Preparing for Ebola: What U.S. Hospitals Can Learn From Emory Healthcare and Nebraska Medical Center
Moderator:Leticia R. Davila
Presenters:RADM Steve Redd, Alexander P. Isakov, MD, MPH, Bruce S. Ribner, MD, MPH, Phillip W. Smith, MD and Angela Hewlett, MD
Date/Time:October 14, 2014 2:00 pm ET
Welcome and thank you for standing by. At this time, all participants are in a listen-only mode. During the question-and-answer session, please press Star 1 on your touchtone phone. Today’s conference is being recorded. If you have any objections, you may disconnect at this time. And now I'll turn today’s meeting over to Leticia Davila. Thank you. You may begin.
Thank you, (Candy). Good afternoon. I am Leticia Davila and I am representing the Clinician Outreach and Communication Activity, COCA, with a Healthcare Preparedness Activity at the Centers for Disease Control and Prevention. I'm delighted to welcome you to today’s COCA call, Preparing for Ebola: What US Hospitals Can Learn from Emory Healthcare and Nebraska Medical Center.
We are pleased to have with us today Rear Admiral Redd from CDC, Drs. Ribner and Isakov from Emory Healthcare, and Drs. Smith and Hewlett from Nebraska Medical Center. They will focus on healthcare systems preparedness and will share how Emory Healthcare and Nebraska Medical Center prepared for patients with Ebola and the lessons learned.
There is no continuing education provided for this call. You may participate in today’s call by audio only and PowerPoint slides are available to download. The PowerPoint slide set can be found on our COCA Web site at emergency.cdc.gov/coca. Click on COCA Calls. The slide set is located under the call in number and call passcode.
Our first presenter will be Rear Admiral Steve Redd. He is a Senior Advisor of the Ebola Response at CDC. Our next presenter is Dr. Alexander Isakov. He is the Director of the Section of Prehospital and Disaster Medicine at Emory Healthcare. He will be followed by Dr. Bruce Ribner, Director of Emory’s Serious Communicable Disease Unit. Our final presenters will be Dr. Phillip Smith, Medical Director of the Biocontainment Unit at the University of Nebraska Medical Center, and Dr. Angela Hewlett, Associate Director of the Nebraska Biocontainment Unit. In addition to today’s presenters, CDC Subject Matter Experts as well as representatives from Emory and Nebraska will be available to answer questions during the Q&A session of today’s COCA call.
At the end of the presentation, you will have the opportunity to ask the presenters questions. On the phone dialing Star 1, will put you in the queue for questions. Questions will be limited to healthcare workers and facilities who would like information on healthcare systems preparedness and not clinical management or clinical guidance for patients with Ebola.
For those who have media questions, please contact CDC Media Relations at 404-639-3286, or send an email to email@example.com. Again, the PowerPoint slide set is available from our COCA Web page at emergency.cdc.gov/coca. At this time, please welcome Rear Admiral Steve Redd.
RADM Steve Redd:
Thanks very much. I think that we may have a record call on our hands with 5,650 call ins up to this point, and let me thank the teams from Emory and from Nebraska to making themselves available to describe their experience in this very hot topic. There’s - as we all know, there’s very - there’s some experience managing Ebola in Africa, but very limited experience in a modern medical system. So without any further adieu, I want to pass the microphone to Dr. Isakov to begin to describe the work that’s been done at Emory.
Dr. Alexander Isakov:
Thanks very much, Steve. I'm Alex Isakov. I'm an Emergency Medicine Physician here at Emory. I'm also an EMS Medicine Physician. It’s a new sub-specialty of emergency medicine, looking specifically at out of hospital care issues.
I was responsible for the safe ground transport of patients that arrived in the metro Atlanta area and then were transported to Emory University Hospital’s Serious Communicable Disease Unit for management of their confirmed Ebola virus disease.
In contemplating that pre-hospital element over a decade ago, we looked at our EMS providers and identified a partner in the community which responds to 911 calls in Atlanta, Grady EMS. And made an effort to close gaps that we recognized about the education and training of EMS providers and what would be necessary to manage a patient with a confirmed serious communicable disease like Ebola virus disease.
And the gaps that we closed were largely around the nature of a viral disease like Ebola virus, how it’s transmitted, what protections are available for healthcare workers in caring for those individuals, great education about infection control measures to provide for the safety of the healthcare provider and others.
We also closed some gaps in training. We all understand standard and transmission-based infection control practice as healthcare workers both in the out-of-hospital environment and the in-hospital environment, but to do that meticulously and to do it exceptionally well we believed required some additional training.
And so there was competency-based training around the applying of the appropriate personal protective equipment, or the donning of PPE, and the appropriate and effective removal of that personal protective equipment, the doffing of PPE, without risk, or limiting, or closing the risk of the possibility of contaminating yourself while removing that material.
We also focused specifically on the decontamination and disinfection of the ambulance after transport of such a patient and how that waste would be managed.
In addition, we work now to prepare our emergency departments and the emergency response system in general in communities, which includes the 911 communication center, the 911 first responders and transport agencies, as well as the emergency departments that might receive patients.
And with that, I'll direct you to the next slide which opens with “my brother just returned from Liberia and has fever and diarrhea.”
From the day we saw the public health emergency in West Africa blossom, and the repatriation of American health workers to the United States, we anticipated that other travelers who haven’t yet developed symptoms, who’ve been to affected areas, may return to our community. And so we also contemplated how best to prepare for that and how best to implement the guidelines that have been offered by CDC and other agencies to help our communities prepare.
First and foremost, we implemented screening at every point that a patient might make entry. Screening for travel outside the United States in the last three weeks and where that travel occurred, specifically looking for areas where patients might have come - become exposed to Ebola virus, meaning the countries where the epidemic is present.
We also screened them for the signs and symptoms of course of Ebola virus disease; nausea, vomiting, headache, and fever in particular.
We do that at every point of entry. Initially when the call comes in to the 911 call center, our public safety answering point and our call takers are interrogating the caller for signs and symptoms of Ebola virus disease as well as the presence of the travel history.
We also encourage our EMS responders to ask those same questions again just as an effort to try and manage that possibility that the PSAP missed the information.
And then third, we of course encourage and we’ve implemented in our emergency departments and points of entry for patients into our health system the same screening measures. Have you traveled outside the United States in the last three weeks? If so, where? Do you have fever? Do you have any other signs and symptoms of Ebola virus disease?
That screening is critical to identifying patients early, and identifying patients early is important so that the appropriate infection control measures can be put in place by healthcare workers both in the out-of-hospital setting and in the emergency department setting.
The safety of the patient, the healthcare workers and others around them is also paramount. When I talk about safety for the patient, I mean timely attention to their medical condition. We certainly make every effort to not allow the travel history and presence of fever or signs and symptoms to paralyze the responder.
It’s as likely or more likely that individuals returning from Africa with fever and other constitutional systems will have Malaria or some acute diarrheal illness, and they may require timely attention. And being paralyzed by the thought they might have Ebola virus is really something we need to avoid. So we provide this education, this training, this screening to provide for the safety of the patient.
Of course we also do it for the safety of the healthcare worker so that they can implement appropriate standard and transmission-based infection control practice. And then at the same time, limit the exposure of that individual to bystanders in the out-of-hospital environment or visitors and other patients when that patient’s transported to the hospital.
If we look at - oh, and other safety factors, protocols, or clinical care guidelines you might consider, especially in out-of-hospital environment, which is less controlled, limiting use of sharps to patients that really require it, and limiting exposure to - or use of aerosol producing procedures.
Destination is important. Every emergency department, every clinic in the United States has to be prepared to manage a patient who’s recently returned from an Ebola-affected country and has fever because they could walk into any clinic, they could walk into any ED, they could dial 911. So everyone has to be prepared to do that, and ways to be prepared to do that, include the screening and the implementation of training and education around infection control practice.
Also, knowing where to take those patients in your community is important. Every ED should be prepared, but communities may make decisions about which facilities are preferred versus others.
In any case, wherever the patient’s being transported, early notification to that emergency department that a patient is coming in with a fever, signs and symptoms, and a concerning travel history needs to be communicated so the emergency department can be best prepared to have a room where that patient can be isolated and healthcare workers receiving the patient be in the appropriate personal protective equipment.
Let me go to the next slide, which is a focus on PPE and infection control. We’re in complete agreement with CDC guidelines around what is required to prevent transmission of Ebola virus disease, and that is to prevent the contact with blood or infectious bodily fluids through implementation of standard precautions as well as contact and droplet precautions.
If you look at the picture on the left, you'll see a healthcare worker that’s wearing a surgical mask, a face shield, a gown, and gloves. He also happens to have booties on. And that would largely be implemented to protect oneself from blood and infectious bodily fluids in keeping with standard contact and droplet precautions.
But what you see on television sometimes, or certainly with the reception of confirmed patients to the US, is an ambulance which is draped out in blue barriers, paramedics who are dressed head to toe in Tyvek, and they’re wearing a powered air purifying respirator.
Let me give that some due explanation. The decisions that were made around that personal protective equipment were made out of operational considerations and practicality. We completely agree with the infection control measures include standard contact and droplet precautions, but through exercising the movement of patients with confirmed diseases over a number of years, what we’ve found in August in Atlanta, eyewear fogs and paramedics, no matter how disciplined and trained, have a temptation to reach up and wipe sweat from their brow, and we don't - can’t accept that kind of lapse in infection control practice.
And so by the application of a Tyvek hooded PAPR, we solved the problem of eyewear fogging. We solved the problem of a healthcare worker in the back of an ambulance in 90-degree heat with the temptation to wipe sweat off their brow and potentially infect themselves.
And by providing that paramedic head to toe skin protection from splash, we give them some confidence that if in the back of an ambulance they have a patient that is having copious vomiting or large volumes of diarrhea or having sites of cutaneous bleeding, that they’re largely protected from that infectious bodily fluid.
Is it strictly required? No. It’s not strictly required. But from an operational perspective, it was the way in which we felt we could best implement standard contact and droplet precautions in that work environment while also being prepared should an aerosol producing procedure be needed, like endotracheal intubation or open airway suctioning, that with the powered air purifying respirator, our healthcare workers were also best prepared to manage the patient that would at that point require aerosol protection.
Next slide in particular is around the recovery. While the TV cameras largely disappear from keeping the ambulance in view after delivery of a patient to the hospital, that’s only half the work done for the pre-hospital providers. What’s necessary now is for them to move into a location where absent bystanders, they can properly decontaminate, disinfect their ambulance, and come out of their PPE, or doff their PPE, in a safe manner.
And ways that are implemented to try and make that more easy, if you can think about a patient in the back of an ambulance who’s vomiting or having a large amount of diarrhea, rather than have that individual vomit into cabinets and shelves where it would be difficult to clean and disinfect, we apply barrier drapes to the inside of our patient compartment. We isolate the driver compartment from the patient compartment to always keep it clean. And in this way, make it easier to disinfect the ambulance.
We also have a buddy (supervised) system for the proper doffing of personal protective equipment so that this process of doffing the PPE while the providers have been trained in meticulous removal of their PPE to avoid cross-contamination, they are still supervised in that process to prevent any break in process and procedure.
The decontamination and disinfection of the ambulance, the PPE doffing, and waste removal are all supervised activities, meaning the primary providers are being supervised by supervisory personnel, in our case, also an EMS medical director, to observe all those procedures and ensure they’re done without any breech.
And lastly, while procedures are clearly in place for any known or recognized exposure to blood or infectious bodily fluids, which would include a quick washing of that material from the skin or wherever it had made contact, followed by alerting supervisors, occupational health, and public health of the recognized exposure, we go an extra measure and our healthcare workers in that environment are monitored for 21 days even in the absence of a recognized exposure just so that any fever or diarrheal illness, or something else that might develop, can be quickly evaluated. While we are almost certain that there was no contact, we wouldn’t want to let those signs and symptoms pass without some type of an evaluation.
I think largely why this is in - all of this is important for healthcare preparedness is for the management of patients with so many conditions, the partnerships between healthcare and their colleagues in the out-of-hospital environment, also healthcare workers, are important for success. And by implementing these measures around education and training, screening of patients, recognition of the appropriate safety measures, appropriate destination, and we believe supervised decon/disinfection and PPE removal, as well as waste management, healthcare workers in the out-of-hospital and in-hospital environment can perform this safely.
And with that, I will stop and pass the lectern to Dr. Bruce Ribner, the Head of the Serious Communicable Disease Unit.
Dr. Bruce Ribner:
Thank you, Alex. So as you’ve just heard, this is Bruce Ribner and I'm the Medical Director for our Serious Communicable Disease Unit at Emory University Hospital. So if you go to the first slide, that’s just the title. The one after that entitled “Planning.” I think it’s critical when you do your facility planning to realize that there are very few departments in your facility that are not involved in the management of patients with Ebola virus disease. You've already heard Dr. Isakov and his discussion of emergency medical services. And for those of you who want additional information on that, you can look actually to an article that Dr. Isakov and I wrote in the Annals of Internal Medicine in September which address many of those issues.
In terms of medical staffing, we have used even amongst those hospitals which have patient Biocontainment units, different models. Some of us use infectious disease physicians as primary care providers. Others have used critical care medicine as the primary care providers. But regardless of which model you use, you have to appreciate that because these patients are critically ill, there are going to be multiple different specialties involved. Anesthesiology, medical specialties, perhaps surgical specialties as well.
Nursing is critically important. Again, these are critically ill patients. In our particular model, because they are so ill, we only use intensive care unit nurses, and that’s especially true because some of our patients have gone on to require dialysis, to require ventilation on a respirator, and these are skills which really floor nurses are not competent to do.
But in addition, as I'll get into in a minute, you have to involve environmental management, facilities, security, and media relations.
On the next slide, I start getting into some of the issues which I think we’re still working out in the United States. So the question that I frequently get asked is what do you do about laboratory testing?
And again, in our particular setting we decided to set aside a separate laboratory. As I have up here, the CDC recommends that laboratory technologists use full personal protective equipment and bio safety cabinets or shields in order to do their testing.
But on the next slide, you'll see that the American Society for Microbiology has come out strongly for point-of-care testing in the patient room or in an associated facility.
When we looked at this - and again, every hospital has to decide what works for them. We decided that if we had a specimen that spilled in our core, our main laboratory, it would create a disaster in terms of work flow and patient care for our 600 bed hospital.
In addition, we did have some technologists express concerns about processing specimens from patients who had Ebola virus disease.
And so what we did is we established a point of care laboratory which was right next to the unit, and if you go to the next slide we have a schematic of that, and you'll see the main part of our unit are two ICU beds with a large anteroom. And just outside that anteroom is the laboratory which we established as a point of care laboratory.
Again, on the next slide, we list the testing that we were able to do in that laboratory. Chemistries, hematology, blood gasses, urinalysis, coags. And as Dr. Isakov said, because these patients are coming back from parts of the world where Malaria is far more likely to be a cause of fever then Ebola virus disease, we had to have Malaria testing in our point of care testing to make sure that we did not miss that potentially lethal infectious disease.
On the next slide, again I'm going to be introducing you to challenges that we encountered. Again, many of them are being worked out. You have to remember that we had the very first two patients cared for with Ebola virus disease in the United States. And for many people, it was a rapid learning curve.
There still may be some issues with commercial carriers. Many of you are going to have to be planning on sending your specimens to Atlanta for testing - to the CDC or to some of the satellite laboratories that they have established around the country. Just make sure - again, you don't want to wait until a patient arrives in order to figure out how your specimens are going to be going to the laboratory. You need to speak with your courier services beforehand in order to make sure that you have a way of getting those specimens in a rapid manner to the laboratories that are doing your testing.
On the next slide, again this is just a reminder. As you do your planning, there are lots of agencies at all levels which are interested in managing patients and waste from patients with Category A agents, and you really have to work with somebody who’s knowledgeable in these many different regulations.
On the next slide, Dr. Isakov has already addressed the matter of personal protective equipment, and we reached our decision pretty much the same way that he did.
If you look on the next slide, I have summarized for you the current recommendations from the Centers for Disease Control. Again, we’re talking about droplet and contact precautions. And so as we see on the left side of this slide, all persons caring for the patient should wear gloves, a fluid-resistant or impermeable gown, eye protection, either in the form of goggles or face shield, and a face mask.
But now, if you look at the right-hand side of the box it says additional PPE may be required in certain situations depending on the patient and the environment, which may include double gloving, disposable shoe covers, and leg coverings.
Again, we had patients who for many days were having large amounts of effluent coming out through various body orifices, and when we decided that we needed to use fluid-resistant or impermeable gowns, leg coverings, and disposable shoe coverings, it was clear that the most efficient and safe way to establish this was by using the body suits that you saw in the previous slide.
In addition, once again as Dr. Isakov said, even though we were not outside, we were inside a patient care unit, there were still issues with goggles and face shields fogging. Our nurses were frequently in the patient room for three to four hours at a time, and it just turned out to be more practical to have our healthcare workers wearing the hooded PAPRs for comfort and convenience while taking care of these critically ill patients.
But again, I emphasize on the next slide thatwhatever form of personal protective equipment that your institution uses to meet contact and droplet precautions, it is critically important to do proper training and competency in donning and doffing of personal protective equipment because we feel very strongly that, especially during the doffing process, individuals who aren’t properly trained are at risk of self-contamination.
On the next slide, we list some of the considerations for PPE in our unit. We had a dedicated staff. Our unit has been in operation for 12 years. We have multiple training sessions. As I said here, even though each one of our providers had had multiple episodes of training over the previous years, we still reinforced that prior to the arrival of our first patient.
And again, removal of the personal protective equipment in a proper fashion is the key to preventing contamination, and so we went with the buddy system. Every individual is observed by another knowledgeable individual as they don and they doff their personal protective equipment. And in addition, we would have a checklist in the area where donning and doffing was done just to make sure that all providers did these procedures properly.
On the next slide, once again, we had the very first patients with Ebola virus disease, and frankly some of our local authorities weren’t quite sure what to do with our patient. We had issues with our watershed department, which we have now resolved, although again, it is important for you to have discussions with your local authorities to see if local regulations allow you to put a Category A agent into your sanitary sewers or whether you have to do disinfection, similar to the process we did. It was not terribly labor intensive or difficult.
And again on the next slide, we are still negotiating, and I think most of you probably are negotiating with your contractors, in terms of exactly how Category A waste will be moved from your facility to whatever the final destination is for your contractor.
In our particular case, the easiest way to do this was to autoclave all of our trash. It did put a fairly large burden on us. I do realize from speaking to a number of institutions that that is not an option. Again, contractors are working with the Department of Transportation, with the CDC, and coming up with solutions which do not require autoclaving on site. And again, the important part of this is just to have a dialog with your contractor and not wait until you have your first patient who may have Ebola virus disease.
On the next slide I talk about another critically important component, communication. There is a lot of anxiety even today, even having had multiple patients with Ebola virus disease on American soil, in terms of community relations, in terms of anxiety. Some of it is appropriate. Some of it is less than appropriate. And it is really critical that you work closely with media relations to get a consistent message out to the public and also to your own employees.
And again, our key messages were we have experience, expertise in treating patients with serious communicable diseases. We are trained. We’re prepared. And, we will protect our patients, our staff, and our community, and take care of patients without endangering other individuals.
On the next slide, I emphasize that you also must deal with your internal clients as well. There is going to be anxiety amongst hospital staff. We addressed that through email communications, through town halls. And in addition, recognizing that some of our patients might be concerned, we gave a letter to each in-patient and to each new admission explaining the situation and our key messages that this was a safe environment for them to be hospitalized in. And with that, I move the lectern along to my colleagues in Nebraska.
Dr. Phillip Smith:
Thank you, Bruce. And since Bruce and Alex covered the basics very thoroughly, and I don't want to be redundant, especially since I suspect there’ll be quite a few questions, Angela Hewlett and I will briefly do kind of a back and forth dialog about some of the variations in our plan and some of the different aspects that may not have been covered entirely by Bruce in his very nice overview.
First of all, administratively we think it’s very important to have an administrative structure in place, and there’s no one right way to do things. We have a leadership team consisting of eight people. Two infectious disease specialists, we have a decontamination specialist who’s a PhD from the College of Public Health, University of Nebraska Medical Center, a transportation specialist who’s also in the College of Public Health’s faculty - and as Dr. Isakov pointed out, transporting the patient is no small feat.
We have a nurse administrator who serves as our incident commander, a head nurse, an education specialist who specializes in PPE, making video tapes and (charts), and finally we have recently added a clinical studies specialist because of the time consuming nature of getting appropriate drugs available on site.
One of the things that worked for us very well was getting an incident command post, and our incident commander basically seized by force two classrooms across the hallway from our biocontainment unit and set that up as - it’s become sort of a permanent incident command structure. It’s a large room where people can meet. And in this room, there are a number of informal meetings that go on throughout the day, we call huddles.
Our - as Bruce mentioned, the nurse staff selection process is critical, and we have - it’s hard to underestimate the depth of nursing staff that you're going to need. We now have about 40 nurses on our team. I should say not all nurses. They’re nurses, respiratory therapists, and techs. And we have at any one time usually about six people on duty in our Biocontainment unit when we have a patient.
We have selected people from a variety of backgrounds. We have mostly intensive care unit nurses, but we have ER nurses, OR nurses, infusion nurses, pediatric care nurses. We tend to have very few nurses do routine floor care. Most of them come from the different intensive care environments, and the diversity of their backgrounds we’ve found is something that’s useful.
We have been doing this for a number of years, and it takes a while to build up momentum, but we have had - not only no nurses quit since the Ebola patients - the two Ebola patients that we have been here, but we’ve had an influx of applicants who are intrigued by the prospect of becoming part of that team. And have at the present time more nurses that we can fully accommodate, but that’s a nice position to be in. Angela?
Dr. Angela Hewlett:
Our waste disposal process is actually very similar to what Bruce discussed at Emory. We do have a pass through autoclave inside of our unit where we are able to autoclave everything that leaves our unit, including linens, trash. That includes all of our personal protective equipment as well, as well as the scrubs that we wear.
Everything that leaves the unit is autoclaved on its way out, and then either goes to the incinerator or goes to the hospital laundry. But again, everything is autoclaved on the way out.
Our liquid waste disposal, also very similar to Emory’s protocol. We use a hospital grade disinfectant. Our quaternary ammonium compound that we pour into the toilet and - with a dwell time of ten minutes prior to flushing the toilet. So again, very similar processes to what Emory is doing.
As far as laboratory goes, we definitely found this a challenge early on, as Bruce mentioned as well. I think it’s very important that you need to really work on a partnership with your laboratory. And the way that we did this was to essentially generate a wish list of laboratory tests that we needed to - you know, to run for these types of patients.
And again, these are critically ill patients. They require fairly intensive electrolyte you know evaluation as well as things like occasional blood cultures may be necessary, and other testing.
Some of these can be accomplished via the point of care testing or i-STAT machines. But, there are definitely things that are not available on those cartridges that you may need, such as blood cultures, magnesium, other things.
And so, we were able to generate a wish list of the appropriate laboratory testing that we desired, and then basically worked with our lab and they worked out protocols in order to do this in a safe manner. Some of that involved centrifuging in places other than the core lab, who you know is not interested in running a centrifuge for the same reasons Bruce mentioned.
But, we were able to - you know, to essentially accomplish the vast majority of these laboratory testing that we need just via working with - as a partner with the laboratory leadership.
Dr. Phillip Smith:
A couple other things we’ve done. As I mentioned, we added an Associate Dean for Clinical Research, who has helped us obtain some of the drugs - experimental drugs for the Ebola patients that we’ve dealt with, and also drugs we might have potentially - help up draw protocols up for drugs we might potentially need if we have an exposed employee.
PPE is obviously a concern that’s on all of our minds, and I agree with Bruce that there’s no one right PPE for everyone. The CDC basic guideline has the principles that can be modified. We have modified to a little more intense protective equipment based on our situation.
For instance, we - with input from our staff, we have added a bonnet which gives you better coverage of the head, neck, and face area. And we also use duct tape to tape the first two layers of gloves -- and we use three by the way -- to the gown. We have our two basic layers of gloves that are taped to the gown and then we use the third one kind of as an needed basis as you might in a normal isolation room when you do a patient-related task. When you're done, you take it off, wash your hands, or in this case your gloved surface, and then put a new set of gloves on.
I agree with Bruce entirely that donning and doffing is the key. More important than the exact nature of the PPE that you select. And we have - I don’t know if you'd call it donning or donning buddies, but we have specialists in donning or doffing that we - the staff members that are taught to do this, and they do this a good percentage of the time.
They have a checklist, as Emory does on the wall, and whether you're the Chief of the unit or you just started two days ago, a person walks through each step with you and our staff takes pride in catching each other in omissions and correcting them before they become something that might be a potential threat to the individual.
Dr. Angela Hewlett:
Another thing that we found very helpful as far as relations with the family or visitors, actually this becomes a very important concept when you have a patient who is hospitalized for several weeks, as our patients have been. Now, we actually assigned a point person as a family advocate to the family of the patient, and that way they provide support for the patient’s family and other - also others who will not necessarily enter the unit. And, we find that to be actually very essential in making arrangements for family, providing coordination for visits with the family.
The way that we’re able to do visits is use of a technology that’s called Vidyo. It’s actually a telemedicine technology. This has been very helpful. We actually are able to have the patient see and talk to their family who is actually outside of the unit, so no one enters the unit other than staff.
They’re able to see and discuss things with their family. Also outside consultants such as physical therapy or nutrition, that sort of thing, are able to actually see and speak with the patient back and forth without ever having to enter the unit, which minimizes the need for direct contact.
We also have a Vidyo unit set up in the nurse’s station inside the unit to where we can do multidisciplinary rounds with one physician entering the room and the other physicians actually sitting out at the nurse’s station and watching everything via our telemedicine equipment.
We are able to communicate back and forth with each other and with the patient. We’re able to demonstrate exam findings on the Vidyo technology, and we’ve found this to be very, very useful.
Dr. Phillip Smith:
(Unintelligible) that in Nebraska, this is...
Dr. Phillip Smith:
...very much a partnership between university and the State Department of Health in Nebraska, and I would encourage anyone starting this up to be in communication with local and state health departments.
Many of the issues you deal with are public health, including the ones mentioned by previous speakers. The calming public fears, communicating, and establishing appropriate environment so that there isn’t an overreaction to the fact you may be taking care of a hazardous infectious diseases in your particular town.
Our unit was developed jointly by Nebraska State Department of Health and University of Nebraska Medical Center. It’s kind of like the safety deposit box. You need two keys. Dr. Joseph Acierno of the Nebraska State Department of Health, the Chief Medical Officer, and I both need to approve in order to admit a patient. And then, we work together after that to craft appropriate announcements.
Public Health is also very helpful in dealing with the enumerable agencies that Bruce mentioned that you have to deal with in order to get appropriate permits and handle the logistics of dealing with a Category A disease.
Dr. Angela Hewlett:
And lastly, as far as our clinical care goes and our physician staffing model, our - as we discussed earlier, our nursing staffing model actually is fairly well delineated. Nurses are doing shifts inside the unit.
Our physician model has been actually modified since we accepted our first patient on the 5th of September. Initially, infectious diseases specialists were the physicians of record in our unit; however, we quickly recognized that we needed input from the critical care medicine specialty just due to the fact that these patients are critically ill.
We’re having to do a lot of fairly aggressive fluid electrolyte management, a TPN and such. And so we recognize need for input from that service.
As I mentioned earlier, we do multidisciplinary rounds with those CCM, or critical care medicine colleagues. Lately, the CCM service has actually accepted the primary responsibility on these patients with heavy input from infectious diseases specialists regarding the use of experimental drugs, monitoring parameters, you know that sort of thing.
We also recognize the need for other specialized care arrangements such as a relationship with anesthesia for potential airway management, with nephrology for patients maybe needing dialysis. And we think it’s very important to identify those participants to assist with these needs you know before they arise.
And so we’ve actually done quite a bit of outreach to other physician groups in the hospital and with - you know, with the intent of making sure that we have a good multidisciplinary team available for anything we should encounter with these patients.
Nebraska, to leave time for question and answers, are there any key points that you would like to say before we open up the lines?
Dr. Phillip Smith:
Okay. Thank you Drs. Redd and Isakov, Ribner, Smith, and Hewlett for providing our COCA audience with such a wealth of information. As a reminder, CDC Subject Matter Experts, as well as representatives from Emory Nebraska, are available during the question and answer portion of today’s call.
Questions are limited to healthcare workers and facilities who would like information on healthcare systems preparedness and not clinical management or clinical guidance for patients with Ebola.
For those who have media questions, please contact CDC Media Relations at 404-639-3286 or send an email to firstname.lastname@example.org.
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Thank you for submitting your pre-question - your pre-call questions. We have received also an overwhelming number of questions for today’s call, and we will try to answer as many as we can from the call line as well as those we received. We will now open up the lines for the question-and-answer session. Operator?
Thank you. At this time to ask a question, press Star 1, please. Please unmute your line and record your name to be introduced. Again for all questions press Star 1. If you'd like to withdraw the request at any time, you may press Star 2. Thank you. One moment please for your first question. Our first question is from (Maxine McNeil). Your line is open, and state your organization.
I have a question.
I'm sorry. Do you have a question?
Okay, thank you. Next question, (Toni Fuze), your line is open, and state your organization.
St. Anthony Hospital, Lakewood, Colorado.
Your line is open. You may ask your question.
Is there - I had heard there a rumor that CDC was thinking about setting up regional health centers or designated facilities where these patients would be transferred to so that like you had one major hospital in a community that’s going to be taking these patients. Is there any truth to that?
RADM Steve Redd:
Yes. There are a lot of options that are being considered now in light of the experience in Dallas. One thing that is a given is that every hospital needs to be prepared to identify, diagnose, and isolate any patient who has Ebola.
As a reminder speakers, please state your name before you answer the question. The next question is, “Recommendations for management of patient under investigation from point of entry to safely in the designated Ebola unit. Can you please share best practices?”
Dr. Dahna Batts:
Dr. Isakov, can you handle that?
Dr. Alexander Isakov:
Sure, I think so. So at the present, it obviously depends on how the patient’s coming in. I think based on the way the question is being asked, it’s when a patient maybe presents to emergency department triage.
Ideally, if an individual already had some concern or suspicion, they might have the wherewithal to make a phone call to provide some advance indication they were either coming into an emergency department or clinic.
But if that’s not the case, and it may not be the case, what we do is one of the first questions we ask patients that present with any condition is have you traveled outside the United States in the last three weeks? And if so, where?
If you - this is just our practice. If you screen positive on that question, you are moved to a private room, which is marked then as requiring standard contact and droplet precautions, and the attending physician in the emergency department is alerted to the presence of that patient. And then, they don the appropriate level of PPE based on the patient’s condition.
I've done these screenings. I wear a gown. I wear gloves. I wear a surgical mask and a face shield because most all the patients I've had the pleasure to interview look very well. They’re not vomiting. They don't have diarrhea. They’re not bleeding. They may have a fever. And usually through just that initial questioning, you determine that they actually have no risk of having Ebola virus disease, because they’ve had no contact with anyone and they haven’t been to the endemic county.
But should that screen turn positive and it turns into a rule out scenario, laboratory testing would be conducted there. The nursing staff, we of course limit our exposure to healthcare workers in the emergency department. So one nurse might be assigned to that individual, and of course it’s always better if they’re not critically ill and requiring a tremendous amount of work.
Then the appropriate destination for that patient would be determined to either be the clinical isolation unit in the hospital or elsewhere, based on how the patient’s doing and the real risk of having the disease.
And if I understand the question correctly, how do we move them from one place to the next? Again, in implementing the idea - or in implementing standard contact and droplet precautions to prevent exposure to any other patient or bystander, or visitor, or other healthcare worker to that patient’s blood or infectious bodily fluid.
Again, depending on what kind of symptoms they’re manifesting, we might have that patient wrapped or draped in a way that if they were having diarrhea, it would all be collected in a container on the stretcher as opposed to being able to drip out. If they were bleeding from any site, we would control that. We would put a mask on the patient.
You've seen the patients actually in something of a personal body wrap and even in a Tyvek suit wearing a surgical mask when we’ve transported them in the out-of-hospital environment. If that was required, we could do that I believe, and safely move the patient to most places in the hospital where they would be isolated.
And then of course limiting movement within the hospital as much as possible would be desired. That’s how - that’s our concept of operations for moving a patient from let’s say the emergency department to another location in the hospital, but I'll ask if Bruce has any further comment or Phil Smith, or others on the call have any other comment on that.
Dr. Phillip Smith:
No. This is Phil Smith. I think that’s a very sensible approach. If the patient does have a lot of secretions, they could be put in a Tyvek suit or even potentially in a - let’s call it an isopod. A self-contained apparatus in which contains all their secretions. It zips up and the exit air from that is HEPA filtered. But that’s not usually necessary.
Dr. Bruce Ribner:
Right. And this is Bruce Ribner. I would just add one thing. Again, most of the patients that we’ve seen on the TV news who have been coming back to us have been sick for on the order of a week, and therefore, they are highly contagious.
The average patient that you're going to see in your clinics or your emergency department have likely only been ill for a day or two, and therefore they are not going to be very contagious and you don't have to go to extraordinary measures in moving them to whatever care setting they require for their level of illness.
Operator, next question, please.
Thank you. (Michelle Vissy), your line is open, and state your organization please.
(Michelle)’s question has been answered, but this is (Pat Kopp). I am with St. Francis in Greenville, South Carolina.
And my question is about the observer for the donning and doffing of the PPE. Is that observer directly assisting the primary care giver in removing the PPE, or is it simply observing and giving some verbal queues?
Dr. Bruce Ribner:
So this is Bruce Ribner, and I'll start addressing that.
I think there are different models. In our particular case, it’s sort of a mixture, so the observer observes the initial part of the removal of the personal protective equipment, but actually when the time comes to remove the disposable hood that goes over our PAPR, the observer actually assists the individual with removing that and putting it into the disposable waste container.
So I think there are different models for this, and really the key to the observer is just to observe everything that’s going on and making sure there isn’t an inadvertent contamination by the individual doffing their personal protective equipment.
Dr. Angela Hewlett:
This is Angela Hewlett from Nebraska. We do a similar protocol here as well where the observer actually does participate some in the removal of the personal protective equipment at certain steps. They also, as Bruce mentioned, do a - you know, use a checklist to document the appropriate chronology of this whole thing.
We do use boot covers in our - as part of our PPE, and those are very difficult to remove on your own. And so our doffing partner is actually in charge of assisting us with that.
That being said, the doffing partner is actually in full PPE themselves, and that way when they are assisting us, they are also very well protected in case we have a surface contamination.
Our next question is, “What was the length of time PPE was worn with each patient encounter? Any maximum?”
Dr. Phillip Smith:
I think we had the same experience that Bruce mentioned in his slides. Three to four hours. We allow our personnel to self-adjust to a certain extent, but generally after three to four hours, they’re getting a little bit overheated. And at that point, we rotate them out of the room to a different task.
Dr. Bruce Ribner:
And this is Bruce Ribner. I'll just add you're likely to see data from various organizations like Physicians Without Borders talking about a maximum of 30 to 40 minutes, and I would ask you to look at the scenario under which they’re measuring that. This is usually in an environment where there is no air conditioning, where the ambient temperature is north of 100 degrees and the humidity is about the same.
And then clearly in that kind of environment, the ability to tolerate personal protective equipment is much more limited. But in our modern air conditioned units where we’re using the cooling effect of the PAPR, we find that most of our nurses can tolerate three to four hours without any difficulty.
Dr. Alexander Isakov:
And I'll add for the EMS encounters that require use of PAPR. The - from the time a patient - first patient contact’s made until the patient is safely delivered in the hospital can sometimes be in the order of about an hour or so. If the paramedic is fatigued after an hour in full Tyvek and PAPR, that - after the patient’s transported and the truck’s moved to a more secure location, they can with assistance and supervision, doff that PPE and rest up until the next phase, which is to properly get - well get back in PPE and properly decontaminate and disinfect the ambulance. If they’re feeling well, they may proceed with the initial decontamination and disinfection before doffing.
Operator, next question.
Thank you. And as a reminder, if your question has already been answered, you may press Star 2, to withdraw your request. Next question, (Amy Nichols), your line is open, and state your organization.
Thank you. This is (Amy Nichols), University of California, San Francisco. I actually have a couple of questions. One is in the hospital in your special units, how is your room outfitted? For example, do you have blue wrap coverings over the surfaces, as we saw in the ambulance? And, how is that room cleaned after the patient is discharged one way or another?
Dr. Dahna Batts:
Dr. Smith, you want to start and then Dr. Ribner you can join in?
Dr. Phillip Smith:
Yes, we’ll start here. We don't have any special coverings like a - the person might wear to protect that, but we tend to select surfaces that are fairly easy to clean.
And as far as just very briefly, we have a somewhat complicated and lengthy decontamination process after the patient leaves, but it involves several days of desiccation. Just leaving the unit empty and with our normal 22 to 25 air exchange per hour, things dry out pretty quickly, then we have a team go through with a bleach-based cleaner and clean everything top to bottom.
And then we have another period of time of rest and then we have another bleach cleaning. So overall, the process takes something like five to seven days.
Dr. Bruce Ribner:
And this is Bruce Ribner. At Emory, we also do not have any special covers, although our nurses are highly meticulous at disinfecting all of the surfaces multiple times a day.
Our terminal cleaning or disinfection process is a little different from what you've heard in Nebraska. Firstly, we have actually done environmental sampling and found that at the time of patient discharge we were not able to document any virus on any of the surfaces either in the bathroom or in the patient environment.
But despite that, what we do is a process which is similar to what is done in our BSL-4 laboratories in our research facilities where we have an individual come in and actually use vaporized hydrogen peroxide and that gives us a somewhat more rapid turnaround time.
But again, the key as we’ve said over and over again is not to fixate on a particular process, but just to make sure that whatever process that you use you pay a lot of attention to detail.
This is not a very hardy virus. As Dr. Smith said, it desiccates in a few hours just normally, and any of the EPA registered environmental disinfectants are more than capable of eradicating this organism.
Thank you both very much. I have one more question for you. Did your staff go home between shifts? We have a lot of anxiety here about staff taking it home to their families.
Dr. Bruce Ribner:
So this is Bruce Ribner, and yes; certainly, we did not segregate or isolate our personnel in any way, shape, or form, but that’s because we have a tremendous amount of confidence in the procedures that we have developed.
Similar to what you heard from Dr. Isakov, we do have a screening process where every individual has - who has had physical contact with the patient is required twice a day, approximately 12 hours apart, to go to a Web-based program which we maintain where they record their temperature and are asked about eight or nine different questions in terms of any symptoms they might be having.
And again, we feel comfortable. We don't anticipate any illnesses in our healthcare workers, but we know from a lot of data that even if we were unfortunate enough to have one of our healthcare workers become ill, they are not considered contagious until at least two to three days after they have onset of fever. And, we think our mechanisms are in place that we would detect that long before they became contagious.
Dr. Phillip Smith:
Bruce, I would also add – that when you enter our unit, the only thing you enter with is what you were born in, and then you put on a pair of scrubs and then all the personal protective apparel. That is taken off by the doffer.
And then the person leaves in their scrubs and they turn in their scrubs and go to a complete head-to-toe shower out. So, we feel confident that when they’ve left our unit that they’re clean and so we let them return to the normal daily life.
Thank you both very much.
Operator, we will take two more questions please.
Thank you. And as a reminder to withdraw your question, you may press Star 2. The next question we have is (Vickie). Your line is open, and state your organization.
Radiology Regional Center, Ft. Meyers, Florida.
My question is as an outpatient center, we probably would not see - an outpatient walk-in imaging center, our chances of seeing those really critical patients would be slim, but we envision a patient coming in for flu-like symptoms getting a chest x-ray. How do we screen for something that’s not as full-blown as what you guys in the hospitals are seeing?
Dr. Bruce Ribner:
Well this is Bruce Ribner. And again as Dr. Isakov said, whatever venue you enter our healthcare system, whoever registers you in whatever capacity, the first question we ask is have you traveled in the last 21 days? Actually, I think we use 30 days just out of an abundance of caution. And anyone who meets that criterion of travel within 30 days is - and again, we focus on African countries. We also focus on the Middle East because of the concern about MERS.
But if an individual is ill and meets any of those travel criteria, as Dr. Isakov elaborated on before, they’re immediately segregated and then evaluated by a healthcare provider to make sure that they do not have one of the targeted infectious diseases that we’re concerned about.
Okay. So if a patient came in and said, “Yes, I've traveled. Yes, I've been to one of the targeted areas,” and they’re running a temp, they have these flu-like symptoms, would that warrant having them transported to a hospital facility at that point?
Dr. Bruce Ribner:
No. That would warrant having them moved to a segregated room someplace where a provider could do further evaluation to see whether or not they were a person of interest or a person under investigation.
Okay. Well not being a treatment facility, though, we’re just - you know, these patients are walking in for a simple x-ray. So I'm kind of not positive how that happens in a facility like ours.
Dr. Bruce Ribner:
Oh, you would just have to work out a mechanism whereby - and you know, it might be that you - again, each facility is going to have to adjust to its particular logistics.
Dr. Bruce Ribner:
And every facility is going to be different. But the bottom line is you have to have a way of rapidly identifying and isolating individuals who might represent a contagion risk to your other patients.
Okay. I appreciate it. Thank you.
Thank you. Next question, Dr. (Richard Pitch), your line is open.
Hi. This is Dr. (Richard Pitts). I'm at the Arrowhead Regional Medical Center in Southern California. I really appreciate this helpful information, but practically speaking I think what you just described would probably bankrupt our hospital.
Virtually all the hospitals in the US don't have containment units, so what the CDC, as everyone knows has been advocating, is droplet and contact precautions.
In - from your expert opinion basis, should we try to duplicate some type of containment unit with all of the areas that you have on the slide in order to adequately take care of not only the patients, but also protect our staff? And also, what are you using for shoes? Thank you very much.
Dr. Angela Hewlett:
This is Angela Hewett from Nebraska. I think that - I firmly believe that any healthcare center actually could care for one of these patients, but I just think it takes a lot of planning - preplanning in order to get everything in place.
These issues that we’ve had with things like waste disposal, you know staffing issues, things like that, I think if we can address those, then I don't think you need the physical structure of the Biocontainment unit that we have.
I think if you have an area that is - that you can designate in your healthcare facility that is possibly isolated in a separate - you know, a separate portion from other patients I would say. A negative pressure room would be preferable in case there’s an aerosol-generating procedure, and things like that - I think that you actually can do all these things.
But again, it takes - it’s going to take a lot of preplanning, which is obviously what this call is about. And you were asking about our footwear, and we wear rubber Crocs in the unit, and we actually - we give them a nice bleach bath on the way out of the unit.
Dr. Bruce Ribner:
And the other sticking - hi, this is Bruce Ribner from Emory. The other sticking point for a lot of facilities is, “Well, we don't have any place to put a laboratory.” And that’s fine. We recognize again each individual facility is going to have to adjust to its own environment.
At a minimum what I would suggest however is that you try and identify some area within the laboratory where you can receive and process samples which is discreet from the main laboratory.
Again, just from the very practical issue, if you have a lab spill and you have to turn - close your laboratory for hours while you do the decontamination, I think for most facilities that would be catastrophic.
So again, it’s - you know, we don't have a prescriptive plan that everybody has to follow. What we’re trying to point out is these are the issues - this is the way Nebraska and Emory have solved them. And now based on that, you need to go back and figure out what works for your particular facility.
Dr. Alexander Isakov:
And this Alex Isakov. I will add another point too, because the question around what a particular hospital or health system can do in part also goes to a community’s preparedness.
I firmly believe that every hospital, and ER, and clinic has to be prepared to receive because they may walk in or they may come in by ambulance - receive a patient with a fever, nausea, vomiting, who has traveled to a Ebola endemic area.
It may not be that every hospital in the United States prepares itself to deal with the critically ill patient with confirmed Ebola virus disease that Emory, and Nebraska, and Presby- in Dallas has managed thus far.
It may be that a community prepares that every hospital will be able to screen for these patients, initially manage these patients, go through the testing that’s necessary to confirm, or refute the notion that they have Ebola virus disease.
And, communities may choose that there are 1 or 2 out of 30, or 3 to 5 out of 30 in a community that are best prepared to manage a patient should they become critically ill, which is where Dr. Ribner and Smith have described where those patients can produce ten quarts of diarrhea per day, which creates quite an issue with regards to healthcare worker protection and critical care interventions to provide the supportive therapy.
So from a community standpoint, every ED and hospital has to be prepared to initially evaluate, but they may not provide the definitive therapy.
No problem with that.
Dr. Alexander Isakov:
That’s my opinion.
No problem with that.
But who’s going to volunteer without any money? Nobody. It’d be foolish.
Excuse me speakers, is that the end of the statement?
Dr. Alexander Isakov:
Well that was the end of my statement. I don’t know if anyone else wants to weigh in.
Thank you. On behalf of COCA, I would like to thank everyone for joining us today, with a special thank you to Drs. Redd, Isakov, Ribner, Smith, and Hewlett. The recording of this call and the transcript will be posted to the COCA Web site at emergency.cdc.gov/coca within the next week. There are no continuing education credits for this call. Resources for clinicians related to Ebola are available on our COCA Call Web page. Go to emergency.cdc.gov/coca. Click COCA Calls and then follow the link for today’s call.
To receive information on upcoming COCA calls, subscribe to COCA by sending an email to email@example.com and write subscribe in the subject line. Thank you again for participating in today’s COCA call. Have a great day.
Thank you for your participation. That does conclude today’s conference. You may disconnect at this time.
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