In early February, Royal Caribbean's Anthem of the Seas docked in Bayonne, New Jersey, in need of a hospital. The cruise ship was carrying patients who had traveled from China, where an outbreak of COVID-19 had taken root. Four passengers needed to go somewhere for further medical observation.
The obvious next step was University Hospital in Newark, a major academic medical center equipped with isolation rooms. "The hospital is following proper infection control protocols while evaluating these individuals," Gov. Phil Murphy said in a statement. The patients tested negative, but the governor was clear. The state's first coronavirus cases would go to University.
That's a hospital that has struggled in recent years with a critical skill essential to battling COVID-19: controlling the spread of infection.
Less than two years ago, a deadly bacteria made its way through the facility. Three babies in the neonatal intensive care unit got infected and died. Government inspectors cited the hospital for being short of staff; failing to maintain a sanitary environment, including improper hand hygiene and sterilization; and inadequately isolating patients with respiratory conditions. They determined the hospital had put patients in "immediate jeopardy."
Today, the state's former health commissioner, Dr. Shereef Elnahal, is in charge of the hospital. He told ProPublica its infection control problems are a thing of the past. The violations cited in the report were corrected with increased screening of patients, improved handwashing and equipment and focused leadership, Elnahal said. "I'm proud of our progress since then," he said. Murphy's office directed inquiries to the state's Department of Health, where a spokeswoman said there is "complete confidence" in the hospital's ability to manage the coronavirus response.
But infection control has been a recurring problem at some of the very hospitals that would likely be called upon to treat COVID-19 patients, a ProPublica review of hundreds of hospital inspection reports found. This raises concerns that they could become hotbeds for disease, putting patients at risk and rendering infected workers unable to care for others.
"Health care workers are my top worry," said Dr. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston. He noted that in China, so far, about 15% of infected hospital workers have become severely ill. "If this takes place in the U.S., and we see those numbers of workers sent home or in the ICU, being taken care of by their colleagues, things will start to unravel. This is the soft underbelly of our preparedness system right now."
At least two health care workers in Northern California had preliminary positive tests for COVID-19 at NorthBay VacaValley Hospital, pending CDC confirmation. The hospital had treated a patient who later tested positive for the disease. Other health care workers who came into contact with the patient are also in quarantine.
There is no list of designated centers to handle the most critical COVID-19 patients, experts said. But the Centers for Disease Control and Prevention, during the 2014-16 Ebola outbreak, named 55 hospitals it considered to be in the first tier of treatment centers to handle that kind of crisis — mostly large, urban teaching hospitals capable of complex care like blood transfusions and ventilation.
ProPublica analyzed five years of federal hospital inspection reports for these facilities and found violations for infection control failures or other factors that could hamper the response to an outbreak at more than half of them. About 1 in 5 of the facilities had four or more violations; the analysis found more than a hundred overall. It's not clear by looking at the reports how many of the violations led to patient infections. Problems that get cited on the inspection reports are required to be corrected as part of the regulation process.
But it's also true that inspections only flag a small number of the actual problems in hospitals. American hospitals, overall, are so bad at preventing infections that hospital-acquired infections are considered a leading cause of death in the United States. The hope would be that the sites designated as specialized infection-control centers would do better.
MedStar Washington Hospital Center in Washington, D.C., says it's ready to screen coronavirus patients. Inspectors have cited the facility more than a dozen times since 2017, including for infection control failures. Among the violations: Staff did not wear and dispose of masks according to federal guidelines. Short staffing caused scores of patients to go without respiratory treatments. There were sewage leaks in operating rooms.
In an email, a spokeswoman said the hospital has addressed the failures: "We maintain a constant state of readiness for treating complex illnesses, including the coronavirus."
Montefiore Medical Center in the Bronx, New York, says on its website COVID-19 patients will be immediately isolated. But it got written up back-to-back, in 2016 and 2017, for violating infection control protocol. Among the shortcomings: "Chronic overcrowding" in its emergency room, not isolating a Hepatitis B-positive patient and contaminated supplies. Infection control breaches put patients and staff at risk, one inspection report said. Hospital officials did not respond to requests for comment.
Medical experts say they wonder: if hospitals can't control the spread of pathogens under normal conditions, what happens if they face a rush of patients with a disease as contagious and serious as the one caused by COVID-19?
During the SARS outbreak in the greater Toronto area, 44% of the total cases were among health care workers. A retrospective study, published in the journal Emerging Infectious Diseases in 2004, hypothesized that "lapses in infection control measures may be responsible," noting that caregivers were particularly at risk during procedures like intubation.
Though COVID-19, with its estimated 2% fatality rate, is far milder than SARS, which killed about 10%, it is thought to have a similar method of transmission and will require similar methods of protection to prevent the disease from spreading throughout hospitals. Without a proven treatment or vaccine, infected patients would need to be handled with the utmost caution. They would be isolated, and caregivers would don protective gear, including gloves, goggles, gowns and masks.
Medical providers across the country told ProPublica that they're worried about their safety and their hospitals' lack of preparation. They spoke on the condition of anonymity because they were not authorized to speak on behalf of their hospitals.
The coronavirus arrived in Washington state "like a slap in the face," a nurse in the Seattle area told ProPublica. Two weeks ago, her hospital was talking about the virus as something it was "watching, but with no big alarm." Now, the state has had the first deaths in the United States and 18 confirmed cases as of Monday. The hospital is "desperately trying to get more supplies," she said, particularly of masks and gowns. She fears that morale will drop. Already, she's heard staff grumbling that only certain units are being allocated higher-protection masks.
An acute-care nurse in Rockford, Illinois, said that just last week, a severely ill patient on her floor initially tested negative for the flu but after nearly a week retested positive. In that period, nurses were in and out of his room, and what's known as "droplet precautions" weren't always taken — for example, sometimes the patient didn't have a mask on, meaning staff members were exposed. "How easily this happened gives me serious concerns about the much more serious infection we face with COVID-19," she said.
Another nurse, at a high-level hospital in western New York that is likely to handle severely ill patients, said the only information he's received is via the hospital's internal newsletter. "Management has just said, 'We're monitoring the situation and we'll keep you updated.' It's ridiculous. They haven't verbalized a specific plan, and that increases the anxiety of a lot of the care providers." He said he and his co-workers are "resigned to the fact that we're all going to get the coronavirus."
The risk to hospital workers could have a dangerous cascading effect, said Dr. Lance Peterson, the recently retired director of clinical microbiology and infectious disease research at the NorthShore University Health System in Evanston, Illinois. He said that hospitals often keep staffing to a minimum, and that could become a problem if there's prolonged spread of the virus. "If hospital workers start getting sick," he said, "you don't want them to come to work."
Some hospitals are more prepared than others for a potential outbreak, said Dr. William Schaffner, professor of preventive medicine and infectious diseases at Vanderbilt University Medical Center. Some have spent recent weeks running drills. Officials at University Hospital in Newark and MedStar in Washington, D.C., count themselves among those.
In many ways, the United States is better prepared than many other countries for an outbreak, Peterson said. Individual patient rooms are common, which makes it easier to isolate infected patients. The SARS and Ebola outbreaks prompted many hospitals to stock up on supplies like gloves and gowns and masks, he said. And The Joint Commission, which accredits hospitals, has been monitoring their level of preparation.
But it is true there are also going to be infection control problems, he said. "Whenever you have humans in the system, there will be lapses." Ariana Tobin and Maya Miller contributed reporting.