in early 2016 , we sent a 70-question survey to the original 56 designated us hlius , including the 10 resptcs .
results were collected through adobe acrobat pro ( https://acrobat.adobe.com/us/en/acrobat/acrobat-pro.html ) and analyzed by using descriptive statistics .
the university of nebraska medical center institutional review board declared the study exempt ( # 17216x ) .
of the 33 that completed the full survey , 3 reported they no longer maintained their hliu capabilities .
the 2 that provided qualitative information about their decision to close reported needing hliu resources for other , more pressing areas and cited close proximity to at least 1 other hliu as reasons for closing .
nineteen ( 58% ) hospitals reported using their hliu for non - hid patients when not activated ; the other 14 ( 42% ) use the unit exclusively for patients with hids or for training ( table 1 ) . when the 19 hospitals with adaptive isolation units ( i.e. , units otherwise used for normal hospital care ) are activated , an average of 6.31 beds ( median  6 , range  212 ) must be taken offline when caring for 1 patient with an hid and an average of 6.97 beds ( median  7.75 , range  212 ) for 2 patients .
ten ( 53% ) hlius with adaptive units stated preference for a unit dedicated to care for patients with hids ; however , when asked the estimated costs of developing a unit for 2 hid patients , estimates ranged from $ 1 million to $ 12 million .
perceived benefits of a dedicated unit included minimizing disruption of other patients ( 4 hospitals ) , a constant state of readiness ( 3 hospitals ) , and an ability to train in the unit ( 4 hospitals ) . * ed , emergency department ; hliu , high - level isolation unit ; pui , patient under investigation . 
average time necessary to activate hliu after notification of pending patient transfer is 4.58 h ( median  4 h , range  1.24 h ) . 
one facility sends a mobile response team to a pui s home for evaluation , and another plans to use a mobile treatment unit ( i.e. , tent ) for pui placement .
our initial 2015 survey reported that hospitals designated as etcs incurred an average per hospital of $ 1,197,993 ( 4 ) . since that time , 25 ( 76% ) of those original facilities reported receiving some degree of federal reimbursement , and 8 ( 24% ) had not received any reimbursement . a cumulative total of $ 28,146,558 in federal funding ( average $ 1,407,328 , range $ 33,650$6,000,000 ) was reported by the 20 ( 60% ) reporting hlius .
after we excluded federally funded resptcs and hlius that did not report initial investments in the pilot survey , the remaining 14 hlius reported a gap in reimbursement of $ 9,113,072.50 ( mean $ 650,933.75 per hliu ) .
although 1 hliu reported lacking specific protocols or an ability to care for patients with an hid other than evd , all other hlius ( 97% ) reported being prepared to care for patients with hids other than evd ( figure 1 ) .
our survey also queried hlius about the challenges they experienced and challenges they foresee in maintaining the capabilities and capacity needed for hid care ( figure 2 ) .
hlius also detailed facility modifications and/or capabilities they would add if additional hypothetical funding were available ( table 2 ) .
challenges to establishing an hliu and to maintaining hid care reported by survey respondents , united states , 2016 ( n = 32 hlius ) .
other challenges include external support , lack of dedicated unit space , competing priorities , staffing needs , and decreasing hospital capacities .
* individual hlius self - reported data through an electronically administered survey administered in 2016 .
developed during the height of the west africa ebola outbreak , most newly established us hlius invested immense resources and effort into preparing for patients with evd .
however , no formal network of hlius has been established in the united states , except for the 10 resptcs , and at least 3 former hlius no longer maintain hliu capabilities . moreover , 14 hlius not designated as resptcs reported having spent $ 9.1 million more than they have been reimbursed to initially develop hliu capabilities . as a result , these hospitals reported struggling to fund ongoing operations and sustain readiness .
although many facilities have created adaptable - use hlius because they lack the capital funds , space , or both to create a dedicated unit , such units have major disadvantages because healthcare workers are unable to train in the unit , existing patients must be relocated when the unit is activated for an hid patient , and multiple additional rooms must be taken off - line for the care of 1 patient with an hid ( 8) .
thus , more than half of us hlius that routinely care for non - hid patients would build an hid - dedicated unit if funds were available .
however , because future funding sources for non - resptcs are unclear , lessons on sustainability might be learned from flexible - use hlius in italy and the netherlands , which offer levels of containment based on a patient s condition and offset costs by routine use ( 1 ) .
the current status of hlius that did not participate in the follow - up survey is unknown .
a decrease in participation from the initial survey to the follow - up could also be due to the longer , more detailed follow - up and could indicate the lack of attention to this area now that the evd outbreak is over .
the study population was based solely on a list published by the centers for disease control and prevention ( 9 ) and does not include data from other hospitals that similarly tried to strengthen their ability to treat hid patients . in conclusion ,
a network of hospitals capable of treating patients with hids was rapidly constructed in response to the recent evd outbreak . however , without the impending threat of evd or another hid on the immediate horizon , public attention on hid preparedness tends to waver , and governments tend to prioritize and shift funding elsewhere .
additional external funding sources remain generally uncertain for us hlius not designated as resptcs ; therefore , these hlius must strategize methods and models of sustainability if they are to maintain capabilities and readiness .
 to identify barriers to maintaining and applying capabilities of us high - level isolation units ( hlius ) used during the ebola virus disease outbreak , during 2016 we surveyed hlius . 
 hlius identified sustainability challenges and reported the highly infectious diseases they would treat . 
 hlius expended substantial resources in development but must strategize models of sustainability to maintain readiness . 
The Study
Conclusions