Local hospitals often serve as the focal point of health preparedness and response programs in communities across the nation. During and after most crisis situations, therefore, a hospital’s emergency department (ED) becomes the epicenter for the diagnosis and treatment of survivors. This status gives them the ability to design the hospital-centered surveillance programs and detection technologies needed to cope with future biologic incidents. As a corollary, the incorporation of additional detection, analysis, and reporting tools into the hospital ED resource inventory can serve as a valuable pathway to build the more effective incident management system needed to deal with all types of biologic threats – both natural and manmade.
The design elements of such a program are already used in such medical incidents as trauma or hazardous materials contamination, and typically encompass most or all of the following elements:
- A threat to community health;
- A facility designed for the management of information relevant to the patients involved, whether presenting themselves one at a time or in groups;
- A reliable method to provide accurate and timely diagnoses of the health threat;
- A reliable system of analysis (often linked with a regional healthcare coordination system);
- The medical systems needed for the safe management of patients contaminated by and/or exposed to the specific health threat involved;
- Links to the community’s overall emergency system and to timely public health education systems; and
- The other systems of various types needed to mitigate the adverse impact on the community.
The principal component or step lacking in the current system is a reliable method for the timely, accurate, and reliable detection of diseases related to biologic agents. It seems likely, though, that evolving technology will resolve this issue, if and when applied in a uniform manner to EDs throughout the nation.
Critical Components of the Biologic Threat-Prepared Hospital In contrast to the visible immediacy of a plane crash, a bombing, a nuclear incident, or a chemical exposure, a biologic incident can, for an extended period of time, be rather difficult both to detect and to specificallyentify. It is crucially important, therefore, to reduce theentification time as quickly as possible when clinical cases start to appear.
Unfortunately, the early symptoms caused by many infectious agents can be and often are mistaken for relatively common clinical ailments. If a large number of patients are seen and quickly released before the first “identifiable case” is recognized, several opportunities both to initiate treatment and to quarantine contacts may be missed.
Because very few people can secure a medical appointment with their doctors on a “same-day” basis, it is very likely that the unsuspecting survivors of a natural event or a bioterror attack will seek care in the EDs of local hospitals. For that reason alone, it makes sense to concentrate a community’s diagnostic, surveillance, and treatment resources at these facilities. As previously indicated, however, the time frame needed to successfully recognize and quarantine a bioterror agent may be rather short, so the capacity to mount an effective public health response should not depend on a fortuitous diagnosis by an overworked clinician.
Infectious Agents, USPS Precedents & Computerized War Rooms To address this specific, but likely, problem, there are two measurably effective operational tools that would be particularly valuable: (1) an infectious-agent detection system; and (2) a data-analysis system to measure ED flows. Following is a brief summary about how each of these tools could be used.
First, a simple but effective infectious-agent detection system could be created, using polymerase chain reaction (PCR)entification, by tapping into the tools already being used for environmental surveillance. More specifically, three types of detection devices could be developed: (a) a “breathalyzer” for patients exhibiting any respiratory symptoms; (b) a “sniffing” system to examine the skin and clothing of persons known or believed to have been exposed to airborne agents; and (c) various analytical devices that could be used to examine body secretions for the detection of agents that predictably would be excreted during the typical disease process. Many if not all of these systems would use detection-device technology – similar to what is used by the United States Postal Service (USPS) – to trigger alarms and activate automatic notification systems that would immediately alert operational and supervisory authorities.
The second “operational tool” mentioned above would require more widespread use of data analyses of ED flows, particularly those relating to specific symptom complexes and/or laboratory tests that indicate the presence of an infectious disease. The electronic patient-tracking systems of EDs, therefore, should be arranged to feed data into a public health “war room” at regional departments of public health. Over a relatively short period of time, computerized analyses would yield both hour-to-hour and day-to-day “profiles” of the normal ebb and flow of patient visits to the EDs.
If and when medical workers detect a sudden increase in ED visits related to a particular complaint or diagnosis, they can contact emergency staff, request additional information, and require all personnel involved to approach such cases with a higher degree of suspicion. If a particular pattern is sufficiently worrisome, additional staff may be dispatched to examine and, if necessary, quarantine not only the patients involved but also their visitors and other contacts.
Funding Challenges, But a Unique Opportunity The application of these tools and technologies should and usually would result in the building of an ED biologic-agent sentinel surveillance system. It is clear that combining public and private funding resources has in recent years become a critical factor in preparedness planning, but a system such as that described here would provide the budgetary framework needed to justify the investment required.
More important, though, is the fact that there is a unique opportunity now available for joint investments by the nation’s federal, state, and local governments that can be carried out in conjunction with the many businesses, charitable organizations, and individual citizens who also want a higher level of emergency preparedness within their communities. In that context, it seems obvious that any federal funding provided for more effective emergency systems should be used to support the central roles of the emergency care system not only in overall community preparedness but also in syndromic surveillance and healthcare forecasting.
The time-sensitive need for technology upgrades related to the detection of biologic agents would modernize emergency departments throughout the nation to not only receive and process everyday patients but also to develop the physical, processing, and procedural changes required to develop and improve the all-hazards preparedness capabilities of all levels of government. In today’s world, the term “hospital preparedness” means that all citizens have early access to critical medical services during a time of need. The development of a national ED-based surveillance system matches the need to further develop and improve the health and prevention efforts of all of the healthcare communities involved.
There have been times in the past when emergency physicians were either praised for their surveillance work or, in other situations, justifiably criticized because of their failure to detect or alert the community in a timely manner about a known or suspected health emergency. A program that applies advanced technology to quickly detect biologic agents, used in concert with an active surveillance and analysis program, would result in a time- and cost-efficient preparedness national network – one that could be used on a day-to-day basis.
________________________ James J. Augustine, M.D., is an emergency physician who serves with the Atlanta Fire Rescue Department and Hartsfield Jackson Atlanta International Airport. A Clinical Associate Professor in the Department of Emergency Medicine at Wright State University in Dayton, Ohio, he previously served as Chair of ASTM Task Group E54.02.01, which developed ASTM Standard E2413 on Hospital Preparedness, under Committee E54 on Homeland Security Applications. He also served as Chair of the Atlanta Metropolitan Medical Response System.