Abstract
In February 2015, the US Department of Health and Human Services developed a tiered hospital network to deliver safe and effective care to patients with Ebola virus disease (EVD) and other special pathogens. The tiered network consisted of regional special pathogen treatment centers, state- or jurisdiction-designated treatment centers, assessment hospitals able to safely isolate a patient until a diagnosis of EVD was confirmed and transfer the patient, and frontline healthcare facilities able to identify and isolate patients with EVD and facilitate transport to higher-tier facilities. The National Emerging Special Pathogens Training and Education Center (NETEC) was established in tandem to support the development of healthcare facility special pathogen management capabilities. In August 2020, 20 hospitals that previously received an onsite readiness consultation by NETEC were surveyed to assess how special pathogen programs were leveraged for COVID-19 response. All surveyed facilities indicated their programs were leveraged for COVID-19 response in at least 1 of the following ways: NETEC-sponsored resources and training, utilization of patient isolation spaces, specially trained staff, and supplies. Personal protective equipment shortages were experienced by 95% of facilities, with 80% of facilities reporting that special pathogens program personal protective equipment was used to support facility response to COVID-19 admissions. More than half of facilities (63%) reported leveraging biocontainment unit staff to provide training and education to frontline staff during initial response to COVID-19. These findings have implications for planning and investments to avoid the panic-then-forget cycle that hinders sustained preparedness for future special pathogens.
Introduction
High-consequence infectious diseases emerge and reemerge, as exemplified by the 2002-2004 severe acute respiratory syndrome outbreak, the 2015 Middle East respiratory syndrome outbreak, multiple Ebola virus disease (EVD) outbreaks over the last decade, and the current COVID-19 pandemic. The 2014-2016 EVD outbreak in West Africa revealed gaps in the capacity of global health systems to manage special pathogens, and many countries throughout the world were compelled to assess their own preparedness and response capacities and to invest in readiness efforts. In response to this outbreak, in early 2015, the US Department of Health and Human Services (HHS) began to systematically invest in hospital-based preparedness and response initiatives for special pathogens. 1
The US HHS developed a tiered national hospital system for special pathogen patient care that includes 10 Regional Emerging Special Pathogen Treatment Centers (RESPTCs), previously referred to as Regional Ebola and Other Special Pathogen Treatment Centers; state and jurisdiction special pathogen treatment centers (SPTCs); assessment hospitals; and frontline healthcare facilities. 2 A frontline facility encompasses any organization where a patient may present seeking medical care; these facilities focused on developing and sustaining the ability to identify persons suspected of having a special pathogen, provide temporary isolation and stabilizing care, and promptly inform local public health partners. Healthcare facilities designated as RESPTCs, SPTCs, and assessment hospitals were required to establish capabilities for special pathogen care, including the ability to (1) quickly identify and isolate individuals suspected or confirmed to have a special pathogen, (2) provide access to laboratory testing to confirm or rule out the presence of a special pathogen, and (3) coordinate either admission for care or transport to a higher tiered facility for treatment. RESPTCs and SPTCs were also required to have staff preidentified and trained to provide comprehensive and definitive inpatient care for individuals confirmed to have a high-consequence infectious disease. 2 Differentiation of requirements for frontline facilities and the higher tiers of designated facilities primarily focused on training and education expectations for staff that would respond to a special pathogen event, identification and enhancement of care spaces for isolation of individuals suspected or confirmed to have special pathogens, and the duration and level of care that would be provided by each facility. 2 The US Assistant Secretary for Preparedness and Response and the US Centers for Disease Control and Prevention established the National Emerging Special Pathogens Training and Education Center (NETEC), a consortium of Emory University, the University of Nebraska Medical Center, and NYC Health + Hospitals/Bellevue. NETEC was established to assess healthcare facility readiness, train healthcare providers, offer assistance in operational and clinical matters, and administer a rapid response research network.
NETEC surveyed SPTCs, assessment hospitals, and frontline facilities that had previously undergone in-person readiness consultation with NETEC to assess how their special pathogen preparedness capabilities were leveraged for COVID-19 pandemic response. The study aimed to assess the ways previous special pathogen preparedness efforts—including NETEC and RESPTC initiatives and engagement with these facilities—affected their COVID-19 response, focusing on individual facility success and challenges.
Methods
In July 2020, NETEC developed an online survey to examine how hospitals within the tiered US system for special pathogens leveraged these unique programs to respond to the COVID-19 pandemic. In August 2020, NETEC distributed the electronic survey via email to a convenience sample of representatives at 39 state- and jurisdiction-designated special pathogen treatment centers, assessment hospitals, and frontline facilities that had participated in a single readiness consultation with NETEC between 2016 and 2020, which was designed to assess special pathogen preparedness and response efforts. RESPTCs were excluded from the sample based on their annual consultations with NETEC and their participation in a separate process that addressed analogous and more extensive evaluation of special pathogen programming between December 2019 and May 2020.
The 32-question survey, developed and administered through Qualtrics (SAP, Seattle, WA), included 3 distinct sections: demographics, special pathogen system support, and facility-specific COVID-19 response. The survey included 10 open-ended questions, 12 dichotomous questions (eg, yes or no), and 10 multiple choice questions (eg, users select their response from a list with an option to provide other responses). The questions were designed to (1) determine how facilities appreciated the impact emerging special pathogen capabilities had on COVID-19 response; (2) provide an understanding of how NETEC and RESPTC initiatives served hospital COVID-19 response activities, and (3) identify successes and challenges experienced in COVID-19 hospital response. The survey allowed participants to opt out of questions, except demographics, so not all questions were answered by all respondents. Data analysis reflects item nonresponse in totals. Basic descriptive statistics (eg, numbers and percentages) were used for the dichotomous and multiple-choice questions. Inductive qualitative analysis, specifically in vivo coding, was used to identify emerging themes from the open-ended questions. Two researchers independently examined the data for themes and reached consensus, and in instances of different interpretations, a third researcher was brought in to reach final consensus. Imputation was used to replace missing data based on information from other questions in the survey.
Results
Demographics
Of the 39 facilities invited to participate, 20 (51%) completed the survey: 7 state- and jurisdiction-designated SPTCs, 11 state- and jurisdiction-designated assessment hospitals, and 2 frontline facilities. Additional survey responses were received after analysis of data used to draft the 2020 NETEC annual report 3 ; those responses are included in this article. Respondents reflect a broad geographic distribution of facilities across the United States, with 7 of the 10 US HHS regions represented (Table 1).
Regional Distribution and Type of Responding Facilities
Abbreviation: DHHS, US Department of Health and Human Services.
Special Pathogen System Support
Five of the survey questions were designed to discern specific ways that special pathogen programs were leveraged to support facility response to COVID-19 (Table 2). Eighteen (90%) of the facilities noted that at least 1 component of their special pathogen program was used to augment response to COVID-19. State- and jurisdiction-designated SPTCs most frequently reported use of special pathogen program components to support COVID-19 response. Of the 19 responding facilities, 12 (63%) reported using a designated biocontainment unit space for initial or continued admissions of patients with COVID-19. Homogeneity was most evident in responses from SPTCs and assessment hospitals related to utilization of special pathogen space and supplies, with about 70% of both tiers using their designated biocontainment unit space for admission of COVID-19 patients. Despite all of these facilities noting use of the space, there were differences in the ways these spaces were used. One facility noted that admitting initial patients to the designated biocontainment unit enabled them to develop workflows to provide safe and effective care for COVID-19 patients while preparing additional surge units throughout the hospital. Another noted that portable negative-pressure units purchased for the biocontainment unit were used to outfit other hospital rooms for patients with suspected and confirmed SARS-CoV-2 infection.
Special Pathogen Program Support for Hospital COVID-19 Response Efforts
Total responses may not equal 100% due to missing responses for some questions.
Special Pathogen Treatment Centers were previously named Ebola Treatment Centers. Abbreviation: NETEC, National Emerging Special Pathogens Training and Education Center.
Rostered biocontainment unit staff were leveraged by the 19 responding facilities to provide training and education during a facility's initial response to COVID-19 (n = 12, 63%) and to care for patients with confirmed or suspected COVID-19 (n = 10, 53%). Respondents from SPTCs and assessment hospitals reported rostered biocontainment unit staff supported organizational initiatives, such as respirator fit testing, serving as safety officers in active care areas, and serving as liaisons to educate and train frontline staff on current and changing clinical guidelines. One respondent noted,
their primary role was to help staff feel safe by providing a calm, thoughtful presence and educating staff on guidance […] the role was not intended to provide patient care but rather act as a quality assurance lead outside the patient care room, visually confirming all infection prevention practices are safely followed and providing real-time coaching.
Sixteen facilities (80%) used special pathogen program personal protective equipment (PPE) to support hospital COVID-19 response (Table 3). Twelve (63%) of 19 facilities reported just-in-time training plans developed for special pathogen preparedness were able to be adjusted to support hospital or health system COVID-19 training needs. Fewer than half of the 19 facilities (n = 8, 42%) addressed healthcare worker resilience in special pathogen training. Six (75%) of the 8 facilities with special pathogen healthcare worker resilience training deployed resilience training as part of COVID-19 response. Cached PPE held for special pathogen activations were deployed to COVID-19 hospital units to bridge gaps in supply chain integrity. Survey respondents noted that the presence of expanded PPE inventory acquired to support the special pathogens program provided an advantage during the response efforts. Respondents specifically reported being able to use N95 respirators, powered air-purifying respirators, gowns, and gloves from these caches. Despite having these additional resources, all respondents reported experiencing substantial supply shortages. Many reported implementing reuse strategies for single-use equipment and having to modify procedures to accommodate decreased inventory.
Personal Protective Equipment Supplies and Reuse Strategies
Total responses may not equal 100% due to missing responses for some questions.
Special Pathogen Treatment Centers were previously named Ebola Treatment Centers. Abbreviations: PPE, personal protective equipment; SPTC, Special Pathogen Treatment Center; UVGI, ultraviolet germicidal irradiation; VHP, vaporized hydrogen peroxide.
Facility-Specific COVID-19 Response
Fourteen (74%) of 19 responding facilities indicated adequate staffing plans were in place to support a surge of COVID-19 patients. Of the 5 (26%) facilities reporting inadequate surge staffing plans, challenges enumerated included managing float staff, managing quarantined staff, and matching available staff with patient acuity demands (Table 2).
However, nearly all of the 20 facilities (n = 19, 95%) reported shortages for PPE and other essential supplies (Table 3). Among those facilities, the most common PPE shortages were for N95 respirators (n = 18, 95%), followed by face shields (n = 16, 84%), procedure masks (n = 15, 79%), gowns (n = 13, 68%), goggles (n = 11, 58%), and gloves (n = 4, 21%). Most facilities (n = 15, 79%) also reported a shortage of hand sanitizer, making it the most frequently selected item outside of PPE. All 20 (100%) of the facilities reported implementing PPE reuse strategies, with the most frequent items noted to be N95 respirators (n = 18, 90%), face shields (n = 18, 90%), goggles (n = 12, 60%), procedure masks (n = 10, 50%), and gowns (n = 10, 50%). Almost all (n = 18, 95%) of the facilities noted that strategies to reprocess PPE for reuse had been developed and implemented in their facilities for items in critical shortage. Of these facilities, 7 (39%) used vaporized hydrogen peroxide, 6 (33%) used ultraviolet germicidal irradiation, and 3 (17%) used both vaporized hydrogen peroxide and ultraviolet germicidal irradiation to reprocess PPE. One facility (6%) reported that it used ionized hydrogen peroxide to reprocess PPE, and 1 facility (6%) reported it used manual disinfection alone.
Of the 20 responding facilities, 17 (85%) reported previous interactions with NETEC and the comprehensive nonpunitive peer-review readiness consultation process helped their facility with preparedness and/or response efforts for COVID-19, particularly through training and education and by updating policies and procedures based on guidance received from the consultation team. Thirteen (65%) facilities used NETEC training and educational resources (eg, webinars, training videos, infographics) to support hospital COVID-19 response.
Responding facilities that noted participating in the readiness consultation process further detailed that these consultations provided a great opportunity to exercise the defined procedures, identify deficiencies, and make improvements before having real-world admissions from the current COVID-19 pandemic. Survey respondents expressed that the information and knowledge they gained during the consultative process, which assisted in advancing biocontainment unit preparedness, further enabled them to prepare other areas of the hospital when COVID-19 was imminent. One respondent reported that the discussion of shared experiences, best practices, and direct feedback on process improvements helped to move their program forward and those practices directly informed their COVID-19 response. Moreover, half (50%) of the 20 responding facilities further clarified in open-ended statements that NETEC guidance—during the consultations, through educational endeavors, and communicated via online resources—was invaluable to prepare their teams and institutions to respond to COVID-19. In contrast to the positive effect a majority (n = 14, 74%) of 19 responding facilities experienced from their interactions with NETEC and the readiness consultation process, 5 (26%) reported that access or interactions with designated RESPTCs assisted the preparedness and/or COVID-19 response efforts for their facilities (Table 2).
Discussion
A recent study has shown that the development of special pathogen programs across healthcare facilities in the US patient care system improved awareness of containment principles including foundational and advanced infection prevention and control processes. 4 Our study further highlights the importance of these programs in improving preparedness for pandemics. For example, survey responding facilities highlighted that having a special pathogen program at their organization (eg, SPTCs, assessment hospitals) or having concerted efforts emphasizing special pathogen preparedness and response in their facility (eg, frontline hospitals) provided access to enhanced patient care spaces, specially trained staff, additional infection prevention and control supplies, and specialized equipment that was used to support COVID-19 response. However, utilization of these components varied across facility types, dependent upon existing tiered system requirements. Frontline facilities that responded to the survey showed the greatest discrepancy in responses. These facilities are not required to have designated space or staff for special pathogen response, thus both frontline facilities that responded to this survey reported not being able to use these assets for COVID-19 response. However, previous efforts to advance special pathogen preparedness, including participation in NETEC readiness consultation, were still seen as beneficial activities that helped their organization respond to the COVID-19 pandemic.
Healthcare workers who support special pathogen programs in designated facilities adhere to rigorous infection prevention and control standards, undergo routine training, and participate in exercises and drills to refine processes used in their biocontainment units. 5 Healthcare workers are the most valuable resource in the health system, a truism laid bare by the number of facilities that turned to those with advanced training in infection prevention and control practices received through established special pathogens programs. Special pathogen PPE caches bolstered initial increased demand for PPE but were not sufficient to address sustained COVID-19 PPE demand, resulting in hospitals implementing extended use and reuse strategies to mitigate critical supply shortages. Local, state, and federal agencies and academic medical facilities published guidance on how to implement extended use and reuse strategies for both contingency and crisis standards of care delivery during the COVID-19 pandemic.6,7 The US Centers for Disease Control and Prevention offered a series of options to enhance the use of N95 respirators when there is limited supply and recommended facilities return to conventional capacity measures as soon as possible. 8
NETEC readiness consultations provide a forum for healthcare workers on the frontlines to interact with subject matter experts from NETEC, RESPTCs, public health authorities, and institutional executives. Healthcare facilities are faced with many competing priorities, and oftentimes, the inclusion of an external group provides the catalyst needed to generate focused attention and accelerate preparedness and response efforts. 9 Undertaking this level of consultation provides an opportunity for these specialized teams to prioritize special pathogen preparedness activities during preparations for, and participation in, the readiness consultation. Providing a nonpunitive and nonregulatory environment for consultation and assessment establishes a collaborative relationship that fosters candid exploration of programmatic gaps, barriers to success, and programmatic strengths. Since the inception of NETEC, readiness consultations emphasized quality improvement and continuous learning, and this emphasis led to more transparent and collaborative discussions than regulatory approaches.
It is important to note that the initial mandate of RESPTCs was to develop a regional concept of operations focused on safe and coordinated special pathogen patient transfer, which focused on interactions with public health agencies and a limited number of hospitals. The ubiquitous presentation of patient surge across multiple regions, supply chain challenges, staffing shortages, and ever-changing guidance also limited the response and regional support efforts of all centers. These results may indicate limitations of the current system to provide regional technical assistance and training during a systemwide response and the value of expanding and formalizing the RESPTCs scope of work to include regional engagement efforts aimed at establishing more robust regional networks augmented and supported by NETEC. Future work should include focused effort to discern strategies NETEC and/or the RESPTCs can implement to more effectively assist and support state- and jurisdiction-designated special pathogen treatment centers, assessment hospitals, and frontline facilities.
NETEC is facilitating investment in the RESPTC network by integrating RESPTC subject matter experts into activities including readiness consultations and technical assistance requests in their respective regions, education and training initiatives, and the development of a National Special Pathogen System of Care. 10 Much of this work and the expansion of support from each RESPTC will require dedicated and ongoing funding, not just at the RESPTC level but across all tiers of the network. Additional focus is needed to elucidate costs associated with implementing and sustaining a special pathogen program, compared with the benefits and cost savings realized by institutions that are able to use these programs to support daily operations and special pathogen events. While funding and resources have been allocated to NETEC and RESPTCs, funding directed to state and jurisdictional facilities for dedicated special pathogen preparedness and response activities has varied greatly and, in many instances, completely lapsed. This represents a profound oversight in the effort to maintain a national system for special pathogen response. Implicit in preparedness initiatives is the fact that individuals with special pathogens can present to any healthcare facility: a critical access hospital in Valentine, Nebraska; a pulsing emergency department in Brooklyn, New York; or a long-term care facility in Kirkland, Washington. Adequate education and readiness efforts at each level of the system may mean the difference between successful containment and global pandemic. 8
This study has limitations that should be considered when interpreting and generalizing the results. First, the small sample size is not reflective of the entire US healthcare system but is a representative sample from the exclusive group of hospitals designated as special pathogen facilities.1,2 The types of facilities that comprised the sample included frontline facilities, assessment hospitals, and special pathogen treatment centers; however, only 2 frontline facilities were surveyed, which may limit generalization of findings to frontline facilities. Each tier of facility has different capability requirements, which influences resources dedicated to the special pathogen program. Frontline facilities are not required to have dedicated space or rostered staff for special pathogen response teams, thus potentially impacting their ability to answer all questions in the survey. The survey design included dichotomous questions and did not provide “not applicable” as an answer choice. Respondents were able to provide open-ended statements to further qualify their responses. Finally, this survey was conducted in August 2020 while many facilities were experiencing substantial challenges due to the pandemic, potentially impacting their ability to respond and provide a comprehensive review of programmatic benefits of special pathogen preparedness efforts on COVID-19 response.4,11,12 Lessons learned from the prolonged response to COVID-19 related to surge capacity, staffing challenges, supply chain integrity, inventory management, and use of PPE, must be considered and merit follow-up assessment and evaluation. This analysis provided unique insights to the real-life experience of hospitals with special pathogen programs, focused special pathogen preparedness and response efforts, and should be contrasted with nonspecial pathogen hospitals to inform generalization of findings to the broader healthcare system.
Conclusion
The inception of a US tiered system for special pathogen treatment of care in 2015 marked the beginning of a new era for the healthcare system preparedness and response efforts for high-consequence infectious diseases. While this study demonstrates the benefits realized from having a special pathogen program by a sample of these facilities, additional research is needed to fully realize and appreciate the impact these programs can have on hospital operations. We need future studies to examine the capacity and capability of healthcare facilities that report having special pathogen programs; the costs associated with implementing and sustaining these programs; return on investment for individuals, facilities, and health systems; and the implications of such a system on public health and global health security.
Footnotes
Acknowledgments
The authors express sincere gratitude to the special pathogen facilities for their ongoing collaboration with NETEC and for participating in this survey during ongoing pandemic response. The authors would like to acknowledge Stephanie Zechmann, NETEC readiness consultation coordinator at Nebraska Medicine, and Andrea Echeverri, NETEC program director at Bellevue Hospital, NYC Health + Hospitals, for their valuable comments and suggestions provided to improve the quality of this manuscript. The authors acknowledge NETEC evaluators Sarah Anderson-Fiore, MPH, CHES, and Chimora Amobi, MD, MPH, at Emory University for their technical support developing the survey used in this project. The views expressed in this article are those of the authors and do not necessarily reflect the views, assertions, opinions, or policies of their respective institutions, the US Department of Health and Human Service, the US Centers for Disease Control and Prevention, or the Office of the Assistant Secretary for Preparedness and Response. NETEC is funded by the Office of the Assistant Secretary for Preparedness and Response, CFDA #93.825.