Chaotic staffing problems and unexpected side effects aside, the worst case scenario is that a patient with smallpox will present to your emergency department (ED). You need a solid strategy in place before this occurs. Here are some effective strategies:
• Isolate the patient at triage.
At University of California-Irvine Medical Center in Orange’s ED, there is a private isolation room with controlled air flow adjacent to triage, says Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, director of emergency and trauma. "Any suspected patient can be harbored there without exposing the main ED or waiting patient population," she says.
At Saint Vincents Hospital in New York City, the ED triage area itself is a negative pressure room, built as a result of a tuberculosis epidemic several years ago, says Suzanne Pugh, RN, ED nurse manager. "If a suspected smallpox patient does present, the triage nurse is not to leave the room, and they are to call for help," she says.
The triage nurse would then put on personal protective equipment and walk the patient directly into a regular isolation room. The charge nurse is called; he or she notifies the ED attending physician, who pages infection control and the facility’s infectious disease fellow. "During this time, both staff and patient would remain in isolation," says Pugh.
• Make sure that staff who aren’t vaccinated don’t have contact with a suspected smallpox patient.
If a case of smallpox is identified, ED staff will be required to be immunized before they are assigned to the isolation area, Bradley says. "Our concern is for staff as well as the patients," she stresses. "If our staff are not safe and protected, they will not be there when the volume of our patient population increases."
• Take the same steps that you would take if you suspected the patient had active tuberculosis.
Eric Lavonas, MD, FACEP, an ED physician and toxicology fellow at Carolinas Medical Center in Charlotte, NC, advises you to follow your hospital protocol for strict respiratory isolation and droplet precautions, and take the following steps:
- Place a mask on the patient and have him/her proceed to a negative pressure room.
- Alert the physician of your concerns without alarming other patients and staff.
- Use gowns, gloves, and respiratory protection as you now do for other highly contagious respiratory diseases.
- If smallpox still is suspected after the patient is examined, notify the county and state health departments immediately.
• Take advantage of real-life experiences with anthrax attacks.
The response to a smallpox scare is in many ways similar to the way EDs nationwide coped with the recent anthrax attacks, says Pugh. She says that in October 2001, her ED was "literally inundated with hundreds of people" who feared they had been exposed to anthrax. "We got a lot of practical experience from that scenario, and we learned a lot about what not to do," she says.
Specifically, Pugh says that ED nurses got hands-on lessons with potentially contaminated patients. "The staff realized that they couldn’t just walk out with the patient," she says. "Once somebody walks into triage, the area is contaminated." As a result of the anthrax experience, she says that nurses aren’t panicked about contamination from smallpox. "Everyone understands that you need to sit tight," she says. "The primary concern is to know what to do to contain it as much as possible and move on from there."
Drills have been conducted at her facility to assess the strategy to isolate suspected smallpox patients, Pugh says. "Practically speaking, it’s the same process as we used for anthrax, except we were also calling the HazMat unit," she says.
The ED has also had real-life experiences to test its process for isolating suspicious rashes. So far all have been children, and two were chickenpox cases, she says. "We’ve been satisfied with how the system works, and the response of infection control has been extremely rapid," she says. "I’m fairly confident at this point that if something like this did happen, that it would be contained."
For more information on avoiding contamination during a smallpox outbreak, contact: Suzanne Pugh, RN, Emergency Department, Saint Vincents Manhattan, 153 W. 11th St., New York, NY 10011. Telephone: (212) 604-2513. Fax: (212) 604-2339. E-mail: email@example.com.