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Saskia v. Popescu, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist with Phoenix Children's Hospital. During her work as an infection preventionist she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She is currently a PhD candidate in Biodefense at 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.

Are Frontline Hospitals Ready for a Patient With Ebola?

MAY 01, 2019 | SASKIA V. POPESCU
Just how well prepared are frontline hospitals for high-consequence pathogens like Ebola? It’s likely you won’t be happy with the answer that is included in a new article from Health Security, which details an evaluation of a multi-hospital system and identifies gaps in their biopreparedness.

Following the Dallas Ebola cluster in 2014, the US Department of Health and Human Services (HHS) created a tiered hospital approach to manage Ebola preparedness. When the first patient in Dallas was identified, hospitals around the United States rushed to acquire the necessary personal protective equipment (PPE), train staff, and identify and correct gaps in their admitting processes to avoid missing symptoms of highly contagious diseases such as Ebola.

From travel screening questions in electronic medical records to special Ebola treatment teams, it was a time of extreme effort and fatigue for health workers. To reduce the burden on the US health care system, HHS created a regional approach that involve 3 tiers—frontline hospitals were expected to identify, isolate, and hold a patient for 12-24 hours; assessment hospitals were tasked with receiving, isolating, and providing laboratory efforts while holding the patient for up to 96 hours; Ebola treatment centers were designated to receive and isolate Ebola patients, and provide care for a minimum of 7 days, while sustaining enough staff and supplies to care for Ebola patients for weeks.

The hope was that this would alleviate the stress of the more than 4845 frontline facilities and establish more treatment centers for special pathogens to ensure that the United States could handle more than a handful of patients with a disease like Ebola. 

Now fast forward to 2019…how prepared are these frontline facilities today? Unlike the treatment centers, they do not receive funding or undergo assessments of their biopreparedness and frankly, there are a lot of competing interests for hospital administrators to invest in the costly PPE for Ebola. Although some hospital systems have run drills on their preparedness for high-consequence pathogens, they are also typically the systems that maintain a heightened level of readiness, and for most of the other facilities it is less likely Ebola or other special pathogens are getting much attention. 

Investigators sampled 5 major frontline hospitals in Maricopa County, Arizona, to perform a gap analysis in how their response would be for a patient with Ebola or another high-consequence pathogen. From entering the hospital through the emergency department to cleansing and disinfecting protocols, the investigators evaluated whether health care workers could still answer the questions that were heavily drilled into these hospitals in 2014.

The investigators report: “Intake staff in the emergency departments (n = 42) were aware of the importance of documenting travel history, but no staff at any of the facilities could speak to how they would respond if a patient had a relevant travel history and symptoms that could indicate EVD [Ebola virus disease] or another high-consequence pathogen. Only 60% of the surveyed individuals could describe a proper communication strategy, and only 20% thought to call the infection prevention and control team. Staff were aware of an algorithm for response but could not describe its location or a mechanism for acquiring it. No staff were confident or comfortable in their ability to don or doff the appropriate PPE, and all requested additional training.”

Moreover, the location of the designated PPE was found to be in locked storage areas, and even the infection prevention staff did not feel entirely comfortable in their abilities to communicate protocols. “Fortunately, the logistics of acquiring additional PPE within 24 hours were in place, and existing waste management containers and contracts for EVD-associated waste removal were available. Laboratory staff were able to report the process and materials for shipping samples to the CDC or state laboratory, as well as point-of-care testing equipment for use in the patient's room.”

This gap analysis was just the tip of the iceberg and although hospitals work to maintain readiness for a multitude of hazards, high-consequence pathogens appear to no longer be on the top. It is likely that these findings represent a trend among other frontline facilities—those with competing priorities and strained budgets that see health care-associated infections as the bigger threat.

Overall, it is important that we consider these facilities in future efforts and work to include frontline hospitals and urgent care facilities in biopreparedness efforts, as the odds are more likely a patient with a high-consequence pathogen will walk into their emergency departments. 
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Big advances in treatment can't make up for an inability to stop new infections, which number 5,000 per day worldwide.
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