(The following article was prepared by the NSMA Commission on Public Health)
Preparation for Disaster
Lawrence K. Sands, D.O.,M.P.H., CoChair-NSMA Commission on
Public Health and Southern Nevada District Health Officer
Mary Anderson, M.D.,M.P.H., CoChair-NSMA Commission on
Public Health and Washoe County District Health Officer
Most physicians are so busy with the everyday demands of practice that they have little time to prepare for a major disaster. Certain specialties e.g. emergency medicine and trauma are better prepared for a disaster by their training and practice. Occasionally, we see the problems associated in a mass casualty situation when a bus rollover, a plane crash, or hotel fire occurs. However, the news quickly fades from our minds.
Usually there is a flurry of activity after a major natural disaster such as hurricane Katrina or LA’s Northridge earthquake due to the large numbers of casualties, the loss of electrical power and communications, and damage to structures including hospitals. How would we respond if we were in that situation? Some have volunteered to help out and gained first hand experience. Others get involved in local disaster planning and training or became volunteers in organizations such as the American Red Cross. Most of us quickly return to our normal routines and the question of disaster preparedness issues forgotten.
What disaster could affect us all? There are several possibilities. A major earthquake could occur in almost any area of the state and has the potential to be devastating. A terrorist attack could occur in Las Vegas, Reno, or a military base and might involve explosives, biologic agents, and/or radioactive materials. An epidemic could occur such as the highly pathogenic avian flu. All of these would tax our resources to the limit.
The good news is that the state and local offices of public health preparedness and emergency management continue to work in partnership to plan and prepare for these situations. Preparedness partners include first responders (police, fire, and ambulance), state and local offices of emergency management, local health districts, the American Red Cross, Southern Paiute tribe, county coroners, mortuaries, and acute and sub-acute hospitals. Planning and coordinating committees at the state and local levels meet regularly and emergency/disaster exercises occur several times each year, and hospitals continue to develop contingency plans to manage sudden patient surges.
All of the agencies have been schooled in the Incident Command System (ICS) structure in order to manage these emergencies. By applying the principles and concepts of ICS multiple and diverse agencies are able to coordinate their activities and manage resources efficiently and effectively by using the same terminology and organizational structure. When you volunteer, volunteer with an organization that uses the ICS management system, such as the Disaster Medical Assistance Team (DMAT), Medical Reserve Corps (MRC) or American Red Cross (ARC).
Unfortunately, most physicians are not aware of the plans that have been developed and don’t have the time to investigate. What would you do if we had a magnitude 7.5 earthquake that knocked out the electricity, shut down communication, started multiple fires around town, and damaged one or more of the hospitals? Do you have a family disaster plan with your spouse and children and a disaster plan for your medical practice and staff? Do you have a continuity of operations plan for your practice? This would include agreements with vendors from where you receive supplies. Do you have a notification system for your office staff?
Resources to aid in the development of a family and/or business disaster plan, including the Pandemic Flu Plan, are available on the Southern Nevada Health District (SNHD) website at: www.southernnevadahealthdistrict.org/preparedness/default.htm. Health-care providers will play a crucial role in the event of a pandemic. Planning for pandemic influenza is key. Checklists, toolkits and guidelines to assist health-care providers and service organizations in planning for a pandemic outbreak can be found on the federal pandemic flu website at: http://www.pandemicflu.gov/plan/healthcare/index.html. Additional information about emergency management planning can be found at www.co.clark.nv.us by clicking on “Emergency Preparedness” for the Office of Emergency Management.
During emergencies uncoordinated volunteer efforts working outside an established ICS structure can actually hinder emergency operations. It is important that volunteers work through an established system such as MRC, DMAT or ARC so that their efforts can be effectively managed and integrated into the overall emergency response plan and ensure that volunteers have liability protection. Physicians can become involved and stay informed by joining their local MRC. The MRC is a committed and available reserve of active, inactive, and retired health care professionals who can be rapidly mobilized to strengthen local medical and public health capabilities in response to large-scale emergencies occurring in their community. To find out how to become part of your local MRC, contact the coordinator in your area:
- Stacey Belt, Carson City Health and Human Services at (775) 887-2109
- Paula Martel, Southern Nevada Health District at (702) 759-0877
- Debra Barone, Washoe County Health Department at (775) 328-6111
The Nevada 1 Disaster Medical Assistance Team (DMAT) is a state-wide emergency response team, as well as a Federal asset to the United States Public Health Service/National Disaster Medical System under the Department of Health and Human Services, commissioned in 2001. DMAT teams provide essential emergency medical care and patient evacuation during time of natural or man-made disasters or in time of a national security emergency and can be assigned to work in hospitals, tents or on sites. The DMAT can assist locally by being requested through your county’s Office of Emergency Management who then submits the request to the state Department of Emergency Management (DEM) and then up to the Federal level. To find out how to become part of the DMAT, contact Administrative Officer Karen Strutynski at (702) 809-5497 (24-hours) or visit their website at www.nv1dmat.com.
Nevada physicians and health care professionals are responsible for completing continuing education on the medical consequences of an act of terrorism under the provisions of Nevada Revised Statutes (NRS) 630.253 passed by the Legislature in 2003. The Area Health Education Center (AHEC) of Southern Nevada offers a class that meets the criteria for licensure and renewal. The class, “Weapons of Mass Destruction: The Health Care Professional’s Role in Nevada’s Preparation and Response” is available statewide. For more information access the AHEC website at www.snahec.org. The course is also held monthly in Clark County at Southern Nevada Health District (SNHD). To register for the course, “Medical Consequences of an Act of Terrorism,” please contact SNHD Nancy Gerken, Nurse Trainer, at (702) 759-1309. CEUs are available for the course.
Participating as a member of a Community Emergency Response Team (CERT) can provide training for assisting your neighbors and/or co-workers in the event of an emergency or disaster. A six-week training meets once a week and includes training in Disaster Preparedness, Fire Suppression, Medical Operations, Light Search and Rescue, Disaster Psychology, Weapons of Mass Destruction, Team Organization and a final exercise. In Clark County contact Rick Diebold of Las Vegas Fire and Rescue at (702) 383-2888. In Washoe County contact Kaydie Paschall at (775) 328-2866.
Other excellent resources are available to learn about these issues including the following:
- Jackett, G., Avian Flu, Preparing for a Pandemic, Am. Fam. Phys., 74:783, Sept. 1, 2006. (An excellent overview of the avian flu and an introduction to the care of one’s patients during an epidemic.)
- Educating Physicians on Controversies in Health at: www.ama-assn.org/ama/pub/category/15369.html
- Disaster Preparedness: Are Physicians Ready?
- Avian Flu: How Real is the Threat of a Human Pandemic?
(The two sessions are part of a series of 5-minute programs in video format, designed to initiate discussion among physicians.)
- New York Consortium for Emergency Preparedness Continuing Education at: www.nycepce.org/courses/ept.htm Emergency Preparedness Training for Hospital Clinicians a series of 6 modules with 1 hour of CME credit for each module. (We recommend all physicians review “The Basics” module and others if interested.)
- Basic Disaster Life Support (BDLS) and Advanced Disaster Life Support (ADLS), two one-day courses patterned after BCLS, ACLS, ATLS, etc. leading to certification. Presented by the UNLV Institute for Security Studies and provides 8 hours of approved CME. Cost of $200 per student per course. Contact: email@example.com or: Mr. Ross Bryant; UNLV Institute for Security Studies; East India Building; 4045 Spencer St. Suite A-41; Las Vegas, NV 89119
- www.redcross.org/services/disaster/ -click on “Be Prepared”, then click on “Family Disaster Planning”. This web site provides excellent, comprehensive recommendations for preparing your family for a major disaster. We would also recommend you review other preparedness topics of interest to you.
- www.nvha.net/bio/intro.htm - Information from the Nevada Hospital Association on statewide disaster planning including hospital surge capacity and a variety of references.
(Thanks for the work of former NSMA Commission on Public Health CoChairs George H. Hess, M.D. & Donald S. Kwalick, M.D., who authored an earlier version of this article.)
A useful overall internet site for updates on the range of issues covered by public health emergency preparedness and response is found at: http://www.emergency.cdc.gov/.
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Hepatitis C Outbreak (Updated July 28, 2008)
On February 27, 2008, the Southern Nevada Health District announced at a press conference that routine epidemiological follow-up to a cluster of 6 acute hepatitis C cases had led them to determine that unsafe procedures during the administration of anesthesia at the Endoscopy Center of Southern Nevada had resulted in the cases. As a result of its investigation with the State Health Division’s Bureau of Licensure and Certification and the State Epidemiologist, it was determined to contact all identifiable patients who had procedures requiring the injection of anesthesia during the previous 4 years. Each of these patients was advised to be tested for possible exposure to blood-borne infections of hepatitis B or C or to HIV. On March 28, 2008, the Southern Nevada Health District published a document, “Interim Report on the Endoscopy Center of Southern Nevada Hepatitis C Investigation”. (http://www.southernnevadahealthdistrict.org/outbreaks/download/interim-hepc-investigation-report.pdf) The conclusion: “Through the combination of observation, interviews, & evaluation of records, it was determined that the reuse of syringes to re-dose a patient, combined with the reuse of single use vials for multiple patients was the most likely source of transmission during the outbreak.” On April 28, 2008 the Southern Nevada Health District reported that it had identified an 8th case of acute hepatitis C at this center. On May 8, 2008, the Southern Nevada Health District reported that 77 additional infections that could be linked to the clinic. On June 5, 2008, the Southern Nevada Health District reported that it had established an acute case of hepatitis C associated with the Desert Shadow Endoscopy Center. On July 24,2008 (http://www.southernnevadahealthdistrict.org/press_releases/2008/072408.html), the Southern Nevada Health District reported that it had: “identified two source cases…One patient had a procedure on July 25, 2007, and the other on September 21, 2007. These are the dates that disease transmission was known to occur. An additional chronic (non-acute) case of hepatitis C infection has also been linked to the September 21 source case. The health district can now link a total of eight hepatitis C cases directly to the Endoscopy Center on Shadow Lane and one acute case to the Desert Shadow Endoscopy Center…”
The federal Centers for Disease Control & Prevention (CDC) in the May 16, 2008 issue of the Morbidity & Mortality Weekly Report, focused on the Las Vegas hepatitis c cluster & related matters (http://health.nv.gov/docs/CDCMMWR.pdf). The CDC “Trip Report” (http://health.nv.gov/docs/FinalEpi2_20080515.pdf) reports about observed infection control behaviors of various professional & staff at the ASC’s that are the center of attention. The State Health Division has proceeded to survey all 50 licensed Ambulatory Surgery Centers and has posted the results at: http://health.nv.gov/docs/ascupdates.htm.
In addition to ongoing followup by the Southern Nevada Health District in contacting all patients who were potentially infected, the State Health Division (under the direction of Acting State Health Officer, Mary E. Guinan, M.D., Ph.D. has undertaken a complete review of infection control issues, which includes new Ambulatory Surgery Center reg’s on injection safety & infection control (http://leg.state.nv.us/register/2008Register/R096-08P.pdf). These new rules were adopted by the State Board of Health on June 20, 2008. NSMA participated in the workshop and the hearing and supported the changes.
On March 23, 2008, NSMA Immediate Past President Edwin C. Kingsley, M.D. and Clark County Medical Society Immediate President and Executive Director Weldon E. Havins, M.D., J.D. published a joint statement in the Las Vegas Review-Journal. The joint statement said in part: “The Clark County Medical Society and the Nevada State Medical Association, representing 1,700 Nevada physicians, would like to express our profound regrets and utmost concern regarding the recent outbreak of hepatitis C in southern Nevada. We express our most sincere regrets to all of those in our community who have been directly or indirectly affected by this tragedy. It is outrageous that any physician would allow any patient to be placed at unnecessary risk of a life-threatening disease and it is unconscionable that any physician would ever knowingly betray the trust of any patient… After all potentially infected patients are counseled, tested and treated and all of the facts are clearly understood, Nevada regulatory agencies, professional licensing boards, prosecutors and the courts are all going to exercise their roles during the coming weeks, months and years. The Governor, the Attorney General and the State Legislature will also be called upon to review the oversight laws to see if they need any revisions. The Clark County Medical Society and the Nevada State Medical Association will cooperate with and assist in these Legislative and regulatory processes to make sure that this never happens again. Patient and public trust in the medical care system have been damaged, but can, and must, be restored. This can be only done one patient at a time.”
On April 1, 2008, NSMA Immediate Past President Edwin C. Kingsley, M.D. and Washoe County Medical Society President David E. Hald, M.D. published an Op-Ed in the Reno Gazette Journal entitled “Trust Must Be Gained One Patient At A Time”.
A principal responsibility for organized medicine is to provide practicing physicians with tools to assist them in their practices. The NSMA is developing supporting materials to help members talk to their patients and their patients’ families about their concerns as a result of this crisis. Even if patients don’t bring the subject up, NSMA as encouraging encouraged to say, “Please Ask Me” about the news stories regarding infections control. NSMA has encouraged physicians to invite patients (and their families) to ask questions on the subjects that bother them based on the coverage of the issues and the releases from government agencies. Physicians are encouraged first make sure that they have reviewed the policies & practices. If the practice is in a licensed facility, physicians are encouraged to make sure that they have talked with the risk management department to clarify the facility’s position regarding disclosure and release of information including policies, plans and infection rates.
The Nevada State Health Division has encouraged patients to ask several questions prior to a surgical procedure (http://health.nv.gov/docs/030308PressRelease.pdf):
- Can you assure me that I am safe in your facility from the transmission of communicable diseases?
- How does the staff at this facility conduct sterilization of diagnostic equipment after each patient use?
- Are single or multiple dose vials used at the facility? Are label instructions followed specifically?
- Are syringes and needles disposed of after each use?
- Has your facility ever received a complaint of the spread of an infectious disease to another patient as a result of staff practices?
NSMA recommends that every physician should consider and adopt as appropriate in his/her practice the Centers for Disease Control and Prevention standards for preventing viral hepatitis transmission in ambulatory care settings (http://www.cdc.gov/ncidod/diseases/hepatitis/spotlights/ambulatory.htm). This site also includes an explicit section about “injection safety” at http://www.cdc.gov/ncidod/diseases/hepatitis/spotlights/ambulatory.pdf)
The Association for Professionals in Infection Control & Epidemiology (APIC) advises (http://apic.informz.net/apic/archives/archive_272235.html) the following points to share with patients:
- The infection prevention & control professionals at our facility have designed a coordinated infection prevention & control program to protect everyone who comes into our facility, including patients, healthcare workers & the public.
- Our program incorporates evidence-based practices from leading authorities in infection prevention including the CDC. In addition, we comply with regulations from government agencies such as the state & local health departments, OSHA & the Centers for Medicare & Medicaid Services, as well as accrediting bodies, such as The Joint Commission.
- The essential elements of an infection prevention & control program include:
- Rigorous hand hygiene practices that ensures healthcare providers clean their hands before & after giving patient care
- Monitoring the cleaning, disinfection and sterilization of instruments and equipment used for patient care
- An Exposure Control Plan that serves to minimize exposure to bloodborne pathogens such as Hepatitis B, C and HIV by patients and healthcare personnel
- As part of that plan, there are measures to prevent the re-use of items that are designed to be used only once then disposed of, such as needles and syringes
- Additionally, in order to ensure patient safety, our staff is trained to identify a breach in infection control practice and intervene if such practices are identified.
NSMA is working with HONOReform (http://www.honoreform.org/) & the Centers for Disease Foundation (http://www.cdcfoundation.org/) to discuss a national campaign responding to the infection control & injection safety issues most recently identified in the Las Vegas hepatitis C outbreak. NSMA will work with them and the State Health Division to pilot a campaign to assure that national standards (http://www.cdc.gov/ncidod/diseases/hepatitis/spotlights/ambulatory.htm) are understood, implemented & communicated to patients. In the coming months, Nevada physicians will be asked to test the information materials for a national campaign that should start this fall.
The latest information about the outbreak and the most comprehensive documentation is available at the Southern Nevada Health District’s internet site: http://www.southernnevadahealthdistrict.org/outbreaks/index.htm.
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Salmonella Outbreak (Updated July 28, 2008)
The Centers for Disease Control and Prevention (http://www.cdc.gov/salmonella/saintpaul/?s_cid=ccu061608_salmonella_e) reports a continuing multi-State outbreak of human Salmonella serotype Saintpaul infections. An initial epidemiologic investigation comparing foods eaten by ill and well persons identified consumption of raw tomatoes as strongly linked to illness. Later study determined that ill persons were “more likely to have recently consumed raw tomotaoes, fresh jalapeno peppers and fresh cilantro.” (As of July 24, 2008 13 cases were reported in Nevada of the 1294 cases nationwide. Cases have been detected in 43 States.)
According to the CDC: “Most persons infected with Salmonella develop diarrhea, fever, and abdominal cramps 12-72 hours after infection. Infection is usually diagnosed by culture of a stool sample. The illness usually lasts 4-7 days. Although most people recover without treatment, severe infections may occur. Infants, elderly persons, and those with impaired immune systems are more likely than others to develop severe illness. When severe infection occurs, Salmonella may spread from the intestines to the bloodstream and then to other body sites, and can cause death. In these severe cases, antibiotic treatment may be necessary.”
The Food and Drug Administration, which shares oversight responsibility with the CDC, has issued the following advice to consumers: “The U.S. Food and Drug Administration (FDA) is advising consumers that jalapeño and serrano peppers grown in the United States are not connected with the current Salmonella St. Paul outbreak and consumers may feel free to eat them without concern of contamination. The FDA's advice to avoid raw jalapeño peppers, and foods that contain them, now applies only to peppers grown, harvested or packed in Mexico. In addition to domestically grown raw jalapeño peppers, commercially canned, pickled and cooked jalapeño peppers from any and all geographic locations also are not connected with the current Salmonella Saintpaul outbreak.” (http://www.fda.gov/oc/opacom/hottopics/tomatoes.html)
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Organ and Tissue Donation/Transplant Issues
Nevada Living Will Lockbox Launched
Secretary of State Ross Miller and the Nevada Center for Ethics & Health Policy (http://www.unr.edu/ncehp/) has announced a new web based Registry for Advance Directives (http://nvsos.gov/online/nadr/). This important new project was created by Assembly Bill 158 (http://www.leg.state.nv.us/74th/Bills/AB/AB158_EN.pdf), a 2007 bill that NSMA supported. A copy of the regulation that describes the registry is available at: http://leg.state.nv.us/register/2008Register/R006-08RP1.pdf.
Every physician is encouraged to participate by completing the form available for downloading at the Living Will Lockbox site. Physicians should consider encouraging patients to look at Nevada advance directives (available at: http://www.unr.edu/ncehp/ADs.html) so they can communicate their desires to physicians and their families I advance of medical events.
Nevada Center for Ethics and Health Policy
NSMA is a founding member and supporter of the Nevada Center for Ethics and Health Policy (http://www.unr.edu/ncehp/), which has been operating since January 1999. The Nevada Center for Ethics & Health Policy with its partners are working together to provide better tools for community and professionals to have caring conversations about death and dying, achieve some consensus on pain management and palliative care while improving the quality of end-of-life care for a more dignified death.
NSMA and the NCEHP are developing plans for a Nevada Health Professionals Ethics Summit to be held in the autumn of 2008. Details will be provided later this summer.
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