Integration, Collaboration Key for Hospitals and Communities in Preparing for Outbreaks

Integration, Collaboration Key for Hospitals and Communities in Preparing for Outbreaks

By Kris Ellis

Healthcare systems in the Untied Statesand around the world must deal with the specter of impending large-scale healthcrises each and every day. Much effort has been put forth to increase theeducation, training, and funding that are vital to establishing and maintainingan optimal level of readiness for such an event, be it in the form ofbioterrorism, pandemic influenza, or any other particularly virulent infectiousthreat. While progress has been made on many fronts, it is incumbent upongovernment officials and healthcare personnel to continue pushing the envelopeof preparedness.

The first critical piece that hospitals and healthcaresystems should be involved in is the process of surveillance, says CharlesBaum, MD, MS, vice president of health affairs and medical director of theNutrition and Disease Prevention Center at the Alexian Brothers HospitalNetwork. Not traditional infectious disease surveillance, but more earlyidentification syndromic surveillance. Its a very interesting new publichealth tool because it deals with disease identification before theres anactual diagnosis.

For example, Baum cites the ESSENCE (Electronic SurveillanceSystem for the Early Notification of Community-based Epidemics) system, which heis assisting implementation of in the northwest Chicago suburbs. The systememploys syndromic surveillance for capturing and analyzing public healthindicators for early detection of disease outbreaks. Its essentially acomputer program that monitors the chief complaints of patients admitted to theemergency room (ER), Baum explains. Four times per day, the system compiles the data and sendsit to the county department of public health. What theyre looking for aretrends if all of the sudden theres been a surge in cough and fever, forexample, that signals to them that theres something going on in thatparticular area around the hospital.

This type of system can allow public health officials todetermine whether or not symptoms are generalizing and spreading. It may alsoprovide hospitals some lead time for preparation since they can monitor the datasimultaneously. The importance of this, particularly with pandemic flu, is itcan 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 fordrug distribution is being implemented and piloted, and actually in ourcommunity its in place, so theres a system for getting it distributed topeople.

In terms of contending with the influx of patients that asituation 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 theER and needing admission, so how do you manage that? Well, you look at the bestcase 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 thehospital, you dont want to affect the currently sick, so thats an area ofongoing discussion; do you keep them in the hospital or do you ship them out toanother site? I think we may see differences across the country in how thatsdone. The hospital infection control staff has to try and maintain them, Ithink, in a quarantine state where theyre separated from the generalpopulation, and then of course enforce strict handwashing. Everybody probablyneeds to be wearing masks at that point, and you hope that you have adequatesupplies of Tamiflu and that its effective. Baum stresses the need forhospitals to work closely with the public health system, even though this maynot be the norm for many. The public health system is not used to workingwith the healthcare system and vice versa, and this brings about a whole lot ofissues.

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 graduatehealth science programs at the Medical University of Ohio at Toledo. Bisesi isalso program director for the Northwest Ohio Consortium for Public Health. Alot of it goes back to education and training, he says.

Certainly hospitals have infection control personnel inplace thats been the baseline for a long time, but the health departmentsare better equipped today than they have been historically. Throughout thecountry theres been increased emphasis on hiring epidemiologists or at leastpublic health personnel with stronger backgrounds in epidemiology. Thats beenwhere communications have been strengthened, because there are larger numbers ofpersonnel, and more qualified personnel, at more health departments than therehave been in the past. These people can interact with hospitals and be moreproactive in the early stages of an outbreak or even a suspected outbreak toattempt to control the spread of an infectious or communicable agent sooner thanwe were in the past.

Bisesi says improved communications and coordination have beenenhanced by federal funding coming into the states and municipalities from theMetropolitan Medical Response System (MMRS). This program began in 1996 as aresult 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 personalprotective equipment in order to achieve the enhanced capability necessary torespond to a mass casualty event such as a terrorist act. There are MMRSsthroughout the country now and they are funded by dollars that have come in fromthe feds to the municipalities allowing them to strengthen the interaction andintegration of all the responding agencies that would be involved, Bisesicontinues. For example, if theres a hospital and public health departmentinvolved, 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 hasbeen expanded. For example, in northwest Ohio in 2000, the city of Toledo inLucas County was at that point designated in the MMRS, and that has now expandedfrom one county Lucas to 19 counties in northwest Ohio, so we now havethe regional medical response system. This way were not dealing only with onecounty but recognizing that these events can certainly overlap, so weactually have a communications network that transcends boundaries.

Notification via various communication modes can be initiatedrapidly in order to promote awareness if a suspected or actual outbreak were tooccur in this model. Not only much sooner, but much more efficiently andeffectively relative to whats been done in the past, Bisesi continues. Its not yet a perfect system, but itsevolving into a much better system than weve had historically.

For hospitals interested in bolstering communications and tieswith public health, Bisesi suggests finding out where the closest MMRS is setup. They can also start with their local health department and try tostrengthen the linkages, and they can contact their state health departments aswell, he notes. For example, if there is relatively slow activity at alocal level, perhaps they can try the state level.

Another thing thats happened is that other resources suchas academic institutions and other public and private entities have gotteninvolved as well. I can speak for northwest Ohio what improved things herewas having consistent interaction; from something as simple as having meetingsall the way to full-scale drills basically emphasizing the need forintegration and strengthened interaction. I think most hospitals would agreethat theyre better prepared today than they were in the past, but they stillfeel that theres room for improvement. What it really comes down to isstrengthening linkages among all those who would be involved.

I think at this stage of the game, hospitals and infectioncontrol professionals need to, in a broad sense, look to the CDC and the federalgovernment, to their state and public health departments, and more importantly,reach out to their local public health entities. If they do that in a proactiveway, that will help tremendously, Baum suggests. In this kind of scenario, top hospitalleadership needs to know and be intimately involved. That also speaks to thepoint that infection control practitioners in hospitals often dont have thatcommunication pipeline, but they need to push for it. They need to really takethis top.

Bisesi points out that more, and more frequent, education andtraining around outbreak preparedness is now conducted within facilities, andthat collaborative efforts between hospitals are on the rise. For example, inthe state of Ohio, we have the Ohio Hospital Association and we have regionalhospital associations such as the Hospital Council of Northwest Ohio. Thatorganization helps to coordinate collaborative activities ranging from orderingthe same type of personal protective equipment and decontamination equipment tomaintaining similar inventories of supplies so that if an event occurs, we havea more coordinated effort to share resources between and among hospitals withina region and also to have more coordinated efforts for education and training.So theres certainly a much more elaborate system that exists today than inthe past for that integration, collaboration, and cooperation.

At the federal level, the United States Department of Healthand Human Services (HHS) has released its Pandemic Influenza Plan, whichincludes supplements dedicated to healthcare planning and infection control as they relate to a possible pandemic situation.¹

According to this document, hospital response plans forpandemic influenza should:

• Outline administrative measures for detecting theintroduction of pandemic influenza, preventing its spread, and managing itsimpact on the facility and the staff.

• Build on existing preparedness and response plans forbioterrorism events, SARS, and other infectious disease emergencies;

• Incorporate planning suggestions from state and localhealth departments and other local and regional healthcare facilities andresponse partners;

• Identify criteria and methods for measuring compliancewith response measures (e.g., infection control practices, case reporting,patient placement, healthcare worker illness surveillance);

• Review and update inventories of supplies that will be inhigh demand during an influenza pandemic;

• Review procedures for the receipt, storage, anddistribution of assets received from federal stockpiles;

• Include mechanisms for periodic reviews and updates.

HHS also details its recommendations around basic infectioncontrol principles for preventing the spread of pandemic flu in healthcaresettings:

• Limit contact between infected and noninfected persons:
  - Isolate infected persons (i.e., confine patients to adefined area as appropriate for the healthcare setting);
  - Limit contact between nonessential personnel and otherpersons (e.g., social visitors) and patients who are ill with pandemicinfluenza;
  - Promote spatial separation in common areas (i.e., sit orstand as far away as possible at least 3 feet from potentiallyinfectious persons) to limit contact between symptomatic and non-symptomaticpersons.

• Protect persons caring for influenza patients inhealthcare settings from contact with the pandemic influenza virus. Persons whomust be in contact should:
  - Wear a surgical or procedure mask3 for close contact withinfectious patients;
  - Use contact and airborne precautions, including the use ofN95 respirators, when appropriate;
  - Wear gloves (gown if necessary) for contact with respiratorysecretions;
  - Perform hand hygiene after contact with infectious patients.

• Contain infectious respiratory secretions:
  - Instruct persons who have flu-like symptoms to userespiratory hygiene/cough etiquette;
  - Promote use of masks by symptomatic persons in common areas(e.g., waiting rooms in physician offices or emergency departments) or whenbeing transported (e.g., in emergency vehicles).

In terms of surge capacity, HHS advises hospitals to planahead in order to address emergency staffing needs and increased demand forisolation wards, ICUs, assisted ventilation, and consumable and durable medicalsupplies. The use of FluSurge software is also recommended to aidfacilities in estimating the potential impact of a pandemic on resources such asbeds and ventilators. This spreadsheet-based application is available from theCDC at http://www.cdc.gov/flu/flusurge.htm

A Case Study

The Nebraska Biocontainment Unit, opened in March 2005, is a10-bed unit located on the Nebraska Medical Center campus, which is a 750-bed hospital. Its a unique unit that was built withspecial air handling its all negative air flow; air flows into the unit,its HEPA filtered, and then the air actually gets discharged outside thebuilding so that none of the air is recirculated, says Pat Lenaghan, RN, MSN,coordinator of the Nebraska Biocontainment Unit. All of the procedures areset up so that anything that leaves the unit is washed, cleaned, decontaminated,and disinfected before it goes to another department. For our staff, theres ashower they can use before they retrieve their personal items, and speciallockers that store their personal things before they go home. The objective isto contain an infection within this unit and prevent its spread, either by airor contact, by the special procedures that we have in the unit.

Philip Smith, MD, medical director of the NebraskaBiocontainment Unit and chief of infectious diseases at the University ofNebraska Medical Center, explains how this project came into being. Thehealth departments have discretionary money they can use for preparedness, andour 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 someof the most contagious patients in the state in one area. The hospitalidentified an area that had formerly been a pediatric transplant ward that wasno longer being used, and after a series of meetings with architects, planners,and infection control specialists, we identified the needs and the structuralelements that were necessary to provide a care area like this, and the hospitalwas able to commit that floor to us.

After becoming involved in the project, Lenaghan had about ayear to open the unit. First on her priority list was the formation of an advisorycommittee 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 thisissue plus some administrative responsibility, she says. Some of the decisions were administrative, likewho authorizes the opening of the unit. Other decisions were clinical, such asthe 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 hirethem, and how do we make sure theyre competent?

Deciding what kinds of patients to plan for was an importantquestion that was evaluated by a work group within the advisory committee usingcurrent national and global research and information. We decided on 11diseases the six Category A bioterrorism agents/diseases from the CDC, aswell as emerging highly infectious diseases that are problems worldwide, andthose are SARS (severe acute respiratory syndrome), monekypox, avian flu, andthen we also decided to take care of two very infectious diseases that areresistant to many drugs, and those are multi-drug resistant tuberculosis (TB)and vancomycin-resistant staph aureus. Those are the diseases that we train ourstaff on.

The basic architectural features of the unit include aseparate area that can be sealed off to secure access. It also has separatestaff entrances and exits, and a decontamination shower. It has a fasterautoclave so if you have, for example, linens from a smallpox patient that aretoo dangerous to put in with the regular laundry, you can sterilize them andthen they can be taken out the other side of the sterilizer by the regularhospital maintenance people, Smith says. We also have a dunk tank. One ofthe reasons we did this at the hospital is because the states bio-preparednesslaboratory is on campus and they can deal with hazardous specimens its aBSL-3 lab. If we draw blood on a patient with a hazardous organism and the labis 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, andthen transporting it. The unit has a virtual staff consisting of nurses, respiratorycare practitioners, and nursing assistants or techs. They all work in otherdepartments, Lenaghan says. After I got here and realized how we weregoing to have to staff the unit, I went to the nurse manager meetings andexplained what we were doing and that I needed competent, skilled staff and theonly way we were going to keep people competent is to have them work in theirexisting units, and they agreed to release their staff to me if we were to havean event. Since staffing the unit is not their primary responsibility, it wasnecessary to establish a method of notifying all staff members in the case of anevent that necessitated opening the unit. We set everybody up on a softwarepackage called Alertcast, Lenaghan says.

Once we hire someone and get them through orientation andtraining, we put them on that Alertcast system. The system allows Lenaghan tonotify all staff members at one time via their personal numbers (e.g. cellphone, home phone, pager, etc.). I make one phone call and then thosehundreds of phone calls go out at the same time to notify them if were goingto have a drill or if we have a real event. They need to respond in 60 minutesto let me know if theyre available to help open or staff the unit.

Planning for the possibility that the 10-bed unit might beoverrun by infectious patients was necessary. If we have a massive outbreakof 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, weveidentified 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 beyondthat the state health department or the CDC would probably be involved. At thatpoint 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 NebraskaBio-containment Unit, Smith advises facilities considering similar efforts to sitdown and do the planning with all parties that will be involved. Some stateshave decided that they will have regular negative airflow TB rooms with strictisolation if they have a hazardous organism, Smith says. Others have decided that theyll use quickly constructedfield tents where they can do special isolation. Weve decided to have sort ofa permanent inpatient unit. Any of those solutions can be right the mostimportant thing is that you have the hospitals infection control personneland public health officials sit down and decide how they want to allocate theirresources and how they want to work together. A lot of planning is going intoplace, but its important to have both parties communicate. Smith also emphasizes the importance of drills in illustratingand enforcing plans, as well as demonstrating aspects that may need improvementor modification.

Lenaghan points out that involving healthcare workers frommany different areas can be invaluable. There are some circumstances whereyou just dont have enough information and thats when experience andthoughtfulness come in thinking about the issue, thinking about how staffwill use the procedures, she notes. It was very important for me to have staff inthe planning stages because theyre going to tell you if somethings notgoing to work. So you need to have people who are going to be doing the work ofpatient care in this unit in order to build the procedures correctly.

Reference:

1. http://www.hhs.gov/pandemicflu/plan/