Middle East Respiratory Syndrome (MERS), Ebola, and measles — or something completely different that arrived via air travel from across the globe — could be festering in an undiagnosed patient in your ED right now. How quickly can you recognize the signs and symptoms and get the patient in isolation before other patients and healthcare workers are exposed?
To test this hypothetical question, the New York City Department of Health and Mental Hygiene (DOHMH) recently conducted elaborate “mystery patient drills” that used in-house collaborators to evaluate clinical readiness in ED staff.
Overall, 95 drills were conducted in 49 NYC hospital EDs. Drill scenarios included patients reporting signs, symptoms, and travel history consistent with possible MERS or measles. In reality, patients with either of these infections have resulted in costly and labor-intensive follow-ups to determine which patients and healthcare workers were exposed. The scenario was somewhat tricky, as the patients reported they had a fever but had taken an over-the-counter fever reducer — meaning the caregiver couldn’t immediately verify their story by taking a temperature. In addition, the measles scenario had actors presenting as patients with some fake rash spots applied with a commercially available kit. The MERS patients presented with respiratory symptoms and also said they had a history of fever.
“Overall, patients were masked and isolated in 78% of drills,” the investigators reported.1 “Masking and isolation occurred significantly more frequently when travel history was obtained (88%) than when it was not (21%). Overall, the median time from patient entry to masking was 1.5 minutes (range = 0-47 minutes) and from entry to isolation was 8.5 minutes (range = 1-57 minutes).”
The exercises were halted and considered failed if the ED wait time exceeded 30 minutes without triaging the patient. Factors assessed during the drill included compliance with hand hygiene and use of personal protective equipment. In addition, screening for travel was noted, as the general expectation in the wake of the Ebola outbreak is to ask patients with unspecified illness if they have recently been in another country. “The exercise was considered successful … if the patient was given a mask and isolated from other patients and staff members,” the authors noted. “Overall, 76 (80%) patients were asked about recent fevers, and 81 (85%) were asked about recent travel. Questions about a rash or unusual skin lesions or respiratory symptoms were asked of 47 (50%) and 69 (68%) patients, respectively. Overall, 84 (88%) patients were given a mask, including 45 (85%) patients in the measles scenarios, and 39 (93%) patients presenting with MERS scenarios.”
“Although the majority of drills were completed successfully by masking and isolating the patient, approximately 40% of hospitals failed at least one drill, and there was considerable variation in the length of time each hospital took to perform these steps,” the authors concluded. (A toolkit is available to assist healthcare facilities and health departments that wish to conduct similar drills at: http://on.nyc.gov/2jzM0hY.)
Hospital Infection Control & Prevention asked lead investigator Mary Foote, MD, senior medical coordinator for communicable disease preparedness at NYC DOHMH, to provide more details on this unusual project. The Q&A session with Foote is presented as follows:
HIC: Looking at the glass half empty for a second — with 40% failing at least one drill, does that mean MERS or measles could have spread in these facilities?
Foote: It definitely leaves them vulnerable because it only takes one miss to facilitate the spread of infection. With MERS there was the case of one super spreader who was left in a crowded emergency room in a Korean hospital. I think he spread to at least 70 to 80 people. So, certainly, we aim for 100%. We want to get as close to that as we can, and anything less than that leaves us vulnerable.
HIC: Will these results be used as a baseline for similar future drills?
Foote: Yes, part of the value of this is that it does give us a baseline. We had done a previous project with Ebola drills. But that wasn’t nearly as rigorous of an evaluation. The format of these drills was based on that, but we plan to repeat this program [with this baseline] in the next year or two and track our progress.
HIC: It’s interesting, because infection prevention has a history of using “secret shoppers” or inconspicuous observers to track hand hygiene and compliance with other infection control measures.
Foote: I think if you talk to any infection preventionist, they will tell you that compliance is one of the biggest struggles — just the most basic practices like hand hygiene and when to use a mask. That is something that we struggle with, and a lot of it has to do with changing behavior and culture. We had 36% hand hygiene compliance — that is definitely low. I expected it to be low, but that was on the lower end of my expectations. But I can’t say I am shocked by those findings. I am also a clinician and I will not point any fingers, but I am surprised sometimes when I see colleagues [whom] I know are very well-educated and very conscientious not wash their hands when they walk into a room.
HIC: Did you see any kind of work culture differences that would explain the hospitals that were recognizing the patients quicker or complying more readily with infection control?
Foote: We didn’t do that analysis and I don’t know if we had the numbers to support a robust look at the association between success with isolation and handwashing. We modified the toolkit for future use to make it a little more rigorous in evaluating these types of questions. The other thing is, we were looking not just at the doctors and nurses — we were looking at the security guards and rest of the staff. I certainly did see that there was a noticeable pattern where those nonclinical staff had much lower rates of hand hygiene. That was just observational. We need to include them in the infection control training, and definitely we need to do more of competency-based training when it comes to these skills. I always tell people if we can get this down better and ingrained in the culture, then a nurse knows when to hand somebody a mask during regular flu season. It’s that same process that you then use if you have pandemic flu. Strengthening these everyday practices can prepare us for a pandemic and other emerging infections.
HIC: Were you surprised that some healthcare workers were not asking about travel history? There was some thought that it may become a routine question after there was so much emphasis on it during the Ebola epidemic.
Foote: That’s something that was a huge focus when we shared our findings with the hospitals. I will say in the months after the Ebola epidemic in West Africa, I had about three phone calls from my colleagues in infection prevention and the emergency room. [The attitude was] “OK, the epidemic is over, can we stop screening for travel history now?”
HIC: How did you present your findings to the hospitals after the drill?
Foote: Once the exercise was called, there was a gathering where we debriefed all of the people involved, including the hospital staff. There was a “trusted agent” [collaborator] who was often the infection preventionist at the hospital. They would review what was missed and what they thought could be done better. It was a real teachable moment for those that participated. After that, each hospital that had a drill received an after-action report, which included our recommendations for improvement.
HIC: Just to clarify, the patients presenting with measles-like symptoms were to say they had recently been to Germany if asked about travel?
Foote: Yes, the expectation is that if they come in reporting a fever, you ask about travel history. If they report a travel history then you follow up with questions about the rash, respiratory symptoms, gastrointestinal symptoms. You do the infection control measures first and then ask more questions.
HIC: The rash was visible. Did it fool healthcare providers?
Foote: They applied it on the neck mostly so they could just pull down their shirt and show them. We went through [a few practice runs] and looked at it. It was a commercial [product] it and looked like sort of an epoxy rash. We found that it was better if they washed off the latex layer and left the red marks kind of faded. That was the best way to get a more authentic-looking rash. It was good enough to get them through to triage.
- Foote M, Styles TS, Quinn CL. Assessment of Hospital Emergency Department Response to Potentially Infectious Diseases Using Unannounced Mystery Patient Drills — New York City, 2016. MMWR 2017; 66(36):945–949.