Smallpox vaccine is here: Avoid 3 worst-case scenarios’ in your ED
Careful planning can avoid a logistical nightmare
It’s the moment of truth. The controversial vaccination of health care workers for smallpox is here, with emergency department (ED) staff among the first to be inoculated. For the ED manager, your nightmares may include staff who are unable or unwilling to have the vaccine, staff who become ill after having the vaccine, and a situation worse than an unannounced accreditation survey: a smallpox outbreak.
"It would be the biggest flu outbreak you could possibly imagine, and then some," says Robert Suter, DO, FACEP, senior consultant for Dallas-based Texas Emergency Physicians and director of physician practice development for Greater Houston Emergency Physicians, both ED physician practice groups. Everything in contact or near each patient would be highly infectious and would require extensive cleaning, he says. "Doing things right would be very staff-intensive, especially for housekeeping and laundering," he says. "It would truly be a nightmare."
Although the plan doesn’t differ greatly from previous announcements, EDs are now receiving detailed instructions and definite timeframes, so managers have the go-ahead to prepare in earnest for staff to receive the vaccine shortly. Experts in emergency planning and ED management agree: To avoid a logistical nightmare during the smallpox vaccination program, you have no choice but to plan carefully in advance. "The goal when giving the vaccines is not to disrupt ED operations," says Katherine Haddix-Hill, RN, MSN, director of emergency services at Brandon (FL) Regional Hospital.
Here are the three "worst-case" scenarios you must plan for:
• Most of your staff could become ill from the vaccine.
Side effects are a major worry for all ED managers, says Val Gokenbach, RN, MBA, CAN, director of emergency services and observation at William Beaumont Hospital in Royal Oak, MI. "We are all concerned about our staff," she says. "However, we would like enough people vaccinated so our staff will be protected."
Virtually all staff members will have swelling and pain in the vaccinated arm that will limit their ability to use it for days or weeks, Suter says. "Beyond that, the CDC [Centers for Disease Control and Prevention] reports that in the past, about 1,000 people for every 1 million people vaccinated for the first time experienced reactions that, while not life-threatening, were serious," he says.
These reactions include the following:
- a toxic or allergic reaction at the site of the vaccination;
- spread of the vaccinia virus to other parts of the body and to other individuals;
- spread of the vaccinia virus to other parts of the body through the blood.
Those reactions would prevent staff from working and may require medical attention, Suter says. "Also, according to the CDC, between 14 and 52 people out of every million people vaccinated for the first time experienced potentially life-threatening reactions to the vaccine," he says.1 Based on past experience, it is estimated that one or two in a million who receive the vaccine may die as a result, Suter adds. "This would probably increase if careful screening of potential vaccine recipients is not done to ensure that those at increased risk do not receive the vaccine," he says.
• Major staffing problems could continue indefinitely.
There is no question that the vaccine program will shake up the way you staff your ED for a long time.
"If you make an institutional commitment to participate, it will impact scheduling until the threat is certified as gone," says Suter.
Staff members may need time off if they become ill with adverse reactions or even basic side effects, says Ann Stangby, RN, CEM, emergency response planner at San Francisco General Hospital. "Staffing assignments may need to be altered," she says.
You always need to schedule a vaccinated person at triage and have one or two others on duty to ensure that vaccinated personnel are available to care for a suspected smallpox patient if needed, Suter says.
"You also would need to always have a vaccinated ED physician on duty or have a smallpox doctor on call to come in and evaluate a possible case, so this would affect scheduling indefinitely," he says.
If possible, staff should be selected from all shifts to ensure availability of the response team around the clock, Haddix-Hill says. "The skill mix should ensure appropriate care for the smallpox patient and still allow the ED to function optimally," she says.
Since there is a possibility that most vaccinated staff will become ill, Gokenbach advises against vaccinating the whole ED staff at once. "That way, you have limited exposure," she says. "Fever and flulike symptoms may prevent people from working for a couple of days. You don’t want half of your staff being sick."
• Staff may be unwilling or unable to receive the vaccine.
A key concern for ED managers is how many staff members actually will volunteer to be vaccinated, Haddix-Hill says. In addition, the ED may not receive enough doses to vaccinate the entire staff. "Also, not all staff will be eligible to receive the vaccine," she notes.
Although you should consider whether staff are vaccinated when scheduling, your planning can’t be foolproof, Haddix-Hill says. While having a vaccinated team member always available in the ED is ideal, there is no way to ensure this staffing situation 100% of the time, she says. "It is something we will take into consideration when doing the schedule, but there are always the last-minute schedule changes when the unexpected occurs," Haddix-Hill says.
The entire ED staff will not be vaccinated initially, she explains. "If a smallpox patient should present to the ED, then the rest of the staff would receive the vaccine," says Haddix-Hill, pointing to CDC guidelines stating that vaccinations within three days of exposure "will completely or significantly modify smallpox in the vast majority of persons."1
Haddix-Hill doesn’t know how many doses of vaccine her facility will receive, but the expected range is 100-200. The number of doses will determine how many of the 150 ED staff members are offered the vaccine, she says.
Develop a policy on whether to allow vaccinated staff to work while potentially infectious and, if so, in what roles, Suter advises. "If not, will the hospital administration fund the time off?" he asks. Agency nurse use is at historic highs, and many ED physicians are independent contractors, he notes. "Both groups don’t have sick days or hospital-sponsored benefits," he says. "Who will compensate them for lost work?"
In the same way that specific nurses manage pediatric, trauma, and cardiac cases, predesignated nurses would care for a suspected smallpox case, Gokenbach says. "That’s why we wanted as large a cadre as possible, so individuals could be pulled in when needed," she says.
Stangby’s facility is surveying the entire ED about willingness to be vaccinated. "This will give us an estimate of how many people not only would be eligible, but willing to be vaccinated," she says.
Reference
1. Centers for Disease Control and Prevention. Smallpox Response Plan and Guidelines, Draft 3.0. Nov. 26, 2002. Web: www.bt.cdc.gov/agent/smallpox/response-plan
Sources
For more information about the smallpox vaccination program, contact:
• Val Gokenbach, RN, MBA, Director of Emergency Services and Observation, William Beaumont Hospital, 3601 W. 13 Mile Road, Royal Oak, MI 48073. Tele-phone: (248) 551-1995. Fax: (248) 551-2017. E-mail: [email protected].
• Katherine Haddix-Hill, RN, MSN, Director of Emer-gency Services, Brandon Regional Hospital, 119 Oakfield Drive, Brandon, FL 33511. Telephone: (813) 571-5156. Fax: (813) 681-4986. E-mail: [email protected].
• Ann Stangby, RN, CEM, Emergency Response Planner, San Francisco General Hospital, 1001 Potrero Ave., San Francisco, CA 94110. Telephone: (415) 206-3397. Fax: (415) 206-4411. E-mail: ann_ [email protected].
• Robert E. Suter, DO, FACEP, Senior Consultant, Texas Emergency Physicians, 5926 Saint Marks Circle, Dallas, TX 75230-4048. Telephone: (214) 739-2776. Fax: (214) 739-0658. E-mail: [email protected].
The controversial vaccination of health care workers for smallpox is here, with emergency department (ED) staff among the first to be inoculated. For the ED manager, your nightmares may include staff who are unable or unwilling to have the vaccine, staff who become ill after having the vaccine, and a situation worse than an unannounced accreditation survey: a smallpox outbreak.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content