An emergency response plan to control emerging infectious disease hazards in Taiwan ’ s Hospitals

1 Department of Health Services Administration, Chung Shan Medical University, Taiwan. 2 Department of Medical Education, Chung Shan Medical University Hospital , Taiwan. 3 Institute of Occupational Safety and Health, Council of Labor Affairs, Executive Yuan, Taiwan. 4 Institute of Medicine, Chung Shan Medical University, Taiwan. 5 Department of Applied Foreign Languages, Chung Shan Medical University, Taiwan.


INTRODUCTION
The phrase "emerging infectious diseases (EIDs)" refers to infectious diseases that have increased in incidences in the past two decades, or that may affect humans in the future.Each occurrence of an emerging or reemerging infectious disease causes great damage to a nation's and/or the world's economies and the lives of its citizens.Cases such as the outbreaks of the Ebola virus (Hoenen et al., 2006), H5N1, the avian influenza virus in Hong Kong (Li et al., 2004), the Nipah virus in Malaysia (Adam, 1999), the West Nile virus (Mostashari et al., 2001), and severe acute respiratory syndrome (SARS) in China, Hong Kong, Singapore, Vietnam, Taiwan and Canada in 2002, are all examples of EIDs (Centers for Disease Control and Prevention, 2005).EIDs are highly unpredictable, because it is unknown when, where or what infectious disease may occur, so no specific corresponding preparation may be taken in advance (Su et al., 2003;Wilson, 1999;Alleyne, 1998).Michael et al (2012) studied International Health Regulations in reporting WHO for EIDs and they found that by setting up more prescriptive criteria, the validity could be improved.However, the criteria should be adjusted in order to adapt to future unknown EIDs' threats.Attacks of EIDs in hospitals and among healthcare workers are far-reaching.Hospitals in the post-SARS era must have proper and complete response measures.There must be a well-structured standard operating procedure (SOP) for each department in a hospital: whether it is the infectious response organization, personnel training, logistic planning and mobilization, infectious disease operation standards, staff protection measures, or others, action must be taken to prevent the re-emergence of infectious diseases so that hospitals are not part of the transmission chain.According to studies (Wilson, 1999;Alleyne, 1998), when there is an EID outbreak, about 3 to 5 percent of patients contract nosocomial infections, leading to longer hospital stays which consume limited hospital resources, expand the actual disease incident and mortality rates, and potentially increase the pressure on hospital healthcare cost controls.Furthermore, the surge of EIDs, the re-emergence of existing infectious diseases, and the increase of multi-drug-resistant bacteria are demonstrating the importance of infectious disease control and the development of SOP guidelines to hospitals (Gamage et al., 2005;Lu et al., 2006;Carrico et al., 2008;Rebmann, 2009a).
Effective emergency response strategies are indispensable in reducing EID transmission in hospitals.Although EIDs are not a prevalent threat, their occurrence often causes panic in a community; consequently, hospitals must invest a considerable amount of resources to curb the crisis brought on by the EIDs, and develop effective emergency response plans (ERPs) to minimize the damage.Rebmann (2009c) points out that hospital emergency management plans not only stop the transmission of infectious diseases-more importantly, they also reduce healthcare workers' fears of becoming infected.However, the establishment of an ERP must be supported within the concept of risk management.Based on the Australian Standard (AS/NZS 4360: 1999), risk control is defined as "part of risk management, which involves the implementation of policies, standards, procedures and physical changes to eliminate or minimize adverse risks".
The purpose of risk control is to reduce the damage caused by catastrophic hazards because the occurrence of a disaster may result in human casualties, financial ruin or environmental damage.Formulating a plan that encompasses staff, facilities and management thus has far-reaching impact for hospitals.
In this study the researchers aim to design and develop an emergency response framework to minimize the probability of healthcare workers becoming infected when a hospital is experiencing an EID outbreak.The results of the study may be used as a reference for hospitals to formulate EID hazard management plans, and the emergency response components proposed in this study may be used to compile more detailed SOPs.

RESEARCH METHODS
The research methods used in this study are document analysis and in-depth interviews, described as follows:

Document analysis
A literature review and document research were conducted for this study.Journals and professional reports were the focus of the literature review and were used to understand EID hazard management measures used overseas.Document research focused on infectious control guidelines and ERPs provided by the World Health Organization (WHO), the U.S. CDC, CDC Taiwan, the Institute of Occupational Safety and Health, and by ten different hospitals in Taiwan.

In-depth interviews
This study conducted in-depth interviews with a total of 15 hospital staffers, including infectious disease specialists, infection control personnel, and occupational safety and health management staff.The interviews primarily focused on the tasks of the infection control department, and the occupational health management procedures, protocols, and tasks of each hospital during the SARS outbreak, in order to gain insights from key personnel from each hospital concerning EID hazards and gather their insights on system design, which was then used as the basis for an emergency response framework.

Formulating and revising the ERP-The PDRA
After reviewing and analyzing the emergency response documentation developed by various hospitals, the researchers selected the management cycle theory proposed by Deming (1986) in which he suggested that a planned management action, PDCA (Plan, Do, Check, Action), should be implemented.The PDCA is illustrated in Figure 1.
In this approach, P stands for plan: all management activities begin with planning, and only with a detailed plan can obstructions to implementation be minimized.D stands for do: a perfect plan relies on its execution, and Deming (1986Deming ( , 1993) ) stresses that execution is necessary to follow a plan through to completion.C stands for check, checking the result of doing: administrators should have a checklist to monitor how many elements of an ERP had been implemented, and to identify obstacles or items that require improvement.A stands for improvements and corrections made to the checked results and the management activities after implementation.The PDCA management cycle is thus repeated, each time bringing it closer to the goal and achieving the best management results.To apply the PDCA approach to formulating and improving hospital ERPs, the researchers drew up a PDRA Emergency Response diagram, shown in Figure 2.
The PDCA approach was modified to PDRA in this study, where C (Check) was replaced by R (Research) for research improvement.Its significance lies in that infectious control personnel and occupational health management staff must continuously research and absorb new information in the process of handling EID hazards.For example, the information gathered from the websites of organizations such as the WHO, the U.S. CDC, the CDC in Taiwan, and other professional medical associations, is used to educate the public and to plan amendments.Furthermore, infectious control personnel are constantly involved in computing the infection rates of various viruses for each clinic, ward, and department, to help find possible infection sources and prevention measures with the help of statistical analysis.These tasks are beyond the description of Checking, and are more in line with Research.The design of the PDRA diagram below is based on the idea of loss control: a hospital is represented in the center as the main structure, surrounded by an inner circle and an outer circle, indicating that an emergency response mechanism activated during an EID outbreak will perform as an elaborate protection system to defend healthcare workers from infection.If a case of nosocomial infection occurs, this emergency response mechanism will contain the damage within the hospital, preventing the spread of the illness to other hospitals or to the public and thus avoiding panic.Arrows of the inner circle point to PDRA, while the outer circle contains the emergency response framework and its components.
Prior to field-testing the framework, experts in the relevant fields were convened for a forum discussion, and thereafter the emergency response management framework was divided into 11 components: 1) emergency response measures; 2) nosocomial infection control of the healthcare unit; 3) patient transfer within the hospital, patient transfer in and out, and patient transport; 4) hospital staff protection; 5) fever screening operation; 6) quarantine area and (negative pressure) isolation ward infection control; 7) protection and safety measures; 8) logistic support operations; 9) training education; 10) audit procedures; and 11) occupational hazard compensation.The P in PDRA means that hospitals must formulate more detailed SOPs, while following the 11 components of the outer circle of this study.D means that ERP drills, or the activation of the emergency response mechanism, must be managed by observing SOPs.R means that if an SOP needs improvement after going through the above-mentioned D process, the infectious control department or occupational health department should study and continuously improve the SOP.A means that in order to verify the ease of implementation of the amended SOP, simulations and drills must be conducted.The 11 components are assessed and improved by using the PDRA periodical cycle mechanism, and include a feedback mechanism.The outer circle indicates that although each of the 11 components operates independently, situations may arise where one can impede another.As such, mutual assistance and support are required to maintain the integrity of the goal.

Formulating the emergency response framework and its components
To further understand the content encompassed in the 11 components, in-depth interviews were conducted.Summaries of these interviews are listed below.

Item 1: What are the top components of the emergency response measures (ERM)?
The ERM in hospitals is determined by top management.In an emergency, the hospital staff would be divided into a logistics group, a medical group, an infection group and other groups, based on their job assignment.Most importantly, there must be clearly defined authority and responsibility.
There must be a clearly defined command center with full-time secretaries who can keep abreast of the immediate situation within the hospital.There must be a complete and thorough reporting process such as the 5W1H (Why, What, Where, When, Who, How) method, and the reporting protocol must be clearly defined.
There must be a drill template setup for the ERM, so that confusion can be avoided when a crisis occurs.Hospitals must set up a quarantine area to avoid transmission between healthcare workers and patients.When hospitals cannot handle infectious patients, a relevant medical care plan may be required.Perhaps patients could be sent to a dedicated hospital, experts could be invited for assistance, or an emergency medical team could be called to help.The ERM should be revised periodically, must comply with the WHO's or the CDC's EID monitoring system, and drills must be conducted so that the staff can cope with the impact of the next wave.

Item 2: What should be included in the nosocomial infection control plan in a healthcare unit?
Departments should be separated based on their infection probability to avoid confusion.The emergency room, being the frontline of the impact, is particularly important.Additionally, the hemodialysis room, burn unit, maternity ward, nursery, intensive care units (ICU), operating rooms, pediatric ICU, respiratory care wards, laboratory unit, pathology unit, and radiology unit are all highly susceptible to infection and must have special attention.The outpatient clinic, general wards, supply center and nutrition department are less susceptible, but they could also be part of the viral transmission chain and will need special attention.
The morgue is also very important.It has been reported that workers at a mortuary contracted SARS when handling the remains of a SARS patient.

Item 3: What should be included in the guidelines for patient transfer within the hospital, patient transfer in and out of the hospital, and patient transport?
Patients with suspect infections may be transferred to isolation wards.It is possible that patients with suspect infections could be transferred in from areas outside of the hospital.
If the hospital is not a dedicated hospital for EID, and is visited by patients with suspected infections, these patients must be transferred to a dedicated hospital for care.
Personnel responsible for transporting specimens taken from hospitalized patients with suspect infections must take precaution to avoid contamination.Precaution should also be taken when taking X-rays of these patients.A mobilized X-ray machine is preferable; however, a hospital without such equipment must have an operating protocol in place to avoid contamination.

Item 4: What kind of personal protection equipment (PPE) should be provided for hospital staff?
Proper use of PPE played an important role in protection during the SARS outbreak.During the outbreak, government agencies issued equipment to hospitals, including a variety of facemasks and other protective equipment, which many healthcare workers did not know how to use correctly.
When several employees come down with fevers, it indicates the possibility of a nosocomial infection outbreak.These cases must be handled carefully.Other people with whom the affected employee(s) may have come into contact must be traced, body temperatures checked and reports submitted.Relevant operation standards must be clearly defined.
Outsourced staff and pharmaceutical representatives go in and out of various units in the hospital.They can easily become part of the viral transmission chain.Their non-hospital employee status makes them blind spots in a disease-prevention plan, so relevant guidelines must be developed to handle non-hospital employees.
Item 5: What processes are to be included in the fever-screening operation?
Fever-screening centers should be established and SOPs developed.During the outbreak of SARS, fever-screening centers were established to prevent the shutdown of emergency rooms due to contamination.
Outpatient nurses must be trained to handle patients with fevers, or lead them to the fever-screening center.If patients are confirmed as suspected infection cases after the screening process, they should be assisted with hospitalization.The ER should be divided into two areas: a general area and a quarantine area.Patients with fevers should be in the quarantine area, in case they are confirmed to be suffering from an infectious disease.

Item 6: What should be included in the infection control operation for the quarantine area and negative-pressure isolation wards?
Hospitals must isolate an area for quarantine, and have an effective control protocol to manage patients and healthcare workers.Thorough disinfection and wearing PPE are absolutely required when entering negative-pressure isolation wards.The protocol for this procedure must be strictly enforced.Isolation wards must be regularly disinfected.A strict infection-control operation standard is required.Moving between isolation wards will require a set of protocols to avoid escalating the suspected cases into confirmed cases.

Item 7: What should be included in protection and safety measures?
There must be a system for patient monitoring, and for keeping abreast of the nosocomial infection issues.Data analysis should also be conducted to detect potential outbreaks or epidemics.Once detected, any incident must be immediately investigated.Environmental facilities and medical equipment that may be contaminated or pose a potential threat to health should also be monitored.Fever-screening stations and negative-pressure isolation wards must be established.

Item 8: What should be included in a logistic support operation?
The handling of clothing, blankets, bed sheets, and hospital gowns of patients with suspected infections is utterly important.The dirty clothing of the patients in the isolation wards must be disinfected before it is taken out of the ward.Process procedures are required to prevent viral transmission via clothing.
There should be a stricter procedure than the general rules for handling hospital waste and infected objects: for example, waste collectors should also wear PPE, and waste and infected objects should be sprayed with high concentrations of disinfectant before collection.
Cautions should be taken for terminal disinfection of the isolation ward.There must be a strict disinfecting operation procedure in place to eradicate any residual virus.
When ERM is activated, special attention must be given to material supplies and control management.For instance, during the SARS outbreak, some healthcare workers had to supply their own facemasks, while there was a significant shortage of protection gear supplies on the open market.Necessary medicine and medical equipment should be delivered on time once a request is submitted.
Particular attention must be taken in the handling of suspect patients' remains.After the remains are placed in body bags, they should be sprayed with disinfectant.It is preferable to double-bag the remains to avoid contaminating mortuary personnel.

Item 9: What should be included in the training education of the ERM?
The ERM drill should be held at least once every six months, or upon a plan being amended.However, to work around busy schedules, each unit may submit its own drill schedule and supervision may be arranged accordingly.The ERM drill should be designed with various conditions in mind, specifically the use of protection gear.The PPE worn by healthcare workers in quarantine areas, negative-pressure isolation wards, and general areas varies.Proper usage of PPE is an indispensable element in epidemic prevention and should be taught in advance.
There should be a standardized process for checking body temperature.Staff responsible for checking temperatures should be able to operate and read the equipment correctly.It is also very important for the healthcare workers to monitor their own temperatures.Workers should be trained to correctly mix and use disinfectants.

Item 10: What should be included in auditing procedures?
There should be a performance-assessment system to check the effectiveness of the implementation.
The assessment system should include internal and external audits, as well as corrective measures and post-correction assessment methods.

Item 11: What should be included in occupational hazard compensation?
Occupational hazard compensation should comply with relevant occupational hazard regulations, which include the Labor Standards Act (2011), Enforcement Rules of the Labor Standards Act (2009), and the Act for Protecting Workers of Occupational Accidents (2001).Summarizing the above, the emergency response framework and its components are presented in Table 1.

DISCUSSON
To prevent EID hazards, discussion on how government and hospitals could implement the ERP are proposed in this study:

Regulations on the handling of biological hazards should be added to the existing Labor Safety and Health Act (2002)
Article 1 paragraph 7, and article 2 of the current Labor Safety and Health Act require that employers provide the necessary safety and health facilities and measures for handling biological pathogen hazards (Council of Labor Affairs, 2002).However, the Act lacks relevant emergency response guidelines, which means that hospitals can only apply nosocomial infection control measures for the prevention of EID hazards.The existing infection control measures have blind spots, that is, when sources of EID hazard are unclear, the means of controlling infection may be inadequate (Rise and Fall of Diseases, 1993;Chang, 2003).As mentioned in the editorial "Rise and Fall of Diseases" (Rise and Fall of Diseases, 1993), EID hazards and relevant information (that is, alerting or not alerting the public to the threat) must be controlled with an epidemiological approach.There is no "gold standard" of quickly acquiring relevant information.Chang (2003) points out that the speed and accuracy of diagnosing SARS is an important factor in controlling an epidemic; thus a rapid screening test method is necessary.Obviously, EID hazard management refers only to the application of infection-control methods.Before EID hazards can be identified, the discrepancies between the various infection control methods must be bridged by an effective ERP.Bryce et al. (2008) suggest that good resource allocation among a hospital's infection control department and occupational health department will promote healthcare workers' understanding of infection prevention practices.Bryce et al. (2008) research indicates that infection control departments and occupational health departments perform core tasks of EIDs prevention.Infection control departments' tasks to prevent EIDs currently include: establishing an infection-control monitoring system and infection-control measures; using an epidemiological approach to investigate and process nosocomial infection incidents; providing information for internal hospital inquiries concerning nosocomial infections; implementing nosocomial infection monitoring and data analysis; and reporting to the relevant authorities concerning the status of nosocomial infection (Rebmann, 2009).The responsibilities of occupational health departments with respect to EID prevention focus on effectively blocking the transmission of pathogens and performing successful risk management, such as: 1) formulating a respiratory protection plan; 2) assisting employees in selecting protective gear to avoid getting infected, such as goggles, gloves, isolation gowns, face masks, and face shields; 3) assisting in the design of negative-pressure isolation wards or negative-pressure workplaces to avoid spreading biological pathogens within the hospital; 4) formulating an ERP so that each hospital department knows how to respond to pathogens in a "rapid" transmission mode; and 5) formulating training education plans so that employees understand the hazards of biological pathogens and their response measures (Chang, 2003), There seems to have been little literature concerning how an occupational health department can contribute to the prevention of EID hazards before the outbreak of SARS.However, since the outbreak of SARS, prevention measures originally designed for occupational hazards (such as the selection and use of PPE, and the industrial ventilation technique, which was adopted in the design of negative-pressure wards) have become effective methods of blocking the spread of EIDs.Subhash and Radonovich (2011) point out that future EID prevention programs may adopt the methods used in the 2003 SARS outbreak, and that prudent planning used in the design of negative-pressure wards successfully blocked the transmission of SARS.

The division of labor between infection control departments and occupational health departments must be coordinated to prevent the outbreak of EIDs
Loss control is an important concept in occupational health management (Badri et al., 2012).A hospital's management measures in responding to EID hazards may include occupational prevention measures such as those used in a factory against the hazards of unknown chemical agents.By introducing effective ventilation techniques and selecting and using proper PPE, a disease may be controlled.In the selection and the usage of PPE, the factory know-how may: 1) introduce healthcare workers to the correct method of using face masks, directing their attention to the different grades of the product and the snug fit of the masks; 2) provide healthcare workers with information on identifying various masks and selecting the appropriate mask to avoid inadequate protection; and 3) advise healthcare workers on protection gear issues and recommend tighter protection measures when providing high-risk medical  (Chang, 2003).Mauner et al. (2003) suggest that many healthcare workers were infected despite wearing masks during the SARS outbreak, and therefore many suffered a great psychological impact.Therefore, the guidance on selecting and using masks is necessary.For ventilation techniques, factory know-how can assist the hospitals in building isolation wards or negative-pressure wards.In terms of isolation ward function tests and the ventilation system assessment of fever clinics and screening stations, factory know-how can provide models for the use of assessment checklists and assist hospitals in performing on-site ventilation system assessments and isolation ward personnel management (Chang, 2003).

Hospitals can refer to the emergency response framework developed in this study to formulate their own SOPs
In this study the researchers developed an ERP based on the concept of loss control, which correspond to logical management processes.With this emergency response framework, each hospital may be in charge of its own detailed operation standards, processes and procedures based on their organization structures and respective tasks, to implement infection control and occupational health management.Corner and Shaw (1989) point out that designing a set of procedures and an advanced warning system will reduce the risk of infection.

Hospitals should set up an EID hazard risk assessment mechanism
To quantify loss-control performance, hospitals can set up a quantified risk assessment mechanism for possible EID damage and its consequences, such as Fault Tree Analysis (FTA) and Preliminary Hazard Analysis (PHA) (among others), which may also further promote the functionality of ERP (Cameron et al., 2008;Fung et al., 2010).

Hospitals should strengthen training, education, and drills to implement EID hazard prevention
The key to implementing ERM is training education and practice, the purpose of which is to let healthcare workers familiarize themselves with the content and processes of ERM, and to have sufficient knowledge on the use of PPE, so as to avoid panic when an ERM is activated.Carrico et al. (2008) proposed that infection control training education must be used with a well-defined training method, and the comprehension levels of medical and non-medical personnel concerning the training content must be closely monitored.John and Zambrano (2004) propose that an ERM must include assessment and continuous updating of the training, education methods and content, and must provide for continuous education.

Hospitals should strengthen communication/ coordination, setting up a framework and a center for incident command structure to deal with various emergency activities regarding EIDs
The communication and coordination network in the emergency response framework is crucial to successfully control EIDs hazards.Rebmann (2009a) emphasized that infection preventionists should play an important role to facilitate emergency response system, including internal/external communication/coordination.Also, each hospital should have their own organizational structures establish an incident command structure and a center to deal with various emergency activities regarding EIDs.

Conclusion
For global EID monitoring, hospitals must pay close attention to information from the World Health Organization (WHO), and reports from newspapers and magazines, in addition to officially provided information, in order to facilitate the activation of ERM.In this study, the researchers adopted Deming (1986Deming ( , 1993) ) PDCA management cycle theory to formulate an emergency response framework, which contained various components for an ERM that correspond to logical management processes.Each hospital may take charge of its own detailed operation standards, processes, and procedures based on its organizational structures and their respective tasks to implement infection control and occupational health management.Bryce et al. (2008) studied infection control and occupational health human resource allocations of hospitals in British Columbia and Ontario in Canada in the post-SARS period.Their results show that human resource allocation was sufficient to control the spread of the infection, but it was inadequate for occupational health, and that this could pose a leak in an EID prevention plan for occupational health management.Information on teaching materials for training education and the usage and maintenance of respiratory protection gear may be placed on an information exchange platform, built by a government or by hospitals, to facilitate healthcare workers easy access to new information and to implement training and education.Rebmann (2009b) also proposed that there must be an internet communication platform for delivering information on infection incident reports, so that healthcare workers may have an immediate grasp of the updated information, and that relevant information on PPE and the risk of EID infection transmission may be provided.Furthermore, Item 2 of the emergency response framework, "medical unit nosocomial infection control guidelines", is included particularly for departments with highly infectious or invasive treatment.If there are specific departments in a hospital not covered by this item, the hospital can still refer to the critical concept or logic proposed here in setting up relevant measures or SOPs.Lastly, hospitals must evaluate their existing nosocomial infection control measures and SOPs, analyze a potential crisis and its impact, strengthen the case monitoring function and infection information judgment, restructure and strengthen their EID prevention system, and establish a brand new EID emergency response system.ABBREVIATIONS EID, Emerging infectious diseases; SOP, standard operating procedure; ERPs, emergency response plans; SARS, severe acute respiratory syndrome; ICU, intensive care units; PPE, personal protection equipment

Figure 2 .
Figure 2. PDRA of the emergency response framework.

Table 1 .
Emergency response management framework and its components.