By Kelly M. Pyrek
Bioterrorism events such as the anthrax cases and global outbreaks such as severe acute respiratory syndrome (SARS) and pandemic influenza underscore the need for hospitals and their staff to remain vigilant. As Rebmann (2009a) explains, "Infection transmission and infectious disease outbreaks can occur during or following any type of disaster. The greatest risk of infection transmission occurs during a disaster involving an infectious disease/agent (i.e., an infectious disease disaster), such as a bioterrorism attack, outbreak of an emerging infectious disease or pandemic."
The Role of Infection Preventionists in Emergency Management
To further define the role of the infection prevention profession in emergency management and to establish partnerships with key agencies, the Association for Professionals in Infection Control and Epidemiology (APIC) sponsored a Mini-Summit on Emergency Management in May 2008. During the summit, participants identified current gaps in emergency management as it relates to infection prevention, especially the lack of education and compliance with basic infection prevention practice across all disciplines of healthcare workers, response-agency employees and the general public. According to Rebmann (2009b) other gaps in emergency management that may affect infection transmission are:
- Community settings lack infection prevention guidance
- Nonhospital-based healthcare workers have historically received the least infection prevention education
- Nonhospital-based healthcare workers may be the first to recognize or respond to an infectious disease issue during a disaster but have received little to no training in this area
- Few infection preventionists are subject matter experts in infectious disease disasters, such as bioterrorism and pandemics
- Infection preventionists need more education related to planning for infectious disease disasters, including triaging patients, social distancing, surveillance methodologies and others
- Effectiveness of current electronic surveillance systems for disasters has not been established
- Public health professionals' knowledge about infection prevention is not known
- Surge capacity as it relates to infection prevention issues (such as negative-pressure room/area surge capacity) is lacking and needs to be better defined
- Crisis standards of care need to be developed and evaluated; may have an impact on infection spread during disasters
- General public requires more education about the potential infectious disease implications of disasters and strategies they can implement to help prevent the spread of infection
The summit participants also identified a number of areas within emergency management that need input from infection prevention professionals:
- Implementing infection prevention programs in alternate-care sites and shelters
- Decision-making regarding surge capacity needs as it relates to infection prevention
- Evaluating current electronic surveillance systems for detecting and monitoring biologic events and infectious disease outbreaks related to disasters
- Developing crisis standards of care that may affect infection spread
The summit participants thought that the primary roles of infection preventionists in emergency management are to serve as educators and consultants on all issues related to infection prevention, including consulting with facility and community disaster planning teams and providing emergency management education related to infection prevention for all disaster response agencies/groups and the general public. They also expressed the importance of infection preventionists addressing the need for response agency workers to have a better understanding of basic infection prevention practices such as wearing personal protective equipment (PPE).
These aforementioned gaps and demands come at a time when infection preventionists are grappling with shortfalls in time, resources, budgets and manpower. At the summit, participants felt that more infection prevention strategies should be integrated into all phases of emergency management, but they also acknowledged barriers to infection preventionists becoming involved in these activities. They said that a number of major barriers to implementing effective infection prevention in emergency management exist, including: a lack of infection preventionist time to engage in these activities; no discernable solution to the increasing need for infection preventionists and demands on their time; lack of infection prevention content provided in nursing, medicine, or public health curricula making for an unprepared workforce; and unwillingness or inability of infection preventionists to get involved in emergency management in the community.
"I believe the average infection preventionist is prepared in the sense that their infection control training lends itself to assisting with most any type of outbreak," says Barbara Russell, chair of the APIC Emergency Preparedness Committee. "Some infection preventionists, like myself and other members of our committee as well as non-members, are more involved than others. Those who are not, many times, is because their other commitments don’t allow them to get directly involved; however, should a disaster, etc. occur, their training kicks in and they can be helpful."
And as for coping with the unexpected while staying on top of their already-burdensome workloads, Russell advises, "Infection preventionists should make sure they have either participated in the development of relevant policies and/or develop infection control-specific ones to pull off the shelf if an event occurs. When the event occurs, they should assist as best they can by offering their infection control expertise."
Rebmann (2009a) points out that "Historically, IPs have responded to healthcare-associated infections and public health infectious disease outbreaks. Toward the end of the 20th century, many IPs expanded their role and became involved in bioterrorism preparedness planning. More recent events, such as SARS and Hurricane Katrina, have illustrated the importance of IPs becoming involved in emergency management for all types of disasters to decrease secondary morbidity and mortality. The IP’s role in emergency management is considered to be essential, regardless of whether it is an infectious disease emergency or some other type of disaster. What is lacking is a delineation of the IP’s role in emergency management. This is needed to help guide IPs as they are called to the emergency management table to help make important planning and response decisions."
Rebmann (2009a) sought to expand upon the 2008 summit's agenda as well as delineate the role of IPs in all phases of emergency management by using an evidence-based approach to review the literature, review the summit's findings, and draft the IP’s role in emergency management with the members of the APIC Emergency Preparedness Committee. Rebmann (2009a) reports that nine domains were identified that describe the role of the infection preventionist in emergency management:
1. Knowledge of disasters and emergency management: IPs should be familiar with the infectious disease impact of a mass casualty incident and the interventions needed to control the situation, as well as Infectious disease disasters such as a pandemic. IPs must also understand the infection prevention strategies needed for mass-casualty/pandemic incidents, including surveillance, patient placement, reporting, outbreak investigation, and communication/coordination. A basic understanding of emergency management principles, including the four phases of emergency management -- mitigation, preparedness, response, and recovery -- is also necessary
2. Assessing readiness and emergency management plans: IPs must be involved in assessing all aspects of readiness for mass casualty events as it relates to potential disease transmission, including being involved in preparedness efforts at the personal, facility and community level for all types of mass-casualty events.
3. Infection prevention coverage: All settings that administer health services need an infection prevention program to prevent the spread of infectious organisms, including having access to an IP for consulting purposes (i.e., having infection prevention coverage) round the clock if possible.
4. Participation in disaster response and recovery: In addition to playing a key role in preparing for mass-casualty incidents, IPs will be essential to an effective response and recovery from an emergency. Regardless of the facility, or type or scope of the disaster, most IPs' primary responsibility during a mass-casualty incident will be to prevent and control infectious disease spread during the event. This will involve implementation of infection prevention strategies outlined in facility policies and procedures and the facility emergency management plan, as well as monitoring the effectiveness of these interventions.
5. Healthcare policy development: Many issues surrounding emergency management have potential policy implications, especially those involving creation of new standards and recommendations related to infection prevention during a mass-casualty incident. One critical policy area in which IPs need to be involved is the development of altered or crisis standards of care. Given the projected lack of resources that will be available during a mass casualty event, alternative approaches to patient care must be considered. Tough decisions need to be made regarding how to allocate limited numbers of ventilators or medications, where contagious patients will be housed if all isolation rooms are full, and which staff will be given PPE if stocks become depleted.
6. Surveillance: Surveillance is a critical component of emergency management, especially for disasters involving a biologic agent. There are two types of surveillance programs needed for disasters: a system that aids in identifying a biologic event and one to monitor an event once it has been identified. IPs need to be involved in the development of these surveillance programs to ensure that appropriate indicators are chosen. In addition, IPs need to assist in surveillance program evaluation to determine the effectiveness of the systems used.
7. Patient management: Patient surge is expected after any type of mass-casualty incident, and, in some events, such as an infectious disease disaster, the patients may pose a risk of infection transmission. Healthcare disaster planners must develop protocols for managing patient surge, including procedures for minimizing the risk of disease transmission.
8. Physical plant issues: Research indicates that the environment can play a part in infection transmission. This is especially true in mass-casualty events when bioburden may be higher than usual, staff shortages may prevent adequate environmental decontamination, and cleaning/disinfection products may be limited. IPs must consult with facility emergency management planners, facilities engineering, and response agencies regarding assessing the physical plant for potential infectious disease implications and implementation of environmental controls for mass-casualty incidents.
9. Infection preventionist as educator: One of the IP’s primary roles is to educate others regarding infection prevention and control strategies, and this remains true for emergency management. IPs should use competency-based curriculum whenever possible when developing infection prevention in emergency management education. Competency domains for hospital-based healthcare workers include basic microbiology, modes/mechanisms of infection transmission, standard and transmission-based precautions, occupational health, patient safety, critical thinking and emergency preparedness.
