The arrival of Thomas Eric Duncan at Texas Health Presbyterian Hospital Dallas 5 years ago was a scenario we probably should have anticipated, but since no hospital in the United States had ever really expected to treat a patient with a viral hemorrhagic fever, this quickly became a “learn as we go” event. In short, Duncan was seen in the emergency department, sent home, and later returned via ambulance when suspicion for Ebola virus disease (EVD) grew. During his care, 2 nurses became infected with the virus and, although they survived, Duncan did not.
The chaotic days and weeks that followed revealed a healthcare system with a woefully inadequate preparedness for infectious diseases on a national level. Since this was a novel situation, guidance for personal protective equipment (PPE) isolation precautions, and even treatment was in a state of flux. One of the infected nurses in Dallas sued the hospital, highlighting its lack of preparedness and adequate response to ensure healthcare workers were protected. Although the lawsuit was settled privately, findings from it note that the hospital failed to provide the necessary protection for nursing staff.
Although the Dallas Ebola cluster taught us a lot about the state of readiness within US hospitals, special pathogens preparedness is an important conversation for infection preventionists (IPs). We now have proof that in these situations, the IP is the subject matter expert and will ultimately play a vital role in educating staff and ensuring response efforts run smoothly.
We are perhaps the only healthcare professionals who understand the full spectrum of disease transmission through the lens of healthcare—from disinfection and sterilization, PPE utilization, patient movement and transport, and risk of medical devices and procedures. Moreover, IPs work across the spectrum of roles within healthcare, from the medical provider to the environmental services worker. IPs are uniquely cognizant of how our healthcare workers function and what will put them at the greatest risk.
Infection preventionists’ knowledge of transmission and interventions, mixed with their emphasis on education across different professions, means that they are especially skilled at responding to outbreaks. Moreover, IPs are already working across nearly every profession within the healthcare environment, which makes them acutely skilled in bringing forth key stakeholders.
We may not have seen the end of Ebola in the United States, and we certainly haven’t seen the end of it globally. Currently, there is an outbreak raging in the Democratic Republic of the Congo (DRC), resulting in more than 3300 cases and 2200 deaths.
Similar to what was seen in the 2013-2016 outbreak in West Africa, healthcare workers have been at increased risk as nosocomial infections have been prolific. In fact, the World Health Organization notes that healthcare workers are 21-32 times more likely to be exposed and infected. The current outbreak is, as of now, the second largest in history, with the 2013-2016 outbreak resulting in over 28,000 cases and 11,000 deaths.
Until Duncan, we had never cared for a patient with EVD in regular, acute care hospitals that were not designated (like Emory) for treating patients infected with special pathogens. The advanced medical setting inherently increases risk for healthcare workers, and this was just one of many lessons learned.
Another was the need to install a tiered hospital system to ensure continued readiness. Having all hospitals prepare for, and act as, treatment hospitals is not sustainable. Not only was expertise limited but maintaining the training and supplies for such infrequent events was extremely taxing on hospitals and healthcare workers. For many, the memories of learning the donning/doffing process for the enhanced PPE that is required for Ebola, are times of stress and excitement. In some ways, it was highly interesting learning a new mechanism to protect against unusual diseases, however the changing guidelines and extreme precision that is needed for PPE was stressful. A single misstep in the process could result in deadly infection. Originally the tiers were frontline, assessment, and then treatment hospitals.
Now, this includes regional Ebola and other special pathogens treatment centers (RESPTC). There are roughly 10 RESPTCs, 63 Ebola treatment centers, 217 assessment hospitals, and more than 4800 frontline hospitals. The RESPTCs were added onto this, which creates a total of 4 tiers. The expectation is that the majority of hospitals are frontline (there are roughly 6000 hospitals in the United States) that can quickly identify, isolate, and inform possible Ebola patients, while assessment hospitals can safely receive and isolate to help determine infection through laboratory measures over 96 hours. Treatment hospitals and RESPCTs are expected to care for one or more patients with special pathogens and provide the highest level of care within biocontainment units. These treatment facilities tend to have a handful of beds and are expected to be able to safely receive a patient within 8 hours.
Assessment and treatment hospitals can apply for and receive federal funding from the Hospital Preparedness Program (through the US Department of Health and Human Services (HHS)) to help offset the cost of these efforts as it can be extremely costly to develop and maintain biocontainment units. It is estimated that the development of 45 treatment centers cost nearly $54 million and the development of a single treatment center cost $1.2 million.
In addition to the development of this tiered approach, there are also training and education opportunities available to healthcare workers through the Center for Domestic Preparedness, (CDP), which provides free courses on enhanced PPE. The National Ebola Training and Education Center (NETEC) was also created, which provides training for healthcare workers and first responders. However, it is not free and requires travel. Fortunately, NETEC offers a wealth of free information online. Hospitals can also apply for funding through the Hospital Preparedness Program (HPP), which provides grants through HHS.
Lastly, it is important to note that there has been increased regulatory focus on emergency preparedness in hospitals. The 2017 Centers for Medicaid and Medicare Services (CMS) Emergency Preparedness Rule required that hospitals maintain and engage in certain levels of preparedness annually to maintain Medicare reimbursement. Unfortunately, this is not specific to infectious diseases and allows the hospitals to determine what they view are hazards and vulnerabilities.
This all sounds wonderful but, unfortunately, the level of readiness we saw in 2014 is not the same as in 2019. When the tiered hospital approach was developed and the outbreak was slowing, the push to throw resources to improve preparedness also waned. Hospital administrators no longer felt the need to spend thousands of dollars on PPE and training when the risk of Ebola was gone. A recent survey of hospital administrators found that while they feel better able to deal with Ebola than in 2014, roughly one-third of them could not state which tier their hospital fell into and that there were competing priorities that diminished the likelihood that they would continue to buy the PPE.
Also, administrators noted that responding to Ebola and special pathogens requires certain knowledge that emergency preparedness people lack, and IPs have. Now, our focus has gone back to preventing health-care-associated infections (HAIs), and the more day-to-day tasks of infection prevention and control. Providing the training and acquiring the PPE for maintaining readiness for special pathogens has nearly fallen off the radar or is something that IPs are limited in doing as it so heavily relies on administrative support.
Nevertheless, it is important to maintain a level of bio-preparedness in healthcare. When nosocomial infections occur, it becomes obvious that there is a breakdown of IPC measures along the way. But this particular outbreak wholly revealed the role of IPs during infectious disease events and emergencies. Research following the outbreak found that in the United States, IPs were primarily responsible for Ebola-readiness efforts within their healthcare facilities, and such work consumed 80% of their time. These findings point to the increasingly important role of IPC in infectious disease preparedness, but also the changing role of IPs as emerging infectious disease threats evolve.
Although the odds of another patient with EVD walking into your emergency department are slim, wouldn’t you rather be prepared? Moreover, working to enhance infectious disease preparedness in staff can help engage them in routine IPC processes, like rapidly identifying and isolating infectious patients, and informing the necessary parties. Have those frank conversations on infectious disease threats and how those important questions (international travel within 21 days, signs/symptoms, relevant exposures) can make a huge difference.
Even if IPs are unable to acquire the administrative support to update their PPE stockpiles and provide extra training for staff, there are small measures that can help instill readiness. Implement travel screening questions on admission and educate staff on what travel abroad signs and symptoms could mean. Provide voluntary classes for staff who want to learn more about special pathogens and what the PPE is like. Do small mini-educational rounds with emergency department staff about which rooms they would put a high-risk patient in. Create a gap analysis and identify the weak points if a patient with Ebola is treated in your facility. Ensure your negative pressure rooms are truly functioning. What PPE would you use if you had a patient under investigation for Ebola?
All of these are small tasks that can enhance readiness for a range of situations, whether it be Ebola or measles. Special pathogens preparedness builds on basic infection prevention practices, so if nothing else, we can focus on building our existing infection control efforts to ensure there is a strong foundation in the face of bigger infectious disease threats.
Saskia v. Popescu, PhD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in biodefense from George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in infection control and has worked in both pediatric and adult acute care facilities.
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