Bizness Lounge: Ebola Disease Units Boast High-Level Tools, Few Rooms

By Robert Langreth and Cynthia Koons

The state-of-the-art infectious disease centers now treating Ebola patients in the U.S. have world-class doctors and nurses with years of training, hot pressure chambers that can sterilize more than a ton of contaminated waste, and a record of success handling some of the world’s most demonic pestilence.
What they don’t have is a lot of room for patients.
Only four hospitals in the country have high-level containment units specially designed for treating exotic infectious diseases such as Ebola, according to the U.S. Centers for Disease Control and Prevention. Each has the capacity to treat
only a handful of Ebola patients at once.
“If there are any more mishaps we’re going to need more beds,” said Robert Glatter, an emergency room doctor at Lenox Hill Hospital in New York. “We need to significantly increase” the number of sophisticated containment units.
The debacle at Texas Health Presbyterian Hospital Dallas, where two health workers were infected with Ebola while treating Thomas Eric Duncan before he died, exposed the lack of preparedness for treating Ebola at many hospitals. While various major hospitals are now gearing up to treat Ebola, for now patients are being treated at just these handful of centers.

Atlanta Hospital

Emory University Hospital in Atlanta, which is treating Amber Vinson, the second Dallas health-care worker to be infected by Ebola, has capacity for three patients in its biocontainment unit, which was created in 2002, said Holly Korschun, an Emory spokeswoman, in an e-mail.

Over the years, its workers “were trained in the use of personal protective equipment like full-body suits, and they ran drills for a dozen different scenarios,” she said.
The National Institutes of Health Clinical Center, which is treating Nina Pham, the first Dallas health-care worker to be infected with Ebola, has capacity to take two patients, an NIH official told Congress on Thursday. The unit, in Bethesda, Maryland, is designed to provide high-level isolation capabilities, the NIH said in a statement.
The biocontainment facility at the Nebraska Medical Center, which is treating NBC cameraman Ashoka Mukpo, would most likely be able to handle two to three patients at a time, depending on the severity of the cases, said Christopher Kratochvil, associate vice-chancellor for clinical research at the University of Nebraska Medical Center, in a telephone interview.

Montana Facility

A fourth biocontainment facility in Montana, designed to treat workers from the NIH’s Rocky Mountain Laboratories in cases of accidental infection, has three patient rooms, according to a 2010 article in Emerging Infectious Diseases.

The high-level containment units weren’t necessarily designed with Ebola in mind, said Rick Davey, deputy clinical director of the National Institute of Allergy and Infectious Diseases division of clinical research, on a conference call with reporters. Instead, they were developed to safely treat workers from various national facilities who became infected with pathogens in accidents, he said. Among other features, the units have state-of-the-art air handling capabilities so microbes can’t get out.
“The staff training and drilling and re-training and re-drilling that all of these units have undertaken over a process of years has prepared them thoroughly for this current outbreak,” Davey said.
Ebola is challenging to treat safely because patients release large amounts of vomit, diarrhea or blood as the disease becomes more advanced, and the fluids can contain large amounts of infectious virus. Patients can lose as much as 5 to 10 liters of bodily fluids a day, according to a presentation by an Emory University infectious disease specialist, Bruce Ribner, at a medical conference in early October.

350 Boxes

At Emory, in just a three-week period after its first Ebola patient arrived, the hospital had to sterilize 350 boxes of medical waste weighing more than 3,000 pounds using a device called an autoclave, according to a webcast of Ribner’s presentation at idweek.org.
They filled several trailers sent off for incineration, according to the presentation.
Dealing with fluids “is a huge problem,” in treating Ebola patients, according to Sean Kaufman, a biosafety expert who was involved in infection control when the first two Ebola patients were treated at Emory in August. “The challenge of cleaning up large spills is substantial,” he said.
Kaufman has since left Emory and is now training doctors in Liberia.

‘Engineered Properly’

Emory “did a lot of things right,” Kaufman said. “They had a beautiful facility that was engineered properly. They had the best personal protective equipment. They had outstanding standard operating procedures. And they had great administrative control.”
For example, Emory used full-body suits and head gear, going beyond the minimum recommendations of the Atlanta-based CDC at the time, because nurses were more comfortable in them, according to Kaufman.
It also was important to have someone not involved in care watching over the caregivers to make sure they don’t inadvertently slip up and infect themselves, Kaufman said. At Emory, he said, “I sat in there with them for 15 hours a day for close to two weeks to make sure they did what they were supposed to do.”
The first two Ebola patients Emory treated -- aid worker Nancy Writebol and doctor Kent Brantly -- recovered and were released. A third patient who arrived at Emory on September 9 is recovering and expects to be released soon, according to a statement from the patient released by Emory on October 15.

Prior Training

The biocontainment facility at the Nebraska Medical Center, which successfully treated doctor Rick Sacra, has 40 employees from a variety of backgrounds. They include surgical nurses, respiratory therapists, nursing assistants and infectious disease doctors.
Five to seven staff members work on the unit at any one time treating a given Ebola patient, said Kratochvil, associate vice-chancellor for clinical research at the University of Nebraska Medical Center.
“To be able to perform at this level will really be based on the prior training of the hospital,” Kratochvil said by telephone. “The level of care required for the personal protective equipment with Ebola is higher than what most hospitals are used to.”
Nebraska’s unit has a dedicated individual who monitors the application and removal of protective equipment.

Less Time

Since receiving a second Ebola patient, the hospital has established a lab within the biocontainment unit to test blood and biological samples on site. That cuts down on the time it would take to sterilize the outside of a sample package before shipping it out for testing.
While the Nebraska facility has 10 beds distributed in five double rooms, Kratochvil said it would be difficult to put two Ebola patients in any one room given the equipment needed to treat them, and that the facility would most likely be able to handle two to three Ebola patients at a time, he said.
At the NIH Clinical Center in Maryland, Nina Pham is overseen by two nurses in her room at any one time, with other nurses outside watching to make sure procedures are followed.
Both Emory University and Nebraska had the advantage of knowing in advance that Ebola patients were coming, giving them time to prepare.

‘Advance Notification’

“They were fortunate that they had advance notification of that these patients were coming, versus the hospital in Texas where the patient just showed up,” said Mark Jarrett, chief quality officer at the North Shore-LIJ Health System, which has 17 hospitals in Long Island and New York. “It gave them a chance to make sure everything was put into place.”
Nurses and doctors need “ample training” in how to isolate and treat Ebola patients safely, including detailed training on how to take protective equipment off and observers who can help nurses and doctors do this, said Glatter, the emergency physician at Lenox Hill Hospital. Holding frequent drills or simulations is crucial for hospitals to be prepared for treating an Ebola patient in case one walks in the door.
Being able to treat an Ebola patient without spreading the disease “is direct proof of how well you are doing” in infection control, said Glatter.

Saturday, 18 October 2014

Ebola Disease Units Boast High-Level Tools, Few Rooms

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