by Tyler Smith and Erin Emery | UCHealth
September 30 was just another normally busy day at University of Colorado Hospital for Safety Officer Pat Conroy. That changed abruptly with news that a patient who traveled from West Africa to Dallas was the first person in the United States diagnosed with a confirmed case of the deadly Ebola virus.
The day became anything but normal as Conroy started getting a stream of calls. “My phone blew up,” he said.
While planning meetings had already started prior to the news from Dallas, leaders launched a series of additional meetings and preparations among dozens of providers and hospital leaders throughout University of Colorado Health. The work continued this week to develop plans and processes to identify and assess people who might come to UCHealth hospitals and clinics with suspected cases of Ebola, transport and treat those who may have the virus, and protect other patients, hospital visitors, staff, and physicians.
The news Oct. 10 that a health care worker at Texas Presbyterian Hospital who cared for the infected patient had also tested positive for the virus added a note of urgency to the preparations. Texas Public Health authorities identified a second health care worker from the same hospital who tested positive for Ebola on Oct. 15.
To ensure policies are standardized and communicated expeditiously across the system, UCHealth’s Senior Executive Group decided Oct. 15 that all recommendations for preparing for and responding to Ebola will be funneled through Chief Medical Officer William Neff, MD. Neff will work closely with clinical and operational leaders in the decision-making process and will report back to system leaders.
“Our goal is to ensure that we coordinate our efforts and ensure that we deliver the highest level of care and protection to our patients, visitors, staff, and physicians across the UCHealth system,” Neff said.
Caution, not panic
A system-wide communication on Oct. 7 from Neff, co-signed by the CMOs from each hospital and Colorado Health Medical Group, stressed that the organization takes the risk of Ebola seriously. At the same time, the message said that all UCHealth hospitals are well-versed in protecting patients and staff from the transmission of other highly contagious diseases and noted that the risk of spreading the Ebola virus – which requires a transfer of bodily fluids from an individual who is symptomatic – is lower than it is for airborne diseases like influenza.
After a series of meetings during the week, UCHealth posted a collection of documents about Ebola that are available on each hospital’s intranet. The information covers infection control, transmission, risk factors, symptoms and more, and includes an “Ebola Triage/Evaluation” flowsheet developed by the Centers for Disease Control and Prevention (CDC).
Many hands for multiple challenges
Meanwhile, 11 different task forces with system-wide representation continue to look at flow in the UCHealth emergency departments, safe methods for donning and removing personal protective equipment, lab logistics, patient transport, staff and family care, communications and marketing, staffing models, handling of hazardous waste, and more.
The question of hazardous waste disposal offers one example of the challenges Ebola presents. Medical waste contaminated with the virus is a Category A infectious substance and is designated as the highest category of hazardous material regulated by the U.S. Department of Transportation (DOT). That means it requires special packaging for transport to a waste-disposal facility for autoclaving, which uses pressurized steam to sterilize contaminated waste.
Conroy said that waste vendor Stericycle is working with the DOT and the CDC on obtaining approved packaging and containers for transport of medical waste contaminated with the Ebola virus. The hospital has a plan to store large quantities of waste temporarily on-site if needed, he said, but declined to elaborate further.
The hospitals also put together isolation carts with personal protective equipment for providers who care for patients with a suspected or confirmed case of Ebola. At UCH, the “high-risk isolation carts” are available in the Emergency Department and in the Central Supply depot in the basement of AIP 1. They are equipped with protective gloves, gowns, masks, booties, goggles, and face shields – equipment necessary to handle any type of isolation, short of the “space suit-looking outfits” now familiar from news reports, said Charles Little, DO, medical director of emergency preparedness for UCH.
The gear on the carts can be updated as needed to provide maximum protection for providers who care for Ebola patients, emphasized Joe Springfield, materials coordinator for Central Supply at UCH.
Protection through process
The second case of Ebola transmission in the United States highlighted the importance of providers following protocols to the letter in caring for Ebola patients. “For clinical staff, it’s making sure that we’ve used the correct protective equipment for our staff and making sure that the correct isolation procedures are in place for the patient so that we can protect ourselves as well as other patients in the hospital,” said Kelly Beach, RN, nursing team lead in the ED at UCHealth South (Memorial Hospital).
The new case also points up the importance not only of donning protective gear but also removing it safely. The CDC recommends that health care workers use a “buddy system” when they remove protective gear, Eric Poeschla, MD, head of the Infectious Disease Division at the CU School of Medicine, said in a television interview Oct. 13 – a recommendation adopted by UCHealth in its “Infection Control Precautions.”
“In both the African hospitals, here and in Spain it turns out that the weakest link in the chain appears to be the taking off of the protective clothing so we are looking at that very hard now,” Poeschla told Fox31 Denver.
But the process starts with identifying patients who may be at risk. Rob Leeret, RN, director of emergency/trauma and capacity at UCH, said Emergency Department staff were instructed last week to ask every patient who arrives in the ED for their travel history to West African countries, including Guinea, Liberia, and Sierra Leone in the past 21 days – the maximum incubation time for the virus – and possible contact with blood or bodily fluids of individuals who had or were suspected to have Ebola.
Those who answer “Yes” to either question are isolated and triaged for fever above 101.5 degrees and diarrhea, vomiting, severe headache and other symptoms. If they meet those criteria, they are considered a “person under investigation.” Infection Control and infectious disease specialists will immediately be notified, and the patient will be admitted to an isolated unit at the hospital.
Late Monday afternoon, providers throughout the system had access to an Ebola screening tip sheet in Epic that includes the questions, a best practice advisory on the steps to follow if a patient answers either question affirmatively, and automated orders for the patient.
Patients admitted with a suspected case of Ebola will be transported along a predetermined route to as-yet unidentified isolation units at each hospital. Infectious Disease will contact the Colorado Department of Public Health and Environment. The house manager will be notified and reassign any patients who might have contact with the infected patient. The Clinical Lab will be alerted to the arrival of hand-carried, high-risk blood specimens, and an internal disaster plan will be called.
Michelle Feller, RN, MS, director of critical care and dialysis for UCH, said the hospital has put together a core group of staff to care for Ebola patients, including critical care nurses, respiratory therapists, radiology technologists, and Environmental Services staff. Feller said she is working with managers to collect additional names of people who express an interest.
There are plenty of operational moving parts, so core staff will participate in exercises to simulate taking patients from the ED an isolation unit, Feller said. “This will include patient flow, patient care workflow and traffic flow to ensure we are fully prepared in the event a patient presents with a potential high-risk infectious disease,” she said.
Conroy said ED simulations will begin once staff in UCH’s WELLS (Work, Education, and Lifelong Learning Simulation) Center coordinate the necessary steps with ED staff. Simulations in the ICUs will begin later, he said.
While a patient with Ebola may never come through the doors of a UCHealth hospital, the efforts to prepare for that happening have been valuable, said Cindy Corsaro, emergency management officer at Memorial.
“This has been a system-wide approach. While there are a few nuances with each location, we have worked to systemize as much as possible and streamline our efforts and communication,” Corsaro said.