Managing Ebola: How ICUs Can Prepare for an Outbreak in the United States

During a plenary session at the American College of Chest Physicians’ CHEST meeting in Austin, Texas, Edgar Jimenez, MD, FCCM, vice president of critical care integration at Baylor Scott and White Health in Central Texas, discussed how to prepare for Ebola in the Intensive Care Unit (ICU) setting. Dr Jimenez began by introducing the session as a way to answer questions and to provide hospital ICU staff with key considerations for Ebola preparation in the United States.

Key considerations for Ebola preparedness include: setting up a clinical chain of command, making provisions for personal protective equipment, and planning for waste management, clinical care, and transport.

While infection control measures have been in place in the critical care community for many years, according to Dr Jimenez, these measures have not been strictly applied. The sudden acute respiratory syndrome (SARS) epidemic of 2003 revealed several problems with infection control procedures. Recommendations were poorly followed, and violations of protocol were common, he noted. Using 1 SARS isolation unit as an example, he described protocol violations ranging from the use of open bays for patient isolation, to using the incorrect type of mask, to inconsistent use of eye protection or gowns.

Use of powered air purifying respirators (PAPRs), N95 masks, double gowning, and double gloving is necessary to reduce the risk of spreading SARS, but even those measures have been insufficient, Dr Jimenez said. Experience with SARS in Canada shows that, even when proper regulations are followed, transmission occurs.¹

One of the problems identified in a paper by Zamora et al published in 2006 is the threat of aerosolization in compromising PAPR gear. This paper showed that, even when CDC recommendations are followed, there is a 4% chance of contaminating the face, and a 96% chance of contaminating the neck with aerosols from the patient. This risk can be reduced by adding a hood layer over the PAPR, which reduces the risk of spread to the facial area to 2%, and reduces the risk of spread to the neck to 18%. However, the risks of spread are virtually unavoidable unless strict protocols are followed.²

The neck and wrists were identified as areas vulnerable to contamination—even with the use of recommended protective gear (see image here).² As a result of this research, it is clear that, even with highly protective systems, checklists are needed, and adherence to proper donning technique is critical. In the current Ebola outbreak, one of the most important recommendations for reducing the risk of spread in healthcare is avoidance of absorbable materials in shoes. Shoes should be made of rubber or another material impermeable to infectious liquids. Another recommendation involves longitudinal taping of gloves. By taping gloves to full-body suits longitudinally along the wrists, it is possible to remove the gown or system in a single motion. This reduces the risk of compromising the wrists, which are often contaminated by removal of gloves. In addition, cleaning between steps and constant spraying with bleach are necessary for full infection control.

Dr Jimenez works with 43 Texas hospitals that serve a total area the size of Massachusetts, Vermont, and New Hampshire combined. For a system this large, he noted, the importance of a centralized command system to organize resources in an emergency is very important.

In this session, Dr Jimenez was joined by experts Michael Connor Jr, MD, of Emory University, and Lewis Rubinson, MD, PhD, of Baltimore Shock Trauma at the University of Maryland Medical Center. Dr Rubinson had recently returned from West Africa and has firsthand experience fighting Ebola in Liberia.

Providing a rare insight into day-to-day Ebola care, Dr Rubinson stated, “You will not be impressed by how ill these patients are....You see much sicker patients every day.” Organ dysfunction, shock, and secondary infections in Ebola are, in Dr Rubinson’s words, “[nowhere] near the extreme of someone with H1N1.” Important care principles include creative use of bedside ultrasound, use of optic nerve inspection to measure intracranial pressures, and finding ways to make diagnostic decisions when radiology and other tests cannot be performed on patients. Establishing central line access in all patients with incident cases of Ebola is also critical to reduce the risk of needle sticks.

Scientists have known for years that even full protective gear is not 100% effective. Care centers around the country and around the world can do more to contain the spread of not only Ebola, but of other viral illnesses, through proper use of protective equipment, noted Dr Jimenez.

Several organizations around the world offer resources to help prepare for these critical tasks, including:

• The CHEST consensus statement “Surge Capacity Principles: Care of the Critically Ill and Injured During Pandemics and Disasters”³
• The Centers for Disease Control (CDC) website on Ebola⁴
• Emory Healthcare’s Ebola preparedness protocols⁵
• The European Centre for Disease Prevention and Control (ECDC), which offers a useful guide for assessing and planning air evacuations of patients with Ebola⁶
• United Kingdom public health guideline for infection control of group 4 hemorrhagic fevers⁷
• Information from Infection Prevention and Control Canada⁸

REFERENCES

1. Update: severe acute respiratory syndrome--United States, May 14, 2003. MMWR Morb Mortal Wkly Rep. 2003;52(19):436-438.
2. Zamora JE, Murdoch J, Simchison B, Day AG. Contamination: a comparison of 2 personal protective systems. CMAJ. 2006;175(3):249-254.
3. Hick JL, Einav S, Hanfling D, et al. Surge Capacity Principles: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement. Chest. 2014;146(4, suppl):e1-e16S.
4. Ebola. CDC website. http://www.cdc.gov/vhf/ebola/. Accessed October 2014.
5. Emory Healthcare. Emory Healthcare Ebola Preparedness Protocols. http://www.emoryhealthcare.org/ebola-protocol/ehc-message.html. Accessed October 2014.
6. Assessing and planning of medical air-evacuations flights to Europe by air to Europe for patients with Ebola virus disease and people exposed to Ebola virus. ECDC website. http://www.ecdc.europa.eu/en/publications/Publications/ebola-guidance-air-transport-update-decontamination.pdf. Accessed October 2014.
7. UK Advisory Committee on Dangerous Pathogens. Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/354640/VHF_guidance_document_updated_links.pdf. Accessed October 2014.
8. Information about Ebola virus. IPAC Canada website. http://www.ipac-canada.org/links_ebolavirus.php. Accessed October 2014.