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When the first Ebola case appeared in the United States last fall, demand for personal protective equipment surged and led to shortages. But as fears of Ebola transmission in the United States subsided, a silver lining emerged: Hospitals are working together to become more prepared not just for Ebola, but for other novel infectious diseases.
Hospitals have been buying powered air-purifying respirators (PAPRs) with disposable hoods, a device that is more protective—but also more expensive—than the N95 respirators typically used with tuberculosis and novel influenza viruses. They are also connecting with regional and state health care coalitions that can manage resources and provide additional protective gear, as needed. The Centers for Disease Control and Prevention also announced a new $2.7 million federal investment in a national stockpile of PPE.
“PPE is expensive, [so] it is much more efficient if it is purchased at a coalition level or a community or state level than it is by every hospital in the country,” Nicole Lurie, Assistant Secretary for Preparedness and Response (ASPR) at the U.S. Department of Health and Human Services, said on a conference call with coalition leaders.
Shortages were predictable as demand surged globally for protective equipment, says Dan Shipp, president of the International Safety Equipment Association in Arlington, VA. The need is obviously intense in West Africa, but U.S. hospitals should conduct a hazard assessment to determine what PPE they need to store and what they could obtain on an as-needed basis, he says.
“The coordination among regional organizations is something that is evolving and is going to be an important part of making sure there’s enough supply and it gets to the right places,” he says.
The infection of two nurses with Ebola placed a harsh spotlight on hospital preparedness. It became a rallying cry as a national nurses’ union held protests around the country, saying that hospitals still did not have adequate protective equipment.
But in the aftermath of the first U.S. Ebola cases, the hazards and the needs became clearer. With CDC screening all travelers to the United States from Liberia, Sierra Leone and Guinea, public health authorities are actively monitoring those with a travel history from West Africa who are at risk for Ebola, says Melissa C. Harvey, RN, MPH, acting deputy director in the Division of National Health Care Preparedness Programs of the Office of the Assistant Secretary for Preparedness and Response in the U.S. Department of Health and Human Services.
“It’s much less likely now that a patient that no one is aware of is going to walk into a random emergency department,” she says.
Still, every hospital needs to have enough PPE, including powered air purifying respirators (PAPRs), to assess and care for a suspected or confirmed Ebola patient until the patient can be transferred to a specialty care facility, she says.
In California, the only state with an Aerosol Transmissible Diseases standard, employees caring for a patient with suspected or confirmed Ebola infection “must use PPE that covers all surfaces of the body so that absolutely no skin is exposed,” according to updated Cal/OSHA guidance. (See editor’s note on resources at the end of this article.) That includes PAPRs if there is a chance that an aerosol-generating procedure might occur or an N95 or higher if there is no risk of an aerosol-generating procedure, Cal/OSHA said.
Through regional planning, hospitals can coordinate so they are using the same models and brands of PPE and can assist each other with supplies, as necessary, says Harvey. (For information on PPE cost, see box on page 3.)
Selecting the right PPE requires some careful consideration of the real-life dynamics – how long it would be worn, which employees would need to wear it, and under what circumstances.
Hospitals should conduct a hazard analysis of every job and determine the potential for exposure and the nature of that exposure, says Shipp. Medical screening may determine that some employees cannot wear the required PPE for extended periods. For example, some hospitals have screened out pregnant women or employees with certain medical conditions, including asthma, diabetes and seizure disorders.
Meanwhile, employee health and infection control professionals should work with purchasing and safety officers to ensure that the PPE meets the appropriate standards, says Shipp.
“All of these things have to go into the hazard analysis to make the decision about not only what articles of PPE the person needs, but the capabilities of the PPE,” says Shipp.
“Human factors” should be part of that evaluation, says Jim Davis, MSN, RN, CCRN, CIC, HEM, infection prevention analyst at the ECRI Institute in Plymouth Meeting, PA. Working in PPE can be cumbersome and uncomfortable, and with Ebola, even just a simple urge to itch could be dangerous, he says.
Davis suggests conducting drills with a real-life scenario, with staff wearing the PPE in the same manner that they would in an actual event. Modifications can then be made either in the PPE selection (such as an N95 versus a PAPR) or in the design of the environment (such as cutting back the continuous wearing time).
“People are realizing the breaches aren’t the fault of the person doing the work,” he says.
And while small, rural hospitals may be unlikely to see an Ebola patient, they should develop an emergency plan that encompasses a high-level pathogen. “One of the things we learned from Katrina is that help might not come if [a situation is] really bad,” he says.
“Even the small places need to have a comprehensive plan. They should have identified teams, do an equipment assessment, know exactly how much PPE they’re going to need, and have training in place,” he says.
Even when Ebola fears subside, training needs to continue at least annually to keep employees current on the use of PPE and other emergency preparedness issues, says Harvey. Again, through regional coalitions, hospitals can collaborate.
“It’s about maintaining the assets. More important than the physical assets is the training component,” she says.
Some hospitals have designated teams of employees who volunteered to care for an Ebola patient, if a case occurs. They receive more intensive training, but other employees with patient care duties who might encounter an Ebola patient also need training, safety experts say.
At Tampa (FL) General Hospital, all employees were required to watch videos with information about the Ebola virus and basics about the required personal protective equipment. The Ebola-designated care teams had training that included hands-on donning and doffing of the hazmat suits and PAPRs.
Providing information to all employees helps them safer, says JoAnn Shea, MSN, ARNP, director of employee health and wellness. “They feel that we’re giving them the resources they need to protect themselves. That’s important. That’s our job,” she says.
Ultimately, the Ebola outbreak may be an impetus to provide more resources for infection control and employee health. As they learn more about protective equipment and how to properly don and doff gloves, respirators and gowns, employees may make changes in their daily practice that help prevent health care associated infections, says Harvey.
The national attention also brought new prominence to worker safety in hospitals and the risks that health care workers face. “The Ebola issue did shed some light on the epidemic of injuries and illnesses among health care workers overall,” says Bill Borwegen, MPH, an occupational health consultant and former health and safety director of the Service Employees International Union.
Employee health and infection control should remain a key part of broader hospital preparedness efforts, including with regional coalitions, Harvey says. Hospitals that never see an Ebola patient still need to be ready for the next infectious disease outbreak — or any other emergency, she says.
“It takes an entire hospital, it takes an entire region, it takes an entire health care system to really do this well,” she says. “There’s never an end state for preparedness.”
Editor’s note: The Occupational Safety and Health Administration recently created a matrix for PPE selection for Ebola: (http://1.usa.gov/1zLQhNO). Other resources include a CDC checklist for hospital preparedness (http://1.usa.gov/1uE4yNP) and PPE guidance (http://1.usa.gov/10hXJoz). The California Aerosol Transmissible Diseases standard is available at: http://bit.ly/1yeHaXA The International Safety Equipment Association provides information on PPE standards at http://bit.ly/1FL296z