Identifying security's role in managing a potential Ebola patient
Identifying security's role in managing a potential Ebola patient
Officers are crucial for screening potentially infected patients, controlling access to the hospital, and managing possible quarantines
Ever since September 25, 2014, when the first Ebola patient in the United States arrived at Texas Health Presbyterian Hospital in Dallas, government officials, public health experts, and health systems around the country have shifted their focus toward preventing a potential epidemic and ensuring healthcare workers are prepared to care for an infected patient.
Much of this focus has naturally revolved around the most pressing issues, namely, how to properly isolate patients, protect healthcare workers, and prevent the spread of the illness to other patients. Although clinicians, infection preventionists, and occupational health experts have been at the center of this health scare, some say hospital security departments have been an afterthought, despite the fact that security officers play an integral role when it comes to access control and patient screening.
"I don't think security has a gotten as big a role as it should have," says Caroline Hamilton, CHS-III, risk expert and president of Risk and Security, LLC, in West Palm Beach, Florida. "I have a feeling this has sort of been taken over by the bureaucracy. It's gone into this other realm where functional, practical things aren't happening."
Security officers frequently serve as de facto utility staff. During any point during a typical day, officers may undertake an array of job duties in addition to traditional security responsibilities.
"It's kind of like a MacGyver role, so to speak," says Christopher Sonne, CHEC, assistant director of healthcare emergency management at HSS, Inc., in Denver. "It's not just physical security; there is a whole lot that falls underneath that umbrella."
In many cases, security officers may be the first member of the hospital staff to come in contact with a person with symptoms of Ebola; they may also be involved with initially screening patients and visitors as they arrive at the ED. For that reason, hospitals need to develop a plan in conjunction with the security department so officers know how to identify patients potentially infected with Ebola and direct them to the appropriate clinical staff and into isolation, while protecting themselves from transmission. However, because this illness is so closely tied to infection control, security officers are frequently left in the dark.
"In my opinion, security is very heavily involved in the planning for the controlled access screening plan for this kind of situation, and should be involved from the very beginning with infection control, emergency management, and senior leadership," says Thomas A. Smith, CHPA, CPP, president of Healthcare Security Consultants, Inc., in Chapel Hill, North Carolina.
Although Ebola has been present in relatively few hospitals, the criticism levied against Texas Health Presbyterian Hospital has made it clear that hospitals need to begin planning for this event now, and those plans need to include the hospital security department.
Developing a plan
Following the isolated cases of Ebola in the United States, the government identified five international airports as the only means to enter the country from affected countries in West Africa. The federal government also identified hospitals across the country that would be designated to handle the care of an Ebola patient. Although these facilities would be specifically equipped for the presence of Ebola patients, the reality is that a symptomatic patient could walk into any hospital ED or clinic at any time, Sonne says.
"It's not just for those hospitals in the five primary cities where patients are coming into, it can happen anywhere and it can happen anytime, which is why we push for a good all-hazards approach for this," he says. "I doubt Texas Presbyterian thought they were going to be on the front line of Ebola. That kind of behooves and strengthens the fact that we need to be prepared because we don't know when or where the next Ebola patient is going to present."
But not enough hospitals have a cohesive plan in place to effectively manage this situation, Hamilton says.
"I'd want to have some kind of screening program in place and have a plan so as soon as you know someone is presenting you can put your plan in place," Hamilton says. "I think that's the first thing that is missing is people don't have a plan."
A multidisciplinary approach is crucial to developing a plan that will be effectively carried out across all units of a health system, Sonne adds.
"If you just have clinicians sitting at the table, you're going to miss an important piece of that puzzle in terms of security, security access, transporting a patient, and those types of things," he says.
Specifically, security should have a role in identifying patients that are exhibiting symptoms of Ebola. Hospitals should be using signage in the parking garages and entrances that instruct patients to alert a staff member if they have been to countries in West Africa, had contact with a person infected with Ebola, and are exhibiting any of the symptoms associated with Ebola.
Depending on the structure of the hospital, security officers may be the first person to come in contact with an Ebola patient. Officers should be trained to gather information about recent travel and symptoms and then appropriately direct those potentially ill patients to the right clinicians.
"Now that we've identified someone, what are we going to do with them?" Hamilton says. "We need to have the isolation areas set up before the first person comes in, even if it's not an isolation area that's going to be the long-term treatment area."
Some hospitals may elect to direct patients toward one or two entry points in the hospital to control patient flow and improve the efficacy of the screening process. The security director should be intimately involved in that controlled access plan and designing the most effective pathway for patients presenting to the ED. Additionally, the hospital may elect to go into a full or partial lockdown if an Ebola case is confirmed.
Security officers also need to receive training from infection control staff members on the proper PPE that is required when coming in contact with an Ebola patient, how the illness is transmitted, and the protocols for preventing transmission.
Smith adds that there is no cookie-cutter plan for this scenario since layout, geographical location, and emergency response plans will vary from hospital to hospital.
"Everyone should be familiar with the incident command, and this is most definitely a case where the incident command system would work very well," Smith says. "It's hard to do a cookie-cutter plan because everyone's organization is a little bit different, but the bottom line is you really need to be using these basic tenets of controlling access."
Three levels of access control
Hospitals can boil down access control for potential Ebola patients into a three-tiered system, Smith says:
- Level 1: Appropriate signage in the parking areas and entrances of the hospital. Information should be sent out to physician offices and clinics to make them aware of certain symptoms (e.g., high fever, vomiting, and diarrhea). In some cases, patients may be given a questionnaire over the phone when scheduling appointments with a physician's office or clinic.
"It's basically a passive screening system," Smith says. "There isn't someone out there taking your temperature, you are just relying on them to read the signs and self-report."
- Level 2: Restricting access to a few entrances. At this level, the hospital would still rely on employees to self-report, but may be doing slightly more active surveillance for patients and visitors. This may include screening patients and visitors at the door by simply asking them questions as they arrive. Hospitals may jump to this level if there is a confirmed Ebola patient in their county or state.
- Level 3: Controlling access to a limited number of doors and actively screening employees, patients, and visitors. This, Smith says, is "a huge, huge task." Hospitals would escalate to level three if there is an Ebola patient in the facility and it's necessary to prevent the spread of transmission by actively controlling access in and out of the building.
"Normally security people are the first folks that are seen by the patients and visitors; they are asking the questions," Smith says. "It's definitely security, valet parking if you have it, and people at the information desks that are at the front line."
It's important to be able to quickly and safely execute this plan to avoid transmitting the disease to other frontline employees, or to patients and visitors within the facility.
"Any time there is a threat to the well-being of those in the facility, it behooves security to develop that situational awareness and control access to the facility," Sonne says. "I'm not saying they are going to restrict people, but just manage the way in which they enter, so if they are symptomatic and need to be isolated right away, we have the ability to do so."
Hamilton adds that valets are a particularly important and often forgotten consideration, but they are the very first people to come in contact with patients and visitors. Valets and security may work hand in hand in getting potentially infected patients to the appropriately designated area of the hospital.
"If the valet opens the door of the car and the patient throws up all over everything, you need to call someone," Hamilton says. "You're not going to call a nurse, you'll probably call security."
Managing a quarantine
Already, issues have emerged regarding the quarantine of potentially infected Ebola patients. In late October, controversy erupted in New Jersey when the state opted to quarantine Kaci Hickox, a nurse returning from an assignment with Doctors Without Borders in Sierra Leone. Hickox was quarantined in an isolation tent at University Hospital in Newark despite testing negative in a preliminary test for Ebola. Hickox published a first-person article in the Dallas Morning News days later, criticizing her treatment at the airport and at the hospital.
Initially, the hospital indicated Hickox would be quarantined for 21 days, but released her from the hospital three days after she was symptom-free for 24 hours. Hickox hired a civil rights attorney and planned to sue for her release. Upon returning to her home in Maine, the state initially said she must comply with a 21-day quarantine in her house, a protocol she publically rebuffed. A judge later lifted the mandatory quarantine and Hickox reached a settlement deal with the state of Maine, allowing her to travel freely in public and self-monitor her health.
The incident has raised a number of concerns about mandatory quarantines, all of which could impact hospital security in some way, Smith says. Although the authority for implementing a quarantine falls to the local health department, enforcement could rest on hospital security and/or local police.
"The reality is, the sheriff's department has very limited resources and they will have to work hand in hand with local police, whether that's city police or municipal police agency, or local security forces of each healthcare system," Smith says.
He adds that hospitals should begin thinking about these issues now and connect with local health agencies and police departments to begin planning the management of potential quarantines.
"Sometimes I find people don't even talk until there is an emergency," he says. "That's not the time to be building relationships. The time to build good relationships and communication with local law enforcement is when you don't have something like this staring you in the face."
Drawing from SARS and H1N1
Although the panic surrounding an Ebola epidemic has reached a fever pitch, this is not the first time the U.S. healthcare system has faced off against a potentially deadly infection.
During the spring of 2003, a global SARS outbreak that originated in Hong Kong and spread to Toronto put U.S. hospitals on high alert. In 2009, the H1N1 flu pandemic swept through the U.S., with particularly severe outbreaks in Texas, New York, Utah, and California.
"[This is] very similar to SARS, and I think the lessons learned from SARS could be used to help people today," Smith says.
In November 2003, following the SARS outbreak, the Institute for Bioethics, Health Policy and Law at the University of Louisville School of Medicine published a report to the CDC entitled Quarantine and Isolation: Lessons Learned From SARS. Among the many lessons learned, the authors pointed out that "to implement successful programs of quarantine and isolation, affected countries needed ancillary services and logistical support, including law enforcement and other measures to ensure compliance."
Sonne says it can be frustrating as an emergency management professional to see how quickly these epidemics are forgotten and discarded, along with the lessons learned. During those outbreaks, Smith adds, security officers played an important role in directing patients to the appropriate part of the hospital, and conducting passive screening by asking pointed questions and recognizing the potential signs and symptoms of the disease.
"It's hard to look forward without looking back," Smith says. "SARS, in my mind, that experience and the lessons learned from that are critical to being successful now with Ebola. If we don't pay attention to those lessons learned for SARS, it's hard to move forward and make sure we're as successful as we can be with an Ebola outbreak."