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Conquering High Consequence Infections in a VA Hospital

02/07/2020

Mark Pelletier, MS, RN, chief operating officer and chief nurse executive

There’s a lot of buzz in the media about high consequence infections (HCIs), or, moderate to highly contagious infections for which no known vaccine exists and are a concern to public safety such as:

  • Ebola
  • SARS
  • MERS-CoV
  • pandemic flu 

While we closely follow daily developments on the novel coronavirus from the Centers for Disease Control and Prevention (CDC), I thought it would be worthwhile to share the success of Northport Veterans Affairs Medical Center (VAMC) in Northport, New York, in conducting a proactive assessment after identifying vulnerabilities in early recognition of HCIs.

Joint Commission Leadership (LD) Standard LD.03.09.01, Element of Performance (EP) 7, requires accredited hospitals and nursing care centers to select one high-risk process and conduct a proactive assessment at least every 18 months.

VAMC selected HCIs as its high-risk process with goals to:

  • establish policies, protocols and procedures for HCI preparedness
  • implement facility-wide education on HCIs
  • meet the VA’s customer requirements for the patient population served as well as promote the health and safety of veterans

Process Tools
Using a Healthcare Failure Mode and Effect Analysis (HFMEA) process tool, the team convened weekly for three months in early 2019 to conduct a hazards analysis. They concentrated on identifying:

  • failure modes
  • causes
  • effects 

Interventions were then applied to a decision tree to drive actions for improvement. Key to the success of this improvement project was an algorithm for a standardized screening process to identify, isolate and inform appropriate authorities of possible HCIs that the team adopted after attending a Special Pathogens course at NYC Health + Hospitals in New York. 

HCI Screening at Check-In
The team recognized two key questions that would identify the risk for HCI and address the first failure mode. The “magic questions” were:

  • In the past week have you had a fever, cough or rash?
  • Have you traveled outside the country or come in contact with someone who traveled outside the country in the past 30 days?

While it was challenging to work these questions into the electronic health record, the team was able to create a new domain called “Check-In Screening”. Patients who answered “no” about fever, rash and cough were automatically removed from the screening pool. Those who answered “yes” were then flagged to the question about international travel. Staff were then prompted to employ standard precautions and notify the proper authorities about a patient’s travel and symptoms.

Isolating Affected Patients Appropriately
With the HCI identification process streamlined, the team focused on isolating patients to minimize infection spread. Patients whose check-in screening answers raised concern were sequestered in a negative pressure room separate from the main waiting area.

At this point in the project, team members identified causes for isolation failures, including a lack of:

  • appropriate isolation carts 
  • special pathogen personal protective equipment (PPE) 
  • spill kits
  • isolation rooms
  • masks
  • alcohol-based rubs
  • hand sanitizers at check-in

Staff Education and Training Gaps
Staff didn’t always know to visit CDC’s real-time travel information website to check for any active illnesses in the geographic area the patient visited. To keep the travel information front of mind, they decided to add a link to the website on Northport’s Intranet.

However, the most critical causes for failure to inform proper authorities of a possible HCI was traced back to education and training.

Staff were unlikely to know to inform the key personnel about the infection risk if they were also not properly trained on:

  • conducting a travel history
  • isolating patients
  • obtaining an isolation cart
  • evaluating for special pathogens

Inadequate training also accounted for poor isolation practice and, ultimately, infection spread. Isolation related knowledge gaps mostly occurred in the areas of donning/doffing PPE as well as disposing and handling of special pathogen PPE and supplies. To address this, staff attended special education and training in donning/doffing techniques.

Improved Processes
Armed with detailed information about their shortcomings, the team was able to make strides in improving their HCI policies. When visitors were flagged as high risk because of their travel to HCI regions (as outlined by the CDC travel notices website), a process was set in motion whereby:

  • infection control/infectious disease departments were alerted
  • Department of Health guidance was implemented

Northport developed special pathogen books and implemented new HCI checklists for:

  • PPE donning and doffing
  • body fluid spill
  • MERS specimen collection

Some process changes were also in order. Northport validated the proper process for transporting waste and cleaning special pathogen rooms with the federal Veterans Integrated Services Network (VISN). 

Because of the nature of their jobs, veterans can show up anywhere in the world and at any stage of illness. This new process gives the Northport staff standardized steps to help reduce the chances of mass casualties from spread of communicable disease long after an initial infection and, subsequently, require specialized mitigation, planning and response to prevent and control the spread of disease. 

Mark G. Pelletier, RN, MS is the chief operating officer, Accreditation and Certification Operations, and chief nursing executive for The Joint Commission. Mr. Pelletier has more than 30 years of experience in hospital operations, performance and quality improvement, process redesign, and program development. Previously, he was the senior vice president and chief operating officer of Condell Medical Center, Libertyville, Illinois. He has also served in executive positions for several hospitals in the Chicago area including Resurrection Health Care, Northwestern Memorial Hospital, Children’s Memorial Medical Center and Mercy Hospital Medical Center.