The Nebraska Ebola Experience. Angela Vasa BSN, RN, CCRN Lead Staff Nurse Nebraska Biocontainment Unit

Transcription

1 The Nebraska Ebola Experience Angela Vasa BSN, RN, CCRN Lead Staff Nurse Nebraska Biocontainment Unit

2 Objectives 1. Recognize processes to educate staff and maintain competencies when caring for Ebola Virus Disease infected patients. 2. Describe the challenges in caring for the Ebola Virus Disease infected patient and how to overcome those challenges. 3. Recognize local, state and national resources for the provision of care to patients with Ebola Virus Disease. Ebola Smallpox SARS Plague

3 What Happened? there was a large Ebola Virus outbreak in West Africa that claimed the lives of thousands of individuals There were limited treatment facilities or resources available in West Africa to treat those infected Healthcare workers travelling to West Africa to provide care who became infected were dying due to lack of treatment facilities The United States reviewed their capabilities to provide aid and tasked those units in existence with providing care to American Citizens who became infected while in West Africa.

4 Why Nebraska? Homeland Security A new Federal agency Monkey Pox Healthcare Workers afraid to care for patients SARS Emerging diseases are a threat to Public Health Active local Omaha community in Emergency Preparedness

5 Partnership Nebraska Medicine Clinical Care and Infectious Disease Support State of Nebraska Health Department CDC Guidelines University of Nebraska Medical Center (UNMC) - Academic Arm for Infectious Diseases The Nebraska Biocontainment Unit opened March 2005

6 Community Support

7 Nebraska Biocontainment Unit Goals Goal Treat patients with serious communicable diseases (Infected pathogens) : Bioterrorist Act, Laboratory Event or Accident Global infectious diseases Smallpox, Plague, Viral Hemorrhagic Fever, Monkey Pox, SARS, Avian Influenza, VRSA, MDR-TB Biocontainment units (BCUs) Clinical facilities specifically designed to minimize nosocomial transmission of highly contagious and hazardous diseases by incorporating engineering and safety measures

8 Nebraska Biocontainment Unit Five (potentially double) patient rooms Secure access Separate air handling system Negative air pressure with air exchanges /hr HEPA filtered exhaust air, over 25 feet from air intakes 2 effluent style autoclaves (pass-through) Point of care lab (collaboration with Nebraska Public Health Lab)

9 What have we been doing for the past 10 years? Practice.. Practice.. Practice..

10 Diversity of Staff Multi-Disciplinary: Physicians Respiratory Care Practitioners Patient Care Technicians Registered Nurses: Critical Care Operating Room/ Procedural Infusion Services Medical/ Surgical Emergency/ Trauma Care Pediatrics Labor and Delivery Special Procedures Cardiac Telemetry

11 Staffing the Unit Candidates: Volunteer to be on the team Hold primary job position within Nebraska Medicine Interviews by nursing director and manager Each candidate must display Strong clinical skills Ability to remain calm in stressful situations Ability to learn quickly Are flexible in their work details Strong sense of team effort

12 Education Coordination: Unique Learning Environment All Staff meet competencies within their primary unit Additional NBU competencies Early process Regular Staff Meetings, routine maintenance, periodic drills Learning Portfolios responsibility on individual, helps to make staffing decisions. Listing of unit policies to review Attendance at meetings recorded Listing of employee health screenings Required certifications

13 Education, Drills and Training Operating Room Staff Care of a PUI Radiology Department Local Responders and the United States Air Force

14 NBU Research Gaseous Ozone decontamination Vaporized Hydrogen Peroxide decontamination of complex medical equipment and rooms Autoclave evaluation for decontamination of soiled items Evaluation of appropriate of PPE usage by healthcare worker Mathematical Air Modeling Infrared Thermal Detection System for Fever Recognition And more.

15 ACTIVATED!

16 NBU Ebola Activations September 5, 2014 Day #8 of illness Discharged on hospital day #21 October 6, 2014 Day # 6 of illness Discharged on hospital day #17 November 15, 2014 Day # 13 of illness Multi-organ failure on admission Died on hospital day #3

17 To protect ourselves, we need to understand the disease How Infectious is it? How Contagious is it? How do we protect ourselves from it?

18 How infectious is Ebola Virus? Influenza 1,000 HIV 100 Ebola 1 From Dr. Sina Bavari, USAMRIID

19 How Contagious is Ebola? Source: NPR

20 Transmission Transmission is via direct contact with infected blood/body fluids -Healthcare workers -Household contacts -Burial practices Infectiousness of body fluids (viral load) increases as patient becomes more ill In late stage illness with copious fluid output, transmission risk is highest Remains from deceased infected persons are highly infectious A person with Ebola is not contagious unless there are symptoms

21 Personal Protective Equipment The level of PPE worn in the NBU while caring for patients with Ebola Virus depended on the risk to health care workers from: Splash or Airborne contaminates. Sharing our Knowledge/ Best Practices Prior to and during the NBU activations, NBU staff prepared video and written education that was made available to the national and international healthcare community

22 Donning Partner Ensures everyone is donned in the proper PPE and that it is worn correctly Wears the level of PPE that is required in the clean zone Unlike the doffer, the donner may don more than one person at a time.

23 Doffing Partner Assists the doffer with removing PPE Wears the same level of PPE as the doffer Supports the patient care RN as needed Transfers waste/ dirty linens to the person performing the autoclaving Transfers specimens from patient room to point of care lab or tasker for processing

24 Transport Process Air Transport

25 Transport Process Ground transportation

26 Lessons Learned Challenges Unique to NBU Diminished tactile sensation Three pairs of gloves Limited ability to auscultate Hood Electronic/ Digital Stethoscopes Headphones Length of time needed to complete routine tasks Communication In the patient room To the nurses station For the family Lab Needed faster turn around time What labs are essential Waste management Complex Larger volume Second autoclave added

27 Staffing Model Staffing ratios (no less than 3 RN s) 6:1 days 5:1 nights Team consists of RN s, RCP s, PCT s Development of staff roles Primary RN RN Tasker/ Donning Partner Doffing Partner Autoclaver Length of time spent in the hot zone

28 Primary RN responsibilities Prepare and provide patient report to oncoming RN s and other staff Determines patient care rotation schedule with other RN s RN s typically worked increments of 4 hours each Responsible for ensuring all physician orders are completed Ensures all relevant charting is being done in the HER Print and interpret an EKG strip at the beginning of each shift if the patient is on cardiac monitoring

29 Registered Nurses All RN s rotate to provide patient care All staff rotate in donning/ doffing and tasking as needed Obtain medications from the automated drug dispensing system as needed Count the narcotics and restock Patient Care Technicians & Respiratory Therapists Perform Autoclaving Gather and deliver supplies Donning and Doffing partners Provide advanced airway support if warranted

30 Maintaining Standards of Care Providing aggressive interventions as warranted by the patient s condition. Performing Invasive Procedures while Maintaining a Sterile Field

31 Protecting Equipment

32 Waste Stream Liquid Autoclavable Suction Heads Solid Dual Autoclaves Disaster Linens

33 Waste Stream Volume of waste generated related to acuity Considerations for processing and storage Biocontainment Unit staff handle all waste processing All waste and laundry is autoclaved (sterilized) prior to leaving the NBU Policies were developed for safe handling of waste and linen in consultation with waste and laundry service partners.

34 Point of Care Lab

35 Communication-Huddles Update on patient status Expected arrival time Treatment plan Staff reassurance

36 Communication-Tele health Minimizes exposure risk Expert consultations Facilitates patient care In room staff support HIPAA Compliant Family visitation

37 Behavioral Health Fears of family, friends and co-workers on home units Arrival of each patient-emotions experienced, preparation, reality versus expected. Our successful discharge of an Ebola free patient Infected health care workers in Texas-fears, doubts, support of upper management.

38 Post-Activation Cleaning

39 Persons Under Observation Persons under observation were monitored by public health twice daily

40 NBU Staff Monitoring NBU staff complete daily temperature monitoring while activated and for 21 days post-activation Interactive system Collaboration with Nebraska Public Health

41 Community Outreach OMMRS Training Tours Presentations at local and national conferences Schools pre-school college Business leaders Churches

42 What are we doing now? Article publications-to help educate others on the knowledge we gained through our experience Present our learnings at appropriate venues to help others develop capability to care for highly infectious disease patients Multi-Agency Drills at Nebraska Medicine Most recently drill with USAF, OFD, EMS for multi-patient transport drill Formation of NETEC Leadership team participating in site visits to other hospitals Educational courses held at Nebraska Medicine in collaboration with Bellevue, Emory University and CDC for designated Ebola treatment and assessment centers. Staff nurses participated in national training courses Maintain a state of readiness here at Nebraska Medicine Provide training for specialty areas likely to be impacted-er and OR Engage our NBU staff with meetings, drills, education and outreach

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44 Resources Available for Public Use HEROES website Nebraska Medicine website CDC website World Health Organization National Ebola Training and Education Center Website under development

45 Unanticipated Rewards The formation of a cohesive team who can trust each other. The empowerment of nurses to adapt and implement new policies and procedures in order to provide innovative care in a safe way. Safe provision of care for three Ebola infected patients with no staff exposures. Provide education and training to colleagues from around the world. Provide once in a lifetime experience for many nurses and ancillary staff.

46 Questions?

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