Pandemic Preparedness. Terri Rebmann, PhD, RN, CIC Associate Professor

Transcription

1 Pandemic Preparedness Terri Rebmann, PhD, RN, CIC Associate Professor

2 Objectives Describe impact of past pandemics Describe evidence-based recommendations related to infection prevention in EM for various healthcare settings Identify how to assess healthcare agency pandemic plans

3 Disasters are increasing

4 Chem terrorism Earthquake Flood BT or EI involving a non-contagious agent BT or EI involving a contagious agent All disasters can have an impact on infection transmission Type of disaster

5 Impact of SARS & H1N1 SARS 8,096 cases 774 deaths 9.6% mortality 44% of cases occurred in HCWs H1N1 214 countries affected million cases in U.S. 8,900 18,300 deaths in U.S.

6 341 pediatric deaths in US ~ 3 times the annual rate

7 Natural Disasters Shelters during Hurricane Katrina Food safety at the Pentagon

8 Potential Future Impact of Pandemic Potential for high morb & mort Costs: $71 - $166 billion 865, million hospital stays

9 Pandemic National and global event Difficult to get outside help Longer event than other disasters Wave: 6 12 weeks High absenteeism rate (>40%) Sick HCWs may contribute to the outbreak

10 Evidence-Based Interventions for Disaster Preparedness Healthcare agencies need EM plan Most agencies have a plan 100% of U.S. hospitals have plan (Niska, 2011) 87% of U.S. home health agencies have pandemic plan (Rebmann, 2011) Nursing homes not as prepared 52% do not have pandemic plan (Smith, 08)

11 Need to Move Beyond Having a Plan: Exercises/Drills Few agencies using IDD scenarios 58.5% of hospitals (Niska, 2011) 30% test med distribution to staff 50% of HH agencies (Rebmann, et al, 2011) 6% of nursing homes (Smith, 2008) Moulaged smallpox patient to test hospital bioterrorism plans

12 Surge Capacity Surge capacity is lacking: 74% of hosp have surge plan (Niska, 2011) Amount of surge capacity not specified 65% of home health agencies have surge capacity (Rebmann, et al., 2011) 37% of nursing homes have surge capacity (Smith, 2008) Need U.S. standards regarding min. surge capacity Israeli hospitals: 20% surge capacity

13 Supply Surge Capacity Lacking Hospitals: 36.3% stockpiling vents 50.1% have 7 days of N95s 46% stockpiled masks Nursing homes 50% stockpiling any supplies 11% stockpiled N95s

14 Supply Surge Capacity Lack of PPE during H1N1 pandemic 65% of U.S. hospitals reported adequate N-95s (Lautenbach, et al, 2010) Early in the pandemic Hospitals received insufficient or wrong type of supplies from stockpiles (Rebmann, et al, 2011) All size small or wrong brand More fit-testing

15 PPE Estimates for Planning & Stockpiling Category of Staff Respirator Gown (disposable) Gloves (disposable) Goggles Little to no exposure 1 disposable per contact/exposure 1 per exposure 1 per contact None Prolonged exposure Infrequent exposure(s) 1 reusable per outbreak (plus 2 cartridges/month*) 1 reusable per outbreak (plus 2 cartridges/month*) 1 per exposure 1 per contact 1 per outbreak 1 per shift 1 per contact 1 per outbreak *Disposable respiratory cartridges are needed for reusable respirators. Estimates provided for masks and other supplies in Radonovich et al. (2009)

16 Incorrect respirator removal Teach & observe staff for compliance with PPE 81% of U.S. hospitals trained staff on PPE use (Morton, 2009) Correct

17 Hard to be compliant with infection prevention over long periods of time

18 Extending the Use/ Reusing Respirators APIC Guidance APIC website

19 Respirator Compliance/Tolerance 2010 study with HCWs 87% reported expected intolerance to N95 for 8 hr shift (Baig, 2010) 30% report difficulty breathing 56% report increased facial heat 11% report it interferes with pt care Studies from NIOSH indicate that C0 2 & O 2 are not negatively affected

20 Respirator Decontamination Decontamination of N95s would allow longer-term & safe use Many decon strategies being tested Some strategies make N95s unusable (Viscusi, 2009)

21 Microwave-generated steam (MGS) [2 min] Causes slight separation of nose foam from N95 Left trace amts of viable virus Warm moist heat (WMH) [30 min] Virus below detection limit Ultraviolet germicidal irradiation (UVGI) [15 min] Left trace amts of viable virus Heimbach, et al. (2011)

22 Medication Surge Capacity Insufficient amount of medication 31% U.S. hospitals reported shortage in anti-virals during H1N1 (Lautenbach, et al, 2010) Only 11% of home health agencies have med stockpile (Rebmann, et al., 2011) 6% of nursing homes stockpiling medication (Smith, et al, 2008) Not enough pediatric doses

23 Pre-Exposure Prophylaxis for HCWs US DHHS recommendation Provide pre-exp prophylaxis throughout each pandemic wave High risk HCWs & emergency responders 10.7 million individuals Preferred over PEP How will we meet this recommendation?

24 Screening & Triage Best Practices Need screening and triage plan 65% of U.S. hospitals have plan (Morton, 2009) Best to use HCW or train well Student screeners used during SARS outbreak in Canada Picture source: Jennie Mayfield

25 Screening Set up outside, if possible Otherwise right inside entrance Lock off other entrances Screening outside of healthcare facility Picture source: Jennie Mayfield

26 Have hand hygiene products at triage area

27 Staff Screening Frequency during infectious disease disaster: - Formal screening before each shift - Report symptoms between shifts Consider separate entrance Medically evaluate sick staff or send home Picture source: Jennie Mayfield

28 Formal Screening Most likely IDDs only Disease/event specific Add avian flu symptoms during pandemic

29 Isolation During Disasters Disease known: Follow HICPAC Undiagnosed: transmission based precautions Symptoms Isolation Precautions Needed Cough, runny nose, watery eyes = Standard Fever & cough (adults) = Droplet Fever & cough (kids) = Droplet & Contact Fever, cough, bloody sputum, & wt loss = Airborne Eye infection or drainage = Standard

30 Better to over-isolate SARS Outbreak in Canada Infected person 10 HCW s infected per day that infected case was not identified & isolated

31 H1N1 in = Symptomatic for ILI NYC* 26 H1N1 pts associated with 277 unprotected staff exposures *Banach, et al., 2011

32 Improvised Isolation (Non-Neg Pressure) Lack of isolation room/area surge in US & Canada (Rebmann, 2009; O Sullivan, 2008) Put PPE for staff outside of room/area Post isolation sign Improvised PPE cart Picture source: Jennie Mayfield

33 Improvised Isolation Area Improvising isolation area Physically separate the pt Building or area outside can be used Best if room/area has walls & a door Makeshift walls/doors Plastic or other barrier material Hang isolation sign near entrance

34 Need Negative Pressure Surge Capacity

35 Airborne Isolation in Ambulatory Care Center Hospital better Bronchoscopy room may be AIIR Improvise negative pressure Temporary negative pressure rooms/areas used in Toronto during SARS Picture source: Jennie Mayfield

36 Use Social Distancing Principles 3 feet 3 feet Bed/stretcher/cot configuration in surge areas

37 Occupational Health Policies Employee health info lacking during H1N1 pandemic (Rebmann, 2009) Flexible sick leave policy for disasters Staff prior. plan for anti-infective tx 46% of U.S. hospitals have emp health plan r/t working when ill (Morton, 2009)

38 SARS Outbreak in Taiwan Infected laundry worker 137 Secondary Cases

39 Animal Management Only service animals allowed in Coordinate with community disaster planners for emergency pet kennels Encourage staff to have disaster plan that includes pet care Photo courtesy of FEMA

40 New Pandemic Planning Documents

41 New Pandemic Planning Documents

42 Hospital Preparedness What should be in a hospital disaster plan r/t infection prevention? Rebmann, T. (2009). Assessing hospital emergency management plans: A guide for infection preventionists. American Journal of Infection Control, 37(9), e4.

43 Home Health Agency Preparedness Rebmann, T., et al. (in press). Assessing the infection prevention components of home health emergency management plans. American Journal of Infection Control.

44 Talk to Staff about Having a Personal/Family Disaster Plan 50% of U.S. IPs have plan (Rebmann 2009) 75% of U.S. HH nurses have plan (Rebmann, 2011) Websites: FEMA Red Cross CDC

45 Major Gaps in Preparedness Increase surge capacity in all areas of healthcare Supplies, bed, personnel Preparedness for non-hospital settings

46 Contact Me Terri Rebmann, PhD, RN, CIC Associate Professor Institute for Biosecurity Saint Louis University, School of Public Health 3545 Lafayette Room 463 St Louis, MO Phone: (314) Fax: (314) Website: