What Would You Do If an Ebola Patient Checked Into Your Hospital?

On a November morning in 2018, a man checked into a crowded emergency department (ED) in California reporting fever and body aches. The clerk who checked him in quickly deduced that he had arrived 2 days prior from the Democratic Republic of Congo (DRC), where an outbreak of Ebola virus disease (EVD) was raging.

Confusion ensued. The patient was swiftly isolated: staff members walked him to a room while maintaining the recommended 6 feet of distance. Once roomed, however, they had difficulty locating the appropriate Tier 3 personal protective equipment (PPE) needed to safely deliver care. Per local protocol, any staff member entering the room was required to wear a Tyvek suit, surgical gown, apron, three pairs of gloves, surgical boots, and a powered air-purifying respirator (PAPR).

Even if they had been able to locate the PPE, none of the clinicians present remembered how to don or doff it -- a multi-step sequence that must be followed meticulously to avoid exposure. In the meantime, the California Department of Public Health instructed staff to maintain the patient's isolation while the state ascertained his risk of EVD. And so, the patient remained in a room for 3 hours, with frustrated clinicians on the other side of the closed door unable to initiate testing or treatment.

The patient didn't have Ebola (he had malaria). If he had, you would have heard of him because a patient with EVD in an American hospital is global news. But it begs the sobering question -- what would you do if a patient with EVD checked into your hospital? For me, as the director of disaster preparedness for Kaiser Permanente Northern California at the time, the case served as a wake-up call and a reminder that hoping for the best is not a viable preparedness strategy.

The likelihood of such an event is, unfortunately, on the riseopens in a new tab or window. Climate change, migration of biological vectors (including humans), antimicrobial resistance, and urbanization have virtually assured that novel pathogens -- recently emerged or re-emerged, high-threat pathogens, also known as "pathogens of high consequence" or "highly infectious pathogens" -- will continue to be introduced into new ecological nichesopens in a new tab or window. This increases both the risk of these infections in the U.S. and the potential for previously unseen host-pathogen dynamics.

As I write this, an outbreak of Sudan virus diseaseopens in a new tab or window has infected a dozen patients in Uganda, and a mysterious febrile diseaseopens in a new tab or window in the DRC has rapidly killed over 50 people. Closer to home, H5N1 bird fluopens in a new tab or window is making its way through various animal species, and measles rages in Texasopens in a new tab or window. Other examples include Lassa, Marburg, smallpox, Hantavirus, SARS, and the dreaded "Disease X.opens in a new tab or window"

Unfortunately, novel pathogens are hard to be prepared for. As noted, there's an extraordinary amount of highly specific PPE that must be maintained and stored in an easily accessible location. Most American physicians' experience with the clinical management of these infections is virtually nonexistent. On top of that, there's a series of complicated infection prevention protocols -- in the absence of clinical experience, proficiency with these protocols can only be achieved through regular, standardized training sessions.

And then there's the nature of novel pathogens themselves. As a group, they share multiple unsettling characteristics. They are highly contagious and infectious; there is often no specific treatment; they are associated with significant morbidity and mortality; and they understandably cause apprehension amongst healthcare workers (there's a reason Ebola is called "the caregiver's disease"). In other words, a single patient infected with a novel pathogen is a high-stakes, possibly disastrous event in any hospital.

Back in 2018, following the Ebola near-miss at one of our hospitals, I realized our organization needed an innovative approach to novel pathogen preparedness. After a multidisciplinary discussion that included infectious disease, infection prevention, and disaster management specialists, we decided to create a mobile response team of physicians and nurses specifically trained in novel pathogen management. We reasoned that a single, highly trained strike team that could be deployed to any number of hospitals to deliver direct clinical care would bypass many of the inherent challenges in novel pathogen preparedness, while simultaneously optimizing available resources (including provider bandwidth).

In 2019, we officially launched the strike team. And then we equipped and trained it for success. We assigned each team member a "go-bag" with a 3M PAPR, two hoods, and two sets of Tier 3 PPE. We required every member to attend an initial orientation session and two training sessions annually. These day-long trainings typically included a didactic portion (global outbreak epidemiology, infection prevention protocols, clinical management) and a skills/simulation portion (donning and doffing Tier 3 PPE, IV placement, or intubation while donned).

We developed checklists and workflows and made sure every member had a copy of these in their go-bag. Recognizing that novel pathogens often lead to more widespread outbreaks, we taught team members how to conduct just-in-time training in order to rapidly scale up response capability should this become necessary.

Along the way, we improved through trial and error. After our first drill, we realized we needed a notification system to contact team members. We discovered myriad human resources considerations, such as what was expected post-deployment (answer: return to both home and work with resumption of the member's usual schedule) or what to do if there was an exposure or breach (answer: individual assessment by a team of employee health, infectious disease, and infection prevention specialists). We secured compensation for team members' training time and, in the event of a deployment, travel time and time spent in deployment. We realized it made sense to deploy team members in pairs.

The venture required time and organization beyond anything I ever anticipated. In retrospect, we grossly underestimated the complexity of managing a patient with a novel pathogen; it was only through tenacity and tinkering that my organization arrived at an acceptable level of preparedness. By the end of the year, we had created a first line of defense against this rare but high-stakes scenario.

Public health in general and global infectious diseases in particular have always suffered from a cycle of panic and neglect. Of late, however, our nation's ability to detect and deter novel pathogens has been dealt multiple significant, if not terminal, blows. In short order, the CDC has been gaggedopens in a new tab or window and its Epidemic Intelligence Serviceopens in a new tab or window placed on the chopping block; the U.S. has withdrawn from the World Health Organizationopens in a new tab or window; and the U.S. Agency for International Developmentopens in a new tab or window has been eviscerated. In an era when novel pathogens emerge consistently and stealthily, the institutions and structures designed to safeguard our communities may fail to do so when the next epidemic threat arrives.

The take-home message is that the cavalry is not coming, but the infectious diseases areopens in a new tab or window. Every American healthcare organization should be prepared to manage a patient with a novel infection, and they should be ready to go it alone. My advice is to determine which strategy works best for your hospital (we chose to pilot a mobile team, but there are many acceptable approaches) and then begin trialing it. You will probably find, as we did, that it takes some time and tinkering to get it right. What is not acceptable is to ignore the warning signs before us.

This perspective is the author's alone and does not necessarily reflect that of any institutions or companies with which she is affiliated.

Mary Meyer MD, MPH, is an emergency physician with The Permanente Medical Group. She also holds a Master of Public Health and certificates in Global Health and Climate Medicine. Meyer previously served as a director of disaster preparedness for a large healthcare system.

With all of the “opens in a new tab or window” junk removed:

The cavalry isn’t coming, but the infectious diseases are

Even if they had been able to locate the PPE, none of the clinicians present remembered how to don or doff it — a multi-step sequence that must be followed meticulously to avoid exposure. In the meantime, the California Department of Public Health instructed staff to maintain the patient’s isolation while the state ascertained his risk of EVD. And so, the patient remained in a room for 3 hours, with frustrated clinicians on the other side of the closed door unable to initiate testing or treatment.

The patient didn’t have Ebola (he had malaria). If he had, you would have heard of him because a patient with EVD in an American hospital is global news. But it begs the sobering question — what would you do if a patient with EVD checked into your hospital? For me, as the director of disaster preparedness for Kaiser Permanente Northern California at the time, the case served as a wake-up call and a reminder that hoping for the best is not a viable preparedness strategy.

Why Worry About Novel Pathogens?

The likelihood of such an event is, unfortunately, on the rise. Climate change, migration of biological vectors (including humans), antimicrobial resistance, and urbanization have virtually assured that novel pathogens — recently emerged or re-emerged, high-threat pathogens, also known as “pathogens of high consequence” or “highly infectious pathogens” — will continue to be introduced into new ecological niches. This increases both the risk of these infections in the U.S. and the potential for previously unseen host-pathogen dynamics.

As I write this, an outbreak of Sudan virus disease has infected a dozen patients in Uganda, and a mysterious febrile disease in the DRC has rapidly killed over 50 people. Closer to home, H5N1 bird flu is making its way through various animal species, and measles rages in Texas. Other examples include Lassa, Marburg, smallpox, Hantavirus, SARS, and the dreaded “Disease X.”

Unfortunately, novel pathogens are hard to be prepared for. As noted, there’s an extraordinary amount of highly specific PPE that must be maintained and stored in an easily accessible location. Most American physicians’ experience with the clinical management of these infections is virtually nonexistent. On top of that, there’s a series of complicated infection prevention protocols — in the absence of clinical experience, proficiency with these protocols can only be achieved through regular, standardized training sessions.

And then there’s the nature of novel pathogens themselves. As a group, they share multiple unsettling characteristics. They are highly contagious and infectious; there is often no specific treatment; they are associated with significant morbidity and mortality; and they understandably cause apprehension amongst healthcare workers (there’s a reason Ebola is called “the caregiver’s disease”). In other words, a single patient infected with a novel pathogen is a high-stakes, possibly disastrous event in any hospital.

An Innovative Approach to Novel Infections

In 2019, we officially launched the strike team. And then we equipped and trained it for success. We assigned each team member a “go-bag” with a 3M PAPR, two hoods, and two sets of Tier 3 PPE. We required every member to attend an initial orientation session and two training sessions annually. These day-long trainings typically included a didactic portion (global outbreak epidemiology, infection prevention protocols, clinical management) and a skills/simulation portion (donning and doffing Tier 3 PPE, IV placement, or intubation while donned).

Along the way, we improved through trial and error. After our first drill, we realized we needed a notification system to contact team members. We discovered myriad human resources considerations, such as what was expected post-deployment (answer: return to both home and work with resumption of the member’s usual schedule) or what to do if there was an exposure or breach (answer: individual assessment by a team of employee health, infectious disease, and infection prevention specialists). We secured compensation for team members’ training time and, in the event of a deployment, travel time and time spent in deployment. We realized it made sense to deploy team members in pairs.

The Cavalry Isn’t Coming

Public health in general and global infectious diseases in particular have always suffered from a cycle of panic and neglect. Of late, however, our nation’s ability to detect and deter novel pathogens has been dealt multiple significant, if not terminal, blows. In short order, the CDC has been gagged and its Epidemic Intelligence Service placed on the chopping block; the U.S. has withdrawn from the World Health Organization; and the U.S. Agency for International Development has been eviscerated. In an era when novel pathogens emerge consistently and stealthily, the institutions and structures designed to safeguard our communities may fail to do so when the next epidemic threat arrives.

The take-home message is that the cavalry is not coming, but the infectious diseases are. Every American healthcare organization should be prepared to manage a patient with a novel infection, and they should be ready to go it alone. My advice is to determine which strategy works best for your hospital (we chose to pilot a mobile team, but there are many acceptable approaches) and then begin trialing it. You will probably find, as we did, that it takes some time and tinkering to get it right. What is not acceptable is to ignore the warning signs before us.

This perspective is the author’s alone and does not necessarily reflect that of any institutions or companies with which she is affiliated.

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