Ebola: Lessons learned in the Nebraska medicine biocontainment unit

The ease of international travel now brings new threats to our EDs and clinics, diseases that we learned about but thought we would never see. That is the challenge to which we in critical care must respond. Intensivists and infectious disease specialists at the University of Nebraska Medical Center/Nebraska Medicine, Omaha, recently cared for three patients in our biocontainment unit, and we would like to share some insights about the preparation for and care of those patients.

The Nebraska Medicine Biocontainment Unit was established in 2005, in the wake of the anthrax attack and 9/11. The staff of the unit was drawn from volunteers across all areas of the hospital, including the emergency department and ICU and included specialists in infectious diseases, epidemiology, and infection control from the School of Public Health. The medical director is an infectious disease specialist, and intensivists were not involved in the training of the staff. The staff was trained in decontamination techniques and the transport and care of patients in strict isolation and was fully prepared for the patients sent to us. The acuity of the patients dictated that a team approach to the physician care of these patients be taken. The intensivists were brought in to obtain central venous access, manage fluid and electrolytes and nutrition, as well as any critical care issues that arose. The infectious disease specialists focused on treatment of the virus, health-care worker protection, equipment decontamination, and investigational new drug applications for the U.S. Food and Drug Administration.

That the Ebola virus is transmitted through contact with secretions is well known. The initial symptoms have been well documented (Bausch et al. Antiviral Res. 2008;78[1]:150-61) and should be a warning to those who have been exposed to seek medical attention. Those with fever should be quarantined and monitored closely for nausea, vomiting, and diarrhea. There appears to be a window of time during which if patients are hydrated and electrolytes monitored closely, the outcomes are improved. These are the patients who should be isolated in our critical care units and given the care that intensivists can deliver. Our biocontainment unit works successfully because the staff is highly trained in isolation procedures and the care of critically ill patients. Teamwork is essential for the care of these patients.

Isolation of patients with exposure to the Ebola virus and new onset fever maintains public safety and provision of proper personal protective equipment (PPE) gives the caregiver the confidence to treat this deadly disease. The key to maintaining isolation is careful attention to the donning and doffing of PPE. All caregivers going into the unit had to change into scrubs and put on the PPE one would use for universal precautions, including a surgical mask, isolation gown, and gloves. For added protection, everyone wore slip-on rubber shoes with shoe covers that were removed on leaving the unit and dipped in bleach solution. Entering the “hot zone” where the patient was located required additional PPE and another team member to observe the donning process to make sure there were no breaks in the PPE. Doffing was also a two-person job, requiring decontamination at each step with alcohol hand gel and new gloves. Resources from the University of Nebraska Biocontainment Unit are available outlining each step of this process (The Nebraska Ebola Method – For Clinicians. Accessed on iTunes U, Dec. 17, 2014).

Each patient that came to our biocontainment unit had a central venous catheter placed, even though some had previously established peripheral access. The reasoning was that these patients were malnourished prior to transfer to the biocontainment unit and would likely not be able to tolerate enteral nutrition for at least 7 days after arrival. The access also afforded us the ability to draw blood for monitoring of electrolytes without needing to do venipuncture, which minimizes health-care workers’ risk of exposure. The process for placement of the central line was different only in the PPE that was required. The PPE required to enter the hot zone included goggles, N-95 face mask, hood, and full face shield, an impervious surgical gown, and boot covers that came up above the calf. Two pairs of gloves were worn with the second pair duct-taped to the cuff of the surgical gown. A third pair of gloves was used to enter the room and position the patient. These were removed, and alcohol sanitizer was used on the second pair of gloves prior to donning a sterile surgical gown and gloves over the PPE worn into the room. The internal jugular vein was the site selected for placement and located using ultrasound guidance. Two nurses were available in the room continuously to provide assistance. An antibiotic-coated quadruple lumen catheter was placed over a guide wire after confirming intravascular placement of the wire with the ultrasound. The lumen was flushed with saline solution and capped and an occlusive dressing placed over the site prior to breaking the sterile field. There were no complications with any of these procedures. There were no alterations in the procedure despite the patients’ infection with the Ebola virus.

One issue we addressed early on was whether we would allow trainees under our supervision to become involved in direct patient care. Once it became known that we would be caring for these patients, a discussion was held with the faculty who would be responsible for these patients to determine if the fellows on critical care rotations should be involved in direct patient care. Given the uncertainty regarding the care of these patients and the additional scrutiny that these patients were under, it was decided that fellows should not be responsible for direct patient care. This was discussed with the fellows, and they were told that they could assist and be involved indirectly by assisting with documentation and writing orders from the nursing station outside the hot zone and interact with the patient and direct caregivers via closed circuit video link. Fellows were allowed to opt out if so desired, but all volunteered that they wanted to be involved in any way allowed. Over the course of the care of the three patients, seven of nine fellows participated in indirect patient care in some manner. Fellows were trained in donning and doffing PPE in preparation for entering the biocontainment unit.

A major issue that the biocontainment unit had to address prior to arrival of patients was what to do in the event of acute decompensation requiring advanced cardiac life support with CPR. Given the mortality reports from West Africa, the physician staff of the biocontainment unit discussed the risks of caregiver exposure if CPR was done, and it was determined that the risk was too high and the likelihood of survival if CPR was needed was too low. Initially, the physicians discussed this with each patient and next of kin and recommended that the patient be placed on DNR [do not resuscitate] status. As we gained experience with these patients, we realized that intubation and mechanical ventilation could be done safely under controlled circumstances, and we developed a policy for intubation and critical care support but no CPR.

It seems clear from the general experience that patients with the Ebola virus who receive standard critical care therapies early following the onset of fever have better outcomes than did those who received this care late. If the virus is not treated and supportive critical care is not given in the first 6-8 days, multisystem organ failure ensues, and mortality is high despite the best medical efforts. Patients may develop hypoxemic respiratory failure, liver failure, and renal failure, in addition to their nausea, vomiting, diarrhea, and delirium. It seems rational but somewhat unclear that these patients develop a syndrome similar to severe sepsis, with an eventual capillary leak syndrome, and that careful attention to volume status early on can help patients avoid the multisystem organ failure. Unfortunately, optimal antiviral therapy has not been determined, but we will learn more as we gain additional experience and perform clinical trials with potential therapies.

The lessons we have learned thus far are as follows:

1. Assemble and train a team of nurses, respiratory therapists, and industrial hygienists who can operate all aspects of biocontainment.

2. Assemble a group of physicians who can provide care for these patients, including intensivists and infectious diseases specialists.

3. Adhere to guidelines for donning and doffing PPE, and designate donning and doffing partners to assist and monitor every step.

4. Consider central venous access in all patients.

5. Establish policy for resuscitation.

6. Establish a role for residents and fellows, and if there is a role in indirect or direct patient care, provide proper training.

7. Treat as severe sepsis, monitoring volume status and electrolytes carefully.

Editor’s Comment

In this first installment of my tenure as the section editor of Critical Care Commentary, I am extremely grateful to Dr. Craig Piquette and colleagues for providing their first-hand insights on treating critically ill patients with the Ebola virus within one of the United States’ most advanced biocontainment units. While optimal Ebola therapies are yet to be fully elucidated, these early experiences highlight several issues this infection – and other, future epidemic illnesses – may superimpose upon routine ICU cares.

The incremental precautions required when performing invasive procedures in highly contagious individuals such as these, while extensive, are not necessarily surprising. However, these early experiences with the Ebola virus have required unique reflections on our self-imposed limits to providing care. What is the point at which the potential benefit to the patient with the Ebola virus becomes outweighed by the risk of harm to the physicians providing their care? It has convincingly been argued that our sacred oath of “Primum non nocere” requires us to be stewards in preventing harm to ourselves as well as to our patients. Withholding cardiopulmonary resuscitation and restricting the roles of trainees in the care of these patients are provocative examples of our competing interests and certainly merit further considerations.

Because this is my first commentary in CHEST Physician, I would like to take this opportunity to thank Dr. Peter Spiro for his astute author selection and insightful editorial comments during his 3-year term as editor of this section. I sincerely hope that my selections in the coming years measure up to the high standards he has firmly established. Readers with comments and/or suggestions should feel free to contact me at any time via e-mail (lmorrow@creighton.edu) as I sincerely welcome your criticisms and collaborations. I look forward to serving both our readers and CHEST in the years to come.

The ease of international travel now brings new threats to our EDs and clinics, diseases that we learned about but thought we would never see. That is the challenge to which we in critical care must respond. Intensivists and infectious disease specialists at the University of Nebraska Medical Center/Nebraska Medicine, Omaha, recently cared for three patients in our biocontainment unit, and we would like to share some insights about the preparation for and care of those patients.

The Nebraska Medicine Biocontainment Unit was established in 2005, in the wake of the anthrax attack and 9/11. The staff of the unit was drawn from volunteers across all areas of the hospital, including the emergency department and ICU and included specialists in infectious diseases, epidemiology, and infection control from the School of Public Health. The medical director is an infectious disease specialist, and intensivists were not involved in the training of the staff. The staff was trained in decontamination techniques and the transport and care of patients in strict isolation and was fully prepared for the patients sent to us. The acuity of the patients dictated that a team approach to the physician care of these patients be taken. The intensivists were brought in to obtain central venous access, manage fluid and electrolytes and nutrition, as well as any critical care issues that arose. The infectious disease specialists focused on treatment of the virus, health-care worker protection, equipment decontamination, and investigational new drug applications for the U.S. Food and Drug Administration.

That the Ebola virus is transmitted through contact with secretions is well known. The initial symptoms have been well documented (Bausch et al. Antiviral Res. 2008;78[1]:150-61) and should be a warning to those who have been exposed to seek medical attention. Those with fever should be quarantined and monitored closely for nausea, vomiting, and diarrhea. There appears to be a window of time during which if patients are hydrated and electrolytes monitored closely, the outcomes are improved. These are the patients who should be isolated in our critical care units and given the care that intensivists can deliver. Our biocontainment unit works successfully because the staff is highly trained in isolation procedures and the care of critically ill patients. Teamwork is essential for the care of these patients.

Isolation of patients with exposure to the Ebola virus and new onset fever maintains public safety and provision of proper personal protective equipment (PPE) gives the caregiver the confidence to treat this deadly disease. The key to maintaining isolation is careful attention to the donning and doffing of PPE. All caregivers going into the unit had to change into scrubs and put on the PPE one would use for universal precautions, including a surgical mask, isolation gown, and gloves. For added protection, everyone wore slip-on rubber shoes with shoe covers that were removed on leaving the unit and dipped in bleach solution. Entering the “hot zone” where the patient was located required additional PPE and another team member to observe the donning process to make sure there were no breaks in the PPE. Doffing was also a two-person job, requiring decontamination at each step with alcohol hand gel and new gloves. Resources from the University of Nebraska Biocontainment Unit are available outlining each step of this process (The Nebraska Ebola Method – For Clinicians. Accessed on iTunes U, Dec. 17, 2014).

Each patient that came to our biocontainment unit had a central venous catheter placed, even though some had previously established peripheral access. The reasoning was that these patients were malnourished prior to transfer to the biocontainment unit and would likely not be able to tolerate enteral nutrition for at least 7 days after arrival. The access also afforded us the ability to draw blood for monitoring of electrolytes without needing to do venipuncture, which minimizes health-care workers’ risk of exposure. The process for placement of the central line was different only in the PPE that was required. The PPE required to enter the hot zone included goggles, N-95 face mask, hood, and full face shield, an impervious surgical gown, and boot covers that came up above the calf. Two pairs of gloves were worn with the second pair duct-taped to the cuff of the surgical gown. A third pair of gloves was used to enter the room and position the patient. These were removed, and alcohol sanitizer was used on the second pair of gloves prior to donning a sterile surgical gown and gloves over the PPE worn into the room. The internal jugular vein was the site selected for placement and located using ultrasound guidance. Two nurses were available in the room continuously to provide assistance. An antibiotic-coated quadruple lumen catheter was placed over a guide wire after confirming intravascular placement of the wire with the ultrasound. The lumen was flushed with saline solution and capped and an occlusive dressing placed over the site prior to breaking the sterile field. There were no complications with any of these procedures. There were no alterations in the procedure despite the patients’ infection with the Ebola virus.

One issue we addressed early on was whether we would allow trainees under our supervision to become involved in direct patient care. Once it became known that we would be caring for these patients, a discussion was held with the faculty who would be responsible for these patients to determine if the fellows on critical care rotations should be involved in direct patient care. Given the uncertainty regarding the care of these patients and the additional scrutiny that these patients were under, it was decided that fellows should not be responsible for direct patient care. This was discussed with the fellows, and they were told that they could assist and be involved indirectly by assisting with documentation and writing orders from the nursing station outside the hot zone and interact with the patient and direct caregivers via closed circuit video link. Fellows were allowed to opt out if so desired, but all volunteered that they wanted to be involved in any way allowed. Over the course of the care of the three patients, seven of nine fellows participated in indirect patient care in some manner. Fellows were trained in donning and doffing PPE in preparation for entering the biocontainment unit.

A major issue that the biocontainment unit had to address prior to arrival of patients was what to do in the event of acute decompensation requiring advanced cardiac life support with CPR. Given the mortality reports from West Africa, the physician staff of the biocontainment unit discussed the risks of caregiver exposure if CPR was done, and it was determined that the risk was too high and the likelihood of survival if CPR was needed was too low. Initially, the physicians discussed this with each patient and next of kin and recommended that the patient be placed on DNR [do not resuscitate] status. As we gained experience with these patients, we realized that intubation and mechanical ventilation could be done safely under controlled circumstances, and we developed a policy for intubation and critical care support but no CPR.

It seems clear from the general experience that patients with the Ebola virus who receive standard critical care therapies early following the onset of fever have better outcomes than did those who received this care late. If the virus is not treated and supportive critical care is not given in the first 6-8 days, multisystem organ failure ensues, and mortality is high despite the best medical efforts. Patients may develop hypoxemic respiratory failure, liver failure, and renal failure, in addition to their nausea, vomiting, diarrhea, and delirium. It seems rational but somewhat unclear that these patients develop a syndrome similar to severe sepsis, with an eventual capillary leak syndrome, and that careful attention to volume status early on can help patients avoid the multisystem organ failure. Unfortunately, optimal antiviral therapy has not been determined, but we will learn more as we gain additional experience and perform clinical trials with potential therapies.

The lessons we have learned thus far are as follows:

1. Assemble and train a team of nurses, respiratory therapists, and industrial hygienists who can operate all aspects of biocontainment.

2. Assemble a group of physicians who can provide care for these patients, including intensivists and infectious diseases specialists.

3. Adhere to guidelines for donning and doffing PPE, and designate donning and doffing partners to assist and monitor every step.

4. Consider central venous access in all patients.

5. Establish policy for resuscitation.

6. Establish a role for residents and fellows, and if there is a role in indirect or direct patient care, provide proper training.

7. Treat as severe sepsis, monitoring volume status and electrolytes carefully.

Editor’s Comment

In this first installment of my tenure as the section editor of Critical Care Commentary, I am extremely grateful to Dr. Craig Piquette and colleagues for providing their first-hand insights on treating critically ill patients with the Ebola virus within one of the United States’ most advanced biocontainment units. While optimal Ebola therapies are yet to be fully elucidated, these early experiences highlight several issues this infection – and other, future epidemic illnesses – may superimpose upon routine ICU cares.

The incremental precautions required when performing invasive procedures in highly contagious individuals such as these, while extensive, are not necessarily surprising. However, these early experiences with the Ebola virus have required unique reflections on our self-imposed limits to providing care. What is the point at which the potential benefit to the patient with the Ebola virus becomes outweighed by the risk of harm to the physicians providing their care? It has convincingly been argued that our sacred oath of “Primum non nocere” requires us to be stewards in preventing harm to ourselves as well as to our patients. Withholding cardiopulmonary resuscitation and restricting the roles of trainees in the care of these patients are provocative examples of our competing interests and certainly merit further considerations.

Because this is my first commentary in CHEST Physician, I would like to take this opportunity to thank Dr. Peter Spiro for his astute author selection and insightful editorial comments during his 3-year term as editor of this section. I sincerely hope that my selections in the coming years measure up to the high standards he has firmly established. Readers with comments and/or suggestions should feel free to contact me at any time via e-mail (lmorrow@creighton.edu) as I sincerely welcome your criticisms and collaborations. I look forward to serving both our readers and CHEST in the years to come.

The ease of international travel now brings new threats to our EDs and clinics, diseases that we learned about but thought we would never see. That is the challenge to which we in critical care must respond. Intensivists and infectious disease specialists at the University of Nebraska Medical Center/Nebraska Medicine, Omaha, recently cared for three patients in our biocontainment unit, and we would like to share some insights about the preparation for and care of those patients.

The Nebraska Medicine Biocontainment Unit was established in 2005, in the wake of the anthrax attack and 9/11. The staff of the unit was drawn from volunteers across all areas of the hospital, including the emergency department and ICU and included specialists in infectious diseases, epidemiology, and infection control from the School of Public Health. The medical director is an infectious disease specialist, and intensivists were not involved in the training of the staff. The staff was trained in decontamination techniques and the transport and care of patients in strict isolation and was fully prepared for the patients sent to us. The acuity of the patients dictated that a team approach to the physician care of these patients be taken. The intensivists were brought in to obtain central venous access, manage fluid and electrolytes and nutrition, as well as any critical care issues that arose. The infectious disease specialists focused on treatment of the virus, health-care worker protection, equipment decontamination, and investigational new drug applications for the U.S. Food and Drug Administration.

That the Ebola virus is transmitted through contact with secretions is well known. The initial symptoms have been well documented (Bausch et al. Antiviral Res. 2008;78[1]:150-61) and should be a warning to those who have been exposed to seek medical attention. Those with fever should be quarantined and monitored closely for nausea, vomiting, and diarrhea. There appears to be a window of time during which if patients are hydrated and electrolytes monitored closely, the outcomes are improved. These are the patients who should be isolated in our critical care units and given the care that intensivists can deliver. Our biocontainment unit works successfully because the staff is highly trained in isolation procedures and the care of critically ill patients. Teamwork is essential for the care of these patients.

Isolation of patients with exposure to the Ebola virus and new onset fever maintains public safety and provision of proper personal protective equipment (PPE) gives the caregiver the confidence to treat this deadly disease. The key to maintaining isolation is careful attention to the donning and doffing of PPE. All caregivers going into the unit had to change into scrubs and put on the PPE one would use for universal precautions, including a surgical mask, isolation gown, and gloves. For added protection, everyone wore slip-on rubber shoes with shoe covers that were removed on leaving the unit and dipped in bleach solution. Entering the “hot zone” where the patient was located required additional PPE and another team member to observe the donning process to make sure there were no breaks in the PPE. Doffing was also a two-person job, requiring decontamination at each step with alcohol hand gel and new gloves. Resources from the University of Nebraska Biocontainment Unit are available outlining each step of this process (The Nebraska Ebola Method – For Clinicians. Accessed on iTunes U, Dec. 17, 2014).

Each patient that came to our biocontainment unit had a central venous catheter placed, even though some had previously established peripheral access. The reasoning was that these patients were malnourished prior to transfer to the biocontainment unit and would likely not be able to tolerate enteral nutrition for at least 7 days after arrival. The access also afforded us the ability to draw blood for monitoring of electrolytes without needing to do venipuncture, which minimizes health-care workers’ risk of exposure. The process for placement of the central line was different only in the PPE that was required. The PPE required to enter the hot zone included goggles, N-95 face mask, hood, and full face shield, an impervious surgical gown, and boot covers that came up above the calf. Two pairs of gloves were worn with the second pair duct-taped to the cuff of the surgical gown. A third pair of gloves was used to enter the room and position the patient. These were removed, and alcohol sanitizer was used on the second pair of gloves prior to donning a sterile surgical gown and gloves over the PPE worn into the room. The internal jugular vein was the site selected for placement and located using ultrasound guidance. Two nurses were available in the room continuously to provide assistance. An antibiotic-coated quadruple lumen catheter was placed over a guide wire after confirming intravascular placement of the wire with the ultrasound. The lumen was flushed with saline solution and capped and an occlusive dressing placed over the site prior to breaking the sterile field. There were no complications with any of these procedures. There were no alterations in the procedure despite the patients’ infection with the Ebola virus.

One issue we addressed early on was whether we would allow trainees under our supervision to become involved in direct patient care. Once it became known that we would be caring for these patients, a discussion was held with the faculty who would be responsible for these patients to determine if the fellows on critical care rotations should be involved in direct patient care. Given the uncertainty regarding the care of these patients and the additional scrutiny that these patients were under, it was decided that fellows should not be responsible for direct patient care. This was discussed with the fellows, and they were told that they could assist and be involved indirectly by assisting with documentation and writing orders from the nursing station outside the hot zone and interact with the patient and direct caregivers via closed circuit video link. Fellows were allowed to opt out if so desired, but all volunteered that they wanted to be involved in any way allowed. Over the course of the care of the three patients, seven of nine fellows participated in indirect patient care in some manner. Fellows were trained in donning and doffing PPE in preparation for entering the biocontainment unit.

A major issue that the biocontainment unit had to address prior to arrival of patients was what to do in the event of acute decompensation requiring advanced cardiac life support with CPR. Given the mortality reports from West Africa, the physician staff of the biocontainment unit discussed the risks of caregiver exposure if CPR was done, and it was determined that the risk was too high and the likelihood of survival if CPR was needed was too low. Initially, the physicians discussed this with each patient and next of kin and recommended that the patient be placed on DNR [do not resuscitate] status. As we gained experience with these patients, we realized that intubation and mechanical ventilation could be done safely under controlled circumstances, and we developed a policy for intubation and critical care support but no CPR.

It seems clear from the general experience that patients with the Ebola virus who receive standard critical care therapies early following the onset of fever have better outcomes than did those who received this care late. If the virus is not treated and supportive critical care is not given in the first 6-8 days, multisystem organ failure ensues, and mortality is high despite the best medical efforts. Patients may develop hypoxemic respiratory failure, liver failure, and renal failure, in addition to their nausea, vomiting, diarrhea, and delirium. It seems rational but somewhat unclear that these patients develop a syndrome similar to severe sepsis, with an eventual capillary leak syndrome, and that careful attention to volume status early on can help patients avoid the multisystem organ failure. Unfortunately, optimal antiviral therapy has not been determined, but we will learn more as we gain additional experience and perform clinical trials with potential therapies.

The lessons we have learned thus far are as follows:

1. Assemble and train a team of nurses, respiratory therapists, and industrial hygienists who can operate all aspects of biocontainment.

2. Assemble a group of physicians who can provide care for these patients, including intensivists and infectious diseases specialists.

3. Adhere to guidelines for donning and doffing PPE, and designate donning and doffing partners to assist and monitor every step.

4. Consider central venous access in all patients.

5. Establish policy for resuscitation.

6. Establish a role for residents and fellows, and if there is a role in indirect or direct patient care, provide proper training.

7. Treat as severe sepsis, monitoring volume status and electrolytes carefully.

Editor’s Comment

In this first installment of my tenure as the section editor of Critical Care Commentary, I am extremely grateful to Dr. Craig Piquette and colleagues for providing their first-hand insights on treating critically ill patients with the Ebola virus within one of the United States’ most advanced biocontainment units. While optimal Ebola therapies are yet to be fully elucidated, these early experiences highlight several issues this infection – and other, future epidemic illnesses – may superimpose upon routine ICU cares.

The incremental precautions required when performing invasive procedures in highly contagious individuals such as these, while extensive, are not necessarily surprising. However, these early experiences with the Ebola virus have required unique reflections on our self-imposed limits to providing care. What is the point at which the potential benefit to the patient with the Ebola virus becomes outweighed by the risk of harm to the physicians providing their care? It has convincingly been argued that our sacred oath of “Primum non nocere” requires us to be stewards in preventing harm to ourselves as well as to our patients. Withholding cardiopulmonary resuscitation and restricting the roles of trainees in the care of these patients are provocative examples of our competing interests and certainly merit further considerations.

Because this is my first commentary in CHEST Physician, I would like to take this opportunity to thank Dr. Peter Spiro for his astute author selection and insightful editorial comments during his 3-year term as editor of this section. I sincerely hope that my selections in the coming years measure up to the high standards he has firmly established. Readers with comments and/or suggestions should feel free to contact me at any time via e-mail (lmorrow@creighton.edu) as I sincerely welcome your criticisms and collaborations. I look forward to serving both our readers and CHEST in the years to come.