Designated Ebola treatment centers provide ID safety net for future emerging infections
A health care worker had arrived from a country with Ebola cases and she had a fever of 102’
U.S. biocontainment facilities that have safely handled Ebola patients now are joined in their preparedness efforts by more than 30 hospitals newly designated as Ebola treatment centers. State and federal health organizations are working to ensure there will be no repeat of what happened last fall when two nurses in a Dallas hospital were infected with Ebola after caring for an infected patient.
The Centers for Disease Control and Prevention, does not determine which hospitals are designated as Ebola treatment centers, but does provide site visits conducted by a CDC Rapid Ebola Preparedness (REP) team, says John Jernigan, MD, deputy of the medical care task force for CDC’s Ebola response.
"State and local health authorities and a hospital administration collaboratively determine whether the hospital will care for a potential or confirmed Ebola patient," Jernigan says.
States likely will suggest more hospitals for the list, and the CDC will assess each.
"CDC REP teams thoroughly assess each potential Ebola treatment center on all infection control aspects of caring for a patient with Ebola, including PPE use, supplies and training, and even details like the route of the trash from the patient’s room," he adds.
The CDC conducted REP team assessments in more than 50 hospitals in 15 states and Washington, DC, through Dec. 1, 2014.
The CDC Ebola Response Team (CERT) is ready to deploy if and when a patient is confirmed to have Ebola and the state requests assistance, Jernigan says.
Coast to coast
Among the 35 health systems on the Ebola treatment center list were five from New York, four from the states of California, Illinois, Minnesota, three from Maryland, Washington, DC, and Wisconsin, two from Virginia, Texas and Pennsylvania and one in Georgia, Nebraska, and New Jersey. The three U.S. biocontainment centers of Emory University Hospital in Atlanta, the Nebraska Medical Center in Omaha, and the National Institutes of Health Clinical Center in Bethesda, MD, are included among the 35 listed.
"Our preparedness planning for Ebola started well before the CDC’s site visit in November," says Costi Sifri, MD, hospital epidemiologist at the University of Virginia (UVA) Medical Center in Charlottesville, which is among the 35 designated Ebola treatment centers.
"Back in the spring we developed an emerging infectious disease group to deal with emerging pathogens," Sifri says. "We were spending a lot of effort preparing for MERS-COV, and then as the Ebola situation grew in West Africa, we folded Ebola planning into our efforts."
U.S. biocontainment centers have had some years of training and preparedness drills to handle highly infectious and dangerous diseases, but the typical hospital has not had much time to understand a disease like Ebola, Sifri notes.
"We’ve been avid students of their experience," he says. "We’ve been listening to their experiences at meetings, webinars, conferences, and in published reports."
Following their lead, the UVA Medical Center’s care plans are patient-centered, he adds.
The University of California Davis Health System in Sacramento, CA another designated Ebola treatment center had begun preparing for Ebola patients in early September, says Carol Robinson, MPA, CNAA, FAAN, chief nursing officer.
As soon as the Dallas hospital admitted an Ebola patient, UC Davis Health System revisited its infectious disease program to determine how to handle such a case, she adds.
"The governor asked the UC system if we were prepared to manage Ebola patients, and we said, Yes,’" Robinson says. "It’s an ongoing process."
It’s also an exhaustive process, Robinson and Sifri note.
Both hospitals screen for potential Ebola patients in the emergency departments (EDs) and on admission. They have front line staff asking about recent travel histories. At UC Davis, signs posted in the ED ask about travel history.
A suspect case
Early in the fall, the UVA Medical Center had a patient who had a travel history and symptoms, including fever, back pain, headache, and anorexia, which suggested Ebola. Ultimately, the patient did not have the virus, but it took something of a live drill to determine the diagnosis, Sifri says.
"A health care worker had arrived from a country with Ebola cases and she had a fever of 102 degrees, so we had that real life experience of a potential rule-out patient," Sifri says. "That experience was very instructive to us and tested our system, helping us to improve it."
Hospital staff developed empathy for the patient, and caring for a potential Ebola patient gave them confidence in their ability to help should a true Ebola case arrive at their doorstep, Sifri adds.
Both hospitals sought staff volunteers to work with Ebola patients. But the training and manpower needs are extensive, and hospitals might not always have enough volunteers to cover all shifts. For instance, UC Davis identified the need for having four nurses on each shift and eight core staff for each Ebola patient per day, Robinson says.
"We work schedules so they don’t have to spend more than three or four hours in any room," she adds. "We have 16 core staff go through training each week."
The staffing and training needs are continually fine-tuned, and more staff might be added to prepare for people being out sick or unavailable at the moment a patient arrives, she says.
Finding and purchasing the best personal protective equipment (PPE) has been one of the huge challenges for hospitals. The type of gowns and PPE recommended by the CDC early on was changed after the nurses were infected.
"There has been a lot of deliberation about equipment, and it’s been instructive and modified with experience through the fall," Sifri says. "It’s also subject to the limitations of supplies right now."
The UVA Medical Center uses an N95-based system that includes impervious gowns, shoes, and lace covers, two sets of gloves, a full face shield, an N95 mask and hood, and an apron, Sifri says.
"We do have plans to also have a full body impervious jumpsuit, but those plans have been limited by the fact that supplies are short," he adds.
At UC Davis, the training and acquisition of additional PPEs also evolved and changed as CDC guidelines changed in response to the Texas nurses’ infections.
"We looked at PPE and went through five or six iterations of that — trying to identify the equipment needed, investigating it, and going to many different vendors," Robinson says.
Based on the first CDC guidelines, the hospital provided staff with gowns in which their necks showed. "But our staff said they didn’t like those gowns — they wanted total coverage," Robinson says.
"Then we found coveralls and hoods, and staff were concerned about comfort," she adds.
Staff had input on PPE
The health system eventually switched to using Powered Air Purifying Respirators (PAPRs). Even though Ebola is not an airborne virus, the CDC decided to recommend respiratory protection as an extra margin of safety. The staff even went online to research additional protective equipment, making recommendations that the health system tested.
"Staff guided us, and we chose a cover gown over a jumpsuit," Robinson says.
Each time the health system purchased new PPE, there were training sessions. Then when staff provided feedback, changes would be made to the equipment and the training would be held again, she explains.
Another factor was that California OSHA required PAPRs for everyone, despite the lack of evidence behind the requirement.
"We provided PAPRs for our staff because it cooled them down and they felt more comfortable with it," Robinson adds. "They also could be used for other infectious diseases. The Ebola scare, has heightened awareness for everybody."
Hospitals now have additional incentive to pay more attention to hand hygiene and infectious disease prevention, she adds.
Neither the UVA Medical Center nor UC Davis Medical Center has had any community pushback regarding their Ebola treatment center status, Sifri and Robinson note.
"Our local community understands we are a major teaching hospital, and we may be called to care for a patient like this," Sifri says. "We have many people with strong international ties and many who travel overseas, so we’ve never felt like the risk was low."