CDC and hos­pi­tals hit re­set on Ebola preparedness

Modern Healthcare - - NEWS - By Beth Kutscher, An­dis Robeznieks and Adam Ruben­fire

Beth Is­rael Dea­coness Med­i­cal Cen­ter found it­self thrust into the Ebola fray last week when it eval­u­ated a pa­tient for a sus­pected Ebola in­fec­tion. The man had re­cently trav­eled to Liberia and first pre­sented with wor­ri­some symp­toms at Har­vard Van­guard Med­i­cal As­so­ciates.

It was the sec­ond time in less than a month that a Bos­ton hos­pi­tal had re­ceived a sus­pected Ebola case. Both were false alarms. But the re­sult­ing me­dia swell height­ened the dis­tress of the city’s al­ready ner­vous health­care work­force.

Hos­pi­tals across the coun­try are step­ping up their preparedness and staff train­ing for the pos­si­ble ar­rival of Ebola cases at their doorsteps, even as fed­eral of­fi­cials have sug­gested that they may shift to a pol­icy of des­ig­nat­ing a limited num­ber of well-pre­pared hos­pi­tals to serve Ebola cases in each ge­o­graphic area. That’s a re­sponse to the fail­ures in han­dling Ebola at Texas Health Pres­by­te­rian Hos­pi­tal Dal­las, where two nurses so far have con­tracted the of­ten-fa­tal virus and dozens of peo­ple they had con­tact with are be­ing mon­i­tored. Ex­perts say the re­sponses of both the hos­pi­tal and the Cen­ters for Dis­ease Con­trol and Preven­tion were se­ri­ously flawed.

Pres­i­dent Barack Obama and CDC chief Dr. Thomas Frieden have come un­der sharp crit­i­cism from politi­cians and pub­lic health ex­perts, and are fac­ing pres­sure to take steps such as block­ing travel to the U.S. from the most af­fected West African na­tions. Obama on Fri­day named Ron Klain, a lawyer who for­merly served as Vice Pres­i­dent Joe Bi­den’s chief of staff, to co­or­di­nate the gov­ern­ment’s Ebola ef­forts. “The big­gest thing we need to do is make sure our health work­ers have more con­fi­dence,” Obama said at a spe­cial news con­fer­ence Oct. 16 on Ebola.

While the over­all risk of Ebola hem­or­rhagic fever to the av­er­age Amer­i­can is van­ish­ingly small, an out­break of the deadly in­fec­tion is par­tic­u­larly wor­ri­some to front-line health­care work­ers. That is es­pe­cially true since two nurses con­tracted the virus. “Ap­pro­pri­ately, health- care work­ers are wor­ried about their risks,” said Dr. Paul Bid­dinger, med­i­cal di­rec­tor for emer­gency preparedness at Mas­sachusetts Gen­eral Hos­pi­tal in Bos­ton.

To re­as­sure em­ploy­ees, Mass Gen­eral’s par­ent sys­tem Part­ners Health­Care has held staff town hall meet­ings. It has spec­i­fied who will and will not be ex­pected to care for pa­tients with Ebola. Those who would be called on to treat Ebola pa­tients have in­ten­sively prac­ticed putting on and tak­ing off pro­tec­tive gear, one of the riski­est parts of car­ing for th­ese pa­tients.

The CDC re­versed course last week and said it would con­sider des­ig­nat­ing a limited num­ber of well-pre­pared hos­pi­tals to han­dle fu­ture cases.

While the agency in­ves­ti­gates what went wrong in Dal­las, the CDC al­ready has changed its pro­ce­dures for how pro­tec­tive gear is used, the train­ing it pro­vides and the level of over­sight at af­fected hos­pi­tals. It also has es­tab­lished a ded­i­cated CDC re­sponse team that can be de­ployed to any hos­pi­tal with a con­firmed Ebola case. Poli­cies re­lated to am­bu­la­tory-care sites re­ceived sim­i­lar up­dates.

There cur­rently are just four hos­pi­tals across the U.S. with spe­cial­ized bio-con­tain­ment units and ex­ten­sive ex­pe­ri­ence in deal­ing with emerg­ing in­fec­tions.

Now there are dis­cus­sions about cre­at­ing another group of hos­pi­tals to serve as go-to fa­cil­i­ties for en­tire states or re­gions. But ex­perts say all hos­pi­tals need to be ready to han­dle po­ten­tial Ebola pa­tients who

walk in the door so they can treat them safely un­til they can be trans­ferred.

In New York City, health of­fi­cials last week said Belle­vue Hos­pi­tal Cen­ter would treat any Ebola pa­tients who ar­rive at the city’s hos­pi­tals or air­ports. It has set up nine iso­la­tion units in its emer­gency depart­ment, as well as four sin­gle-bed rooms in its in­fec­tious dis­ease ward, a spokesman said.

Rush Univer­sity Med­i­cal Cen­ter in Chicago also has be­gun ex­ten­sive prepa­ra­tions. A spokesman said Rush is among a num­ber of hos­pi­tals un­der con­sid­er­a­tion by the CDC to be des­ig­nated as an area re­source fa­cil­ity but that there has been no agree­ment or an­nounce­ment yet.

The CDC did not re­spond to a re­quest for com­ment at dead­line.

Part­ners Health­Care has not yet been called on to serve in such a ca­pac­ity, Bid­dinger said Thurs­day. But the sys­tem has been in con­stant con­tact with col­leagues at Emory and Ne­braska Med­i­cal Cen­ter.

One fac­tor that el­e­vates the risk to health­care work­ers is that an Ebola pa­tient can ex­pel 10 to 12 liters of bod­ily flu­ids per day—a far greater vol­ume than pre­vi­ously thought. “We have made sure that we have the ca­pac­ity to ac­com­mo­date that much waste con­trol,” Bid­dinger said.

The CDC ini­tially thought it could train hos­pi­tals through guid­ance it had de­vel­oped on how to con­tain the Ebola in­fec­tion, said Julie Fis­cher, an as­so­ciate re­search pro­fes­sor of health pol­icy at George Wash­ing­ton Univer­sity. Most hos­pi­tals have iso­la­tion units and at least some ex­pe­ri­ence man­ag­ing pa­tients with in­fec­tious dis­ease.

But the agency now re­al­izes that en­sur­ing com­pli­ance with pro­to­cols is not easy when health­care work­ers face the in­tense stress of car­ing for an Ebola pa­tient. “The CDC has re­vis­ited the as­sump­tion that the di­dac­tic part is suf­fi­cient,” Fis­cher said. “It made a fun­da­men­tal mis­step in as­sum­ing that the level of preparedness was higher.”

As an ex­am­ple of a bet­ter ap­proach, she pointed to the hands-on, two-week train­ing course de­vel­oped by hu­man­i­tar­ian group Doc­tors With­out Bor­ders, which has been on the front lines car­ing for Ebola pa­tients in West Africa.

Some states have co­or­di­nated their own ef­forts. Sens. Bar­bara Boxer and Dianne Fe­in­stein of Cal­i­for­nia on Oct. 3 asked two Cal­i­for­nia hos­pi­tal as­so­ci­a­tions to as­sess their mem­bers’ level of preparedness. While 90% of hos­pi­tal re­spon­dents told the Cal­i­for­nia Hos­pi­tal As­so­ci­a­tion that they had re­ceived suf­fi­cient guid­ance from the CDC, one-third re­ported that they had prob­lems im­ple­ment­ing the guide­lines, pri­mar­ily due to con­flict­ing in­struc­tions from fed­eral, state and lo­cal agen­cies.

In Florida, Gov. Rick Scott asked hos­pi­tals on Oct. 12 to es­tab­lish manda­tory train­ing pro­grams for health­care per­son­nel; 46 had com­plied as of late last week.

Dr. Stephen Moore, chief med­i­cal of­fi­cer at Catholic Health Ini­tia­tives, said the events in Dal­las “opened our eyes” and led to a re-eval­u­a­tion of his hos­pi­tal sys­tem’s in­fec­tion-con­trol pro­ce­dures. CHI is con­duct­ing a gap anal­y­sis look­ing for short­com­ings in per­sonal pro­tec­tion equip­ment and poli­cies, stan­dard­iz­ing the types of pro­tec­tion equip­ment used, and con­duct­ing tele­phone sur­veys and site vis­its.

CHI will be is­su­ing a com­puter-based learn­ing mod­ule on Ebola that is manda­tory for all clin­i­cal staff. Emer­gency and in­ten­sive-care unit staff also will re­ceive face-to­face in­struc­tion. “We’re fo­cus­ing on the ap­pro­pri­ate way to de-gown and de-glove,” Moore said.

San­ford Health has 15 hos­pi­tals in Min­nesota, home to one of the na­tion’s largest Liberian com­mu­ni­ties. It will ask all newly ar­riv­ing pa­tients about their travel his­tory over the past 21 days. Pa­tients who have been to Guinea, Liberia or Sierra Leone will be moved to a pri­vate room and may be put in iso­la­tion if they meet CDC cri­te­ria. “We have to plan that it will hap­pen to our sys­tem,” said Dr. Wen­dell Hoff­man, San­ford Health Sioux Falls Re­gion’s med­i­cal di­rec­tor for in­fec­tion preven­tion and con­trol. “And, if we’re go­ing to do that, we have to be good.”

Em­ploy­ees are re­ceiv­ing com­puter-based train­ing, and a video is be­ing dis­trib­uted show­ing proper tech­niques for don­ning and doff­ing pro­tec­tive gear, said Mona Hohman, chief nurs­ing ex­ec­u­tive for the San­ford Health Net­work.

In ad­di­tion, a multistate emer­gency drill is be­ing planned, and pro­ce­dures are be­ing de­vel­oped for trans­port­ing Ebola pa­tients from San­ford’s ru­ral fa­cil­i­ties to its big­ger fa­cil­i­ties and de­con­tam­i­nat­ing ve­hi­cles after the trans­port.

“Our world has been turned up­side down in five days,” Hoff­man said.

North Shore-Long Is­land Jewish Health Sys­tem in Great Neck, N.Y., has been run­ning fre­quent drills with staff mem­bers through­out the health sys­tem for the past few weeks. Dr. Michael Guttenberg, North Shore-LIJ’s med­i­cal di­rec­tor for emer­gency med­i­cal ser­vices, said em­ploy­ees now un­der­stand the Ebola threat to be more real and more se­ri­ous than past in­fec­tious dis­eases such as Mid­dle East res­pi­ra­tory syn­drome.

“This is no longer a drill,” he said.

One fac­tor that el­e­vates the risk to health­care work­ers is that an Ebola pa­tient can ex­pel 10 to 12 liters of bod­ily flu­ids per day—a far greater vol­ume than pre­vi­ously thought.

Texas Health Pres­by­te­rian nurse Nina Pham’s physi­cian recorded a video of her be­fore she was trans­ported to the Na­tional In­sti­tutes of Health’s Clin­i­cal Cen­ter, Bethesda, Md.

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