Considering measles cases in the United States have been surging to numbers not seen since 1992, infectious disease experts are urging hospitals and EDs to devise response plans that they can trigger quickly should a patient with measles present. The biggest issue is the fact that the highly contagious nature of measles can prove especially challenging in the ED, putting other patients and unprotected staff at risk.
• Since 1989, Children’s Minnesota, with campuses in Minneapolis and St. Paul, has handled three measles outbreaks. Thus, leaders developed a plan to respond if even a single measles case presents to one of the health system’s EDs. During the 2017 outbreak, Children’s Minnesota activated its incident command system after two patients from the same daycare center presented to the ED with measles.
• Among the interventions that can be deployed in the case of a measles outbreak is the use of “pivot nurses” to quickly assess patients and families before they enter the ED, and universal masking of all patients — at least until their immunity status can be verified.
• One step that all health systems can take before any measles cases present is to verify the immune status of all employees, and take steps to vaccinate any individuals who are not adequately protected. Over the past year, that is what BJC HealthCare did in St. Louis, even though there have been no measles outbreaks reported in the region yet.
Although the incidence of measles cases remains a relatively rare occurrence in the United States, public health authorities are concerned about the growing incidence of the disease over the past year. From January through the early part of November 2019, the CDC reported that more than 1,260 cases were confirmed in 31 states, the highest number of cases recorded in the United States since 1992. Among these patients, 123 had to be hospitalized, and 61 suffered complications such as pneumonia and encephalitis.1
Measles poses particular risk for children younger than age 5 years, pregnant women, and people with compromised immune systems. Further, the highly contagious nature of measles presents huge challenges for hospital EDs. Many clinicians have never encountered a measles case and may not immediately suspect measles in their initial evaluation of a patient. Also, once a measles case is identified, emergency staff must scramble to identify any persons who may have come into contact with the patient, and take steps to prevent transmissions to other patients or staff.
For all these reasons, infectious disease experts insist that it is important for all hospitals and EDs to think about these challenges ahead of time and to put a measles response plan in place, particularly as the number of cases is expected to rise by late winter and early spring. Some even say that at this rate, it is not a matter of whether a case will present in your ED, it is only a matter whether you will be ready when it happens.
Children’s Minnesota, a pediatric hospital system with campuses in Minneapolis and St. Paul, has a good bit of experience in dealing with measles. Since 1989, there have been three measles outbreaks in the region, explains Patricia Stinchfield, RN, MS, CPNP, CIC, the health system’s senior director of infection prevention and control.
“[For] the first one, in 1989-90, there were hundreds of cases in the state. That was during a nationwide measles outbreak,” she recalls. “We had a smaller outbreak in 2011 that involved 22 cases, and then there was an outbreak in 2017.” In the most recent outbreak, the first case came through a Children’s Minnesota ED and was identified by hospital personnel. “The patient had symptoms that [clinicians] thought were [indicative of] strep throat and amoxicillin rash, so the patient was not in isolation,” Stinchfield reports.
However, concerns that the patient might have measles quickly escalated when a second patient presented to the ED with similar symptoms. “They were both from the same daycare center and both had fever, cough, and rash,” Stinchfield shares. “[Clinicians] called us in infection control and said we think we might have measles here, so we are going to do a test.”
When the test returned positive for measles in both patients, clinicians strongly suspected there would be more patients to follow. Hospital leaders quickly activated the health system’s incident command system. It was an aggressive move, but one that turned out to be well-founded. The outbreak endured for five months, involving 75 measles cases and 22 inpatient hospitalizations, all of which were at Children’s Minnesota.
“If you have one case of measles, it should be considered an emergency. It takes sort of an all-hands-on-deck approach to determine where was the patient and were there others exposed,” Stinchfield observes.
For instance, this means determining where the patient attended daycare or school, and leveraging community relationships to ensure any additional cases are identified quickly to stop further spread of this highly contagious disease. “When you have a complex problem that is urgent, you have to have some order to it. The best thing to do is just up your hospital incident command early on,” Stinchfield offers. “If there is one case, there are likely more.”
During the 2017 measles outbreak, no patient died, and no patient was in the ICU. The vast majority of cases, if not all of them, came through a Children’s Minnesota ED, Stinchfield says. To handle this emergency, infection control worked with ED staff to bolster their defenses and minimize the potential for a measles patient to transmit the disease to others in the department.
“We consider the ED as the front door to the community. Whatever is going on in the community, whether it is measles or pertussis or influenza ... the ED tends to see it first. You have to make sure [ED personnel] are aware and prepared,” Stinchfield stresses.
Infection control collaborated with ED leadership to develop what they call a “pivot nurse” role, which involved quickly assessing patients and families even before triage. The pivot nurse was stationed outside the ED so that patients or families that present any risk of exposure could be identified before they entered the department.
“As the outbreak was going on, we were adding interventions in the ED and measuring which strategies helped us to reduce the potential spread of infection,” Stinchfield recalls.
For example, the pivot nurse and triage staff started a practice that Stinchfield refers to as universal masking. This involved equipping every patient and family member who presented to the ED with a mask, regardless of why they were there. Then, ED staff would work to determine what the patient’s immunity status was regarding measles.
Stinchfield acknowledges that it can be difficult to determine every patient’s immunity status during a measles outbreak. Thus, the hospital moved functionality into the ED’s electronic medical record (EMR) to make this information more easily attainable. “The ED nurse can actually open up our state immunization registry right in the EMR and look at what [a patient’s] immunity is,” she explains.
Finesse Triage Questions
As the outbreak was unfolding and disease investigators were learning more about where most of the patients with measles were contracting the illness, infection control worked with the ED to finesse the questions triage nurses were posing to patients and/or their parents.
For instance, during this outbreak, it became clear that most of the measles cases involved young children from a particular Somali community where there was some hesitancy about the MMR vaccine.
However, rather than asking directly about ethnicity, which might not be well-received, the triage nurses were instead encouraged to ask about whether the children presenting attended any schools or childcare centers that had received notifications about measles.
“It was a more sensitive way to get the information required,” Stinchfield explains. “You need to make sure you are tweaking your questions related to the outbreak. It also is important to be able to do this in a nimble way.”
Today, Children’s Minnesota has a protocol in place for how to deal with measles that includes the many layers needed to respond effectively while protecting staff and patients. Stinchfield encourages all hospitals to establish similar plans so that they are ready for when a measles case presents.
“If we are going to roll out messages to the community, [the hospital public information officers] have those on file. If we are going to implement special ED triage procedures [during a measles outbreak], we have those on file,” Stinchfield relates. “We have learned a lot over the years.”
In fact, there are multiple ways hospitals can act in advance so that if a measles case presents in the ED, they will be prepared. For example, Stinchfield advises EDs to work with their IT department to devise a way to easily identify all the patients who are in the ED at a particular time, and pull that data into a report.
This kind of information is critical if staff need to contact all the people potentially exposed to a patient who presented to the ED with measles.
Also, as Children’s Minnesota has done, implement a way to easily identify the immunization status of patients, Stinchfield suggests. During an outbreak, this information can help investigators stratify patients into different risk groups.
Another tactic is providing education on how a measles case typically presents. “Getting pictures of individuals with measles in front of emergency staff brings the disease more to the front of their minds. They will know what a measles rash looks like,” Stinchfield advises.
Ensure staff know that the rash typically starts at the scalp and progresses across the face and down the trunk, she explains. Also, patients typically cough and register a fever; some may exhibit red, watery eyes. Staff members must realize this constellation of symptoms should move a patient to the front of the line so that he or she can be placed in isolation, Stinchfield stresses.
“If staff don’t really know [what to look for], then you are going to create more work in terms of additional exposures and follow-up,” she warns.
Verify Immune Status
The last thing one wants to worry about during a measles outbreak is whether facility employees are susceptible. But this is yet another issue leaders can address before a measles case presents. Hilary Babcock, MD, medical director of occupational health at Barnes-Jewish and St. Louis Children’s Hospitals in St. Louis, decided to take this issue on in the spring of 2019.
“I heard from some colleagues that were dealing with these outbreaks in their communities and at their facilities. That really highlighted for me how much work that was, and how difficult it was to respond,” explains Babcock, professor of medicine in the infectious diseases division at Washington University School of Medicine. “Whatever you can do in advance to be ready is definitely an advantage. That is what really prompted us to go ahead and do a deeper exploration of our current [immunity] status, and work on getting everybody up to the standard that they need to be.”
By “everybody,” Babcock is referring to all 30,000 of BJC HealthCare’s employees. “We have a mandatory influenza vaccination program that has been in place since 2008 ... and the MMR vaccine was also [at the time] required upon being hired,” she explains. “But because the requirements for the MMR vaccination of healthcare workers has changed a little bit over time, we had some employees who had been in alignment with the guidance when they were hired, but weren’t anymore. We had not gone back and found those people, so we set out to do that.”
For example, the criteria used to state that being born before 1957 was evidence of immunity. In recent years, the CDC has toughened the criteria for healthcare workers to include physician documentation that an individual born before 1957 had a case of measles. “If, in fact, someone has a letter from their physician that states they saw this person and [he or she] had measles in 1952, then no, that person doesn’t have to get vaccinated, but most people don’t have that,” Babcock shares. “People might say that they think they had measles ... but that is not acceptable evidence of immunity anymore.”2
Fortunately, the health system had acceptable documentation of immunity from measles for most employees. However, the remainder had to undergo testing to check their immune status. These employees were contacted through a standardized email notification, explaining that the health system wanted to be prepared in the event of a measles outbreak. The employees received instructions on where they should go for testing, and they were given 30 days to complete the task.
“We started drawing titers on them, and 80% to 85% of these employees were immune. Either they had been vaccinated for measles but didn’t have the records, or they had had the measles when they were young, but didn’t have documentation of that fact,” Babcock observes. “With a blood draw, we were able to confirm they were immune, and that they didn’t need to do anything further.”
Employees found not to be immune were notified of the results and instructed to come in for a MMR vaccine within a specified period. “Some of the facilities that didn’t have a lot of employees sent their emails out all at once, and got all the immunizations completed within six weeks,” Babcock shares. Alternatively, some hospitals staggered their email notifications, handling specific groups at a time, so it took them a bit longer to complete the process, she says.
The health system already had a process in place for employees who have a medical contraindication or a religious objection to receiving mandated vaccines, Babcock notes. “We provide for them an accommodation plan,” she explains.
Such employees need to wear masks when taking care of patients. Further, if they are exposed to measles or the flu, they need to report this exposure and will be off from work for a specified period. “We make clear what the process is for employees if they are unable to be vaccinated,” Babcock adds. While making sure that employees are protected or immune from measles is just one aspect of the measles response plan that the health system has put in place, it is an important part, Babcock stresses.
“If you have a lot of staff, and you don’t know their immune status, and then you have a measles patient come through, you will end up having staff members who can’t come to work who have been exposed. That can really create big problems for care delivery,” she explains. “While it is hard to do this work, in some ways it is the easier piece than trying to be assured that every triage person throughout your system remembers to think of measles every minute.”