Zika changing how hospitals manage pregnant patients
When a pregnant woman arrives at the front desk of the University of Miami Hospital or its resident training facility, Jackson Memorial Hospital, the first questions she is asked are: Have you traveled? Where did you travel? Did you get mosquito bites?
Those questions are now required at point of contact for all pregnant women, whether they’ve come for a clinic appointment, triage, or some other appointment. Intake not only wants to know if a woman has traveled in a country where the Zika virus is active but also where she’s traveled in the Miami area now that local transmission has been documented there.
Flagging high-risk cases
“There’s a map, as well as street descriptors at every front desk check in so that the patient can point to where she lives,” says Christine Curry, an assistant professor of obstetrics and gynecology at the University of Miami Miller School or Medicine at Jackson Memorial. If a woman is at high risk for Zika exposure, that information is flagged to providers via a yellow sticker on her chart.
Women who actually test positive for the mosquito-borne virus are automatically funneled into an intensified ultrasound surveillance process, providing ultrasounds throughout the baby’s gestation. They have the option of being seen by a high-risk provider, or staying with their own obstetrician and getting consultation from high-risk providers.
These are just a few of the protocol changes UM and Jackson Memorial have put in place to deal with the growing public health threat of Zika, which has been linked to congenital birth defects such as hydrocephalus and microcephaly.
To date, the two hospitals have managed some part of the pregnancies of more than two dozen women who tested positive for Zika.
Rewiring how women plan their pregnancies
As of Aug. 10, there were 1,955 reported cases of travel-associated Zika infection in the U.S. and six locally acquired cases, according to the Centers for Disease Control and Prevention. The CDC has recommended Zika testing for all pregnant women who have spent any time since June 15 in Wynwood and Midtown, a one-square-mile section of Miami where all of the local cases occurred.
“It’s changing how women think about reproduction in this hemisphere,” says Curry, who has a background in infectious disease. “Certainly, in Miami, the last two weeks have accelerated the dialogue about getting pregnant and pregnancy risk in a way that no amount of media [coverage] would have done prior to local transmission.”
These days, Curry, who took the lead early on at UM in researching the emerging health crisis, serves an interdisciplinary emergency response team at both campuses, continually adapting and revising workflow and protocol so that they are up to date with CDC and World Health Organization guidelines, as well as compliant with Florida Department of Health requirements.
At UM, she also consults with patients who are interested in learning about how to get pregnant and avoid Zika infection, and how to manage pregnancy if they are already pregnant and positive for Zika. At Jackson Memorial, Curry devotes a half day a week in her obstetrics clinic to care for women who are either waiting for test results or want to have a conversation about how to proceed, based on those results.
Between the two campuses, she sees about 30 patients a day.
“We talk about what trimester they’re in, about mosquito prevention — literally showing them the EPA website on repellents, talking about long sleeves, long pants, modifying their daily routines to avoid parts of the city or areas where there are lots of mosquitos or known transmission, then talking about standing water,” she tells Healthcare Dive. The conversations also cover use of condoms and the importance of ensuring that partners take steps to prevent mosquito bites or spread Zika infection.
Because Zika is transmitted through the bite of an infected mosquito and not person-to-person by coughing or sneezing, universal precautions instituted in all hospitals for infection control are sufficient for specimen handling and drawing blood. But that doesn’t mean the virus doesn’t impact the specimen workflow.
The UM computer system now recognizes orders that are unique to Zika and correlates that with the fact that these specimens are going to the health department, Curry says. This helps to manage workflow, keep track of specimens and make sure the documentation is there and health officials get what they need.
UM is also working to build into the computer system drop downs that will capture places of travel, mosquito bites and other patient information so that clinicians can check “yes” or “no” from the computer screen and have that data for documentation and future research, she says.
In labor and delivery, physicians and nurses are notified on a patient’s arrival if she is Zika positive. The placentas, cord blood, and the neonatal specimens are all sent to the CDC.
“Logistically, keeping track of everything is a challenge,” Curry says. “All of that workflow had to be created in terms of the orders and order system, chain of command, making sure specimens are divided up and sent to the appropriate places.”