( UPDATED October 17, 2014 ) Conventional medical centers may not be prepared or equipped to manage an outbreak of Ebola virus disease in the United States, a group of infectious disease experts write in an article published online today in the Annals of Internal Medicine.
The experts advocate for building a network of "strategically located regional referral centers" that would serve a defined geographic area and be associated with major medical centers.
"With the recent death of a patient with Ebola virus disease at a hospital in Dallas, Texas, and the sobering reality that nosocomial spread has occurred in a U.S. facility, U.S. medical centers are coming to grips with the need to prepare for care of patients with this devastating disease," Mark G. Kortepeter, MD, MPH, from the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and colleagues write.
They note that the Centers for Disease Control and Prevention (CDC) has issued guidelines and a checklist for hospitals, and in recent experience, Ebola-infected patients have been successfully cared for in facilities that are adequately prepared (in Nebraska and Georgia).
However, many medical centers are now learning that caring for patients with viruses at the biosafety level of 4 (BSL-4), such as Ebola, in a conventional setting "presents enormous challenges, many of which can be mitigated through the use of specialized facilities with highly trained staff practiced in the nuanced art of safely delivering [high-level containment care]," they write.
BSL-4 facilities offer measures not available in most hospitals, including positive-pressure suits, compressed in-line air, an airlock, and a decontamination shower.
Dr Kortepeter and colleagues argue that care for patients with BSL-4 virus infections involves "more than checklists and standard operating procedures. The training, policies, procedures, and logistics necessary for the provision of such care are significant, cannot be assumed, are optimally in place well in advance of actual need, and must be continually reinforced through repetitious training."
The types of centers they recommend could be national resources coordinated by the US Department of Health and Human Services and the CDC, they write."As such, their focus would be on continuous preparation for the next emerging outbreak," they conclude.
Other Infectious Disease Experts Concur
"It's become clear...that not all hospitals are equipped to handle Ebola patients. That's true for other diseases too. Not all hospitals can care for stroke or trauma patients," Amesh Adalja, MD, a representative of the Infectious Diseases Society of America, told Medscape Medical News.
"It makes a lot of sense now, until we figure out what happened in Texas — why these two healthcare workers were infected — that we think about using our biocontainment facilities as the primary places to take care of these patients, and then offloading if we can to select tertiary care centers where we can ensure that they are going to practice biosafety in a way that will not give any more healthcare workers infections," he added.
The first step has already been taken, he said, with the current patients being treated in the special facilities.
He continued, "I don't believe we are going to get a large number of Ebola patients [in the United States]. However, we will still have imported cases from Africa. All hospitals have to be able to identify, isolate, and get the ball rolling with Ebola patients. This is a virus that isn't very forgiving, and we can't tolerate lapses in infection control. Though Ebola is not very contagious, it is deadly, and it requires meticulous attention."
"The strategy that they lay out is pretty practical. Having a BSL-4 unit is really impractical for the majority of hospitals in the US," Daniel P. McQuillen, MD, from the Center for Infectious Diseases and Prevention at Lahey Hospital and Medical Center, Burlington, Massachusetts, and president of the Massachusetts Infectious Diseases Society, told Medscape Medical News. "It makes sense to have regional centers that can take care of this efficiently."
"This is really an unprecedented infection control problem in this country. A lot of places have had to sort of learn this stuff on the fly. Planning about what kind of facilities you need and the techniques is kind of a work in progress," he continued. "Most hospitals would have a staff that are capable of taking care of a patient like this, but the real problem comes in when you have to train people on proper donning of protective gear and properly taking it off. The other big problem in any place is handling of medical waste."
He added, "You can build a great facility to house these people, but if you don't train and retrain your people in proper use of protective equipment and infection control practices, it doesn't really make that much difference. It's also hard to engineer out things like needlesticks. Not only do you need to know how to put on and take off protective equipment, it's really crucial to have a partner that watches you do it."
More Resources Needed
"Hospitals all over the country are not going to have these units like they have at Emory, but I think what we've learned from our experience is that we need a two-fold approach," Linda R. Green, RN, MPS, manager of infection prevention at Highland Hospital, Rochester, New York, told Medscape Medical News. "The first one is that every hospital in the United States needs to be able to identify [Ebola] patients and immediately isolate them. And then call in expertise," she said, speaking on behalf of the Association for Professionals in Infection Control and Epidemiology.
What could also help would be to organize a network of regional hospitals with appropriately trained personnel, as has been done in New York State, she added. That approach already exists for specialties such as burn and trauma units and specialty rehabilitation units.
Gaining more resources would help also, she said. "From an infection prevention perspective, we are under-resourced in many hospitals." Hospitals need more infection control specialists. "I think we have to recognize that infection preventionists in particular have this unique skill set that is really being called upon in these times."
One coauthor reports that he is the chairman of the Healthcare Infection Control Practices Advisory Committee to the CDC and chairman of the board of trustees of the Society for Healthcare Epidemiology of America Education and Research Foundation. Another coauthor reports currently serving as president of the Society for Healthcare Epidemiology of America and is a member of the CDC's Healthcare Infection Control Practices Advisory Committee. The other authors and Dr Kortepeter and Dr McQuillen have disclosed no relevant financial relationships.
Ann Intern Med. Published online October 16, 2014. Full text
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Cite this: US Hospitals Unequipped to Deal With Ebola, Experts Warn - Medscape - Oct 16, 2014.