The CDC issued on Oct. 20 much-anticipated new guidelines for healthcare workers who will be using personal protective equipment when treating patients with the Ebola virus. The revisions which are similar to those used by Doctors Without Borders came in response to the news that two nurses became infected while treating Thomas Eric Duncan, who died Oct. 8 of the disease at Texas Health Presbyterian Hospital Dallas.
The updated guidelines stress the importance of three principles: rigorous and repeated training to use PPE, no skin exposure and supervision from a trained monitor who watches workers don and doff the equipment. While the new guidelines initially might seem overwhelming with the lengthy list of detailed procedures and equipment, the meticulous descriptions are instilling confidence in caregivers who may come into contact with a patient who has Ebola, nurse leaders said.
Nurses want to deliver exceptional patient care, but they are fearful based on what happened [to the nurses in Texas], said Maralyn Spittler, MPA, BSN, RN, vice president and chief quality and patient safety officer at Kaleida Health in Buffalo, N.Y. As we have started implementing the new guidelines, we are giving nurses reassurance that we have diligently selected the best supplies and they are receiving superb training. They will also have a partner observing them to identify any breach in the PPE procedure.
At Kaleida Health, infection control nurses trained clinical education nurses in the PPE donning and doffing procedures. The clinical education RNs then trained approximately 100 caregivers including a majority of the ED nurses and physicians, several labor and delivery nurses and a number of RNs and physicians in adult and pediatric critical care and specialty services. The infection control nurses verified competency in PPE donning and doffing procedures for every trained caregiver, and will reverify competency every 30 days, Spittler said. The infection control nurses also regularly round during PPE training to ensure caregivers are learning proper techniques.
We made the decision not to train environmental services employees, certified medical assistants and medical students and residents, Spittler said. For the safety of our staff, we felt it was wise to train a select group of people and minimize the number of people entering the isolation room.
When a patient is suspected of having Ebola, the new guidelines recommend wearing a disposable fluid-resistant or impermeable gown that extends to at least mid-calf or a coverall without an integrated hood; a disposable full-face shield; a surgical hood that covers the head and neck; two pairs of gloves; and waterproof boot covers that go to at least mid-calf or leg covers.
If a patient with Ebola is vomiting or has diarrhea, then the PPE should include a waterproof apron that covers the torso to mid-calf and top of the boots. The CDC also cautions against using goggles, which may not cover the skin and fog after extended use. The guidelines instruct caregivers to wear a respirator, either a power air purifying respirator or an N95 respirator. The nurses interviewed for this story said getting the equipment they need has not been a challenge.
Although it is safer to wear the PPE described by the CDC, one of the issues has been the impact of wearing so many layers of impermeable clothing, Spittler said.
One of the significant challenges we are seeing is that once caregivers spend a period of time in the PPE, they are sweating because it is so hot, she said. We are encouraging our staff to hydrate before they put it on, and we are limiting the shifts to four hours.
The buddy system
The third principle in the new guidelines highlights the concept of using a trained observer someone who not only reads aloud each step in the donning and doffing procedure checklist, but also documents that each step has been completed. At Stony Brook University Hospital, one of eight New York State hospitals designated to treat patients with Ebola, trained observers also monitor buddies who are in the isolation room treating a patient, which theyve added as part of their own protocol.
One of the things that we have learned is how important it is to have an observer, said Dan Roberts, PhD, RN, associate director of nursing quality, research and medicine at Stony Brook on Long Island. They really have to trust each other and communicate well together. The observer might tell someone that they need to take off a favorite ring because it will make it more difficult to remove gloves later, or make sure they are not panicked while in the suit.
To facilitate nonverbal communication, the nurses at Stony Brook started creating hand signals to help buddies exchange information in isolation conditions, Roberts said. The language of nursing is very different when you are separated from one another by a wall, Roberts said. They are using a hand on top of the head to signal help, and a hand swung out from the heart meaning I am coming out, he said. If a buddy outside the room needs to get the attention of the nurse in the room, the buddy will flicker the lights outside the room.
At Stony Brook, nurses expressed an interest in choosing their buddies because they knew who they worked well with, and the administration supported the idea. So far the hospital has trained a core group of approximately 100 caregivers the vast majority of whom are nurses that includes emergency nurses and physicians as well as medical intensive care nurses.
While buddies at Stony Brook watch their partners throughout the donning, doffing and patient care process, the system is slightly different at North Shore-LIJ Health System on Long Island, which also is a designated Ebola treatment hospital in New York. There, one buddy usually an emergency management employee rather than a nurse monitors the donning and doffing procedure, and a nurse buddy watches the RN caring for the patient in the isolation room.
The nursing buddy in the anteroom might receive specimens in a disinfected, sealed bag that is dropped into a secondary bag held by the nurse in the anteroom, said Donna Armellino, DNP, RN, CIC, vice president of infection prevention at North Shore-LIJ Health System. The nursing buddy might also retrieve and hand the isolation nurse a piece of equipment or prescribed medication, or bring food if the patient is hungry. The buddies in the anteroom do not need to have the same level of PPE as the nurse treating the patient in the isolation room.
According to CDC guidelines, buddies who are not in the isolation room should wear a fluid-resistant gown or a coverall, a disposable face shield, two pairs of gloves and shoe covers.
Although the CDCs new guidelines identify additional precautions to help prevent further infections among nurses who treat patients with Ebola in the U.S., nurse leaders hope the lessons learned from the Texas cases will instigate changes that will continue long after the Ebola crisis subsides in the United States.
The idea of a trained observer highlights some practices we should be doing every day, said Linda Greene, MPS, RN, CIC, an infection prevention manager at Highland Hospital in Rochester, N.Y., and a member of the regulatory review panel for the Association for Professionals in Infection Control and Epidemiology. There are many more things that could be on the horizon when it comes to infection, and the CDCs new guidelines are a reminder that we have the ability to watch out for each other. Small decisions like pointing out an error or reminding someone about something can mean the difference in infection and prevention.