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Are we ready?
How the Milwaukee health care community is indeed prepared to handle a major health outbreak


August 2015

When Ebola first arrived stateside last September, the Centers for Disease Control and Prevention and the Department of Health and Human Services launched a nationwide initiative to combat the virus at home — an effort that included increasing the number of U.S. facilities qualified to contain and treat Ebola from three to 51 and developing countermeasures, like the first Ebola vaccine to progress to Phase 2 testing, to prevent and treat the virus. Domestic preparedness became (and continues to remain) a top priority.

But how exactly do these efforts trickle down to the local level? Is the Milwaukee health care community prepared to handle a major outbreak? The last epidemic to hit Cream City was 22 years ago ­­— in 1993, when two of the city’s water treatment plants became contaminated with cryptosporidium. The parasitic disease infected more than 400,000 people, causing nearly 70 deaths. A 1994 report issued by the CDC pronounced it the largest waterborne outbreak in U.S. history. And what’s even more frightening? The cause of the contamination was never found.

Rest assured, there is good news. Significant progress has been made locally over the last two decades regarding disease control and prevention. All parties, from private health care physicians to public health officials, recognize that medical technology can only extend its reach so far; staff training and education and the effective dissemination of critical information are crucial to ensuring patient, public and caregiver safety. Read on to learn just how prepared Milwaukee is to handle a major outbreak.

Infection Preventionists

Like many local health care systems, Aurora Health Care employs infection preventionists at each of its hospitals and outpatient clinics. Many are nurses or have a microbiology background. "They do daily surveillance — what are they seeing? How do we prevent them (outbreaks)?" says Dr. Angela Tonozzi, director of infection prevention for Aurora Health Care. "They also receive the alerts to prevent a communicable disease outbreak." These alerts are usually issued by the CDC or the state health department, and their purpose is to keep the disease and the possibility of a subsequent outbreak top of mind.

Thinking Globally

Equally important is being aware of what is happening at the global level. "What you see happening within our area is that we’re always on the lookout for what’s happening at the local level, at the state level, at the national level, and at the global level regarding communicable diseases," says Tonozzi. "It’s important to be aware of what’s going on and to anticipate and diagnose correctly."

Paul Biedrzycki, director of disease control and environmental health for the City of Milwaukee Health Department, says there are currently five influenza candidates circulating in the world. "There are a number of small clusters of influenza that we follow very closely globally," he says.

Their true danger, says Biedrzycki, lies in their ease of transmissibility. The global economy, which often demands frequent international travel, and the abundance of air travel enhance the mobility of these viruses, and many go undetected and unnoticed before becoming communicable. A proactive and informed approach to global health is crucial. "We need to be aware of disease emergence and surprise clusters of outbreaks at the source and then engage the public in isolation or quarantine," adds Biedrzycki.

Universal Precautions

Dr. Rita Hanson, chief medical officer for Wheaton Franciscan Healthcare, oversees patient safety and emergency preparedness for the health care system, and she says routine preventative tactics, including wearing gowns and gloves, are effective in dealing with less severe outbreaks like influenza or measles. "With the exception of Ebola, all of the things that we do routinely — the universal precautions for protecting the staff and the public — are sufficient in protecting people," she explains. "But with Ebola, the universal precautions are insufficient. That’s what made it such a big thing, plus the mortality of the virus. That combination of factors was pretty unique, and in that instance, universal precautions and our usual things would not get the job done."

Approach and Analysis

Once the guidelines are disseminated from the CDC or health departments, Tonozzi and her team draft them into a usable document and strategize how to put them into practice. "We as a group take those guidelines and say, ‘How would this affect patients and caregivers? How do we prepare and how do we protect safely?’" she explains. "The main thing that you try to do when you get these types of information is getting the right people at the table to flush through the information, disseminate the information, and then practice. Translating those guidelines into practice requires the best people to implement them."

Hanson says Wheaton’s approach to preparing for an Ebola outbreak involved a thorough risk analysis assessment. "Our approach — and I think this is consistent with our colleagues — was to do a risk analysis based on the nature of different roles and the likelihood of it (Ebola) coming into contact," she says. "Our training focused on: What is your role? And what is the risk to you as a person? And what kind of training do you need in the context of your role to contain and to protect yourself? We thought about all the points of entry into our system and the people that would be there, and we tailored education at that level."

An office assistant, for example, would need to be able to recognize the illness but have little to no patient contact, so extensive response training was unnecessary. Those engaged in direct patient care and therefore exposed to a high-risk illness like Ebola, however, received much more comprehensive training. "The number of people trained is pretty small," Hanson adds. "This decreases the number of people exposed, and the training is better and more concentrated."

Level 1 Trauma Center

Froedtert & the Medical College of Wisconsin’s designation as the only adult Level 1 Trauma Center in eastern Wisconsin solidifed its status as Milwaukee’s go-to hospital for Ebola cases last fall. A "Level 1" classification means the facility meets strict national standards and is equipped to provide the highest level of specialty expertise in the event of a trauma. Interestingly enough, Froedtert even started preparing for an outbreak before the virus officially arrived stateside.

"Before it (Ebola) hit the national news as an event, we received a call that a traveler who was aggressively providing care (in West Africa) identified Froedtert as a resource hospital if this person were to become ill," recalls Susan Huerta, VP of quality, patient safety & performance improvement at Froedtert & the Medical College of Wisconsin. She says the system immediately went on high alert. "As an academic medical center, we not only back up community hospitals, but we have a commitment to our patient base to treat the more unusual things they may experience." Once the first Ebola case was later confirmed in Dallas, the system developed a more sophisticated approach, involving the entire organization and its constituents.

Communication is Key

Such an effort requires the coordination of numerous individuals, from administrators and physicians to public relations officials and emergency medical technicians, and effective communication between all parties is imperative. Tonozzi says it best: "Communicate, communicate, communicate." Targeted informational brochures and materials are dispersed to their intended audiences, approaches to care and procedural rationals are communicated, and appropriate signage is displayed throughout hospitals and clinics.

In the case of Ebola, webinars carrying the same message were available to all health care systems. Hanson was especially impressed by how the CDC and health departments disseminated consistent information, ensuring all systems were readily prepared and responding in sync. "There was a great deal of effort to ensure we were up to date and to standardize on what the guidelines were," she says.

Huerta says Froedtert & the Medical College of Wisconsin made a concerted effort to remain scientific in their approach. "Information, in this case, was absolutely powerful in helping people work through what was scary national press," she explains. "We sifted through what made scientific sense — Is this based on science or is this based on public opinion? I believe our staff, at the end of the day, appreciated the fact that we stuck with science."

Actionable Risk Messaging

Biedrzycki agrees that communication is key, but tailors his department’s efforts from a public health standpoint. "We’re looking across the board — at the entire population, including those that are under-insured or not insured. Those individuals are typically not seen by private health care individuals," he explains. His department concentrates on actionable risk messaging, which builds public awareness and engages the public in prevention. He cites "wash your hands," "get a vaccination" and "take your antibiotics" as examples.

In addition to pharmaceutical-based messaging, Biedrzycki says non-pharmaceutical efforts are just as important. His department practices a model of voluntary compliance. "We tell people to quarantine themselves, isolate themselves or observe good hygiene," he says. "Mandatory (compliance) is impractical. We expect people to do the right thing for the benefit of the community. It’s not about you getting sick, it’s about you affecting others that might get very sick."

Competitor Cooperation

Despite the fact that many local health care systems compete with each other, their primary goal is the same — to keep everyone safe. "It was wonderful to see how well we collaborated because we’re all trying to maintain that same patient and caregiver safety," says Tonozzi, referring to how the systems banded together last fall to prepare for a possible Ebola outbreak.

"Because of the nature of Ebola and how it might affect the community, for us to be effective required an unusual level of cooperation and coordination between the systems and administrators," adds Hanson. "Until something happens, you don’t know how it’s going to play out. I think we all felt gratified by the natural, immediate partnership formed between the community systems and national and state health departments."

"I continue to be impressed with the collaboration," says Huerta of the relationship between public and private health care. "I think it’s important to continue that. This (Ebola) is one infection, but there are outbreaks every year. I think we formed some relationships that will serve us well in the future."

Public/Private Partnership

The partnership formed between public and private health is not an entirely new phenomenon, but one that’s improved significantly. "This public/private health care relationship was jump-started by 9/11," says Biedrzycki, referring to the 2001 anthrax attacks. "It was a defining moment for public health awareness."

Biosurveillance (the early detection of disease in the community) is one example of this partnership at work. "Since we’re a small organization, we rely on the sublines of private health care through information exchange and sharing to enhance our biosurveillance," explains Biedrzycki. Private health care systems report what types of diseases are circulating, lab diagnostics and results, and suspicious activity or unusual clusters.

The Wisconsin Electronic Disease Surveillance System (WEDSS) was designed to facilitate this process. A web-based reporting system, WEDSS allows clinicians, labs and state and local health departments to report, record and analyze diseases and trend them. "(WEDSS) helps us in understanding what diseases are prevalent and what diseases are increasing and decreasing over time," says Biedrzycki. Strategy and intervention can then be developed accordingly.

This exchange of information also assists in practicing syndromic surveillance, which involves analyzing symptoms of diseases before they occur. For example, when crypto hit Milwaukee in 1993, anti-diarrheal medications had been flying off the shelves for weeks. "Now, I can assure you that if there’s a run toward any kind of medication in this community, we’ll know about it," says Biedrzycki.

Ebola’s Effect

Ebola was especially pivotal in changing the relationship between public and private health care, says Biedrzycki. "It sent us on a trajectory to improve infection control practices in both private health care and in the community in a way that I’ve never seen in my 30 years."

The virus’ mobility demanded a need for entry and exit screenings at airports, requiring a new level of cooperation between airport staff, health care professionals and third-party technology providers. "That created a new model of infectious disease screening and created new protocols for infectious control," Biedrzycki explains. "In one short year, we’ve advanced this country. Ebola had a payoff in a big way."

"I think the pathways will stand up quickly in the future," says Huerta of the virus’ impact on emergency preparedness and infection prevention. "We’re in it for the long haul, for whatever comes up next. The commitment to our patient population is very, very strong."

Southeast Wisconsin Healthcare Emergency Readiness Coalition Inc.

The Southeast Wisconsin Healthcare Emergency Readiness Coalition Inc. was established to build a regional and diverse approach to health care. The coalition covers nine Wisconsin counties and involves a variety of health care professionals, from private and public health administrators to animal health physicians.

Biedrzycki, who sits on the organization’s board, says HERC hosted two summits within the past year regarding Ebola and emergency preparedness. Each summit featured a panel discussion that allowed attendees to speak openly and honestly about the possibility of an outbreak. "I would have to say that Milwaukee kind of took the bull by the horns, if you will, with appropriate fear. This was not cavalier," says Huerta of HERC’s responsive effort.

Community Resilience

Biedrzycki says one mission of public health is to enhance community resilience, an initiative he says has made considerable progress over the last five years. "We have to engage communities to take responsibility and control," he says. "Public health is not just a government-centric function."

He says public health departments are there to "connect the dots," but all institutions, from citizens and families to Corporate America, must work together. "If you keep a community healthy economically and socially, you have a much better chance of reducing illness and death. The resources will flow, and the people will pull together," explains Biedrzycki. "That’s been the new thinking about how to approach any type of preparedness."

"The public is the innovators, the doers, the people that can build this community resiliency," he stresses. "We’re trying to engage the community and work with them to develop sustainable health models for public health."


This story ran in the August 2015 issue of: