Though an upcoming CMS regulation1 calls for an “all-hazards” approach to disasters, a pandemic or infectious disease outbreak brings some unique characteristics to the tabletop planning.
Though certainly unwelcome events, it may actually help that hospitals have had to prepare for a succession of infectious disease threats that include anthrax (2001), SARS (2003) pandemic flu (2009) MERS (2012) Ebola (2014) and currently Zika. That said, however, a recently issued emergency planning document by HHS focuses primarily on healthcare planning for natural disasters.2
“Every emergency event presents different sets of challenges, so in the planning process healthcare officials really need to think a little bit about all the different types of disasters,” says Melissa Harvey, RN, MSPH, director of National Healthcare Preparedness Programs at the HHS. “For example, this [HHS] document is more about natural disasters that affect the physical infrastructure of individual homes. Their houses may be flooded, or their children’s daycare may not be open and, therefore, they can’t come to work. That certainly is very different from something you would expect during a pandemic, where you are dealing with the staff or their families being ill and that’s why they can’t come to work. Planning for those two types of scenarios is going to be very different.”
While natural disasters raise important issues about accommodating healthcare workers’ needs and taking care of their families, the prospect of treating patients who have a contagion that is typically not well understood in the initial phases of an outbreak puts a whole different set of fears in play. It goes beyond the issue of “able” to work and raises questions about whether healthcare workers are “willing” to report for duty.
“We know what it takes to get people to report,” says Robyn Gershon, MHS, DrPH, a professor who researches and teaches disaster preparedness at the University of California, Berkeley. “They want to know that they are going to be safe, and when it comes to infectious diseases they want to know that they will not bring it home to their family. They need utter assurance and reassurance that they are going to be protected from infection.”
Indeed, the desire to protect family is a more compelling emotion than self-preservation, according to a study published earlier this year.3 The researchers found that healthcare worker fears about potentially exposing their families and friends to Ebola (90%) was more than five-fold greater than their concern for personal safety (16.8%). The study also found that some 25% of healthcare workers may refuse to treat patients with the next novel pandemic pathogen that is perceived as life-threatening. (For more information, see the article in the March 2016 issue of HEH.)
Able but Unwilling?
Gershon’s research has revealed similar trends, in part because a novel pathogen often emerges in the absence of a vaccine, proven treatment, and certainty about the routes of transmission.
“In the beginning, we sometimes don’t know all of the routes of transmission,” Gershon says. “Look at how much we are finding out about Zika: how long it survives in semen, maybe it’s in saliva, it’s definitely in blood. We have to act in the absence of complete information in the most proactive way that we can. In order to do that, healthcare facilities have to be on the top of these evolving and emerging trends so they are as ‘close’ to the outbreak as they can be in terms of preparedness.”
A study by Gershon and colleagues found that only 65% of healthcare workers would be willing to report to duty during a pandemic.4 She also found in another study that workers are more willing to report during a natural disaster than a major infectious disease outbreak, going from 80% willingness during a snowstorm to 48% for SARS.5
One preparedness factor is that, given the unknowns of a novel pathogen, heavy use of personal protective equipment may be recommended until the routes of transmission are clear. That can immediately present PPE supply problems, which were widely reported during the Ebola scare in the U.S.
“It’s always hard because you don’t want too much [stock] of PPE,” Gershon says. “It’s very difficult, but on the other hand, in the absence of complete information about the risk of transmission you have to take an abundance of caution.”
Having worked in high-hazard biosafety labs, Gershon was surprised that, as Ebola emerged, the CDC initially took the position that any hospital could handle a case and airborne precautions were only recommended for aerosol-generating procedures. That changed rather dramatically with the death of a patient and transmission to two nurses in Dallas, as the CDC began advising respirator use and setting up response teams and designated Ebola hospitals.
“I knew it had to be treated at the utmost level of containment, and what they were proposing to do was simply not going be enough,” Gershon says. “Why that happened, I do not know. [Ebola] patients are incredibly infectious and they have a lot of body fluids. I was, frankly, a little amazed and I think a lot of people in the biosafety community were similarly amazed, but [the CDC] quickly changed that.”
Duty to Warn
Employee health professionals have a duty to keep abreast of the threats to staff, and this knowledge can make them a valuable asset to their communities as well, she says.
“They can do a great service by keeping their staff updated and informed about what’s happening and what do we know about this virus or agent,” she says. “They need to develop a plan — and then adjust it depending on the agent, of course — but you need to have a plan for surge capacity, what kind of PPE is needed, and if specialty training on certain respirators is needed. This is one thing healthcare facilities can do. We are lifelong learners in healthcare and that’s what I advocate.”
In terms of willingness and ability to work under such conditions, Gershon is researching a new set of emergency preparedness measures, including whether staff have the “capability” and knowledge needed to protect themselves and patients. Other research questions go beyond willingness to report and assess whether workers will be compliant with measures the hospital may put in place.
“During a public health emergency, we may have measures instituted like quarantine and social distancing,” she says. “Are you willing to not only abide by your hospital’s recommendations, but by your local health department measures? What we have found in our research is a lot of people say, ‘I’m willing, but I’m not able because I have additional responsibilities like taking care of my children or elders.’ This was in answer to, ‘Could you be quarantined like they had to do for SARS in some hospitals?’”
The threat to healthcare workers will continue as pathogens of zoonotic origin emerge and pass between humans and animals.
“This Zika is not the same virus that was originally in Africa,” Gershon says. “This is a more virulent strain of Zika. It’s mutated.”
- CMS. Proposed rule: Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. Fed Reg Dec. 27, 2013: 79081-79200. http://bit.ly/1dtMEmx.
- HHS. Tips for Retaining and Caring for Staff after a Disaster. August 18, 2016, https://asprtracie.hhs.gov/.
- Narasimhulu DM, Edwards V, Chazotte C, et al. Healthcare Workers’ Attitudes Toward Patients With Ebola Virus Disease In The United States. Open Forum Infect Dis 2016;3(1):doi:10.1093/ofid/ofv192.
- Gershon RRM, Magda LA, Qureshi KA, et al. Factors Associated with the Ability and Willingness of Essential Workers to Report to Duty During a Pandemic. Jrl Occ Environ Med 2010; 52: 995-1003.
- Qureshi K, Gershon RRM, Sherman MF, et al. Health Care Workers’ Ability and Willingness to Report to Duty During Catastrophic Disasters. Journal of Urban Health 2005: doi:10.1093/jurban/jti086.