A page from his chief operating officer at Emory University Hospital (EUH) on August 31, 2014, alerted Charles E. Hill, MD, PhD, FCAP, that an evacuee who had tested positive for Ebola Virus Disease (EVD) was en route to Emory's Serious Communicable Diseases Unit (SCDU).
Dr. Hill, an associate professor of pathology and laboratory medicine at the Emory University School of Medicine and medical director of the SCDU, says the Ebola team had been expecting that news—and not. Tightly scripted, frequently drilled safety and infection control procedures had long-since dictated the hospital's priorities. The team had practiced donning and doffing personal protective gear (PPG) and talked about effective safety meaning consistent use of all the gear they had trained on. They had executed patient care maneuvers while wearing impermeable suits, double gloves, and face shields.
Still, the 12-year-old, high-level biocontainment facility had never before hosted a patient for any length of time—which would turn out to be three weeks on average. And in three days, they would take responsibility for the care of Kent Brantly, MD, a humanitarian volunteer and the first patient with EVD to be treated on US soil.
Ebola had been much in the news, generating anxieties among patients, families, and hospital neighbors. Dr. Hill, a molecular and genetic pathologist who is also director of the EUH Molecular Diagnostics Laboratory, knew that clear, timely internal and external communication would be critical. And if patient census metrics were any measure, they nailed it. "The message from our communications office was that safety was high priority," he says, "and the public heard that message. Our patient volumes actually went up while the SCDU was activated."
Everyone on the SCDU Ebola team was a volunteer, including infectious disease physicians, pathologists, critical care nurses, and laboratory professionals "It was an extremely high-functioning, fully integrated team," Dr. Hill says. "The bond we formed was extraordinary."
Emory's decision to build a family waiting room within the unit proved to be a powerful motivator, Dr. Hill says. It was also a metaphor for the family-centered care and institution-wide commitment that enabled the recovery of all four EVD patients who eventually occupied the SCDU. Environmental health and safety, occupational injury management, facilities engineering, and communications personnel had their roles. It was the occupational injury management team, for example, that enabled the team to capture warning signs of trouble in real time. "We were monitoring our temperature twice a day and logging in to report it on the electronic tool," Dr. Hill says. "If you hadn't logged in one night, you got a call from OIM the following morning."
The SCDU plan1 called for a degree of biocontainment substantially exceeding that required by the Centers for Disease Control and Prevention (CDC). Initially, critical care nurses inside the patient room performed a limited menu of assays using standard point-of-care (POC) instruments, and a Class 2 biosafety cabinet was positioned in an anteroom to accommodate more complex testing. But by the time the team learned that a second Ebola patient was en route, it was clear that the configuration would not safely accommodate the traffic. "So the Emory facilities group recreated our laboratory in what had been a small office," Dr. Hill says. "They redid the ductwork, got us negative pressure, and realigned the temperature to protect blood-gas calibration quality—all in 24 hours."
Each morning, the SCDU team convened for a clinical update from the overnight staff and collective recommitment to standard operating procedures (SOPs). In time, "clinical update" was shortened to "family meeting." And their shared accountability was captured in the "family rules." (See Table 1 below.)
Dr. Hill had seen the value of safety protocols as a CAP Laboratory Accreditation Program inspector. "It really changed the way we thought about safety," he says. "The family rules were almost a mantra; we would go through them as a group every day. I can still quote them off the top of my head."
Table 1 – SCDU Family Rules
|1.||I will follow all SOPs to the best of my ability.|
|2.||I will ensure all others follow SOPs|
|3.||I will report any new signs and symptoms in myself.|
|4.||I will report any clinical changes and any new medical conditions in the patients.|
|5.||I will report any and all near-misses or incidents|
The tip of the aftermath
It was during follow-up testing for their third patient, Ian Crozier, MD, an infectious disease physician who had contracted EVD in Sierra Leone, that uncertainties about sequelae became hauntingly concrete.
"I vividly remember the staff member who was doing the testing on the aqueous humor from [Dr Crozier's] eye," says Dr. Hill. "None of us were anticipating that he would be positive; he was 14 weeks from initial symptoms and had been discharged. But when I called down and asked for the lab results, they said, 'you're not going to believe it—the eye fluid is positive.'"
"We did a collective inhale and went right back into our standard safety mode," Dr. Hill remembers. "Everybody got involved again as though we had an active patient in the unit." That infection nearly blinded Dr. Crozier, who has since contributed to the literature on Ebola and given talks about precautionary measures. Although his uveitis has resolved, he has other lingering symptoms, as do other recovered Ebola patients.
Dr. Hill is among many who believe these kinds of crises are likely to recur. Through the National Ebola Training and Education Center, he is collaborating with colleagues from high-containment units in Maryland, Missouri, Nebraska, and New York to prepare personnel at CDC-designated patient assessment and treatment hospitals. The CDC has added 54 facilities to its Laboratory Response Network, dramatically expanding testing capacity and collapsing turnaround time.
"This was a wake-up call," Dr. Hill says. "Every section of the laboratory needs to look at safety precautions and how we can make sure that we positively reinforce doing the safety procedures the same way every day, even every hour."
1. Hill CE, Burd EM, Kraft CS, Ryan EL, Duncan A, Winkler AM, et al. Laboratory test support for Ebola patients within a high-containment facility. Lab Med. 2014;45(3):e109–111. doi: 10.1309/LMTMW3VVN20HIFS.