Health

Infection control in your practice (AAFP annual scientific assembly)

■ Experts warn that primary care physicians will be at the center of detecting, treating and managing an outbreak when it hits.

By Victoria Stagg Elliott — Posted Nov. 19, 2007

WITH THIS STORY:
» Infection control fashion
» Doctors consider when to return injured athletes to play
» Research findings: Lifestyle change motivators; aspirin for CVD prevention; health literacy and diabetes
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The next big respiratory disease epidemic could be in the form of the annual flu or something more exotic. But it is coming, and doctors should change what their offices look like in order to ensure they don't contribute to its spread. Plans also need to be in place to make it more likely that care will be provided to the usual cadre of patients along with those infected by this pathogen, whatever it may be, according to several presentations at the American Academy of Family Physicians' annual scientific assembly last month in Chicago.

"The key message is start now," said Charles W. Mackett III, MD, associate professor and executive vice chair of the Dept. of Family Medicine at the University of Pittsburgh. "We don't want to plan for the next epidemic a week before it happens. Plan now, little bit by little bit."

In such a situation, waiting room signs should instruct patients to alert staff if they have a respiratory illness. In addition, patients should then be seated at least three feet away from each other and given surgical masks. Magazines and toys are to be removed. Upholstered furniture should be swapped for easier-to-disinfect plastic. The office should be cleaned with mops and buckets that are discarded after each use.

"During SARS, people came into the hospital. They didn't have SARS, but they left with SARS," Dr. Mackett said. "We don't want to spread things around."

Outbreak preparation is part of the AAFP's educational focus for the next year, along with more routine infectious disease issues. Experts want primary care physicians ready for these situations, ranging from an expected influenza pandemic to more remote possibilities, such as a return of SARS. After all, the vast majority of those infected never end up in a hospital. Rather, they end up in the office of their primary care doctor where, if precautions are not taken, these infections can spread to others.

"Think about your clinical setup, how you have your waiting room set up, how you bring people in and how you segregate patients," said Jonathan L. Temte, MD, PhD, associate professor of family medicine at the University of Wisconsin in Madison. "Reducing the number of secondary cases makes an impact."

Why think about it now?

One recommendation in terms of advance planning is the development of telephone triage systems to mitigate further the strain on primary care practices in the case of an epidemic. This mechanism could weed out patients with serious issues and prevent other patients from leaving their homes for an unnecessary doctor's appointment. The result would cut the risk of further infection spread and reduce the chance the office will be buried by the demands of patients who are worried about infection but are otherwise well.

Such a system is particularly important because many health care facilities may be on their own if an outbreak is widespread, as in the case of pandemic influenza. No help may be coming from elsewhere.

"Family physicians are going to be on the front line. Our offices will see 100 to 200 times the volume of the local emergency department," Dr. Mackett said. "And help is not going to come. We need to be ready to take care of ourselves."

In addition to protecting patients, experts also say that additional measures are needed to protect staff and keep the health system running. Many of those infected by SARS were health care workers who were exposed at work. Pandemic influenza may result in an absentee rate of 40%, and American Medical Association policy states that health care professionals should be prioritized to receive vaccine if available. Experts also say that staff should be fitted with N-95 respirators if deemed appropriate, and everyone in an office should be trained in all duties essential to keeping the office operational.

"If you have one appointment person and that one person is sick or dead, who is going to make appointments?" Dr. Mackett said. "If you can't keep your doors open, you're not helping anyone."

In addition to creating plans for their practices, experts also urge physicians to contact public health officials to learn the details of theirs.

"It's very important to coordinate with them. You may be surprised what plans they have for you," Dr. Mackett said.

Several sessions also focused on infectious diseases that may not reach pandemic levels but are periodically creating smaller outbreaks. A prime example: pertussis. Physicians should be aware, according to presentations, that this infection has become more common in adolescents and adults, but the symptoms may not necessarily include the characteristic "whoop."

"This is the only vaccine-preventable disease in the U.S. that has an increasing death rate," said David Gregory, MD, assistant professor of family medicine at the University of Virginia, Charlottesville. "And people at different ages have a different illness. We need to be thinking of pertussis a little bit differently."

He recommended vaccinating adults with the new combination shot and considering pertussis as a possibility for any patient with a long-lasting cough. Confirming the diagnosis also needs to be done with a combination of polymerase chain reaction testing and culturing.

The public health department also should be contacted as soon as possible.

"Public health is your friend. Let them handle it," Dr. Gregory said.

ADDITIONAL INFORMATION

Infection control fashion

The threat of a respiratory disease outbreak can dictate what items should be considered "in" and "out" at your office.

What's in:

Signs instructing patients to alert staff if they have a respiratory illness
Cough etiquette education posters
Tissues
Hands-free wastebaskets
Alcohol-based hand rub and wipes for anything that might be touched by someone who is sick
Protective clothing and masks for staff
Surgical masks for coughing, sneezing patients
Single-use buckets and mops
Plastic furniture

What's out:

Upholstered furniture
Magazines
Toys

Source: American Academy of Family Physicians

Doctors consider when to return injured athletes to play

Whether to put an athlete back in the game after a concussion is a decision tasked to many primary care physicians -- a decision fraught with difficulty. For starters, existing guidelines are based on expert opinion rather than science. Also, the science that does exist shows a loss of consciousness, long viewed as a marker of severity, is not that reliable.

Symptoms can develop hours or days after the incident. Non-medical issues, such as a player's need to compete or a coach's desire to win, may complicate the process. But putting an athlete back in too early can compound the original injury or even turn it deadly, according to several presentations at last month's American Academy of Family Physicians' annual scientific assembly in Chicago.

"Athletes lie, especially high school and college age athletes. You have parents who want them to play. Coaches want them to play and push you to let them play sooner than they should," said Jeffrey A. Zlotnick, MD, assistant clinical professor of family medicine and primary care sports medicine at University of Medicine & Dentistry of New Jersey-Robert Wood Johnson Medical School in Piscataway. "But the key thing here is that this is cumulative. You never, ever completely recover from a concussion. If you get one after another, you get more damage."

Experts recommended paying the most attention to confusion and amnesia as indicators of a possible concussion and of its severity. They also suggested that younger athletes be held back from play longer than older ones. These players also may need to be prevented from carrying out mentally draining tasks as well, because evidence is growing that both mental and physical exertion may slow recovery.

In preparation for treating and assessing possible concussions, presenters advocated carrying out short neuropsych evaluations on all athletes before participation. "Some kid gets hit, you give them the test again, and they have to get to baseline before they start any sport. You don't want to let them go back until they're really ready to go," Dr. Zlotnick said.

But those who work with athletes cautioned against being too restrictive and making the assessment and return-to-play process too onerous, because concussions are already underreported. "We think that 50% of concussions we never see or hear about," said W. Mark Peluso, MD, head team physician at Middlebury College in Middlebury, Vt. "We need to make sure that what we do is not so draconian that they're not going to report the next one."

Research findings: Lifestyle change motivators; aspirin for CVD prevention; health literacy and diabetes

Ill health may make patients more likely to want to quit smoking, reduce alcohol intake, increase daily exercise and eat more nutritionally, according to a study presented during the American Academy of Family Physicians' annual scientific assembly in Chicago last month.

"This is the population that tends to get the least counseling, because we focus on the medical problem and may not even think that they may be interested in change," said Rajasree Nair, MD, one of the authors and a faculty member at Baylor Family Medicine Residency in Garland, Texas.

Researchers surveyed 1,171 patients presenting to eight family medicine residency program clinics in Texas. Those in poor or fair health were 28% more likely to want to reduce their drinking and 21% more likely to be interested in improving their diet than those who were better off. Those who smoked and had health problems were 40% more likely to want to quit.

Another paper suggested the focus of discussions regarding the use of aspirin to preserve cardiovascular health should be different for men and women. A data review by researchers at the Agency for Healthcare Research and Quality found men tend to have a reduced risk of heart attack if they take this drug regularly. Women cut their chances of ischemic stroke.

Meanwhile, another study found that improving health literacy of diabetics translated into improvements in glycemic, blood pressure and lipid control. Researchers used AHRQ literacy tools for 18 months. During this time, the percentage of people with a HbA1c less than seven increased from just over 10% to nearly 55%.