What worked during Ebola: An open letter to healthcare facilities

By Michelle Niescierenko MD, MPH and Bernice Dahn MD, MPH, FLCPS, FWACP

The spread of COVID-19 across the globe is a clear indication that there are always weaknesses in every health care delivery system, and we need to better understand them. During outbreaks, the public cannot triage or diagnose themselves with the novel offending pathogen. This makes healthcare facilities ground zero — where patients must go to get diagnosed and receive care.

Just as public health advocates have instituted a radical reframing of American life in order to address the pandemic, American medical facilities too must reframe their “business as usual” procedures. This shift has been successfully executed before in hospitals around the world and it can be done at home too.

We did it during the West African Ebola outbreak in Liberia. Across 23 hospitals, with 3,779 healthcare workers, 80 metric tons of supplies and a dedicated team of 50 that kept the hospital doors open, we managed zero patient or healthcare worker Ebola infections.

We reached a zero infection rate at our hospitals through empowering healthcare workers to rigorously implement new strategies for infection control using common principles customized to the unique situation of to each hospital.

Healthcare facilities in the US and abroad can learn from our lessons in curtailing the Ebola outbreak and change now for everyone’s sake. They can also add to our collective knowledge with their innovations in public health — something that is usually deferred in favor of more cutting-edge science.

Here is what worked for us:

Change is hard but necessary.

To successfully implement emergency infection control in the Liberian health system for a highly infectious pathogen such as Ebola, we applied a train, mentor, supply and improve approach. We then trained and empowered a team of Liberian healthcare workers to go into each hospital like a SWAT team and apply this strategy.

They equipped the staff from each hospital with the knowledge needed to keep providing services in the context of the outbreak. They then mentored them to apply new concepts to their clinical space while making the hard changes effecting patient flow and physical set up necessary to keep everyone safe. Each hospital was provided with the materials needed to do what they learned and maintain newly implemented changes. Lastly, healthcare workers were given agency to improve or fix whatever was broken or buy items necessary to make a functional space, like shelves for storing eye protection. Ultimately, the team reconfigured healthcare environments to optimize conditions for patient care and healthcare worker safety. Reconfigure is a nice word for change because change is hard but necessary.

Empower healthcare workers.

Physicians, nurses, registration staff and cleaners are all precious resources. Without them you have an empty building, not a hospital or clinic. Like other first responders, healthcare workers run towards the so-called fire and need to be educated, empowered and mobilized to support the facility’s response to putting that fire out. They are all smart individuals who have capacity to understand a response plan and their role in carrying out that plan as a team. Engage them in the plan to ensure full, unwavering participation.

Communication is key.

Using structured response systems like incident command or incident management frameworks is critical. However, these systems are often misused allowing information to flow downstream but not back up again. The key to empowering healthcare workers to keep providing care is providing them a place to give input and be heard. The power of being heard and having concerns validated even if they cannot be addressed should not be underestimated. It prevents harmful rumors from spreading and behaviors going ‘underground’ only to resurface later as a problem.

Reconfigure your space.

Apply public health principles to gradually narrow the circles of risk within your facility. Screen everyone upon entering the building for symptoms, perform medical triage at the point of first clinical care, cohort patients by risk categories while providing care, further cohort patients by test results when available, then disposition carefully considering vulnerable populations in the community and good discharge teaching.

To reconfigure what are normally very streamlined and formal processes in hospitals and clinics will require new vision. Take a step back and truly look at your space. You will need to flow patients through it differently, you will need to perform different functions in different spaces than normal. Step out of the box — reconfiguring will require critical self-appraisal of what can be done safely where — from both infection control and patient safety perspectives.

Be Flexible.

Healthcare workers are going to have to be flexible. In order to reconfigure space, you will need to move the healthcare workers to where the patients are — not the patients to the healthcare workers. This may mean floating to different units, moving between departments or performing a new role that didn’t exist before. Physicians need to be willing to do nursing tasks like vital signs and comfort measures and we will rely on nurses’ strong clinical assessments as we minimize traffic into high risk areas.

Triage is no longer just for the ER.

It becomes an ongoing process that starts with identifying those patients, visitors or staff who meet the case definition upon arrival at the hospital. Then comes medical triage to determine the severity of illness for the patient. This is where triage usually ends. Our patients, however, don’t know this and continuously evolve with new symptoms, like fevers, at any time. We have to be alert to apply the case definition when this happens and immediately activate all the downstream changes in precautions, PPE and cohorting that go with it.

Personal Protective Equipment (PPE)

We need to innovate our care to reduce use and come up with new PPE ‘hacks’ while the suppliers catch up to this sudden increase in demand. These hacks should be evidence based and tested. While the life sciences community is working on drugs, vaccines and clinical diagnostics our engineering and materials science colleagues could be testing new PPE hacks to help ensure they are safe substitutes for what we commonly use.

Engage your community of health workers.

Everyone in the healthcare facility is part of the ecosystem — participation can’t be optional and groups cannot be excluded. Ways to motivate, encourage, reassure, train, laugh, participate and care for the patients and each other must be embedded into all processes. Additionally, everyone must be their neighbor’s keeper during a time of crisis. American values of individualism and self-reliance will not help to slow transmission. Collective action and communal responsibility will.

We know these things work because we did them to stop the spread of Ebola in Liberian hospitals among patients and healthcare workers. In our nine months of teamwork from 2014 to 2015 we managed zero patient and zero healthcare worker infections across 23 hospitals. Zero.

To get to zero, healthcare facilities need to look at their disaster and response plans and think about the modifications needed for this pandemic. It is likely that the lengthy duration of this outbreak risks excess morbidity and mortality in our patients from their underlying diseases and new undiagnosed conditions that will go untreated. Healthcare facilities need to treat this as a new normal to get ahead of the curve, keep patients cared for across all needs, and maintain healthcare worker safety. This will require implementation of new systems and strategies and call for significant change. Change is hard but this is not business as usual. As we say in Liberia — Keep Safe, Keep Serving.

Michelle Niescierenko MD, MPH is the Director of the Global Health Program and Pediatric Emergency Medicine at Boston Children’s Hospital. She is also an Assistant Professor of Emergency Medicine & Pediatrics at Harvard Medical School and faculty at the Harvard Humanitarian Initiative.

Bernice Dahn MD, MPH, FLCPS, FWACP is the Vice President/Executive Dean for Health Sciences at the University of Liberia and former Minister of Health for the Republic of Liberia.