0
Ideas and Opinions |

Caring for Patients With Ebola: A Challenge in Any Care FacilityEbola Containment Care FREE

Mark G. Kortepeter, MD, MPH; Philip W. Smith, MD; Angela Hewlett, MD; and Theodore J. Cieslak, MD
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 16 October 2014.


From the Uniformed Services University of the Health Sciences, Bethesda, Maryland; University of Nebraska Medical Center, Omaha, Nebraska; and San Antonio Military Medical Center, Fort Sam Houston, Texas.

Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army and Department of Defense, or the U.S. government.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2289.

Requests for Single Reprints: Mark G. Kortepeter, MD, MPH, Office of the Dean, School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.

Current Author Addresses: Dr. Kortepeter: Office of the Dean, School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.

Drs. Smith and Hewlett: Division of Infectious Diseases, Biocontainment Unit, University of Nebraska Medical Center, Omaha, NE.

Dr. Cieslak: Department of Pediatrics, San Antonio Military Medical Center, Fort Sam Houston, TX.

Author Contributions: Conception and design: M.G. Kortepeter, T.J. Cieslak.

Analysis and interpretation of the data: T.J. Cieslak.

Drafting of the article: M.G. Kortepeter, P.W. Smith, A. Hewlett, T.J. Cieslak.

Critical revision of the article for important intellectual content: M.G. Kortepeter, P.W. Smith, A. Hewlett.

Final approval of the article: M.G. Kortepeter, P.W. Smith, A. Hewlett.


Ann Intern Med. 2015;162(1):68-69. doi:10.7326/M14-2289
Text Size: A A A

The largest outbreak of Ebola virus continues unabated in West Africa. With the recent death of a patient with Ebola virus disease at a hospital in Dallas, Texas, and the sobering reality that nosocomial spread has occurred in a U.S. facility, U.S. medical centers are coming to grips with the need to prepare for care of patients with this devastating disease. The Centers for Disease Control and Prevention has developed a hospital preparedness checklist, and the latest guidelines continue to express confidence that patients with Ebola can be cared for safely in a conventional medical facility by using barrier methods (standard, contact, and droplet precautions) as the primary means of protecting medical staff (1, 2). Recent experience with several Ebola-infected patients in the United States provides validation that such patients can be cared for safely in a facility that is adequately prepared.

Since the first reported outbreaks of Marburg (1967) and Ebola (1976), there has been an evolution in our thinking about the optimal personal protective measures for medical staff caring for patients infected with these viruses. From 1972 to 2010, a high-level containment care (HLCC) unit at the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), often called “the slammer,” was considered the gold standard for such care. The unit's engineering controls were modeled after a biosafety level–4 (BSL-4) laboratory, with positive-pressure “space” suits, compressed in-line air, HEPA filtration, a decontamination shower, ultraviolet light pass boxes, an airlock, and antiseptic dunk tanks for movement of items in and out of the containment area. Toilet waste was discharged into the laboratory sewer system, and the facility possessed its own autoclave, operating room, and bedside laboratory. These built-in capabilities significantly reduced logistics challenges and provided reassurance that nosocomial spread could be reduced to near zero. Given the relatively high percentage of caregivers who have died of filoviral and other BSL-4 virus infections in the field, and the prior uncertainty in whether such high infection rates might be caused by droplet or airborne spread, utilization of such a containment facility seemed reasonable. Although used on occasion to quarantine field workers potentially exposed to highly hazardous viruses, the unit was used primarily for isolating individuals exposed to a BSL-4 virus in the laboratory. During the unit's 38 years of operation, 21 patients were quarantined after potential exposures—and none became ill (3).

Over time, we learned that the spread of filoviruses occurs primarily by direct contact with blood and body fluids (1). Thus, it was determined that a patient care facility with the full panoply of BSL-4 laboratory–like features was no longer needed. The facility was decommissioned and refurbished as a training facility for scientists working in the institute's containment laboratories.

If the USAMRIID HLCC is no longer needed because patients with filoviruses may be managed safely using barrier methods, one might ask whether any HLCC or biocontainment patient facilities are needed at all (4). Currently, 4 such facilities exist in the United States, operating at a higher level of containment (and possessing more sophisticated engineering controls) than a conventional hospital isolation room but lacking some BSL-4 features present in the USAMRIID HLCC: Emory University Hospital, Atlanta, Georgia; University of Nebraska Medical Center, Omaha, Nebraska; Saint Patrick's Hospital, Missoula, Montana; and the National Institutes of Health Clinical Center, Bethesda, Maryland. All except the University of Nebraska serve as referral centers for laboratories that work with BSL-4 viruses. Although patients infected with such diseases as Lassa and Marburg have been safely managed in conventional settings, the serious nature of filoviral and arenaviral infections, their rarity and unfamiliarity to clinicians in developed settings, the lack of effective treatments and vaccines, their propensity to infect health care staff, and the infection control challenges they present argue for, in our opinion, specialized containment and treatment facilities.

As many medical centers are no doubt learning in their preparation drills, caring for patients with filovirus and arenavirus infections in a conventional setting presents enormous challenges (5), many of which can be mitigated through the use of specialized facilities with highly trained staff practiced in the nuanced art of safely delivering HLCC. However, even in such facilities, it is impossible to completely engineer out human error, eliminate the risk for sharps or needlestick injury, or prevent inadvertent contact contamination. Care for such patients in a conventional setting, therefore, is more than checklists and standard operating procedures. The training, policies, procedures, and logistics necessary for the provision of such care are significant, cannot be assumed, are optimally in place well in advance of actual need, and must be continually reinforced through repetitious training. Every piece of the care continuum must be well-choreographed with significant attention to detail. At a minimum, preparations must be made for patient entry and movement pathways, optimal patient location and access control, safe donning and doffing of personal protective equipment (PPE), handling and testing laboratory specimens, disposal of significant volumes of waste, safe and unexpected cleanup of spills and bodily waste, and minimizing use of sharps. Donning and doffing PPE need to be regimented and monitored, with plans in place for peer policing. Lapses inevitably occur in infection control routines in conventional medical settings, but once a patient enters the facility, there is no margin for error. Significant risk for infection control errors occurs especially during doffing potentially contaminated PPE (6).

While the physical features of high-containment isolation units like that previously housed at USAMRIID (3) are formidable, low-tech measures, such as checklists and the use of doffing partners, may be as important to optimizing the safety of health care workers, whether in an HLCC unit or in a conventional facility. Owing to the very limited number of existing HLCC beds and the fact that patients with highly contagious diseases can present unannounced, conventional facilities may be required to triage these patients and even provide definitive care, despite the enormous challenges they would inevitably face. Immediate and thorough preparation is thus imperative.

Despite this necessary reliance on conventional facilities, we recognize the challenges inherent in maintaining a high nationwide state of readiness over the long term. Hence, we envision the need for a network of strategically located regional referral centers serving designated catchment areas tied to BSL-4 laboratories or airport quarantine stations. As such, transport of patients to these referral centers would constitute the preferred clinical option (4). These units would be associated with major medical centers and provide day-to-day routine care, but they would have the capability for rapid conversion to an HLCC unit without adversely affecting their primary activities. These could serve as national resources, coordinated through the Department of Health and Human Services and Centers for Disease Control and Prevention, with certification (much like trauma centers) to provide a higher level of care. As such, their focus would be on continuous preparation for the next emerging outbreak.

References

Centers for Disease Control and Prevention.  Infection prevention and control recommendations for hospitalized patients with known or suspected Ebola virus disease in U.S. hospitals. Accessed at www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html on 15 September 2014.
 
Centers for Disease Control and Prevention; Assistant Secretary of Preparedness and Response.  Health care provider preparedness checklist for Ebola virus disease. Accessed at www.cdc.gov/vhf/ebola/pdf/healthcare-provider-checklist-for-ebola.pdf on 30 September 2014.
 
Kortepeter MG, Martin JW, Rusnak JM, Cieslak TJ, Warfield KL, Anderson EL, et al. Managing potential laboratory exposure to Ebola virus by using a patient biocontainment care unit. Emerg Infect Dis. 2008; 14:881-7.
PubMed
CrossRef
 
Smith PW, Anderson AO, Christopher GW, Cieslak TJ, Devreede GJ, Fosdick GA, et al. Designing a biocontainment unit to care for patients with serious communicable diseases: a consensus statement. Biosecur Bioterror. 2006; 4:351-65.
PubMed
CrossRef
 
Armstrong LR, Dembry LM, Rainey PM, Russi MB, Khan AS, Fischer SH, et al. Management of a Sabiá virus-infected patients in a US hospital. Infect Control Hosp Epidemiol. 1999; 20:176-82.
PubMed
CrossRef
 
Fischer Ii WA, Hynes NA, Perl TM. Protecting health care workers from Ebola: personal protective equipment is critical but is not enough. Ann Intern Med. 2014 August 26 [Epub ahead of print].
 

Figures

Tables

References

Centers for Disease Control and Prevention.  Infection prevention and control recommendations for hospitalized patients with known or suspected Ebola virus disease in U.S. hospitals. Accessed at www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html on 15 September 2014.
 
Centers for Disease Control and Prevention; Assistant Secretary of Preparedness and Response.  Health care provider preparedness checklist for Ebola virus disease. Accessed at www.cdc.gov/vhf/ebola/pdf/healthcare-provider-checklist-for-ebola.pdf on 30 September 2014.
 
Kortepeter MG, Martin JW, Rusnak JM, Cieslak TJ, Warfield KL, Anderson EL, et al. Managing potential laboratory exposure to Ebola virus by using a patient biocontainment care unit. Emerg Infect Dis. 2008; 14:881-7.
PubMed
CrossRef
 
Smith PW, Anderson AO, Christopher GW, Cieslak TJ, Devreede GJ, Fosdick GA, et al. Designing a biocontainment unit to care for patients with serious communicable diseases: a consensus statement. Biosecur Bioterror. 2006; 4:351-65.
PubMed
CrossRef
 
Armstrong LR, Dembry LM, Rainey PM, Russi MB, Khan AS, Fischer SH, et al. Management of a Sabiá virus-infected patients in a US hospital. Infect Control Hosp Epidemiol. 1999; 20:176-82.
PubMed
CrossRef
 
Fischer Ii WA, Hynes NA, Perl TM. Protecting health care workers from Ebola: personal protective equipment is critical but is not enough. Ann Intern Med. 2014 August 26 [Epub ahead of print].
 

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment/Letter
Submit a Comment/Letter

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)