The diagnosis of physician Craig Spencer with Ebola in New York City on Thursday reinforced the fact that Ebola could arrive at any hospital at any time. Are facilities and health care workers ready to properly care for an infected patient—while also staying safe and preventing further spread of the disease?
The answer to that question would appear to be no, given the case of Thomas Duncan, the Liberian patient who died from Ebola earlier this month in a Dallas hospital and infected two nurses. In the intervening weeks, agencies and advocacy groups have beefed up recommendations, training and response protocols.
Initial protocols set forth by the U.S. Centers for Disease Control and Prevention (CDC), combined with reportedly minimal training at hospitals, left health care workers vulnerable to the often-fatal disease. After consulting with the nation's top high-level biocontainment facilities, however, the CDC on Monday issued detailed guidelines for hospitals and health care workers that are more robust than earlier instructions. The CDC now recommends, for example, full-body covering with no skin exposure for workers caring for infected patients—adding coveralls and full hoods to their earlier guidelines. The agency advises multiple hands-on practice sessions for workers to learn how to properly don and safely doff their protective gear. It also recommends having a full-time, trained observer to ensure that workers stay safe. Although these guidelines are an improvement, they still might not adequately protect health workers if an Ebola patient walks into the emergency room, health experts say.
Are new protocols enough?
The new standards are a step forward, some say, because they also offer under-resourced hospitals ways to do a better job with what equipment and training they have. "I think that the new guidelines really assisted community hospitals," many of which are learning as they go, says Meika Roberson, chief medical officer and chief of emergency medicine at Hoboken University Medical Center. Not only do they provide more specific and thorough instructions, but the recommendations also allow for some flexibility, welcome news for smaller hospitals might not be able to afford the most expensive protective equipment—or have not been able to get it due to high demand. The CDC currently allows facilities to decide precisely what equipment and protocols they will use in training and in practice. Such a "do the best you can with what you have" approach is a big help to many resource-strapped community hospitals, Roberson says.
Some health experts, however, are not mollified by the new recommendations and be-resourceful admonitions. They say hospitals unaccustomed to handling highly infectious patients need much more than illustrated instruction posters, such as those put forth by the CDC. Gavin Macgregor-Skinner, an assistant professor in the Department of Public Health Sciences at Pennsylvania State University who has been training workers on how to safely care for Ebola patients, warns, "We have hospitals and clinics around the country calling us saying, 'We have a person who fits the case description, and we don't have personal protective equipment—what should we do?'"
Although health care workers are highly trained for precise tasks and complex situations, Ebola requires a new level of diligence. When Duncan was diagnosed with Ebola in Dallas in late September, the country was not up to speed on the best way to contain the disease. "For many years, agencies like Doctors Without Borders have known what Ebola containment takes—the degree of personal protective equipment," says Amy Ray, an assistant professor focusing on infectious disease at the Case Western Reserve University School of Medicine and chair of the University Hospitals System Infection Control Committee. "That degree of personal protective equipment is not standardly practiced in U.S. hospitals."
Community hospitals are also not likely to be experienced in working safely with the large amounts of contaminated waste such patients create—including equipment, such as suits and gloves, as well as bodily fluids. Emory University Hospital's isolation unit, where nurse Nina Pham was treated, uses disinfectants to decontaminate all of the liquid waste generated by patients before it is released into the sewage system. Macgregor-Skinner is doubtful that most other hospitals are preparing for that. "In the U.S. a lot of decision-makers are overconfident; their underestimation of what it takes to look after just one Ebola patient is significant," he says.
Need for training and planning
Even with protocols and protective gear, hospital workers who have not undergone training might still be at risk. "It's not sufficient to just say, 'here is the personal protective equipment you must wear,'" Ray says. "It has to be trained." For that, says Macgregor-Skinner, the CDC resources are sorely lacking in good tools. Although the CDC has a host of instruction sheets and detailed documents, that information then needs to be interpreted and recommunicated. Training videos, he notes, would be much more helpful.
In addition to practicing the best ways to put on and remove protective equipment, workers also need practice wearing it. "The thing that is perhaps underappreciated is the difficulty of delivering care with that much equipment on," Ray notes. Inside—even in a climate-controlled hospital setting—"health care workers can easily become overheated and dehydrated," she says. (Instructions for suiting up at the University of Nebraska Medical Center's biocontainment unit (pdf) include a specific step for the worker to hydrate before stepping into the outer gear—as well as a reminder to rehydrate afterward (pdf).)
Drills are also important for finding unexpected holes in preparations and plans. "Drills are the best time to see who are the points of contact who would need to be trained," Roberson says. It also helps staff and administrators "evaluate what entrances and exits the patients are going to be coming in and out of" to prepare hospital staff and facilities. Such drills to prepare for highly infectious patients have generally been practiced more commonly by top biocontainment facilities and other large hospitals.
Perhaps one of the most important steps for reducing the risk from a patient infected with Ebola is to quickly identify the infection. That step failed in the case of Duncan, who was sent home from the hospital on his first visit despite his symptoms and travel history. Protocols and guidelines are only effective if health workers are adequately trained to implement them. "Everyone should know how to triage," Macgregor-Skinner says. "The first question you should ask is 'Have you recently traveled to West Africa—and/or had contact with an Ebola patient.'" It is not just a matter of training hospital staff, he notes. "Every facility in the U.S. needs to be able to do this"—including urgent care centers, travel health centers, even CVS and other pharmacies that offer walk-in care. "We need to look at how we're going to handle infectious disease throughout the whole U.S. health system," he says.
"This is all about behavior change, working in a different way," Macgregor-Skinner says. It is a rare instance of "putting the safety of the health care worker first—a complete paradigm shift of what we usually do in a hospital." As an example, he notes, if an Ebola patient were to go into cardiac arrest in isolation, what is a health care worker to do? He or she must still carefully don personal protective equipment—which takes precious minutes—before going into the room. "You can't just rush in."
Similarly, Ray says, hospitals might not be preparing for new ethical questions, such as whether to use more invasive procedures for Ebola patients that might increase the risk of exposure for health care workers while providing unknown benefit to an ill patient.
Another important way for community hospitals to prepare for an Ebola patient is to have an exit strategy. "The best way to handle it is to have designated hospitals in each state to contain patients," Roberson says. Currently the CDC is providing an on-the-ground team to any hospital that admits a patient with Ebola, such as New York City's Bellevue. That team will presumably be in charge of helping to decide whether—and where—the patient should be transferred to a better-prepared facility. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, agrees: "Community hospitals should not be providing care to Ebola patients. Every hospital needs to be able to identify a possible case," he says, but such cases should be transported to a higher-level facility, possibly even one of the four designated biocontainment units in the U.S., as the two nurses infected in Dallas were.
"It wasn't a surprise to me that care for [Duncan] was difficult [at a community hospital]," Ray says. "In the absence of a containment unit it's hard to feel that any U.S. hospital is completely prepared to take care of a patient with Ebola."
Holistic approach to Ebola
To reduce the risk that highly infectious patients will turn up unexpectedly at clinics or emergency rooms, the CDC is leading a new active-monitoring program. Starting on October 27, it will have health officials begin daily follow-ups with anyone who is entering the country from the three most affected countries in western Africa. Each of these entering travelers, whether an American citizen or a visitor, will receive a kit that includes a thermometer, instructions on how to use it and health information. Then for the next 21 days they are to report their temperatures to a state or local health department, which will track down any individuals that stop reporting. Identifying a potential case before a person develops severe symptoms reduces the likelihood that the virus will spread to others. It also improves the patient’s chances of survival. Careful monitoring and dedicated contact tracing is credited with stopping an outbreak of Ebola in Nigeria.
Macgregor-Skinner thinks the government can go further. "We're not taking a holistic, systems approach. We haven't set up a national training program. We haven't set up a national communication center," he says. And the risks are not just biological. He sees a large need for counseling for health care workers. The virus is scary, he says, and workers need help dealing with it psychologically as well as physically.