What is the most appropriate action for a patient with Ebola who insists on leaving the hospital to buy a drink despite being in isolation?

Management of Ebola Patient Attempting to Leave Isolation

The most appropriate action is to consult hospital administrators (Option D) to invoke legal quarantine authority and prevent the patient from leaving, as Ebola poses an extreme public health threat requiring mandatory isolation to prevent community transmission and potential mortality in exposed individuals.

Rationale for Administrative Consultation

This situation requires immediate escalation beyond bedside clinical decision-making because:

• Ebola is transmitted through direct contact with bodily fluids and contaminated fomites, with documented chains of secondary spread resulting in high mortality rates 1, 2
• The Dallas Ebola case demonstrated catastrophic consequences when a single patient was not properly isolated, resulting in the patient's death and infection of two nurses, highlighting that hospitals must act as part of a public health system with responsibilities to the community 3
• Hospital administrators have the authority and responsibility to engage public health departments and invoke legal quarantine measures that individual clinicians cannot implement alone 3

Why Other Options Are Inadequate

Security Alone (Option A) - Insufficient

• Security personnel lack the legal authority to detain a patient without proper administrative and legal framework in place
• Physical restraint without proper legal backing could constitute unlawful detention
• This approach fails to engage the public health system, which is essential for managing highly consequential infections 3

Infectious Disease Referral (Option B) - Misses the Point

• The patient is already diagnosed with Ebola and under appropriate medical care
• The issue is not medical management but preventing a public health catastrophe through legal containment
• ID consultation does not address the immediate threat of the patient leaving isolation

DAMA (Option C) - Dangerous and Inappropriate

• Allowing a patient with confirmed Ebola to leave against medical advice would violate the hospital's responsibility to the community 3
• This could result in widespread community transmission, as Ebola has a case-fatality rate of approximately 40% and spreads through contact with infected individuals 4, 5
• Caregivers' movement must be restricted to designated areas with strict infection control, let alone allowing an actively infected patient to leave 3

Immediate Action Algorithm

1. Immediately notify hospital administration while keeping the patient engaged in conversation to delay departure
2. Hospital administrators should contact state/local public health authorities to invoke mandatory quarantine orders 3
3. Security should be positioned (but not act independently) to support the legal quarantine once administrative/legal authority is established
4. Document the patient's request and all interventions for legal and medical records

Critical Public Health Context

The hospital has legal and ethical obligations that supersede individual patient autonomy when dealing with highly contagious, lethal diseases like Ebola:

• Persons with confirmed Ebola must have movement restricted to patient care areas only, with strict adherence to infection control protocols 3
• The 2014 Dallas case resulted in death and secondary infections precisely because the hospital failed to act as part of the public health system 3
• Risk of transmission is highest through direct physical contact, and allowing the patient into the community would expose countless individuals 2, 1

Common Pitfalls to Avoid

• Do not attempt to handle this situation at the bedside level alone - this requires institutional and governmental authority 3
• Do not delay notification - every minute increases the risk the patient may successfully leave
• Do not rely solely on persuasion - while therapeutic communication is important, legal quarantine authority must be established
• Do not sign DAMA under any circumstances - this would be a catastrophic failure of public health responsibility 3