October 27, 2014


Although contracting Ebola represents a small risk for US healthcare providers taking care of patients—as only two secondary cases of infection have been identified in the United States thus far—it is vital that all medical providers working in US emergency departments (EDs) be familiar with the donning and doffing of personal protective equipment (PPE), as well as the importance of taking a detailed travel history in patients presenting with fever to the ED.

In all reality, as we head into November, the risk of transmission of influenza is certainly more concerning than Ebola. However, with the heightened state of awareness in the United States after missteps in Dallas, it is vital that all medical providers understand their role in the triage and evaluation of persons who could potentially harbor Ebola.

Travel History: Asking the Key Questions

A proper travel history consists of asking whether a patient hasdeparted from West Africa in the past 3 weeks, or has had contact with anyone from West Africa who may have been ill with fever or viral type symptoms in the past 3 weeks.

Any person who answers “yes” to any of the above questions and has recent fever or flu-like symptoms requires immediate isolation in the ED. Ideally, this would occur within minutes of presentation to the ED.


The Isolation Room

Current isolation rooms vary in EDs, with the vast majority not equipped with a secondary room or “anteroom” for decontamination practices prior to re-entering the main ED. Many hospital systems are now upgrading their isolation rooms after recent recommendations by the CDC that such a room is vital for healthcare workers removing their contaminated PPE.

The “anteroom” serves as a buffer to the ED, where providers can perform hand hygiene after exiting the isolation room, removing soiled equipment prior to re-entering the main ED.

It is vital that a designated isolation room have its own bathroom so that there will be no contamination in the main ED. One recommendation has been to pour bleach onto any human waste prior to disposal or flushing.


PPE Recommendations

This week, the CDC announced changes to include a policy to cover all exposed areas of the body when screening and evaluating patients with stable or mild symptoms of Ebola, with emphasis on covering the scalp and neck. This includes donning a protective impervious head drape that also covers the neck.

Goggles are also no longer recommended because of issues with fogging up and not providing full skin coverage, along with the risk of being manipulated and spreading disease should a worker adjust the goggles with potentially contaminated gloved hands.

Other important changes regarding the new guidelines include training and demonstration of competency in donning and doffing PPE, and having each step supervised by a trainer/observer to ensure compliance with all steps of the process.

These updates for protection were not included in CDC guidelines previously released, on August 1, which were based on prior World Health Organization recommendations for treating patients with Ebola. The new updates reflect the consensus of experts and help to improve safety for all healthcare workers in light of the two secondary infections in nurses who cared for Thomas Eric Duncan, the nation’s first Ebola patient.

Level 2 PPE is essential when screening or evaluating patients with stable or mild symptoms of Ebola. This includes the following:

Single-use impervious gown extending to mid-calf;

Single-use full-face shield;

Optional protective plastic eyewear (not goggles);

An N-95 respirator or powered air-purifying respirator (PAPR);

Full impervious head drape;

Two pairs of disposable nitrile gloves with extended cuffs; and

Disposable impermeable shoe covers to mid-calf.

If an unstable patient presents to the ED with possible Ebola or potential exposure to Ebola, level 3 PPE is recommended. Level 3 PPE entails the use of an impervious full-body suit along with a PAPR.

In more specialized biosafety level 4 (BSL-4) containment facilities labs such as the ones at Emory University Hospital and Nebraska Medical Center, or the biocontainment center at the National Institutes of Health, personnel wear positive-pressure suits (often referred to as “moon suits” or “space suits”) that contain their own purified air–powered systems. These facilities have showers for decontamination after patient treatment, along with compressed in-line air and an airlock system that prevents any recirculation of air that could lead to contamination.

However, as we know that the Ebola virus is not airborne, using level 2 or -3 PPE would be sufficient depending on the stability of the patient and potential risk for contamination from body fluids such as diarrhea or vomit.

EM Thought Leaders Weigh In

Al Sacchetti, MD, chief of Emergency Services at Our Lady of Lourdes Medical Center in Camden, New Jersey, and a spokesperson for the American College of Emergency Physicians (ACEP), said most emergency medicine clinicians are “concerned but comfortable at present with the potential of treating an Ebola patient.

“That said, the added PPE requirements needed to manage an Ebola patient have the staff a little nervous because of the reports of the nurses in Dallas contaminating themselves while getting in and out of the equipment,” Dr Sacchetti said. “I think that as we get more hands-on practice with donning and doffing PPE, this unease will pass.”

David A. Talan, MD, professor emeritus at the David Geffen School of Medicine at the University of California, Los Angeles, and chairman emeritus of the Department of Emergency Medicine Faculty, Division of Infectious Diseases,
Olive View-UCLA Medical Center, expressed similar feelings about the impact of Ebola in his current practice.

“I don’t see panic from the patients at all; I think they seem pretty calm,” said Talan, “A lot of them—since we have made screening at triage so routine—understand that the questions don’t really apply to them.”

“Obviously it’s going to be pretty rare that someone shows up from these high-risk areas with compatible symptoms,” added Talan, “but I think the patients are reassured that we are asking the right questions. But I don’t sense that the patients are scared.”

During the past few weeks, the question has been asked frequently as to whether, as a nation, we are prepared for Ebola in America.

“No, and why would we be?” explained Sacchetti. “I know that we have been warned over and over that a pandemic could spread quickly, given easy access to air travel. But to be honest, until the first case [in Dallas] no one took it seriously.

“And any hospital that claims otherwise is simply deluding itself, with the obvious exception of the BSL-4 sites,” added Sacchetti.

When asked whether more Ebola cases are expected in the coming weeks, Talan said, “Probably; you would expect that there would be. As the epidemic continues to grow in West Africa, the chance of something happening, like [the case of] Mr Duncan, would only be greater.

“At the same time,” added Talan, “we are also becoming much better at screening, much more aware of the consequences and possibilities of missed screening, and we are much more aware of how to protect ourselves.”


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