Emerging Pathogen Management

HealthTrust on the Front Lines

Last summer’s Ebola outbreak in several West African countries prompted worldwide fears that the disease would eventually find its way to other nations. Concern rose in July when aid worker Dr. Kent Brantly was diagnosed with the disease and airlifted back to the United States for treatment at Emory University Hospital in Atlanta—the first case of Ebola on American soil.

Concern turned to alarm in late September when Thomas Eric Duncan, a Liberian man visiting family in Dallas, tested positive for the disease after several days of living in close contact with family members. He died Oct. 8 at Texas Health Presbyterian Hospital in Dallas. When two healthcare workers who had tended to Duncan were diagnosed with Ebola, near-panic ensued as the public and many media outlets foresaw an uncontrollable epidemic.

Over time, the fear subsided as the two healthcare workers recovered and no one with whom they had contact contracted the disease. When several subsequent cases were also successfully treated without a mass outbreak, it appeared the United States had dodged a bullet.

But the weeks of worry made a lasting impact on our healthcare system. It put Ebola squarely on the list of once-exotic infectious agents like MERS (Middle East Respiratory Syndrome), severe acute respiratory syndrome (SARS) and bird flu that U.S. hospitals had to be prepared to handle.

News of the initial outbreak prompted Nashville, Tennessee–based HCA to begin preparing its more than 160 hospitals in July to handle Ebola cases. As part of those preparations, HCA asked HealthTrust to assist in evaluating the potential threat, determining what equipment was needed to meet it and acquiring the necessary items.

The collaboration ensured that both HCA and HealthTrust stayed ahead of the evolving crisis, providing accurate, up-to-the-minute information and securing the equipment to keep HCA staff and patients safe. Other HealthTrust members can draw on the purchasing group’s expertise in making their preparations, as well.

“Supply chain is critical to making sure we have enough of the proper equipment and supplies,” says Dr. Edward Septimus, medical director, Infection Prevention and Epidemiology Clinical Services Group at HCA.

Dispelling Fear

Ebolas Economic Fallout Cant Be Contained in Rising Africa
A worker at Medline Industries gathers exam gloves to include in personal protection equipment (PPE) kits to be shipped out to various health facilities.

Ebola presents a unique challenge to healthcare providers because it’s a disease that can appear without warning anywhere and anytime, says Tom Griffin, vice president, SolutionsTrust. “You don’t know which facility is likely to be impacted, so you have to prepare as though all could be affected.

“Previously there was never a need to prepare for such a potentially widespread pandemic like this,” Griffin continues. “It was unpredictable where the event cycle would begin. We had to be far ahead of the curve to be ready to respond at all locations simultaneously.”

One of the first steps taken was to provide hospital staff with solid, accurate information “in order to remove the fear and give them the science about Ebola,” Septimus says.

“There has been a lot of misinformation about it on the Internet and from pundits. The CDC [Centers for Disease Control and Prevention] has changed its own guidelines [multiple times], which has lessened public confidence,” Septimus notes.

In working with HCA, HealthTrust created two teams led by Vice Presidents of Supply Chain Steve Tarkington and James Tavenner to tackle different aspects of the challenge. Tarkington’s team was tasked with determining what kinds of equipment would provide protection for caregivers, while Tavenner’s team worked on sourcing the items.

In collaboration with HealthTrust, HCA distributed its initial guidance on infection prevention and treatment in July, even before the CDC issued its first guidance, according to Scott Cormier, director, Emergency Preparedness & Management Clinical Services Group at HCA. Eventually, HealthTrust would create a number of educational and training materials for its member facilities.

Tarkington’s team began reviewing a wide range of products such as gloves, masks, gowns, aprons and covers for shoes and hair. They found themselves in a race against time, as other healthcare facilities—and the public—were also searching for the same types of protective gear.

For instance, fully contained biohazard suits known as PAPRs (powered air purifying respirators) are considered the gold standard for working with highly infectious diseases. Though expensive, the available supply of PAPR suits was snapped up almost immediately.

But PAPRs aren’t necessary for someone who spends minimal time with a patient or only observes that patient from a distance. So Tarkington’s team looked at what combination of items would provide the necessary protection and developed protocols for safely using them.

Once Tarkington’s team had identified the appropriate equipment, Tavenner’s team went to work on locating sources, securing contracts, acquiring items and determining where to store them. The heavy demand for all kinds of protective gear meant the team “had to engage nontraditional vendors in nontraditional places,” Griffin says.’

“We ultimately purchased several million dollars’ worth of supplies. We’re now monitoring any demand on supplies in order to keep sufficient amounts on hand.”
—James Tavenner, vice president of supply chain, HealthTrust

“We ultimately purchased several million dollars’ worth of supplies. We’re now monitoring any demand on supplies in order to keep sufficient amounts on hand,” he continues.

HCA has centralized inventories that enable it to move supplies to hospitals quickly, so the facilities don’t have to maintain large inventories. It was decided to provide each hospital with enough equipment to care for potential Ebola patients for several days, with more readily available if required.

“There was a lot of confusion about what was needed to protect against infection,” Cormier says.“Working with HealthTrust, we were able to ensure that we had the proper equipment and standardize it. HealthTrust’s purchasing power helped ensure that we could procure the right equipment promptly.

“Going forward, we were also able to make sure the equipment would be on hand or readily available anywhere it was needed, and that there wasn’t any hoarding at our facilities,” Cormier adds.

Each HCA hospital formed an infectious disease response team to treat patients who may have Ebola.

Screening and Training

Patient screening is the first line of defense in infection prevention. Several years ago, HCA hospitals began asking incoming patients a short set of questions designed to screen for diseases such as flu, meningitis and tuberculosis.

Over time, questions were added to screen for highly infectious exotic diseases such as MERS, SARS and bird flu. Ebola-oriented questions about travel to or contacts with people from West Africa were added to the list last summer, says Julia Moody, director, Infection Prevention, Clinical Services Group at HCA.

The screening takes into account the different incubation times for each disease, with a safety margin. “Patients are not always sure when they traveled somewhere,” Septimus says. “MERS takes less than two weeks to develop, while Ebola can take as long as three weeks. So we allow a generous timeframe to offset errors or uncertainty.”

Standardizing the intake questions ensures patients will be screened and also enables HCA to mine the data in a number of ways beyond just tracking a possible Ebola case, explains Jason Hickok, assistant vice president of Research and Academic Affairs, Infection Prevention and Lab at HCA, whose team developed and manages the software.

On Oct. 20, 2014, warehouse workers at Medline Industries in Mundelein, Illinois, assembled personal protection equipment (PPE) kits, which typically include a hooded body suit, face shield, boot covers, mask, gloves, Epi-clenz hand sanitizer and a biohazard bag. These items can be used by healthcare professionals who are treating patients with the Ebola virus.
On Oct. 20, 2014, warehouse workers at Medline Industries in Mundelein, Illinois, assembled personal protection equipment (PPE) kits, which typically include a hooded body suit, face shield, boot covers, mask, gloves, Epi-clenz hand sanitizer and a biohazard bag. These items can be used by healthcare professionals who are treating patients with the Ebola virus.

“We collect the data in our data warehouse, and we can analyze it in various ways. For example, we can see where flu outbreaks are occurring and how severe they are,” Hickok says. “We’ve validated that our data mirrors the CDC models, but ours is more current. The CDC data has approximately a week-long lag; ours is 48 hours.”

If a patient’s travel history and symptoms indicate a possible Ebola infection, the emergency response team dons protective gear and takes over care.

The patient is isolated and stabilized, and tested for the Ebola virus. If the test is positive, the hospital will care for the patient until he or she can be transported to one of 49 (as of Jan. 15, 2015) facilities the CDC has designated as Ebola treatment centers. This process can take several days, during which time the local hospital must care for the patient.

Proper use of personal protective equipment (PPE) is vital to prevent infection,se, not just Ebola,” Moody adds.

“One thing we learned right away was that many staffers didn’t know how to put on and remove the protective equipment in a way that was 100 percent safe. So we needed to train people how to do that so they didn’t inadvertently contaminate themselves or others.”
—Julia Moody, director, Infection Prevention, Clinical Services Group at HCA

“One thing we learned right away was that many staffers didn’t know how to put on and remove the protective equipment in a way that was 100 percent safe,” Moody says. “So we needed to train people how to do that so they didn’t inadvertently contaminate themselves or others.

“And we used it as a golden opportunity to re-educate everyone in our hospitals, including support staff, on the proper techniques for preventing infection from any kind of disea

The kind of PPE worn by each member of the team depends on how sick patients are and how much exposure a caregiver has to patients and their bodily fluids. “The more direct contact with the patient, the greater the level of protection needed—and the greater the drain on personnel, because the gear can be very fatiguing,” Septimus says.

The robing/disrobing process is very similar to that used by surgical staff, so HCA tapped those resources to assist with training to help the response team members cope with the rigors of using PPE.

The PPE traps body heat and taxes caregivers’ stamina so that they can work for only a few hours. “It’s like a close-fitting cocoon,” Moody says. “You get warm even if you aren’t doing any work. Once you start working, you quickly get very warm—a challenge for staff who may be in with a patient for several hours.

“You’re totally covered, and that changes some basic procedures,” Moody adds. “For instance, if you have a hood over your head, you can’t use a stethoscope, so you have to rely more on technology to evaluate the patient.”

Besides wearing PPE, the protocol for treating Ebola calls for minimizing the amount of potentially contaminated material leaving the isolation unit. This means doing as many tests as possible at the bedside. HCA hospitals use a bedside lab testing technology device called the iStat that performs many of the most common tests without needing to transport samples to a lab.

HCA hospitals also have the company’s emergency management program available. It is designed to support its facilities through all hazards, whether hurricanes, tornadoes, earthquakes or infectious disease outbreak, Cormier says.

When an emergency happens, the appropriate HCA division office serves as an emergency operations center providing support, guidance and resources to the affected facility so staff can focus on patient care. The corporate emergency response team oversees and assists in any way it can, such as expediting delivery of needed supplies.

Watchful Waiting

In early 2015, Ebola was still a concern in parts of West Africa, though it had retreated from most of the region. It now appears to pose less of a threat outside of those areas.

Public health and healthcare officials are using this respite to evaluate their response and fine-tune protocols in anticipation of a future crisis.

But Ebola has a well-established pattern—vicious, unpredictable outbreaks that slowly burn out followed by a period of dormancy—so it’s certain that it will appear again sometime. HCA and HealthTrust stand ready to respond should the need arise.

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