Ebola - Education for the American Healthcare System

The few cases of Ebola in the United States to date have motivated hospitals and other healthcare facilities to take a serious look at their readiness to manage these types of patients. Caring for a suspected or confirmed Ebola patient is providing the U.S. healthcare system with a just-in-time education on challenges that healthcare workers may encounter in the future for a more widespread highly infectious disease outbreak.

Potential Threats & Treatment Concerns The immediate recognition of a suspect case is critical for providing effective patient care, while preserving the health and safety of the treatment personnel and maintaining the operational integrity of the treating healthcare facility. Hospitals have been the focus of preparedness efforts for many communities, but a suspect case could just as easily arrive at an urgent care center or a community clinic. Warning signage is now common at the front door or window of many healthcare facilities. The instructions ask visitors who are exhibiting fever and flu-like symptoms and have recently travelled to affected countries to promptly report their illnesses to front-desk personnel, who should ask them to don masks and perhaps gloves. But patient failure to comply with these instructions and/or staff not maintaining constant vigilance and asking key questions and listening to the answers provided can lead to delayed recognition of a patient’s condition – and potential exposure of others – as has already been seen in Dallas, Texas.

Once a suspect case arrives, the impacted healthcare facility must now implement a series of steps – as outlined by the U.S. Centers for Disease Control and Prevention (CDC) – in a timely manner regardless of the day or time. In many facilities, clinical workspace already is limited, staffing is at minimum levels, and storage space is at a premium. These needed response steps include, but are not limited to:

• Identifying where the patient goes next to receive an evaluation without further risk to staff and facility;

• Understanding how staff can gather other needed clinical information safely;

• Knowing which type of personal protective equipment (PPE) should be worn by those assessing the patient;

• Verifying whether those working are trained to use the PPE; and

• Determining the availability of necessary PPE and other response equipment and supplies.

The confirmation that a patient has Ebola or some other similar illness – for example, malaria also is often a final diagnosis – requires blood work testing not typically done at a healthcare facility lab. Thus, the facility’s link with the local and state health department that can do the required testing has proven vital. Even then, results may take hours to several days before the final diagnosis can be determined in conjunction with the CDC. In the meantime, patient care must continue.

Under the current outlined U.S. Department of Health and Human Services system, there are three levels of facilities with neither a frontline nor assessment facility ultimately being expected to treat a confirmed case. However, these facilities still have to be prepared to recognize cases, respond safely, send test specimens, and care for suspect cases before transferring a confirmed case to one of the designated Ebola treatment centers. This transfer, though, requires utilization of suitably prepared emergency medical system agency (public or private), but these agencies too may be “learning on the fly.”

Protection of Healthcare Workers The CDC has outlined PPE ensembles for medical staff to wear when working with a suspect or confirmed case. However, acquiring the recommended items has proven universally frustrating as the sudden “rush order” requests by everyone to a limited number of vendors has resulted in backorders lasting weeks to months. In the meantime, facilities scramble to assemble what they can through individual, corporate, or coalition related efforts. The recent build up ofentified PPE by the Strategic National Stockpile may help a facility that has a confirmed case but does little to help facilities trying to protect staff treating suspect cases while they await test results.

Training is another focus area. Determining how many and who to train is a critical start. How best to conduct training on proper PPE donning and doffing techniques as well as working in hazardous materials suits while performing various patient care skills can be challenging. For the original three federally designated highly infectious disease centers – Emory University Hospital, University of Nebraska Hospital, and National Institutes of Health – this training and team building has been performed regularly for years, but how best to do that for all of the other healthcare facilities is a work in progress.

Ongoing Challenges Another challenge is trying to first conceptualize then rehearse how to set up and operate a biocontainment unit, whether in a temporary or permanent site. Centers that have treated Ebola patients have done an outstanding job of sharing the lessons they have learned with others via teleconferences, at conferences, and most recently by hosting site visits. Although there is no substitute for actual practice, a challenge that remains is practicing without disrupting normal operations, thus incurring expensive and uncompensated overtime costs as well as increasing the need for already scarce PPE.

As with most educational experiences, the invaluable lessons learned from the Ebola response to date are just the beginning. There are many more lessons to learn about this deadly disease, including how to prevent further spread, respond to new and existing cases, and sustain the ongoing Ebola effort.