- Email: [email protected]
Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England
Journal of Hospital Infection xxx (2015) 1e8 Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England T.C.S. Martin a, b, *, M.A. Chand a, c, P. Bogue a, A. Aryee a, b, D. Mabey d, S.D. Douthwaite a, S. Reece c, P. Stoller e, N.M. Price a a
Guy’s and St Thomas’ NHS Foundation Trust, London, UK King’s College London, London, UK c Public Health England, London, UK d London School of Hygiene and Tropical Medicine, London, UK e La Jolla Country Day, San Diego, CA, USA b
A R T I C L E
I N F O
Article history: Received 9 March 2015 Accepted 5 April 2015 Available online xxx Keywords: Ebola virus disease Preparedness
S U M M A R Y
Background: The largest outbreak of Ebola virus disease (EVD) is ongoing in West Africa. Air-travel data indicate that outside Africa, the UK is among the countries at greatest risk of importing a case of EVD. Hospitals in England were therefore instructed to prepare for the assessment and early management of suspected cases. However, the response of hospitals across England is undetermined. Aim: To evaluate the readiness of acute hospitals in England, and to describe the challenges experienced in preparing for suspected cases of EVD. Methods: A cross-sectional study using semi-structured telephone interviews and online surveys of all acute National Health Service (NHS) hospital trusts in England (hospital trusts are the vehicle by which one or more NHS hospitals in a geographical area are managed). Findings: In total, 112 hospital trusts completed the survey. All interviewed hospital trusts reported undertaking preparedness activities for suspected cases of EVD, and 97% reported that they were ready to assess suspected cases. Most hospital trusts had considered scenarios in accident & emergency (97%). However, fewer hospital trusts had considered specific obstetric (61%) and paediatric scenarios (79%), the provision of ventilatory and renal support (75%), or resuscitation in the event of cardiorespiratory arrest (56%). Thirty-four hospital trusts reported issues with timely access to category A couriers for sample transportation. Challenges included the choice, use and procurement of personal protective equipment (71%), national guidance interpretation (62%) and resource allocation/management support (38%).
* Corresponding author. Address: Department of Infection, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK. Tel.: þ44 (0) 20 7188 7188. E-mail addresses: [email protected], [email protected] (T.C.S. Martin). http://dx.doi.org/10.1016/j.jhin.2015.04.021 0195-6701/ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Martin TCS, et al., Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.04.021
2
T.C.S. Martin et al. / Journal of Hospital Infection xxx (2015) 1e8 Conclusion: English hospital trusts have engaged well with EVD preparedness. Although subsequent national guidance has addressed some issues identified in this study, there remains further scope for improvement, particularly in a practical direction, for acute care services encountering suspected cases of EVD. ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction
Methods
The ongoing outbreak of Ebola virus disease (EVD) in West Africa is unprecedented. To date, over 10,000 deaths and in excess of 26,000 confirmed, probable and suspected cases have been reported.1 Consistent with previous outbreaks of EVD, the case fatality rate during this outbreak is estimated at 70%.2e4 In total, 24 cases have been confirmed outside West Africa.5 Of these, 18 were medical evacuations including a single case to the UK. The remaining six cases were diagnosed outside Africa: two returning travellers to the USA, one returning traveller to the UK, and three incidents of secondary transmission to healthcare workers (one in Spain and two in the USA).6 Although the overall risk of unintentionally importing a case is low, analysis of air-travel data suggests that outside Africa, the UK is among the countries at greatest risk of importing a case of EVD, possibly due to its position as an international travel hub.7e9 The risk may be further augmented by UK humanitarian workers returning from affected areas, as illustrated by recent cases in the UK, and the large number of West African communities originally from affected countries living in the UK but travelling frequently to epidemic zones. As a consequence, on 2nd July 2014, the Chief Medical Officer and Public Health England (PHE), a governmentassociated body responsible for protecting and improving the public’s health, advised all acute National Health Service (NHS) hospitals in England through the central alerting system to prepare for suspected cases of EVD. Hospitals were advised to implement existing guidance on the management of viral haemorrhagic fevers as published by the UK Department of Health’s expert scientific committee on dangerous pathogens, the Advisory Committee on Dangerous Pathogens (ACDP).10e13 On 15th August 2015, PHE also published a patient pathway algorithm to facilitate the early identification, isolation, risk assessment and investigation of suspected cases of EVD.11 As highlighted by the substantial number of healthcare workers infected during the outbreak, patient care requires meticulous training in the safe use of personal protective equipment (PPE) and observation of strict infection control procedures. However, the isolation and management of suspected cases should cause minimal disruption to the provision of normal clinical services. National exercises in October 2014 tested EVD preparedness at two hospitals in London and Newcastle, including a simulated transfer to the High Level Isolation Unit (HLIU) at the Royal Free Hospital in London; however, the response among other NHS hospitals in England is unknown. Therefore, this study was undertaken to evaluate the progress made by English hospitals in preparing for suspected cases of EVD, and to identify any challenges and obstacles.
A cross-sectional study was undertaken of all NHS acute hospital trusts in England with access points for suspected cases of EVD including: accident & emergency (A&E), acute admitting general medicine, paediatric or obstetric services (NHS hospitals in England are managed by hospital trusts, which represent one or more hospitals in a geographical area). Data collection was undertaken in the form of a semi-structured telephone interview with the hospital trust Ebola preparedness lead. Interviews were recorded, if permission was granted, to ensure factual accuracy. An online survey was offered as an alternative in the event that the hospital trust Ebola preparedness lead could not be contacted or the interview was declined.
Assessment of preparedness Measures of preparedness were derived from the ACDP guidance (September 2014, Version 4) on the management of viral haemorrhagic fevers, PHE guidance for acute hospitals, and the authors’ local experience.10,11 Questions were designed to cover a range of realistic clinical scenarios at initial presentation, and assess aspects of the patient pathway thereafter. Hospital trust EVD leads were asked to assess their preparedness on a scale of 1e5 (1 ¼ poorly prepared, 5 ¼ well prepared), and to estimate the number of patients assessed for suspected EVD to date.
Description of challenges Interviewees were asked open-ended questions about internal and external challenges experienced in preparing for suspected cases of EVD. If the information was not volunteered spontaneously, interviewees were prompted to comment specifically on any difficulties experienced in choice and procurement of PPE, working with contracted services (e.g. waste/sewage, laundry, transport, couriers, ambulances), laboratory processing and procedures, senior management support, resource allocation, and interpretation and implementation of existing national guidance.
Additional data Data concerning the number and location of cases referred for EVD detection were requested from the Rare and Imported Pathogens Laboratory (RIPL), PHE Porton Down, Salisbury, UK.
Analysis Where hospital trusts had only partially completed a category of preparedness, the outcome recorded was decided through discussion between two of the study investigators.
Please cite this article in press as: Martin TCS, et al., Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.04.021
T.C.S. Martin et al. / Journal of Hospital Infection xxx (2015) 1e8
3
tested their preparedness with ‘table-top’ or simulation exercises. Substantial variation existed regarding the provision of ventilatory or renal support for suspected cases: 20% of the hospital trusts reported that these would be offered, 23% reported that they would not be offered, and 47% reported that they would offer such support on a case-by-case basis. Most of the hospital trusts (97%) were using higher-level PPE for the initial patient assessment than was recommended at the time in the ACDP guidance for patients at risk (September 2014 version). Finally, over one-third (35%) of the hospital trusts did not believe that they could arrange for a category A sample courier for sample transportation within 2 h. On a scale of 1e5 (1 ¼ poorly prepared, 5 ¼ well prepared), 107 (97%) hospital trusts rated themselves as 3 (mean 3.6, 95% confidence interval 3.5e3.7) on their ability to safely assess, investigate and manage a suspected case of EVD.
Case assessments to date
Figure 1. Distribution of hospital trusts included in the study by region in England. Number indicated by circle size and number within circle. Location of Public Health England laboratory is provided to demonstrate the relative distance for sample transport for hospital trusts included in the study.
Data were anonymized prior to analysis. A descriptive analysis of challenges faced during preparedness activities was undertaken, with outcomes recorded under defined themes.
Results In total, 150 NHS acute hospital trusts across England were contacted, and 112 responses (75%) were received between 31st October and 16th November 2014. Responsibility for preparation varied across hospital trusts including directors of infection prevention and control (IPC); senior IPC nurses; infection physicians; and emergency preparedness, resilience and response leads. Figure 1 shows the distribution of participating hospital trusts across England. Ninety-nine hospital trusts completed telephone interviews, with the remainder completing the online survey. Three hospital trusts declined to participate; among the remaining 35 hospital trusts, it was not possible to contact the responsible person, or they did not complete the online survey when offered.
Preparedness activities All of the hospital trusts that responded reported that they had prepared for suspected cases of EVD related to the current outbreak. The breakdown of preparedness activities undertaken is shown in Table I. Most of the hospital trusts had considered detailed clinical scenarios involving A&E (97%), but fewer had considered obstetric (61%) or paediatric service (79%) scenarios. Over half (55%) of the hospital trusts had
Seventy-nine hospital trusts (71%) reported that they had assessed at least one suspected case of EVD during 2014. In total, 268 patients had been assessed, of which 64 (24%) were referred to RIPL for Ebola virus detection. The remaining cases were de-escalated without the need for sample processing. Data from RIPL showed that by the end of November 2014, 90 cases across England had been referred for Ebola virus detection. Figure 2 shows the number and distribution of cases referred to RIPL for Ebola virus detection.
Challenges in preparing for suspected cases of EVD Almost all hospital trusts (96%) reported at least one challenge in preparing for suspected cases of EVD; the most common are shown in Table II. Issues with PPE were the most frequently encountered challenges. Many hospital trusts reported that frontline clinical staff preferred to use higher levels of PPE to assess suspected cases and then to de-escalate according to the risk assessment, rather than the escalation approach advised by the September 2014 version of the ACDP guidelines (allowance for this has been made in the updated and simplified November 2014 ACDP guidance). Many hospital trusts also expressed the need for a centrally approved list of PPE providers to facilitate procurement. Almost half of the hospital trusts reported that guidance was not sufficiently practical on a range of issues, particularly regarding the correct usage of PPE. Other concerns included the potential for malaria and EVD co-infection, leading to inappropriate early de-escalation of patients with a positive malarial film (this has also been addressed in the updated November 2014 ACDP guidance). Finally, over one-quarter of the hospital trusts reported inadequate allocation of staff time or resources for preparedness; some felt that the burden on IPC teams was excessive, and to the detriment of their other duties.
Discussion This study investigated preparations for suspected cases of EVD undertaken by NHS acute hospital trusts in England. The results represent a snapshot of preparedness four months after the Chief Medical Officer issued instructions to make preparations for suspected cases of EVD, and three months after the
Please cite this article in press as: Martin TCS, et al., Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.04.021
4
T.C.S. Martin et al. / Journal of Hospital Infection xxx (2015) 1e8
Table I Specific preparations undertaken by acute National Health Service hospital trusts in England for the assessment of suspected cases of Ebola virus disease (EVD) Measure
Number of hospital Percentage of hospital trusts responding trusts undertaking activity
Senior infection prevention and control and/or board meetings regarding preparedness Generation of new and/or updated local viral haemorrhagic fever guidelines Consideration given to detailed clinical scenarios in the following settings 1. A&E 2. Waste/laundry/spillage 3. Critical care case 4. Paediatric case 5. General medical ward case 6. Obstetric case 7. Case presenting to outpatient setting 8. Elective admission case Detailed consideration of suspected case management 1. Implementation of an appropriate treatment ‘ceiling’ 2. Actions in the event of cardiorespiratory arrest 3. Provision of ventilatory or renal support a. Would be offered b. Would not be offered c. Offered on a case-by-case basis d. Undecided Generation of new or modification of existing PPE protocols Staff PPE training undertaken Staff PPE training undertaken by department: 1. A&E 2. General medicine 3. Critical care 4. Paediatrics 5. Obstetrics 6. Facilities Locally defined PPE for use when performing invasive procedures (e.g. central line insertion) Defined PPE for use in obstetric emergencies Local PPE standard considered to exceed ACDP guidelines (September 2014) PPE used for ‘staff at risk’ (exposure to individual with fever >38 C and contact or possible contact with viral haemorrhagic fever 1. Gloves, plastic apron, surgical facemask, eye protection 2. Double gloves, fluid-repellant disposable gown/suit, eye protection, FFP3 respirator 3. As per (2) plus head covering and/or boots/shoes 4. Double gloves, fluid-repellant gown/suit, plastic apron, eye protection, FFP3 respirator 5. As per (4) plus any of head covering/neck covering/boots/shoes or PPE in excess of this Laboratory procedures/protocols updated Verification that category A courier will transport EVD samples Access to category A sample couriers in under 2 h ‘Table-top’ exercise or real-time simulation Created dedicated specialist team(s) for assessment and management of suspected cases
112
98
111 112
90 97 96 87 79 66 61 42 32
109 112 110
112 111
56 56 75 20 23 47 10 95 92
110
92 60 54 32 24 17 59
103 107
43 97
3 9 23 8 56 112 102 97 110 111
79 89 65 55 40
A&E, accident and emergency; PPE, personal protective equipment; ACDP, Advisory Committee on Dangerous Pathogens.
World Health Organization declared the outbreak as a public health emergency of international concern.13,14 The excellent response rate to this survey (75%) and the geographical distribution of the participating hospital trusts provide a representative picture of the general state of national readiness.
Overall, there was an excellent level of awareness and engagement, with all hospital trusts reporting that they had undertaken preparations for suspected cases of EVD. At the time of interview, 97% of the hospital trusts reported that they were ready to safely assess a suspected case. The vast majority
Please cite this article in press as: Martin TCS, et al., Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.04.021
T.C.S. Martin et al. / Journal of Hospital Infection xxx (2015) 1e8
Figure 2. Distribution of cases referred to the Rare and Imported Pathogens Laboratory for Ebola virus detection up to 30th November 2014. Circle size represents number of patients investigated (total referred ¼ 90).
of the hospital trusts had considered detailed clinical scenarios involving A&E, and provided PPE training to relevant personnel. Over half of the hospital trusts had tested their preparedness with real-time mock simulations or ‘table-top’ exercises.
5
Nevertheless, the overall picture was not without challenges and was not to the complete satisfaction of staff. Many of the challenges faced in preparing for cases of EVD relate to the uncertainty of diagnosis at the time of assessment. The vast majority of suspected cases will have an alternate diagnosis, such as malaria or influenza, and clinicians will want to ensure that patients are still treated in a timely and appropriate way. However, before test results are available, the possibility of EVD may cause patients and staff significant anxiety, further exacerbated by the likelihood of intense media attention and the risk of significant disruption to other clinical services. Practical guidance needs to address the major issue facing most hospitals, which is how to manage a suspected case before a test result is available. Some practical measures implemented locally by the authors are outlined in Table III. Almost all hospital trusts reported that they had prioritized staff training in A&E, where most suspected cases of EVD are likely to be encountered. While most patients may be managed effectively in A&E, this may prove difficult if it takes over 12 h for a diagnostic test to be performed, or if formal inpatient admission and specialist input is required. In such circumstances, it may be preferable to designate a suitable isolation room on a general medical ward to provide care pending diagnostic confirmation. Care can be provided by specific teams trained for patient assessment and management, thus reducing the burden of training and skill maintenance; this was instigated by almost half of the hospital trusts. To avoid the risks associated with transferring the patient and/or interference with unrelated services, mobile teams from key clinical specialties (e.g. general medicine, critical care, obstetrics and paediatrics) could attend the patient in this location. Hospitals should aim to be capable of providing continuous care for a 24h period, which should permit a diagnosis of EVD to be confirmed or excluded in most cases. The risk to staff from a patient with an uncertain diagnosis can be reduced through ensuring access to rapid EVD
Table II Challenges encountered by acute National Health Service hospital trusts in England in preparing for suspected cases of Ebola virus disease Category (% of hospital trusts)
PPE (71%)
Guidance (62%)
Staff concerns (60%) Staff time and resource issues (38%)
Hospital infrastructure (24%) Contracted services (23%) Laboratory (13%)
Response breakdown (% of hospital trusts)
Guidance on PPE was insufficient (43%) Procurement difficulties (34%) Guidance on PPE varied between authorities (PHE, CDC, WHO) (25%) Insufficiently practical (27%) General guidance differing between authorities (CDC, PHE, WHO) (20%) Algorithm for management of cases was too complicated (10%) Staff anxiety over PPE usage and protection (54%) Media coverage leading to unrealistic staff expectations (16%) Staff-time allocation for preparedness activities issues was insufficient (28%) Resource allocation/cost issues (19%) Lack of adequate rooms for suspected case management (19%) Cleaning services did not agree to hospital preparedness plans (12%) Difficulty processing samples from suspected cases (7%) Time for relay of results from PHE laboratory (5%)
PPE, personal protective equipment; PHE, Public Health England; CDC, US Centers for Disease Control and Prevention; WHO, World Health Organization. Please cite this article in press as: Martin TCS, et al., Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.04.021
Requirement
Staff information and support
Case identification
Minimize risk and disruption from suspected cases of EVD
PPE training and usage
Ensure access to rapid diagnostic tests and other pathology tests Escalation of care decisions Assess preparedness
Actions
Comment
Provide regular face-to-face briefings and e-mail bulletins, plus regularly updated ‘frequently asked questions’. Keep all policies, information, clinical guidance and video versions of briefings on a dedicated Ebola webpage on the hospital intranet Provide all reception areas with cue cards with risk-factor screening questions and actions to take if a person at risk is identified Conduct simple audits to confirm active screening is being undertaken
Do not rely exclusively on e-mail cascades to disseminate information
Instigate occupational health policy for healthcare workers who have travelled to affected countries Reschedule non-urgent, elective admissions for patients who have returned from an outbreak country within 21 days. Provide information for patients if elective admission is delayed Identify and equip a dedicated isolation cubicle in A&E and also on the medical wards for suspected cases of EVD. Involve estate departments early to ensure adequate development of facilities. Plan patient transfer from A&E to the inpatient bed in advance to minimize exposure risk Plan to provide specialty input through mobile teams to minimize patient movement around hospitals Ensure adequate supplies of PPE and deliver face-to-face training. Ensure A&E trained first and then roll out to general medicine, critical care, obstetrics and paediatrics Use checklists to ensure correct donning and doffing procedures are followed, and display these outside isolation rooms Ensure there is a competent PPE trainer on site 24 h/day Each clinical department should have a nominated ‘Ebola lead’ who has responsibility for ensuring that a rota of trained staff is available and for disseminating important information Agree a timeframe for sample collection with courier providers Audit response times during exercises Ensure local laboratories are prepared for sending away diagnostic samples and to process other samples from suspected cases as directed by the ACDP guidelines Agree a formal process by which decisions regarding escalation of care will be made. The agreed process should have formal support from senior hospital managers Introduce programme of unannounced clinical simulations starting with A&E
If a positive screen is encountered, ensure family members and individuals accompanying the patient are also screened Periodic ‘walk-about’ is a highly effective method of gauging compliance Guidance is available from PHE for the management of returning healthcare workers16 Outpatient visits and non-invasive investigations can continue if patient is asymptomatic
If possible, enable higher-level support interventions to be performed in the dedicated isolation room (e.g. portable ventilator) The use of dedicated teams may reduce the number of staff that require training Use locally or nationally produced videos to support PPE training
Leads are responsible for submitting formal preparedness reports to provide board-level assurance Additional laboratories for EVD testing are expected to reduce sample transport times
Decisions regarding escalation should involve senior physician, critical care consultant, hospital management and experts from the high-level isolation unit and/or the Imported Fever Service (see text) Emphasis should be on assessing processes, not staff. Consider using approved checklists (e.g. CDC, WHO) to ensure all appropriate actions are taken
Introduce debriefing meetings after suspected cases have been dealt with to identify areas for improvement A&E, accident and emergency; PPE, personal protective equipment; PHE, Public Health England; ACDP, Advisory Committee on Dangerous Pathogens; CDC, US Centers for Disease Control and Prevention; WHO, World Health Organization.
T.C.S. Martin et al. / Journal of Hospital Infection xxx (2015) 1e8
Minimize contact with individuals at risk of EVD
6
Please cite this article in press as: Martin TCS, et al., Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.04.021
Table III Practical measures adopted locally by study authors in preparing for suspected cases of Ebola virus disease (EVD)
T.C.S. Martin et al. / Journal of Hospital Infection xxx (2015) 1e8 diagnostics. As a viable virus capable of causing lifethreatening disease, Ebola is a category A pathogen, meaning that transportation can only be provided by couriers complying with national road transport regulations. It was therefore of concern that over one-third of the hospital trusts did not believe that they had timely access to category A sample couriers. This was further exacerbated by the fact that, at the time, there was only one designated national testing facility (PHE Porton Down; see Figure 1 for location relative to hospital trusts), with an estimated turnaround time of 8e12 h at present. Access to more rapid diagnostics is highly desirable to allow either resumption of ‘normal clinical services’ in the case of a negative result, or transfer to the HLIU in the case of a positive result. The subsequent decisions by PHE to introduce further testing centres in more convenient locations, and to improve the availability of nationally arranged couriers are therefore extremely welcome. Laboratory tests within hospitals may also be delayed due to difficulties working with highrisk samples, as reported by almost 10% of the hospital trusts. Highlighted issues included: analysers are not a closed system, training of laboratory staff had not been completed, time delays with transport of samples to a centralized laboratory, and protracted fee negotiations with couriers. Up to three-quarters of the hospital trusts reported that they had discussed the escalation of care for deteriorating patients with suspected EVD. Expert opinion regarding the management of a deteriorating patient with confirmed EVD has been published; however, this is not the situation confronted by the vast majority of physicians managing individuals while confirmatory test results are pending.15 In reality, decisions will be made on a case-by-case basis in conjunction with national centres of expertise, such as the HLIU and the Imported Fever Service (an expert clinical advisory and diagnostic service provided by PHE for medical professionals managing patients who have returned to the UK with a fever). While it is impossible to devise a plan for every scenario, it may be useful to agree a formal decision-making algorithm that could assist clinical staff confronted by difficult management choices. One approach might involve telephone agreement between the offsite experts, the responsible senior clinician and critical care consultant, with endorsement by senior managers. Endorsement by senior hospital management is important because clinicians will naturally be troubled about the risk of undertreating patients due to safety considerations while uncertainty exists regarding the diagnosis. Most hospital trusts cited the choice, use and procurement of PPE as the greatest challenge faced during preparations, with many concerns voiced about national guidance. At the time of the study, 97% of the hospital trusts reported using PPE in excess of that recommended in the ACDP guidance. Hospital trusts frequently cited the anxiety of frontline staff regarding the transmission risk of EVD, media-driven hysteria and inconsistency of guidance with other national bodies as drivers towards using higher-level PPE. In the face of the emerging threat, national and international agencies updated their viral haemorrhagic fever guidance at various points, often with advice that was conflicting between agencies, most notably around PPE practice. The authors found that this created local difficulties in ensuring that involved teams received a single consistent message, and retained confidence in the procedures in which they had been trained. This was addressed locally by devising a PPE strategy that anticipated and addressed the
7
majority of local concerns, and a clear communication strategy, often during face-to-face PPE training, to explain the rationale where this was at variance with published guidance. These difficulties could possibly be avoided through national guidance placing greater emphasis on the evidence base underpinning current recommendations, and particularly an explanation of risks vs benefits where UK recommendations diverge from those issued by other reputable authorities (e.g. the World Health Organization or the US Centers for Disease Control and Prevention). More explicit guidance on what level of PPE is appropriate for specific interventions on suspected cases (e.g. central venous line insertion) should also be considered. Future guidance should ensure that practical aspects are unambiguous. For example, the updated ACDP guidance states that total skin coverage is desirable, but concurrently refers to the use of ‘surgical caps’ that will not achieve this requirement for the neck area. Finally, procurement of PPE remains an issue, and a central system of coordinating supply, or at least a list of approved suppliers, would be welcomed. At present, each hospital trust has done this independently in an uncoordinated and often time-inefficient manner as stock has become depleted. This study had a number of limitations. Data collected may include recall bias of those interviewed, and selection bias as non-responding hospital trusts may have been less well prepared. This study focused solely on acute care hospitals, but the authors recognize that a true assessment of national preparedness would include primary care. Due to time limitations inherent in structured interviews, the authors were unable to address a number of important issues in depth, including the development of triage services, hospital and community decontamination services, protocols for environmental contamination, use of information leaflets for staff education, clinical waste management, endoscope decontamination, laboratory personnel PPE, laboratory equipment decontamination, and sample tracing protocols. While these issues were not addressed directly, interviewees were prompted in general fields that would cover these issues during the open questions regarding preparedness. English hospitals are often required to respond to emerging infections with a range of clinical and epidemiological features. The results of this study will support local and national preparations for future epidemics, and the development of improved permanent and event-related guidance. Hospitals should ensure that they consolidate the generic skills attained during this outbreak, and that the facilities made available, such as isolation rooms and improved courier services, are maintained for future use. Through these actions, the resources invested in preparing for Ebola can contribute to a permanent improvement in the ability of health services to respond rapidly to emerging infectious threats.
Acknowledgements The authors wish to thank all the individuals who took part in this study, and RIPL, PHE Porton Down for providing national data on EVD samples. Conflict of interest statement None declared.
Please cite this article in press as: Martin TCS, et al., Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.04.021
8
T.C.S. Martin et al. / Journal of Hospital Infection xxx (2015) 1e8 Funding source TM received funding from the National Institute of Health Research.
References 1. World Health Organization. Ebola response roadmap situation report update. Geneva: WHO; 2014. Available at: http://www. who.int/csr/disease/ebola/situation-reports/en/ [last accessed April 2015]. 2. Kucharski AJ, Edmunds WJ. Case fatality rate for Ebola virus disease in West Africa. Lancet 2014;384:1260. 3. Schieffelin JS, Shaffer JG, Goba A, et al. Clinical illness and outcomes in patients with Ebola in Sierra Leone. N Engl J Med 2014;371:2092e2100. 4. WHO Ebola Response Team. Ebola virus disease in West Africa d the first 9 months of the epidemic and forward projections. N Engl J Med 2014;371:1481e1495. 5. Public Health England. Ebola epidemiological update No. 17: 9 January 2015. London: PHE; 2015. 6. Centers for Disease Control and Prevention. Cases of Ebola diagnosed in the United States. Atlanta, GA: CDC; 2014. Available at: http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/ united-states-imported-case.html [last accessed May 2015]. 7. Gomes M, Pastorey y Piontti A, Rossi L, et al. Assessing the international spreading risk associated with the 2014 West African Ebola outbreak. PLOS Curr 2014; September 2;6. 8. Bogoch II, Creatore MI, Cetron MS, et al. Assessment of the potential for international dissemination of Ebola virus via commercial air travel during the 2014 West African outbreak. Lancet 2015;385:29e35.
9. Public Health England. Risk assessment of the Ebola outbreak in West Africa: 20 October 2014. Report No. 2014384. London: Department of Health; 2014. 10. Advisory Committee on Dangerous Pathogens, Department of Health. Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence. London: Department of Health; 2014. Available at: https://www.gov.uk/ government/publications/viral-haemorrhagic-fever-algorithm-andguidance-on-management-of-patients [last accessed September 2014]. 11. Public Health England. Summary guidance for acute trust staff: identifying and managing patients who require assessment for Ebola virus disease. London: PHE; 2014. Available at: https://www.gov. uk/government/publications/ebola-virus-disease-identifying-andmanaging-patients-for-assessment-in-acute-trusts [last accessed October 2014]. 12. Chief Medical Officer. Ebola outbreak in West Africa. London: Department of Health; 2014. Available at: https://www.cas.dh. gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID¼102228 [last accessed October 2014]. 13. Public Health England. Ebola outbreak in West Africa. London: Department of Health; 2014. Available at: https://www.cas.dh. gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID¼102185 [last accessed July 2014]. 14. World Health Organization. Statement on the 1st meeting of the IHR Emergency Committee on the 2014 Ebola outbreak in West Africa. Geneva: WHO; 2014. 15. Jacobs M, Beadsworth M, Schmid M, Tubridge A. Provision of care for Ebola. Lancet 2014;384:2105e2106. 16. Public Health England. Ebola: information for humanitarian aid and other workers intending to work in Ebola affected countries in West Africa. London: PHE; 2015.
Please cite this article in press as: Martin TCS, et al., Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.04.021
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England T.C.S. Martin a, b, *, M.A. Chand a, c, P. Bogue a, A. Aryee a, b, D. Mabey d, S.D. Douthwaite a, S. Reece c, P. Stoller e, N.M. Price a a
Guy’s and St Thomas’ NHS Foundation Trust, London, UK King’s College London, London, UK c Public Health England, London, UK d London School of Hygiene and Tropical Medicine, London, UK e La Jolla Country Day, San Diego, CA, USA b
A R T I C L E
I N F O
Article history: Received 9 March 2015 Accepted 5 April 2015 Available online xxx Keywords: Ebola virus disease Preparedness
S U M M A R Y
Background: The largest outbreak of Ebola virus disease (EVD) is ongoing in West Africa. Air-travel data indicate that outside Africa, the UK is among the countries at greatest risk of importing a case of EVD. Hospitals in England were therefore instructed to prepare for the assessment and early management of suspected cases. However, the response of hospitals across England is undetermined. Aim: To evaluate the readiness of acute hospitals in England, and to describe the challenges experienced in preparing for suspected cases of EVD. Methods: A cross-sectional study using semi-structured telephone interviews and online surveys of all acute National Health Service (NHS) hospital trusts in England (hospital trusts are the vehicle by which one or more NHS hospitals in a geographical area are managed). Findings: In total, 112 hospital trusts completed the survey. All interviewed hospital trusts reported undertaking preparedness activities for suspected cases of EVD, and 97% reported that they were ready to assess suspected cases. Most hospital trusts had considered scenarios in accident & emergency (97%). However, fewer hospital trusts had considered specific obstetric (61%) and paediatric scenarios (79%), the provision of ventilatory and renal support (75%), or resuscitation in the event of cardiorespiratory arrest (56%). Thirty-four hospital trusts reported issues with timely access to category A couriers for sample transportation. Challenges included the choice, use and procurement of personal protective equipment (71%), national guidance interpretation (62%) and resource allocation/management support (38%).
* Corresponding author. Address: Department of Infection, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK. Tel.: þ44 (0) 20 7188 7188. E-mail addresses: [email protected], [email protected] (T.C.S. Martin). http://dx.doi.org/10.1016/j.jhin.2015.04.021 0195-6701/ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Martin TCS, et al., Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.04.021
2
T.C.S. Martin et al. / Journal of Hospital Infection xxx (2015) 1e8 Conclusion: English hospital trusts have engaged well with EVD preparedness. Although subsequent national guidance has addressed some issues identified in this study, there remains further scope for improvement, particularly in a practical direction, for acute care services encountering suspected cases of EVD. ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction
Methods
The ongoing outbreak of Ebola virus disease (EVD) in West Africa is unprecedented. To date, over 10,000 deaths and in excess of 26,000 confirmed, probable and suspected cases have been reported.1 Consistent with previous outbreaks of EVD, the case fatality rate during this outbreak is estimated at 70%.2e4 In total, 24 cases have been confirmed outside West Africa.5 Of these, 18 were medical evacuations including a single case to the UK. The remaining six cases were diagnosed outside Africa: two returning travellers to the USA, one returning traveller to the UK, and three incidents of secondary transmission to healthcare workers (one in Spain and two in the USA).6 Although the overall risk of unintentionally importing a case is low, analysis of air-travel data suggests that outside Africa, the UK is among the countries at greatest risk of importing a case of EVD, possibly due to its position as an international travel hub.7e9 The risk may be further augmented by UK humanitarian workers returning from affected areas, as illustrated by recent cases in the UK, and the large number of West African communities originally from affected countries living in the UK but travelling frequently to epidemic zones. As a consequence, on 2nd July 2014, the Chief Medical Officer and Public Health England (PHE), a governmentassociated body responsible for protecting and improving the public’s health, advised all acute National Health Service (NHS) hospitals in England through the central alerting system to prepare for suspected cases of EVD. Hospitals were advised to implement existing guidance on the management of viral haemorrhagic fevers as published by the UK Department of Health’s expert scientific committee on dangerous pathogens, the Advisory Committee on Dangerous Pathogens (ACDP).10e13 On 15th August 2015, PHE also published a patient pathway algorithm to facilitate the early identification, isolation, risk assessment and investigation of suspected cases of EVD.11 As highlighted by the substantial number of healthcare workers infected during the outbreak, patient care requires meticulous training in the safe use of personal protective equipment (PPE) and observation of strict infection control procedures. However, the isolation and management of suspected cases should cause minimal disruption to the provision of normal clinical services. National exercises in October 2014 tested EVD preparedness at two hospitals in London and Newcastle, including a simulated transfer to the High Level Isolation Unit (HLIU) at the Royal Free Hospital in London; however, the response among other NHS hospitals in England is unknown. Therefore, this study was undertaken to evaluate the progress made by English hospitals in preparing for suspected cases of EVD, and to identify any challenges and obstacles.
A cross-sectional study was undertaken of all NHS acute hospital trusts in England with access points for suspected cases of EVD including: accident & emergency (A&E), acute admitting general medicine, paediatric or obstetric services (NHS hospitals in England are managed by hospital trusts, which represent one or more hospitals in a geographical area). Data collection was undertaken in the form of a semi-structured telephone interview with the hospital trust Ebola preparedness lead. Interviews were recorded, if permission was granted, to ensure factual accuracy. An online survey was offered as an alternative in the event that the hospital trust Ebola preparedness lead could not be contacted or the interview was declined.
Assessment of preparedness Measures of preparedness were derived from the ACDP guidance (September 2014, Version 4) on the management of viral haemorrhagic fevers, PHE guidance for acute hospitals, and the authors’ local experience.10,11 Questions were designed to cover a range of realistic clinical scenarios at initial presentation, and assess aspects of the patient pathway thereafter. Hospital trust EVD leads were asked to assess their preparedness on a scale of 1e5 (1 ¼ poorly prepared, 5 ¼ well prepared), and to estimate the number of patients assessed for suspected EVD to date.
Description of challenges Interviewees were asked open-ended questions about internal and external challenges experienced in preparing for suspected cases of EVD. If the information was not volunteered spontaneously, interviewees were prompted to comment specifically on any difficulties experienced in choice and procurement of PPE, working with contracted services (e.g. waste/sewage, laundry, transport, couriers, ambulances), laboratory processing and procedures, senior management support, resource allocation, and interpretation and implementation of existing national guidance.
Additional data Data concerning the number and location of cases referred for EVD detection were requested from the Rare and Imported Pathogens Laboratory (RIPL), PHE Porton Down, Salisbury, UK.
Analysis Where hospital trusts had only partially completed a category of preparedness, the outcome recorded was decided through discussion between two of the study investigators.
Please cite this article in press as: Martin TCS, et al., Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.04.021
T.C.S. Martin et al. / Journal of Hospital Infection xxx (2015) 1e8
3
tested their preparedness with ‘table-top’ or simulation exercises. Substantial variation existed regarding the provision of ventilatory or renal support for suspected cases: 20% of the hospital trusts reported that these would be offered, 23% reported that they would not be offered, and 47% reported that they would offer such support on a case-by-case basis. Most of the hospital trusts (97%) were using higher-level PPE for the initial patient assessment than was recommended at the time in the ACDP guidance for patients at risk (September 2014 version). Finally, over one-third (35%) of the hospital trusts did not believe that they could arrange for a category A sample courier for sample transportation within 2 h. On a scale of 1e5 (1 ¼ poorly prepared, 5 ¼ well prepared), 107 (97%) hospital trusts rated themselves as 3 (mean 3.6, 95% confidence interval 3.5e3.7) on their ability to safely assess, investigate and manage a suspected case of EVD.
Case assessments to date
Figure 1. Distribution of hospital trusts included in the study by region in England. Number indicated by circle size and number within circle. Location of Public Health England laboratory is provided to demonstrate the relative distance for sample transport for hospital trusts included in the study.
Data were anonymized prior to analysis. A descriptive analysis of challenges faced during preparedness activities was undertaken, with outcomes recorded under defined themes.
Results In total, 150 NHS acute hospital trusts across England were contacted, and 112 responses (75%) were received between 31st October and 16th November 2014. Responsibility for preparation varied across hospital trusts including directors of infection prevention and control (IPC); senior IPC nurses; infection physicians; and emergency preparedness, resilience and response leads. Figure 1 shows the distribution of participating hospital trusts across England. Ninety-nine hospital trusts completed telephone interviews, with the remainder completing the online survey. Three hospital trusts declined to participate; among the remaining 35 hospital trusts, it was not possible to contact the responsible person, or they did not complete the online survey when offered.
Preparedness activities All of the hospital trusts that responded reported that they had prepared for suspected cases of EVD related to the current outbreak. The breakdown of preparedness activities undertaken is shown in Table I. Most of the hospital trusts had considered detailed clinical scenarios involving A&E (97%), but fewer had considered obstetric (61%) or paediatric service (79%) scenarios. Over half (55%) of the hospital trusts had
Seventy-nine hospital trusts (71%) reported that they had assessed at least one suspected case of EVD during 2014. In total, 268 patients had been assessed, of which 64 (24%) were referred to RIPL for Ebola virus detection. The remaining cases were de-escalated without the need for sample processing. Data from RIPL showed that by the end of November 2014, 90 cases across England had been referred for Ebola virus detection. Figure 2 shows the number and distribution of cases referred to RIPL for Ebola virus detection.
Challenges in preparing for suspected cases of EVD Almost all hospital trusts (96%) reported at least one challenge in preparing for suspected cases of EVD; the most common are shown in Table II. Issues with PPE were the most frequently encountered challenges. Many hospital trusts reported that frontline clinical staff preferred to use higher levels of PPE to assess suspected cases and then to de-escalate according to the risk assessment, rather than the escalation approach advised by the September 2014 version of the ACDP guidelines (allowance for this has been made in the updated and simplified November 2014 ACDP guidance). Many hospital trusts also expressed the need for a centrally approved list of PPE providers to facilitate procurement. Almost half of the hospital trusts reported that guidance was not sufficiently practical on a range of issues, particularly regarding the correct usage of PPE. Other concerns included the potential for malaria and EVD co-infection, leading to inappropriate early de-escalation of patients with a positive malarial film (this has also been addressed in the updated November 2014 ACDP guidance). Finally, over one-quarter of the hospital trusts reported inadequate allocation of staff time or resources for preparedness; some felt that the burden on IPC teams was excessive, and to the detriment of their other duties.
Discussion This study investigated preparations for suspected cases of EVD undertaken by NHS acute hospital trusts in England. The results represent a snapshot of preparedness four months after the Chief Medical Officer issued instructions to make preparations for suspected cases of EVD, and three months after the
Please cite this article in press as: Martin TCS, et al., Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.04.021
4
T.C.S. Martin et al. / Journal of Hospital Infection xxx (2015) 1e8
Table I Specific preparations undertaken by acute National Health Service hospital trusts in England for the assessment of suspected cases of Ebola virus disease (EVD) Measure
Number of hospital Percentage of hospital trusts responding trusts undertaking activity
Senior infection prevention and control and/or board meetings regarding preparedness Generation of new and/or updated local viral haemorrhagic fever guidelines Consideration given to detailed clinical scenarios in the following settings 1. A&E 2. Waste/laundry/spillage 3. Critical care case 4. Paediatric case 5. General medical ward case 6. Obstetric case 7. Case presenting to outpatient setting 8. Elective admission case Detailed consideration of suspected case management 1. Implementation of an appropriate treatment ‘ceiling’ 2. Actions in the event of cardiorespiratory arrest 3. Provision of ventilatory or renal support a. Would be offered b. Would not be offered c. Offered on a case-by-case basis d. Undecided Generation of new or modification of existing PPE protocols Staff PPE training undertaken Staff PPE training undertaken by department: 1. A&E 2. General medicine 3. Critical care 4. Paediatrics 5. Obstetrics 6. Facilities Locally defined PPE for use when performing invasive procedures (e.g. central line insertion) Defined PPE for use in obstetric emergencies Local PPE standard considered to exceed ACDP guidelines (September 2014) PPE used for ‘staff at risk’ (exposure to individual with fever >38 C and contact or possible contact with viral haemorrhagic fever 1. Gloves, plastic apron, surgical facemask, eye protection 2. Double gloves, fluid-repellant disposable gown/suit, eye protection, FFP3 respirator 3. As per (2) plus head covering and/or boots/shoes 4. Double gloves, fluid-repellant gown/suit, plastic apron, eye protection, FFP3 respirator 5. As per (4) plus any of head covering/neck covering/boots/shoes or PPE in excess of this Laboratory procedures/protocols updated Verification that category A courier will transport EVD samples Access to category A sample couriers in under 2 h ‘Table-top’ exercise or real-time simulation Created dedicated specialist team(s) for assessment and management of suspected cases
112
98
111 112
90 97 96 87 79 66 61 42 32
109 112 110
112 111
56 56 75 20 23 47 10 95 92
110
92 60 54 32 24 17 59
103 107
43 97
3 9 23 8 56 112 102 97 110 111
79 89 65 55 40
A&E, accident and emergency; PPE, personal protective equipment; ACDP, Advisory Committee on Dangerous Pathogens.
World Health Organization declared the outbreak as a public health emergency of international concern.13,14 The excellent response rate to this survey (75%) and the geographical distribution of the participating hospital trusts provide a representative picture of the general state of national readiness.
Overall, there was an excellent level of awareness and engagement, with all hospital trusts reporting that they had undertaken preparations for suspected cases of EVD. At the time of interview, 97% of the hospital trusts reported that they were ready to safely assess a suspected case. The vast majority
Please cite this article in press as: Martin TCS, et al., Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.04.021
T.C.S. Martin et al. / Journal of Hospital Infection xxx (2015) 1e8
Figure 2. Distribution of cases referred to the Rare and Imported Pathogens Laboratory for Ebola virus detection up to 30th November 2014. Circle size represents number of patients investigated (total referred ¼ 90).
of the hospital trusts had considered detailed clinical scenarios involving A&E, and provided PPE training to relevant personnel. Over half of the hospital trusts had tested their preparedness with real-time mock simulations or ‘table-top’ exercises.
5
Nevertheless, the overall picture was not without challenges and was not to the complete satisfaction of staff. Many of the challenges faced in preparing for cases of EVD relate to the uncertainty of diagnosis at the time of assessment. The vast majority of suspected cases will have an alternate diagnosis, such as malaria or influenza, and clinicians will want to ensure that patients are still treated in a timely and appropriate way. However, before test results are available, the possibility of EVD may cause patients and staff significant anxiety, further exacerbated by the likelihood of intense media attention and the risk of significant disruption to other clinical services. Practical guidance needs to address the major issue facing most hospitals, which is how to manage a suspected case before a test result is available. Some practical measures implemented locally by the authors are outlined in Table III. Almost all hospital trusts reported that they had prioritized staff training in A&E, where most suspected cases of EVD are likely to be encountered. While most patients may be managed effectively in A&E, this may prove difficult if it takes over 12 h for a diagnostic test to be performed, or if formal inpatient admission and specialist input is required. In such circumstances, it may be preferable to designate a suitable isolation room on a general medical ward to provide care pending diagnostic confirmation. Care can be provided by specific teams trained for patient assessment and management, thus reducing the burden of training and skill maintenance; this was instigated by almost half of the hospital trusts. To avoid the risks associated with transferring the patient and/or interference with unrelated services, mobile teams from key clinical specialties (e.g. general medicine, critical care, obstetrics and paediatrics) could attend the patient in this location. Hospitals should aim to be capable of providing continuous care for a 24h period, which should permit a diagnosis of EVD to be confirmed or excluded in most cases. The risk to staff from a patient with an uncertain diagnosis can be reduced through ensuring access to rapid EVD
Table II Challenges encountered by acute National Health Service hospital trusts in England in preparing for suspected cases of Ebola virus disease Category (% of hospital trusts)
PPE (71%)
Guidance (62%)
Staff concerns (60%) Staff time and resource issues (38%)
Hospital infrastructure (24%) Contracted services (23%) Laboratory (13%)
Response breakdown (% of hospital trusts)
Guidance on PPE was insufficient (43%) Procurement difficulties (34%) Guidance on PPE varied between authorities (PHE, CDC, WHO) (25%) Insufficiently practical (27%) General guidance differing between authorities (CDC, PHE, WHO) (20%) Algorithm for management of cases was too complicated (10%) Staff anxiety over PPE usage and protection (54%) Media coverage leading to unrealistic staff expectations (16%) Staff-time allocation for preparedness activities issues was insufficient (28%) Resource allocation/cost issues (19%) Lack of adequate rooms for suspected case management (19%) Cleaning services did not agree to hospital preparedness plans (12%) Difficulty processing samples from suspected cases (7%) Time for relay of results from PHE laboratory (5%)
PPE, personal protective equipment; PHE, Public Health England; CDC, US Centers for Disease Control and Prevention; WHO, World Health Organization. Please cite this article in press as: Martin TCS, et al., Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.04.021
Requirement
Staff information and support
Case identification
Minimize risk and disruption from suspected cases of EVD
PPE training and usage
Ensure access to rapid diagnostic tests and other pathology tests Escalation of care decisions Assess preparedness
Actions
Comment
Provide regular face-to-face briefings and e-mail bulletins, plus regularly updated ‘frequently asked questions’. Keep all policies, information, clinical guidance and video versions of briefings on a dedicated Ebola webpage on the hospital intranet Provide all reception areas with cue cards with risk-factor screening questions and actions to take if a person at risk is identified Conduct simple audits to confirm active screening is being undertaken
Do not rely exclusively on e-mail cascades to disseminate information
Instigate occupational health policy for healthcare workers who have travelled to affected countries Reschedule non-urgent, elective admissions for patients who have returned from an outbreak country within 21 days. Provide information for patients if elective admission is delayed Identify and equip a dedicated isolation cubicle in A&E and also on the medical wards for suspected cases of EVD. Involve estate departments early to ensure adequate development of facilities. Plan patient transfer from A&E to the inpatient bed in advance to minimize exposure risk Plan to provide specialty input through mobile teams to minimize patient movement around hospitals Ensure adequate supplies of PPE and deliver face-to-face training. Ensure A&E trained first and then roll out to general medicine, critical care, obstetrics and paediatrics Use checklists to ensure correct donning and doffing procedures are followed, and display these outside isolation rooms Ensure there is a competent PPE trainer on site 24 h/day Each clinical department should have a nominated ‘Ebola lead’ who has responsibility for ensuring that a rota of trained staff is available and for disseminating important information Agree a timeframe for sample collection with courier providers Audit response times during exercises Ensure local laboratories are prepared for sending away diagnostic samples and to process other samples from suspected cases as directed by the ACDP guidelines Agree a formal process by which decisions regarding escalation of care will be made. The agreed process should have formal support from senior hospital managers Introduce programme of unannounced clinical simulations starting with A&E
If a positive screen is encountered, ensure family members and individuals accompanying the patient are also screened Periodic ‘walk-about’ is a highly effective method of gauging compliance Guidance is available from PHE for the management of returning healthcare workers16 Outpatient visits and non-invasive investigations can continue if patient is asymptomatic
If possible, enable higher-level support interventions to be performed in the dedicated isolation room (e.g. portable ventilator) The use of dedicated teams may reduce the number of staff that require training Use locally or nationally produced videos to support PPE training
Leads are responsible for submitting formal preparedness reports to provide board-level assurance Additional laboratories for EVD testing are expected to reduce sample transport times
Decisions regarding escalation should involve senior physician, critical care consultant, hospital management and experts from the high-level isolation unit and/or the Imported Fever Service (see text) Emphasis should be on assessing processes, not staff. Consider using approved checklists (e.g. CDC, WHO) to ensure all appropriate actions are taken
Introduce debriefing meetings after suspected cases have been dealt with to identify areas for improvement A&E, accident and emergency; PPE, personal protective equipment; PHE, Public Health England; ACDP, Advisory Committee on Dangerous Pathogens; CDC, US Centers for Disease Control and Prevention; WHO, World Health Organization.
T.C.S. Martin et al. / Journal of Hospital Infection xxx (2015) 1e8
Minimize contact with individuals at risk of EVD
6
Please cite this article in press as: Martin TCS, et al., Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.04.021
Table III Practical measures adopted locally by study authors in preparing for suspected cases of Ebola virus disease (EVD)
T.C.S. Martin et al. / Journal of Hospital Infection xxx (2015) 1e8 diagnostics. As a viable virus capable of causing lifethreatening disease, Ebola is a category A pathogen, meaning that transportation can only be provided by couriers complying with national road transport regulations. It was therefore of concern that over one-third of the hospital trusts did not believe that they had timely access to category A sample couriers. This was further exacerbated by the fact that, at the time, there was only one designated national testing facility (PHE Porton Down; see Figure 1 for location relative to hospital trusts), with an estimated turnaround time of 8e12 h at present. Access to more rapid diagnostics is highly desirable to allow either resumption of ‘normal clinical services’ in the case of a negative result, or transfer to the HLIU in the case of a positive result. The subsequent decisions by PHE to introduce further testing centres in more convenient locations, and to improve the availability of nationally arranged couriers are therefore extremely welcome. Laboratory tests within hospitals may also be delayed due to difficulties working with highrisk samples, as reported by almost 10% of the hospital trusts. Highlighted issues included: analysers are not a closed system, training of laboratory staff had not been completed, time delays with transport of samples to a centralized laboratory, and protracted fee negotiations with couriers. Up to three-quarters of the hospital trusts reported that they had discussed the escalation of care for deteriorating patients with suspected EVD. Expert opinion regarding the management of a deteriorating patient with confirmed EVD has been published; however, this is not the situation confronted by the vast majority of physicians managing individuals while confirmatory test results are pending.15 In reality, decisions will be made on a case-by-case basis in conjunction with national centres of expertise, such as the HLIU and the Imported Fever Service (an expert clinical advisory and diagnostic service provided by PHE for medical professionals managing patients who have returned to the UK with a fever). While it is impossible to devise a plan for every scenario, it may be useful to agree a formal decision-making algorithm that could assist clinical staff confronted by difficult management choices. One approach might involve telephone agreement between the offsite experts, the responsible senior clinician and critical care consultant, with endorsement by senior managers. Endorsement by senior hospital management is important because clinicians will naturally be troubled about the risk of undertreating patients due to safety considerations while uncertainty exists regarding the diagnosis. Most hospital trusts cited the choice, use and procurement of PPE as the greatest challenge faced during preparations, with many concerns voiced about national guidance. At the time of the study, 97% of the hospital trusts reported using PPE in excess of that recommended in the ACDP guidance. Hospital trusts frequently cited the anxiety of frontline staff regarding the transmission risk of EVD, media-driven hysteria and inconsistency of guidance with other national bodies as drivers towards using higher-level PPE. In the face of the emerging threat, national and international agencies updated their viral haemorrhagic fever guidance at various points, often with advice that was conflicting between agencies, most notably around PPE practice. The authors found that this created local difficulties in ensuring that involved teams received a single consistent message, and retained confidence in the procedures in which they had been trained. This was addressed locally by devising a PPE strategy that anticipated and addressed the
7
majority of local concerns, and a clear communication strategy, often during face-to-face PPE training, to explain the rationale where this was at variance with published guidance. These difficulties could possibly be avoided through national guidance placing greater emphasis on the evidence base underpinning current recommendations, and particularly an explanation of risks vs benefits where UK recommendations diverge from those issued by other reputable authorities (e.g. the World Health Organization or the US Centers for Disease Control and Prevention). More explicit guidance on what level of PPE is appropriate for specific interventions on suspected cases (e.g. central venous line insertion) should also be considered. Future guidance should ensure that practical aspects are unambiguous. For example, the updated ACDP guidance states that total skin coverage is desirable, but concurrently refers to the use of ‘surgical caps’ that will not achieve this requirement for the neck area. Finally, procurement of PPE remains an issue, and a central system of coordinating supply, or at least a list of approved suppliers, would be welcomed. At present, each hospital trust has done this independently in an uncoordinated and often time-inefficient manner as stock has become depleted. This study had a number of limitations. Data collected may include recall bias of those interviewed, and selection bias as non-responding hospital trusts may have been less well prepared. This study focused solely on acute care hospitals, but the authors recognize that a true assessment of national preparedness would include primary care. Due to time limitations inherent in structured interviews, the authors were unable to address a number of important issues in depth, including the development of triage services, hospital and community decontamination services, protocols for environmental contamination, use of information leaflets for staff education, clinical waste management, endoscope decontamination, laboratory personnel PPE, laboratory equipment decontamination, and sample tracing protocols. While these issues were not addressed directly, interviewees were prompted in general fields that would cover these issues during the open questions regarding preparedness. English hospitals are often required to respond to emerging infections with a range of clinical and epidemiological features. The results of this study will support local and national preparations for future epidemics, and the development of improved permanent and event-related guidance. Hospitals should ensure that they consolidate the generic skills attained during this outbreak, and that the facilities made available, such as isolation rooms and improved courier services, are maintained for future use. Through these actions, the resources invested in preparing for Ebola can contribute to a permanent improvement in the ability of health services to respond rapidly to emerging infectious threats.
Acknowledgements The authors wish to thank all the individuals who took part in this study, and RIPL, PHE Porton Down for providing national data on EVD samples. Conflict of interest statement None declared.
Please cite this article in press as: Martin TCS, et al., Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.04.021
8
T.C.S. Martin et al. / Journal of Hospital Infection xxx (2015) 1e8 Funding source TM received funding from the National Institute of Health Research.
References 1. World Health Organization. Ebola response roadmap situation report update. Geneva: WHO; 2014. Available at: http://www. who.int/csr/disease/ebola/situation-reports/en/ [last accessed April 2015]. 2. Kucharski AJ, Edmunds WJ. Case fatality rate for Ebola virus disease in West Africa. Lancet 2014;384:1260. 3. Schieffelin JS, Shaffer JG, Goba A, et al. Clinical illness and outcomes in patients with Ebola in Sierra Leone. N Engl J Med 2014;371:2092e2100. 4. WHO Ebola Response Team. Ebola virus disease in West Africa d the first 9 months of the epidemic and forward projections. N Engl J Med 2014;371:1481e1495. 5. Public Health England. Ebola epidemiological update No. 17: 9 January 2015. London: PHE; 2015. 6. Centers for Disease Control and Prevention. Cases of Ebola diagnosed in the United States. Atlanta, GA: CDC; 2014. Available at: http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/ united-states-imported-case.html [last accessed May 2015]. 7. Gomes M, Pastorey y Piontti A, Rossi L, et al. Assessing the international spreading risk associated with the 2014 West African Ebola outbreak. PLOS Curr 2014; September 2;6. 8. Bogoch II, Creatore MI, Cetron MS, et al. Assessment of the potential for international dissemination of Ebola virus via commercial air travel during the 2014 West African outbreak. Lancet 2015;385:29e35.
9. Public Health England. Risk assessment of the Ebola outbreak in West Africa: 20 October 2014. Report No. 2014384. London: Department of Health; 2014. 10. Advisory Committee on Dangerous Pathogens, Department of Health. Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence. London: Department of Health; 2014. Available at: https://www.gov.uk/ government/publications/viral-haemorrhagic-fever-algorithm-andguidance-on-management-of-patients [last accessed September 2014]. 11. Public Health England. Summary guidance for acute trust staff: identifying and managing patients who require assessment for Ebola virus disease. London: PHE; 2014. Available at: https://www.gov. uk/government/publications/ebola-virus-disease-identifying-andmanaging-patients-for-assessment-in-acute-trusts [last accessed October 2014]. 12. Chief Medical Officer. Ebola outbreak in West Africa. London: Department of Health; 2014. Available at: https://www.cas.dh. gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID¼102228 [last accessed October 2014]. 13. Public Health England. Ebola outbreak in West Africa. London: Department of Health; 2014. Available at: https://www.cas.dh. gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID¼102185 [last accessed July 2014]. 14. World Health Organization. Statement on the 1st meeting of the IHR Emergency Committee on the 2014 Ebola outbreak in West Africa. Geneva: WHO; 2014. 15. Jacobs M, Beadsworth M, Schmid M, Tubridge A. Provision of care for Ebola. Lancet 2014;384:2105e2106. 16. Public Health England. Ebola: information for humanitarian aid and other workers intending to work in Ebola affected countries in West Africa. London: PHE; 2015.
Please cite this article in press as: Martin TCS, et al., Cross-sectional study of Ebola virus disease preparedness among National Health Service hospital trusts in England, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.04.021