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Pre-Event Planning. Evaluating your facility. Plan of Action. Emergency management plan Mitigation Preparedness Response Recovery. Identifying a Problem. Most common features of an outbreak caused by a bioterrorism agent Influenza-like illness Viral exanthem: rash/fever

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pre event planning

Pre-Event Planning

Evaluating your facility

plan of action
Plan of Action
  • Emergency management plan
    • Mitigation
    • Preparedness
    • Response
    • Recovery
identifying a problem
Identifying a Problem
  • Most common features of an outbreak caused by a bioterrorism agent
    • Influenza-like illness
    • Viral exanthem: rash/fever
    • Gastrointestinal complaints
surveillance methods
Surveillance Methods
  • Databases
    • Mainframe systems
      • Admissions
      • Emergency department
      • Microbiology
surveillance methods5
Surveillance Methods
  • Mainframe systems
    • Laboratory
    • Pathology
    • Radiology
    • Pharmacy
surveillance methods6
Surveillance Methods
  • Access to system
  • Report distribution
  • Computer access
  • Patient electronic medical record
    • HIPAA concerns ?
confirming the diagnosis
Confirming the Diagnosis
  • Coordination of surveillance plan
  • Review of symptoms
  • Gathering data
  • Communication with internal and external resources
facilities environmental
Facilities/Environmental
  • Isolation Rooms
  • Negative Pressure
    • Alternatives
  • Transportation Routes
  • Lockdown
  • Disinfectants
  • PPE
laboratory support
Laboratory Support
  • Level of involvement
    • Level A: Initial work- r/o BT agents
    • Level B: County/state- agent confirmation
    • Level C: Large state lab/ advanced labs
    • Level D: CDC/DOD labs
laboratory support10
Laboratory Support
  • BSL levels
    • 1: General office
    • 2: Biosafety cabinets
    • 3: Negative airflow
    • 4: “Moon suits”
specimen collection
Specimen Collection
  • Collection
  • Preparation
  • Media
  • Preservation
  • Shipping
  • Notification
smallpox diagnosis
Smallpox Diagnosis
  • Traditional confirmatory methods
    • Electron microscopy of vesicle fluid
      • Rapidly confirms if orthopoxvirus
    • Culture on chick membrane or cell culture
      • Slow, specific for variola
  • Newer rapid tests
    • Available only at reference labs (e.g. CDC)
    • PCR, RFLP
lab methods for confirmation of orthopoxvirus diagnosis
Lab Methods for Confirmation of Orthopoxvirus Diagnosis
  • PCR related methods for DNA identification, (e.g., real-time PCR)
  • Electron microscopy
  • Histopathology
  • Culture
  • Serology
    • Antigen detection (IFA, EIA ag capture)
    • IgM capture
    • Neutralization antibodies
    • IgG ELISA
specimen collection16
Specimen Collection
  • Vaccinia and variola specimen collection essentially the same
  • Check CDC website for:
    • Recent updates in orthopox specimen collection specifics
    • Appropriate infection control practices
    • Shipping criteria
    • Laboratories
    • www.bt.cdc.gov/agent/smallpox/ response-plan/files/guide-d.pdf
specimens for vaccinia related disease vesicular rash
Specimens for Vaccinia-Related Disease: Vesicular Rash
  • Lesion ‘roofs’ and crusts
  • Vesicular fluids:
    • Touch prep
    • EM grid
  • Biopsy
  • Serum
  • Others (e.g., CSF)
specimen procurement handling
Specimen procurement/handling
  • By recently successfully immunized person
    • Appropriate PPE (gowns, gloves, mask, protective eyewear)
  • Open vesicle with blunt end of blade
  • Collect with cotton swab
  • Place swab into sealed vacuum blood tube
  • Place tube in larger jar, tape lid
handling vhf specimens
Handling VHF Specimens
  • Sample for serology - 10-12 ml
    • ship on dry ice
  • Tissue for immunohistochemistry
    • formalin-fixed or paraffin block
    • ship at room temperature
  • Tissue for PCR/virus isolation
    • ante-mortem, post-mortem; ship on dry ice
  • Ship serum cold or on dry ice in a plastic tube

Centers for Disease Control and Prevention

yersinia pestis specimen selection
Yersinia pestis:Specimen Selection
  • Specimen selection is important
    • Bubonic - bubo - lymph node aspirate
    • Septicemic - blood - Obtain three sets 10-30 minutes apart
    • Pneumonic
      • Sputum/throat
      • Bronchial washings

Centers for Disease Control and Prevention

yersinia pestis specimen inoculation
Yersinia pestis:Specimen inoculation
  • Inoculate routine plating media and make thin smear for DFA
      • Use Wayson only if DFA is unavailable

Centers for Disease Control and Prevention

laboratory confirmation
Laboratory Confirmation
  • By State Health Dept., CDC and Military labs-
    • Antigen detection
    • PCR
    • IgM enzyme immunoassay
    • Immuno-staining
level a lab procedures yersinia pestis
Level A Lab ProceduresYersinia pestis
  • Gram stain
  • Wayson stain
  • Growth characteristics on agar
  • Growth characteristics in broth

Centers for Disease Control and Prevention

yersinia pestis gram stain
Yersinia pestisGram stain
  • Small, gram-negative bipolar-stained coccobacilli

Must confirm by DFA and mouse inoculation

Centers for Disease Control and Prevention

gram negative coccobacilli
Most likely

Acinetobacter

Actinobacillus

H. aphrophilus

Bordetella spp.

Pasturella spp.

Least likely

DF-3

Brucella spp.

Francisella spp.

Gram Negative Coccobacilli
level a lab procedures francisella tularensis
Level A Lab Procedures Francisella tularensis
  • This is a dangerous, highly virulent organism and it should not be manipulated at the bench, but under a controlled environment
  • Gram stain
  • Growth characteristics in broth
  • Growth characteristics in agar

Centers for Disease Control and Prevention

transportation mission
Transportation Mission
  • Organize and coordinate the transportation of all casualties, ambulatory and non-ambulatory
  • Arrange for the transportation of human and material resources to and from the facility
anticipate transportation needs
Anticipate Transportation Needs:
  • Transfer agreements with lower levels of care:
    • Which patients?
    • What facilities?
    • How…what means of transportation?
anticipate transportation needs37
Anticipate Transportation Needs:
  • Transporting discharged patients (or getting family members to pick them up)
    • Limited or no access to facility
    • Difficulty contacting families
    • Secure private ambulance/cabs for discharged patients
anticipate transportation needs38
Anticipate Transportation Needs
  • Plan for transportation of staff and supplies to and from your organization:
    • Off sight gathering locations:
      • Private vehicle vs. group (bus/van) transportation
      • Non essential employees?
        • Housekeeping
anticipate transportation needs39
Anticipate Transportation Needs
  • Provisions
    • Agreements in place to have vendors send supplies without actual request
    • Need for identification system of suppliers to pass through police or security checkpoints
transportation40
Transportation
  • Utilize personnel from labor pool as patient transporters
  • Assemble stretchers and wheelchairs in proximity to ambulance off loading and triage area
  • Identify transportation needs of `walking’ decontaminated or non-injured individuals
communications mission
Communications Mission
  • Organize and coordinate internal and external communications
  • Act as custodian of all logged/documented communications
anticipate communication needs
Anticipate Communication Needs:
  • Provisions for normal system overloaded or inoperable:
    • Telephone
    • Page
    • Cellular
    • Fax
  • Alternative arrangements:
    • Telephone trees
    • Pay phones
    • Walkie-talkies
anticipate communication needs44
Anticipate Communication Needs:
  • Organized runner or messenger system:
    • Area layout maps
  • Established communications with local emergency medical services or management agencies
  • Plans to keep staff informed
internal communication
Internal Communication
  • Systems and equipment
    • Train staff to repair equipment
    • Availability of replacement parts
    • Telephone lines buried, marked and protected
internal communication46
Internal Communication
  • Keep written records
  • Radio transmitter/receivers equipped to operate on multiple frequencies
  • Potentially use closed circuit TV or broadcast one-way messages
internal communications patient records
Internal Communications:Patient Records
  • Updating and keeping track of patient records essential
    • Triage tags
    • Medical records
      • Registration
      • History
      • Treatment
communications staff information
Communications:Staff Information
  • Frequent communications of accurate information
    • What has happened
    • How many patients to expect and when
    • How organization will help meet needs
  • Recognize healthcare workers’ needs to contact families
    • Call trees
    • Designated phone number
external communications
External Communications:
  • Establish communication lines with community and national disaster agencies
    • Employees, medical staff and volunteers
    • Family members, friends and visitors
    • Community office of emergency management
external communications50
External Communications:
  • Law enforcement or military
  • EMS dispatch/services
  • Public utilities
  • Radio operations
  • Public safety communication services
  • Health Department
security mission
Security Mission
  • Ensure any activity is done with maximum security
  • Provide personal security to staff, patients, visitors and property
anticipate security needs
Anticipate Security Needs:
  • Nuclear, biological, chemical and explosive
  • Internal vs. external
    • Internal
      • Damage to structure
        • Evacuation while minimizing passage through contaminated areas
      • Damage to support systems: water or electric
    • External
      • Prevailing winds
      • Evaluate need to turn off air conditioning, seal windows
security54
Security
  • Personnel trained:
    • Early recognition
    • Procedure to lock down or minimize access and egress
      • Direct exposed foot traffic to decontamination
      • Direct families/friends to centralized area
      • Direct media to designated spokesperson
security55
Security
  • Entry route for staff, supplies etc
  • Personnel identification policy
  • Establish ambulance entry and exit routes
  • Secure triage, ER, morgue and other sensitive areas
security56
Security
  • Maintain effective crowd control
  • Maintain chain of evidence for any criminal or other investigation
  • Provide vehicular and pedestrian traffic control
    • Parking and decontamination issues
security57
Security
  • Secure food, water, medical and blood reserves
  • Credentialing/screening process of volunteers
  • Initiate contact with fire, police agencies through communication liaison when necessary
anthrax
ANTHRAX
  • Use Standard Precautions
  • Patient Placement
    • Private rooms not necessary
    • Skin lesions may be infectious by direct contact
  • Patient Transport
    • Use Standard Precautions
  • Cleaning, disinfection, sterilization
    • Use facility procedures for surfaces, equipment
    • Bleach
  • Standard Precautions for post-mortem care
botulism
BOTULISM
  • Use Standard Precautions
  • Patient Placement
    • No person-to-person transmission
  • Patient Transport
    • Use Standard Precautions
  • Cleaning, disinfection, sterilization
    • Use facility procedures for surfaces, equipment
  • Standard Precautions for post-mortem care
plague
PLAGUE
  • For pneumonic plague, Droplet Precautions until 72 hours of anti-microbial therapy completed
  • Patient Placement
    • Place infected patients in private room
    • Cohort symptomatic patients with similar symptoms when private rooms not available
    • Maintain at least three feet between infected patients and others when cohorting is not possible
    • Avoid placing patients requiring Droplet Precautions with immunocompromised patients
plague63
PLAGUE
  • Patient Transport
    • Transport for essential purposes only
    • Patient should wear surgical mask
  • Cleaning, disinfecting, sterilization
    • Use facility procedures for surfaces, equipment
  • Standard plus Droplet Precautions for post-mortem care
smallpox
SMALLPOX
  • Airborne and Contact Precautions
  • Patient Placement
    • Monitored negative pressure room
    • Doors must remain closed
    • Facilities without negative pressure rooms should have plans for transfer of patients
    • Cohorting maybe be used in outbreaks
smallpox65
SMALLPOX
  • Patient Transport
    • Transport for emergencies only
    • Patient must wear surgical mask and be completely covered
  • Cleaning, disinfection, sterilization
    • Ensure management of contaminated surfaces and equipment
  • Airborne and Contact Precautions for post-mortem care
  • Glass vials or tubes should not be used for laboratory specimens
tularemia
TULAREMIA
  • Use Standard Precautions
  • Patient placement
    • No person-to-person transmission
  • Patient transport
    • Use Standard Precautions
  • Cleaning, disinfection, sterilization
    • Use facility procedures for surfaces, equipment
  • Standard Precautions for post-mortem care
viral hemorrhagic fevers vhf
VIRAL HEMORRHAGIC FEVERS (VHF)
  • Use Airborne Precautions
    • If negative pressure room not available, use HEPA filtration unit
    • Face shields in addition to N95 respirators
  • Patient Placement
    • Monitored Negative pressure room
    • Cohort patients with similar symptoms
  • Patient transport
    • Transport for essential purposes only
    • In elevator, all personnel should wear PPE
    • Patient must wear surgical mask and be completely covered
slide68
VHF
  • Cleaning, disinfection, sterilization
    • Meticulous cleaning daily of all surfaces and equipment in patient’s room
    • Disinfectant discarded before exiting patient’s room
    • Reusable cloths and mop heads should not be reused and sent for disinfection/laundering
    • All reusable equipment to be cleaned and disinfected before taking from room
    • Curtains and linens should be changed when soiled or on discharge
slide69
VHF
  • Cleaning, disinfection, sterilization continued
    • Cleaning bucket and mop handle to remain in patient’s room.
  • Contact and Airborne Precautions for post-mortem care
brucellosis
BRUCELLOSIS
  • Use Standard Precautions
  • Patient placement
    • Not transmitted person-to-person
  • Patient transport
    • Use Standard Precautions
  • Cleaning, disinfection, sterilization
    • Use facility procedures for surfaces, equipment
  • Standard Precautions for post-mortem care
q fever
Q FEVER
  • Use Standard Precautions
  • Patient placement
    • No person-to-person transmission
  • Patient transport
    • Use Standard Precautions
  • Cleaning, disinfection, sterilization
    • Use facility procedures for surfaces, equipment
  • Standard Precautions for post-mortem care