Don’t miss smallpox/plague outbreaks: Adapt strategies to track bioterrorism
Your ED can’t afford to miss suspicious symptoms
If a bioterrorism attack occurs in your community, one thing is certain: The eyes of the world will be on your ED. You’ll need to have effective strategies in place to make sure that an outbreak is not missed.
"The savvy nurse, nurse practitioner, or physician who notices multiple cases of ED patients with similar or unusual symptoms may be the key to early detection of a bioterrorism event," says Ann Stangby, RN, CEN, emergency response planner for San Francisco General Hospital.
You face three major challenges in doing this, according to Eric Lavonas, MD, FACEP, an ED physician and toxicology fellow at Carolinas Medical Center in Charlotte, NC: Recognizing unusual disease patterns early, notifying local health officials, and then informing staff about specific precautions to take for self-protection.
Here are effective strategies to ensure that potential acts of bioterrorism are identified:
• Provide staff with the right information.
Although most EDs have provided general awareness inservicing since the Sept. 11 terrorist attacks, that may be the wrong approach, argues Lavonas. "In my opinion, a one-hour general talk on all aspects of ED response to chemical and biological warfare is too unfocused to help anyone deal with any single situation," he says. "In fact, I worry that a little knowledge is a dangerous thing. All one can take away from such a session is the worst-case scenario." Instead, Lavonas recommends having a local expert focus on a specific agent, such as anthrax or smallpox.
Every ED staff member must know how to report, whom to report to, and where to access information, says Stangby. "In our ED, we have information on surveillance issues and watching for patterns of illness posted in all clinical areas," she says.
Invite local toxicologists, infectious disease experts, and ED physicians with training in chemical and biologic terrorism to give lectures, suggests Robert Schafermeyer, MD, FACEP, immediate past president of the Dallas-based American College of Emergency Physicians (ACEP) and associate chair for the department of emergency medicine at Carolinas Medical Center. "State EMS medical directors have resources for training, response plans, and practice drills for use at facilities and in communities," he adds.
Lavonas recommends having experts "train the trainer" by teaching the charge nurse or other supervisory personnel. "This allows new information to be disseminated quickly," he says. Lavonas uses a combination of one-page "key points" information sheets plus small group meetings. (See "Patient information sheet: Anthrax" in this issue. To see "Distinguishing Smallpox from Chickenpox," click here.)
"The big issues for nurses and technicians are isolation procedures and early recognition," he says. In your information sheets, Lavonas recommends answering such questions as: "Can the patient give me this disease?" "How do I prevent this patient from spreading the infection to other patients?" "How do I handle linens?" and "Exactly which patients need to go into an isolation room right away?" The needs of ED staff are very different from other departments and should focus on triage and early identification of possible cases, the need for isolation, procedures for interfacing with EMS, security, and control of patient flow, according to Lavonas.
• Use a web site.
Obtain educational materials on recognition of bioterrorism from public health web sites and send it to staff electronically, Schafermeyer suggests. "This could be done as simply as downloading the information into a Word document and posting a link to the documents on the Desktop Windows page," he says. "This allows anyone to access the information." Because of changing recommendations, the information needs to be checked and updated on a regular basis, he adds. "Thus, someone must be designated as the responsible person to do the updates," says Schafermeyer.
• Consider after-hours reporting.
You’ll need to ensure that your internal reporting structure is operational and active 24 hours a day, says Stangby. "Often, current reporting structures are passive, and a report is filed to an infection control nurse who works days Monday through Friday," she says. "After-hours reporting should occur in an active manner, such as by computer, or a call to a live person at the health department." This system should be developed in cooperation with your local and state health department, office of emergency management, safety officer, and infection control nurse, says Stangby. (See "Cutting-edge system spots outbreaks before you do" in this issue.)
You should be informed on how your local health department tracks outbreaks, says Stangby. "As a public health hospital, we are fairly familiar with this, but many private hospitals may not be," she adds. "Make contact with your hospital infection control nurse, epidemiologist, and local health department."
• Build relationships with key players in your community.
Take steps to get involved parties together before an incident occurs.
"You are not only planning together, but also establishing rapport and relationships on a personal and professional level," says Craig DeAtley, PA-C, associate professor of emergency medicine at George Washington University School of Medicine and Health Sciences in Washington, DC. When planning strategies for bioterrorism, DeAtley advises involving "anyone and everyone you foresee yourself having to integrate with." He points to public health departments, public utilities, police, fire fighters, and EMS as examples.
• Have a system to alert staff immediately if an outbreak is suspected.
Explain to staff that standard triage policies and procedures should be used until something unusual is suspected, says DeAtley. "Once there is recognition that something out of the ordinary has happened, then give staff the plan for what, if anything, above the normal they should do," he advises. This may mean taking extra precautions, asking additional questions, or bringing some patients directly to a new location, says DeAtley. Possible ways to disseminate this information include overhead paging, word of mouth, handheld pagers, or printed instructions, he says.
At West Virginia University’s ED in Morgantown, staff receive an e-mail listserve from the hospital’s infectious disease experts. "We are constantly communicating the latest developments or cases, to keep staff informed of any changes," says Janet Williams, MD, FACEP, director of the hospital’s Center for Rural Emergency Medicine.
• Encourage staff to report all suspicions.
Staff should not hesitate to "raise the flag" if something doesn’t seem right, says Williams. "If there is a disease process that is not commonly seen, or if there are clusters of illnesses that are not typical, staff should be suspicious that there may be something unusual going on," she says. "You want to strive for overreporting, rather than underreporting."
Have a specific individual, such as a nurse manager, report high-likelihood cases to your county health department without waiting for laboratory confirmation, Lavonas recommends. He points to a patient who came to the ED with fever, hemoptysis, and shock. "If his initial chest X-ray showed a widened mediastinum, or if tests for alternate diagnoses were negative, I would have drawn appropriate cultures for anthrax — but also called my county health department to let them know of a likely case," he explains, adding that in this case the patient turned out to have a pulmonary embolism.
• Consider patient confidentiality issues.
If a bioterrorism incident occurs, there will be epidemiological investigations that potentially could breach patient confidentiality, says DeAtley. "Outsiders such as the health department and law enforcement personnel may need to evaluate patient records, which they normally wouldn’t have access to," he explains. Be aware of local and state regulations regarding medical record access, says DeAtley. " Clearly, there is some latitude in a public health emergency that is rightfully authorized [and] has to be used with discretion," he adds. "Your disaster committee needs to address this in consultation with risk managers who know what the rules allow in this particular situation."
Sources
For more information about tracking bioterrorism, contact:
• Craig DeAtley, PA-C, Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Ave. NW, Washington, DC 20037. Telephone: (202) 257-4714. Fax: (703) 503-1361. E-mail: [email protected].
• Eric Lavonas, MD, FACEP, Department of Emergency Medicine, Carolinas Medical Center, 1000 Blythe Blvd., Charlotte, NC 28203. Telephone: (704) 355-4212. Fax: (704) 355-8356. E-mail: [email protected].
• Robert Schafermeyer, MD, FACEP, Department of Emergency Medicine, Carolinas Medical Center, 1000 Blythe Blvd., Charlotte, NC 28203. E-mail: [email protected].
• Ann Stangby, RN, CEN, San Francisco General Hospital, 1001 Potrero Ave., San Francisco, CA 94110. Telephone: (415) 206-3397. Fax: (415) 206-4411. E-mail: [email protected].
• Janet Williams, MD, FACEP, Center for Rural Emergency Medicine, West Virginia University, P.O. Box 9151, Morgantown, WV 26506-9151. Telephone: (304) 293-6682. Fax: (304) 293-0265. E-mail: [email protected].
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