By Betsy Todd, MPH, RN, CIC, AJN clinical editor. (See also her earlier post, “Ebola: A Nurse Epidemiologist Puts the Outbreak in Perspective.”)
This is not a time to panic. It is a time to get things right.—John Nichols, blogging for the Nation, 10/12/2014
Scanning electron micrograph of filamentous Ebola virus particles budding from an infected VERO E6 cell (35,000x magnification). Credit: NIAID
For years, nurses have tolerated increasingly cheap, poorly made protective gear—one result of health care’s “race to the bottom” cost-cutting. Now the safety of personal protective equipment (PPE) is being hotly debated as the Ebola epidemic spills over into the U.S.
If all nurses had access to impermeable gowns that extended well below the knee (and could be securely closed in back, had real cuffs, and didn’t tear easily); faceguards that completely shielded; N95 respirator masks that could be properly molded to the face; and disposable leg and shoe covers, we might not be having the same conversation. Yet how much protection can we count on from the garb we now have available, especially considering the minimal donning and doffing training given to most nurses?
While there is more to be learned about possible “outlier” modes of Ebola transmission, it’s pretty clear from past experience (including recent Ebola hospitalizations at Emory University Hospital and the University of Nebraska Medical Center, where no transmission has occurred) that standard, contact, and droplet precautions will virtually always prevent Ebola virus transmission. Because of the theoretical possibility that the virus could be aerosolized during procedures like intubation or suctioning, airborne precautions are usually added. (And from what we’ve seen, they’re being followed routinely, and not used only during aerosolizing procedures.)
Many organizations, including National Nurses United, are calling for hazmat-type gear and PAPR hoods (powered air-purifying respirators, which are HEPA-filtered) for staff who care for Ebola patients. Because most nurses have not used these, this more complex gear presents new challenges, especially because of the potential for self-contamination when worn and removed by untrained staff.
Specific techniques for donning and doffing PPE are not new, but many nurses have never been taught to pay attention to these details. One has only to look at staff in a contact precautions room, only half covered by their untied gowns, to understand why resistant organisms continue to spread within hospitals. Many clinicians may not have believed that their cavalier attitude towards PPE had anything to do with the next patient’s nosocomial MRSA pneumonia. During this Ebola epidemic, though, we are quickly learning that the proper use of PPE is a matter of life and death—ours.
On an October 14th CDC Clinician Outreach and Communication Activity (COCA) call, medical directors in charge of special infectious disease units at Emory University Hospital and the University of Nebraska Medical Center shared their recent experiences with Ebola. (The recording of the call will soon be available online at this link.) These physicians noted that the CDC, while recommending typical standard, contact, droplet precautions gear, also recommends the use of more extensive PPE if the situation calls for it.
Therefore, for example, we see total-body coverage in photos of workers in West African field hospitals, where the environment can be heavily contaminated because—without running water, electricity, or solid flooring—real disinfection is impossible. Likewise, handling bodies, performing environmental clean-ups, or working within the very tight confines of an ambulance all clearly point to the need for total body protection.
At both Emory and Nebraska, the decision was made to use full-body suits and PAPR hoods for Ebola patient care. Their “risk assessment” regarding whether to go beyond gowns, gloves, and masks included this reasoning:
- First, PAPR hoods, with their continuous air circulation, are more comfortable for long wear (especially in Atlanta’s heat) and less likely to fog up than regular mask/face shield combinations. This meant staff would be less likely to accidently contaminate themselves by trying to wipe sweat from their faces or clear a fogged face shield.
- They also noted that concentrating on the correct on/off procedures for full body suits was simpler than attending to the donning and doffing of gowns, leg and shoe covers, masks, etc. (Of note: footwear consisted of rubber clogs that could be fully disinfected with a bleach solution after each shift.)
Both groups of physicians emphasized that the key to protection was not the exact garments chosen (as long as they comply with precautions recommendations), but meticulous attention to PPE donning and doffing. (“There is no one right PPE.” “Don’t fixate on a particular process; just pay attention to detail with whatever you choose.”) This means:
- excellent, repeated training and practice
- a checklist of donning/doffing procedures to be strictly followed
- and always, always a trained supervisor (“buddy”) to ensure that all gear is in place and to monitor and assist with its removal
The biggest question now is not “what protective gear should we be wearing?” but rather “will hospitals invest in good-quality PPE and thorough, ‘in-the-trenches’ training?” Or will nurses once again be expected to “manage” without adequate resources?
It is unfortunate that item cost prevails over employee safety at some healthcare facilities. I believe that good quality personal protective equipment (PPE) and strict isolation precautions procedures are paramount to prevent the next nosocomial infection. As the blog states, proper donning/doffing procedures must be meticulously followed in order to remain properly protected. In most cases, healthcare staff received initial PPE training once during their orientation. Unfortunately, it’s probably safe to say, that there are breaks in isolation precautions procedures and techniques daily on any given floor. This is either because staff does not know proper isolation procedures and techniques when donning/doffing PPE or they are in a rush and do not follow procedures properly. Continued reinforcement through education and annual competencies are good methods to ensure proper isolation procedures and techniques are being used at all times.
I too believe that health care professionals should have proper equipment when dealing with a patient with/or perceived to have Ebola. Working as an ER nurse I have been trained once on donning/doffing and it was not a pleasant experience. I hyperventilated thinking about how this low quality PPE would be all that protect me from this deadly virus. I felt exposed. I would have rathered worn the PPE I saw worn by the nurses in Emory University Hospital, because they seem well covered. If I felt that my barrier material was of great quality I would have been more at ease. Also, the lack of continuous training on donning/doffing made the anxiety level rise. This training should continue today, even when we perceive the threat to be contained.
Nurses and other healthcare employers should have the best personal protective equipment available. Personal protective equipment can mean life or death. There are many complaints about PPE, especially about heat stress. Obama announced last year that the National Institute for Occupational Safety and Health are collaborating with other organizations to create improved and comfortable PPE. He stated that the government would be paying for it and it as soon as it is available it would be sent over seas to West Africa for those caring for patients at the front line. I believe there is proper PPE for Ebola and one must pay meticulous attention to donning and doffing of PPE. Hospitals must invest in these items in order to provide safe patient care and have maintain infection control.
http://blogs.cdc.gov/niosh-science-blog/2015/02/05/ebola-ppe/
It is unfortunate that the uncontrollable rise of cost within health care has resulted in putting health care professionals at risk for what would normally be a preventable spread of disease. I understand that one of the many ways to control cost is to avoid buying pricey and unnecessary equipment, but superior personal protective equipment (PPE) is indispensable for optimal quality of care, therefore, medical facilities should invest in the best PPE available. In addition, for years many hospitals have done a poor job controlling the spread of MRSA within their wards, this reality is clear proof that the quantity and quality of PPE training, specifically when treating isolated patient, lacks consistency. The bottom line is that substandard equipment plus complacency over the years has placed unnecessary risks upon nursing professionals and their patients.
I am grateful to have worked at a hospital that took preparation for biological and chemical hazards. we were trained from universal precautions and the use of tyvek suits with donning and removal of the garments. This training started in the 90’s and has progressed throughout th 2000’s. I is not difficult to learn, and not difficult to refresh. When a hospital puts staff and patients as a high priority the training occurs. And it is not only the gear, one of my concerns is taking care of patients like this when we are fatigued. Long hrs. and day after day of caring for this type of patient causes us to be extremely tire. As we become more tired it is more likely to became more lax with out being aware of it. Nurses also need shorter work days with these patients whenever possible. Off my soap box now. Have a wonderful day,
Three days ago, CNN broadcast a demonstration of PPE removal by Dr. Sanjay Gupta. It’s no wonder that Dr. Gupta became “contaminated” (with chocolate sauce as a stand-in for virus) while removing his gear. Steven Bock RN, CIC, who brought this video to our attention, accurately describes Gupta’s technique as “reckless and incorrect.”
It all boils down to the bottom line for hospitals in regards to PPE’s. After 27 years, I have watched a steady decline in the “permeability” and quality of same said items. We cannot and should not be tolerating this among our colleagues. Stand up to admins who wish to treat patients with a level 4 virus like Ebola and demand proper PPE’s. And please, cease insulting us with charts re: proper donning and discarding of PPE’s…just what we learned in our first clinicals as students and have repeated numerous times throughout years of service. It’s all about the proper equipment and standards of care like a negative pressure room for these unfortunate patients. Hazmat suits with a bleach spray prior to removal, if good enough in the lab to protect scientists studying a test tube vial of a level 4 virus should indeed be in order for any RN cleaning up body fluids.
I am so frustrated by this issue. Those 2 Dallas nurses may die because of the age old “well you’ll just have to make do” attitude from hospital administrations. Not well trained on a topic? “You can do it, it isn’t all that different.” Take another patient when you are already swamped? “You will be fine, it’s just until the end of the shift.” Most of the time, because nurses are bright, capable people who want to do a good job, they do manage for it to be “alright.”
But it is a disservice to our patients, ourselves.
We needed this information, so timely for nurses to support and educate each other. Thank you. I’ll pass it on.
I appeciate this article but nurses can only do so much with what they are given! This country has reacted instead of being proactive! I work in a large ED in Atlanta and can tell you the hospital IS NOT PREPARED! The management team at the upper most level cannot even agree on a policy to put in place, the ED is appallingly lacking any way of isolating a possible Ebola patient which is extremely scary. We have been given less than what the nurses in Texas had to work with yet I am told it is business as usual. We are being asked to see more and more “hall” patients yet our safety takes the back seat to seeing more patients and bringing in more revenue! EMORY has the facilities to PROPERLY care for the patient and planned ahead. The patient didn’t come to the ED. When is nursing going to make a stand because the government was very quick to blame the nurses in Texas for the breach despite being given inadequate tools.
So true – the brand does not matter as much as consistently using adequate PPE in the correct manner – with reinforced training as the key element. Still, it all depends on hospitals supplying the needed products. Also see http://www.whatmotivatesanurse.com “See no Ebola…”
what about us all who are just your everyday place hospitals, nursing home, offices etc…. no special instructions for us…….do we matter!!! so pissed!!!!
Thank you Betsy for this ongoing Ebola discussion! From what I’ve read and experienced in performing training for nurses, doctors, and other staff with both PAPR/Tyvek suit (Tier 2) and more traditional PPE (Tier 1), I agree that the exact combo of PPE is not the most critical feature in worker protection. As long as the PPE is carefully chosen and instantly available to the workers who may receive a patient with no warning (e.g., ER presentation), and as long as staff are well trained AND have a spotter co-worker to be a pair of trained eyes to make sure PPE is worn and removed appropriately, worker safety is readily achievable with results like we see in Emory & Nebraska Medical Centers. Not all Ebola patient care needs PAPRs and full body suits but we need to have them readily available as patient conditions can change. Keep on training and working carefully, and we will be safe and secure in giving the utmost compassionate care to people suffering from this terrible disease. There is no better time to be a nurse!
Great article. The world is doomedcbecause governments will only ever fund anything nursing to the bare minimum.. as usual, the nursing profession remains at the level of prostitutes in the eyes of the authorities, as evidenced also by their wage rises.
It seems preparation may have been helpful? Both Emory and the University of Nebraska Medical Centers knew exactly when the ebola patients were coming. This permitted careful consideration of all interventions/precautions wanted or needed to in place before the patients arrived. With the Texas incident, a clear message has now been sent all US hospitals… Be prepared…
Glad to hear Pam Cipriano ( on CNN) say that total coverage is the only way to go….and I would add that a ‘buddy’ to watch as you disrobe is a necessity as well.
Bravo, bravo, bravo, as always. Thanks for the unbiased, cutting edge, applicable truth. Twitter in your future? 😉 #firstcomment #ebola #betsytoddajn