Quantitative Results

About half of the respondents (132; 57%) indicated that their hospital could admit a suspected EVD patient; others felt their hospital could not (46; 20%) or were unsure (53; 23%). When asked who had provided necessary information or resources to care for potential EVD patients, more respondents agreed or strongly agreed that their home institution had done so (162; 70%) compared to the federal government (140; 61%) or state health department (128; 55%). However, most were confident that state, regional, or local resources were available for assistance to care for EVD patients (150; 65%).

Some aspects of preparedness were stronger than others in the respondents’ hospitals. Nearly all respondents indicated that triage and assessment for potential EVD always or usually includes a travel history (218; 94%). One-third (81; 35%) noted that their hospital had conducted an Ebola drill. About two-thirds indicated that their hospital was either somewhat prepared (115; 50%) or very prepared (37; 16%) to handle EVD patient waste; a similar proportion (159; 69%) indicated that their hospital has a decontamination room. However, only about half (111; 48%) indicated that their hospital staff had received practical PPE training, with the same number indicating that their hospital required a monitor for donning and doffing PPE (116; 50%); a PPE monitor (ie, an observer to ensure appropriate donning and doffing of PPE) was recommended in the hospital of an additional 41 (18%). The hospital’s laboratory had communicated with EDs of only about half the respondents (104; 45%) about procedures for handling specimens from EVD patients. Furthermore, only one-fourth (68; 29%) had a plan to manage EVD if their hospital’s capacity was exceeded.

We examined factors that might contribute to a hospital’s readiness to admit EVD patients. The consistency of taking a travel history and the availability of most individual PPE items were not statistically associated with admission ability; however, the availability of 3 specific PPE items did reach statistical significance: hood (P=0.0085, one-tailed Fishers exact test [FE]), boots with leg coverings (P=0.0171, FE), and booties (P=0.0492, FE ). Nonmaterial dimensions of hospital preparedness were even more important (Table 1). Factors that were statistically significantly associated with a hospital’s ability to admit EVD patients included hospitals where:

• ∙ Staff had received practical PPE training and a monitor for PPE donning and doffing was required;

• ∙ An Ebola drill had been conducted;

• ∙ The laboratory had communicated with the ED on how to handle EVD specimens;

• ∙ There were a greater number of isolation rooms or the ability to isolate a greater number of EVD patients;

• ∙ There was a decontamination room;

• ∙ EVD medical waste could be handled;

• ∙ The hospital had a plan for managing EVD patients if its own capacity was exceeded.

Table 1

Survey 2: Ability to Admit EVD Patient, by PPE Training and Other PreparednessFootnote ^a

^a Abbreviations: EVD, Ebola virus disease; PPE, personal protective equipment.

We also examined whether the ability of a hospital to admit EVD patients was associated with the degree of information and other support received or expected from various sources (Table 2). The most strongly associated sources of information and resource support were the home institution (P=0.017) and the state health department (P=0.017); support from the federal government was not associated with the ability to admit EVD patients, nor was the expectation of assistance from state, regional, or local sources to care for EVD patients.

Table 2

Survey 2: Ability to Admit EVD Patient, by Information and Resources Available or ProvidedFootnote ^a

^a Abbreviation: EVD, Ebola virus disease.

Qualitative Results

Respondents were asked about what education or assistance is needed from ACEP. Many reported being inundated with Ebola information from many sources. Several suggested that ACEP serve as a central hub to provide concise and current information and educational and training materials on best practices related to PPE donning and doffing, screening, isolation, preventing and dealing with contamination of waiting room and ED, clinical management, and standards of care. They suggested channels for disseminating such information, such as a website, 24-hour hotline, or regular social media updates. Another recommendation was for ACEP to serve as an advocate for frontline emergency physicians and local, state, and federal government entities. Respondents indicated that ACEP should work with other entities to downplay fear and hysteria in public communications.

Respondents were also asked about what education or assistance is needed from government sources. Many cited confusing, overlapping, frequently changing, and at times contradictory guidance from government sources, as well as a need for government to provide consistent, trustworthy, actionable guidance.

Respondents also called for more resources from government, including funding for PPE, isolation, and quarantine equipment, as well as CDC rapid response teams that could be deployed to hospitals to guide EVD care. Some urged government action to designate and certify Ebola treatment centers and to establish a 24-hour information hotline. A few respondents suggested learning from the positive experiences of the Nebraska Ebola treatment center and Doctors Without Borders.

Quantitative Results

About half of the respondents (514; 46%) were from large hospitals with an annual ED census of at least 60,000. About half (481; 43%) were from the Mid-Atlantic or Midwest region. Roughly half (485; 44%) indicated that their hospital could screen and admit EVD patients (Table 3). About three-fourths (869; 78%) indicated that their hospital had “adequate PPE for a potential EVD case,” but only about half (617; 55%) indicated they had “enough PPE for a proven EVD case.” More respondents were unsure of the latter (265; 24%) than of the former (106; 10%). Respondents felt that fewer physicians had adequate practical PPE training (611; 55%) compared to their ED nurses and technicians (664; 60%), but these emergency physician respondents were more unsure about level of training for nurses and technicians (179; 16%) than for physicians (96; 9%). Two-thirds of respondents (766; 69%) indicated that their hospital had screened no suspected EVD cases, and most of the rest (335; 30%) had screened 1 to 10 suspected cases; very few (13; 1%) had screened more than 10 cases.

Table 3

Survey 3: Frequency Distributions of Selected VariablesFootnote ^a

^a Abbreviations: ED, emergency department; EVD, Ebola virus disease; PPE, personal protective equipment.

Some outcomes varied significantly by hospital size. Larger hospitals were significantly more likely to have a plan for managing EVD in the ED, to have adequate PPE, and to have screened at least one patient for EVD (Table 4). At larger hospitals, physicians were significantly more likely to have had PPE training compared to smaller hospitals; training of ED nurses and technicians did not vary by hospital size. At the smallest hospitals, Ebola preparedness was led significantly more frequently by safety management and administrative personnel and less frequently by infectious disease physicians and nurses.

Table 4

Survey 3: Relationships Between Hospital Size and Outcomes of InterestFootnote ^a

^a Abbreviations: ED, emergency department; EVD, Ebola virus disease; PPE, personal protective equipment.

^b P value: chi-square test.

^c Number of patients screened: “None” versus one or more

Most elements of Ebola preparedness varied significantly by region (Table 5). These included having enough PPE (highest in Midwest and Rocky Mountain West regions); having physicians, nurses, and technicians who received PPE training (highest in Rocky Mountain West region for both groups); and having screened at least one patient for EVD (highest in North Central and New England regions).

Table 5

Survey 3: Relationships between Outcomes of Interest and RegionFootnote ^a

^a Abbreviations: ED, emergency department; EVD, Ebola virus disease; PPE, personal protective equipment.

^b P value: chi-square test.

^c Excludes “unsure” responses.

^d “None” versus “1-10” versus “11+.”

^e Number of patients screened: “none” versus one or more.

We first used bivariate analysis to assess factors potentially associated with a hospital’s ability to screen and admit an EVD patient rather than screen and transfer. Hospitals that were more likely to be able to admit an EVD patient were larger, had adequate PPE, had physicians or nurses who had received PPE training, had already screened at least one patient for EVD, or had Ebola preparedness efforts led by infectious disease physicians and nurses (Table 6).

Table 6

Survey 3: Factors Potentially Associated with Ability to Screen and Admit an EVD PatientFootnote ^a

^a Abbreviations: ED, emergency department; EVD, Ebola virus disease; PPE, personal protective equipment.

^b P value: chi-square test.

^c Excludes “unsure” response.

^d Excludes “still being decided” response.

^e Yes/no by admit or transfer.

^f None versus one or more by admit or transfer.

To gain further insight we used logistic regression to evaluate the relationship between each factor from Table 6 and a hospital’s plan to either screen and admit or screen and transfer EVD patients. Through sensitivity analysis and forward stepwise model fitting, we determined that only 3 factors had independent and statistically significant relationships to the dependent variable at a standard threshold of 0.05: (1) annual ED census, (2) the number of potential EVD patients the hospital had screened, and (3) whether infectious disease physicians and nurses led the preparedness efforts. Each of these factors had an independent positive relationship with a hospital’s self-determined capacity to admit EVD patients. The odds ratio that a hospital is capable of screening and admitting EVD patients increases by 1.57:1 as the hospital daily census increases across size categories. Similarly, the odds ratio increases by 2.4:1 as the hospital gains experience screening EVD patients. Finally, the odds ratio that the hospital will be capable of admitting EVD patients increases by 1.64 when infectious disease physicians and nurses lead preparedness efforts.

Qualitative Results

The qualitative data in this third survey derived from one open-ended question that asked respondents for anecdotes in dealing with Ebola. The largest number of comments related to PPE availability and training. Most hospitals had either trained their staff in PPE use, including practical training in donning and doffing, or were in the process. However, many questioned the adequacy of the PPE and felt that there was not enough post-training practice to ensure that skills for PPE remained current.

Several respondents commented on their hospital’s overall level of preparedness. Some described efforts to prepare for Ebola, such as establishing patient screening and isolation areas in underutilized hospital spaces. Ebola preparedness—especially PPE availability and training, hospital drills, and “false alarms” of patients who were ruled out—increased staff confidence in some hospitals. Moreover, the drills helped to identify preparedness gaps, such as guidance for laboratory specimen handling. Some respondents perceived a gap between their hospital’s ability to plan and to execute, commenting that their training did not adequately prepare them to manage Ebola.

Respondents tended to support a collaborative regional approach to EVD management. Well-exercised hospital plans were important, but the quality and level of detail in hospital plans seemed to vary widely. Moreover, in areas that took a regional approach to Ebola management, the burden for planning was shared among facilities and the process was cooperative; respondents from such areas expressed more comfort with their plans.

Many respondents commented on hospital leadership in Ebola preparedness, including both who the leaders were (or should be) and their effectiveness. Respondents commented most favorably on multidisciplinary leadership schemes, especially those that include infectious disease and ED physicians and engaged frontline practitioners. Administrative and corporate leadership schemes received the most negative comments.

Many respondents voiced concerns about the burden that Ebola preparedness was placing on their EDs. One characterized the burden as “crippling” when even one patient is admitted to the ED to rule out EVD; the 72-hour rule-out can lead to closing down part or all of the ED and take clinicians “off-line” for quarantine or disrupt hospital services. Others noted that being designated as an Ebola treatment center stigmatizes the hospital and can reduce patient volume.

Many respondents commented on ethical issues. They expressed concerns about the fairness to both the suspected Ebola patients and others in the ED and whether some hospital policies violated the Emergency Medical Treatment and Labor Act (EMTALA). In one instance, the hospital administration had directed the hospital to refuse treatment to any suspected Ebola patients.

Several respondents suggested potential roles for ACEP to improve preparedness. For example, ACEP might explore alternative approaches to reduce ED burden while maintaining the norms of safety, medical ethics, and legality.