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 dont 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 IPs 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 IPs 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 IPs 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 IPs 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.
The State of Preparedness in U.S. Hospitals
For a more updated report of findings issued after this article went to press, CLICK HERE.
A report released in December 2010 revealed that some states achieved high scores for health emergency preparedness but progress was threatened by budget cuts. In the eighth annual "Ready or Not: Protecting the Public from Diseases, Disasters and Bioterrorism" report, 14 states scored nine or higher on 10 key indicators of public health preparedness. Three states (Arkansas, North Dakota, and Washington State) scored 10 out of 10. Another 25 states and Washington, D.C. scored in the 7 to 8 range. No state scored lower than a 5. The scores reflect nearly a decade of progress to improve how the nation prevents, identifies and contains new disease outbreaks and bioterrorism threats and responds to the aftermath of natural disasters in the wake of the 9/11 and anthrax tragedies. In addition, the real-world experience responding to the H1N1 flu pandemic -- supported by emergency supplemental funding -- also helped bring preparedness to the next level.
The report, released by the Trust for America's Health (TFAH) and the Robert Wood Johnson Foundation, notes that the almost decade of gains is in real jeopardy due to severe budget cuts by federal, state and local governments. The economic recession has led to cuts in public health staffing and eroded the basic capabilities of state and local health departments, which are needed to successfully respond to crises. Thirty-three states and Washington, D.C. cut public health funding from fiscal years (FY) 2008-09 to 2009-10, with 18 of these states cutting funding for the second year in a row. The report also notes that just eight states raised funding for two or more consecutive years. The Center on Budget and Policy Priorities has found that states have experienced overall budgetary shortfalls of $425 billion since FY 2009. In addition to state cuts, federal support for public health preparedness has been cut by 27 percent since FY 2005 (adjusted for inflation). Local public health departments report losing 23,000 jobs -- totaling 15 percent of the local public health workforce -- since January 2008. The impact of the recession was not as drastically felt by the public health workforce until more recently because supplemental funds received to support the H1N1 pandemic flu response and from the American Recovery and Reinvestment Act have almost entirely been used.
Some key findings from the "Ready or Not" report include:
- Seven states cannot currently share data electronically with healthcare providers
- 10 states do not have an electronic syndromic surveillance system that can report and exchange information to rapidly detect disease outbreaks
- Only four states report not having enough staffing capacity to work five, 12-hour days for six to eight weeks in response to an infectious disease outbreak, such as novel influenza A H1N1
- Only one state decreased their Laboratory Response Network for Chemical Threats (LRN-C) chemical capability from Aug. 10, 2009 to Aug. 9, 2010.
The report also looked at findings from a recently released report from the Centers for Disease Control and Prevention (CDC) based on activities in 2007-08 that focus on emergency operations and food outbreak identification.
- Only two states reported that pre-identified staff members were not able to acknowledge notification of emergency exercises or incidents within 60 minutes a minimum of two times, the target established by the CDC:
- Six states did not activate their emergency operations center (EOC) a minimum of two times, the target established by the CDC
- Only two states did not develop at least two After Action Report/Improvement Plans (AAR/IPs) after exercises or real incidents in 2007-08
- 21 states were not able to rapidly identify disease-causing E. coli O157:H7 and submit the lab results in 90 percent of cases within four days.
According to the report, while states have made progress, there are still a series of major ongoing gaps in preparedness, including in basic infrastructure and funding, bio-surveillance, maintaining an adequate and expertly trained workforce, developing and manufacturing vaccines and medicines, surge capacity for providing care in major emergencies, and helping communities cope with and recover from emergencies.
The "Ready or Not" report provides a series of recommendations that address the ongoing major gaps in emergency health preparedness, including:
- Gaps in funding and infrastructure: The resources required to truly modernize public heath systems must be made available to bring public health into 21st century and improve preparedness;
- A surveillance gap: The U.S. lacks an integrated, national approach to bio-surveillance, and there are major variations in how quickly states collect and report data which hamper bioterrorism and disease outbreak response capabilities;
- A workforce gap: The U.S. has 50,000 fewer public health workers than it did 20 years ago and one-third of current workers are eligible to retire within five years. Policies must be supported that ensure there are a sufficient number of adequately trained public health experts including epidemiologists, physicians, nurses, and other workers to respond to all threats to the public's health;
- Gaps in vaccine and pharmaceutical research, development and manufacturing: The U.S. must improve the research and development of vaccines and medications;
- A surge capacity gap: In the event of a major disease outbreak or attack, the public health and healthcare systems would be severely overstretched. Policymakers must address the ability of the healthcare system to quickly expand beyond normal services during a major emergency;
- Gaps in community resiliency support: The U.S. must close the existing day-to-day gaps in public health departments which make it difficult to identify and service the most vulnerable Americans, who often need the most help during emergencies.
Another report says that more than 76 percent of hospitals participating in the National Hospital Preparedness Program (HPP) met 90 percent or more of all program measures for all-hazards preparedness in 2009. The document, "From Hospitals to Healthcare Coalitions: Transforming Health Preparedness and Response in Our Communities," released in May 2011 by the U.S. Department of Health and Human Services (HHS) identifies the advances that states have made in preparing hospitals for all types of disasters. The report also discusses the next steps the program will take to boost community resilience. All states, eight U.S. territories and four large metropolitan areas participate in the cooperative agreement grant program, which provides federal funds, technical assistance, and guidelines for hospital preparedness. Of the more than 6,300 hospitals across the nation, more than 85 percent take advantage of the program.
Hospitals meeting preparedness performance measures have dedicated redundant, interoperable systems in place to communicate between hospitals, public health agencies and emergency managers. These hospitals can report the number of available beds to a state, territory or city emergency operations center within 60 minutes of a request during a disaster. These hospitals also have plans to handle a surge in demand for hospital services during a disaster, as well as plans for hospital evacuation, sheltering patients and staff in place during a disaster, and to respond to mass fatalities.
Hospitals meeting program measure demonstrate their response capability during emergency exercises, including statewide or regional exercises, or actual incidents. The hospitals develop improvement plans based on after-action reports from these events. During a disaster, they use the incident command system, and have adopted the National Incident Management System through the hospital organization. These systems standardize response terminology and command-and-control structure across the emergency response. To meet some of these performance measures and enhance the response capability, states, territories, cities, and participating hospitals also use HPP funding to purchase emergency equipment, such as mobile medical units to bring medical care to survivors during disaster response and back-up generators to keep participating hospitals running when power is otherwise unavailable.
The report suggests that, as an increasing number of hospitals meet performance measures program, participants also focus on building coalitions within communities so that hospitals, government agencies, nongovernment organizations, businesses, and community residents work as a team to prepare for and respond to disasters. The report recommends that these coalitions involve all populations within communities, including children, pregnant women, the elderly, and those who are vulnerable in other ways.
"In general I would say that most hospitals are better prepared," says Russell. "Sometimes different hospitals have a different interpretation of 'better.' I am sure funding is an issue for many facilities. There are grants to help but they too are getting scarcer plus sometimes the requirements hold folks back from applying."
The government has recently infused states with a significant amount of cash. In July 2010, states, territories, and large metropolitan areas received HPP grants totaling $390.5 million to help hospitals and other health care organizations strengthen the medical surge capability across the nation. HPP funding focuses on enhancing planning, increasing integration between public and private sector medical planning and assets, and improving infrastructure. And in July 2011, the U.S. Department of Health and Human Services (HHS) awarded more than $352 million to continue improving disaster preparedness of hospitals and healthcare systems within every state, and three large metropolitan areas.
Using HPP funds, grant recipients put systems in place to track the number of hospital beds available which helps hospitals handle a surge of patients after disasters, as well as systems to register volunteers. The funds also support planning, training and exercises for evacuating facilities, for sheltering patients and staff in place, and for managing mass fatalities. In addition, HPP funds may be used to purchase pharmaceutical caches for use during an emergency response. The HPP encourages grant recipients to develop healthcare coalitions with other hospitals and healthcare systems, community businesses and non-government organizations which can support a facility in caring for patients.
Rebmann T. APIC State-of-the-art Report: The role of the infection preventionist in emergency management. Am J Infect Control 2009(a);37:271-81.
Rebmann T, Wagner W, Warye K. APIC's role in emergency management: proceedings of the 2008 APIC Emergency Preparedness Mini-Summit. Am J Infect Control. 2009(b) May;37(4):343-8. Epub 2009 Mar 14.
As the height of the flu season approached in December 2010, a survey of 525 nurses from U.S. hospitals revealed that 93 percent of nurses are confident that hospitals are "far better prepared" to handle a potential pandemic than they were this time last year. Additionally, 91 percent of the nurses responded that their hospitals had fully incorporated flu outbreaks into their emergency preparedness systems. The H1N1 influenza outbreak in 2009 seems to have played a part in enhanced planning and awareness according to the nurses, with 82 percent indicating that the H1N1 pandemic was "a humbling lesson from which we learned a lot." The survey was jointly conducted by Kimberly-Clark Health Care and Baylor Health Care System in cooperation with the American Nurses Credentialing Center (ANCC).
Each year, more than 200,000 people are hospitalized for flu-related complications and the CDC estimates that approximately 200,000 to 400,000 hospitalizations occurred during the 2009 H1N1 flu season. One area of concern for the nurses was that public knowledge of healthcare-associated infections (HAIs), the prevention of which is important to containing illness in hospitals, was low. Only 40 percent of the nurses surveyed feel that the public is well informed on this issue.
Other important findings from the survey reflect flu preparedness and the need for further (HAI education:
- 73 percent of nurses expected the 2011 flu season to be somewhat severe, but are prepared with the flu vaccine (92 percent plan to get it), flu education materials appropriate for all staff (69 percent of respondents have these) and a pandemic planning committee (68 percent of respondents have this).
- 60 percent of nurses noted that their hospitals HAI prevention program was nearly the same or only somewhat improved over the past year.
- 54 percent of nurses believe the public needs more education about the benefits of HAI prevention programs.