In late July, two months before the first Ebola case was diagnosed in the United States, a feverish patient who had traveled to West Africa arrived in the emergency room at Carolinas Medical Center in Charlotte. The patient was immediately isolated until doctors and nurses could rule out Ebola.
That quick response differs from what happened in September, when a Dallas hospital initially failed to realize that Thomas Eric Duncan might have Ebola, even though he had symptoms and had traveled from Liberia. He died Oct. 8, after infecting two nurses who cared for him.
As those two scenarios show, Ebola preparedness varies from hospital to hospital.
In response to mistakes in Texas, the federal Centers for Disease Control and Prevention last week tightened recommended protocols for infection control, and hospitals across the country have ramped up training for employees.
But for now, it’s still difficult to tell which hospitals are ready and which ones aren’t.
“If a hospital says, ‘We’re ready,’ you’ve got to take them at their word without any sort of validation today,” said Dr. Jeffrey Engel, executive director of the Council of State and Territorial Epidemiologists, based in Atlanta. “There’s no way to know today.”
But Engel said things are changing rapidly as the result of the mistakes at Texas Presbyterian Hospital Dallas.
“Texas was almost a month ago,” Engel said, “and boy, things have changed in a month. . . . We’ve learned quickly, and this will not happen again to the best of our ability. We’ve made adjustments.”
The CDC’s new, stricter protocols for health care workers more closely match those used by Doctors Without Borders in West Africa, ground zero for the current Ebola outbreak. The new guidelines call for health care workers to wear more protective gear that covers every inch of their skin and to have trained “buddies” who monitor them as they put on and take off that protective gear.
The hard part will be making sure the recommendations are followed.
“Implementation is going to be everything,” said Engel, an epidemiologist and former North Carolina health director. “Hospitals are already on razor-thin margins. They don’t exactly have personnel to throw around at this. . . . It’s going to be a problem.”
That’s why he supported the CDC’s decision to transfer the two Texas nurses to Emory University Hospital in Atlanta and the National Institutes of Health in Bethesda, Md., which have special intensive care and isolation units for patients with infectious diseases. Engel also endorses the idea he has heard under discussion by national experts about designating regional hospitals to accept known Ebola patients for treatment.
For now, it’s up to each hospital to spend the money and take the time to train and equip their staffs.
“Today I can’t say that every small general county hospital is going to be ready (if an Ebola patient shows up),” Engel said. “The triage systems have to be prepared as best they can. It’s not going to be leak proof.”
Nurses call for preparedness
Suspected Ebola cases have been appearing at hospitals across the country, and in many instances, health care workers have responded quickly, isolating the patients until testing or further investigation can determine if they have the infection.
Just Thursday in New York City, a 33-year-old doctor who had recently traveled from Guinea arrived at Bellevue Hospital with a 103-degree fever and nausea, symptoms of Ebola. Dr. Craig Spencer, who works for Doctors Without Borders, tested positive for Ebola, and public health workers began tracking down anyone he’d been in contact with since returning from West Africa.
In recent weeks, nurses and their union representatives have complained about the lack of sufficient protocols and equipment at the Texas hospital and others around the country.
In testimony Friday before Congress, National Nurses United called again for better preparedness, in light of the latest Ebola case in New York. The union asked Congress to mandate that all U.S. hospitals follow the highest possible Ebola standards and protocols to protect nurses, other front-line health care workers and patients.
Last week, American Federation of Teachers president Randi Weingarten praised the CDC’s new protocols but called for “expanded guidance to guarantee wages and benefits” if health care workers must be quarantined and lose time on the job after taking care of an Ebola patient.
Under-staffing at hospitals is a potential weakness as the U.S. health care system struggles to respond to a threat like Ebola.
“Across our country, 50,000 jobs were lost in the public health sector after the recession, and they were not restored,” said J. Stephen Morrison, senior vice president at the Center for Strategic and International Studies and director of its Global Health Policy Center in Washington.
Still, health care workers are preparing.
In North Carolina, 76 of 100 hospitals in the state have reported doing drills to familiarize health care workers with safety precautions in case they are presented with a potential Ebola patient.
But officials acknowledge they have to presume each hospital is doing its best to protect patients and staff. “That is a presumption,” said Dr. Megan Davies, North Carolina’s state epidemiologist. “We have no ability from Raleigh to inspect that that is the case.”
State health officials asked the North Carolina Hospital Association to survey members to find out which ones have the capability and capacity to treat potential Ebola patients and “might wish to serve” as a referral center.
The Ebola situation “is constantly evolving, and we are all learning from everyone else,” said hospital association spokeswoman Julie Henry. “It’s one thing to drill on things, it’s another thing for it to be reality.”
Confusion among hospitals
Rapidly changing protocols and recommendations result in what looks like confusion in some areas.
For example, in Charlotte, the 40-hospital system that owns Carolinas Medical Center planned from the start to funnel any potential Ebola patients to that hospital, the largest in the chain. Officials at Charlotte’s other system, Novant Health, initially said Ebola patients would be treated at any of its 15 hospitals in four states. After the Texas case, Novant officials changed that plan and designated three referral centers in North Carolina and Virginia for treatment of Ebola.
Earlier this month, Virginia Hospital Center in Arlington, Va., refused to accept a patient suspected of having an Ebola infection who was transported there by an Arlington paramedic crew. Hospital officials told the paramedics to leave and take the patient to Inova Fairfax Hospital, where she was treated, said Lt. Sarah Marchegiani, spokeswoman for Arlington County Fire Department.
The patient, who was vomiting and having diarrhea and said she had traveled to Africa recently, did not have Ebola.
“I don’t think (the patient) was in any life-threatening situation,” Marchegiani said. “But also if it was an Ebola patient, it prolonged our risk. We were in an enclosed space with her. . . . Any responder would be stressed in that situation.”
In a published statement, Virginia Hospital Center said it took proper action because construction was still underway on a biocontainment area. It is “now complete and the hospital is prepared to isolate, test and treat a suspected Ebola patient,” the hospital said.
“We learned some things and the hospital learned some things,” Marchegiani said.
‘I think we’ve got this’
After news broke on Oct. 15 that a second Texas nurse was diagnosed with Ebola and that the CDC had allowed her to fly on a plane to Cleveland even though she had an elevated temperature, public confidence in the CDC fell from 73 percent to 62 percent, according to a Kaiser Health Tracking Poll conducted this month.
Despite early mistakes in the U.S. response, a majority of Americans – at least 60 percent of Republicans, Democrats and independents – have a “great deal” or “fair amount” of confidence in state, local and federal authorities to contain the spread of Ebola, according to the poll. Seventy-three percent said they trusted the CDC to prevent the spread of Ebola and 64 percent expressed confidence in the preparedness of their local hospitals.
But some public health officials outside the CDC say the agency has been unfairly and prematurely panned during this rapidly evolving crisis.
“This is actually a federal agency that is working very well under the circumstances,” said Dr. Howard Markel, a professor of pediatrics and communicable diseases at the University of Michigan. “Was everything perfect? No. But they’re getting better as each week goes along. That’s what’s important. . . . We’re on the right path. Could there be another case? Sure. But I think we got this.”
Given there had never been a case of Ebola diagnosed in this country before Duncan arrived, it isn’t surprising that training and research for the disease wasn’t previously a priority for the U.S. government, Markel said.
“With budget cuts and so on you can’t prepare for everything,” he said. “It would have been considered a squandering of resources if you had put a gagillion dollars in the 2012 federal budget to train and educate health care workers in the U.S. about Ebola.”
Even if health care workers had received such training, that’s no guarantee that they would implement it perfectly in a real-life scenario, Markel said.
“The reality is, gosh, I’ve been a doctor 27 years, and I’ve never put on a hazmat outfit, and that’s not something you take a class on one day and a year later you remember how to do it,” he said.
In hindsight, it would have been better if the Dallas hospital had immediately sent Duncan to one of the country’s four hospitals with bio-containment units, including Emory University Hospital in Atlanta, where missionaries Nancy Writebol and Dr. Kent Brantly were treated and recovered from the Ebola infections they contracted in Liberia.
But Markel said the CDC couldn’t have forced the hospital to do so unless the president chose to invoke a 19th century quarantine law for the first time in history. The National Quarantine Act of 1893 originally was put in place to contain cholera. It allows the president to “federalize just about anything” – including hospitals – to fight an epidemic, Markel said.
“Government can’t just go into a local or state health matter. There are very strict laws about that,” he said. “It goes back to 19th century. Public health was a state concern. So (federal agencies) have to either be invited, or if it gets really serious, the president does have power to say this is a serious epidemic and we need to go in there.”
Even though Ebola has been recognized as a public health hazard in Africa since the 1970s, it wasn’t perceived as a serious threat in the United States, said Morrison of the Global Health Policy Center.
“Up until this outbreak there was no serious threat of importation into the U.S.,” he said. “Every other outbreak was on a small scale and in remote locations, in relatively small numbers, and it tended to burn out.”
As a result, Morrison said, the three cases diagnosed in Dallas put the U.S. health system through “a crash course” as hospitals and government agencies swung into gear, refining and strengthening protocols and getting health care workers trained up and familiar with what they should be doing if a suspected Ebola patient walked into an emergency room.
“There were some significant mishaps that were deeply upsetting and aggravated the situation, and those lessons have been hard lessons, but there’s been a lot of learning and adjustments,” he said.
Learning from West Africa
Adjustments should have been expected because Ebola hadn’t been encountered in the United States before, said Dr. Lance Plyler, medical director of the disaster response unit for Samaritan’s Purse, the Boone, N.C.-based mission organization.
Plyler, who spent two months this summer in Liberia, said his agency had never provided medical care for Ebola patients until June, when it responded to the call for help from Doctors Without Borders. “We learned firsthand from them” that people treating Ebola patients had to follow very strict protocols to protect against infection – complete skin coverage, N95 respirator masks, and having a buddy to observe the donning and doffing of protective gear.
In the United States, the CDC’s less-strict guidelines were “deemed appropriate for previous outbreaks, and by and large, they worked,” Plyler said.
But he praised the CDC for recently adopting “much more robust” guidelines. “I applaud them. I have faith that they’ll do a good job going forward,” Plyler said. “I think they were caught off guard. . . . A lot of us were caught off guard.”
Since July, when fellow missionaries Writebol and Brantly contracted Ebola in Liberia, Plyler said Samaritan’s Purse has shut down its general hospital, although it still operates an Ebola unit. Because the sheer number of cases in West Africa has become overwhelming, Plyler said, Samaritan’s Purse has turned its attention to providing family members with the knowledge and equipment to care for Ebola patients at home.
But the outbreak rages on, and CDC Director Tom Frieden has repeatedly said the threat from Ebola to the United States won’t end until the epidemic is contained in West Africa.
‘This sounds real’
In the United States, hospitals large and small are holding drills, not only training employees to “don and doff” protective gear they would wear while treating an Ebola patient, but reminding them to ask the right questions to identify potential Ebola infections in the first place.
At Kansas Medical Center near Wichita on Oct. 13, nurse Joy Stephenson was managing the emergency room when a 33-year-old man walked in complaining of muscle weakness, headache and vomiting. She took him to a room and started asking questions about his symptoms, as she would with any patient.
When the man said his temperature had been 101 degrees, the nurse asked whether he had traveled recently. When he said he’d been on a hunting trip to South Africa, the nurse became alarmed.
“Immediately I’m thinking in my head, ‘Oh my goodness, this sounds real,’” Stephenson said. “I honestly wanted to get out of the room.”
The nurse told a doctor she suspected the man might have Ebola, and “we started having a conversation about putting on protective equipment and called the chief nursing officer.” At the time, she said the hospital didn’t have a policy in place for handling Ebola.
Minutes later, the CEO of the hospital came in, asking to see the patient, who was his friend. When Stephenson refused to allow a visit, the CEO surprised her by telling her the whole scenario was a drill.
Since then, the hospital has changed its procedures so that a patient is asked about recent travel at the start of the triage process, before being escorted to an exam room. If they’ve been to Africa and have Ebola symptoms, they will be immediately isolated, ER staff will don protective equipment and the hospital will notify the Kansas Department of Health and Environment.
“We’re trying to be as prepared as we can be,” Stephenson said, “but I’m not sure we can be completely 100 percent prepared until it happens.”
Daryl Thornton, Kansas Medical Center’s chief operating officer, said the unannounced drill “definitely made us realize how prepared we were at that point and how much more prepared we needed to be.”