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Nursing organizations collaborate to identify gaps, make system improvements
As the Centers for Disease Control and Prevention (CDC) scrambles to get in front of the fast-moving Ebola crisis with strengthened guidance for health care workers and a new dedicated response team, there is no question that hospitals are on edge. The fervently reported missteps in Dallas, where two health care workers contracted the disease while caring for a patient with Ebola virus disease (EVD), have clearly highlighted kinks in this country’s fragmented health care system. Further, some experts are questioning whether the country is really prepared to deal with an epidemic of infectious disease, let alone a handful of cases. However, it is also clear that these unfortunate early experiences with the first EVD cases to be diagnosed in this country have gotten the attention of everyone who works on the front lines in health care — especially ED leaders and the many layers of diverse personnel that keep patients moving through the system. (Also see: "State, local authorities in the driver’s seat for much of the Ebola response," p. 136.)
The CDC’s new updated guidance for health care workers regarding personal protective equipment (PPE) emphasizes three core principles:
While the appropriate use of PPE is critically important, it is only one aspect of preventing the spread of EVD, according to Arjun Srinivasan, MD, the associate director of health care-associated infection prevention programs at the CDC.
"We have all recognized this fact. It is the [aspect] that tends to get attention because it is something that is visible that people can see," said Srinivasan, when speaking about the new guidance during a webinar sponsored by the New England Journal of Medicine on October 22. "But there are other aspects of infection control — including aggressive screening and evaluation, and then appropriate disinfection — that are also critically important to preventing the spread of Ebola."
Srinivasan emphasized that the CDC’s recommended infection-control strategies for preventing the spread of Ebola are based on the "fundamental issue" that Ebola is transmitted through contact with infectious substances from patients. However, he also acknowledged that the earlier guidance needed to be amended based on the initial early experiences that providers have had in caring for patients with Ebola in the United States.
"It is important to note the previous guidance that the CDC had issued for the care of patients with Ebola in the U.S. was based exclusively on experience — albeit extensive experience — from groups like Medicins Sans Frontieres, Doctors Without Borders, and with CDC experience in dealing with Ebola, and all of that experience had come from Africa," said Srinivasan. "We had not cared for a patient with Ebola in the U.S. As has been pointed out, we now do have some degree of clinical experience managing patients with Ebola in the United States, and we thought there was a need to update the guidance with that clinical experience."
One notable change in the new guidance deals with the type of respiratory protection that the CDC is recommending. "The new guidance recommends that health care workers use either an N-95 [respirator] mask or a powered air purifying respirator (PAPR) when they are providing care to a patient with Ebola," explains Srinivasan. "This recommendation is not because we think the route of Ebola transmission has changed. Ebola is not spread through an airborne route. However, we understand from some of the experts we have been consulting in the U.S. that there are times when the level of care and the need to perform an aerosol-generating procedure in a patient with Ebola might change unexpectedly, and there may be some need to do something that could generate an aerosol."
The thinking behind this more stringent standard is that health care workers shouldn’t have to leave the room of an Ebola patient they are caring for to put on the proper equipment to perform a needed procedure, noted Srinivasan. "We need them to be prepared for the potential for aerosol generation at all times, and that is why we have gone this route. It is an issue of preparation."
Srinivasan added that the specialized bio-containment unit at the University of Nebraska has been utilizing N-95 respirators, and the specialized unit at Emory University has been using PAPRs. "There is successful experience with providing safe care using either one of these types of protection," he said.
Another change in the new guidelines is that during the removal of PPE, the CDC is now recommending steps to provide for the disinfection of any visibly contaminated PPE or gloves. This is to further increase the margin of safety, said Srinivasan.
The safe utilization of PPE is so important that the CDC is emphasizing that health care workers need to be trained carefully on the proper procedures before they take care of any patients with Ebola, and they need to practice those procedures until they are confident in them, stressed Srinivasan.
"Training on the use of PPE is not something that we have focused on previously in U.S. hospitals," emphasized Srinivasan, noting that even he hasn’t received this kind of formal training even though he is an infectious disease specialist. "We need to do more to train personnel on how to directly use PPE, and these guidelines highlight that fact."
While some regions have quickly moved toward a strategy of designating specific centers that are best equipped to care for patients with Ebola, Srinivasan stated that all hospitals have to be prepared to evaluate a patient with potential Ebola and to provide immediate care. "We don’t know where a patient with Ebola might present for care or what hospital he might present to in the U.S.," he observed. "But we also believe that it may be preferable to have a smaller number of hospitals that are providing the full course of treatment for Ebola — hospitals that are well-equipped and well-prepared to provide the full and very complex course of care for a patient with Ebola."
There are still many challenges and unanswered questions, acknowledged Srinivasan. "One of the big ones is how we manage and handle the evaluation of suspect cases in the ED setting and, even more challenging perhaps, in the outpatient setting," he said. (See CDC algorithm for managing patients with suspected Ebola in the emergency setting, p. 137.)
However, Srinivasan added that in more than 400 instances where the CDC has been called upon to work through an evaluation of a suspected case of EVD, the disease has been ruled out in the vast majority of cases, with testing required in fewer than 10% of these patients. Further, in the cases that required a test, only one case — the index case involving a man from Liberia, Thomas Eric Duncan — turned up positive, he noted.
Duncan later died from the disease at Texas Health Presbyterian Hospital in Dallas, TX. Two of the nurses who cared for Duncan contracted EVD, but have since recovered from the disease. Also, an American physician who spent time in West Africa caring for Ebola patients before returning to the United States has since been diagnosed with EVD and is undergoing treatment at Bellevue Hospital in New York City.
"I think it is important to emphasize that while we need to make sure that there are aggressive screening programs in place, we need to balance our recommendations for PPE during screening with the needs of all of you who are providing frontline care to be able to provide that care effectively," said Srinivasan. "That is something we are working on right now. We are working in partnership with a number of organizations."
Amid sharp criticism by some nursing unions that hospitals and public health officials aren’t doing enough to protect frontline personnel from the risks posed by EVD, three of the nation’s largest nursing organizations have pledged to work together to identify problems and improve safety for both caregivers and patients. The Emergency Nurses Association (ENA), the American Association of Critical Care Nurses, and the American Organization of Nurse Executives have committed to collaborate in identifying resources and system gaps that have the potential to harm patients or caregivers, explains Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN, president of the ENA.
"We are actively seeking out information about where we could do better, and we are going to work together as quickly as possible to put solutions in place that will prevent the spread of disease," says Brecher. "We are going to commit to our patients and their families that they will receive excellent care regardless of where they are."
Brecher notes that the ENA website already has a page devoted to EVD. "It is a one-stop shop for resources and information, the current recommendations, and some translation of the CDC information into ED-speak," she says. "We have heard from some of our members that they want a quick and easy resource, so that would be the first place to look. At the same time, we need them to partner with their nursing leadership, their ICU colleagues, and their infection control and infectious disease partners in their hospital and come up with a plan." (See Editor’s note below for CDC and ENA resource information.)
Speaking about the missteps in the handling of the first Ebola case in Dallas, TX, Brecher says that there was no single person to blame. "The system failed, and what we need to do is learn from that, see where our own systems in our own hospitals need to be improved, and improve them," she stresses.
Further, Brecher notes that while all clinicians have a professional responsibility to keep themselves informed about new threats or risks, hospitals have a responsibility to provide the appropriate education and training. "We have an opportunity to provide real-time, just-in-time, hands-on training to every nurse who is going to be caring for a patient who could or does have Ebola, and that is something that we probably haven’t done before because we weren’t faced with something like this," she explains. "This is one of those things that is constantly going to be changing. The more information we get, the more the recommendations are going to change, and the more information we are going to have to safely treat these patients. It is ever-evolving and it is going to continue to evolve because we don’t really have an evidence base for this."
Editor’s note: Visit the CDC’s website on Ebola virus disease to access a full range of resources for health care providers: http://www.cdc.gov/vhf/ebola/. Also, access the ENA webpage to find more resources specifically geared to emergency nurses: http://www.ena.org/about/media/ebola/Pages/default.aspx.