Treating Ebola Patients in the United States: Health Care Delivery Implications
Amanda K. Sarata, Specialist in Health Policy (firstname.lastname@example.org, 7-7641)
November 4, 2014 (IN10173)
On September 30, 2014, the Centers for Disease Control and Prevention (CDC) confirmed the first case
of Ebola diagnosed in the United States. This patient was the first in the United States to be treated for
Ebola outside of a specialty hospital with a biocontainment unit. Shortly after this diagnosis, CDC
Director Thomas Frieden expressed his confidence in the U.S. health care system, stating that we will
"stop Ebola in its tracks." Despite the assurances, two nurses who cared for the patient were diagnosed
with and have since recovered from Ebola. In the wake of these additional cases, Dr. Frieden stated
that the agency has had to reconsider its approach to containing the disease. In addition, the hospital
where the patient received his care, Texas Health Presbyterian Hospital, has stated that it may have
done things differently.
While the U.S. health care system has the resources to effectively identify and treat Ebola cases, a
situation that is novel, emergent, and resource-intensive may test the system's ability to effectively
mobilize those resources. The care of the initial U.S. patient highlighted several system delivery issues,
including (1) inefficient use of finite healthcare resources due, at least in part, to gaps in preparation;
(2) challenges in coordination between local, state, and federal public health systems and the health
care delivery system, including in basic infection control procedures; and (3) care coordination issues.
This Insight focuses only on the first issue.
All components of the health care system are actively responding to these issues by identifying,
learning from, and disseminating lessons learned. The adaptability of the system may be tested in the
coming months, as experts predict that additional Ebola cases are possible as long as the outbreak
persists in West Africa.
Resource Use or Diversion
Care for the first U.S. Ebola case—and subsequent care for suspected or confirmed cases—highlighted
issues around the use and diversion of health system resources. Decisions about resource use and
diversion may affect the system's ability to ensure access to care that is not related to Ebola, and may
impact both patient care and protection for health care providers.
Facility and Unit Closures. Texas Health put its Emergency Department (ED) on diversion status after
having treated the patient, as he was initially treated in the ED (diversion status means emergent cases
arriving by ambulance are diverted to other EDs). Subsequently, he was treated in a 24-bed ICU that
was converted into an isolation unit, thus taking 23 ICU beds out of use.
In several cases where Ebola has not subsequently been diagnosed, suspected cases have resulted in
the temporary closure of health care facilities; in addition, Bellevue Hospital in New York City has
transferred some ICU patients to an alternate hospital to facilitate treatment of a confirmed Ebola case.
Health Care Provider Staffing. The Texas Department of State Health Services has had to monitor
about 170 people, mostly health care workers, who came into contact with the patient during his illness
or the course of his care. The ambulance used to transport the patient was taken out of circulation
temporarily for decontamination, and three paramedics were taken off duty for three weeks.
As workers are taken off the job for monitoring, it creates staffing issues for the facility, and possible
subsequent access issues for patients. In addition, the use of so many health care workers in the care
of a single patient increases the possibility of exposure as well as the burden of contact tracing.
Consolidating screening (where possible) and provision of care for suspected and confirmed Ebola
cases—for example, by providing care primarily at designated regional or specialized national facilities,
using a core staff at each facility—may facilitate the health care system's ability to efficiently mobilize
resources. Such an approach could involve the regionalization of care—specialized care delivery
concentrated with certain regional providers—similar to how trauma care is organized. Recognizing that
screening may occur at any entry point to the health care system despite efforts to direct suspected
cases to specific facilities, especially among those patients who self-present, all providers would need
to be prepared to identify, isolate, and appropriately triage suspected cases (e.g., small hospitals,
primary care offices, urgent care facility).
This type of approach may serve multiple purposes, including to (1) maximize finite resources; (2)
decrease the risk of unintentional exposure; (3) decrease the burden of contact tracing; (4) preserve
access to other care for the community; (5) streamline provision of supplies, such as personal
protective equipment; (6) facilitate oversight efforts at the state and federal levels; and (7) facilitate
staff training in care delivery and infection control procedures.
Specific steps could include those listed below, among others, and could be assisted and supported at
the federal level, with state and local entities responsible for implementation:
Designating specific medical facilities as preferred entry points for suspected cases (as has been
done in New York); an entry point to each facility other than the ED may be considered to
minimize disruption to other care.
Educating the public, primary care providers, Emergency Medical Services (EMS), and others
about where to seek care or send suspected cases.
Identifying a limited, well-trained core staff at each of these facilities to provide screening,
evaluation, and treatment.
Referring confirmed Ebola cases, when needed, to one of four specialized hospitals that have
biocontainment units (Emory University Hospital, Nebraska Medical Center, the National Institutes
of Health, and St. Patrick Hospital).
The dissemination of best practices could be facilitated at the federal level; for example, as the four
specialized hospitals gain experience treating Ebola patients, and they identify best practices, CDC (or
another agency, e.g., Agency for Healthcare Research and Quality) could disseminate them and/or
provide technical assistance to other large regional hospitals for their implementation. This could
potentially expand the number of facilities equipped to treat confirmed Ebola cases or future disease