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Source: http://www.medscape.com/viewarticle/702417
Emergency Staff Need Protection, Training for Infectious Pandemic
Neil Osterweil
May 6, 2009 ? The threat has changed, but the advice remains the same: make sure that emergency department (ED) staff have the right personal protection equipment (PPE), see to it that everyone knows their roles and where they are needed, and plan for contingencies such as childcare and feeding and housing of vital medical personnel.
Guidelines for ED staff developed in response to the threat of an avian influenza pandemic and based on real-world experience with the severe acute respiratory syndrome (SARS) were rushed to print in the online edition of the Emergency Medicine Journal, a BMJ publication.
The recommendations have a British flavor, but similar, more practical recommendations are currently in the works from the American College of Emergency Physicians, with the help of the Department of Health and Human Services and the Centers for Disease Control and Prevention, and should be ready for promulgation, says Jeffrey W. Runge, MD. Dr. Runge is a consultant to the American College of Emergency Physicians and is the former assistant secretary for health affairs and chief medical officer of the Department of Homeland Security.
"Certainly, the issues for H5N1 are the same for H1N1," Dr. Runge said in an interview with Medscape Infectious Diseases. "This all comes down to transmissibility and virulence. This looks like it will be a less virulent flu than the 1918 flu epidemic, but still, there needs to be some preparation for surge capacity in the hospital, and not just in the emergency room."
The EMJ article describes the logistical challenges of coping with a rapidly evolving pandemic and also delves into issues such as family concerns, housing, feeding, and staff morale that could detract from the efficient running of EDs that are likely to bear the brunt.
Susan Robinson, MD, from the ED at Addenbrookes Hospital, in Cambridge, United Kingdom, and colleagues visited hospitals in Hong Kong to study how their counterparts there coped with the SARS outbreak in 2003 and came away with both practical advice about screening, isolation procedures, staff training and allocation, and ethical issues, and cautions about the effects on individual staff members.
"[T] he most important lesson learnt was that living through an epidemic or pandemic would be one of the most emotive and challenging experiences of our professional lives," the authors write. "The best method of mitigating against this is for emergency departments to ensure they have prepared their staff for such an eventuality to the best of their ability."
Recommended Steps for EDs
The authors recommend steps that ED directors should take to prepare the ED. The steps are summarized as follows:
1. Make sure that the department is represented at the institutional level
An ED staff liaison can lobby management/ownership for issues such as stocking up on PPE, financial planning, and staff training.
2. Discuss pandemic flu with staff
Department management should discuss national and regional planning for flu pandemics and discuss how coping with such an episode may involve changes in departmental procedures and routines.
3. Establish a process for testing that masks, gowns, etc, properly fit all staff; train staff in the proper use in the use of PPE; and consider stocking enough protective equipment to cope with an extended emergency
Masks are not one-size-fits-all, so the department may need to stock several different mask types to accommodate all of the staff. Personnel in charge of purchasing supplies should also consider that during an emergency, masks and other protective equipment are likely to be in short supply, but must also take into account the shelf life of such products and establish a plan for rotating supplies so that they are used in a timely fashion but are always on hand for emergencies.
4. Establish protocols for managing potentially infected patients within the ED
"Assume every febrile patient could be infectious until you know otherwise. Consider how your department will screen for these febrile patients at the point of entry to the ED and subsequently isolate them from other non-febrile patients," the authors write.
The EDs in Hong Kong established criteria for isolation and rapid assessment of patients. Fever and the answer of "yes" to any 1 of 4 criteria will trigger isolation and assessment. (The criteria apply to avian flu, but could easily apply to swine flu.):
? Travel to high-risk areas
? Occupational history of exposure
? Contact history of exposure to other persons with febrile illness, particularly those with known disease
? Clustering or the presence of multiple patients from the same village, school, workplace, or residence
5. Consider that staff roles in the hospital and within the ED may change during a pandemic
Staff from other areas may need to be reassigned to the ED, for example, or staff such as those who routinely handle bumps, bruises, and other minor problems might be called on to aid in more severe cases.
6. Establish systems for communicating with staff during a pandemic
"Discuss what information staff would wish to receive," Dr. Robinson and colleagues write. "This may be the numbers of patients admitted with flu, the progress of sick colleagues or available supplies of PPE. Assign this role to a senior clinician or manager who is able to produce this information on a daily basis."
7.Consider methods for improving staff morale
The authors recommend steps such as making healthy food, coffee, and snack freely available; laundry facilities; arranging for free calls to family and friends; etc.
8. Consider and discuss the ethical decisions that staff may be required to make
"It will not be possible to admit all patients with flu during a pandemic outbreak. Difficult decisions will need to be made," the authors caution. "Advice sheets may be prepared in advance to be distributed to patients and to caregivers at home. This should include advice on avoidance of cross-infection, symptoms which should lead to a further consultation with medical services (this advice may vary depending on the level of pandemic outbreak) and details of the likely course of the illness."
The US Response
"There are issues of triage, there are issues of staff attendance, personal protective equipment, and physical facilities like sufficient negative-pressure rooms and isolation facilities," Dr. Runge says. "Even the waiting room can be a potentially problematic thing, and all of these things need to be addressed at an operational level, and nobody's done that yet."
"What's going to happen here [in the event of a pandemic] is that we'll have 3 classes of patients," he adds. "One will be patients who have sniffles and come in because they're worried about the swine flu, you'll have another group that has bona fide flu symptoms with fevers, myalgia, and respiratory symptoms who either have or don't have the flu and can go home and take care of it there, or there will be some people who have a severe case and need hospitalization, and all those people are going to show up through that common pathway, the emergency department."
The authors have disclosed no relevant financial relationships.
Emerg Med J. Published online April 22, 2009.
Emergency Staff Need Protection, Training for Infectious Pandemic
Neil Osterweil
May 6, 2009 ? The threat has changed, but the advice remains the same: make sure that emergency department (ED) staff have the right personal protection equipment (PPE), see to it that everyone knows their roles and where they are needed, and plan for contingencies such as childcare and feeding and housing of vital medical personnel.
Guidelines for ED staff developed in response to the threat of an avian influenza pandemic and based on real-world experience with the severe acute respiratory syndrome (SARS) were rushed to print in the online edition of the Emergency Medicine Journal, a BMJ publication.
The recommendations have a British flavor, but similar, more practical recommendations are currently in the works from the American College of Emergency Physicians, with the help of the Department of Health and Human Services and the Centers for Disease Control and Prevention, and should be ready for promulgation, says Jeffrey W. Runge, MD. Dr. Runge is a consultant to the American College of Emergency Physicians and is the former assistant secretary for health affairs and chief medical officer of the Department of Homeland Security.
"Certainly, the issues for H5N1 are the same for H1N1," Dr. Runge said in an interview with Medscape Infectious Diseases. "This all comes down to transmissibility and virulence. This looks like it will be a less virulent flu than the 1918 flu epidemic, but still, there needs to be some preparation for surge capacity in the hospital, and not just in the emergency room."
The EMJ article describes the logistical challenges of coping with a rapidly evolving pandemic and also delves into issues such as family concerns, housing, feeding, and staff morale that could detract from the efficient running of EDs that are likely to bear the brunt.
Susan Robinson, MD, from the ED at Addenbrookes Hospital, in Cambridge, United Kingdom, and colleagues visited hospitals in Hong Kong to study how their counterparts there coped with the SARS outbreak in 2003 and came away with both practical advice about screening, isolation procedures, staff training and allocation, and ethical issues, and cautions about the effects on individual staff members.
"[T] he most important lesson learnt was that living through an epidemic or pandemic would be one of the most emotive and challenging experiences of our professional lives," the authors write. "The best method of mitigating against this is for emergency departments to ensure they have prepared their staff for such an eventuality to the best of their ability."
Recommended Steps for EDs
The authors recommend steps that ED directors should take to prepare the ED. The steps are summarized as follows:
1. Make sure that the department is represented at the institutional level
An ED staff liaison can lobby management/ownership for issues such as stocking up on PPE, financial planning, and staff training.
2. Discuss pandemic flu with staff
Department management should discuss national and regional planning for flu pandemics and discuss how coping with such an episode may involve changes in departmental procedures and routines.
3. Establish a process for testing that masks, gowns, etc, properly fit all staff; train staff in the proper use in the use of PPE; and consider stocking enough protective equipment to cope with an extended emergency
Masks are not one-size-fits-all, so the department may need to stock several different mask types to accommodate all of the staff. Personnel in charge of purchasing supplies should also consider that during an emergency, masks and other protective equipment are likely to be in short supply, but must also take into account the shelf life of such products and establish a plan for rotating supplies so that they are used in a timely fashion but are always on hand for emergencies.
4. Establish protocols for managing potentially infected patients within the ED
"Assume every febrile patient could be infectious until you know otherwise. Consider how your department will screen for these febrile patients at the point of entry to the ED and subsequently isolate them from other non-febrile patients," the authors write.
The EDs in Hong Kong established criteria for isolation and rapid assessment of patients. Fever and the answer of "yes" to any 1 of 4 criteria will trigger isolation and assessment. (The criteria apply to avian flu, but could easily apply to swine flu.):
? Travel to high-risk areas
? Occupational history of exposure
? Contact history of exposure to other persons with febrile illness, particularly those with known disease
? Clustering or the presence of multiple patients from the same village, school, workplace, or residence
5. Consider that staff roles in the hospital and within the ED may change during a pandemic
Staff from other areas may need to be reassigned to the ED, for example, or staff such as those who routinely handle bumps, bruises, and other minor problems might be called on to aid in more severe cases.
6. Establish systems for communicating with staff during a pandemic
"Discuss what information staff would wish to receive," Dr. Robinson and colleagues write. "This may be the numbers of patients admitted with flu, the progress of sick colleagues or available supplies of PPE. Assign this role to a senior clinician or manager who is able to produce this information on a daily basis."
7.Consider methods for improving staff morale
The authors recommend steps such as making healthy food, coffee, and snack freely available; laundry facilities; arranging for free calls to family and friends; etc.
8. Consider and discuss the ethical decisions that staff may be required to make
"It will not be possible to admit all patients with flu during a pandemic outbreak. Difficult decisions will need to be made," the authors caution. "Advice sheets may be prepared in advance to be distributed to patients and to caregivers at home. This should include advice on avoidance of cross-infection, symptoms which should lead to a further consultation with medical services (this advice may vary depending on the level of pandemic outbreak) and details of the likely course of the illness."
The US Response
"There are issues of triage, there are issues of staff attendance, personal protective equipment, and physical facilities like sufficient negative-pressure rooms and isolation facilities," Dr. Runge says. "Even the waiting room can be a potentially problematic thing, and all of these things need to be addressed at an operational level, and nobody's done that yet."
"What's going to happen here [in the event of a pandemic] is that we'll have 3 classes of patients," he adds. "One will be patients who have sniffles and come in because they're worried about the swine flu, you'll have another group that has bona fide flu symptoms with fevers, myalgia, and respiratory symptoms who either have or don't have the flu and can go home and take care of it there, or there will be some people who have a severe case and need hospitalization, and all those people are going to show up through that common pathway, the emergency department."
The authors have disclosed no relevant financial relationships.
Emerg Med J. Published online April 22, 2009.