This summer, Carolyn Hill, MSN, RN-BC, and 20 other nurses at Emory University Hospital in Atlanta were among the first nurses to treat patients with the Ebola virus in the U.S. Most of the nurses who stayed in the room [with a patient] can say it was an emotional journey, said Hill, nursing unit director of the serious communicable disease unit at Emory. They knew what to do clinically, but you can get very connected to a patient after spending four hours in a room with someone. These patients thought they were going to die.
Two patients were released in August after spending three weeks in the hospitals special isolation unit, and a third patient who contracted the disease in Sierra Leone arrived on Sept. 9. This patient is still being treated there. On Sept. 16, Hill and several other members of the Emory Ebola care team met with President Barack Obama at the Centers for Disease Control and Prevention in Atlanta to share what they had learned.
Practicing what we had learned during training versus applying it in a real situation were quite different experiences, Hill said. We had to adapt and customize along the way. We had trained for the nurses to work 12-hour shifts, but we realized that wearing the PPE [personal protective equipment] for that long was not going to work. It can get claustrophobic staying in one room wearing a white suit with a helmet and hood for so many hours.
While treating the first two patients simultaneously, there were three nurses on duty at all times wearing PPE one in each room with a patient, and one in the adjoining anteroom. Instead of 12-hour nursing shifts, the team switched to eight-hour shifts with one break, Hill says. After four hours in one of the three rooms, nurses would doff their PPE, take a shower and then break for 30 to 45 minutes while physicians relieved them, Hill said. Then the nurses returned for the 18-step process of donning the Tyvek suit a 25-minute task that included putting on eye protection, two pairs of gloves, a plastic apron and protective booties. Another critical step included checking the gauge for the powered air purifying respirator, which cleans air before it is inhaled.
We had always trained for one patient, and one of the challenges we faced was the logistics of adding another nurse to care for the second patient, Hill said. With an extra nurse donning and doffing PPE, we had to figure out how to get three people in and out in a timely manner. We had also never trained for that amount of waste, which all has to be autoclaved and then thrown away.
The nurse in the anteroom was in charge of charting, while the nurses in the rooms with the patients provided supportive care, which included checking vital signs, replacing fluids and encouraging patients to perform simple range of motion exercises, Hill said. They also helped the patients improve their lung capacity using an incentive spirometer and took blood tests to monitor electrolytes. Given the quarantine constraints, nurses did not have access to the usual support staff. The nurses did everything while they were in there, Hill said. They kept the room clean, changed the trash cans, cleaned the toilet and performed some physical therapy.
Preparing for the future
In addition to emergency and critical care nurses, the other members of the care team included five infectious disease physicians, two microbiologists and five laboratory technologists. The team had completed annual eight-hour trainings, but the recent Ebola experience has prompted the hospital to start offering quarterly trainings to help team members keep their skills current.
Training once a year is not enough to maintain the rigorous competencies for donning, doffing and operating the PPE equipment, Hill said. In addition, nurses normally have respiratory therapists who maintain the settings on a ventilator, but in this situation the nurses had to maintain it. We need more frequent training to remember the nuances of operating a vent.
Emory University Hospital is one of four facilities in the country including the University of Nebraska Medical Center in Omaha, the U.S. Army Medical Research Institute of Infectious Diseases in Fort Detrick, Md., and St. Patrick Hospital in Missoula, Mont., with a special isolation unit. The unit was formed 12 years ago with an eye toward caring for CDC employees or those in the field from the CDC, said Nancye Feistritzer, DNP, RN, CNO at Emory University Hospital and vice president of patient care services. The CDCs primary facility is a few blocks away.
Before the Ebola cases, Emorys isolation unit had only been used one time, and that was in 2007. In the last month, organizations such as the National Institutes of Health and the University of Nebraska Medical Center have contacted Emory to gather information about treating patients with Ebola, Hill said. Early in September, an American doctor, Rick Sacra, MD, was infected with the virus was transferred to Nebraska Medical Center for treatment, where he spent three weeks in treatment. A second patient, freelance camerman Ashoka Mukpo, arrived for treatment in early October.
Power of communication
To facilitate open communication, the care team met every morning to discuss possible changes, and everyone in the team had a voice in making decisions about safety. It was also important for the isolation unit team to have the support they needed to talk about the experience they were having, so we were deliberate about providing resources such as daily rounds by the spiritual healthcare team, Feistritzer said.
Feistritzer also was instrumental in advocating for transparent communication to the entire hospital staff about the situation in the isolation unit. She was part of a team of administrators and physicians who organized daily emails to update staff and regular town hall meetings in which staff could ask questions.
As 3,000 military personnel enter West Africa in an effort to control the outbreak and Americans watch the news for details on Ebolas emergence in the U.S., Hill hopes the lessons learned at Emory will benefit patients and caregivers overseas and at home. According to a study published in the New England Journal of Medicine on Sept. 23, if there are no changes in control measures for the epidemic, by early November the total number of confirmed and probable cases is predicted to exceed 20,000 approximately four times the current number. Based on my experience I think it is important to prepare, but also be flexible, Hill said. Each patient is different. For me, it was an amazing experience to see a patient come in very sick and then watch that patient walk out of the room and actually hug his wife. It was incredible.