Mark A. Hastings spends the first 15 minutes of his day scanning email alerts and international news for reports of outbreaks and epidemics. After all, you never know when preparedness will pay off. In 2008, Hastings was looking through an infectious disease alert from the University of Pittsburgh reporting a novel swine flu in two kids in California.
“I just thought, this is really odd, because this is normally not the time of year,” says Hastings, director of emergency management, EMS and trauma coordinator for Southern NH Health System in Nashua. “I ran this by our infection prevention folks and they said, ‘It’s probably just a little quirk,’ and I said, ‘I think we should gear things up and keep watching,’ and within a few weeks it hit and the rest is history.” (See sidebar at the end of this article.)
Replace swine flu with Ebola, Norwegian scabies or Middle East Respiratory Syndrome (MERS) and you get the idea. Outbreaks are happening around the world all the time, and hospitals are constantly working to be prepared. Both Hastings and Antonia Altomare, an infectious disease physician and hospital epidemiologist at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, say they are always keeping an eye out for MERS since so many people in NH travel to and from the Middle East.
Hospital officials in NH are also watchful for news about Zika, and have helped get the word out to OBGYNs about potential birth defects the virus can cause in unborn children. The Zika virus, which is spread by mosquitoes, causes fever, rash, joint pain and conjunctivitis. It is usually mild with symptoms lasting for several days to a week, according to the CDC. “People usually don’t get sick enough to go to the hospital, and they very rarely die of Zika. For this reason, many people might not realize they have been infected. However, Zika virus infection during pregnancy can cause a serious birth defect,” the CDC states on its website.
Jose Montero, former NH director of public health and now vice president of population health and health system integration at Cheshire Medical Center/Dartmouth-Hitchcock Keene, says it is important to pay attention to Zika given the risk for congenital problems (microcephaly) for fetuses. “That said,” Montero continues, “At this time in New Hampshire, we don’t have any mosquitoes that have been identified as capable of transmitting this virus, so our local risk is low. For our population, the risk is related to travel to areas where active transmission is occurring.” He adds Zika can be transmitted through sexual contact.
Montero says that the state needs to remain engaged in surveillance. He says we must keep track of which mosquito species are present and if there is any evidence of local transmission. “We need to remember that this already happened when West Nile Virus was introduced to our country back in the late 90s,” he says.
Montero says that while planning is important for dealing with emerging diseases like Zika, early diagnosis and care is key.
“Normally ongoing infections and transmission of endemic diseases like influenza are more relevant for our internal emergency trainings and response,” Montero says. “On the national and worldwide horizon things such as Ebola are still important.”
Planning for Outbreaks
As it turns out, NH and all NH hospitals have emergency response and preparedness plans for a variety of threats, including disease outbreaks, says Rick Cricenti, director of the Emergency Services Unit for the NH Department of Health and Human Services. Cricenti says the State of NH, the NH Hospital Association and individual hospitals are all on the same page with regard to planning efforts. “Similar processes are followed, allowing for individual situations, but they are coordinated,” he says. “In an actual response, all activities would be coordinated between hospitals through mutual aid agreements and the Emergency Support Function for Health and Medical Services at the state level.”
Each hospital has a unique plan based on its location, available beds and specialization, but some common protocols include alerting the state and public to health threats, how to evacuate patients, when to use isolation units and when and how to mobilize an incident command team, says Darlene Saler, associate chief nursing officer for DHMC.
Even when there is no active threat, these teams of preppers across the state are tasked with keeping stockpiles of supplies, updating staff training and knowing the latest directives in massive emergency preparedness.
All this preparation takes both time and money. Hospitals receive state and federal funds to prepare for outbreaks based in large part on their size and the scope of potential outbreaks they are likely to treat. In NH, that tends to range from $7,500 or less for small hospitals up to a five-year $208,000 federal grant that Dartmouth-Hitchcock received when it was identified as an Ebola assessment hospital for epidemic preparedness. (Assessment hospitals must be able to receive and isolate a person under investigation for Ebola and provide up to 96 hours of care until an Ebola diagnosis can be confirmed or ruled out and until discharge or transfer is completed.)
Ready for Worst Case Scenarios
The state’s job in an emergency is to prevent the transmission of contagious disease and mitigate community impact, explains Montero. “So most of the time for most of these situations, we all operate as part of a system, a system where each one of us has a role.”
No hospital can work in isolation when there is an outbreak of a highly pathogenic condition, Montero says. But not all hospitals can respond exactly the same way to an outbreak either. “Clearly we have different levels of hospital complexity, and each hospital has a level that they can respond up to; they cannot do everything,” he says.
New Hampshire’s small hospitals, known as critical access hospitals, typically don’t have more than 25 beds, have small emergency rooms and don’t necessarily have a full emergency room staff all the time, Montero explains. “They cannot really isolate people in a long-term situation or even really fully isolate patients [at all],” he says.
Intermediate size hospitals, such as Cheshire Medical Center/Dartmouth-Hitchcock Keene, have more resources to better deal with an outbreak. “We actually have a really new emergency room where we have really good isolation rooms where we have negative pressure, where we can vent the air to the outside,” Montero says. “We don’t have the capacity to manage the patient in a long-term condition because we don’t have all the room, all of the capacity or even the clinical capacity to manage all those patients.”
And then there are more complex, large hospitals, like DHMC, that can handle most outbreak emergencies, although Saler points out even they can’t take an Ebola patient for long-term care. They are equipped and authorized to do initial testing and hold an Ebola patient until he or she is transferred to one of three hospitals in the country equipped to handle such a dangerous and highly contagious disease.
Hospitals develop and update plans based on data and lessons learned from specific outbreaks. The Ebola threat in Africa helped inform all hospitals as to what to do in case an Ebola patient walked through the doors, says Deborah Yeager, director of emergency preparedness for the NH Hospital Association. “When we went through that, all of the hospitals had to make sure that they had the right kind of protective equipment and that they had plans in place to route people through the hospital,” Yeager says. “We had to look at who would take care of them, who would draw their blood, who would take them in the ambulance, all of this very, very detailed work. And that’s what they would do for any emerging threat.”
Saler says an outbreak two years ago of Norwegian Scabies, a contagious skin rash caused by dermis-burrowing mites, at DHMC ultimately helped other hospitals in the state. She explains DHMC documented what worked, what didn’t and what they learned, and then shared that with Dartmouth-Hitchcock Manchester clinics and Catholic Medical Center when they experienced outbreaks.
In addition to written plans, there is constant training at the hospital and state levels. Montero says that no one knows when that contagious patient is going to walk into the emergency room and what disease he or she will be presenting. These trainings help to develop the right questions to start pinpointing the problem and to mitigate the risk of spread to other patients and staff.
Trainings also help get staff familiar with special equipment that might be necessary to use during an outbreak. Again, during the Ebola outbreak scare, Saler says, Dartmouth officials held several trainings for staff on how to don and take off protective equipment.
These trainings can be valuable for finding solutions before the situation is dire, she says. For example, it was through the donning and doffing practice that staff discovered it was next to impossible to actually communicate with patients through the thick and cumbersome full body personal protective equipment suits. So, they decided to write into the plan the use of some of the hospital’s telemedicine equipment, which would allow patients to communicate with a staff member standing on the other side of the door with an iPad.
In addition to these hospital specific trainings, the state and NH Hospital Association host drills where various disasters are recreated in order to give health-care workers practice going through a variety of protocols in a realistic scenario.
Hastings says constant planning and drills are important as it creates awareness. “With awareness comes improved responses to minimize the impact, such as getting pertinent travel information for someone presenting with symptoms consistent with MERS-CoV or a novel flu strain. In 2015, one person was improperly triaged by a hospital in South Korea, resulting in nearly 200 cases of MERS-CoV and 36 deaths. Many of these victims were hospital workers who were not well prepared,” he says.
Funding Preparedness
The federal government, through the CDC and the Assistant Secretary for Preparedness and Response (ASPR), which are both part of the U.S. Department of Health and Human Services, provides state funding for public health and hospital preparedness. Those funds are dispersed to state government agencies. In NH, the CDC funds go through the NH Department of Public Health, which contracts with several organizations for specific preparedness components. The ASPR funds go through the NH Hospital Association.
The State of NH, through its Hospital Preparedness Program and working with the NH Hospital Association, ensures all hospitals have the appropriate personal protective equipment available and that staff is trained to put on and take off such equipment.
Southern NH Health System and Cheshire Medical Center each received $7,500 from ASPR’s Hospital Preparedness Program this year. Significant funding from ASPR’s Hospital Preparedness Program started to flow not long after events such as 9/11 and Hurricane Katrina, Hastings says. “There were a couple of additional one-time allocations that came as a result of the H1N1 and Ebola events, which were somewhat helpful but not significant. The Feds have been cutting back on the ASPR funds,” he says, noting such grants come with a long list of requirements.
Decontamination training at Southern NH Health System in Nashua. Courtesy Photo.
“I’m not sure what is going to happen first: the funds drying up or hospitals refusing to participate in ASPR because it costs more to participate than what is received,” Hastings says. Still, he stresses Southern NH Health System will remain a key player in emergency preparedness with Greater Nashua and the state.
Cheshire budgeted $81,738 for emergency preparedness activities for FY 2016, such as education, training, travel, exercises, drills and supplies. That includes $7,500 from the Hospital Preparedness Program through the NH Hospital Association and $15,000 from state and federal agencies for Ebola preparedness to be used over five years.
DHMC received several state and federal grants in 2015 to support emergency services, including $20,000 from the state for emergency preparedness drills and to fund radio equipment to improve disaster communications, and the $208,000 federal grant.
Training for Disaster
A recent training in Nashua laid out a scenario where a category three storm hit NH, knocking out power and other infrastructure. Within a few days, a surge of patients start arriving showing symptoms of tularemia, a severe, infectious bacterial disease, Hastings says. As part of the scenario, participants were asked to consider the possibility that this is a bioterrorism attack.
While unlikely, the scenario, Hastings says, is designed to test as many systems and protocols as possible that are common to any disaster to look for weaknesses and areas of improvements. Such training scenarios are time consuming and expensive, although it is hard to pinpoint just how much such preparedness costs, according to the half dozen hospital officials interviewed.
“I don’t think it’s possible to calculate,” says Hastings. “[Southern NH Health System] has a very engaged senior management team who realizes the value of emergency preparedness, not just to the organization but also to the community.” He explains that emergency preparedness is a monthly agenda item with senior management and part of orientation for all new employees with a focus on the organization, the community and what staff should be doing at home. Further, he says, at least twice annually the hospital holds full-scale exercises involving dozens of staff members, including physicians, nurses, engineering, communication, marketing and management. Saler and Yeager also say it is difficult to calculate the cost of preparedness efforts and training.
Having the right equipment and training is only part of being prepared. Hospital epidemiologists, members of hospital infectious disease teams and emergency managers try to be ahead of emerging diseases and clusters of existing diseases around the world. Altomare at DHMC says she regularly checks for threats listed by the Centers for Disease Control on its website and receives daily and weekly alerts from local, regional, national and international health agencies. She also keeps tabs on international news for disease outbreaks.
“The first part of my job is to keep my eye on worldly and infectious disease so I can keep an eye on anything that might be coming our way,” she says.
When these issues arise, depending on the threat level, she might meet with members of DHMC’s emergency response team to review plans and supplies. And as co-chair of DHMC’s Readiness and Response to Epidemic Threats Committee, she shares her observations with that group, which meets monthly to review impending threats.
Committees like this act as a sort of liaison between state and federal health agencies, and epidemiologists often turn to them for guidance during a pending or actual emergency as well as for help when they run short on medication or supplies, Altomare says. When DHMC had its scabies outbreak, Altomare says the medical center did not have enough medication to treat the disease. “We don’t often have the drug on hand because that’s not something that occurs that often and pharmacies don’t stock a whole lot of it,” she says. “So we ended up pulling from all our local resources, including hospitals as far away as Boston, to try to send us what we needed in supplies.”
In addition to having a plan and point person in place when it comes to medication shortages, preparedness plans must also consider staffing during a disaster. This was relevant last year when a particularly bad strain of flu hit the region, Altomare says. “The vaccine [last year] didn’t quite match what the circulating virus was,” she says. “We had to deal with the fact that we had multiple outbreaks not only in patients but in work staff.”
Altomare says the hospital had to close beds and turn people away because it didn’t have enough staff after so many employees were sick. “From the staff perspective, the workforce was greatly diminished,” she says, as staff could not work for seven days after symptom onset due to being contagious. “So it took people out of work for a week, all staggered on different days. [The impact] was tremendous.”
The event triggered the incident command team, Altomare says, which helped to coordinate the hospital’s float staff—nurses and health care workers who move around the hospital to where they are needed. She adds that the hospital’s epidemic response plan lays out protocols and is tweaked when the hospital experiences a different disease.
“I think it’s very important that in all the systems and in all the buying of equipment and all the training and exercising that we don’t forget that we do it to protect patients,” Yeager says. “So it really comes down to the one individual that is cared for or evacuated safely. It’s really all about the patient. I think sometimes people lose sight of that.”
SIDEBAR:
Anatomy of an Epidemic
As a novel swine flu swept across the country in 2008, health care officials in NH prepared for the outbreak. “We began by participating in meetings with local and state public health officials reviewing screening and treatment guidance provided by CDC [Centers for Disease Control and Prevention] and WHO [World Health Organization],” sometimes meeting several times per week, says Mark Hastings, director of emergency management, EMS and trauma coordinator for Southern NH Health System in Nashua.
It ended up being a fast moving flu epidemic. Worldwide, millions contracted the flu with deaths estimated upwards of 575,000, Hastings says. In the United States, there were about 115,000 confirmed cases and 3,400 resulting deaths. Of those, there were under 1,000 confirmed cases in NH and 10 deaths.
When cases began developing closer to NH, Southern NH Health System gathered members of its Incident Management Team to set up screening and treatment criteria based on the constantly changing CDC and WHO guidance. “We also considered how to cohort these patients so as to not possibly infect other patients. So for example, since H1N1 hit the pediatric population fairly hard, we made plans to expand inpatient pediatric services to other locations within SNHMC,” Hastings says. “We also had to consider the possible changes in how we delivered care if the number of flu patients exceeded our capacity.” That could include implementing tactics used to combat the 1918 epidemic where schools and other large public buildings were turned into treatment centers.
Combating the Epidemic
At all Southern NH Health System locations, any patient presenting flu-like symptoms was isolated and tested. As there initially was no vaccine, staff wore protective masks, gowns and gloves.
The health system provided daily data about suspected cases to the Nashua Public Health Department. Once a vaccine was available, the Southern NH Health System vaccinated all staff involved in direct patient care, including fire, law enforcement and EMS personnel often in contact with patients.
The health system also engaged in a public relations and information effort that included all health care providers in the Greater Nashua region.“All staff understood the possible magnitude of the epidemic and responded very well,” Hastings says.
Among the lessons the health system learned was to make decisions locally versus waiting for guidance from state or federal public health officials, Hastings says. “As an example, we were sent a response plan template and told we should use it. It was poorly written and impractical. After reviewing it with our other local health care responders, we said no and collectively wrote our own,” he says.
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