Hospitals must stay on guard for emerging infectious diseases

Joint Commission and the CDC push for better preparedness

The flu season may be coming to a close, but the push for hospitals to improve their preparedness to prevent the spread of emerging infectious diseases is just gathering steam.

The Joint Commission on Accreditation of Healthcare Organizations has proposed a new infection control standard that would require hospitals to be ready to respond to epidemics.

The Centers for Disease Control and Prevention (CDC) has coordinated tabletop exercises and drills at hospitals around the country to enhance planning. As of late February, both avian flu and severe acute respiratory syndrome (SARS) still were confined to a handful of cases in Asia, but that doesn’t reassure public health authorities; it just makes them more vigilant. Eventually, an emerging infectious disease will wreak havoc in the nation’s hospitals, they predict.

"We haven’t had a SARS case so far this year. That’s about all we can say," says Deborah Levy, PhD, MPH, a senior epidemiologist with CDC and a commissioned officer with the U.S. Public Health Service. "We have no way of knowing what’s going to happen in the future. I don’t think you can ever consider yourself out of the woods."

Last year’s SARS epidemic in Toronto showed the vulnerabilities of hospitals as they struggled with work-home quarantines of staff and screening of visitors and workers. The proposed Joint Commission standard, which was under field review in February, goes beyond the general emergency management standard.

"We’re trying to push organizations to think through what potentially are we going to do if something happens," says Nancy Kupka, DNSc, MPH, RN, project director at the JCAHO Division of Standards and Survey Methods. "We’re asking people to think about what’s going to happen if your organization has to manage a large number of potentially infectious patients over a period of time. There are a lot of experts in this field who think [eventually] something is going to happen."

Protecting health care workers is a cornerstone. Although the proposed Joint Commission standard doesn’t specifically mention protection of staff, it is included in the broader concept, Kupka says.

"We don’t in many of our standards specifically address staff. But staff are what makes up the organization. Staff are everything. You have to have enough staff. You have to have sufficient personal protective equipment [PPE]. [Staff] were kind of subsumed into the larger picture," she adds.

Emergency preparedness is not disease-specific, and it is not activated by evidence of an epidemic. It should be integrated with everyday practice, says Will Shelton, M(ASCP), CIC, manager of epidemiology and employee health at Swedish Medical Center in Seattle.

Swedish Medical Center has implemented respiratory hygiene, as recommended by the CDC. Patients with a fever, fever and a cough, or fever and a rash receive a surgical mask and tissues. The hospital keeps alcohol-based gels in waiting areas for hand hygiene.

Swedish purchased masks that have built-in eye protection and disposable face shields that can be used with N95 filtering face-piece respirators.

"It’s a challenge," Shelton says. "The majority of health care workers in the United States are not accustomed to wearing masks with eye protection. Masking is a new behavior we need to learn and implement."

Swedish recently participated in a National Military Defense System drill. In the scenario, 15 soldiers arrived in Seattle from Southeast Asia with respiratory symptoms. Health care workers immediately donned PPE as they began to evaluate the quarantined soldiers.

Shelton says he would like to see them grab the PPE in much less dramatic situations. For example, when an infant recently was hospitalized with suspected respiratory syncytial virus (RSV), health care workers wore PPE to prevent nosocomial spread. As soon as RSV was ruled out and the child was ready for discharge, the staff removed the PPE. It turned out the child had pertussis, and health care workers had been exposed when they removed their masks prematurely.

That’s why any cough may be of concern, he says. "Seattle is in a 30-year high with TB. We’re at a 20-year high for whooping cough [pertussis]. Everyone’s aware of the major influenza activity this year. Our particular hospital has the largest neonatal ICU [intensive care unit] in our state [and has concerns about RSV]. We’re encouraging a much greater use of masking of patients and personal protective equipment for our employees."

Shelton anticipates that preparedness for SARS and pandemic influenza will alter attitudes toward PPE. "All the work we’re doing is for SARS, but it’s not really for SARS," he says. "It’s to protect [workers] against all the airborne infectious diseases we’re dealing with all the time.

"[The danger] may not be SARS or avian influenza. It may be organism X," he says. "We don’t know what’s next. It is forcing us to do things we should do. Our concern for SARS may give us better personal protective equipment and habits for things we deal with every day."

Yet hospitals also need to think about and plan for a worst-case scenario: an influx of patients with a highly infectious disease that could be transmitted throughout the hospital. How would you move sick patients from the emergency department to the ICU to avoid infecting other patients or staff? How would you expand your isolation capacity? How would you monitor the health of health care workers? How would you make sure your staff felt safe enough to come to work? What do you do about staff who work at more than one hospital? If staff are quarantined, how will you provide for their basic family needs?

Hospitals can use the CDC’s SARS preparedness checklist to pose these sorts of questions and come up with answers in a tabletop exercise that involves a hypothetical scenario but not an enactment, Levy says. "You have to work through your plan periodically. Just having a plan is really not good enough."

At Evergreen Healthcare in Kirkland, WA, the emergency preparedness team includes members from communications and social services as they consider how to support the frontline health care workers. "What would we tell the staff? How could we support them from a human resources standpoint to help with their fears?" says Sarah Smith, RN, CIC, infection control manager.

Evergreen purchased additional powered air purifying respirator units for higher-level respiratory protection. They evaluated the traffic flow of patients and the negative airflow rooms. But not all preparations are easy to accomplish. Hospital engineers designed a system that would create negative airflow in an entire unit. But that carried a price tag of $50,000. The hospital is considering other options as well.

Evergreen’s multidisciplinary preparedness team has fielded other issues and found ways to problem-solve, even conducting role-playing to decide the best way to don and remove PPE. "We’ve even thought about how we would provide child care for our staff," says Smith.

The CDC hopes that hospitals around the country will continue to pose questions — and find answers that make them more prepared. "Having all the [relevant] people at the table and talking together is the best way to manage this," says Smith. "You can never do it alone."

Editor’s note: For more information on SARS, go to: www.cdc.gov/ncidod/sars/guidance/C/index.htm.