Ebola in the pregnant patient

[obrn23]

I work in labor and delivery. Yesterday we were given the latest education on Ebola preparedness at our hospital. We have been designated as the receiving hospital for positive screens at a major international airport. If they are entering from a affected by Ebola (Liberia, Sierra Leon, Guinea), and they have a fever of 100.4+ w/ other symptoms, they are coming to us. We currently have had 6 patients present to our ED this week to be ruled out for Ebola, so I believe this is a real threat to us.

The CDC guidelines don't really transfer well to L&D and I feel like we are in imminent danger.

We spoke with administration after our "training", and it went nowhere. They stood by the recommendations already in place.

Here's what we are currently being told. Anyone who enters the hospital is asked screening questions. Have you been to Liberia, Sierra Leon, or Guinea? Do you have a fever? (this is self reported, not taken) If they say yes, they are put in an isolation room. (Of which we only have 1 in L&D) Then, we are to call the house supervisor, the administrator, and the CDC. We are to put on our PPE (tiny plastic shower cap that doesn't hold my hair, N95 mask, gown with cotton wrist elastic, 2 pair of gloves, boot covers, and plastic "safety" glasses.) We are to draw their blood for the Ebola test, but do not start an IV. We are not to provide any other care until the "team" gets there.

If they say no to a fever, but yes to travel, and are found during assessment to have a fever, then we leave them where they are in a non-isolation room, as not to contaminate and have to incinerate supplies in 2 rooms. All visitors are self reporting temps, and there was back and forth on whether it was allowed to take their temperatures if they answered yes to travel.

The issues we had and the answers we received:

Q: Pregnant patients are likely to report to the hospital hemorrhaging, not with other Ebola symptoms. Will we be provided hazmat suits to care for a suspected Ebola patient (answered yes to the questions) who is delivering or hemorrhaging?

A: No. Hazmat suits are only provided for confirmed Ebola patients.

Q: How long does it take to get the Ebola test back?

A: 12 hours

Q: If they are positive for Ebola do we plan to transfer them out?

A: That would be the plan, but there are no hospitals who are willing to accept the transfer of a pregnant Ebola patient, so we will likely keep them.

Q: What are we supposed to do if the patient comes in, answers yes, and is bleeding severely or delivering and the CDC team hasn't arrived?

A: This is backwoods nursing. We bring in limited equipment, because everything will have to be incinerated. You will give minimal care. You do not go into that room. If the baby delivers in the bed, so be it.

Q: Will we have fetal monitors in there?

A: Yes.

Q: If the strip is bad, and we need to do a c-section, where do we go?

A: We may do it at the bedside. We don't know.

Q: A bedside c-section on a suspected Ebola patient?

A: No, I don't know. No.

Q: Will there be a policy in place to protect our license if we withhold care to this patient because the team isn't there, and there is a negative outcome, and she turns out NOT to have ebola?

A: If you follow our policies you will be protected. There will not be a specific policy.

Q: Will care be on a volunteer basis, or will it be mandatory?

A: We will ask for volunteers, then it will be mandatory. If you refuse a patient, that would be patient abandonment, and would be dealt with on a case by case basis.

Q: Say this patient has Ebola. Dialysis and intubation are considered high risk procedures requiring a respirator. Is lady partsl delivery or c-section considered a high risk procedure that produces aerosol? And if so, will we be provided a respirator?

A: We will not be providing any respirators.

Q: What do we do if we have someone who presents with a temp of 99.5 or 100, but they have been to Liberia?

A: That does not meet the criteria per the CDC, so you will treat them as a normal patient.

Q: Will we be taking care of any other patients?

A: No, you will be 2:1. You will have a buddy who watches you don and doff PPE and watches you in the room to make sure you don't self contaminate. They will also be in PPE so they can help you in the room if necessary.

Q: I've seen workers using decontamination chlorine bleach spray. Will we have that?

A: No, but we have bleach wipes you will use to wipe your outside set of dirty gloves with.

Q: I heard we have a patient who will deliver in 2 weeks who has a husband who is in Sierra Leon, but is coming back for delivery. Is he allowed to be in the room?

A: Yes, he will be allowed in the room as long as he does not have a fever above 100.4.

We were also told that we needed to stop watching tv, that we were hysterical, that this is just like AIDS, that they are exceeding CDC guidelines, that this is part of nursing, that we need to educate ourselves, that we needed to reevaluate if we really wanted to be in healthcare at this time..

What are your hospitals doing the same? What are they doing differently? I feel extremely under protected! My biggest fear is being in contact with the amount of blood and body fluids we have in a delivery in CDC recommended PPE. If the patient doesn't have a fever, but presents with severe bleeding, and has been to one of the 3 countries.. I feel like we should be in the zip up Tyvek suits with hoods. My concerns are falling flat though.

From this study (which is really the only pregnancy ebola study I can find): http://jid.oxfordjournals.org/content/179/Supplement_1/S11.long

"All women presented with severe bleeding."

"They all presented with signs of hemorrhage, including severe genital bleeding (100%)"

"Only 1 woman survived. She was 32 years old and had had a curettage because of an incomplete abortion after 8 months of amenorrhea. The patient survived despite hypovolemic shock caused by severe genital bleeding. One of the women was prematurely delivered of a stillbirth at 32 weeks. Four women died during the third trimester of their pregnancy. Only 1 woman delivered a full-term baby. The mother of this baby had developed fever 4 days before delivery. The delivery took place at the home of the mother, and the baby developed fever and died 3 days later. The mother died because of extremely severe genital bleeding."

"A clinical diagnosis of hemorrhagic fever in a pregnant woman is complicated because pregnant women may bleed for other reasons, such as abortion unrelated to EHF or a placenta previa. During an EBO epidemic, every pregnant woman with genital bleeding should be considered as a suspected case of EHF."

"Pregnant women with EHF may present with severe genital bleeding and may need a blood transfusion or curettage (or both). Therefore, health care workers caring for these women have a particularly high risk of acquiring EHF if they do not apply barrier nursing techniques. This includes wearing double gloves, a plastic or rubber apron over a long sleeve gown, a mask, and a full face protector (if available) or protective glasses for personal protection. Moreover, linens, instruments, bedding, and floors that have been soiled with blood or other body fluids should be disinfected with sodium hypochlorite. The application of universal precautions and barrier nursing techniques is not only of particular importance in maternity units in Africa to protect health care workers against EBO infection but also against other infections that are transmissible by blood, such as HIV and hepatitis."

• © 1999 by the Infectious Diseases Society of America (I know it's old, but it's all I can find!)
  

[iluvgusgus]

I dont see how refusing a patient assignment would be patient abandonment if you didnt accept them as your assignment nor received report on them? That's not how it works and that would not be right, and yes I will be refusing to care for an ebola pt should that situation ever occur at my place of work. We received an email that said we should use universal PPE for ebola pts! Are you kidding me! I dont think ebola should even be entering any hospital, they are placing all patients and healthcare workers at risk and that is not fair.

[Elvish, BSN, DNP, RN, NP]

The plan at my place is to do a similar screen and if they meet the fever + travel criteria, they go to a designated area of the ICU which has negative pressure rooms and the most air exchange of any unit in the hospital. Once they are down there they stay until the Ebola test is confirmed neg, or they are discharged. If they have to deliver down there, so be it, whether C/S or lady partsl. It's an ICU so if it came down to it, they could do surgery down there. Hazmat suits and PAPRs.

Can't wear a stethoscope with the hazmat suits. It will also be interesting to try and intubate or start an IV on a baby should the need arise with all that PPE.

The plan is to have 2 nurses per patient plus a team to help specifically with putting on/taking off/cleaning PPE, plus a decon shower for after the fact.

The thought of doing it with all that is still pretty daunting, even if risk is pretty low on an individual basis that a given nurse will have to do this. The thought of doing it with less than that such as you describe is terrifying. Here's hoping you won't actually have to. You'd think with all the bad press one hospital got from providing less than stellar PPE that other hospitals would take note.

[obrn23]

Elvish- Your hospital is providing hazmat suits for people answering yes to the screen without a confirmed ebola blood test? I think the way that they are handling it would have bumps in the road, but at least it would keep everyone safe and guarantee care for the patient. Would an L&D RN be attending delivery, or is the whole thing strictly handled by ICU?

[Elvish, BSN, DNP, RN, NP]

Elvish- Your hospital is providing hazmat suits for people answering yes to the screen without a confirmed ebola blood test? I think the way that they are handling it would have bumps in the road, but at least it would keep everyone safe and guarantee care for the patient. Would an L&D RN be attending delivery, or is the whole thing strictly handled by ICU?

I went back and reread my mgr's email to be sure I'm not lying to you. The way I read the email is that fever + travel = hazmat and isolation. I'm Nursery/NICU and go to all the deliveries, so I'm not 100% sure how L&D is preparing or if they plan to labor the patient(s) in the ICU or what. We have a volunteer team that is doing all the initial training, including a SIM lab, and the plan is to expand it to any nurse who may care for an Ebola pt in the future.

I'll check with my L&D colleagues and see what their mgmt has told them and get back to you.

[imenid37]

Ours go to a designated area off of the ED. It can be partitioned and adapted for any type of patient. I am sure they would want some of our staff if the patient was pregnant. Scary stuff. Hopefully, it won't be an issue.