Preparedness, Evaluation, and Care of Pediatric ...

Invited Review

Preparedness, Evaluation, and Care of Pediatric Patients Under Investigation for Ebola Virus Disease: Experience From a Pediatric Designated Care Facility Roberta L. DeBiasi,1,12,13 Xiaoyan Song,2,12 Krista Cato,3 Tara Floyd,3 Linda Talley,3,4 Kathy Gorman,5 Martha Parra,6 Venkat Shankar,7,12 Joseph Campos,8,12,13 James Chamberlain,9,12 Denice Cora-Bramble,10,12 Craig Sable,12,14,15 Kurt Newman,11,12 and David Wessel7,10,12; on behalf of the CNHS Ebola Response Task Force Divisions of 1Pediatric Infectious Diseases, 2Epidemiology and Infection Control, 3Nursing, 4Chief Nursing Officer, 5Chief Operating Officer, 6Patient Services, 7Critical Care Medicine, 8Laboratory Medicine, 9Emergency Medicine, 10Chief Medical Officer, 11Chief Executive Officer, Children’s National Health System, 12Departments of Pediatrics, 13Tropical Medicine/Microbiology/Immunology, 14 Telemedicine, and 15Cardiology, The George Washington University School of Medicine, Washington, DC Corresponding Author: Roberta L. DeBiasi, MD, MS, Division of Pediatric Infectious Diseases, Children’s National Medical Center, West Wing 3.5, Suite 100, Washington, DC 20010. E-mail: [email protected]. Received May 1, 2015; accepted September 9, 2015; electronically published October 29, 2015.

Key words.

designated Ebola centers; Ebola virus disease; pediatrics; preparedness.

INTRODUCTION The recent and world’s largest Ebola virus outbreak demonstrated that exportation of Ebola virus disease (EVD) can occur outside of West Africa [1]. The 2014–2015 Ebola virus epidemic that affected West Africa led to the realization that hospitals must be highly prepared to screen and initially evaluate patients with suspected EVD who present for care within the United States [2]. Effective hospital planning involves every department of the institution. The care of a pediatric person under investigation (PUI) presents additional challenges for which consensus guidelines are still emerging. Pediatric-specific components of an institutional response plan that must be considered include the involvement of child life services, family services, and public relations (to develop appropriate and reassuring messaging for families at the point of screening), initial intake and isolation, parental presence policies, education and messaging for community members and families, and provisions for the potential care of neonatal PUI for EVD or patients with EVD. The Children’s National Health System (CNHS) in Washington, DC, developed a comprehensive institutional Ebola response plan for the care of pediatric PUI and/or patients with proven EVD. The CNHS includes a 310licensed-bed freestanding independent pediatric referral center located in close proximity to several international

airports. As such, the institution deemed EVD response as an institutional priority and implemented system-wide protocols to screen, isolate, transport, monitor, and treat patients with EVD beginning August 1, 2014. After the creation of an interdisciplinary Ebola Task Force and an initial hospital-wide tabletop drill, weekly meetings were initiated to further expand and refine the institutional plan. The leadership structure of the Ebola Task Force included direct engagement of institutional administrative leadership and the incident command structure (ie, Chief Operating Officer, Chief Nursing Officer, and Chief Medical Officer). The Chief of Infectious Diseases and the Director of Infection Control led the task force, which included representation from critical care, hospitalist, emergency, and neonatology physicians, nursing, emergency response, laboratory, transport, environmental services, family services, nutrition, and other support services. Modification of the existing hospital space was initiated to create a specially designed biocontainment unit (Special Isolation Unit [SIU]) with full capability to care for critically ill patients in a manner that is safely isolated from other patients admitted to the institution. Since August 2014, 6 pediatric PUI for EVD, 4 of whom required inpatient hospitalization (Table 1), have been cared for by the CNHS in collaboration with local and federal health authorities. In this capacity, we have had the

Journal of the Pediatric Infectious Diseases Society, Vol. 5, No. 1, pp. 68–75, 2016. DOI:10.1093/jpids/piv069 © The Author 2015. Published by Oxford University Press on behalf of the Pediatric Infectious Diseases Society. All rights reserved. For Permissions, please e-mail: [email protected].

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Pediatric Ebola Preparedness

Table 1. Summary of Inpatient PUI at CNHS

Date of Admission

Site at Which Patient Was Identified as a PUI External ED transfer

Sex

Age (y)

August 2014

Male

11

Nigeria

14

September 2014 Early November 2014

Male

7

4

Male

10

Sierra Leone Sierra Leone

Late November 2014

Female

7

Country of Origin

Days Elapsed Since Travel

Sierra Leone

3

5

Symptoms

Fever, hypotension, tachycardia Direct presentation to Fever, respiratory CNHS ED symptoms Direct identification Initially asymptomatic; from within developed CNMC inpatient high-grade fever and unit vomiting while hospitalized for another indication External ED transfer Fever, hypotension, vomiting, tachycardia, diarrhea

EVD PCRDepartment of Health NA NA Negative (1 sample)

Ultimate Diagnosis Severe malaria, 27% parasitemia Respiratory viral infection Osteomyelitis, methicillin-susceptible Staphylococcus aureus

Negative Severe malaria, 33% (3 samples) parasitemia

Abbreviations: CNHS, Children’s National Health System; CNMC, Children’s National Medical Center; ED, emergency department; EVD, Ebola virus disease; NA, not available; PCR, polymerase chain reaction; PUI, person under investigation.

opportunity to test, evaluate, and optimize multiple aspects of our institutional Ebola response plan. In recognition of our preparedness, the CNHS was designated a tier 1 Ebola care center in December 2014. Key lessons learned from this experience are summarized in 8 major areas: staff education and engagement; institutional plan and preparedness; personal protective equipment (PPE) acquisition and training; facility and transport retrofit; care model; logistics and communication during isolation unit activation; parental presence; and institutional administration engagement. KEY LESSON 1: STAFF EDUCATION AND ENGAGEMENT ARE AS HIGH A PRIORITY AS DEVELOPMENT OF THE INSTITUTIONAL RESPONSE PLAN ITSELF The CNHS took a proactive stance with regard to educating all employees about the necessity for hospital preparedness for Ebola virus and engaged all employees across all departments (not limited to clinical units) in the process. An initial hospital-wide grand rounds was conducted and immediately followed up by the construction of a dedicated educational web site call Ebola Hub. The Ebola Hub was created on the hospital intranet with high visibility to provide immediate employee access to key background information and links to internal and external guidance materials and documents. A FAQ section was posted on the Ebola Hub so that employees could benefit from questions and responses provided by a content expert, which were posted within a 24-hour (or less) time frame. A hospital-wide mandatory Web-training module was created and implemented to ensure a basic level of education;


>95% compliance was achieved in a 6-week time frame. Webinars for community-based providers were instituted to engage primary care physicians and nurse leaders. Amid growing national concern about providers’ risk of exposure to Ebola, a team of self-selected clinicians created a structure of continual meetings and training to advise and lead the institutional task force in areas such as parental presence, staffing models, PPE training, and emotional support [3]. In addition, multidisciplinary education (with input from the departments of infectious diseases, infection control, and child psychology) was developed for parents and families in the community. This education was made easily accessible on the institution’s public Internet site and focused on how to speak to children appropriately about Ebola, particularly during periods of intense media coverage of US cases. KEY LESSON 2: DEVELOPING AN INSTITUTIONAL RESPONSE PLAN REQUIRES NOT ONLY MULTIDISCIPLINARY ENGAGEMENT BUT ALSO ONGOING REFINEMENTS AFTER EACH PUI ENCOUNTER Debriefing sessions after each encounter enable all involved services to identify challenges and areas for improvement and to engage directly in the process of refinement. An initial multidisciplinary tabletop drill was valuable in assessing and building on the initial institutional response plan. Active screening for appropriate travel exposure was implemented at all points of entry to the hospital, including emergency department triage and clinic registration desks. A designated area, isolation, the use of PPE, and communication procedures were clearly defined in response to any

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patient/family for whom a positive travel history was elicited. Activation of the communication cascade began with pager notification to the attending infectious diseases physician on call, who then assessed the patient and notified infection control, the administrator on call, the laboratory, and the Department of Health. After assessing the patient and consulting with the Department of Health, a decision was then made regarding the need to activate the isolation unit. Once a decision for activation was made, activation checklists (developed by the multidisciplinary task force and included within the detailed institutional plan housed on the intranet) were deployed to ensure systematic preparation of all aspects of the isolation unit, the care team, and support services. After the care of each and every PUI patient, a multidisciplinary debrief session was held and was critical for identifying gaps and opportunities for continuously refining the processes. For instance, debriefing sessions revealed the need to develop detailed checklists specific to each of the 3 phases (ie, isolation unit activation, operation, and deactivation). Checklists tailored for each component of the care and support teams enabled an increasingly systematic approach with each subsequent PUI. This optimized care improved communication and decreased stress among caregivers and supporting services.

KEY LESSON 3: EXISTING INSTITUTIONAL STRUCTURES CAN BE MODIFIED AND/OR RETROFITTED TO BE FLEXIBLE WITH REGARD TO SPACE AND RESOURCE UTILIZATION DURING PERIODS OF ISOLATION UNIT ACTIVATION AND DEACTIVATION (1) Transport Retrofit: Transport of a PUI in a standard ambulance necessitates removal of that vehicle from the pool of available transport vehicles until effective decontamination has occurred. To facilitate the rapid and effective decontamination of transport vehicles, our institution developed a unique solution for the transport of PUI. We designed a modular fiberglass retrofit of the interior of a standard ambulance that can be assembled within 1 hour, can be decontaminated completely and easily after use with a sprayed bleach solution, and can be disassembled and stored after PUI transport (Figure 1). (2) Special Isolation Unit: The CNHS modified its existing federally funded decontamination unit, subsequently termed the SIU, to be suitable for use in the care of patients with Ebola (Figure 2). Unique features of this unit include dedicated entry at the ambulance port into an area that is isolated from the remainder of the emergency department on the first floor and is suitable for initial intake and


Figure 1. Interior of retrofitted ambulance for transport of pediatric PUI. Abbreviation: PUI, person under investigation.

evaluation; dedicated elevators that link the first-floor component of the SIU to a fifth-floor inpatient unit in which care can be provided to 2 to 4 patients with Ebola in a fully isolated manner. When not activated, the inpatient space serves as regular inpatient unit space. When activated, routine patients are relocated out of the unit, and isolation doors are activated to separate the SIU from other areas of the hospital. Entry and egress via a single point (designated decontamination elevator) is monitored 24 hours/day, 7 days/week by Children’s Special Police to prevent any unauthorized entry or accidental exposure and to ensure the safety and confidentiality of the patients and staff on the unit. Additional features of the SIU include isolated telephone lines, separate rooms for changing (disposable scrubs and shoes are provided to staff ) and showering, dedicated medication storage/Pyxis machine, clean equipment and supply storage, trash and dirty utility storage, and a team area for breaks and meals [4]. Standup of the unit takes approximately 4 hours from the decision to activate to full readiness, which is in line with standup times reported by other US biocontainment units. Systematic standup is critical for a safe and smoothly operating unit. (3) Remote Monitoring Solution: PUI are placed in the SIU in a private room with an anteroom. We designed


Figure 2. CNHS Special Isolation Unit schematic. Abbreviation: CNHS, Children’s National Health System.

and implemented a telemedicine solution (ViTel Net, McLean, VA) that enables continuous audio, visual, and cardiorespiratory monitoring of the patient from within the room (up to 2 rooms at a time) to the central nursing station, enables consultants to provide care from within the unit (and from anywhere the consultant has Internet access) without entering the room, and enables parents and patients to interact via a secure encrypted video network (Cisco Jabber, San Jose, CA), all while limiting risks of exposure (Figure 3). The telemedicine solution integrates peripheral devices, including a high-resolution dermascope (AMD Global Telemedicine, Chelmsford, MA) and digital extended-frequency stethoscope (Telehealth Technologies, Viera, FL), with a chest piece transmitter that does not require anyone in the room to hold the chest piece on the patient. The ViTel Net MedVizer specialty Infectious Disease (Ebola) module on the receiving workstations enable digital capture of incoming video streams, dermascope images, and auscultation audio files that can then be stored within MedVizer as a stand-alone medical record and/or transmitted to the patient’s electronic medical record.


KEY LESSON 4: PROCUREMENT AND MAINTENANCE OF CENTERS FOR DISEASE CONTROL AND PREVENTION–RECOMMENDED PPE SUPPLIES REQUIRE PARTNERSHIP WITH OTHER INSTITUTIONS AND DILIGENT ONGOING INVENTORY Although all staff must receive a basic level of PPE training, higher-level training and drilling must be tailored to the specific situation/unit in which patient interaction will occur and must be continuously monitored during patient interactions. (1) PPE Procurement: As was the case with all institutions, the acquisition of an adequate supply of Centers for Disease Control and Prevention (CDC)-recommended PPE is a significant challenge [5]. However, this need was met in advance of our first managed PUI by forming early partnerships with other institutions. Diligent inventory of each and every component of PPE at 12-hour intervals during the care of a PUI is critical to ensure adequate ongoing supply. Early communication with the

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Figure 3. CNHS Telemedicine Solution. Abbreviation: CNHS, Children’s National Health System.

CDC regarding a potential need for activation of the Strategic National Stockpile was used during the care of a PUI, when local inventory and backupsupply were evaluated as low. The site managerand nursing team created an excel spreadsheet system that facilitated systematic and accurate inventory for each shift, and this spreadsheet revealed an approximate 11to 12-PPE set requirement per 12-hour shift using the 5:1 nurse staffing model used at our institution, as described below. (2) PPE Training: Training of physician, nursing, and ancillary staff in appropriate donning/doffing of PPE was achieved by using a model of “super users,” identified from each department, who received intensive 1-to-1 training with experienced infection control staff [6]. These super users then served as trainers of other members of their group. Groups themselves took ownership of developing and scheduling drills to practice PPE donning/doffing and other aspects of patient intake, transport, and care. Critical care staff performed additional team-based drilling while donned in full PPE to gain expertise/experience with common procedures, such as line placement and intubation, while under the constraints of PPE. In the course of care of PUI, further strategies for optimizing errorless donning and doffing of PPE included construction of posters to provide step-by-step visual clues (not to replace the role of the WatSan [a term first used by Doctors Without Borders, short for Water-Sanitation monitor] in direct monitoring of donning/doffing by staff ), organization of the PPE cart


in a step-by-step manner to correspond to PPE checklists, and securing PPE carts after deactivation of the SIU to avoid loss [6].

KEY LESSON 5: STAFFING MODELS MUST INCLUDE CONSIDERATION OF FLEXIBILITY WITH REGARD TO PUI ACUITY (FOR EXAMPLE CRITICAL CARE VERSUS NON–CRITICAL CARE PHYSICIANS AND NURSES) Staffing models must take into account the need for rotating short shifts in full PPE to promote staff comfort and safety and must include a site manager on the unit at all times to ensure smooth operation. Recognizing the concern for potential risk of staff exposure to Ebola, we developed our Ebola response team, which consisted entirely of self-selected and motivated clinicians who chose to become well-trained experts in the care of patients with this disease. Designating this select group was helpful from the standpoint of maintaining high morale and trust in a stressful situation and maintaining consistency in procedures and PPE techniques for staff and for patient/family interactions. The staffing model for the care of a pediatric PUI in the activated SIU included the following: 1 attending physician (24-hour shift), 5 clinical nurses (12-hour shift), and 1 registered nurse site manager (nurse manager or nursing


director [12-hour shift]). The team of 5 nurses included 2 teams of 2 patient care nurses and 1 WatSan. The nurse serving as the WatSan remained in the anteroom at all times in PPE of the same level as the care team in the patient room. The WatSan’s primary functions included logging entry into the patient room, monitoring for any exposures while in the room, and directly assisting and monitoring staff in doffing their PPE while leaving the isolation room. The WatSan ensured compliance with appropriate PPE doffing by using verbal doffing checklists in conjunction with step-by-step photographic posters. The additional 4 nurses worked in teams of 2; 1 nurse provided clinical care for the patient and the other, working simultaneously, disinfected all surfaces touched by the clinician during care. Because of the rigors of working in full PPE, teams of 2 nurses working within the patient room alternated every 2 hours to avoid fatigue and potential error. Staff who performed patient care within the patient room remained within the confines of the SIU until completing their shift, showering, and changing into clean clothes before exiting the unit into the regular hospital space. The site manager provided logistical support and oversight (eg, communicating with central supply when additional supplies were needed). Site managers also received advanced training in PPE donning, doffing, and inspection. It was notable that the on-site clinical team featured clinical nurses in leadership and expanded roles. Nurses continue to advise and lead the group in training, policy development, and supportive measures for both patients and staff. From a physician standpoint, the Ebola response team initially included emergency medicine physicians, primarily involved in initial intake/transport and stabilization, and critical care medicine physicians for inpatient care. However, after the management of several PUI, our institution added representation from hospitalist physicians to provide an expanded pool of care givers appropriate to the level of acuity of the PUI. To prepare for the possibility of a neonatal PUI, we later expanded the response team to include neonatologists. We held a series of meetings with obstetrics colleagues at the adult Ebola management center in our region to jointly develop clear guidelines for communication, transport, and care of a neonatal PUI born to a maternal PUI at the adult institution.

KEY LESSON 6: LOGISTICS AND COMMUNICATION DURING SIU ACTIVATION ARE COMPLEX AND MULTIDISCIPLINARY (1) Logistics and Resources: Support provided to the care team was extensive. Central supply was available


24 hours/day, 7 days/week for special needs and requests. Infection control personnel, infectious disease physicians, and nurse educators consulted clinically as needed and provided continuous education on PPE and related topics. Environmental services (EVS) provided a dedicated EVS technician, who had special training in the handling of infectious disease waste, around the clock. EVS did not participate in disinfection of the patient room while occupied by the PUI (which was performed by nursing staff within the room) but provided support as needed for surface cleaning within the cold zone during unit activation. EVS contained waste within the unit, consistent with class A waste precautions, until the ultimate status of the patient as uninfected was determined and terminal cleaning could be performed. Food and nutrition services provided 3 meals per day to all staff assigned to the SIU. Educational posters, relevant contact/on-call numbers, and staff feedback boards were displayed in the SIU while the unit was activated. Security officers were posted at entry points at all times. (2) Communication: During activation of the SIU and active management of a PUI, a minimum of once-daily conference calls with representation/participation from each member of the institutional task force (including institutional administration leadership and public relations) were held, and a systematic checklist agenda was used to ensure that all groups were simultaneously apprised of the patient’s status and plan. These internal calls were scheduled to be held immediately after the daily conference calls held jointly with local Department of Health and CDC officials. These calls were critical for providing clinical updates and mutually agreed-upon plans for clinical management and decisions regarding Ebola and non– Ebola-related laboratory testing. (3) Laboratory: The director of the laboratory was notified immediately at the time of an identified PUI, far in advance of any request for laboratory testing. This notice was critical for preventing inadvertent and inappropriate transport of specimens to the laboratory and providing lead time for the laboratory to prepare for the receipt of specimens with proper laboratory and PPE precautions. Point-ofcare testing (eg, chemistry, complete blood count) was performed by using dedicated epoc instruments within the patient care room on the SIU [4]. A restricted amount of additional testing was available within the main hospital laboratory under a designated biosafety cabinet, including malaria smear testing (thin smear only using modified procedures), Binax Malaria test, and blood culture [7]. The importance of predetermined and detailed laboratory standard operating procedures, including modifications necessary when handling blood specimens from PUI, cannot be overstated. Drilling by laboratory staff on these

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specific standard operating procedures was critical in identifying streamlined procedures and minimizing any potential risk to laboratory personnel. Construction of a satellite laboratory within the SIU was also undertaken to further minimize risks associated with the transport of specimens to the main laboratory. Expanded capabilities will include coagulation and creatinine assays. Centers should be aware that although state departments of health and/or the CDC perform Ebola polymerase chain reaction (PCR) testing, it is the responsibility of the institution to have class A– trained and -certified staff available on call to pack specimens appropriately for transport by courier. Decisions regarding the timing of PCR testing were based on consultation with the CDC and the Department of Health. For some patients, a single test was used if symptoms had been present for 72 hours at the time of testing or if an alternative diagnosis was secured. For other patients, serial testing was required because of clinical concern for Ebola infection and lack of a clear alternative diagnosis.

KEY LESSON 7: INSTITUTIONAL RESPONSE PLANS MUST ADDRESS PARENTAL PRESENCE AND INCLUDE SUPPORT FOR FAMILIES USING THE EXPERTISE OF FAMILY SERVICES STAFF The issue of parental presence has multiple facets that must be considered carefully. The potential benefits of allowing parental presence in the isolation room include (1) emphasizing family-centered care, which aids in child and parent satisfaction, (2) assisting with care for patients who are not critically ill or are very young, and (3) reducing continuous time in the room for staff, which results in potentially less exposure. However, there are multiple potential risks associated with parental presence, including (1) an added burden of responsibility for staff to train and monitor parents in the donning and doffing process, which is difficult even for trained medical personnel, (2) potentially increased exposure to staff because parents are sharing donning/doffing areas and may inadvertently contaminate warm/cold zones, (3) risks of exposure to the family member, even if no overt break in PPE is observed, (4) potential fear induced in pediatric PUI when seeing a parent in this equipment, and (5) an increased usage of the already-limited PPE supply. At our institution, the current policy is for parents to interact with their child only remotely by using the telemedicine solution, which enables parents to see, hear, and speak with their child via iPad from the time of initial intake throughout the admission in the isolation unit. During care of their child in the isolation unit, parents of PUI were provided with frequent clinical updates, sleeping accommodations, and meals. Child life, family services,


patient experience, and volunteer services representatives were available for remote consultations and were updated by clinicians regularly.

KEY LESSON 8: INSTITUTIONAL ADMINISTRATIVE LEADERSHIP AND PUBLIC RELATIONS PLAY A KEY ROLE IN THE SUCCESSFUL DEVELOPMENT, DISSEMINATION, AND EXECUTION OF THE INSTITUTIONAL EBOLA RESPONSE PLAN The financial effects of preparing and caring for a pediatric PUI are substantial and require firm institutional commitment. (1) Institutional Administrative Leadership: Full engagement and support of institutional leadership and activation of the incident command system for any PUI were critical aspects of efficient and clear communication and implementation of the hospital plan. The Chief Operating Officer, Chief Medical Officer, and Chief Nursing Officer were integral members of the Ebola Task Force and participants in the weekly task force meetings, played critical roles in leveraging planning and agreements with referral institutions, and providing transparency to the institution and its staff. Partnerships were forged early with regional referring institutions that would likely be seeking assistance with the transfer and management of neonatal and pediatric PUI. In the midst of the focus on patient care and staff safety during management of a pediatric PUI, institutional leadership played a vital role in garnering support and maintaining close communication with the hospital board. A dedicated board-to-bedside session was organized early to educate, apprise, and seek approval from the hospital board for all Ebola preparations and decisions regarding acceptance as a designated Ebola care center. Board chairs were notified during each activation of the SIU to proactively open communication and preempt any potential public relations miscommunications. (2) Financial Considerations: Significant expenditures are necessary for the preparation and activation phases of pediatric Ebola care. Costs associated with PPE acquisition (for a minimum 4-day supply to be on hand at all times), training, and drilling were approximately $250 000. The fixed costs for retrofitting our existing hospital space to be suitable from an infection control standpoint were approximately $50 000 for construction (including development of proper egress routes), $50 000 for the telemedicine solution, and $200 000 for satellite laboratory construction and equipment. However, it should be stated that our modification costs were less than would likely be required at many institutions because of a previous $14


million investment to create a decontamination unit, within which the current SIU unit was created. Calculated direct patient care expenses were approximately $35 000 to $40 000 per day for the management of each pediatric PUI and would be expected to be equal or higher in the case of a proven Ebola-positive patient. (3) Public Relations and Confidentiality: The institution’s public relations group was engaged from the very earliest inception of the Ebola Task Force and was present at all meetings. Clear and transparent hospital-wide communications were crafted in partnership with key task force leaders to ensure that staff were frequently and regularly apprised of national, regional, and local planning efforts and all educational resources. Communications regarding Health Insurance Portability and Accountability Act (HIPAA) compliance and confidentiality of PUI were clearly stated early in the process and reinforced frequently to employees. The hospital information technology department implemented active monitoring of access to the electronic medical record to ensure that only care providers directly involved in the care of the patient and other key personnel were accessing the medical record. No breaches in confidentiality occurred either within or external to the hospital for any of the PUI who were cared for at CNHS. (4) Employee Issues: Throughout the entire response planning and implementation phases, it was made clear to everyone that staff and patient safety was our top priority. Management fully supported staff during the care process of a PUI. We maintained already-close partnerships with the District of Columbia Nursing Association to keep its leadership informed and a key part of all decisionmaking processes, which greatly facilitated its cooperation in the design and operationalization of staffing plans. Care was taken to keep the identity of Ebola care team members relatively confidential to avoid any subsequent stigma to them within the hospital or within their communities. (5) Advocacy: By nature of our geographic location in the nation’s capital, the CNHS was called on to provide testimony to Congress and the DC City Council with regard to pediatric aspects of Ebola response planning. For institutions that care for both adult and pediatric patients, ensuring the presence of a pediatrician on the institutional Ebola Task Force is key. We recognized the importance of community partnerships early and decided that the most effective way to decrease fear and hysteria was through excellent practice, creating a standard process, and maintaining strong communication with all stakeholders while creating collaborative partnerships. CONCLUSIONS The care of pediatric PUI presents additional challenges that must be considered proactively in the development of


institutional Ebola response plans. We as pediatric care providers have cared for patients with serious communicable diseases for many years, including polio, tuberculosis, pertussis, measles, HIV, hepatitis, and influenza. Ebola virus is no exception. We have the knowledge and capacity to care safely for pediatric patients with suspected and proven EVD by using the same sound infection control principles that have served us well in the past and will carry us into the future for this and other emerging threats [8]. Acknowledgments We are grateful for support and collaboration from the District of Columbia Department of Health, the District of Columbia Hospital Association, the American Hospital Association, and the Centers for Disease Control and Prevention. We also appreciate advice and guidance received from the National Institutes of Health Biocontainment Unit. We thank ViTel Net, for developing a customizable telemedicine solution that will enable improved patient care, optimal family and staff safety, and enhanced patient and family communication and satisfaction. Additional CNHS Ebola Response Task Force team members include Robert Beckwith, Elizabeth Berg, Lanita Daffin, Lauren Fisher, Jacquelyn Forbes, Monica Monteon, Scott Pettinichi, Mary Fuska, Ekaterina Solovieva, Matthew Sharon, Karen Smith, Jo Talley, and Anthony Vaul. Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

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