Ebola Readiness—A False Sense of Security?

Last week an American health care worker was flown to Nebraska to be monitored following an Ebola exposure while working in the Democratic Republic of the Congo. Although the Nebraska Medical Center houses the largest of only a few biocontainment units in the United States and is a premier center, this incident is a stark reminder that high-consequence pathogens, such as Ebola virus disease, are just a flight away.

For many of us who worked in health care during the 2014-2016 Ebola outbreak, memories of those months are filled with frantic efforts to bring ourselves and staff up to par on personal protective equipment (PPE) guidelines, confirm there were patient movement algorithms, and ensure that if someone with Ebola walked through our doors, we would rapidly identify and isolate them. To say that it was a stressful time would be an understatement.

The question is: are we better off than we were in 2014?

The answer? Somewhat.

Investigators on a new report by the Office of the Inspector General evaluated hospital preparedness across the United States for emerging infectious diseases (EIDs) after the Ebola outbreak. Administrators from 368 hospitals around the United States were surveyed, of which 10 were Special Pathogens Centers.

When surveyed in 2017, 14% of administrators felt their facilities were unprepared for a patient with Ebola or an EID. Conversely, 71% of hospital administrators reported that their facilities were unprepared to receive an Ebola patient in 2014.

Many administrators felt prepared; however, they noted that their resources would be strained should they receive a patient infected with Ebola. Critical access hospitals reported a lower level of preparedness.

Overall, all hospital administrators took actions during and following the 2014 outbreak to help strengthen their preparedness, whether that was seeking guidance from the US Centers for Disease Control and Prevention, or purchasing the necessary supplies and equipment. Those hospital administrators who felt unprepared had also taken fewer actions to increase preparedness and experienced more challenges in preparing (ie, maintaining adequate supplies, etc).

Despite these reported levels of increased preparedness, one-third of hospital administrators could not verbalize their hospital designation in the Ebola hospital-tiered system. Hospital administrators reported challenges and concerns with sustaining levels of preparedness for EIDs and 95% reported competing priorities that reduced the ability to focus on EIDs. One administrator was quoted in saying that, “preparing for Ebola took countless hours from many departments and one could argue [that it] detracted from normal infection prevention and control tactics to prevent hospital-acquired infections.”

The financial cost of maintaining competencies, PPE, and other specialized equipment was a challenge for many and ultimately, 79% of hospital administrators reported that other types of emergencies were more likely to occur than EID threats. The challenges of training necessary and often critical staff, obtaining full participation from clinicians, and even combating frequent turnover in staffing, all stressed the capacity for hospitals to maintain readiness.

These findings are interesting and shed light on many of the issues that were present during the 2014 outbreak. Hospitals often feel they are doing more and that they are better prepared for biological events than they truly are. When asked more specific questions about their preparedness efforts, the administrators reported issues that would stress the health care system in similar ways, such as staffing and resource challenges. Awareness of Ebola has grown stronger in the United States, but some of the core issues that we saw, for example, in the Dallas, Texas, Ebola cluster, are all still present—infection prevention failures, lack of necessary resources, new health care staff, competing interests, etc.

This report should be seen as an insight into the vast amount of work that is still needed in hospitals across the United States. A false sense of readiness for a single disease creates a moral hazard that does us a disservice. Strengthening basic things, like infection prevention and hospital emergency preparedness, are critical before we should expect hospitals to manage patients with highly infectious diseases.