Lack of preparation for bioterrorism puts health workers at risk
December 1, 2000 6 minutes read
Lack of preparation for bioterrorism puts health workers at risk
Experts urge education, better use of precautions
May 19, 2000: Patrons are watching a performance in the Denver Performing Arts Center while, silently, pneumonic plague is unleashed through air conditioning vents. The first symptoms are benign: cough, fever, achiness. Yet within days, symptoms worsen as some victims begin coughing up blood. Eventually, thousands of people become ill and flock to area hospitals. This act of bioterrorism leads to secondary infections in dozens of health care workers who are treating the patients. Delays in recognition of the infectious threat leads to deaths.
This scenario, created as an unannounced exercise to test readiness for a bioterrorism threat, revealed serious weaknesses in hospitals’ ability to respond to that kind of crisis. Hospitals quickly became overwhelmed with patients and, after multiple shifts without rest, hospital staff became fatigued, stressed, and fearful.
While national bioterrorism experts dissect what they learned from the Denver exercise, they have a simple message for employee health professionals: Do more of what you do best.
Staff education and awareness can make a difference in how effectively hospitals respond to bioterrorism or naturally emerging infectious diseases, experts say. Employees who are careful about complying with standard precautions, including giving masks to patients with respiratory symptoms and wearing masks themselves, will be better protected from new pathogens.
"We’ve led health care workers down a path so they’re waiting to know which patients are infectious and [when they need] to do something special," says Lynn Steele, MS, CIC, epidemiologist with the Hospital Infections Program at the Centers for Disease Control and Prevention in Atlanta. Instead, employees should routinely use protective equipment to protect against bodily fluids.
"Doing the right thing as consistently as possible is the key," concurs Michael Bell, MD, bioepidemiologist for the Hospital Infections Program and lead CDC author of a guidance paper on bioterrorism. (For more information, see editor’s note at the end of this article.)
The agents considered most likely to be used in bioterrorism at first don’t present symptoms that seem alarming. Victims of smallpox won’t feel sick at all for a few days or more than a week while the virus incubates. They’ll first get a rash and fever, but when smallpox symptoms worsen, the disease causes disfigurement, pain, and, for many, death.
Pneumonic plague, a pulmonary version of the ancient bacterial disease, begins with symptoms that seem like the common cold. But "by the time some of the patients present with severe symptoms, even antibiotics will not save their lives," says Stephen Cantrill, MD, associate director of emergency medicine at Denver Health Medical Center and a participant in the exercise. "It’s by and large a matter of time before they die."
While some possible bioterrorism agents, such as anthrax, don’t involve person-to-person transmission, smallpox and plague could spread through secondary infections.
In Denver, Cantrill and his colleagues considered health care workers at risk for infection from plague if they had contact within two feet of the patient and weren’t using protective gear. The numbers reached into the dozens before the bioterrorism event would have been detected. "This represents a real dilemma, quite honestly," says Cantrill. "We can’t all dress up like spacemen when someone has the symptoms of a cold."
But using masks and goggles after the outbreak has been identified leaves many unprotected. "Once the institution realizes it’s dealing with an epidemic of a significant disease, then everyone is going to follow appropriate precautions," says Cantrill. "Are you closing the barn door after the horses escape? How much damage was done before you realized that?"
The Denver exercise raises more questions than answers. But Cantrill and others say the real possibility of bioterrorism, or of an emerging infectious disease, provides a basis for employee awareness and greater vigilance toward standard precautions.
Research shows that physicians, nurses, and other hospital staff follow appropriate hand-washing procedures in only 25% to 75% of all patient encounters.1,2 One study found that only about half of operating room personnel wore protective eyewear.3
And while wearing gloves has become routine, the use of masks remains low. "We hope to change the culture, so it becomes the norm to put on a mask and eye protection until you evaluate that the patient is not coughing or is not going to have any potential to transmit body fluids, instead of waiting for that label to know this is something extra you have to do," says Steele.
Employee health professionals also have a role in the broader preparations that should occur hospitalwide. The Denver exercise pointed to the importance of communication, particularly as a part of detection of emerging diseases.
While infection control staff take the lead in surveillance and reporting to public health authorities, employee health professionals would be an important link in the education of health care workers. In the case of an outbreak, many employees would turn to employee health staff with concerns about safety, prophylaxis, and possibly vaccination.
In the wake of the bioterrorism exercise, the Medical Center of Aurora (CO) is currently developing protocols to enhance the early recognition of new disease clusters. While the test case of pneumonic plague presented a difficult scenario, it pointed to the importance of staff education and staff awareness when a cluster of patients presents with the same symptoms, says Sandy Hawkins, RN, MS, CIC, the hospital’s infection control coordinator.
She echoed the importance of communication, particularly within the emergency department. "We have a very large emergency department. Physically, there are five different areas, and, at any given time, we have six physicians on duty. The staff soon discovered that communication within the department for updates was a priority.
"Team members need to meet every 20 minutes for updates, with an open line to the command center," she says. "That way team members have the most current information about patients, causative agent, treatment recommendations, and other matters."
Rapid dissemination of information can diffuse rumors and fears, notes Tara O’Toole, MD, MPH, deputy director of the Center for Biodefense Studies at Johns Hopkins University in Baltimore. "It is very important that hospital personnel of all stripes are aware of the possibility of a bioterrorism attack and have enough factual information about what they should do, how they could be protected. Should an attack occur, someone needs to be able to get information out to everyone from professional staff to support workers. [Hospitals need to] communicate very rapidly to people whether they are at risk and how."
Hospitals also may develop systems that could be adapted to address a bioterrorism emergency, notes O’Toole. For example, a computer system used to monitor medical errors could be designed to adapt to outbreak response. Collaborative efforts among hospitals would enhance the community’s emergency readiness.
"The possible consequences of a bioterrorism attack are so dire that I think there are solemn responsibilities that the hospital community and the medical community more generally have to accept in preparing for such an event," she says. "There’s an awful lot we can do to prepare that would limit suffering and death. It would be too late once an attack occurs to make the arrangements that would mitigate the situation."
(Editor’s note: The CDC and the Association for Professionals in Infection Control and Epidemiology have developed a "Bioterrorism Readiness Plan: A Template for Healthcare Facilities," which is available on the CDC’s Web site at www.cdc.gov/ncidod/hip/Bio/bio.htm.)
References
1. Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999; 130:126-30.
2. Simon A, Hugonnet S, Perneger T, et al. Doctor, why do you wash your hands so little? Presented at the Fourth Decennial International Conference on Nosocomial and Healthcare-Associated Infections. Atlanta; March 2000.
3. Kim L, Freeman B, Jeffe D, et al. Educational intervention improves compliance with universal precautions in
the operating room for two years after training. Presented at the 10th annual meeting of the Society for Healthcare Epidemiology of America, during the Fourth Decennial International Conference on Nosocomial and Healthcare-Associated Infections. Atlanta; March 2000.
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