Bird Flu, Actors, Unannounced Drills … CDC Study Has It All

Unannounced drills that used professional actors posing as patients exposed some gaps in how healthcare facilities respond to a potential infectious disease outbreak, according to a study of three jurisdictions.

Among 73 drills conducted at 69 healthcare facilities in New Jersey, New York, and the U.S. Virgin Islands using a simulated avian influenza A(H5) scenario, patient actors were successfully masked and isolated in 60.3% of drills, reported Nang Thu Thu Kyaw, PhD, of the New York City Department of Health and Mental Hygiene, and colleagues in the Morbidity and Mortality Weekly Report.

However, fewer than half of the drills hit the target times of 1 minute for masking (43.1%) and 10 minutes for isolation (48.1%).

Recent infectious disease outbreaks “have reinforced the importance of rapidly recognizing and safely managing patients with potentially severe transmissible infections,” Kyaw and colleagues wrote. “These drills identified needs for healthcare workers and healthcare facility staff member training to achieve earlier identification, masking, and isolation of potentially infectious febrile patients.”

Unannounced drills are valuable “because they test what actually happens during day-to-day operations, not just what’s written in a protocol,” Kyaw told MedPage Today. “Sending trained patient actors into healthcare facilities without warning captures how frontline teams — including non-clinical staff — respond in real time to identify practical strengths and gaps.”

The drills show that many facilities had important infection prevention practices in place, Kyaw noted. But the results also underscored that urgent care centers and outpatient clinics, not just emergency departments, are common settings for patients seeking acute care. “It is vital that all these settings establish robust screening and rapid isolation protocols, keeping staff updated on current threats and using standardized decision-support tools,” she explained.

The New York University Standardized Patient Program conducted the drills from January to June at emergency departments, hospital outpatient clinics, and urgent care centers in New York City, New York state, New Jersey, and the U.S. Virgin Islands. Patient actors, also known as mystery patients, ages 20 to 28 years self-reported avian flu-like symptoms and histories, including stories of recent contact with sick or dead birds, and no recent travel.

In 63.4% of the drills, clinicians correctly identified the patient actors as being at risk of avian flu, and infection prevention and control (IPC) staff were notified in 54.8% of the drills.

Almost every healthcare facility drill (93.2%) led to symptom screening, and clinicians took patients’ travel history in 79.5% of the drills. However, patients were asked about avian flu-specific exposure history in only 9.6% of the drills. Symptom screening occurred a median 4 minutes after a patient’s arrival (interquartile range [IQR] 2.0-9.0).

In the 82.2% of drills that led to patient masking, median time to masking was 2 minutes (IQR 1.0-6.0). Most facilities had masks available in their waiting areas (80.8%), but availability varied by setting, from 57.9% for outpatient sites to 95.2% for emergency departments.

Patient actors were isolated in 71.2% of drills, with median times from entry to isolation of 11 minutes (IQR 8.0-19.2). While isolation occurred in 100% of urgent care center drills, only 57.1% of emergency department drills did the same.

To help shorten delays in masking and isolation, screening protocols and IPC training should include staff who are likely to encounter patients first, such as receptionists, registrars, greeters, and security personnel, Kyaw and colleagues noted. In more than half of the drills, security or reception staff members performed symptom screening (52.9% of drills) and gave patient actors masks (64.4% of drills).

The evaluation also found that facilities used respiratory personal protective equipment inconsistently. Nearly one in five facilities (18%) didn’t give a mask to a patient actor who was visibly coughing and reported having a fever, while 19% of clinicians didn’t wear a mask or a respirator when they performed clinical evaluations.

The New York City Department of Health and Mental Hygiene offers a mystery patient drill toolkit online.

Study limitations included the relatively small number of drills at hospital outpatient and urgent care centers, which could limit the findings’ generalizability. Patient actors also couldn’t exhibit all avian flu symptoms, such as fever or conjunctivitis, which could have limited consideration of avian flu in differential diagnoses.