CDC demon­strates new Ebola pro­to­cols

Modern Healthcare - - BEST PRACTICES - By Mau­reen McKinney

Don’t rush. Take your time. Be care­ful and de­lib­er­ate.

Fed­eral of­fi­cials re­peated that guid­ance again and again last week as they re­viewed their new, more-strin­gent Ebola-pro­tec­tion pro­to­cols be­fore an au­di­ence of thou­sands of health­care work­ers in New York City. The three­hour ed­u­ca­tion ses­sion, or­ga­nized by the Greater New York Hos­pi­tal As­so­ci­a­tion and 1199 SEIU, a health­care work­ers’ union, in­cluded a step-by-step demon­stra­tion of how to don and re­move the many lay­ers of per­sonal pro­tec­tive equip­ment (PPE) now rec­om­mended for Ebola care. It was sober­ing to watch.

“When we use equip­ment we’re not re­ally fa­mil­iar with, it takes time and prac­tice,” said Dr. Ar­jun Srini­vasan, an as­so­ciate di­rec­tor at the Cen­ters for Dis­ease Con­trol and Preven­tion.

Bryan Chris­tensen, a CDC epi­demi­ol­o­gist, and Bar­bara Smith, a nurse at Mount Si­nai Health Sys­tem, demon­strated the proper way to per­form the in­tri­cate PPE process. Chris­tensen served as the trained ob­server all hos­pi­tals should have over­see­ing each step of the process, while Smith played the part of the treat­ing clin­i­cian and Srini­vasan nar­rated.

Srini­vasan said hos­pi­tals need to des­ig­nate two roomy ar­eas for putting on and re­mov­ing pro­tec­tive gear. “Th­ese ar­eas need to be care­fully thought out and sup­plies need to be read­ily avail­able,” he said. Hos­pi­tals should limit the num­ber of peo­ple who will come in con­tact with Ebola pa­tients, and fo­cus on in­ten­sively train­ing those des­ig­nated work­ers.

Chris­tensen and Smith be­gan by me­thod­i­cally re­view­ing a check­list and tak­ing inventory of PPE. Chris­tensen demon­strated how the ob­server checks to en­sure the health­care worker is wear­ing scrubs and wash­able footwear, and has re­moved any jew­elry, dig­i­tal de­vices, or other wear­able items. Then, Smith cleaned her hands with al­co­hol-based san­i­tizer, al­lowed them to dry, and put on a pair of nitrile rub­ber gloves.

Once her gloves were on, Smith sat on a clean chair to put on shoe cov­ers, pulled up to mid-calf. Next, she put on a gown. “Know what sizes your de­sig- nated folks are ahead of time so you can make sure your sup­ply area is stocked for them,” Srini­vasan said.

Next, Smith put on an N95 res­pi­ra­tor, tak­ing care to po­si­tion the bot­tom strap on her neck and the up­per strap above her ears, and mak­ing sure the mask was sealed. Un­der the new pro­to­cols, ei­ther an N95 res­pi­ra­tor or a pow­ered air pu­ri­fy­ing res­pi­ra­tor is ac­cept­able. That level of res­pi­ra­tory pro­tec­tion is a ma­jor change in the guide­lines, Srini­vasan said.

“We’re not rec­om­mend­ing this be­cause we think Ebola is air­borne,” he said. The CDC is rec­om­mend­ing it be­cause staff may need to per­form aerosol-gen­er­at­ing pro­ce­dures such as in­tu­ba­tion or suc­tion­ing of air­ways.

Next, with Chris­tensen’s as­sis­tance, Smith donned a sur­gi­cal hood that cov­ered her face and neck. She put on a sec­ond pair of gloves, pulling them over the sleeves of her gown. Then she put on a face shield. After a fi­nal in­spec­tion by Chris­tensen, Smith dis­in­fected her gloved hands with al­co­hol-based san­i­tizer, a new rec­om­mended step.

While Smith pre­tended to treat a pa­tient, Srini­vasan nar­rated ad­di­tional guid­ance to the au­di­ence. “She will not leave the pa­tient’s room and be­gin re­moval of PPE un­til the ob­server is there and ready to help,” he said.

After treat­ment, Smith en­tered the des­ig­nated re­moval area and be­gan by san­i­tiz­ing her gloved hands while Smith ob­served from a dis­tance. She sat on a chair—one used only in the re­moval area—slowly re­moved her booties and placed them in a red-bag trash can. She cleaned her hands with san­i­tizer once again and re­moved her outer gloves.

Next, Smith in­spected and dis­in­fected her in­ner gloves. She re­moved her face shield us­ing the straps to avoid touch­ing the front, then did another round of hand hy­giene with al­co­hol-based san­i­tizer. Smith tilted her head for­ward and re­moved her sur­gi­cal hood and did another round of hand hy­giene.

Then she slowly re­moved her gown, step­ping on the inside of it and rolling it to avoid touch­ing the outer sur­face. Again, she cleaned her hands with san­i­tizer. She re­moved her in­ner gloves, san­i­tized her hands once again, al­lowed them to dry and donned a new pair of gloves. Then she re­moved her res­pi­ra­tor by tilt­ing her head for­ward and us­ing the straps. She san­i­tized her hands again.

Next, Smith sat on a clean chair, wiped her shoes with dis­in­fec­tant wipes, and dis­in­fected her hands. Fi­nally, she re­moved her gloves, did a fi­nal round of hand hy­giene and stood still while Chris­tensen in­spected her scrubs for visual con­tam­i­na­tion.

“Prac­tice, prac­tice, prac­tice,” Smith said as the au­di­ence applauded en­thu­si­as­ti­cally. “Have some­one vet that you re­ally know how to do all of the steps.”

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