Emerging infectious diseases: An emergency or an operational pivot?

By John Maurer, Vizient accreditation advisor

Every year, new and different healthcare emergencies emerge, each presenting unique challenges to healthcare facilities. But how can healthcare leaders tell which is an emerging infectious disease (EID), such as COVID-19 or West Nile virus, and which is an operational pivot — an issue that requires a process change from normal operations but that doesn’t escalate to an emergency?

The key to effective healthcare facility planning is to remain vigilant and adaptable by continually evaluating risk. This keeps healthcare leaders prepared and empowers them to address potential threats proactively.

In 2014, the Centers for Medicare and Medicaid Services (CMS) published its Survey and Certification Memorandum 15-12, which released three worksheets for its hospital surveyors — one of which was the Hospital Infection Control Worksheet. This worksheet runs through a litany of questions relative to infection control, including the prevention of infection and communicable diseases.

In 2016, CMS implemented its emergency preparedness rule in its State Operations Manual Appendix Z, Emergency Preparedness for All Provider and Certified Supplier Types Interpretive Guidance, with its latest update in its Quality, Survey and Operations Memorandum 21-15-ALL, effective 2021. Noncompliance with these regulations can have serious consequences, underscoring the crucial role of healthcare professionals in ensuring preparedness in their healthcare facilities.

CMS’s actions have led to changes in accrediting organizations' requirements. One of the latest changes, effective July 1, is The Joint Commission standard IC.07.01.01: The Hospital Implements Processes to Support Preparedness for High-consequence Infectious Diseases or Special Pathogens. In this standard, hospitals must:

• have procedures for screening at points of entry
• set transmission-based precautions (such as isolation)
• inform public health officials and staff
• have and use personal protective equipment
• provide safe care and reduction techniques for exposure

These requirements will help hospitals prepare for an impact from an EID. Read more about the five key strategies to mitigate high-consequence infectious diseases in hospitals.

CMS Appendix Z also requires hospitals to identify EIDs with their community partners in their emergency preparedness planning activities and identifying high-consequence infectious diseases or special pathogens can help with that process. EIDs should not be noted in general terms, such as epidemic, pandemic or infectious disease.

Beyond collaborating with the community and local and state health departments, hospitals can keep a pulse on EIDs that may impact their operations via the Center for Disease Control and Prevention’s, Emerging Infectious Diseases. The U.S. Department of Health and Human Services Administration for Strategic Preparedness and Response also provides regular updates to Critical Infrastructure Protection for Healthcare and Public Health relative to preparedness, resilience and response. When leaders develop and update the hazard vulnerability risk assessment, EIDs must be explicitly listed, and it is crucial to understand which ones can impact the hospital.

But when is a risk operational versus an emergency? It depends on understanding a particular risk and its level of impact.

Open and transparent communication within the hospital is important for noting when a risk is operational. This includes awareness and understanding of when a risk only has a localized impact within a department that may require isolation versus when the risk’s impact is larger than the entire organization.

Some hospitals stratify levels of risk to determine when an emergency condition exists. Understanding the level of risk with early identification can help hospitals provide the proper support and engagement to minimize risks in their comprehensive all-hazards approach to managing emergencies. This takes diligence at departmental, committee and leadership levels and may not always require activation of the hospital’s emergency operations plan.

For more information on Vizient Regulatory and Accreditation Consulting Services and how Vizient can help by assessing your emergency preparedness program, contact Diana Scott at diana.scott@vizientinc.com.