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
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?