Hospital Emergency Departments - Infectious Diseases: The First Line of Defense

The first symptoms of a biological attack by terrorists – or of an emerging infectious disease – will usually be somewhat similar to those of the common cold or flu. Such symptoms as respiratory coughs, fever, and/or body aches may therefore be the chief complaints noticed by the first victims. How the victims react, though, then how public health services respond, can determine just how deadly an outbreak is likely to become. If the first cases of an outbreak can beentified, isolated (if infectious), and possibly treated, the public health agencies involved probably can control not only the outbreak itself but also the potential panic that might quickly follow.

Over the past decade, health care has seen several newly emerging infectious diseases that have provided a blueprint that also can be useful in reacting to a terrorist bio-warfare attack. Avian flu, SARS (severe acute respiratory syndrome), and most recently the H1N1 global pandemic flu virus have provided health care institutions several valuable lessons that show what to do – and, of sometimes greater importance, what not to do – toentify and, if possible, counter an infectious disease. Those same outbreaks have shown health care institutions, and public health services: (a) how most if not all people will react to their symptoms; and (b) how most citizens are likely to react after the outbreak of a major infectious disease has become public knowledge. The avian flu, SARS, and H1N1 outbreaks provided several valuable “lessons learned,” therefore, that – prior to those outbreaks – public health personnel could only theorize about on the basis of other outbreaks in the more distant past – the so-called “Spanish” flu global pandemic of 1918-20, for example.

The U.S. health care system has found that the initial indicator of such outbreaks is, in many albeit not all cases, a significant increase in the number of patients showing up at the emergency departments (EDs) of local hospitals. When an unusually large number of patients present themselves to an ED during a short period of time, or when a large number of patients report the same suspiciously acute symptoms or circumstances – e.g., recent travel overseas, or an inexplicable rash accompanying other health problems – health-care providers should recognize that such symptoms may be the first indicators of a potentially major outbreak. They also might turn out to be the index cases of a new disease outbreak – or of a new wave, in a new community, of an already existing outbreak The patients involved, and the valuable information they provide when arriving in a hospital’s ED, may quickly become the human “new frontier” where the disease battle will be fought.

OTC Medications, Insurance Issues & the EMTALA Factor Today’s health-care reality in many areas of the country is one in which the local hospital ED is what most people consider their primary-care facility. If a person develops a significant medical symptom that an OTC (over-the-counter, or non-prescription) medication cannot help, he or she usually goes to the nearest local hospital’s ED to seek medical treatment. The principal reasons for this almost instinctive reliance on local EDs are that many Americans either: (a) do not have a primary care physician; or (b) usually face a sometimes long delay in obtaining an appointment with their physicians; or (c) have various insurance “issues” to resolve. Whatever the reason, though, the ED at the local hospital must – by law (EMTALA–the Emergency Medical Treatment and Active Labor Act) – evaluate all patients regardless of their financial status. This is perhaps the principal reason why local EDs are the first health care facilities where victims of an outbreak usually seek medical relief – it also is why the resulting surge in ED patients following an outbreak should trigger an alarm for a quick public health response.

Most states now have computerized systems in place to ensure that a sudden influx or surge of patients into a local ED automatically alerts public health officials – especially when a high percentage of those patients exhibit flu-like symptoms. The computerized systems help local agencies implement response plans quickly – while also sending experienced professionals to investigate the surge. Such computerized systems therefore serve, in effect, as an early warning alarm system for the local community (or for the nation as a whole), especially if the systems provide real-time information and/or are linked to several hospital departments – e.g., pharmacy, laboratories, and/or electronic medical records – that can provide valuable corroborating information. The same systems can be used, of course, to detect potential patterns in the early stages of an outbreak, a capability that can lead to early decisions by local public health agencies to seek an aggressive release of medicines and medical equipment from geographically dispersed PODs (points of distribution) of the Strategic National Stockpile (SNS) of pharmaceuticals, medications, and medical systems and devices.

The development and improvement of these surveillance systems, along with other systems thatentify certain sales of over-the-counter medications being purchased from pharmacies or chain stores, can give the same agencies a much earlier start on their response and recovery plans. For several reasons, though, it would be a serious mistake to rely exclusively on these computerized systems. For one thing, if a hospital’s own computer system is offline, the data it normally provides might well be delayed for a period of several hours, if not longer. Also, if a true ED surge does occur at a hospital, and/or if a hospital’s departments are suddenly overwhelmed by an unexpected number of patients, the hospital staff may revert to the use of a paper system and not enter the data until much later – i.e., when there is more time available for non-medical tasks such as the updating of files and similar office chores. Whatever the reason, such occurrences could significantly delay the data showing up in an electronic form to other health care agencies and facilities, and for that reason might indefinitely prevent the sounding of an alarm that could have triggered a much quicker public health response.

Hospitals must realize, therefore, that they not only must put their emergency plans in motion as early as possible when reacting to an unexpected surge in patients that overcrowds the hospital’s ED (and/or other departments), but also must establish and maintain continuing and effective communications with other health agencies and facilities in the local community. In short, reliable and continuous communications are the best (and sometimes only) way to keep all health care organizations in the same community quickly and fully aware of unusual surges of patients — and/or of the sudden presentation of even a relatively small number of severely acute patients exhibiting unusual symptoms – e.g., flu patients before or after the normal flu season, or a very large number of rashes and other symptoms of certain diseases.

Reluctant Compliance vs. Overcrowding vs. Code Violations In most U.S. hospitals, their public health service agency usually also serves as their compliance agency. For that reason alone, there is often an inherent reluctance to bring public health officials into the hospital itself. Probably most but certainly not all hospital administrators may obviously be concerned that representatives of the local or state public health agency may see a potential health code violation during such visits. When an ED is overcrowded, to cite but one example of many situations when patient-care issues may easily be delayed – a potential health code violation may last for a brief but legally measurable period of time. If a public health agency responds as it should during an unexpected surge of patients, certain code violations may be both obvious and visible – stretchers in hallways, for example, or a large number of patients already admitted, but remaining in the ED for several hours. These situations, and many others that might be cited, understandably make some hospitals reluctant to voluntarily notify a public health agency of certain temporary medical difficulties – particularly if such notification might expose the hospital to a violation warning and/or a potential fine.

If hospitals work more closely, though, with their public health agencies on emergency preparedness – through plan development, POD (points of distribution) activations [for medicines and medical supplies], surge drills, and frequent meetings – the hospitals and public health agencies involved all will feel more comfortable about communicating during potential real-life incidents and events. Both of these important organizational stakeholders must feel comfortable when they react and when they report unusual issues. In short, hospital ED staff must serve as the “fail-safe” backup if and when electronic systems are not available, for whatever reason, to alert public health agencies. The ED staff also must feel reasonably comfortable, as must hospital administrators, in notifying public health agencies of any potentially dangerous and/or difficult situations that might develop.

In addition, the public health agencies involved must use both logic and common sense when they are asked to respond to information provided by a hospital’s ED. When a sudden patient surge event occurs hospital EDs almost always react as best they can, and as fast as they can – but still, because of overcrowding and/or other circumstances beyond their own control, may not be capable of adhering to all normal health codes at the same time. The best, longest lasting, and perhaps only effective long-term solution in such circumstances, therefore, is to develop and maintain the mutual respect and confidence needed to form the true working partnership necessary to develop and implement the effective response system required to protect the public from an unexpected outbreak.