Houston, We Have a Problem

By Jennifer Schraag

Margaret Price, PhD, CIC, infection control coordinator at St. Lukes Episcopal Hospital in Houston, Texas, co-chair of the regional hospital preparedness planning group, and a fellow of the Society for Healthcare Epidemiology of America (SHEA), worked countless hours in aiding Katrinas refugees in the days following the catastrophic event. She shares with ICT her experience and what she learned from the chaos that ensued.

As a receiving entity, from an infection control standpoint here in Houston, the key elements, I think, are communication of the patients arriving, she begins.

Price says her and fellow emergency personnel rushed to prepare for the arriving refugees, and while they knew they were coming, there seemed to be only sporadic reports of how many they could expect to arrive and even less information on exactly when.

Once the planes began to land, a whirlwind a preparations and procedures unfolded.

Price said the evacuees were screened for contagious diseases as they arrived. Mostly tuberculosis and diarrhea were the ones we were really worried about, she said.

From there it was decided which evacuees would go where.

This region has in excess of 95 hospitals in an 11 county area. Most of us are linked by a Web page system. The system includes the number of beds available at each facility and what kind of beds they are that are available. This includes emergency room beds, how many dialysis beds, etc., because this was a problem early on.

All requests for a bed came to our command center. We would coordinate who went where, with who had what kind of beds. For facilities who are receiving patients, there is a screen so we know whats coming in. So, when infectious patients were to be transported, the facilities were called so they could take the necessary precautions upon admitting the patient.

I think we did pretty well, she continues. We never reached capacity. We kept the system working. We kept our trauma centers open, we kept our acute care centers open and everybody worked really well together. We worked with emergency management and the health department, we had a unified command and were really happy with it. Were kind of tired, but were really happy with it.

Price says over the many years her team has worked in preparing and planning for such events, this is the first time it has truly been challenged. That said, she was pleased with some of the advance planning they did and how it helped to ease the current situation.

For example, they had in place a plan that includes extra negative pressure rooms to be ready upon command. So if we needed to, we could activate that, but we never needed to do that. Weve been working on this for quite a number of years, she says.

Another thing we did here in Houston that helped us a lot, is the big centers such as the convention center and the Astrodome, set up clinics where the simplest of the cases could be taken care of. That helped us also.

The most beneficial aspects in the whole ordeal, according to Price, were the availability of the alcohol hand gels. She could not emphasize enough the importance of ensuring each and every evacuee -- and the staff -- receive the gel so as to limit their exposure out in the community.

Personal protective equipment was another imperative IC barrier, especially upon the refugees arrival. Were okay, so far. Our hospitals had some and then we worked with the emergency management folks who, they help us if the local supplies dry up by bringing more in from the outside. Masks and gloves have been of the highest demand.

Educating the volunteers was pretty straight forward, says Price. The health department had some preprinted information sheets in different languages -- primarily it was on the standard contagious diseases. We used contact isolation -- gloves, masks, etc., -- and made sure all of our workers had access to the gloves that they needed and soap and water or hand gel. The hand gel was a big plus.

Preparing for such catastrophic events as hurricane Katrina proved to be is challenging; yet an ongoing initiative throughout America. These types of readiness programs are imperative, according to Price. She advises all infection control practitioners (ICPs) to participate in their local preparedness groups. All across the country there are regional planning groups that have been set up to deal with these kinds of emergencies and bioterrorism. They [ICPs] must participate. Get in there and find out whats going on and make sure theyre important in those groups.

She points out that widespread use of IC personnel and practices at these types of command centers is challenged, at best. I dont know that its (the usage of ICPs in the command centers) gone that far. Health department people do not always understand what goes on in hospitals so theyre looking more to a community thing. So, I think its very important to have infection control people active in the local planning and in the local command centers when they are established.

Its really important for the IC people to be in there. Be in the exercises. This is a mass casualty event. We have to be part of it. Get to know your local emergency department. Make sure all your hospitals are talking to each other. I think that really makes a huge difference.

The ongoing IC measures are just as critical as those in the beginning, Price confirms. Well continue to monitor because there is concern of hepatitis A and other infectious agents the evacuees were exposed to while in Louisiana, Price says. We always report to the health depart infectious disease and well continue to be very careful to do that.

I also think well have to be very careful Im worried about the wound infections that we might have from being in the water so long and with the reports of Vibrio vulnificus, thats a really bad organism. Whoever is getting these people, I think we have to be careful.

The spread of diarrheal infections will remain at the forefront of concern for quite some time. Price shares that three of their radiology techs had come down with diarrhea after caring for an evacuee. They organized some cultures in the area to test for organisms and initiated contact precautions. Nothing grew and it turned out to be a virus the evacuee had. Problem is, you dont know right away. We werent expecting to see cholera, but you never know.

Preparedness will never be 100 percent, but measures can be taken to ease the chaos when proper planning is in place.

Initially, it was very hectic. It seems with these things, no matter how prepared you are, its always chaotic. The first 24 to 48 hours it seems. You just have to be flexible and adapt to that, Price advises.

Other tips and things to consider, according to Price, include:

Think ahead of time how your screening system is going to work and communicate that to the people who are going to be screening. We came up quickly with the guidelines for what to look out for, from an infection control standpoint, when these people came.

Our region is divided into different corridors and we wanted someone from each corridor there. Because of the holiday, we had trouble getting a hold of people to come and work at the command center.

I probably would have made sure we had a lot more hand gel available. We didnt run out, we had sent out for it and we got it, but we had hundreds of thousands of refugees. I dont know that we could stock that, but it is something that if we couldnt have gotten it, it would have been a major issue.

One of our centers made it a prerequisite that before they ate every single person would use the hand gel. That included the police, everybody, that was the rule. I really think it helped limit the problems that occur when you have crowds of people together.

In this kind of emergency situation, theres not a lot of time to think about what to do, Price warns. You need to come up with an intermediate solution -- even if you change it later, it is okay, but you need to come up with a plan, then modify it as you get more information.

In infection control we usually know all the facts up front. We usually know if it might be tuberculosis and then we can say, do that and then, you know, theres no rush, theres no situation you havent faced before usually, but these were situation I hadnt faced before. So it was interesting.

Price says she learned a lot from this experience, one of the most valuable being a comforting though for future events, should they occur.

What Ive learned was actually a definite plus, and that was how well we actually worked together. Its not always clear that we do, but I have to say I was incredibly impressed with how facilities worked together, sent staff to the command center and some were infection control people, some were emergency department people, some were facilities people, and we all managed to make it work.

Communication and knowledge is incredibly important.