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At a glance: New CDC guidelines are a step in the right direction
In the wake of criticism by nurses and other healthcare workers over the absence of clear guidelines for protecting hospital personnel treating patients infected with Ebola, the Centers for Disease Control and Prevention issued updated recommendations outlining proper use of personal protective equipment (PPE). The 17-page document, “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 (Doffing),” outlines administrative, environmental, and management efforts needed to prevent hospital personnel from contracting the virus and to ensure their safety.
The new CDC guidelines came weeks after two Dallas nurses were infected with Ebola while caring for a man who had recently traveled from Liberia. The West African countries of Liberia, Sierra Leone and Guinea are currently suffering the largest Ebola epidemic in history. The guidelines were updated on Oct. 20 to include the following substantive changes:
| OLD | NEW | |
|---|---|---|
| Presenting symptoms | Fever > 101.5 | Fever > 100.4 |
| Respiratory protection | Face mask, | Respirators |
| Other PPE | Standard precautions as outlined in 2007 guidelines | "all skin covered" |
| Eye, face and neck protection | Goggles or face shields |
|
| Hand protection | Single gloves | Double gloving with gloves taped to sleeves to completely cover skin on arms |
| Body protection | Fluid-resistant gowns | Fluid-resistant or impermeable gowns; Tyvek/coveralls or hazmat suits and aprons when caring for highly symptomatic patients; shoe coverings; boots or leg coverings |
| Process | Individual gowns and gloves at doorway | "Buddy" system in place to monitor PPE process. Observer actively supervising donning and doffing process. Two “vestment” areas (one dirty, one clean) for removing protective gear; frequent disinfection of visibly contaminated PPE before removal and hand-sanitizing repeatedly with assistance of observer during doffing process. |
| Cleaning and disinfection | Standard precautions for environmental services personnel cleaning patient rooms | "Clinical staff" (attending doctors and nurses) perform cleaning and disinfection of Ebola patient rooms. When patient room is vacated, environmental services staff wear PPE recommended for direct care clinicians. |
| Training recommendations | All healthcare workers involved in the care of Ebola patients should receive repeated training and have demonstrated competency in performing all Ebola-related infection control practices and procedures, and specifically in donning/doffing proper PPE. |
What’s missing from the new guidelines?
Nurses and other health professionals are quick to note that the guidelines are just that—voluntary guidelines. The CDC does not have the authority to enforce them in every hospital. Only local and state health departments can make these guidelines mandatory. In the absence of any other enforcement mechanism, the OSHA Bloodborne Pathogens Standard provides some protection.
Despite early promises, the CDC cannot send a team to every location where Ebola is suspected, given that hundreds of suspected cases have been reported since the traveler and nurses in Dallas contracted the disease. But if a case is confirmed, the CDC will send a team of medical personnel to help out and ensure compliance with the guidelines, Shortly after it was confirmed that Dr. Craig Spencer, an attending physician at New York-Presbyterian Hospital/Columbia University Medical Center and volunteer with Doctors Without Borders, tested positive for the virus after returning from treating Ebola patients in Guinea, the CDC had a team in place at Bellevue Hospital where Spencer is now a patient.
Equally important, these extensive protection guidelines require both more time and staff to ensure no breaks in protocol. No staff caring for suspected cases should move beyond the screening and isolation areas to care for other patients. And, the layers of protective clothing result in an accumulation of heat and physical stress that limit the time the nurse is able to care for patients. U.S. hospitals with sophisticated cooling capacity allow nurses to spend 60 minutes in PPE; nurses in field hospitals are generally limited to 45 minutes in full protective gear.
The AFT will press CDC to improve this new guidance as follows:
- More guidance on the process in the emergency department. The current guidelines are limited to direct care clinicians who are caring for a suspected or confirmed case. Guidance is essential for nurses and other ED staff who will perform the initial screening and triage. There must be PPE guidelines for them.
- Recommendations for the amount of training and practice time required for staff to become proficient in donning and doffing PPE.
- Recommendations that direct hospitals on whether clinicians caring for an Ebola patient should be restricted in caring for other patients.
- Recommendations for nonhospital settings such as ambulatory care centers or offices; home health care; public health clinics.
More extensive recommendations on follow-up of clinicians who have had inadvertent exposure to an Ebola patient’s blood or body fluid. We need guidance that encourages hospitals to provide administrative pay (wages and benefits) to healthcare workers who are quarantined or put under precautionary isolation. Guidance on providing emotional and social support to exposed nurses/clinicians and assistance in returning to work when they are released from quarantine.