Flu Drive-Through:

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Americans have drive-through everythings: fast food, coffee, banks, weddings, prayer and now, thanks to the inventiveness of a pair of California emergency physicians, even drive-through emergency care.

This June, Stanford Hospital in Palo Alto, CA, conducted a successful drive-through exercise in treating pandemic flu patients. The experiment came after hundreds of patients flooded the Stanford emergency department (ED) last spring fearing they were sick with H1N1 influenza. Although McTriage is perhaps the most unique approach to coping with the expected surge demand this winter from influenza, it is far from the only one hospitals across the United States have scrambled to set up this summer and early fall.

“Hospitals definitely need to prepare for increased visits this flu season,” said Francis Counselman, MD, chairman of Department of Emergency Medicine at Eastern Virginia Medical School in Norfolk, VA. “If a drive-through emergency department works for you, great. I don't think there's any one-size-fits-all solution. People need to look at their resources and facilities, and have made their plans accordingly.”

For Stanford emergency physician Eric Weiss, MD, those plans were nurtured during a vacation to Montana earlier this year, when he and his family pulled into a McDonald's restaurant. A cursory glance showed the fast food restaurant's interior to be filled with coughing and sick-looking people, so the family chose instead to go to the drive-through window.

When he returned to Stanford, Dr. Weiss worked with Stanford's Gregory Gilbert, MD, to develop their own drive-through plan in an effort to divert contagious patients from the ED waiting room. As they discussed the idea, its benefits multiplied: the car was a perfect compartment to control the spread of the disease; patients probably could be seen more quickly thereby extending the hospital's capacity; and patients probably would feel more comfortable in their own vehicles rather than a crowded, cough-filled waiting room.

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• Figure 1. 

  Several dozen drivers play the role of patients in a Stanford Hospital exercise to prepare for the onslaught of patients that could occur in a pandemic. Photo credit: Stanford Hospital.

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• Figure 2. 

  Photo credit: Stanford Hospital.

The exercise, which was facilitated by American Red Cross volunteers, involved 40 patients with pretend symptoms who went through a full battery of triage, testing and analysis that would be performed on ill patients in the regular ED. The result of the study, Dr. Weiss said, was a safer environment for patients and medical personnel and an average reduction in wait time of 86 minutes compared to H1N1 influenza patients treated in Stanford Hospital's regular ED.

“And by the way, the patients loved it too,” said Dr. Weiss, medical director for both Stanford Hospital and Lucile Packard Children's Hospital.

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• Figure 3. 

  Stanford Hospital emergency physician gathers vital signs from pretend patient, Marika O'Bair-Kark, in the first test of an innovative pandemic drive-through screening and treatment protocol. Photo credit: Stanford Hospital.

Patients drove to a lane near the entrance of an open-sided parking garage next to the hospital. They were screened by a nurse, and if the patients were deemed stable they were directed to enter the ground level of a parking structure by security staff. At a triage station, a nurse measured vital signs such as blood pressure and oxygen saturation. Then they were sent to a medical screening station for a full physical exam and briefly led into a heated, screened area where patients could lie on cots to have their lungs and heart examined. Blood tests were done at the side of the car, and if needed, a portable digital X-ray machine was available. More details on the design and results of this experiment can be found in Dr. Weiss' article on pages 268-273.

Hospital officials tested carbon monoxide levels at the beginning and end of the exercise and didn't find a significant increase. In colder weather, patients could find comfort inside their cars for most of the time, Dr. Weiss said. They could listen to their radios and the hospital could direct them to a specific public broadcast station for information about procedures and wait times. In short, the test was entirely satisfactory, saving a considerable amount of time with patients seen and evaluated in 45 minutes, he said.

“Most importantly we feel like we mitigated the spread of infectious disease by families and patients congregating in the waiting room,” Dr. Weiss said.