Caring for Patients with Ebola in U.S. Hospitals: A Nursing Perspective

Coordinator:

Welcome and thank you for standing by. At this time all participants are in a listen-only mode. During the question and answer session please press star 1.

Today’s conference is being recorded. If you have any objections you may disconnect at this time. I would now like to turn the meeting over to Leticia Davila. Thank you, you may begin.

Leticia Davila:

Thank you, Diane. Good afternoon. I am Leticia Davila and I am representing the Clinician Outreach and Communication Activity, COCA with the Emergency Communication System at the Centers for Disease Control and Prevention. I am delighted to welcome you to today’s COCA Call, Caring for patients with Ebola in U.S. Hospitals: A Nursing Perspective.

We are excited to partner with HHS, Health Resources and Services Administration, the American Association of Critical Care Nurses, American Nurses Association and Emergency Nurses Association to provide nurses and other health care workers with information on preparing for and responding to patients with Ebola.

There is no continuing education provided for this call. PowerPoint slide sets are available to download for today’s presentation. The PowerPoint slide set can be found on our COCA Web site at emergency.cdc.gov/coca. Click on COCA calls. The slide set is located under the call in number and call pass code.

And the end of the presentation you will have the opportunity to ask the presenters questions. On the phone dialing star 1 will put you in the queue for questions.

Questions will be limited to clinicians who would like information on caring for patients with

Ebola. For those who have media questions please contact CDC Media Relations at 404-639-

3286 or send an email to media@cdc.gov. Again the PowerPoint slide set is available on the COCA Web site at emergency.cdc.gov/coca. I would now like to turn the call over to today’s moderator, Dr. Mary Wakefield, Administrator for HRSA.

Dr. Mary Wakefield:

Thanks so much. And hello everyone and thanks to each of you who have joined us on the call today. I am Mary Wakefield and I am the administrator of the Health Resources and Services Administration. That is one of the agencies within the U.S. Department of Health and Human Services and I would say a sister agency to CDC.

As a fellow nurse, I am really pleased to have the opportunity to facilitate this very important call that is designed to provide a nursing perspective on the care of patients with Ebola in U.S. hospitals. This particular call is being held in response to feedback that we received from leadership of a number of our national nursing organizations, at HRSA and the Centers for Disease Control and Prevention and the Office of the Assistant Secretary for Preparedness at HHS.

We have all been in fairly regular and frequent contact with national nursing organizations. And in one of our recent calls with them, it was shared with us that nurses from across the country would benefit from learning more about care management of patients infected with Ebola by facilitating a call with nurse experts.

And so that is exactly what brings us to this call today. The nurses that we have invited to speak work in U.S. facilities that have been responsible for doing just that.

They have been responsible for caring for patients infected with the Ebola virus. So the expertise that they are sharing with you today is also informed by experience. I will introduce those four nurses in just a moment.

First though, I am also joined today on the call by my colleague, Dr. Michael Bell. Dr. Bell is the

Deputy Director of the Division of Healthcare Quality Promotion at the CDC.

And Dr. Bell will provide you with an overview of information recently released by the CDC that should be of interest to nurses across the country.

Following Michael’s comments you will have the opportunity to hear from our nurse colleagues.

They are colleagues from Emory University Hospital and Nebraska Medical Center.

Nurses who have been central to efforts to care for patients with Ebola in those institutions. Let me tell you just now who those presenters are. First from the Nebraska Medical Center,

Shelly Schwedhelm. Shelly is the Director of ED, Trauma and preparedness services at Nebraska Medical Center.

And joining her from the same facility is Kate Boulter. Kate is the lead nurse for the Biocontainment Unit at Nebraska Medical Center.

Shifting to Emory, Emory University Hospital, we have with us Dr. Nancye Feistrizer. She is the Vice President of Patient Care Services and Chief Nursing Officer at Emory University Hospital.

And joining her is Sharon Vanairsdale. Sharon is a clinical nurse specialist with the Emergency Department at Emory University Hospital.

So the nurses from Emory and Nebraska who are on the call will be focused on policies and procedures pertaining to hospital based care primarily talking about the care provided in emergency departments and in critical care units for this patient population.

They have crafted their presentations based on the feedback that we received from national nursing organizations. Regarding the questions that the associations are hearing from their membership.

And this is part of a promise that I made on our last call on this topic with nurses from across the country. That is to have communications targeted to the nursing community in order to help nurses both protect themselves while providing the very best nursing care possible for patients with this disease. And with that I will turn the call over first to Dr. Bell from the CDC for his comments.

Dr. Michael Bell:

Hello everybody, and thank you very much Dr. Wakefield. I am going to say a few quick words to open this presentation about infection control at large when it comes to Ebola and the current situation in North America.

I will start by saying that screening and identification are at the top of the list when it comes to the important elements of what we do. The worst thing to do is not recognize a case of infectious Ebola infections until after the patient has been in the hospital for a while.

We have seen this occur in the past and with other diseases. And so one of the very strong focuses that we are taking as a country is (to focus) on early identification and triage of individuals who might be infected.

The entire country is systematically looking at individuals who are traveling from affected areas and individuals who are known to have contact with individuals that might be infectious. So that we can track them, and if they become ill direct them to prespecified locations.

And this is just for the screening and testing step. We are working with individual state health authorities to identify which facilities in each state would be appropriate for this and that is a work in progress. But the key here is that we want to know who we are dealing with up front.

The other side of that discussion is that you can never be 100% certain and it is certainly still possible that someone could wander into an emergency room unannounced.

And so that reinforces what we always say about always using standard precautions. You never want to be exposing yourself to any blood or body fluids regardless of what you think the individual has. That is certainly never more the case than with an outbreak like this.

Regarding protective equipment, there is a tremendous amount of appropriate focus on personal protective equipment. And the first thing to recognize is that while the goal of the equipment is always the same, there are multiple ways of achieving that goal.

And so when you talk to various centers of excellence around the country you will find that there are small variations in what each location is doing. But regardless of which version is used, the strongest and most [I think] clearly observed need is for training in the consistent and successful use of that package of PPE.

There are two things that we are focusing on at the federal level. One is encouraging facilities to take a standardized approach. I can’t say enough the importance of having everyone be doing the same thing with the same equipment.

It is very, very difficult to look across a room and understand who is doing things right and who is not if you are allowing people to do things in an extremely variable way.

In contrast, it is very efficient to have someone take a look and see that everyone is dressed the same way in that setting. And there is much to be said for that kind of ability to look at how people are working.

It is related if you think about it to how we handle people with chicken pox. It is transmitted by airborne routes and so we use the negative pressure room. And frequently people ask well if I have had chicken pox do I still need a respirator?

And the answer is you probably don’t, but as a facility I want to make sure that I can see everyone walking in that room using a respirator appropriately. And therefore we are asking that everyone simply does.

And it is a similar sort of thing where you want to be able to make sure everyone is complying the same way.

The other important aspect of this is working with facility leadership to ensure that they support the need for training. They support the systemization and standardization of personal protective equipment that is selected.

One last element that I will add is the importance of – [I think you will hear this from our speakers]… of careful removal of used PPE.

There is a substantial risk of self-contamination and because of that we are taking the step of recommending that there be an observer who is trained to make sure that if someone has taken care of an Ebola-infected patient the process of removing used PPE is done meticulously and safely every single time.

I will leave the details to our experienced speakers to share with you, but also direct you to some of the resources that we have available and are continuing to update on CDC’s Web site.

If you go to CDC.gov there is a big picture of the Ebola virus. You just click on Ebola. It will take you to a page with an array of information including a link specific to healthcare professionals. And that is where you will find all of our PPE recommendations including the latest updates.

Let me stop there in the interest of time, and I will hand it to our next speaker.

Shelly Schwedhelm:

Good afternoon this is Shelly Schwedhelm from Nebraska and that was a great segway Dr. Bell into I thought I would spend a couple of moments just talking about the front end screening given that one of my roles and responsibilities here at Nebraska is the emergency department.

So as you think about the emergency department it is going to be different obviously for everyone across the country. You may have various small EDs to a very large ED but the most important thing is that you are actually doing 100% screening at all of your entry points not just your emergency department.

And how you achieve that is going to be different also at different organizations depending on your depth and your mix of entry gate clinicians or folks at your front desk areas.

So I would just encourage you to think about what are the tools are going to work best for your organization. One of the things that I have seen and is started to be very successful is building in some of the screening tools to the electronic health record and then providing some decision support behind that to kind of alert the caregivers to the next stage and next step.

From an emergency department perspective, you may be in a situation where you need to think about having this person who is under investigation who meets the case definition but yet is not ruling in or ruling out just yet.

That could be 72 hours before you have that opportunity to rule in or rule out. So it is going to be important for you think about where you are going to go.

And in some organizations that may be staying in the emergency department and in others that may be going to another defined location or as Dr. Bell mentioned it may be transferring to another adjacent location near your hospital and your community.

So the thing to think about as far as where to go in your organization if you are staying put is really trying to identify an area that is out of the main thoroughfare. Identifying whether a bathroom can be adjacent, that is very, very important.

An extra room perhaps in the zone of that area that you might be able to think about staging trash or other things that you may be using for the patient.

And then really thinking about kind of your safety aspects as well. What is the egress options that you would have from that space depending on how you organize it.

And then running through maybe some of the what ifs. What if this patient you are going to looking for a lot of perhaps differential diagnoses? And so how are you going to manage your lab? How are you going to perhaps do an X-ray or a CAT scan if you need to?

And then what are all the steps you are going to take in that process to be able to do those things safely? And clean appropriately based upon the fact that you haven’t ruled in or ruled out at this time.

You need to think about who you would put on your team of folks who would really think critically through those certain scenarios such as your infection control practitioner should be involved with your ED leadership from both a physician and a nursing perspective.

Perhaps somebody from facilities and obviously engaging your front line staff in being involved in those steps as well.

Some tools or some things to think about would be as far as the PPE, your personal protective equipment goes. Definitely practice in those intricate areas. You practice like you play just like in sports. You know we wouldn’t dare step on the basketball court if we hadn’t done a little practicing in advance of that.

Making sure that you have a way in your work environment that you are going to identify who that donning and doffing partner are going to be. Who is going to be helpful in that scenario?

And then I think from an emergency room perspective I think one of the things we are not used to or good at doing is slowing down.

So making sure that if you have somebody who meets the case definition, you really need to slow down, take your time, do your personal protective equipment correctly and then go through the motions of providing the care for the patient that is needed.

You might also think about putting together a go kit that could be easily grabbed by your staff in the emergency department. Perhaps it would have some IV start kits, appropriate lab tubes that might be needed, maybe a container of bleach wipes, a disposable stethoscope.

And just really anything else that you think might be necessary for that first person who would don their PPE and go into the room. That could be helpful to them in those first short period of time once they get into the room.

Some of these tools we have put together and I will talk about that at the end of our presentation into an app in iTunes University and you are welcome to download those there and use as you wish if they can be helpful to your organization.

So kind of transitioning then into the Nebraska Biocontainment Unit and the care of patients in that unit, one of the things I wanted to spend a couple of minutes on was to talk to you about selection of our staff.

And I often look back and wonder how did this team get to be the high functioning team that it is. And I think it’s because the type of individuals who were involved in this team are all volunteer and they were drawn to doing this type of care because I think they had really a hunger for new knowledge.

Perhaps they are the ones who wanted to kind of stretch their minds a little bit and critically think about how things kind of work maybe in a different circumstance.

So the process that we go through to select these individuals there is a formal interview where I ask a lot of questions about things such as self-directed teamwork capabilities and various things like that.

But I think the piece done after I kind of identify that yes, this seems like somebody who’s really high energy, passionate about learning new knowledge and has those skills that I’m looking for is to really validate what their home unit manager because all of our staff also have full-time part-time jobs outside of our unit in other areas of the health system.

So typically what I found is in probably 95% of the case these folks are rock star clinical experts as well. So we’ve really been lucky with that. And the staff are just amazing folks.

We then put them through an employee health screening because if they need to be in PAPRs for a long period of time part of their screening includes a pulmonary function test and then just other basics just making sure that everything’s up to speed from an immunization perspective.

And then the staff once we get all of those steps done then they come for their orientation with our clinical education coordinator and our lead nurse. And she’ll talk a little bit more about that as we move forward.

The other thing that’s really cool about this team is I really found that the diversity of the background of the staff has really added a dimension of teamwork and clinical skill mix that’s been superb as far as the care that’s been provided.

I have nurses from the intensive care. And of course you’re definitely going to want a good solid mix of ICU nurses to be on this team because of being able to care for the levels of the patient that may be necessary.

But I also have ER nurses. I have med/surge nurses, operating room nurses, labor and delivery nurse even and infusion center nurses. And they all brought something a little bit unique and different to the team dynamics as we’re putting this group together.

I have nurses, respiratory therapists and techs. So the nurses by far predominate. And then I have about seven of my forty are respiratory therapists. And about four of the forty are care techs.

So I’m going to transition to Kate and she’s going to talk a little bit about the staff rules within the Nebraska Biocontainment Unit.

Kate Boulter:

Hi everyone. I’m glad to be here, letting you know a little bit of what we do here at Nebraska. In order for the work to flow in this unit we have different roles. And all our staff participate in each of the roles that we have for them.

So we have a primary RN. We have RNs. We have doffing partners. We have autoclavers and we have taskers. So the role of the primary RN is mainly to coordinate all patient care activities within - with the other RNs. And they also have to provide a nursing report to the oncoming shift who’s coming on after them.

The RNs they take turns at taking care of the patient. They support the primary RN. And they also rotate within all the other roles. So we do everything on the unit ourselves. We don’t have EBS or anybody else come in.

We have a doffing partner. And that person’s job is primarily to help people get out of PPE and then are an active participant in that process.

We have an autoclaver. They’re the ones that are responsible for processing or trashing or linens and getting that out of the unit.

And then we have a tasker. And that tasker is a person who performs any kind of tasks that need to be done in the unit such as stocking the shelves, helping to coordinate the cleaning activities. They also get to do the donning partner and rotate in with the autoclaver as well.

But when they’re in the tasking position they stay in the clean zone all the time.

Taking care of a patient in the bio containment unit is not significantly different than caring for patients in any other unit.

Our nurses still have to chart in the electronic health record. They complete their nursing care plans, provide the patient care. They coordinate all the care needs with the multidisciplinary team, the (unintelligible) and the medication.

They help to process and complete all their medical orders. They count narcotics into automated dispensing system and they consult and communicate with the medical team.

And they provide support to the patient’s family or significant others as well. The main difference for us in the bio-containment unit is doing our duties while we adhere to strict isolation - I’m sorry, infection control procedures.

These procedures are the donning and doffing of PPE. Our staff are meticulous in the way that they put it on and take it off.

There’s designation areas where they put on their PPE and they take it off.

We also have designated clean and dirty zones within the unit. So if somebody’s say for example the doffing partner then there’s specific areas to where they can travel while they’re doing that job.

We have daily checklists. There’s dedicated cleaning equipment for each zone. There’s areas where we keep clean equipment such as the x-ray machine before it’s used. So that’s kept in a clean room.

After it gets used it gets transferred into what we call the dirty room. The items in there aren’t necessarily dirty, they’ve just been in the patient room.

We have designated pathways for removing waste and used linen from the unit. And we have a method for transferring equipment, medications and other supplies whether it’s from clean to dirty or dirty to clean.

And we have a method for communication as well. So, we have - we can do provider to provider, provider to patient or family to patient or significant others.

Our standard operating procedures, you need to think about how you’re going to do things such as for how you’re going to get IV access if it’s going to be peripheral versus a central line, how are you going to do your lab tests, how are you going to get diagnostic services in and out of the unit.

You need to have protocols already in place for specialized care such as dialysis or mechanical ventilation. And you need to get agreements and up front with public utilities for waste management.

And think about in the event the patient does pass away then you need to have an agreement with crematoriums and how you’re going to get the deceased back.

Our advice would be to plan, practice, learn and adapt. Everybody’s situation is going to be unique. And I do believe that we can help everybody with that.

Shelly Schwedhelm:

So to kind of finish off this is Shelly again from Nebraska. I wanted to talk with you a little bit about how our bio containment unit team takes care of themselves, how we take care of them as an organization.

And we really continue our care delivery strategy of using Watson’s caring theory in relationship-based care which is basically care of the patient’s family, care of self and care of others such as colleagues, et cetera.

So the way that we do that is our staff is very involved from a shared government’s perspective and decision-making and in developing our protocols and procedures.

We have approximately 70 protocols and procedures. And the staff have been very involved in all of those including tweaking those and adjusting those as we see fit during drills and actually during our activations of late using an after action report and debrief kind of strategy to then enhance our systems and our processes.

Hydration and nutrition, we do provide our staff during activation meals. We have Gatorade and waters and snacks available in the staff lounge as well.

And then clothing we provide them with scrubs and socks and shoes to wear while they’re in the unit, a place to shower, a place to rest, coaching and support as needed.

Kate and I structured our time so that we were here at the beginning. I would come in early, Kate would come in a little bit later.

Kate would stay late and meet the 7:00 PM shift and I would come in early again and meet the night shift on the backend so that we had a strategy of support in place for them.

Self-scheduling is something that we used and the staff did great with that. And in fact even when we’re not activated we still have a schedule. And that way it helps everybody to kind of know what their schedule plans are going to be accordingly.

And then of course leadership steps in and the balances to the schedule as needed.

Daily communications, we have a huddle procedure at change of shift. And then we also put something in writing for those staff who may not have been on duty today and then it’s just kind of a chronological. So the most up-to-date huddle information is first in the document.

And that goes out routinely along with the staff schedule for people to see and know. And we have a team email address to do updates and share interesting information and positives. So I think overall our staff would say that we’ve taken really good care of them throughout the process.

And then I’d like to just finish for a moment and tell you about we have what’s called the Nebraska Ebola method app.

And if you download iTunes University and then within that you can find our app. And that’s where we’ve got all of our tools.

So from our ED algorithms, our clinic information, some best practices related to waste management and transport as well as some video clips also that we’ve done with our physicians talking to each other and nursing staff talking to each other about how to care for a patient with Ebola virus.

And then in closing I put a quote here, “True heroism is remarkably sober, very undramatic. It’s not the urge to surpass all others at whatever cost but the urge to serve others at whatever cost.”

And I just wanted to remind us of those on the front lines and asked if today working to reduce the outcomes of this disease and to try to help stop it where it’s at.

And I also wanted to give a shout out to Texas Presbyterian because I feel as a result of their unfortunate situation that America has stepped up and is better prepared as a result of that. And I thank them for their bravery and courage in that.

And so I will turn it over now to our Emory colleagues.

Nancye Feistritzer:

This is Nancye Feistritzer from Emory University Hospital. I’m going to be joined shortly by Sharon Vanairsdale.

I would echo Shelly’s comments with respect to the fact that we have been able to use some of our events in these last weeks and months to improve and enhance our preparedness across the country.

So at Emory Healthcare we began receiving our patients in the first week of August, our first patients.

And we were building on a strong tradition of having a serious containment, a serious communicable disease unit previously developed in concert with the CDC but built on a culture that you see reflected here in our care transformation model.

And as Shelly referenced whatever the model might be in your own organization being able to hook into and hang onto that model as a driver of how one response to the kinds of circumstances faced when taking care of a patient with Ebola virus disease is very helpful and very comforting to the staff.

It’s important to not lose sight of the fact that many of these activities are (unintelligible) to what we do for patients every day. And being patient centered and family centered is a very important part of this.

I’m going to speak to a couple of elements here within the model in terms of shared decision- making transparency and then the ribbons you see there in terms of teamwork.

Our serious communicable disease unit just to frame this for you is shown on the slide that is next and provides the opportunity to have both a single patient in each of the units but also an anteroom.

Whether or not you actually have an anteroom set up is less important. It is just very important to have clearly delineated clean and dirty areas.

You also see a reference, a lab in the bottom corner of the slide for those of you looking at it. And this was a very important part of our ability to respond nimbly to the changing clinical situation to be able to have that immediately available lab testing.

However again, you don’t have to have this kind of a facility to care for patients with Ebola. You just need to have good reliable processes for providing this kind of capability.

The Emory SCDU team as we call it is comprised of 19 critical care nurses. In the Emory model all of our nursing staff are critical care.

They are partnered with five infectious disease physicians. And then a number of other individual representing different areas from within the Emory system in terms of bio safety, our lab colleagues, spiritual health both in supporting the families and their patients but also in providing support for the staff.

In our model we do have designated EBF personnel for the waste management stream but they are all outside of the anteroom and never enter into the actual patient care areas.

Occupational health is very involved to do monitoring of staff providing direct care or handling waste or handling to do monitoring of staff provided direct care or handling waste or handling specimens for processing in the laboratory.

Assumptions for the care model include that only direct care providers are in the patient room. In our model, that meant the critical care nurses as well as the infectious disease physicians who were the managing physicians. No person enters the room without mandatory training and demonstrated competence.

That is a very important part of the way in which we were able to focus on safety -- to ensure that we had no one entering that patient care environment without having been thoroughly conversant in donning and doffing protocols. Sharon will review that for you shortly.

Importantly, these individuals need to be comfort with autonomous practice -- whereby they are in the room providing care -- but supported by expert through consultative means. They do ventilator management, CRRT, physical and occupation therapy and environment decontamination within the patient care room and anteroom themselves.

This is grounded in a culture of safety, very important in terms of creating shared accountability for safety. The buddy system, the ability to monitor each other as members of the team for safety and adherence to the protocols was a central element of the way in which we delivered care here at Emory. That means effective and assertive communication is central to the safety of the team.

We did a specific preparation around strategies to use communication -- both in terms of direct care about the patients and their clinical situation but also through daily team huddles. Those team huddles were an opportunity each morning for all members of the term to be present and/or call in. They were concluded each day through the recitation of a set of family rules as was called by the team.

And those are to follow all standard operating procedures to the best of their ability to ensure that others follow the standard operating procedures, to report all accidents and/or near misses, to report any symptoms that match the pathogen and to report any new medical conditions. I'm going to turn it now to Sharon Vanairsdale to talk about the standard operating procedures.

Sharon Vanairsdale:

Thank you, Nancye. You heard Shelly and Kate mention earlier the importance of the standard operating procedures. The reason those are so important is because they provide consistency in how procedures are performed in the unit and that allows staff to identify possible deviations when performing the procedure.

Dr. Bell mentioned before we got started it's important that staff are donning and doffing the same thing and in the same manner so that you can identify if there are any variations in that. And that's really, really important. It didn't matter what shift or which staff. We were all doing the same thing and things were executed the exact same way. And that really gave staff confidence knowing that they were performing procedures consistently.

The SCDU SOPs - staff - it was really important that staff knew what those SOPs were. You know, it's great that the facility have the SOPs but it's no good if the staff don't know them. So it's important that they know them, that they're trained in them and that you validate competency; specifically, the donning and the doffing of the personal protective equipment.

We utilize the buddy system but staff also didn't know how to do waste management, decons and containment protocols, especially handling for diagnostics.

Some of the SOPs that we utilize at Emory included donning -- and that's for both the patient room and for the ante room -- doffing, again for the patient room and anteroom, toileting, waste management, stool cleanup, needle stick, you know, chemical mats. These are just to name a few. There are several. Waste management -- how much water does one add to each bag before they get autoclaved? How many bags are we using? How do you tie the bags? It's the little details that were so important in containing a pathogen such as Ebola.

The same thing with toileting. We pretreated our toilets before patients could use the restroom. So it's important that we knew how to calculate that, that we knew how to use the disinfectants. Same thing if the patient disinfects their commode. You know, we needed to be sure that everybody was doing the same thing each and every time which is why we utilize these standard operating procedures.

There was an article written. It was called "Protecting Health Care Workers from Ebola." Personal protective equipment is critical but is not enough. As I said, Dr. Bell mentioned doffing is a critical time for the staff. Although PPE is effective is effective at decreasing exposure to infected bodily fluids among healthcare workers, it's presence is simply not enough. PPE itself can introduce risks. And it's really, really important your facilities ensure that there is proper training and competency in donning and doffing because that is critical.

So what we did, we utilized the buddy system. We had monitors that would come in and out just to ensure - they would audit to ensure that the buddy system was effective.

I also want to talk about some considerations for PPE. Again, all staff at our facility underwent training and refresher training for each patient that arrived. All of the SOPs were reviewed by the staff and they were reviewed by infection control nurses at the hospital, by our biosafety department and the infectious disease physicians. It was a multidisciplinary approach.

Again, when moving PPE properly is the key to preventing contamination. I'd have to emphasize this. More PPE is not always better because the more you don the more you doff. So three gloves is not better than two. I just kind of want to put that out there.

There are a lot of SOPs out there. There are a lot that the staff had to remember. So we gave them visual clues on how to make sure - to ensure that they knew how to do it. So donning - we would have checklists in the anteroom for staff to refer to and they were in blue. So everybody knew to look for the blue donning sign. And the same thing with doffing. They would have a buddy who would be monitoring them, but they also could refer to the checklist that was hanging on the wall right by the doffing area, again, in red so that they knew visually what to look for.

So when you guys get the opportunity to look at the PowerPoint, you'll see that we've included two matrixes. These are our PPE matrix. This is how we determined which level of PPE we would use. It's, again, based on clinical condition of the patient. So this is not only for emergency departments, this is for our labor and delivery but this is also for the care of our patients in our isolation unit. So we have it divvied out sort of by role and what that nurse will be doing -- if it's a nurse or if it's environmental services -- and then the clinical condition of the patient.

So if the patient is symptomatic -- which means that they're wet -- I think that's a term that a lot of folks are using now, is if they are wet. They're having diarrhea or vomiting. In our facility we're saying, "Are they wet and are they able to control? Are they able to manage their own toileting or do I as the nurse need to go into the room and help manage that?" And so that helps us differentiate which level of PPE we are going to use.

If you guys have any questions at all, you know, regarding our SOPs or do you want to refer to anything that Nancye and I have talked about today, we do have everything up on our Ebola prep Web site and that is  emoryhealthcare.org/ebolaprep. We welcome you guys to use anything that you possibly need.

Leticia Davila:

Thank you, Dr. Mary Wakefield, Dr. Michael Bell and nurse leaders from Emory and Nebraska for providing our COCA audience with such a wealth of information. As a reminder, questions are limited to clinicians who would like information on caring for patients with Ebola. For those who have media questions, please contact CDC media relations at 404-639-3286 or send an e-mail to media@CDC.gov. We will now open the lines for the question and answer session.

Coordinator:

Thank you. We will begin the question and answer session. If you would like to ask a question, please press Star 1. Please ensure your phone is unmuted and clearly record your name when prompted. To withdraw your question, please press Star 2. One moment, please, while we wait for the first question. Karen, your line is open.

Karen:

Yes, thank you. I would like two things. One for you to repeat that last Web - that last thing that you gave us on where to get information from Emory. And then my question is -- We have access to not very many PAPRs. I was wondering if we could use the MaxAirs? Now I realize the hood is not exactly impermeable. I had heard that Emory was using MaxAirs, is that correct?

Sharon Vanairsdale:

This is Sharon from Emory. I can go ahead and answer both of your questions.

(Karen):

Okay.

Sharon Vanairsdale:

To repeat the Website, it is emoryhealthcare.org/ebolaprep, that's P-R-E-P.

(Karen):

Thank you.

Sharon Vanairsdale:

Sure, no problem. When you get there, you have to insert a couple of questions to say we want to keep track of who is accessing the Web site. But all the information that we talked about is here today. And as far as the PAPRs, you are correct. We do use MaxAirs. I just want to reiterate, you know, how do we get Ebola? How does Ebola spread? And so it's protecting those mucous membranes.

The hoods are completely impervious but we're protecting the eyes, the nose and the mouth with shield. And all of our nurses felt 100% safe in that PPE.

(Karen):

Do you do goggles at all?

Sharon Vanairsdale:

We do not.

(Karen):

Okay. I didn't know with the doffing procedure if the goggles might help.

Sharon Vanairsdale:

We do not use any goggles underneath our PAPRs.

(Karen):

Thank you.

Sharon Vanairsdale:

You're welcome.

Dr. Mary Wakefield:

Thank you. We'll take the next question. Operator?

Coordinator:

(Ann Long), you're line is open.

(Ann Long):

Is there a policy that you guys have for any exposed staff that's caring for the patient as far as what we can do?

Shelly Schwedhelm:

This is Shelly from Nebraska. We do have an employee exposure protocol and that is out on our app. It just basically just walks through the type of exposure - things that can happen and then how to mitigate those and then what are the actions that are needed on the part of the individuals involved.

(Ann Long):

Okay. And that's on the Web site?

Shelly Schwedhelm:

We have an app in ITunes University and that's where ours would be located. I would guess Emory has got theirs on their Website.

(Ann Long):

Okay. All right. Thank you.

Nancye Feistritzer:

This is Nancye Feistritzer. We also have the occupational health protocol for tracking twice daily in terms of temperature monitoring and symptom monitoring. And so that's also available to you on the Emory Website.

Sharon Vanairsdale:

This is Sharon. I just want to add that in addition to that we also have a specific exposure in the room SOP for needle sticks or contaminated gloves, so feel free to refer to that at our Website.

(Ann Long):

Thank you.

Dr. Mary Wakefield:

Thanks so much. Operator, we'll take the next question.

Coordinator:

(Karen), your line is open.

Sharon Kestinger:

Thanks. (Sharon Kestinger) from Baptist Health, Louisville, Kentucky. I know with each one of these cases we get better at what we do. I wonder if our colleagues from Nebraska could share any recent learnings from the care of the patient who passed away recently?

Kate Boulter:

Hi. This is Kate. In learnings, there was a lot that we learned from this patient. Without getting into patient specific care, I really can't go into that very much. Our staff, though, we are very resilient. We know that our training works. We - I'm not really sure how much I can really divulge.

Shelly Schwedhelm:

This is Shelly. I think I would share we have had for nine years now -- since our unit was operational -- a plan for how to care for the remains of a highly infectious patient. That's one of the things that we really - not a lot of surprises in our policy or process that we used. But it was certainly something that needed to be tweaked and refined a bit based upon the outcome that we had, unfortunately.

But certainly some learnings around that as well as, I think, you know, one of the things that we did that was very meaningful -- again, talking about care of self and care of others -- was we had a memorial service for our staff, even though the wife and the family had gone home. The following Monday we had a memorial service with our staff. And so there was information just kind of shared about this physician and his passion and his work in Africa that we were able to glean from other sources. And then all of the staff just kind of talked, you know. And it was -- not an opportunity to de-brief -- but it was a very meaningful thing for the staff to do. So I think that that was a very positive thing.

Sharon Kestinger:

Yeah, exactly what I was looking for. Thanks for sharing. And we've taken the time to check on your app and it looks very helpful; thanks.

Kate Boulter:

Thanks.

Dr. Mary Wakefield:

Thanks much. We'll take the next question, please, Operator.

Coordinator:

(Kristen Cramer), your line is open.

Kristen Cramer:

Hey, this is (Kristen Cramer) from Children's Healthcare of Atlanta. I just wanted to clarify; I had heard someone mention that to be medically screened for wearing a PAPR that we had to have a pulmonary function test. That's not something we've heard before, so I just wanted someone to be able to clarify that.

Shelly Schwedhelm:

This is Shelly from Nebraska. That's not a requirement; it's just something that we had in our process. We just thought it would be helpful to just make sure. And that was put in place well before the Ebola Virus, you know, of knowing kind of we would go with three to four hour shifts for the nursing staff and other things. So it was just always something we had in our process.

And honestly, never had any issues with it. Probably - definitely not necessary, but was just something we had in our process steps.

Kristen Cramer:

Okay, thank you so much.

Coordinator:

Okay, your line is now open.

(Gay Hay):

Yes, this is (Gay Hay) from Hendricks Medical Center in Abilene. And our question is; we understood that the employees may be taking care of patients in other areas. So what are the considerations for allowing patients to work not only in this unit, but in other units as well?

Nancye Feistritzer:

This is Nancy Feistritzer from Emory. So when we had our unit activated, we basically lifted folks out of their critical care unit and did our best to dedicate them to the unit, primarily in order to -- because this is very intense care -- to allow them to be focused with the shifts that are required within the unit. And we did not -- from a fatigue management perspective -- want them to basically be going - having to fill any obligations for their critical care shift that they had left behind, if you will.

Parenthetically, for the critical care nurses or any individuals that are covering areas where staff have left to go work in the particular unit, that is a consideration that you need to really manage proactively is how do you backfill those shifts? Having said that, as the acuity of patients evolves and the same staffing level may not be needed, we do have a transition period where individuals can be working back within their unit.

But I think it's important to acknowledge that these individuals follow very, very strict PPE and the doffing and de-contamination procedures are extremely rigorous. You know, they're doffing and they're showering every time they leave the area. And so there was no need to quarantine them or keep them away from other individuals.

So it was really a matter of how do we support them, how do we meet the needs of our SCDU as well as our critical care units -- their home units -- and how do we ensure that we don't put those staff kind of in the middle of needing to meet two staffing needs. Sharon, what would you add to that?

Sharon Vanairsdale:

I think you nailed it, Nancye. Again, remembering how is Ebola spread? Is, you know, somebody asymptomatic and they have nausea, vomiting, you know, diarrhea, you know, they're symptomatic. And none of our staff would ever go to their units being symptomatic because of the occupational health and the plan we have in place. So - thank you.

Shelly Schwedhelm:

This is Shelly from Nebraska and Kate and we totally agree with our Emory colleagues on this. Many of our staff, you know, they all went home at night and some of them were grad school students, some of them were coaches in - on community boards. There was just no need to do any kind of isolation or anything of that nature, given the fact that these are non-symptomatic people who took every precaution necessary. So...

Woman:

And who were being monitored actively.

Shelly Schwedhelm:

Correct. Very good point.

(Gay Hay):

Thank you, that helps tremendously.

Dr. Mary Wakefield:

Next question, please.

Coordinator:

(Terri Roberts), your line is open.

(Terri Roberts):

Hello. My name is (Terri Roberts), I'm from Children's Hospital of Pittsburgh and I have a question; after the donning - or doffing procedure is completed, do you do anything specific to decontaminate personal eyeglasses?

Sharon Vanairsdale:

This is - go ahead, Shelly.

Kate Boulter:

Actually, this is Kate in Nebraska. Yes, we bleach dump them. So we would wipe them first with a bleach wipe and then we would put them in a container of bleach water, 1 in 10 solution. After it dried, then we would have the people wash it with soap and water, just to get the bleach residue away from it.

(Terri Roberts):

Okay. And another question that I did have from a nurse who asked me after they showered, what would they do with their undergarments? Do they dispose of them?

Kate Boulter:

This is (Kate) in Nebraska. Yes. We provided our staff with underwear and yes, we had them dispose of it afterwards. Because, you know, it could be laundered after it was put through the autoclave, but no one really wanted to wear underwear that was worn by someone else before.

(Terri Roberts):

Alright, thank you so much.

Shelly Schwedhelm:

This is Shelly from Nebraska and I'll have our Emory colleagues jump in here, too. Obviously this is not something that's required or an absolute. It was something that just added a dimension of support for the staff that they requested. So...

(Terri Roberts):

Okay, thank you.

Dr. Mary Wakefield:

Next question, please.

Coordinator:

(Linda Cain), your line is open.

(Linda Cain):

This is (Linda Cain), Concord Hospital. Question; did you have all your SOPs available and - beforehand, before you took care of the Ebola patient? And also, did you drill anything further besides donning and doffing and decon? Thank you.

Nancye Feistritzer:

This is Nancye Feistritzer. We did in fact have many of our protocols in place and twice annually drilled on a number of possible pathogens and the transportation methods for transporting patients via EMS. In fact, we have done a drill the week before we received our first patient. Having said that, one of the most important aspects of this is to be able to evolve your protocols to meet the unique needs of the situation. And so I would say that our protocols evolved rapidly and consistently with a good way to communicate that.

(Linda Cain):

Great.

Dr. Mary Wakefield:

Next question, please.

Coordinator:

(Cindy), your line is open.

(Cindy):

Hi, this is (Cindy) from Altman Hospital in Canton, Ohio. Can you please describe the process of utilizing a disposable stethoscope without touching your donned PTE? Do you use multiple stethoscopes and discard them or - we tried to mimic that process here and we can't quite figure it out.

Kate Boulter:

Okay, this is Kate in Nebraska. So yes, when we had our first patient, we were using disposable stethoscopes. And our method was to put them in our ears before we went into the room while during the donning process. Once you used it in the room, then someone else with clean gloves on would remove it from you without actually touching you. And then they were just put in the trash right away and not re-used again.

We have since moved on as well to use now an electronic stethoscopes, but it's kind of the same process, where we put the ear buds into our ears before we go into the room and they're disposable as well. And so - and then you plug it into the stethoscope in the room. After you're done doing your auscultation, then you remove the ear buds and dispose of them. And the actual electronic stethoscope doesn't leave the room.

Sharon Vanairsdale:

And this is Sharon from Emory. We actually were able to auscultate through our PAPRs. The MaxAir allowed us to auscultate, so we kept a reusable stethoscope; it stayed in the room and was disinfected between each use, but we were able to auscultate through our PPE.

(Linda Cain):

Thank you.

Dr. Mary Wakefield:

Next question, please.

Coordinator:

(Stephanie), your line is open.

(Stephanie):

Yes, this is (Stephanie) from Udville Medical Center. And I have a question about the undergarments and shoes and things. To - I mean, you get patients frequently -- or are expecting them, I guess -- do you keep a variable amount of sizes of those on hand? Or do you go out and buy them just in time for the people that you know are going to be in the room?

Sharon Vanairsdale:

This is (Sharon) from Emory. We actually keep multiple sizes of each. So we keep shoes in our - where we don and we keep two sizes of all shoes and they're reused - they're cleaned after each time that the individual doffs and they go up back on the drying rack to be reused the next time. And the same thing with the disposable undergarments. Shelly and Kate, do you want to add on?

Kate Boulter:

We would agree with that. That's - we kept some of every size, small, medium, large, extra large of both, you know, sports bras and underwear. And then our shoes are reused just like you do, Sharon at Emory with - we dunk them in the bleach and then dried them.

(Stephanie):

And do you have a specific shoe that you find that works well for you?

Shelly Schwedhelm:

This is Shelly at Nebraska. We use the Crocs with the back - they need the back sling on them.

Sharon Vanairsdale:

And this is Sharon from Emory. We use something very similar to that plastic material. It definitely has to have the back on it so that you don't - your shoes don't come off when you're coming out of your PPE. But we don't like the ones with holes. You know, sometimes Crocs have like holes and there's a bunch of them. They're completely closed.

Shelly Schwedhelm:

Yeah, and ours are, too. The closed toe Crocs, yep.

(Stephanie):

Thank you very much.

Dr. Mary Wakefield:

(Unintelligible). We'll take one more call, Operator. Or excuse me, one more question, Operator.

Coordinator:

Thank you. Our next question comes from (Mary). Your line is open.

(Mary Newton):

My - this is (Mary Newton) at Flaget Hospital in Bardstown, Kentucky. And I was wondering if we don't have a Smartphone, then can we get your information, Nebraska, that's on your app?

Shelly Schwedhelm:

Yes. Actually it can also be downloaded in Moodle.

(Mary Newton):

What's that?

Shelly Schwedhelm:

Let's see. It's - actually if you go the slides out on the Website, you can get the address there. It's http://phtc.unmc.edu/moodle.

Dr. Mary Wakefield:

Thanks so much. This is Mary Wakefield again and I want to bring this call to a close. In just a moment I'll refer back over to my colleague Leticia and CDC, but first let me thank Dr. Bell from CDC for spending some time with us and sharing information. And also special thanks to our nurse presenters from the two institutions that joined us today who shared just a wealth of experience and expertise. On behalf of all the nurses who are on the phone, let me say a special thanks to the four of you who so generously gave of your time not just in presenting and taking questions but also in preparation - the preparation that went into coming into this particular call.

Leticia, I'd like to refer to you now and have you share the information sources -- the PowerPoint slides -- the source where people can find those slides I think would be very helpful, because some of the questions about Websites, etcetera, that information -- from Emory and Nebraska Medical Center -- are located as part of the slide set.

So for folks on the phone who'd like to get that information that was covered or know where to go on the Web, etcetera for the two institutions, they should be able to find that information if they go to the CDC site. And Leticia will provide you with that information now. From the Health Resources and Services Administration, let me say again thank you to all of the presenters. Leticia?

Leticia Davila:

Yes, thank you. On behalf of COCA, I would like to thank everyone for joining us today with a special thank you to our presenters. The recording of the call and the transcript -- along with the PowerPoint slides -- will be posted to the COCA Website at emergency.cdc.gov/coca within the next week. The PowerPoint slide set is now available on that Website.

There are no continuing education credits for this call. Resources for clinicians related to Ebola are available on the COCA Call Web page. Go to emergency.cdc.gov/coca. Click on COCA Calls and then follow the links for today's call. To receive information on upcoming COCA Calls, subscribe to COCA by sending an e-mail to coca@cdc.gov and write subscribe in the subject line. Thank you again for participating in today's COCA Call. Have a great day.

Coordinator:

This concludes today's conference call. Thank you for participating. You may disconnect at this time.

END