Beyond Ebola: Lessons Learned in Infectious Disease Outbreak

Robin Carlascio. Healthcare Executive. Volume 30, Issue 4. Jul/Aug 2015.

During the four-month period in which hospitals dealt with this virus, the strengths and weaknesses of the American healthcare system in dealing with infectious disease outbreak quickly became apparent.

In the months after the emergence of Ebola hemorrhagic fever in the United States put the nation on high alert, the overwhelming feeling among healthcare workers was that Ebola was a small-scale test of hospitals’ ability to treat infectious disease.

They point out that America’s first foray into the global Ebola pandemic involved just eight patients, most of whom were identified in Africa and transported via a U.S. State Department jet specially outfitted to transport patients with communicable diseases.

What lessons did U.S. hospitals learn in responding to the Ebola epidemic last year-and how could those lessons be applied to other infectious disease outbreaks? Hospitals and health systems that dealt with the Ebola crisis firsthand share their experiences.

Tales from the Frontlines

Texas Health Presbyterian Hospital Dallas had the unenviable role of admitting the first Ebola patient identified on U.S. soil after lab tests were performed based on the patient’s symptoms and travel history (the patient had traveled to Texas from Liberia). Subsequently, two staff also tested positive for the disease.

Jeffrey Canose, MD, FACHE, senior executive vice president and system COO for Texas Health Resources, said the experience provided valuable lessons for everyone involved. Long days and nights spent studying every facet of the case resulted in a list of changes that have made the health system even stronger.

“Among the many lessons we learned, three principles of leadership stand out,” Canose says. “Leadership-especially in a crisis-begins with actively listening to the verbal and nonverbal signals coming from key groups of internal and external stakeholders.

“A leader has to be willing to do things differently in the face of unique circumstances,” Canose says. “You have to trust your leadership team and the judgment of others, even when the stakes are extremely high.”

Within 30 days, the health system had implemented a series of innovations. For example:

A triage nurse in the health system’s emergency departments obtains the patient’s specific travel history and the reason for the ED visit within five minutes of the patient’s arrival to ensure those who potentially have been exposed to an infectious disease are identified at the first point of contact with ED staff.

A unique screening tool designed to identify patients at risk for serious diseases based on their symptoms, travel history and exposure has been built into the health system’s EHR.

Safeguards added to the EHR guarantee the attending physician reviews vital information with the patient before the physician can advance specific screens. In addition, the topography of the screens has been augmented to visually highlight crucial information.

Texas Health also has renewed its emphasis on face-to-face dialogue between physicians, nurses and patients in identifying patients who may be at risk for carrying a communicable disease.

“On an operational level, one of the key lessons we learned is that the presence of data alone does not ensure that the data has been seen or communicated,” Canose says. “It is essential that data is presented in such a way that it can make a difference in the decisionmaking process of caregivers and those who support them administratively and operationally.”

Lessons from the Heartland

When the Centers for Disease Control and Prevention announced in July 2014 that U.S. healthcare workers infected with Ebola in Africa would be treated at Emory University Hospital in Atlanta or the University of Nebraska Medical Center in Omaha, Shelly Schwedhelm, nursing director of Nebraska Medicine’s biocontainment unit, was proud her hospital had been selected: It was an opportunity to put the knowledge and preparation the unit had been developing for more than a decade into practice.

A drive to create a biocontainment unit at Nebraska Medicine began in the months following 9/11 to enhance the hospital’s capacity to respond to unanticipated healthcare needs. Nebraska Medicine was able to tap into a small pool of federal preparedness funds to support its efforts.

Schwedhelm credits ongoing drills and dedication to education and training for enabling Nebraska Medicine’s biocontainment unit to evolve into a model for the nation’s hospitals.

“For the past decade, we have drilled down on our processes at least once each quarter,” Schwedhelm says. “Each drill involves a different scenario and follow-up discussions to determine what we learned and what we can do better. The more we practice, the more we learn and the better prepared we get.”

Between drills, a team that comprises 22 nurses, six respiratory therapists, five care techs and 15 physicians who specialize in infectious disease, critical care, anesthesia and nephrology continues to test and hone processes that prevent cross-contamination, help patients get better and provide vital support for families.

From protocols that involve isolating and treating patients to practices that allow for the on-site sterilization of all waste produced within the five-room, 10-bed unit, lessons learned at Nebraska Medicine are becoming the national standard.

“When we received our first patient with Ebola virus disease, we were gratified to find there were no surprises,” Schwedhelm says. “We tweaked some of our processes, but these were minor items, such as moving a mobile satellite lab into the unit, which improved turnaround times.”

Containing transmission of the deadly virus has meant employing best-available protections-sometimes in triplicate.

Beyond a secured entrance, all staff who work in the biocontainment unit are equipped with face shields, respirators, gowns and three layers of gloves duct-taped to their sleeves. Bluetooth stethoscopes that eliminate ear canal exposure are also the standard.

That’s for starters.

Mobile devices track and upload vital sign patient data in real time, while the use of digital X-ray units eliminates the transport of potentially contaminated cassettes outside the unit.

All waste products, including those that would have been flushed down a toilet, are neutralized and/or autoclaved on-site, killing any potential virus in the process. Destroying waste products on-site dramatically reduces per-patient costs by hundreds of thousands of dollars.

Learnings from the Big Apple

Shortly after the nation’s first Ebola case was diagnosed in Dallas, Mark Jarrett, MD, senior vice president and chief quality officer at North Shore LIJ, a 19-hospital system that treats patients in and around New York, was tasked with developing Ebola policies and procedures over a period of three weeks and converting an existing hospital unit to make it suitable for treating Ebola in just four days.Seven million people rely on North Shore LIJ for their care each year, and millions more walk through the hospital’s doors each year to visit family and friends. “What we had to learn to do with Ebola was to restrict points of entry into the system for patients who were at risk either because they had traveled to an area where they may have been exposed to Ebola or because their family members may have been exposed to the virus,” Jarrett says. “We have a very mobile population. Our goal is to identify at-risk patients quickly and isolate those for whom the likelihood that they have been exposed to the virus is high, so that we may limit the impact of the virus. That can be tough to do in New York City.”

To contain exposure, isolation areas have been created within each of the health system’s hospitals, and an Ebola treatment unit was established in unused ICU space at North Shore LIJ’s Glen Cove facility.

In December, the CDC designated Glen Cove one of five Ebola treatment centers in New York. Critical in helping hospitals ramp up quickly to deal with a pandemic-type situation is a 450-page manual North Shore LIJ created. It details the treatment processes in place, along with special protocols for treating patients with unique health concerns such as pregnant women and children.

“The manual we created is applicable any time we are dealing with something very contagious that carries a high rate of mortality,” Jarrett says. “It is a living document that is modified as we learn more.

“In the world in which we live, where people have ready access to travel, we are never far removed from a new contagious disease,” he says. “How much of a threat a particular disease poses depends on how quickly we are able to identify the threat and mobilize resources to contain it.”

Tallying the Cost

Meeting CDC standards for identifying and caring for Ebola patients carried high price tags for hospitals. For North Shore LIJ, preparedness efforts alone cost the health system nearly $12 million, which included the cost of training 80 nurses and 18 physicians-and thousands of staff-from across the system who have volunteered to care for patients who are diagnosed with Ebola or other pandemic-like illnesses according to Jarrett. Training is ongoing. Other New York hospitals have estimated costs ranging from $150,000 to several hundred thousand dollars, with costs of personal protective equipment ranging from $75,000 to $100,000, according to an article in the December 2014 issue of hfm magazine, “Hospitals’ Ebola Preparation Costs Can Vary Widely.”

Following a successful lobbying effort by U.S. Sen. Charles Schumer of New York, the U.S. Department of Health and Human Services announced in February that the agency would reimburse New York’s designated Ebola treatment centers more than $32 million through two existing programs: the Public Health Emergency and Preparedness Program and the Hospital Preparedness Program. Hospitals in New York City received the lion’s share of funding-about $22 million-while other hospitals in the state shared $7.5 million from the two funds.

Also in February, HHS announced it would award $194.5 million to states and other grantees through the Hospital Preparedness Program Ebola Preparedness and Response Activities and another $145 million through the Public Health Emergency Preparedness program.

Jarrett says the funds have helped reimburse his system for less than half its costs for Ebola preparation and treatment.

Nebraska Medicine’s Schwedhelm acknowledges the amount of federal dollars appropriated for Ebola does not approach the actual cost of treatment, estimated at about $30,000 per day per patient.

Still, she says hospitals know the investments they have made are invaluable in protecting the public health from a far greater calamity tomorrow.

“Most patients are getting well and going back to their lives,” she says. “The same precautions that have been developed to keep our staff and physicians safe will work no matter what the illness. Every time a new deadly disease emerges, we evaluate it to guarantee we are doing everything we need to do. Today, it’s Ebola. Tomorrow, it might be something else. Whatever it is, we need to be prepared.”

“We live in a mobile society where we never used to worry as much if someone got on an airplane when they didn’t feel well,” Jarrett agrees. “Today, we know there can be far-reaching consequences when that happens. We were lucky we didn’t have an outbreak of Ebola in the United States. Every step we take through our public health system and our hospitals helps increase the likelihood that we will be able to identify patients and treat them before a deadly organism that infects one patient and becomes an epidemic.”