Protection of Health Care Workers and Public Health During Initial Assessment: Scene Safety and Triage Vital Signs
Health care providers are familiar with the classic four vital signs of pulse, blood pressure, respiratory rate, and temperature as typically measured during initial hospital triage. A fifth vital sign of pain has also been proposed. Yet, as the Ebola outbreak has illustrated, it may be unsafe to approach a patient to perform a triage assessment and collect initial vital signs if potential hazards are present. These hazards can include direct threats to first responders and other health care providers and indirect threats to the public health if a chain of disease spread inadvertently ignites.
Every EMS responder knows that “scene safety” trumps patient assessment; if you become the victim, you can no longer be the provider of patient care. Unlike a standard hazmat situation, however, with a bioagent, you cannot see a cloud of smoke or hear an explosion or smell a noxious agent or readily detect a chemical or radiological agent. While traditional teaching has been that intact skin provides adequate protection for biological weapons other than mycotoxins, Ebola is different.Reference Koenig, Majestic and Burns1-Reference Koenig3 Secondary contamination or exposure may be possible—in fact, the bodily fluids of an infected Ebola patient can be transmitted in much the same way as a chemical agent. Furthermore, decontamination, eg, of personal protective equipment and transport vehicles, may be necessary.
Classically, we consider transmission of a biological agent with short-term lethality to health care providers to be by airborne routes (such as illustrated by World Health Organization modeling for aerosolized release of other Category A bioterrorism agents), rather than by direct contact with blood and bodily fluids.Reference Koenig, Kahn and Schultz2, Reference Koenig3 Ebola has caused us to rethink this strategy for protection of health care workers.
Advanced Trauma Life Support teaches us to assess not only ABCs in our primary survey, but also D and E, with E indicating “exposure.” Should we not also primarily assess for the risk of “exposure” to a contagious infectious disease for frontline health care providers?
Goal of Triage
We must also understand the goal of triage and how to apply triage in different settings. Under standard operations in a hospital setting with sufficient resources, triage is performed to sort through and rapidly identify the sickest patients first. These patients would then be the first to receive treatment. In the prehospital setting with a mass casualty incident where there are sufficient resources and intact communications and transportation infrastructures, the goal of triage may be to identify which patients have the highest priority for transport to definitive care. The key decision would be which patients need the quickest access to resources available in the hospital that are not available in the field (eg, surgery for uncontrolled internal hemorrhage).
In a scarce resource environment, the goal of triage shifts from optimizing individual outcomes to maximizing population outcomes.Reference Koenig, Lim and Tsai4 When does disaster triage become daily triage?Reference Davidson, Koenig and Cone5 Sometimes it is difficult to have situational awareness that provides an accurate real-time assessment of the adequacy of resources and the extent of the population needs. Cone and Koenig discuss triage in the case of a biological agent as part of the model they developed for the chemical, biological, radiological, or nuclear (CBRN) environment.Reference Cone and Koenig6 This situation can be challenging because incubation period and degree of contagiousness vary by agent. In addition, unlike Ebola according to the current state of the science, some biological agents can be transmitted from person to person before patients display signs or symptoms.
A useful triage methodology for conceptualizing a bioevent is Burkle’s SEIRV model.Reference Burkle7 According to this construct, the population is categorized as susceptible, exposed, infectious, removed, or vaccinated (leading to the acronym SEIRV). It is possible that patients can present with combined conditions (eg, Ebola plus malaria, a traumatic injury, or a myocardial infarction); hence, it is important to perform an initial screening on all patients. Health care workers and the public health must be protected, yet delays in treating other emergency conditions must be avoided. Just as we must not be too focused on radiation as attention to traumatic injuries is the priority in patients exposed to a radiological dispersion device,Reference Koenig, Hatchett and Mettler8 we must be cautious to strike the appropriate balance when treating people who may have a risk of spreading Ebola. We must not let patients die from trauma or myocardial infarction while we are screening for a travel history and exposure.
Proposal for a New “Vital Sign Zero”
By adding a new “vital sign zero” at the beginning of triage, we can increase the likelihood of early identification of at-risk populations and provide appropriate levels of personal protective equipment to health care workers. This concept extends far beyond the current situation with Ebola and would increase our preparedness to tackle other existing emerging infectious diseases (such as Middle East respiratory syndrome coronavirus) and the, as yet unnamed, next big thing.Reference Gamage, Kravolic and Roselle9
To protect individual health care providers and the public, vital sign zero must be taken before the others. Routine triage becomes similar to triage in a scarce resource environment where we must “do the most good for the most people,” which, at times, might not be the best for the individual patient. We should also involve palliative care experts in discussions about what to do in futile cases when risk to providers and public health may far outweigh any remote chance of benefit to the patient.
If vital sign zero is abnormal, the alarm must sound immediately. We need 24/7 access to public health (including infection control) and law enforcement authorities, whether in an out-of-hospital or health care facility setting. In addition, there is no time to change policy on the fly. Therefore, we must be proactive in developing all-hazard policies and procedures. This extends to regulation and legislation. For example, the Pandemic and All-Hazards Preparedness Act (PAHPA, P.L.109-417) legislation should be amended to include generic, descriptive language that encompasses any contagious infectious disease so that it does not have to be amended for every emerging infectious disease, as was the case when severe acute respiratory syndrome had to be added by executive order. We need to focus on managing emerging events rather than reacting to rapidly evolving, yet anticipated, situations.
Population triage is a new concept with important public health implications in today’s globalized world. We ask everyone about tetanus, but why are we not routinely screening for serious contagious infectious diseases? Let’s consider public health as the new vital sign zero!
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Protection of Health Care Workers and Public Health During Initial Assessment: Scene Safety and Triage Vital Signs
Health care providers are familiar with the classic four vital signs of pulse, blood pressure, respiratory rate, and temperature as typically measured during initial hospital triage. A fifth vital sign of pain has also been proposed. Yet, as the Ebola outbreak has illustrated, it may be unsafe to approach a patient to perform a triage assessment and collect initial vital signs if potential hazards are present. These hazards can include direct threats to first responders and other health care providers and indirect threats to the public health if a chain of disease spread inadvertently ignites.
Every EMS responder knows that “scene safety” trumps patient assessment; if you become the victim, you can no longer be the provider of patient care. Unlike a standard hazmat situation, however, with a bioagent, you cannot see a cloud of smoke or hear an explosion or smell a noxious agent or readily detect a chemical or radiological agent. While traditional teaching has been that intact skin provides adequate protection for biological weapons other than mycotoxins, Ebola is different.Reference Koenig, Majestic and Burns1-Reference Koenig3 Secondary contamination or exposure may be possible—in fact, the bodily fluids of an infected Ebola patient can be transmitted in much the same way as a chemical agent. Furthermore, decontamination, eg, of personal protective equipment and transport vehicles, may be necessary.
Classically, we consider transmission of a biological agent with short-term lethality to health care providers to be by airborne routes (such as illustrated by World Health Organization modeling for aerosolized release of other Category A bioterrorism agents), rather than by direct contact with blood and bodily fluids.Reference Koenig, Kahn and Schultz2, Reference Koenig3 Ebola has caused us to rethink this strategy for protection of health care workers.
Advanced Trauma Life Support teaches us to assess not only ABCs in our primary survey, but also D and E, with E indicating “exposure.” Should we not also primarily assess for the risk of “exposure” to a contagious infectious disease for frontline health care providers?
Goal of Triage
We must also understand the goal of triage and how to apply triage in different settings. Under standard operations in a hospital setting with sufficient resources, triage is performed to sort through and rapidly identify the sickest patients first. These patients would then be the first to receive treatment. In the prehospital setting with a mass casualty incident where there are sufficient resources and intact communications and transportation infrastructures, the goal of triage may be to identify which patients have the highest priority for transport to definitive care. The key decision would be which patients need the quickest access to resources available in the hospital that are not available in the field (eg, surgery for uncontrolled internal hemorrhage).
In a scarce resource environment, the goal of triage shifts from optimizing individual outcomes to maximizing population outcomes.Reference Koenig, Lim and Tsai4 When does disaster triage become daily triage?Reference Davidson, Koenig and Cone5 Sometimes it is difficult to have situational awareness that provides an accurate real-time assessment of the adequacy of resources and the extent of the population needs. Cone and Koenig discuss triage in the case of a biological agent as part of the model they developed for the chemical, biological, radiological, or nuclear (CBRN) environment.Reference Cone and Koenig6 This situation can be challenging because incubation period and degree of contagiousness vary by agent. In addition, unlike Ebola according to the current state of the science, some biological agents can be transmitted from person to person before patients display signs or symptoms.
A useful triage methodology for conceptualizing a bioevent is Burkle’s SEIRV model.Reference Burkle7 According to this construct, the population is categorized as susceptible, exposed, infectious, removed, or vaccinated (leading to the acronym SEIRV). It is possible that patients can present with combined conditions (eg, Ebola plus malaria, a traumatic injury, or a myocardial infarction); hence, it is important to perform an initial screening on all patients. Health care workers and the public health must be protected, yet delays in treating other emergency conditions must be avoided. Just as we must not be too focused on radiation as attention to traumatic injuries is the priority in patients exposed to a radiological dispersion device,Reference Koenig, Hatchett and Mettler8 we must be cautious to strike the appropriate balance when treating people who may have a risk of spreading Ebola. We must not let patients die from trauma or myocardial infarction while we are screening for a travel history and exposure.
Proposal for a New “Vital Sign Zero”
By adding a new “vital sign zero” at the beginning of triage, we can increase the likelihood of early identification of at-risk populations and provide appropriate levels of personal protective equipment to health care workers. This concept extends far beyond the current situation with Ebola and would increase our preparedness to tackle other existing emerging infectious diseases (such as Middle East respiratory syndrome coronavirus) and the, as yet unnamed, next big thing.Reference Gamage, Kravolic and Roselle9
To protect individual health care providers and the public, vital sign zero must be taken before the others. Routine triage becomes similar to triage in a scarce resource environment where we must “do the most good for the most people,” which, at times, might not be the best for the individual patient. We should also involve palliative care experts in discussions about what to do in futile cases when risk to providers and public health may far outweigh any remote chance of benefit to the patient.
If vital sign zero is abnormal, the alarm must sound immediately. We need 24/7 access to public health (including infection control) and law enforcement authorities, whether in an out-of-hospital or health care facility setting. In addition, there is no time to change policy on the fly. Therefore, we must be proactive in developing all-hazard policies and procedures. This extends to regulation and legislation. For example, the Pandemic and All-Hazards Preparedness Act (PAHPA, P.L.109-417) legislation should be amended to include generic, descriptive language that encompasses any contagious infectious disease so that it does not have to be amended for every emerging infectious disease, as was the case when severe acute respiratory syndrome had to be added by executive order. We need to focus on managing emerging events rather than reacting to rapidly evolving, yet anticipated, situations.
Population triage is a new concept with important public health implications in today’s globalized world. We ask everyone about tetanus, but why are we not routinely screening for serious contagious infectious diseases? Let’s consider public health as the new vital sign zero!