Abstract
Introduction
T
Throughout the COVID-19 response, nurses demonstrated their ability to adapt, problem solve, and overall move the needle forward in times of crisis as frontline leaders; however, it was not the first time nurses have displayed strong leadership during the unknown and under the threat of infectious diseases.
History of NETEC and RESPTCs
During the 2014-2016 Ebola outbreak, the US Department of Health and Human Services Administration for Strategic Preparedness and Response (ASPR), in collaboration with the US Centers for Disease Control and Prevention, funded a consortium of 3 institutions, which successfully cared for patients infected with Ebola virus. This consortium is now known as the National Emerging Special Pathogens Training and Education Center (NETEC). NETEC is charged with increasing US healthcare system capacities and capabilities to safely and effectively care for patients infected with special pathogens that cause immense impact on healthcare worker safety and hospital operations, by conducting targeted outreach, trainings, program consultation and assessment, and research. 8 NETEC partners with healthcare organizations, public health agencies, emergency medical services providers, and frontline staff to improve overall healthcare system preparedness for special pathogen events.
In addition to the creation of NETEC, ASPR designated Regional Emerging Special Pathogen Treatment Centers (RESPTCs) to maintain capacity to rapidly respond to and safely manage patients suspected or confirmed to have high-consequence infectious diseases (HCIDs) in clinical spaces called biocontainment units (BCUs), special pathogens units, or high-level isolation units (HLIUs). 9 Originally, each Department of Health and Human Services region had 1 RESPTC; 3 additional RESPTCs were added in 2022 to expand the RESPTC network to 13 centers. 10 Together, NETEC and the RESPTCs prepare the nation for special pathogen events by “driving best practices, closing knowledge gaps, and developing innovative resources.” 11
The collective experiences of RESPTC nurse leaders offer a blend of clinical and operational perspectives. These experiences highlight their central role in implementing the National Special Pathogen System (NSPS) in the United States. The NSPS, aimed at addressing special pathogen preparedness and response gaps through the development of a coordinated and standardized tiered healthcare network, can enable safe, responsive, and high-quality care across the care delivery continuum. 12 RESPTC nurse leaders were critical in establishing and building the current state of BCU care; they will continue to be essential in advancing knowledge and practice within this emerging specialty field and in the continued growth of the NSPS.
Exemplars of Special Pathogens Nursing Leadership
Nurses serve as bedside conduits who translate the abstraction of science and medicine into the functional and tangible art of care. The American Organization for Nursing Leadership’s Nurse Leader Core Competencies frame the content and scope of desired and necessary leadership attributes: professionalism, communication and relationship management, knowledge of the healthcare environment, business skills and principles, and leadership. 13 RESPTC nurse leaders exemplify these core competencies by operationalizing diverse programmatic preparedness strategies to maintain readiness for rapid activation of patient care capacity in HLIUs.
Overall, operational readiness of an RESPTC depends on consistent training and preparation of multidisciplinary frontline teams of clinicians and other healthcare staff. Nurses have developed training modules and structured curriculum aimed to prepare clinicians to safely provide BCU care. 14 Specific skills training have included enhanced personal protective equipment (PPE) ensemble donning and doffing procedures, clinical skill simulations, and intensive infection prevention and control (IPC) practices. Further, nurses have taken the lead in developing simulations and exercises to test established plans and procedures. Such exercises and drills, a core activity in emergency management, require extensive planning and an arduous review process. Nurses are leveraging Homeland Security Exercise and Evaluation Program guidelines 15 to develop exercise objectives, scenario and planning documents, and evaluation measures; coordinate key partners’ participation; and facilitate after-action reviews and improvement plan implementation.16-18
RESPTC programs have expanded in scope over the last 2 years to serve as a resource hub on special pathogen preparedness for other healthcare facilities, emergency medical service agencies, and public health authorities within the RESPTC’s designated Department of Health and Human Services region. Responsibilities for regional preparedness include developing and implementing special pathogen training and education programs, coordinating with key community and regional partners on regional concepts of operations and transport plans, and collaborating with other regional hospitals offering special pathogen care services. These outreach responsibilities and relationship-building functions are facilitated and managed by RESPTC nurse leaders.
Nurses have also participated in special pathogens research. They were key in implementing rapid research studies during recent special pathogen outbreaks. This was demonstrated during the COVID-19 pandemic with the Adaptive COVID-19 Treatment Trial that was implemented at RESPTC sites in an expedited fashion. 19 Leveraging existing research infrastructure and expanding access to qualified personnel to successfully implement the trial were challenging. Nurse leaders were thrust into these research roles because they had the expertise and experience of navigating the hospital environment and were well positioned to assist research personnel with successful implementation, coordination, and communication with clinicians at the bedside.
As the RESPTC programs have matured and expanded their operational scope and regional presence, the role of the principal investigator for cooperative agreements has been filled by nurse leaders at several RESPTCs; this role has historically been occupied by physicians or senior researchers. The responsibilities of the principal investigator include completing all proposed deliverables, overseeing the activities outlined in the scope of work, developing and monitoring budgets, and maintaining the integrity of the program.
Many of the leadership roles and responsibilities described here are fulfilled wholly or in part by nurses, demonstrating their strength and flexibility as leaders in special pathogens preparedness and response. The growth that has occurred in this specific area is undoubtedly due in large part to the nursing profession’s active participation and successful demonstration of its expertise in healthcare operations by coordinating diverse teams, translating science and research into practice, and accelerating progress to the benefit of quality patient care and the advocacy of healthcare worker safety.
Special Pathogen Response Gaps
The tiered structure of special pathogen hospitals established across the United States between 2015 and 2020 through ASPR’s Hospital Preparedness Program has largely dissipated beyond the RESPTC level.20,21 NETEC and the RESPTCs have continued to receive dedicated funding from ASPR; however, the remaining tiers have been reliant on variable levels of state-directed funds or institutional investments to maintain this niche field of preparedness. The instability of dedicated funding, competing organizational priorities, lack of exigency to undergo program assessment for special pathogen preparedness, and staffing constraints have created an environment fraught with challenges for maintaining response capabilities.22,23
Moreover, the structure of the US healthcare system, comprising mostly private hospitals that can determine their own level of biopreparedness, contributes to an approach to preparedness for biological threats that is fragmented outside of the RESPTCs. 24 This individualist approach to priority training and preparedness, despite healthcare administrators’ perception that the threat of HCID events is lower, means that even 1 patient with a special pathogen that is not properly identified and isolated can have devastating effects on the personnel delivering care, the healthcare system, and the public’s confidence in the nation’s ability to keep its citizens and communities safe. 25
In December 2023, the Joint Commission released new and revised requirements for IPC that will take effect in July 2024. 26 The requirements included the development and implementation of preparedness programs for HCIDs or special pathogens, including protocols for identification and isolation of persons under investigation as well as associated training curriculum and competencies.
Nurse leaders have the ability, and the responsibility, to educate hospital executives on the importance of establishing special pathogen preparedness programs and to help build the foundational elements required to maintain healthcare system response capabilities that safeguard healthcare workers and sustain a healthy workforce. 27 The nursing profession can also be a powerful force of advocacy at various levels of government. As trusted healthcare professionals with frontline experiences in several outbreaks and pandemics in recent memory, nurses can petition government drivers of policy and appropriations to support funding growth.
Since its inception in 2015, NETEC, funded by ASPR, has conducted readiness consultations with the RESPTCs. These consultations include a thorough review of 13 operational readiness domains, many of which are the direct accountability of nursing leadership. Findings from the consultations showed that even with dedicated funding and program personnel, the RESPTCs face operational challenges to maintaining readiness to manage a significant number of patients with HCIDs. 28 Restricted access to designated isolation care spaces, inconsistent implementation of infectious disease screening processes at initial patient encounters and healthcare facility points of entry, and the number of trained staff were all opportunities for advancement noted in 2022. 29 The surge of COVID-19 patients resulted in the transition of dedicated special pathogen space to additional inpatient care delivery units, voluntary turnover that reduced the number of staff on special pathogen response teams, and mandatory overtime that created a barrier to attending additional training and education. 30
Providing care in BCU settings requires advanced IPC training, diligent adherence to enhanced practices, and use of expert clinicians to maintain overall healthcare team safety. The majority of BCUs across the United States rely on voluntary staffing models comprising primarily critical care nursing staff. 27 The sharp decline in nursing personnel working at the bedside during and since the COVID-19 pandemic has also contributed to the challenge of maintaining an adequate roster. 31 The success of special pathogen programs to deliver safe and effective care is reliant on accessing a qualified workforce that is willing to join BCU teams and train consistently. Nurses leading the development and implementation of the NSPS must create systems that promote recruitment and retention of nurses and help combat the systemic issues contributing to stress and burnout.12,32,33
Investing in Nursing’s Future in Emerging Infectious Disease
The nursing profession has maintained significant representation and influence in the current stage of US special pathogens preparedness. However, the projected growth and development of the NSPS calls for greater awareness and expanded nursing involvement at multiple levels of the profession and beyond.
Although the COVID-19 pandemic elevated the profile of HCID, now is the time to take those hard lessons learned and incorporate some level of special pathogens training into all levels of nursing education, including prelicensure curriculum. 34 By introducing best practices in PPE and foundational to high-level IPC practices early, nurses can build confidence in their ability to safeguard their wellbeing during infectious disease encounters. In the pandemic’s wake and as the persistent threat of emerging infectious disease outbreaks continues to unfold, arming the future workforce to be knowledgeable of biological threats, competent in PPE and IPC measures, and empowered to protect themselves and their peers can only contribute to greater retention and foster the next generation of special pathogen nurse leaders.
In addition to prelicensure curriculum, continuing education forums within professional organizations can be leveraged to increase visibility of the strategic national and international infrastructures to address special pathogens in healthcare. These could also provide a forum to disseminate the growing body of scientific and clinical knowledge on special pathogen preparedness. Involvement with professional organizations can also spur the development of a certification that recognizes nursing expertise in special pathogens preparedness and response, akin to certifications that can be found in other specialty settings like critical care and emergency care. BCU care is a burgeoning specialty that requires a set of specific skills and an entrenched understanding of a unique patient population.
The global issue of special pathogens preparedness within the built environments of HLIUs should also be addressed as recent infectious disease outbreaks have shown their latitude and reach across international borders. The complexity of some processes and procedures necessitates a collaboration with nursing leaders worldwide working in the specific niche of HCID preparedness and response.
Nurse leaders across multiple HLIUs representing 15 countries (Australia, Austria, Belgium, Denmark, France, Germany, Ireland, Italy, the Netherlands, Norway, Portugal, Spain, Sweden, the United Kingdom, and the United States) have joined forces to brainstorm solutions, develop strategies, and discuss common challenges experienced during the preparedness or care of HCID patients as part of the International HLIU Nurses Association. During the summer of 2023, the initiators of this network from Germany and Ireland conducted a preliminary survey of participants. The survey results highlighted a great interest in discussing staff training models and frequency, PPE guidelines and equipment supply/inventory, and management of emergency scenarios. They also showed interest in sharing relevant literature, research, knowledge, and expertise.
This collaborative was launched in August 2023 with its first videoconference. Videoconferences will be continued quarterly with additional country representatives recruited through professional networks and relationships. Nurses are playing a pivotal role in this field of practice, and an international network has borne the foundations of a growing diverse platform and venue of peer support.
Growing global tourism, climate change, and greater accessibility to once remote countries can increase the likelihood of HCID case imports into the northern latitudes; therefore, there is a need to be ready. Recognizing that the current representatives on the International HLIU Nurses Association are from high-resource countries where special pathogens are not known to be regularly treated, there is an opportunity to engage nurses and frontline clinicians who have direct experiences caring for patients with HCIDs, like those from Bangladesh, the Democratic Republic of the Congo, Guinea, Liberia, Nigeria, Sierra Leone, and Uganda. They could provide an inclusive, broad, and diverse platform through which sharing experiences and ideas can better inform future preparedness and response approaches universally.
Conclusion
Nurses have built a foundation of active leadership in special pathogens preparedness and HCID response; however, the field’s projected exponential growth necessitates a shift toward the development of a new generation of special pathogen nurse leaders. A future state of BCU care is on the horizon, and nurses are a critical component to its next stage of development and legacy.
Footnotes
Acknowledgments
The authors would like to acknowledge the nurse clinicians, educators, coordinators, researchers, and leaders working in special pathogens preparedness at every level of the healthcare system and represented in this article. Through the continued efforts of special pathogen nurses, quality patient care and healthcare worker safety are safeguarded in the biocontainment unit care environment.