By Tyler Smith | UCHealth

A month after the first person was diagnosed in the United States with the Ebola virus, University of Colorado Health continues a sweeping effort to prepare should a suspected Ebola case arrive at its doors.

Space in the old ED at UCH before and after remodeling to create an isolation unit.

The work includes regular updates to a deep collection of information on the system’s intranet, periodic email updates from Chief Medical Officer William Neff, MD, and daily briefings among system leaders. Administration leaders and infectious disease specialists delivered additional news and answered questions about its Ebola preparations at a system-wide “Town Hall” video conference Oct. 27.

In addition, UCHealth acquired high-level personal protective equipment (PPE) that includes PAPR (powered-air purifying respirator) hoods to provide maximum contamination protection for providers.

At UCH, the Emergency Department launched staff training in donning and doffing the PPE Oct. 17. By Oct. 26, a total of 177 staff, physicians, and residents had been trained, said Kari Waterman, MS, CNS, RN-BC, manager of clinical education and professional development for UCH.

System leaders also decided that whenever possible, patients who test positive for Ebola will be cared for at a dedicated, secure unit at University of Colorado Hospital. The hospital last week completed construction of an eight-bed infectious disease isolation patient care unit, isolated from other patient-care areas and carved from the vacant space formerly occupied by the Emergency Depart­ment. To staff it, UCH leaders assembled a high-risk infectious disease patient-care team of nurses and respiratory therapists who offered their services to care for suspected Ebola cases. The team is supported by critical-care physicians and radiology technicians, as well as staff from the Clinical Lab and Environmental Services.

Hospital staff at work last week setting up a patient care room in the isolation unit.

The high-risk team began intensive 12-hour training sessions Oct. 21, led by a team of seven nurse educators and one clinical nurse specialist, with oversight from the isolation unit’s four-person leadership team (see box). The training includes an overview of the disease, PPE safety skills, unit operations and procedures, and simulated scenarios to practice caring for Ebola patients, Waterman said.

Organized response

The broad system response to Ebola began in earnest Sept. 30 after a patient who traveled to the United States from the West African nation of Liberia was diagnosed with the virus at Texas Presbyterian Hospital in Dallas. Two nurses who cared for the patient subsequently contracted the virus; both survived.

Member of high-risk team clad in protective equipment prepares to exit a patient care room during training.

After the Sept. 30 announcement, groups from across UCHealth quickly came together to formulate plans to identify, isolate, test, and treat patients at risk of carrying the virus. The overarching aim: protect patients, visitors, staff, and physicians and prevent additional exposures. On Oct. 15, the system centralized decision-making, with all recommendations on Ebola policies and procedures funneled through Neff, who reports back to UCHealth’s Senior Executive Group.

In addition, a core group of leaders, including the system’s chief nursing, operating, and medical officers, began and continue daily briefings to coordinate responses to the Ebola threat. The preparations were swift. On Oct. 17, plans were underway to build the isolation unit at UCH; by Oct. 21, it was ready to admit patients, said Cathleen Ehrenfeucht, RN, MS, associate chief nursing officer at UCH.

Pop-up unit

The hospital had never constructed a unit in so short a time, Ehrenfeucht said. The remodeling job required quickly pulling together large numbers of teams, including Facilities, Information Services, Infection Control, Clinical Lab, Environmental Services, Transport, and many more to create critical-care rooms sandwiched around an “anteroom,” where providers will doff and dispose of PPE.

“The teams came to the plate,” Ehrenfeucht said. “We tried to pull in everyone who might touch care for these patients.”

Through Oct. 21, Facilities Management staff spent more than 500 hours remodeling and constructing an isolation unit, reported department manager John Morrow. The work included patching and painting rooms, building new walls, removing and installing new flooring, replacing ceiling tiles, retesting the nurse call system, installing cameras, and other work.

The isolation unit’s design and equipment address the potential risk to providers, Ehrenfeucht said. Ebola can only be spread through direct contact with the patient’s bodily fluids, so much of the training focuses on minimizing the risk of possible exposure. Providers don PPE according to a precise protocol, assisted by a buddy. When they complete direct patient care, they exit the direct patient care area and doff the PPE, while standing on a special mat. Two people assist, with an observer reading the step-by-step instructions and ensuring they are followed to the letter.

“The idea is that you tell me what to do, and then check to make sure that I did it,” Waterman said.

The patient care rooms themselves are glassed in, with white­boards and cameras to allow providers to communicate with staff, monitoring them and minimize contact between them. Providers will be able to perform point-of-care testing at the bedside, while the Clinical Lab will have a dedicated unit outside the rooms for additional daily testing. That arrangement avoids sending samples to the main lab, where a blood tube break would shut down operations, Ehrenfeucht said.

The steps for preparing to open the unit and training staff to work in it were established during the opening of AIP 2, said Pol Senecal, RN, clinical nurse educator for the Medical Intensive Care Unit and the isolation unit. The concept is straightforward: once the unit is stocked with supplies and equipment is in place, providers come in to get acquainted with the layout and practice working in it.

“It’s to help staff get an idea of what their day will look like and feel comfortable doing what they do,” Senecal said.

Proper protocols

Also firmly in place system-wide is a protocol for responding to a suspected case of Ebola. Providers in the EDs, hospitals and clinics ask patients if they have traveled to Liberia, Guinea, or Sierra Leone within the past 21 days or have had contact with someone with Ebola. A “yes” answer to either question triggers notification to the infection prevention or infectious disease specialist on call. The patient is isolated and examined by the infectious disease specialist. Providers don full PPE gear before making any contact with the patient.

If the evidence is sufficient to suspect Ebola, members of the high-risk team collect blood specimens and coordinate with the Colorado Department of Public Health and Environment (CDPHE) testing at a Centers for Disease Control and Prevention (CDC) facility. Results of the test would be reported within 24 hours after the lab receives the sample. Whenever possible, a person under investigation would be transferred to UCH from another UCHealth hospital.

“During that time, we treat it as if we have a case of Ebola,” Ehrenfeucht said. The hospital calls an internal disaster plan and sets up a command center. At UCH, members of the high-risk infectious disease team get ready in the isolation unit, awaiting transporters who wheel the patient to elevator bays at the east end of AIP 1, then up to the unit, following a route cleared by security. If CDPHE tests reveal the patient does not have Ebola, he or she moves to the appropriate level of care. With a positive test, the high-risk team continues care.

If the unit treats a confirmed Ebola case, providers will treat only that patient, with around-the-clock support from one of the clinical nurse educators or specialists to reinforce the care and safety protocols and answer questions.

“We understand that anxiety is going to be through the roof,” Senecal said. “There will be someone there to walk them through the steps.”

The work came against the backdrop of CDPHE’s announcement Oct. 17 that it had identified UCH as one of three hospitals in the state – Children’s Hospital Colorado and Denver Health are the other two – prepared to provide a higher level of care to Ebola patients. Neff and UCHealth President and CEO Liz Concordia both emphasized, however, that all the system’s hospitals must be prepared to identify, isolate, and care for suspected cases, as it might not be safe to transport patients.

The CDPHE identified UCH based on surveys to assess the “levels of preparedness” among hospitals to care for Ebola patients, said Michelle Barron, MD, infectious disease medical director for UCH. However, this does not mean UCH will take all transfers of Ebola patients from hospitals outside the UCHealth system.

“After patients are identified, the level of subsequent care is variable,” Barron said. “Some hospitals can’t care for critically ill patients. But no hospital is released from the obligation to provide [necessary] care.”

A flyer at the front desk of the Interventional Pain Management Practice advises patients that staff will ask about their travel histories.

Realistic response

Barron acknowledged the importance of the preparations, but stressed that Ebola “is not a U.S. disease. We need to focus our energy on Africa if we are going to contain it.”

She also pointed out sophisticated equipment and finely tuned processes ultimately hinge on accurate screening. Recent reports, which she emphasized are still unconfirmed, suggest that the infection of the two nurses in Texas occurred in a four- to six-hour window when the patient was not under precautions.

“It shows the importance of the screening process,” Barron said. “We have to be able to identify suspected cases. The key is to ask, isolate, and treat. We do this with possible tuberculosis patients. It can be inconvenient for patients and staff, but if we fail to do it in even one case, we can have an exposure.”

The threat of Ebola is real, but it shouldn’t be overblown, Barron added. Transmission of the virus requires contact with bodily fluids from a person who is symptomatic. Unlike an air-borne virus like influenza, it can’t be contracted by being near someone who sneezes or coughs. She pointed out that none of the people who lived in the same household with the patient in Dallas who died have gotten sick.

Barron contrasted the current Ebola outbreak with the SARS (severe acute respiratory syndrome) epidemic of 2002. Caused by a corona virus, SARS wasn’t recognized for several months.

“That was a lot scarier,” Barron said. “No one had ever heard of it. We know Ebola, we’ve studied it, and we have lots of science today that we didn’t have with SARS. We understand how it’s transmitted and how to follow precautions to protect ourselves. That knowledge gives me security.”

Ehrenfeucht said she understands the anxiety Ebola causes among staff, particularly those who deliver direct patient care. She acknowledged that information about the hospital’s and the system’s plans has taken time to assemble. But she too urged calm.

“We’ve known about this disease a long time,” Ehrenfeucht said. “We know how to isolate patients who may have it, just as we do other patients with highly infectious diseases. We want people to know we’ve been thinking about this non-stop.”

An Ebola patient may never cross the door of a UCHealth facility, but the October preparations are improving the system’s ability to respond to any emergency, Senecal concluded.

“Whether it is Ebola or SARS or the next great infectious disease, it is reassuring that we have a system that can respond quickly and safely,” he said.

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