The Ebola Epidemic 2014

NIH Clinical Center Experience

Robin T. Odom, MS, MLS

Infection Control Consultant

NIH Clinical Center

Hospital Epidemiology Service

“There’s No Other Hospital Like It”

The NIH Clinical Center

Special Clinical Studies Unit (SCSU)

• 7-bed containment unit completed in 2009 as a high-containment facility for researchers with occupational exposures

• Patients are enrolled in clinical research protocol

• Infection control and medical care procedures were generated for the most likely high-concern pathogens

• Procedures were practiced using drills every six months

NIH Clinical Center Special Clinical Studies Unit

SCSU Containment Barrier

Schematic of NIH Clinical Center Special Clinical Studies Unit

Autoclave Areas

Clean Utility

Locker Room

Don

Doff Meds

Soiled Utility

Equip-ment

Patient Room Isolation

Room

Ante-room

Patient Room

Patient Room

Corridor

Nurses Station Staff

Support

Vesti-bule

Vestibule

Storage

Exit for Sterile Waste

Special Clinical Studies Unit

First Cases to Be Brought to the US: Ebola Infections Documented in Two

Humanitarian Aid Workers

Kent Brantly, M.D. Nancy Writebol

Intensive preparations and training

• Revision of all existing infection control procedures

o Anticipating all scenarios (e.g., dialysis, ventilation)

• Preparation of training materials for all involved clinical disciplines (videos, posters)

• Ordering of additional supplies

• Developed cadre of volunteers

• Training of critical care specialists, nurses, infectious diseases physicians

o Simulated procedures in isolation room

o Training in donning and doffing

Courtesy of Kevin Barrett

Four admissions

September

2014

High-risk

exposure

October

2014

Ebola virus

disease

December

2014

High-risk

exposure

March

2015

Ebola virus

disease

Infection control challenges

Assure the provision of compassionate care that is safe for patients, healthcare personnel, and the public.

o Transportation

o Laboratory testing

o Managing the waste stream

o Communication

o Managing risk and the perception of risk

Transportation • Private medical air transport with isolation pod

• Met by ambulance draped in plastic sheeting, crew in full protective gear

• Patient transported to and within Clinical Center in mobile, negative pressure isolation pod

Transportation

Special Respiratory Isolation (SRI)

• Full personal protective equipment (PPE): Contact + droplet + airborne precautions

• Anteroom PPE: Contact + droplet precautions (modified SRI)

SECURE DISPOSABLE SHROUD TO PAPR HELMET USING SNAPS, THEN CONNECT BATTERY PACK TO HELMET TO TEST FUNCTIONALITY. 3 GREEN LIGHTS CONFIRM PAPR IS READY FOR USE

AFTER CHANGING INTO PAPER SCRUBS, PERFORM HAND HYGIENE USING ALCOHOL HAND RUB.

REMOVE SHOE COVERS

DON BELT, AND THEN DON ABOVE ANKLE SHOE COVERS OVER SHOES

SPECIAL RESPIRATORY ISOLATION APPROPRIATE DONNING TECHNIQUE

LEAVE PAPR TURNED ON, AND SECURE BATTERY PACK TO WAIST AT CENTER OF LOWER BACK, USING THE BELT

DON PAPR AND ADJUST TO FIT USING THE WHEEL LOCATED AT THE BACK OF THE HELMET

PREPARE TWO PIECES OF TAPE, EACH APPROXIMATELY 18 INCHES IN LENGTH. CREATE A TABBED END TO EACH PIECE

DON FIRST PAIR OF GLOVES ENSURING GLOVES ARE PULLED UNDER CUFFS OF TYVEK SUIT. SECURE GLOVES TO TYVEK USING TAPE, WITH TABS FACING OUT

DON DISPOSABLE GOWN, AND HAVE BUDDY TIE SECURELY IN THE BACK

DON SECOND PAIR OF GLOVES ENSURING GLOVES ARE PULLED OVER THE CUFFS OF THE DISPOSABLE GOWN

INSPECT PPE FOR ANY TEARS USING THE BUDDY SYSTEM

12 11 10 9 8

PULL TYVEK SUIT UP OVER BATTERY PACK AND PAPR, ENSURING INNER LAYER OF SHROUD IS UNDER TYVEK SUIT. THEN, ZIP TYVEK SUIT CLOSED.

7

1 3 2 4 5 6

DON TYVEK SUIT TO WAIST, AND THEN DON SECOND PAIR OF ABOVE ANKLE SHOE COVERS OVER TYVEK SUIT

USE A DISINFECTANT WIPE TO OPEN PATIENT ROOM DOOR. EXIT TO ANTEROOM. IMMEDIATELY PERFORM HAND HYGIENE ON GLOVES USING ALCOHOL HAND RUB

AFTER PERFORMING HAND HYGIENE ON GLOVES USING ALCOHOL HAND RUB, REMOVE SHOE COVERS

REMOVE SHOE COVERS

PERFORM HAND HYGIENE ON GLOVES USING ALCOHOL HAND RUB

SPECIAL RESPIRATORY ISOLATION APPROPRIATE DOFFING TECHNIQUE

UNZIP TYVEK SUIT TO WASTE AND OPEN TO SHOULDERS

UNSNAP SHROUD FROM HELMET

WIPE BOTH FOREARMS AND WRISTS OF TYVEK SUIT WITH DISINFECTANT

UNTAPE GLOVES FROM TYVEK SUIT REMOVE TYVEK SUIT BY HOLDING THE OUTSIDE AND PEELING TO WASTE, KEEPING GLOVES ON. THEN REMOVE BY GENTLY STEPPING IT TO THE FLOOR

PERFORM HAND HYGIENE ON GLOVES, THEN REMOVE EACH SHOE COVER AS YOU STEP OVER THE THRESHOLD INTO THE CLEAN AREA

REMOVE GLOVES AND DISCARD INTO ANTEROOM AUTOCLAVE BAG. PERFORM HAND HYGIENE.

12 11 10 9 8

REMOVE PAPR HOOD BY HOLDING THE OUTSIDE AND PULLING AWAY FROM YOUR HEAD, AND THEN PERFORM HAND HYGIENE ON GLOVES

7

1 3 2 4 5 6

REMOVE GOWN AND OUTER GLOVES AS ONE UNIT, ENSURING THAT THE INNER PAIR OF GLOVES STAYS ON

Staffing the unit • Core nursing staff of the SCSU + volunteers from

nursing, infectious diseases, critical care o No trainees – no students, residents, or fellows

• Trained observers (WatSan) to ensure safe donning and doffing

• Dedicated staff for waste autoclaving and removal

Laboratory specimens • Focus on safety

• Ebola virus testing Ft. Detrick o Blood cultures, malaria rapid testing

• Chemistry, hematology testing BSL-3 clinical laboratory

• Point-of-care testing

Waste management • Human waste

• Medical waste

• Uncontaminated waste

Dissolvable clear plastic liner inside

orange autoclave bag

Autoclaved

30 ml H20

Boxed

Incinerated

• Landfills refused to take ashes of autoclaved, incinerated waste from SCSU

• Waste was eventually accepted by Ft. Detrick landfill

Uncontaminated waste • Most housekeepers would not enter the

unit

• Those who did enter the unit were ostracized by others

• Multiple meetings with entire housekeeping department

• Training and volunteers

Disinfection of equipment and environment

Bleach or hydrogen peroxide wipes to clean surfaces

Hydrogen peroxide vapor to disinfect patient room and any reusable equipment

Wheels rolled over mat saturated with

disinfectant

Communication • Communication among the team

o Daily multidisciplinary meetings

o Weekly calls with key clinicians

• Communication with staff

o Emails

o Town hall meetings

o White paper

• Communication with public health officials

• Communication with the media and the public

After each patient, procedures were reassessed and refined

• For example: o Cut the ties off the respirator shroud

o Disinfect forearms of coverall before removal

o Avoid having nurses transport waste and operate autoclave

o Gloves

• Some changes were triggered by new CDC recommendations: o Shoecovers

o Addition of fluid impermeable gown

* Guidance issued October 27, 2014; available at http://www.cdc.gov/media/releases/2014/fs1027-monitoring-symptoms-controlling-movement.html

Staff monitoring • Designated Occupational Medicine Service

(OMS)

• Monitoring of healthcare staff* o Everyone that entered the unit had to sign in, but OMS only

monitored/followed any staff that accessed the warm or

hot zones – twice daily temp/symptom monitoring for 21

days

o Healthcare workers that were being monitored were

required to notify OMS if they left the DC metro area – OMS

reported to public health

o OMS sent spreadsheet to public health department

Occupational and patient safety converge

Patient

safety

Occupational

safety

Minimize

procedures X X

Deep sedation X X

Abundant staffing X X

Adverse impacts on personnel

• Staff member’s child prohibited from

attending daycare

• Staff member’s spouse was told to

telecommute

• Staff member sent back from Caribbean (on

spring break trip w/ family)

Screening Clinical Center Patients

• Travel history is imperative • Has the patient been or had contact with someone who has been

to Sierra Leone, Liberia, and/or Guinea in the last 21 days

Conclusions • Care of Ebola-infected or -exposed patients

was labor-intensive and required many staff members from multiple disciplines

• Managing patients with the most conservative approach to infection control minimized concerns

• Managing perception of risk was the most stressful aspect

Acknowledgments • The >120 NIH personnel who contributed to

the care of the patients

• Many others at CDC, USAMRIID, Ft. Detrick

• The patients who entrusted us with their care

Questions? Robin T. Odom, MS, MLS

Infection Control Consultant

National Institutes of Health

Clinical Center, Hospital Epidemiology Service

Bethesda, MD

Office: 301-594-9433

Email: odomr@cc.nih.gov