MJ Podcast #231 Cruise Ship Medicine

                                An introduction to life as a Chief Medical Officer with Evelyn B, Sklair, RN, EMTP

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How would you like to live and work on a cruise ship? That's exactly what today's guest does! Evelyn Sklair, RN, EMTP is a Chief Medical Officer for Holland America Cruise Lines and she is going to share with us what its like to work (and live) in this unique environment.

Evelyn is a Registered Nurse and has been active in EMS as a Paramedic for many years. She was instrumental in the development of prehosptial care at the Eastman Kodak Company and an EMS leader in Monroe County, NY for many years.


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The Coming Public Health Collapse

Co-posted on Genesee Valley Nurse

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The Anthrax attacks that followed in the days after 9/11/01 reminded us of the need for public health emergency preparedness.

Public health efforts have vaccinated millions, crushed Polio, and eradicated Smallpox, and they've done so while operating in the background of emergency management in relative obscurity...until September, 2001. The Anthrax attacks provided a wake up call to the Nation that our public health system was vital to the effectiveness of domestic preparedness efforts. Public Health was thrust into the public safety arena. With emerging biologic threats that jumped off the pages of a novel and into reality, it looked as if public health was destined to remain a part of the new traditional responder group.

Not so fast.

In Ready or Not? 2011, Protecting the Public from Diseases, Disasters, and Bioterrorism, the Trust for Americas Health reports that "key programs that detect and respond to bioterrorism, new disease outbreaks and natural or accidental disasters are at risk due to federal and state budget cuts."

We're still searching for preparedness in America. Rather than continuing to support efforts to maintain a durable healthcare/public health preparedness system, we're going to go backwards.

"We're seeing a decade's worth of progress eroding in front of our eyes," said Jeff Levi, PhD, Executive Director of TFAH. "Preparedness had been on an upward trajectory, but now some of the most elementary capabilities - including the ability to identify and contain outbreaks, provide vaccines and medications during emergencies, and treat people during mass traumas - are experiencing cuts in every state across the country."

Here are a few examples of the capabilities that will be lost:

• 51 cities at risk for elimination from the Cities Readiness Initiative
• 10 state labs at risk for losing "Level 1" chemical testing abilities
• 24 states at risk to lose Career Epidemiology Field Officers
• 14 universities at risk to lose Preparedness and Emergency Response Learning Center funds

Why? Because when nothing happens, nothing happens. And nobody wants to pay when nothing happens. We've seen concern and hype over SARS, Avian Flu, Swine Flu - and nothing not much happened. Our impression of preparedness is high visibility people with uniforms, badges, guns under the failed approach of Homeland Security. Healthcare and public health operate in the background of preparedness and lack that high visibility until some biologic threat is exposed. Then, and only then, is the value of a durable healthcare/public health system realized...temporally. Katrina reminded healthcare systems to be ready. How can they be if they're not assisted with the same level of resources afforded to other Homeland Security measures?

Preparedness for biologic events, natural or intentional, requires funding to remain constant for healthcare and public health. That funding needs to be on par with other traditional response groups. Without healthcare/public health we will face what it  means to live or die in disaster.

Failure to maintain healthcare/public health durability will worsen the ripple effect from biologic events by increasing strain on traditional responders and healthcare systems and by worsening the impact on special needs and at-risk populations. These things add up to poor outcomes from natural or intentional biologic events. Poor outcomes that can be predicted, and prevented if we'd change the way we think.

Get this Biosecurity app before your next shift

Co-posted on Genesee Valley Nurse

The Clinicians Biosecurity App for healthcare providers from the Center for Biosecurity of UPMC is one app you'll want before your next shift.

Home screen on iPad

The Center for Biosecurity of UPMC has released their latest app for iOS. The Clinicians Biosecurity Resource (CBR) App covers the basics of several diseases with feature rich content for further leaning. CBR easily overpowers their prior offering, BioAgent Facts app. Click here for my review of the BioAgnet Facts app.

Disease list on iPad

The CBR app covers six diseases with enough detail to make this a worthwhile reference to assist in the recognition of a naturally occurring or intentional biologic event. The information for each pathogen is broken down into categories and is  referenced to fact sheets from the Centers for Disease Control and Prevention (CDC) and he Center for Biosecurity. The value of the CBR app is increased substantially by the addition of sections for each pathogen on naturally occurring states, post exposure prophylaxis, personal protective equipment (PPE). The content is digestible, concise, and easily accessed through the apps interface. Images of x-ray findings are included (see Anthrax below).

Access to Biosecurity News

Notification option

You can also access Clinicians Biosecurtiy News (CBN), published twice monthly, directly from the home screen. Clicking on the wrench icon on the CBN page provides an option to be reminded about CBR updates. The information icon (i) links to the 'about' page containing a disclaimer, developer credits and additional links for reference.

Typical bioagent page layout shown below (Anthrax page as example)

 

The Clinicians Biosecurity Reference (CBR) will be useful for emergency medical service professionals, nursing, as well as physicians. The layout/design and feature rich content take this app above and beyond. Navigation and user interface are simple and CBR runs smoothly on iPhone/iPad running iOS 5.0.1. The color scheme is much easier to read than BioAgent Facts. I highly recommend the CBR app.






Final Score 0-5: The CBR app gets a 4.5
Content: 4.5 Solid information from a trusted resource, easy to access and scan. External links to CDC and Biosecurity News add value. CBR app can go a long way being used as reference and learning tool. Dumping the Zombie section (as seen in BioAgents Facts) and adding sections for Naturally Occurring, PPE, and Post Exposure information is a major improvement.

Aesthetics/graphics: 4.0 Detailed graphics and color combinations that are easy on the eyes.

Ease of Use: 4.5 I found the tabs/buttons easy to navigate. Text is clear with pleasing color combinations. Stable on an iPhone/iPad (iOS 5.0.1) there is no clear support/FAQ available.

Wishlist for CBR:
Allow screens to rotate. This would be especially helpful for iPhone.
Enable gestures. Again, a big advantage for iPhone

Fight Fatigue, Reduce Error

The Joint Commission says fatigue risks patient care

The Joint Commission has issued a position warning  healthcare agencies to fight medical errors by fighting fatigue. Citing the link between health care worker fatigue and adverse patient care events, the Joint Commission revisited the issue of extended shifts and fatigue in a recent Sentinel Event Alert. 

According to the Joint Commission: 

Fatigue resulting from an inadequate amount of sleep or insufficient quality of sleep over an extended period can lead to a number of problems, including:

• lapses in attention and inability to stay focused
• reduced motivation
• compromised problem solving
• confusion
• irritability
• memory lapses
• impaired communication
• slowed or faulty information processing and judgment
• diminished reaction time 
• indifference and loss of empathy

 In 2007, the JC noted that strong evidence exists linking medical error, fatigue, and extended duration shifts. The findings indicate that exteded shift and night shift workers make 36% more serious preventable adverse errors than others and have a 61% more needlestick or sharps injuries. 

The take home message is that healthcare organizations need to assess the shift work/hours worked environment in their institutions for patient and provider safety. Key to reducing errors is to provide a culture of proactive safety. Staff should be able to express concerns about fatigue in the same way they would express concern if a colleague were impaired by intoxication.

Can these findings be applied to prehospital care? Certainly. While not be the norm in prehospital care, many services do work 24 hour shifts. It's far more common to find EMS professionals who may work far more than 24 hour shifts between multiple jobs. That is, work 12 or 16 hours at one EMS agency then go work another 8 or 12 at a part-time gig. Part-time work and other "off duty" work is not addressed by the JC in terms of healthcare providers. The fact remains that many EMS professionals do work more than one job. There is, of course, the dreaded "late call" that threatens to turn you 16 hour shift into much, much more.

Read The Joint Commission News Item/Action Alert: Click here
Direct Download Sentinel Event Alert: Click here

MJ 230 Your 2012 Preparedness To-Do List

 Welcome to 2012 and another year with Mitigation Journal. This weeks podcast is a summary of the challenges we face for planning and what we can do about it! Rather than give my predictions (as good as they are) I'd like to share a to-do list - a list of items that will help prepare for large scale events as well as the every day events.

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Less than lethal can still be deadly

Planning, decontamination, proactive response is needed. 

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Riot control agents are considered “less-than-lethal” but they possess the potential to create multiple patients, decontamination issues, and respiratory hazards to the responders. Although usually not deadly, exposure to riot control agents stress the respiratory and cardiovascular systems. Like many other respiratory irritants they exacerbate a variety of respiratory and cardiovascular medical conditions and cause hypoxia resulting in critical patients.

Exposed persons with liquid product remaining on the skin or clothing is another concern. Certain types of chemical mace and pepper spray can cause skin irritation and burns. Ocular exposure can result in loss of sight.  Persons who remain contaminated with product also threaten secondary contamination by exposing responders to off-gassing. If exposed, contaminated persons are allowed to get into an ambulance or worse, into the hospital, without proper decontamination, the risk of significant secondary contamination and potentially hinder hospital efforts. Along the same theme is the risk of self-referring victims. People who have been exposed to a riot control (or any other irritant liquid or gas) may leave the scene prior to being decontaminated and triaged. Victims self referring to hospitals or urgent care centers pose a significant threat of secondary contamination. This risk is even greater when the local health care institutions are left out of the pubic service information loop. 

When encountering a situation involving riot control gases, I recommend the following:

• Never assume the obvious threat is the only threat; other potentials should be considered. When someone tells you "its only pepper spray", don't believe them. Consider the potential of other agents such as cyanide, hydrogen sulfide, nitrates, chlorine, and phosgene can cause similar signs and symptoms to riot control agents.

• Proper personal protective equipment and atmospheric monitoring devices must be used. This should include respiratory protection for responders. Canister masks or self contained breathing apparatus may be the appropriate level of protection. Atmospheric monitoring and non-invasive monitoring of patients should also be considered to help identify the agent. 

• Anyone with reasonable exposure to the material should be assessed and decontaminated prior to leaving the scene. Little can be done for the internal exposure a gas. Those with exterior contamination, those who have residual agent on the skin or clothing, must undergo emergency mass decontamination prior to transport.

• Local health care systems, including urgent care centers and walk-in care centers, must be informed of a chemical event occurring in their area. Health care systems must be able trigger their Emergency Operations Plans as soon as possible in order to prepare for the possibility of contaminated self-referring victims.

• Fire and EMS resources should be deployed to appropriate health care locations in effort to assist with secondary decontamination efforts and management of contaminated self-referrals. 

Priority must be given to pre-planning at areas of critical infrastructure. Schools, hospitals, government buildings, and sporting venues are examples of soft targets that may also be considered critical infrastructure. Collaborative planning and training efforts between traditional and non-traditional responders (ie: EMS/Fire and school officials) will pay big dividends during crisis.

Response plans must be tested, practiced and revised. Tabletop exercises are a great low-cost way of doing this. Plans should be general in scope with annexes for specific threats. Planning for school events must include accounting for weather, media, dispersal of victims prior to arrival and site security. Don’t forget to build in communication with local hospitals.

Concern over too much school security has asserted that school security measures are a result of paranoia and not actual potential for an event. My stance is that schools are facilities of critical infrastructure by virtue of occupancy and potential impact of an attack/event. A natural disaster such as an earthquake or a Columbine-like attack will yield panic and disruption in any community. We cannot simply dismiss an event, any event, involving health care facilities, schools or other areas of critical infrastructure. They are soft targets and should be hardened and protected.

Four Drugs Cause Most Problems for Seniors

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A study published in the New England Journal of Medicine indicates that four medications cause the most adverse drug reactions resulting in hospitalization of seniors. According the CDC study and Medscape article, two thirds of the 100,000 hospitalizations of seniors each year are caused by Adverse Drug Reactions (ADR) involving anticoagulants and diabetic medications.

According to the CDC website, four medications, used alone or together, accounted for two–thirds of the emergency hospitalizations:

• 33 percent, or 33,171 emergency hospitalizations, involved warfarin, a medication used to prevent blood clots.

• 14 percent involved insulins.  Insulin injections are used to control blood sugar in people who have diabetes.

• 13 percent involved antiplatelet drugs, such as aspirin or clopidogrel, which prevent platelets, or pieces of blood cells from clumping together to start a clot.

• 11 percent involved diabetes medications that are taken by mouth, called oral hypoglycemic agents.

The Centers for Disease Control and Prevention define an Adverse Drug Events (ADE’s) as a serious health problem, and have published the following Key Facts on Medication Safety:

It is estimated that:

• 82% of American adults take at least one medication and 29% take five or more [1];

• 700,000 emergency department visits and 120,000 hospitalizations are due to ADEs annually [2];

• $3.5 billion is spent on extra medical costs of ADEs annually [3];

• At least 40% of costs of ambulatory (non-hospital settings) ADEs are estimated to be preventable [3].

The numbers of adverse drug events will likely grow due to:

• Development of new medications
• Discovery of new uses for older medications
• Aging American population
• Increase in the use of medications for disease prevention
• Increased coverage for prescription medications

For more on this topic, visit the CDC Medication Safety Program.

2012 To-do List

No predictions! - Four actions for preparedness in the New Year

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Like many of you, I like to make predictions around this time of year and, like many others, these predictions fall short of reality and are forgotten in a few weeks. We can do better! For 2012 I’m not making any predictions...I’m giving you a to-do list! A four point list of actions to take that will make you, your agency, and your community more prepared for naturally occurring disasters and intentional events. Take these items one at a time...and take your time with each. You’ll be surprised how fast you’ll be able to improve your preparedness.

Conduct a Hazard Vulnerability Assessment (HVA). Some might call this a hazard vulnerability inventory (HVI). The Hazard Vulnerability Assessment (HVA) examines the occurrence or potential occurrence of a given hazard(s) in your community. The impact of the hazard(s) should be measured in terms of impact or threat to life and health, physical damage, and damage/disruption to critical infrastructure.  Your HVA should also account for economic and social factors that will increase vulnerability to any given hazard. The Hazard Vulnerability Assessment is not a prediction but an analysis designed to answer questions or “what if” scenarios.
If you’ve done your Hazard Vulnerability Assessment, great. Then add a review and validation of that assessment to your To-do List for 2012.

Work on your Pre Incident Plans. Pre planning can be a never ending chore. Hazards change, threats increase and decrease, and capabilities may also change. The general basis for pre planning emergency and disaster situations is to maintain a certain level of preparedness and interoperability. Your pre plans should include regional and local response to biological events, both naturally occurring and intentional acts. Consider incorporating regional plans into your local pre planning as well. I’d also suggest a review of any plans to receive assets and resources during crisis situations. One such area to consider is a plan to receive assets from the Strategic National Stockpile or other supply. Consider including or updating pre plans that are specific for public information, explosive events, and active shooter events. Click here for more on Pre Incident Planning.

Define your Target Hazards. A target hazard can be defined as a location or area that poses an increased level of interest or attraction to an intentional event. Target hazards can also be identified as those areas or locations that have increased life hazard or secondary risk associated with them. Locations of critical infrastructure should be on your target hazard list as well. Critical infrastructure includes any location or service that, if lost or compromised, would limit or stop your ability to provide service. Power generation, water treatment, hospitals, public service should all be considered areas of critical infrastructure. When defining your target hazards, don’t limit yourself to those locations within your community. You should consider the high value/critical infrastructure locations in neighboring jurisdictions as well. Doing so will increase your preparation and effectiveness during mutual aid responses.

Combine your Hazard Vulnerability Assessment (HVA), Pre Incident Plans, and Target Hazard Identification into training. Use the Exercise Design Process to build realistic training opportunities. Don’t be afraid to start small or call on an outside expert to help construct your training activities. Build on what you do now...start with small seminars to summarize the training objectives and raise awareness to the situation, then conduct a tabletop exercise to add an element of stress yet provide a safe training environment. After you’ve built your training base, move on to a series of drills that test one or two elements of your plan. You can then move on to conducting functional exercises testing large plans in realistic field scenarios. For 5 tips to improve your exercise design click here.