Many months into a still-worsening epidemic of Ebola virus disease (EVD) in three West African nations, the U.S. health care system was challenged by its first undiagnosed EVD patient presenting to a hospital emergency department (ED) in Dallas, Texas.1 Despite attempting to follow infection control guidance extant at the time,2 two nurses who cared for this patient acquired EVD.1 Previously, U.S. health care workers infected while working in Ebola-affected countries had been repatriated and treated in established, high-level containment facilities in U.S. hospitals.3 However, the well-publicized events in Dallas, including commercial air travel by one of the infected nurses,4 prompted immediate, widespread efforts to better prepare hospitals nationwide for possible EVD patients. Over the ensuing weeks, numerous federal policies were implemented, and extensive guidance related to EVD was disseminated by the U.S. Centers for Disease Control and Prevention (CDC). CDC response teams were assembled to assist hospitals that were caring for confirmed EVD patients. Various team configurations were designed to deliver public health and/or medical expertise to these hospitals.5, 6 In addition, CDC's Division of Global Migration and Quarantine, with the Department of Homeland Security's Agency for Customs and Border Protection, jointly determined that all flights originating in or passing through Ebola-affected areas would land at one of five U.S. airports, and all debarking passengers would undergo enhanced screening according to criteria outlined by the CDC.7, 8 The CDC proposed that states stratify their hospitals with respect to their capabilities to safely manage “patients under investigation” (PUI) and patients with confirmed EVD. According to this nomenclature, hospitals and their EDs were considered “frontline,” “Ebola assessment,” or “Ebola treatment” facilities, with the expectation that staffing, logistics, and transportation infrastructure would support integration of all three types of hospitals into geographic networks coordinated by the states.9, 10 To address these issues, the authors' institution requested state disaster response assets in the form of Western Shelters, and outfitted them as mobile isolation units inside of a building of opportunity adjacent to their ED. They used hazmat-trained emergency medical technicians (EMTs) who had previously responded with the portable units to support this facility. The EMTs assisted hospital medical personnel with training and supervising PPE donning and doffing processes. They also served as command staff in the incident command system that was organized for the facility. While not necessarily a feasible solution for most Ebola assessment hospitals, sharing their approach should generate further discussion and innovation to mitigate the problems associated with trying to accommodate PUIs in high-volume EDs. The high-level medical biocontainment units that are scattered around the United States and initially identified as the optimal destinations for patients acutely ill with EVD each have very few beds. They were primarily commissioned and scaled to evaluate and treat workers in the unlikely event of an accidental exposure to a serious communicable pathogen at a nearby biocontainment laboratory or exposure during deployment to an outbreak.3, 12 Since the beds in these units fortunately remain empty most of the time, some have also been available to evaluate travelers arriving in the United States with an illness and travel history suggestive of infection with a serious communicable disease. In view of the limited capacity of these dedicated facilities, and little ability to “surge” in response to the possibility of an increasing need to care for greater numbers of EVD patients in the United States, the CDC advised states to train, equip, and designate their medical facilities as outlined previously to manage EVD patients and PUIs.9, 10 The instinct to try to emulate some of the characteristics of the high-level units in preparing EVD evaluation and treatment capabilities in hospitals is understandable. The requirements for effective isolation of hospital staff and other patients from infectious materials remain absolute and are technically more difficult to achieve in the normal patient care setting. Opportunities to provide these services in separate but nearby settings are worthy of exploration. … the Willesden portable hospitals, consisting of a framework covered with the well-known Willesden paper and canvas, deserve notice, as offering very substantial advantages in connexion with the provision of temporary buildings for isolation purposes. They can be erected with great rapidity, and they are, compared with certain other means of isolation, by no means costly. They can be well-ventilated … With regard to all temporary hospital provision, we cannot omit to point out that … a site has to be in readiness, that drainage and water-supply and other requisites are needed, and that these cannot be provided on the spur of the moment …”13 (see Figure 114). Alternate care facilities (ACFs) operated by hospitals or communities to provide surge capacity during medical contingencies comprise either modularized logistics packages of beds, equipment, and supplies that can be deployed in various types of buildings of opportunity or free-standing mobile hospitals in the form of tents or trailers. The evolution of ACFs to current formats, including the shelters described by Sugalski et al.,11 has been reviewed, and characteristics, site requirements, and concepts of operation of the various options have been described.15 The solution developed by Sugalski et al. is a hybrid of the portable hospital unit and the building of opportunity that offered discrete isolation spaces, as well as all of the utilities and other service requirements identified in both historical and current documents.11 In most recent planning documents and deployments, the mission of ACFs was to decompress hospitals by treating large numbers of lower-acuity and/or palliative care patients in the surge facilities, allowing hospitals to manage those requiring procedures or medical support that can only be provided there. Most scenarios that involve use of ACFs are mass casualty incidents such as detonation of an improvised nuclear device or high-intensity earthquakes; however, ACFs were employed during the 1918 influenza pandemic and are included in current pandemic flu plans.15 It is important to understand that the present discussion involves utilization of these resources for surge capability rather than surge capacity. Surge capability has been defined as the “ability of the health care system to manage patients who require specialized evaluation or interventions (e.g., contaminated, highly contagious, or burn patients).”16 The methods that are typically used by health care facilities to generate surge capacity may be unlikely to generate significant surge capability.17 Previous planning assumptions have considered that surge capability was best addressed through transportation networks that could accomplish expeditious delivery of patients to the appropriate specialty care facilities.16 Ebola assessment hospitals in the United States are presently faced with developing surge capability to safely evaluate and care for small numbers of patients who potentially “overwhelm” the health care facility not by their volume, but by their unique requirements and disruption of normal hospital operations. While the CDC's concept of networking hospitals with the different categories of EVD capability does involve some use of transportation for redistribution of patients to the appropriate facilities, the designated hospitals must develop their own solutions to the challenges of evaluating and caring for these patients. As indicated in the present report,11 the costs associated with preparing for and providing care to PUIs can be substantial. The position paper jointly developed by the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine, on “Ethical Issues in the Response to Ebola Virus Disease in United States Emergency Departments,” appearing in this issue of Academic Emergency Medicine,18 outlines important ethical responsibilities of all hospitals in support of such networks. The article points out that the principle of reciprocity should apply to appropriately credentialed staff, sharing equipment and supplies and “reputational” support, i.e., publicly endorsing the safety and quality of care offered at institutions caring for EVD patients and PUIs. The use of ACFs in the disaster setting is usually an indication that the incident has degraded or outstripped available assets, resulting in resource-constrained conditions, with a presumed adjustment to public expectations and standards of medical care.19 Since these are not the conditions that are driving the use of the portable isolation facilities described by Sugalski et al.,11 normal standards of care must be provided there. Some PUIs may be or may become more seriously ill with either EVD or another febrile illness acquired during travel before definitive diagnosis. Neither scarcity of resources nor medical futility would be viable arguments against providing mechanical ventilation, central pressure monitoring, transfusion, renal dialysis, or other aggressive care of these patients.18 Availability of more rapid diagnostic testing for Ebola infection should shorten the duration of the assessment phase of care of PUI and facilitate more rapid transfer of critically ill patients to regular intensive care units or transport to Ebola treatment hospitals. Meanwhile, as appeared to be true of the isolation unit in Sugalski's facility, Ebola assessment hospitals must be prepared to manage such patients for a period of time. A description of the requirements for providing critical care to patients with EVD has been published.20 In addition to meeting the medical requirements, use of an ACF for assessment of PUI should address the five-item problem list enumerated above. Most of the issues were at least partially solved simply by use of a separate facility that was visibly remote from the main patient care areas. Selection, acquisition, and training staff in the use of appropriate PPE are essential, but the addition of personnel trained and experienced in PPE donning and doffing to supervise these procedures,9, 11 and adjusting both shift length and work/rest cycles,21 appear to allay apprehension of providers working with EVD patients. Finally, while there are allowances for sharing personally identifiable, protected health information during public health emergencies,22 this should not extend to uncontrollable media identification of PUIs and medical personnel caring for them. The physical characteristics of the ACF were reported by the authors to improve the hospital's ability to protect patient privacy.11 There is also a need for training and practice in PPE beyond just donning and doffing. There should be operational drills with mannequins or volunteers to ensure that all protocols, from notification through transfer of patients in and out of the facility, are feasible and are efficiently carried out by all who may be called upon to do so. Methods for performing critical care procedures while wearing appropriate PPE must also be practiced. The ACF described and its staffing may offer opportunities for effective training of health care workers from that and other hospitals as part of networked, regional preparedness. The management of patients with suspected or confirmed serious communicable disease is a health care capability that requires dedicated education and training of both prehospital and hospital-based health care workers. The development and implementation of institutional policies and procedures are also vital for the safe management of these patients, as well as operational efficiency and effectiveness. All health care workers must be capable of evaluating and caring for patients while fastidiously applying sound infection control practice. More effective application of infection control ties directly to health care quality. A recent survey indicated that on any given day, one in 25 inpatients had at least one health care–associated infection, and there were an estimated 722,000 such infections in U.S. acute care hospitals in 2011.23 Furthermore, the financial implications for institutions that lose the public's confidence to provide care safely can be devastating. For example, Texas Presbyterian Hospital in Dallas reported a 50% decrease in ED patient volume and a net revenue loss of over $8 million associated with its EVD experience.24 In an ideal state, all health systems could safely and effectively manage any patient, while meticulously implementing standard and transmission-based infection control precautions. But management of patients with EVD from arrival to discharge in the U.S. health system has underscored what was already well known by clinicians in Ebola-affected countries in West Africa. Good outcomes require abundant resources, and prevention of secondary transmission during the phase of EVD, accompanied by monumental fluid losses, poses challenges best managed by health care workers with proven competencies. In much the same way that hospitals are verified to have special capabilities to manage trauma, stroke, and heart attack victims, and designated as such, hospitals can be identified as having the special capabilities needed to effectively manage patients with EVD and other serious communicable diseases. These capabilities have been outlined in guidance published by the CDC.9 Special attributes include prehospital transport plans and robust EMS interfaces, care team competencies, isolation and patient placement policies, PPE and procedures for donning and doffing it, health care personnel monitoring, lab safety, environmental infection control, management of waste, and communications, among others. The management of EVD in the United States demonstrates that health care workers and their patients are best served by systems that ensure necessary competencies for daily delivery of quality care, and regional networks of facilities and transportation for patients in need of special expertise.