Outsmarting Outbreaks: Case Lessons from One Children’s Hospital

How Cleveland Clinic Children’s prepares for evolving viral threats

In September 2014, Cleveland Clinic Children’s was deluged with babies and children in severe respiratory distress. Most cases followed a similar course: lingering runny nose, occasionally with fever, followed by a rapid decline in respiratory status marked by difficulty breathing, hypoxemia, wheezing and other lower respiratory symptoms.

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Early on, many patients required mechanical ventilation; some required intubation during transport. Virtually overnight, the pediatric intensive care unit (PICU) was filled with these patients.

On the trail of a novel virus

Nasal swabs indicated the patients had rhinovirus, but staff knew this was something different: Whereas rhinovirus is common throughout the year, both the number of infected children and the severity of symptoms were unprecedented. Moreover, children with pre-existing lung disease were preferentially affected, and their symptoms often worsened with shocking speed.

“It was clear this was a novel virus,” says Camille Sabella, MD, Head of the Center for Pediatric Infectious Diseases.

As fast as the disease struck, Cleveland Clinic Children’s was prepared to handle it. Thanks to a proactive, systemwide emergency preparedness program and the full cooperation of Cleveland Clinic’s specialists and leadership, a plan for managing the unknown virus was developed and implemented. The plan created a safe environment for infected patients while protecting other hospital patients and caregivers from the pathogen — all with minimal disruption to normal hospital and surgical services.

Figuring out which pathogen had struck would be key to understanding its infectious potential — as well as the possibility of treatment.

Resourcefulness in response to EV-D68

Cleveland Clinic Children’s infectious disease and pulmonary physicians had been following similar outbreaks in children’s hospitals across the country. The Centers for Disease Control and Prevention (CDC) had confirmed that these cases were caused by enterovirus D68 (EV-D68), a rare relative of the rhinovirus.

“EV-D68 is not one of the viruses we normally look for in patients hospitalized with a respiratory infection,” says Dr. Sabella.

Even before the CDC confirmed that the cases at Cleveland Clinic Children’s were also caused by EV-D68, members of the infection prevention, intensive care, infectious disease, pulmonary medicine and administrative teams decided to concentrate patients in respiratory distress on Cleveland Clinic’s main campus, where they would have access to tertiary care specialists and facilities.

“We had to make sure we had PICU beds for the sickest patients,” explains Leticia Castillo, MD, Chair of the Department of Pediatric Critical Care Medicine. “So we decided who needed to be at the main campus and who could be managed safely at one of our nearby regional hospitals within the Cleveland Clinic Children’s network, which are staffed by the same pediatric subspecialist teams who practice at the main campus.”

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Several specific measures were taken:

  • To free up PICU beds for the neediest patients, teenagers in the PICU with other conditions were moved to beds in Cleveland Clinic adult ICUs.
  • Provisional plans were made for a step-down unit for children with EV-D68 who could leave the PICU but required more intensive support before being ready for care on the regular floor.
  • Patient flow was changed to prevent cancellation of surgeries or elective PICU admissions due to a lack of PICU beds, with some elective cases and patients with nonrespiratory conditions triaged to pediatric services at regional hospitals within the Cleveland Clinic Children’s network.

Within a couple of weeks, the EV-D68 crisis passed. In total, 45 percent of the 22 patients with a confirmed respiratory enterovirus infection were admitted to the PICU.

Promoting a culture of preparedness

If the outbreak had exploded beyond these numbers, however, Cleveland Clinic Children’s would have been as ready as possible, thanks to a culture of planning for nearly any contingency.

“Not long before this happened, I received a call from Cleveland Clinic’s Emergency Preparedness staff,” notes Dr. Castillo. “They asked what we would do to prepare the PICU if 50 children were involved in a bus crash. Whether it’s a tornado, an attack or an epidemic, you need to be prepared so that when an emergency happens, you know what to do.”

Case studies from two influenza scares

Teamwork was especially evident during the 2009 outbreak of H1N1 virus, a flu strain that had not circulated for years and was not included in the annual flu vaccine. Although masks and hand-washing protect against typical flu viruses spread in tiny droplets caused by coughing and sneezing, there was concern at the outset that transmission of H1N1 might be airborne.

As soon as the H1N1 vaccine was available, Cleveland Clinic began vaccinating staff and patients, starting with those at highest risk. Comprehensive efforts ensured that the vaccine and personal protective gear were made available systemwide, especially in pediatric care areas. These actions stemmed from Cleveland Clinic’s long-standing recognition of the importance of immunizing healthcare workers and its requirement that all employees be vaccinated against the flu and childhood diseases.

This past flu season, a large number of children contracted influenza A, in part due to a mismatch between this year’s vaccine formulation and the circulating strain of virus. The virus hit those with asthma and chronic lung disease particularly hard. Their pediatric physicians struck back with aggressive use of oseltamivir (Tamiflu®). “If you can attenuate the duration of the illness, it lowers hospitalizations,” explains pediatric pulmonologist John Carl, MD.

Unfortunately, many Northeast Ohio pharmacies ran out of the antiviral medication. Cleveland Clinic Children’s provided some of its stock to parents of the most at-risk patients. The experience spurred Dr. Carl and colleagues to draw up plans to prompt parents of selected patients with chronic lung diseases to obtain oseltamivir in advance of the next flu season.

Preparing for the unthinkable: Ebola

When Ebola broke out in West Africa in 2014, Cleveland Clinic pediatricians and adult-care providers began taking steps to handle potential patients infected with the deadly virus. “We were concerned it was only a matter of time,” says Dr. Sabella.

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“We knew we had to work as a system to figure out how to recognize a child or adult with Ebola, whether they showed up at our main campus, a regional hospital or an outpatient clinic,” adds pediatric infectious disease specialist Charles Foster, MD.

Providers from Cleveland Clinic Children’s worked with adult-care colleagues to develop best practices for screening and treating patients. Six teams that included all necessary caregivers were formed.

“We couldn’t have all six PICU physicians on Ebola teams since the practice has been that every doctor is furloughed for 21 days after going off service,” says Dr. Foster. Instead, they partnered with the adult ICU and integrated a pediatric nurse and pediatric specialist within each Ebola team.

Medical personnel were trained in donning and doffing personal protective gear and drilled in the procedure. “Having a well-trained partner to help doff turns out to be very important,” Dr. Foster notes.

An unused area near the emergency department on Cleveland Clinic’s main campus was converted to a high-risk isolation ward with proper air handlers and antechambers. Although it has not yet been used, it is ready for the next virus that requires it.

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Cleveland Clinic staff practice donning and doffing protective gear as part of recent Ebola preparedness efforts.

Readiness for the next outbreak

Fortunately, Ebola never arrived at Cleveland Clinic in 2014. If it had, all key medical and nonmedical personnel would have been immediately notified on their home, office and cell phones. Because they had undergone recurring emergency training, caregivers were thoroughly prepared to respond immediately and appropriately.

Although EV-D68, influenza and Ebola no longer fill the headlines, another viral outbreak is inevitable. When it arrives, Cleveland Clinic Children’s will be as ready as possible. “These were wake-up calls,” notes Dr. Foster.