Infection control

By Robert Neil

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As the threat of a potential influenza pandemic looms, some experts warn that the health care community will need to go far beyond President Bush’s general appeal for planning. Some argue that without a coordinated, standardized and nationwide initiative there could be sporadic shortages of essential supplies in hospitals while vendors and distributors try to keep pace with demand. Meanwhile, guidelines from HHS offer direction on areas that hospitals need to prepare to address.

President Bush’s call to prepare for a potential influenza pandemic placed the nation’s health care system in the spotlight, and in particular, hospitals, which carry the burden of being ready to treat as well as help prevent the spread of a deadly virus. Infection control professionals, key players in protecting communities, say the president’s plan is a good first step, but more information is needed.

“We generally applaud the president and the administration for recognizing the imminent threat of pandemic influenza and taking significant steps toward preparedness,” says Kathy L. Warye, executive director of the Association for Professionals in Infection Control and Epidemiology (APIC), Washington, D.C. “The fact that our government is being proactive in addressing this threat, rather than reactive, is very positive to us.”

APIC also is pleased that the president’s plan, which has a medical and public health component written by HHS, includes strategies covering supplies that go beyond the need for antivirals and vaccines. Although a viral pandemic would obviously require health care providers to have access to a large stockpile of those types of drugs, basic medical supplies also would be needed, Warye says.

Front-line medical workers would need special items to protect themselves against contracting the virus from a patient. Therefore, an abundant supply of masks, gowns, gloves and other such items would need to be stockpiled as well. “The plan advises hospitals to have eight weeks’ worth of supplies, which is significantly greater than the three-day supply hospitals currently keep on hand,” Warye says.

It’s hard to say how soon manufacturers of medical supplies and pharmaceuticals might be able to produce and distribute the goods that would satisfy an eight-week supply at every U.S. hospital were a pandemic to strike.

The HHS portion of the plan asks hospitals to “review and update inventories of supplies that will be in high demand during an influenza pandemic.”  Warye, however, says that more specific information is needed because standardized planning is essential in battling a virus of this nature.

Beyond the treatment

Without a standard guide for supplies, every hospital, or community of hospitals, could potentially determine different sets of products that would be needed in the event of a viral outbreak.

Warye hopes the strong attention the media and others are paying to drugs that can fight a possible avian flu pandemic won’t overshadow the need for other medical supplies that are just as essential.

“I don’t know that anyone yet has focused on the need for things like ventilators or injection devices. We will need significantly greater numbers of those critical medical devices in the event of a pandemic,” she says.

Kathi Pressley, the director of materials management at Olympic Medical Center, Port Angeles, Wash., has concerns about the same issues.

Her facility is in the early stages of determining what services would be affected by a pandemic and what products would be required that aren’t already part of normal disaster protocols.

To make an effective plan she, as well as materials managers around the country, will need to determine the capabilities of her supply partners. She’s also obligated to help with contingency plans to address the possibility of a supply shortage, and under those circumstances, hard choices would have to be made.

A shortage of surgical masks, for example, might force a hospital to use linen to make emergency masks, she says. “That’s not something infection control wants to hear, but there has to be a backup plan,” Pressley says.

Although most health care experts believe the biggest pandemic threat, avian flu, is at least a year away from having a chance of reaching the United States, hospitals need to have plans and backup plans in place soon, says, Francesca Torriani, M.D., director of the infection control and epidemiology unit at the University of California, San Diego (UCSD), Medical Center.

Plan for payoff

If an epidemic hits, it would be too late to start calling suppliers and expect that orders could be filled in time. Once a problem of that magnitude occurs, suppliers could be overwhelmed with calls.  Facilities with better existing plans will have an easier time meeting the requirements of the president’s pandemic plan, she says.

Specifically, HHS says hospitals will be responsible for developing a planning structure capable of responding to pandemic influenza. Such a plan needs to cover the following areas:

• A written strategy that addresses disease surveillance
• Hospital communications
• Education and training
• Triage and clinical evaluation
• Facility access
• Occupational health
• Use and administration of vaccines and antiviral drugs
• Surge capacity
• Supply chain and access to critical inventory needs
• Mortuary issues
• Participation in pandemic influenza response exercises and drills
• Incorporation of lessons learned into response plans.

Torriani believes San Diego County may be as well prepared for a pandemic as any place in the country. Hospitals in the region have worked with local and state health agencies since 9/11 to develop a communitywide response to a large-scale event. As a result, key hospital personnel from various departments communicate with their counterparts at other facilities on a regular basis.

Torriani and other members of UCSD’s infection control department discuss surveillance strategies, worst-case scenario plans, surge capacity and other essential issues that could come into play in the event of a pandemic.

“We have a multihospital commission where we meet with the county officer and the different hospital people in emergency preparedness, and we strategize about how we would modify the county plan to our hospitals,” Torriani says.

Although the United States hasn’t had to face a pandemic in decades—flu epidemics were responsible for millions of deaths in 1918, 1957 and 1968—hospitals and infection control professionals have learned lessons from the more recent past.

History lessons

Preparation leading up to Y2K, the 9/11 attacks in 2001, an outbreak in Toronto of severe acute respiratory syndrome (SARS) in 2003 and the aftermath of Hurricane Katrina in 2005 have all provided lessons about how health care should prepare for a disaster.

“SARS was really the wake-up call in terms of how to think about a pandemic or epidemic situation,” Torriani says. “It really helped us model our plan.”

Of the 358 confirmed SARS cases that occurred in Toronto, 70 percent were contracted while in hospitals. That figure included a number of medical and support staff who contracted the virus, which spread rapidly before it was identified and infection control measures were put into place. A total of 38 deaths are attributed to the Toronto outbreak, but Canadian health care officials say the epidemic could have been much worse if infection control strategies hadn’t been implemented when they were. Infection control professionals have had many opportunities to study the details, and the industry has presented numerous papers and reports on the subject because the outbreak presents a modern-day example of how to deal with a viral pandemic, Torriani says.

Although a number of comparisons to avian flu have been made to the 1918 and 1957 influenza outbreaks in America, Torriani says SARS may provide a better study example, because it deals with technology, practices and industry standards that didn’t exist in the past.

The lesson learned from Katrina was that hospitals and communities need to be more self-sufficient than previously thought, and part of that thinking is reflected in HHS’ call for hospitals to have eight days’ worth of supplies. However, in light of events that occurred after Hurricane Katrina, calculating how long a hospital’s stockpile of supplies will last isn’t a simple matter, says Sue Sebazco, R.N., an infection control professional and president of APIC. She was in the Dallas area when victims from Katrina were brought in, and she saw firsthand that supply stocks can be depleted quickly. Not only was it unclear how many patients would need treatment, but also the local health department was asking some hospitals for supplies. So, even if hospitals are able to get all the supplies they need to care for patients, there still could be supply shortages if health departments are not fully prepared, she says.

Responding as one

Planning to battle a pandemic is clearly a community issue, not a single hospital issue. Since 9/11, the threat of a bioterrorism attack has brought more infection control professionals into disaster planning. Nevertheless, there are places where hospitals and community leaders are working on disaster planning without including infection control professionals in the conversation.

“Sometimes we’re not even aware that some of those meetings are going on—and we could bring value to the table,” Sebazco says. “There’s a definite recognition that an infection control professional needs to be present, but I’m not sure they are included when they need to be.” During any dialogue about responding to a threat like a pandemic flu, it’s essential that infection control professionals be involved, she says, because they understand the transmission of disease and how to protect both the public and health care workers. Under any circumstances—especially in light of the plan for a possible pandemic—it would be helpful for hospitals to have more robust infection control staffing. The guide for the industry in the past has been to have a ratio of one infection control professional for every 250 beds, but APIC released a study in 2000 that found a better relation would be 1:100.

“Now, one of the challenges we face,” Sebazco says, “is trying to get our health care administrators to recognize how we can do a better job with more resources.”

Attaining the proper ratio of infection control professionals is just one of the things the health care industry needs to consider as the president’s plan to deal with a pandemic begins to take shape.

HHS Secretary Mike Leavitt says the country is in the early stages of preparation, and coordination plans are still being assembled. A series of in-state, pandemic-planning summits will take place in every state over the next several months. The meetings are designed to help the public health and emergency response communities have blunt discussions on practical strategies that take into consideration political, economic and community leadership issues.

Despite those plans, there’s still debate on whether the nation will be adequately prepared for a pandemic flu that could infect as many as 25 percent of the population. Hospitals need to work to ensure they’re as prepared as possible, and that will require a great deal of communication and coordination with supply partners, local health care agencies and state and federal officials, Sebazco says.

“We have to have a structure in place that’s prepared to deal with any sort of emergency or disaster that comes our way,” she says.  

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