Preparing Frontline Hospitals for Dangerous Special Pathogens Beyond Ebola

Introduction

The 2014-2016 West Africa Ebola virus disease (EVD) epidemic and secondary infections of EVD in a Dallas hospital dismissed the notion that any hospital in the United States at that time could effectively and safely identify, isolate, and treat an EVD patient. The combination of fear, increased travel associated illnesses, and lack of training and awareness within healthcare systems across the country served as a reminder that preparedness and response to highly infectious diseases must be prioritized. In 2015, the US Department of Health and Human Services (HHS) established a tiered approach for response to highly infectious diseases across the country, using frontline healthcare facilities, assessment hospitals, state or jurisdictional Ebola treatment centers (ETCs), and regional Ebola and special pathogen treatment centers (RESPTCs). Each tier builds upon a more robust response to caring for 1 or more patients with a potential highly infectious disease or special pathogen (Table 1). Special pathogens are defined as highly hazardous, easily transmissible, and capable of causing life-threatening illnesses with limited treatment options. ³

Based on the HHS hospital-tiered approach, the role of frontline healthcare facilities is to identify possible patients with EVD through relevant exposure history and Ebola-compatible signs and symptoms, isolate patients, and take appropriate steps to adequately protect staff, inform health departments, and, if warranted, initiate testing if patients are low risk and transfer the patient to an Ebola assessment hospital or ETC. ⁴ The minimum requirements for frontline healthcare facilities includes having enough personal protective equipment (PPE) on hand for at least 12 to 24 hours of care, trained staff on specimen transport, waste management, proficiency in donning and doffing PPE and providing stabilizing treatment, per the Emergency Medical Treatment and Labor Act requirements. ⁴ The next tiers require more advanced capabilities and reach. Assessment hospitals, ETCs, and RESPTCs possess more advanced capabilities in the areas of facility infrastructure patient rooms, laboratory, staffing, training, PPE, waste management, worker safety, environmental services, clinical competency, and operations coordination. ⁵ The Regional Treatment Network, established by HHS, designated 10 RESPTCs in geographically dispersed regions throughout the United States with the ability to provide clinically complex, technologically advanced care with highly skilled healthcare providers. ¹

Unlike assessment hospitals, ETCs, and RESPTCs, frontline healthcare facilities do not receive any direct funding for preparedness for Ebola or other special pathogens, but they may be eligible to receive emergency preparedness funds through their healthcare coalitions, which receive funding through the Hospital Preparedness Program. Nonetheless, frontline healthcare facilities make up the large majority of US hospitals. With over 4,000 frontline healthcare facilities, the state of readiness at these facilities is questionable ² and varies drastically from one locality to the next, as there is currently no mandatory requirement for training or competency assessment related to Ebola and special pathogens preparedness (Table 1).

New York City Health + Hospitals (NYC H+H) is the nation's largest public healthcare delivery system, with 70 locations across New York City's 5 boroughs including 11 acute care hospitals, 5 post-acute/long-term care facilities, and 5 ambulatory care/federally qualified health center clinics. ⁶ Of the 11 acute care hospitals, 10 are classified as frontline hospitals and 1 is the designated Region 2 Ebola and Special Pathogen Treatment Center.

Between 2014 and 2015, NYC H + H received 19 persons under investigation for EVD infection and 1 confirmed EVD patient at its Bellevue hospital. During this time, and at the height of the epidemic, NYC H + H developed new strategies to effectively prepare staff to respond safely to suspected or confirmed EVD patients. These strategies included PPE refresher courses, travel screening, and the development of various special pathogens tools and resources, such as checklists, questionnaires, and job action sheets.

At the 10 NYC H + H frontline hospitals, PPE refresher training for Ebola is conducted at least once every 12 months for its covered personnel in the system. Covered personnel is defined as any staff that may come in contact with a suspected or confirmed EVD patient. While compliance to this PPE refresher training had been close to 90% systemwide for fiscal years 2015 through 2018, the training has been met with significant challenges. These challenges include (1) no sustained funding source, (2) a high resource demand and low patient volume paradox, (3) competing priorities and budget constraints, and (4) Ebola-specific training fatigue among covered personnel. To address Ebola-specific training fatigue at NYC H+H, the PPE refresher training was transitioned to an Ebola and other special pathogen PPE refresher training. The new training encompasses donning and doffing of the levels of PPE established for NYC H + H frontline hospitals for Ebola and other special pathogen cases.

To address federal funding limitations, a sustained funding source must be considered. This includes making funds available to frontline hospitals annually through the Hospital Preparedness Program, Centers for Medicare and Medicaid Services, or other federal funding sources, instead of using emergency supplemental funding that typically has a short shelf life. Sustained funding will help support frontline hospitals with ongoing preparedness and maintaining a state of readiness for future outbreaks of special pathogen diseases and other emerging/reemerging infectious disease threats. The minimum amount of funding per hospital should be enough to cover the salary and fringe of a full-time, dedicated emergency coordinator. This could vary from below $100,000 to close to $200,000 depending on jurisdiction and cost of living.

Identify, Isolate, and Inform Screening

The 3 I's coined by the US Centers for Disease Control and Prevention stand for Identify, Isolate, and Inform, ⁷ which relate to the role of frontline facilities in EVD preparedness in the HHS hospital-tiered approach. At face value, it is much easier said than done. To operationally use and implement the 3 I's in a healthcare delivery system requires a systematic process from greeter to triage to isolation and clinical assessment by a clinician. NYC H + H quickly adopted the 3I approach and ensured each level of patient encounter was given the appropriate resources and attention (eg, visual cues such as posters seeking travel history from patients at front desk) and training was provided to healthcare workers.

Once the 2014-2016 Ebola outbreak was declared over, enhanced screening of travelers returning from a country with active Ebola transmission entering healthcare delivery facilities was no longer needed. While the threat of Ebola is ongoing, there are a number of other special pathogens that continue to threaten healthcare delivery systems worldwide. Healthcare delivery facilities, whether they are frontline hospitals or RESPTCs, are at constant risk of encountering patients with travel-associated diseases (eg, malaria), emerging and reemerging pathogens (eg, Middle East respiratory syndrome coronavirus [MERS-CoV], Zika, measles) and special pathogens (eg, Marburg, smallpox, SARS-CoV-2). To follow the same premise of “Identify, Isolate, Inform,” NYC H + H developed an initial patient screening algorithm for emergency departments to aid in screening for travel-associated infectious diseases using a syndromic-based approach (Figure 1). This syndromic-based approach initially focuses on hallmark signs/symptoms of an infectious disease (ie, fever plus cough or rash) without inundating the greeter or triage with a laundry list of signs/symptoms. Basic infection control precautions are implemented by providing the patient a simple mask and asked to perform hand hygiene.

OPEN IN VIEWER

Figure 1.

Initial patient screening algorithm for infectious diseases for emergency departments.

Travel history is solicited as a secondary question and reaffirmed once patient is with a clinician but prior to be being seen by a provider. Utilizing a NYC H + H homegrown infectious disease dashboard, an electronic site available on the system's intranet and internet, the areas of travel are added to an external website that shows current outbreaks occurring in that particular country. If a patient traveled to an area with active infectious disease outbreak, the patient is isolated and the provider dons appropriate PPE prior to entering the patient room for further evaluation.

In the event there is an active outbreak of concern in a said country, patients are isolated immediately and further history is taken in an enclosed patient care environment.

The NYC H + H Infectious Disease Dashboard is a decision-support tool developed to aid clinicians in rapid identification, isolation, and notification of appropriate contacts (eg, local public health department to ascertain risk of patient). The infectious disease dashboard aims to provide information in 4 main areas: (1) it shows where are infectious disease outbreaks occurring (internationally and domestically) through embedded links to travel health alerts; (2) it provides links to infectious disease case definitions to assess patient and evaluate for risk factors; (3) provides information on infection control measures including appropriate PPE for special pathogens; and (4) it provides contact information for internal and external contacts, such as number to local health department's provider access line.

The overall algorithm is based on simple, basic, operationally logical steps to be followed and is rooted in basic infection control and prevention principles. While it is not 100% foolproof, and there may be cases that do not fit this criteria for screening, it offers healthcare delivery systems a standardized baseline screening process (Figure 1).

Special Pathogens Warranting Transport

While the HHS hospital-tiered structure was initially built for Ebola preparedness and response, the potential to expand the use of such a network of assessment hospitals, ETCs, and RESPTCs to other special pathogens is invaluable. While a prescriptive national list of diseases may not be a viable option, given the emergence and reemergence of highly infectious diseases, a set of defining characteristics of special pathogens can assist healthcare delivery sites, specifically frontline hospitals, in knowing which disease characteristics would potentially warrant the transfer of a suspected special pathogen disease patient to a specialty hospital like an ETC or RESPTC. These defining characteristics of a special pathogen could include:

Pathogen associated with high morbidity and/or mortality

To accompany the initial patient screening algorithm for those patients identified as having a high likelihood of a special pathogen disease, NYC H + H developed a Special Pathogen Response Matrix to provide additional clarity to its 10 frontline hospitals on which diseases would warrant transport to the Region 2 Ebola and Other Special Pathogen Treatment Center in consultation with local public health officials and those diseases that would be assessed on a case-by-case basis. The Special Pathogen Response Matrix is based on both the defining characteristics of a special pathogen and those diseases that would alter normal operational processes such as laboratory practice (eg, not using pneumatic tube system), and waste management (eg, Category A waste).

Special pathogens—viral hemorrhagic fevers (eg, Ebola, Marburg), highly pathogenic respiratory diseases (eg, MERS-CoV, SARS-CoV), and other high-consequence diseases (eg, variola) may fit within 1 or more or all of these characteristics. It is also important to note each ETC and RESPTC may have differing capabilities and abilities to support and provide definitive treatment to patients with special pathogens besides EVD. This matrix is only applicable to NYC H + H and its Region 2 Ebola and Other Special Pathogen Treatment Center.

Conclusion

“Ready or not, patients will present” is a paradigm that healthcare delivery systems must embrace, whether they are small, rural frontline hospitals or large, urban RESPTCs, or any facility in between, to ensure constant readiness. This readiness includes the ability to provide safe and effective care for all who present and encompasses safe and effective structures and processes for clinical and nonclinical staff to make certain that they too, are safe. A steady emphasis on standardized, basic approaches, applied here via tools for frontline facilities, can minimize risk and maximize safety for all involved.