] TJ ET BT 26.250 268.658 Td /F1 9.8 Tf [(performed a review of the existing academic literature to identify potential ED and hospital-based interventions to manage )] TJ ET BT 26.250 256.753 Td /F1 9.8 Tf [(crowding from a respiratory infectious disease outbreak.)] TJ ET BT 26.250 237.348 Td /F1 9.8 Tf [(This initial list of potential interventions was distributed to the 34 invited panelists who committed to attend the conference one )] TJ ET BT 26.250 225.444 Td /F1 9.8 Tf [(month in advance. In addition, study investigators distributed definitions and brief descriptions of four types of infectious )] TJ ET BT 26.250 213.539 Td /F1 9.8 Tf [(respiratory disease outbreaks to allow the panelists the opportunity to express their varied opinions on interventions relative to )] TJ ET BT 26.250 201.634 Td /F1 9.8 Tf [(expected patient volume and severity of illness. These four scenarios were: 1\) low volume/low severity \(e.g. seasonal )] TJ ET BT 26.250 189.729 Td /F1 9.8 Tf [(influenza\), 2\) high volume/low severity \(e.g. 2009 H1N1\), 3\) low volume/high severity \(e.g. Severe Acute Respiratory Syndrome )] TJ ET BT 26.250 177.825 Td /F1 9.8 Tf [([SARS]\), and 4\) high volume/high severity \(e.g. 1918 H1N1\).)] TJ ET BT 26.250 158.420 Td /F1 9.8 Tf [(Panelists were instructed to separately rate each intervention by both ease of implementation and importance for each of the )] TJ ET BT 26.250 146.515 Td /F1 9.8 Tf [(four infectious respiratory disease outbreak scenarios using a 1-5 Likert scale. Ease of implementation included: consideration )] TJ ET BT 26.250 134.610 Td /F1 9.8 Tf [(of factors such as cost, operational complexity, facility \(time\) of setup, and intensity of resource utilization. Importance was )] TJ ET BT 26.250 122.706 Td /F1 9.8 Tf [(defined as the likely effectiveness of the intervention in reducing ED or hospital crowding or augmenting surge. Panelists were )] TJ ET BT 26.250 110.801 Td /F1 9.8 Tf [(encouraged to suggest additional write-in interventions not already listed. Results were tallied in advance of the conference.)] TJ ET BT 26.250 91.396 Td /F4 9.8 Tf [(Conference Proceedings)] TJ ET BT 26.250 71.991 Td /F1 9.8 Tf [(A full 1-day conference was held at the National Center for the Study of Preparedness and Catastrophic Response \(PACER\).)] TJ ET 0.267 0.267 0.267 rg BT 565.454 73.499 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 26.250 60.087 Td /F1 9.8 Tf [(Overview presentations were conducted by selected experts summarizing the current state of emergency department and )] TJ ET BT 26.250 48.182 Td /F1 9.8 Tf [(hospital crowding, existing and novel surveillance mechanisms, and potential interventions to mitigate crowding as published in )] TJ ET BT 26.250 36.277 Td /F1 9.8 Tf [(the peer-reviewed literature. 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After these initial presentations, the panelists completed two exercises for which )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(they were assigned to one of two equally sized groups, based upon panelists relevant expertise. One group evaluated ED-)] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(based interventions, and one evaluated hospital-based interventions. Each group was co-moderated by two subject matter )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(experts \(AD, MM, JP, JB, GK\) with previous training through numerous instructional meetings and two mock moderation )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(sessions to ensure uniform and unbiased facilitation of the proceedings.)] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(During Exercise One, panelists were asked to prioritize potential interventions to mitigate surge in response to an infectious )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(respiratory disease outbreak for each of four defined scenarios. Interventions were separated into two groups; those specifically )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(for patients presenting with influenza-like illness \(ILI\) and those for patients without ILI. Infection control measures were included )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(among the proposed interventions to focus efforts toward reducing disease spread and potentially reducing future patient )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(volume. Using the nominal group technique, each of the two break-out groups \(i.e. ED and hospital\) was asked to discuss each )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(associated intervention, \(including the pre-panel write-in interventions\), and suggest and similarly discuss any additional )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(interventions not yet considered. Panel members were then asked to anonymously and independently categorize each )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(intervention as low, medium, or high priority. Panelists were asked to consider both the ease of implementation and importance )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(for a final overall priority consideration specific for each of the four respiratory infection outbreak scenarios.)] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(In Exercise Two, panelists were asked to identify key data sources to trigger the implementation of a specific intervention in a )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(given respiratory virus illness scenario. Considering the worst case scenario \(high volume and high severity\) and the recent )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(2009 H1N1 scenario \(high volume, low severity\), each group was given one intervention, which was highly rated in Exercise )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(One, for each of the four scenarios. Additionally, each group was given a list of potential data sources based on those used in )] TJ ET BT 26.250 538.191 Td /F1 9.8 Tf [(the literature, current medical practice, and current surveillance systems, but was also encouraged to consider and suggest )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(alternate data sources that may serve as a trigger for implementation of the selected intervention. Examples of such data )] TJ ET BT 26.250 514.381 Td /F1 9.8 Tf [(sources included ED wait times, hospital volume, laboratory data, syndromic and laboratory-based surveillance systems, and )] TJ ET BT 26.250 502.476 Td /F1 9.8 Tf [(novel data sources that might be used to indicate increasing respiratory disease \(e.g. Twitter\). Panelists were asked to )] TJ ET BT 26.250 490.572 Td /F1 9.8 Tf [(individually select the top three data sources that could be useful to ED or hospital leaders to trigger the decision to implement )] TJ ET BT 26.250 478.667 Td /F1 9.8 Tf [(the top-rated interventions to mitigate ED or hospital crowding due to a respiratory infection outbreak. Similarly, using the )] TJ ET BT 26.250 466.762 Td /F1 9.8 Tf [(nominal group technique, panelists proposed other potential data sources. All potential data sources were discussed and each )] TJ ET BT 26.250 454.857 Td /F1 9.8 Tf [(panel member anonymously rated them on a 1-5 Likert scale with 1 being not at all important as a trigger and 5 as very )] TJ ET BT 26.250 442.953 Td /F1 9.8 Tf [(important for a trigger for the selected interventions.)] TJ ET BT 26.250 423.548 Td /F4 9.8 Tf [(Data Analysis)] TJ ET BT 26.250 404.143 Td /F1 9.8 Tf [(To evaluate data from Exercise One, final categorization data were assigned a numerical score where Low Priority = 1, Medium )] TJ ET BT 26.250 392.238 Td /F1 9.8 Tf [(Priority =3, and High Priority =5. These numerical scores were averaged by scenario to obtain a numerical final score for each )] TJ ET BT 26.250 380.334 Td /F1 9.8 Tf [(intervention in each scenario. These final means were then categorized as either, Low Priority \(1.0-2.0\), Medium Priority \(2.1-)] TJ ET BT 26.250 368.429 Td /F1 9.8 Tf [(4.0\), or High Priority \(4.1-5.0\). Additionally, numerical scores were averaged across all scenarios to obtain a total prioritization )] TJ ET BT 26.250 356.524 Td /F1 9.8 Tf [(score for each intervention across all scenarios. Finally, scores for each intervention within a scenario were averaged to obtain )] TJ ET BT 26.250 344.619 Td /F1 9.8 Tf [(a scenario prioritization score. For Exercise Two, the individual resultant ratings for each potential data source were averaged to )] TJ ET BT 26.250 332.715 Td /F1 9.8 Tf [(obtain a mean importance score for each potential data source.)] TJ ET BT 26.250 296.112 Td /F4 12.0 Tf [(Results)] TJ ET BT 26.250 276.158 Td /F1 9.8 Tf [(Among all of the potential interventions to mitigate ED crowding, the following interventions had the highest priority across all )] TJ ET BT 26.250 264.253 Td /F1 9.8 Tf [(four outbreak scenarios: standardizing ED discharge and admission criteria for patients with respiratory symptoms \(4.0\), )] TJ ET BT 26.250 252.348 Td /F1 9.8 Tf [(informing patients of the most appropriate setting for care either through a website \(4.0\) or telephone call center \(3.9\), and )] TJ ET BT 26.250 240.444 Td /F1 9.8 Tf [(instituting infection control measures including hand sanitizers and masks \(4.1\), cohorting patients with ILI \(4.0\), or ED signage )] TJ ET BT 26.250 228.539 Td /F1 9.8 Tf [(\(3.9\). Tables 1 and 2 demonstrate the final ED scenario-based prioritization for each potential intervention for both ILI patients )] TJ ET BT 26.250 216.634 Td /F1 9.8 Tf [(\(Table 1\), and non-ILI patients \(Table 2\).)] TJ ET BT 26.250 197.229 Td /F1 9.8 Tf [(When considering a low volume/low severity scenario such as Scenario 1/Seasonal Influenza, no individual ED intervention )] TJ ET BT 26.250 185.325 Td /F1 9.8 Tf [(ranked above medium priority which included standardization ED discharge and admission criteria for patients with respiratory )] TJ ET BT 26.250 173.420 Td /F1 9.8 Tf [(symptoms \(3.1\), setting up a website to advise patients on the most appropriate setting for care \(3.1\), using hand sanitizer and )] TJ ET BT 26.250 161.515 Td /F1 9.8 Tf [(masks \(3.1\), and ED signage for influenza \(3.1\). In the scenario with the highest volume and severity, Scenario 4/1918 H1N1, )] TJ ET BT 26.250 149.610 Td /F1 9.8 Tf [(many interventions received high priority even if they had received a lower priority in all previous scenarios, such as; Opening )] TJ ET BT 26.250 137.706 Td /F1 9.8 Tf [(an annex areas for patient care \(4.7\), coordination of influenza surge plans with the public health department \(4.6\), and )] TJ ET BT 26.250 125.801 Td /F1 9.8 Tf [(protocols for non-medical volunteers \(4.6\).)] TJ ET BT 26.250 106.396 Td /F1 9.8 Tf [(Panelist ratings for hospital interventions identified the following as highest priority across all four outbreak scenarios: )] TJ ET BT 26.250 94.491 Td /F1 9.8 Tf [(mandatory vaccinations \(4.9\), coordinating a public health message \(4.1\), creating a treatment algorithm for antiviral use \(3.8\), )] TJ ET BT 26.250 82.587 Td /F1 9.8 Tf [(modifying visitation policies \(3.7\), screening employees \(3.6\), setting up alternate care systems \(3.6\), stockpiling isolation )] TJ ET BT 26.250 70.682 Td /F1 9.8 Tf [(equipment \(3.5\), and setting up an inpatient quarantine area \(3.5\). Individual scenario-based ratings for the hospital )] TJ ET BT 26.250 58.777 Td /F1 9.8 Tf [(interventions are shown in Tables 3 and 4.)] TJ ET BT 26.250 39.372 Td /F1 9.8 Tf [(The only hospital intervention to receive high priority in the low volume/low severity scenario, Scenario 1/Seasonal Influenza, )] TJ ET Q q 15.000 25.087 577.500 751.913 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(these results to the panelists in tabular form. After these initial presentations, the panelists completed two exercises for which )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(they were assigned to one of two equally sized groups, based upon panelists relevant expertise. One group evaluated ED-)] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(based interventions, and one evaluated hospital-based interventions. Each group was co-moderated by two subject matter )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(experts \(AD, MM, JP, JB, GK\) with previous training through numerous instructional meetings and two mock moderation )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(sessions to ensure uniform and unbiased facilitation of the proceedings.)] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(During Exercise One, panelists were asked to prioritize potential interventions to mitigate surge in response to an infectious )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(respiratory disease outbreak for each of four defined scenarios. Interventions were separated into two groups; those specifically )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(for patients presenting with influenza-like illness \(ILI\) and those for patients without ILI. Infection control measures were included )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(among the proposed interventions to focus efforts toward reducing disease spread and potentially reducing future patient )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(volume. Using the nominal group technique, each of the two break-out groups \(i.e. ED and hospital\) was asked to discuss each )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(associated intervention, \(including the pre-panel write-in interventions\), and suggest and similarly discuss any additional )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(interventions not yet considered. Panel members were then asked to anonymously and independently categorize each )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(intervention as low, medium, or high priority. Panelists were asked to consider both the ease of implementation and importance )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(for a final overall priority consideration specific for each of the four respiratory infection outbreak scenarios.)] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(In Exercise Two, panelists were asked to identify key data sources to trigger the implementation of a specific intervention in a )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(given respiratory virus illness scenario. Considering the worst case scenario \(high volume and high severity\) and the recent )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(2009 H1N1 scenario \(high volume, low severity\), each group was given one intervention, which was highly rated in Exercise )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(One, for each of the four scenarios. Additionally, each group was given a list of potential data sources based on those used in )] TJ ET BT 26.250 538.191 Td /F1 9.8 Tf [(the literature, current medical practice, and current surveillance systems, but was also encouraged to consider and suggest )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(alternate data sources that may serve as a trigger for implementation of the selected intervention. Examples of such data )] TJ ET BT 26.250 514.381 Td /F1 9.8 Tf [(sources included ED wait times, hospital volume, laboratory data, syndromic and laboratory-based surveillance systems, and )] TJ ET BT 26.250 502.476 Td /F1 9.8 Tf [(novel data sources that might be used to indicate increasing respiratory disease \(e.g. Twitter\). Panelists were asked to )] TJ ET BT 26.250 490.572 Td /F1 9.8 Tf [(individually select the top three data sources that could be useful to ED or hospital leaders to trigger the decision to implement )] TJ ET BT 26.250 478.667 Td /F1 9.8 Tf [(the top-rated interventions to mitigate ED or hospital crowding due to a respiratory infection outbreak. Similarly, using the )] TJ ET BT 26.250 466.762 Td /F1 9.8 Tf [(nominal group technique, panelists proposed other potential data sources. All potential data sources were discussed and each )] TJ ET BT 26.250 454.857 Td /F1 9.8 Tf [(panel member anonymously rated them on a 1-5 Likert scale with 1 being not at all important as a trigger and 5 as very )] TJ ET BT 26.250 442.953 Td /F1 9.8 Tf [(important for a trigger for the selected interventions.)] TJ ET BT 26.250 423.548 Td /F4 9.8 Tf [(Data Analysis)] TJ ET BT 26.250 404.143 Td /F1 9.8 Tf [(To evaluate data from Exercise One, final categorization data were assigned a numerical score where Low Priority = 1, Medium )] TJ ET BT 26.250 392.238 Td /F1 9.8 Tf [(Priority =3, and High Priority =5. These numerical scores were averaged by scenario to obtain a numerical final score for each )] TJ ET BT 26.250 380.334 Td /F1 9.8 Tf [(intervention in each scenario. These final means were then categorized as either, Low Priority \(1.0-2.0\), Medium Priority \(2.1-)] TJ ET BT 26.250 368.429 Td /F1 9.8 Tf [(4.0\), or High Priority \(4.1-5.0\). Additionally, numerical scores were averaged across all scenarios to obtain a total prioritization )] TJ ET BT 26.250 356.524 Td /F1 9.8 Tf [(score for each intervention across all scenarios. Finally, scores for each intervention within a scenario were averaged to obtain )] TJ ET BT 26.250 344.619 Td /F1 9.8 Tf [(a scenario prioritization score. For Exercise Two, the individual resultant ratings for each potential data source were averaged to )] TJ ET BT 26.250 332.715 Td /F1 9.8 Tf [(obtain a mean importance score for each potential data source.)] TJ ET BT 26.250 296.112 Td /F4 12.0 Tf [(Results)] TJ ET BT 26.250 276.158 Td /F1 9.8 Tf [(Among all of the potential interventions to mitigate ED crowding, the following interventions had the highest priority across all )] TJ ET BT 26.250 264.253 Td /F1 9.8 Tf [(four outbreak scenarios: standardizing ED discharge and admission criteria for patients with respiratory symptoms \(4.0\), )] TJ ET BT 26.250 252.348 Td /F1 9.8 Tf [(informing patients of the most appropriate setting for care either through a website \(4.0\) or telephone call center \(3.9\), and )] TJ ET BT 26.250 240.444 Td /F1 9.8 Tf [(instituting infection control measures including hand sanitizers and masks \(4.1\), cohorting patients with ILI \(4.0\), or ED signage )] TJ ET BT 26.250 228.539 Td /F1 9.8 Tf [(\(3.9\). Tables 1 and 2 demonstrate the final ED scenario-based prioritization for each potential intervention for both ILI patients )] TJ ET BT 26.250 216.634 Td /F1 9.8 Tf [(\(Table 1\), and non-ILI patients \(Table 2\).)] TJ ET BT 26.250 197.229 Td /F1 9.8 Tf [(When considering a low volume/low severity scenario such as Scenario 1/Seasonal Influenza, no individual ED intervention )] TJ ET BT 26.250 185.325 Td /F1 9.8 Tf [(ranked above medium priority which included standardization ED discharge and admission criteria for patients with respiratory )] TJ ET BT 26.250 173.420 Td /F1 9.8 Tf [(symptoms \(3.1\), setting up a website to advise patients on the most appropriate setting for care \(3.1\), using hand sanitizer and )] TJ ET BT 26.250 161.515 Td /F1 9.8 Tf [(masks \(3.1\), and ED signage for influenza \(3.1\). In the scenario with the highest volume and severity, Scenario 4/1918 H1N1, )] TJ ET BT 26.250 149.610 Td /F1 9.8 Tf [(many interventions received high priority even if they had received a lower priority in all previous scenarios, such as; Opening )] TJ ET BT 26.250 137.706 Td /F1 9.8 Tf [(an annex areas for patient care \(4.7\), coordination of influenza surge plans with the public health department \(4.6\), and )] TJ ET BT 26.250 125.801 Td /F1 9.8 Tf [(protocols for non-medical volunteers \(4.6\).)] TJ ET BT 26.250 106.396 Td /F1 9.8 Tf [(Panelist ratings for hospital interventions identified the following as highest priority across all four outbreak scenarios: )] TJ ET BT 26.250 94.491 Td /F1 9.8 Tf [(mandatory vaccinations \(4.9\), coordinating a public health message \(4.1\), creating a treatment algorithm for antiviral use \(3.8\), )] TJ ET BT 26.250 82.587 Td /F1 9.8 Tf [(modifying visitation policies \(3.7\), screening employees \(3.6\), setting up alternate care systems \(3.6\), stockpiling isolation )] TJ ET BT 26.250 70.682 Td /F1 9.8 Tf [(equipment \(3.5\), and setting up an inpatient quarantine area \(3.5\). Individual scenario-based ratings for the hospital )] TJ ET BT 26.250 58.777 Td /F1 9.8 Tf [(interventions are shown in Tables 3 and 4.)] TJ ET BT 26.250 39.372 Td /F1 9.8 Tf [(The only hospital intervention to receive high priority in the low volume/low severity scenario, Scenario 1/Seasonal Influenza, )] TJ ET Q q 15.000 25.087 577.500 751.913 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(these results to the panelists in tabular form. After these initial presentations, the panelists completed two exercises for which )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(they were assigned to one of two equally sized groups, based upon panelists relevant expertise. One group evaluated ED-)] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(based interventions, and one evaluated hospital-based interventions. Each group was co-moderated by two subject matter )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(experts \(AD, MM, JP, JB, GK\) with previous training through numerous instructional meetings and two mock moderation )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(sessions to ensure uniform and unbiased facilitation of the proceedings.)] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(During Exercise One, panelists were asked to prioritize potential interventions to mitigate surge in response to an infectious )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(respiratory disease outbreak for each of four defined scenarios. Interventions were separated into two groups; those specifically )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(for patients presenting with influenza-like illness \(ILI\) and those for patients without ILI. Infection control measures were included )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(among the proposed interventions to focus efforts toward reducing disease spread and potentially reducing future patient )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(volume. Using the nominal group technique, each of the two break-out groups \(i.e. ED and hospital\) was asked to discuss each )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(associated intervention, \(including the pre-panel write-in interventions\), and suggest and similarly discuss any additional )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(interventions not yet considered. Panel members were then asked to anonymously and independently categorize each )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(intervention as low, medium, or high priority. Panelists were asked to consider both the ease of implementation and importance )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(for a final overall priority consideration specific for each of the four respiratory infection outbreak scenarios.)] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(In Exercise Two, panelists were asked to identify key data sources to trigger the implementation of a specific intervention in a )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(given respiratory virus illness scenario. Considering the worst case scenario \(high volume and high severity\) and the recent )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(2009 H1N1 scenario \(high volume, low severity\), each group was given one intervention, which was highly rated in Exercise )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(One, for each of the four scenarios. Additionally, each group was given a list of potential data sources based on those used in )] TJ ET BT 26.250 538.191 Td /F1 9.8 Tf [(the literature, current medical practice, and current surveillance systems, but was also encouraged to consider and suggest )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(alternate data sources that may serve as a trigger for implementation of the selected intervention. Examples of such data )] TJ ET BT 26.250 514.381 Td /F1 9.8 Tf [(sources included ED wait times, hospital volume, laboratory data, syndromic and laboratory-based surveillance systems, and )] TJ ET BT 26.250 502.476 Td /F1 9.8 Tf [(novel data sources that might be used to indicate increasing respiratory disease \(e.g. Twitter\). Panelists were asked to )] TJ ET BT 26.250 490.572 Td /F1 9.8 Tf [(individually select the top three data sources that could be useful to ED or hospital leaders to trigger the decision to implement )] TJ ET BT 26.250 478.667 Td /F1 9.8 Tf [(the top-rated interventions to mitigate ED or hospital crowding due to a respiratory infection outbreak. Similarly, using the )] TJ ET BT 26.250 466.762 Td /F1 9.8 Tf [(nominal group technique, panelists proposed other potential data sources. All potential data sources were discussed and each )] TJ ET BT 26.250 454.857 Td /F1 9.8 Tf [(panel member anonymously rated them on a 1-5 Likert scale with 1 being not at all important as a trigger and 5 as very )] TJ ET BT 26.250 442.953 Td /F1 9.8 Tf [(important for a trigger for the selected interventions.)] TJ ET BT 26.250 423.548 Td /F4 9.8 Tf [(Data Analysis)] TJ ET BT 26.250 404.143 Td /F1 9.8 Tf [(To evaluate data from Exercise One, final categorization data were assigned a numerical score where Low Priority = 1, Medium )] TJ ET BT 26.250 392.238 Td /F1 9.8 Tf [(Priority =3, and High Priority =5. These numerical scores were averaged by scenario to obtain a numerical final score for each )] TJ ET BT 26.250 380.334 Td /F1 9.8 Tf [(intervention in each scenario. These final means were then categorized as either, Low Priority \(1.0-2.0\), Medium Priority \(2.1-)] TJ ET BT 26.250 368.429 Td /F1 9.8 Tf [(4.0\), or High Priority \(4.1-5.0\). Additionally, numerical scores were averaged across all scenarios to obtain a total prioritization )] TJ ET BT 26.250 356.524 Td /F1 9.8 Tf [(score for each intervention across all scenarios. Finally, scores for each intervention within a scenario were averaged to obtain )] TJ ET BT 26.250 344.619 Td /F1 9.8 Tf [(a scenario prioritization score. For Exercise Two, the individual resultant ratings for each potential data source were averaged to )] TJ ET BT 26.250 332.715 Td /F1 9.8 Tf [(obtain a mean importance score for each potential data source.)] TJ ET BT 26.250 296.112 Td /F4 12.0 Tf [(Results)] TJ ET BT 26.250 276.158 Td /F1 9.8 Tf [(Among all of the potential interventions to mitigate ED crowding, the following interventions had the highest priority across all )] TJ ET BT 26.250 264.253 Td /F1 9.8 Tf [(four outbreak scenarios: standardizing ED discharge and admission criteria for patients with respiratory symptoms \(4.0\), )] TJ ET BT 26.250 252.348 Td /F1 9.8 Tf [(informing patients of the most appropriate setting for care either through a website \(4.0\) or telephone call center \(3.9\), and )] TJ ET BT 26.250 240.444 Td /F1 9.8 Tf [(instituting infection control measures including hand sanitizers and masks \(4.1\), cohorting patients with ILI \(4.0\), or ED signage )] TJ ET BT 26.250 228.539 Td /F1 9.8 Tf [(\(3.9\). Tables 1 and 2 demonstrate the final ED scenario-based prioritization for each potential intervention for both ILI patients )] TJ ET BT 26.250 216.634 Td /F1 9.8 Tf [(\(Table 1\), and non-ILI patients \(Table 2\).)] TJ ET BT 26.250 197.229 Td /F1 9.8 Tf [(When considering a low volume/low severity scenario such as Scenario 1/Seasonal Influenza, no individual ED intervention )] TJ ET BT 26.250 185.325 Td /F1 9.8 Tf [(ranked above medium priority which included standardization ED discharge and admission criteria for patients with respiratory )] TJ ET BT 26.250 173.420 Td /F1 9.8 Tf [(symptoms \(3.1\), setting up a website to advise patients on the most appropriate setting for care \(3.1\), using hand sanitizer and )] TJ ET BT 26.250 161.515 Td /F1 9.8 Tf [(masks \(3.1\), and ED signage for influenza \(3.1\). In the scenario with the highest volume and severity, Scenario 4/1918 H1N1, )] TJ ET BT 26.250 149.610 Td /F1 9.8 Tf [(many interventions received high priority even if they had received a lower priority in all previous scenarios, such as; Opening )] TJ ET BT 26.250 137.706 Td /F1 9.8 Tf [(an annex areas for patient care \(4.7\), coordination of influenza surge plans with the public health department \(4.6\), and )] TJ ET BT 26.250 125.801 Td /F1 9.8 Tf [(protocols for non-medical volunteers \(4.6\).)] TJ ET BT 26.250 106.396 Td /F1 9.8 Tf [(Panelist ratings for hospital interventions identified the following as highest priority across all four outbreak scenarios: )] TJ ET BT 26.250 94.491 Td /F1 9.8 Tf [(mandatory vaccinations \(4.9\), coordinating a public health message \(4.1\), creating a treatment algorithm for antiviral use \(3.8\), )] TJ ET BT 26.250 82.587 Td /F1 9.8 Tf [(modifying visitation policies \(3.7\), screening employees \(3.6\), setting up alternate care systems \(3.6\), stockpiling isolation )] TJ ET BT 26.250 70.682 Td /F1 9.8 Tf [(equipment \(3.5\), and setting up an inpatient quarantine area \(3.5\). Individual scenario-based ratings for the hospital )] TJ ET BT 26.250 58.777 Td /F1 9.8 Tf [(interventions are shown in Tables 3 and 4.)] TJ ET BT 26.250 39.372 Td /F1 9.8 Tf [(The only hospital intervention to receive high priority in the low volume/low severity scenario, Scenario 1/Seasonal Influenza, )] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(3)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 216 0 obj << /Type /Page /Parent 3 0 R /Annots [ 218 0 R 220 0 R 222 0 R 224 0 R 226 0 R 228 0 R 230 0 R 232 0 R 234 0 R 236 0 R 238 0 R 240 0 R 242 0 R 244 0 R 246 0 R 248 0 R 250 0 R 252 0 R 254 0 R 256 0 R 258 0 R 260 0 R 262 0 R 264 0 R 266 0 R 268 0 R 270 0 R 272 0 R 274 0 R 276 0 R 278 0 R 280 0 R 282 0 R 284 0 R 286 0 R 288 0 R 290 0 R 292 0 R 294 0 R ] /Contents 217 0 R >> endobj 217 0 obj << /Length 32293 >> stream 0.271 0.267 0.267 rg q 15.000 40.087 577.500 736.913 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(was mandatory vaccinations \(4.6\). The remaining interventions received moderate or low prioritization. For the worst scenario )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(with high volume/high severity, Scenario 4/1918 H1N1, all hospital interventions received high priority with the following )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(interventions receiving the highest score of 5.0; modifying visitation policies, stockpiling isolation equipment for inpatient staff, )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(creating a triage protocol for ventilator use, rescheduling or canceling elective procedures, and double-bunking inpatient rooms.)] TJ ET BT 26.250 712.357 Td /F1 9.8 Tf [(Overall, most individual ED-based interventions had higher priority ratings for scenarios which generated high patient volumes, )] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(such as Scenario 2/2009 H1N1 \(3.6\) and Scenario 4/1918 H1N1 \(4.0\), versus those with lower patient volumes, such as )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(Scenario 1/Seasonal Influenza \(2.0\) and Scenario 3/SARS \(3.0\). Conversely, hospital-based interventions had higher priority )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(ratings for scenarios with a high severity such as Scenario 3/SARS \(3.8\) and Scenario 4/1918 H1N1 \(4.8\) versus Scenario )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(1/seasonal influenza \(1.8\) and Scenario 2/2009 H1N1 \(3.1\).)] TJ ET BT 26.250 645.333 Td /F1 9.8 Tf [(The highest ranked interventions noted above were chosen for subsequent prioritization of potential data elements to employ as )] TJ ET BT 26.250 633.429 Td /F1 9.8 Tf [(triggers \(Table 5\). ED interventions selected were: \(1\) establishing an ED annex \(1918 H1N1 Scenario\), and \(2\) constructing a )] TJ ET BT 26.250 621.524 Td /F1 9.8 Tf [(website to advise patients on the most appropriate setting for care \(2009 H1N1 Scenario\). The hospital interventions selected )] TJ ET BT 26.250 609.619 Td /F1 9.8 Tf [(were: \(1\) developing and implementing a ventilator triage protocol \(1918 H1N1 Scenario\), and \(2\) establishing alternate care )] TJ ET BT 26.250 597.714 Td /F1 9.8 Tf [(sites \(2009 H1N1 Scenario\). The main data sources identified to serve as triggers came largely from medical center level )] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(crowding data as can be seen in Table 5. Top rated data sources consisted mainly of patient volume metrics \(hospital volume, )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(ED volume, boarding time in the ED, percent of patients with ILI, hospital capacity\), patient acuity metrics \(acuity ratio, ED )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(admission rate, number of low acuity ILI patients\), as well as measures of resource availability \(ventilator supply, and staff )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(availability\).)] TJ ET BT 26.250 513.493 Td /F4 12.0 Tf [(Discussion)] TJ ET BT 26.250 493.539 Td /F1 9.8 Tf [(Many EDs and hospitals are currently operating at or over capacity much of the time, where even small increases in patient )] TJ ET BT 26.250 481.634 Td /F1 9.8 Tf [(volumes, such as those seen during seasonal influenza, worsen ED crowding and further prolong patient waiting times, which )] TJ ET BT 26.250 469.729 Td /F1 9.8 Tf [(has been shown to be associated with untoward patient outcomes.)] TJ ET 0.267 0.267 0.267 rg BT 313.485 471.236 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 318.304 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 320.713 471.236 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 325.532 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 327.941 471.236 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 332.760 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 335.169 471.236 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 339.988 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 342.397 471.236 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 347.216 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 349.625 471.236 Td /F4 8.7 Tf [(10)] TJ ET 0.271 0.267 0.267 rg BT 359.262 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 361.672 471.236 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 371.309 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 373.718 471.236 Td /F4 8.7 Tf [(19)] TJ ET 0.271 0.267 0.267 rg BT 383.356 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 385.765 471.236 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 395.402 469.729 Td /F1 9.8 Tf [( A large-scale infectious respiratory )] TJ ET BT 26.250 457.824 Td /F1 9.8 Tf [(disease outbreak requires advanced medical center planning and response in order to maintain good ED and hospital flow, and )] TJ ET BT 26.250 445.920 Td /F1 9.8 Tf [(avoid any associated adverse impacts on patient care or outcomes. Although some interventions to manage ED and hospital )] TJ ET BT 26.250 434.015 Td /F1 9.8 Tf [(crowding can be carried out at the institutional level, others, as noted by our expert panelists, require coordination with the local )] TJ ET BT 26.250 422.110 Td /F1 9.8 Tf [(public health department, neighboring medical centers, or state and federal government to ensure alignment with the existing )] TJ ET BT 26.250 410.205 Td /F1 9.8 Tf [(level of regulatory standards \(e.g. suspension of the emergency medicine treatment and labor act [EMTALA]\). Communication )] TJ ET BT 26.250 398.301 Td /F1 9.8 Tf [(and coordination between all of these stakeholders increases the breadth of potential response options, and the overall )] TJ ET BT 26.250 386.396 Td /F1 9.8 Tf [(effectiveness. Beyond the individual responses, these same organizations, with appropriate and timely sharing of data, )] TJ ET BT 26.250 374.491 Td /F1 9.8 Tf [(combined with current surveillance systems, can inform the timing of when to implement the appropriate response. This expert )] TJ ET BT 26.250 362.586 Td /F1 9.8 Tf [(panel sought to combine knowledge and experience of leaders in each of these fields to provide initial broad guidance and )] TJ ET BT 26.250 350.682 Td /F1 9.8 Tf [(recommendations for prioritization and implementation of responses to mitigate crowding in the event of an infectious )] TJ ET BT 26.250 338.777 Td /F1 9.8 Tf [(respiratory disease outbreak.)] TJ ET BT 26.250 319.372 Td /F1 9.8 Tf [(For ED settings, panelists gave overall higher priority to interventions in outbreak scenarios with high volume of patient visits, )] TJ ET BT 26.250 307.467 Td /F1 9.8 Tf [(indicating the greatest concern for addressing outbreaks where ED crowding caused by sudden increased patient volume might )] TJ ET BT 26.250 295.563 Td /F1 9.8 Tf [(worsen regardless of disease severity. To address a high patient volume outbreak, panelists prioritized several interventions, )] TJ ET BT 26.250 283.658 Td /F1 9.8 Tf [(such as creating a website or telephone call center, to advise patients when to seek medical care and what the most )] TJ ET BT 26.250 271.753 Td /F1 9.8 Tf [(appropriate setting for that care would be. Other highly ranked ED interventions were simple precautionary measures to protect )] TJ ET BT 26.250 259.848 Td /F1 9.8 Tf [(non-ILI patients from being infected, such as hand sanitizers, masks, and cohorting infected patients, which are likely to have a )] TJ ET BT 26.250 247.944 Td /F1 9.8 Tf [(delayed impact on ED crowding. Placing these highly rated interventions in the context of the often used ED crowding model of )] TJ ET BT 26.250 236.039 Td /F1 9.8 Tf [(input, throughput and output, the majority of highly rated interventions focused on ED input, or reducing the number of patients )] TJ ET BT 26.250 224.134 Td /F1 9.8 Tf [(presenting to the emergency department.)] TJ ET 0.267 0.267 0.267 rg BT 204.548 225.641 Td /F4 8.7 Tf [(21)] TJ ET 0.271 0.267 0.267 rg BT 214.186 224.134 Td /F1 9.8 Tf [( Conversely, the majority of interventions presented in the peer-reviewed literature )] TJ ET BT 26.250 212.229 Td /F1 9.8 Tf [(focus on interventions to impact ED throughput, or the speed at which ED patients are managed.)] TJ ET 0.267 0.267 0.267 rg BT 443.004 213.737 Td /F4 8.7 Tf [(22)] TJ ET 0.271 0.267 0.267 rg BT 452.641 212.229 Td /F1 9.8 Tf [( Most of the literature )] TJ ET BT 26.250 200.325 Td /F1 9.8 Tf [(evaluating the impact of interventions evaluates the combined impact of multiple interventions, making it difficult to isolate the )] TJ ET BT 26.250 188.420 Td /F1 9.8 Tf [(effect of a single intervention. To our knowledge, only one paper isolates an ED input intervention showing that an ED )] TJ ET BT 26.250 176.515 Td /F1 9.8 Tf [(vaccination campaign reduces ED visits for respiratory illness by 34%.)] TJ ET 0.267 0.267 0.267 rg BT 328.598 178.022 Td /F4 8.7 Tf [(23)] TJ ET 0.271 0.267 0.267 rg BT 338.235 176.515 Td /F1 9.8 Tf [( Despite this evidence, this particular input intervention )] TJ ET BT 26.250 164.610 Td /F1 9.8 Tf [(\(ED vaccination\) was rated lower by this expert panel, suggesting that cost and ease of implementation were important factors )] TJ ET BT 26.250 152.706 Td /F1 9.8 Tf [(considered by the panel.)] TJ ET BT 26.250 133.301 Td /F1 9.8 Tf [(When considering hospital crowding, the panelists overall prioritized measures aimed at outbreaks with high severity. Unlike ED )] TJ ET BT 26.250 121.396 Td /F1 9.8 Tf [(volume issues which are more related to overall patient volume, severity of illness, even with low volume of patients, stressed )] TJ ET BT 26.250 109.491 Td /F1 9.8 Tf [(demand for inpatient resources such as hospital beds, intensive care unit \(ICU\) space and ventilators. Here, the highly rated )] TJ ET BT 26.250 97.587 Td /F1 9.8 Tf [(interventions also focused on measures to protect staff and non-ILI patients from disease transmission, including setting up an )] TJ ET BT 26.250 85.682 Td /F1 9.8 Tf [(inpatient quarantine area and stockpiling isolation equipment. This is consistent with previous task force recommendations to )] TJ ET BT 26.250 73.777 Td /F1 9.8 Tf [(maximize ICU resources \(both beds and staffing\) as well as maintain strict infectious control policies.)] TJ ET 0.267 0.267 0.267 rg BT 459.725 75.284 Td /F4 8.7 Tf [(24)] TJ ET 0.271 0.267 0.267 rg BT 469.363 73.777 Td /F1 9.8 Tf [( Additionally, a treatment )] TJ ET BT 26.250 61.872 Td /F1 9.8 Tf [(algorithm for antiviral use rated highly, as antivirals would likely be in short supply and would require appropriate, scenario-)] TJ ET BT 26.250 49.968 Td /F1 9.8 Tf [(driven allocation management.)] TJ ET Q q 15.000 40.087 577.500 736.913 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(was mandatory vaccinations \(4.6\). The remaining interventions received moderate or low prioritization. For the worst scenario )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(with high volume/high severity, Scenario 4/1918 H1N1, all hospital interventions received high priority with the following )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(interventions receiving the highest score of 5.0; modifying visitation policies, stockpiling isolation equipment for inpatient staff, )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(creating a triage protocol for ventilator use, rescheduling or canceling elective procedures, and double-bunking inpatient rooms.)] TJ ET BT 26.250 712.357 Td /F1 9.8 Tf [(Overall, most individual ED-based interventions had higher priority ratings for scenarios which generated high patient volumes, )] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(such as Scenario 2/2009 H1N1 \(3.6\) and Scenario 4/1918 H1N1 \(4.0\), versus those with lower patient volumes, such as )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(Scenario 1/Seasonal Influenza \(2.0\) and Scenario 3/SARS \(3.0\). Conversely, hospital-based interventions had higher priority )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(ratings for scenarios with a high severity such as Scenario 3/SARS \(3.8\) and Scenario 4/1918 H1N1 \(4.8\) versus Scenario )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(1/seasonal influenza \(1.8\) and Scenario 2/2009 H1N1 \(3.1\).)] TJ ET BT 26.250 645.333 Td /F1 9.8 Tf [(The highest ranked interventions noted above were chosen for subsequent prioritization of potential data elements to employ as )] TJ ET BT 26.250 633.429 Td /F1 9.8 Tf [(triggers \(Table 5\). ED interventions selected were: \(1\) establishing an ED annex \(1918 H1N1 Scenario\), and \(2\) constructing a )] TJ ET BT 26.250 621.524 Td /F1 9.8 Tf [(website to advise patients on the most appropriate setting for care \(2009 H1N1 Scenario\). The hospital interventions selected )] TJ ET BT 26.250 609.619 Td /F1 9.8 Tf [(were: \(1\) developing and implementing a ventilator triage protocol \(1918 H1N1 Scenario\), and \(2\) establishing alternate care )] TJ ET BT 26.250 597.714 Td /F1 9.8 Tf [(sites \(2009 H1N1 Scenario\). The main data sources identified to serve as triggers came largely from medical center level )] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(crowding data as can be seen in Table 5. Top rated data sources consisted mainly of patient volume metrics \(hospital volume, )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(ED volume, boarding time in the ED, percent of patients with ILI, hospital capacity\), patient acuity metrics \(acuity ratio, ED )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(admission rate, number of low acuity ILI patients\), as well as measures of resource availability \(ventilator supply, and staff )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(availability\).)] TJ ET BT 26.250 513.493 Td /F4 12.0 Tf [(Discussion)] TJ ET BT 26.250 493.539 Td /F1 9.8 Tf [(Many EDs and hospitals are currently operating at or over capacity much of the time, where even small increases in patient )] TJ ET BT 26.250 481.634 Td /F1 9.8 Tf [(volumes, such as those seen during seasonal influenza, worsen ED crowding and further prolong patient waiting times, which )] TJ ET BT 26.250 469.729 Td /F1 9.8 Tf [(has been shown to be associated with untoward patient outcomes.)] TJ ET 0.267 0.267 0.267 rg BT 313.485 471.236 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 318.304 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 320.713 471.236 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 325.532 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 327.941 471.236 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 332.760 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 335.169 471.236 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 339.988 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 342.397 471.236 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 347.216 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 349.625 471.236 Td /F4 8.7 Tf [(10)] TJ ET 0.271 0.267 0.267 rg BT 359.262 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 361.672 471.236 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 371.309 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 373.718 471.236 Td /F4 8.7 Tf [(19)] TJ ET 0.271 0.267 0.267 rg BT 383.356 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 385.765 471.236 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 395.402 469.729 Td /F1 9.8 Tf [( A large-scale infectious respiratory )] TJ ET BT 26.250 457.824 Td /F1 9.8 Tf [(disease outbreak requires advanced medical center planning and response in order to maintain good ED and hospital flow, and )] TJ ET BT 26.250 445.920 Td /F1 9.8 Tf [(avoid any associated adverse impacts on patient care or outcomes. Although some interventions to manage ED and hospital )] TJ ET BT 26.250 434.015 Td /F1 9.8 Tf [(crowding can be carried out at the institutional level, others, as noted by our expert panelists, require coordination with the local )] TJ ET BT 26.250 422.110 Td /F1 9.8 Tf [(public health department, neighboring medical centers, or state and federal government to ensure alignment with the existing )] TJ ET BT 26.250 410.205 Td /F1 9.8 Tf [(level of regulatory standards \(e.g. suspension of the emergency medicine treatment and labor act [EMTALA]\). Communication )] TJ ET BT 26.250 398.301 Td /F1 9.8 Tf [(and coordination between all of these stakeholders increases the breadth of potential response options, and the overall )] TJ ET BT 26.250 386.396 Td /F1 9.8 Tf [(effectiveness. Beyond the individual responses, these same organizations, with appropriate and timely sharing of data, )] TJ ET BT 26.250 374.491 Td /F1 9.8 Tf [(combined with current surveillance systems, can inform the timing of when to implement the appropriate response. This expert )] TJ ET BT 26.250 362.586 Td /F1 9.8 Tf [(panel sought to combine knowledge and experience of leaders in each of these fields to provide initial broad guidance and )] TJ ET BT 26.250 350.682 Td /F1 9.8 Tf [(recommendations for prioritization and implementation of responses to mitigate crowding in the event of an infectious )] TJ ET BT 26.250 338.777 Td /F1 9.8 Tf [(respiratory disease outbreak.)] TJ ET BT 26.250 319.372 Td /F1 9.8 Tf [(For ED settings, panelists gave overall higher priority to interventions in outbreak scenarios with high volume of patient visits, )] TJ ET BT 26.250 307.467 Td /F1 9.8 Tf [(indicating the greatest concern for addressing outbreaks where ED crowding caused by sudden increased patient volume might )] TJ ET BT 26.250 295.563 Td /F1 9.8 Tf [(worsen regardless of disease severity. To address a high patient volume outbreak, panelists prioritized several interventions, )] TJ ET BT 26.250 283.658 Td /F1 9.8 Tf [(such as creating a website or telephone call center, to advise patients when to seek medical care and what the most )] TJ ET BT 26.250 271.753 Td /F1 9.8 Tf [(appropriate setting for that care would be. Other highly ranked ED interventions were simple precautionary measures to protect )] TJ ET BT 26.250 259.848 Td /F1 9.8 Tf [(non-ILI patients from being infected, such as hand sanitizers, masks, and cohorting infected patients, which are likely to have a )] TJ ET BT 26.250 247.944 Td /F1 9.8 Tf [(delayed impact on ED crowding. Placing these highly rated interventions in the context of the often used ED crowding model of )] TJ ET BT 26.250 236.039 Td /F1 9.8 Tf [(input, throughput and output, the majority of highly rated interventions focused on ED input, or reducing the number of patients )] TJ ET BT 26.250 224.134 Td /F1 9.8 Tf [(presenting to the emergency department.)] TJ ET 0.267 0.267 0.267 rg BT 204.548 225.641 Td /F4 8.7 Tf [(21)] TJ ET 0.271 0.267 0.267 rg BT 214.186 224.134 Td /F1 9.8 Tf [( Conversely, the majority of interventions presented in the peer-reviewed literature )] TJ ET BT 26.250 212.229 Td /F1 9.8 Tf [(focus on interventions to impact ED throughput, or the speed at which ED patients are managed.)] TJ ET 0.267 0.267 0.267 rg BT 443.004 213.737 Td /F4 8.7 Tf [(22)] TJ ET 0.271 0.267 0.267 rg BT 452.641 212.229 Td /F1 9.8 Tf [( Most of the literature )] TJ ET BT 26.250 200.325 Td /F1 9.8 Tf [(evaluating the impact of interventions evaluates the combined impact of multiple interventions, making it difficult to isolate the )] TJ ET BT 26.250 188.420 Td /F1 9.8 Tf [(effect of a single intervention. To our knowledge, only one paper isolates an ED input intervention showing that an ED )] TJ ET BT 26.250 176.515 Td /F1 9.8 Tf [(vaccination campaign reduces ED visits for respiratory illness by 34%.)] TJ ET 0.267 0.267 0.267 rg BT 328.598 178.022 Td /F4 8.7 Tf [(23)] TJ ET 0.271 0.267 0.267 rg BT 338.235 176.515 Td /F1 9.8 Tf [( Despite this evidence, this particular input intervention )] TJ ET BT 26.250 164.610 Td /F1 9.8 Tf [(\(ED vaccination\) was rated lower by this expert panel, suggesting that cost and ease of implementation were important factors )] TJ ET BT 26.250 152.706 Td /F1 9.8 Tf [(considered by the panel.)] TJ ET BT 26.250 133.301 Td /F1 9.8 Tf [(When considering hospital crowding, the panelists overall prioritized measures aimed at outbreaks with high severity. Unlike ED )] TJ ET BT 26.250 121.396 Td /F1 9.8 Tf [(volume issues which are more related to overall patient volume, severity of illness, even with low volume of patients, stressed )] TJ ET BT 26.250 109.491 Td /F1 9.8 Tf [(demand for inpatient resources such as hospital beds, intensive care unit \(ICU\) space and ventilators. Here, the highly rated )] TJ ET BT 26.250 97.587 Td /F1 9.8 Tf [(interventions also focused on measures to protect staff and non-ILI patients from disease transmission, including setting up an )] TJ ET BT 26.250 85.682 Td /F1 9.8 Tf [(inpatient quarantine area and stockpiling isolation equipment. This is consistent with previous task force recommendations to )] TJ ET BT 26.250 73.777 Td /F1 9.8 Tf [(maximize ICU resources \(both beds and staffing\) as well as maintain strict infectious control policies.)] TJ ET 0.267 0.267 0.267 rg BT 459.725 75.284 Td /F4 8.7 Tf [(24)] TJ ET 0.271 0.267 0.267 rg BT 469.363 73.777 Td /F1 9.8 Tf [( Additionally, a treatment )] TJ ET BT 26.250 61.872 Td /F1 9.8 Tf [(algorithm for antiviral use rated highly, as antivirals would likely be in short supply and would require appropriate, scenario-)] TJ ET BT 26.250 49.968 Td /F1 9.8 Tf [(driven allocation management.)] TJ ET Q q 15.000 40.087 577.500 736.913 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(was mandatory vaccinations \(4.6\). The remaining interventions received moderate or low prioritization. For the worst scenario )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(with high volume/high severity, Scenario 4/1918 H1N1, all hospital interventions received high priority with the following )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(interventions receiving the highest score of 5.0; modifying visitation policies, stockpiling isolation equipment for inpatient staff, )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(creating a triage protocol for ventilator use, rescheduling or canceling elective procedures, and double-bunking inpatient rooms.)] TJ ET BT 26.250 712.357 Td /F1 9.8 Tf [(Overall, most individual ED-based interventions had higher priority ratings for scenarios which generated high patient volumes, )] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(such as Scenario 2/2009 H1N1 \(3.6\) and Scenario 4/1918 H1N1 \(4.0\), versus those with lower patient volumes, such as )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(Scenario 1/Seasonal Influenza \(2.0\) and Scenario 3/SARS \(3.0\). Conversely, hospital-based interventions had higher priority )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(ratings for scenarios with a high severity such as Scenario 3/SARS \(3.8\) and Scenario 4/1918 H1N1 \(4.8\) versus Scenario )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(1/seasonal influenza \(1.8\) and Scenario 2/2009 H1N1 \(3.1\).)] TJ ET BT 26.250 645.333 Td /F1 9.8 Tf [(The highest ranked interventions noted above were chosen for subsequent prioritization of potential data elements to employ as )] TJ ET BT 26.250 633.429 Td /F1 9.8 Tf [(triggers \(Table 5\). ED interventions selected were: \(1\) establishing an ED annex \(1918 H1N1 Scenario\), and \(2\) constructing a )] TJ ET BT 26.250 621.524 Td /F1 9.8 Tf [(website to advise patients on the most appropriate setting for care \(2009 H1N1 Scenario\). The hospital interventions selected )] TJ ET BT 26.250 609.619 Td /F1 9.8 Tf [(were: \(1\) developing and implementing a ventilator triage protocol \(1918 H1N1 Scenario\), and \(2\) establishing alternate care )] TJ ET BT 26.250 597.714 Td /F1 9.8 Tf [(sites \(2009 H1N1 Scenario\). The main data sources identified to serve as triggers came largely from medical center level )] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(crowding data as can be seen in Table 5. Top rated data sources consisted mainly of patient volume metrics \(hospital volume, )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(ED volume, boarding time in the ED, percent of patients with ILI, hospital capacity\), patient acuity metrics \(acuity ratio, ED )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(admission rate, number of low acuity ILI patients\), as well as measures of resource availability \(ventilator supply, and staff )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(availability\).)] TJ ET BT 26.250 513.493 Td /F4 12.0 Tf [(Discussion)] TJ ET BT 26.250 493.539 Td /F1 9.8 Tf [(Many EDs and hospitals are currently operating at or over capacity much of the time, where even small increases in patient )] TJ ET BT 26.250 481.634 Td /F1 9.8 Tf [(volumes, such as those seen during seasonal influenza, worsen ED crowding and further prolong patient waiting times, which )] TJ ET BT 26.250 469.729 Td /F1 9.8 Tf [(has been shown to be associated with untoward patient outcomes.)] TJ ET 0.267 0.267 0.267 rg BT 313.485 471.236 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 318.304 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 320.713 471.236 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 325.532 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 327.941 471.236 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 332.760 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 335.169 471.236 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 339.988 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 342.397 471.236 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 347.216 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 349.625 471.236 Td /F4 8.7 Tf [(10)] TJ ET 0.271 0.267 0.267 rg BT 359.262 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 361.672 471.236 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 371.309 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 373.718 471.236 Td /F4 8.7 Tf [(19)] TJ ET 0.271 0.267 0.267 rg BT 383.356 473.617 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 385.765 471.236 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 395.402 469.729 Td /F1 9.8 Tf [( A large-scale infectious respiratory )] TJ ET BT 26.250 457.824 Td /F1 9.8 Tf [(disease outbreak requires advanced medical center planning and response in order to maintain good ED and hospital flow, and )] TJ ET BT 26.250 445.920 Td /F1 9.8 Tf [(avoid any associated adverse impacts on patient care or outcomes. Although some interventions to manage ED and hospital )] TJ ET BT 26.250 434.015 Td /F1 9.8 Tf [(crowding can be carried out at the institutional level, others, as noted by our expert panelists, require coordination with the local )] TJ ET BT 26.250 422.110 Td /F1 9.8 Tf [(public health department, neighboring medical centers, or state and federal government to ensure alignment with the existing )] TJ ET BT 26.250 410.205 Td /F1 9.8 Tf [(level of regulatory standards \(e.g. suspension of the emergency medicine treatment and labor act [EMTALA]\). Communication )] TJ ET BT 26.250 398.301 Td /F1 9.8 Tf [(and coordination between all of these stakeholders increases the breadth of potential response options, and the overall )] TJ ET BT 26.250 386.396 Td /F1 9.8 Tf [(effectiveness. Beyond the individual responses, these same organizations, with appropriate and timely sharing of data, )] TJ ET BT 26.250 374.491 Td /F1 9.8 Tf [(combined with current surveillance systems, can inform the timing of when to implement the appropriate response. This expert )] TJ ET BT 26.250 362.586 Td /F1 9.8 Tf [(panel sought to combine knowledge and experience of leaders in each of these fields to provide initial broad guidance and )] TJ ET BT 26.250 350.682 Td /F1 9.8 Tf [(recommendations for prioritization and implementation of responses to mitigate crowding in the event of an infectious )] TJ ET BT 26.250 338.777 Td /F1 9.8 Tf [(respiratory disease outbreak.)] TJ ET BT 26.250 319.372 Td /F1 9.8 Tf [(For ED settings, panelists gave overall higher priority to interventions in outbreak scenarios with high volume of patient visits, )] TJ ET BT 26.250 307.467 Td /F1 9.8 Tf [(indicating the greatest concern for addressing outbreaks where ED crowding caused by sudden increased patient volume might )] TJ ET BT 26.250 295.563 Td /F1 9.8 Tf [(worsen regardless of disease severity. To address a high patient volume outbreak, panelists prioritized several interventions, )] TJ ET BT 26.250 283.658 Td /F1 9.8 Tf [(such as creating a website or telephone call center, to advise patients when to seek medical care and what the most )] TJ ET BT 26.250 271.753 Td /F1 9.8 Tf [(appropriate setting for that care would be. Other highly ranked ED interventions were simple precautionary measures to protect )] TJ ET BT 26.250 259.848 Td /F1 9.8 Tf [(non-ILI patients from being infected, such as hand sanitizers, masks, and cohorting infected patients, which are likely to have a )] TJ ET BT 26.250 247.944 Td /F1 9.8 Tf [(delayed impact on ED crowding. Placing these highly rated interventions in the context of the often used ED crowding model of )] TJ ET BT 26.250 236.039 Td /F1 9.8 Tf [(input, throughput and output, the majority of highly rated interventions focused on ED input, or reducing the number of patients )] TJ ET BT 26.250 224.134 Td /F1 9.8 Tf [(presenting to the emergency department.)] TJ ET 0.267 0.267 0.267 rg BT 204.548 225.641 Td /F4 8.7 Tf [(21)] TJ ET 0.271 0.267 0.267 rg BT 214.186 224.134 Td /F1 9.8 Tf [( Conversely, the majority of interventions presented in the peer-reviewed literature )] TJ ET BT 26.250 212.229 Td /F1 9.8 Tf [(focus on interventions to impact ED throughput, or the speed at which ED patients are managed.)] TJ ET 0.267 0.267 0.267 rg BT 443.004 213.737 Td /F4 8.7 Tf [(22)] TJ ET 0.271 0.267 0.267 rg BT 452.641 212.229 Td /F1 9.8 Tf [( Most of the literature )] TJ ET BT 26.250 200.325 Td /F1 9.8 Tf [(evaluating the impact of interventions evaluates the combined impact of multiple interventions, making it difficult to isolate the )] TJ ET BT 26.250 188.420 Td /F1 9.8 Tf [(effect of a single intervention. To our knowledge, only one paper isolates an ED input intervention showing that an ED )] TJ ET BT 26.250 176.515 Td /F1 9.8 Tf [(vaccination campaign reduces ED visits for respiratory illness by 34%.)] TJ ET 0.267 0.267 0.267 rg BT 328.598 178.022 Td /F4 8.7 Tf [(23)] TJ ET 0.271 0.267 0.267 rg BT 338.235 176.515 Td /F1 9.8 Tf [( Despite this evidence, this particular input intervention )] TJ ET BT 26.250 164.610 Td /F1 9.8 Tf [(\(ED vaccination\) was rated lower by this expert panel, suggesting that cost and ease of implementation were important factors )] TJ ET BT 26.250 152.706 Td /F1 9.8 Tf [(considered by the panel.)] TJ ET BT 26.250 133.301 Td /F1 9.8 Tf [(When considering hospital crowding, the panelists overall prioritized measures aimed at outbreaks with high severity. Unlike ED )] TJ ET BT 26.250 121.396 Td /F1 9.8 Tf [(volume issues which are more related to overall patient volume, severity of illness, even with low volume of patients, stressed )] TJ ET BT 26.250 109.491 Td /F1 9.8 Tf [(demand for inpatient resources such as hospital beds, intensive care unit \(ICU\) space and ventilators. Here, the highly rated )] TJ ET BT 26.250 97.587 Td /F1 9.8 Tf [(interventions also focused on measures to protect staff and non-ILI patients from disease transmission, including setting up an )] TJ ET BT 26.250 85.682 Td /F1 9.8 Tf [(inpatient quarantine area and stockpiling isolation equipment. This is consistent with previous task force recommendations to )] TJ ET BT 26.250 73.777 Td /F1 9.8 Tf [(maximize ICU resources \(both beds and staffing\) as well as maintain strict infectious control policies.)] TJ ET 0.267 0.267 0.267 rg BT 459.725 75.284 Td /F4 8.7 Tf [(24)] TJ ET 0.271 0.267 0.267 rg BT 469.363 73.777 Td /F1 9.8 Tf [( Additionally, a treatment )] TJ ET BT 26.250 61.872 Td /F1 9.8 Tf [(algorithm for antiviral use rated highly, as antivirals would likely be in short supply and would require appropriate, scenario-)] TJ ET BT 26.250 49.968 Td /F1 9.8 Tf [(driven allocation management.)] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(4)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 218 0 obj << /Type /Annot /Subtype /Link /A 219 0 R /Border [0 0 0] /H /I /Rect [ 313.4850 470.4347 318.3037 479.2530 ] >> endobj 219 0 obj << /Type /Action >> endobj 220 0 obj << /Type /Annot /Subtype /Link /A 221 0 R /Border 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293 0 R /Border [0 0 0] /H /I /Rect [ 328.5975 177.2207 338.2348 186.0390 ] >> endobj 293 0 obj << /Type /Action >> endobj 294 0 obj << /Type /Annot /Subtype /Link /A 295 0 R /Border [0 0 0] /H /I /Rect [ 459.7253 74.4827 469.3626 83.3010 ] >> endobj 295 0 obj << /Type /Action >> endobj 296 0 obj << /Type /Page /Parent 3 0 R /Annots [ 298 0 R 302 0 R 306 0 R ] /Contents 297 0 R >> endobj 297 0 obj << /Length 23879 >> stream 0.271 0.267 0.267 rg q 15.000 18.979 577.500 758.021 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(For the low volume, low severity outbreak scenario \(i.e. seasonal influenza\), respondents gave higher prioritization to )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(interventions that would be easier to implement \(e.g. hand hygiene and masks\), both for the ED and hospital. However, for )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(either increased volume or severity outbreaks, respondents shifted prioritizations to those interventions requiring more intensive )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(resources. For example, for the high-volume, high severity outbreak scenario \(1918 pandemic\), establishing an ED annex, )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(stockpiling equipment, and adding staff were rated as highest priority.)] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(This study evaluates the priority of interventions across a variety of potential infectious respiratory disease outbreak scenarios )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(encompassing a range of patient volumes and disease severities. Although the exercise was designed to assess multiple )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(epidemiological scenarios, it is often the case that the exact parameters of the outbreak \(i.e. disease severity and patient )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(volume\) are not completely known at the outset of the outbreak. Thus, information gleaned from this exercise may be most )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(helpful for understanding overall priority of interventions rather than their priority in a specific artificial scenario. However, given )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(that there is often some advanced indication of the nature of an impending outbreak, and outbreak characteristics such as )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(volume and severity affect prioritization of resulting interventions, detailed prioritization based on the volume and severity of an )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(outbreak may prove beneficial.)] TJ ET BT 26.250 597.714 Td /F1 9.8 Tf [(Similar to other group consensus methods, results can vary based on the composition of the group. To mitigate this potential )] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(selection bias, we selected individuals across a wide range of expertise who are integral to the process of disease surveillance )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(and implementation of clinical interventions. These selected individuals represented those in decision making positions from )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(numerous geographic regions and organizations, academic institutions and levels of government. However, the results )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(represent panelists opinions, and not the results of a formal literature meta-analysis or quantitative data analysis of U.S. )] TJ ET BT 26.250 538.191 Td /F1 9.8 Tf [(hospitals; the inherent difficulty of which was described earlier in this article. Although further breakdown of the rankings )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(according to the panelists self-identified expert group category would be an interesting analysis, this was not possible as several )] TJ ET BT 26.250 514.381 Td /F1 9.8 Tf [(panelists identified themselves as belonging to more than one expert group, preventing clear categorization.)] TJ ET BT 26.250 494.976 Td /F1 9.8 Tf [(Information generated from these exercises may serve to guide ED and hospital administrators to focus on the highest-priority )] TJ ET BT 26.250 483.072 Td /F1 9.8 Tf [(interventions for a particular scenario, based on anticipated patient volumes or disease severity. However, there is a need for )] TJ ET BT 26.250 471.167 Td /F1 9.8 Tf [(more formal methods of assessing intervention quality and efficacy. Although conducting randomized controlled trials may not )] TJ ET BT 26.250 459.262 Td /F1 9.8 Tf [(be possible for public health interventions, standardizing reporting and assessment of interventions could provide a framework )] TJ ET BT 26.250 447.357 Td /F1 9.8 Tf [(for describing and comparing interventions which could be reported in the literature.)] TJ ET BT 26.250 427.953 Td /F1 9.8 Tf [(Although many of the highly rated interventions require, or would benefit from, coordination with departments of public health, )] TJ ET BT 26.250 416.048 Td /F1 9.8 Tf [(local medical centers, and local and federal governments, the decision of whether and when to implement many of these )] TJ ET BT 26.250 404.143 Td /F1 9.8 Tf [(interventions currently appears to occur at the medical center level. Further, virtually all of the most highly rated data sources to )] TJ ET BT 26.250 392.238 Td /F1 9.8 Tf [(trigger the decision of when to implement these interventions are collected directly by individual hospitals or EDs. These data )] TJ ET BT 26.250 380.334 Td /F1 9.8 Tf [(sources, such as ED and hospital volume and admission rates, and ED waiting times, are institutional data, monitored closely at )] TJ ET BT 26.250 368.429 Td /F1 9.8 Tf [(the institutional level, but frequently have lags before reporting and analysis at the public health level. Despite emphasis on )] TJ ET BT 26.250 356.524 Td /F1 9.8 Tf [(infectious respiratory disease surveillance, surveillance tools did not rank in the top three triggers for any of the four included )] TJ ET BT 26.250 344.619 Td /F1 9.8 Tf [(scenarios. These recommendations highlight the importance of advancing capabilities of surveillance systems to collect and )] TJ ET BT 26.250 332.715 Td /F1 9.8 Tf [(coalesce institutional data sources in a timely manner, to provide both public health departments and medical institutions with )] TJ ET BT 26.250 320.810 Td /F1 9.8 Tf [(better situational awareness which could improve the timeliness and effectiveness of planned responses.)] TJ ET BT 26.250 284.207 Td /F4 12.0 Tf [(Conclusion)] TJ ET BT 26.250 264.253 Td /F1 9.8 Tf [(Expert panelists placed highest priority on ED interventions to mitigate surge in the setting of an infectious respiratory disease )] TJ ET BT 26.250 252.348 Td /F1 9.8 Tf [(outbreak scenario with high patient volume, indicating the greatest concern for addressing outbreaks where ED crowding )] TJ ET BT 26.250 240.444 Td /F1 9.8 Tf [(caused by sudden increased patient volume might worsen regardless of disease severity. Disease severity, in and of itself, was )] TJ ET BT 26.250 228.539 Td /F1 9.8 Tf [(felt to be a lesser issue in the ED setting. Conversely, panelists concluded that interventions addressing disease severity were )] TJ ET BT 26.250 216.634 Td /F1 9.8 Tf [(the most important for inpatient management, operations and resource distribution, with less emphasis decreasing total )] TJ ET BT 26.250 204.729 Td /F1 9.8 Tf [(numbers affected in the population. Data useful for setting triggers to implement high priority measures were predominantly )] TJ ET BT 26.250 192.825 Td /F1 9.8 Tf [(those available at the local institutional level. Strikingly, public health surveillance data were not considered as one of the top )] TJ ET BT 26.250 180.920 Td /F1 9.8 Tf [(triggers to operationalize any of the priority measures, either for the ED or the inpatient services. We believe this study )] TJ ET BT 26.250 169.015 Td /F1 9.8 Tf [(represents the first step in delineating high impact interventions according to hospital service \(ED verses inpatient\) and )] TJ ET BT 26.250 157.110 Td /F1 9.8 Tf [(infectious disease outbreak characteristics.)] TJ ET 0.965 0.965 0.965 rg 26.250 18.979 555.000 128.250 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 147.229 m 581.250 147.229 l 581.250 146.479 l 26.250 146.479 l f q 112.500 0 0 112.500 35.250 24.979 cm /I4 Do Q q 35.250 18.979 537.000 0.000 re W n Q Q q 15.000 18.979 577.500 758.021 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(For the low volume, low severity outbreak scenario \(i.e. seasonal influenza\), respondents gave higher prioritization to )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(interventions that would be easier to implement \(e.g. hand hygiene and masks\), both for the ED and hospital. However, for )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(either increased volume or severity outbreaks, respondents shifted prioritizations to those interventions requiring more intensive )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(resources. For example, for the high-volume, high severity outbreak scenario \(1918 pandemic\), establishing an ED annex, )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(stockpiling equipment, and adding staff were rated as highest priority.)] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(This study evaluates the priority of interventions across a variety of potential infectious respiratory disease outbreak scenarios )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(encompassing a range of patient volumes and disease severities. Although the exercise was designed to assess multiple )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(epidemiological scenarios, it is often the case that the exact parameters of the outbreak \(i.e. disease severity and patient )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(volume\) are not completely known at the outset of the outbreak. Thus, information gleaned from this exercise may be most )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(helpful for understanding overall priority of interventions rather than their priority in a specific artificial scenario. However, given )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(that there is often some advanced indication of the nature of an impending outbreak, and outbreak characteristics such as )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(volume and severity affect prioritization of resulting interventions, detailed prioritization based on the volume and severity of an )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(outbreak may prove beneficial.)] TJ ET BT 26.250 597.714 Td /F1 9.8 Tf [(Similar to other group consensus methods, results can vary based on the composition of the group. To mitigate this potential )] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(selection bias, we selected individuals across a wide range of expertise who are integral to the process of disease surveillance )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(and implementation of clinical interventions. These selected individuals represented those in decision making positions from )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(numerous geographic regions and organizations, academic institutions and levels of government. However, the results )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(represent panelists opinions, and not the results of a formal literature meta-analysis or quantitative data analysis of U.S. )] TJ ET BT 26.250 538.191 Td /F1 9.8 Tf [(hospitals; the inherent difficulty of which was described earlier in this article. Although further breakdown of the rankings )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(according to the panelists self-identified expert group category would be an interesting analysis, this was not possible as several )] TJ ET BT 26.250 514.381 Td /F1 9.8 Tf [(panelists identified themselves as belonging to more than one expert group, preventing clear categorization.)] TJ ET BT 26.250 494.976 Td /F1 9.8 Tf [(Information generated from these exercises may serve to guide ED and hospital administrators to focus on the highest-priority )] TJ ET BT 26.250 483.072 Td /F1 9.8 Tf [(interventions for a particular scenario, based on anticipated patient volumes or disease severity. However, there is a need for )] TJ ET BT 26.250 471.167 Td /F1 9.8 Tf [(more formal methods of assessing intervention quality and efficacy. Although conducting randomized controlled trials may not )] TJ ET BT 26.250 459.262 Td /F1 9.8 Tf [(be possible for public health interventions, standardizing reporting and assessment of interventions could provide a framework )] TJ ET BT 26.250 447.357 Td /F1 9.8 Tf [(for describing and comparing interventions which could be reported in the literature.)] TJ ET BT 26.250 427.953 Td /F1 9.8 Tf [(Although many of the highly rated interventions require, or would benefit from, coordination with departments of public health, )] TJ ET BT 26.250 416.048 Td /F1 9.8 Tf [(local medical centers, and local and federal governments, the decision of whether and when to implement many of these )] TJ ET BT 26.250 404.143 Td /F1 9.8 Tf [(interventions currently appears to occur at the medical center level. Further, virtually all of the most highly rated data sources to )] TJ ET BT 26.250 392.238 Td /F1 9.8 Tf [(trigger the decision of when to implement these interventions are collected directly by individual hospitals or EDs. These data )] TJ ET BT 26.250 380.334 Td /F1 9.8 Tf [(sources, such as ED and hospital volume and admission rates, and ED waiting times, are institutional data, monitored closely at )] TJ ET BT 26.250 368.429 Td /F1 9.8 Tf [(the institutional level, but frequently have lags before reporting and analysis at the public health level. Despite emphasis on )] TJ ET BT 26.250 356.524 Td /F1 9.8 Tf [(infectious respiratory disease surveillance, surveillance tools did not rank in the top three triggers for any of the four included )] TJ ET BT 26.250 344.619 Td /F1 9.8 Tf [(scenarios. These recommendations highlight the importance of advancing capabilities of surveillance systems to collect and )] TJ ET BT 26.250 332.715 Td /F1 9.8 Tf [(coalesce institutional data sources in a timely manner, to provide both public health departments and medical institutions with )] TJ ET BT 26.250 320.810 Td /F1 9.8 Tf [(better situational awareness which could improve the timeliness and effectiveness of planned responses.)] TJ ET BT 26.250 284.207 Td /F4 12.0 Tf [(Conclusion)] TJ ET BT 26.250 264.253 Td /F1 9.8 Tf [(Expert panelists placed highest priority on ED interventions to mitigate surge in the setting of an infectious respiratory disease )] TJ ET BT 26.250 252.348 Td /F1 9.8 Tf [(outbreak scenario with high patient volume, indicating the greatest concern for addressing outbreaks where ED crowding )] TJ ET BT 26.250 240.444 Td /F1 9.8 Tf [(caused by sudden increased patient volume might worsen regardless of disease severity. Disease severity, in and of itself, was )] TJ ET BT 26.250 228.539 Td /F1 9.8 Tf [(felt to be a lesser issue in the ED setting. Conversely, panelists concluded that interventions addressing disease severity were )] TJ ET BT 26.250 216.634 Td /F1 9.8 Tf [(the most important for inpatient management, operations and resource distribution, with less emphasis decreasing total )] TJ ET BT 26.250 204.729 Td /F1 9.8 Tf [(numbers affected in the population. Data useful for setting triggers to implement high priority measures were predominantly )] TJ ET BT 26.250 192.825 Td /F1 9.8 Tf [(those available at the local institutional level. Strikingly, public health surveillance data were not considered as one of the top )] TJ ET BT 26.250 180.920 Td /F1 9.8 Tf [(triggers to operationalize any of the priority measures, either for the ED or the inpatient services. We believe this study )] TJ ET BT 26.250 169.015 Td /F1 9.8 Tf [(represents the first step in delineating high impact interventions according to hospital service \(ED verses inpatient\) and )] TJ ET BT 26.250 157.110 Td /F1 9.8 Tf [(infectious disease outbreak characteristics.)] TJ ET 0.965 0.965 0.965 rg 26.250 18.979 555.000 128.250 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 147.229 m 581.250 147.229 l 581.250 146.479 l 26.250 146.479 l f q 112.500 0 0 112.500 35.250 24.979 cm /I6 Do Q q 35.250 18.979 537.000 0.000 re W n Q Q q 15.000 18.979 577.500 758.021 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(For the low volume, low severity outbreak scenario \(i.e. seasonal influenza\), respondents gave higher prioritization to )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(interventions that would be easier to implement \(e.g. hand hygiene and masks\), both for the ED and hospital. However, for )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(either increased volume or severity outbreaks, respondents shifted prioritizations to those interventions requiring more intensive )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(resources. For example, for the high-volume, high severity outbreak scenario \(1918 pandemic\), establishing an ED annex, )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(stockpiling equipment, and adding staff were rated as highest priority.)] TJ ET BT 26.250 700.452 Td /F1 9.8 Tf [(This study evaluates the priority of interventions across a variety of potential infectious respiratory disease outbreak scenarios )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(encompassing a range of patient volumes and disease severities. Although the exercise was designed to assess multiple )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(epidemiological scenarios, it is often the case that the exact parameters of the outbreak \(i.e. disease severity and patient )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(volume\) are not completely known at the outset of the outbreak. Thus, information gleaned from this exercise may be most )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(helpful for understanding overall priority of interventions rather than their priority in a specific artificial scenario. However, given )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(that there is often some advanced indication of the nature of an impending outbreak, and outbreak characteristics such as )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(volume and severity affect prioritization of resulting interventions, detailed prioritization based on the volume and severity of an )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(outbreak may prove beneficial.)] TJ ET BT 26.250 597.714 Td /F1 9.8 Tf [(Similar to other group consensus methods, results can vary based on the composition of the group. To mitigate this potential )] TJ ET BT 26.250 585.810 Td /F1 9.8 Tf [(selection bias, we selected individuals across a wide range of expertise who are integral to the process of disease surveillance )] TJ ET BT 26.250 573.905 Td /F1 9.8 Tf [(and implementation of clinical interventions. These selected individuals represented those in decision making positions from )] TJ ET BT 26.250 562.000 Td /F1 9.8 Tf [(numerous geographic regions and organizations, academic institutions and levels of government. However, the results )] TJ ET BT 26.250 550.095 Td /F1 9.8 Tf [(represent panelists opinions, and not the results of a formal literature meta-analysis or quantitative data analysis of U.S. )] TJ ET BT 26.250 538.191 Td /F1 9.8 Tf [(hospitals; the inherent difficulty of which was described earlier in this article. Although further breakdown of the rankings )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(according to the panelists self-identified expert group category would be an interesting analysis, this was not possible as several )] TJ ET BT 26.250 514.381 Td /F1 9.8 Tf [(panelists identified themselves as belonging to more than one expert group, preventing clear categorization.)] TJ ET BT 26.250 494.976 Td /F1 9.8 Tf [(Information generated from these exercises may serve to guide ED and hospital administrators to focus on the highest-priority )] TJ ET BT 26.250 483.072 Td /F1 9.8 Tf [(interventions for a particular scenario, based on anticipated patient volumes or disease severity. However, there is a need for )] TJ ET BT 26.250 471.167 Td /F1 9.8 Tf [(more formal methods of assessing intervention quality and efficacy. Although conducting randomized controlled trials may not )] TJ ET BT 26.250 459.262 Td /F1 9.8 Tf [(be possible for public health interventions, standardizing reporting and assessment of interventions could provide a framework )] TJ ET BT 26.250 447.357 Td /F1 9.8 Tf [(for describing and comparing interventions which could be reported in the literature.)] TJ ET BT 26.250 427.953 Td /F1 9.8 Tf [(Although many of the highly rated interventions require, or would benefit from, coordination with departments of public health, )] TJ ET BT 26.250 416.048 Td /F1 9.8 Tf [(local medical centers, and local and federal governments, the decision of whether and when to implement many of these )] TJ ET BT 26.250 404.143 Td /F1 9.8 Tf [(interventions currently appears to occur at the medical center level. Further, virtually all of the most highly rated data sources to )] TJ ET BT 26.250 392.238 Td /F1 9.8 Tf [(trigger the decision of when to implement these interventions are collected directly by individual hospitals or EDs. These data )] TJ ET BT 26.250 380.334 Td /F1 9.8 Tf [(sources, such as ED and hospital volume and admission rates, and ED waiting times, are institutional data, monitored closely at )] TJ ET BT 26.250 368.429 Td /F1 9.8 Tf [(the institutional level, but frequently have lags before reporting and analysis at the public health level. Despite emphasis on )] TJ ET BT 26.250 356.524 Td /F1 9.8 Tf [(infectious respiratory disease surveillance, surveillance tools did not rank in the top three triggers for any of the four included )] TJ ET BT 26.250 344.619 Td /F1 9.8 Tf [(scenarios. These recommendations highlight the importance of advancing capabilities of surveillance systems to collect and )] TJ ET BT 26.250 332.715 Td /F1 9.8 Tf [(coalesce institutional data sources in a timely manner, to provide both public health departments and medical institutions with )] TJ ET BT 26.250 320.810 Td /F1 9.8 Tf [(better situational awareness which could improve the timeliness and effectiveness of planned responses.)] TJ ET BT 26.250 284.207 Td /F4 12.0 Tf [(Conclusion)] TJ ET BT 26.250 264.253 Td /F1 9.8 Tf [(Expert panelists placed highest priority on ED interventions to mitigate surge in the setting of an infectious respiratory disease )] TJ ET BT 26.250 252.348 Td /F1 9.8 Tf [(outbreak scenario with high patient volume, indicating the greatest concern for addressing outbreaks where ED crowding )] TJ ET BT 26.250 240.444 Td /F1 9.8 Tf [(caused by sudden increased patient volume might worsen regardless of disease severity. Disease severity, in and of itself, was )] TJ ET BT 26.250 228.539 Td /F1 9.8 Tf [(felt to be a lesser issue in the ED setting. Conversely, panelists concluded that interventions addressing disease severity were )] TJ ET BT 26.250 216.634 Td /F1 9.8 Tf [(the most important for inpatient management, operations and resource distribution, with less emphasis decreasing total )] TJ ET BT 26.250 204.729 Td /F1 9.8 Tf [(numbers affected in the population. Data useful for setting triggers to implement high priority measures were predominantly )] TJ ET BT 26.250 192.825 Td /F1 9.8 Tf [(those available at the local institutional level. Strikingly, public health surveillance data were not considered as one of the top )] TJ ET BT 26.250 180.920 Td /F1 9.8 Tf [(triggers to operationalize any of the priority measures, either for the ED or the inpatient services. We believe this study )] TJ ET BT 26.250 169.015 Td /F1 9.8 Tf [(represents the first step in delineating high impact interventions according to hospital service \(ED verses inpatient\) and )] TJ ET BT 26.250 157.110 Td /F1 9.8 Tf [(infectious disease outbreak characteristics.)] TJ ET 0.965 0.965 0.965 rg 26.250 18.979 555.000 128.250 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 147.229 m 581.250 147.229 l 581.250 146.479 l 26.250 146.479 l f q 112.500 0 0 112.500 35.250 24.979 cm /I8 Do Q q 35.250 18.979 537.000 0.000 re W n Q Q q 112.500 0 0 112.500 35.250 24.979 cm /I10 Do Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(5)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 298 0 obj << /Type /Annot /Subtype /Link /A 299 0 R /Border [0 0 0] /H /I /Rect [ 35.2500 24.9795 147.7500 137.4795 ] >> endobj 299 0 obj << /Type /Action /S /URI /URI (https://currents.plos.org/disasters/files/2012/11/Table-1.png) >> endobj 300 0 obj << /Type /XObject /Subtype /Image /Width 150 /Height 150 /Filter /FlateDecode /DecodeParms << /Predictor 15 /Colors 1 /Columns 150 /BitsPerComponent 8>> /ColorSpace /DeviceGray /BitsPerComponent 8 /Length 161>> stream x1 7 䂣Q9_ׁ]-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QK\6 endstream endobj 301 0 obj << /Type /XObject /Subtype /Image /Width 150 /Height 150 /SMask 300 0 R /Filter /FlateDecode /DecodeParms << /Predictor 15 /Colors 3 /Columns 150 /BitsPerComponent 8>> /ColorSpace /DeviceRGB /BitsPerComponent 8 /Length 9869>> stream x}/x8@ @ @ @ @ `@  \p  |`(0 `AA@@@@\*j8vڝ}z<Զ::g8k-I)ec9JZ1*""ιPDȯ|sb$Rfe{1{KXz,0c K^)vmXjP0XkHʻˮ2c8ιsN](5K%z׿L&sfmfٟgˇ~R.K99|o6<⍍_BRRJu{9(r"rc0xE 12~ڍe朓R7p)! !4uιS9G !Y>2KX<+s5VeY[o@ E%c)7b(1BIr\zrΕR8{/Grap99ͮ2\:N` 6Zf9Ot7ݟģdShVFQ.K<1ZcʲLTk)\D< ʖ%La7+^"CeN֚k+FBkez>A 1Fey-Z+W^k^eYREnH:|fe,c"'B719#c[$e$GZ9ǥXҋ47az4Mu!/%rE&Rbĺ$" y).-^d✳Zí~[H*cſx"UMqEQl{gEۺ7^dz9,T~< Q9W.KY؀AD]r[緞 `o=tcöoy鷞1&p˲ #~aJEZJ)d P^jX{dz]HVCNpʉ2(!;D8Lc6ה?S8`RJDyF {댈1ф$p8j|=z~mOfPgB0%?fj%W"m8XzN1r pcAcf*N1&bM z1fx3:Zlȑ5n8DkS86RbB(ʲ#ID[m)=: 0"4^k]e19B8Cz؀M?L!R%%0!2KL9r"Rc^[?~*R͍s nZ붎%̲ dm~R*>,"R"9Ln뤔Y !'HpOѧԁ"Q>\VN͒e BkJO)eA4MB||%HJ)cR,K5VZn;H{K)BL?L˦%$;W0Ʀө+s.GRcL)X@No 6sNXc0(h1+CDzYSxYGi/H_t=S Ym9m<~g 9RH/RƘ:qd+ /KY3W!"_yb#n/fm $:nñISGg,/aneV'L1TQYvFh1Y!zfR^A]kODr,X=!Yj)bnI)NA9˲N7r`6-3/s o*bٵeTAC W>i 1fmXFMb+łsTq7]M_r qvck|YHkmV&|>e␾a/X^2uX,4e9ښq[,<ϝsn~ NXC×m49g׶a:[- z? ɀ_Dٍ-tS1ˢ^L9_NP;^eW쫝Fbg9!>cj4MPQBˇ yuAXfV+DD,K_y>n<¡N&!s:܋ӵGҋR$b("[F =]Z.ڈY̵WO"b(Վ sEQϊSvwr,o]z z9i1RJ1zpƄyΚ s',aED:_X<:Ei6RT?zjv!{Tl(;n\z(cuF%nfm4k/r$"`] ,`Q +R 顟NSt#딈"V~q^e8KPx^DzH_ =h{sJ࿲S#kl/oG 5,8ԇb_ @>><P(cnb=|{;]SDd7+5PóG{$偟r,Qj,;pX:Mb]eHhDX) _yk-c%"q(R"# نXODC*i,ai P=KXfef1v%k7s})-=10/!R%(SԢg2,1# /4*ǺX,elPJRCuNE=E.K-4|,?%ľ`6@]j&_:F"/bK4<6Kb@ 4M_iBQpXɅUy`[(xaK%`-&@6> ;vF\rʚfŔm^~U~G8ZN fS 1]c7+ߔk,aQ>(!} W}xiZʱ4L&, \rΧXvm4U .sNx MQ'F! 3ـ,}4w ס$$ǁgIUIC]e|VP~m6DJц@StJX p&C4BAmggs赮=2C9Y$c&l>W CDj" kpts1]){˻EZ/b$&Q&@*ϒ0 XwhJٿft}. 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"D _#?<:R12`M.Bak"vdfV&MSt9砹|*G'YAzO%ʚ@ PƠ11aRyvEKY6F:9.)<4 (|WiCQFD]Agn=k_+i kmQ¢.1&MX̑"p)@B[S} UKMI}6kX,SެYYO 7zbr=)˲=%_,>+ٵd*nC;xXD岴4k(0|qP^N~4^>$&g@jr8vJ<`!T1q ܵ}i Vu zS6,KtC:T 1旛׹K5{hZt1DdZ;o]TA9 o&BG;i+χgprJPrSۢH`XtgYwww\m.dzWC~W޳)ZakX?MD'ܟ>LK@CGP9e0PuWm0VeJDZ4Mq7m3vn(:m~3K`łj?S.,pAF7M˲RhF%CYpv!i\;?[$31@ݷ'_mJz<*lS:S>` ߸⡀@XlUF !^.0<z 8u`k#0OFTڒ  '߱5cAmӎ8chvX DaP"}&"U)Tkz¶}mjߊiHcr@dDW-1HtMTEHˇr~ P} ,OėA7_eYN&'ݻ.b~fWb`m+hyo"ݗe1aKBb2@N vc]ɯ_$ޟ hߡQx aNȊ{ >BZ=;jPEߟ[^^hV\]P8n9*KtJZ>Ίfxfmh"Fso]KBm1";B2s<1Q>$Hk(Ϲ`nn@{FG/(1DZ5xE1Pj6 p0j& Jc:b(\D%B Ӱ$RBJ*&IMUD-95E[Rc6ء l$уC] z?5on9OHb%#MPx~q=3hޝގDJXPI]K;X/V>2^##'%F]`L{Dz*љ+%!g4V BbZZSYt.mrr$+B]d~kVH>?a7dT:2#=/x"; м'/UނJg(^c#/ )X zCPob` H9Z"MhaJD\ ҖRU~q,5M4D#=@lXW9W2V`1"%d SE  {M<&ڎS;jt6N_N $m_S*U@sÄAE"4ud2 uD@ G@HE>}kj>U[W|/P#{kRb-"6=,i(T)U|/nw'gYjWU6w:vSe\s#޶+=R&#IW]Iz‡}$d2C0K/8nC@X,B%Mkw׾, L76m1qSb2r,O)Rc bEJY{LxV~wܤfmcRJisʢ (&mZuwř xڵkH /PraWeР-1 `@tTPڵ#1:҄ (b|(|8;P;Nn!Y{BkCkeF˱W }OԅRNp]yk IM/7衙Qڵ})Jw^TWK!w93釃7)yH%/Y|;e򳘟הw׾FPKtvy K)ݶCNOm61RkۼljxN]+cu,2]]_CUEˋBԧ>͍ޮҰV=8s uPqŷEMƮl6/؛=,K(9+dp,23oL'#KEz(2~x3ƴcʣXyx:|(n|YY?tдg >;!O}jY :3?}d2ǖ҇^}6"ĦE~G`leYʣ ߸c̀-"T% M7>S |[kc F;"kZ&1ߡ  |OWc 0=Pم4HyGwSaDdz5  H t g܍777?b*-R+T~1vwwz Bc }pƽ"m6;пM+H3ڀ *P7cQR z~ kd2 +ʯ&/S?_E꽟sH4Z99BEkzG2C| "A,:?ϓ9 %+9lFD~IOKDLuADGK]/~'qE }aݰ́a߂@;ŶM;N)]\I罰^Dc7+ޒ(}Iׁڌ^w ^դE.[.yŸ^ާ)} zyŸ^ާ)} zyŸ^5_I endstream endobj 310 0 obj << /Type /XObject /Subtype /Image /Width 150 /Height 150 /Filter /FlateDecode /DecodeParms << /Predictor 15 /Colors 1 /Columns 150 /BitsPerComponent 8>> /ColorSpace /DeviceGray /BitsPerComponent 8 /Length 161>> stream x1 7 䂣Q9_ׁ]-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QKD-QK\6 endstream endobj 311 0 obj << /Type /XObject /Subtype /Image /Width 150 /Height 150 /SMask 310 0 R /Filter /FlateDecode /DecodeParms << /Predictor 15 /Colors 3 /Columns 150 /BitsPerComponent 8>> /ColorSpace /DeviceRGB /BitsPerComponent 8 /Length 9869>> stream x}/x8@ @ @ @ @ `@  \p  |`(0 `AA@@@@\*j8vڝ}z<Զ::g8k-I)ec9JZ1*""ιPDȯ|sb$Rfe{1{KXz,0c K^)vmXjP0XkHʻˮ2c8ιsN](5K%z׿L&sfmfٟgˇ~R.K99|o6<⍍_BRRJu{9(r"rc0xE 12~ڍe朓R7p)! !4uιS9G !Y>2KX<+s5VeY[o@ E%c)7b(1BIr\zrΕR8{/Grap99ͮ2\:N` 6Zf9Ot7ݟģdShVFQ.K<1ZcʲLTk)\D< ʖ%La7+^"CeN֚k+FBkez>A 1Fey-Z+W^k^eYREnH:|fe,c"'B719#c[$e$GZ9ǥXҋ47az4Mu!/%rE&Rbĺ$" y).-^d✳Zí~[H*cſx"UMqEQl{gEۺ7^dz9,T~< Q9W.KY؀AD]r[緞 `o=tcöoy鷞1&p˲ #~aJEZJ)d P^jX{dz]HVCNpʉ2(!;D8Lc6ה?S8`RJDyF {댈1ф$p8j|=z~mOfPgB0%?fj%W"m8XzN1r pcAcf*N1&bM z1fx3:Zlȑ5n8DkS86RbB(ʲ#ID[m)=: 0"4^k]e19B8Cz؀M?L!R%%0!2KL9r"Rc^[?~*R͍s nZ붎%̲ dm~R*>,"R"9Ln뤔Y !'HpOѧԁ"Q>\VN͒e BkJO)eA4MB||%HJ)cR,K5VZn;H{K)BL?L˦%$;W0Ʀө+s.GRcL)X@No 6sNXc0(h1+CDzYSxYGi/H_t=S Ym9m<~g 9RH/RƘ:qd+ /KY3W!"_yb#n/fm $:nñISGg,/aneV'L1TQYvFh1Y!zfR^A]kODr,X=!Yj)bnI)NA9˲N7r`6-3/s o*bٵeTAC W>i 1fmXFMb+łsTq7]M_r qvck|YHkmV&|>e␾a/X^2uX,4e9ښq[,<ϝsn~ NXC×m49g׶a:[- z? ɀ_Dٍ-tS1ˢ^L9_NP;^eW쫝Fbg9!>cj4MPQBˇ yuAXfV+DD,K_y>n<¡N&!s:܋ӵGҋR$b("[F =]Z.ڈY̵WO"b(Վ sEQϊSvwr,o]z z9i1RJ1zpƄyΚ s',aED:_X<:Ei6RT?zjv!{Tl(;n\z(cuF%nfm4k/r$"`] ,`Q +R 顟NSt#딈"V~q^e8KPx^DzH_ =h{sJ࿲S#kl/oG 5,8ԇb_ @>><P(cnb=|{;]SDd7+5PóG{$偟r,Qj,;pX:Mb]eHhDX) _yk-c%"q(R"# نXODC*i,ai P=KXfef1v%k7s})-=10/!R%(SԢg2,1# /4*ǺX,elPJRCuNE=E.K-4|,?%ľ`6@]j&_:F"/bK4<6Kb@ 4M_iBQpXɅUy`[(xaK%`-&@6> ;vF\rʚfŔm^~U~G8ZN fS 1]c7+ߔk,aQ>(!} W}xiZʱ4L&, \rΧXvm4U .sNx MQ'F! 3ـ,}4w ס$$ǁgIUIC]e|VP~m6DJц@StJX p&C4BAmggs赮=2C9Y$c&l>W CDj" kpts1]){˻EZ/b$&Q&@*ϒ0 XwhJٿft}. "D _#?<:R12`M.Bak"vdfV&MSt9砹|*G'YAzO%ʚ@ PƠ11aRyvEKY6F:9.)<4 (|WiCQFD]Agn=k_+i kmQ¢.1&MX̑"p)@B[S} UKMI}6kX,SެYYO 7zbr=)˲=%_,>+ٵd*nC;xXD岴4k(0|qP^N~4^>$&g@jr8vJ<`!T1q ܵ}i Vu zS6,KtC:T 1旛׹K5{hZt1DdZ;o]TA9 o&BG;i+χgprJPrSۢH`XtgYwww\m.dzWC~W޳)ZakX?MD'ܟ>LK@CGP9e0PuWm0VeJDZ4Mq7m3vn(:m~3K`łj?S.,pAF7M˲RhF%CYpv!i\;?[$31@ݷ'_mJz<*lS:S>` ߸⡀@XlUF !^.0<z 8u`k#0OFTڒ  '߱5cAmӎ8chvX DaP"}&"U)Tkz¶}mjߊiHcr@dDW-1HtMTEHˇr~ P} ,OėA7_eYN&'ݻ.b~fWb`m+hyo"ݗe1aKBb2@N vc]ɯ_$ޟ hߡQx aNȊ{ >BZ=;jPEߟ[^^hV\]P8n9*KtJZ>Ίfxfmh"Fso]KBm1";B2s<1Q>$Hk(Ϲ`nn@{FG/(1DZ5xE1Pj6 p0j& Jc:b(\D%B Ӱ$RBJ*&IMUD-95E[Rc6ء l$уC] z?5on9OHb%#MPx~q=3hޝގDJXPI]K;X/V>2^##'%F]`L{Dz*љ+%!g4V BbZZSYt.mrr$+B]d~kVH>?a7dT:2#=/x"; м'/UނJg(^c#/ )X zCPob` H9Z"MhaJD\ ҖRU~q,5M4D#=@lXW9W2V`1"%d SE  {M<&ڎS;jt6N_N $m_S*U@sÄAE"4ud2 uD@ G@HE>}kj>U[W|/P#{kRb-"6=,i(T)U|/nw'gYjWU6w:vSe\s#޶+=R&#IW]Iz‡}$d2C0K/8nC@X,B%Mkw׾, L76m1qSb2r,O)Rc bEJY{LxV~wܤfmcRJisʢ (&mZuwř xڵkH /PraWeР-1 `@tTPڵ#1:҄ (b|(|8;P;Nn!Y{BkCkeF˱W }OԅRNp]yk IM/7衙Qڵ})Jw^TWK!w93釃7)yH%/Y|;e򳘟הw׾FPKtvy K)ݶCNOm61RkۼljxN]+cu,2]]_CUEˋBԧ>͍ޮҰV=8s uPqŷEMƮl6/؛=,K(9+dp,23oL'#KEz(2~x3ƴcʣXyx:|(n|YY?tдg >;!O}jY :3?}d2ǖ҇^}6"ĦE~G`leYʣ ߸c̀-"T% M7>S |[kc F;"kZ&1ߡ  |OWc 0=Pم4HyGwSaDdz5  H t g܍777?b*-R+T~1vwwz Bc }pƽ"m6;пM+H3ڀ *P7cQR z~ kd2 +ʯ&/S?_E꽟sH4Z99BEkzG2C| "A,:?ϓ9 %+9lFD~IOKDLuADGK]/~'qE }aݰ́a߂@;ŶM;N)]\I罰^Dc7+ޒ(}Iׁڌ^w ^դE.[.yŸ^ާ)} zyŸ^ާ)} zyŸ^5_I endstream endobj 312 0 obj << /Type /Page /Parent 3 0 R /Annots [ 314 0 R 318 0 R 322 0 R 326 0 R 330 0 R 334 0 R 338 0 R 342 0 R 346 0 R 350 0 R 354 0 R 358 0 R ] /Contents 313 0 R >> endobj 313 0 obj << /Length 9488 >> stream q 15.000 33.107 577.500 743.893 re W n 0.965 0.965 0.965 rg 26.250 735.941 555.000 41.059 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 735.941 m 581.250 735.941 l 581.250 736.691 l 26.250 736.691 l f q 35.250 747.191 537.000 29.809 re W n 0.271 0.267 0.267 rg BT 35.250 767.476 Td /F4 9.8 Tf [(Fig. 1: Scenario based prioritization for interventions to mitigate emergency department \(ED\) crowding in the event )] TJ ET BT 35.250 755.571 Td /F4 9.8 Tf [(of an infectious respiratory virus outbreak designed to impact patients presenting with influenza-like illness \(ILI\))] TJ ET Q 0.965 0.965 0.965 rg 26.250 559.131 555.000 169.310 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 728.441 m 581.250 728.441 l 581.250 727.691 l 26.250 727.691 l f 26.250 559.131 m 581.250 559.131 l 581.250 559.881 l 26.250 559.881 l f q 112.500 0 0 112.500 35.250 606.191 cm /I12 Do Q q 35.250 570.381 537.000 29.810 re W n 0.271 0.267 0.267 rg BT 35.250 590.667 Td /F4 9.8 Tf [(Fig. 2: Scenario based prioritization for interventions to mitigate emergency department \(ED\) crowding in the event )] TJ ET BT 35.250 578.762 Td /F4 9.8 Tf [(of an infectious respiratory virus outbreak designed to impact patients without influenza-like illness \(ILI\))] TJ ET Q 0.965 0.965 0.965 rg 26.250 382.321 555.000 169.310 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 551.631 m 581.250 551.631 l 581.250 550.881 l 26.250 550.881 l f 26.250 382.321 m 581.250 382.321 l 581.250 383.071 l 26.250 383.071 l f q 112.500 0 0 112.500 35.250 429.381 cm /I14 Do Q q 35.250 393.572 537.000 29.809 re W n 0.271 0.267 0.267 rg BT 35.250 413.857 Td /F4 9.8 Tf [(Fig. 3: Scenario based prioritization for interventions to mitigate hospital crowding in the event of an infectious )] TJ ET BT 35.250 401.952 Td /F4 9.8 Tf [(respiratory virus outbreak designed to impact patients presenting with influenza-like illness \(ILI\))] TJ ET Q 0.965 0.965 0.965 rg 26.250 205.512 555.000 169.310 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 374.821 m 581.250 374.821 l 581.250 374.071 l 26.250 374.071 l f 26.250 205.512 m 581.250 205.512 l 581.250 206.262 l 26.250 206.262 l f q 112.500 0 0 112.500 35.250 252.571 cm /I16 Do Q q 35.250 216.762 537.000 29.810 re W n 0.271 0.267 0.267 rg BT 35.250 237.048 Td /F4 9.8 Tf [(Fig. 4: Scenario based prioritization for interventions to mitigate hospital crowding in the event of an infectious )] TJ ET BT 35.250 225.143 Td /F4 9.8 Tf [(respiratory virus outbreak designed to impact patients presenting without influenza-like illness \(ILI\))] TJ ET Q 0.965 0.965 0.965 rg 26.250 40.607 555.000 157.405 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 198.012 m 581.250 198.012 l 581.250 197.262 l 26.250 197.262 l f 26.250 40.607 m 581.250 40.607 l 581.250 41.357 l 26.250 41.357 l f q 112.500 0 0 112.500 35.250 75.762 cm /I18 Do Q q 35.250 51.857 537.000 17.905 re W n 0.271 0.267 0.267 rg BT 35.250 60.238 Td /F4 9.8 Tf [(Fig. 5: Linking Data Sources to Intervention Implementation)] TJ ET Q Q q 15.000 33.107 577.500 743.893 re W n 0.965 0.965 0.965 rg 26.250 735.941 555.000 41.059 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 735.941 m 581.250 735.941 l 581.250 736.691 l 26.250 736.691 l f q 35.250 747.191 537.000 29.809 re W n 0.271 0.267 0.267 rg BT 35.250 767.476 Td /F4 9.8 Tf [(Fig. 1: Scenario based prioritization for interventions to mitigate emergency department \(ED\) crowding in the event )] TJ ET BT 35.250 755.571 Td /F4 9.8 Tf [(of an infectious respiratory virus outbreak designed to impact patients presenting with influenza-like illness \(ILI\))] TJ ET Q 0.965 0.965 0.965 rg 26.250 559.131 555.000 169.310 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 728.441 m 581.250 728.441 l 581.250 727.691 l 26.250 727.691 l f 26.250 559.131 m 581.250 559.131 l 581.250 559.881 l 26.250 559.881 l f q 112.500 0 0 112.500 35.250 606.191 cm /I20 Do Q q 35.250 570.381 537.000 29.810 re W n 0.271 0.267 0.267 rg BT 35.250 590.667 Td /F4 9.8 Tf [(Fig. 2: Scenario based prioritization for interventions to mitigate emergency department \(ED\) crowding in the event )] TJ ET BT 35.250 578.762 Td /F4 9.8 Tf [(of an infectious respiratory virus outbreak designed to impact patients without influenza-like illness \(ILI\))] TJ ET Q 0.965 0.965 0.965 rg 26.250 382.321 555.000 169.310 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 551.631 m 581.250 551.631 l 581.250 550.881 l 26.250 550.881 l f 26.250 382.321 m 581.250 382.321 l 581.250 383.071 l 26.250 383.071 l f q 112.500 0 0 112.500 35.250 429.381 cm /I22 Do Q q 35.250 393.572 537.000 29.809 re W n 0.271 0.267 0.267 rg BT 35.250 413.857 Td /F4 9.8 Tf [(Fig. 3: Scenario based prioritization for interventions to mitigate hospital crowding in the event of an infectious )] TJ ET BT 35.250 401.952 Td /F4 9.8 Tf [(respiratory virus outbreak designed to impact patients presenting with influenza-like illness \(ILI\))] TJ ET Q 0.965 0.965 0.965 rg 26.250 205.512 555.000 169.310 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 374.821 m 581.250 374.821 l 581.250 374.071 l 26.250 374.071 l f 26.250 205.512 m 581.250 205.512 l 581.250 206.262 l 26.250 206.262 l f q 112.500 0 0 112.500 35.250 252.571 cm /I24 Do Q q 35.250 216.762 537.000 29.810 re W n 0.271 0.267 0.267 rg BT 35.250 237.048 Td /F4 9.8 Tf [(Fig. 4: Scenario based prioritization for interventions to mitigate hospital crowding in the event of an infectious )] TJ ET BT 35.250 225.143 Td /F4 9.8 Tf [(respiratory virus outbreak designed to impact patients presenting without influenza-like illness \(ILI\))] TJ ET Q 0.965 0.965 0.965 rg 26.250 40.607 555.000 157.405 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 198.012 m 581.250 198.012 l 581.250 197.262 l 26.250 197.262 l f 26.250 40.607 m 581.250 40.607 l 581.250 41.357 l 26.250 41.357 l f q 112.500 0 0 112.500 35.250 75.762 cm /I26 Do Q q 35.250 51.857 537.000 17.905 re W n 0.271 0.267 0.267 rg BT 35.250 60.238 Td /F4 9.8 Tf [(Fig. 5: Linking Data Sources to Intervention Implementation)] TJ ET Q Q q 15.000 33.107 577.500 743.893 re W n 0.965 0.965 0.965 rg 26.250 735.941 555.000 41.059 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 735.941 m 581.250 735.941 l 581.250 736.691 l 26.250 736.691 l f q 35.250 747.191 537.000 29.809 re W n 0.271 0.267 0.267 rg BT 35.250 767.476 Td /F4 9.8 Tf [(Fig. 1: Scenario based prioritization for interventions to mitigate emergency department \(ED\) crowding in the event )] TJ ET BT 35.250 755.571 Td /F4 9.8 Tf [(of an infectious respiratory virus outbreak designed to impact patients presenting with influenza-like illness \(ILI\))] TJ ET Q 0.965 0.965 0.965 rg 26.250 559.131 555.000 169.310 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 728.441 m 581.250 728.441 l 581.250 727.691 l 26.250 727.691 l f 26.250 559.131 m 581.250 559.131 l 581.250 559.881 l 26.250 559.881 l f q 112.500 0 0 112.500 35.250 606.191 cm /I28 Do Q q 35.250 570.381 537.000 29.810 re W n 0.271 0.267 0.267 rg BT 35.250 590.667 Td /F4 9.8 Tf [(Fig. 2: Scenario based prioritization for interventions to mitigate emergency department \(ED\) crowding in the event )] TJ ET BT 35.250 578.762 Td /F4 9.8 Tf [(of an infectious respiratory virus outbreak designed to impact patients without influenza-like illness \(ILI\))] TJ ET Q 0.965 0.965 0.965 rg 26.250 382.321 555.000 169.310 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 551.631 m 581.250 551.631 l 581.250 550.881 l 26.250 550.881 l f 26.250 382.321 m 581.250 382.321 l 581.250 383.071 l 26.250 383.071 l f q 112.500 0 0 112.500 35.250 429.381 cm /I30 Do Q q 35.250 393.572 537.000 29.809 re W n 0.271 0.267 0.267 rg BT 35.250 413.857 Td /F4 9.8 Tf [(Fig. 3: Scenario based prioritization for interventions to mitigate hospital crowding in the event of an infectious )] TJ ET BT 35.250 401.952 Td /F4 9.8 Tf [(respiratory virus outbreak designed to impact patients presenting with influenza-like illness \(ILI\))] TJ ET Q 0.965 0.965 0.965 rg 26.250 205.512 555.000 169.310 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 374.821 m 581.250 374.821 l 581.250 374.071 l 26.250 374.071 l f 26.250 205.512 m 581.250 205.512 l 581.250 206.262 l 26.250 206.262 l f q 112.500 0 0 112.500 35.250 252.571 cm /I32 Do Q q 35.250 216.762 537.000 29.810 re W n 0.271 0.267 0.267 rg BT 35.250 237.048 Td /F4 9.8 Tf [(Fig. 4: Scenario based prioritization for interventions to mitigate hospital crowding in the event of an infectious )] TJ ET BT 35.250 225.143 Td /F4 9.8 Tf [(respiratory virus outbreak designed to impact patients presenting without influenza-like illness \(ILI\))] TJ ET Q 0.965 0.965 0.965 rg 26.250 40.607 555.000 157.405 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 198.012 m 581.250 198.012 l 581.250 197.262 l 26.250 197.262 l f 26.250 40.607 m 581.250 40.607 l 581.250 41.357 l 26.250 41.357 l f q 112.500 0 0 112.500 35.250 75.762 cm /I34 Do Q q 35.250 51.857 537.000 17.905 re W n 0.271 0.267 0.267 rg BT 35.250 60.238 Td /F4 9.8 Tf [(Fig. 5: Linking Data Sources to Intervention Implementation)] TJ ET Q Q q 112.500 0 0 112.500 35.250 606.191 cm /I36 Do Q q 112.500 0 0 112.500 35.250 429.381 cm /I38 Do Q q 112.500 0 0 112.500 35.250 252.571 cm /I40 Do Q q 112.500 0 0 112.500 35.250 75.762 cm /I42 Do Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(6)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents 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Gaydos, MD, MPH; Rebecca Gluskin, MS, Ph.D.; )] TJ ET BT 26.250 638.053 Td /F1 9.8 Tf [(Mitchell Goldstein, MD; Julia Gunn, RN, MPH; Howard Gwon, MS; Daniel Hager, MHA; Dan Hanfling, MD; Peter Hill, MD; )] TJ ET BT 26.250 626.148 Td /F1 9.8 Tf [(Darren Mareiniss, MD; Jennifer Martin, JD; Larissa May, MD, MSPH; Mark McClelland, DNP, RN; Kompan Ngamsnga, MPH; )] TJ ET BT 26.250 614.244 Td /F1 9.8 Tf [(Don Olson, MPH; Julie Pavlin, MD, MPH; Trish Perl, MD, MS; Philip Polgreen, MD, MPH; Mustapha Saheed, MD; Jim )] TJ ET BT 26.250 602.339 Td /F1 9.8 Tf [(Scheulen, PA-C, MBA; Michael Silverman, MD; Michael Stoto, Ph.D.; Dianne Whyne, RN, MS; Lucy Wilson, MD; Ying Zhang, )] TJ ET BT 26.250 590.434 Td /F1 9.8 Tf [(PhDc. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the )] TJ ET BT 26.250 578.529 Td /F1 9.8 Tf [(views of the Centers for Disease Control and Prevention \(CDC\).)] TJ ET BT 26.250 549.427 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 521.973 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 521.973 Td /F1 9.8 Tf [(Institute of Medicine. The future of emergency care in the United States health system. Ann Emerg Med 2006; 48\(115-20\).)] TJ ET BT 26.250 502.568 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 502.568 Td /F1 9.8 Tf [(Bernstein SL, Aronsky D, Duseja R, et al.: The effect of emergency department crowding on clinically oriented outcomes. )] TJ ET BT 26.250 490.663 Td /F1 9.8 Tf [(Acad Emerg Med. 2009; 16\(1\): 1-10.)] TJ ET BT 26.250 471.258 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 471.258 Td /F1 9.8 Tf [(Pines JM, Hollander JE, Localio AR, et al.: The association between emergency department crowding and hospital )] TJ ET BT 26.250 459.354 Td /F1 9.8 Tf [(performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction. Acad Emerg Med. )] TJ ET BT 26.250 447.449 Td /F1 9.8 Tf [(2006; 13\(8\): 873-878.)] TJ ET BT 26.250 428.044 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 428.044 Td /F1 9.8 Tf [(Pines JM, Pollack CV, Dierks DB, et al.: The association between emergency department crowding and adverse )] TJ ET BT 26.250 416.139 Td /F1 9.8 Tf [(cardiovascular outcomes in patients with chest pain. Acad Emerg Med. 2009; 16\(7\): 617-625.)] TJ ET BT 26.250 396.735 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 396.735 Td /F1 9.8 Tf [(Pines JM, Shofer FS, Isserman JA, et al.: The effect of emergency department crowding on analgesia in patients with back )] TJ ET BT 26.250 384.830 Td /F1 9.8 Tf [(pain in two hospitals. Acad Emerg Med. 2010; 17\(3\): 276-283.)] TJ ET BT 26.250 365.425 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 365.425 Td /F1 9.8 Tf [(Sills MR, Hall M, Fieldston ES, et al.: Inpatient capacity at childrens hospitals during pandemic \(H1N1\) 2009 outbreak, )] TJ ET BT 26.250 353.520 Td /F1 9.8 Tf [(United States. Emerg Infect Dis. 2011; 17\(9\): 1685-1691.)] TJ ET BT 26.250 334.116 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 334.116 Td /F1 9.8 Tf [(Graham J, Shirm S, Storm E, et al.: Challenges and solutions: pandemic 2009 H1N1 influenza A in a pediatric emergency )] TJ ET BT 26.250 322.211 Td /F1 9.8 Tf [(department. Am J Disaster Med. 2011; 6\(4\): 211-218.)] TJ ET BT 26.250 302.806 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 302.806 Td /F1 9.8 Tf [(Sugerman D, Nadeau KH, Lafond K, et al.: A survey of emergency department 2009 pandemic influenza A \(H1N1\) surge )] TJ ET BT 26.250 290.901 Td /F1 9.8 Tf [(preparedness--Atlanta, Georgia, July-October 2009. Clin Infect Dis. 2001; 52\(Suppl 1\): S177-182.)] TJ ET BT 26.250 271.497 Td /F1 9.8 Tf [(9.)] TJ ET BT 38.132 271.497 Td /F1 9.8 Tf [(Miroballi Y, Baird JS, Zackai S, et al.: Novel influenza A\(H1N1\) in a pediatric health care facility in New York City during the )] TJ ET BT 26.250 259.592 Td /F1 9.8 Tf [(first wave of the 2009 pandemic. Arch Pediatr Adolesc Med. 2010; 164\(1\): 24-30.)] TJ ET BT 26.250 240.187 Td /F1 9.8 Tf [(10.)] TJ ET BT 43.553 240.187 Td /F1 9.8 Tf [(Sills MR, Hall M, Simon HK, et al.: Resource burden at children's hospitals experiencing surge volumes during the spring )] TJ ET BT 26.250 228.282 Td /F1 9.8 Tf [(2009 H1N1 influenza pandemic. Acad Emerg Med. 2011; 18\(2\): 158-166.)] TJ ET BT 26.250 208.878 Td /F1 9.8 Tf [(11.)] TJ ET BT 43.553 208.878 Td /F1 9.8 Tf [(Scarfone RJ, Coffin S, Fieldston ES, et al.: Hospital-based pandemic influenza preparedness and response: strategies to )] TJ ET BT 26.250 196.973 Td /F1 9.8 Tf [(increase surge capacity. Pediatr Emerg Care. 2011; 27\(6\): 565-572.)] TJ ET BT 26.250 177.568 Td /F1 9.8 Tf [(12.)] TJ ET BT 43.553 177.568 Td /F1 9.8 Tf [(Cooper MC, Walz K, Brown MG, et al.: Boston Medical Center Pediatric Emergency Response to H1N1. J Emerg Nurs. )] TJ ET BT 26.250 165.663 Td /F1 9.8 Tf [(2009; 35\(6\): 580-583.)] TJ ET BT 26.250 146.259 Td /F1 9.8 Tf [(13.)] TJ ET BT 43.553 146.259 Td /F1 9.8 Tf [(Weiss EA, Ngo J, Gilbert GH, et al.: Drive-through medicine: a novel proposal for rapid evaluation of patients during an )] TJ ET BT 26.250 134.354 Td /F1 9.8 Tf [(influenza pandemic. Ann Emerg Med. 2010; 55\(3\): 268-273.)] TJ ET BT 26.250 114.949 Td /F1 9.8 Tf [(14.)] TJ ET BT 43.553 114.949 Td /F1 9.8 Tf [(Cruz AT, Patel B, DiStefano MC, et al.: Outside the box and into thick air: implementation of an exterior mobile pediatric )] TJ ET BT 26.250 103.044 Td /F1 9.8 Tf [(emergency response team for North American H1N1 \(swine\) influenza virus in Houston, Texas. Ann Emerg Med. 2010; 55\(1\): )] TJ ET BT 26.250 91.140 Td /F1 9.8 Tf [(23-31.)] TJ ET BT 26.250 71.735 Td /F1 9.8 Tf [(15.)] TJ ET BT 43.553 71.735 Td /F1 9.8 Tf [(Teijlingen E, Pitchforth E, Bishop C, et al.: Delphi method and nominal group technique in family planning and reproductive )] TJ ET BT 26.250 59.830 Td /F1 9.8 Tf [(health research. J Fam Plann Reprod Health Care. 2006; 32\(4\): 249-252.)] TJ ET Q q 15.000 49.949 577.500 727.051 re W n 0.271 0.267 0.267 rg BT 26.250 750.278 Td /F4 12.0 Tf [(Competing Interests)] TJ ET BT 26.250 730.324 Td /F1 9.8 Tf [(The author have declared that no competing interests exist)] TJ ET BT 26.250 693.722 Td /F4 12.0 Tf [(Acknowledgements)] TJ ET BT 26.250 673.767 Td /F1 9.8 Tf [(PACER Expert Surge Panel Members \(Panel members did not contribute to study design, analysis, interpretation, or )] TJ ET BT 530.208 673.767 Td /F1 9.8 Tf [(manuscript )] TJ ET BT 26.250 661.863 Td /F1 9.8 Tf [(preparation.\): Atar Baer, Ph.D., MPH; Douglas Baker, MD; John Brownstein, Ph.D.; Howard Burkom, Ph.D.; Neil Cohen, MBA; )] TJ ET BT 26.250 649.958 Td /F1 9.8 Tf [(Sylvain Delisle, MD, MBA; John Donohue; Ashley Fowlkes, MPH; Joel C. Gaydos, MD, MPH; Rebecca Gluskin, MS, Ph.D.; )] TJ ET BT 26.250 638.053 Td /F1 9.8 Tf [(Mitchell Goldstein, MD; Julia Gunn, RN, MPH; Howard Gwon, MS; Daniel Hager, MHA; Dan Hanfling, MD; Peter Hill, MD; )] TJ ET BT 26.250 626.148 Td /F1 9.8 Tf [(Darren Mareiniss, MD; Jennifer Martin, JD; Larissa May, MD, MSPH; Mark McClelland, DNP, RN; Kompan Ngamsnga, MPH; )] TJ ET BT 26.250 614.244 Td /F1 9.8 Tf [(Don Olson, MPH; Julie Pavlin, MD, MPH; Trish Perl, MD, MS; Philip Polgreen, MD, MPH; Mustapha Saheed, MD; Jim )] TJ ET BT 26.250 602.339 Td /F1 9.8 Tf [(Scheulen, PA-C, MBA; Michael Silverman, MD; Michael Stoto, Ph.D.; Dianne Whyne, RN, MS; Lucy Wilson, MD; Ying Zhang, )] TJ ET BT 26.250 590.434 Td /F1 9.8 Tf [(PhDc. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the )] TJ ET BT 26.250 578.529 Td /F1 9.8 Tf [(views of the Centers for Disease Control and Prevention \(CDC\).)] TJ ET BT 26.250 549.427 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 521.973 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 521.973 Td /F1 9.8 Tf [(Institute of Medicine. The future of emergency care in the United States health system. Ann Emerg Med 2006; 48\(115-20\).)] TJ ET BT 26.250 502.568 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 502.568 Td /F1 9.8 Tf [(Bernstein SL, Aronsky D, Duseja R, et al.: The effect of emergency department crowding on clinically oriented outcomes. )] TJ ET BT 26.250 490.663 Td /F1 9.8 Tf [(Acad Emerg Med. 2009; 16\(1\): 1-10.)] TJ ET BT 26.250 471.258 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 471.258 Td /F1 9.8 Tf [(Pines JM, Hollander JE, Localio AR, et al.: The association between emergency department crowding and hospital )] TJ ET BT 26.250 459.354 Td /F1 9.8 Tf [(performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction. Acad Emerg Med. )] TJ ET BT 26.250 447.449 Td /F1 9.8 Tf [(2006; 13\(8\): 873-878.)] TJ ET BT 26.250 428.044 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 428.044 Td /F1 9.8 Tf [(Pines JM, Pollack CV, Dierks DB, et al.: The association between emergency department crowding and adverse )] TJ ET BT 26.250 416.139 Td /F1 9.8 Tf [(cardiovascular outcomes in patients with chest pain. Acad Emerg Med. 2009; 16\(7\): 617-625.)] TJ ET BT 26.250 396.735 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 396.735 Td /F1 9.8 Tf [(Pines JM, Shofer FS, Isserman JA, et al.: The effect of emergency department crowding on analgesia in patients with back )] TJ ET BT 26.250 384.830 Td /F1 9.8 Tf [(pain in two hospitals. Acad Emerg Med. 2010; 17\(3\): 276-283.)] TJ ET BT 26.250 365.425 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 365.425 Td /F1 9.8 Tf [(Sills MR, Hall M, Fieldston ES, et al.: Inpatient capacity at childrens hospitals during pandemic \(H1N1\) 2009 outbreak, )] TJ ET BT 26.250 353.520 Td /F1 9.8 Tf [(United States. Emerg Infect Dis. 2011; 17\(9\): 1685-1691.)] TJ ET BT 26.250 334.116 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 334.116 Td /F1 9.8 Tf [(Graham J, Shirm S, Storm E, et al.: Challenges and solutions: pandemic 2009 H1N1 influenza A in a pediatric emergency )] TJ ET BT 26.250 322.211 Td /F1 9.8 Tf [(department. Am J Disaster Med. 2011; 6\(4\): 211-218.)] TJ ET BT 26.250 302.806 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 302.806 Td /F1 9.8 Tf [(Sugerman D, Nadeau KH, Lafond K, et al.: A survey of emergency department 2009 pandemic influenza A \(H1N1\) surge )] TJ ET BT 26.250 290.901 Td /F1 9.8 Tf [(preparedness--Atlanta, Georgia, July-October 2009. Clin Infect Dis. 2001; 52\(Suppl 1\): S177-182.)] TJ ET BT 26.250 271.497 Td /F1 9.8 Tf [(9.)] TJ ET BT 38.132 271.497 Td /F1 9.8 Tf [(Miroballi Y, Baird JS, Zackai S, et al.: Novel influenza A\(H1N1\) in a pediatric health care facility in New York City during the )] TJ ET BT 26.250 259.592 Td /F1 9.8 Tf [(first wave of the 2009 pandemic. Arch Pediatr Adolesc Med. 2010; 164\(1\): 24-30.)] TJ ET BT 26.250 240.187 Td /F1 9.8 Tf [(10.)] TJ ET BT 43.553 240.187 Td /F1 9.8 Tf [(Sills MR, Hall M, Simon HK, et al.: Resource burden at children's hospitals experiencing surge volumes during the spring )] TJ ET BT 26.250 228.282 Td /F1 9.8 Tf [(2009 H1N1 influenza pandemic. Acad Emerg Med. 2011; 18\(2\): 158-166.)] TJ ET BT 26.250 208.878 Td /F1 9.8 Tf [(11.)] TJ ET BT 43.553 208.878 Td /F1 9.8 Tf [(Scarfone RJ, Coffin S, Fieldston ES, et al.: Hospital-based pandemic influenza preparedness and response: strategies to )] TJ ET BT 26.250 196.973 Td /F1 9.8 Tf [(increase surge capacity. Pediatr Emerg Care. 2011; 27\(6\): 565-572.)] TJ ET BT 26.250 177.568 Td /F1 9.8 Tf [(12.)] TJ ET BT 43.553 177.568 Td /F1 9.8 Tf [(Cooper MC, Walz K, Brown MG, et al.: Boston Medical Center Pediatric Emergency Response to H1N1. J Emerg Nurs. )] TJ ET BT 26.250 165.663 Td /F1 9.8 Tf [(2009; 35\(6\): 580-583.)] TJ ET BT 26.250 146.259 Td /F1 9.8 Tf [(13.)] TJ ET BT 43.553 146.259 Td /F1 9.8 Tf [(Weiss EA, Ngo J, Gilbert GH, et al.: Drive-through medicine: a novel proposal for rapid evaluation of patients during an )] TJ ET BT 26.250 134.354 Td /F1 9.8 Tf [(influenza pandemic. Ann Emerg Med. 2010; 55\(3\): 268-273.)] TJ ET BT 26.250 114.949 Td /F1 9.8 Tf [(14.)] TJ ET BT 43.553 114.949 Td /F1 9.8 Tf [(Cruz AT, Patel B, DiStefano MC, et al.: Outside the box and into thick air: implementation of an exterior mobile pediatric )] TJ ET BT 26.250 103.044 Td /F1 9.8 Tf [(emergency response team for North American H1N1 \(swine\) influenza virus in Houston, Texas. Ann Emerg Med. 2010; 55\(1\): )] TJ ET BT 26.250 91.140 Td /F1 9.8 Tf [(23-31.)] TJ ET BT 26.250 71.735 Td /F1 9.8 Tf [(15.)] TJ ET BT 43.553 71.735 Td /F1 9.8 Tf [(Teijlingen E, Pitchforth E, Bishop C, et al.: Delphi method and nominal group technique in family planning and reproductive )] TJ ET BT 26.250 59.830 Td /F1 9.8 Tf [(health research. J Fam Plann Reprod Health Care. 2006; 32\(4\): 249-252.)] TJ ET Q q 15.000 49.949 577.500 727.051 re W n 0.271 0.267 0.267 rg BT 26.250 750.278 Td /F4 12.0 Tf [(Competing Interests)] TJ ET BT 26.250 730.324 Td /F1 9.8 Tf [(The author have declared that no competing interests exist)] TJ ET BT 26.250 693.722 Td /F4 12.0 Tf [(Acknowledgements)] TJ ET BT 26.250 673.767 Td /F1 9.8 Tf [(PACER Expert Surge Panel Members \(Panel members did not contribute to study design, analysis, interpretation, or )] TJ ET BT 530.208 673.767 Td /F1 9.8 Tf [(manuscript )] TJ ET BT 26.250 661.863 Td /F1 9.8 Tf [(preparation.\): Atar Baer, Ph.D., MPH; Douglas Baker, MD; John Brownstein, Ph.D.; Howard Burkom, Ph.D.; Neil Cohen, MBA; )] TJ ET BT 26.250 649.958 Td /F1 9.8 Tf [(Sylvain Delisle, MD, MBA; John Donohue; Ashley Fowlkes, MPH; Joel C. Gaydos, MD, MPH; Rebecca Gluskin, MS, Ph.D.; )] TJ ET BT 26.250 638.053 Td /F1 9.8 Tf [(Mitchell Goldstein, MD; Julia Gunn, RN, MPH; Howard Gwon, MS; Daniel Hager, MHA; Dan Hanfling, MD; Peter Hill, MD; )] TJ ET BT 26.250 626.148 Td /F1 9.8 Tf [(Darren Mareiniss, MD; Jennifer Martin, JD; Larissa May, MD, MSPH; Mark McClelland, DNP, RN; Kompan Ngamsnga, MPH; )] TJ ET BT 26.250 614.244 Td /F1 9.8 Tf [(Don Olson, MPH; Julie Pavlin, MD, MPH; Trish Perl, MD, MS; Philip Polgreen, MD, MPH; Mustapha Saheed, MD; Jim )] TJ ET BT 26.250 602.339 Td /F1 9.8 Tf [(Scheulen, PA-C, MBA; Michael Silverman, MD; Michael Stoto, Ph.D.; Dianne Whyne, RN, MS; Lucy Wilson, MD; Ying Zhang, )] TJ ET BT 26.250 590.434 Td /F1 9.8 Tf [(PhDc. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the )] TJ ET BT 26.250 578.529 Td /F1 9.8 Tf [(views of the Centers for Disease Control and Prevention \(CDC\).)] TJ ET BT 26.250 549.427 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 521.973 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 521.973 Td /F1 9.8 Tf [(Institute of Medicine. The future of emergency care in the United States health system. Ann Emerg Med 2006; 48\(115-20\).)] TJ ET BT 26.250 502.568 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 502.568 Td /F1 9.8 Tf [(Bernstein SL, Aronsky D, Duseja R, et al.: The effect of emergency department crowding on clinically oriented outcomes. )] TJ ET BT 26.250 490.663 Td /F1 9.8 Tf [(Acad Emerg Med. 2009; 16\(1\): 1-10.)] TJ ET BT 26.250 471.258 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 471.258 Td /F1 9.8 Tf [(Pines JM, Hollander JE, Localio AR, et al.: The association between emergency department crowding and hospital )] TJ ET BT 26.250 459.354 Td /F1 9.8 Tf [(performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction. Acad Emerg Med. )] TJ ET BT 26.250 447.449 Td /F1 9.8 Tf [(2006; 13\(8\): 873-878.)] TJ ET BT 26.250 428.044 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 428.044 Td /F1 9.8 Tf [(Pines JM, Pollack CV, Dierks DB, et al.: The association between emergency department crowding and adverse )] TJ ET BT 26.250 416.139 Td /F1 9.8 Tf [(cardiovascular outcomes in patients with chest pain. Acad Emerg Med. 2009; 16\(7\): 617-625.)] TJ ET BT 26.250 396.735 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 396.735 Td /F1 9.8 Tf [(Pines JM, Shofer FS, Isserman JA, et al.: The effect of emergency department crowding on analgesia in patients with back )] TJ ET BT 26.250 384.830 Td /F1 9.8 Tf [(pain in two hospitals. Acad Emerg Med. 2010; 17\(3\): 276-283.)] TJ ET BT 26.250 365.425 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 365.425 Td /F1 9.8 Tf [(Sills MR, Hall M, Fieldston ES, et al.: Inpatient capacity at childrens hospitals during pandemic \(H1N1\) 2009 outbreak, )] TJ ET BT 26.250 353.520 Td /F1 9.8 Tf [(United States. Emerg Infect Dis. 2011; 17\(9\): 1685-1691.)] TJ ET BT 26.250 334.116 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 334.116 Td /F1 9.8 Tf [(Graham J, Shirm S, Storm E, et al.: Challenges and solutions: pandemic 2009 H1N1 influenza A in a pediatric emergency )] TJ ET BT 26.250 322.211 Td /F1 9.8 Tf [(department. Am J Disaster Med. 2011; 6\(4\): 211-218.)] TJ ET BT 26.250 302.806 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 302.806 Td /F1 9.8 Tf [(Sugerman D, Nadeau KH, Lafond K, et al.: A survey of emergency department 2009 pandemic influenza A \(H1N1\) surge )] TJ ET BT 26.250 290.901 Td /F1 9.8 Tf [(preparedness--Atlanta, Georgia, July-October 2009. Clin Infect Dis. 2001; 52\(Suppl 1\): S177-182.)] TJ ET BT 26.250 271.497 Td /F1 9.8 Tf [(9.)] TJ ET BT 38.132 271.497 Td /F1 9.8 Tf [(Miroballi Y, Baird JS, Zackai S, et al.: Novel influenza A\(H1N1\) in a pediatric health care facility in New York City during the )] TJ ET BT 26.250 259.592 Td /F1 9.8 Tf [(first wave of the 2009 pandemic. Arch Pediatr Adolesc Med. 2010; 164\(1\): 24-30.)] TJ ET BT 26.250 240.187 Td /F1 9.8 Tf [(10.)] TJ ET BT 43.553 240.187 Td /F1 9.8 Tf [(Sills MR, Hall M, Simon HK, et al.: Resource burden at children's hospitals experiencing surge volumes during the spring )] TJ ET BT 26.250 228.282 Td /F1 9.8 Tf [(2009 H1N1 influenza pandemic. Acad Emerg Med. 2011; 18\(2\): 158-166.)] TJ ET BT 26.250 208.878 Td /F1 9.8 Tf [(11.)] TJ ET BT 43.553 208.878 Td /F1 9.8 Tf [(Scarfone RJ, Coffin S, Fieldston ES, et al.: Hospital-based pandemic influenza preparedness and response: strategies to )] TJ ET BT 26.250 196.973 Td /F1 9.8 Tf [(increase surge capacity. Pediatr Emerg Care. 2011; 27\(6\): 565-572.)] TJ ET BT 26.250 177.568 Td /F1 9.8 Tf [(12.)] TJ ET BT 43.553 177.568 Td /F1 9.8 Tf [(Cooper MC, Walz K, Brown MG, et al.: Boston Medical Center Pediatric Emergency Response to H1N1. J Emerg Nurs. )] TJ ET BT 26.250 165.663 Td /F1 9.8 Tf [(2009; 35\(6\): 580-583.)] TJ ET BT 26.250 146.259 Td /F1 9.8 Tf [(13.)] TJ ET BT 43.553 146.259 Td /F1 9.8 Tf [(Weiss EA, Ngo J, Gilbert GH, et al.: Drive-through medicine: a novel proposal for rapid evaluation of patients during an )] TJ ET BT 26.250 134.354 Td /F1 9.8 Tf [(influenza pandemic. Ann Emerg Med. 2010; 55\(3\): 268-273.)] TJ ET BT 26.250 114.949 Td /F1 9.8 Tf [(14.)] TJ ET BT 43.553 114.949 Td /F1 9.8 Tf [(Cruz AT, Patel B, DiStefano MC, et al.: Outside the box and into thick air: implementation of an exterior mobile pediatric )] TJ ET BT 26.250 103.044 Td /F1 9.8 Tf [(emergency response team for North American H1N1 \(swine\) influenza virus in Houston, Texas. Ann Emerg Med. 2010; 55\(1\): )] TJ ET BT 26.250 91.140 Td /F1 9.8 Tf [(23-31.)] TJ ET BT 26.250 71.735 Td /F1 9.8 Tf [(15.)] TJ ET BT 43.553 71.735 Td /F1 9.8 Tf [(Teijlingen E, Pitchforth E, Bishop C, et al.: Delphi method and nominal group technique in family planning and reproductive )] TJ ET BT 26.250 59.830 Td /F1 9.8 Tf [(health research. J Fam Plann Reprod Health Care. 2006; 32\(4\): 249-252.)] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(7)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 372 0 obj << /Type /Page /Parent 3 0 R /Contents 373 0 R >> endobj 373 0 obj << /Length 9658 >> stream 0.271 0.267 0.267 rg q 15.000 456.405 577.500 320.595 re W n 0.271 0.267 0.267 rg BT 26.250 759.976 Td /F1 9.8 Tf [(16.)] TJ ET BT 43.553 759.976 Td /F1 9.8 Tf [(Uscher-Pines L, Babin S, Farrell C, et al.: Research Priorities for Syndromic Surveillance Systems Response: Consensus )] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(Development Using Nominal Group Technique. Journal of Public Health Management and Practice. 2010; 16\(6\): 529-534.)] TJ ET BT 26.250 728.667 Td /F1 9.8 Tf [(17.)] TJ ET BT 43.553 728.667 Td /F1 9.8 Tf [(National Center for the Study of Preparedness & Catastrophic Event Response \(PACER\): Available at: )] TJ ET BT 26.250 716.762 Td /F1 9.8 Tf [(https://www.pacercenter.org/. Accessed May 26th, 2012.)] TJ ET BT 26.250 697.357 Td /F1 9.8 Tf [(18.)] TJ ET BT 43.553 697.357 Td /F1 9.8 Tf [(Kelen GD, Kraus CK, McCarthy ML, et al.: Inpatient disposition classification for the creation of hospital surge capacity: a )] TJ ET BT 26.250 685.452 Td /F1 9.8 Tf [(multiphase study. Lancet. 2006; 368\(9551\): 1984-1990.)] TJ ET BT 26.250 666.048 Td /F1 9.8 Tf [(19.)] TJ ET BT 43.553 666.048 Td /F1 9.8 Tf [(Glaser CA, Gilliam S, Thompson WW, et al.: Medical care capacity for influenza outbreaks, Los Angeles. Emerg Infect Dis. )] TJ ET BT 26.250 654.143 Td /F1 9.8 Tf [(2002; 8\(6\): 569-574.)] TJ ET BT 26.250 634.738 Td /F1 9.8 Tf [(20.)] TJ ET BT 43.553 634.738 Td /F1 9.8 Tf [(Schull MJ, Mamdani MM, Fang J. Community influenza outbreaks and emergency department ambulance diversion. Ann )] TJ ET BT 26.250 622.833 Td /F1 9.8 Tf [(Emerg Med. 2004; 44\(1\): 61-67.)] TJ ET BT 26.250 603.429 Td /F1 9.8 Tf [(21.)] TJ ET BT 43.553 603.429 Td /F1 9.8 Tf [(Asplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie N, Camargo CA. A conceptual model of emergency department )] TJ ET BT 26.250 591.524 Td /F1 9.8 Tf [(crowding. Ann Emerg Med. 2003;42\(2\):173-180.)] TJ ET BT 26.250 572.119 Td /F1 9.8 Tf [(22.)] TJ ET BT 43.553 572.119 Td /F1 9.8 Tf [(Morton M, Jeng K, Beard R, Dugas AF, Pines JM, Rothman R. Systematic Review of Interventions to Mitigate the Effect of )] TJ ET BT 26.250 560.214 Td /F1 9.8 Tf [(Emergency Department Crowding in the Event of a Respiratory Disease Outbreak. Acad Emerg Med. 2012;19\(4\):Supp 1, )] TJ ET BT 26.250 548.310 Td /F1 9.8 Tf [(Abstract 114.)] TJ ET BT 26.250 528.905 Td /F1 9.8 Tf [(23.)] TJ ET BT 43.553 528.905 Td /F1 9.8 Tf [(Parry MF, Grant B, Iton A, Parry PD, Baranowsky D. Influenza vaccination: a collaborative effort to improve the health of the )] TJ ET BT 26.250 517.000 Td /F1 9.8 Tf [(community. Infect Control Hosp Epidemiol. 2004;25\(11\):929-932.)] TJ ET BT 26.250 497.595 Td /F1 9.8 Tf [(24.)] TJ ET BT 43.553 497.595 Td /F1 9.8 Tf [(Sprung CL, Zimmerman JL, Christian MD, et al. Recommendations for intensive care unit and hospital preparations for an )] TJ ET BT 26.250 485.691 Td /F1 9.8 Tf [(influenza epidemic or mass disaster: summary report of the European Society of Intensive Care Medicine's Task Force for )] TJ ET BT 26.250 473.786 Td /F1 9.8 Tf [(intensive care unit triage during an influenza epidemic or mass disaster. Intensive Care Med. 2010;36\(3\):428-443.)] TJ ET Q q 15.000 456.405 577.500 320.595 re W n 0.271 0.267 0.267 rg BT 26.250 759.976 Td /F1 9.8 Tf [(16.)] TJ ET BT 43.553 759.976 Td /F1 9.8 Tf [(Uscher-Pines L, Babin S, Farrell C, et al.: Research Priorities for Syndromic Surveillance Systems Response: Consensus )] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(Development Using Nominal Group Technique. Journal of Public Health Management and Practice. 2010; 16\(6\): 529-534.)] TJ ET BT 26.250 728.667 Td /F1 9.8 Tf [(17.)] TJ ET BT 43.553 728.667 Td /F1 9.8 Tf [(National Center for the Study of Preparedness & Catastrophic Event Response \(PACER\): Available at: )] TJ ET BT 26.250 716.762 Td /F1 9.8 Tf [(https://www.pacercenter.org/. Accessed May 26th, 2012.)] TJ ET BT 26.250 697.357 Td /F1 9.8 Tf [(18.)] TJ ET BT 43.553 697.357 Td /F1 9.8 Tf [(Kelen GD, Kraus CK, McCarthy ML, et al.: Inpatient disposition classification for the creation of hospital surge capacity: a )] TJ ET BT 26.250 685.452 Td /F1 9.8 Tf [(multiphase study. Lancet. 2006; 368\(9551\): 1984-1990.)] TJ ET BT 26.250 666.048 Td /F1 9.8 Tf [(19.)] TJ ET BT 43.553 666.048 Td /F1 9.8 Tf [(Glaser CA, Gilliam S, Thompson WW, et al.: Medical care capacity for influenza outbreaks, Los Angeles. Emerg Infect Dis. )] TJ ET BT 26.250 654.143 Td /F1 9.8 Tf [(2002; 8\(6\): 569-574.)] TJ ET BT 26.250 634.738 Td /F1 9.8 Tf [(20.)] TJ ET BT 43.553 634.738 Td /F1 9.8 Tf [(Schull MJ, Mamdani MM, Fang J. Community influenza outbreaks and emergency department ambulance diversion. Ann )] TJ ET BT 26.250 622.833 Td /F1 9.8 Tf [(Emerg Med. 2004; 44\(1\): 61-67.)] TJ ET BT 26.250 603.429 Td /F1 9.8 Tf [(21.)] TJ ET BT 43.553 603.429 Td /F1 9.8 Tf [(Asplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie N, Camargo CA. A conceptual model of emergency department )] TJ ET BT 26.250 591.524 Td /F1 9.8 Tf [(crowding. Ann Emerg Med. 2003;42\(2\):173-180.)] TJ ET BT 26.250 572.119 Td /F1 9.8 Tf [(22.)] TJ ET BT 43.553 572.119 Td /F1 9.8 Tf [(Morton M, Jeng K, Beard R, Dugas AF, Pines JM, Rothman R. Systematic Review of Interventions to Mitigate the Effect of )] TJ ET BT 26.250 560.214 Td /F1 9.8 Tf [(Emergency Department Crowding in the Event of a Respiratory Disease Outbreak. Acad Emerg Med. 2012;19\(4\):Supp 1, )] TJ ET BT 26.250 548.310 Td /F1 9.8 Tf [(Abstract 114.)] TJ ET BT 26.250 528.905 Td /F1 9.8 Tf [(23.)] TJ ET BT 43.553 528.905 Td /F1 9.8 Tf [(Parry MF, Grant B, Iton A, Parry PD, Baranowsky D. Influenza vaccination: a collaborative effort to improve the health of the )] TJ ET BT 26.250 517.000 Td /F1 9.8 Tf [(community. Infect Control Hosp Epidemiol. 2004;25\(11\):929-932.)] TJ ET BT 26.250 497.595 Td /F1 9.8 Tf [(24.)] TJ ET BT 43.553 497.595 Td /F1 9.8 Tf [(Sprung CL, Zimmerman JL, Christian MD, et al. Recommendations for intensive care unit and hospital preparations for an )] TJ ET BT 26.250 485.691 Td /F1 9.8 Tf [(influenza epidemic or mass disaster: summary report of the European Society of Intensive Care Medicine's Task Force for )] TJ ET BT 26.250 473.786 Td /F1 9.8 Tf [(intensive care unit triage during an influenza epidemic or mass disaster. Intensive Care Med. 2010;36\(3\):428-443.)] TJ ET Q q 15.000 456.405 577.500 320.595 re W n 0.271 0.267 0.267 rg BT 26.250 759.976 Td /F1 9.8 Tf [(16.)] TJ ET BT 43.553 759.976 Td /F1 9.8 Tf [(Uscher-Pines L, Babin S, Farrell C, et al.: Research Priorities for Syndromic Surveillance Systems Response: Consensus )] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(Development Using Nominal Group Technique. Journal of Public Health Management and Practice. 2010; 16\(6\): 529-534.)] TJ ET BT 26.250 728.667 Td /F1 9.8 Tf [(17.)] TJ ET BT 43.553 728.667 Td /F1 9.8 Tf [(National Center for the Study of Preparedness & Catastrophic Event Response \(PACER\): Available at: )] TJ ET BT 26.250 716.762 Td /F1 9.8 Tf [(https://www.pacercenter.org/. Accessed May 26th, 2012.)] TJ ET BT 26.250 697.357 Td /F1 9.8 Tf [(18.)] TJ ET BT 43.553 697.357 Td /F1 9.8 Tf [(Kelen GD, Kraus CK, McCarthy ML, et al.: Inpatient disposition classification for the creation of hospital surge capacity: a )] TJ ET BT 26.250 685.452 Td /F1 9.8 Tf [(multiphase study. Lancet. 2006; 368\(9551\): 1984-1990.)] TJ ET BT 26.250 666.048 Td /F1 9.8 Tf [(19.)] TJ ET BT 43.553 666.048 Td /F1 9.8 Tf [(Glaser CA, Gilliam S, Thompson WW, et al.: Medical care capacity for influenza outbreaks, Los Angeles. Emerg Infect Dis. )] TJ ET BT 26.250 654.143 Td /F1 9.8 Tf [(2002; 8\(6\): 569-574.)] TJ ET BT 26.250 634.738 Td /F1 9.8 Tf [(20.)] TJ ET BT 43.553 634.738 Td /F1 9.8 Tf [(Schull MJ, Mamdani MM, Fang J. Community influenza outbreaks and emergency department ambulance diversion. Ann )] TJ ET BT 26.250 622.833 Td /F1 9.8 Tf [(Emerg Med. 2004; 44\(1\): 61-67.)] TJ ET BT 26.250 603.429 Td /F1 9.8 Tf [(21.)] TJ ET BT 43.553 603.429 Td /F1 9.8 Tf [(Asplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie N, Camargo CA. A conceptual model of emergency department )] TJ ET BT 26.250 591.524 Td /F1 9.8 Tf [(crowding. Ann Emerg Med. 2003;42\(2\):173-180.)] TJ ET BT 26.250 572.119 Td /F1 9.8 Tf [(22.)] TJ ET BT 43.553 572.119 Td /F1 9.8 Tf [(Morton M, Jeng K, Beard R, Dugas AF, Pines JM, Rothman R. Systematic Review of Interventions to Mitigate the Effect of )] TJ ET BT 26.250 560.214 Td /F1 9.8 Tf [(Emergency Department Crowding in the Event of a Respiratory Disease Outbreak. Acad Emerg Med. 2012;19\(4\):Supp 1, )] TJ ET BT 26.250 548.310 Td /F1 9.8 Tf [(Abstract 114.)] TJ ET BT 26.250 528.905 Td /F1 9.8 Tf [(23.)] TJ ET BT 43.553 528.905 Td /F1 9.8 Tf [(Parry MF, Grant B, Iton A, Parry PD, Baranowsky D. Influenza vaccination: a collaborative effort to improve the health of the )] TJ ET BT 26.250 517.000 Td /F1 9.8 Tf [(community. Infect Control Hosp Epidemiol. 2004;25\(11\):929-932.)] TJ ET BT 26.250 497.595 Td /F1 9.8 Tf [(24.)] TJ ET BT 43.553 497.595 Td /F1 9.8 Tf [(Sprung CL, Zimmerman JL, Christian MD, et al. Recommendations for intensive care unit and hospital preparations for an )] TJ ET BT 26.250 485.691 Td /F1 9.8 Tf [(influenza epidemic or mass disaster: summary report of the European Society of Intensive Care Medicine's Task Force for )] TJ ET BT 26.250 473.786 Td /F1 9.8 Tf [(intensive care unit triage during an influenza epidemic or mass disaster. 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