Abstract
The Ebola virus was first discovered in 1976, but the outbreak of Ebola virus disease that began in Guinea, West Africa, in December 2013 shocked the world. It is the largest and most severe epidemic of Ebola virus disease to date. The US Centers for Disease Control and Prevention confirmed that inadequate implementation of the policy of acquiring travel history led to a delay in identifying the first imported Ebola virus disease case. The Taiwan Centers for Disease Control developed a no-notice drill that used a simulated patient to assess hospitals' emergency preparedness capacity in responding to Ebola virus disease. Despite the fact that regular inspection shows that more than 90% of regional hospitals and medical centers inquired about patients' travel history, occupation, contact history, and cluster information, the no-notice drill revealed that more than 40% of regional hospitals and medical centers failed to ask emergency room patients about these factors. Therefore, to assist in inquiries about travel history, occupation, contact history, and cluster information in emergency triage and outpatient settings, the Taiwan CDC revised the criteria for hospital infection control inspection. It requested that hospitals issue appropriate reminders and implement process control mechanisms to block diagnostic processes in instances in which healthcare workers do not inquire about travel history, occupation, contact history, and cluster information. Furthermore, the Taiwan CDC will continue no-notice inspections in order to strengthen hospitals' infection control measures and reduce the risk of infectious disease transmission in the healthcare system.
The US CDC confirmed that inadequate implementation of the policy of acquiring travel history led to a delay in identifying the US's first imported Ebola virus disease case. The Taiwan Centers for Disease Control developed a no-notice drill that used a simulated patient to assess hospitals' emergency preparedness capacity to respond to Ebola virus disease. Routine inspections showed that more than 90% of regional hospitals and medical centers inquired about patients' travel history, occupation, contact history, and cluster information, but the no-notice drill revealed that more than 40% of regional hospitals and medical centers failed to ask emergency room patients about these factors. Therefore, the Taiwan CDC revised the criteria for hospital infection control inspection. It requested that hospitals issue appropriate reminders and implement process control mechanisms to block diagnostic processes in instances in which healthcare workers do not inquire about travel history, occupation, contact history, and cluster information. The Taiwan CDC will continue no-notice inspections in order to strengthen hospitals' infection control measures and reduce the risk of infectious disease transmission in the healthcare system.
I
Because of the lack of effective vaccines and the high mortality rate of Ebola virus disease, control of the disease depends on adequate management of patients and the people with whom they come in contact. Therefore, the Taiwan Centers for Disease Control (Taiwan CDC) requested that healthcare workers inquire about patients' travel history, occupation, contact history, and cluster information while diagnosing patients in order to assist the medical team in prescribing the most appropriate infection control measures.
Furthermore, the Taiwan CDC developed hospital emergency preparedness checklists for Ebola virus disease, a poster describing how to prevent Ebola virus disease, a demonstration video and posters describing how to wear and remove personal protective equipment (PPE), and practical tools to assist hospitals in building up the preparedness capacity following these guidelines. The Taiwan CDC also sent official documents to local health departments and asked them to supervise and follow up with the hospitals to ensure that hospitals were actively improving awareness and infection control measures. The health departments were asked to collect the self-evaluation results of hospital emergency preparedness checklists for Ebola virus disease 2 and to take pictures with clear dates and locations to show that hospitals had posted notices in emergency departments, examination rooms, and at hospital entrances to remind patients to self-report their travel histories.
The first imported case of Ebola virus disease in the United States started the discussion about whether healthcare providers were well prepared to take care of Ebola virus disease cases. According to a survey of registered nurses by National Nurses United (NNU) in the United States, more than 60% of respondents reported that their hospitals were not prepared for Ebola virus disease. 3 Therefore, the Taiwan CDC developed a plan to inspect the emergency departments of regional hospitals and medical centers without advance notice to evaluate their emergency preparedness capabilities to respond to Ebola virus disease.
Materials and Methods
Preparation
Before conducting the no-notice drill, the Taiwan CDC requested that local health authorities, through official documents, inform hospitals in the governing area that they were to establish infection control measures and strategies based on guidelines published by the Taiwan CDC. 4 In addition, the Taiwan CDC requested that hospitals self-evaluate their emergency preparedness, strengthen their emergency traffic flows, and drill their healthcare personnel in the proper wearing and removal of PPE. Finally, health authorities informed hospitals that they would inspect hospitals' emergency preparedness for Ebola virus disease without forewarning.
This was the first time that the Taiwan CDC had used no-notice drills to randomly inspect hospitals' emergency preparedness. To ensure the accessibility and appropriateness of a no-notice drill that can be performed without disturbing a hospital's daily operation, the Taiwan CDC planned to carry out this no-notice drill in 2 phases. Phase 1 of the no-notice drill was a pilot study that prioritized medical centers as study subjects. Inspectors observed hospital responses for their emergency preparedness, including inquiring about travel history, occupation, contact history, and cluster information; traffic flows for patient arrangement; and notification and transferring processes of suspected cases. This was done by simulating a scenario of a patient who began showing symptoms of Ebola virus disease 3 days after returning from an epidemic area of Ebola virus disease. Based on the study methods and results from phase 1, phase 2 of the no-notice drill used the same simulated scenario as phase 1 and carried out no-notice drills in regional hospitals and medical centers across the nation. In order to avoid disturbing the hospitals' operations and the health authority's administrative operations, the main focus of phase 2 inspections was to evaluate the hospital's implementation of inquiring about travel history, occupation, contact history, and cluster information in the emergency department. Therefore, during the simulated inspection process, inspectors revealed their identities and completed the no-notice drill after emergency triage staff or emergency department physicians had inquired about travel history, occupation, contact history, and cluster information.
Phase 1
The names of 21 medical centers in Taiwan were sealed in official envelopes and randomly labeled 1 to 21. Witnessed by 2 deputy directors-general of the Taiwan CDC and the director of the division of infection control and biosafety, the director-general of the Taiwan CDC randomly selected a sealed envelope to determine a target hospital on December 3, 2014. The director of the division of infection control and biosafety, with colleagues, immediately conducted the first inspection without notice at the target hospital.
A colleague acted as a patient. The details of the patient included that she was single, had no past disease history, and was formerly a registered nurse but was currently unemployed. The patient had traveled through Kenya in East Africa for 10 days starting on November 1 and then had gone to Sierra Leone in West Africa to visit a senior colleague. The husband of the senior colleague worked at the local medical corporation, and the patient stayed in the local area and assisted with some simple tasks at the local medical corporation (such as dressing or feeding patients) for 15 days. On November 26 the patient left Sierra Leone, and on November 29 she started to show symptoms of a cough, fever, and mild diarrhea. The patient sought medical advice at a nearby clinic and took prescribed medicine for fever and common cold. However, her symptoms of diarrhea and fever did not improve, and the patient began to vomit on December 2. Afterward, the patient sought emergency medical care, accompanied by a roommate.
Phase 2
In order to investigate the emergency preparedness for Ebola virus disease in other medical centers and regional hospitals, the Taiwan CDC selected regional hospitals and medical centers as inspection objectives in phase 2 based on the information from Taiwan's medical affairs management system and excluding psychiatric hospitals, cancer hospitals, and designated emergency response hospitals. A total of 99 regional hospitals and medical centers, grouped under 6 command centers, were inspected from December 8 to 10, 2014 (Table 1). In order not to disturb hospital daily operation, the inspection was conducted by a pair of colleagues using the same model and simulated scenario as had been performed in phase 1 to investigate the hospital's fulfillment in inquiring about travel history, occupation, contact history, and cluster information.
Total Inspected Hospitals Grouped by Areas of 6 Command Centers
According to the Medical Affairs Management system, Ministry of Health and Welfare.
Results
During phase 1 of the no-notice drill, the patient sought medical advice at the emergency department of the inspected hospital. The colleague that played the patient's roommate assisted in the registration process. While in emergency triage, the patient described her symptoms as fever, diarrhea, and vomiting, and noted that she had taken antipyretic medicines to relieve her symptoms before seeking medical advice. The emergency department staff measured the patient's body temperature and confirmed that the patient did not have a fever during triage. The emergency department staff did not inquire about travel history, occupation, contact history, and cluster information and asked the patient to wait in the hall for an emergency department physician. During the examination process, the physician provided the patient with a surgical mask because of her persistent coughing. The emergency department physician diagnosed the patient with gastroenteritis, prescribed an intravenous injection, and asked the patient to go home without inquiring about travel history, occupation, contact history, and cluster information.
To observe the hospital's operation mechanism and process for identifying and handling suspected Ebola virus disease cases, the patient voluntarily informed the emergency department physician about her travel and contact history at the end of the examination. The physician alerted other staff by phone about the possibility of an Ebola virus disease case. Medical staff guided the patient to an isolation room and immediately provided a surgical mask to the roommate. In addition, they activated the emergency preparedness procedures for Ebola virus disease, including clearing traffic flow toward the isolation room, notifying the health authorities of the suspected case, collecting specimens, and arranging for patients to transfer to a designated emergency response hospital. Local health authorities arrived at the hospital immediately after receiving notification. They provided health education to the roommate and talked to the patient by mobile phone to obtain more detailed information and to inform her about the necessity of isolation and her arraignment rights.
The no-notice drill ended when the ambulance from the designated emergency response hospital arrived at the inspected hospital, and the patient then revealed her true identity. The superintendent, directors, and local health authorities immediately held a meeting at the inspected hospital to discuss inspection results. Summaries of the inspection are listed below:
Strengths
1. Once activated, the hospital responded quickly according to their standard operating procedures, including immediately notifying the response team of the situation in the hospital, clearing the traffic flow to the isolation room, and giving clear explanations to other patients and people in the emergency department regarding the situation.
2. The hospital implemented isolation precautions automatically, including voluntarily providing the patient as well as her roommate with surgical masks; having physicians and other medical staff dress in full PPE, according to Taiwan CDC's guidelines, 5 when entering the isolation room to perform examinations; and using safety needles to collect specimens.
3. The hospital notified health authorities immediately. The infection control personnel of the inspected hospital phoned local health authorities first and then reported the case to the national notifiable disease surveillance system through a web-based interface.
Aspects Needing Improvement
1. Emergency triage staff and the physician did not inquire about travel history, occupation, contact history, and cluster information because the patient did not have a fever during her examination.
2. The traffic flow from the physician room to the isolation room needed to pass many other patients in the emergency department.
3. The equipment and functions of the isolation room should be properly maintained, especially intercom and call buttons, beds, and hand hygiene equipment.
4. The waiting time in the isolation room was too long. The patient waited for approximately 2.5 hours in the isolation room until staff came to explain why the patient was under isolation and other relevant procedures.
The inspection results for phase 2 of the no-notice drill are shown in Table 2. Of the 99 inspected hospitals, 41 (41%) did not inquire about travel history, occupation, contact history, and cluster information during examinations. Nine of 32 (28%) inspected hospitals that did not inquire about travel history, occupation, contact history, and cluster information were in the Taipei area, including Taipei City, New Taipei City, Keelung City, and Yilan County. There was no statistically significant difference in inquiries about travel history, occupation, contact history, and cluster information among regional hospitals and medical centers of the 6 command areas (chi-square: 5.588; p-value: 0.348).
Inspection Results in Regional and Above Hospitals
TOCC=travel history, occupation, contact history, and cluster information. There is no statistically significant difference in TOCC inquiries among regional hospitals and medical centers of the 6 command areas (chi-square: 5.588; p-value: 0.348).
Discussion
This is the first time that the Taiwan CDC has designed and executed hospital inspections using a simulated scenario without notification to hospitals and local health authorities in order to determine hospital preparedness for an emerging infectious disease. Requesting physicians to inquire about travel history, occupation, contact history, and cluster information in the emergency department and outpatient settings is one of the policies for infection control in hospitals that the Taiwan CDC has implemented for years, and it is also one of the assessment benchmarks for hospital accreditation 6 and hospital infection control annual inspection. 7 Hospital infection control inspection is conducted every year by local health authorities and infection control accreditation commissioners according to the hospital infection control annual inspection guideline among local hospitals, regional hospitals, and medical centers across the nation. Local health authorities issue hospitals official notifications 2 weeks before field inspections occur. Based on records of previous routine inspections performed over the years, more than 90% of hospitals across the nation inquired about travel history, occupation, contact history, and cluster information in emergency department settings during regular inspections; however, the results of the no-notice drill revealed that only 60% of regional and higher level hospitals inquired about travel history, occupation, contact history, and cluster information effectively in emergency departments during this inspection. In other words, 40% of regional hospitals and medical centers failed to implement actual inquiries about travel history, occupation, contact history, and cluster information in this no-notice drill.
The differences in results between regular hospital infection control inspection and the no-notice drill may be due to different methods that were used in conducting the 2 procedures. In addition, the design of many existing mechanisms set a body temperature of 38 degrees Celsius as the threshold to trigger inquiries about travel history, occupation, contact history, and cluster information. Therefore, even if hospitals set up reminder mechanisms for inquiring about this information, hospital staff would likely neglect to inquire about it if the patient did not have fever at emergency triage. Thus, additional actions would not occur, including the failure to activate a response mechanism during the emergency triage and to guide the patient to the isolation ward through planned traffic flow.
The first imported Ebola virus disease case in the United States was delayed in case identification because of the inadequate implementation of procedures to inquire about travel history during the patient's first emergency department visit, eventually leading to a major issue of international concern. Thus, asking patients about their travel history, occupation, contact history, and cluster information is absolutely one of the most important tools for a physician to diagnose emerging and reemerging infectious diseases, as well as the key to informing the hospital and staff that they need to apply appropriate isolation and protection measures as soon as possible to lower the risk of the pathogen spreading in the hospital.
In light of recent emerging infectious diseases such as Ebola virus disease, the Middle East respiratory syndrome (MERS), and novel influenza A (H1N1) virus infection, it is impossible to predict when an infected patient will appear to seek medical services in healthcare settings. Therefore, to assist emergency department staff and physicians in implementing timely inquiries about travel history, occupation, contact history, and cluster information in emergency triage and outpatient settings, the Taiwan CDC revised the criteria for hospital infection control inspections in 2015 and requested that hospitals implement appropriate mechanisms to remind staff and have in place procedures to block further diagnostic processes if healthcare workers do not inquire into a patient's travel and contact history. This systemic mechanism would be helpful to reduce man-made errors that introduce emerging infectious diseases such as Ebola virus disease to hospital settings and to ensure the safety of healthcare workers and patients. In addition, the Taiwan CDC will continue making no-notice inspections to strengthen hospitals' infection control measures in response to emerging infectious diseases as well as to reduce the risk of infectious disease transmission in the healthcare system.
Footnotes
Acknowledgments
We would like to express our gratitude to all command centers of the Taiwan Centers for Disease Control and participants who conducted the no-notice drill for their help and support.