In an epidemic of fear, the antidote is education

Miami hospital calms workers as it treats anthrax

When Cedars Medical Center in Miami treated the nation’s second pulmonary anthrax case, there was an outbreak of one fast-spreading by-product: fear. Moving quickly to educate employees and allay their fears is a critical part of the first response to a bioterrorism event, says Anexis Lopez, RN, BHSA, the hospital’s director of infection control.

As the anthrax scare unfolded with cases in four states, hospitals around the country mobilized to reassure health care workers and reinforce infection control practices. The Cedars experience illustrates the importance of clear guidance and hospital preparedness.

Shortly after Ernesto Blanco, an employee at American Media in Boca Raton, was assessed for anthrax, Cedars employees began asking about antibiotic prophylaxis. Two employees called and said they were afraid to come to work. Everyone from housekeepers to nurses became worried, even though anthrax isn’t spread from person-to-person contact. Lopez immediately went from unit to unit with reassuring information. "The minute we started to [evaluate] this patient for anthrax, we started the education."

Although experts say standard precautions are sufficient when dealing with anthrax cases, Cedars raised the level of protection to droplet precautions when caring for Blanco. Employees entering the room wore masks. "That calmed a lot of anxiety in the beginning," Lopez says. "The CDC [Centers for Disease Control and Prevention] agreed with us on [the added precaution]."

For several years, Lopez had provided hospital units with a simple matrix of bioterrorism agents, listing the risks and precautions. Her monthly newsletters also contained information about bioterrorism preparedness. (To see matrix, click here.) But when anthrax cases occur, that information needs to be reinforced, she says. "Even though they know what needs to happen, people just panic. I can’t imagine if we hadn’t been prepared for this. [The anxiety] would have been worse."

With new cases appearing around the country, any sign of white powder can cause fear. In one case, powder found on a medical cart raised an alarm at Cedars Medical Center. Closer inspection showed that it simply was dried-up Maalox.

After the Sept. 11 terrorist attack, hospitals around the country began updating their disaster plans, as biological and chemical terrorism suddenly became a more realistic possibility. (For more on preparedness, see Hospital Employee Health, November 2001, p. 121.) The Department of Veterans Affairs (VA) quickly produced pocket cards with biological and chemical agents, their signs and symptoms, appropriate precautions, and possible prophylaxis. (For copies of the cards, click here. For a biological agent treatment chart, click here.)

"They’re just reminders of what you need to do," says Michael Hodgson, MD, MPH, director of the VA’s occupational health program. The cards provide detailed guidelines about whom to call and what to do if an unusual cluster of illnesses occurs. Swift identification of the first cases of a biological terrorism attack allows not only for proper treatment of the victims, but for adequate protection of health care workers and the general public. "Stay calm is the best advice anybody can get or give," he says. "The issue, as always, is that when you are worried you don’t think as clearly."

Smallpox and plague, both highly contagious, are likely to incite more fear than anthrax. But infection control procedures, such as using negative pressure rooms, cohorting patients, and using respirators, can protect against occupational exposure. Hospitals also should be prepared to handle patients who suffer from chemical exposure, whether it’s caused by an industrial accident or a terrorism event, Hodgson adds. "The bottom line for all of this, once you’ve [decontaminated] what you need to decontaminate, they’re patients like anybody else."

CDC: Get flu vaccine to allay anxiety

Amid the anthrax scare, the emergence of the flu season may lead to some increased anxiety. That’s because inhaled anthrax may present with flu-like symptoms. Hospitals, which long have sought to raise the immunization rate of health care workers, now have a new and compelling impetus. "It’s going to be interesting to see if more people are going to be more willing to take [the vaccine]," says Vicky McGavack, RN, COHN-S, manager of occupational health services at Hoag Memorial Hospital Presbyterian in Newport Beach, CA.

Meanwhile, the CDC ordered enough smallpox vaccine to immunize the general population. In a bioterrorism event, health care workers would be among the first to receive the vaccine, says CDC spokesman Tom Skinner. The CDC developed a smallpox response plan that would go into effect with the first identified cases of the disease. Smallpox is highly contagious, often fatal, and has no effective treatment. But the CDC stopped short of advocating widespread vaccination because of the rare but potentially fatal side effects of the smallpox vaccine.

"My personal opinion is that smallpox vaccination should be an option. It should be available to those individuals who understand the risks and benefits," comments Stephen Cantrill, MD, associate director of emergency medicine at Denver Health Medical Center. Cantrill participated in a bioterrorism exercise last year that dealt with a hypothetical spread of plague. "Would I be vaccinated? Without question. But that’s a personal decision," he says.

The anthrax cases, while frightening, presented public health officials with a more benign scenario of bioterrorism. The CDC mobilized within hours to provide antibiotics to those who were potentially exposed to anthrax in Florida, notes Hodgson. That illustrated the nation’s capability to react swiftly, he says. "I’m no longer so concerned that people need three days of antibiotics until the public health response gears up."

Hospital disaster preparedness already had come under increasing scrutiny from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL. "This is not a new concern for JCAHO," says Geoff Kelafant, MD, MSPH, FACOEM, medical director of the occupational health department at the Sarah Bush Lincoln Health Center in Mattoon, IL. "It was a concern before Sept. 11. I’m sure it’s going to be put way up on the front burner now."

The Joint Commission’s new standard on emergency preparedness became effective Jan. 1, requiring hospitals to "establish and maintain a program to ensure effective response to disasters or emergencies affecting the environment of care." As of Sept. 11, Joint Commission surveyors have increased their focus on biological and chemical terrorism as possible disaster scenarios. In October, Kelafant says surveyors who visited his hospital made it clear that "this is something JCAHO was looking at very carefully."

How do you coordinate with local authorities to report unusual patterns of illness? How do you verify that the isolation rooms are working under negative or positive pressure? Those questions now have new implications. "I think people should reliably expect they’re going to asked [such questions]," says Kelafant, who is chairman of the medical center occupational health section of the American College of Occupational and Environmental Medicine in Arlington Heights, IL.

The anthrax cases have spurred communities to address some of the weaknesses revealed in the Denver drill, such as communication and coordination, says Cantrill. That may be the "silver lining" of the incidents. "I think this has been overall very good for the medical community," he says. "It has brought bioterrorism up on the radar."

Yet even as new cases of anthrax occurred, the fear of exposure remained much greater than the risk itself. At hospitals around the country, everyone from mail clerks to clinical personnel began asking about precautions. At Sarah Bush Lincoln Health Center, mailroom workers asked if they should wear gloves to protect against any letters that might contain a suspicious powder. But Kelafant had to consider the implications of gloving one group of workers and not another. "What about the end-users of the mail? Are we going to put the whole chain of mail users in gloves and masks?" he asks. "We decided to identify suspicious packages and letters and set them aside, then decide what to do with them. I think that’s the best [way to handle it]."