ED Accreditation Update

Are you ready for an influx of SARS patients?

By Jan. 1, you must comply with new Joint Commission standard

If several patients with severe acute respiratory syndrome (SARS) started coming into your ED, would you be prepared to separate them? Could you triage to alternative off-site areas, if needed?

As of Jan. 1, 2005, you’d better be prepared. A new infection control standard requires that EDs and other departments of the hospital be prepared to respond to an influx or the risk of an influx of infectious patients, according to the Joint Commission on Accreditation of Healthcare Organizations.

The biggest changes for EDs? "Probably deciding on the capacity that they want to prepare for, and how they are going to prepare for that in a setting where their ED is likely to be full and the hospital will be full," says Thomas Terndrup, MD, professor and chair of the department of emergency medicine at the University of Alabama, Birmingham School of Medicine.

"It’s a challenge we all face: preparing and exercising toward the notion of improving their response capability for an infectious disease outbreak, especially a respiratory infection that is transmissible," such as SARS, he explains.

EDs always have faced the challenge of an influx of patients, says Nancy Kupka, DNSc, MPH, RN, project director of the Division of Standards and Survey Methods at the Joint Commission.

"This challenge is compounded now by the nature of disease, rather than a massive influx of trauma patients from a building explosion, for example," she says. "It may be unknown how it’s transmitted."

The ED will have to work with infection control and other departments of the hospital to have a concrete plan to meet the standard, sources say.

At University of California, San Francisco (UCSF) Medical Center, hospital disaster committees are developing protocols and obtaining supplies and equipment for handling an influx of infectious patients, says Jinhee Nguyen, RN, MS, CEN, clinical nurse specialist in the ED and assistant clinical professor at UCSF School of Nursing.

In addition, they are working with the materials services department to obtain ample backup supplies of protective gear and equipment, Nguyen says.

ID, contain, mobilize resources, and treat

The ED will play a crucial role in identification, containment, mobilization of resources, and treatment during an influx of infectious patients, she points out.

How can you plan your response? First read through all of the infection control standards and ensure you are in compliance, Kupka suggests.

Secondly, consider networking outside of your own hospital system with other providers and your local board of health, she notes. "We don’t require it, but they network to say, We’re all in this together; let’s set up lines of communication,’" Kupka says.

Work with your local emergency management agency to identify a plan in which patients would be distributed to a variety of facilities in a logical process so that no one facility is completely overwhelmed, Terndrup says.

Also, ED managers need to ensure they are part of the communication loop to submit information about infectious diseases to the proper agencies, Kupka says. "It could be a grand influx of patients, but it could be one patient with a serious illness," adds Kupka, pointing to the small number of monkeypox cases in 2003.

The Centers for Disease Control and Prevention and county public health departments have set up processes for faxing out information about unusual cases in communities, she explains. "One of the challenges is to make sure that the ED works with the infrastructure of bigger organizations to make sure they’re apprised of information," Kupka says.

Are your staff ready? Find out!

Training and drilling your staff is a critical part of complying with this standard, sources say.

Train the ED staff and the rest of the medical staff on how to handle an influx of infectious patients, Nguyen says.

"Emergency department staff, particularly the triage nurses, would need further training in early recognition of presenting symptoms of infectious diseases, which could potentially lead to mass casualties," she adds.

Every facility should prepare for at least a handful of patients it could isolate and manage, Terndrup says.

In annual exercises, consider incorporating an outbreak of a respiratory pathogen that can be transmitted person to person, he adds.

"The challenge is to identify the person early; isolate the expired particles from that person’s respiratory apparatus, mouth, and nose by putting a mask on him or her; and then putting the person in a room with a closed door, preferably with air-handling capability — either filtering or laminar flow," he says.

Once people are confirmed as having an infectious disease, they need to be transported to an area of the hospital that previously has been identified as being able to hold a number of patients reflective of their overall facility capacity, says Terndrup. For example, the average hospital might want to be capable of identifying and grouping 25 patients, he suggests.

UCSF has conducted disaster drills involving influx of infectious patients, which tested the ED’s protocols, readiness, and effectiveness, Nguyen says.

"This is an evolving and ongoing process for our department and the hospital," she points out.

The University of Alabama at Birmingham Health System held a disaster exercise in August that included mock patients assumed to have smallpox, Terndrup says.

"We learned from that," he adds. For example, staff needed to know where to get a N-95 mask, Terndrup says. Additionally, staff learned how to handle droplet precautions and how to submit samples for confirmations of smallpox to the CDC, he notes. They also learned how to safely transport and group patients, Terndrup says.

There’s nothing like a practice session, he says. "You can have all the policies you want, but it shows operationally what you need to do to be ready," Terndrup explains. "You can’t prepare sitting in your office writing a policy."

Sources

For more information on meeting the new infection control standard, contact:

  • Jinhee Nguyen, RN, MS, CEN, Clinical Nurse Specialist, Emergency Department, University of California, San Francisco (UCSF) Medical Center; Assistant Clinical Professor, UCSF School of Nursing, Phone: (415) 353-1444. Pager: (415) 719-7583.
  • Joint Commission on Accreditation of Healthcare Organizations, Standard Interpretation Group. Phone: (630) 792-5900. Web: www.jcaho.org. Click on "Standards FAQs — Ask a Question" and "Go to the Standards Online Question Submission Form."
  • Thomas Terndrup, MD, Professor and Chair, Department of Emergency Medicine, University of Alabama at Birmingham, 619 19th St. S., Birmingham, AL 35249 -7013. Fax: (205) 975-4662. E-mail: tterndrup@uabmc.edu.