The sudden appearance of Ebola virus disease (EVD, known previously as Ebola hemorrhagic fever) in America in 2014 touched off a nationwide firestorm of activity across all healthcare segments. For areas impacted by the few patients with active disease, there was no time to plan. For the rest of the country, EVD presented as a real-world threat with the relative luxury of at least some time to approach the problem.
In Washington, the state Department of Health (DOH) activated its incident management team (IMT) and opened its agency coordination center at DOH headquarters in early October 2014. Approximately 60 DOH staff from multiple divisions worked under the IMT to prepare to receive and care for patients with, or suspected of having, EVD. After roughly seven weeks the IMT was deactivated, but an EVD work group continued planning and reporting activities.
In its after-action report, DOH identified a number of advantages the EVD experience brought to the agency, including:
Testing existing and developing new plans all across the agency;
Significant hands-on experience using the Incident Command System (ICS) in real time on a real event;
Developing and testing quarantine capabilities, including patient transport and logistical facility support for the first identified need in decades;
Coordinating between headquarters and satellite offices around the state and across all divisions within DOH;
The effectiveness of daily policy briefings;
Effectively engaging executive leadership during an emergency; and
Proof the heavy investment in incident management training in recent years for staff in the DOH Office of Emergency Preparedness and Response (OEPR) resulted in improved performance.
Along with its after-action report, DOH wrote an improvement plan that continues to guide preparedness and response activities across the agency and state. Some key elements include:
Expanding ICS training beyond OEPR staff;
More clearly defining and preparing for DOH's roles during public emergencies;
Identifying key strategies for collaboration with all healthcare sectors;
Developing EMS transport guidelines for highly infectious patients.
Problems and Pressures
As the IMT began its work, it faced a number of problems and distractions. Problems centered around preparing for the possible spread of EVD to Washington. Distractions involved political and societal pressures that were not always supported by science. According to Nathan Weed, deputy chief of response operations for the OEPR, this pressure was largely due to misconceptions about the spread of the disease. "People were more anxious than they perhaps should have been," Weed says.
OEPR emergency preparedness specialist Kevin Wickersham says, "The real emergency here at first was public concern, which became an opportunity to see where we had gaps in our crisis and emergency communications capabilities." An early objective was to counter misinformation and show political leaders and the public that the disease at that time was relatively contained and more difficult to catch than the media may have portrayed.
Another initial problem was creating a structure to combine different programs within DOH that were geographically separated yet needed to contribute from their different areas of focus. Guidelines from different operational groups were influencing other groups without their knowledge or input, leading to confusion.
"Interdependencies were not clear from the start," Weed says. For example, different areas of responsibility, such as the epidemiology lab, EMS and hospitals, all had roles to play against EVD but all also had their own unique guidance for their healthcare professionals. According to Weed, using ICS allowed DOH to collaborate successfully using what he called a "whole agency" response. "ICS allowed issues to be better identified and resolved collaboratively," he says.
The experience led DOH to commit to expanding staff ICS training beyond headquarters OEPR staff to other programs and locations throughout the agency (see sidebar).
Shortages in appropriate personal protective equipment (PPE) rapidly became a cause for concern. DOH used a two-pronged approach to ensure adequate supplies of the correct PPE would be available where and when they were needed. First, PPE needs were determined based on patient presentations. Second, hospitals across the state were divided into tiers based on their anticipated roles.
"Dry" patients are those who may have been exposed or have active disease; they may show fever, sore throat, arthralgia, myalgia, headache and weakness, but no diarrhea and vomiting. As this is a fluid-borne disease and viral load directly correlates to severity of symptoms, it is highly improbable that one would contract EVD by caring for a patient with only dry symptoms. Thus, for those with dry symptoms, standard precautions should be sufficient. Patients with active disease, diarrhea and vomiting are labeled "wet" patients and present a more serious PPE challenge.
OEPR EMS emergency response consultant Michael Smith says, "The standard PPE available for use every day to hospitals and EMS responders was perfectly good for dry patients." He says DOH determined that if staff in hospitals and EMS systems strictly followed universal standard precautions, they would be safe.
"Hospitals have adopted universal precautions and follow them well," Smith says. However, he adds that in general, EMS does not place the same level of emphasis on infection prevention and control as hospitals. "One of the solutions we are looking at is to work with EMS medical directors to add an emphasis on PPE use to annual responder training requirements across the state."
Washington has an inclusive statewide requirement for basic infection control training for licensed healthcare providers, including EMS personnel. Post-EVD, the original HIV/AIDS BBP curriculum was adapted to also include novel and highly infectious diseases.
The potential for caregivers to be exposed is very high with wet patients. "There is a phenomenal level of fluids exchanged around patients with active disease," Wickersham says. Protection from wet patients requires PPE that provides respiratory protection and impermeable protection from fluids. This is the type of PPE that was in short supply as healthcare systems nationwide sought to stock up.
Tiered Hospital Designations
To develop an efficient and coordinated approach to preparing for EVD, DOH followed the CDC's tiered hospital designation system. This reduced the number of hospitals that would need scarce PPE and the associated costs. Hospitals across the state were designated at one of three levels:
Front-line hospital: All hospitals in the state were expected to be able to refer to the "identify, isolate and inform" guidance. They needed to have PPE for at least 24 hours, but the goal was to identify a suspect patient very quickly, isolate them, notify local public health and transfer them to an assessment hospital immediately. Standard PPE readily available and already in use in the hospitals was deemed sufficient protection.
Assessment hospital: Six hospitals around the state were designated to accept symptomatic dry patients from receiving facilities, EMS or self-referral. An assessment hospital was characterized by 96 hours' worth of PPE and capability to assess a patient and perform laboratory testing to rule out EVD while at the same time meeting the clinical needs of the patient.
Treatment center: Three hospitals—Harborview Medical Center and Children's Hospital in Seattle and Providence Sacred Heart in Spokane—were designated to receive and treat patients with confirmed EVD. Treatment centers had the ability to provide full-spectrum care for the full duration of the patient's illness, potentially as long as 4–6 weeks. Furthermore, as the HHS Region X regional treatment center, Harborview also maintained the capability to treat two EVD patients at once in addition to having 10 additional negative-pressure isolation rooms.
"Hospital designations were tied to their ability to manage all emergent needs," Weed says. By adopting a tiered system, Washington was able to speed up the process of making treatment facilities operational. PPE needs were reduced for the same reason.
"The PPE was for special needs. It was not an off-the-shelf product. It had to be manufactured," says Weed. "A key strength of the tiered hospital approach was that we reduced the extraordinary level of time, training and cost to set up and maintain such a high level of PPE. By concentrating the capability in key hospitals, we created a statewide capacity to treat while minimizing the other issues."
Along with the establishment of the tiered hospital system came the problem of how to get patients from one level to the next. An early suggestion for symptomatic dry patients was to have them travel in their own cars to the next level of care. At least one county health officer expressed concern over the risk of them traveling long distances by car. He was concerned that if they were injured in a traffic accident, the responding EMS crew had no way of knowing they may be exposing themselves to EVD and may fail to take proper precautions.
Planners looked to EMS agencies for a possible solution. "Twelve EMS services heard the call and stepped up to fill the need," Wickersham says. Adds Weed: "Planners learned to look for groups willing to do the extra bit of work to solve the problem for everyone else. These agencies were eager to see how we could get through the transport issue and let planners get on to the next threat."
An EMS Ebola transport matrix was developed and distributed that covered the 39 counties and all tribes of the nine public health regions in Washington, along with cross-border transport coverage from Idaho, Oregon and British Columbia, Canada. Transport agencies signed on, and DOH helped ensure each had the proper vehicles, training, PPE and decontamination procedures to ensure everyone's safety.
EMS medical directors developed protocols and procedures to guide how EMS responders in their jurisdictions would respond to and treat a patient showing signs and symptoms of EVD or an Ebola-like disease. Procedures were also shared with E9-1-1 centers.
An operational procedure was developed for activating an Ebola transport unit for patients exhibiting Ebola-like signs and symptoms. An activation request could come from:
A receiving or assessment hospital to transport a patient to the next appropriate level of care;
An EMS agency on scene in a patient's home;
A public safety answering point in lieu of dispatching local EMS resources; or
A county health officer seeing travelers during their 21-day monitoring period.
Which agency responded to transport the patient was determined geographically as well as by the patient's condition. In some areas a single agency would transport any wet or dry patient. In others a local agency might transport a dry patient, but another resource from another county would have to be called for a wet one.
An EMS transport request would begin with a call to the DOH duty officer in Tumwater using a single statewide phone number. Callers would report the patient's location, condition and desired destination, and the duty officer would dispatch the appropriate resource according to the transport matrix. Because the patients would most likely not be presenting initially with life-threatening signs or symptoms, transport units could come from two hours or more away without undue concern for the patient's welfare.
While not used during that period for an EVD patient, protocols, procedures and the transport matrix all remain active and ready for the next time they may be needed.
Solving this issue gave public health and EMS an opportunity to learn more about each other's duties and capabilities. "EMS is a well-oiled machine. You call 9-1-1, and they show up and deal with anything. Public health, as a rule, is not fully aware of all the multifaceted roles EMS plays," says Smith.
One of Wickersham's main duties going into the future is to expand public health/EMS interactions and understanding. "EMS is a key consideration for all preparedness activities at DOH," he says. He hopes to build a culture of close collaboration with EMS and public health at all levels. "I frequently ask others in public health and healthcare, 'Have you included EMS in your plans?'" he says. "Your best plans don't work without them."
EVD served as an important "full-scale exercise" for those in Washington who stepped up to plan but were not directly impacted. Weed says that while DOH activities were centered around the potential threats from EVD, the agency benefited in many more ways.
"As it turned out, we were not just responding to Ebola but testing our ability to handle any novel disease," he says. He notes that infectious diseases seem to be emerging and re-emerging faster than before, and with worldwide travel spreading farther and more easily. For DOH, "This was an opportunity to build or retool our capabilities for rapid-cycle planning, training, equipment acquisition and overall system development for next time."
Ed Mund began his fire and EMS career in 1989. He currently serves with Riverside Fire Authority, an ALS-level fire department in Centralia, WA. His writing and photos have been published in several industry publications. Contact him at firstname.lastname@example.org.