By Gary Evans, Senior Writer
The Ebola outbreak that fueled fear in America and still smolders on in West Africa has left infection preventionists with a legion of lessons to ponder. Accordingly, practical points on improving communications, training, donning and doffing of protective gear were recently discussed in Nashville at the opening session of the annual APIC conference. But in addition to some 4,300 infection preventionists, there was an elephant in the room.
Michael Bell, MD, deputy director of the division of healthcare quality promotion at the CDC, started the topic once the discourse on the rigorous demands of Ebola infection control concluded.
“I will ask you based on what we have seen, is this what [infection control] looks like when we decide we are really going to do it for real?” he said. “There are hundreds of thousands of infections being caused, transmitted through hands, a soiled environment — all of the things that we paid attention to for Ebola, but we seem to be doing it in a different way. Granted, it is a more threatening infection, we certainly fear it a great deal more, but the person who just had a bypass operation is fearful of MRSA. What does this mean for us as a profession down the road?”
It was a tough question, implying that some, if not many, of the 75,000 patients lost every year to healthcare-associated infections (HAIs) could be alive today if they had been treated with the vigilance applied to Ebola. Indeed, in the silence after his comments, Bell asked, “Was that too honest?”
Applying some of the approaches used in the care of the 10 Ebola patients treated in the U.S. would cause some culture shock at hospitals using the entrenched, hierarchical approach of traditional medicine. Imagine going from that to a system where all healthcare workers are empowered to speak up about a breach or oversight that may endanger other healthcare workers or the patient.
“There’s no hierarchy. Everybody was expected — not only allowed to, but expected to go up to anybody else and say, ‘The back of your gown isn’t taped,’ or, ‘I saw you accidently touching your visor,’” said Philip Smith, MD, medical director of the Nebraska Medicine Biocontainment Unit in Omaha. “It was a classless society, and that’s the only way we could get it done and achieve maximal safety.”
Citing this concept of a “level playing field,” APIC 2015 President Mary Lou Manning PhD said, “I think that is something we are challenged with all the time. How did you do that?”
“We really put a premium on it,” Smith said in the panel discussion. “We did it in our drills and in real life. Basically, if somebody came up to me and said, ‘I made a suggestion to Dr. X and they didn’t like it,’ Dr. X was not invited back. It [extends to] leadership, too — they loved to catch us. I would say ‘thank you.’ And at our next team meeting I would stand up and say, ‘thank you [again], you may have saved my life.’”
No room for error
One of only four medical biocontainment units in the country, the Nebraska unit has a staff of volunteers that continuously train to prepare for any and all emerging infections and bioterror agents. “We drilled ad nauseum and we are really glad we did because it is hard to be prepared enough,” Smith said. “Was it like we expected? Yes and no. Some things were different, most of them we tried to anticipate. But it is hard to anticipate what it is going to be like when they are rolling an Ebola patient on a cart down the hall. Suddenly, nine years of drills have been translated to reality and there is not much room for error.”
One of the three Ebola patients admitted to the unit last year required dialysis and a ventilator, examples of advanced medical practices that may not be available in an Ebola treatment tent in Africa. “In resource-limited settings we very specifically tried not to do things that could be more dangerous — things that could be at risk of tipping the patient over, when you can’t rescue them again with things like dialysis,” said Bell, who has experience treating Ebola patients in Africa. “In U.S. hospital settings, we are able to do more and the challenge becomes … what are the new things we need to implement to make sure that the healthcare delivery can be done safely?”
Such procedures may increase the risk to healthcare workers, as they create more opportunities for body fluid exposures and the possible generation of aerosols. Smith showed a slide of an intensivist working in the unit in full gear and three layers of gloves to put an intravenous line in an Ebola patient.
“Even though he practiced many times putting a line in with three pairs of gloves on a simulation model, it is just not the same as real life,” Smith said. “One is very cognizant of the needle’s potential contamination.”
After a procedure is performed and a worker is ready to leave the patient care area, there is a huge emphasis on carefully and correctly removing each piece of PPE in an order and manner that will not expose the worker. The emphasis on carefully removing PPE using a buddy system could have implications for control of other infections like Clostridium difficile, he said.
“We realize not every floor in the hospital can have a doffing partner when you come out of a C. diff isolation room, [but] I think there are some lessons that can be learned from this,” he added.
An immediate application of the Ebola training in donning and doffing of personal protective equipment is the continuing emergence of Middle Eastern Respiratory Syndrome (MERS) coronavirus, said Russell Olmsted, MPH, CIC, director of infection prevention and control at Trinity Health in Livonia, MI.
“Clearly with Ebola we understand that doffing is the critical control point, so we want to make that as safe as possible,” he told APIC attendees. “Lessons learned from that we can easily extend to MERS coronavirus. It’s the same issue.”
Challenge of change
But could such attention to detail — such equanimity among doctors and nurses, for example — be applied to day-to-day infection control? Some of the volunteers in the Ebola care unit took their team’s mindset back to their regular jobs at the University of Nebraska Medical Center, but found a very different reaction from co-workers.
“They went back to their normal floors and when they found someone not washing their hands or changing a dressing without gloves, they mentioned this to them,” Smith said. “The person would not say thank you — they would growl at them. This in a way caused more frustrations. This is something we have to do and it is something that we can do: insist on a level playing field.”
This concept is not completely foreign to infection control; indeed, it was used to great effect in the step-by-step checklist for central line insertion developed by Peter Pronovost, MD, at Johns Hopkins. A key feature of the program, which resulted in dramatic reductions in central line-associated bloodstream infections (CLABSIs) nationwide, is that all team members are empowered to “stop the line” if they see a break in the protocol.
“There are a lot of people who contribute to the care of the individual patient,” Bell said. “It’s an extension of the CLABSI approach: If you insert the central line perfectly every time, you can reduce central line-associated infections by 70%. So therefore you have to because that’s an ethical imperative. What is the same sort of concept when it comes to the rest of care? It’s daunting — it’s a huge issue.”
The Ebola response teams essentially systematized every step of healthcare and practiced transparency by removing traditional barriers to open dialogue during patient care.
“There’s nothing more valuable than a pair of fresh eyes to give you an external perspective of what you’re doing,” Bell said. “We all become very comfortable with our way of doing things, with our habits. I think this kind of approach is new to American medicine. It ties into some of what we are doing with HAIs. We are now tracking how facilities are doing. If a facility, a unit, is having a high rate of something, we can call and ask to come [in and] help. It’s not punitive. This is a very forward-leaning approach to improving quality. I’m looking ahead at how this [kind of] relationship may lead to a new kind of medical care.”
Indeed, in the wake of a historic Ebola outbreak, such transformations of safety culture could have momentum.
“Really looking at this level playing field — no more hierarchy — I am thinking of the entire culture of safety,” Olmsted said. “Co-workers feeling comfortable to bring up concerns, accountability, and also the receptivity to that accountability. They are the key lessons learned and improvements we could spread for not only a response to a new zoonotic disease, but also the daily stuff that we deal with: CLABSIs, CAUTIs, C. diff, MRSA, you name it.”
One striking difference
With the notable exception of MERS, many HAIs have one striking difference when compared to Ebola. Healthcare workers may acquire nosocomial pathogens, but they rarely die of them. In the Ebola outbreak in West Africa that is still receding, 509 healthcare workers have given their lives trying to save others. As of July 5, the deaths translate to a mortality rate of 58% of the 875 infected healthcare workers, the WHO reports. (See related story, p. 90.) Two Dallas nurses acquired Ebola, but both survived. Of the 10 patients treated for Ebola in the U.S., two died, one at Texas Health Presbyterian Hospital in Dallas, and the other at the Nebraska biocontainment unit.
“A sad moment — our 3rd patient arrived in florid shock,” Smith said. “We had him for 36 hours and we were never able to save him. People for 36 hours solid put their heart and soul into it. And they could not save this individual. Afterward, even though we didn’t know the family very well, we had a memorial ceremony. Lots of hugs, kisses, crying, and individuals standing up spontaneously and calling out their partners on the team and saying, ‘We did everything we could, we did great as a team.’”
Victories were celebrated as well, as Smith showed a slide photo of the first patient running down the hall giving the healthcare team high fives after being discharged Ebola-free. Indeed, for all the hysteria, the medical response to Ebola in the U.S. was really a success story made possible by the infection control infrastructure in this country, said Patti Grant, RN, BSN, MS, CIC, a former APIC president and the director of infection prevention and quality at Methodist Hospital for Surgery in Addison, TX.
“The discipline [of infection control] is so important,” Grant said in a video montage of IP comments shown during the APIC Ebola session. “Think about what would have happened if we were not here when this happened in the United States. We did have healthcare transmission, but it stopped dead in its tracks. We have so many resources here that other countries don’t have. We need to take advantage of that and get as close to zero infections as we can.” (See related story, this page.)
Eye of the storm
Echoing a theme underscored by Manning in her APIC presidential address, Bell concurred that IPs provide a calm voice of assurance in an infectious disease crisis. (See related story, p. 89.)
“This is part of the stock and trade of IPs,” he said. “When things are messy, when things are confusing, when things are frightening, the calm voice of evidence-based rationale is what people are hungry for. I see this again and again where the trusted source of information ends up being an IP.”
In the aftermath of Ebola, IPs should extend outreach and form relationships with those they work with for the next infectious disease threat, he said. Another critical role IPs can fill is to explain to healthcare workers and others the rationale for barrier precautions and other infection control measures.
“Explain the reasons for the rituals,” he said. “I think this group, in particular, APIC is well poised to bring that knowledge to the people that we work with so they understand why a gown is important, they understand why it is the face we are focusing on.”
If nothing else, every IP should be overly familiar with all manner of protective gear after the gold rush for PPE when it appeared that an Ebola patient could walk into any hospital in the country. Actually, that is still the case.
“Suddenly we are all simultaneously gathering all types of equipment, especially the gowns and PAPRS — going from a minimum stock to a hundred. The scalability was absolutely huge,” Olmsted said. “And there are some great lessons we’ve taken away from that. The biggest question I get almost every day is, ‘When can we take the signs down, Russ?’ I say stay the course. It’s not all clear.”
Indeed, there were 30 confirmed cases of Ebola virus disease (EVD) reported in the week ending July 5 in Guinea, Liberia, and Sierra Leone. “Although this is the highest weekly total since mid-May, improvements to case investigation and contact tracing, together with enhanced incentives to encourage case reporting and compliance with quarantine measures, have led to a better understanding of chains of transmission than was the case a month ago,” the WHO reported. As of July 5, there were a total of 27,573 reported confirmed, probable, and suspected cases of Ebola in West Africa, with 11,246 reported deaths. That translates to a mortality rate of 41%.