Health Care Facilities and Bioterrorism Preparedness A Template for Healthcare Facilities.
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Transcript of Health Care Facilities and Bioterrorism Preparedness A Template for Healthcare Facilities.
Health Care Facilities and Health Care Facilities and Bioterrorism PreparednessBioterrorism Preparedness
A Template for Healthcare A Template for Healthcare FacilitiesFacilities
Presented byPresented by
Ohio Department of HealthOhio Department of HealthBureau of Environmental Health Bureau of Environmental Health
Bureau of Infectious Disease ControlBureau of Infectious Disease Control
Disaster Preparedness and Response Disaster Preparedness and Response ProgramProgram
Bioterrorism Surveillance and Bioterrorism Surveillance and Epidemiology ProgramEpidemiology Program
IntroductionIntroduction
The Association for Professionals in The Association for Professionals in Infection Control and Epi (APIC) along Infection Control and Epi (APIC) along with the Center for Disease Control with the Center for Disease Control and Prevention (CDC) created and Prevention (CDC) created templatetemplate
The Bioterrorism Readiness Plan is The Bioterrorism Readiness Plan is offered as a tool for planning and to offered as a tool for planning and to facilitate preparation of bioterrorism facilitate preparation of bioterrorism readiness for individual institutions.readiness for individual institutions.
Telephone notification numbers Telephone notification numbers necessary for a readiness plannecessary for a readiness plan
Internal Internal contactscontacts
Infection controlInfection control EpidemiologistEpidemiologist Administration/ Administration/
Public AffairsPublic Affairs
External contactsExternal contacts
Local & State Health Local & State Health DepartmentDepartment
Local EMSLocal EMS Local Law EnforcementLocal Law Enforcement Local EMA AgencyLocal EMA Agency Regional Poison Regional Poison
ControlControl CDC Hospital CDC Hospital
Infections ProgramInfections Program
Reporting Requirements Reporting Requirements and Contact Informationand Contact Information
If a bioterrorism If a bioterrorism event is event is suspected, local suspected, local emergency emergency response response systems should systems should be activated.be activated.
Prompt Prompt communication communication is essential.is essential.
Detection of OutbreaksDetection of Outbreaks
Unannounced (covert) Unannounced (covert) eventsevents
Announced (overt) Announced (overt) eventsevents
Possibility of Possibility of bioterrorism event bioterrorism event should be ruled out should be ruled out with assistance of the with assistance of the FBI and state health FBI and state health officials.officials.
Detection Criteria Detection Criteria (continued)(continued)
Syndrome-Syndrome-basedbased
May be necessary May be necessary to initiate to initiate response based response based on the recognition on the recognition of high-risk of high-risk syndromessyndromes
EpidemiologicalEpidemiological
Epi principles used to Epi principles used to assess whether assess whether patient’s patient’s presentation is presentation is typical of endemic typical of endemic disease or is an disease or is an unusual event that unusual event that should raise concern.should raise concern.
Four Potential Bioterrorism Four Potential Bioterrorism AgentsAgents
Anthrax (bacteria)Anthrax (bacteria) Botulism (toxin)Botulism (toxin) Plague (bacteria)Plague (bacteria) Smallpox (virus)Smallpox (virus)
Some More Bio Agents...Some More Bio Agents...
Q FeverQ Fever TularemiaTularemia BrucellosisBrucellosis Viral Hemorrhagic Viral Hemorrhagic
FeversFevers Viral EncephalitisViral Encephalitis Staphylococcal Staphylococcal
enterotoxin B (SEB)enterotoxin B (SEB)
Transmission Type: Transmission Type: NaturalNatural
Direct Contact (skin-skin, etc.)Direct Contact (skin-skin, etc.)– Anthrax (animal to human)Anthrax (animal to human)– like STD’s or common coldlike STD’s or common cold
Direct Large Droplet Spread (Direct Large Droplet Spread ( 1 m 1 m projection)projection)– Pneumonic Plague (secondary)Pneumonic Plague (secondary)– like Influenza (also droplet nuclei)like Influenza (also droplet nuclei)
Transmission Type: NaturalTransmission Type: Natural
Indirect Vehicle-borneIndirect Vehicle-borne– Brucellosis (milk, meat)Brucellosis (milk, meat)– Hep A (water)Hep A (water)– Anthrax (meat)Anthrax (meat)
Indirect Vector-borneIndirect Vector-borne– Bubonic plague (fleas)Bubonic plague (fleas)– like Lyme disease (ticks)like Lyme disease (ticks)
Transmission Type: NaturalTransmission Type: Natural
Airborne Droplet NucleiAirborne Droplet Nuclei
(Particles (Particles 5 microns) 5 microns) – Q feverQ fever– Smallpox (also direct and fomites)Smallpox (also direct and fomites)– like Tuberculosislike Tuberculosis
Airborne DustAirborne Dust– HantavirusesHantaviruses– AspergillosisAspergillosis
Transmission Type: Transmission Type: BioTBioT AerosolizedAerosolized
– AnthraxAnthrax– SmallpoxSmallpox– Q FeverQ Fever– TularemiaTularemia– PlaguePlague
FoodborneFoodborne– RicinRicin– BotulinumBotulinum
PRIMARY PREVENTION PRIMARY PREVENTION Pre-Exposure (DPre-Exposure (DPPRP)RP)
Immunization (Active)Immunization (Active)
Drug ProphylaxisDrug Prophylaxis
Training and EducationTraining and Education
SECONDARY PREVENTIONSECONDARY PREVENTIONIncubation Period (DIncubation Period (DPRPRP)P)
Diagnosis (Class or Agent Diagnosis (Class or Agent Specifics)Specifics)
Passive Immunization (Immune Passive Immunization (Immune Serum)Serum)
Pre-Treatment (Drugs)Pre-Treatment (Drugs)
TERTIARY PREVENTIONTERTIARY PREVENTIONCrisis Management of Overt Crisis Management of Overt
Disease (DPDisease (DPRRP)P) DiagnosisDiagnosis
TreatmentTreatment
CommunicationCommunication
Infection Control Practices for Infection Control Practices for Patient ManagementPatient Management
Two-Tier PrecautionsTwo-Tier Precautions Patient PlacementPatient Placement Patient TransportPatient Transport Cleaning, Disinfecting, Cleaning, Disinfecting,
and Sterilization of Equipment and Sterilization of Equipment and Environment and Environment
Discharge ManagementDischarge Management Post-Mortem carePost-Mortem care
Isolation PrecautionsIsolation Precautions
All patients in All patients in healthcare facilities healthcare facilities should be managed should be managed using using Standard Standard Precautions.Precautions.
Some patients will Some patients will need need Transmission Transmission Based Based Precautions.Precautions.
Standard PrecautionsStandard Precautions
HandwashingHandwashing GlovesGloves Masks/Eye Masks/Eye
Protection or Protection or Face ShieldsFace Shields
GownsGowns
Patient PlacementPatient Placement Infection control practices should be Infection control practices should be
followed in small-scale events.followed in small-scale events. Large-scale events should Large-scale events should
incorporate triage & isolation incorporate triage & isolation strategies.strategies.– Grouping patients with similar Grouping patients with similar
syndromes.syndromes.– The IC Committee should establish The IC Committee should establish
cohorting sites.cohorting sites.
Patient TransportPatient Transport
Should be limited to Should be limited to movement that is movement that is essential to provide essential to provide patient care.patient care.
Should reduce the Should reduce the opportunities for opportunities for transmission of transmission of microorganisms microorganisms within healthcare within healthcare facilities.facilities.
CleaningCleaning, , Disinfecting, and Disinfecting, and Sterilization of Equipment and Sterilization of Equipment and
EnvironmentEnvironment
Standard Precautions should be Standard Precautions should be generally applied for the management generally applied for the management of patient-care equipment and of patient-care equipment and environmental control.environmental control.
Each facility should have guidelines in Each facility should have guidelines in place for proper treatment of equipment place for proper treatment of equipment and a contaminated environment. and a contaminated environment.
Discharge ManagementDischarge Management
Ideally, patients Ideally, patients should be should be declared declared noninfectious.noninfectious.
Home care may Home care may be considered be considered (and may be (and may be DESIRABLE.)DESIRABLE.)
Post-mortem CarePost-mortem Care
Inform pathology departments and clinical Inform pathology departments and clinical labs of a potentially infectious outbreak prior labs of a potentially infectious outbreak prior to submitting specimens for exam or to submitting specimens for exam or disposal.disposal.
All autopsies should be performed using All autopsies should be performed using Standard Precautions.Standard Precautions.
Instructions for funeral directors should be Instructions for funeral directors should be developed and incorporated into the developed and incorporated into the Bioterrorism Readiness Plan.Bioterrorism Readiness Plan.
Post Exposure Post Exposure ManagementManagement
Decontamination of Patients and Decontamination of Patients and EnvironmentEnvironment
Prophylaxis & Post-exposure Prophylaxis & Post-exposure immunizationimmunization
Triage & Management of Large Scale Triage & Management of Large Scale Exposures or Suspected ExposuresExposures or Suspected Exposures
Psychological Aspects of BioterrorismPsychological Aspects of Bioterrorism
Decontamination of Decontamination of Patients & EnvironmentPatients & Environment
Goal =Goal = reduce extent of external reduce extent of external contamination of the patient & contain contamination of the patient & contain contamination to prevent further spread.contamination to prevent further spread.
Decontamination should Decontamination should onlyonly be used in be used in instances of gross contamination.instances of gross contamination.
Decisions regarding DECON needs should Decisions regarding DECON needs should be in consultation with state and local be in consultation with state and local health departments and health departments and in advancein advance..
Decontamination Decontamination (continued)(continued)
There is no likelihood for re-aerosolization There is no likelihood for re-aerosolization of a bio agent off a patient and little risk of a bio agent off a patient and little risk associated with cutaneous exposure. associated with cutaneous exposure. – Shower with soap and waterShower with soap and water– Clean water, saline solution or commercial Clean water, saline solution or commercial
ophthalmic solutions are recommended for ophthalmic solutions are recommended for rinsing eyes.rinsing eyes.
– Potentially harmful practices, such as Potentially harmful practices, such as bathing patients with bleach solutions bathing patients with bleach solutions should be AVOIDEDshould be AVOIDED
Prophylaxis and Post-Prophylaxis and Post-exposure Immunizationexposure Immunization
Recommendations Recommendations for prophylaxis are for prophylaxis are subject to change.subject to change.
So are the So are the treatment treatment recommendations!recommendations!
STAY TUNED!!!STAY TUNED!!!
Triage & Management of Large Triage & Management of Large Scale Exposures / Suspected Scale Exposures / Suspected
ExposuresExposures Establish lines of communication and Establish lines of communication and
authority (ICS!)authority (ICS!) Plan to cancel non-ER services and Plan to cancel non-ER services and
procedures.procedures. ID sources for supply of TX resources (e.g., ID sources for supply of TX resources (e.g.,
vaccines, immune globulin, antibiotics, vaccines, immune globulin, antibiotics, botulinum anti-toxin)botulinum anti-toxin)
Plan for efficient evaluation & discharge of Plan for efficient evaluation & discharge of patients (existing patients and incoming patients (existing patients and incoming victims.)victims.)
Triage & Management of Large Triage & Management of Large Scale Exposures / Suspected Scale Exposures / Suspected
ExposuresExposures
Determine availability & sources for Determine availability & sources for additional medical equipment & additional medical equipment & supplies.supplies.
Plan for allocation or re-allocation of Plan for allocation or re-allocation of scarce equipment. scarce equipment.
ID ability to manage a sudden ID ability to manage a sudden increase in the number of cadavers on increase in the number of cadavers on site.site.
Psychological aspects of Psychological aspects of bioterrorismbioterrorism
Following a Following a bioterrorism-bioterrorism-related event, related event, fear & panic can fear & panic can be expected from be expected from both patients and both patients and healthcare healthcare providers.providers.
Strategies to address fearsStrategies to address fears
Patient & general Patient & general public fearspublic fears– Explain risks, offering Explain risks, offering
careful but rapid careful but rapid treatment and support.treatment and support.
– Treat anxiety in Treat anxiety in unexposed persons unexposed persons who experience who experience somatic symptoms.somatic symptoms.
Healthcare worker Healthcare worker fearsfears– Provide Bioterrorism Provide Bioterrorism
readiness training.readiness training.– Invite active, Invite active,
involvement in the involvement in the bioterrorism readiness bioterrorism readiness planning process.planning process.
– Encourage Encourage participation in participation in disaster drills. disaster drills.
Laboratory Support & Laboratory Support & ConfirmationConfirmation
Obtain diagnostic Obtain diagnostic samplessamples
Lab criteria for Lab criteria for processing processing potential potential bioterrorism agentsbioterrorism agents
Transport Transport requirementsrequirements
Laboratory Criteria for Processing Laboratory Criteria for Processing Potential Bioterrorism Agents: Potential Bioterrorism Agents: 4 4
LevelsLevels
Level A:Level A: Clinical laboratories- Clinical laboratories-minimal identification of agents.minimal identification of agents.
Level B:Level B: County/State/ other County/State/ other labs- ID, confirmation, labs- ID, confirmation, susceptibility testing.susceptibility testing.
Laboratory Criteria for Processing Laboratory Criteria for Processing Potential Bioterrorism Agents: Potential Bioterrorism Agents: 4 4
LevelsLevels
Level C:Level C: State & other large facility State & other large facility labs with advanced capacity for labs with advanced capacity for testing-some molecular technologies.testing-some molecular technologies.
Level D:Level D: CDC or select Dept. of CDC or select Dept. of Defense labs-Bio Safety Level 3 & 4 Defense labs-Bio Safety Level 3 & 4 labs with special surge capacity & labs with special surge capacity & advanced molecular typing advanced molecular typing techniques.techniques.
Transport RequirementsTransport Requirements Must be coordinated Must be coordinated
with local & state with local & state health departments health departments & the FBI.& the FBI.
A chain of custody A chain of custody document should document should accompany the accompany the specimen from the specimen from the moment of moment of collection.collection.
Patient, Visitor, & Public Patient, Visitor, & Public Info.Info.
Methods & channels Methods & channels of communication of communication used to inform used to inform public should be public should be planned in advance.planned in advance.
Decide how Decide how communication & communication & action across action across agencies will be agencies will be accomplished accomplished (ICS!)(ICS!)
AnthraxAnthrax
Description of Agent/SyndromeDescription of Agent/Syndrome Preventive MeasuresPreventive Measures Infection Control Practices for Infection Control Practices for
Patient ManagementPatient Management Post Exposure ManagementPost Exposure Management Laboratory Support & ConfirmationLaboratory Support & Confirmation Patient, Visitor & Public InformationPatient, Visitor & Public Information
Description of Description of AnthraxAnthrax
EtiologyEtiology Clinical FeaturesClinical Features Modes of Modes of
transmissiontransmission Incubation PeriodIncubation Period Period of Period of
CommunicabilityCommunicability
Preventive Measures: Preventive Measures: AnthraxAnthrax
A: Vaccine A: Vaccine availability- limited availability- limited
B: Immunization B: Immunization recommendations-recommendations-administered to administered to select military select military personnel. No personnel. No routine vaccination routine vaccination of civilians .of civilians .
Infection Control Practices Infection Control Practices for Patient Management: for Patient Management:
AnthraxAnthrax
Isolation PrecautionsIsolation Precautions Patient PlacementPatient Placement Patient TransportPatient Transport Cleaning EquipmentCleaning Equipment DischargeDischarge Post-mortem CarePost-mortem Care
Post Exposure Management:Post Exposure Management: AnthraxAnthrax
Decontamination of Decontamination of Patient/EnvironmenPatient/Environmentt– Contaminated Contaminated
clothing should be clothing should be removed.removed.
– Shower with soap & Shower with soap & water.water.
– Decontaminate Decontaminate surfaces with surfaces with approved solution.approved solution.
Prophylaxis & Prophylaxis & Post-exposure Post-exposure ImmunizationImmunization– Recommendations Recommendations
are subject to are subject to change.change.
– Should be initiated Should be initiated upon confirmation upon confirmation of an anthrax of an anthrax exposure.exposure.
Post Exposure Post Exposure Management (cont’d)Management (cont’d)
Triage & management of large Triage & management of large scale: advance planning should scale: advance planning should include ID ofinclude ID of– Sources of prophylactic antibioticsSources of prophylactic antibiotics– Location, personnel needs & protocols for Location, personnel needs & protocols for
administering prophylactic post-exposure administering prophylactic post-exposure care to large number of individualscare to large number of individuals
– Follow-up information & other public Follow-up information & other public communication services.communication services.
– How to obtain additional ventilatorsHow to obtain additional ventilators
Laboratory Support & Laboratory Support & Confirmation: Confirmation: AnthraxAnthrax
A: Diagnositc A: Diagnositc SamplesSamples
B: Laboratory B: Laboratory selectionselection
C: Transportation C: Transportation requirementsrequirements
Patient, Visitor & Public Patient, Visitor & Public Information: Information: AnthraxAnthrax
Fact sheets should be prepared to Fact sheets should be prepared to explain: explain: – that people recently exposed are that people recently exposed are notnot
contagious & antibiotics are available contagious & antibiotics are available for prophylactic therapy along with the for prophylactic therapy along with the anthrax vaccine.anthrax vaccine.
– Dosing information with side effects Dosing information with side effects should be explained clearlyshould be explained clearly
– Decontamination proceduresDecontamination procedures
BotulismBotulism
Description of Agent/SyndromeDescription of Agent/Syndrome Preventive MeasuresPreventive Measures Infection Control Practices for Infection Control Practices for
Patient ManagementPatient Management Post Exposure ManagementPost Exposure Management Laboratory Support & ConfirmationLaboratory Support & Confirmation Patient, Visitor & Public InformationPatient, Visitor & Public Information
Description of Description of BotulismBotulism
EtiologyEtiology Clinical FeaturesClinical Features Mode of TransmissionMode of Transmission Incubation PeriodIncubation Period Period of CommunicabilityPeriod of Communicability
Prevention Measures: Prevention Measures: BotulismBotulism
A: Vaccine availabilityA: Vaccine availability B: Immunization B: Immunization
RecommendationRecommendation
Infection Control Practices Infection Control Practices for Patient Management: for Patient Management:
BotulismBotulism
Isolation PrecautionsIsolation Precautions Patient PlacementPatient Placement Patient TransportPatient Transport Cleaning EquipmentCleaning Equipment Discharge ManagementDischarge Management Post-mortem CarePost-mortem Care
Post Exposure Post Exposure Management: Management: BotulismBotulism
A: Decontamination of A: Decontamination of patients/environmentpatients/environment
B: Prophylaxis & post-exposure B: Prophylaxis & post-exposure immunizationimmunization
C: Triage & management of large C: Triage & management of large scale exposures/potential scale exposures/potential exposuresexposures
Laboratory Support & Laboratory Support & Confirmation: Confirmation: BotulismBotulism
Diagnostic SamplesDiagnostic Samples – a.) limited value in diagnosis of botulism a.) limited value in diagnosis of botulism – b.) detection is possible from serum, stool or b.) detection is possible from serum, stool or
gastric secretionsgastric secretions
Laboratory SelectionLaboratory Selection - handling - handling coordinated with local & state health coordinated with local & state health departments & the FBIdepartments & the FBI
Transport RequirementsTransport Requirements - chain of - chain of custody document should accompany the custody document should accompany the specimen from the moment of collection.specimen from the moment of collection.
Fact sheets should be prepared, including: Fact sheets should be prepared, including: Emphasis botulism toxin is not contagious person-personEmphasis botulism toxin is not contagious person-person Clear description of symptomsClear description of symptoms Instructions to reportInstructions to report
for evaluation if symptomsfor evaluation if symptoms
developdevelop
Patient, Visitor & Public Patient, Visitor & Public Information: Information: BotulismBotulism
SmallpoxSmallpox
Description of Agent/SyndromeDescription of Agent/Syndrome Preventive MeasuresPreventive Measures Infection Control Practices for Infection Control Practices for
Patient ManagementPatient Management Post Exposure ManagementPost Exposure Management Laboratory Support & ConfirmationLaboratory Support & Confirmation Patient, Visitor, & Public InformationPatient, Visitor, & Public Information
Description of Description of SmallpoxSmallpox & & Preventive MeasuresPreventive Measures
EtiologyEtiology Clinical FeaturesClinical Features Mode of Mode of
TransmissionTransmission Incubation PeriodIncubation Period Period of Period of
CommunicabilityCommunicability
Vaccine Vaccine AvailabilityAvailability
Immunization Immunization RecommendationRecommendationss
Infection Control Practices for Infection Control Practices for Patient Management:Patient Management:
SmallpoxSmallpox
Isolation PrecautionsIsolation Precautions Patient PlacementPatient Placement Patient TransportPatient Transport Cleaning, disinfection, & Cleaning, disinfection, &
sterilization of equipment & sterilization of equipment & environmentenvironment
Post-mortem CarePost-mortem Care
Post-Exposure Management & Post-Exposure Management & Laboratory Support & Laboratory Support &
ConfirmationConfirmation
Decontamination of Decontamination of patients & patients & environmentenvironment
Prophylaxis & post-Prophylaxis & post-exposure exposure immunizationimmunization
Triage & Triage & Management of Management of large scale large scale exposureexposure
Diagnostic Diagnostic Sample Sample
Laboratory Laboratory SelectionSelection
Transport Transport RequirementsRequirements
Patient, Visitor & Public Patient, Visitor & Public Information: Information: SmallpoxSmallpox
Fact sheets should Fact sheets should include:include:– clear description of clear description of
symptomssymptoms– where to report for where to report for
evaluation & care if evaluation & care if such symptoms are such symptoms are recognized.recognized.
– details of type & details of type & duration of isolation duration of isolation
IN Summary...IN Summary...
INVITATIONAL FORUM on HOSPITAL INVITATIONAL FORUM on HOSPITAL PREPARENESS for MASS CASUALTIESPREPARENESS for MASS CASUALTIES – Chicago, March 2000 by AHAChicago, March 2000 by AHA– Attendees Grouped Needs into FOUR Broad Attendees Grouped Needs into FOUR Broad
CategoriesCategories: : Community Wide PreparednessCommunity Wide Preparedness StaffingStaffing CommunicationsCommunications Public PolicyPublic Policy
Community Wide Community Wide PreparednessPreparedness
SUSTAINED Demand to be SUSTAINED Demand to be expectedexpected
Hospital Viewed as VITAL Hospital Viewed as VITAL RESOURCE with 24/7 RESOURCE with 24/7 capabilitiescapabilities
Prior Hospital Preparedness Prior Hospital Preparedness focused on narrow band of focused on narrow band of disasterdisaster
Planning usually has not Planning usually has not factored in “hospital as factored in “hospital as victim”victim”
REALISTIC Response not REALISTIC Response not necessarily being necessarily being addressedaddressed
STAFFINGSTAFFING RESERVE STAFFRESERVE STAFF
– retiredretired– career changedcareer changed– adminadmin– QUIT duplicating QUIT duplicating
count (e.g., temp)count (e.g., temp) TEMPORARY TEMPORARY
PRIVILEGESPRIVILEGES– Licensure Licensure – CredentialingCredentialing
COMMUNICATIONSCOMMUNICATIONS Backup and Backup and
RedundantRedundant
Regular Briefings Regular Briefings for Press and Mediafor Press and Media
Community Wide Community Wide Systems for Patient Systems for Patient Location with Single Location with Single POCPOC
PUBLIC POLICYPUBLIC POLICY
There must be vehicle for moniesThere must be vehicle for monies– Frist-Kennedy legislationFrist-Kennedy legislation– Stafford Act, FEMA Stafford Act, FEMA
Approach should be understood as Approach should be understood as GENERAL strengthening of system GENERAL strengthening of system for any disaster responsefor any disaster response