Named 2014’s top news story today by Katie Couric, the Ebola epidemic “raised serious questions about the capacity of US hospitals to effectively treat the disease and to protect healthcare workers treating the infected.”
Mark Jarrett, MD, is on the front line of preparation for epidemics. As the North Shore-LIJ’s chief quality officer, Dr. Jarrett discusses how hospitals can address infectious disease threats effectively in the following interview--the second installment of our Health Care Leadership series.
Dr. Jarrett reviews how the news media and the public dealt with Ebola; how the US could have been better prepared; the challenges of pandemics; and how biological containment units help to manage serious infectious diseases.
Question from Interviewer: Why did so many people get panicked over Ebola when we’ve seen these kinds of things before—like the flu and polio epidemics of the 20th Century?
Mark Jarrett, MD: The fear about Ebola was partially fomented by the media. Because Ebola comes from somewhere else and has a high fatality rate, people were much more fearful. Most people who get the flu get sick, but don’t die. Many less get Ebola, but those who do have a high mortality rate. That scares people much more. They feel there is no treatment and that most people are not going to do well if they have the disease.
Q: If you look at American news reports about healthcare--hospitals in particular--it seems that the country was woefully unprepared for something like Ebola.
Dr. Jarrett: Although we’re prepared all the time for infections, the US was not as prepared for a major infection like Ebola as it could have been.
All intensive care units have isolation rooms, so we can handle the standard infections. But an infection like Ebola requires very specific personal protective equipment and additional staff training at a high level. In the United States, we did not have enough personnel trained at that level, nor the equipment ready so that Ebola patients could receive treatment.
Q: Are there other diseases like Ebola that we should be concerned about?
Dr. Jarrett: Unfortunately, there are a lot of diseases like Ebola that we should be prepared for. For example, we all went through the SARS epidemic from 2002 to 2004. Everybody was very concerned then, because the virus affected young people and had a relatively high mortality rate, compared to the flu.
There are many other viruses in other parts of the world. Now that people can travel everywhere, there are many visitors to the United States. It’s more likely that a rare disease that may not spread much in one country could spread much more quickly when released in the United States, Europe or other very populated areas. So we need to be prepared at all times for that possibility.
Q: What threat are you looking at right now?
Dr. Jarrett: There is no one, single threat.
The challenge in American medicine is to change the culture so that everything is always done safely and we develop highly reliable organizations. A frequent example is the nuclear industry. Thankfully, there are almost no accidents in the field. Everything runs pretty much like a clock all the time. That is a model the medical field can follow. Or like an aircraft carrier, where a 17-year-old on the deck can stop all planes from landing because he or she thinks something is wrong. That is the culture that we need to develop in American medicine -- in all facilities, both inpatient and outpatient. When we do that, we will truly have safer care.
Q: There seems to be a loss of public trust in hospitals. And, maybe a little in the medical profession--at least in our government’s handling of infectious diseases. Would you agree with that? And if you do, what should the medical profession do to recapture that public trust?
Dr. Jarrett: There has been a decrease in public trust with both hospitals and doctors in general. The Ebola crisis magnified that.
People got the message that everything would be okay and it wouldn’t come here -- then it came here. That type of thing can make distrust worse. People weren’t, perhaps, as forthcoming. Treating Ebola in the U.S. is very different than treating it in west Africa. For instance, we isolate patients in private rooms. But in west Africa, Ebola patients stayed in open hospitals and open wards. We’re going to learn as we go along. That type of transparency was not apparent in the beginning. I think that further increased the concerns that people had about Ebola.
Threats and Solutions
Q: What are other pandemics we haven’t heard much about that we should look at in the coming years?
Dr. Jarrett: Well, other infections might come up. Clearly, we’re all concerned about the MERS-CoV, which has been seen mostly in Saudi Arabia plus some other Middle Eastern countries. It is a little bit like SARS. Certainly, there can be flu that mutates and spur a flu epidemic. And there are other viruses--Lassa hemorrhagic fever, Marburg--that are very similar to Ebola.
Our biggest risk comes from the fact that any of these viruses--which right now we know a lot about--can mutate and become much more dangerous. That’s why we need to be prepared for any type of infection in the United States, so we can handle anything that comes about.
Q: We’re conducting this interview in a special treatment unit at Glen Cove Hospital created to address diseases like Ebola. Tell us what you’ve done here.
Dr. Jarrett: The Glen Cove Hospital facility was designed not only to address Ebola, but also to handle any serious infectious disease that would would require a lot of intensive care. This unit can last a long time. We’re also talking about building a larger unit to include other equipment for an outbreak that might last for a long time, if there were prolonged exposure to infection. What we have here is great as a temporary and intermediate use, and it will last for years.
Like many major health systems and medical centers, we’re going to have to consider permanent structures that will always last. And again, with that goes the key of training the staff and keeping the staff trained all the time. It’s not just the physical facility. Much more important is our staff who, number one, must know what to do and be trained what to do. And number two, we need to keep them safe.
Q: When we came in today, we saw a lot of training going on.
Dr. Jarrett: We’ve done a lot of in-house training. It’s all about staff protection. One of the tenets of emergency management is to protect your staff. If you don’t protect your staff, there’s no one to care for the patients.
We have three levels of training. First is electronic training on the computer. Number two is learning how to get in and out of protective equipment -- the Tyvek suits, the respirators. They are complicated to put on, and it’s much more complicated to remove safely. The third aspect of training, which the unit is engaging in as we speak, is learning how to work in the protective suits within the actual environment and practicing different procedures with actors who simulate the disease and with simulation mannequins. So you become comfortable doing it and you gain muscle memory. You learn how to work in the suits, doing the things that you’re going to have to do with an actual patient.
Q: There’s been a lot of coordination between the New York State Department of Health, the Centers for Disease Control and Prevention [CDC] and other agencies. Would you talk a little bit about that?
Dr. Jarrett: We have worked very closely with local health departments, the New York State Department of Health and the CDC. They’ve visited all of our sites--including Glen Cove Hospital--several times, to confirm we’re doing the right things and to discuss potential future challenges. Because the way we practice medicine in the United States in the tertiary center is different than what goes on in West Africa. And that may be part of the reason why in the United States, we see Ebola patients who have been treated and survive, whereas, unfortunately, mortality in Africa is anywhere from 40% to 60% to 70%.
Q: That’s a good lesson learned. Are there others?
Dr. Jarrett: The other lesson learned is to reach out to other places that have already had patients, which we have done. We’ve worked with the University of Nebraska, Emory and with Bellevue [Hospital Center]. We’ve had weekly calls with the Bellevue staff to discuss what they’ve learned so far -- what things worked and what didn’t. Sometimes what sound like minor details could be very important in making it easier for the staff and also delivering the right care to the patient.
Q: Is the medical community getting the most support it can from the government regarding infectious diseases?
Dr. Jarrett: Right now the government is providing a lot of support to hospitals. Obviously, some health systems and some hospitals are more prepared than others. So it’s easier for them to ramp up.
The government is trying to bring everybody up to a certain level. I believe there will be designated centers and specialized areas beyond the four that exist now in the United States, or the five including Bellevue that will be permanent structures that can provide this care. The medical community shares; we’ve been sharing. We’ve published our protocols and policies online -- about 380 pages. Web site visitors from 48 different states and multiple countries have downloaded those protocols and policies. That is the kind of sharing that needs to go on with these types of epidemics or clinical situations.
Q: You have a terrific title--chief quality officer. Tell me a little bit about what your role.
Dr. Jarrett: As the health system’s chief quality officer, I make sure that we deliver the right care to all patients. We deliver great care all the time, but not everything is perfect, and we need to get it to perfect. Less than perfect is not acceptable. My role is overseeing the quality programs at all our hospitals and ambulatory sites. Working to provide what's needed, making sure that treatment is standardized--that clinicians are doing things the same way--because a lot of variation is not good. And if a situation doesn’t go well, making sure we learn from that situation, then sharing that throughout the North Shore-LIJ Health System.
Q: Are there one or two areas that you see in American medicine, let alone North Shore-LIJ, that is getting more of your attention right now?
Dr. Jarrett: We’re devoting our attention to things like hospital-acquired conditions. It’s not just patients coming in with infections, but sometimes patients who get infections within a hospital. We should be doing things that prevent us from causing diseases as well as curing diseases.
Q: Clearly all of this comes at a cost--a financial cost, a facilities cost and a human cost. Does new money have to be found to address these issues?
Dr. Jarrett: I think the cost of this is very high. Both in terms of quality and also in building a unit like this and training personnel for it. Right now there is no extra money for it. So we have to figure out where it should come from. I believe this is one of those areas where the government probably should provide support. Because it really is a community need. It’s a public need, above specific patients. Hopefully, we will not need a unit like this, even for Ebola. But meanwhile, we had to have the expense. And we must be prepared and continue to be prepared in the future--even if the Ebola crisis in West Africa gets solved over the next six months to a year. Preparation costs money--just always to be ready. Again, we don’t know when the next viral or bacterial threat will come.
Q: Is there anything that you want to say that we haven’t covered so far?
Dr. Jarrett: Physicians, nurses, everybody else in a hospital comes in every day wanting to deliver the best care and not wanting to make a mistake. We have to recognize that mistakes happen because human beings make errors, no matter how good they are. We need to build systems around the people to catch mistakes if they happen and to protect against adverse effects.