“This one of my all-time favorite quotes because I think it is reassuring in some ways,” says Stephen Weber, MD, an epidemiologist and chief medical officer at the University of Chicago. “It is a realization that our best plans foster collaboration, flexibility and adaptability. Even with new tools, resources, and networks to detect emerging pathogens — early warnings for outbreaks and epidemics — the fact is the next thing that affects the American and international health system from an infectious standpoint may be something we are not familiar with today. Our planning — which challenges us to be effective decision-makers — is much more valuable than the prescriptive information about any one single pathogen.”
Speaking at a recent emergency preparedness webinar held by the CDC, Weber urged infection preventionists to prioritize risk assessments that are somewhat introspective in that they go beyond next-threat thinking to assess where your skills and program fit into the response plan.
“Risk assessment is the cornerstone,” he says. “It is the foundation, the starting point for our planning. If you think as a team — no matter the resource base, the experience you have — that you don’t have time for risk assessment and planning, I think you’re wrong.”
IPs and hospital epidemiologists who are not well-positioned within their organization and connected to key collaborators during routine operations will be severely challenged when an infectious disease emergency strikes, he warns.
And that is “when,” not “if,” as we have already seen the anthrax attacks, SARS, H1N1 pandemic flu, MERS, and Ebola occur in this young century. Weber spoke of lessons learned dealing with a series of threats over the years at his hospital, which is a cab ride away from one of the world’s busiest airports.
“We [became] very familiar with the schedule of direct flights from West Africa to O’Hare because we felt like we were on the front lines,” he says. “We ultimately took care of a handful of patients with possible or suspect Ebola — all of them ultimately excluded — but any of you who have been in that position know that is small comfort when you are in the moment.”
Thus, before the next infectious disease event, consider your place in the organization, assess your authority to act to protect patients, and honestly evaluate if you need to improve your skills and knowledge base to be prepared for a major event, he says.
Questions for the IP
Weber posed a series of rhetorical questions to construct a kind of overall risk assessment for infection control effectiveness and resilience under fire. IPs can consider these factors in the calm before the next ID emergency, which may reveal everything from adequate PPE supplies to the grace under pressure of individuals and teams. Consider some of Weber’s points on these key tenets:
Authority: “Not in the setting of an outbreak, not in the moment of a crisis, but do you have the statutory authority, either externally or by internal policy, to say that you and your team will [protect] the safety of patients [with regard to] infection prevention? Put simply, can you be outvoted by another department, or even an executive, in the management of infections?”
Planning: “Are you tied to operational plans and strategic planning? Are you embedded in the work of determining of the priorities of the organization? Are you placed in the right level of the organization? Do you have access up and down the chain of command?”
“All-access” pass: “I like to use this [term] as a bit of shorthand — the idea of an organizational ‘all-access pass.’ Does the infection control and hospital epidemiology program have the access and visibility that they need? Put simply, is your ID or swipe badge a master key? Does it get you into to every room, every place, and every operating theater in the organization? Because I submit to you, if an infection prevention program is blocked access to any of the geographical places in an organization, then you have got more than just a lockout situation. You may not not be [effectively] placed in terms of the tasks ahead, whether they be emergency or routine.”
Collaboration: This includes partnerships within and without your hospital, from quality improvement, risk management, business continuity, and operating teams. Build relationships in local government, public health, even hospitals normally seen as competitors, Weber advises.
“I don’t have a clear answer for all of this, but these are the folks you need to be collaborating with — in partnership, not in an adversarial or competitive relationship,” he says. “It needs to be sorted out, and I submit to you it needs to be sorted out well in advance of any kind of event. It’s these connections throughout the team — with everyone from food service to physical plant, to laboratory and nursing. These are interpersonal connections. These are relationships that need to be built.”
Even so, IPs need to keep a professional edge, as there will be stressful situations where patient safety trumps collegial bonds. “The friendships can’t come at the expense of what needs to be done for our patients,” Weber says.
A Look in the Mirror
Credibility: “Do I have and demonstrate expertise?” he says. “It’s not enough to sit quietly in the room and know that you’re right. Do I speak up, can I assert myself? And when I do, is my information and knowledge up to date? The time that we spend on continuing education, collaboration, teaching, and education is essential. Because the moment we get scooped in our core content expertise by someone else inside or out of our organization, our credibility falls a notch. That’s a lot of pressure for all of us because it takes time. But the reality is it is time well spent.”
Reliability: “Am I present? Am I consistent, in or out of crisis?” he says. “That internal consistency is really a key feature. Is it your management style to drag your organization from one crisis to another? The sky is falling – it’s CRE today, its C. diff tomorrow, its disinfection the next day. That is going to make it really hard to manage a real-time crisis. Those issues are obviously significant and important for our patients, but can we be consistent and levelheaded in our work?”
Approachability: “A big part of approachability is flexibility,” Weber notes. “We want people to understand that we are speaking for the safety of our patients, but we can’t be so predictable that folks feel we are going to be [overly rigid]. We need to be ready to listen to new ideas and concerns, and particularly when we get into the kind of events we’re talking about because in those cases, there is often not an existing policy or a best practice.”
Supplies: For most organizations, it is not prudent or economical to stockpile critical equipment for emergencies when there are existing pressing needs, he notes.
“Look, we’ve all had or we will have a time when we wish we had stockpiled more equipment,” Weber says. “The reality is with capital budgets and resources for storage at your places — that are probably not much different than mine — it is probably not economical to stockpile large numbers of critical equipment. It’s just not going to happen. When we are choosing between life-saving technology that can be applied to the next patient that comes into our ED, the next cancer patient, versus this hypothetical [threat], it’s hard to make the case.”
One approach to this problem is to be flexible in purchasing to ensure that newly purchased devices are suitable for use routinely and in an emerging-pathogen event, he says.
“Be flexible and judicious with your purchasing folks when you’re cycling through new ventilators, new anesthesia machines,” Weber says. “Are the devices suitable for managing emerging pathogen events? Can they be safely cleaned and disinfected? Are they durable enough for higher potency disinfection and cleaning? Those are things that can be embedded now.”
In the Event: Prepare job action sheets relevant to the anticipated event in accordance with standards and sometimes independent of usual or routine responsibilities, he says. For example, you don’t necessarily want the people who know the most about the infectious disease in the room trying to perform the procedures.
“What’s the right role for an infection preventionist and for an infectious disease doc?” Weber says. “During the Ebola situation, we said the last person we want in a space suit in the room is an ID doc. I say this as a board-certified ID doc. I don’t need to be in the room. I’m not so great with the procedures, moving around in that kind of suit to put in a line or secure access. We opted for a model where our intensivists really became the folks in the room and those with expertise in disease management stayed out. People can have different plans for that and there is no right answer, but it shouldn’t end up being a coincidence of who is at the bedside. It should be thought out in advance.”
IPs should serve in some capacity as medical technical specialist with open lines to communication across the response chain, he adds.
“In a primary biological or infectious incident or event, I submit that the infection preventionists or healthcare epidemiologists should serve as ‘medical technical specialists,’” he says. “You need to have the ear of that incident commander so that she or he knows that there is no decision that is going to be made without your input.”
Likewise, know who is on your B team, as everyday concerns about burnout and fatigue in healthcare workers will multiply exponentially in a crisis. Moreover, key staff may be missing when an event unfolds.
“Because you know what, this might happen in the middle of APIC or IDWeek,” he says. “You may not be there. It may be that new person you just hired who might be at the table on that first day.”