Step inside All Children's Hospital and you're greeted with three things: hand sanitizer, tissues and masks decorated with little cartoon Band-Aids with legs, feet and smiles. "Dirt Squirt Alert!" a sign says. "Stop the spread of germs that make you and others sick!"
A sign at the check-in counter calls on people to immediately tell the triage nurse if
anyone in the family has a cough, fever and/or runny nose and has been to the Middle East, part of a check for Middle East Respiratory Syndrome. Now they ask another question to anyone with flu-like symptoms: Have you been to a country with an Ebola outbreak?
As questions persist over the handling of an Ebola patient who has since died at a Dallas hospital, it has become clear that the key to containing the disease in the U.S. lies with the response of local hospitals, like All Children's. And the problem of containing the outbreak extends far beyond using hand sanitizer.
"The next patient with Ebola will show up at a smaller community hospital somewhere," said Ashish Jha, a professor of international health and the director of the Harvard Global Health Institute. "We need a strategy now."
Nurses staged protests this week around the country, saying that smaller hospitals aren't prepared and employees haven't been trained to safely deal with Ebola cases. About 75 nurses participated in a union-organized rally Wednesday in Tampa.
Florida Gov. Rick Scott asked the federal Centers for Disease Control and Prevention to explain what Florida hospitals must do if they get an Ebola patient. Officials in California said they are trying to determine whether to send Ebola patients to specific hospitals.
Jha agreed that each state should designate certain hospitals as "centers of excellence" available to treat Ebola patients with Centers for Disease Control and Doctors Without Borders protocols. But smaller facilities would still need to brief staff on how to identify Ebola patients, and then designate a team of caregivers who can treat them for about 24 hours until a CDC SWAT team could get there for a transfer, he said.
At All Children's, which treats some 45,000 patients a year in its emergency room along Florida's Gulf Coast, some doctors and nurses have been assigned to a team to respond to possible Ebola cases. They started receiving training with hazardous materials suits and gear in the past couple of months, since the Ebola outbreak emerged in Africa, said Dr. Juan Dumois, the director of infectious disease at All Children's.
But it's a balancing act, Dumois said. It's not like the hospital will put front-line check-in employees in hazmat suits.
To be sure, All Children's ER does differ from other emergency centers. It's not as busy as a big-city ER because it caters only to kids. And because the facility is only 5 years old, all rooms are private, which means each patient is effectively quarantined in a room upon admittance to the ER.
Yet Ebola still poses problems for its emergency room because some of its symptoms — fever, headache, muscle pain, weakness — mirror a host of other common viruses, said Dumois. As hospitals prepare for flu season, the difficulty could increase.
"You can't use initial symptoms to identify Ebola," he said.
Dumois said the first line of defense for All Children's is questions. Staffers in the emergency room ask whether a patient has been to an Ebola-affected country, been in contact with someone who had Ebola or treated patients with Ebola, he said.
If the patient answers no to those questions, it's easier for the staff to rule Ebola out, he said.
If the answer is yes to any of the questions, hospital workers would immediately call the local and state health department and the CDC, he said.
"You wouldn't want them to leave if you suspected Ebola," said Dumois. "They'll likely get sicker and by being in the hospital, we can treat them, and they will avoid infecting others in the community."
That's where things started to break down in Dallas, when Thomas Eric Duncan first sought care at a hospital ER late on Sept. 25 and was sent home the next morning. He was rushed by ambulance back to the hospital on Sept. 28, where mention of his recent arrival from Liberia finally roused Ebola suspicions, records show.
Duncan died a few weeks ago. Two of his nurses have since contracted Ebola, raising more questions about whether American hospitals and their staffs are adequately prepared to contain the virus.