Transcript The Emergency Department in the Post SARS era

The Emergency
Department in the Post
SARS era
Peter Cameron
Previously
Prince of Wales Hospital
Chinese University of Hong Kong
Emergency Department First line
-The Problem
• Ability of ED to identify Potential high risk patients
– SARS demonstrated that non specific features most common
• EDs Poorly constructed to manage an Infectious
Disease Outbreak
• Processes within ED increase risk
• Staff not good at basic ID control procedures
• Balance between high volume service commitments
and potential risk
ED as first line
• Communication with hospital
• Communication with community
• Communication with region
SARS
It is not ”Severe”
Or “Acute”
Or “Respiratory”
At the outset
Front line experience with SARS
• ICU and Ward healthcare workers more at risk
than ED
• Cross infection amongst patients was less than
expected
• Despite high risk environment many HCWs did
not follow guidelines
• Virtually all hospital infections could have been
prevented by basic infection control
Staff getting sicker
Future Potential Risk
• SARS could come back
• Other infectious disease outbreaks could occur
– Most likely Influenza
• Routine presentations(eg TB,gastro) put
patients/staff at risk
• Therefore at a staff health and safety level
action should be taken
Response
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Engineering
Patient Processes
Staff training
PPE
Outbreak response
Engineering
• Avoid crowded EDs
– >1 m between pts
• Where possible have physical
barriers between patients
– Separate hand washing for
each pt
• Avoid prolonged stay in ED
– Separate toileting
– Washing
• Ventilation – negative
pressure rooms?
• Adequate sewage system
Busy ED
Shut Down By the Plague?
• Emergency closed at
PWH
• No elective operations at
PWH
Patient Processes
• Track pt cohorts through different areas
– Eg injury/fever
• Avoid unnecessary pt contact
• Separate work bench areas from pt care areas
• Avoid high risk procedures where possible
– Eg nebulisers/NIVA
• Avoid unnecessary admissions
– Hospitals dangerous places
– Avoid Unnecessary Patient movement b/n areas
• Only necessary Traffic through ED
Staff Training
• Accredit staff in ID procedures
• Audit infection control
• Incorporate into undergraduate training
Droplet Precautions in every ward
Personal Protective equipment
• Simplicity
• Long term practicality
• Masks/handwashing easy
– N95 vs surgical masks?
• Space suits expensive and impractical
• Identify particularly high risk groups
– Eg contact history/atypical/severe presentation or
procedures – eg ETT
– ?triage to different area/negative pressure
Outbreak response
• Local
• Regional
• National/International
Local
• Identification of
Outbreak
– Background monitoring
– Awareness through health
department
– Unusual case
• ++High Index of
Suspicion
• Command team
• Communication
• Contact tracing
Predetermined Communication
Protocol
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Meetings of Senior staff
Departmental meeting
Staff Forum
Email
Web site
Rumours are always worse than reality
Local
• Screening – in community + hospital
– Best site?
• ED
• OPD
• Health Department
– Facilities
• XRAY
• CT
• PATHOLOGY
• PPE
• VENTILATION
• SPACE
Local
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Plan for service distribution in outbreak
Knowledge of resources
Practice
Incorporation of plan into normal service
Regional
• Above issues +
• Schools
• Public announcements – panic vs ignorance
– Experience suggests that transparency creates less panic
• Quarantine
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Restrictions on movement cause panic
May lead to opposite effects to what you want
Effectiveness of home quarantine?
Is it right to house those with disease and without together?
National/International
• Effect on economy/business/Travel
Vs International responsibilities
• Resources diverted to maintain
infrastructure/training for possible outbreak vs
provide routine services
Every Hospital Should Have
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A disaster Plan
An infectious disease outbreak plan
Regular review/audit and practice of plan
Integration with regional hospitals and
ambulance
• Disease monitoring and reporting capability
Unsolved Problems
• Specialised ID hospital takes all?
– At Princess Margaret in HK–quickly overwhelmed
– Danger that expertise is concentrated
– Also abrogation of responsibility from non specialised
hospitals
– Primary triage to right hospital first time preferable
– However
• In small numbers –processes at ID hospital good
• Allows collaboration b/n experts
– Mixed model may be best
Unsolved Problems
• Staff Quarantine?
– May lose staff
• Immediate
• Long term
– Alternatives can be almost as bad
• Eg no physical contact etc
• Visitor policy
– Introduce early
• But very hard on pts/relatives
Unsolved Problems
• Contact Quarantine
– Ideally all isolated
– BUT
• Facilities
• Cross infection
• Deters people from coming forward
– Compromise
• High risk – formal quarantine
• Low risk - +responsible
Home with restrictions
Conclusion
• The biggest gains in risk reduction
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Simple infection control measures
Simple ED design changes
Staff training/auditing
Good ED pt processes
• ie avoid overcrowding etc
• Little evidence for negative pressure/space suits/ID
hospitals
– This is probably true even for diseases other than SARS