After the death of the nation's first Ebola patient diagnosed in the US and subsequent infection of two Texas nurses who cared for the patient, the protocol was under great scrutiny. Although many teams have investigated the chain of events leading to the 2 nurses' contracting the virus, the specific problem leading to the exposures may never be known.
NursesAnnouncementsArchive
On Monday evening, October 20, the US Centers for Disease Control (CDC) unveiled new PPE recommendations for healthcare workers who will be dealing with Ebola patients. The new guidelines reflect the protocol practiced in Emory University Hospital, Nebraska Medical Center, and the National Institutes of Health Clinical Center. The new guidelines focus on specific personal protective equipment for health care workers and "offers detailed step by step instructions for how to put the equipment on and take it off safely." While the main change is no exposed skin, there are two options for respiratory protection.
At a media telebriefing, CDC Director Tom Frieden said of the initial Ebola recommendations released on August 1, 2014:
"The bottom line is that the recommendations didn't work for that hospital,"
"[T]he new PPE recommendations are designed to increase the margin of safety for frontline health workers and reflect an expert consensus."
The enhanced guidance is centered on three principles:
All healthcare workers undergo rigorous training and are practiced and competent with PPE, including taking it on and off in a systemic manner
No skin exposure when PPE is worn
All workers are supervised by a trained monitor who watches each worker taking PPE on and off.
Principle #1: Rigorous and repeated training
Focusing only on PPE gives a false sense of security of safe care and worker safety. Training is a critical aspect of ensuring infection control. Facilities need to ensure all healthcare providers practice numerous times to make sure they understand how to appropriately use the equipment, especially in the step by step donning and doffing of PPE. CDC and partners will ramp up training offerings for healthcare personnel across the country to reiterate all the aspects of safe care recommendations.
Principle #2: No skin exposure when PPE is worn
Given the intensive and invasive care that US hospitals provide for Ebola patients, the tightened guidelines are more directive in recommending no skin exposure when PPE is worn.
CDC is recommending all of the same PPE included in the August 1, 2014 guidance, with the addition of coveralls and single-use, disposable hoods. Goggles are no longer recommended as they may not provide complete skin coverage in comparison to a single use disposable full face shield. Additionally, goggles are not disposable, may fog after extended use, and healthcare workers may be tempted to manipulate them with contaminated gloved hands. PPE recommended for U.S. healthcare workers caring for patients with Ebola includes:
Double gloves
Boot covers that are waterproof and go to at least mid-calf or leg covers
Single-use fluid resistant or impermeable gown that extends to at least mid-calf or coverall without an intergraded hood.
Respirators, including either N95 respirators or powered air purifying respirator(PAPR)
Single-use, full-face shield that is disposable
Surgical hoods to ensure complete coverage of the head and neck
Apron that is waterproof and covers the torso to the level of the mid-calf should be used if Ebola patients have vomiting or diarrhea
The guidance describes different options for combining PPE to allow a facility to select PPE for their protocols based on availability, healthcare personnel familiarity, comfort and preference while continuing to provide a standardized, high level of protection for healthcare personnel.
The guidance includes having:
Two specific, recommended PPE options for facilities to choose from. Both options provide equivalent protection if worn, donned and doffed correctly.
Designated areas for putting on and taking off PPE. Facilities should ensure that space and layout allows for clear separation between clean and potentially contaminated areas
Trained observer to monitor PPE use and safe removal
Step-by-step PPE removal instructions that include:
Disinfecting visibly contaminated PPE using an EPA-registered disinfectant wipe prior to taking off equipment
[*]Disinfection of gloved hands using either an EPA-registered disinfectant wipe or alcohol-based hand rub between steps of taking off PPE.
Principle #3: Trained monitor
CDC is recommending a trained monitor actively observe and supervise each worker taking PPE on and off. This is to ensure each worker follows the step by step processes, especially to disinfect visibly contaminated PPE. The trained monitor can spot any missteps in real-time and immediately address.
PPE is Only One Aspect of Infection Control
It is critical to focus on other prevention activities to halt the spread of Ebola in healthcare settings, including:
Prompt screening and triage of potential patients
Designated site managers to ensure proper implementation of precautions
Limiting personnel in the isolation room
Effective environmental cleaning
Think Ebola and Care Carefully
The CDC reminds health care workers to "Think Ebola" and to "Care Carefully." Health care workers should take a detailed travel and exposure history with patients who exhibit fever, severe headache, muscle pain, weakness, diarrhea, vomiting, stomach pain, unexplained hemorrhage. If the patient is under investigation for Ebola, health care workers should activate the hospital preparedness plan for Ebola, isolate the patient in a separate room with a private bathroom, and to ensure standardized protocols are in place for PPE use and disposal. Health care workers should not have physical contact with the patient without putting on appropriate PPE.
CDC's Guidance for U.S. Healthcare Settings is Similar to MSF's (Doctors Without Borders) Guidance
Both CDC's and MSF's guidance focuses on:
Protecting skin and mucous membranes from all exposures to blood and body fluids during patient care
Meticulous, systematic strategy for putting on and taking off PPE to avoid contamination and to ensure correct usage of PPE
Use of oversight and observers to ensure processes are followed
Disinfection of PPE prior to taking off: CDC recommends disinfecting visibly contaminated PPE using an EPA-registered disinfectant wipe prior to taking off equipment. Additionally, CDC recommends disinfection of gloved hands using either an EPA-registered disinfectant wipe or alcohol-based hand rub between steps of taking off PPE. Due to differences in the U.S. healthcare system and West African healthcare settings, MSF's guidance recommends spraying as a method for PPE disinfection rather than disinfectant wipes.
Five Pillars of Safety
CDC reminds all employers and healthcare workers that PPE is only one aspect of infection control and providing safe care to patients with Ebola. Other aspects include five pillars of safety:
Facility leadership has responsibility to provide resources and support for implementation of effective prevention precautions. Management should maintain a culture of worker safety in which appropriate PPE is available and correctly maintained, and workers are provided with appropriate training.
Designated on-site Ebola site manager responsible for oversight of implementing precautions for healthcare personnel and patient safety in the healthcare facility.
Clear, standardized procedures where facilities choose one of two options and have a back-up plan in case supplies are not available.
Trained healthcare personnel: facilities need to ensure all healthcare providers practice numerous times to make sure they understand how to appropriately use the equipment.
Oversight of practices are critical to ensuring that implementation protocols are done accurately, and any error in putting on or taking off PPE is identified in real-time, corrected and addressed, in case potential exposure occurred.
