As director of biomedical engineering for the 678-bed multihospital and academic medical center that is Nebraska Medicine, Randy Peacock keeps busy even on a routine day. When things aren’t routine, on the other hand—as they definitely were not last September when word went out that an American in Liberia had contracted Ebola and would soon be airlifted to Omaha for treatment—well, that’s where the training kicks in.
Nebraska Medicine is one of a small but growing number of healthcare facilities on the list of designated Ebola treatment centers maintained by the US Centers for Disease Control and Prevention (CDC). As such, certain volunteers from the Nebraska Medicine staff, including nurses, physicians, respiratory therapists, and Peacock, along with others in biomed, have undergone extensive training in Ebola infection-control protocols and the highly specific responsibilities they would each have should an Ebola patient walk through its doors.
That September alert was delivered to facility directors, including Peacock, via confidential email “a couple days before the patient potentially would be arriving here,” he recalls. That gave him plenty of time to convene a department meeting to discuss next steps. The individuals among his staff who have stepped up for this work are all exceptionally experienced BMET IIIs, Peacock says. They are all also very familiar with Nebraska Medicine’s Biocontainment Patient Care Unit (BCU), an air-locked, 10-bed division designed in 2005 to “provide the first line of treatment for people affected by bio terrorism or extremely infectious naturally occurring diseases.”
Peacock sent those techs to the unit “to make sure everything was in good working order” ahead of the patient’s arrival. He also met with facility administrators and BCU executive staff to assure them his department would be easy to reach the entire time the patient was on site, and that a full arsenal of portable medical equipment, including an X-ray unit, a dialysis machine, and a ventilator, would be at the ready in the event a replacement was needed. “We had everything,” he recalls. “We were good to go.”
A Matter of Planning
They were good to go, of course, because they’d prepared in advance. “That’s key,” Peacock says. “You want everything in place,” from the primary and backup medical equipment itself to the roles and responsibilities of each member of the biomed team. And no, he adds, your facility doesn’t need to be specially designated by the CDC as an “Ebola treatment center” to make such planning worthwhile.
Nebraska Medicine took that first Ebola patient, Richard Sacra, because it happened to be home to one of the most advanced biocontainment units on the planet, but it also did so because US health authorities knew about Sacra and his immediate needs for treatment and quarantine. The fact is, an individual with Ebola (or, for that matter, the SARS virus, avian influenza, or any number of other highly contagious diseases) could be admitted to any hospital in the country, at any time. It’s just good practice to be ready, whether you’re a nurse, a physician, or—like Peacock—among the many professionals handling equipment support. With these diseases, Peacock notes, “don’t think you can just go in and set things up” once the patient is in the room. “You have to plan ahead.”
A Wealth of Resources
Chris Lavanchy, engineering director of ECRI Institute’s Health Devices Group (and co-presenter, with Peacock and one other, of the recent ECRI webinar, “Ebola: Medical Devices and Personal Protective Equipment Preparedness”), agrees. “You don’t want to wait until you have a patient at your doorstep to figure all this out,” he says. Toward that end, he recommends that biomed departments—and hospitals in general—refer to the various Ebola-related resources posted online by the CDC, the Environmental Protection Agency (EPA), and ECRI itself.
To Help in West Africa
While the handful of Ebola patients here in the United States have received significant attention in the media, the real crisis remains in West Africa, and especially in Sierra Leone, Liberia, and Guinea. (Through December 8, 2014 there had been 6,331 deaths and 17,800 confirmed and suspected cases in those three countries, according to the World Health Organization.)
That region’s desperate need for medical volunteers is well known, and many physicians, nurses, and others are now risking their lives alongside local health workers in the West African Ebola treatment centers where patient care is offered. Less publicized, but equally critical if the virus is to be stopped, is the need in those same treatment centers for medical devices, personal protective equipment, and the experienced biomedical professionals who can clean, repair, and maintain it all. Still, the WHO did put out a call for such equipment, as well as volunteers, in October, asking for donations of everything from blood pressure cuffs and pulse-oximeters to autoclaves, syringes, and glucometers, and providing a link that prospective volunteers could follow to search for professional vacancies. For more information on volunteer opportunities, or to donate equipment, email email@example.com or see the WHO employment page.
The EPA page features a lengthy list of disinfectants healthcare facilities can employ to remove Ebola virus from hard, non-porous surfaces, including medical equipment. The CDC site, meanwhile, is intended to be a comprehensive resource for “health departments, hospitals, and other emergency care settings” developing Ebola preparedness plans, and includes guidance on everything from personal protective equipment (PPE) for healthcare workers to infection prevention and control recommendations. ECRI’s Ebola Resource Center, Lavanchy says, links to a number of official agency sites and publications, including the ones above, but it also features unique ECRI content, including articles that address concerns specific to HTM professionals.
The institute recently conducted a survey of hospitals to determine “the equipment-related issues they’re dealing with” as they prepare to treat patients with Ebola or other “high-risk infectious diseases,” he says. “And the results were really interesting.” Facilities reported difficulties in obtaining PPE, for instance, as “there is apparently a shortage of the gowns and suits” that healthcare workers must wear around patients.
Other feedback concerned the thorny issue of potentially contaminated equipment. With an Ebola patient, Lavanchy notes, “they’d be using ventilators and dialysis machines, devices that are very expensive and not necessarily easy to replace. So would they have to dispose of them after treatment? Or is there a way they could reprocess them so they could safely use them on other patients?” The Ebola virus presents “a unique situation for HTM folks because” with most diseases and conditions, “they generally don’t have to go to great lengths to protect themselves while they’re working on equipment,” Lavanchy says. But when a patient has Ebola, “you’re going to have equipment that is potentially contaminated in many ways,” and it will be up to HTM to get it back in service and to do it in a way that is not only safe, but also effective. “If there’s good news” here, Lavanchy notes, it’s the fact that Ebola is “not a very rugged virus.” It can be killed, that is, “if you do it right.” And that other issue—the lack of PPE? That’s a problem that needs to be addressed, he says.
One Facility’s Approach
While there is plenty of personal protective equipment on hand at the Nebraska isolation unit, if Randy Peacock has his way, no one on his team will ever need to use it. In fact, Peacock notes, while his higher-level BMETs have received training in the donning and doffing of PPE and are familiar with the protocols of entering and exiting the unit—just in case—HTM was never called into the BCU during Richard Sacra’s stay. And that was exactly according to plan. For safety reasons, “they did not and do not want us in there,” he says of the medical staff who attended to Sacra 24 hours a day. “With an Ebola patient, we’re only entering that room if it’s absolutely necessary.”
The ECRI Institute’s “Checklist: Equipment-Related Preparedness for Ebola” provides a list of precautions HTM personnel should keep in mind when working with devices used on patients with “high-risk infectious diseases.” Among them (see the Checklist for details):
1. Use needlestick-prevention devices
2. Ensure effective cleaning and disinfection of reusable devices
3. Safely manage dialysis equipment
4. Prepare for autoclaving of discarded devices and other waste
5. Ensure safe setup and use of suctioning equipment
6. Effectively clean and disinfect channeled endoscopic devices
7. Consider video communication with patients
Source: ECRI Institute. Checklist: equipment-related preparedness for Ebola. Health Devices 2014 Nov 12.
To minimize the chances of that ever happening, every room in the Nebraska unit includes a video monitor with a two-way camera, microphone, and speakers. “The patient can use it to communicate to their family,” Peacock says, “but it also provides a direct link to the nurses’ station and their physicians, and it’s a way for us, if we need to, to troubleshoot any problems that come up” without having to go into the unit.
If such a scenario did arise (it hasn’t), he explains, “we’d try to talk whoever’s in there through what they needed to do” to address the issue. If that approach wasn’t possible, HTM’s next move would be to replace the device in question. “We have at least one spare”—sanitized and ready for use—“for each item in the room.” Those spares are stored in a clean area, “and they’re always available; we can get them at a moment’s notice.”
The only Ebola-related equipment issues Peacock’s team had to deal with involved the sterilizer, which by design has a “clean” side outside of the isolation room. “So [in each case] we were actually able to work on it externally and do the job dressed in normal scrubs.” Nebraska Medicine’s biomeds would go into that unit only if “a major fault was indicated,” Peacock adds. “And when we went in—that’s when we’d don the PPE.” (Note: Nebraska Medicine videos showing the donning and doffing process can be viewed on its website at app1.unmc.edu/nursing/heroes. Also see “The Nebraska Ebola Method,” a comprehensive guide to the organization’s Ebola-management protocols, at nebraskamed.com/biocontainment-unit/ebola.)
The Payoff of Training
Peacock recalls “a heightened sense of urgency” on the day it was announced that an Ebola patient was on his way. But he also remembers the smooth sailing—the way his team, clearly prepared for such an event, stepped up to the challenge the same way it would have for any high-stress job. Their mission, he notes, was straightforward: to manage the equipment in the BCU. “To make sure everything that was needed was in place and functional, to have additional equipment available in case something broke, and to be prepared to go in” if necessary; and then, once the patient was out, to clean up and disinfect, to dispose of the items that required disposal, to check the equipment to make sure it still worked, and to prepare the room so it could be used again. Things certainly were different with an Ebola patient on site, he says. But that didn’t change the outlook for his team. They were well trained; they knew what they were doing.
That was good news for Richard Sacra, a physician from Massachusetts who had traveled to West Africa as a volunteer with the Christian organization SIM USA. Sacra, thanks in large part to the care he received at Nebraska Medicine, survived the ordeal, as did a second patient with Ebola who arrived at the facility in early October, not long after Sacra was discharged. (A third patient, also a physician, was admitted to the unit in November with advanced symptoms of Ebola, including kidney and respiratory failure, and died shortly thereafter.) Despite the fact that the Nebraska BCU has been up and running for nearly a decade, these three individuals are the first patients Peacock can recall ever being isolated in the unit. And now that they’re gone? “You never know what might be next,” he says. Ebola, smallpox, a victim of bioterrorism….for a biomed, they’re all basically the same. “We’re ready.”
Chris Hayhurst is a contributing writer for 24×7. For more information, contact editorial director John Bethune at firstname.lastname@example.org.