Note: This is the fourth of a series of clinical briefs on the coronavirus outbreak. The information on this subject is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available.

Clinical Context

The 2019-nCoV outbreak is a global health emergency, as declared by the World Health Organization (WHO) on January 30, 2020.^[1] The Wuhan, China coronavirus outbreak which started on December 31, 2019, is rapidly unfolding, and clinicians are faced with a daunting amount of information to stay abreast. With mounting numbers of infected cases (20,647 confirmed cases, 361 confirmed deaths as of February 4^th, 2020), the virus is moving at unprecedented speed. The first incidence of person-to-person transmission has already been reported in the United States. There is much scientific and epidemiologic knowledge lacking that clinicians need to know about 2019-nCoV.

How should healthcare systems and clinicians respond to the novel coronavirus?

For an epidemic of any magnitude, prevention and preparation are essential, especially for healthcare personnel in the clinical setting. In dealing with a global threat in similar or greater magnitude than that of severe acute respiratory syndrome (SARS), we need to reach into history to identify lessons learned. The goal of this educational brief is to address prevention methods as lessons learned from recent studies including those identified by the Centers for Disease Control and Prevention (CDC). These identify the importance of coordinated care among team members, which calls for team-based strategies for surveillance, prevention, and management of the outbreak. Lessons learned from the SARS epidemic will help guide response to the emergence of the current 2019-nCoV. One clear lesson derived from recent outbreaks is that it takes a team to contain and combat a virus outbreak.

Healthcare facilities should have a planning and decision-making structure. Leaders should organize a multidisciplinary and interdisciplinary working committee to address issues.

Synopsis and Perspective

In a recent study in the November 2013 issue of Antiviral Research,^[2] Cheng and colleagues recount key lessons learned on the clinical management and infection control of SARs, including focusing on measures to identify and isolate patients, prevent the transmission of infection to healthcare workers, and developing effective therapies.

The following are important issues that need to be addressed.

Infection Control

According to Cheng and colleagues, infection control is the most important way to prevent human-to-human transmission of virus outbreak considering the lack of effective antiviral therapy and vaccines. Infection control measures (personal protective equipment [PPE], isolation of patients, etc) should be implemented early. The importance of following infection control guidelines (eg, strict adherence to contact and droplet precautions, along with eye protection) cannot be overemphasized. Infection control committees are vital to ensure compliance among staff. Key members include an infection preventionist, infectious disease physician, and representation from nursing (e.g., nurse educator), lab (e.g., microbiologist), pharmacy (e.g., clinical pharmacist), quality control, information technology, administration, and other team members as needed.

The team should discuss strategies for triage and admission that minimize the risk for transmission to staff, patients, and visitors. Patient placement and isolation precautions should be in effect. Team members should determine a method for tracking and monitoring all infected patients in a facility. It may be necessary to designate a particular unit or floor for those infected. Patient education is also key in preventing the spread of the virus. The CDC recommends the respiratory hygiene/cough etiquette: specific behavior for persons with signs and symptoms of a respiratory infection to help contain the spread of the virus, such as covering the nose/mouth when coughing or sneezing, using tissues to contain respiratory secretions, disposing of tissues quickly and efficiently, and performing hand hygiene as often as possible and after contact with respiratory secretions and contaminated objects/materials. An appropriate hand hygiene agent should be available at all times in patient care areas. Hand hygiene with use of an alcohol-based rub is a key infection control measure, as identified by Cheng and colleagues. Directly observed hand hygiene and electronic monitoring of compliance yielded better control. Other members of the healthcare team can assist nurses in observing proper hand hygiene on patient units.

Establish a Surveillance Method

Surveillance is the basis for control in any infectious disease process. Undetected cases of 2019-nCoV disease in staff, patients, and visitors can contribute to spreading the virus rapidly. The CDC recommends that the team should establish a process for early detection (eg, clusters of unexplained respiratory infections that may signal pneumonia). This may occur among healthcare staff as well. Incorporate this into facility guidelines for all patients admitted to the emergency department or an outpatient facility. Visual alerts can be posted in these areas as well as in physician offices and incorporated into the registration process for patients. Educating healthcare personnel on prompt reporting is imperative as well. All persons coming into a facility should be screened. There should be a feedback loop from surveillance teams to leadership to ensure reliable communication and preparedness. They should know when and where to report. For long-term management, this should be Incorporated into facility yearly staff training and personnel onboarding.

Establish Resources

A response to a virus outbreak can strain the resources and capacity of a healthcare facility as was witnessed in the case of SARs. Healthcare facilities can designate a department to take an inventory of supplies of PPE (ie, gowns, gloves, masks, eye protection) and keep ample inventory. The pharmacy should be able to track needed medications (vaccines, antibiotics, fluids, etc), as there can be critical drug shortages that can have monumental impact. Respiratory therapists can fit test users with disposable respirator masks for maximal effectiveness. In a clinical review of a critical care unit's response to the SARS outbreak in Toronto, Ontario, Canada, published in the August 2005 issue of Critical Care,^[3] Hawryluck and colleagues identified significant challenges with intensive care unit resource management, such as manpower and beds because of an overly high census. They recommended organizing critical care resources to meet the needs of all critically ill patients. Daily rounds with key personnel in interprofessional collaboration can ensure open lines of communications.

The social and psychological effect of a virus outbreak can be substantial during and after an outbreak, and, as in the case of SARS, stress because of the overwhelming nature of an outbreak or pandemic can pose challenges for individuals affected and persons caring for the incurable, uncured, survivors, and their families. This can place an unprecedented demand on mental health care workers and social workers. Collaborating with mental health care workers and social workers is a great tool to ease public concern about the 2019-nCoV outbreak and provide assistance to healthcare workers who may feel isolated, as identified by Hawryluck's study.

Establish an Effective Communication System

Communication needs can overwhelm and paralyze response capacity. Good information management strategies are essential to an efficient and effective response. This is relevant for healthcare professionals and the public as well. Inconsistent and inaccurate information can create unnecessary confusion, fear, anxiety, and even chaos. Leaders should establish a team and system to harmonize messages used at the national and local levels (ie, CDC, state and local government, hospital or health facility leadership) to keep staff informed. Communication should be accurate, up-to-date information and relevant to the current reports. Information can be overwhelming, so developing a library of resources can be helpful (eg, resource booklet with pertinent information [hotline, etc]). It is important to have websites providing the most up-to-date information on outbreak, modes of transmission, clinical presentation, etc. Designating an individual as an information specialist to give key messages can help keep staff informed and not overwhelmed with information. Use other healthcare professionals. In the outpatient setting, HCPs such as pharmacists can serve an important role in early detection as the most accessible HCPs in the community. Along with nurse practitioners, and physicians in the clinic setting, they can be the first line of reliable information when infectious disease outbreaks occur for both patients as well as other HCPs. Establishing a strong communication network among the healthcare team can stop the spread of a potentially fatal pathogen.

Interprofessional Collaboration

There is a greater need for medical resources during a pandemic. In the study by Hawryluck et al, in recounting the lessons learned in their disaster management of SARS, a key takeaway was that appointed leaders should have the capacity to quickly gather a team of professionals to help address issues within their domain. They emphasized the importance of eliminating silos and implementing system-based thinking. For outbreaks of this magnitude, information sharing and learning from collective experience is essential. This requires open communication between all levels of government as well as healthcare organizations and healthcare disciplines including frontline workers. Interprofessional collaboration eliminates political barriers, institution-based thinking, role bickering, and personal professional gain. Institution-based thinking can hinder much needed communication and collaboration, which we cannot afford in an outbreak situation, as it leads to wasted resources, duplication of efforts, and worsening impact, which can lead to deleterious outcomes, including increased mortality.

Examples of interdisciplinary and interprofessional team members include the following (not all-inclusive):

CDC website.^[4]

Interprofessional collaboration is essential in improving health outcomes.

Highlights

• The CDC has established checklists for hospitals^[5] and HCPs^[6] to prepare for 2019-nCoV. These checklists are not meant to be mandatory but are based on best practices in outbreaks of novel viral infections.
• Hospitals should review procedures for rapidly identifying and isolating patients with suspected coronavirus.
• Triage of patients with possible infection should be reviewed and should include telephone protocols to enhance the efficiency of care.
• Negative-pressure airflow rooms should be available and should be checked to assure proper function.
• PPE supplies for both HCPs and patients should be stocked. A contingency plan should be in place if supplies are depleted.
• Standards for surge capacity and crisis standards of care should be reviewed.
• The effectiveness of environmental cleaning procedures should be assessed.
• The hospital should review policies for the management of HCPs who are exposed to 2019-nCoV, including urgent access to medical consultation for these providers.
• Hospitals should identify the personnel who will communicate internally with providers and also externally with public health officials about the coronavirus outbreak.
• HCPs should immediately place masks on patients with cough. They should at least be placed in a well-ventilated area ≥ 6 feet from other patients while waiting to be seen. Alternatively, the patients can wait in their personal vehicles and be contacted via phone when they are ready to be seen.
• PPE should include masks, gowns, and eye protection when seeing patients with possible 2019-nCoV infection.
• The healthcare team should coordinate testing of specimens with local health officials. Testing for 2019-nCoV is only available at the CDC.
• The study by Cheng V and colleagues emphasized measures to identify and isolate patients, prevent the transmission of infection to healthcare workers, and develop effective therapies.
• The study by Hawryluck et al stressed the importance of appointed leaders to be able to quickly gather a team of professionals to help address issues within their domain pertaining to the virus outbreak.
• Interprofessional collaboration is essential in improving health outcomes

Clinical Implications

• Team-based strategies for surveillance and prevention of 2019-nCoV include developing a team to implement infection control measures and surveillance systems, addressing resources, and effectively communicating.
• Hospitals and health systems along with local and state governments should eliminate silos and implement system-based thinking. For outbreaks of this magnitude, information sharing and learning from collective experience is essential. This requires open communication between all levels of government as well as health care organizations and healthcare disciplines, including frontline workers.
•  Implications for the Healthcare Team: There is a greater need for medical resources during a pandemic. Preparation by the healthcare team and the systems they work in will make a tremendous difference in the impact of 2019-nCoV. Interprofessional collaboration is essential in improving healthcare outcomes.

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