Are we prepared? Outcomes of contagion control response drills
DeborahBloch, M.D., FAAP and Larry K.Pickering, M.D., FIDSA, FPIDS, FAAP
MMWR in Review
Foote MMK, et al. “Assessment of Hospital Emergency Department Response to Potentially
Infectious Diseases Using Unannounced Mystery Patient Drills – New York City, 2016.”
MMWR Morb Mortal Wkly Rep. 2017;66:945-949, https://www.cdc.gov/mmwr/volumes/66/wr/mm6636a2.htm.
Every year, many and varied infectious disease epidemics occur following exposure
to travel, animals, food, water and other people. Ill people often seek medical care
in emergency departments (EDs), highlighting the importance of rapid recognition,
diagnosis and isolation of people with infectious diseases.
Unannounced patient drills have been used in EDs and other health care settings where
protocols and ability of staff to recognize and appropriately manage patients with
potential infectious diseases are assessed.
This report adds to the literature demonstrating that patient simulations can be an
effective method for examining preparedness, including training for and recognition
of highly communicable diseases. In this study conducted in New York City (NYC) EDs,
asking about a travel history led to a higher proportion of successful drills than
when travel history was not obtained. In addition, adherence to infection-control
procedures, including masking and isolation, occurred significantly more frequently
when travel history was obtained.
From December 2015 to May 2016, 49 EDs across NYC underwent 95 drills to assess appropriate
isolation of mock patients presenting with either a rash after recent travel to Europe
(measles) or respiratory tract symptoms after recent travel to the Middle East (Middle
East respiratory syndrome [MERS]).
Designed by the U.S. Department of Homeland Security Exercise and Evaluation Program,
this study sought to measure frequency of patients given a mask, placed in airborne
isolation or both, and time to each event from the time of ED entry.
Secondary outcomes included association between obtaining a travel history and activation
of the isolation protocol as well as proper infection-control techniques such as hand
hygiene, use of personal protective equipment (PPE) and placement of isolation signs
outside patient rooms.
Of the 95 scenarios, 53 involved a case of measles, and 42 involved a case of MERS.
There was a 78% pass rate of timely activation of isolation procedures (mask and airborne isolation), with no significant difference between cases of measles compared
For the measles scenarios, the median times for masking patients and isolation from
time of entry were one minute and eight minutes, respectively. For MERS cases, masking
occurred at two minutes (median) and a median of 11 minutes to isolation.
A travel history was obtained in 81 of the scenarios and led to an 88% pass rate.
However, the pass rate was only a 21% in the 14 scenarios in which no travel history
was obtained, a statistically significant difference, which emphasizes the importance
of travel history.
Regarding infection-control practices, only 36% of staff members were reported to
have performed hand hygiene, and 74% used recommended PPE when entering rooms. In
the 76 drills that resulted in a patient being isolated, precaution signage was posted
outside 70% of the patients’ airborne isolation rooms.
Airborne isolation and infection preparedness
Infections such as measles and MERS are relatively rare in the United States. There
were 120 cases of measles in 2017 and only two ever reported cases of MERS, both in
2014, according to the Centers for Disease Control and Prevention (CDC). Still, pediatricians
need to be familiar with clinical syndromes associated with airborne-transmitted pathogens,
as well as their associated risk factors. Measles, MERS, varicella, severe acute respiratory
syndrome-coronavirus and Mycobacterium tuberculosisall are transmitted by airborne mechanisms.
A complete history should include travel and vaccination histories, sick contacts
and animal exposures. Masking and isolating patients and possibly their family members
in a negative pressure room and utilizing PPE for clinical staff and laboratory personnel
should be implemented. In addition, departments of health/CDC should be notified (reportable
diseases vary by state, https://wwwn.cdc.gov/nndss/data-and-statistics.html). Infectious disease physicians and infection prevention teams consisting of microbiologists,
epidemiologists and industrial hygienists can assist with infection diagnosis and
Drills similar to those conducted by the NYC EDs should be performed regularly across
Which of the following are recommended for rapid recognition of and infection control
for potentially severe infectious diseases in an ED?
A. Travel history
B. Patient masking and isolation
C. Staff hand hygiene and use of personal protective equipment
D. Use of precaution signage
E. All of the above
Dr. Bloch is a pediatric infectious diseases fellow at Emory University School of
Medicine. Dr. Pickering is adjunct professor of pediatrics at Emory University School of Medicine.