Preparedness is the key for
an organization and individual staff members to deal effectively with threats,
and that's especially important with threats from infectious diseases that could spread
and cause harm if not well managed and contained.
We've seen this from the coronavirus or SARS.
We've seen this from the Middle Eastern Respiratory Syndrome or MERS and we've seen
this with novel forms of flu, such H1N1.
And in all of those cases, preparedness is the key
to containing and mitigating these threats. Because
with containment and preparedness, we can reduce the harm to our patients,
to our staff and to our organizations. We are now facing
another threat. A threat from Ebola. And just like the past,
preparedness is the key. There's a number of modules and we hope
you find them beneficial and useful on your journey to make sure
that you can provide safe care for your patients. In the first module, we will
outline considerations for preparedness planning for
acute care facilities who provide emergency care services.
The second module will discuss how to screen and identify
patients who may have risk factors for or symptoms of Ebola virus disease.
In the third module, we will outline how to safely
isolate patients who are under investigation for Ebola
and in the fourth and final module, how to evaluate and briefly
manage these patients. On behalf of my colleagues and
collaborators at the Centers for Disease Control and Prevention,
Johns Hopkins Medicine, The Armstrong Institute,
The Association for Professionals in Infection Control and Epidemiology,
The Society for Healthcare Epidemiology of America,
The Emergency Nurses Association, The American College of Emergency
Physicians, Miami University and Salesforce,
I would like to thank you for your time and enjoy the modules.
This preparedness module
focuses on ED leadership actions and planning to occur
prior to any patient arrival. This module will be built
around dialogue occurring in a planning meeting. An effective
and safe response to a suspected or confirmed Ebola patient requires significant
and collaborative preparedness planning. This module focuses on
planning and actions by an emergency department and other organizational leaders
that needs to occur before any patient arrival. This series of modules
will cover issues of preparedness planning, such as prehospital transport
and EMS, patient arrival, the triage process,
staffing the patient care team, patient transport
from points of entry to the designated treatment area, patient placement,
personal protective equipment procedures,
laboratory safety, environmental infection control,
equipment reprocessing, management of waste and
defining communication protocols within your organization.
Addressing these issues and your institution's preparedness planning will
require collaborative partnerships from leaders across your organization.
CDC provides detailed guidance on preparedness for each of these topics
as well as management of the deceased and special populations.
After viewing these modules and seeking additional information on the CDC
website, and in the CDC guidance documents, it will be important
to convene a multidisciplinary team, including physicians,
nurses, pharmacy,
health care administration, facilities,
security, communications,
laboratory, health, safety and environment,
and other experts to tailor this guidance
to fit your organization's particular circumstances and meet the needs of your staff
and patients. "Let's get started. We're here to
"discuss the hospital's response to Ebola, how we,
"our staff, and our hospital can be prepared. We have several items
"to cover today. Let me pass out the agenda."
"First we'll discuss how we can safely transport a patient under
"investigation for Ebola." The arrival of a patient
who reports risk factors or symptoms that can might be consistent with Ebola
can present numerous potential risks. To minimize these risks and help staff
feel prepared and remain calm, each institution should develop plans
for key issues around patient arrival. First, prepare a plan
for how a patient under investigation for Ebola will be transported from the point of entry
to the designated Ebola treatment area.
Second, develop a plan for managing medical equipment as well as hospital equipment
and facilities. For example, if you use a wheelchair to
transport a patient with suspected Ebola within your facility, how will that chair
be decontaminated?
Third, ensure staff understand how to protect others from contaminated fluids such as
vomit or loose stools in public areas and that all needed supplies are readily
accessible. Fourth, decide how the patient care team
will be staffed, keeping in mind that the care providers should be fully
trained on the procedures and protocols, including the proper and safe use of personal
protective equipment. "Next on our agenda is from the emergency department."
"We'll have a discussion on patient flow and patient
"placement." Because of ongoing monitoring of
returning travelers by public health authorities, the risk of these patients arriving in
emergency departments without warning is low. However, Ebola screening
protocols need to be integrated within your ED triage processes.
Consider reviewing your ED work flow and triage process to clarify roles
and responsibilities that make sense to staff and fit current practices.
For example, determine who will be asking which
screening questions and if registrars, greeters, or security personnel are
expected to ask travel screening and exposure questions.
You will also need to collaboratively decide how patient flow and placement within
your screening and triage area will work and how staff will hand patients off
to ensure no critical information is lost and in a way that minimizes
risk of exposure to staff and other patients.
"Next on our agenda is the discussion about the importance of designating an isolation room
"within the ED, making sure the room is properly serviced and maintained
"so our colleagues here from facilities and the emergency department can start that discussion."
The management of a patient with suspected Ebola within
the physical space of your facility is critical to minimizing risk of infection.
Key decisions about patient flow and room management
should be decided in advance of patient arrival and in collaboration
with nursing, supply management, facilities management, environmental services and
infection prevention. Patient placement is important and you will need
to decide which room will be your isolation room. To decide, you should
consider your ED layout, as well as flow of patients, staff, supplies
and waste. You should also clarify a plan
for putting the chosen room into service. For example, decide what
equipment needs to be removed and what equipment needs to be placed in the room before
the patient with suspected Ebola enters. Define your plan to
meet room logistic requirements as well. This includes the availability
of waste management resources, such as large biohazard bags,
cleaning products and removal of waste. Also, identify
the bathroom considerations for the isolation room. If the isolation room
does not have a bathroom, ensure that it does have a covered bedside commode.
"Next, on our agenda, we would like our infection prevention
"colleagues and our communication colleagues to have a discussion about the lines
"of communication and the plans for such." "I'm interested to know exactly
"who and when will be contacting the local public health authorities."
In critical safety situations, effective communication is essential.
To prepare for a patient under investigation for Ebola, you should develop
protocols and consistent expectations for how to communicate critical information.
Specifically, your institution needs to define
internal communication protocols, including an up-to-date contact list
of who needs to be informed when the Ebola preparedness plan is activated
when a patient under investigation for Ebola arrives and how they should be notified.
Additionally, your insitution needs to define external
communication protocols. Specifically, designate who
is responsible for contacting the local public health authorities and what information
they need to provide these officials. Consider how your facility will communicate with
the press and the public. After defining these communication protocols,
ensure staff are familiar with them by providing training and job aids
such as scripts and call lists.
"Next agenda item is laboratory safety."
"Thanks for the opportunity to share with the team. We've been working on safe
"handling and management protocols. The CDC has some very specific guidelines on how to do this."
The issue of laboratory safety is most relevant to Ebola
assessment hospitals, where evaluation of patients under investigation
for Ebola will likely include testing laboratory specimens or transporting
samples to another laboratory facility for testing. Partnerships between
ED leadership, laboratory services and infection prevention
will be necessary to define your institution's protocols and procedures
for Ebola testing as well as other laboratory testing that may be needed during
patient evaluation and care. In addition to clarifying
where and how Ebola testing will be performed, it is necessary to
define how other laboratory tests will be completed for patients
under investigation for Ebola when needed. For example, as
detailed in the management module, alternative diagnoses should be considered
including other infectious diseases such as influenza or malaria.
Each facility should plan for how these tests will be conducted and
how the potentially infectious nature of samples will be communicated to internal
or external laboratory services.
"Next topic on our agenda would be an update from the emergency department and our IP colleagues
"to give us an update on plans for designating the isolation and
"controlling access to those isolation areas." "Sure, we've already
"designated the isolation room and also, I've brought some examples
"of signs we've developed to control access to that area. We have a stop sign
"for the patient room door and also a log that we'll be using to have people
"sign in as they enter and exit the room." While managing the care
of a patient under investigation for Ebola, it is important to be deliberate
and efficient. Develop a plan to minimize risks associated
with staff going into and out of the patient room. For instance,
signage on the door can indicate that no one is to enter the room without obtaining
permission at the desk. A sign in log should be used to identify
all personnel entering the room. A key strategy for minimizing
risk to staff is to limit the number of individuals who enter the room
and develop a plan for clustering care. This mean that tasks should be bundled together
to minimize the number of trips into and out of the room.
Consider the communication tools your facility will use to minimize time in the room such
as an intercom or telephone. These tools may also be used to allow the
patient to communicate with their family and visitors.
Prepare a plan for the possibility of a patient leaving the room when unauthorized to do so
and work in conjunction with your local public health authorities
and security personnel on this planning.
"Next on the agenda item will be managing waste. If we could have facilities
"EVS and the emergency room nursing have a discussion
about our plans for managing waste. "Facilities has made plans with nursing
"and EVS for disinfecting and disposing of medical equipment."
Facilities management, environmental services, nursing,
and infection prevention leaders need to develop plans for cleaning and
decontamination in general areas as well as patient care areas.
This plan should cover how to clean, disinfect or dispose
of all medical equipment. This includes
portable items like thermometers and EKG wires, as well
as devices that require more than surface decontamination.
Both internal and external waste management must be planned. For instance,
determine how your facility will manage contaminated waste within the local
regulations. Consider whether your facility has the option of
autoclaving or incinerating the waste on site and if the facility
has a vendor capable of removing contaminated waste from the institution.
Check with your local public health authorities to confirm the procedures
and any local requirements for dealing with liquid waste.
"Can someone please clarify the difference in PPE for the ED versus the inpatient setting?"
"That's a great question, thank you. The CDC guidance outlines two different levels
"of PPE." Preparations and planning must address methods for ensuring
proper use of personal protective equipment, or PPE. All heath care workers
who have contact with the patient should put on appropriate PPE based on the
patients clinical status. If the patient is exhibiting obvious bleeding,
vomiting, diarrhea or a clinical condition that warrants invasive
or aerosol generating procedures, such as intubation,
suctioning or active resuscitation, PPE designated for the care
of hospitalized patients as outlined in CDC guidance should be used.
If the patient requires active resuscitation, this should be done in a
predesignated area, using equipment dedicated to the patient.
If these signs and symptoms are not present and the patient is clinically stable
and under investigation, health care workers should at minimum wear fluid-resistant
gown, surgical face mask, face shield,
and two pairs of gloves.
All equipment used in the care of these patients should not be used
for the care of other patients until appropriate evaluation and decontamination.
These PPE requirements are detailed on the CDC website
and in training modules on donning, doffing and the trained observer.
Leadership at each institution needs to ensure that adequate supplies
and materials are available and that an ongoing training and competency
program for staff is in place.
"Next on the agenda is training and education. If we could have a discussion about training and
"educating our staff." "Sure, we've developed a training and competency plan
"and this plan includes the use of super users, and in addition we're
"developing a plan for drills and ongoing training competency."
Define your institutions training plan and consider options for reinforcement
of skills and opportunities to practice.
For example, in addition to a single training session to build basic competence with donning,
doffing and observing PPE protocols, it is also
recommended that facilities use ongoing practices and drills.
Each institution should develop a plan for how to reinforce communication protocols,
work flows and other aspects of their Ebola preparedness response.
Consider how you would develop local coaches and leaders for other staff in each area
and how local staff will know chain of command and where to obtain relevant
information. These considerations will help form your training and preparedness plan
so that staff in your facility can safely and calmly
recognize, isolate and evaluate
a patient under investigation for Ebola. Walking through your
hospital's specific work flows, protocols, staffing issues, physical space, etc.
is a path to the safest prepaeredness to care for a patient
under investigation for Ebola. "I appreciate your time, thank you."