Ebola plus one: Lessons to learn, actions to take

By Martie Moore | 12/03/2015

A year after the 2014 outbreak, the author reflects and looks ahead.


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It gets the attention of a chief nursing officer to receive a phone call informing him or her that the hospital is activating the incident command center and be told, “This is not a drill!” In my career, I have dealt with fires, floods, patient surges, shootings, and other emergency events that make the evening news.
 
Moore_Martie_ID_embed_SFWTo prepare for such disasters, organizations must regularly simulate and train for them. This emergency preparedness training takes those who will run the incident command center through pragmatic processes that enable them to bring order from chaos and move the organization forward despite unusual circumstances. In 2003, the U.S. Department of Homeland Security introduced the National Incident Management System (NIMS), a systematic, proactive approach that helps organizational leaders—such as those in hospitals—effectively manage incidents that involve threats and hazards.
 
Questions and polarization
The emergence of Ebola within the U.S. health system in the latter part of 2014 called the nation’s hospital preparedness into question. Were health care personnel adequately trained and ready for emergent crises such as a pandemic or an act of bioterrorism? Almost immediately, opinions were polarized. Suddenly, donning and doffing of personal protective equipment (PPE) became a media hot topic, and many health care providers commented that they did not feel adequately trained on the correct processes to avoid contamination. Hospitals quickly set about securing proper supplies and rapidly training teams to be ready to receive patients who might be infected with Ebola. As understanding of the disease grew, designated centers were proposed and established to care for and manage individuals infected with the virus.
 
Lost in the complexity of the nation’s coming to terms with this highly infectious disease was recognition that hospitals were attempting to approach their response to Ebola in a way that was similar to how they manage other disasters. As depicted in the “Disaster Cycle” graphic below (published by the U.S. Department of Health & Human Services Office of the Assistant Secretary for Preparedness and Response), hospitals responded rapidly, mobilized resources, developed readiness plans, and assured their communities they were ready to care for them. And as the crisis subsided, affected organizations moved back toward equilibrium.
 
Moore_Disaster Cycle
Click here for larger image.
Source: http://www.phe.gov/preparedness/planning/hpp/reports/
documents/capabilities.pdf
 Used with permission.

Not disaster as usual
The call to action to combat infectious diseases, however, is not to move back to normal operations, because management of infectious diseases should not be approached in the same manner as other disasters. We may have more outbreaks of infectious disease—diseases far more deadly than Ebola. In the United States alone, influenza and pneumonia kill nearly 57,000 people yearly, significantly more than the 11,314 deaths in 19 months worldwide associated with the recent Ebola outbreak. The call to action in managing infectious disease, in other words, is to move organizations not to a cyclic approach but to a perpetual state of readiness.
 
We currently have two systems of emergency management: normal operations for infectious disease, which utilize a surveillance-and-prevention management system, and the disaster management system. Both systems strive to assist organizations in maintaining or regaining control. Both objectives are important, but when it comes to managing infectious disease, we need to merge the two mindsets. The sense of urgency that is felt and the resources that are mobilized in response to disasters also need to be utilized in our approach to infectious disease. Ebola showed us that, while we are comfortable with our routines, our routines do not meet the needs of today’s environment.
 
Simulation reveals reality
What actions should we take? A recent study published in JAMA Internal Medicine found that contamination of the skin and clothing of health care personnel occurs frequently during removal of contaminated gloves or gowns. Educational interventions that involve removal of PPE and provide immediate visual feedback about skin and clothing contamination during such removal lead to improvement in technique. The study used simulation to reveal practice variations and breaks in processes.
 
Why simulation? Simulation hardwires behaviors. The old adage “practice makes perfect” has validity when applied to the situation facing health care today. Trauma teams, sports teams, NASCAR pit crews, NASA, and nuclear reactor management teams all understand the value of practice and simulation to assure highest-level performance of both teams and individuals. Although simulation drills are commonly used to train for disaster management, simulation has only been dabbled with when it comes to infectious disease programs, specifically those that involve hand-hygiene feedback.
 
In disaster management, simulation resources are allocated to high performing groups to assure a perpetual sense of readiness. In health care, however, resources are often limited, and there are conflicting priorities. One approach is to expand resources allocated for disaster drills to include infectious disease outbreaks within the hospital and community. Using drills, the organizational system can be pushed to expose potential points of failure.
 
Hardwire for “next Ebola”
Organizations need to drill not once, but repeatedly—as the term “drill” suggests—to create hardwired behaviors within teams. Through repetitive training, stressors, such as unknown infectious diseases, should be introduced to test participant knowledge and use of PPE. Surveillance mechanisms, such as fluorescent testing methodology, should be utilized to observe containment processes and possible exposures and breaks in the response system.
 
To reinforce organizational readiness, activities should be performed at both macro and micro levels. Charge nurses can utilize huddles during a “spontaneous” PPE donning and doffing practice that includes observation by team members. For example, mark areas with highest likelihood of possible contamination with black X’s, and watch how many times there is cross-contamination. Shift huddles can focus on known and suspected infections within a care setting to assure that the team uses best practices for containment.
 
To further augment emergency response preparedness, organizations should empower health care workers to take online courses. For example, at Medline Industries—where I am chief nursing officer—some 40,000 such courses are taken monthly by health care professionals through Medline University.
 
As we move forward to face whatever the “next Ebola” will be, we need to ensure that we are ready for whatever comes. Walk through situations and simulations constantly and consistently, not only to hardwire responses but to ensure that all staff members are educated regardless of turnover. Don’t just train for today. Train for tomorrow and every day after that, so that no matter what comes in the door next, you’ll be ready to meet it head on. RNL
 
Martie L. Moore, MAOM, RN, CPHQ, is chief nursing officer at Medline Industries, Inc., a manufacturer and distributor of medical supplies and clinical solutions. In addition to membership in the Honor Society of Nursing, Sigma Theta Tau International, American Organization of Nurse Executives, and National Association for Healthcare Quality, she represents Medline on the Corporate Advisory Council of the National Pressure Ulcer Advisory Panel and the Corporate Advisory Board of the American Nurses Foundation, the philanthropic arm of the American Nurses Association.
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