The Elephant in the Room for First World Health Care Providers. (That's my title). Posted by Pixie at the PFI Forum this morning around the Hour of the Wolf.
Hospitals in the U.S. Get Ready for Ebola
By CATHERINE SAINT LOUISAUG. 15, 2014
http://www.nytimes.com/2014/08/16/health/hospitals-in-the-us-get-ready-for-ebola.html?_r=0
Hospitals nationwide are hustling to prepare for the first traveler from West Africa who arrives in the emergency room with symptoms of infection with the Ebola virus.
Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention, has said such a case is inevitable in the United States, and the agency this month issued the first extensive guidelines for hospitals on how recognize and treat Ebola patients.
The recommendations touch on everything from the safe handling of lab specimens to effective isolation of suspected Ebola patients. But one piece of advice in particular has roused opposition from worried hospital administrators.
The C.D.C. says that health care workers treating Ebola patients need only wear gloves, a fluid-resistant gown, eye protection and a face mask to prevent becoming infected with the virus. That is a far cry from the head-to-toe “moon suits” doctors, nurses and aides have been seeing on television reports about the outbreak.
Some hospital officials are skeptical of the new advice. “It’s not going to be enough for my health care workers to feel comfortable going into an isolation room,” said Peggy Thompson, the director of infection prevention at Tampa General Hospital.
If a suspected Ebola patient arrives at her hospital, Ms. Thompson intends to outfit staff members in fluid-resistant jumpsuits with bootees, taped seams and hoods. They cost about $175 per dozen. She has not decided how many to order.
Faced with “copious amounts” of vomit or diarrhea, the C.D.C. acknowledges that leg coverings or double gloving might also be needed.
But, “We don’t always know when a patient is going to vomit,” Ms. Thompson, a former nurse, pointed out. “You get into that situation quickly, so you better go into the room prepared for that exposure.”
The Ebola virus is spread through contact with body fluids, such as those in blood, sweat, saliva or feces. While it is not an airborne virus like the flu, contaminated droplets can be released briefly into the air during procedures performed on infected patients, such as the insertion of a breathing tube. In that case, the C.D.C. recommends the use of air-purifying respirators.
In recent weeks, C.D.C. officials have said repeatedly that any hospital in the United States can safely provide care for a patient with Ebola by following their exacting infection-control procedures and isolating the patient in a private room with an unshared bathroom.
“What’s needed to fight Ebola is not fancy equipment,” Dr. Frieden said in a message posted during a Twitter chat with concerned members of the hospital staff. “What’s needed is standard infection control, rigorously applied.” {I'm certain you'll be right there to demonstrate, Dr. Frieden, changing bed pans, cleaning vomit off your patient, changing bloody dressings}
Nancy E. Foster, the vice president of quality and patient safety policy at the American Hospital Association, agreed that gloves, gown, face mask and eye protection are “perfectly fine” and called the C.D.C. guidance the “best advice.”
But Dr. Michael V. Callahan, an infectious disease specialist at Massachusetts General Hospital who has worked in Africa during Ebola outbreaks, does not think it is wrong for hospitals to opt for more protective equipment.
The minimal precautions recommended by the C.D.C. “led to the infection of my nurses and physician co-workers who came in contact with body fluids,” Dr. Callahan said. “I understand the desire to maintain absolute protection in U.S. hospitals.”
Dr. Justin Fairless, an emergency physician in Tulsa, Okla., said that health care workers in Africa “are wearing the highest level of protection, but the C.D.C. recommendation lets us go down to the lowest level of protection.”
Dr. Fairless is considering buying his own air-purifying respirator to pair with a head-to-toe coverall. “I am not comfortable going to see an Ebola patient wearing a paper mask that doesn’t cover my entire face,” he said.
He is hardly alone. In recent weeks, several hospital workers have expressed concerns, asking why head coverage is not necessary and suggesting their emergency department doctors would get hard-to-tear hooded suits.
Dr. David Kuhar, the health care and worker safety team leader for C.D.C.’s Ebola response, argued that caring for patients in Africa is “very different” from caring for those in a hospital in the United States. {and there's that "very different from Africa" meme, right on schedule}
“In a field setting, there may be many patient beds close together, as well as behind you,” he said. “It would be very difficult, or impossible, to predict when you may be exposed to infectious bodily fluids, so you might want equipment to cover your back and head, to protect your exposure.”
Yet until recently, the health care workers tending to Dr. Kent Brantly and Nancy Writebol, the aid workers infected with Ebola in Liberia, were outfitted in head-to-toe protective suits at Emory University Hospital in Atlanta — which in no way resembles an African field hospital.
On Wednesday, Dr. Phyllis E. Kozarsky, a professor of medicine and infectious diseases at Emory, disclosed that the nurses had shed their full-body gear and were following “what C.D.C. guidance says for the management of these patients.” {the patients have probably cleared the virus and at the very least are now well enough not to be vomiting, bleeding, etc.}
High-tech protective gear may pose dangers of its own, experts noted. It may be difficult to remove a hood or respirator, for instance, without accidentally touching the wearer’s face or eyes, giving the virus an entry point.
Hospitals purchasing head-to-toe gear may find another unforeseen risk: cleaning it.
“It’s easier to grab a new disposable than to repeatedly clean the nooks and crannies of devices,” said Dr. Mark D. Rowland, medical director of epidemiology for St. Francis Health System in Tulsa.
What sort of protective equipment to wear, and who should wear it and when, is only one of the most pressing of dozens of logistical issues now facing hospitals. Already, triage nurses at some hospitals are asking emergency room patients about recent travel to Guinea and Sierra Leone.
Those with fevers or other suspicious symptoms probably do not have Ebola, said Dr. Melvin Weinstein, chief of infectious diseases at Rutgers Robert Wood Johnson Medical School. But now, he said, “we have had to think about how to transport blood specimen to the lab” and keeping technicians safe.
On Aug. 5, more than 5,400 health care professionals were called into a briefing about Ebola hosted by the C.D.C.
Hospital administrators and infection control specialists asked dozens of questions. Is the virus in breast milk or semen? (Yes to both.) Can the soiled linens of an Ebola patient be cleaned off-site without spreading the virus? (Unknown.)
In response, agency officials are scrambling to develop additional guidance on handling laundry, patient waste and the bodies of any American patients killed by Ebola.
“Just in case,” Dr. Kuhar said.
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PIXIE'S COMMENTARY, (one of her best!):
Question:
What is the reason for the new recommendation from CDC that those administering care to New Ebola patients "wear gloves, a fluid-resistant gown, eye protection and a face mask to prevent becoming infected with the virus"?
Answer:
1.
Because there are not enough Tyvek suits in the world.
2. From a "risk communications" standpoint, presenting this virus as something requiring only "normal" infection control measures makes it appear far less "scary" for health care worker consumption. (Most HCWs are not reading PFI so CDC feels it has a chance to get away with this, at least for a while).
Reality:
The R0 for this New Ebola virus can be estimated to be around 8.
It's not a pretty disease and it's likely fatal.
The folks over at CDC are either:
1. Out of their minds. (Or beyond inept).
or
2. The CDC feels that the New Ebola will sweep America and that basic infection control will be, very quickly, all that can be practiced.
This is such a huge, huge issue.
CDC can either:
1. Attempt to "risk communicate" to health care workers that their risk is minimal and that only standard, normal, infection control protocols are needed while treating New Ebola patients in U.S. hospitals.
(This is indeed what they are doing).
or
2. CDC can order that mega-quantities of the proper PPE be produced on an emergency basis, thus tipping off the nation as to what CDC may expect will happen.
You can see which tactic CDC decided to take.
CDC is going to have an increasingly difficult time keeping its activities, it's internal voice-in-head thoughts, and its "risk communications" messaging, consistent.
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MY COMMENT:
Gold Help Us! An Agency of the Executive has pretty much decided that our HCWs are to be Ebola Fodder, if the pandemic reaches our shores.
