With the newly minted Ebola "czar" now in place, it is time to take a look at how to treat future Ebola patients. The Centers for Disease Control and Prevention (CDC) has released updated guidelines, including equipment and processes, to better protect healthcare workers from the virus; however, this is just one aspect of the care for such patients. To date, one patient was taken care of in a community hospital environment, and that endeavor ended poorly. With no slowing of the spread of Ebola in western Africa, the probability of another Ebola patient entering a community hospital in the United States is still concerning. In looking at the lessons learned in the case of Mr Duncan in Dallas and the ensuing social disruption, it seems only logical that all patients with Ebola virus infection should be treated in a biocontainment facility. Here are eight reasons why.
Hospitals are poorly prepared to take care of complex Ebola patients. As we have seen in the case in Spain as well as in Dallas, just because hospitals have medical personnel capable of treating infectious diseases, intensive care capabilities, and an understanding of infection control, these are not surrogates for taking care of complex patients with highly infectious diseases. A lack of respect for the virus, and perhaps some hubris on the capabilities of the US healthcare system, has brought us to this point.
We need to assure a high standard of care. It is a standard of care in medicine to move patients to higher levels of care when a patient has exceeded a hospital's capacity and capability. This occurs every day when patients with significant trauma are taken directly to designated trauma centers, bypassing other community hospitals, or are transferred to trauma centers after being stabilized. This construct is accepted by the medical community and should be used as a model for the treatment of patients with Ebola.
It is essential to lower the risk for community healthcare workers. The prospect of potentially training thousands of healthcare workers to effectively take care of a rare but lethal disease over the course of the patient's illness, where the probability of contracting the virus increases as the patient becomes progressively sicker, is fraught with error. It is unrealistic and unethical to ask healthcare workers who have never taken care of patients with such a disease, have never been trained to work in the required personal protective equipment, and have no experience in working in such a high-risk environment, to care for these patients when an alternative, such as a specially built biocontainment center, is available. Healthcare workers can be trained to isolate, perform diagnostics to confirm Ebola, and then prepare patients for transport. Beyond this and we are beginning to increase risk for little benefit.
Precious community healthcare resources must be managed judiciously. The amount of resources that a community healthcare center would devote to a single highly infectious patient diverts attention away from normal operations. It is not just the healthcare team that is now taken out of commission for a considerable period of time, assuming a 21-day monitoring period for all who are exposed, but now the community hospital must deal with the media, security, and all of the other issues that come with caring for these types of patients. Placing patients in biocontainment centers allows the hospital to get back to normal operations and meet the needs of the community it serves. Alexander Garza, MD, MPH
We should match the United States' clinical policies on Ebola to our existing research protocols. Performing research on Ebola is restricted to the highest-level laboratories in the world—a biosafety level 4 (BSL-IV) laboratory. These laboratory workers are well trained, follow intensive protocols, and have robust security systems to ensure that there are no adverse events. Even a single mishap involving Ebola sends shockwaves through the research community and the government. Sick patients with Ebola are teeming with the virus; our clinical policy should match the research policy.
We should expect a minimal number of patients with Ebola in the United States. The low likelihood of a large-scale outbreak has been preached since day one and is still correct. Given that there will be few patients with this rare yet deadly disease in the United States, having all of the patients treated at these specialized facilities would not cause an undue burden. If more capacity is needed, as Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, discussed on the Sunday talk shows this past week, then the CDC should consider designating treatment centers in high-population areas, including New York, Los Angeles, and Chicago.
Instead of Ebola SWAT teams, we need Ebola extraction teams. Teams of professionals, such as the recently constituted Department of Defense teams, should be designed to move quickly into a community and stabilize and remove the patient from a high-risk environment and into a more secure, lower-risk environment, allowing the community to resume normal operations.
We must concentrate both research and knowledge. Placing all patients with Ebola into biocontainment facilities will allow reliable data collection as well as a single place for experimental therapy to be delivered. This will build a fund of knowledge that can then be distributed to other countries. Having patients dispersed into multiple community hospitals will hinder these efforts.
This may become a moot point with the states already making plans ahead of the CDC. At least two states, New York and Texas, have already announced that all confirmed Ebola patients will be treated at specific hospitals. This makes sense because it is the states that are ultimately responsible for the care of the citizens. However, it would be comforting and appropriate for the CDC or other federal entity to clarify exactly what that means and institute a process where all confirmed patients are treated at these specialty centers. This is what is best for the healthcare workers, the community, and the patients.