The ease of international travel now brings new threats to our EDs and clinics, diseases that we learned about but thought we would never see. That is the challenge to which we in critical care must respond. Intensivists and infectious disease specialists at the University of Nebraska Medical Center/Nebraska Medicine, Omaha, recently cared for three patients in our biocontainment unit, and we would like to share some insights about the preparation for and care of those patients.
The Nebraska Medicine Biocontainment Unit was established in 2005, in the wake of the anthrax attack and 9/11. The staff of the unit was drawn from volunteers across all areas of the hospital, including the emergency department and ICU and included specialists in infectious diseases, epidemiology, and infection control from the School of Public Health. The medical director is an infectious disease specialist, and intensivists were not involved in the training of the staff. The staff was trained in decontamination techniques and the transport and care of patients in strict isolation and was fully prepared for the patients sent to us. The acuity of the patients dictated that a team approach to the physician care of these patients be taken. The intensivists were brought in to obtain central venous access, manage fluid and electrolytes and nutrition, as well as any critical care issues that arose. The infectious disease specialists focused on treatment of the virus, health-care worker protection, equipment decontamination, and investigational new drug applications for the U.S. Food and Drug Administration.
That the Ebola virus is transmitted through contact with secretions is well known. The initial symptoms have been well documented (Bausch et al. Antiviral Res. 2008;78[1]:150-61) and should be a warning to those who have been exposed to seek medical attention. Those with fever should be quarantined and monitored closely for nausea, vomiting, and diarrhea. There appears to be a window of time during which if patients are hydrated and electrolytes monitored closely, the outcomes are improved. These are the patients who should be isolated in our critical care units and given the care that intensivists can deliver. Our biocontainment unit works successfully because the staff is highly trained in isolation procedures and the care of critically ill patients. Teamwork is essential for the care of these patients.
Isolation of patients with exposure to the Ebola virus and new onset fever maintains public safety and provision of proper personal protective equipment (PPE) gives the caregiver the confidence to treat this deadly disease. The key to maintaining isolation is careful attention to the donning and doffing of PPE. All caregivers going into the unit had to change into scrubs and put on the PPE one would use for universal precautions, including a surgical mask, isolation gown, and gloves. For added protection, everyone wore slip-on rubber shoes with shoe covers that were removed on leaving the unit and dipped in bleach solution. Entering the “hot zone” where the patient was located required additional PPE and another team member to observe the donning process to make sure there were no breaks in the PPE. Doffing was also a two-person job, requiring decontamination at each step with alcohol hand gel and new gloves. Resources from the University of Nebraska Biocontainment Unit are available outlining each step of this process (The Nebraska Ebola Method – For Clinicians. Accessed on iTunes U, Dec. 17, 2014).
Each patient that came to our biocontainment unit had a central venous catheter placed, even though some had previously established peripheral access. The reasoning was that these patients were malnourished prior to transfer to the biocontainment unit and would likely not be able to tolerate enteral nutrition for at least 7 days after arrival. The access also afforded us the ability to draw blood for monitoring of electrolytes without needing to do venipuncture, which minimizes health-care workers’ risk of exposure. The process for placement of the central line was different only in the PPE that was required. The PPE required to enter the hot zone included goggles, N-95 face mask, hood, and full face shield, an impervious surgical gown, and boot covers that came up above the calf. Two pairs of gloves were worn with the second pair duct-taped to the cuff of the surgical gown. A third pair of gloves was used to enter the room and position the patient. These were removed, and alcohol sanitizer was used on the second pair of gloves prior to donning a sterile surgical gown and gloves over the PPE worn into the room. The internal jugular vein was the site selected for placement and located using ultrasound guidance. Two nurses were available in the room continuously to provide assistance. An antibiotic-coated quadruple lumen catheter was placed over a guide wire after confirming intravascular placement of the wire with the ultrasound. The lumen was flushed with saline solution and capped and an occlusive dressing placed over the site prior to breaking the sterile field. There were no complications with any of these procedures. There were no alterations in the procedure despite the patients’ infection with the Ebola virus.