Dr. David Relman, a professor of infectious disease, microbiology and immunology at Stanford University's medical school, was quoted recently saying of the Ebola virus: “As best we can tell right now, it is quite possible that every major city will see at least a handful of cases."
Healthcare providers and health systems across the United States now are seeking to understand how to recognize potential infections of Ebola virus disease (EVD), and to ready themselves to handle these as soon as they are identified.
Below are some of the key considerations for hospitals in dealing with infectious diseases like EVD, based on information provided by the Centers for Disease Control, Emory University and the World Health Organization. While we are focusing on Ebola, the same overall recommendations apply to outbreaks of any highly infectious disease.
1. Understand the threat
Initial signs of EVD are nonspecific and may include elevated body temperature or fever, chills, muscle pains and malaise. Particularly early in the course, EVD can often be confused with other, more common infectious diseases, such as malaria, typhoid fever or pneumonia.
Furthermore, according to the CDC, the Ebola virus spreads through contact with infected blood and other bodily fluids (saliva, mucus, vomit, feces, sweat, tears, breast milk, urine, semen).
As a result, healthcare workers and other caregivers who do not use appropriate personal protective equipment and hygiene, and persons handling the bodies of deceased EVD patients (which are highly infectious), are at high risk for Ebola virus exposure and infection.
Hospital-grade disinfectants (such as household bleach) kill the virus. Ebola virus on dry surfaces, such as doorknobs and countertops, can survive for several hours; in body fluids at room temperature, the virus can survive up to several days.
2. Preparation and education
- Review infection control procedures and care protocols provided by subject matter experts. The CDC, Emory University and the American Hospital Association, among others, offer extensive information on their websites. The CDC has issued extensive protocols and checklists about identifying and handling patients who may be infected with Ebola, which will likely be considered the standard of care going forward.
- Complete a risk assessment and develop a mitigation plan. In the case of EVD, can the CDC’s recommendations for the cycle of care be implemented? If not, can the risks otherwise be appropriately mitigated (as determined by an infectious disease expert) or should EVD patients be transferred to another facility? If transfer is necessary, what facility has the capacity to (and is willing to accept) EVD patients? It is possible your state has identified the facilities that will treat EVD patients, in which case this step is a less complicated one. Transferring facilities may want to establish transfer agreements with the accepting facility, in order to establish the responsibilities of the parties with respect to determination of infection status, notification, transport and infection control.
- Identify needed resources. Ask yourself which additional services, supplies and expertise may be necessary in managing and treating patients with EVD, and be proactive about obtaining what you need. For example, place orders for personal protective equipment (PPE) sooner rather than later, well in advance of any potential shortages. Smaller facilities without significant infectious disease expertise should consider how to best obtain additional guidance regarding infection control procedures, risk mitigation and patient treatment - for example, consulting agreements or telemedicine arrangements may make sense.
- Establish an internal response team. In order to provide 24-7-365 coverage, consider who should be on the team that responds to patients who could be infected and how many members should be on the team.
- Implement updated infection control procedures. Develop and implement policies and procedures based on your risk assessment and mitigation plans. Review exposure incidents for gaps in procedures and update them accordingly.
- Provide regular training to physicians and staff. Regular infection control training and targeted education to improve Ebola-specific protocol adherence is necessary, and to achieve the desired changes and identify additional and continuing education needs, so is periodic assessment and feedback. All healthcare workers should undergo rigorous training and practice with PPE, including putting it on and taking it off in a systematic manner.
- Establish communication and notification plans. What are your state and/or local health department procedures for notification and consultation? Designate points of contact within your hospital responsible for communicating with state and local public health officials. Keep in mind thatEbola is a nationally notifiable disease and must be reported to local, state and federal public health authorities.
3. Safety precautions
- Patient screening – internal response team activation. Patients should be screened for Ebola using CDC protocols at all points of entry to the facility/system, including but not limited to facility transfers, emergency departments, labor and delivery departments, outpatient clinics and ambulatory surgery centers. Once a potential Ebola case is identified, immediately activate your internal response team.
- Patient isolation. Isolate patients who could be infected with the Ebola virus in a single patient room (containing a private bathroom) with the door closed.
- Personal protective equipment. OSHA standards will apply. The CDC recommends hospitals have an adequate supply, for all healthcare personnel, of:
- Impermeable gowns (fluid resistant or impermeable)
- Gloves (account for use of double gloves)
- Shoe covers, boots and booties and
- Appropriate combination of the following:
- Eye protection (face shield or goggles)
- Facemasks (goggles or face shield must be worn with face masks)
- N95 respirators (for use during aerosol-generating procedures)
- Other infection control supplies (e.g. hand hygiene supplies and disinfectants).
- Establish “clean” vs. “contaminated” areas. Ensure that designated spaces and layout allow for a clear separation between clean and potentially contaminated areas. Physical barriers (e.g., plastic enclosures) should be used where necessary, along with visible signage, to separate distinct areas and ensure a one-way flow of care moving from clean areas (e.g., area where PPE is donned and unused equipment is stored) to the patient room and to the PPE removal area (where PPE is removed and discarded).
- Environmental infection control
- Be sure environmental services staff wear recommended personal protective equipment to protect against direct skin and mucous membrane exposure of cleaning chemicals, contamination and splashes or spatters during environmental cleaning and disinfection activities.
- Use US EPA-registered hospital disinfectants with a label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus) to disinfect environmental surfaces in rooms of patients with suspected or confirmed Ebola virus infection.
- Avoid contamination of reusable porous surfaces that cannot be made single use. Routine cleaning of the PPE doffing area should be performed at least once per day and after the doffing of grossly contaminated PPE.
- To reduce exposure among staff to potentially contaminated textiles (cloth products) while laundering, discard all linens, non-fluid-impermeable pillows or mattresses, and textile privacy curtains into the waste stream and disposed of appropriately.
- Biohazard waste management
- Any item transported offsite for disposal that is contaminated or suspected of being contaminated with Ebola must be packaged and transported in accordance with the Hazardous Materials Regulations (HMR, 49 C.F.R., Parts 171-180).
- Consider the increased volume of biohazardous waste that could be generated in treating EVD patients and plan accordingly.
- Laboratory and specimen protocols. Ensure that laboratory personnel are aware of current guidelines for specimen collection, transport, testing, and submission for patients who may be infected.
- Employee health screening. Employee health monitoring systems should include symptom tracking, exposure incident procedures and tracking, and reporting of acute symptoms to employee health immediately.
- Employee shifts and supervision. Consider what steps can be taken to avoid human error and consult CDC guidance regarding shifts and supervision. All workers should be supervised by a trained monitor who watches each worker putting PPE on and taking it off. EVD patient care shifts should be structured to avoid employee/physician fatigue.
4. Individual rights
- Quarantine. State and local governments may establish isolation and quarantine requirements, as well as other measures that resemble isolation and quarantine, for individuals who have been exposed to the Ebola virus. Since healthcare workers are at high risk for exposure, it will be important for hospitals and health systems to understand the state and local requirements.
- HIPAA and privacy rights. Ebola infection does not trump a patient’s right to privacy under HIPAA, and there may be additional rights provided under state law. EVD patients will be high profile and of significant interest to the media. Physicians and staff should be regularly reminded of how a suspected/confirmed Ebola patient’s information, including health care providers that may have been exposed, may be used and disclosed under HIPAA and state law. We also recommend that all communications with the media regarding potential Ebola patients should be handled through a single point of contact who reviews all information with the HIPAA Privacy Officer prior to release.
- Employment issues. Treatment of patients with highly infectious disease raises a host of employment issues from a legal perspective. For more information, see our alert.
5. Ethical considerations
- Healthcare provider shortage. In Toronto during the SARS outbreak, healthcare providers went under voluntary quarantine if potentially exposed to the virus. Eventually, there were so many providers under quarantine that the hospitals were understaffed. Consider what should be done if this happens in connection with Ebola, or any outbreak of highly infectious disease. At what point should potentially exposed providers be allowed to treat EVD patients? And what protective measures will providers need to institute in order to safely do so?
- Travel restrictions. When is it appropriate to restrict travel to certain countries by your physicians and staff? If you don’t restrict travel, how will you handle the return of physicians and staff from high-risk areas?
- Care decisions. Under what circumstances is it legally and ethically appropriate for a healthcare provider to refuse care to a patient due to the risk of contracting Ebola? When is it appropriate for physicians to order aggressive treatments that put the rest of the staff at a higher risk of contracting Ebola?
- Burial, cremation and tradition. Consider how you will handle the remains of EVD patients, how those procedures will be communicated to loved ones and how you will respond to requests that are against infection protocol or that you otherwise have decided pose unnecessary risk.
The importance of clear protocols and procedures
These days it is often noted that the ease of global travel has cleared a path for novel, highly infectious diseases. Health systems are on the front lines of containment. As it grows increasingly likely that many hospitals throughout the world will encounter Ebola, or an as yet unknown disease, putting in place and practicing clear protocols and procedures is the wise route.