Ebola: Why Respiratory Protection MUST Be Worn

MissyWrite · Oct 18, 2014

We must err on the side of precaution, have maximum protective equipment

Agreed. I can't understand the disparity between the CDC's recommendations for lab workers vs those for clinical workers. It's well known that healthcare workers on the front lines are at the highest risk. In West Africa, for every 10 Ebola patients there has been one infected healthcare worker. Even Dr Sheikh Hummar Khan, the leading Ebola expert of Sierra Leone, who had already treated many Ebola patients using full PPE, was infected and died from the disease.

I can't understand the disconnect. I just heard the CDC is updating their PPE guidelines and will release them today. Let's hope they'll be somewhere closer to reality.

"The Centers for Disease Control and Prevention will issue new guidelines for healthcare workers handling Ebola patients as soon as Saturday..." CDC to issue Ebola guidelines for healthcare workers as soon as today - LA Times

GrannyRRT · Oct 18, 2014

Aerosolized particles from just a simple mask:

http://journal.publications.chestnet.org/article.aspx?articleID=1085316

We go through the droplet/airborne discussion every year. Unfortunately the US is actually slower at learning from past mistakes or gives a knee jerk reaction focusing on another tangent.

Yes the flu kills more than Ebola and in many ways we are very lax with our precautions.

Once the respiratory system is affected and any device is added to improve breathing, precautions need to be ramped up. RT has taken this concern to many administrators to push for better protection. Some just shrug and say " The CDC sees no reason...".

Here is what was learned from one patient with SARS 10 years ago.

Cluster of Severe Acute Respiratory Syndrome Cases Among Protected Health-Care Workers --- Toronto, Canada, April 2003

I cringe every flu season when we have patients on nebulizers in a busy hallway.

EMS also likes to try out their new CPAP device putting it on everybody with a little shortness of breath or using a NRB mask to what they thought "prevent spray from cough". Other countries learned from SARS and use the masks with the filters. The US does not. But, once someone comes into the ED with CPAP by EMS it is often expected that patient will go on the hospital's more powerful machine which usually has limited filtering ability and vents into the air. And they sit in an open bedspace or get transported to x-ray.

I don't care what precautions ( or none) the patient is on, protect yourself around nebulizers and any oxygen device generating a high flow. If you have ever been hit by the spray from a vent circuit you can see how easily that could blast through or under any PPE. We also definitely make sure there is a filter attached to all the BVMs, intubated or not. If you have ever worked with aerosolized Ribiviran, which is also used to treat several viruses affecting the pulmonary system, you have seen the precautions with double filtering and how long before it is safe to enter the room hoping all aerosolized particles have settled.

mariebailey, MSN, RN · Oct 18, 2014

First of all, there is a difference between 'airborne' and 'aerosolized' transmission. Aerosol (or droplet) transmission occurs when contagious droplets produced by the infected host are propelled a short distance and come into contact with another person's conjunctiva, mouth or nasal mucosa, or are inhaled. These droplets travel 3 to 6 feet. They can remain suspended in the air for up to 90 minutes.

Looks like there's some confusion. Aerosolized implies that it can be suspended in the air & inhaled into your lungs. It is not associated with droplet transmission, but with airborne. Diseases transmitted by droplet, but not airborne, are not aerosolized. TB can be aerosolized, & the flu is not. http://www.medscape.com/viewarticle/741245_3

MissyWrite · Oct 18, 2014

Looks like there's some confusion. Aerosolized implies that it can be suspended in the air & inhaled into your lungs. It is not associated with droplet transmission, but with airborne. Diseases transmitted by droplet, but not airborne, are not aerosolized.

When a virus is aerosolized, that means that it's suspended in the air in droplets. Aerosol transmission occurs via droplets.

As per the article you cited,

"NIOSH defines aerosols as a suspension of tiny particles or droplets in the air."

http://www.medscape.com/viewarticle/741245_3

"Aerosol is defined as small droplet usually 5µm or less in diameter, which can remain suspended in air for some time."

http://www.nacd.in/ijda/volume-02-issue-01/23-aerosols-a-concern-for-dentist

"When someone coughs, sneezes or, in the case of Ebola, vomits, he releases a spray of secretions into the air. This makes the infection droplet-borne. Some hospital procedures, like placing a breathing tube down a patient’s air passage to help him breathe, may do the same thing...

Read this to get a better understanding of how Ebola spreads

"What Bailey learned from the episode informs his suspicion that the current strain of Ebola afflicting humans might be spread through tiny liquid droplets propelled into the air by coughing or sneezing.

"We know for a fact that the virus occurs in sputum and no one has ever done a study [disproving that] coughing or sneezing is a viable means of transmitting," he said. Unqualified assurances that Ebola is not spread through the air, Bailey said, are "misleading."

Peters, whose CDC team studied cases from 27 households that emerged during a 1995 Ebola outbreak in Democratic Republic of Congo, said that while most could be attributed to contact with infected late-stage patients or their bodily fluids, "some" infections may have occurred via "aerosol transmission."

Some Ebola experts worry virus may spread more easily than assumed - LA Times

GrannyRRT · Oct 18, 2014

Quote from the article cited in mariebailey's post for those who do not have a sign on ID:

In spite of the distinction made between droplet and airborne transmission, current knowledge of aerosols indicates that there is no clear line differentiating droplet and airborne transmission, as currently defined, on the basis of particle size. Coughing, sneezing, talking, exhalation, and certain medical procedures generate respiratory particles in a wide range of sizes -- not just very large droplets that launch directly to the mucosal surfaces or drop to the floor. In addition, particles begin to evaporate and become smaller immediately upon emission, and particles ranging from very small up to 100 μm can be inhaled by persons in the near vicinity of the source (Figure).[28]
In the current infection control paradigm, airborne transmission is synonymous with long-range transmission of pathogens that can be inhaled and require special air handling to contain. This contrasts with droplet transmission, in which infectious particles are thought to be deposited on a mucous membrane, are not inhaled, and do not require special air handling. However, the association of droplet exposure with infection is confounded by inhalation exposure because close contact with infectious people permits droplet exposure but also maximizes inhalation exposure. Therefore, it is incorrect to conclude that because long-range transmission of infection is not observed, a pathogen is transmitted only by the droplet route.
Absence of long-range transmission, as demonstrated for tuberculosis and measles, does not mean that a pathogen cannot be transmitted by inhalation. As currently defined, the terms "droplet" and "airborne transmission" are inadequate to describe aerosol transmission by inhalation at short range.

Essentially we are unsure what is droplet or airborne. Many variables can change the size and distribution.

macawake, MSN · Oct 18, 2014

You're right, Ebola is not airborne. I'm sorry I didn't make that clear. I don't think there should be fear that it will 'mutate' to become airborne, either -- we just need to deal with it as it is now.

Thank you for your reply, I genuinely appreciate it. I’m also very glad that you agree that the Ebola Virus Disease isn’t airborne (in the measles sense). This has been an ongoing discussion for quite some time here on AN, and I believe that many members still harbor that mistaken fear. I don’t want that fear to gain any more traction. I think it leads to panic in a situation where clear heads are needed.

One thing that I have been thinking about lately, do nurses caring for patients with infectious disease (like the current Ebola patients) wear their own scrubs underneath whatever PPE they’re wearing? Does the nurse take these scrubs home with them after the shift ends?

I’m a Scandinavian nurse and although our healthcare system (like most others) is far from perfect there is one thing we do rather well, infection control. Scrubs have been hospital-owned and laundered for at least as long as I can remember (80s). Scrubs aren’t allowed to be worn outside the hospital. We have very strict hygiene and infections prevention protocol. No hair touching your collar, disposable aprons in all patient contacts, (of course gloves when needed) change scrubs immediately if wet (water or bodily fluids) or soiled,

no rings allowed including wedding bands, short nails/no nail polish and sleeves end approximately four inches above the elbow. You can wear longer sleeves if you’re cold when you’re not in a patient care area, but as soon as you approach a patient you have to remove the jacket (this clothing item is of course also hospital-laundered). This applies to all categories of healthcare workers. Physicians aren’t allowed to wear their coat (or personal clothes) in direct patient care. They are relentlessly pestered if they forget to remove their coat. We use hand sanitizer like we’re addicted to it.

I’ve seen nurses here on AN voice the opinion that they prefer dark scrubs because stains don’t show as easily on them as on white/light scrubs. That always makes me shake my head in bewilderment. Why would anyone want to walk around with some biological crud on their clothes (posing a risk to both themselves and others)? This is the exact reason why our scrubs are white or pale blue, stains will be noticed and you can change into a clean set.

I’ve been a nurse for ~seven years (med-surg, ER, PACU) and I’ve administered Vanco to four patients if memory serves. On the few occasions that I’ve had MRSA positive patients I’ve been that patient’s designated nurse for the shift. I’m not allowed to come in contact with any other patient or even enter another patient’s room during that shift. If the patient’s condition warrants it, there’s also a CNA designated to care solely for the MRSA + patient. This patient can be a relatively healthy walkie-talkie elective surgery, so sometimes these shifts were pretty much spent twiddling my thumbs and catching up on email.

The luxury to be able to focus on infection prevention, rather than on maximizing profit/productivity is one advantage of having a healthcare model that isn’t profit-driven. We probably go a bit overboard at times, but as I said earlier better safe than sorry.

For quite some time now it’s only been a question of when, not if, an Ebola infected patient would turn up in one of our or one of your ER’s. On my local news there was a thing about hospital preparedness in early August, with two nurses demonstrating the PPE that would be used in the care of an Ebola patient. It was the fluid impermeable full body suit, including hood and built-in air supply/air purifier.

The first briefing I received at work regarding the spreading outbreak was in June, and I work in a PACU, hardly the most at risk unit to first encounter Ebola patients. One of my former coworkers who still work in the ER has told me that they receive regular briefings regarding the spread of the outbreak and which protocols apply when a patient suspected to be infected with Ebola show up. She and her coworkers feel like they are adequately prepared to handle the situation.

Despite what I believe is adequate information and training I still wouldn’t be surprised if a patient could slip through the cracks. It’s hard to be hyper-vigilant at all times and anyone who’s ever worked in an ER knows that sometimes the situation is rather chaotic. Add to that, the fact that humans can and do make mistakes. It only takes one moment of lost focus or fatigue for a breech or mistake to happen. The best thing we can do it to have a protocol in place that minimizes the risk that human error leads to serious consequences.

I was very dismayed to note that the nurses in Dallas seemed so unprepared to handle an Ebola patient. I don’t have all the facts needed to draw any definite conclusions but it really seems like hospital management/the organization has utterly failed to address this matter ahead of time, there didn’t seem to be much of a plan/protocol (if any) in place nor any training provided to staff before an actual patient turned up.

Even with bureaucratic inertia and penny-pinching tendencies taken into account this seems indefensible to me, given what we all know about the spread of the Ebola outbreak.

MissyWrite · Oct 18, 2014

Essentially we are unsure what is droplet or airborne. Many variables can change the size and distribution.

All that matters is that the virus can be suspended in droplets, which are generated during sneezing, vomiting, suctioning, etc., and that these droplets may be capable of transmitting the virus.

"Personal protective equipment guidelines should not be based on presumed mode of transmission alone, but also on uncertainty around transmission, on the severity of the disease, on health worker factors, and on available treatments or preventions."

Ebola is highly lethal. There is no vaccine or cure. Routes of transmission are still uncertain. PPE guidelines should be based upon these things.

MissyWrite · Oct 18, 2014

Even with bureaucratic inertia and penny-pinching tendencies taken into account this seems indefensible to me, given what we all know about the spread of the Ebola outbreak.

I LOVE your entire post, macawake!

It is indefensible, with what we know about Ebola. Indefensible. I can't comprehend it. That's why I'm here, writing. It helps me to feel I'm doing something to combat whatever ignorance has gripped the "Centers for Disease Control"

More than 100,000 people here in the US suffer hospital-aquired infections each year. The costs, on so many levels, are astounding. It's as if we don't understand basic infection control!

Scrubs have been hospital-owned and laundered for at least as long as I can remember (80s). Scrubs aren’t allowed to be worn outside the hospital. We have very strict hygiene and infections prevention protocol. No hair touching your collar, disposable aprons in all patient contacts, (of course gloves when needed) change scrubs immediately if wet (water or bodily fluids) or soiled, no rings allowed including wedding bands, short nails/no nail polish and sleeves end approximately four inches above the elbow. You can wear longer sleeves if you’re cold when you’re not in a patient care area, but as soon as you approach a patient you have to remove the jacket (this clothing item is of course also hospital-laundered). This applies to all categories of healthcare workers. Physicians aren’t allowed to wear their coat (or personal clothes) in direct patient care. They are relentlessly pestered if they forget to remove their coat. We use hand sanitizer like we’re addicted to it.

On the few occasions that I’ve had MRSA positive patients I’ve been that patient’s designated nurse for the shift. I’m not allowed to come in contact with any other patient or even enter another patient’s room during that shift.

Yes! This is so basic, yet so totally foreign to the way things are done here.

On my local news there was a thing about hospital preparedness in early August, with two nurses demonstrating the PPE that would be used in the care of an Ebola patient. It was the fluid impermeable full body suit, including hood and built-in air supply/air purifier.

I just can't understand why anyone would consider doing any less. It's mind-boggling.

Thank you for posting this.

GrannyRRT · Oct 18, 2014

All that matters is that the virus can be suspended in droplets, which are generated during sneezing, vomiting, suctioning, etc., and that these droplets may be capable of transmitting the virus.
"Personal protective equipment guidelines should not be based on presumed mode of transmission alone, but also on uncertainty around transmission, on the severity of the disease, on health worker factors, and on available treatments or preventions."
Ebola is highly lethal. There is no vaccine or cure. Routes of transmission are still uncertain. PPE guidelines should be based upon these things.

But in the US we use the standard definitions for the type of isolation and many of the other factors are not taken into consideration.

Once oxygen is initiated and intubation is done, the standard precautions for "droplet" no longer apply.

The patient was probably on significant oxygen with a high flow and he was later intubated. From the moment he went on oxygen or care was being done at close range, you can not assume standard droplet precautions are enough. This can apply to many diseases and not just Ebola. H1N1 was a good example were we went beyond standard flu droplet precautions to protect the staff. The flu kills many people every year including those in healthcare facilities. So maybe we don't understand all the transmission factors or might be less cautious because it "is only droplet".

In the 1980s_ and early 90s we did isolate MRSA patients with separate staff especially in hospitals which did a high number of surgeries. NICU also has a separate area for infectious diseases thought to spread easily. They also swabbed the staff regularly if we floated.

lifelearningrn, BSN, RN · Oct 18, 2014

MissyWrite- I can tell you're a very intelligent person and you present good arguments. I just don't believe that there is a major risk of respiratory transmission. I think the fact that the virus, for the most part, has stayed confined to West Africa in this globalized world is pretty compelling evidence of that. So far, the only people to become infected in the US were in direct contact with body fluids of an infected patient. JMO

I do thank you for your passion and concern for nurses still in the profession. :)

GrannyRRT · Oct 18, 2014

MissyWrite- I can tell you're a very intelligent person and you present good arguments. I just don't believe that there is a major risk of respiratory transmission. I think the fact that the virus, for the most part, has stayed confined to West Africa in this globalized world is pretty compelling evidence of that. So far, the only people to become infected in the US were in direct contact with body fluids of an infected patient. JMO
I do thank you for your passion and concern for nurses still in the profession. :)

The mode of transmission is not based solely on the disease but also the interventions.

MissyWrite · Oct 18, 2014

I just don't believe that there is a major risk of respiratory transmission.

I don't believe there's a major risk, either. But there is some risk. Especially to nurses and other HCWs. And as long as there is ANY risk of this highly lethal virus infecting someone, maximum precautions are necessary. That's what I'm saying here.

The CDC itself categorizes Ebola as a biosafety level 4 pathogen because it's highly lethal and without a vaccine or cure. Yet the precautions they've advised so far (for clinical staff) fall way short of that.

Thank you :)