Many hospitals unprepared for a bioterrorism event
ICPs key to gearing up readiness
Distracted by fiscal pressures and reluctant to dedicate time and money addressing a theoretical concern, many of the nation’s hospitals are unprepared to deal with a bioterrorism incident in their communities, experts tell Hospital Infection Control. But infection control professionals and hospital epidemiologists can play vital roles in upgrading preparedness, and many are already doing so, they add.
Should a bioterrorist attack occur, hospitals would inevitably become the front-line institutions for dealing with the response, regardless of the pathogen involved, says Tara O’Toole, MD, MPH, senior research fellow at the Center for Biodefense Studies at Johns Hopkins University in Baltimore. But many hospitals are not well-prepared to deal with a mass casualty situation, she warns, noting that economic pressures have reduced staff, intensive care and isolation beds are scarce, and medical supplies are too often being purchased on an "as-needed" basis. While the situation has been gradually improving as the issue of bioterrorism continues to emerge as a legitimate concern, the economic climate that hospitals face does not lend itself to increased training and preparedness issues.
"Until quite recently — really until the last several months — I don’t think bioterrorism was on the attention screens of most hospitals," she tells HIC. "Most hospitals are preoccupied with financial survival and delivering health care right now. It is a very competitive time. Secondly, the policy-making and funding efforts in the federal government that have been quite active over the last couple of years have really not addressed hospitals. It’s only now that the policy-makers are really coming to understand that when you are talking about terrorism or even weapons of mass destruction, bioterrorism is a completely different kettle of fish than a chemical explosion or even a big conventional or nuclear explosion."
An unannounced bioterrorist attack would likely come to attention gradually, as health care workers became aware of an accumulation of inexplicable deaths and illness among previously healthy people, she notes. Routine infection control surveillance could provide a critical early warning sign, but communication with public health officials must follow. "One of the things that has to happen for bioterrorism preparedness is that the current gulf between the world of medicine and the world of public health — between hospitals and state health agencies — has got to be bridged," O’Toole says.
In that regard, there have been memorable cases where ICPs working with public health officials have identified and solved mysterious community outbreaks. For example, ICPs at various hospitals in the Blacksburg, VA, area alerted public health officials to an unusual increase in community-acquired pneumonias that infected 23 people and caused two deaths in 1996. Public health investigators — who tracked the outbreak of Legionella pneumophila to a whirlpool display at a home improvement store — credited the ICPs with sounding the alarm in the case. (See Hospital Infection Control, April 1997, pp. 51-53.) Similarly, the Centers for Disease Control and Prevention advises health care workers to look for clusters and syndromes to determine if a bioterrorism event may be unfolding.
"The sentinel manifestations of that are likely to be a couple of uncommon cases rolling into the emergency room first or perhaps [to] primary care physicians, followed by a larger cluster," says Michael Bell, MD, an epidemiologist and bioterrorism specialist in the CDC hospital infections program. Bell is the lead CDC author of bioterrorism guidance published in conjunction with the Association for Professionals in Infection Control and Epidemiology.1
The document focuses on issues of preparedness for smallpox, anthrax, botulism, and pneumonic plague. Since few clinicians have seen such infections and laboratory diagnostics are limited, the CDC/APIC document includes a list of syndromes to help identify possible infections. (See related story, p. 36.) If a bioterrorism infectious agent were suspected, contacting local public health authorities would be the logical next step. "But it’s not as if once you call your public health department, your patients are going to disappear," Bell emphasizes. "They are still going to be sitting there in your waiting room. So if we don’t in advance discuss some of the issues related to that, the scrambling at the last minute is going to be a fiasco."
As a practical matter, an influx of infectious patients (i.e., smallpox or pneumonic plague) could quickly overwhelm available isolation rooms, O’Toole adds. "It’s probably not going to be necessary to make capital investments and build a lot of isolation rooms, but it would be a good idea for people to look around and see if there are certain floors or wings that could become separate areas of air flow. Most hospitals have such areas," she says. "Some advance sleuthing as to what a hospital would do if it were confronted with a whole bunch of very ill, infectious patients would probably be worthwhile."
In that regard, infection control professionals at Walter Reed Army Medical Center (WRAMD) in Washington, DC, have taken the step of creating an infection control isolation precautions matrix to instruct and educate health care workers should a bioterrorist exposure occur. (See chart, p. 38.) Designed to provide an easy reference for infection control precautions for the most likely agents to be used by bioterrorists, the matrix also addresses such issues as patient placement and transport, cleaning and disinfection of equipment, and discharge and post-mortem care.
Lt. Col. Suzanne Johnson, RN, MSN, chief of infection control at WRAMD, who designed the matrix, based it on the CDC/APIC document and materials on other biological agents from the U.S. Army’s facility in Fort Detrick, MD. "This is the nation’s capital. If they — whoever they’ are — can get to the [government], I’m sure they would want to," Johnson says. "From my standpoint as the chief of infection control, I want to provide the people that work here with as much information as possible."
Indeed, the seat of U.S. political power would be in the "top five" of virtually any assessment of bioterrorist targets, says Allan J. Morrison Jr., MD, MSc, FACP, health care epidemiologist for the four-hospital Inova Health System in Washington, DC. Accordingly, Morrison stresses bioterrorism preparedness, including meetings with members of the infection control, safety, and disaster committees for discussions. "Between those three committees, there is incremental work going forward," he says, adding that he would like to conduct drills with regional law enforcement, fire, and rescue.
Mass drills shouldered aside by fiscal needs
However, it is difficult to organize the kind mass drills needed to simulate a bioterrorist event, particularly because hospitals beset by real world fiscal pressures are reluctant to give up the minimum of a half-day of down time to conduct drills, he notes. "Human nature being what it is, it is difficult to impress upon people the importance of preparing for this," Morrison says. "When you have the financial pressures that health care systems have, getting something to percolate to senior leadership — to the level it will actually be strongly endorsed — is a difficult thing compared to the realities of this fiscal quarter’s budget."
Preparedness might be enhanced if accrediting organizations added a few "nudge points" regarding appropriate funding for bioterrorism response, he says. O’Toole concurs, though she notes that "paper plans" in the absence of drills will not be sufficient to address the problem. She has testified before Congress to request funding for the issue, noting that only about 14% of the $10 billion currently spent on counterterrorism efforts is earmarked for biological threats.
"Some combination of incentives to get busy hospitals engaged in this issue would make sense," she says. "Exactly what those incentives should be — carrots or sticks — is something that should be worked out in the next year." As national plans continue to develop, infection control professionals and hospital epidemiologists will inevitably be called upon because of their expertise with communicable diseases, Bell says.
"Both infection control and hospital epidemiology [professionals] are very well-placed to take a leadership role," he says. "They have a history of communications in this role — spreading the word about hand washing and cohorting, and teaching patients what it means, for example, to be on contact precautions. That is the kind of thing we are going to be needing in the event of a bioterrorism [incident]," he says.
Reference
1. Association for Professionals in Infection Control and Epidemiology Bioterrorism Task Force and Centers for Disease Control and Prevention Hospital Infections Program Bioterrorism Working Group. Bioterrorism Readiness Plan: A Template for Healthcare Facilities. 1999. http://www.cdc. gov/ncidod/hip/Bio/bio.htm.
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