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Emory and Nebraska Medical Center

Rear Admiral Red 
responsible for ground transport for 2 patients from africa
closed gaps in education and training of EMS providers
	• nature of viral dz
	• protection
	• infection control measures
gaps in training
	• competency based training donning of PPE
	• removal of PPE closing risk of contamination of self
	• decontamination and disinfection of ambulance
emergency departments
	• 911 comm center
	• repsonse vehicles and staff
	
implemented screening 
	• travel outside US last 3 weeks, where that travel occurred
	• signs and symptoms - n/v, HA, fever
	• screening at every point of entry
	• call center is asking questions
	• first responders ask the same questions again
	• encouraged and implemented at emergency departments
	• screening critical to id'ing patients early

safety for patient
	• timely attention to medical condition
	• don't allow history or symptoms to paralyze response
safety for healthcare worker
	• appropriate infection control
	• protection of other patients
	• limiting use of sharps
	• limiting aerosol procedures
destination
	• everyone needs to be prepared - any patient can enter any clinic, ED, call 911
	• communities decide what facilities to transport to
	• prepare isolation room and PPE 
	
PPE & infection control
	• complete agreement with CDC guidelines
	• standard, contact, droplet precautions
	• surgical mask, face shield, glove, booties
	• on TV: respirators, suits, etc.
		○ operational considerations and practicality
		○ eyewear fogs and people wipe sweat from brow
			§ Kivec hooded prevented this in hot ambulance
			§ ambulance tight environment
		○ endotracheal intubation, open airway suction - aerosol procedures
recovery
	• after ambulance delivers patient
	• ambulance needs to be disinfected
	• crew needs to remove PPE safely
	• barrier drapes to inside of pt compartment
	• isolate driver compartment
	• buddy system for donning/doffing of PPE - prevents break in procedure
	• any known exposure
		○ quick washing of skin or area of contact
		○ monitored for 21 days even in absence of recognized exposure
	

Dr. Bruce Ritner medical director emory hospital

planning
	• all departments are involved
	• patient biocontainment units - infectious disease or crtiical care as primary providers
	• multiple different specialties involved
	• nursing critically important
		○ only used ICU nurses
		○ ventilation, dialysis
	• environmental mgt, security, media relations
laboratory techs
	• full safety gear, cabinets
	• point of care testing
	• they decided laboratory was too risky for rest of patients
	• point of care lab established - schematic in slide
	• two ICU beds with large anteroom 
	• malaria testing
challenges encountered
	• issues with commercial carriers
	• figure out how specimens getting to lab
	• agencies at all levels interested in managing patients and waste of category A agents
PPE
	• droplet, contact precautions
	• gloves, gown impervious, goggles/faceshield, mask
	• additional PPE 
		○ double glove, disposable shoes
		○ large amounts of effluent
		○ leg covering 
		○ bodysuits deemed best protection
		○ issues with goggles/shields fogging
			§ more practical to wear hooded suit
	• critically important for competency based training for donning and doffing, especially doffing procedure
	• removal of PPE is key
	• buddy system - observe doffing procedure by another trained individual
local authorities
	• check if category A agent okay for sewers
	• how will waste will be removed
	• contractors working with DOT
	• autoclaving on site
communications
	• anxiety with community
	• work closely to get a message out to public and employees - trained, prepared, we will protect you
	• internal clients - email communications, patients concerns - a letter given to each patient ensuring safety
	
Smith & Hewlit - Nebraska

administrative structure
	• leadership team: ID specialist, decontamination specialist, transport specialist, nurse adminstrator, head nurse, education specialist, clinical studies specialist (appropriate drugs available)
	• incident commander - meeting room "huddles"
	• nurse staff selection process is critical
	• 40 nurses on team, RTs, techs
	• 6 people on duty in unit
	• diverse nursing backgrounds useful
	• nurses quit since ebola pts but also influx of applicants
waste disposable
	• autoclave in unit
		○ linens, scrubs, trash - every autoclaved on way out
	• lab
		○ partnership with lab - wishlist tests for patients
			§ blood cultures, electrolytes
			§ protocols
there's no one right PPE for everyone
	• modified 
		○ bonnet - better coverage for head, neck , face
		○ duct tape first 2 layers of gloves to gown, 3rd gloves are changed as necessary in pt rooms - 2nd gloves washed as hands
		○ donning/doffing specialists - walk through each step 
family
	• designate one person for communications
	• audio visual communication with family via technology
	• minimize need for direct contact
nursing station
	• telecom one physician in room other at monitor
	• minimize people going into room
nursing staffing model/physician model
	• needed input from critical care physicians - fluid and electrolyte mgmt
	• heavy input from ID
	• anesthesia - airway mgmt
	• dialysis
	
Q&A
	• CDC thinking about setting up regional healthcenter for taking patients?
		○ options are being considered after dallas, every hospital needs to be prepared to identify, diagnose and treat
	• recommendations for mgmt for point of entry to designated unit
		○ depends on how patient comes in, if presents to ED. patients should call and let them know they are coming in. first ask about travel, if screened positive, move to private room and use contact/droplet precautions. if you have a r/o scenario - lab testing, assign 1 nurse to individual, determine appropriate destination - clinical isolation unit. move patient within facility - wrapped or draped stretcher, mask on patient, limit movement within hospital. possibly put pt in suit or self-contained apparatus (isopod) not usually necessary. patients sick for a week are highly contagious. most patients in ED will only have been sick for a day or two.
	• Observer for donning/doffing PPE - are they directly assisting or observing and giving verbal cues
		○ different models exist. bruce used a mixture, observe donning. observer assists with doffing and places it into waste container. key to observer is to observe and ensure no contamination. Hewlit: use of checklist, boot covers (difficult to remove). doffing partner is in full PPE themselves
	• length of time PPE is worn... max time?
		○ 3 to 4 hours then they are rotated out of room. overheated. in the field like physicians without borders max is 45 minutes because no air conditioning. EMS - an hour or so 
	• in hospital, in special unit. how is room outfitted? coverings over surfaces? how is cleaned?
		○ no special coverings. select easy to clean surfaces. complicated decontamination process. several days of dessication air exchange. bleach based cleaning top to bottom x2 over 7 days. nurses are highly meticulous disinfecting surfaces. environmental sampling - no virus detected on any surface. vaporized hydrogen peroxide - more rapid turnaround time. it's not a hardy virus, desicates in a few hours
	• did staff go home between shifts? concern about taking it home to family.
		○ personnel not isolated. confidence in procedures they developed. every individual is screened - web based program Q12 hrs record temp and answer screening questions. not considered contagious until 2 to 3 days after onset of fever. when you enter unit you are naked, don and doff scrubs in unit, shower out. 
	• as an outpatient center, how do you screen?
		○ whoever registers into any part of healthcare system first questions is asking about travel within 30 days - african countries, middle east countries. each facility needs to have a way to identify and isolate at risk individuals
	• many hospitals don't have containment units - many hospitals would be bankrupted. do we need to make a containment unit. what are you using for shoes?
		○ any healthcare center could care for one of these patients. takes a lot of planning. waste disposal & staffing issues. designate an isolated area, negative pressure room preferable. rubber crocs worn in unit and given bleach bath on way out. at a minimum identify an area within the lab to receive and process samples away from main lab. lab spill would be catastrophic. community preparedness - every hospital has to be prepared to receive a patient with fever, n/v and travel hx. a community may choose a few hospitals in community that are best prepared.
		
	recording and transcripts will be posted within next week.