Integration, Collaboration Key for Hospitals and Communities in Preparing for Outbreaks
By Kris Ellis
Healthcare systems in the Untied States and around the world must deal with the specter of impending large-scale health crises each and every day. Much effort has been put forth to increase the education, training, and funding that are vital to establishing and maintaining an optimal level of readiness for such an event, be it in the form of bioterrorism, pandemic influenza, or any other particularly virulent infectious threat. While progress has been made on many fronts, it is incumbent upon government officials and healthcare personnel to continue pushing the envelope of preparedness.
The first critical piece that hospitals and healthcare systems should be involved in is the process of surveillance, says Charles Baum, MD, MS, vice president of health affairs and medical director of the Nutrition and Disease Prevention Center at the Alexian Brothers Hospital Network. Not traditional infectious disease surveillance, but more early identification syndromic surveillance. Its a very interesting new public health tool because it deals with disease identification before theres an actual diagnosis.
For example, Baum cites the ESSENCE (Electronic Surveillance System for the Early Notification of Community-based Epidemics) system, which he is assisting implementation of in the northwest Chicago suburbs. The system employs syndromic surveillance for capturing and analyzing public health indicators for early detection of disease outbreaks. Its essentially a computer program that monitors the chief complaints of patients admitted to the emergency room (ER), Baum explains. Four times per day, the system compiles the data and sends it to the county department of public health. What theyre looking for are trends if all of the sudden theres been a surge in cough and fever, for example, that signals to them that theres something going on in that particular area around the hospital.
This type of system can allow public health officials to determine whether or not symptoms are generalizing and spreading. It may also provide hospitals some lead time for preparation since they can monitor the data simultaneously. The importance of this, particularly with pandemic flu, is it can provide a 24-48 hour window of opportunity to get medication to the public, which would be Tamiflu, provided theres enough of it. That whole system for drug distribution is being implemented and piloted, and actually in our community its in place, so theres a system for getting it distributed to people.
In terms of contending with the influx of patients that a situation such as a pandemic would precipitate, Baum notes that variation may exist in how different facilities react. Within a hospital, youll have people presenting to the ER and needing admission, so how do you manage that? Well, you look at the best case scenario which would be positive pressure rooms there arent enough, so thats not a legitimate approach, he says.
Then if you look at where you would put them in the hospital, you dont want to affect the currently sick, so thats an area of ongoing discussion; do you keep them in the hospital or do you ship them out to another site? I think we may see differences across the country in how thats done. The hospital infection control staff has to try and maintain them, I think, in a quarantine state where theyre separated from the general population, and then of course enforce strict handwashing. Everybody probably needs to be wearing masks at that point, and you hope that you have adequate supplies of Tamiflu and that its effective. Baum stresses the need for hospitals to work closely with the public health system, even though this may not be the norm for many. The public health system is not used to working with the healthcare system and vice versa, and this brings about a whole lot of issues.
Strengthening communication between these two entities is key, according to Michael Bisesi, PhD, professor of public health and pharmacology, chairman of the Department of Public Health, and associate dean of graduate health science programs at the Medical University of Ohio at Toledo. Bisesi is also program director for the Northwest Ohio Consortium for Public Health. A lot of it goes back to education and training, he says.
Certainly hospitals have infection control personnel in place thats been the baseline for a long time, but the health departments are better equipped today than they have been historically. Throughout the country theres been increased emphasis on hiring epidemiologists or at least public health personnel with stronger backgrounds in epidemiology. Thats been where communications have been strengthened, because there are larger numbers of personnel, and more qualified personnel, at more health departments than there have been in the past. These people can interact with hospitals and be more proactive in the early stages of an outbreak or even a suspected outbreak to attempt to control the spread of an infectious or communicable agent sooner than we were in the past.
Bisesi says improved communications and coordination have been enhanced by federal funding coming into the states and municipalities from the Metropolitan Medical Response System (MMRS). This program began in 1996 as a result of an increased emphasis on terrorism preparedness at the federal level, and is currently a part of the United States Department of Homeland Security. The program assists highly populated jurisdictions in developing plans, conducting training and exercises, and acquiring pharmaceuticals and personal protective equipment in order to achieve the enhanced capability necessary to respond to a mass casualty event such as a terrorist act. There are MMRSs throughout the country now and they are funded by dollars that have come in from the feds to the municipalities allowing them to strengthen the interaction and integration of all the responding agencies that would be involved, Bisesi continues. For example, if theres a hospital and public health department involved, law, fire, emergency management agencies, emergency medical systems, public utilities, and so forth would all be involved as well.
Bisesi notes that in many regions within states, the MMRS has been expanded. For example, in northwest Ohio in 2000, the city of Toledo in Lucas County was at that point designated in the MMRS, and that has now expanded from one county Lucas to 19 counties in northwest Ohio, so we now have the regional medical response system. This way were not dealing only with one county but recognizing that these events can certainly overlap, so we actually have a communications network that transcends boundaries.
Notification via various communication modes can be initiated rapidly in order to promote awareness if a suspected or actual outbreak were to occur in this model. Not only much sooner, but much more efficiently and effectively relative to whats been done in the past, Bisesi continues. Its not yet a perfect system, but its evolving into a much better system than weve had historically.
For hospitals interested in bolstering communications and ties with public health, Bisesi suggests finding out where the closest MMRS is set up. They can also start with their local health department and try to strengthen the linkages, and they can contact their state health departments as well, he notes. For example, if there is relatively slow activity at a local level, perhaps they can try the state level.
Another thing thats happened is that other resources such as academic institutions and other public and private entities have gotten involved as well. I can speak for northwest Ohio what improved things here was having consistent interaction; from something as simple as having meetings all the way to full-scale drills basically emphasizing the need for integration and strengthened interaction. I think most hospitals would agree that theyre better prepared today than they were in the past, but they still feel that theres room for improvement. What it really comes down to is strengthening linkages among all those who would be involved.
I think at this stage of the game, hospitals and infection control professionals need to, in a broad sense, look to the CDC and the federal government, to their state and public health departments, and more importantly, reach out to their local public health entities. If they do that in a proactive way, that will help tremendously, Baum suggests. In this kind of scenario, top hospital leadership needs to know and be intimately involved. That also speaks to the point that infection control practitioners in hospitals often dont have that communication pipeline, but they need to push for it. They need to really take this top.
Bisesi points out that more, and more frequent, education and training around outbreak preparedness is now conducted within facilities, and that collaborative efforts between hospitals are on the rise. For example, in the state of Ohio, we have the Ohio Hospital Association and we have regional hospital associations such as the Hospital Council of Northwest Ohio. That organization helps to coordinate collaborative activities ranging from ordering the same type of personal protective equipment and decontamination equipment to maintaining similar inventories of supplies so that if an event occurs, we have a more coordinated effort to share resources between and among hospitals within a region and also to have more coordinated efforts for education and training. So theres certainly a much more elaborate system that exists today than in the past for that integration, collaboration, and cooperation.
At the federal level, the United States Department of Health and Human Services (HHS) has released its Pandemic Influenza Plan, which includes supplements dedicated to healthcare planning and infection control as they relate to a possible pandemic situation.1
According to this document, hospital response plans for pandemic influenza should:
- Outline administrative measures for detecting the introduction of pandemic influenza, preventing its spread, and managing its impact on the facility and the staff.
- Build on existing preparedness and response plans for bioterrorism events, SARS, and other infectious disease emergencies;
- Incorporate planning suggestions from state and local health departments and other local and regional healthcare facilities and response partners;
- Identify criteria and methods for measuring compliance with response measures (e.g., infection control practices, case reporting, patient placement, healthcare worker illness surveillance);
- Review and update inventories of supplies that will be in high demand during an influenza pandemic;
- Review procedures for the receipt, storage, and distribution of assets received from federal stockpiles;
- Include mechanisms for periodic reviews and updates.
HHS also details its recommendations around basic infection control principles for preventing the spread of pandemic flu in healthcare settings:
- Limit contact between infected and noninfected persons:
- Isolate infected persons (i.e., confine patients to a defined area as appropriate for the healthcare setting);
- Limit contact between nonessential personnel and other persons (e.g., social visitors) and patients who are ill with pandemic influenza;
- Promote spatial separation in common areas (i.e., sit or stand as far away as possible at least 3 feet from potentially infectious persons) to limit contact between symptomatic and non-symptomatic persons.
- Protect persons caring for influenza patients in
healthcare settings from contact with the pandemic influenza virus. Persons who
must be in contact should:
- Wear a surgical or procedure mask3 for close contact with infectious patients;
- Use contact and airborne precautions, including the use of N95 respirators, when appropriate;
- Wear gloves (gown if necessary) for contact with respiratory secretions;
- Perform hand hygiene after contact with infectious patients.
- Contain infectious respiratory secretions:
- Instruct persons who have flu-like symptoms to use respiratory hygiene/cough etiquette;
- Promote use of masks by symptomatic persons in common areas (e.g., waiting rooms in physician offices or emergency departments) or when being transported (e.g., in emergency vehicles).
In terms of surge capacity, HHS advises hospitals to plan ahead in order to address emergency staffing needs and increased demand for isolation wards, ICUs, assisted ventilation, and consumable and durable medical supplies. The use of FluSurge software is also recommended to aid facilities in estimating the potential impact of a pandemic on resources such as beds and ventilators. This spreadsheet-based application is available from the CDC at http://www.cdc.gov/flu/flusurge.htm
A Case Study
The Nebraska Biocontainment Unit, opened in March 2005, is a 10-bed unit located on the Nebraska Medical Center campus, which is a 750-bed hospital. Its a unique unit that was built with special air handling its all negative air flow; air flows into the unit, its HEPA filtered, and then the air actually gets discharged outside the building so that none of the air is recirculated, says Pat Lenaghan, RN, MSN, coordinator of the Nebraska Biocontainment Unit. All of the procedures are set up so that anything that leaves the unit is washed, cleaned, decontaminated, and disinfected before it goes to another department. For our staff, theres a shower they can use before they retrieve their personal items, and special lockers that store their personal things before they go home. The objective is to contain an infection within this unit and prevent its spread, either by air or contact, by the special procedures that we have in the unit.
Philip Smith, MD, medical director of the Nebraska Biocontainment Unit and chief of infectious diseases at the University of Nebraska Medical Center, explains how this project came into being. The health departments have discretionary money they can use for preparedness, and our health department decided that they wanted to set up a specialized unit, he says. Part of the reason for this is the convenience of consolidating some of the most contagious patients in the state in one area. The hospital identified an area that had formerly been a pediatric transplant ward that was no longer being used, and after a series of meetings with architects, planners, and infection control specialists, we identified the needs and the structural elements that were necessary to provide a care area like this, and the hospital was able to commit that floor to us.
After becoming involved in the project, Lenaghan had about a year to open the unit. First on her priority list was the formation of an advisory committee to help make decisions about moving forward. We had physicians, infectious disease specialists, pulmonologists, pediatric specialists, nurses, administrators, safety officers, security officers, laboratory personnel, radiology personnel anyone who would have contact with patient care for this issue plus some administrative responsibility, she says. Some of the decisions were administrative, like who authorizes the opening of the unit. Other decisions were clinical, such as the kinds of diseases we should prepare for and how we would prepare the staff. There were also hiring decisions how many people do we need, how do we hire them, and how do we make sure theyre competent?
Deciding what kinds of patients to plan for was an important question that was evaluated by a work group within the advisory committee using current national and global research and information. We decided on 11 diseases the six Category A bioterrorism agents/diseases from the CDC, as well as emerging highly infectious diseases that are problems worldwide, and those are SARS (severe acute respiratory syndrome), monekypox, avian flu, and then we also decided to take care of two very infectious diseases that are resistant to many drugs, and those are multi-drug resistant tuberculosis (TB) and vancomycin-resistant staph aureus. Those are the diseases that we train our staff on.
The basic architectural features of the unit include a separate area that can be sealed off to secure access. It also has separate staff entrances and exits, and a decontamination shower. It has a faster autoclave so if you have, for example, linens from a smallpox patient that are too dangerous to put in with the regular laundry, you can sterilize them and then they can be taken out the other side of the sterilizer by the regular hospital maintenance people, Smith says. We also have a dunk tank. One of the reasons we did this at the hospital is because the states bio-preparedness laboratory is on campus and they can deal with hazardous specimens its a BSL-3 lab. If we draw blood on a patient with a hazardous organism and the lab is going to deal with it, how do we get it from our patient care unit to the lab without exposing anybody?
The way we get around that is by sealing it in plastic, putting it in a dunk tank that has a disinfectant to sterilize the outside, and then transporting it. The unit has a virtual staff consisting of nurses, respiratory care practitioners, and nursing assistants or techs. They all work in other departments, Lenaghan says. After I got here and realized how we were going to have to staff the unit, I went to the nurse manager meetings and explained what we were doing and that I needed competent, skilled staff and the only way we were going to keep people competent is to have them work in their existing units, and they agreed to release their staff to me if we were to have an event. Since staffing the unit is not their primary responsibility, it was necessary to establish a method of notifying all staff members in the case of an event that necessitated opening the unit. We set everybody up on a software package called Alertcast, Lenaghan says.
Once we hire someone and get them through orientation and training, we put them on that Alertcast system. The system allows Lenaghan to notify all staff members at one time via their personal numbers (e.g. cell phone, home phone, pager, etc.). I make one phone call and then those hundreds of phone calls go out at the same time to notify them if were going to have a drill or if we have a real event. They need to respond in 60 minutes to let me know if theyre available to help open or staff the unit.
Planning for the possibility that the 10-bed unit might be overrun by infectious patients was necessary. If we have a massive outbreak of a disease that overwhelms the system, we have plans in place, Smith says. For instance, based on the air flow and traffic flow in our institution, weve identified a whole ward that we could convert if we had between 10 and 30 cases. If there are over 30, weve identified a second unit we would add, and beyond that the state health department or the CDC would probably be involved. At that point probably every hospital is going to have cases. We do have plans in place, because outbreaks can certainly expand quickly.
After having participated in the development of the Nebraska Bio-containment Unit, Smith advises facilities considering similar efforts to sit down and do the planning with all parties that will be involved. Some states have decided that they will have regular negative airflow TB rooms with strict isolation if they have a hazardous organism, Smith says. Others have decided that theyll use quickly constructed field tents where they can do special isolation. Weve decided to have sort of a permanent inpatient unit. Any of those solutions can be right the most important thing is that you have the hospitals infection control personnel and public health officials sit down and decide how they want to allocate their resources and how they want to work together. A lot of planning is going into place, but its important to have both parties communicate. Smith also emphasizes the importance of drills in illustrating and enforcing plans, as well as demonstrating aspects that may need improvement or modification.
Lenaghan points out that involving healthcare workers from many different areas can be invaluable. There are some circumstances where you just dont have enough information and thats when experience and thoughtfulness come in thinking about the issue, thinking about how staff will use the procedures, she notes. It was very important for me to have staff in the planning stages because theyre going to tell you if somethings not going to work. So you need to have people who are going to be doing the work of patient care in this unit in order to build the procedures correctly.