Addressing Infection Prevention and Control in the First U.S. Community Hospital to Care for Patients With Ebola Virus Disease: Context for National Recommendations and Future Strategies
Key Summary Points Health care personnel (HCP) caring for patients with Ebola virus disease (EVD) are at increased risk for infection. While providing care to a patient with EVD and to 2 nurses who became infected while caring for him, a U.S. community hospital strengthened a system of controls aimed at preventing disease transmission, including engineering and administrative controls and personal protective equipment (PPE) Changes to the hospital's physical layout, procedures for handling clinical specimens and waste, job duties of HCP, and PPE ensembles required substantial investments of time, personnel, and resources. This experience contributed to informing national policies for preparedness for EVD and has implications for other high consequence emerging infectious diseases. The recent outbreak of Ebola virus disease (EVD) in West Africa is the largest in history (1) Ebola virus is transmitted through direct contact with an infected person's blood or bodily fluids (2) Health care personnel (HCP) caring for patients with EVD are at increased risk for infection with the virus. In West Africa, 881 HCP were infected, 513 of whom died (3) Experience treating patients with EVD in specialized biocontainment units has been reported (47) In 2014, a hospital in Dallas, Texas, became the first community hospital in the United States to care for a patient with EVD; 2 nurses were infected while providing care. In this article, we describe the infection prevention and control measures implemented to strengthen this hospital's capacity to safely diagnose and treat patients with EVD. Prevention of transmission of infectious pathogens, including Ebola virus, to HCP includes 3 tiers of the hierarchy of controls (811) This standard approach to controlling workplace hazards involves using physical engineering controls that can remove or reduce exposure to a hazard; administrative controls that involve management policy and work practice training; and personal protective equipment (PPE) a supplementary method when engineering and administrative controls alone cannot provide sufficient protection (10, 11) Effective use of PPE requires comprehensive supporting programs for medical evaluation and training of employees and proper selection, fit, maintenance, and storage of equipment (12) On 25 September 2014, a 42 year old Liberian man presented to an emergency department in Dallas, Texas, with abdominal pain and headache (Figure 1) (13) After an evaluation described previously (13) he was treated for presumed sinusitis and discharged. On 28 September, he returned with fever, abdominal pain, and diarrhea (Figure 1) Ebola virus disease was suspected on the basis of his symptoms and his reported recent travel from Liberia, and he was placed in an isolation room (13) The patient was admitted to the medical intensive care unit (MICU) on 29 September, and EVD was confirmed by laboratory testing on 30 September. The patient's clinical course was notable for explosive diarrhea (up to 10 L/d) requiring placement of a rectal tube, development of renal failure requiring continuous venovenous hemodialysis, and a need for endotracheal intubation and mechanical ventilation for 5 days until his death on 8 October of multiorgan failure (13) On 11 October and 15 October, laboratory testing confirmed EVD in 2 MICU nurses who cared for him (14) The nurses were admitted to the MICU and later transferred to facilities with biocontainment units. Figure 1. Timeline of events at the first U.S. community hospital to care for patients with EVD in Dallas, Texas, September to October 2014. ED= emergency department; EVD= Ebola virus disease; MICU= medical intensive care unit. On 1 October 2014, staff from the Centers for Disease Control and Prevention (CDC) began arriving at the hospital and collaborating with the hospital's infection preventionists to provide infection control recommendations. The CDC staff included physicians and industrial hygienists with experience in occupational safety and health and infection prevention for conventional and emerging infectious agents, including Ebola virus. Efforts to determine how the nurses were infected were limited by the wide range of the incubation period (2 to 21 days) the lack of systematic observation, and the reliance on HCP recall to retrospectively identify instances of exposure. As such, the precise time of infection could not be determined and specific exposures that led to infection could not be identified. Thus, the approach taken to infection control was ultimately a comprehensive one, focused not on a single source of exposure but on implementing a system of controls that addressed all workplace hazards that may have contributed to the nurses' infections. In this typical community hospital that did not have a dedicated biocontainment unit, an on site autoclave capable of handling large volumes of waste, an on site incinerator, or staff with pre event specialized training related to EVD, the team interviewed HCP, facility managers, laboratorians, and environmental services (EVS) managers and observed patient care activities, laboratory practices, and the management of regulated medical waste. The team developed and refined recommendations in an iterative process, building on existing controls and taking into account observations and feedback. In this article, we describe the system that was ultimately developed, emphasizing general principles, highlighting unanticipated challenges, and noting practical solutions so that our experience may benefit others faced with caring for patients with EVD or similarly challenging infectious diseases. MICU Engineering Controls Engineering controls were implemented to change the layout of the 24 bed MICU (Figure 2, top) It was closed to patient care except for a 4 bed section demarcated by 3 tear resistant, fire retardant fabric walls with integrated zippers (Figure 2, bottom) The area inside the zippered walls was designated the hot zone, and the area outside the zippered walls was designated the cold zone. This approach demarcated for all HCP the area that posed a potential risk for exposure and clarified where PPE was required. A family waiting room adjacent to the hot zone was converted into the PPE donning area, and an area near the exit of the hot zone was designated as the PPE doffing area. In some biocontainment units, HCP doff PPE in a closed patient room while being observed by other HCP through a window (15) In this unit, given the staff's limited experience with specialized PPE, doffing outside the small patient room was preferable because it minimized barriers to verbal communication between the HCP and the observer. Figure 2. The original (top) and final (bottom) layouts of a section of the medical intensive care unit used for care of patients with Ebola virus disease at a community hospital in Dallas, Texas, September to October 2014. The unnamed rooms in the final layout were not used. PAPR= powered air purifying respirator; PPE= personal protective equipment. Separate entrance and exit doors for the hot zone enabled unidirectional flow and reduced the chances of clean HCP who were entering the hot zone being inadvertently contaminated by dirty HCP exiting. To enter the hot zone, HCP changed into disposable scrubs, donned PPE in the PPE donning room, and entered the hot zone through a zippered wall. To exit, HCP doffed PPE in the PPE doffing area, exited the hot zone through another zippered wall, and showered. Administrative Controls Early placement of an ultrasound guided peripherally inserted central catheter minimized the need for phlebotomy and shorter term peripheral intravenous lines. Several policies limited and tracked hot zone entry: Logs that included date and time of entry and contact information were maintained; videoconferencing capacity was established for physicianpatient interactions; orders for radiology services were scrutinized to eliminate those that were not essential; and the patient care nurse assumed duties typically performed by EVS staff, such as cleaning and disinfecting the patient room and removing waste. In this way, only a limited number of staff (the patient care nurse, a second nurse to assist with patient care, and the doffing coach [described in the next section] were routinely in the hot zone. The treating physician, consultants, and radiology technicians entered the hot zone only as needed. Others, such as the runner (who coordinated transfer of medication and supplies to the hot zone) and the donning coach (described in the next section) remained in the cold zone. Training HCP in infection control procedures, including donning, use, and doffing PPE, was instituted. To reduce the frequency of PPE doffing, it was recommended that patient care nurses remain in the patient room continuously for up to 6 hours. PPE Personal protective equipment ensembles initially used by HCP inside the hot zone varied over time and were influenced by job duty, HCP preference, and availability of PPE items. A standard PPE ensemble was ultimately established for all HCP at all times inside the hot zone (Table 1) This fostered clarity about what PPE items were required, facilitated development of uniform donning and doffing procedures, and ensured that any HCP in the hot zone could quickly enter the patient room in an emergency. Table 1. Final PPE Ensembles Used for Care of Patients With Ebola Virus Disease and Handling Clinical Specimens in a Community Hospital in Dallas, Texas, in October 2014 The variable practice of augmenting the number of PPE items was discouraged. For example, instead of wearing the recommended 2 pairs of gloves, some HCP wore 3 or 4 pairs. The additional layers of PPE could make it more difficult to perform patient care duties and increase the risk for exposure during doffing (16) Because each additional PPE item worn could lead to a change in the doffing sequence, variability in the nu
Annals of Internal Medicine