When Ebola reached US shores in 2014, healthcare workers and experts were kicking themselves for not being ready for a major infectious disease outbreak—and promising themselves that next time, they would be.
"We often talk about a panic/neglect cycle," said Eric Toner, MD, a senior scholar at the Johns Hopkins Center for Health Security. "Every time there's a crisis, people get into panic mode and there's a lot of intense response for a short amount of time. Then the crisis passes and no one pays attention until the next crisis."
Now that the next crisis seems to be arriving in the form of the novel coronavirus disease COVID-19, exactly how ready are US hospitals?
Most agree that the good intentions of 2014 prompted some progress, but whether it's enough is the $10 million question.
As the challenges specific to this virus begin to emerge, experts say hospitals are—or should be—preparing for a surge in patients, training healthcare workers in the proper use of personal protective equipment (PPE), and coordinating with public health officials on testing procedures.
Progress since earlier outbreaks
The SARS (severe acute respiratory syndrome) epidemic of 2003 offers perhaps the best lesson for hospitals, Toner said: "The greatest risk is from an unsuspected patient in an unprepared hospital."
More recently, the Ebola scare underscored the need for streamlined communication and collaboration, something not easy to accomplish in the disjointed US healthcare system.
To address that need, the US Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) formed the National Ebola Training and Education Center (NETEC) in 2015. Led by three organizations that successfully treated Ebola patients—Emory University, the University of Nebraska Medical Center/Nebraska Medicine and the New York Health and Hospitals Corporation, Bellevue Hospital Center—NETEC now offers hospitals centralized knowledge: resources, including education and training; readiness consultations; and a research network that can fast-track studies through its own institutional review board.
HHS also created a network for future infectious disease outbreaks, designating 10 hospitals as regional special pathogen treatment centers. Not only are those 10 frontline hospitals better prepared for an outbreak, but they educate other hospitals between outbreaks, said Courtney Gidengil, MD, MPH, a senior physician policy researcher at the Rand Corporation who co-authored a report on hospital readiness for infectious disease outbreaks in 2018.
That report applauded those efforts, but also recommended steps to strengthen and build on them and formalize networks, since the degree to which the more than 5,000 US hospitals use those resources varies. And which hospital a patient with COVID-19 presents to is completely random: there's no path to direct a patient to a hospital that's particularly well prepared, Gidengil said.
"One of the biggest concerns is that while front-line hospitals are prepared, it's completely unpredictable where a patient will present," she said, referring to the regional hub hospitals.
Most healthcare centers, Toner noted, don't even have a full-time emergency manager. The person tapped for that job usually has other responsibilities, most of which appear more urgent until an outbreak arrives.
"I think that most hospitals probably have plans which they probably have not looked seriously at since Ebola in 2014 or the 2009 H1N1 pandemic. And if they looked at their plans, they probably have not done the same degree of education, training, and practice that they needed to do since the last infectious disease emergency."
A likely hospital scenario
Ideally, said Paul Biddinger, MD, chief of the division of emergency preparedness at Massachusetts General Hospital, the Region 1 regional special pathogen treatment center, each hospital would be prepared now to treat a patient having COVID-19 symptoms like this:
As soon as someone walks into a hospital, signage, questionnaires, and prompts in the electronic health record would be in place to ask about possible symptoms and exposure to the COVID-19 virus. Once the person is suspected of having COVID-19, that patient would be given an N95 respirator (see yesterday's CIDRAP News story) and placed in an isolation room.
Then, only staff who have been trained in proper protocols for donning and doffing PPE—likely from the emergency department—would provide clinical assessment and care. If the patient's symptoms warrant testing, the hospital would contact the state public health department. If health department experts agreed with the need for testing, they would contact the CDC. The hospital would send the sample to the state, and the state would pass it on to the CDC.
If COVID-19 patients are generally well, they could be isolated at home and carefully monitored by public health officials. If they need to be hospitalized, they would need to be in an airborne infection isolation [AII] room with trained staff and overall guidance to manage visitors and items entering and leaving the room. "They need to manage as though they are infected until we know they are not," Biddinger said.
But even if a hospital can perform those steps successfully on a few patients, what happens if the caseload increases 100-fold?
Only limited surge capacity
It's still unclear exactly how contagious COVID-19 is, but experts say it transmits similar to the flu, and it has spread rapidly in China and appears to be escalating in Singapore.
Especially if patients continue to need isolation rooms, hospitals could quickly get overwhelmed, Biddinger said.
"The more patients we have, the harder it will become," Biddinger said. "It places a severe demand on personal protective equipment and on the spaces we have available."
Even the regional hubs, which are required to have at least 10 AII rooms, would be hard-pressed to treat masses of patients with COVID-19 simultaneously. Some hospitals have the ability to turn an entire floor or wing into a negative-pressure area, Biddinger said, but that produces other challenges, such as requiring healthcare workers to wear PPE the entire time they're in the space, and the ability to make a definitive diagnosis before a patient enters the area. It also displaces the patients who had been housed in that section.
"If we start to see large numbers of patients presenting for diagnosis or who need hospitalization or intensive care, we already operate at full capacity or beyond, so it's extremely challenging to change quickly and make sure we can provide safe care for everyone," Biddinger said.
Indeed, if the mortality rate of COVID-19 continues to drop as many experts expect, the bigger health threat could become the lack of services for critically ill people in overcrowded hospitals, Gidengil said.
A surge of patients could also pose supply issues, experts said, especially PPE. Not only is there already a tremendous demand for PPE in China, but an escalating outbreak could shut down many of the factories that manufacture such supplies in China.
Challenges posed by PPE
When two nurses who treated the first Ebola patient in the country contracted the diseasein 2014—even though adequate facilities and equipment were available—the lesson of proper donning and doffing of PPE hit home.
Now, with more than 1,700 health care workers infected in China, experts are reminding hospitals that training staff on proper protocols could be critical in preventing COVID-19 spread in healthcare settings.
Even though healthcare workers should be relatively familiar with the PPE, including N95s, Gidengil said, healthcare facilities should be fitting the respirators, offering refreshers on donning and doffing, and reviewing best practices.
"You can contaminate yourself by touching the outside of the equipment and then touching yourself," Toner said. "Or by taking things off in the wrong order."
The good news is that message is better received now, Biddinger said.
Over the past 5 years, Mass General has developed a toolkit of plans, protocols, exercises and videos for various diseases requiring different types of PPE "We've pushed that out across the entire region to help other hospitals get ready faster," Biddinger said.
Offsite testing slows hospital response
Complicating matters at the moment is the current cumbersome process of testing patients. In the beginning stages, all tests for COVID-19 in the country had to be sent to the CDC in Atlanta, via state public health departments, a process that quickly created bottlenecks.
Several public health labs received their own test kits on Feb. 7, but some reported glitches when they tried to validate the tests, including the Minnesota Department of Health, according to Richard N. Danila, PhD, MPH, deputy state epidemiologist. The CDC has said it will send replacements "soon." Once state public health labs—and eventually, major hospitals—have effective kits, the turnaround time should be reduced. But for now the lag time to get results is several days, Danila said.
In the meantime, hospitals have to figure out who needs to be treated with special precautions and how to best isolate patients.
It's a predicament complicated by high flu activity. Distinguishing between the flu and COVID-19—especially with a rapid flu test that is not highly sensitive—is tricky, Toner said. At the moment, hospitals can earmark potential COVID-19 cases by the person's connection to China or someone known to have the disease. But if the virus starts spreading locally, it will become even harder to discern without distinguishing features from the flu, Toner said.
"Part of the question remains, prepared for what?" Biddinger said in pondering how the outbreak might evolve. "Obviously it is very hard to plan because there are so many significant unknowns."
As understanding of the COVID-19 virus and transmission pattern builds over the coming weeks, hospitals will have to refine readiness efforts, he said.
In some scenarios, that could come as a relief: If evidence points toward transmission via large droplets only, for example, "that would be a clear game-changer," Biddinger said, since AII rooms and N95 respirators wouldn't be needed.
In the meantime, healthcare leaders should be managing fear and building trust in US healthcare, experts said.
"The more we feed fear about the virus and only talk about the narrative of its deadly potential, the more we run the risk of overloading hospitals with patients with mild illness," he said, noting that that has happened in China.
"There's no question we are in a better position now to follow the CDC's 'Identify, Isolate and Inform' guidance than we were in 2014-15," Biddinger said. "Emergency departments have good training resources, they understand the importance of this, and they can build on previous plans for prior outbreaks."
Feb 13 CIDRAP News story "China reports gush of retrospective COVID-19 cases"
Feb 12 CIDRAP News story "Glitch delays COVID-19 tests for states as first evacuees cleared"