The 2014 Ebola Virus Disease (EVD) outbreak of West Africa was a wake-up call for healthcare administrators and clinicians in the United States. EVD had been viewed as a third world problem, a crisis that would most likely never strike America. Last October, however, we witnessed the first patient diagnosed with EVD on U.S. soil, a Liberian man who ultimately passed away in a Dallas hospital after infecting two of his nurses, both of whom fully recovered. At the time, healthcare providers faced with the potential spread of the infectious disease had to piece together protocols based on limited knowledge and standards of care for patients infected with EVD. The majority of hospitals were unprepared should an infected patient walk into its Emergency Department (ED). Most did not have appropriate isolation rooms, personal protective equipment (PPE) or adequate staffing to safely care for these patients.
According to the World Health Organization (WHO), EVD remains a Public Health Emergency of International Concern (PHEIC)
1. Two active chains of EVD transmission continue, one in New Guinea and one in Sierra Leone, resulting in approximately 5 new cases each week
1. Are U.S. hospitals better prepared and are nurses safer today to care for patients with highly infectious diseases than they were a year ago? The answer may be yes for a handful of centers that have received advanced training, education and government funding, however, that is not the case for over 5,000 hospital institutions across the country.
In response to the outbreak, the Centers for Disease Control and Prevention (CDC) established a three-tiered approach to guide hospitals and other emergency healthcare clinics in developing preparedness plans for patients under investigation (PUI) or with confirmed EVD
2. According to this plan, hospitals can serve in one of three roles: as a frontline healthcare facility, an Ebola Assessment Hospital or an Ebola Treatment Hospital.
All hospitals are considered
frontline healthcare facilities and each plays a critical role in the identification, isolation and evaluation of PUIs for EVD. Once identified, the institution is responsible for informing the facility infection control department, as well as the state and local public health agency, and promptly placing the patient in isolation. The frontline hospital is not expected to provide prolonged care for the patient for more than 12 to 24 hours and should coordinate immediate transfer of the patient to an Ebola assessment hospital or Ebola treatment hospital.
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.PNG.aspx "Ebola assessment hospitals")
Ebola assessment hospitals are facilities that are prepared to receive and isolate PUIs and care for the patient until diagnosis of EVD can be ruled out or confirmed and until discharge or transfer is completed. They should be prepared to care for PUIs for up to 96 hours, should be equipped with adequate PPE for four to five days and ensure that staff members involved in or supporting patient care are appropriately trained for their roles. This includes demonstrated proficiency in putting on and taking off PPE, proper waste management, infection control practices, and specimen packaging and transport.
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Ebola treatment hospitals are facilities that plan to care for and manage a patient with confirmed EVD for the duration of the patient’s illness. These centers must meet minimum criteria determined by the CDC, including infection control capacity, physical infrastructure, staffing resources, PPE supplies, waste management processes, worker safety training, environmental services and laboratory set up.
3 Staff must be trained in and have practiced putting on and taking off PPE for Ebola, as well as providing clinical care using PPE. CDC Ebola Response Teams (CERTs) are ready to deploy to any Ebola treatment center to provide technical assistance for infection control procedures, clinical care and logistics of managing patients with EVD as soon as the health department or hospital requests assistance.
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Fifty-five hospitals have been identified as Ebola assessment centers. Of those, nine hospitals have been designated as Ebola regional treatment centers and have received government support and advanced training to meet the CDC minimum criteria. The Department of Health and Human Services (HHS) does not mandate that every state adopt this approach, however, all are encouraged to identify Ebola assessment hospitals that can successfully manage PUIs or confirmed cases of EVD.
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The CDC released
comprehensive guidelines for frontline hospitals in the management of patients with EVD from identification through treatment. The recommendations are not government mandated and can be expensive to implement, therefore most facilities have not instituted these safe practices nor have they provided training to their frontline nurses. The responsibility falls on healthcare administrators, local state departments of health and the Occupational Safety and Health Administration (OSHA) to ensure these guidelines have been executed.
California is one state that has issued mandatory safeguards to protect healthcare workers from EVD by requiring hospitals to provide head-to-toe PPE and comprehensive training for staff caring for Ebola patients.
4 The guidelines require California hospitals to provide staff with full-body protective suits that meet the ASTM F1670 standard for blood penetration and the F1671 standard for viral penetration and that leave no skin exposed or unprotected.
4 Hospitals must also provide powered air-purifying respirators with a full cowl or hood for the head, face and neck of any RN or other staff member who provides care for a suspected or confirmed Ebola patient. Hands-on training must be provided for any worker who is at risk of exposure.
4 These regulations are mandatory in California and if hospitals do not comply with the guidelines, they will incur fines and penalties.
The precedent set by California is one that should be adopted by every state and local health department across the country. All nurses deserve adequate information and training on the care of EVD patients and their safety and well-being must remain the highest priority. Do you believe that your institution is prepared today to care for an EVD patient? Do you feel that you have received adequate training and that you would be at minimal risk of contracting EVD or other highly contagious diseases? (
You can see how some nurses responded to this question in this JONA article.) Please let us know how you feel by leaving a comment!
In-Person Ebola Training should be mandatory and include:5
- Learning to don (put on) and doff (remove) the PPE – performed under direct observation following itemized and standardized verbal instructions; practiced four to six times; no one is allowed in the warm zone (anteroom) or hot zone (patient room) without donning full PPE under close observation and direction of trained nurses
- Performing routine tasks while wearing multiple layers of PPE
- Enhancing safety skills: slowing down; paying attention to sharp objects, stopping and thinking through movements before beginning a task; placing one’s immediate safety before the needs of the patient; always working in pairs – one nurse cares for the patient, while the second nurse watches for breaks in PPE, disinfects the environment, prepares trash for removal, and assists with turning or two-person procedures
- Handling waste: moving slowly when handling bedpans, canisters and urinals, always covering the container; all liquid waste is decontaminated for 15 minutes before flushing
- Cleaning and disinfecting healthcare environments
Myrna B. Schnur, RN, MSN
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