Planning and preparedness are critical to mitigating the impact of an infectious disease outbreak. Here's how three children's hospitals are getting ready.
By Jill Fragoso, B.S.N., M.A., R.N., CHON-S, FACHE; Mary Cooney, B.S.N., R.N., CHON-S; Terri Thrasher, M.S.N., R.N.
Despite remarkable advances in medical research and treatments during the 20th century, infectious diseases remain among the leading causes of illness and death worldwide and account for about 20 percent of the global mortality rate, according to the National Institute of Allergy and Infectious Diseases. Three major reasons for this continued threat are the:
- Emergence of new infectious diseases, previously unknown or newly appearing in a population
- Re-emergence of known infectious diseases after significant decline
- Persistence of hard to control infectious diseases, often in developing countries
Many infectious diseases have never been adequately controlled, for example, food and waterborne infections like dengue or West Nile virus are prevalent. International travel and other changes in human behavior can result in a persistent disease emerging in a developed country. Other reasons for the emergence and re-emergence of diseases include: natural genetic variations, re-combinations and adaptations like influenza; the increased or imprudent use of antimicrobial drugs and pesticides leading to the development of resistant pathogens like tuberculosis, malaria, nosocomial and foodborne infections; and decreased compliance with vaccination policies leading to outbreaks of previously controlled diseases, like measles and mumps.
In addition, the use of deadly pathogens, such as smallpox or anthrax as agents of bioterrorism, is an increasingly acknowledged threat. Also, the increased use of viral vectors—tools molecular biologists commonly use to deliver genetic material into cells to treat other diseases, such as cancer—is gaining popularity in the research community and may present an additional risk.
There is a need in health care to develop robust programs around emerging infectious diseases. Health care providers, lab animal researchers and laboratory workers have an increased risk of exposure to infectious diseases and an increased potential to expose and infect coworkers and patients. As employers, hospitals have an obligation to ensure a healthy workforce capable of providing the critical services to support patient care and world-class research. It's important to understand the impact and implication of disease transmission to patients. The goal is four-fold: Protect against the introduction of illness to employees; prevent the transmission of illness to other employees; prevent transmission of illness to patients, and maintain the health of the community.
There are basic tenets of occupational health practice that support these goals, and this starts with the new hire process. New hospital employees should undergo a health screening, provide a full immunization history and undergo respiratory fit testing as required. A hospital representative can educate new employees on the full suite of occupational health-related services available to them. Programs targeted to staff members with particular risks should be well defined and communicated.
Planning and prepping for an infectious disease outbreak
Advanced planning and preparedness are key to helping to mitigate the impact of an infectious disease outbreak. Make sure preparedness plans are flexible enough to respond to outbreaks of various illnesses and intensities. Thought and planning before an outbreak occurs will save time, resources and energy that an organization will need during an event. Planning also helps guarantee an organization will achieve important outcomes.
Most recently, the Ebola outbreak in West Africa challenged U.S. health care facilities and public health systems to respond to a global concern.
Here are examples of how three children's hospitals—The Children's Hospital of Philadelphia (CHOP), Cincinnati Children's Hospital Medical Center and Texas Children's Hospital—planned to provide care for a highly contagious patient with a potentially deadly disease before the first Ebola case hit the United States. They examined current systems and the development of expanded programs. Assuring the right people are leading this work and all stakeholders are actively involved resulted in systems that provide optimal staff member safety and patient care.
Working as a team
At CHOP, the medical director of infection prevention leads this work in collaboration with the Emergency Preparedness (EP) Department. EP facilitates and ensures all stakeholders are involved, identifies functional roles, applies the framework of the Incident Command System, and builds and maintains an effective communication system among teams.
As the first cases of Ebola began appearing in international headlines, the hospital created an Ebola taskforce to identify streams of work, define roles and responsibilities, serve as content experts and evaluate progress. The taskforce tackled two major projects, including educating and training staff members on the use of personal protective equipment (PPE) and assuring the organization had the facility and knowledge to care for any patient suspected of having Ebola.
In addition, the Environmental Health and Safety Department was instrumental in choosing the PPE for staff members to wear and adjusted this based on Centers for Disease Control and Prevention recommendations and by observing staff members testing the suits. Once the hospital identified which clinical staff members would provide care during an Ebola situation, the occupational health team reviewed the staff members' medical history and ensured they could wear the chosen PPE while meeting the physical and psychological demands of providing care for up to four hours. After clinicians established the flow plans needed to assure that the principals of a biocontainment unit care were mapped out, the facilities department modified an existing space in the Pediatric Intensive Care Unit to serve this purpose.
With a goal of establishing high-reliability systems, the hospital included additional staff members and communication tools in planning. CHOP developed an internal-facing Ebola website and updates it with all relevant policies and procedures. Staff members from the social work, family relations and ethics teams were engaged, as well as leadership from the ambulatory network. Including these groups involved in the process ensured consistency and clarity in the policies.
Equipment and space needs for treating infectious diseases
In the battle against infectious diseases, it's important for hospitals to have respiratory programs that meet OSHA regulations. In 2014, Cincinnati Children's Hospital Medical Center's (CCHMC) Employee Health and Occupational Safety and Environmental Health Department identified a PPE preparedness improvement opportunity after the department recognized there was confusion and inconsistency among staff members about when respirators were needed.
This translated to panic and a lack of preparedness when staff members encountered patients with suspected or confirmed diseases. Because of this, teams were not optimally using resources. To solve the issue, CCHMC implemented new measures to identify staff members who are cleared to use a surgical N95 respirator or powered air purifying respirator (PAPR).
To help with staff member education and awareness, the department developed an internal respiratory protection website with links to relevant documents on the home page. This includes links for N-95 and PAPR fit testing; staff rosters with medical clearance status, fit test dates and type of respirator clearance; a decision algorithm for respirator use; and a list of available respirators. The department updates rosters weekly and makes sure the information is readily accessible.
Having this information easily available ensures that hospital leadership and staff members can respond quickly and safely to critical infectious disease situations. CCHMC also assures consistency in its approach with its one-stop hotline for patient and employee safety concerns. CCHMC's 803-SAFE line receives and triages all concerns providing consistency in response.
In 2014, Texas Children's Hospital began constructing and staffing an eight-bed unit to care for critically ill children with any serious infectious disease, including Ebola. Features include air-handling systems with HEPA filtration and negative-air flow. Additionally, the unit has three separate pass-through autoclaves for biohazardous category A trash, surfaces which are seamless and easy to disinfect, and a dedicated Biosafety Level 3 laboratory and staff locker rooms within the unit.
All workflows and protocols were designed around patient and health care team safety, with dirty-to-clean workflow though the unit, high visibility and communication systems, including telemedicine, to limit exposure of health care workers to highly infectious pathogens. See "Special isolation unit design," for more.
Increased international travel places hospital employees, contractors, volunteers and patients at higher risk of contracting illness. Travel screening is an essential part of differential diagnosis. For diseases like Ebola, hospitals should use appropriate travel screening algorithms. Ideally those algorithms should be built into the electronic medical record admission process and available at all possible points of entry, for example ambulatory and the emergency department.
Take care of employees
One way to make sure staff members are prepared is to have a global approach to their overall well-being. For employees to be fully engaged and present while working with emerging diseases and to stay focused during times of pandemic illness, they need to be as healthy and strong, physically and mentally.
To help with this, employers are taking a comprehensive approach to improving the physical, emotional, social and financial health of the workforce. Traditionally, measuring the return on investment for wellness programs includes health care cost savings, risk reduction and absenteeism. Looking beyond the immediate health care costs will help organizations understand the broader value of its investment. Human Resources should be involved in creating employee policies including sequestration or home monitoring, furlough, pay and benefits, housing for providers, housing for infected or infectious employees, food, child care, emotional and spiritual support. These actions and policies provide reassurance, a sense of safety and reduce employee stress.
Texas Children's began taking steps last year toward developing a health and wellness program. The hospital conducted an analysis focused on the health status of employees. This helped the hospital identify employee segments and determine health-supporting infrastructure priorities. The project identified stress as a high-priority area of focus. Knowing that emerging diseases and caring for patients in pandemic situations is likely to cause great amounts of stress, being able to combat stress and teach caregivers how to manage it is of highest priority.
To help employees with stress, Texas Children's developed a Wellness Ambassador program where designated enthusiastic ambassadors in each unit serve as extensions of the wellness team. They engage with colleagues about upcoming wellness events, provide consistent well-being messaging and provide positive interaction, which yields improved engagement.
All employees need to be knowledgeable about current diseases including prevention, transmission modes, incubation periods and treatment. For example, mosquito-borne illnesses like Chikungunya, which is not transmissible person to person, are now present in the Unites States. Many hospitals have employees who contracted Chikungunya during work-related travel. Also, vaccine-preventable illnesses continue to be a challenge, mostly due to unimmunized populations. Liberia halted immunization programs during the Ebola crises due to lack of sufficient public health infrastructure to do both.
More than 850 cases of measles have been reported in Liberia the last six months. Liberia is now working with international agencies to resume an aggressive measles vaccination program. It's important for hospitals to be alert to this situation if there is a large Liberian population in the geographical service area. Pediatric patients may be susceptible to measles if they are too young to be vaccinated or are severely immunocompromised.
The most recent infectious disease concern is in South Korea. As of June, 138 new cases of Middle East Respiratory Syndrome (MERS) were diagnosed, and 14 people have died. All of them were elderly or suffering from co-morbid illness. The index case for this outbreak traveled to the Middle East and returned with fever and cough. He visited several health centers seeking treatment before he was diagnosed. So far, all of South Korea's cases have been linked to health facilities.
Keeping everyone safe
There are additional ways health care professionals can help to mitigate risk and ensure hospitals apply the practices of high reliability organizations:
- Ensure staff members are immunized against all vaccine-preventable contagious illnesses, and educate them about travel and associated risks.
- Participate in and lead organizational work to protect staff members and collaborate with infection control colleagues.
- Recognize the challenges of populations common to some health care facilities, such as immigrant workers fearful of disclosing illness, international researchers and international observers.
Continuing to share best practices with colleagues within the organization and with other children's hospitals will also help mitigate risk and keep patients, employees and the community safe.
Jill Fragoso is director of Employee Health and Wellness at Texas Children's Hospital; Mary Cooney is nurse manager of Occupational Health at The Children's Hospital of Philadelphia; and Terri Thrasher is senior director of HR Professional Services at Cincinnati Children's Hospital Medical Center. Send questions or comments to firstname.lastname@example.org.