With summer over, time to assess outbreak practices

Hospitalists play key role in ensuring effective response to disease outbreaks.

As mosquito season—and its associated diseases—wanes in many parts of the country, it's a good time for hospitals to evaluate their performance in dealing with disease outbreaks.

This summer, the mosquito- transmitted chikungunya had infected 357 people in U.S. states and 123 patients in Puerto Rico and the U.S. Virgin Islands by mid-July. Meanwhile, the first 2 U.S. cases of Middle East Respiratory Syndrome (MERS) were confirmed in travelers returning to Indiana and Florida in May, the CDC reported.

Photo from Thinkstock
Photo from Thinkstock.

The majority of hospitals have outbreak protocols and plans in place to address potential epidemics from diseases like these, largely due to the 2009 worldwide influenza outbreak, said Robert H. Hopkins Jr., MD, FACP, professor of internal medicine and pediatrics at the University of Arkansas for Medical Sciences in Little Rock and immediate past governor for the ACP Arkansas Chapter.

“If we hadn't had those experiences, I don't think we'd have much in the way of awareness and preparedness,” he said. “But now, we're in a better place. Most hospitals, whether it is a city or small community hospital, have some level of preparedness.”

However, challenges remain as hospital resources and populations change and novel strains of illness develop. Friction can also arise from the fine balance between patient privacy and public reporting.

Hospitalists should not underestimate their roles in improving response to illness epidemics, disease experts say. From first recognition to public reporting to treatment to spread prevention, hospitalists are involved in every stage of a potential outbreak, said ACP Member Christopher S. Kim, MD, a hospitalist and associate professor of internal medicine for the University of Michigan Health Center in Ann Arbor.

“While infection control [specialists] as well as epidemiologists are surveying the trends, hospitalists will be seeing these patients and will be able to recognize how sick these patients are and provide guidance on the acuity of services needed,” Dr. Kim said. “This is an area where hospitalists are well primed to take on a leadership role.”

Recognizing illness, isolating patients

Keeping abreast of current and potential disease dangers is the first step to managing a possible outbreak, said David A. Pegues, MD, medical director of healthcare epidemiology and infection prevention and control for the University of Pennsylvania Health System in Philadelphia.

Physicians should ensure they are aware of disease updates from city and county public health officials, read news alerts, and retain an index of suspicion when treating patients, he added.

“It's really important that physicians maintain some awareness of what's going on in their local area and region as it relates to contagious disease,” Dr. Pegues said. “Know what the clinical manifestations are.”

Clinicians generally can sign up for electronic public health alerts from their state departments of health. Large cities have similar city resources and county departments of health may have monthly newsletters, Dr. Pegues said.

“These alerts are timely and focus on risk factors, clinical recognition, and reporting requirements for novel infections or outbreaks,” he said. “Recent alerts by the Pennsylvania Department of Health (for example) have included reports of human cases of imported chikungunya viral infection, measles and MERS-CoV infection in the state and U.S.”

If hospitalists suspect a patient is experiencing an illness linked to an outbreak, they should immediately contact their hospital's infection control and prevention department, added ACP Member Judith A. O’Donnell, MD, chief of the division of infectious diseases and hospital epidemiologist and director of the Penn Presbyterian Medical Center's department of infection prevention and control in Philadelphia. Infection control specialists can help answer physicians' questions and assist with the proper diagnosis.

All acute care hospitals are mandated to have a person or persons tasked with infection prevention and control activities, although such leaders are likely to have other responsibilities and job duties at smaller facilities. If you're not familiar with who is responsible for infection prevention and control, ask a colleague, floor nurse, or the director of the microbiology laboratory.

“Epidemiologists who head up those departments are generally aware of what is happening in the city, region, state, or nationally with respect to outbreaks and exposures,” Dr. O’Donnell said. “If you think you're seeing a case that could be [related to an outbreak], the next call you should make is to your infection control and prevention department.”

Patients conceivably exposed to contagious disease should quickly be isolated from other patients and civilians, Dr. Pegues said. They should be separated to a private room and away from open bays and semi-private areas. Health care staff should use masks when appropriate.

“Do not wait around until you get a diagnostic test,” Dr. Pegues said. “It's much better to place a patient presumptively in isolation [while you wait for results]. The worst situation is when you fail to recognize a patient with a highly transmittable disease and expose others, particularly vulnerable patients.”

Teamwork in reporting

Hospitalists play a uniquely important role in the public reporting of contagious disease exposures and possible outbreaks, said Dr. O’Donnell.

While infection specialists and epidemiologists are obligated to report laboratory results to local and state health departments, hospitalists can provide specifics gleaned from treating patients and speaking to families.

“The lab can only provide confirmation of the test; they can't provide the details around the case,” Dr. O’Donnell said. “Physicians will often be asked to assist in speaking directly to the health department to provide pertinent clinical information.”

Physicians should work with their infection control and prevention departments to learn which agencies they should provide information to and when. In some locales, health workers must report data to county health departments, while in others, the information is reported to state authorities. The timing and details of such information also differ by jurisdiction.

Hospitalists also should be prepared to interact with their hospital's media affairs office or news outlets when potential outbreaks arise, said William Schaffner, MD, MACP, professor of preventive medicine and infectious diseases for Vanderbilt University School of Medicine in Nashville. Such communications can be challenging for the average hospitalist who is unfamiliar with the media world, he said.

“For many of these infections, there will be interest in the news media,” said Dr. Schaffner, who is past president of the National Foundation for Infectious Diseases. “You have this interesting intersection of caring for the patient and being obligated to give information to public health [agencies], but then protecting it from public information.”

In some cases, it may be necessary to release to the news media private details of a patient's illness and activities in order to locate others who may be exposed and raise awareness, he noted. For instance, one may need to disclose that a patient visited a local restaurant where others may have become infected. Hospitalists also need to know which information is OK to divulge and which should be kept private in order to maintain a patient's rights under HIPAA, and their hospital's media department can help with that.

Focusing on strong communication with patients and families during such crises also is important, said Daniel J. Castillo, MD, medical director for the division of healthcare quality evaluation for The Joint Commission in Washington, D.C.

“Organizations that can manage their message and keep vital communication lines open succeed much more readily,” he said. “This involves making sure physicians who are taking care of patients have access to the most up-to-date and accurate information, so developing a mechanism for this to occur is paramount.”

One way to improve communication could be to develop social media channels, such as Twitter, to convey information in a way that the public is accustomed to receiving it, Dr. Castillo adds. Physicians should also work closely with hospital public relations departments and local media since they will be reporting on the issue, and ensuring accurate and timely information is key.

Good communication among health care teams, and between hospitalists themselves, also is essential in spotting outbreak risks and preventing spread of illness.

“Multiple hospitals working with different teams of hospitalists, you need to make sure those hospitalists are communicating with each other to make sure we're not missing an opportunity or missing a trend that's emerging right in front of [us],” Dr. Hopkins said. “The hospitalists, much like the primary care physician on the frontline, are in the best position to be looking for these outbreaks.”

Drilling for best practices

Along with the influenza scare of 2009, other real-world events have helped shape policies and improve outbreak procedures at hospitals. The SARS epidemic, for instance, was particularly sobering and enlightening for clinicians, said James Pile, MD, FACP, a hospitalist and infectious disease specialist for the Cleveland Clinic in Ohio. The 2003 outbreak killed 44 people and sickened 400 others. A total of 25,000 Toronto residents had to be placed in quarantine.

“Lessons that emerged from that experience involved the importance of careful and thorough outbreak plans that include attention to triage, communication (both internal and external to the hospital), surge capacity, coordination across the health care system regionally and beyond, and focus on the protection of health care workers as well as their loved ones,” said Dr. Pile, who is vice-chair for faculty development in the Cleveland Clinic's department of hospital medicine.

Large-scale simulations of epidemics by hospitals are a crucial component to proper preparation and planning for real events, Dr. Castillo said.

The Joint Commission requires that hospitals conduct at least 2 emergency preparedness drills a year. One drill should include an influx of patients and the other should include other community leaders such as fire, police and public health officials, Dr. Castillo said. Hospitalists should take part in such drills, he said.

The community “drill can be conducted as a tabletop exercise,” he said. “Since we accredit the institutions and not the community organizations, we expect to see at least an effort if a hospital cannot get the community leaders to the table. Our goal with this is to move emergency preparedness from the hospital-centric silo to the community, since it takes a well-prepared community to truly be prepared for all hazards.”

As part of the drills, hospitals must perform a hazard vulnerability analysis in which they assess weak areas and document their findings.

Whether they're actively running drills or just going about their day-to-day work, doctors and hospitals always should be thinking about the possibility of an outbreak and not become complacent, Dr. Castillo advised.

The potential for outbreaks “is something that needs to be on the forefront of our brain every day,” he said. “If we don't keep some sort of public health hat on, we're not doing all of our due diligence as physicians.”