Anthrax attacks are stark wake-up call for quality managers, EDs
Anthrax attacks are stark wake-up call for quality managers, EDs
Emergency departments seen as front line’ for response
Everybody knew it could happen, but few believed it would. That seems to be the predominant theme as quality professionals respond to incidents of anthrax infection in the United States, predominantly along the East Coast.
At press time, no one was entirely sure if the attacks had ended or whether all of the sources of infection had been discovered. Public agencies such as the Centers for Disease Control and Prevention (CDC) in Atlanta have swung into action, providing coordination and guidelines for health care facilities across the country.
Health care facilities may not be as prepared to face this situation as once was believed. A recent survey of 30 hospitals in FEMA (the Federal Emergency Management Agency) Region III published by the Irving, TX-based American College of Emergency Physicians revealed that none of the respondents believed their sites were fully prepared to handle such an incident.
This finding may not be quite as alarming as it seems at first glance, offers James Espinosa, MD, FACEP, FAAFP, chairman of the emergency department (ED) at Overlook Hospital in Summit, NJ. "It is the rare ED that would ever say it’s fully prepared, because doctors and nurses are by nature very conservative in responding to that kind of question," he says. Nevertheless, Espinosa concedes that the anthrax outbreak was, indeed, a "wake-up call" for hospitals across the country.
"It certainly brought to light the fact that these kinds of things would happen," adds Patricia Gabriel, RN, BSN, CEN, nurse manager of the ED at Overlook. "We already knew that they could."
"This also highlights a very positive thing that could be lost here," adds Espinosa. "That is, of all the branches of medicine, the American College of Emergency Physicians has been talking about this, studying it and preparing its members for years; so while the notion that it would actually happen is new, there have been interested folk speaking on this for years, and I’m proud of that.
"We do not want to lose sight of the tremendous depth of interest and experience there is available," he continues. "But we should also bear in mind that when we are asked questions concerning anthrax or bioterrorism, it’s really a species of the larger question of being prepared for disaster."
How things have changed
Nevertheless, things will never be quite the same again — not for the country, and surely not for the health care professionals who must be prepared to respond to such challenges.
Have things changed much at Overlook in response to the anthrax attacks? "Really, the biggest change, and the only change here, is related to updating the matrix we have for notification," says Gabriel. "That was the thing we felt would make a difference. We felt that beyond that our disaster plans were generic enough to walk through the initial steps."
The matrix involves letting the community at large and the organization as a whole know when Overlook has a bioterrorism issue. "There are two places that information can come from," says Gabriel. "One is the ED. The second is the lab. If a patient presented with unusual symptoms, it’s possible the lab could be the first group to identify whatever the agent was. This information should be shared with the ED, administration, infection control, public relations, community health departments, and federal agencies, if appropriate." Nurses and physicians also have been flooded with educational materials, Gabriel notes.
But Espinosa is quick to point out that this is not entirely new or different for the Atlantic Health System, of which Overlook is one of four facilities. "We already had in place education planning for bioterrorism before this, and more importantly, as a system, the four facilities have been involved collaboratively in looking at adaptations in change of demand on a daily basis," he explains. "This put us in a whole different place than we otherwise would have been."
All types of staff and ancillary services in the system are involved in what Espinosa describes as "a bold new approach" called "Flow,’’ which is involved with "the matching of capacity and demand on a daily basis within an ED in an attempt to reduce the amount of diversion."
Beyond the four walls
When they consider the quality issues raised by bioterrorism, it’s critical for hospital quality professionals to recognize that they are not alone, that they are part of something far bigger than their own institution or system, Espinosa notes.
"Because the problem has a certain inherent unpredictability to it, the kind of things that would build for what we would call the reliability of a system require communicating a lot with each other — a lot of face-to-face discussion. But it is also very important that the larger or virtual organization is never forgotten. It’s easy to think of oneself as the ED within a larger organization known as a hospital. But this is only one part of a larger reality; we are part of the state department of health, for example, and we are also part of a federal emergency response structure that has had years of experience with this type of situation, and has been monitoring it."
In terms of communication, then, hospital quality professionals must not only communicate laterally, but vertically as well — to local, state, and federal agencies. "It’s the knowledge of those vertical links that gives you the sense of security beyond your little world," says Gabriel. "There are resources and experts out there that you could never muster yourself."
Richard Levinson, MD, DPA, associate executive director of the American Public Health Association in Washington, DC, agrees. "I think it’s critical that any hospital crisis response plan have definitive lines of communication outlined, not only with public health agencies, but with police, fire departments, and other groups that will hopefully work in full coordination," he says.
Levinson notes that to date there have only been a few anthrax deaths. "But in the future, if we have an outbreak of something like smallpox, hospitals will have to be supported by . . . some type of triage system. They will be asked to discharge their less critical patients and become a repository for the most critically ill. You have to be prepared to do this when and if it becomes necessary; you should be in close communication with specialized laboratories dealing with these types of diseases, because normal hospital labs are not able to do so.
"When a patient comes in, the hospital personnel will be on the front line; they must take appropriate specimens, ship them to the most appropriate place by the least common path, and be prepared to react very rapidly," he points out. "With something like smallpox, you have to immunize anyone who has come in contact with infected individuals."
If there is such an outbreak, "The front line health workers need to be protected," he advises. "If there is fear of smallpox, they should be the first ones vaccinated. If it’s anthrax, they should have an adequate supply of antibiotic. They must be treated on a high-priority basis." Then, they must work very closely with those organizations coordinating health-related events, Levinson says.
"There must be a constant flow of information — what has been discovered in the hospital, what has been learned epidemiologically on the outside," he says. "If the hospitals need additional supplies, they must know where they can get them, or if supplies need to be shared with other facilities, they need to know that as well. And, of course, anything unusual that has been detected must be reported."
Levinson says that it’s one thing to have a disaster response plan, "but it’s essential to totally [work together] with government agencies and closely correlate with public health departments and other frontline responders who might be handling agents of concern to the hospital."
Less stress, better response
"We always knew we needed to work with pre-hospital providers," Gabriel says. "But recent events have brought a better understanding of our role, and of how to interact within each group."
"The larger problem," says Espinosa, "is matching capacity demand and having hospitals respond as part of a cohesive organism, and having a flexible matrix through which it responds to all types of situations. It’s all about communication." It’s also about developing a sense among hospitals that "we’re all in this together," he declares. "There’s a call to share capacity and to match up capacity demand among hospitals that was never there before," he observes.
"A lot of what has existed in the past in terms of competition based on history and insurance have to all break down when everybody’s health and well-being are at stake. ED nurses and physicians should feel good about the fact that they are warriors in this epic battle of our time. We are on the front line; we are exposed, but we are in brotherhood with the police, the firemen, the FBI, and that has never before been so clear to the public. We should be proud," Espinosa says.
Need more information?
For more information, contact:
• James Espinosa, MD, FACEP, FAAFP, Chairman, Emergency Department, Overlook Hospital, 99 Beauvoir Ave., P.O. Box 220, Summit, NJ 07902-0229. Telephone: (908) 522-5310.
• Patricia Gabriel, RN, BSN, CEN, Emergency Department Nurse Manager, Overlook Hospital, 99 Beauvoir Ave., P.O. Box 220, Summit, NJ 07902-0229. Telephone: (908) 522-5310.
• Richard Levinson, MD, DPA, Associate Executive Director, American Public Health Association, 800 I St. N.W., Washington, DC 20001-3710. Telephone: (202) 777-APHA. Web site: www.apha.org.
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