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CDC issues guidelines for healthcare facilities for preventing the next outbreak


February 1, 2018

Infection control experts have been warning for some time now that the newest, and perhaps worst, infectious illness outbreak is yet to hit the U.S., and some agencies appear ready to prepare the country’s healthcare facilities.

In a joint venture, the Society for Healthcare Epidemiology of America (SHEA), with the support of the CDC, has released a new guidance document designed to help hospitals and smaller healthcare facilities respond to outbreaks of infectious diseases quicker and more efficiently.

The document, titled “Outbreak Response and Incident Management: SHEA Guidance and Resources for Healthcare Epidemiologists in United States Acute-Care Hospitals,” was published in the December 2017 issue of the journal Infection Control & Hospital Epidemiology.

“This guidance details the role of the healthcare epidemiologist as an expert and leader supporting hospitals in preparing for, stopping, and recovering from infectious diseases crises,” said David Banach, MD, co-chair of the writing panel, assistant professor of medicine at the University of Connecticut, and hospital epidemiologist at UConn Health, in a written statement. “Armed with the resources to develop and support key activities, healthcare epidemiologists can utilize their skills and expertise in investigation and response to infectious disease outbreaks within a hospital’s incident command system.”

While the document’s primary use is to help hospitals craft and refine their response protocols to potentially overwhelming outbreaks such as SARS in 2010 and Ebola in 2014, it is expected that medical walk-in clinics, physician’s offices, long-term care facilities, and smaller hospitals will also benefit from the document. Many smaller clinics are quickly becoming part of larger healthcare systems, and under new CMS emergency management regulations, they are required to train and prepare for emergencies such as infectious disease outbreaks. In addition, it is widely accepted that in the event of major disease outbreaks, medical clinics would be inundated with walk-in cases and therefore become the frontlines of the country’s response to the outbreak.

In October 2014, Thomas Eric Duncan, a Liberian national who was visiting family in Dallas, became the first confirmed U.S. case of Ebola when he checked into Texas Health Presbyterian Hospital with symptoms. He later died; two nurses that had been caring for Duncan at the hospital also came down with symptoms, but were treated and recovered. In October, a New York City doctor who had been treating patients in Guinea tested positive for the virus and was later cured at Bellevue Hospital.

The cases, the first ever in American hospitals, set off a near-panic in the United States as the CDC became involved, releasing a new set of guidelines and videos to help healthcare workers learn how to better work with PPE and keep their cool when dealing with one of the most infectious diseases on the planet.

That Ebola outbreak, which had its origins in Africa, killed more than 11,000 people in the African nations of Liberia, Sierra Leone, and Guinea before world health authorities declared Africa free of the virus. It was the first time Americans got a taste of how quickly a disease could spread by travel on modern transportation systems, and the first time American nurses and healthcare workers realized how quickly they could be overwhelmed—and how underprepared they were.

World health authorities warn that the newest outbreak may be right around the corner. Scientists in December 2017 announced that they found the source of the 2002 outbreak of SARS that killed hundreds of people: a bat cave in China. In Canada, 44 people died from the outbreak, around 400 became ill, and 25,000 Toronto residents were placed in quarantine, while hospitals struggled to maintain order and keep their own staff healthy. All it takes is for a mutation to occur and to get out into the general public, they say, for another major outbreak to occur.

According to a press release, SHEA and CDC collaborated in 2016 to form the Outbreak Response Training Program to guide healthcare epidemiologists in maximizing their facilities’ preparedness and response efforts to combat outbreaks such as Ebola, Zika, pandemic influenza, and other infectious diseases. The new document leads epidemiologists through how to apply, use, and interact with emergency response structures, groups, and frameworks from the institutional to the federal levels, and provides an overview of essential resources. The principles in the guidance are intended for acute care hospitals, but they may apply to other types of healthcare organizations, such as freestanding emergency departments and long-term care facilities.

Hospitals and medical clinics have already begun training with the intricate PPE staff will need to wear when dealing with very infectious organisms. Ebola, for example, is so dangerous that it only takes a very small drop of blood to infect a person. That’s why the CDC recommends full body coverage, tape over seams, Powered Air Purifying Respirators (PAPR), and about 35 steps for putting the PPE on and taking it all off (donning and doffing). Many hospitals also have begun stocking the equipment in easy-to-access cabinets outside patient safety rooms.

Clinics have already begun changing the way they approach sick patients that could potentially harbor dangerous infectious diseases. In fact, one of the simplest protocols to come out of the 2014 Ebola outbreak was a series of questions that clinic staff could use to triage patients. By asking where they have traveled in the last three weeks, whether they have a fever or any other specific symptoms, and who else they may have been exposed to, healthcare workers were able to immediately make an informed decision about possible Ebola risk. Among other things, clinic workers are being encouraged to train and drill with their hospital counterparts, isolate patients that may be highly contagious, and stock up on supplies they may need until more advanced help can take over the response.

“Community and critical access hospitals and other healthcare facilities, such as long-term care facilities (LTCF), face unique challenges when approaching incident management for infectious diseases outbreaks because of significant variability in available resources,” according to the guidance document recommendations. “During the preparedness stage, such facilities should conduct HVAs/risk assessments to identify gaps, including potential for decreases in number of personnel due to illness and limitations due to the facility’s location (e.g., rural). Once resource gaps are identified, the facility should contact local hospitals or public health partners to assist in mitigating gaps.

“Facilities can improve response plans though collaboration with other local facilities, partnership with a larger facility or network of hospitals with established infection prevention and control policies, and hiring a consultant HE. As resource-limited facilities may not be equipped to handle all emerging pathogens, hospitals should work with state and public health departments to facilitate transfer of patients to the closest facility in their region with the appropriate level of care.”

Also, according to the guidance document from SHEA, during a crisis, an epidemiologist provides medical and technical expertise and leads infection prevention and control efforts, coordinates with institutional stakeholders, and provides input into internal and external communications.

“We will always be faced with new and re-emerging pathogens,” said Lynn Johnston, MD, co-chair of the writing panel and professor of medicine and infectious diseases at Dalhousie University in Halifax, Canada, in the statement. “This guidance is part of an ongoing effort to develop tools and strategies to prevent and manage contagious diseases to ensure patient and public safety.”

The document is part of a partnership between SHEA and CDC to prepare for emerging and re-emerging infections by providing training, educational resources, and expert guidance for dealing with outbreaks in healthcare facilities. The program is designed to train U.S. healthcare epidemiologists, who oversee infection control programs, in the skills, abilities, and tools to implement infection control practices and provide a leadership voice in responding to infectious threats.

SHEA began conducting outbreak response workshops in January, and it will develop and post toolkits based on the recommendations as well as provide online training modules and webinars. According to the SHEA website, the workshop modules will be developed as decision-support tools, hard-copy “pocket cards,” mobile applications including forms and checklists, at-a-glance summaries of recommendations, and other educational activities. Some of the planned toolkit topics include the following infectious outbreak measures: preparedness, response actions, incident management principles, and recovery and evaluation.

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