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The
U.S. health care apparatus is so unprepared and short on resources to
deal with the deadly Ebola virus that even small clusters of cases could
overwhelm parts of the system, according to an Associated Press review
of readiness at hospitals and other ...
AP IMPACT: US Health Care Unprepared for Ebola
The U.S. health care apparatus is so unprepared and short on resources
to deal with the deadly Ebola virus that even small clusters of cases
could overwhelm parts of the system, according to an Associated Press
review of readiness at hospitals and other components of the emergency
medical network.
Experts broadly agree that a widespread outbreak across the country is
extremely unlikely, but they also concur that it is impossible to
predict with certainty, since previous Ebola epidemics have been
confined to remote areas of Africa. And Ebola is not the only possible
danger that causes concern; experts say other deadly infectious diseases
— ranging from airborne viruses such as SARS, to an unforeseen new
strain of the flu, to more exotic plagues like Lassa fever — could crash
the health care system.
To assess America's ability to deal with a major outbreak, the AP
examined multiple indicators of readiness: training, manpower, funding,
emergency room shortcomings, supplies, infection control and protection
for health care workers. AP reporters also interviewed dozens of top
experts in those fields.
The results were worrisome. Supplies, training and funds are all
limited. And there are concerns about whether health care workers would
refuse to treat Ebola victims.
Following the death of a patient with Ebola in a Texas hospital and the
subsequent infection of two of his nurses, medical officials and
politicians are scurrying to fix preparedness shortcomings. But remedies
cannot be implemented overnight. And fixes will be very expensive.
Dr. Jeffrey S. Duchin, chairman of the Public Health Committee of the
Infectious Diseases Society of America and a professor of medicine at
the University of Washington, said it will take time to ramp up
readiness, including ordering the right protective equipment and
training workers to use it. "Not every facility is going to be able to
obtain the same level of readiness," he said.
AP reporters frequently heard assessments that generally, the smaller
the facility, the less prepared, less funded, less staffed and less
trained it is to fight Ebola and other deadly infectious diseases.
"The place I worry is: Are most small hospitals adequately prepared?"
said Dr. Ashish Jha, a Harvard University specialist in health care
quality and safety. "It clearly depends on the hospital."
He said better staff training is the most important element of
preparation for any U.S. Ebola outbreak. He believes a small group of
personnel at each hospital needs to know the best procedures, because
sick people are likely to appear first at medium-size or small medical
centers, which are much more common than big ones.
Jha pointed to stepped-up training in recent weeks but wondered, "Will it be enough? We'll find out."
———
AN OVERTAXED EMERGENCY CARE SYSTEM
Without any stress caused by Ebola cases, the emergency care system in
the U.S. is already overextended. In its 2014 national report card, the
American College of Emergency Physicians gives the country a D-plus
grade in emergency care, asserting the system is in "near-crisis,"
overwhelmed even by the usual demands of care.
According to data from the Centers for Medicare & Medicaid Services,
patients spend an average of 4 1/2 hours in emergency rooms of U.S.
hospitals before being admitted. The data also show that 2 percent of
patients leave before even being seen.
In a U.S. Centers for Disease Control and Prevention study on hospital
preparedness for emergency response in 2008, the latest data available,
at least a third of hospitals had to divert ambulances because their
emergency rooms were at capacity.
Add an influx of people with Ebola, along with those who fear they might
have the disease, and the most vulnerable segments of the health care
system could wobble.
"Even though there have been only a couple cases, many health systems
are already overwhelmed," said Dr. Kenrad Nelson, a professor at Johns
Hopkins Bloomberg School of Public Health and former president of the
American Epidemiological Society, referring to new federal procedures
for screening, tracking and treating the disease and people who are
exposed. He added that if a major flu outbreak also occurred, "it would
be really tough."
"We're really going to have to step up our game if we are going to deal
with hemorrhagic fevers in this country," said Lawrence Gostin, a global
health law expert and professor at Georgetown University.
How big of an outbreak would it take to overpower the U.S. health care system?
"It would have to be only a mediocre outbreak," said Gostin. "The
hospitals will be flooded with the 'worried-well.' People with influenza
or other infections that are not Ebola could jam up the public health
system."
One federal study on emergency room visits indicated that at least 4
percent of visits involved patients with fever — a common symptom of
Ebola. Combining fevers with stomach pain, headaches and coughs, about a
fifth of emergency visits involve symptoms often seen in Ebola
patients.
A doctor who had recently treated Ebola patients in West Africa came
into Bellevue Hospital in New York City last week with a fever and
gastrointestinal symptoms. In announcing the man had been placed in
isolation, officials pointed out how his symptoms also could be
consistent with salmonella, malaria or the stomach flu.
Last Thursday, the doctor tested positive for Ebola.
———
UNEVEN LEVEL OF PREPAREDNESS
National surveys have repeatedly found that while most health care
providers are willing to care for people with dangerous diseases like
Ebola, they generally feel unprepared to do so.
This summer, health care research group Black Book Rankings sought
opinions from hospital administrators, doctors and nurses at all U.S.
hospitals and health care facilities about infection control, emergency
planning and disaster readiness regarding Ebola. Nearly 1,000 personnel
at 389 facilities, including 282 hospitals, participated.
Personnel at almost all hospitals in the Black Book survey said their
facilities were not capable of quarantining large numbers of people
possibly exposed to Ebola.
Nearly three-quarters of emergency doctors and four in five infection
specialists at large hospitals felt their facilities were not adequately
prepared to deal with Ebola patients.
Hospital administrators and medical staff had widely divergent
perspectives on their facilities' ability to treat the disease. Among
medical staff at big hospitals, nearly all who participated in the
survey believed their hospitals were not adequately staffed and trained
for Ebola patients. About two in three of administrative and financial
staff shared that worry.
Among emergency nurses, nearly all worried about the impact of emergency
department crowding on the ability to deal with Ebola patients; just
more than half of administrative and financial managers felt that way.
Other striking results: Personnel at only 1 percent of surveyed acute
care hospitals said they can handle more than 10 Ebola patients at once.
That was true at just about one-quarter of academic medical centers.
A demonstrated weakness of U.S. hospitals in controlling other
hospital-acquired infections also suggests a soft spot in Ebola
readiness. In 2011, the most recent year of data, about 75,000 hospital
patients with health care-associated infections died during their
hospitalizations, according to a national CDC survey published this
year. Such infections are considered to be a proxy to measure hospitals'
readiness to contain Ebola.
Added Douglas Brown, managing partner at Black Book: "We got a lot of
feedback that community hospitals aren't the place for Ebola patients to
come."
———
SUPPLY SHORTAGES AND SURGE WORRIES
Shortages abound, beginning with the fact there are only four
specialized containment care facilities set up to isolate and treat
patients with Ebola and other very dangerous diseases. In any sizable
outbreak, those dozen or so beds would fill up very quickly.
Appropriate equipment could be in short supply for mid-size and smaller
hospitals, and even some larger ones. CDC estimates from 2008, the most
recent available national figures, put the average number of protective
suits with powered air-purifying respirators per hospital at 10. The
average hospital had six mechanical ventilators, which could be needed
for Ebola patients with breathing problems.
A recent nationwide survey of state public health departments suggests
not all are ready to ramp up quickly. The 2013 National Health Security
Preparedness Index, carried out by CDC in partnership with the
Association for State and Territorial Health Officials, ranks state
health departments on a scale of 1 to 10 on numerous emergency measures.
In the category of "surge management," the average score was 5.8.
Dr. Amesh Adalja, a member of the Public Health Committee of the
Infectious Disease Society of America, says some emergency departments
are so consumed by the typical number of patients that a surge of any
kind can overwhelm them. With an Ebola outbreak, he said, "they're not
just getting a surge of patients, they're getting a surge of patients
with special needs."
The AP review found evidence that the federal emergency public health
network, which is designed to step in to prevent shortages of medicine
and medical supplies while local response capacity ramps up, is failing
to perform as planned.
Since 2007, Ebola has been identified as a potential threat requiring
priority attention under the Public Health Emergency Medical
Countermeasures Enterprise, which coordinates the development,
stockpiling and dispensing of drugs during a massive disease outbreak or
to protect against chemical, biological, radiological or nuclear
agents.
The National Institute of Allergy and Infectious Diseases has spent
nearly $500 million on Ebola research since 2003. At least another $269
million has been spent on Ebola research under a Defense Department
chemical and biological defense program. Some of that funding was spent
on vaccine research and better diagnostic testing.
But in October 2011, the Government Accountability Office reported that
an anticipated budget for drug acquisitions still had not been produced.
Without clear guidance about government funding, pharmaceutical and
other medical companies might not want to invest millions of dollars to
develop vaccines that are less lucrative than other drugs they could
make, the report underscored.
The GAO issued another critical report in December 2013, faulting the
program for its "almost 10-year efforts and the continuing lack of
available countermeasures."
None of that stopped a top federal preparedness official from telling
Congress in February that the program is "a model for innovative
governance and accountable decision-making."
In fact, the feds' Biomedical Advanced Research and Development
Authority did not fund its first investment in an experimental Ebola
treatment until this year because that program only supports potential
treatments in a later phase of development. The U.S. Department of
Health and Human Services said a relatively modest $25 million has gone
to study ZMapp, an experimental drug in short supply that has been
provided to numerous infected Ebola patients.
Given that there is no Ebola vaccine, the government does not have a
stockpile of disease-specific drugs on hand, as it has had for pandemic
flu.
Also, as of last week, there were no national emergency stockpiles of
the waterproof gowns, surgical hoods, full face shields, boot covers or
other gear that the CDC recommends for treating Ebola patients. CDC's
$6.2 billion Strategic National Stockpile had just a small quantity of
older model gowns on hand, since most were sent to the states during the
2009 swine flu pandemic and had not been replenished, said Greg Burel,
director of the agency's stockpile division. Last Thursday, the agency
placed an order to purchase a limited amount of Ebola-specific personal
protective equipment, but Burel would not say how much was ordered, or
when the goods would be available for distribution.
If the U.S. sustains a major Ebola outbreak, the mechanism for
confirming individual patient test results also could be quickly
overwhelmed, though the testing situation suddenly is improving. For
years, spending on diagnostic research has lagged under the National
Institute of Allergy and Infectious Diseases and a Defense Department
chemical and biological defense program. The CDC noted in August that
the agency and the military had "the only U.S. laboratories capable of
conducting diagnostic testing to confirm that a patient has Ebola and
not some other illness." As of Friday, though, the CDC said there were
23 additional labs that have the expanded diagnostic technology,
primarily local and state health departments.
———
WORRIES ABOUT TRAINING
Shortcomings in training and preparedness for health care workers are pronounced, and chronic.
More than half of working registered nurses reported they neither
received nor provided emergency training during the previous year,
according to a study HHS published in 2010 using 2008 data. Of those
registered nurses who did receive or provide emergency training, 44
percent felt somewhat or not at all prepared.
Regarding epidemic response planning, a third of hospitals had no plans
for alternate care areas with beds, staffing and equipment, according to
a study published in 2011 by CDC's National Center for Health
Statistics, again based on 2008 data. Only half had priority-setting
plans to get the most use from a limited supply of ventilators. More
than a third had no plans for on-site, large-capacity morgues, and a
third had no plans for staff absences as a result of the personal or
family impact of any epidemic.
A recent survey of 2,500 members of the local health officials'
association found that only one in three local health departments had
participated in full-scale emergency preparedness exercises or drills.
Gostin, the global health law expert from Georgetown, thinks the
contamination of two nurses at Texas Health Presbyterian hospital in
Dallas, where the first person diagnosed with Ebola in the U.S. died,
"was not an anomaly."
He said the U.S. may have the most advanced health care system in the
world, but the system is very fragmented because "there's no uniform
national quality control."
There is great inconsistency in the frequency of emergency drills.
According to the Black Book report, only a quarter of academic medical
centers had epidemic or biological warfare drills in the previous year,
but just 4 percent of medium-size hospitals ran such exercises, and no
small hospitals did.
Kristi L. Koenig, director of the Center for Disaster Medical Sciences
at the University of California-Irvine, said every hospital needs to
have some basic level of preparation, in order to manage the initial
treatment. But she suggested the best solution is to increase the number
of specialized biocontainment centers.
Such centers would help keep workers safe and properly prepared, not
just for Ebola but also for other very dangerous diseases like SARS —
severe acute respiratory syndrome — or influenza.
Dr. Patrick Smith, who leads the Biocontainment Unit at the University
of Nebraska Medical Center, said that staffers in the typical hospital
isolation ward have had little or no practice in putting on and taking
off safety gear, or following other procedures for handling Ebola
patients. Such practices are second nature at field hospitals and
clinics operating in Africa, and are drilled regularly at specialized
containment facilities in the U.S.
———
FEARS OF ABANDONMENT
Like nuclear radiation, the Ebola virus, which causes massive internal
bleeding and organ failure, touches on deep human fears of a fatal
invisible menace. Those fears are shared not only by patients, but also
by some professionals who treat them.
In the Black Book Ebola readiness survey released in August, some
medical staff said they believed they would stay away from work to shun
Ebola patients admitted to their hospitals.
Among isolation care doctors and nurses, 14 percent said they'd call in
sick, and one in four critical care and emergency staff said the same.
Among the isolation care staff, 17 percent said they wouldn't work near
Ebola patients; half of critical care and emergency staff said the same.
"I think that's a very valid concern," said Dr. Melinda Moore, a
scientist at Pardee RAND graduate school who has worked as a global
health expert for the CDC. "It's been described in literature and
studies."
She said training on safe Ebola treatment and education for health care workers is the antidote.
Adalja, a member of the Public Health Committee of the Infectious
Disease Society of America, called the survey findings troubling and
contended they show that many medical staffers "are not confident in the
infection control procedures at their hospital."
Dr. Kenneth Anderson, who leads the research and education affiliate of
the American Hospital Association, confidently pointed to the
professionalism of most health care workers in the AIDS, H1N1 flu and
other past American epidemics as an indication "our staff will step up."
But Nelson, of Johns Hopkins, pointed to the "huge problem" in Africa,
where health care workers have walked off the job. "I think that could
be a problem in the United States, because a lot of the population is
really terrified," he said.
———
AP national investigative reporters Holbrook Mohr in Jackson,
Mississippi; Michael Kunzelman in Baton Rouge, Louisiana; and David B.
Caruso in New York contributed to this story.
The AP National Investigative Team can be reached at investigate@ap.org
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