Is your staff prepared if a patient with Ebola walks in the front door? Eye surgeon’s office shares experience with potential exposure
By Joy Daughtery Dickinson
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Outpatient surgery staff and their physicians’ offices are accustomed to reacting quickly when a potentially dangerous situation arises, but until recently, you probably never thought that you would ever have a patient who potentially has Ebola. However, an Alabama ophthalmology practice, next to a surgery center, found itself in this situation during October. An 84-year-old woman of Nigerian descent showed up with a swollen neck and aches and pains. The staff asked her if she had traveled outside of the country. The woman replied that her son, who lived with her, had returned from Nigeria in the past few days.
Just before noon, the woman had arrived alone, in a wheelchair, via public transportation at Montgomery (AL) Eye Physicians. The staff immediately ramped up to follow the practice’s contagious infectious disease protocol. "So she was placed in a room by herself, outside of, obviously, the general patient population and away from employees until such time as we could determine what the true situation was," says Barbara Cardinal, public relations, marketing, and refractive surgery manager with Montgomery Eye Physicians.
The woman’s temperature was taken, and it was elevated. It was taken again within 30 minutes, and it was more elevated than it was the first time.
The woman’s primary care physician was contacted, who would not see her at his office and requested that she be transported to the hospital. The ophthalmology practice contacted a private ambulance transport company. Staff members also contacted the Alabama Department of Public Health and the Centers for Disease Control and Prevention (CDC).
The CDC confirmed that staff members took the correct step in isolating the patient and advised them to manage the patient flow in and out of the practice as well as keep employees at the practice for the time being. "We had to close the doors to limit the potential for exposure until we could contain the situation," Cardinal says. A staff member stood outside, in front of the main entrance, and told arriving patients that there was a medical situation inside the practice being addressed and that they would be contacted to reschedule their appointments. The schedulers called patients and cancelled the afternoon appointments.
When the ambulance EMTs, paramedics, and the ambulance service supervisor arrived, the staff told them that the CDC and the state health department wanted them to follow Ebola guidelines because of the patient’s potential exposure. The ambulance staff had personal protective equipment (PPE), but they didn’t have with them the level of hazmat suits required to transport a potential Ebola patient. The ambulance company contacted the fire department for assistance, and that department’s fire and rescue hazmat team transported the patient to the hospital on a stretcher covered by a plastic isolation bubble.
In the meantime, staff members had been unable to reach the son or other family members. Eventually a staff member reached a grandson who said that he wasn’t sure whether that relative had returned recently from Nigeria, but he said he knew his aunt currently was in Nigeria.
The areas where the woman had been sitting, as well as her wheelchair, were decontaminated with a bleach spray by the hazmat team. An employee of the state health department met with staff members and advised them to follow the CDC protocol until they were notified otherwise. They were instructed to take their temperature twice a day for 21 days and to report any changes in their health.
However, within a short time, the CDC confirmed that the patient’s son had not traveled outside of the country in seven years. Staff members and patients who were in the center at the time of the woman’s visit were informed. The woman was found to have a virus that was not Ebola.
Looking back, Cardinal says the office’s procedures worked exactly as they were outlined, and she has advice for other ambulatory providers: "Make sure your office is prepared," she says. "It doesn’t matter the size of your office. They could walk into any medical facility at any time."
OR guidelines created
In guidelines from the American College of Surgeons, the group points out that when this most recent outbreak started, there were no guidelines for OR staff and surgical providers who might be called up to perform surgery on a patient with confirmed or suspected Ebola.1
The surgeons group subsequently took relevant recommendations from the CDC and applied them to the OR environment in a document titled Surgical Protocol for Possible or Confirmed Ebola Cases. (See resources at the end of this article.) The guidelines were co-authored by Adam Kushner, MD, MPH, FACS, a general surgeon and associate at the Johns Hopkins Bloomberg School of Public Health in Baltimore, MD, and founder of Surgeons OverSeas (SOS), which supports surgeons, hospitals, and Ministries of Health in low- and middle-income countries to help develop long-term surgical capacity.
"Hopefully most outpatient surgery centers and hospitals will be unaffected by the Ebola crisis," Kushner says. "However, it is important to realize that Ebola is a very dangerous and contagious disease and, as we have seen in Dallas, there is the possibility of it in the U.S."
Until Ebola is controlled in West Africa, it can spread, he warns. "While most managers may feel that their centers will be unaffected, it is still prudent to understand the risk factors, prepare for a possible infected patient, and make sure that all staff are aware and prepared on how to deal with an Ebola-positive patient," Kushner says.
Here are suggestions about how to be prepared:
Have protocols in place to screen patients.
The CDC as well as the American College of Surgeons recommends that patients with suspected or confirmed Ebola not have elective surgical procedures. While there was no specific guidance for outpatient surgery providers at press time, the CDC is recommending these providers have protocols to screen patients for illness, says Amber Wood, MSN, RN, CNOR, CIC, perioperative nursing specialist at AORN. Wood is the author of Ebola: perioperative considerations, an open access Special Feature on the AORN Journal home page. (See resources at end of this article).
"We’re preparing ourselves should the need arise," Wood says. "All [of the Perioperative Considerations] are evidence-based. It’s a rapidly evolving situation, so we’ve incorporated some good old common sense and heightened precautions."
Familiarize yourself with guidance on screening for Ebola from the CDC and other sources, and develop Ebola protocols for your facility, Kushner advises. "Hopefully they would never be used, but at this point education, preparation, and planning is important," he says.
Use airborne precautions if a patient with Ebola is having non-elective surgery.
AORN recommends that airborne precautions be taken when caring for an Ebola patient in the surgical setting in addition to standard, contact, and droplet precautions.
"Airborne precautions are necessary in the OR because most invasive procedures involve aerosol-generating procedures such as airway management of the patient during intubation and extubation," Wood says. (For the latest information on aerosol-generating procedures from the CDC, go to the CDC Web site: http://1.usa.gov/1pvUSQz.)
The AORN’s Recommended Practices for Prevention of Transmissible Infections in the Perioperative Practice Setting provides detailed guidance for perioperative RNs on implementing standard precautions and transmission-based precautions, the association says.
Stay updated on CDC guidelines.
The Ebola crisis is "a developing situation," so monitor CDC guidelines, as they are continually updated, Kushner says. The American College of Surgeons’ guidelines also are expected to be updated as new information comes available, he says.
Cardinal offers some final words of advice: Have a procedure in place.
"You never know," she says. "It sounds cliche, but it’s far better to be prepared and have a procedure in place, discuss with your staff, discuss with your managers, so in the event that it happens, they are prepared."
And rehearse, just as you do with fire drills, Cardinal advises.
"You don’t have a chance after the fact to go back and say, Well, if we’d done this, maybe the building wouldn’t have burned down,’" she says. "With a true Ebola exposure, you don’t get a second chance with it." [For information on an Ebola-related lawsuit, see the related story below. For more about Ebola and surgery, see our publisher’s Hospital Report blog, http://bit.ly/1nT4gAm. For information on a checklist from the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), see "Surgery centers provided Ebola checklist," Same-Day Surgery, November 2014, p. 123.]
1. Wren SM, Kushner AL. Surgical protocol for possible or confirmed Ebola cases. Oct. 7, 2014. Web: https://www.facs.org/ebola/surgical-protocol.
- The American College of Surgeons has a Surgical Protocol for Possible or Confirmed Ebola Cases. Web: https://www.facs.org/ebola/surgical-protocol. It has an ACS Ebola Virus Transmission Resources & News website. Web: https://www.facs.org/ebola.
- The Ambulatory Surgery Center Association has an Ebola Information Center web site. Web: http://bit.ly/1pbXDoi.
- The American Hospital Association has an Ebola Preparedness Resources webpage. Web: http://bit.ly/1u9uATM. The AHA also has provided an Ebola education package for CME providers. It includes Informational PowerPoint: Ebola Facts (Web: http://bit.ly/1sXvFSx) and FAQ: Safe Management of Patients with Ebola Virus Disease (EVD) in U.S. Hospitals (Web: http://bit.ly/1xZzg2s).
- The Association of periOperative Registered Nurses (AORN), in the online edition of AORN Journal, has published a special open-access feature titled Ebola: perioperative considerations. Web: http://www.aornjournal.org. The association also has a web page for frequently asked questions. Web: http://bit.ly/1rA4hV3. AORN also is posting updates to its AORN Facebook page. Web: https://www.facebook.com/AORN.
- Officials with the Centers for Disease Control and Prevention are available to assist 24/7 by calling the CDC Emergency Operations Center at (770) 488-7100 or via email at firstname.lastname@example.org. The CDC also has an Ebola page. Web: http://www.cdc.gov/vhf/ebola.
- • The Joint Commission has an Ebola Preparedness Resources section. Web: http://bit.ly/ZH9Ryi.