After two nurses in Dallas tested positive for Ebola after helping to care for Thomas Eric Duncan, the Liberian who died of the disease last week, federal health officials decided to tighten the guidelines for American hospitals with Ebola patients. Many hospitals, including those in the North Shore Long Island Jewish Health System and the Nebraska Medical Center in Omaha — one of four facilities in the country with biocontainment units equipped to isolate patients with dangerous infectious diseases — have long had more stringent guidelines than the C.D.C.
The enhanced guidance is centered on three principles:
- All healthcare workers undergo rigorous training and are practiced and competent with PPE, including putting it on and taking it off in a systemic manner
- No skin exposure when PPE is worn
- All workers are supervised by a trained monitor who watches each worker putting PPE on and taking it off.
All patients treated at Emory University Hospital, Nebraska Medical Center and the National Institutes of Health Clinical Center have followed the three principles. None of the workers at these facilities have contracted the illness.
Principle #1: Rigorous and repeated training
Focusing only on PPE gives a false sense of security of safe care and worker safety. Training is a critical aspect of ensuring infection control. Facilities need to ensure all healthcare providers practice numerous times to make sure they understand how to appropriately use the equipment, especially in the step by step putting on and taking off of PPE. CDC and partners will ramp up training offerings for healthcare personnel across the country to reiterate all the aspects of safe care recommendations.
Principle #2: No skin exposure when PPE is worn
Given the intensive and invasive care that U.S. hospitals provide for Ebola patients, the tightened guidelines are more directive in recommending no skin exposure when PPE is worn.
CDC is recommending all of the same PPE included in the August 1, 2014 guidance, with the addition of coveralls and single-use, disposable hoods. Goggles are no longer recommended as they may not provide complete skin coverage in comparison to a single-use, disposable full-face shield. Additionally, goggles are not disposable, may fog after extended use, and healthcare workers may be tempted to manipulate them with contaminated gloved hands. PPE recommended for U.S. healthcare workers caring for patients with Ebola includes:
- Double gloves
- Boot covers that are waterproof and go to at least mid-calf or leg covers
- Single-use fluid resistant or impermeable gown that extends to at least mid-calf or coverall without integrated hood.
- Respirators, including either N95 respirators or powered air purifying respirator (PAPR)
- Single-use, full-face shield that is disposable
- Surgical hoods to ensure complete coverage of the head and neck
- Apron that is waterproof and covers the torso to the level of the mid-calf (and that covers the top of the boots or boot covers) should be used if Ebola patients have vomiting or diarrhea
The guidance describes different options for combining PPE to allow a facility to select PPE for their protocols based on availability, healthcare personnel familiarity, comfort and preference while continuing to provide a standardized, high level of protection for healthcare personnel.
The guidance includes having:
- Two specific, recommended PPE options for facilities to choose from. Both options provide equivalent protection if worn, put on and removed correctly.
- Designated areas for putting on and taking off PPE. Facilities should ensure that space and layout allows for clear separation between clean and potentially contaminated areas
- Trained observer to monitor PPE use and safe removal
- Step-by-step PPE removal instructions that include:
- Disinfecting visibly contaminated PPE using an EPA-registered disinfectant wipe prior to taking off equipment
- Disinfection of gloved hands using either an EPA-registered disinfectant wipe or alcohol-based hand rub between steps of taking off PPE.
Principle #3: Trained monitor
CDC is recommending a trained monitor actively observe and supervise each worker putting PPE on and taking it off. This is to ensure each worker follows the step by step processes, especially to disinfect visibly contaminated PPE. The trained monitor can spot any missteps in real-time and immediately address.
The CDC link for the new regulations is http://www.cdc.gov/media/releases/2014/fs1020-ebola-personal-protective-equipment.html
The NYT link below shows the difference between the old PPE requirements and the new requirements in Ebola protection. Click on the link below: