High-Consequence Infectious Disease Prepare in Partnership: Infection Prevention 
and Emergency Management

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Infection prevention and emergency management have always played their own critical roles in patient safety, but they are even better together when facing the threat of high-consequence infectious diseases (HCIDs) or special pathogens. Building a solid preparation plan to execute when an advisory becomes a reality will require the skill sets of both experts.

In 2014, 2 health care workers with Ebola were medically evacuated from an outbreak in West Africa to the US for treatment. The Ebola virus also traveled internationally and domestically by commercial airlines in human hosts. Two nurses contracted Ebola after direct care of an infected patient. At the highest level, collaboration was needed between multiple agencies to screen travelers and strengthen infection prevention preparedness to apply in hospitals.¹ The critical nature of travel history was highlighted at that time. The global COVID-19 pandemic taught the world that a virus can travel broadly and quickly, along with the rapidly changing recommendations to respond to a new, unknown illness to mitigate risk to health care personnel and the public.

In 2023, the CDC issued 19 health advisories through their Health Alert Network, and 14 more advisories were released between January and September 2024.² States sent out their notices; for example, in Georgia, where the CDC is located, the Georgia Department of Public Health additionally distributed their statewide alerts each year: 2 in 2023 and 6 in 2024, to date of the writing of this article.³ During the same time, local public health departments communicated other issues with public health and infection prevention implications, such as boil-water advisories.

Regulatory Compliance Response

In response to events like these and growing concerns for health care
facility readiness to have standard processes in place, The Joint Commission (TJC) revised standards to include a requirement, Standard IC.07.01.01, that directs hospitals to implement “processes to support preparedness for high-consequence infectious diseases or special pathogens.”4 There are 2 related elements of performance to guide facilities in implementing the standard. The first includes the principles of identifying, isolating, and informing; personal
protective equipment (PPE) use; exposure reduction measures; and environmental management. The second addresses the related education, training, and competency of the staff who put the processes into practice.

Although most US hospitals and hospital systems follow TJC standards, some use Det Norske Veritas, which applies National Integrated Accreditation for Healthcare Organizations standards that are also in keeping with Centers for
Medicare & Medicaid Services expectations to mitigate risk and apply quality standards for accreditation.

Figure. National Institute for Occupational Safety

and Health’s Hierarchy of Controls (Credit: NIOSH)

With routine daily work, alerts and advisories, travel history and special pathogens, regulatory compliance, and more, the infection preventionist (IP) has much to remember. In addition, the IP may be a solo artist or may have a team to rally; still, they must act on the information received, assess the risk, and determine the potential mitigation needed to protect patients, team members, and the community. The good news is that IPs do not have to start from scratch or face the challenge alone, as tools and resources are available to customize a program for each facility.

A partnership of like-minded professionals working toward a common goal does not mean that one discipline of many people should make all the decisions—that describes a silo. Instead, people with similar methods and strategies but different discipline perspectives will create a dynamic, innovative team. Emergency management professionals are well-versed in creating concepts and plans to reduce vulnerability and respond to potential or actual threats or hazards. The Federal Emergency Management Agency (FEMA) describes the emergency management culture as having 8 principles to “guide the development of a doctrine of emergency management,”5: comprehensive, progressive, risk driven, integrated, collaborative, coordinated, flexible, and professional. These principles are also common to those in infection prevention.

Put the Partners to Work

Frontline health care personnel must be prepared to act quickly. Does the patient present to the facility, emergency department, outpatient urgent care, ambulatory clinic, or another location? That is the point of entry and where screening procedures start to identify the potential for possible infectious illness. Initiate appropriate transmission-based precautions, to include the safe provision of care to isolate using the hierarchy of controls (Figure) to reduce exposure among health care personnel, other patients, and visitors.

Next, determine who and how to inform key stakeholders both inside and outside your organization. Your policies and procedures should guide the processes for determining the deployment of other emergency operations activities.

Training, education, and competency in readiness for emerging infectious diseases are imperative. Some organizations may have internally developed content available for their staff. The National Emerging Special Pathogens Training & Education Center6 has created best practice resources to train personnel to manage special pathogens. Their website provides easily accessible, free webinars and continuing education units that apply not only to infection prevention professionals but also to emergency management, Hospital Incident Command System (HICS) participants, and frontline personnel.

When constructing a preparedness program, consider a basic template with common elements that are customizable for any HCID of current public health concern. Association for Professionals in Infection Control and Epidemiology playbooks7 are available for download and distribution and can be paired with just-in-time training for ready-to-apply examples. Many disciplines will have valuable input to operationalizing an HCID plan, but a template in hand to guide the discussion and preparation will provide a solid foundation.

Identification. Determine screening criteria for the organism or disease to specify definitions for a suspect, probable, or confirmed case. Exclusion criteria should also be considered. Once identified, ascertain any additional public health guidance for public health epidemiologic criteria, travel considerations, exposure definition, specific collection or testing criteria, and any bioterrorism threat or antimicrobial resistance.

Prevention of transmission. Determine PPE requirements, adequate supply, and readily available point-of-use storage. Plan for waste management handling, storage, and transportation. Safe patient transport management within the facility and coordination with emergency medical services partners will be needed. Verify and validate special air handling needs. Confirm Environmental Protection Agency–approved products for disinfection of the environment and equipment. Establish possible transmission and exposure monitoring through surveillance for hospital-onset cases.

Providing patient care. Evaluate the necessity and capability of performing high-risk procedures. Establish visitor management protocols. Prepare for postmortem care, handling of the deceased, temporary holding, and safe release to the mortuary or coroner. Determine realistic infection prevention department resources for staffing and availability.

Patient discharge. Prepare specific, consistent patient instructions for a safe return home or to communal living. Coordinate and communicate with public health and, if applicable, with the receiving facility, including diagnosis confirmation, date of illness, treatment, and health department notification.

Occupational health. Determine an exposure definition. Prepare and provide pre- and postexposure information, such as vaccine availability, to prevent or lessen illness severity. Be ready to guide employees through furlough and return to work if necessary. Conduct contact tracing if applicable. Determine employees who may be at increased risk for severe disease.

Involve other key health care stakeholders. Engage senior leadership in preparedness activities and ask for a sponsor or champion to help pave the way. Advise that readiness brings protection of their workforce and the community, better patient outcomes, continuity of care, and high reliability with deference to the expertise of their infection prevention and emergency management partners. The cost of failure to prepare brings increased length of stay, decreased staff safety, lost workdays, long-term health exposure consequences, loss of community confidence, and reputational risk.

Nurses, physicians, and other direct caregivers must be able to follow the plan’s workflow. The preparedness plan fails if it cannot be applied. Although IPs serve as subject matter experts for HCIDs, engage in the art of humble inquiry to ensure a keen understanding of barriers and challenges to overcome. These most at-risk colleagues must be proficient and confident in the steps to take when facing an HCID.

Ensure the pharmacy and laboratory are informed so each can be aware of treatment and testing recommendations to allow for ordering and storing adequate medication and other related supplies. The supply chain department will coordinate just-in-time readiness of supplies to manage those initially presenting patients with HCID. It will work with emergency management to establish a cache of materials to have ready in the event of rapid supply depletion or supply disruption.

Infectious diseases will always be coming and going (pun intended, to underscore the importance of travel history). Patients are going to choose the facility they are physically nearby. They choose the hospital they know or trust. The public is not likely to know to call ahead or put on PPE before arriving at the emergency department.

However, they do know that they returned from vacation with a new rash, fever, cough, or other symptoms, and they need help. The time to plan for safe management of patients who come through the door is now. You can have a dynamic response to HCIDs when you plan a program outside a single silo. Engage that planning with the team in the facility but with a vision that considers the associated health system, community, region, state, and national collaborators. The topics to follow in this series will include collaboration on the influx of infectious patients and infection prevention at the HICS table for emergency preparedness in an HCID event.

References

1. Ebola: outbreak history. CDC. May 6, 2024. Accessed September 8, 2024. https://www.cdc.gov/ebola/outbreaks/index.html#:~:text=1989&text=High%20mortality%20among%20Cynomolgus%20macaques,symptoms%20of%20Ebola%20Virus%20Disease
2. Emergency preparedness and response. CDC. Reviewed March 28, 2019. Accessed October 2, 2024. https://emergency.cdc.gov/han/2023.asp
3. Georgia’s Health Alert Network (GAHAN). Georgia Department of Public Health. Updated August 29, 2024. Accessed September 20, 2024. https://dph.georgia.gov/epidemiology/epidemiology-emergency-preparedness/gahan
4. R3 report: requirement, rationale, reference. The Joint Commission. December 20, 2023. Accessed September 28, 2024. https://jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_report_ic_rewrite-hap_cah.pdf
5. Emergency management overview. Federal Emergency Management Agency. Accessed September 20, 2024. https://emilms.fema.gov/is_0230e/groups/999.html#:~:text=Emergency%20management%20is%20the%20managerial,hazards%20and%20cope%20with%20disasters
6. National Emerging Special Pathogens Training and Education Center. Accessed September 28, 2024. https://netec.org
7. Emerging infectious diseases. Association for Professionals in Infection Control and Epidemiology. Accessed October 2, 2024. https://apic.org/emerging-infectious-diseases/