Pandemic Plan
Faculty of Medicine

Dalhousie University
August 2009

Introduction

This planning document is meant to guide individual departments and units within the Faculty of Medicine as they develop detailed plans for their particular office.  This document will also need to link with pandemic plans from the Nova Scotia Department of Health, Capital Health, the IWK, Dalhousie University, and the New Brunswick Department of Health all of which are in various stages of development.  The plan is a template built around the current scenario which has been adapted from various documents developed by the World Health Organization (WHO) and national bodies.  An influenza pandemic will be a unique event that will challenge the Faculty of Medicine, due to the uncertainties, risks, and conflicts that will be presented to physicians in their duty to care at the outset.

Goals of the Plan

1. To minimize harm to medical learners
2. To minimize disruption of the Faculty of Medicine commitment to educate physicians
3. To model a just and compassionate response to patients and the community in a time of disaster.

Planning Principles

• Complementary:  The Pandemic Plan for the Faculty of Medicine will complement plans by Dalhousie University, Capital Health/IWK, the Nova Scotia Department of Health, New Brunswick Department of Health and the Federal Government of Canada.  If conflicts arise between these plans, the overall goals of the Provincial and Canadian plans will guide conflict resolution.
• Coherent:  Each academic unit within the Faculty of Medicine will have a detailed Pandemic Plan, adhering to the template outline.
• Respect for Health and Safety:  The health and safety of all staff, students, and faculty of the Faculty of Medicine will be of high priority. Faculty, residents and staff will be located in their home communities to keep families together whenever feasible.

• Voluntary:  Faculty, residents, students, and staff will contribute to the pandemic clinical plans on a voluntary basis, depending on their skill set. Some aspects of pandemic care such as quarantine are not voluntary and physicians have an ethical obligation to provide care despite potential health risks.
• Accountable:  There is a need for clear lines of authority and responsibility to manage the pandemic response.
• Transparent:  Information regarding pandemic plans will be communicated in an open, transparent, and equitable manner.
• Equitable:  In the implementation of the Pandemic Plan, resources must be allocated fairly.  Differences in power and voice need to be acknowledged and addressed.
• Evidence-based:  As the pandemic develops, information with respect to diagnosis and treatment will be rapidly evolving.  It will be critical that all decisions are made on the best available evidence.

Background to a Pandemic

The WHO declares a Pandemic when an influenza virus becomes virulent, with high transmission rates between humans.  The initial source will likely originate in SE Asia.

It is unclear when a pandemic would arrive in Nova Scotia, but the Faculty of Medicine likely would have up to two months of notice for final preparations.

A Pandemic Plan activation for Canada will be declared by Health Canada with close communication to provincial departments of health.

A Pandemic will have unique features including uncertainty, high levels of risk, high mortality and morbidity, disruption of social functioning, and pressures on health scientists, physicians, and pubic health officials.

Dr. Robert Strang, as the Chief Public Health Officer for Nova Scotia would have the responsibility to activate the Nova Scotia plan. Current government departments involved in planning include: Department of Health, Emergency Management Office, Departments of Agriculture, Environment, and Labour.  A new pandemic committee has been formed involving Doctors Nova Scotia.  The current plans have a limited role for quarantines and school cancellations. 

Stage 1

• Weeks 1 – 8:  High rate of illness, 50% of population affected
• Significant morbidity and mortality
• Unclear of age group with highest morbidity/mortality – may be 18-29 year olds i.e. med students and residents, but we will not know until pandemic hits
• Hospital and community plans in full activation mode
• All clinical staff will be required to provide health care
• Request for students and residents to assist with care
• Assumption that vaccines and antivirals would not be available

Stage 2

• 2 months - 8 months
• Lower level of illness
• Most activities will return to normal or slightly reduced schedule i.e. surgery will resume, most staff back to work

Stage 3

• Second phase - second wave of influenza
• Likely less acute than first wave and presumably lessons learned from first wave would help to mitigate effects.
• Possible vaccine available at this time

Pandemic Plan
Faculty of Medicine

In the Faculty of Medicine Pandemic Plan, a key distinction must be made between medical students and residents.  The ethical obligations and potential clinical duties of medical students are quite different from postgraduate residents and faculty.  Medical students do not yet have any formal obligations as physicians.  In addition, non clinical faculty do not have the ethical obligations of physicians and thus would contribute to clinical pandemic requirements in a voluntary capacity.  Every effort will be made to provide antivirals and vaccines to faculty, residents, students and staff providing care in high risk pandemic environments.

Undergraduate
Med 1 and 2

• cancellation of program for Stage 1
• resumption of programs for Stage 2
• possible on-line programs for Stage 3
• Unit Heads will be key decision makers for the educational program

Med 3 and 4

• Stage 1 – assist with medical plans, seminars/teaching online using CLIP cases and other components of the E-curriculum
• Stage 2 – resumption of rotations
• Stage 3 – perhaps continue rotations, with on-line seminars

Medical students will be available to assist with clinical care on a voluntary basis.  In general, they will be providing non-medical patient support.  All medical students providing care will be considered as one uniform cohort, and will be assigned activities with the Pandemic Plan to support other health care workers.  The decision to utilize medical students in support or clinical care will be made by the health authority, not Dalhousie. Again, it must be emphasized that decisions for medical students to assist with clinical care in a pandemic must be made on a voluntary basis and the Faculty of Medicine may need to act as an advocate in this regard.

Dalhousie will not participate in the CARMS match during a pandemic.  The academic year will be extended to August 30 and graduating medical students will be matched to Postgraduate program at Dalhousie only.

The Dalhousie Medical Students Society [DMSS] is represented on the pandemic working group and this plan aligns very well with the position paper developed by the Canadian Federation of Medical Students [CFMS] in 2007.

The Undergraduate Associate Dean will need to have an alternate named.

Postgraduate
It needs to be acknowledged that residents working in hospital and tertiary care centres will be in a high risk environment.  Ethical and psychological stresses are at least as important as physical risks during a pandemic. 
Phase 1 and 3

• residents may participate in hospital Pandemic Plan to deliver care
• residency directors will be key decision makers for determining the appropriateness of resident assignments to hospital Pandemic Plan and modification of educational programs
• licensure with the College of Physician and Surgeons of Nova Scotia and College of Physician and Surgeons of New Brunswick have been developed.   Residents in Royal College specialty program in the final two years of residency, and the final six months of the Family Medicine Program, will be able to provide independent care with minimal supervision as per the guidelines of defined licensure for NS and NB.  The guidelines are being reviewed and at this time by the College of Physician and Surgeons of PEI.

Deployment of Residents

The health care system, including hospital services, will not function normally in the event of a pandemic crisis. Clinical training programs, clinical services and many other aspects of resident life will be disrupted. It is estimated that up to half the residents will either be ill or will be caring for family members who are ill and will not be available. Those residents who can work in the health care system will be needed to provide care to patients, both in the hospital setting and possible other settings. All deployment of residents must be directed and approved by that resident’s program director or designate. Residency directors and Postgraduate office will need to act as an advocate for residents to make sure they are in a safe clinical environment during a pandemic.

Supervision of Residents

Supervision of residents will be the responsibility of the appropriate department or division service chief.

CME

• change programs to videoconference and online
• cancellation of large meetings during Stage 1 and 3
• CME programs will focus on pandemic assessment/treatment updates
• [will need to liaise with Public Health since education i.e. mumps epidemic did not utilize CME resources/network]

Research

• essential research labs to be maintained, but limited resources available for ongoing research
• animal facility must be maintained

Dean’s Office

• will be command/control centre
• working with communications office to provide updates to faculty and students
• managing student logistics [illness, returning home, etc.]
• issues of sick leave approval/documentation and cross training need to be addressed with unions.

Communications Office

• communication needs assessment now complete – email is likely prime mode of communication during pandemic
• text messaging will be utilized to communicate with medical students and residents
• some key gaps identified – clarification of meaning of “cancellation” that may or may not include clinical rotations – also relationship of communication office with hospital and upper campus communication needs
• Dalhousie webpage has a separate information update for the Faculty of Medicine

MedIT

• very important role for supporting online programs and videoconference programs throughout the pandemic
• capacity of internet unknown during pandemic

Bioethics

• faculty can assist with developing an ethical decision making framework and staff can assist the Dean’s office with logistics and support.

DME/IHO/Basic Science Departments

• staff will need to assist the Dean’s office with logistical support – training of staff should begin now
• some work may be possible at home – there may be equipment and IT issues – this work option should be pilot tested in 2008

Ethical Considerations
From a Faculty of Medicine role, two key themes can be identified – the role of service and the role of support to students/faculty/staff who become ill.  Both are important and must be addressed by a transparent, fair process.  All pandemic clinical assistance, especially by medical students must be on a voluntary basis.

Residents, being licensed physicians have a clear duty to provide care, as do faculty.  Medical students do not have a duty to care, but are learning about this duty and should be offered an opportunity to participate in pandemic care.

All faculty, staff, residents and students must be supported with accurate information, a transparent process on pandemic care plans and suitable protection from illness for themselves and families.

Conclusions and Next Steps
This template represents the approach the Faculty of Medicine will take during a pandemic and, with some adaptations, any disaster.  Clearly, with the activation of a national pandemic plan, additional detailed work will be needed within all the academic units of the faculty to develop the finalized operational plan.  This plan must closely align with the pandemic plans of a number of key partners, including Dalhousie University, the local hospitals, and the NS and NB Departments of Health.  Critical next steps include the development of business continuity plans within the Faculty of Medicine and further discussions with our partners.

Doug Sinclair
Associate Dean
Continuing Medical Education