Ebola: Education trumps panic

Resources and information on effective Ebola protocols

Editor’s Note: With a few exceptions, cooler heads prevailed during the height of the Ebola scare. Rather than press the panic button, the Centers for Disease Control and Prevention, infection preventionists and other professional societies disseminated information on how to manage and control the virus. The Journal of Healthcare Contracting offers a few resources to which readers can refer for factual information.

Centers for Disease Control and Prevention

The CDC Ebola website – http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html – contains the latest outbreak information as well as guidance on how to deal with Ebola patients, how to minimize the spread of the virus, and more. Among the many resources CDC offers is the following on “Recommended Personal Protective Equipment”:

Powered air-purifying respirator (PAPR) or N95 Respirator. If a NIOSH-certified PAPR and a NIOSH-certified fit-tested disposable N95 respirator is used in facility protocols, ensure compliance with all elements of the OSHA Respiratory Protection Standard, 29 CFR 1910.134, including fit testing, medical evaluation, and training of the healthcare worker.

  • A PAPR with a full face shield, helmet, or headpiece. Any reusable helmet or headpiece must be covered with a single-use (disposable) hood that extends to the shoulders and fully covers the neck and is compatible with the selected PAPR. The facility should follow manufacturer’s instructions for decontamination of all reusable components and, based upon those instructions, develop facility protocols that include the designation of responsible personnel who assure that the equipment is appropriately reprocessed and that batteries are fully charged before reuse.
  • A PAPR with a self-contained filter and blower unit integrated inside the helmet is preferred.
  • A PAPR with external belt-mounted blower unit requires adjustment of the sequence for donning and doffing.
  • N95 Respirator: Single-use (disposable) N95 respirator in combination with single-use (disposable) surgical hood extending to shoulders and single-use (disposable) full face shield. If N95 respirators are used instead of PAPRs, careful observation is required to ensure healthcare workers are not inadvertently touching their faces under the face shield during patient care.

Single-use (disposable) fluid-resistant or impermeable gown that extends to at least mid-calf or coverall without integrated hood. Coveralls with or without integrated socks are acceptable. Consideration should be given to selecting gowns or coveralls with thumb hooks to secure sleeves over inner glove. If gowns or coveralls with thumb hooks are not available, personnel may consider taping the sleeve of the gown or coverall over the inner glove to prevent potential skin exposure from separation between sleeve and inner glove during activity. However, if taping is used, care must be taken to remove tape gently. Experience in some facilities suggests that taping may increase risk by making the doffing process more difficult and cumbersome.

Single-use (disposable) nitrile examination gloves with extended cuffs. Two pairs of gloves should be worn. At a minimum, outer gloves should have extended cuffs.

Single-use (disposable), fluid-resistant or impermeable boot covers that extend to at least mid-calf or single-use (disposable) shoe covers. Boot and shoe covers should allow for ease of movement and not present a slip hazard to the worker. Single-use (disposable) fluid-resistant or impermeable shoe covers are acceptable only if they will be used in combination with a coverall with integrated socks.

Single-use (disposable), fluid-resistant or impermeable apron that covers the torso to the level of the mid-calf should be used if Ebola patients have vomiting or diarrhea. An apron provides additional protection against exposure of the front of the body to body fluids or excrement. If a PAPR will be worn, consider selecting an apron that ties behind the neck to facilitate easier removal during the doffing procedure.


On Oct. 14, the Association of periOperative Nurses issued guidelines for perioperative personnel. AORN recommends that airborne precautions be taken when caring for an Ebola patient in the surgical setting in addition to standard, contact, and droplet precautions. (The “AORN Recommended Practices for Prevention of Transmissible Infections in the Perioperative Practice Setting” are said to provide detailed guidance to perioperative RNs for implementing standard precautions and transmission-based precautions, i.e., contact, droplet, airborne.)

Environmental cleaning team members should follow CDC recommendations when cleaning the OR after a patient with Ebola, according to Amber Wood, MSN, RN, CNOR, CIC, AORN. The CDC advises higher levels of precaution toward potentially contaminated surfaces because of Ebola’s apparent low infectious dose and disease severity.

Contaminated instruments should be placed in puncture- and leak-proof containers and transported to the decontamination area as soon as possible after completion of the procedure. Sterile processing team members should follow standard precautions and wear personal protective equipment (PPE) including:

  • Fluid-resistant gown with sleeves
  • Gloves (i.e., general purpose utility gloves with a cuff that extends beyond the cuff of the gown)
  • A mask and eye protection or a full face shield
  • Shoe covers or boots designed for use as PPE

Wood recommends a review of AORN’s “Recommended Practices for Cleaning and Care of Surgical Instruments and Powered Equipment” for detailed guidance for the safe handling and decontamination of soiled surgical instruments.

Read the AORN recommendations at http://www.aorn.org/about_aorn/media_resources/press_releases.aspx

Processing biohazardous medical waste

On Oct. 23, five societies issued a joint statement offering guidance on handling biohazardous medical waste, including waste contaminated with the Ebola virus. Specifically, the statement addresses the use of sterilizers for processing biohazardous waste in the healthcare facility. The five societies are: International Association of Healthcare Central Service Materiel Management (IAHCSMM), Association for the Advancement of Medical Instrumentation (AAMI), AORN, Association for Professionals in Infection Control and Epidemiology (APIC) and Association of Surgical Technologists (AST).

The five societies recommend that:

  • Healthcare organizations should not circumvent established protocols for handling biohazardous medical waste.
  • Biohazardous medical waste should not be brought into clean areas where processing reusable medical devices is performed.
  • Biohazardous medical waste should not be inactivated in a sterilizer that is used for processing reusable medical devices.
  • Sterilizers used to inactivate biohazardous medical waste should be designed and validated for that particular purpose.
  • Organizations should work with infection preventionists and keep abreast of evolving professional and regulatory guidelines for handling biohazardous medical waste.

Read the statement at https://www.iahcsmm.org/resources/ebola-resources.html

Texas Health Resources

Texas Health Presbyterian Hospital Dallas, where the country’s first Ebola patient was treated, presented a webinar in late October on “Learnings and Lessons.” Among the actions taken by the hospital were:

  • Upgraded medical record software to clearly highlight travel risks. Medical record software at Texas Health Dallas now includes a robust screening tool specifically asking where a patient has recently travelled and highlights that information in a large, red box at the top of the medical record.
  • New triage procedures initiated to quickly identify at-risk patients. Generally, within five minutes of entry, patients will be asked about travel history and the patient’s chief complaint.
  • A triage procedure to move high-risk patients immediately from Emergency Department. High-risk patients will be taken to an isolation unit by a nurse in full protective gear – gloves, gown, shoe covers, face mask and face shield – or immediately taken to a hospital with an isolation unit.
  • A final step for cleared patients. Thirty minutes prior to discharge, vital signs will be rechecked. If anything is abnormal, the physician will be notified.
  • Increased emphasis on face-to-face communication. Nurses and doctors will increase face-to-face exchange of information so that they do not solely rely on electronic medical records.

Other resources

  • North Shore-LIJ Health System in Great Neck, N.Y., released an Ebola preparedness guide. The facility is one of eight New York hospitals and health systems designated as Ebola treatment centers. (http://www.nslijalerts.com/homepage/ebola-virus/for-healthcare-organizations/north-shore-lij-ebola-virus-preparedness-manual/?utm_source=pr&utm_medium=bitly&utm_campaign=ebola-pr-bitly)
  •  The University of Nebraska Medical Center’s Center for Continuing Education created a free online course called “The Nebraska Ebola Method,” to enable the learner to better understand the pathogenesis and epidemiology of Ebola, safe treatment practices, public health management, and subsequent systems change that result from an Ebola outbreak. Topics include: choosing required personal protection using national guidelines; safely putting on and removing personal protection equipment to prevent contact with infectious materials; and incorporating personal protection strategies based on the successful experience treating patients with Ebola by the Nebraska Biocontainment Unit. Also available are free, printable handouts on “Donning and Doffing PPE.” Commissioned by the CDC in 2005, the Nebraska Biocontainment Patient Care Unit was designed to provide the first line of treatment for people affected by bioterrorism or extremely infectious naturally occurring diseases. For more information, go to http://app1.unmc.edu/nursing/heroes/
  • During the annual meeting of the American College of Emergency Physicians, the CDC published Ebola guidelines for emergency departments. The guidelines include advice for: 1) assessing patients, including those for whom travel histories are unavailable (for example, when patients are unconscious); 2) donning and doffing personal protective equipment; 3) managing and isolating patients who may have Ebola; 4) informing hospital personnel and other authorities about possible infection; and 5) providing direct observation of healthcare workers during the donning and doffing processes for PPE. http://www.cdc.gov/vhf/ebola/pdf/ed-algorithm-management-patients-possible-ebola.pdf
  • The American Medical Association created an online Ebola Resource Center (http://www.ama-assn.org/ama/pub/physician-resources/public-health/ebola-resource-center.page), including Ebola basics, how to prevent transmission, monitoring people exposed to the virus, etc.
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