Accepted Manuscript Ebola preparedness: a personal perspective E.P. Yiannakis, T.C. Boswell PII:

S0195-6701(15)00254-6

DOI:

10.1016/j.jhin.2015.06.009

Reference:

YJHIN 4573

To appear in:

Journal of Hospital Infection

Received Date: 12 June 2015 Accepted Date: 15 June 2015

Please cite this article as: Yiannakis EP, Boswell TC, Ebola preparedness: a personal perspective, Journal of Hospital Infection (2015), doi: 10.1016/j.jhin.2015.06.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Commentary

Ebola preparedness: a personal perspective E.P. Yiannakisa,*, T.C. Boswella a

Nottingham University Hospitals NHS Trust, Nottingham, UK

_____________________ *

Corresponding author. Address: Department of Clinical Microbiology, Nottingham

NG7 2UH, UK. Tel.: +44 (0)1159 249924. E-mail addresses: [email protected] (E.P. Yiannakis) SUMMARY

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University Hospitals NHS Trust, Queen’s Medical Centre, Derby Road, Nottingham

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The outbreak of Ebola virus disease (EVD) in West Africa and the concomitant implications for healthcare services have resulted in unique and complex challenges for infection

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prevention and control teams (IPCTs) worldwide. A substantial weight of responsibility was placed on IPCTs to adequately protect both patients and colleagues in the face of sometimes discrepant and often rapidly evolving national and international guidance. We reflect on our local experiences and describe some of the barriers that we faced when preparing our organization for EVD. Keywords:

Preparedness Background

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Ebola virus disease

The outbreak of Ebola virus disease (EVD) in West Africa and the concomitant

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implications for healthcare services have resulted in unique and complex challenges for infection prevention and control teams (IPCTs) throughout the UK and elsewhere. The article

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by Martin et al.1 in this issue demonstrates that although there has been individual variation in the approach to EVD preparedness, many of the obstacles encountered have been common to all healthcare facilities. A substantial weight of responsibility was placed on IPCTs to adequately protect both patients and colleagues in the face of sometimes discrepant and often rapidly evolving national and international guidance. The article’s description of these responsibilities and challenges resonated with us and prompted a personal reflection on some of the barriers that we faced in preparing our organization for a suspected case of EVD. Initial assessment and identified deficiencies Following the publication of updated Advisory Committee on Dangerous Pathogens (ACDP), Public Health England (PHE) and Centers for Disease Control and Prevention (CDC) guidance advocating enhanced precautions, we undertook an assessment of our local

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EVD preparedness, including an evaluation of our existing personal protective equipment (PPE).2-4 In view of the evolving evidence that removal of PPE was particularly associated with EVD acquisition, doffing was an area for specific focus. On first observation of a simulated donning and doffing procedure in a designated isolation room of our infectious diseases unit, it soon became apparent that the side-room lobby was too small for safe doffing. Clinicians were unable to remove their PPE without high risk of contact with the

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walls, waste-bin, and sink. Similarly, there was insufficient space in the lobby to allow for the presence of a ‘buddy’ to oversee the doffing process. The PPE itself also raised concerns: shoe covers were fragile and tore easily; the combination of an FFP3 mask, visor, and surgical cap did not eliminate areas of exposed skin around the neck; staff were allocated disposable

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scrubs, but what about socks and underwear? The more we observed, the more questions we asked. Which team members were best placed to act as buddies? How did we prevent alcohol

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gel dispensers from becoming contaminated and acting as a transmission point? Where were we going to store clinical waste on a fully occupied ward? Answers led to further questions. Solutions, such as successfully selecting suitable PPE, often led to further problems, namely the effective procurement of said PPE in the face of national shortages. Hospital infrastructure

Despite this plethora of concerns, the overwhelming initial issue for us was one of

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space. It seemed imperative to find a more appropriate area for the receipt of at-risk patients. Reports that a nearby hospital was conducting major structural changes to side-rooms as part of their EVD response further highlighted the potential inadequacy of local facilities. Disruption to clinical service and financial constraints were just two of the barriers preventing

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reactive modification of our existing environment. Our solution was to ‘customise’ an unoccupied ward directly above our infectious diseases (ID) unit. This ward was closed

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pending other remedial work and we were uniquely fortunate to be given permission to use the space on a temporary basis. The environment addressed many of our chief concerns allowing us to allocate an entire room (the day lounge) to waste storage and to designate whole bays to donning, clinical care, and doffing. An additional advantage was the existence of an external staircase that provided direct access to the ward, circumventing an ambulant atrisk patient’s transport through the main hospital corridors. As pleased as we were with this development, the new ward environment immediately created an unexpected issue. It became clear that the ID team did not have sufficient personnel, especially out of hours, to staff the base ID ward, provide patient care to a suspected case of EVD on a different ward, and to operate the buddy system. After much discussion and deliberation, the unconventional decision was made to train our entire IPCT,

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including the infection control doctor, infection control fellow, and all the infection control matrons and nurses, as buddies. We committed ourselves to a 24 h on-call service to support our clinical colleagues in the event of patient assessment being required. However, even in the context of our well-staffed and experienced infection control team, this additional responsibility placed further strain on our already over-extended resources. Selection of PPE, staff concerns, and training

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The issue of assessing and caring for patients with suspected EVD has been emotive for staff. In view of the high mortality associated with this epidemic, our healthcare workers (HCWs) were apprehensive not only about the personal risk related to patient care, but also about the potential risk of secondary exposure of their loved ones. The media hysteria

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surrounding reports of healthcare-associated transmission of infection to HCWs in Spain and the USA compounded this anxiety.

The desire to protect our clinical colleagues as much as possible contributed to our

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decision to select PPE that was in excess of that recommended in the ACDP guidance.2 We had particular concerns about accidental contamination of the face when staff members were removing masks, caps, and visors. After reviewing multiple PPE options, we found an item that seemed ideal: the hood and helmet component of the Stryker Flyte Personal Protective System (Kalamazoo, MI, USA), which was already being used in our trust by the orthopaedic

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surgeons for high-risk cases. The hood, made from a ‘breathable viral barrier’, had the advantages of providing full face, head, and neck coverage, with an inbuilt visor. More importantly, it was easily removable in one step that reduced any potential contact with the face or neck. Again, however, the benefits of these hoods were not without drawbacks, the

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chief one being their cost. Protracted negotiations were required before the items could be procured. Even once approval for procurement had been obtained, it took weeks before the

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equipment materialized. Excessive lead times on PPE also applied to other items. For example, there were delays in the arrival of stocks of our chosen coveralls, necessitating the repeated use of a single, increasingly dilapidated, coverall for training. Others will sympathize with the difficulties associated with effective training.

Devising our local donning and doffing procedure took considerable effort and the protocol underwent multiple drafts and modifications, a process that continued even after training had commenced. The temptation to provide very detailed guidance had to be balanced against the potential for over-complicating the multi-step doffing protocol. As we wanted to allay the anxiety of HCWs as much as possible, we took the approach of delivering face-to-face training to small groups, with sufficient time allowed for addressing any questions and concerns. We also incorporated an additional assessment step into our training,

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‘contaminating’ the visor, coverall, and outer gloves of each trainee with UV disclosing lotion (GlitterBug Potion, DaRo UV Systems Ltd, Colchester, UK). Following doffing we assessed the hands and face of the HCW to ensure there was no transmission of UV lotion. As a relatively objective measure of competent doffing, this provided an element of reassurance to both clinical staff and ourselves. An unexpected but ultimately helpful repercussion of this procedure was the identification of alcohol gel dispensers as a contamination point. The

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resulting outcome was the incorporation of multiple hand-cleansing points for different stages of doffing and the procurement of automatic no-touch alcohol gel dispensers.

This high-input approach to training required substantial flexibility on the part of the IPCT, as we had to fit training sessions around the clinical commitments and responsibilities

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of our colleagues. Inevitably, other non-urgent projects were deferred such that the team could accommodate and deliver this enhanced programme of training.

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The future

Certainly for our IPCT there has been a steep learning curve associated with preparing for a case of EVD. Despite the amount of work that we have done and the volume of knowledge that has been gained, there are still several components of our local response requiring further improvement. We have focused most of our efforts on adult accident and emergency and infectious diseases, considering these to be the highest risk areas, with fewer resources being

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diverted into obstetrics and paediatrics. Much of our response has been reactionary and facilities have been allocated on a temporary basis. With an increasingly mobile global population and the associated transport of infectious diseases, isolation facilities and enhanced PPE are likely to become even more important as time progresses. However, can an already

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over-stretched National Health Service afford to perform expensive hospital infrastructure modifications as a fail-safe against theoretical future threats? From an IPC perspective, the

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outbreak of EVD in West Africa and its accompanying implications for IPCTs demonstrate that this would be money well spent. Conflict of interest statement None declared.

Funding source None declared. References 1.

Martin et al.

2.

Advisory Committee on Dangerous Pathogens, Department of Health. Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious disease of high consequence. London: Department of Health; 2014. Available at:

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https://www.gov.uk/government/publications/viral-haemorrhagic-fever-algorithm-andguidance-on-management-of-patients [last accessed May 2015]. 3.

Public Health England. Summary guidance for acute trust staff: identifying and managing patients who require assessment for Ebola virus disease. London: PHE; 2014. Available at: https://www.gov.uk/government/publications/ebola-virus-disease-

2015].

Centers for Disease Control and Prevention. Guidance on personal protective equipment to be used by healthcare workers during management of patients with Ebola virus

disease in U.S. hospitals, including procedures for putting on (donning) and removing

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(doffing). Atlanta, GA: CDC; 2014. Available at:

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http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html [last accessed May 2015].

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4.

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identifying-and-managing-patients-for-assessment-in-acute-trusts [last accessed May

Ebola preparedness: a personal perspective.

The outbreak of Ebola virus disease (EVD) in West Africa and the concomitant implications for healthcare services have resulted in unique and complex ...
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