Vituity

Hospitals — and Emergency Departments — Have Little to Lose By "Overpreparing" for Ebola

Many of you reading this blog will take a lead role in your hospital’s Ebola preparedness planning. Currently it seems unlikely that your facility will encounter a patient with a true Ebola virus infection, but it’s certainly possible that you will care for patients who are concerned they might have the disease. In fact, several of our Vituity emergency departments (EDs) have already seen patients concerned they’ve contracted Ebola.  In these cases, having a solid plan in place can alleviate the fears of patients and staff and maintain public faith in the hospital.
 
To this end, Vituity is currently working closely with our hospital partners. With over one hundred sites, we have access to a wide variety of existing protocols as well as up-to-the-minute feedback from medical directors and nurse managers.
 
The conversation will likely continue for a while, but so far four areas of consensus seem to be emerging:
 
1. The moment we "know" something about Ebola prevention, it’s outdated. Our understanding of Ebola virus disease (EVD) is advancing quickly, but as the Texas case showed, we still don’t have all the answers. There, as with another patient in Spain, nurses were presumably infected while wearing personal protection equipment (PPE), though it’s unclear how well the hospital had implemented these protocols.
 
This is complicated by the fact that much useful information about EVD transmission may be "unknowable," at least in the short term. The risk of fomite and aerosol transmission (during aerosol generating procedures such as intubation) is unclear, the risk of blood draws versus the value of lab results remains to be defined and the value of heroic resuscitation measures in a coding patient are debated.
 
Operational best practices are also unclear.  Should suspected cases be placed in negative pressure ventilation rooms?  Should they bypass the ED immediately and be initially evaluated in the same inpatient room where they might be hospitalized?  What is the role of telemedicine in patients suspected of Ebola?  
 
That being said, we need to stay as informed as possible so that we can update and refine our preparedness plans. It’s important to view our EVD protocol as evolving and responsive — not a final or long-term solution. Perhaps, like SARS in Canada, EVD will be a viral disease that will disappear suddenly after only a few months.  Or perhaps like HIV, this will be a condition we will need to deal with on a regular basis.
 
Given the confusion around EVD, we also need to be critical consumers of "expert" advice and resources. For example, there are plenty of personal protection equipment (PPE) videos extant that show healthcare workers leaving skin exposed or removing equipment in ways that might contaminate the environment. And while self-proclaimed EVD "experts" have proliferated, their knowledge can be grounded in anecdotes or outdated information.
 
2. CDC guidelines are a starting point. Since the first Ebola cases appeared in the United States, the Centers for Disease Control (CDC) has made several changes in its recommendations to healthcare providers. Naturally, the physicians, nurses and staff on the front lines are frustrated by this.
 
It’s important to remember that while the CDC’s guidelines may be imperfect, they probably represent the most up-to-date information available. Unlike individual providers and physicians, the CDC can dedicate itself to monitoring the EVD situation 24/7. It’s theoretically informed of every case and suspected case. And it’s in contact with the research teams that are working on the problem.
 
Is its response infallible? Well, no. But it’s perhaps the best-equipped entity to make high-level recommendations to healthcare providers in need of immediate, evidence-based guidance.
 
Again, as with anything EVD-related, our understanding is fast-moving and subject to change. Healthcare leaders should view CDC recommendations as a starting point, but not as a long-term prescription.
 
3. Hospitals have little to lose by erring on the side of caution. While the CDC guidelines are a starting point, we’ve seen several hospitals go beyond them to develop even more stringent protocols. These take many forms, from expanding the definition of a "high-risk" patient to stricter rules around the use of PPE.
 
In my opinion, a cautious approach is reasonable. Hospitals have little to lose and much to gain by adopting such measures. For one, being prepared for a rigorous response doesn’t cost the hospital much money beyond some initial investment in equipment and training, and it doesn’t disrupt ED flow (except on rare occasions a high-risk patient shows up).
 
In addition, the business cost of not being highly prepared may be extreme, given the high level of public concern about EVD.  If a hospital responds inadequately to a real or suspected case, public faith in the organization may be lost for years to come. Furthermore, nursing and medical staff will quickly lose faith in a hospital administration that doesn’t prioritize their safety in this emotionally charged situation.
 
Finally, being highly prepared would be to both hospitals’ and patients’ advantage in the unlikely case that the number of EVD patients increases. (And in such an event, the CDC would likely strengthen its guidelines as well, forcing hospitals to take more stringent measures.)
 
4.  Preparedness is important, but these measures should be applied only to appropriately selected cases.  The vast majority of patients presenting to EDs will not have Ebola, even if they are traveling from an endemic area.  Overreacting to these cases will harm other patients in the ED, due to significant disruption in workflows delaying care. Overreaction could also unnecessarily stress an already worried staff.  We have seen several cases in our EDs where appropriately concerned triage nurses isolate a patient, after which multiple staff members don PPE to focus on the “Ebola rule-out," spending hours isolated and unable to care for the rest of the patients in the ED.
 
Rather than pulling away multiple staff members, EDs could assign only a single person to more thoroughly evaluate a stable patient whose travel history indeed warrants concern for Ebola.  (In our limited experience so far, the answer is usually “no.”)  Even better, EDs could consider placing the patients in isolation and using telephones, video conferencing, or walkie-talkies to take this more detailed history.
 
In summary, the immediacy of EVD and evolving nature of our knowledge about it present substantial challenges to preparedness. However, healthcare leaders would be wise keep a pulse on the latest CDC recommendations, and then take them several steps further. While it's unlikely they’ll ever encounter a bona fide case of EVD, the modest cost—applied to appropriately selected patients — seems justified, especially when serving a very concerned public.

[Image credit: "Naval Medical Research Center labs support Operation United Assistance" by US Army Africa licensed under CC BY 2.0]