A man in traditional African clothing presents to the emergency department (ED) with flulike symptoms and is immediately isolated from triage for suspected Ebola virus disease (EVD). A physician and two nurses don PPE and enter the isolation room while a tech acts as safety monitor. The hospital’s incident command system is activated, and the infectious disease (ID) physician on call contacts the CDC.
Two hours later, the CDC finally clears the patient. As it turns out, the man is from Cameroon (several countries away from the epidemic) and therefore not an Ebola risk.
Unfortunately, four key team members have now been diverted from patient care for hours as they wait to be "cleared." All team members are exhausted and emotionally drained. Meanwhile, the ED waiting room is backed up, ambulances have been diverted and some patients with painful or life-threatening conditions have endured long waits for care.
Dangerous in More Ways Than One
As this fictional example illustrates, the ongoing EVD epidemic in Africa poses two distinct public health problems in the United States:
- A patient with actual Ebola might present to an ED
- A patient without Ebola, who staff suspect has the disease, will present to an ED and delay the care of other patients with true emergent medical conditions
While hospitals tend to focus on the first problem, currently the chances of encountering a bona fide EVD case are extremely remote. The second problem also has potential for harm — yet gets far less attention from administrators and ED teams.
Given the enormous public concern over EVD, it’s probable that most EDs will have to clear a "potential" case in the near future (if indeed they haven’t already). However, a typical busy ED can’t lose three to four team members for up to 12 hours and continue to provide timely, effective care to people with heart attacks, strokes, appendicitis, kidney stones and the like.
To protect the public health, it's imperative we mitigate the danger an EVD "rule out" presents to all patients.
Granted, our understanding of Ebola and its transmission — particularly in US healthcare settings — is both imperfect and rapidly evolving. However, by surveying experiences and protocols across over a hundred Vituity hospitals, we've learned some useful lessons:1. The initial interview need not happen in person.
There's no reason this initial patient interview must be conducted face-to-face with the physician and other staff in PPE. Instead, physicians can use phones, walkie-talkies and technologies like video conferencing and Vocera to communicate with the patient while preventing potential exposure.
This is important, because while donning PPE requires time and human and emotional capital, sometimes the initial interview can clear a patient within minutes. The most common example: I’ve encountered several cases in which African patients were isolated even when they hadn’t visited Liberia, Sierra Leone or Guinea. (Now granted, we're not all geography whizzes, but given the outbreak’s current location, isolating someone from Cameroon or Ghana is about as logical as isolating a Portuguese patient because there’s an outbreak in Poland.) Once we've realized this mistake, we can take everyone off alert and proceed with the patient's care.2. It sometimes makes sense to isolate the patient outside the ED.
Very few EDs are set up to provide the level of isolation experts recommend for EVD (e.g., a negative pressure ventilation rooms with an antechamber for the donning and removal of PPE). However, many hospitals have such a facility on inpatient floors. If this is the case, it's probably safer to move the potential EVD patient from triage directly to the inpatient isolation room for assessment.
I realize that to emergency physicians, this suggestion may sound as if we’re shirking our duty. But we also need to think in terms of public safety. The ED is one of the most highly trafficked areas of the hospital. It’s unlikely to have optimal isolation facilities. Why risk exposing hundreds of patients to a deadly virus when safer facilities are in the same building?
If the patient truly does have Ebola, they’re going to be moved to inpatient isolation anyway. By moving them through the ED first, we only increase potential exposures. While we can't prevent all contamination, the shortest, most direct route through the hospital is generally safest.
3. For stable patients, wait for a "rule out." As emergency physicians, we make every effort to initiate a workup as quickly as possible. Ideally, providers swarm in for a team intake. They order any number of labs and tests to be processed in parallel. Speed and efficiency are emphasized, because for many patients, every second really does count.
But in a case of potential EVD, it may make more sense to hold back — and take a thoughtful, measured approach — until we know for sure what we’re dealing with. After all, most EVD "rule out" patients present with flulike symptoms like fever, chills, myalgia and malaise. They’re quite stable and can generally wait several hours without comprehensive care.
A real life example: One our Vituity hospitals is located in an area with a large West African population. In the past few weeks, they’ve seen about one case of "potential" EVD each day. (All have been ruled out.) When these patients are identified in triage, they're immediately placed in isolation. The physician conducts the initial assessment by phone. If the patient is not immediately cleared, one nurse dons PPE and enters the room to take vitals and draw blood (for the Ebola test only). When needed, the nurse also gives fluids and medications for symptom control. Otherwise, if the patient is stable, no one else enters the room until a negative test result is confirmed. At that point, care commences as usual.
Granted, this approach may seem a little draconian. Depending on the time of day, the CDC can take many hours to turn around test results. However, the delay in treatment must be balanced against the very real risk to other patients when three to four team members must leave the ED (and of course, the remote but serious risk of contamination in the case of a true infection). This may be a rare case in emergency medicine where less is actually more.
Changing Our Thinking
The current Ebola epidemic presents an enormous challenge for acute care providers. On one hand, we must act cautiously to contain a rare but deadly disease. On the other hand, we must do everything we can to keep ourselves and our facilities available to patients who depend on us for life-saving care.
To meet the challenge requires adjustments in our thinking. Doing the right thing may require us to go against our training and instincts. We don't feel good about delaying care, moving a patient upstairs or conducting our assessment at a distance. However, when we apply the ethical principles of nonmaleficence, beneficence and justice, such choices may represent the most ethical path.
[Image credit: "Telemedicine Consult"
by Intel Free Press
licensed under CC BY 2.0