Bird flu pandemic may not be certainty, but it’s not too early to start preparing

Improved ED infection controls badly needed, they warn

The avian influenza A (H5N1) virus, more commonly known as bird flu, is capturing headlines around the world. President Bush has even announced a plan to prepare the United States for a possible pandemic. But with no confirmed record yet of human-to-human transmission — and the possibility that the virus may never mutate to that deadly state — is it too soon for ED managers to have the virus on their radar screens?

Not at all, says infectious disease and emergency medicine experts. They note that steps taken today, such as encouraging your entire staff to receive the flu vaccine, will lessen the possibility their immune systems will be weakened should they eventually be exposed to bird flu or other infectious diseases. What’s more, they note, it presents an opportunity to hone what some say are woefully inadequate infection control practices.

"Bird flu needs to be on our radar screens because preparedness in general has not been really successful," asserts Katherine West, BSN, MSED, CIC, infection control consultant at Infection Control/Emerging Concepts in Manassas, VA.

Michael Moon, RN, MSN, CNS-CC, CEN, a director of the Emergency Nurses Association (ENA) in Des Plaines, IL, says, "While we don’t have any actual avian flu here in the U.S., the CDC [Centers for Disease Control and Prevention] is recommending that ED managers start establishing plans to monitor the population."

Not only are the plans of many individual EDs inadequate, but so is the president’s plan, say observers. The American College of Emergency Physicians, while commending the Bush administration for releasing its long-awaited plan, expressed concern that it does not address the lack of surge capacity and isolation capability in the nation’s hospital emergency departments. Its quarantine strategy is also inadequate, says West.

"Our government plan to ensure that people stay home is for volunteers to call their homes twice a day," she says. "That just won’t cut it."

A new planning issue

The possibility of an avian flu outbreak adds a new issue to the ED disaster plan, says West. "ED managers have to look at their physical setup to triage or cohort suspected cases, should they occur," she advises. Look at the floor plan for your department and figure out how to best make it work, West says. "A bay area, a large room with multiple beds, is needed because people with the same illness can go in together," she says.

In addition, travel history needs to be a part of routine patient assessment questions, she says. "ED managers should be preparing now," West insists. Hurricane Katrina taught valuable lessons about being sure to involve not just the upper echelon in making plans, but include the rank and file, she says. "You also need to have community buy-in in the planning, or you’ll have mass hysteria," West says.

Another point that needs to be considered when your ED does its planning is, assuming there is no vaccine for the avian flu, what percentage of staff may get sick and be out, says West. "Or, how many spouses will say, Don’t go to work, this is much too risky. You could bring it home to the family,’" she adds. Assess staff attitudes, West says. "Look at the number of police officers who failed to report to work in New Orleans."

The biggest issue at this point is surveillance, says Moon. "Look for trends of symptoms in patients that come in the department," he says. "The CDC has a pretty extensive resource list of recommendations of what to do and what to be watching for." In general, Moon continues, the CDC recommends "disaster-type" planning. "In other words, how would you handle a mass influx of patients with flu-like symptoms?" he says. "The worry is, once it hits it will spread very quickly."

The Joint Commission on Accreditation of Healthcare Organizations also is involved. The agency has a new surge capacity standard (IC.6.10) that says "as part of emergency management activities, the organization prepares to respond to an influx, or the risk of an influx, of infectious patients."

Staff should be vaccinated

Experts agree that in terms of infection control, it would be best for all ED staff to have a flu vaccination this year, even though it is not a vaccine for H5N1.

"Health care workers need to participate in the annual flu vaccine program," says West. "We’re only seeing 30%-35% participate. The Joint Commission [on Accreditation of Healthcare Organizations] is looking at failure of health care workers to volunteer as a patient safety issue, as they believe many patients get the flu from staff."

There can also be a connection to bird flu, she says. "The current concern is that avian flu will be transmitted human to human, but there’s another part to that concern; someone who is infected with regular flu could also contract avian flu," West explains. "The two strains would merge together, and we would not have anything to fight it, so there’s a big push to take the annual flu shot."

Moon also encourages health care providers to obtain their vaccine. This vaccine will be protection for ED nurses against nosocomial infection, he says. Nurses also have a tendency to show up for work when they are sick, Moon says. "The CDC is charging hospitals to evaluate the potential risk to patients when staff comes in sick — especially in departments where there are very vulnerable patients, such as the ICU and the ED," he says. "You want to have your staff not show up if they are sick."

While totally supportive of staff vaccination, Henry Siegelson, MD, FACEP, an emergency physician with Apollo MD, an Atlanta group of emergency physicians who provide emergency care throughout the Southeast, has even more far-reaching concerns.

"If someone comes in today with a cough and fever, in some departments masks are given to patients, but they are not mandated to wear them, and in virtually no ED will health care practitioners wear a mask when they evaluate patients or deliver care," he says. During the severe acute respiratory syndrome (SARS) epidemic of 2003, Siegelson gave a lecture to 300 respiratory therapists in Atlanta. "I asked them how many wear masks when they give a breathing test to someone with a cough or fever," he says. "Zero percent raised their hands."’

As he travels around the country, Siegelson speaks with infection control professionals who are passionate about wearing protective gear. "They feel there is at best 18%-20% compliance," he says.

Protective gear, for example, should include gloves for any hands-on care of patients, but Siegelson says he has pictures of his own nurses starting intravenous lines with a finger of the glove cut off, "so they can feel the vein."

Siegelson warns ED managers to review their policies on protective gear and to adjust them "to more adequately protect health care practitioners now, before bird flu transmission from human to human becomes a daily event."

What exactly does he recommend? "When a patient comes in with a runny nose or a cold, we don’t wear masks at the nurse’s station or in the doctors’ charting area," Siegelson notes. "For some people, that may lead to something as serious as viral meningitis, which could keep them from going to work."

He goes even further and raises the question of whether providers should wear masks at home if their kids are sneezing. "We have to look at the ways we live our lives and our responsibilities as health care workers in the ED," Siegelson says.

ED managers should consider consequences for staff who fail to follow policies and procedures regarding protective gear, he says. "After maybe a warning, if you start an IV and you’re not wearing gloves, you should be penalized," Siegelson says. "If you come to work with a cough and runny nose, you should be penalized."

The bottom line, says West, is that tightening infection control practices makes sense, whether or not a bird flu pandemic is imminent. We don’t know if the bird flu will strike, she concedes. "But what we do know is that it used to be every 30-40 years that diseases jumped from animal to man."

Now, it happens much more frequently, she says. "We’ve had AIDS, monkeypox, SARS, West Nile Virus . . . and now, avian flu," West says.

Sources/Resource

For more information on preparation for bird flu, contact:

  • Michael Moon, RN, MSN, CNS-CC, CEN, Director, Emergency Nurses Association, 915 Lee St., Des Plaines, IL 60016-6569. Phone: (800) 900-9659.
  • Henry Siegelson, MD, FACEP, Apollo MD, Atlanta. E-mail: siegelson@mindspring.com.
  • Katherine West, BSN, MSED, CIC, Infection Control Consultant, Infection Control/Emerging Concepts, Manassas, VA. Phone: (703) 365-8388. E-mail: info@ic-ec.com.

For the CDC's recommendations for bird flu preparations, go to www.cdc.gov/flu/avian/. Then, scroll down the "Health Professionals" link, and click, then click on "Infection Control in Health-Care Facilities."