Amidst growing concerns among healthcare workers, about 5,000 gathered in NYC to hear elected officials, public health experts, and hospital leaders give reassurances that if hospitals aren't yet prepared for the virus, they soon will be.
Many healthcare workers, especially nurses, are nervous, tired, frightened, and angry. Every day, they take risks that something they do or don't do might make a patient sicker.
Or that they themselves will become infected by a patient under their care.
Bill de Blasio |
Ebola has magnified that dread.
Tensions ratcheted up this month when the Dallas hospital that treated Thomas Eric Duncan implied that an emergency department nurse failed to tell doctors about his recent travel from Africa. Or when a top federal health official implied that two ICU nurses who became infected caring for Duncan had failed to properly use protective gear in a breach in protocol.
Healthcare workers' concerns were evident Tuesday during what amounted to a 3.5-hour Ebola pep rally and demonstration event at New York City's Jacob K. Javits Convention Center.
About 5,000 healthcare workers gathered—and thousands more viewed by webcast—to hear New York political, public health, and hospital leaders give reassurances that if hospitals aren't yet prepared for the virus, they soon will be.
The high-level, informational event was organized by the 150-hospital Greater New York Hospital Association and the 400,000-member 1199 SEIU United Healthcare Workers East, folks who have been at ground zero before, during the AIDS epidemic in the 80s, during 9/11, and during Hurricane Sandy.
New York City has one of the highest percentages of African populations in the nation. It may again become ground zero when the next infected Ebola patient flies into JFK.
(Editor's note: Within hours of this column, it was discovered that the nation’s newest Ebola patient, Craig Spencer, MD, had indeed flown into JFK airport after returning from west Africa, where he had been treating patients in the epidemic there.)
New, More Rigorous Protocol
Tuesday's event was perfectly timed, coming just a few hours after the Centers for Disease Control and Prevention released new, specific, and more rigorous Ebola personal protective equipment (PPE) guidelines than had been previously issued. Many have said the guidelines, which now call for no exposed skin, a buddy system, and more frequent disinfection during garb removal, are long overdue.
More specifically, the new CDC recommendations show an extended, much more complicated sequence of events for dressing and undressing before and after an encounter with a suspected or confirmed Ebola patient.
The process now takes at least five times longer, and require at least twice as many people. It will require two vestment areas, one dirty and one clean, with two separate chairs to use during the doffing process. A monitor or buddy will watch, check, double check, and assist.
And the areas where all this will happen should be spatially generous so caregivers have plenty of unfettered room to move their arms without touching anything or anyone else.
In a 20-minute demonstration, two healthcare workers went through each slow and thoughtful motion, reminding themselves to wash their hands with alcohol rub after every step to avoid contaminating another article after touching a soiled part of the gear.
Questions and Answers
The rigorous process left some unsure. And there were many questions, deftly fielded by Mary Bassett, MD, MPH, Commissioner, NYC Department of Health and Mental Hygiene and others.
One question provoked the loudest applause:
Who is going to be responsible for checking on the hospital administration to provide proper protection for their healthcare workers?
Arjun Srinivasan, MD |
Bassett replied that the New York State Health Department, which has regulatory authority over hospitals, "has issued commissioner's orders requiring compliance with protocols issued by the state, which are in line with both federal and of course our city guidelines." GYHA President Kenneth Raske said hospitals can expect "compliance checks and routine inspections along those lines."
Other questions showed how complex the process will be too learn.
How can you take off the boots, remove the gown, and stand in a contaminated area in the same shoes after taking care of an infected patient?
The CDC's Arjun Srinivasan, MD, Associate Director for Healthcare Associated Infection Prevention Programs, tackled this one. "Excellent question," he said. "This is one of the reasons why there's physical separation… A chair you sit in immediately coming out, and a chair that's separate for after you've removed the gown." The shoes were covered by shoe covers, but the initial step should be to disinfect the shoes with a wipe, he added.
Brian Koll, MD, executive director of infection prevention at Mount Sinai Health System in New York, said that "with these new guidelines, there really are going to be designated areas for where you can remove the PPE….So you should not be taking them off in a dirty zone."
"It shouldn't be crowded," Srinivasan added. "You shouldn't be struggling for space here."
What should one do about cleaning up infectious fluids that land on the floor?
Another excellent question, Srinivasan said. "The area where the PPE is removed does need to be cleaned on a regular basis… [to be] ready for the next person to come and remove PPE."
What kinds of measures should housekeeping staff take when cleaning a patient's room, either while the patient is there or after the patient leaves? Shouldn't they be fully protected as well?
"Absolutely," Srinivasan said. But he emphasized that the daily cleaning of high-touch surfaces, such as bed rails and equipment in the patient's room, should be done by the people who are going in to take care of the patient.
We don't think housekeeping should be going in every day to clean the rooms." But after the patient leaves the room, housekeeping staff "would follow the same type of protective equipment, protection and training and procedures as everybody else."
What is recommended as a cleaning solution and how can you make it if you're making a home-made solution?
"You're looking for an EPA-registered disinfectant that's effective against non-enveloped viruses... Products that are active against norovirus would not just kill Ebola, but would provide an extra margin of safety," Srinivasan said.
How long does the virus survive on a surface?
Not for extended periods of time. "It's not like [Clostridium difficile] that we know forms spores and lives for a very long period of time," Srinivasan said. The only place where the Ebola virus was recovered in a room where a patient had stayed "was in a couple of spots where there was blood."
What is the recommended size of the care team?
Koll replied that Nebraska Medical Center in Omaha, one of the nation's few Ebola expert centers, there is a team of 60 nurses, four to six physicians, and specialists in dialysis, phlebotomy, and other fields. "That tells you this is not going to be a simple thing."
At Mount Sinai, he said, there now "is never a point in time" when there is not someone fully trained to take care of an Ebola patient should one come through the emergency room door.
One question prompted Bassett to crack a slightly salty joke.
What do you do if your hands don't fit in the gloves?
"There should be no one that has gloves that don't fit them," she said. "There are gloves that fit all hand sizes, big and small. I feel like I'm talking about some other latex materials now."
There will no doubt be more demonstrations in other states as healthcare workers grasp these new guidelines, and as hospitals work to implement them and secure the equipment they need for the next case of Ebola.
Whenever and wherever it comes.