LA Peds Ready Podcast: Special Pathogens – Part 1

LA Peds Ready is a collaborative effort to ensure that every emergency department in Los Angeles County is prepared to provide high-quality, life-saving care for children. High levels of Pediatric Readiness are associated with:

• Up to 76% reduction in mortality for critically ill children
• Up to 60% reduction in mortality for injured children
• An estimated 2,143 children’s lives saved each year nationwide
• ED costs ranging from $4 to $48 per child

The following is the first of 2 podcasts discussing considerations for special pathogens exposure in the community and how EDs can prepare for it. In this episode, we are joined by Brad Goldberg, MD (Children’s Hospital Los Angeles), Erika Cheung, RN (Children’s Hospital Los Angeles), and Pooja Nawathe, MD (Cedars-Sinai)—leaders from the LA County Special Pathogens Program. Together, we discuss how emergency clinicians can recognize, isolate, and respond to patients with emerging infectious diseases using the practical Identify, Isolate, Inform (III) framework. From travel screening and PPE to isolation protocols and communication with public health, this episode is packed with practical pearls to help your team prepare before the next outbreak arrives.

Show notes by: Samara Fattal, Undergraduate Scholar – University of California, Berkeley

• Special pathogens are high consequence infectious pathogens or those that are emerging or novel agents for which no current vaccine or cure exists, and where mortality rate is expected to be high. (e.g. Ebola, SARS Cov-2)
• They are highly transmissible, require special isolation and biocontainment units, and are difficult to rapidly recognize and detect. Many emerging or novel pathogens are respiratory in nature.
• Specific terminology and acronyms:
  • IPC (infection prevention and control)
  • VHF (viral hemorrhagic fever)
  • III (identify, isolate, inform)
    • Note: Isolation refers to the act of separating suspected infected patients from non-infected patients, whereas quarantine refers to separating exposed, asymptomatic patients from others during an incubation period.
  • Pathogen levels by hospital centers (levels 1-4)
    • Levels 1 and 2 centers serve as treatment centers and treat patients throughout the duration of their illness.
    • Levels 3 and 4 centers are assessment hospitals and other healthcare facilities with lower capabilities. They serve to recognize a diseased patient and provide care up to for 36 hours before transfer to a treatment center.
  • The identify, isolate, inform (III) system is a structured approach to managing infectious disease while screening patients.
    • Identify: Targeted screening questions to recognize concern early. This screening should take less than 2 minutes and follow the goal of recognizing risk rather than identifying the pathogen. High yield screening questions include:
      • Has the patient traveled within the last 21 days, if so to what regions/provinces?
      • Did the patient have any contact with sick travelers (including animals)?
      • Was the patient in any high-risk scenarios including a hospital or funeral?
    • Isolate: To limit exposure to others, including staff. Isolation happens as soon as suspicion arises during screening, with masking for the patient and family members. While isolating the patient, a negative pressure room is ideal; however, if not available, use a room which has a door, an individual bathroom, and not in a high traffic area (to the extent possible).
    • Inform: This involves notification of public health partners. Information includes timeline of travel, cities and provinces visited, airports attended during travel, reason for travels (funeral attendance, alongside a sick loved one, hospital visits, nearby animals), and the symptomatology of the patient (when they first got sick, who around them is sick, what are their symptoms).
    • Who to inform and when to do so is reliant on a hospital’s specific protocol. If a hospital has no subject matter experts, public health should be included early.
    • A potential 4th I: Initiate care: While not an official step, it is the next logical action to be taken after informing others. If the patient is stable, they should be taken to a room where vitals are collected and need for expanded evaluation is determined (public health protocols must be followed when taking labs on an infection patient). If the patient is unstable, treatment should be started immediately with necessary PPE being used. Point of care should be utilized as much as possible, communication with laboratory staff is paramount, and no blood should be sent through a tube system.
  • Personal protective equipment (PPE) is a crucial step when dealing with special pathogens. If the pathogen is unknown, baseline PPE includes a face shield (eye protection), a fit tested N95, a gown, and gloves. In situations with aerosol generation, hazmat suits are preferred, but for less equipped hospitals CAPR’s or PAPR’s should be used. Training resources are necessary for all PPE, otherwise its purpose is defeated.
  • For administrators looking to create protocols, alerts should be used from the CDC, WHO, and local health departments. Someone must be designated to translate alerts into actual changes. Flexibility and updates based on recent literature is key.
  • It is crucial to remember supportive therapy and management principles for the patient. Continuously, consider the whole team and be methodical. Early decisions and utilizing resources can make a large difference.