CDC, hospitals hit reset on Ebola preparedness

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, healthcare 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-to-face 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.

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