CDC demonstrates new Ebola protocols

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.”