News, Operations, Patient Care

Staging Our Response to Ebola and Other Contagious Diseases

The Ebola challenge for the American emergency system has arisen very quickly, and provides us with another opportunity to refine the approach to contagious diseases. As emergency providers sit together to draft regional plans, there’s a responsibility to take what we learned from Bhopal, SARS, H1N1, anthrax, smallpox and Sarin.

It’s uncomfortable to watch the criticism of the Centers for Disease Control and Prevention (CDC) and the emergency providers in Dallas. The CDC has clearly done an outstanding job. Over the course of a few weeks, it’s provided a tremendous amount of guidance through the ability to do worldwide investigation, gather statistics, interview providers and apply known science about the virus.

But it’s the responsibility of emergency care providers, in the prehospital environment and in the ED, to figure out how to apply this knowledge. It’s EMS leaders’ responsibility to build our algorithms, do our training, buy the right products and listen for more science. It’s likely that emergency leaders will need to continue to make the quick, agile decisions needed to respond to this crisis.

In the past, emergency leaders have utilized a staged approach to this effort. The response and planning for Ebola will need a similar effort.

A three-stage approach is a rational place to begin:

Stage 1 is taking place now, when rare cases occur, but local areas are affected in a major way.

Stage 2 is when there are multiple small regional outbreaks.

Stage 3 is needed when there are multiple significant outbreaks.

We are in a Stage 1 at this point, looking for very rare cases and screening a lot of people to try to find those few patients. Emergency leaders in the Dallas region had to make action-oriented decisions right away to address concerns in public health, public safety, and the emergency care system. They have simple protocols for 9-1-1 centers, destination decisions, decontamination and use of PPE.

In other regions, many hospitals and EMS systems are meeting with public health providers, following the Dallas lead and publishing their practices. These early meetings help EMS and ED leaders build a rational staged approach if Stage 2 or Stage 3 occur.

Stage 1 operations are a wonderful use of time. Even if Ebola progresses no further, Stage 1 planning operations allow providers to design good programs for many contagious diseases. This activity prepares the emergency system for routine occurrences of influenza, Clostridium difficile (CDiff) and other exposures.

This process is one all leaders would like to do on an ongoing basis, but often gets lost in other priorities. Ebola gives the system a very focused opportunity. Importantly, it allows leaders to build credibility with the emergency care work staff, not only for Ebola, but for the next outbreak of SARS, or H1N1, or whatever.

There are numerous opportunities with Ebola to advocate at the local, regional and national levels for correct funding and preparatory work. Our lead organizations need to consider these priorities:

• Reach out to ASPR/ECCC for Executive branch support for preparedness and funding;
• Cooperate with the CDC on gathering evidence and building credible preparedness programs. At this time of the year, emergency leaders should use this opportunity to ask all Americans to get a flu vaccine, so that if Ebola does expand we won’t have a big flu population to confuse a febrile illness with. As CDC workers develop good science, they should be comfortable with the partnerships in emergency care to respond in information distribution.
• The criticism of individual hospitals, physicians, nurses and emergency providers is very disappointing. These providers are critical to public health and emergency care. Our emergency organizations need to make sure we are viewed as positive for the entire health system, as emergency providers are all “front line” providers.
• There are clearly opportunities to design and staff some “centers of excellence” as we move through Stage 1. That should be done region by region, and we shouldn’t wait for the government to have to designate that. This is just like a hazmat incident; the management of these incidents will require us to “dirty” only the smallest number of hospitals and keep the others clean. Do just-in-time training to get the staff at the designated centers functioning at a high level, and equipped to do so.
• Emergency care can’t take place in front of the media. The health care system hasn’t been granted tort protection.
• In planning for Stage 2 or Stage 3 operations, there has to be an adequate supply of PPE. Past experience would suggest there will be shortages of protective gear, and it will get incredibly expensive. The federal government needs to assure adequate supply at a fair price. We can further damage our economy by just asking for the federal government to pick up an inflated price. This is where regional centers may be a great idea, so that every hospital and EMS system doesn’t need to build a huge “war chest” of supplies.
• In Stage 2 and Stage 3, there’s a critical need for the Hospital Incident Management System to work. It’s time now to pull out the NIMS handbooks! The further stages will have critical roles for safety officers and logistics. This is another opportunity to get this training out, and build algorithms and worksheets for those roles related to Ebola.

Stage 2 operations will occur when there’s a spread of disease, and fatalities, in multiple regions of the country. At that point we will all need to staff our emergency care systems, and public health programs for isolation and quarantine, and algorithms for rapid rule-in and rule-out. The emergency organizations need to be more active in sharing best practices on emergency treatment and prevention.

Stage 3 operations occur when there’s widespread disease and fatalities, in multiple regions of the country. At that point there will be a need for massive public health efforts, and a two-tier emergency care system: one for contagious disease patients, and one for everything else that still goes on. There is a need now to develop and build efficient algorithms for rapid rule-in and rule-out.

The attached chart outlines the basic elements of a regional planning model for Ebola, in a staged format. With each evolution, more agencies need to participate in the planning and operations, and already-tight budgets need to be squeezed. Planning for Ebola can be matched to the timely responses to the pediatric enterovirus, CDiff, tuberculosis and seasonal influenza.

Don’t miss the opportunities!