(See the article by Morgan et al, on pages 627–631.)

Over the past 6 months, infection preventionists and hospital epidemiologists have been scurrying, constantly responding to infectious disease threats both new and old. To name a few, we recently witnessed outbreaks related to the Middle Eastern respiratory syndrome coronavirus, enterovirus D68, Ebola virus disease (EVD), and measles. Many of these pathogens are associated with high transmissibility, morbidity, and mortality. EVD has been the most feared because of its striking associated mortality (up to 50%–70%). In this issue, Morgan et alReference Morgan, Braun and Milstone ¹ report the results of a Society for Healthcare Epidemiology of America (SHEA) membership survey (60% of them hospital epidemiologists) regarding Ebola preparedness in the weeks following the first case diagnosed on US soil. The respondents felt moderately prepared to screen and triage patients with possible EVD, a very important step to contain and prevent further transmission. Furthermore, extraordinary efforts from infection prevention departments were invested in achieving preparedness, diverting them from essential daily commitments, with little financial support. The main challenges reported were related to personal protective equipment (PPE), rapidly evolving recommendations, and addressing fears related to the disease—a reflection of the ambiguous environment hospitals were facing at that point. The majority of hospitals evaluated a suspected EVD case and identified delays in care. In addition, about 45% reported being able to create isolation units separate from other patient care areas. About two-thirds anticipated some healthcare workers would refuse to care for EVD patients, and the respondents were neutral to whether their EVD preparedness helped their readiness for other diseases. The survey is a convenience sample of SHEA members of a very select group of healthcare workers that disproportionately represent large or academic centers with expertise in infection prevention. These results apply to those centers and may not be generalizable to the whole country, where preparedness may be even more limited.

Traditionally, hospitals have relied on federal, state, and local public health support to address emerging pathogens. However, such support has dwindled over the past few years with decreased resources and scarce funding for public health.Reference Kuehn ^{2 –} Reference Gostin, Hodge and Burris ⁴ In addition, smaller hospitals may not be prepared or are not expected to have expertise in managing these emerging pathogens. With the coalescing of many hospitals into health systems to optimize quality and cost, these alliances can play an important role in building capacity of their individual hospitals, improving safety, and promptly addressing any potential risks of exposure to emerging pathogens. Health systems are capable of making resources more readily available, compared with standalone hospitals. They often include elements of the continuum of care from acute to ambulatory, home, and long-term care services, making them better representatives of the complex healthcare structure.

We report our experience at Ascension, the largest nonprofit health system in the United States, with more than 100 acute care hospitals in 23 states and Washington, DC. Including its acute care hospitals, Ascension has about 1,900 locations where medical services are rendered. Immediately after the first EVD case was identified in Texas, a system communication was issued to all hospital leaders and infection preventionists that addressed the following: epidemiologic and symptom screening for EVD, appropriate PPE availability and training, laboratory testing, environmental cleaning, and waste disposal. A national leadership system taskforce was established, composed of care excellence, infection prevention, medical resource group, clinical informatics, legal, risk management, finance, human resources, ethics, ambulatory physician practices, home health, senior care, environmental services, and communications. The Ascension system infection prevention team met repeatedly and was key in engaging all other stakeholders, particularly occupational health. It also established guidance on the development of isolation areas for patients suspected of EVD, the choice of appropriate PPE, training of healthcare workers in donning and doffing PPE, and laboratory testing.

As part of our evaluation for facility-level preparedness, a survey was sent to Ascension hospitals in mid-October 2014, with 91 hospitals responding. At that point, 79 hospitals (87%) reported having completed an assessment for EVD readiness, and 87 (96%) had a mechanism to evaluate, isolate, and treat suspected or confirmed cases. Seventy-three hospitals (80%) had a multidisciplinary team to plan EVD management, but only 42 (46%) had addressed resuscitation or end-of-life care. More facilities used paper tools to screen for EVD (58 [64%]) than electronic means (32 [35%]). EVD screening processes were established in 86 (95%) of the emergency departments and 78 (86%) of the ambulatory areas managed by the acute care facilities. When specifically asked about the ambulatory setting, 42 hospitals (46%) reported processes in place to evaluate and manage EVD-suspected patients until transfer, 19 (21%) had an established process to contact their local acute care facility for transfer, and 22 (24%) had the logistics to isolate patients on site awaiting transfer.

We found strong engagement from many of the hospital disciplines in EVD readiness and local emergency preparedness teams. The most engaged groups included infection prevention (81 [89%]), senior leadership (75 [82%]), emergency medicine (78 [86%]), and the laboratory (74 [81%]). Other groups included environmental services (70 [77%]), quality (64 [70%]), communications/public relations (64 [70%]), security (57 [63%]), ambulatory practices (45 [49%]), infectious diseases physicians (39 [43%]), and the medical resource group (36 [40%]).

What are the benefits of a broad-system multidisciplinary approach? First, EVD preparedness was made a priority at a system and facility leadership level, ensuring commitment and swift collaboration among all stakeholders and subject matter experts. It was important to build immediate confidence and trust with our care providers and associates. The president and CEO of Ascension Health delivered a videotaped message to all associates and providers, communicating the system’s intent to keep everyone safe while also ensuring that access to care was not compromised. Second, many system decisions were based on the direct input of experts from our diverse hospitals. This gave us collective insights into unique aspects of the suspected-EVD patient care processes and also helped us prioritize areas where comprehensive national recommendations were not yet available (eg, patients in labor or those requiring surgery, ethics, and treatment). Third, we decided, as a system, on the optimal PPE to use and arranged for acquiring adequate inventory to share among all facilities (not only acute care, but also ambulatory sites), without hoarding due to scarcity of product availability. The Resource Group (the Ascension subsidiary responsible for purchasing equipment and supplies) was instrumental in acquiring and planning for the delivery of needed PPE to any system facility. Fourth, we engaged our ambulatory services organizations to ensure that they had an established mechanism to screen for EVD and minimize any exposures in outpatient settings. Fifth, our clinical information system group worked with all hospitals, using electronic screening and promptly updating the travel areas of epidemiologic significance, on the basis of EVD activity. Sixth, we were able to plan regionally which hospitals could best treat these patients. Seventh, we devised a unified approach to screen and follow up healthcare workers caring for or exposed to EVD patients. Finally, a well-established Ascension Health Infection Prevention Committee allowed us to disseminate timely information and create standardized care approaches within a short period.Reference Mermel ⁵

Ebola is only one of many emerging pathogens, with only 2 cases acquired in the United States. However, it has been an eye opener for many of us, realizing the limitations of our country’s preparedness for emerging infectious agents. Fortunately, none of our patients screened positive for EVD. This raises the question of how lessons learned from preparedness for EVD can inform efficient and effective program design to address all emerging pathogens. Federal, state, and local public health entities should lead our pathogen preparedness, but close collaboration with and within health systems may provide a better care model to achieve the desired readiness when knowledge can be converged rapidly. Our experience taught us the importance of developing an emergency preparedness structure covering the care continuum—multidisciplinary in nature and flexible enough to accommodate any emerging pathogen with minimal adjustments.