EXECUTIVE SUMMARY

Although a recent outbreak of Ebola in the Democratic Republic of the Congo has been contained successfully, it is likely that the crisis failed to come to the attention of many frontline providers in the United States. This must change, according to experts, who note that while the country has implemented several improvements to its defenses against an infectious disease outbreak, early recognition is critical.

  • Experts say that situational awareness of infectious disease threats needs improvement, and that hospitals must devise ways to filter information so that frontline providers focus on the most important data.
  • When a contagious disease is suspected, experts advise frontline staff to use person-to-person communication to ensure that the information is conveyed to colleagues and administrators properly.
  • The CDC and the U.S. Department of Health and Human Services have established the National Ebola Training and Education Center to provide guidance to hospitals. They also have created a system of “assessment hospitals” and “designated treatment centers” for patients diagnosed with infectious diseases of high consequence.
  • The “vital sign zero” concept instructs frontline providers to ask themselves first whether a patient potentially is contagious, requiring protective measures before taking the standard vital signs and proceeding with other care tasks.

An outbreak of Ebola in the Democratic Republic of the Congo (DRC) in early May has been contained successfully, but some observers wonder what would have happened if an infected individual from the region had traveled to the United States and presented to a community hospital ED. Would this person have been identified quickly and isolated, preventing a repeat of the Ebola crisis that unfolded at Texas Health Presbyterian Hospital in Dallas in 2014?

Patricia Abbott, PhD, RN, BC, FAAN, FACMI, an associate professor at the University of Michigan School of Nursing and a member of the national panel that reviewed the hospital’s response to the first case of Ebola to be diagnosed in the United States, is concerned that such a case might get overlooked again.

“I have been immersed in this space and even I missed [the outbreak in the DRC], so what about everyday, frontline healthcare workers, the people in the ambulances, and the people at the airport?” she asks.

That “situational awareness” still needs improvement, Abbott suggests. “No matter where you live, you should be aware that there has been a flare-up of an incredibly dangerous [infectious disease] in an area of the world,” she says. “The issue is how you become aware of it, because we are bombarded with tons of information day in and day out. It is just really hard to do.”

On a deeper level, situational awareness involves understanding that there are varying levels of risk in different areas. For example, Abbott points out that Dallas is home to an international airport and one of the largest expat populations of Liberians in the country. “Hindsight is 20/20, but the fact that those things weren’t put together [during the 2014 Ebola crisis] speaks to our naiveté as humans,” she says.

However, Abbott notes that the 2014 crisis also illustrates the need for an effective mechanism for filtering information so that the most important data are disseminated to frontline providers in a focused way. “Everyone needs to have situational awareness, but we have to have more effective ways of creating that situational awareness because humans are humans. They can’t process everything,” she says.

Further, while hospitals routinely prepare for shootings, natural disasters, and other mass casualty events, there is not enough emphasis or practice focused on scenarios similar to what happened in 2014, Abbott notes. “Even though there was a lot of hoopla about this in the year following the Ebola crisis, I would guarantee that there are probably very few places that are practicing disaster drills in relation to an infectious disease outbreak,” she says. “We learned the lesson once, but we forgot it.”

Take Advantage of Training

While there remains ample room for improvement, numerous steps have been taken to bolster the nation’s defenses against a dangerous infectious disease.

For instance, the Department of Health and Human Services (HHS) has funded the National Ebola Training and Education Center (NETEC), which is led by faculty from Emory University in Atlanta, the University of Nebraska Medical Center in Omaha, and Bellevue Hospital in New York.

The three institutions work together to educate hospitals across the country on how to address infections of high consequence such as Ebola, explains Marshall Lyon, MD, MMSc, a professor of medicine at the Emory School of Medicine and a subject matter expert with NETEC.

Additionally, HHS and the CDC have created a network of hospitals across the country designated as “assessment hospitals” for patients suspected of carrying an infectious disease of high consequence, Lyon notes. “Once an assessment has been made on a patient, these hospitals will then transfer the patient either to a state-designated treatment center or, if it is confirmed that a higher level of care is needed, the patient could be transferred to a regional treatment center,” he explains. “There are 10 regions designated by HHS, and within each of those regions there is a regional treatment center.”

Most states have been working to educate their frontline hospitals about this new arrangement so that if they receive a patient of concern, these healthcare workers can move him or her to an assessment hospital or to a designated treatment center quickly, Lyon shares. However, he acknowledges that community hospitals have to proactively seek the needed training and expertise for their clinical staff.

“What we are trying to do is have the training and information and education all trickle down [throughout the healthcare system],” Lyon explains. “NETEC is the central organization that works mainly with the state treatment centers and regional treatment centers, and then the regional treatment centers are then trying to do some of the education within their region, but hospitals have to want to get this training and education.”

Similar to when there is a mass-casualty event involving scores of injured patients, when there is an infectious disease outbreak there must be regional coordination involving multiple hospitals, and this goes well beyond any specific disease outbreak, Lyon observes. “We are moving beyond Ebola because it is hard to know what the next threat will be,” he says. “It might be MERS [Middle East respiratory syndrome] coronavirus out of the Saudi Arabian Peninsula, or it could be SARS [severe acute respiratory syndrome], or it could be another hemorrhagic fever or pandemic influenza. There are any number of things that could possibly feed into this virus containment system that has been developed.”

Implement ‘Vital Sign Zero’ Concept

The system involving NETEC, assessment hospitals, and designated treatment centers is a robust response to one of the biggest lessons learned during the Ebola crisis of 2014. “Everybody believed that any hospital could handle [Ebola] because you would just use the isolation precaution measures,” Abbott recalls. “We found out the hard way that that wasn’t true.”

As healthcare personnel who were caring for Ebola patients became infected with the disease themselves, it became clear that stronger protective measures were needed. Further, to protect healthcare workers in cases involving the potential for infectious disease, Kristi Koenig, MD, FACEP, FIFEM, the EMS director for San Diego County in California and professor emeritus of emergency medicine and public health at the Center for Disaster Medical Sciences at the University of California, Irvine, established the “vital sign zero” concept to illustrate to healthcare workers the importance of first making sure there is no hazard or threat involved before taking the standard vital signs on a patient.1

“Before we jump in ... we have to ask ourselves is this patient a danger to staff or others in the ED, and do we immediately need to don disease-appropriate protective equipment and isolate the person — if it is involves someone with symptoms we would isolate — before touching them and taking their pulse and measuring their blood pressure,” Koenig asks. “Ebola is highly infectious once the person has symptoms, and it can be transmitted by touching that person and being exposed to their bodily fluids.”

Koenig stresses that emergency clinicians tend not to think first about the risk of contagion because they want to jump in and take care of people. However, she observes that the “vital sign zero” concept may be more in line with the thinking of prehospital providers. “Every prehospital provider knows you don’t go into the scene until you are sure it is safe, whether the situation involves gunshots or some sort of chemical exposure. It is a concept that is pretty well built in,” she says. “But in the ED, where [clinicians] are used to having open doors with people coming in, this can be an issue if a patient has a disease that is contagious from person to person, and could be a threat to the public health and others in the ED.”

For cases in which a patient is potentially contagious, Koenig also developed what she calls the 3-I tool, which stands for identify, isolate, and inform. Originally developed for Ebola, the tool has been adapted for measles, Zika, and other infectious diseases. In fact, Koenig is developing an adaptation of the tool for hepatitis A.2

Under the 3-I construct, once a healthcare provider has identified that a patient potentially is contagious, the next step is to appropriately isolate the patient. “You have to look at the disease characteristics, so if it is something contagious from person to person, then how is it transmitted? Is it something that can be transmitted prior to symptom onset?” Koenig asks. “Usually, people will have symptoms when they come to the ED, but they might say they were exposed to measles, for example.”

Once a provider is highly suspicious that the patient carries a serious infectious disease, the next step is to inform both the hospital’s infection control department and public health authorities. “You have to know how to do that, even during the off hours,” Koenig stresses.

One of the problems that came to light during the 2014 Ebola crisis was that key clinical information was not always conveyed in a consistent and reliable way, and there was too much reliance on electronic communications. This is one of the areas that NETEC faculty members address during their training.

“We encourage person-to-person communication to make sure a message is not lost within the system,” Lyon says. “We also encourage health systems to empower their frontline people, meaning the receptionists and registration staff and triage nurses, to immediately notify and engage the system because you don’t want someone with Ebola sitting in your waiting room for a while,” Lyon explains. “Then, you would have more cases.”

Abbott echoes these sentiments, adding that communications are even more challenging when hospitals need to communicate with each other because electronic medical record (EMR) systems have a long way to go before they are interoperable. This is true even for hospital systems that use the same EMR technology because every hospital employs different fixes and features in their customization of the software. As a result, information is not necessarily shared seamlessly, even within a single hospital system, she says. “The communications piece is huge. It is not just that people don’t talk to one another, it is that the systems don’t talk to one another,” Abbott notes.

Follow the Science

Another issue that added to the confusion during the 2014 crisis was that it was clear that both healthcare providers and local authorities seemed unclear about who was responsible for managing the situation. “I think there was an expectation that the CDC was going to come in and essentially take over the entirety of patient care,” Lyon recalls. “That is not the mission of the CDC, to take care of patients, and yet that was the expectation of many people on the ground in Dallas.”

Koenig notes that while it is always difficult to be the first hospital or community to have to deal with one of these highly contagious infectious diseases, there is no getting around the fact that these dangerous pathogens first present at the local level. “In the United States, the way the emergency management system is organized ... generally, the local authorities would be in charge,” she explains. “There are some exceptions when there is a homeland security threat, but, generally, local authorities would be in charge, and only when local resources are exceeded would they go to the state for help, and only when state resources are exceeded would they request federal assistance.”

Koenig notes that this alignment of jurisdiction was very well communicated during the 2009 swine flu pandemic. “It was made very clear that local authorities needed to have some level of preparedness and ability to manage the situation and the initial aftermath,” she explains, although Koenig acknowledges that this approach has not always been enforced at the federal level.

One problem that emerged in 2014 was agencies and state governments were following different approaches to address precisely when healthcare workers returning from Ebola-affected areas in Africa should be quarantined. In fact, many of these approaches did not follow the science, Koenig observes. “It doesn’t make scientific sense to quarantine asymptomatic healthcare workers because they are not contagious,” she explains. “Different states interpreted this differently, and I think there is still confusion on that particular piece of [the infectious disease response.]”

Even the military made a high-profile decision to quarantine personnel who had been working in West Africa to help with the crisis. “They were placed in quarantine first in West Africa and then again an additional 21 days in Europe before being allowed to come home,” Koenig notes. “That is not evidence-based, but at the same time I have a picture of healthcare workers coming back home from West Africa and hugging the president.”

Koenig notes that given the government does everything possible to protect the president from any kind of risk, it was clear that there was an understanding that these healthcare workers did not pose a risk for transmitting Ebola.

It never helps when an infectious disease response becomes politicized, but Koenig observes that healthcare providers always should be prepared to emphasize the science. “Certainly, you have to deal with the politics, and you have to deal with the perception ... but we really need to push to make things evidence-based,” she stresses. How can emergency medicine leaders improve the odds that their hospitals will be prepared in the event of an infectious disease emergency similar to what happened in 2014? First, it is important to understand that infectious disease outbreaks are one of the biggest global health threats, Koenig observes. She points to statistics from a report from the National Academies of Science, Engineering, and Medicine released in May that indicate even a moderately severe influenza pandemic could lead to 2 million or more deaths (http://bit.ly/2qt4tzL).

“[An infectious disease outbreak] is not as visible as a shooting or a bombing or something like that, so it is more difficult to conceptualize, but it is one of the biggest threats — both in terms of the lives lost and economics — that we are facing, so we really do need to be preparing for it,” Koenig stresses.

Emergency providers should pay close attention to the Health Alert Network (http://bit.ly/2wXjQnF) as well as information from their local health departments, Koenig advises. “I know it is really challenging for hospitals that are facing to many day-to-day crises and financial pressures, but if we aren’t aware of what is happening, we can’t be prepared,” she says.

Also, make sure systems are in place to address epidemiological risk factors. For example, Koenig explains if one knows there is an outbreak of Ebola in the Congo, he or she must take a travel history to know if patients have traveled to the region recently.

“We have to be doing this routinely,” she says. “We have done a really good job in the past of mobilizing our strengths and coming together in short order and working with guidance, but when something is not on the radar screen, it tends to fall out of sight, out of mind because we are so busy with our day-to-day emergencies.” Another step that could be useful in containing infectious disease outbreaks is if EDs got more involved with providing vaccinations, Koenig suggests. She notes that such a step is under consideration in San Diego, where there is an outbreak of hepatitis A. “We give tetanus shots in the ED, so why can’t we give a hepatitis vaccine or other types of vaccine in the ED?” she asks. “It is not a simple matter to set up ED-based vaccination programs, but we know that vaccines are effective in controlling outbreaks, so I think we need to think about EDs playing a greater role in public health and helping with things that will, in fact, protect the public.”

Lyon advises hospital leaders to include an infectious disease scenario in their mandatory emergency preparedness practice exercises. “If you go to our website, we have some exercises that are ready for people to adapt to their own situations,” he explains. Koenig agrees with this advice, noting that it also would be helpful to include the media in such drills. “Work with them up front because they are the experts in communication and getting out messages,” she notes.

Lyon says that NETEC is a resource for hospitals on training and guidance on infectious diseases, much of which can be delivered via telemedicine. In addition, NETEC retains a team of subject matter experts that includes nurses and physicians who can be deployed to help care for a patient until he or she is transferred to a treatment center. “However, all of this depends on recognition [of the infectious disease], which was one of the problems that happened in Dallas in 2014,” he cautions. To improve recognition and response, the subject matter experts at NETEC routinely travel to hospitals to evaluate their preparations and protocols, and identify where there might be strengths or weaknesses, Lyon adds.

In addition to all the clinical guidance regarding Ebola the CDC offers, it is important for hospital and emergency medicine leaders to understand fully what their obligations are under the Emergency Medical Treatment and Labor Act (EMTALA). HHS has issued a memorandum offering guidance on the requirements and implications of Ebola (http://go.cms.gov/2wN7nE2).

HHS also provided a memorandum containing answers to common questions pertaining to Ebola and EMTALA (http://go.cms.gov/2xHgmD1).

REFERENCES

  1. Koenig KL. Ebola triage screening and public health: The new “vital sign zero.” Disaster Med Public Health Prep 2015;9:57-58.
  2. Koenig KL. Identify, isolate, inform: A 3-pronged approach to management of public health emergencies. Disaster Med Public Health Prep 2015;9:86-87.

SOURCES

  • Patricia Abbott, PhD, RN, BC, FAAN, FACMI, Associate Professor, University of Michigan School of Nursing, Ann Arbor, MI. Email: pabbott@umich.edu.
  • Kristi Koenig, MD, FACEP, FIFEM, EMS Director, San Diego County, San Diego; Professor Emeritus, Emergency Medicine and Public Health, Center for Disaster Medical Sciences, University of California, Irvine, CA. Email: kkoenig@uci.edu.
  • Marshall Lyon, MD, MMSc, Professor of Medicine, Emory University School of Medicine, Atlanta; Subject Matter Expert, National Ebola Training and Education Center. Email: gmlyon@emory.edu.