Nursing and the Ebola Virus

[0.adamantite]

For those of us in unaffected countries, are you concerned about the ebola virus spreading? Would you care for ebola patients? I live in an area with a very high density of African immigrants and come into contact with these individuals regularly. We have a lot of African immigrants who bring back tuberculosis from their home countries and at my unit we end up caring for them. We take care of a lot of rare infectious diseases. I was reading an article and it dawned on me how plausible it would be for me to encounter this virus. And I admit, it's terrifying and I might refuse that assignment. Many healthcare workers in Africa are dying because of caring for the ill.

[dream'n, BSN, RN]

I'm not talking about the bond, which is subjective. I am talking about objectively determining which human life is the most valuable, and I think all human lives are (more or less) equally valuable. Other nurses' children are humans. My best friend is a human, too. So is the person in line in front of me at the grocery store. I don't think that, objectively, any of these people are more important than the others, and I don't think that any of them particularly deserve to be exposed to Ebola.

Of course to you my children are just other human beings, but to ME they are not. Every parent is ultimately responsible for their own. When I brought my children into the world I made a promise to care for them, above all others, at the least while they are of a dependent age. That is how it is, and how it should be. I take my duty to my patients very seriously, but my responsibility to my children is my ultimate priority.

And on another topic, I'm just going to say something that's been on my mind. The US is SUCH a schizophrenic nation. I keep reading (not just on Allnurses), Americans crying out that these are "American citizens that are entitled to the best care available" yet I see patients regularly that present to the ER with late-stage cancer, etc that haven't received any previous care due to a lack of health insurance. Aren't these people Americans too?

[edmia, BSN, RN]

I received this via email so I am sharing the information:

This is an official

CDC HEALTH ADVISORY

Distributed via the CDC Health Alert Network

August 1, 2014 20:00 ET (8:00 PM ET)

CDCHAN-00364

Guidelines for Evaluation of US Patients Suspected of Having Ebola Virus Disease

Summary

The Centers for Disease Control and Prevention (CDC) continues to work closely with the World Health Organization (WHO) and other partners to better understand and manage the public health risks posed by Ebola Virus Disease (EVD). To date, no cases have been reported in the United States. The purpose of this health update is 1) to provide updated guidance to healthcare providers and state and local health departments regarding who should be suspected of having EVD, 2) to clarify which specimens should be obtained and how to submit for diagnostic testing, and 3) to provide hospital infection control guidelines.

U.S. hospitals can safely manage a patient with EVD by following recommended isolation and infection control procedures. Please disseminate this information to infectious disease specialists, intensive care physicians, primary care physicians, hospital epidemiologists, infection control professionals, and hospital administration, as well as to emergency departments and microbiology laboratories.

Background

CDC is working with the World Health Organization (WHO), the ministries of health of Guinea, Liberia, and Sierra Leone, and other international organizations in response to an outbreak of EVD in West Africa, which was first reported in late March 2014. As of July 27, 2014, according to WHO, a total of 1,323 cases and 729 deaths (case fatality 55-60%) had been reported across the three affected countries. This is the largest outbreak of EVD ever documented and the first recorded in West Africa.

EVD is characterized by sudden onset of fever and malaise, accompanied by other nonspecific signs and symptoms, such as myalgia, headache, vomiting, and diarrhea. Patients with severe forms of the disease may develop hemorrhagic symptoms and multi-organ dysfunction, including hepatic damage, renal failure, and central nervous system involvement, leading to shock and death. The fatality rate can vary from 40-90%.

In outbreak settings, Ebola virus is typically first spread to humans after contact with infected wildlife and is then spread person-to-person through direct contact with bodily fluids such as, but not limited to, blood, urine, sweat, semen, and breast milk. The incubation period is usually 8-10 days (ranges from 2-21 days). Patients can transmit the virus while febrile and through later stages of disease, as well as postmortem, when persons touch the body during funeral preparations.

Patient Evaluation Recommendations to Healthcare Providers

Healthcare providers should be alert for and evaluate suspected patients for Ebola virus infection who have both consistent symptoms and risk factors as follows: 1) Clinical criteria, which includes fever of greater than 38.6 degrees Celsius or 101.5 degrees Fahrenheit, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage; AND 2) Epidemiologic risk factors within the past 3 weeks before the onset of symptoms, such as contact with blood or other body fluids of a patient known to have or suspected to have EVD; residence in--or travel to--an area where EVD transmission is active; or direct handling of bats, rodents, or primates from disease-endemic areas. Malaria diagnostics should also be a part of initial testing because it is a common cause of febrile illness in persons with a travel history to the affected countries.

Testing of patients with suspected EVD should be guided by the risk level of exposure, as described below:

CDC recommends testing for all persons with onset of fever within 21 days of having a high-risk exposure. A high-risk exposure includes any of the following:

 percutaneous or mucous membrane exposure or direct skin contact with body fluids of a person with a confirmed or suspected case of EVD without appropriate personal protective equipment (PPE),

 laboratory processing of body fluids of suspected or confirmed EVD cases without appropriate PPE or standard biosafety precautions, or

 participation in funeral rites or other direct exposure to human remains in the geographic area where the outbreak is occurring without appropriate PPE.

For persons with a high-risk exposure but without a fever, testing is recommended only if there are other compatible clinical symptoms present and blood work findings are abnormal (i.e., thrombocytopenia

Persons considered to have a low-risk exposure include persons who spent time in a healthcare facility where EVD patients are being treated (encompassing healthcare workers who used appropriate PPE, employees not involved in direct patient care, or other hospital patients who did not have EVD and their family caretakers), or household members of an EVD patient without high-risk exposures as defined above. Persons who had direct unprotected contact with bats or primates from EVD-affected countries would also be considered to have a low-risk exposure. Testing is recommended for persons with a low-risk exposure who develop fever with other symptoms and have unknown or abnormal blood work findings. Persons with a low-risk exposure and with fever and abnormal blood work findings in absence of other symptoms are also recommended for testing. Asymptomatic persons with high- or low-risk exposures should be monitored daily for fever and symptoms for 21 days from the last known exposur e and evaluated medically at the first indication of illness.

Persons with no known exposures listed above but who have fever with other symptoms and abnormal bloodwork within 21 days of visiting EVD-affected countries should be considered for testing if no other diagnosis is found. Testing may be indicated in the same patients if fever is present with other symptoms and blood work is abnormal or unknown. Consultation with local and state health departments is recommended.

If testing is indicated, the local or state health department should be immediately notified. Healthcare providers should collect serum, plasma, or whole blood. A minimum sample volume of 4 mL should be shipped refrigerated or frozen on ice pack or dry ice (no glass tubes), in accordance with IATA guidelines as a Category B diagnostic specimen. Please refer to http://www.cdc.gov/ncezid/dhcpp/vspb/specimens.html for detailed instructions and a link to the specimen submission form for CDC laboratory testing.

Recommended infection control measures

U.S. hospitals can safely manage a patient with EVD by following recommended isolation and infection control procedures, including standard, contact, and droplet precautions. Early recognition and identification of patients with potential EVD is critical. Any U.S. hospital with suspected patients should follow CDC's Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals (http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html). These recommendations include the following:

 Patient placement: Patients should be placed in a single patient room (containing a private bathroom) with the door closed.

 Healthcare provider protection: Healthcare providers should wear: gloves, gown (fluid resistant or impermeable), shoe covers, eye protection (goggles or face shield), and a facemask. Additional PPE might be required in certain situations (e.g., copious amounts of blood, other body

fluids, vomit, or feces present in the environment), including but not limited to double gloving, disposable shoe covers, and leg coverings.

 Aerosol-generating procedures: Avoid aerosol-generating procedures. If performing these procedures, PPE should include respiratory protection (N95 filtering facepiece respirator or higher) and the procedure should be performed in an airborne isolation room.

 Environmental infection control: Diligent environmental cleaning and disinfection and safe handling of potentially contaminated materials is paramount, as blood, sweat, emesis, feces and other body secretions represent potentially infectious materials. Appropriate disinfectants for Ebola virus and other filoviruses include 10% sodium hypochlorite (bleach) solution, or hospital-grade quaternary ammonium or phenolic products. Healthcare providers performing environmental cleaning and disinfection should wear recommended PPE (described above) and consider use of additional barriers (e.g., shoe and leg coverings) if needed. Face protection (face shield or facemask with goggles) should be worn when performing tasks such as liquid waste disposal that can generate splashes. Follow standard procedures, per hospital policy and manufacturers' instructions, for cleaning and/or disinfection of environmental surfaces, equipment, textiles, laundry, food utensils and dishware.

Recommendations to Public Health Officials

If public health officials have a patient that is suspected of having EVD or has potentially been exposed and intends to travel, please contact CDC's Emergency Operations Center 1 [phone].

The Centers for Disease Control and Prevention (CDC) protects people's health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national, and international organizations.

[Spangle Brown]

We don't know what the precautions will entail. I think in a situation like this they should accept volunteers to care for the patients, not force the staff. I wonder if they will have the staff stay at the hospital, but they haven't said. Too bad there isn't a nurse that works with these special isolation units that can give us more details.

Force staff? More like specialized and trained staff doing the job they have been trained to do. I highly doubt it's like TV, where the pretty nurses get forced into doing the job. I'm sure it's the ones who have been trained to deal with situations like this.

Do we put L&D personal with the Heart patients?

[heron, ASN, RN]

Yep - déjà vu all over again.

Edmia, thank you for the info.

Here we go down the rabbit hole ...

[AWanderingMinstral]

I think nurses should be allowed to refuse, we know our limits and we know how to prioritize. If we prioritize our children over our call to nursing, that is our business. Doesn't make us a bad person.... That being said I would be willing to work with the patients because I find bacteria, viruses, bacteriophages, and genetics fascinating. ^.^

You are free to refuse a patient assignment, but the facility is free to fire you too.

[Spangle Brown]

But all that is different when you have children and there's no way to explain it. I felt the same way you do but once I had a child everything changed. I value the life of a child above the life of an adult. You cannot understand unless you have a child. I think it would be perfectly ok to refuse an assignment due to the possibility of infecting your children with ebola.

I must be missing something here. I am not sure what their bond with their children has to do with this. BTW, I am a parent. Because the NURSE has a special bond with her child, she/he shouldn't have to do their job? Not seeing the connection.

What is at issue here is dependent care. Those with dependents will need to care for them. Wither they are children or adult. If there is another parent, then that should NOT be an issue, as the other parent/person can deal with the family matters.

Through out history, this has been an issue. It is not a new, or special issue. People have had to deal with this. Surely, as a parent in the medical field, you have all ready realized that there might be an issue where you can not come home. Surely you have a back up plan. IF you don't, it's not everyone elses fault.

[tntrn, ASN, RN]

Force staff? More like specialized and trained staff doing the job they have been trained to do. I highly doubt it's like TV, where the pretty nurses get forced into doing the job. I'm sure it's the ones who have been trained to deal with situations like this.

Do we put L&D personal with the Heart patients?

yes, some hospitals put L and D and NICU in places they have never worked...it is called floating....and where I worked it was not safe formthe patients or the nurses' licenses.

[CateB]

Now that they are bringing infected cases to the US, is it time to ask that those physicians who believe that they are immune to infection by virtue of the letters MD after their name will start taking proper precautions to protect themselves and others? We all know the ones, those who go from patient to patient in the ER and elsewhere without going anywhere near a sink. If they are in charge we may as well shut up shop now and just accept that Ebola, among other things is here to stay.

[Spangle Brown]

yes, some hospitals put L and D and NICU in places they have never worked...it is called floating....and where I worked it was not safe formthe patients or the nurses' licenses.

Do you really think they are going to float people into that isolation? We are not talking "some hospital" we are talking Atlanta's Emory University Hospital which has a special isolation unit. This has the ability to be a media nightmare, that IMHO, only trained personal will be ALLOWED near it. I don't think any floater will be considered trained enough to be allowed. This same University Hosiptal has been doing research on an Ebola Vaccine. Which again, another reason they would only allow trained personal near the patients.

Edit: Emory is 1 of 4 hospitals in the US that has these special isolation units.

Emory has had this isolation area for awhile. I am sure they have a trained staff prepared to use it. Such staff surely already thought of all the possible reasons such a room could be used for. Including Ebola.

IMHO, I see a group of trained personal getting a chance to use specialized training in a research setting.

[Spangle Brown]

Now that they are bringing infected cases to the US, is it time to ask that those physicians who believe that they are immune to infection by virtue of the letters MD after their name will start taking proper precautions to protect themselves and others? We all know the ones, those who go from patient to patient in the ER and elsewhere without going anywhere near a sink. If they are in charge we may as well shut up shop now and just accept that Ebola, among other things is here to stay.

They are going to Emory University Hospital, where they are working on an Ebola Vaccine. Ebola virus uses protein decoy to subvert the host immune response | Emory University | Atlanta, GA

[Miss.LeoRN]

If you read the actual study, they clearly report they could not determine if the virus was spread by respiratory droplets, or even the floor cleaning causing overspray. It's flawed to say it proves airborne transmission when the researchers can't even determine if they caused it themselves or not.

That was my point. There were other explanations.

Ebola isn't suddenly going to mutate and become airborn out of no where just because, one of the primary factors preventing this is that ebola kills is host far too fat in order to mutate to such an extreme.

[0.adamantite]

So back to Ebola...

There's footage of the first guy arriving at the hospital and he was able to walk. Maybe he's recovering?

Do you have a link? I thought I read that the patient was in "grave but stable" condition.