PPE for Ebola?

firstinfamily, RN · Oct 9, 2014

Still waiting to see what the acute hospitals recommend. I don't think it is droplet but more direct contact isolation. Droplet would indicate it is passed like TB and that is not what the CDC is saying. Body fluids, all body fluids have been the method of transmission. There should be a full PPE hood, gown, pants for every healthcare worker on every shift who is caring for these Ebola patients. I think the Hazmat teams are responding to the environmental hazards--any body fluids in the car, apartment etc. Which would be standard procedure for any liquid type contamination. I would print out the CDC recommendations and pass them along to your infection control nurse or who ever is making the recommendations for your facility. It is here in the US and in more than one state now. Plus we have an entero-virus that is present in most states affecting children. You can be the advocate for your safety!!

Willow_RN · Oct 9, 2014

Thank you for the response.

PopcornRN36 · Oct 12, 2014

If the Dallas healthcare worker (now being treated for Ebola) was donning PPE (Personal Protective Equipment i.e. mask, gloves, gown, etc) perhaps the removal of their PPE needs to be reviewed? I note the CDC's recommendation of removing gloves/eyewear does not include mandatory steps of washing hands in between these steps (only if contamination occurs). For the donning of PPE for infectious care (respiratory) in Australia we 'always' had to do that. Perhaps assuming the virus has airborne transmission capabilities (versus just contact precautions) and more prudent PPE removal steps are required. Why are so many HCW are being infected with Ebola? And I agree with the suggestion that covering for clothing should be more than just a gown.

http://www.flupandemic.gov.au/internet/panflu/publishing.nsf/Content/safe-use-dvd-transcript

http://www.cdc.gov/vhf/ebola/pdf/ppe-poster.pdf

SandyB · Oct 13, 2014

Sue Ellen Kovack, 56

Australian Red Cross nurse, Kenema, Sierra Leone

At the start of the day, I check my hands for any cuts or scrapes that will bar me from donning PPE. Entering the centre, I must wash my hands in a 0.05% chlorine solution. I balance on one foot as someone sprays the bottoms of my shoes with 0.5% chlorine before being allowed entry to the low-risk area.

I search for a pair of cold wet boots in my size, which have been soaking in chlorine for the night, and I change into my scrubs. I go straight to the whiteboard to see who has passed away during the night; today, it's one of three nurses who became infected at work. One is on his way to good health, the other is still hanging on.

We need to synchronise putting the PPE on with other team members, because if one is slower than the rest we end up waiting and baking in the sun. We have a dresser to make sure we are completely covered, or we work in pairs and check each other. First on are gloves and a jumpsuit. Then a second pair of gloves, a thick duckbill mask, a hood, and an apron that is tied by the dresser so we can untie it with one pull. Then on go the goggles with a generous drizzle of antifogging spray, a final check in the mirror and a final check with each other. The checking does not stop there, as we must ensure during our time in the high-risk area that we are still covered, that a mask has not slipped, or that a piece of skin has not been exposed. If that happens, we leave the area immediately. We check the time - 45 minutes to one hour is the maximum allowed in the PPE.

We have the luxury of four nurses today. Patients who are feeling well enough are sitting on plastic chairs waiting for a meal. We might offer some pain relief, or a smile from beneath our PPE (yes, you can smile with your eyes).

Hannah (not her real name) is sitting outside, greeting us with a big smile. She has lost all her children to Ebola as well as her husband. And here she is asking me how my evening was. The staff tell me she has had some bad moments, but all they can do is reassure her that she is young and can bear more children.

Others have not fared so well - too weak to sit up, or get to the toilet or the shower block. We do our best to offer fluids, a wash and some paracetamol. The local nursing staff have amazing courage to work in our centre. Their families ostracise them, but they still come, to try to bring an end to this brutal, invisible "war". In Africa, it is usually the family that feeds, washes and comforts the patients. But no family members are allowed inside our treatment centre.

My three key words are warm, dry and comfortable. Patients who are too weak to move away from their own vomit, faeces and urine need the most help. We clean and care for as many as we can, but if we need to leave the area because of heat exhaustion or feeling unwell, the priority is to get out. You are a danger to your colleagues if you go down in your PPE.

After our nursing team goes in, the hygiene team suits up for their rounds. They clean up the vomit, diarrhoea and urine spills, the garbage and the nappies. Their task is monumental and they can be at most risk.

A minimum of five minutes is needed to undress. We have two tents, where the undressers and sprayers need to be on the ball. The urge to just pull the suit off is strong, but we wait. First, the chlorine spray to the hands. Then, feet apart, arms in the air, we are sprayed from head to toe, first the front, then the back. We wash our hands in 0.5% chlorine. Off come the first set of gloves.

We wash our hands again. Off comes the apron and hopefully it was tied perfectly, as we have to blindly reach around to release the knot; we pull it over our heads. Into the chlorine soak it goes. We wash our hands.

Next go the goggles. We bend over, close our eyes and gently remove them, dunk them three times in the strong chlorine-filled bucket, and then place them in water. We wash our hands.

The hood comes off next. Once again, we bend over, closing our eyes to avoid contamination and dispose of the hood in the garbage. We wash our hands.

Next, the removal of our heavy PPE. Moving slowly - we do everything slowly here - we carefully expose the zipper, hidden under a taped-down flap. We wash our hands. Blindly, we have to find the zipper, as our undressers and sprayers guide us. We wash our hands.

As we shimmy out of our PPE, we are soaked to the bone in sweat, but it feels great. This is the hardest part: to ease off the jumpsuit while kicking your legs back, at the same time standing on it so it doesn't fly away from you. It's a balancing act. The sprayer sprays the entire jumpsuit with a stronger chlorine solution and we put it in the garbage. We wash our hands.

Our heavy-duty filtration mask is next. I close my eyes and hope it doesn't catch in my ponytail. We wash our hands.

The last pair of gloves comes off. Our boots are sprayed from all angles and we have to balance on one foot to cross the line from high risk to low risk. We wash our hands and we are done, stripped down to our scrubs, soaked with sweat.

I need a rehydration solution or water. No food is allowed in the low-risk area. It is too risky to put anything near your mouth from your hands. But I still see people biting their nails, touching their face, rubbing their eyes - risky but automatic responses. Your hands have been washed a trillion times in chlorine, but still, you don't know how safe your other colleagues have been. You are literally entrusting your life to your work mates. Before I left Australia, I took to wearing a rubber band and each time I caught myself touching my face, I snapped it painfully so I would remember not to do it.

I hear an ambulance and the siren is going fast - it may pass us and head to the next treatment centre, hours away. But it abruptly turns into our driveway and we run out to greet it. I suit up and prepare for the admissions with a package consisting of a blanket, soap, towel, cup, toothbrush and toothpaste, all in a covered bucket that will be used for vomit/faeces or urine if the person is unable to get to the latrines.

The ambulance door is opened and I can see a man on the stretcher, two legs in the air, stiff as a board. They slowly drop and I realise this patient is dying. But he walked into the ambulance in Freetown. It is a five-hour drive through a dozen checkpoints and deterioration comes rapidly. I pronounce him dead, and move on to the other patient.

The female patient is lying on the floor between the seat and the stretcher, strapped in by seatbelts. She is trapped, a terrorised look in her eyes. She is flailing wildly, a dangerous situation in itself. I try to calm her while maintaining my distance. We move her as best we can, but then I realise that she is just trying to cover her exposed area below her waist. In her last moments, this is her concern. We manage to get her into a tent. We ask her name, if she is married. She responds, "I am married", looks away and dies. All that struggle and desperation in the ambulance and she only wanted to preserve her dignity. That was a tough moment.

http://www.theguardian.com/world/2014/oct/13/ebola-nurses-describe-life-death-on-frontline-liberia-sierra-leone

I'm reading and seeing too many differences between what we say is safe and what they do in Africa.

firstlight · Oct 13, 2014

Thank you for this post.

You gave me a glimpse of the horror that you have witnessed on a daily basis.

I will go to the web site that you have posted.

I am speechless of your selfless acts.

Bless all of you.

PopcornRN36 · Oct 13, 2014

To reiterate firstlight, 'Thank you' for providing us this article which provides insight into what those on the front line are dealing with on a daily basis.

mariebailey, MSN, RN · Oct 13, 2014

I personally think they wear HAZMAT suits, not because of how Ebola is spread, necessarily, but because the consequences of transmission of such a virus in these here United States of America. They want to be darn sure they don't come into contact w/it, & they want to be seen on CNN taking every precaution possible. Contact & droplet precautions do they job though, with the exception of when patients undergo aerosol-inducing procedures.

[h=2]If a patient in a U.S. hospital is identified to have suspected or confirmed EVD, what infection control precautions should be put into place?[/h]If a patient in a U.S. hospital is suspected or known to have Ebola virus disease, healthcare teams should follow standard, contact, and droplet precautions, including the following recommendations:

Isolate the patient: Patients should be isolated in a single patient room (containing a private bathroom) with the door closed.
Wear appropriate PPE: Healthcare providers entering the patients room should wear: gloves, gown (fluid resistant or impermeable), eye protection (goggles or face shield), and a facemask. Additional protective equipment 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.
Restrict visitors: Avoid entry of visitors into the patient's room. Exceptions may be considered on a case by case basis for those who are essential for the patient's wellbeing. A logbook should be kept to document all persons entering the patient's room. See CDC's infection control guidance on procedures for monitoring, managing, and training of visitors.
Avoid aerosol-generating procedures: Avoid aerosol-generating procedures. If performing these procedures, PPE should include respiratory protection (N95 or higher filtering facepiece respirator) and the procedure should be performed in an airborne infection isolation room.
Implement environmental infection control measures: Diligent environmental cleaning and disinfection and safe handling of potentially contaminated materials is of paramount importance, as blood, sweat, vomit, feces, urine and other body secretions represent potentially infectious materials should be done following hospital protocols.

Safe Management of Patients with Ebola Virus Disease (EVD) in U.S. Hospitals | Ebola Hemorrhagic Fever | CDC

Doc Brown · Oct 14, 2014

I live in VA off I95 near DC which Dulles is very popular with flights coming from Africa. My critical care unit only calls for gown, gloves, surgical mask, paper gown, and face shield. We are barely covered if we have a pt come in with suspected ebola. Is there any hospital where they are implementing more cautious precautions? Such as full suit that is fluid proof?

Sloan RN · Oct 14, 2014

Ebola is spread by contact, like RSV. The reason you see stuff like Hazmat suits on the news is due to an abundance of caution.

At my hospital the recommendation is booties, a surgical gown (they're waterproof unlike our typical isolation gowns), an N95 (apparently due to concern that procedures like suctioning and intubation could somehow aerosolize the virus although I haven't seen any literature supporting that), a face shield to prevent direct splashes, and double-gloving. Any Ebola patient is supposed to have two nurses, so we can take turns in the room and help each other take off PPE without infecting ourselves. They're also putting Ebola patients in a negative-pressure room, which isn't really necessary, except for the aforementioned concern that some procedures may aerosolize the virus temporarily.

Apparently in Emory, as the patients got better and were moving around the room themselves, PPE was scaled back accordingly (i.e. a regular surgical mask instead of N95s, no booties, etc).

It's important that healthcare workers educate themselves about Ebola using reliable resources. I've been a little disappointed to see fellow nurses either knowing nothing about it or believing some ridiculousness they've seen on the news. UpToDate has made their articles on Ebola free to the public, and the CDC has good information as well.

Ebola is no joke, but I don't think it's quite as terrifying as the media is making it out to be.

P.S. As far as Hazmat suits in hospitals, it's my understanding that they are very difficult to take off without infecting yourself, and that some healthcare providers in Africa wear them because they don't have the luxury of disposable PPE that can be changed between patient encounters.

Doc Brown · Oct 14, 2014

"We have to rethink the way we approach Ebola infection control, because even a single infection is unacceptable," said Centers for Disease Control and Prevention director Tom Frieden.

Frieden spoke to reporters a day after Texas Health Presbyterian Hospital Dallas announced one of its staff members had contracted Ebola -- marking the first case of infection inside the United States.

However, he gave few specifics about what precisely was going to change.

"What we will be doing in the coming days and weeks is doubling down on the amount of education, training, outreach and support we provide," Frieden said.

https://www.yahoo.com/news/texas-case-forces-us-rethink-ebola-approach-170405665.html

This and many other articals state that we are not prepared in hospitals. That's probly why several medical staff are becoming infected. In my opinion I don't trust the cdc or the govt to respond in a timely manner to any disaster. Since the spread is a few now in the U.S. as we know of, early prevention and overprecaution is key. I don't think the CDC is a good resource for this topic because they are too political and they don't want to cause any further scare. Just like the govt, they won't admit research is inadequate to provide us facts. It would just be nice to be told to overdress rather than underdress.

Our ID Dr. Had said he had a meeting on increasing precautions above CDC standards but nothing has returned yet.

stargarden · Oct 14, 2014

I think the CDC recommendations are a joke and if Ebola came to my hospital I would refuse to work with anything less then what they are outfitting the healthcare workers in Africa with. We are entitled to safe working conditions under the rules of OSHA. I pray they did not send any workers in to assist in toileting with just a gown, gloves, mask and goggles when they on the other hand send men in with hazmat suits to touch the carpets and furnishings in the home. It is dumbfounding.