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In mid-December, a woman comes to your ED complaining of headache and a sore throat with a temperature of 104°. The patient works at a news station and says she hasn’t felt well for several days. Until recently, you probably would assume this patient has the flu, but now you have to suspect a more frightening scenario: exposure to anthrax or another biological agent.
EDs have been inundated with a "huge influx" of people who believe that they have been exposed to anthrax, reports Steve Weinman, RN, BSN, CEN, director of the office of continuing medical education and the center for nursing education at Excerpta Medica in Hillsborough, NJ, and per diem instructor in emergency and trauma care at New York Presbyterian Hospital — Cornell Medical Center in New York City. "This will only become worse as the flu season sets in," Weinman predicts. "This situation is not going to be an easy one to wade through, especially if public exposure continues to escalate."
Because anthrax starts out with flu-like symptoms, the flu season will definitely "cloud the issue," he says. "It is better to be safe than sorry. So if you suspect anthrax, treat as anthrax," Weinman recommends. (Steps to take if you suspect anthrax are listed below.)
4 steps to take if you suspect anthrax
Here are four steps to take if you suspect a patient has been exposed to anthrax, according to Steve Weinman, RN, BSN, CEN, director of the Hillsborough, NJ-based Office of Continuing Medical Education and the Center for Nursing Education at Excerpta Medica in Hillsborough, NJ, and per diem instructor in emergency and trauma care at New York Presbyterian Hospital — Cornell Medical Center in New York City:
Here are items to consider when treating a patient who may have been exposed to anthrax:
• Take a thorough history. Although no anthrax patient so far has had nasal congestion, don’t assume those symptoms mean it’s "only the flu," cautions Sharon S. Cohen, RN, MSN, CEN, CCRN, trauma clinical nurse specialist at North Broward Hospital District in Fort Lauderdale, FL. "A thorough history must be taken from the patient or whomever is available who can provide any history," Cohen advises. (See list of questions to ask patients, below.)
Ask patients these 6 questions
Ask potential anthrax patients the following questions, recommends Steve Weinman, RN, BSN, CEN, director of the Hillsborough, NJ-based office of continuing medical education and the center for nursing education at Excerpta Medica in Hillsborough, NJ, and per diem instructor in emergency and trauma care at New York Presbyterian Hospital — Cornell Medical Center in New York City:
You must determine if the patient has any flu-like symptoms and, if so, for how long, says Cohen. "Also find out if the patient came into contact with any unusual powder or suspicious mail," she adds. "Simple questions can help you determine what path to take and diagnosis to make."
Weinman notes that the reason no anthrax patient has presented with nasal congestion is because anthrax seeds in the lymphatic system of the lungs. "This would not be a reliable method to exclude anthrax if the patient has other symptoms," he says. The rapid-flu test relies on the laboratory, and most hospitals don’t provide this test on a 24-hour basis, says Weinman. "It is very expensive to use this test on everyone who you think may have the flu," he adds.
You also need to consider the possibility of concurrent infection with the flu and anthrax, warns Weinman. "The rapid-flu test will not rule out anthrax. Even if it is positive for flu, that does not mean that the patient does not also have anthrax," he says.
At North Broward Hospital District’s EDs, patients with possible anthrax exposure is asked if they have aches and pains or a cough (productive or nonproductive) and vital signs are checked to see if they are febrile. "Next, we check out the patient’s skin to see if there are any lesions and ask if they have had any nausea, vomiting, or diarrhea," says Cohen. Those are typical symptoms of the cutaneous, gastrointestinal, and pulmonary versions of anthrax, says Cohen. "If the patient answers no’ to all of those, then we send the patient home," she adds.
• Identify possible risk factors for anthrax. Although you must consider any patient presenting with a complaint of new onset rash for the potential of cutaneous anthrax, a few high-risk groups have emerged, says Weinman. As this issue went to press, these high-risk individuals are postal workers, members of the media, and staff of political figures, says Weinman. "However, as the true magnitude of this event unfolds, this high-risk group undoubtedly will grow and merge with the landscape of the general population," he cautions.
• Try to streamline your decontamination process. According to Cohen, each potential anthrax patient is a significant drain on the ED’s resources. (See "Here’s how one ED manages suspected anthrax patients" in this issue.) "That includes donning protective equipment, putting the patient through fine decontamination, bringing the patient back to the ED, and educating the patient," she says.
It takes at least six ED staff members several hours to get each patient through the system, says Cohen. She reports that Broward General’s ED has done more than a dozen decontaminations for suspected anthrax to date. The ED’s HazMat areas are left partially set up, because of the volume of patients being decontaminated. "The one positive thing that came out of this is that we’ve really fine-tuned our HazMat decontamination. We can get our people suited up in 15 minutes," says Cohen.
Normally, the area would take four or five people about an hour to set up properly, notes Cohen. "We have the proper water runoff and hot and warm water worked out, a curtain for privacy set up, and scrub brushes, disinfectants, and biohazardous bags for waste available," she explains.
• Create a quick-reference tool. Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, director of emergency and trauma services at University of California at Irvine Medical Center in Orange, created a tool for ED nurses to use when caring for patients with possible anthrax exposure. (To see Anthrax tool for ED nurses, click here.)
"Everything nurses need to know from the ED perspective is included on the form," she says. The form contains assessment and treatment information for each of the three possible modes of transmission. "As the ED nurse is taking a history, she can review the incubation period to verify that it is within range," says Bradley. The form lists associated risks and appropriate personal protective equipment. "The aftercare section includes what special instructions would be given to the patient or what education is required before he or she goes home," says Bradley.
• Don’t become complacent. It’s easy to become frustrated to have numerous patients come in for a time-consuming decontamination process when you realize most have not been exposed, Cohen acknowledges. However, she warns that you must always take the appropriate precautions. "If it comes in as a white, powdery substance unknown,’ that could be anything," she says. "Your thought process may be, It’s only anthrax,’ but you can’t think like that. You have to assume the worst — that it’s an organophosphate [nerve agent]." Cohen says that even if there is a "remote potential" for this, the patient is immediately walked outside, and HazMat is called to do gross decontamination.
For anthrax, as with any biological or unknown chemical, you must protect yourself, says Weinman. "Nurses have subscribed to the notion that the patient comes first, and delays in providing treatment — especially if it’s believed to be lifesaving — should be avoided," he notes. Times have changed, and you must protect yourself during this threat of biochemical terrorism, just as you would if caring for a trauma patient with massive external hemorrhage, says Weinman. Universal precautions are a must, he stresses. "This is sufficient to prevent cutaneous cross-contamination, in the event that anthrax spores are present in sufficient quantity and quality on the patient’s clothes or skin," he says.
For more information on anthrax exposure, contact:
• Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, Emergency/Trauma Services, University of California at Irvine Medical Center, 101 The City Drive, Route 128, Orange, CA 92868-3298. Telephone: (714) 456-5248. Fax: (714) 456-5390. E-mail: email@example.com.
• Sharon S. Cohen, RN, MSN, CEN, CCRN, North Broward Hospital District, 1600 S. Andrews Ave., Fort Lauderdale, FL 33316. Telephone: (954) 355-4990. Fax: (954) 468-5270. E-mail: firstname.lastname@example.org.
• Steve Weinman, RN, BSN, CEN, Office of Continuing Medical Education and the Center for Nursing Education, Excerpta Medica, 105 Raider Blvd., Suite 101, Hillsborough, NJ 08844. Telephone: (908) 281-3651. Fax: (908) 874-5633. E-mail: RescSteve@aol.com.
• The American Hospital Association (AHA) in Chicago has issued an advisory to address the problem of large numbers of people seeking anthrax testing at EDs. The bulletin includes a document from the Department of Health and Human Services answering common questions about anthrax prevention and treatment. The bulletin is on the AHA web site (www.aha.org). Click on "Disaster Readiness," and then click on "Advocacy" and scroll down to "Readiness Bulletin: What to tell your community about anthrax" that was issued Oct. 19, 2001.
• The Kaiser Mid-Atlantic Permanente Medical Group, based in Oakland, CA, is making anthrax screening and treatment guidelines available to other health care providers. Physicians in the Kaiser Permanente mid-Atlantic region have treated two confirmed pulmonary anthrax cases and say the group has learned about treatment with multiple antibiotics, the course of recovery over the first several days, more targeted screening of suspicious cases, and the best ways to handle the large numbers of people coming in to be tested. The guidelines are at www.kp.org/ and will be revised as the situation evolves. (Click on "Anthrax Clinical Guidelines for Physicians.")
• The Centers for Disease Control and Prevention in Atlanta has several resources relating to anthrax on its web site (www.cdc.gov). Click on "Anthrax Information and Public Health Emergency Preparedness and Response." Resources include an information sheet titled "Facts about Anthrax, Botulism, Pneumonic Plague, and Smallpox," "Frequently Asked Questions about Anthrax," and a link to video/satellite broadcasts including "Anthrax: What Every Clinician Should Know Part II, Nov. 1, 2001" "Response to Bioterrorism: Overview and Clinical Aspects of Critical Biological Agents" "Response to Bioterrorism: The Laboratory Response Network and Agents of Bioterrorism" and "Anthrax: What Every Clinician Should Know, Oct. 18, 2001."
• In April 1999, the Association for Professionals in Infection Control and Epidemiology and the Centers for Disease Control and Prevention prepared the report Bioterrorism Readiness Plan: A Template for Health Care Facilities to serve as a reference document and initial template for health care facilities’ bioterrorism readiness plans. The full text of the report, including specific responses to agents like anthrax, can be found at www.aha.org. Click on "Disaster Readiness." Under "Readiness Resources," click on "Hospital Readiness, Response, and Recovery," then "Bioterrorism Readiness Plan: A Template for Health Care Facilities." The report also is available at www.apic.org/bioterror. Scroll down to the "Readiness Planning" category, where you’ll see the report listed.