Fig. 56.1
Correct Gear EVD flyer. Courtesy of NYC Health + Hospitals, Bellevue
Protocols and Policies
The precautions instituted when caring for a patient with suspected or confirmed EVD add complexity to nearly every aspect of patient care. In many ways, the precautions necessitate a deviation from regular work flow, creating a risk for errors. Therefore, when time allows, protocols should be drafted and distributed ahead of time. Some issues that are particularly amenable to prospective planning include:
Specimen Collection and Handling
Most of the blood samples from the patient will be obtained within the contaminated isolation room, and will be packaged and transported the satellite laboratory. Depending on the design of the isolation unit, the samples may be carried through clean areas en route to the laboratory. Some samples (such as those for EVD PCR) will need to be packaged and transported out of the hospital to specialized laboratories capable of running the test. The way in which the samples are collected, packaged, and transported should be practiced ahead of time.
Decontamination
Equipment used in the room of a patient with confirmed EVD cannot be immediately removed from that room without special precautions. Protocols for disinfecting or destroying such equipment should be developed. Staff should be aware of this issue before bringing equipment into the room that is vitally important to other patients in the hospital.
Waste Management
The PPE of providers combined with contaminated patient materials (especially those with severe nausea, vomiting, or hemorrhagic complications) can create a tremendous amount of waste. This waste is considered highly infectious, and potentially represents a public health risk if mismanaged during transport within or outside the hospital [1]. Some have raised concern about the use of EVD as an agent of bioterrorism, making this waste a potential national security threat. Thus, the process by which this waste is collected, transported, and destroyed is of paramount importance. The protocols that outline waste management should include waste in trash cans and sharps containers, waste in the patient toilets, dialysis effluent, supplies used to clean the room, and anything else potentially contaminated with infectious materials.
Provisions of Clinical Care
The precautions described above will significantly alter the way in which critical care services are delivered to patients with suspected or confirmed EVD. This alteration in workflow creates a potential for errors that may put the patient or staff at risk. If time allows, all aspects of clinical care should be considered ahead of time. Some example of topics to be considered are:
Team Structure
Typically, a critically ill patient has a complex interdisciplinary team addressing their needs. This team may include physicians, nurses, respiratory therapists, physical therapists, clinical pharmacists, social workers, nutritionists, chaplaincy personnel, and others [1]. In patient with suspected or confirmed EVD, all efforts should be made to limit the number of people who come into direct contact with the patient. Below are considerations for many of these disciplines:
Physicians: Clearly, the patient will have a team of primary physicians. While a larger team of physicians may distribute the work more evenly, this will also impact other clinical services substantially if these physicians are not allowed to care for other patients while caring for a patient with suspected or confirmed EVD. Thus, a smaller physician team may be more sustainable. Consideration should be given to the necessary skill set to serve as one of these primary providers. Ideally, one would be comfortable with airway management, central line placement, and the use of bedside ultrasound to make assessments of the cardiac and respiratory symptoms (rationale discussed in detail below.) When specialty consultation is required, careful consideration should be given to whether the consultant needs to perform a bedside assessment. If possible, “cognitive consultation” can be performed via chart review, discussion with primary physician, and possibly patient interview via video conferencing. If a small team of physicians cares for a patient for a prolonged period, attention should be paid to the psychological impact of caring for such a disease under social isolation.
Nurses: Patients with suspected or confirmed EVD are extremely nurse-intensive. These patients may require frequent assessments and interventions. However, as mentioned above, the moment of highest risk for disease transmission is during the doffing of PPE. Therefore, efforts should be made to minimize the number of times the bedside nurse enters and exits the room. One solution is for the nurse to stay in the room in full PPE for longer periods, thus minimizing the number of doffing procedures. The amount of time one can spend in full PPE will vary to some degree based on the equipment being used. However, the equipment is heavy and occlusive, leading to significant discomfort when worn for prolonged periods. Based on the need to relieve this nurse, to have another nurse available to obtain supplies, and to allow necessary breaks during a shift, at least 6 nurses per day are required to care for a patient under these precautions. It should be noted that the nurses are in the closest contact with the patient for the longest periods of time and are more likely to be exposed to infectious materials. The psychological stress put on nurses performing this role cannot be overstated. This should be accounted for during and after the care of a patient with suspected or confirmed EVD.
Respiratory Therapists: Consideration should be given to respiratory therapists providing cognitive consultation as well. This would require that they train either the physicians or nurses on how to perform the standard tasks they typically perform at the bedside. Specific examples include setup and initiation of mechanical ventilators, daily ventilator checks, alarm modulation, and ventilator troubleshooting. Even if this method is employed, however, a group of therapists should be trained in EVD precautions and PPE in the event that an unanticipated circumstance arises and they are required to enter the patient room. The therapists staffing structure should be designed such that at least one therapist trained in EVD precautions and the use of PPE is on duty at any given time.
Others: the remainder of the critical care team (pharmacists, nutritionists, social workers, chaplains, and others) can likely provider their services by chart review and patient interview without the need to enter the room.
Monitoring
Much of the monitoring that is typically done in a critical care patient can be done under these precautions. Telemetry, non-invasive blood pressure measurements, and pulse oximetry are not affected. The risks/benefits of invasive blood pressure monitoring should be considered carefully given the desire to minimize contact with blood specimens and the possibility that these patients may develop hemorrhagic complications. If available, End-tidal CO2 monitoring may make it possible to avoid arterial blood sampling.
Bedside Assessments
In patients under EVD precautions, the process of going to the bedside is complicated. Careful consideration should be made about which assessments truly require a provider to go to the bedside and which can be done via video conferencing or other means. Efforts should be made to “bundle” necessary bedside tasks to avoid the need for multiple donning and doffing procedures. With all of this being said, consideration should also be given to the mental health of the patient. If they remain awake and alert, they are likely to suffer from social isolation and may benefit greatly from seeing their providers on a regular basis.
Diagnostic Testing
Blood Analysis
The array of testing available for a patient with suspected or confirmed EVD is likely to be limited, particularly if the analysis is being done in a satellite laboratory. If time allows, providers should work with laboratory staff to discuss the testing that will be available and ensure that it will be adequate to monitor a patient at risk for severe volume losses, electrolyte abnormalities, multi-organ failure, and bleeding complications [4]. Point of care testing, to the extent it is available, may be an option that simplifies many of these issues. As noted above, the process of drawing and analyzing a blood sample under these precautions is complex and also requires laboratory staff to don and doff PPE. Therefore, whenever possible, all necessary testing should be done at one time to avoid having to repeat this process throughout the day.
Imaging
While it may be possible to perform standard imaging studies (such as xrays and CT scans) under EVD precautions, it is quite complex. Efforts should be made to avoid such testing unless absolutely critical. In well-trained hands, bedside ultrasound may provide an alternative to many of the imaging studies typically done in critically ill patients, and also eliminates the need for an additional person (such as an ultrasound technician) to enter the room. It should be noted, however, that the ultrasound machine used will likely be unavailable for immediate use on other patients once used on a patient with confirmed or suspected EVD.
Invasive Procedures
The use of PPE significantly alters the process of performing invasive procedures by restricting range of motion, altering tactile sensation, and limiting the field of view [1]. These changes create a risk for errors that represent a danger to both the patient and the providers. If time allows, careful planning and simulation of procedures while wearing PPE should be performed. Some specific areas of consideration are given below.
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