'This is doable': A roadmap to monkeypox response from Providence, 2 more systems

With a low hospitalization and death rate for monkeypox, health systems don't expect the outbreak to pose a large burden on inpatient care. Still, ramping up communication and infection control policies are key to alleviating employee concerns and providing effective care to infected patients who may show up in ambulatory settings, healthcare leaders say.

The World Health Organization declared monkeypox a global emergency July 23 and the U.S. declared its own public health emergency Aug. 4. Nearly 14,000 cases had been confirmed in the U.S. as of Aug.17, CDC data shows. Ninety-nine percent of cases have occurred in men, most of whom reported recent male-to-male sexual or close intimate contact, according to a recent CDC report. There have been 12 deaths among more than 35,000 cases worldwide, the WHO said Aug. 17. Research also suggests hospitalization rates are low — in  a recent global study of 528 infected people, just 13 percent were hospitalized. 

"We are not anticipating that there will be a significant surge within the hospital because most individuals who are impacted by monkeypox are able to be supported and treated as outpatients," Fritz Francois, MD, chief of hospital operations at New York City-based NYU Langone Health, told Becker's. "Nevertheless, there's a small subset of individuals who might need to be hospitalized, and I think it's important that hospitals be prepared for those individuals and to provide symptomatic relief and other treatments as needed." 

Clear communication 

Health systems have been trying to stay ahead of staff concerns by bolstering education efforts around monkeypox symptoms, clinical guidelines and prevention. 

In addition to livestream meetings where administrative leaders present systemwide updates, NYU Langone Health worked with its infection control partners to build a website dedicated to monkeypox. The site is a one-stop shop for information and outlines the system's policies on source control, isolation, exposure, as well as clinical guidelines for things like sample collection, Dr. Francois said. Routine email updates with information on case numbers, vaccine and treatment availability are also sent to team members. 

At Los Angeles-based Keck Medicine of USC, leaders meeting directly with caregivers has been helpful to ensure clear communication, said Stephanie Hall, MD, chief medical officer of Keck Hospital of USC and USC Norris Cancer Hospital. She's said she's reminded caregivers to pull from what they know about other diseases that present similarly to monkeypox to respond to the current outbreak.

"Remind them that this is doable. Don't be overwhelmed. Remember to use your skills and your training, because we've all been trained in how to doff and don our protective equipment," Dr. Hall told Becker's

Much of health systems' communication efforts on monkeypox have focused on infection prevention and personal protective equipment use. 

At Providence, a 52-hospital system based in Renton, Wash., PPE for employees is the same whether the worker is caring for a COVID-19 patient or potential monkeypox patient.

"The COVID PPE and isolation is unique in comparison with anything else we've done before. And so, it took us a while to hardwire and build all of those processes. But because monkeypox [requires the same PPE], we've been able to really leverage what we've already built," said Becca Bartles, DrPH, executive director of infectious disease management and prevention at Providence.

Providence staff members are wearing respirators when in contact with patients diagnosed with monkeypox. Moving forward, Dr. Bartles said she hopes that requirement may be limited to solely aerosol-generating procedures. 

The health system has clinical decision teams for infectious diseases and infection prevention that partner to respond to all relevant issues.

The partnership is the organization's "way of bringing together all of the stakeholders from those two specialties across the different regions," said Dr. Bartles. Leaders from both teams meet weekly.

Those teams have been in place "since well before COVID. But obviously, COVID usurped almost all of our topics for the last two years. And just as we were starting to move on to other things, monkeypox came in," Dr. Bartles said.

In addition to employee updates, part of the teams' collaborative work is providing infectious disease updates to the public.

Dr. Bartles said system infection prevention, or infectious disease management, and the Providence communications team work together to provide those updates, something that has been a work in progress since the health system has facilities in seven states. Her team reviews CDC and WHO updates daily, then works with the communications team to ensure any updates are provided appropriately. 

Though it may seem like a simple focus on the surface, the COVID-19 pandemic revealed just how important clear communication is in alleviating employees' concerns, leaders told Becker's. Worrying about what they might be exposed to at work and bring home to their families is a key driver of employee fatigue during periods of disease outbreak. 

"That's what staff are often concerned about," NYU Langone's Dr. Francois said. "This is the reason we put so much emphasis and effort on education and telling people about precautions and what to do to keep themselves and others safe." 

Streamline processes for patients 

Health systems are also working to ensure clear and efficient processes are in place for patients who may develop symptoms and seek testing or care for monkeypox. 

One difference between monkeypox and COVID-19 screening at Providence pertains to an infectious risk screening tool that asks patients symptom-based questions when they arrive at a Providence facility.

Dr. Bartles said the health system built the tool in 2016 to help prevent employee exposures, and it was tweaked during the pandemic to include COVID-19 exposure questions. Now, Providence has added questions related to monkeypox, including whether the individual has had exposure to someone diagnosed with the disease.

 If somebody reports having a rash, the questionnaire also asks the person whether they have had contact with somebody with a similar rash.

"Those are the CDC epidemiological questions. And that allows us then to initiate isolation of that patient at the very earliest point of entry and reduce the risk of exposure to staff," Dr. Bartles said.

Keck Medicine of USC is tapping their ambulatory clinic leadership to develop a streamlined approach for patients with symptoms and for those who may have been exposed, Dr. Hall said. 

"We can do telehealth and arrange for testing," she said. Monkeypox testing can now be performed within the system's laboratory and if specimens test positive, they're routed to a regional CDC lab for verification. 

Keck Medicine is also doing what it can to help ease access issues to tecovirimat or Tpoxx — an experimental drug being used to treat monkeypox patients. Because it's an investigational drug that's only been approved for smallpox, physicians must go through a lengthy and complicated series of steps to prescribe Tpoxx to monkeypox patients, including registering as an investigator in a clinical trial.

For help navigating the process, Keck physicians can call an antimicrobial pharmacist to determine whether a patient meets criteria for the treatment. 

"That call goes directly to the pharmacist who pulls in our antimicrobial physician, and that specialist will consult with the care provider to ensure that the patient meets criteria," before they proceed with the process, Dr. Hall said. The system has not yet issued any doses. 

Hospitals should also be ready to administer the Jynneos monkeypox vaccine, should it become widely available, Dr. Francois said. 

"The vaccine issue is obviously beyond us because all institutions have been at the mercy of the availability of vaccines," he said. "However, operationally, we are very ready to participate and to provide a vaccine … just as we did with the COVID vaccine."

Combating stigma 

Because the virus is predominately spreading among men who have sex with men,  health systems must be prepared to address any discriminatory behavior in the workplace, along with increased anxiety and other employee concerns.

Dr. Bartles said Providence takes any discrimination seriously and has prioritized educating people on the science of monkeypox transmission. 

"Gender and sexual preferences are completely unrelated to how the disease spreads, the risk factor is skin-to-skin contact, or close contact with someone who's infected or somebody who has [the virus]," she said. "And so, I don't expect, given that our caregivers have had experience with similar things spread by contact, like [Methicillin-Resistant Staphylococcus Aureus], that this will be perceived any differently."

Ultimately, COVID-19 has left health systems well-versed in responding to an infectious disease outbreak, and the quick identification of patients who are at risk or exhibiting early symptoms should be a top priority, according to Dr. Bartles.

"This is one of those diseases where we need to take it seriously, obviously … I think we can expect to see a lot more cases. But transmission in the healthcare setting itself is extremely preventable," she said.  







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