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Even before the Centers for Disease Control and Prevention (CDC) unveiled its strengthened guidelines on the identification and management of patients with Ebola virus disease (EVD) in mid-October, hospitals around the country were already in drill mode, in some cases trying to play catch-up after events in Dallas, TX, exposed what can happen if a hospital is caught unprepared to safely handle a suspected EVD case. However, even for major academic medical centers that are accustomed to preparing for large medical emergencies and threats, there has been some added urgency to their EVD preparations.
For instance, on October 17, Ronald Reagan UCLA Medical Center in Los Angeles, CA, held an "Ebola preparedness exercise" designed to test the hospital’s policies and procedures for identifying and managing a patient with EVD. "We’re working with our Los Angeles Department of Public Health as well, our colleagues at other University of California medical centers, and we are basically critically evaluating all of our protocols and making sure that they are appropriate," explains Robert Cherry, MD, chief medical and quality officer at UCLA. "We have only one chance to get this right, so we want to make sure now — while we don’t have a patient — that our protocols are effective."
Part of the exercise involved actually going through the process of identifying a patient suspected of having EVD, isolating the patient in a designated room, and deploying protocols for both the safe treatment of this type of patient and the bio-containment of any waste. "We have exceeded the CDC recommendations for personal protective equipment (PPE), and we are trying to really lock down the processes to make sure that all of our patients and staff are as safe as possible," observes Zachary Rubin, MD, the medical director of infection prevention at the medical center.
Another step UCLA took to stay ahead of the outbreak: The hospital prepared PPE kits based on the practices developed at Emory University Hospital, which has thus far had the most experience in this country in caring for patients with EVD. During the Ebola exercise drill, clinicians donned PPE under the watchful eye of a designated safety officer, they transferred the simulated patient with EVD to the ICU, performed the requisite blood tests, and engaged in waste removal activities. Eventually, clinicians removed the PPE — also while being observed by the safety officer to ensure that the PPE was being removed in a way that prevented any opportunities for contamination.
"We know from both [the University of] Nebraska and Emory that they have been able to care for patients safely with appropriate safety gear, and that’s exactly what we are trying to do — to make sure that UCLA is prepared in exactly the same way as Emory and Nebraska are," notes Daniel Uslan, MD, a UCLA clinical professor of infectious diseases and public health. "The likelihood of us seeing a patient with Ebola at any given hospital in the United States remains very low. It is still a very rare disease and there has still only been a handful of cases in this country, but the likelihood of us seeing patients who might have Ebola is fairly high, so we want to be prepared because we won’t know until tests come back whether a patient truly has Ebola or not. We have to be prepared as if they truly do."
Under UCLA’s response plan, health care workers cannot enter or leave an EVD treatment room without a safety officer’s approval. Officials say such precautions are in line with both CDC standards and standards set by California’s Division of Occupational Safety and Health. Officials add that these are the same precautions that health care workers use when caring for any patient with a potentially infectious disease.
As part of its Ebola preparations, the UCLA Health System has adjusted its medical record system so that a red flag is placed on the electronic medical record [EMR] of any patient who has recently traveled to a high-risk area. Further, blood testing on any patient suspected of having EVD will be conducted in a mobile, in-room lab rather than the medical center’s regular laboratory. This will insure that blood samples do not leave the patient’s room, according to the hospital.
William Dunne, the UCLA Health System’s director of emergency preparedness, safety and security, says the Ebola patient tracer exercise will help the medical center identify both the strengths in the medical center’s response plan as well as areas in need of improvement. "We’ll take those lessons learned as well as things learned from other institutions and other agencies to make sure that we provide an even safer practice and more effective patient care," he notes.
The University of Alabama at Birmingham Medical Center in Birmingham, AL, began stepping up its preparations for potential EVD cases nearly three months before the first case was diagnosed in the United States, explains Sarah Nafziger, MD, an associate professor in the Department of Emergency Medicine at UAB and the assistant state emergency medical services medical director for the Alabama Department of Public Health. "We were watching developments in West Africa with the current outbreak and saw that it was larger than any previous outbreak, so we began looking at our processes, pulling out our plan, and started thinking about what steps or preparations we needed to make," says Nafziger.
Similar to the exercise at UCLA, staff at UAB have been running through their EVD response plans with simulated patients, and they have practiced putting on and taking off PPE. "There is a lot of value in working things out on paper in a tabletop setting, but there is even more value when you physically walk through your process," observes Nafziger.
Further, even before the CDC began to emphasize stronger policies with respect to PPE, protective gear for health care workers figured prominently in UAB’s response plan. "We have always looked at PPE as an essential piece in taking care of these patients [with EVD]," says Nafziger. "The PPE was really at the forefront for us in our interpretations of the [earlier] guidelines, but maybe that is because we have been thinking about this for a long time."
At press time, UAB had not yet seen a patient who tested positive for EVD, but staff did encounter several patients who had risk factors that required more intensive screening and questioning. "After talking with the patients, we figured out that they did not indeed have Ebola but we walked through our process of screening and that was very helpful for us," says Nafziger.
In fact, as a result of these early experiences with suspected patients as well as the ongoing practice sessions, the hospital has made a few improvements in its protocol for EVD. "One of the tweaks is we decided to add another piece of PPE to our PPE ensemble, a hood that covers the neck," notes Nafziger. "We found that some of our PPE was a little bit scratchy and just uncomfortable, so we added another layer to make it more comfortable."
The hospital has also digitized what had been a paper-and-pencil screening tool for EVD. "We have been able to incorporate that now into our EMR [electronic medical record] system so that it is computerized just like everything else is in our triage process," notes Nafziger. "These are small things that we have been able to streamline into the process to make it work more smoothly."
Nafziger acknowledges that the news that two nurses contracted EVD while caring for a patient with the disease in Dallas has heightened concerns about staff and patient safety. "As health care providers, we understand that there is some risk of exposure to infectious diseases, but the bottom line is nobody wants to go to work and have it cost them their life," she observes. "I think the solution for that is to arm ourselves with knowledge about how the disease is spread and how to use our protective equipment."
The evidence base from people who have taken care of patients with EVD in Africa during the past 20 years is that PPE does work when it is used appropriately, stresses Nafziger. "That is really what we are focused on: making sure everyone has the proper information," she adds, noting that this policy extends to the EMS personnel who work in the field.
"In the EMS setting, our crews most likely would be the first health care providers to encounter an Ebola patient. That scenario is very likely, so not only have they been trained in the use of PPE, but we have to make considerations for how to make sure that we have processes in place for decontaminating the interior of the ambulance, so we certainly have had to make preparations in that regard," explains Nafziger. "In addition, we have had to make preparations with our public safety answering points — our 911 call centers — to make sure they are screening patients for Ebola risk factors so that we have that information prior to the arrival at the scene of an emergency."
Making sure that all members of the health care team are communicating effectively — with each other as well as members of the public — becomes particularly important when there is an outbreak of infectious disease, notes Nafziger. "One of the worst things that can happen in a situation like this is hysteria, and something that you frequently see happen in these situations is partial or incorrect information gets conveyed from person to person, and that can create some very undesired results," she observes.
"Let’s be very specific in the information we share with one another so that we don’t induce exaggerated responses," notes Nafziger. "We have to look at those risk factors [for EVD] before we come to conclusions."
One way UAB is keeping hospital leadership informed about the EVD outbreak as well as the medical center’s preparations for potential cases is by holding meetings twice a week at a minimum, says Nafziger. "Hopefully our preparations won’t be needed, but we are all thinking about this very intently, we are following the guidance on a minute-to-minute basis, and continuously checking for new updates and information," she explains. "The information and guidance we are getting has been very fluid, and we are trying to keep up with that."
While many organizations are looking to the CDC to make sure that the American health care system is prepared to handle EVD patients, there is only so much that the agency can do, notes Nafziger. "Everyone is going to have to take the initiative for preparedness. It is not going to be handed to you. Each individual hospital and each individual provider has to take that initiative to make sure they are ready."