Guidance for Health Services Planning in Remote and Isolated Communities in the Context of Pandemic (H1N1) 2009

November 17, 2009

Introduction

This guidance document has been developed to provide guidance to health services planners in remote and isolated communities. 

Health care is delivered through a primary health care model which includes primary, home and community care.  It will also include some public health programming such as control of communicable diseases, as well as environmental health programming such as monitoring the safety of drinking water and household mold.

Health care services in many remote and isolated communities are carried out in nursing stations and health centers.  Primary health care is often provided by a small number of permanent staff or by visiting staff.  Since visiting staff may not always be available or may be delayed due to extraneous factors such as weather, transportation or accommodations their presence cannot be guaranteed.  Weather can also affect such critical issues such as evacuating ill patients, delivery of food and prescription drugs into the community and availability or reliability of telecommunications.

This guidance document has been developed to provide guidance to planners who plan for the provision of health services in these situations.

Objectives of the Health Services Planning Response

The objective of the health services planning response is to:

1. Maintain key health services during pandemic H1N1
2. Support community members who may need to be cared for in their homes during pandemic H1N1

Coordination of Health Services Planning

Coordination of health services in collaboration with local, regional, provincial/territorial and federal partners are critical. Therefore these relationships need to be fostered prior to a pandemic. The first and most important partners in a community are the community members.
Other partners that planners might consider liaising with include:

• Emergency departments in neighbouring communities that may receive seriously ill patients from remote and/or isolated communities
• Telehealth/telemedicine information lines/technology that are available in the region
• Hospital care (including intensive care)
• Community care, or contract agencies that deliver home care services and other services
• Paramedics
• Private medical transportation services
• Med-Evac system
• Laboratory services including the public health lab
• Nursing stations and health centers
• Developing linkages with neighbouring communities in an area, to strengthen communication and sharing of information

Health Services Delivery

Keeping the health facility open and operating in most communities will be dependent on the availability of staff and supplies. Planners in remote and isolated communities may need to consider alternative methods available for health care delivery, especially when surge demands begin to exhaust the current resources.  The key considerations to ensure that the health facility remains open include planning for available staff, supplies and accommodations.

1.  Challenge:  Availability of Health care workers

Currently, there are limited health human resources in remote and isolated communities.   This situation may be compounded during a pandemic when an increased demand for services or illness could impact the community. The capacity to move extra staff into the community in a timely manner may be limited or prevented by the availability of transportation, lack of accommodations, environmental factors and/or lack of available health human resources. This may impact planning for mass immunization, surge capacity or replacement of ill health service staff.

Strategies to consider: 

• Remote and isolated communities should be encouraged to work with other agencies/organizations and the general public when developing their community pandemic plans to identify all potential resources beyond health care workers.
• Consider additional support workers, such as those who are not health care workers (e.g. volunteers, community elders).
• Identify early in the planning process what the essential services are, as well as, the skill sets and/or knowledge required to carry them out.  Identify individuals in the community who can fulfill these functions and determine what additional training is required.  Gaps should be clearly identified and communicated with the larger organization for regional and/or national planning purposes.
• A centrally located list should be maintained in each community to ensure those planning human resources have ready access to the contacts and their skill set.
• Consider training existing staff to fulfill expanded roles (e.g.  Community Health Representatives (CHRs) to do influenza specific health assessments, training them in basic life support until replacements can be flown in). 

2.  Challenge:  Communities with no health care providers

There are communities that do not have health care staff or have health care staff on a part time basis.  Remote and/or isolated communities need to plan for situations in the absence of health care staff.

Strategies to consider:

• Designate some of the tasks required during a pandemic to a health services planning committee or to elders in the community, a civic leader or other who is recommended to bridge this apparent gap in services until a health service provider is available.
• Consultation with other health care professionals through various means of communication and technologies is an alternative means that can be explored by communities.

3.  Challenge: Shortage of Supplies

Remote and isolated communities may not have ample supplies to manage a large outbreak where there may be more patients presenting to the clinic than in usual. In addition, the potential for unreliable transportation to resupply the stock may leave clinics short of certain supplies. 

Strategies to consider:
Communities should have a plan in place for maintaining a minimum of a four week supply of clinic supplies including personal protective equipment (PPE) and alcohol-based hand rubs. It is important to note that 4 weeks is only a guideline, and that stockpiled quantities should be assessed based on a community's best anticipation of delays.

• Triggers need to be in place for when the supply is diminishing (frequent checking of inventory is recommended).  Minimum and maximum thresholds should be developed to trigger reordering, anticipating delays.  
• Frequently monitor inventory and establish triggers for requisitioning of new stock well in advance, taking transportation and weather delays into account.
• Health care providers should consider Mutual Aid Agreements with neighbouring health care authorities for stockpile supplies.

4.  Challenge: Secure Storage Space

There may be limited secure storage space in a remote and isolated community.

Strategies to consider:

• Investigate the possibility of using other facilities for storing of extra supplies within the community.  Health service planners will need to investigate what facilities are available within the community and assess the willingness of the facilities management to allow usage of these facilities during an outbreak.  Possible locations are churches, recreation centers and schools.

• The storage area should be protected from damage by the elements.  Areas should be neat, clean and free from fire hazards, dampness and rodents. Keeping the items located in temperature controlled areas (between 15-30 °C) with relative humidity between 30-50% will assist in this goal. Also, supply items should be at least 15cm (6 inches) off the floor and at least 91cm (3 feet) away from any heat sources. When storing hand sanitizers, please take into account that they should be kept away from fire or flame, including electrical outlets.
• In order to maintain satisfactory storage conditions, the storage area should be inspected periodically for any evidence of leakage, ground seepage, insect or rodent infestation, pilferage and deterioration of any of the supplies.
• The storage area should be secured by lock and key. Security measures should also be taken for windows, if any.

5.  Challenge:  Alternative sites for provision of health services may be limited

In a pandemic, alternative sites may need to be identified for events such as mass immunization clinics, flu centres, or supply storage.  This may be operationally difficult in a remote and isolated community due to the limited space and resources. 

Strategies to consider:

• Consideration should be given to alternative sites for managing patients when planning for health service delivery.  These sites will sometimes be called Influenza Centers or Flu centers and may be utilized to provide primary assessment, mass vaccination or treatment with antivirals. 
• Alternative sites such as schools, recreation centers or churches should be assessed for suitability and prior arrangements with community members responsible for those sites should be considered.
• Consideration should be given to setting up a call-in center as an alternative means of providing health care support.  This call-in center does not necessarily need to be staffed by health care providers.  If health care professionals are not available to staff a telephone call-in centre during all hours of its operation, consideration could be given to employing lay-staff with very clear triage guidance. It is recommended that jurisdiction-specific triage guidance be developed or adapted from other jurisdictions.
• Communities preparing for mass vaccination clinics can refer to the document, Mass Immunization Clinics in Remote and Isolated Communities, available at http://www.phac-aspc.gc.ca/alert-alerte/h1n1/pdf/massvacc09-eng.pdf¹ .

Other Challenges

Transportation of patients

Remote and isolated communities are highly dependent on land and air transportation to transport ill patients from community to urban hospitals.

Strategies to consider:

• Plans should be implemented where remote and isolated communities enter into agreement with private transportation companies or other federal organizations (such as Department of National Defence) for transportation needs during the pandemic (H1N1) 2009.
• When transportation is not available, telehealth/telemedicine could be considered a viable option to provide support to the health care staff in the community and care to the clients.

Communications

In remote and isolated communities, communication should be an integral part of maintaining essential health services; however, without preplanning, communication during a pandemic could negatively impact a timely response.

Strategies to consider:

• Preplanning should be encouraged to identify current means of obtaining key information about health updates. Special consideration may need to be given to camps and mining communities who may not have a formal communication process.
• A variety of mechanisms should be used to communicate with the public, such as community bulletins, public service messages, community radio, flyers, and local media.
• Request people self-identify if they need assistance in the event of an outbreak.  A roster/list can be located in the community in an central/accessible location.
• Pandemic plans could include a flag system to enable community members to identify and communicate if they need assistance if there is an outbreak.

Technology

While access to technology in some communities may be limited, the various means of technology have the ability to transport information to all areas of Canada in a more timely fashion than traditional methods such as postal service.

Strategies to consider:

• Communities and companies should link with the Provincial Health Authority to develop a mechanism to consider inclusion for obtaining and dissemination of pertinent information via E-technology such as:

• Videoconferencing 
• Telehealth/telemedicine
• Internet connections
• Cell phones
• Podcasts 
• Vodcasts

Ethical Considerations

As outlined in the Canadian Pandemic Influenza Plan for the Health Sector (CPIP)², there are ethical principles that health care planners and clinicians will want to consider when planning for pandemic (H1N1) 2009. 

For specific guidance on ethical situations please refer to your professional association or college website.

References