Since Thomas Eric Duncan was diagnosed with Ebola virus on his second trip to a Dallas hospital after initially being discharged despite his travel history, hospitals nationwide have been scrambling to ensure that they are prepared.
Once it was confirmed that two nurses caring for Duncan at Texas Health Presbyterian Hospital Dallas contracted Ebola during his care, one question resonated throughout hospitals in the United States: Just how ready are we?
“The Dallas situation was a wake-up call to almost every hospital in the country,” Thomas R. Talbot, MD, MPH, associate professor of medicine and preventive medicine at Vanderbilt University School of Medicine and chief hospital epidemiologist at Vanderbilt University Medical Center, told Infectious Disease News. “It went from being just a potential scenario to a very real possibility for most places.”
Until Duncan, the only patients with Ebola in the US had been humanitarian workers who had been flown in from West Africa after being infected in the outbreak zone. All of those patients had been sent to specialized biocontainment units at Emory University Hospital in Atlanta, the Nebraska Medical Center in Omaha and the NIH Clinical Center in Bethesda, Md. These facilities and their staff were prepared, having undergone rigorous training in handling patients with Ebola or other dangerous pathogens.
When the outbreak in West Africa began, the CDC said that any hospital in the US with single rooms can safely care for patients with Ebola. After Dallas, that message changed.
Infectious Disease News spoke with experts in hospital infection prevention to discuss the lessons learned from Dallas, how hospitals are preparing for potential cases of Ebola and the risks for health care workers (HCWs) tasked with caring for patients with the infection.
Thomas R. Talbot, MD, MPH, of Vanderbilt University School of Medicine, said the case in Dallas was a wake-up call to every hospital.
Photo courtesy of Talbot TR
Lessons from Dallas
It was just coincidence that the hospital in Dallas saw the first case of Ebola diagnosed in the US, according to Keith S. Kaye, MD, MPH, professor of internal medicine and infectious diseases at Wayne State University School of Medicine, and an Infectious Disease News Editorial Board member.
“What happened there could have happened at any hospital in the United States,” Kaye, who is also a corporate director of infection prevention, hospital epidemiology and antibiotic stewardship at Detroit Medical Center, said in an interview. “The difference between Duncan and the patients at Emory, Nebraska and the NIH is that he was an unexpected patient. The other hospitals cared for patients with a known diagnosis and knew ahead of time that they were coming. The Dallas hospital missed Duncan’s initial diagnosis and sent him home. It was a mistake, but it could have happened to any hospital.”
There is no definitive answer for what went wrong and led to two nurses becoming infected with Ebola while caring for Duncan. Both nurses had been wearing personal protective equipment (PPE) while working with Duncan. The CDC currently is investigating how the nurses acquired the infection. CDC Director Thomas R. Frieden, MD, MPH, said he was most concerned with the process HCWs used to remove the contaminated PPE.
According to Amesh A. Adalja, MD, senior associate at the Center for Health Security at the University of Pittsburgh Medical Center, a key lesson from Dallas is that preparation for patients with Ebola is about more than just having protocols in place.
Linda R. Greene
“It’s more important to be able to execute those protocols,” Adalja, speaking on behalf of the Infectious Diseases Society of America (IDSA), told Infectious Disease News. “Hospitals need to make sure that they are able to do things such as practice stringent infection control and ensure that their health care workers are well trained in the use of PPE. We saw two health care workers become infected, and that never should have happened.”
Identify, isolate, communicate
Perhaps the single most important lesson that hospitals can take away from the events in Dallas is the early recognition of Ebola.
“The mantra for every hospital in the United States is to identify, isolate and communicate,” Linda R. Greene, RN, MPS, CIC, infection prevention manager, University of Rochester Medical Center, Highland Hospital in Rochester, N.Y., and spokeswoman for the Association for Professionals in Infection Control and Epidemiology (APIC), told Infectious Disease News. “All hospitals and emergency departments must be prepared to identify and isolate potential patients with Ebola. Health care workers need to recognize the signs and symptoms, including travel histories. Many hospitals have integrated this into routine screening questions.”
For the nurses from Dallas, the early recognition of their symptoms and immediate isolation is likely what led to their fairly quick recoveries, Greene said.
Handling a potential case of Ebola is complex, according to Talbot. It ranges from identifying potential cases as early as possible, while screening and evaluating the individuals to see if they have another disease with similar symptoms, such as malaria.
In a study of exit screening from the affected countries, 77 people had been flagged at airports as potential Ebola cases due to symptoms, Talbot said. None had Ebola, but many had malaria. For most patients with symptoms of Ebola and a history of recent travel to West Africa, the likelihood is that they will have another disease, like malaria, not Ebola.
“The challenge is going to be treating another infectious disease safely, while also practicing the precautions in case the patient does have Ebola,” Talbot said. “If we have a patient with malaria, who is a potential Ebola patient, the care team may not think about other diagnoses until the Ebola test results come back, which can take 2 to 3 days. Meanwhile, the patient has morbidity from forgoing treatment.”
Use of PPE has become a major area of focus after it was learned that discrepancies in its use may have been responsible for the nurses’ infections.
“One of the major messages is that preparedness for the safe care of Ebola patients is difficult, requires a lot of practice and requires meticulous use of PPE, which is something you can’t really do on the fly,” Daniel J. Diekema, MD, director of the division of infectious diseases at the University of Iowa Carver College of Medicine and president of the Society for Healthcare Epidemiology of America (SHEA), told Infectious Disease News. “It emphasizes the degree to which hospitals need to prepare for this in order to keep their health care workers safe.”
The CDC has updated its guideline on PPE donning and doffing for HCWs. The guideline has three key principles for those requiring PPE to care for a patient with Ebola: HCWs involved must undergo repeated training and demonstrate competency in donning and doffing PPE; HCWs should have no exposed skin while wearing PPE; and each step of donning and doffing PPE must be supervised by a trained observer.
In addition, the CDC has developed web-based training modules to educate HCWs on the proper steps for PPE use.
The message is clear: All hospitals must be able to recognize a potential case of Ebola. But in the event that a patient does present with the disease, what next? Before Duncan arrived at the hospital in Dallas, the message was that every hospital is capable of caring for a patient across the entire continuum of the illness. But that message has changed.
“All hospitals need to be prepared to identify and triage a potential patient with Ebola,” Kaye said. “Beyond that, it’s not realistic to think that all hospitals could deliver equally effective chronic care, nor is it practical to have all hospitals be prepared to do so.”
Keith S. Kaye
Adalja said the Dallas experience has shown that outside of recognizing the disease, not every hospital has the resources to care for patients with Ebola. Thirty-five hospitals throughout the country have been designated by health officials as Ebola treatment centers. Each hospital was assessed by a CDC Rapid Ebola Preparedness team and have the necessary resources with patients with Ebola. A list of the centers can be found at www.cdc.gov/vhf/ebola/hcp/current-treatment-centers.html.
The designated hospitals will be a complement to the biocontainment facilities that have been used to treat patients with Ebola, Adalja said. These hospitals have demonstrated an adeptness at treating infectious diseases and practicing meticulous infection control.
There are four biocontainment units in the United States: Emory, the NIH and Nebraska, which all have cared for patients with Ebola, and St. Patrick Hospital in Missoula, Mont. In addition to having the specialized facilities and equipment, these units also have highly trained staff that undergo regular drills to ensure their readiness for accepting patients with Ebola or other dangerous infections.
“If a patient presents to a community hospital, the hospital needs to identify and isolate that patient until the patient can be transferred to a biocontainment facility or designated Ebola hospital that is equipped to handle patients with Ebola in a safe manner,” Adalja said. “We do that for several conditions, like trauma and stroke, and the same principles apply to Ebola. We learned the hard way that not every hospital can do this.”
Greene said this model is frequently used in health care for a variety of specialties. For example, every hospital can provide acute care for an emergency patient; but not every hospital has a burn unit.
“In health care, there are degrees of specialization in every hospital,” Greene said. “What we have learned is that when we identify patients who have Ebola, they might be better served at regional hospitals that have the resources to provide the intense patient care needed when a patient becomes symptomatic and the illness really takes its toll.”
Beyond disease recognition
There are many factors at play when caring for patients with Ebola, most importantly the need for the appropriate facilities and a trained staff that has the level of expertise needed to handle the care, Talbot said.
“We’ve learned from Emory, the NIH and Nebraska that some places can care for these patients, but it really requires a cadre of highly trained health care workers who are very familiar with the equipment and protocols,” Talbot said. “Outside of those biocontainment units, that’s not something close to common practice.”
These other hospitals can prepare only so much for something they have never experienced, Greene said.
“The Dallas hospital, like many other hospitals in the country, was prepared as well as it could be, but didn’t realize all of the things that happen when caring for a patient with Ebola,” Greene said. “One of the major issues it reported was how to dispose of the patient’s waste. Things like that may not be first and foremost when planning.”
Along with waste management, Talbot said there are several downstream issues that could go unaddressed when planning care for Ebola patients, including laboratory testing, environmental cleaning and clinical care planning.
One significant consideration is the impact an Ebola patient will have on busy medical centers. Because these patients require more manpower and isolated space, one patient could potentially close an ICU.
“If you’re at capacity, how do you ensure that you effectively care for this single patient while also having the resources to treat other patients safely?” Talbot said. “That’s part of the struggle.”
Another challenge to safely caring for Ebola patients in the US is the dwindling PPE supply.
“There are plenty of problems with the availability and the supply chain of PPE,” Diekema said. “There is no question that there is enough PPE in the United States to care for the few patients with Ebola that we expect to see, but the available PPE is not sufficient enough that every hospital can have a supply.”
According to Diekema, the CDC and public health departments are working to improve the distribution of PPE to hospitals that may be required to evaluate a person under investigation or care for a patient with confirmed Ebola.
Daniel J. Diekema
The good news is that there is now active monitoring of people who are returning to the US from the outbreak zone, so cases will likely be identified earlier before they become extremely infectious.
“The public health response has been greatly enhanced since Dallas in terms of tracking people at high risk, so it’s much more likely now that a hospital will have advance warning from the health department of a potential patient with Ebola,” Diekema said. “But still, all hospitals need to be prepared to detect patients who arrive with Ebola unannounced.”
The CDC also has ordered $2.7 million in PPE to increase Strategic National Stockpile supplies to assist US hospitals caring for patients with Ebola. The products will be configured into 50 kits that can be delivered to hospitals quickly, and each kit will include the PPE needed to manage care for one patient with Ebola for up to 5 days.
Hospitals are to coordinate with state public health departments to request PPE supplies from the CDC, and the health department will follow the established protocol to submit the request to the CDC.
Since the nurses in Dallas became infected with Ebola, the CDC has redoubled its efforts to ensure that HCWs remain safe when faced with potential Ebola cases. In October, Frieden announced some new initiatives, which include requiring a site manager to oversee every aspect of infection control around the clock, increased infection control training for HCWs and reducing the number of HCWs entering isolation units.
In addition, Frieden said a CDC team will be dispatched to any hospital and arrive on site within a few hours after an infection is confirmed.
“I’ve been hearing loud and clear from health care workers from around the country that they’re worried, that they don’t feel prepared to take care of a patient with Ebola, and that they’re very distressed that colleagues have contracted Ebola in Dallas,” Frieden said during a press conference. “A single infection in a health care worker is unacceptable, and what we’re doing at this point is looking at everything we can do to minimize that risk.”
Along with the updated PPE guidelines, the CDC has released interim guidance regarding environmental infection control in hospitals for Ebola virus. The agency continuously reminds HCWs of other areas of infection control that still need attention, including background checks, prompt screening, fewer HCWs in isolation rooms, effective sanitation and the presence of designated site managers to ensure procedure implementation.
Ending the outbreak
Experts agree that to effectively fight the Ebola outbreak, it needs to be stopped at its source. As of Dec. 2, there have been 17,256 cases of Ebola throughout the world and 6,113 deaths, according to WHO. A recent CDC report suggested that without significant global response, the number of cases could swell to more than 1 million by mid-January. The Ebola outbreak has been designated a public health emergency of international concern by WHO and a national security priority by President Barack Obama. The United Nations launched a mission for Ebola emergency response — the first UN mission ever for a public health emergency.
Given the magnitude of the outbreak in West Africa, it is likely that there will be a small handful of Ebola cases across the US within the next several months, Kaye said. The odds of an individual hospital seeing a patient with Ebola, however, is extremely low, he said, especially with the mandatory monitoring of people arriving from the outbreak zone.
Talbot said Ebola preparations are nonetheless important because although the likelihood of seeing a patient with Ebola is low, the training and activities of Ebola preparation help to strengthen the basic infection prevention practices in the normal hospital setting.
“Today, it’s Ebola, but tomorrow, it could be a different disease,” Talbot said. “It’s important to be trained and prepared for everything.” – by Emily Shafer
Meltzer M. MMWR. 2014;63(supplement):1-14.
For more information:
Amesh Adalja, MD, can be reached at: email@example.com.
Daniel Diekema, MD, can be reached at: firstname.lastname@example.org.
Linda Greene, RN, MPS, CIC, can be reached at: email@example.com.
Keith S. Kaye, MD, MPH, can be reached at: firstname.lastname@example.org.
Thomas R. Talbot, MD, MPH, can be reached at: email@example.com.
Disclosure: Adalja, Diekema, Greene, Kaye and Talbot report no relevant financial disclosures.
How much PPE should a hospital have on hand to prepare for a potential Ebola patient?
All hospitals should have enough to evaluate a patient for 48 hours.
We know that a patient with Ebola could go to pretty much any hospital in the United States. Every hospital should have enough PPE to evaluate a patient for 48 hours. It’s not necessary for all hospitals to have enough to care for a patient during the entire course of the disease because if they’re diagnosed, they will likely be transferred to another hospital that can provide that different level of care. However, that doesn’t happen instantaneously, so having supplies for 48 hours would be wise. It’s hard to say that no hospital needs it, because we know that travelers can go anywhere in the United States.
It’s unlikely that someone will show up unannounced with Ebola or not until they’re very sick because travelers are monitored for 21 days when they return from the affected countries, so it would be arranged for them to be evaluated in a hospital much sooner than they might if they were on their own. It’s possible to argue that if they go to an area where the closest hospital doesn’t have adequate PPE, the PPE could be provided to that hospital for the period of time that the traveler is being monitored.
In general, all hospitals have some type of PPE. They all follow standard precautions that require a certain level of gowns and gloves, but not necessarily enough to care for a patient with Ebola. They have access to respirators and face shields, all of which goes along with standard and airborne precautions. To care for patients with Ebola, however, particularly if they have vomiting, diarrhea or bleeding, you have to use more than that. Those PPE components are not as common.
One complication is that health care workers are trained with one type of PPE. When a particular component of PPE is no longer available, and they get something equivalent, it will appear new and may result in some inadvertent compliance issues or anxiety that could lead to incorrect use. For this reason, many hospitals try not to switch PPE type, but there are challenges to the current supply chain.
Patients early in the infection who have a fever are not as infectious as those in the later stages of the infection, but health care personnel should still use the full PPE. But it’s not necessary to have a 2 week supply on hand. In the later stages of the infection, when the patients become quite ill with vomiting and diarrhea, a hospital can go through 50 or more changes of PPE a day while caring for a patient. Some places will need to have that large amount on hand — but only the places that will be caring for patients for 2 or more weeks.
Louise Dembry, MD, is vice president, Society for Healthcare Epidemiology of America (SHEA). Disclosure: Dembry reports no relevant disclosures.
Hospitals need enough for the time it takes to confirm an Ebola infection.
We have to work with the local and state health departments, as well as the CDC, to determine how much PPE to have on hand. The White House is working with state and local authorities, as well as with domestic and global manufacturers, to ensure an effective Ebola PPE supply chain. The government is also working with PPE distributors and manufacturers to prioritize and redirect PPE supplies as needed. The CDC has the Strategic National Stockpile (SNS), which currently has 50 days of Ebola PPE that is available within 24 hours to hospitals should they have an Ebola patient.
It’s important to talk to the state and local health departments to determine what their level of support would be beyond what the SNS would be able to provide, and then figure out how long it would take for you to determine if a suspected Ebola case is a confirmed patient. That involves how long would it take to draw the sample and get it to the sentinel laboratory and confirm the disease. We’re really looking at a much shorter time frame of PPE to have on hand than originally thought. The plan for specialized Ebola centers will minimize the amount of exposure that might occur were a patient actually to have Ebola.
The basic protective equipment, such as gowns, gloves and masks, will be in supply at every hospital on a regular basis. I would also say that almost all hospitals will have PPE for hazmat decontamination, which includes a high level of PPE, such as full body suits and hoods, that provide full body coverage for a chemical event. This can also be used for a biological event. Although most hospitals will have some kind of that level of PPE on hand, it is only enough to deal with a limited number of events in the immediate present — not the ongoing care of a patient with Ebola.
Jacie Volkman, MPH, CIC, is director of Infection Prevention, Mission Health, Asheville, NC. He is also a board member of the Association of Professionals in Infection Control and Epidemiology (APIC). Disclosure: Volkman reports no relevant disclosures.