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Mole Hills with Mountainous Potential: Facing the Challenges of Health Care Institutions

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Title: Mole Hills with Mountainous Potential: Facing the Challenges of Health Care Institutions


1
Mole Hills with Mountainous Potential Facing the
Challenges of Health Care Institutions
  • Churton Budd
  • Paul Rega
  • Kelly Burkholder-Allen

2
In every country, we should hit their
organizations, institutions, clubs, and
hospitals, it reads. The targets must be
identified, carefully chosen and include their
largest gatherings so that any strike should
cause thousands of deathsFrom the Manual of
Afghan JihadHamza Hendawi, The Associated Press
Feb. 2, 2002
3
State of Health Hospital Preparedness
  • In spite of preparedness requirements within the
    industry, hospitals typically are the weakest
    link with respect to community preparedness
  • Systemic constraints are the major cause
  • Analysis of numerous exercises conducted
    throughout the U.S. have yielded a predictable
    list of pitfalls that continue to hinder
    hospitals in effective preparedness

4
Ten Commandments of State and Local Emergency
Management for Health Care Administrators
  • Thou shall respect that all disasters are local
  • Thou shall recognize FEMAs influence on the
    Health Care Industry
  • Thou shall know the terms Pre-hospital,
    EMAs, EOCs, and recognize that they are
    different
  • Thou shall participate WILLINGLY in local
    emergency preparedness activities
  • Thou shall drill and exercise internally and
    externally, and play well with others
  • Thou shall forget the misguided notion that you
    may know everything there is to know about
    emergency management
  • Thou shall meet and greet.forming mutual aid
    agreements and addressing contract issues before
    they are needed
  • Thou shall make up for lost time as soon as
    possible
  • Thou shall lead responsibly those in your charge
  • Thou shall be prepared to deliver medical care
    for at least 72 hours.ALONE

5
Systemic ConstraintsMinimal Surge Capacity
  • 30 operating at a financial loss
  • Increasing costs, decreasing reimbursement
  • EDs have become PCPs for many
  • Staffing shortages are becoming a norm
  • Loss of experienced and mature staff
  • Increasing governmental regulations and un-funded
    mandates
  • Accreditation Requirements

6
Predictable Pitfallsinherent system limitations
  • Communications
  • Security
  • Management of Staff
  • Decontamination equipment, procedures, and
    training
  • JIT inventory management
  • Management of Behavioral Casualties
  • Management of Special Needs population
  • Underestimating the media response
  • Exercise realism, content, and corrective actions

7
Financial Resources
  • Profit margins are declining
  • From 5.8 to 4.2 from 2002-2003 (AHA)
  • Plan development, staff training, equipment
    maintenance are not reimbursable
  • HRSA funding just recently began to trickle
    down498 million to states, territories, and
    freely associated states (OH 1/17 states to
    receive double digit figure)
  • Empty beds do not generate revenue

8
Hospital Surge Capacity EDs
  • Surge capacity is a significant issue
  • 900 hospital closures since 1980
  • ED visits rose to 95 million in 1997 to 108
    million in 2000
  • Less than 10 of all ED visits are classified as
    non-urgent by CDC standards (ACEP)
  • Many of the nations EDs are operating at/above
    capacity---crowding is the most severe in major
    metropolitan area EDs
  • A GAO report revealed that two thirds of our EDs
    are diverting ambulance patients
  • 20 of the time (4 hours/day)
  • Diversion has a cascade affect on hospitals in
    the surrounding area

9
Staffing
  • Hospitals are experiencing shortages of a variety
    of health care providers
  • Nursing shortages continue and will get worse
  • More care delivered by physician extenders and
    nursing assistants
  • GAO Report revealing that large numbers of
    hospital staff working overtime and taking call
  • Numerous published studies highlighting the
    selectivity that staff may exhibit in their
    willingness to report for duty in a variety of
    disasters/WMD events, and their perception of
    barriers that would impact the ability of staff
    to report for duty in such events

10
Mr. Administrator----TEAR DOWN THOSE BARRIERS!!!
  • Fear for safety (self and family)
  • Transportation issues
  • Conflicting emergency response obligations
  • Military reserves
  • Volunteer firefighting
  • Affiliation with DMATs
  • Issues
  • Long distance phone service
  • Ability to utilize email
  • Pet care
  • Child care
  • Elder care

11
Un-Funded Mandates and Accreditation Requirements
  • Clarification for HIPPA, EMATALA, OSH, and EPA
    regulatory requirements and their applications in
    emergency situations is vital
  • JCAHO adaptation to a post-September 11, 2001
    world
  • Mandates imposed by other accrediting agencies

12
Communications
  • Redundant communications are essential
  • Both internal and external
  • Interoperability of communication equipment
    within a community is a must
  • The PIO managing both internal and external
    communications must be in sync with hospital
    policy and community activities

13
Security
  • Hospital Security forces to maintain
  • daily operations are stretched at present
  • Local law enforcement will not be able to assist
    in the event of a large scale event
  • Instituting a Lock Down will require additional
    security challenges
  • In the event of an epidemic such as SARS,
    securing the quarantined and limiting entry will
    create additional issues

14
Management of Staff
  • Even staff with specific roles and defined tasks
    must have an understanding of the roles of other
    participants
  • HEICS clearly delineates lines of authority, yet
    provides flexibility to adapt to evolving events
  • Frequent training is the key to success by
    promoting standardization and interoperability

15
JIT Inventory Management
  • Hospitals have transitioned to JIT inventory
    management strategies raising concerns about
    surge capacity for essential suppliesthe 24-48
    hour Stand Alone is jeopardized
  • Pharmaceuticals
  • Soft medical supplies
  • Hard medical supplies
  • Other resources necessary to maintain a sudden
    increase in daily operations

16
Behavioral Casualty Management
  • Few hospital plans address the needs that the
    behavioral casualties will bring with them
  • It is estimated that for every physical casualty
    caused by a terrorism, there will be 4-20
    psychological victims
  • In the first two weeks following 9/11, St.
    Vincents Hospital in NYC provided counseling and
    support to more than 7,000 people and received
    more than 10,000 calls to its help line

17
Family Information
  • In large scale events hospitals will receive an
    influx of family members seeking information
    regarding loved ones. They will have needs as
    well
  • Clerical and Social Service
  • Food and possibly Shelter
  • Information about and location of loved one
  • Space away from Media
  • If your EMP has not planned for the management
    of families---take action immediately!

18
Special Needs Population
  • The disabled
  • Mobility impaired
  • Hearing impaired
  • Visually impaired
  • Cognitively impaired
  • Elderly
  • Pediatric
  • Pregnant females
  • Non-English speaking

19
The Disabled
  • One out of every five Americans has a disability
  • One out of ten has a severe disability
  • Approximately 9 million have disabilities so
    severe that they require personal assistance with
    ADLs---many of these individuals receive this
    assistance from family
  • 54 million US citizens have a disability
  • 58 have NO PLANS for safe and expedient
    evacuation from their homes
  • 50 of the employed disabled report that there
    are no plans in their workplace for safe and
    expedient evacuation
  • Nearly 800,000 disabled persons live in assisted
    living facilities

20
People with Disabilities
  • Prior to the 1993 WTC attack, people with
    disabilities opted not to be identified as
    disabled---that changed!
  • A December 2001 survey released by the National
    Organization on Disability yielded the following
  • 58 of people with disabilities said that they
    did not know who to contact about emergency plans
    for their community
  • 61 said that they had not made plans to evacuate
    their homes quickly and safely
  • Among the employed, 50 said that no plans have
    been made to evacuate their workplace safely

21
Planning for Management of Disabled Individuals
  • Persons with a disability have unique limitations
    and abilities
  • Include outside agencies in your hospital
    planning activities and exercisestheir input and
    feedback is essential to success
  • Practice evacuation plans by having the planners
    simulate disabilities---much can be learned on
    either end

22
Service or Assistance Animals
  • There are many types of specially trained dogs
    providing assistance to disabled individuals have
    you factored these animals into your planning
  • Hearing dogs for the deaf
  • Seeing-eye-dogs
  • Motor or mobility assistance dogs

23
Mobility Impaired
  • People who use wheelchairs or other assistance
    devices may have a wide variety of abilities and
    limitationsit is difficult to generalize their
    needs
  • 1.5 million Americans use a wheelchair
  • How would you evacuate wheelchair dependent and
    other mobility impaired individuals in
    stairwells?
  • Does your facility have evacuation devices that
    can be used?

24
Hearing Impaired
  • Hearing impairments range from a mild loss of
    hearing to profound deafness
  • 28 million Americans have a hearing deficit
  • 500,000 are completely deaf
  • Communication in times of an emergency can be
    aided by
  • Establishing eye contact and facing the light
  • Speaking slowly and clearly
  • Using facial expressions and hand gestures
  • Providing written instructions or other written
    communication
  • Providing flashlights for signaling to health
    care providers
  • Using pictographs and communication boards

25
Visually Impaired
  • 8 million Americans live with limited vision
  • 130,000 are legally blind
  • The visually impaired may vary in degree from
    having limited to no vision, planning for the
    safe management and care of these individuals
    cannot be overlooked
  • Even those who are independent, cannot be left in
    unfamiliar surroundings without assistance
  • In an emergency situation, provide clear and
    simple instructions---practice evacuation
    simulating visual impairment
  • Braille

26
Cognitively Impaired
  • 7 million Americans have mental retardation
  • People with developmental disabilities may
    experience limitations with cognitive abilities,
    motor abilities, and social abilities---they may
    have difficulty recognizing rescuers or being
    motivated to act in an emergency
  • Visual perception of written instructions or
    signs may be confused
  • Sense of direction may be limited
  • Ability to understand is often more developed
    than the individuals vocabulary
  • The individual should be treated as an adult who
    happens to have a cognitive or learning
    disability

27
Assisting the Cognitively Disabled
  • Be patient
  • Break down information into simple steps
  • Use signs and symbols
  • Read information to them
  • Do not talk down to or treat as if they are a
    child

28
The Elderly
  • By 2020 California and Florida will double their
    1993 elderly population
  • By 2030, older adults will account for 20 of our
    population in the U.S.an increase from 13 in
    2001
  • 1994-1995, 1.86 million individuals gt65 reported
    difficulties with 2 or more ADLs
  • Between 1960 and 1994, the oldest old increased
    by 274

29
Defining the Elderly
  • Elderly gt65
  • Young Old 65-74
  • Aged 75-84
  • Oldest Old gt85

30
The Elderly
  • Many of the services traditionally provided at
    hospitals are now being delivered in the home
    setting
  • More elderly are living independently longer
  • Greater dependency upon health care
    infrastructure to provide life-sustaining
    equipment, treatments, and medication
  • ? age ? vulnerabilities
  • ?sensory perception
  • ? strength
  • Poor exercise tolerance
  • Poor thermoregulation
  • Pre-existing conditions
  • Socio-economic hardships

31
Children Are Not Little Adults
32
Pediatric Patients
  • Pediatric patients differ from adults
    physiologically, psychologically, anatomically,
    cognitively, and mentally
  • They have immature motor and cognitive skills
    which predispose them to remain in harms way
  • Triaging Pediatric patients presents
    challengesespecially if your facility does not
    have a pediatric department
  • JUMP-Start Triage captures the subtle nuances of
    the pediatric population
  • Pediatric patients are at risk for emotional
    trauma---assessment of emotional trauma should be
    included in the triage process
  • Work with staff from the Pediatrics Department to
    establish Mass Casualty management of pediatric
    patients

33
Pediatrics
  • Greater number of respirations
  • ? risk for inhalation aerosolized agent or toxic
    substance
  • Short in stature
  • ? risk of inhaling more concentrated dose of
    substance that is heavier than air
  • Inadequate skin keratinization
  • ? capacity to protect skin from dermal injury
  • ? capacity to absorb toxins thru skin
  • Greater Body Surface Area
  • ? potential to lose body heat
  • ? potential to absorb toxins thru skin
  • Less Internal Fluid Reserves
  • Prone to dehydration and shock---making timely
    fluid replacement a priority

34
Pediatrics
35
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36
Pregnant Females
  • Performing triage on pregnant females can be
    present challenges
  • Involve OB/Gyn staff in the planning for
    reception of pregnant females
  • Pre-position ultrasound equipment in ED, or work
    with OB department to set up and staff a
    secondary Triage area

37
The Non-English Speaking
  • The use of pictographs can be used to replace
    spoken language
  • Does your facility have large pictographs that
    can be used with traditional signage to direct
    individuals?
  • In the absence of an interpreter, communication
    boards can bridge many of the language barrier
    gaps in emergency situations

38
Underestimating the Media
  • If it happens.they will come
  • Preparation is a must
  • Review and define the roles and responsibilities
    of the PIO
  • Your PIO should be planning today for tomorrows
    events

39
Exercise Planning and Realism
  • Large plans ? preparedness.in fact, they
    frequently invoke a false sense of preparedness
  • Preparedness is more of a process than a
    product---exercising the plans is a vital part of
    the process
  • As with plans, exercises should be flexible yet
    have pre-determined objectives
  • Whether conducting a full functional or a
    tabletop exercise---an After Action Report and a
    hot wash should be the beginning point for plan
    revisions

40
The only thing harder than explaining why you
need to prepare for a disaster is to explain why
you didnt Leslie Stein-SpencerChief of
EMSIllinois Department of Public Health
41
Using JCAHO Standards!
  • E.C.1.4. requires development of an EMP that
    ensures an effective response to emergencies
    affecting the environment of care
  • E.C.2.4. requires implementation of the EMP
  • E.C.2.9. requires execution by conducting drills

42
Keeping the mole hills mole hills
  • E.C.1.4---The organization has an Emergency
    Management Plan
  • Intent The EMP comprehensively describes the
    organizations approach to responding to
    emergencies within the organization or in its
    community that would suddenly and significantly
    affect the need for the organizations services,
    or its ability to provide those services. The
    plan addresses the following
  • Mitigation actions taken in attempt to lessen
    the severity and impact of a potential
    emergency
  • Preparedness actions taken to build capacity and
    identify resources that may be used in an
    emergency
  • Response
  • Recovery

43
Maintaining the mole hills
  • E.C.2.9.1. Drills are conducted regularly to
    test emergency management
  • Intent The response phase of the EMP is tested
    twice a year, either in response to an actual
    emergency or in planned drills. Drills are
    conducted at least four months apart and no more
    than eight months apart.

44
E.C.1.4 and E.C.2.4 Requirements
  • Execute Hazard and Vulnerability Analysis
  • Identify all of the hazards that could occur in
    your community, their likelihood, and their
    probable impact
  • Security
  • Utility Failures
  • Natural Events, Technological Events, Human
    Events
  • Structural Implications
  • Other
  • Your local EMA already has already performed a
    HVA for your community----use it as a springboard
  • www.ashe.org for Hazard Vulnerability Assessment
    Tool

45
Analyzing and Integrating the HVA
  • Organize the analysis so that it integrates into
    the overall EMP
  • Assess each risk according to your organizations
    ability to
  • prepare for
  • respond to
  • mitigate against
  • recover from

46
Mitigation, Preparedness, Response, and Recovery
Identification and Processes for
  • Coordination with Community Emergency Planners in
    establishing priorities among the potential
    emergencies
  • Identification of procedures to mitigate, prepare
    for, respond to, and recover from the priority
    emergencies
  • Defining the role that your institution will play
    and integrate it into your communitys EMP
  • Delineating lines of authority

47
Processes for
  • Activation of the EMP
  • Notification of outside agencies
  • Notification of personnel
  • Back-up communication systems
  • Management of all resources
  • personnel, materiels
  • Management of patient care activities
  • Evacuation
  • Transportation and transfer of patients
  • Establishment of alternate care sites
  • Back-up utility services
  • Re-establishment of continuous operations

48
Processes for
  • Identification of isolation and decontamination
    sites and practices
  • Orientation and education programs for the staff
  • Ongoing monitoring of performance in drills and
    actual emergencies
  • Annual review of the EMP
  • Post exercise corrective action planning post
  • Staff Needs
  • housing
  • transportation
  • incident stress debriefing
  • family support activities

49
Decontamination Issues
  • Little attention has actually been paid to the
    decontamination process
  • Even experienced HazMat teams have limited
    experience
  • Protocols to meet the needs of the chemical and
    vapor decontaminated are necessary
  • Critical assessment of
  • Inherent delays in mass decon at a scene
  • Decision-making process to provide water decon
    (ambient temperature, type of agent exposure,
    symptomatology, liquid vs. vapor vs. radiological
    vs. biological)

50
Mass Decontamination
  • Identify the agent
  • Evacuate from the source
  • Decontaminate--timely
  • Treat the symptomatic
  • Observe the asymptomatic for delayed onset of
    symptoms
  • The reality is that those who survive to rescue
    will survive

51
  • Decontamination is the process of removing or
    reducing the concentration of harmful substances.
    It should be performed whenever there is a
    likelihood of contamination or risk of secondary
    exposure. The most important step in
    decontamination is the speed of the removal of
    the agent. (Levitan et. al)

52
Points to Ponder
  • Vapor exposure does not require decontamination,
    removal from the source and possibly removal of
    clothing is sufficient---
  • Removal of clothing eliminates 80-90 of
    contaminants and minimizes the risk of spreadbut
    is dependent upon the amount of clothing warn at
    time of exposure
  • Removal of clothing is the minimal acceptable
    level of decontamination after a hazardous
    chemical, radioactive contamination, or terrorist
    event
  • Nothing has been proven to be more effective than
    soap and water, bleach is contraindicated
  • Decontamination of known radiological agents
    parallels that for chemicals, with the exception
    that life-threatening injuries are managed prior
    to decontamination
  • The Radiation Safety Officer should oversee the
    monitoring of the victims and make determination
    of adequate decontamination
  • Decontamination after known exposure to
    biological agents is controversial---these agents
    are non-volatile and do not off-gas
  • T2-Mycotoxins and Sarin are exceptions
  • Weaponized Anthrax can act as a vapor

53
Hospital Decontamination Considerations
  • Will the victims remove their clothing? How will
    you manage these items?
  • How long will they remain cooperative pending the
    decon process?
  • What impact does modesty or inclement weather
    play in the decision-making process?
  • Have you taken cultural and religious issues into
    consideration?
  • Will the ambulatory willingly proceed thru a
    decon corridor?
  • How long will they need to remain in the line?
  • How will inclement weather Impact the decisions
    made?
  • Is triage feasible? How will it be performed?
  • What level of PPE is necessary for the staff?
  • What ratio of trained staff to victims is
    necessary?
  • Is removal of clothing only a suitable form of
    decon? What criteria determines this?
  • Gender separation? Family separation?

54
Management of the Contaminated Patient
  • The most important step in decontamination is the
    speed of the removal of the agent!
  • Equipment, staffing, and training all require
    funding and maintenancefrequent drills as well
  • What are your facilitys capabilities?
  • Can your facilitys plan be rapidly expanded?
  • Nearly 70 of hospitals can provide 5 minute
    decontamination for up to 10 victims per hour per
    100 staffed beds (GAO-2003)
  • 50 of these hospitals could handle lt6 per hour

55
HRSA Recommendations
  • Portable or fixed decontamination systems for
    managing 500 adult and pediatric victims and
    health care workers per 1,000,00 population---
    our RMRS is already working to accomplish this!
  • Where does your facility factor into providing
    these capacities?

56
1995Tokyo, Japan
  • Sarin gas release in subway system
  • 12 exposed victims died, thirty-seven were
    critically ill, and several hundred were
    symptomatic and sought treatment
  • Over 30 of the first responders and hospital
    staff developed symptoms related to exposure to
    the Sarin that remained in their clothing
  • gt5,500 sought evaluation in already burdened
    hospitals

57
1987Goiania, Brazil
  • 1987 accidental release of cesium-137 from a
    medical device in an abandoned clinic
  • yielded 4 deaths from ARS and 249 with internal
    or external contamination
  • 125,000 people sought screening for radiological
    contamination (10 of population)
  • Of the first 60,000 screened, 5,000 complained of
    actual sx of ARS

58
2001Alliance, OH
  • Meningococcal Meningitis outbreak
  • Two deaths of teenage high school students
  • One teenager was hospitalized after attending
    funeral service for friend who died from
    meningitis
  • gt10,000 presented to medication dispensing sites

59
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60
Lacking resources to manage infectious diseases
  • A recent GAO Report revealed the following
  • Less than 10 PPE suits per 100 staffed beds
  • 40 had fewer than 2 suits
  • Less than 10 isolation beds per 100 staffed beds
  • 50 had fewer than 4 isolation beds
  • Most hospitals have lt10 ventilators per 100
    staffed beds

61
What if we applied the Regionalized Trauma Care
Model to Bioterrorism and EIDs?
  • Formalized protocols for pre-hospital and
    hospital care contribute to improved patient
    outcomes
  • Established communication networks have been
    essential to coordinated regionalization of
    trauma
  • Outreach activities
  • High quality, cost-effective specialty care in
    specifically designated hospitals

62
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63
2003Singapore
  • SARS Outbreak initiated by a traveler to Hong
    Kong, in February, 2003 (Pt. A)
  • Tan Tock Seng Hospital admitted traveler on March
    1, 2003 (dx atypical pneumonia)
  • Removed from 6 bed ward and placed into isolation
    on March 6th
  • 24 of this patients primary contacts were
    diagnosed with probable SARS
  • 9 health care workers (8 nurses), five patients,
    and 10 visitors
  • EID.www.cdc.gov/eid Vol. 10, No. 3, March, 2004

64
Tan Tock Seng Hospital Singapore
  • Pt. AA (a nurse caring for Pt.A) was admitted on
    March 10 to an open ward
  • Pt. AA was isolated on March 13, but by this
    time, 25 persons had been infected 12 health
    care workers, 4 patients, 8 visitors, 1 household
    contact
  • Pt. AAA from the above population of exposed
    contacts was admitted to CCU from March 12-19 for
    what appeared to be a non-SARS admission (Pt. AAA
    with an extensive medical history)
  • Pt. AAA then spread the infection to 27 5
    physicians, 13 nurses, 1 ultrasonographer, 1
    attendant, 2 cardiac techs, and 5 visitors

65
TTSH Spread
  • On March 15, probable SARS was diagnosed in 13
    persons all of whom were admitted to TTSH
  • 6 were family and friends of Pt. A
  • 6 were health care workers who attended to Pt. A
    while in open ward
  • 1 was a health care worker who attended to Pt.
    AAA in CCU
  • There were additional employees at home ill with
    fever who had worked on the open wards
  • The spread of SARS continued until March 22, 2003
    when all normal operations were suspended at TTSH
    and it functioned as a dedicated SARS facility

66
Tan Tock Seng Hospital
  • It took 3 weeks to stem the spread at TTSH
  • In addition to the SARS spread within TTSH, the
    infection was spread outside by infected
    visitors, healthcare workers, and household
    contacts to other hospitals
  • Singapore was removed from WHOs list of areas
    with local SARS transmission until May 31, 2003
  • At that time, 206 probable SARS cases had been
    diagnosed 40.8 in health care workers, 39.8 in
    family, friends, or visitors to hospital, and
    12.2 were in inpatients

67
Singapore General Hospital
  • Index case Pt. B who did not exhibit typical
    SARS symptoms, was admitted to an open ward on
    March 24 for GI bleeding
  • Fever was attributed to a UTI which developed on
    March 26
  • Was transferred to another open ward on March 29
    and remained there until April 2
  • On April 4, a cluster of 13 health care workers
    developed fevers 1 physician, 11 nurses, and an
    x-ray tech---all had attended to Pt. B---probable
    SARS developed in all 13
  • The SGH outbreak totaled 60 24 health care
    workers, 11 inpatients, two outpatients, 12
    visitors, and 11 household contacts
  • Because SGH was the largest hospital, closing it
    was not an option---all SARS patients and those
    exposed were taken to TTS, followed up by phone,
    or quarantined for ten days
  • Containment measures worked within 10 days

68
National University Hospital
  • Pt. C was treated in the ED on April 8, remaining
    for approx. 4 hours
  • Was transported to an open ward and remained
    there for approx. 8 hours prior to requiring
    intubation and transfer to isolation in an ICU
  • The next morning Pt. C was transported to TTSH
  • Within two days, a physician who had attended Pt.
    C spiked a fever---at that point, all exposed
    persons were isolated (no new admissions or
    discharges for 10 days), staff members were
    quarantined after work
  • The inpatients who developed fever were
    transferred to TTSH and two nurses were isolated
    at NUH after developing fevers

69
Protecting Your Staff
  • During a biological event or a naturally
    occurring disease outbreak, strategies to protect
    your staff and their families is an essential
    component of maintaining a robust workforce
  • Communications and cooperation with your facility
    and local public health cannot be overestimated

70
Screening is just the beginning!
  • All screened contacts must be logged
  • Information must be carefully managed
  • Information must be shared
  • Follow-up is essential
  • Screening efforts are part of overall
    surveillance activities
  • Where will the personnel come from?
  • What forms will they use?
  • How will the information be managed?
  • Working with local Public Health officials

71
Establishing the Screening Process for Disease
Outbreaks
  • Determine all portals of entry
  • Delivery entrances, public access entrances,
    ambulatory department entrances, ED entrance
  • Provide for mandatory temperature screening of
    every individual who enters (name should be
    logged as well)
  • Provide appropriate PPE for all staff and
    visitors
  • Screen all staff at beginning and end of every
    shift
  • Implement algorithms for movement of visitors and
    patients

72
Establish a Logging/Tracking Process for Disease
Outbreaks
  • Everyone who enters the facility should be logged
    as well as their travels throughout the facility
  • Minimize movement of staff from respective units
  • EVERY patients contact history must be thorough

73
Isolation and Quarantine of Staff
  • Where will you isolate staff who are ill?
  • How many of your staff are immunosupressed?
    Pregnant?
  • What if they have family members who are
    immunosuppressed or pregnant?
  • If an entire unit is in isolation, who will
    enforce the no admissionno discharge policy?
  • Where will the extra security come from?

74
Backfill to cover Staff
  • Quarantined staff coverage
  • Exposed to probable SARS or another contagious
    disease at work
  • Exposed as household contacts
  • Many health care workers are employed at several
    hospitals in one community---how will you stop
    the spread?
  • Will quarantined staff members be able to work if
    they are asymptomatic?
  • Ill staff member coverage
  • If one hospital becomes the designated
    contaminated hospital will staff be able to
    work or make rounds in other hospitals?
  • Who will choose which hospital physicians will
    practice at during EID or bioterrorism-related
    outbreak?

75
Keeping the bad in and the good out?
  • Enforcement of isolation and quarantine?
  • Cancellation of visitation for patients
  • Restriction of movement of staff?
  • Intra-facility employment yields intra-facility
    spread of infectious diseases

76
References
  • Regionalization of Bioterrorism Preparedness and
    Response. AHRQ, Evidence/Technology Report No.
    96. available at
  • www.ahrq.gov
  • Mobilizing Americas Health Care Reservoir.
    Joint Commission Perspective 200121(12)1-23.
    available at
  • www.jcrinc.com
  • Hazard Vulnerability Analysis. 2000, American
    Society of Engineering. Available at
    www.ashe.org
  • Health Care at the Crossroads Strategies for
    Creating and Sustaining Community-wide Emergency
    Preparedness Systems. Joint Commission on
    Accreditation of Healthcaer Organizations, 2003.
  • Orientation Manual for First Responders on the
    Evacuation of People with Disabilities. U.S. Fire
    Administration. FEMA FA-235/August 2002.
  • Family Survival Guide Preparing Your Family For
    Times of Emergency. American Red Cross,
    Washington, D.C., 2000.
  • Census Brief Disabilities Affect One-Fifth of
    All Americans. U.S. Department of Commerce,
    Bureau of The Census, Washington, D.C.,
    CENBR/97-5, December, 1997

77
References
  • Public Health Preparedness Response Capacity
    Improving, but Much Remains to Be Accomplished.
  • McGlown, JCoordinating Roles at the Community
    and State Levels, presented at When Disaster
    Strikes The Role of the Hospital, ACHE,
    Washington, DC, February, 2002.
  • Lanzilotti, S, et al Hawaii Medical
    Professionals Assessment A study of the
    availability of doctors and nurses to staff
    non-hospital, field medical facilities for mass
    casualty incidents resulting from use of weapons
    of mass destruction and the level of knowledge
    and skills of these medical professionals as
    related to the treatment of victims of such
    incidents. Study conducted through contract No.
    282-97-0049 with DHHS.

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80
References
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  • Arnold J, et al Mass-Casualty Terrorist
    Bombings Epidemiological Outcomes, Resource
    Utilization, and Time Course of Emergency Needs
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  • Burkle, F Measures of Effectiveness in
    Large-Scale Bioterrorism Events. Prehosp Disaster
    Med 200318(3)258-262.
  • Daub, E Hospital Emergency Preparedness
    Assessment A Framework for Integrated
    Bioterrorism Planning and Response. White Paper
    WHP032-A. 2003 Scientific Technologies Corp.
  • Fields, W Calculus, Chaos, and Other Models of
    Emergency Department Crowding. Annals Emerg Med
    2003 42(2)181-184.
  • Halperin et al Mass-Casualty Terrorist Bombings
    Epidemiological Outcomes, Resource Utilization,
    and Time Course of Emergency Needs (Part 2).
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  • Keim, M, et al Lack of Hospital Preparedness for
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  • Barbera, J, et al Ambulances to Nowhere
    Americas Critical Shortfall in Medical
    Preparedness for Catastrophic Terrorism. Homeland
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  • Okamura, T, et al The Chemical Disaster Response
    System in Japan. Prehosp Disaster Medicine
    200318(3)189-192.
  • Noji, E Introduction Consequences of Terrorism.
    Prehosp Disaster Med 200318(3)163-164.
  • DiGiovanni, C The Spectrum of Human Reactions to
    Terrorist Attacks with Weapons of Mass
    Destruction Early Management Considerations.
    Prehosp Disaster Med 200318(3)253-257.
  • Hick, J, et al Protective Equipment for Health
    Care Facility Decontamination Personnel
    Regulations, Risks, and Recommendations. Ann
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  • Hick, J, et al Establishing and Training Health
    Care Facility Decontamination Teams. Ann of Emerg
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  • Day, T Predicting Quarantine Failure Rates.
    Emerg Infec Disease 200410(3)487-488.
  • Koenig, K Strip and Shower The Duck and Cover
    for the 21st Century. Ann Emerg Med
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