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Patient Care

Keeping Calm in the Time of Ebola

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Ed’s Note: Information in this article is current as of October 16, 2014.

Fear and hysteria have been spreading very fast in the U.S. This seems to happen with every new disease outbreak. It started with HIV, then SARS, then H1N1.

In the early 1980s, vehicles were being lined with plastic and care providers were covered from head to toe. Compare that to our calmer, more evidence-based approach with HIV today. When any new disease threat emerges, science should prevail over fear and emotion. Seek credible information from the World Health Organization (WHO), as well as the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH). Evidence should drive how we practice and what we purchase.

We are, and have been for many years, a global society. Educators have stressed the importance of getting travel histories on patients since the time of SARS. This should be a routine part of patient assessment in today’s world, and assessment forms need to reflect this.

Now Ebola cases have come to this country. That is not surprising. There are more diseases that are coming due to climate change. Mosquito-borne diseases such as dengue fever, West Nile virus and Lyme disease are examples. They are moving north as the temperature changes.1,2

Personal Protection

The manner in which a disease is transmitted determines the personal protective equipment needed. Ebola is a known virus that has been around for many years. It is transmitted by direct contact with blood or body fluids of a symptomatic infected person. As with all communicable diseases, one cannot transmit a disease until they have signs and symptoms of the disease.2,3

In some cases it has not been made clear that there needs to be blood-to-blood contact, contact with contaminated surfaces or direct droplet contact to be exposed. This disease is prevented through the use of routine standard precautions along with droplet and contact precautions (see sidebar). There is currently no science to support that Ebola is an airborne-transmitted disease. No special cleaning solutions are needed. For contaminated laundry, there are no special solutions or processes and no need to burn or destroy.3,4

Focus needs to be placed on proper use and removal of PPE after care of an Ebola patient. This should be part of training and compliance monitoring. Neither of these have received a major focus in education and training (see Figures 1 & 2). Expensive equipment will not change or reduce possible exposure if technique is improper. Breaches in proper technique have been the cause of a healthcare worker contracting Ebola in Spain, as well as the two in the U.S. How many healthcare workers wash their hands after glove removal? Not doing so is an infection-control breach; gloves are known to have holes and viral penetration.5 Hand-washing after glove removal is important and a good compliance measure to monitor.

Keeping perspective, yes, two healthcare workers to date have contracted Ebola, but how many have cared for the Ebola patients in this country thus far? Remember that being a healthcare provider places one at risk for exposure to many diseases every day, and this risk comes with the job. We minimize this risk with appropriate infection-control practices. The first healthcare worker to be infected is doing well. The second is under care, and contacts are being followed. All contacts of the original patient were on quarantine. This second case is one who was in that group. This worker reported many lapses beyond the use and removal of PPE.6 She traveled out of state, which should not have been permitted.

How many hospital workers and EMS personnel have had adequate training on infection-control practices? This is an area that often gets the short stick. National Nurses United reported the results of a study involving 1,400 nurses who said they didn’t feel they had proper training to prepare them.7

In contrast, with all the elaborate PPE we have available to use, look at the 22-year-old student nurse in Africa who cared for four family members with Ebola. She did not have the protective equipment we have, but she cared for them using improvised PPE. She used trash bags over her socks and boots, gloves and a surgical mask; she wrapped her hair in a pair of stockings with a plastic bag over that, and wore a raincoat. The result of her efforts: Three of her four family members survived, and she has not contracted the disease. Her method is now being taught to others who want to care for family members at home.8

On October 14 Tom Frieden, MD, director of the CDC, announced that in the future a response team will be sent to care for Ebola patients. Also, more Web-based training is being conducted by the staff from Emory University Hospital that cared for the first Ebola patient transferred to the U.S. from West Africa. The response team will work with the staff of the medical facility to assist with training and compliance with infection-control techniques.

Consideration is being given to revert to the original plan of having the patient transferred to one of the 4 centers set up for such patients. Perhaps Ebola will highlight a stronger focus on proper use of PPE with a practice element.

Transmission-based precautions

Transmission-based precautions are used in addition to standard precautions when use of standard precautions alone does not fully prevent communicable disease transmission. There are three types of transmission-based precautions: contact, droplet and airborne. The type used depends on the mode of transmission of a specific disease. Some diseases require more than one type of transmission-based precaution (e.g., SARS, which requires airborne and contact precautions as well as eye protection with all client contact).

Standard Precautions

  • Good hand-washing;
  • Use gloves when in contact with open patient wounds, mucous membranes, non-intact skin or contaminated surfaces.

Contact Precautions

Use the following measures in addition to standard precautions when in contact with individuals known or suspected of having diseases spread by direct or indirect contact (examples include norovirus, rotavirus, draining abscesses, head lice):

  • Wear gloves and gown when in contact with the individual, surfaces or objects within his/her environment;
  • All reusable items taken into an exam room or home should be cleaned and disinfected before removal. Discard all disposable items at the point of use.

Droplet Precautions

In addition to standard precautions, wear a surgical mask when within 3 feet (6 feet for smallpox) of persons known or suspected of having diseases spread by droplets (examples include influenza, pertussis, meningococcal disease).

References

1. Natural Resources Defense Council. Infectious Diseases: Dengue Fever, West Nile Virus, and Lyme Disease, www.nrdc.org/health/climate/disease.asp.

2. Lippman D, ClimateWire. How the Spreading Symptoms of Climate Change Can be Deadly. Scientific American, www.scientificamerican.com/article/how-the-spreading-symptoms-of-climate-change-can-be-deadly/.

3. World Health Organization. Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola, http://apps.who.int/iris/bitstream/10665/130596/1/WHO_HIS_SDS_2014.4_eng.pdf?ua=1&ua=1.

4. CDC. Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola Virus Disease in the United States, www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html.

5. Neal JG, Jackson EM, Suber F, Edlich RF. Latex glove penetration by pathogens: a review of the literature. J Long Term Eff Med Implants, 1998; 8(3–4): 233–40.

6. Schmall E, Merchant N. 2nd Texas Health Worker Tests Positive for Ebola. ABC News, http://abcnews.go.com/Health/wireStory/texas-dept-2nd-person-tests-positive-ebola-26206324.

7. Verel D. Majority of nurses, front-line health workers ‘don’t feel prepared’ for Ebola. MedCity News, http://medcitynews.com/2014/10/majority-nurses-front-line-health-workers-dont-feel-prepared-ebola/.

8. Cohen E. Woman saves three relatives from Ebola. CNN, http://edition.cnn.com/2014/09/25/health/ebola-fatu-family/.

Katherine West, RN, BSN, MSEd, is an infection-control consultant for Infection Control/Emerging Concepts in Manassas, VA, and a member of the editorial advisory board for EMS World.

 

 

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