Ebola preparation: issues to consider for healthcare institutions

Dec. 14, 2014

Ebola preparedness is definitely on the minds of laboratory professionals in the United States, at large and small hospitals alike. Everyone wants to be ready, should an unfortunate event occur that brings a suspected Ebola patient to an emergency room.

Establishing a chain of command

Although there have been discussions about having core hospitals nationwide that would take care of Ebola patients in each region, as of this writing no final decisions have been made. So what can health systems, laboratories, clinics, and physicians’ offices do to prepare? First, they need to have an established and readily available chain of command. Second, each hospital needs to have an internal conversation about its strengths and potential weaknesses regarding the possibility of treating a patient diagnosed with Ebola. The hospital’s physician offices need to be part of that conversation.

More than likely, an individual who may have had exposure to Ebola and shows possible symptoms will show up in a large facility. Once a diagnosis has been made, it is relatively straightforward what steps to follow, whether you take care of patients in your own facility or transfer them to another for treatment. The challenge is what to do in the first 24 hours—when you don’t know whether it is Ebola.

There should be written protocols on what to do with a patient, where he or she should be isolated, what tests to order, and which tests to delay. Healthcare professionals should consider using only point-of-care tests that can be safely contained and disinfected after use. There should be a list of tests to be ordered in the containment area, and tests should not be sent to the general laboratory for processing until the CDC has confirmed that the patient has tested negative for Ebola.

Physician offices should be ready to contain a patient in a room if a suspect patient has been seen; appropriate infection control personnel should be notified; and the patient should be transferred to a hospital or facility capable of treating the Ebola patient. The office staff who had direct contact with the patient before he or she was isolated in a room should be put on a 21-day watch for fever or symptoms of general illness if the patient is later confirmed to be Ebola-positive.

Communication is critical

The Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and other public health agencies are advising and leading the preparedness efforts. The American Society for Clinical Pathology (ASCP) is in direct contact with the Ebola response team at the CDC and has posted the latest CDC information on Ebola on its website at www.ascp.org. ASCP leaders are having conversations with the CDC about ways in which the organization can assist in providing preparedness support to medical laboratories around the country.

The New York State/New York City Departments of Health also have guidelines regarding Ebola that provide concrete actions to take “in the trenches,” first to protect the healthcare infrastructure (personnel, equipment, and facilities); and second, to protect the public and support the patient. This is clearly a “low incidence, high consequence” situation, where preparedness is paramount to assure that participation in patient care is not risky.

Effective communication of information is as vital as infection control. Each healthcare organization should post links to the CDC guidelines and WHO guidelines regarding Ebola on their websites. These guidelines will be the most current sources that should have the most reliable data. Within healthcare organizations, each needs a direct and simple way to connect with key personnel.

Designate an infection “czar”

NorthShore University HealthSystem (NorthShore), a fully integrated healthcare delivery system with four hospitals serving Chicago’s northern suburbs, has developed a plan which provides for an infection preventionist to be on call 24-7. Telephone operators need to know only one pager number if there is concern that an individual may be infected with Ebola. The infection preventionist is responsible for contacting one of three people identified within the organization who will make a determination if an individual is deemed high-risk for Ebola and notifying the lab that specimens will be coming.

A patient who may have Ebola is directed to the emergency department at one of NorthShore’s hospitals. If an individual walks into a physician’s office associated with the health system and the question arises, the patient stays in a designated room, the phone chain is initiated, and the health system’s three designated specialists assess how to respond. If the patient is deemed high-risk, every precaution is followed. In this plan, even transporting someone on a transport bed or cart through the hospital requires four people, two assisting with moving the cart, someone going ahead to open the door, and someone behind to decontaminate everything touched by the patient.

In reality, virtually any infectious disease on the planet is only one day away from us, whether it is Ebola or any other dangerous, exotic, incurable illness. Healthcare staff—from custodial staff to surgeons—need to accept the fact that this is no longer a routine patient or procedure. Training and education is one thing, but we learned during the anthrax events that when the real event occurs, we could still use more training and practice. Personal protective equipment is the main barrier for this virus, and workers should drill, drill, drill.  They need to work as partners and make sure they can help protect each other.

Survey results: microbiologists and Ebola preparedness

A small survey, which we conducted on the American Society for Microbiology (ASM) ClinMicroNet and DivC listservs, indicates that laboratories under the direction of specially trained and certified microbiologists are more likely to have initiated or joined a necessary discussion and planning venue for Ebola preparedness. Microbiology laboratories under the direction of American Board of Medical Microbiology (ABMM) or American Board of Pathology Special expertise in Medical Microbiology-certified professionals are always strong.

The survey posed two questions to two distinct audiences: Does your lab have a dedicated microbiologist director? Have you been involved with your hospital in Ebola preparedness?

The first query, which was sent only to MD- or PhD-level leadership, received 227 responses, the largest response ever to a query on the ASM listserv. Only two U.S. respondents whose labs had a doctoral-level microbiologist director said they had not been involved in Ebola preparedness at their health system.

The second query was sent to ASM’s clinical microbiologists whose laboratories had non-doctoral level leadership. Nearly 64 percent of respondents in this group said they were involved in their hospital’s Ebola preparedness. Yet, of those whose labs that had no dedicated microbiologist director, only 28.6 percent said they are involved in Ebola preparedness. To us, this clearly suggests the advantage of having a certified specialist who is dedicated to running the microbiology lab in situations such as emergency preparedness for hemorrhagic fever virus patient care.

Lance R. Peterson, MD, FASCP, is a spokesperson for the American Society for Clinical Pathology and is the Director of Clinical Microbiology and Infectious Diseases Research in the Department of Pathology and Vice-Chair of Pathology for Research at NorthShore University HealthSystem in Evanston, IL. He is also an epidemiologist at NorthShore University HealthSystem and a Clinical Professor at the University of Chicago Pritzker School of Medicine. J. Michael Miller, PhD, D(ABMM), is a clinical and public health microbiologist and former Associate Director for Laboratory Science for the National Center for Emerging and Zoonotic Infectious Diseases of the Centers for Disease Control and Prevention (CDC). He founded the American Society for Microbiology (ASM) ClinMicroNet and DivC listserv and moderates their discussions. He is presently owner and director of Microbiology Technical Services, LLC, in Dunwoody, GA.