Add Biopreparedness to IP Checklist

Infection preventionists’ (IPs) roles in emergency response efforts historically have been minimal in health care settings. Typically, the emergency response program completes a risk assessment annually, the Hazard Vulnerability Analysis (HVA).¹ In these reviews, all hazard risks are ranked according to likelihood of occurrence, severity of impact, and current capabilities to mitigate risks. Natural disasters, manmade disasters, and pandemics were included in the analyses. I believe most health care facilities would have ranked the likelihood of a pandemic as low, severity of a pandemic as high, and the capability to manage a pandemic would vary greatly from facility to facility.

As the heightened sense of awareness faded after the Ebola response in 2014 and 2015,² the funding that had been assigned because of that outbreak began to dissipate and other priorities overtook efforts to maintain biopreparedness programs. Maintaining a strong program is expensive for health care facilities, and many of those costs are not redeemable through reimbursement from payers or funding from outside resources.

Along those same concerns, infection prevention staff were pulled into the efforts to reduce health care–acquired infections (HAIs) as those metrics became part of the Hospital Value-Based Purchasing Program and directly affected a facility’s payments from the Centers for Medicaid & Medicare Services (CMS).³

Tested by Surges

The COVID-19 pandemic exposed many areas of challenge to broad pandemic response. The first surges showed how quickly personal protective equipment (PPE) supplies could be decimated and testing capabilities stretched thin beyond use. Later surges tested capacity, staffing, treatment development, and resilience of a health care force. Throughout the pandemic, misinformation and disinformation made coordinated efforts even more challenging and perhaps highlighted an unforeseen challenge to biopreparedness programs.⁴ How can health care providers be prepared to handle the deluge of opinions from nonexperts on responding to a pandemic response that affect the behaviors and choices of patients and staff alike?

Crisis standards of care were developed by the Centers for Disease Control and Prevention in response to the shortages and challenges facing health care.⁵ These standards are a framework to help facilities determine thresholds for staging out mitigation factors, such as PPE reuse, staffing models, and capacity limits. Based on these existing guidelines, biopreparedness programs can develop local models of crisis standards that act as triggers for next steps or mitigation factors.⁶

As COVID-19 becomes endemic (as of this writing the threat that the Omicron variant poses is still unknown), now is the time for IPs to harness the current attention to biopreparedness and use the momentum to build the foundations for strong local programs that can be sustained through future waves of competing priorities.

The first step is to gather leadership support to establish a formal program, if one doesn’t exist, or the support to formalize the existing program and expand on its capabilities.⁷ The next step is to conduct a gap analysis to determine what worked well during the COVID-19 response, what innovations were developed that can become standard practice, and what areas are still opportunities for improvement. Existing gap analyses (eg, the High-Consequence Infectious Disease Preparedness Checklist from the Joint Commission) can be used.⁸ Part of the gap analysis could include a run-through of a scenario to determine what actions to take if a patient with a high-consequence disease (HCD) comes into the emergency department.

Once the gap analysis is completed, the results will guide the next steps. A formal committee or workgroup of multidisciplinary members who are all stakeholders can be established to take on action items specific to each department. A written plan can be the cornerstone of the committee’s work; however, the document must be flexible and able to be molded to any new HCD encountered. Having a response plan that isn’t focused on 1 specific disease type (ie, Ebola or influenza) allows for adaptation to the unknown—such as COVID-19 was at first—and is essential to be able to quickly respond when all the information isn’t known.7 Additionally, the committee and plan must have a multiyear strategy, as the work cannot be expected to be completed quickly if it is to be built into the foundations of the organization.⁹

Training Staff

Once the plan is established and the committee is meeting routinely, the next step is to train frontline staff and build competency within your workforce. Training is essential to ensure all who may encounter patients with an HCD can quickly recognize potential transmission threats and enact appropriate isolation precautions and escalate quickly.

Education plans need to include training current employees and making biopreparedness training part of orientation and onboarding for new staff. Turnover in hospitals always presents challenges to maintaining efforts, so having a plan to include biopreparedness in the clinical orientation process will be key to making it part of the organization’s culture. Along with training staff, training the infection prevention team to build expertise also will create the strong leadership in the program. Free programs, such as those sponsored by the Center for Domestic Preparedness in Anniston, Alabama, are a great option to immerse IPs in biopreparedness with others who want to learn more.¹⁰

Another way IPs can help sustain biopreparedness efforts is to be a leader in their organization’s safety culture. IPs can take a leadership role in facility initiatives such as High Reliability, Lean Six Sigma Management, and other concepts and work to integrate biopreparedness into those initiatives.^11,12 Early response and recognition and escalating safety concerns all fit into those safety culture concepts and can help sustain biopreparedness.

Information technology infrastructure needs to be supported in infection prevention programs in general, including biopreparedness. Analytics and surveillance programs that detail threat assessments and detect syndromic patterns and trends across states and regions help predict risk and develop countermeasures. Barriers to communication across international and national surveillance systems need to be addressed to improve the public health response. Collaboration in public health efforts is needed to ensure outbreaks are addressed early and information shared to prevent transmission.

Federal government investment into biopreparedness would increase interest and ability for individuals and organizations to obtain funding in areas of infectious disease that are lacking across the country. The Infectious Diseases Society of America recently released a statement supporting one such effort, the BIO Preparedness Workforce Act.¹³ This act would increase funding and loan repayment for health care professionals who spend at least half of their time working in biopreparedness roles or providing infectious disease care in underserved communities. The act is still pending review in the US Congress but would be a strong show of support for bolstering the workforce in this up-and-coming field.

Make It Work

Mandating biopreparedness also could be part of CMS conditions of participation or accrediting bodies. As was demonstrated with HAI prevention, once money was tied to outcomes, focus improved and more efforts were made to bolster IPs’ capabilities. The same could potentially be done for biopreparedness, including mandating training, drills, and comprehensive high-consequence disease plans for health care facilities.

IPs can work with their local health departments to build links within acute care, long-term care, community health, and public health surveillance. If your local public health jurisdiction has a biosurveillance program, have your organization join and become part of a larger network feeding information into larger national databases. Then those databases need to be able to generate useful information that can quickly be passed to local providers who are seeing patients in clinics and emergency departments to apply clinical assessments based on known risk factors.

As we continue into the second year of COVID-19 response, IPs are at the front line to ensure biopreparedness programs become a priority for their organizations. Collaboration and advocacy efforts can build the foundation at local levels, but for true sustainability, federal and state regulatory bodies need to take notice and ensure biopreparedness programs become a primary issue going forward.

REBECCA LEACH, MPH, BSN, RN, CIC, has been an infection preventionist since 2010 with a background in nursing and epidemiology. Leach, a member of theInfection Control Today® Editorial Advisory Board, works at a health care system in Phoenix, Arizona, that includes 5 hospitals and more than 100 outpatient treatment centers.

References:

1. What are the requirements related to the hazard vulnerability analysis (HVA) for organizations and off-site facilities? The Joint Commission. Updated November 16, 2016. Accessed November 30, 2021. https://www.jointcommission.org/standards/standard-faqs/home-care/emergency-management-em/000001196/
2. Popescu SV. Preparing for special pathogens: an IP perspective. Infection Control Today®. 2020;24(1):12-14. https://www.infectioncontroltoday.com/view/preparing-special-pathogens-ip-perspective
3. The Hospital Value-Based Purchasing Program. CMS. Updated February 18, 2021. Accessed November 30, 2021. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HVBP/Hospital-Value-Based-Purchasing
4. Leach R. How infection preventionists can battle misinformation. Infection Control Today®. 2021;25(10):32-33. https://www.infectioncontroltoday.com/view/how-infection-preventionists-can-battle-misinformation
5. Optimizing supply of PPE and other equipment during shortages. CDC. Updated July 16, 2020. Accessed November 8, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/general-optimization-strategies.html
6. Franco C, Hansen M. The state of biopreparedness: lessons from leaders, proposals for progress. Conference Reports. Center for Biosecurity of UPMC. Accessed November 30, 2021. https://www.centerforhealthsecurity.org/our-work/events-archive/2010_state_of_biopreparedness/conf_report.pdf
7. Popescu S, Leach R, Robinson K. Establishing a pre-COVID-19 hospital biopreparedness initiative. Disaster Med Public Health Prep. 2021;25:1-4. doi:10.1017/dmp.2021.91
8. The Joint Commission Guide to Risk Assessment, Joint Commission Resources, 2021. The Joint Commission. August 25, 2021. Accessed November 5, 2021. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/joint-commission-online/aug-25-2021/new-risk-assessment-guide-available-from-jcr/
9. Atkinson MK, Cagliuso NV Sr, Hick JL, et al. Moving forward from COVID-19: organizational dimensions of effective hospital emergency management. Health Secur. 2021;19(5):508-520. doi:10.1089/hs.2021.0115
10. Center for Domestic Preparedness. Training the best for the worst. FEMA. Accessed November 30, 2021. https://cdp.dhs.gov
11. High reliability and infection prevention. The Joint Commission. Accessed November 30, 2021. https://www.jointcommission.org/resources/patient-safety-topics/infection-prevention-and-control/high-reliability-and-infection-prevention/
12. Montella E, Di Cicco MV, Ferraro A, et al. The application of Lean Six Sigma methodology to reduce the risk of healthcare-associated infections in surgery departments. J Eval Clin Pract. 2017;23(3):530-539. doi:10.1111/jep.12662
13. IDSA and HIVMA Support BIO Preparedness Workforce Act. IDSA. News release. October 25, 2021. Accessed November 11, 2021. https://www.idsociety.org/news--publications-new/articles/2021/idsa-and-hivma-support-bio-preparedness-workforce-act/