Randall B. Charpentier, HEM, President/Principal Consultant: HealthSafe New England
Peggy Berry, PhD candidate, MSN, RN, COHN-S, SPHR, PLNC, Consultant: Thrive_At_Life: Working Solutions
Beth Boynton, RN, MS, Organizational Development Consultant, Author, Speaker
The spot light is shining bright and hot on healthcare and the world population. Mainstream media constantly is broadcasting messages on the progress of those exposed or potentially exposed to the Ebola virus in the U.S. and abroad. Where is it, how widespread is it, how many humans are being affected, and where is it going are constant questions associated with this exotic virus?
As information became available, postings were reposted on various articles with links throughout LinkedIn and shared within our networks of colleagues, peers and professionals who work hand in hand to protect the front line healthcare workers tasked with containing Ebola. Healthcare is undergoing a transformation unlike anything seen within our professional experiences. With Value Based Purchasing, Affordable Care Act implementation, and hospitals fined by CMS for high readmission rates, the rumblings of needed change are loud and clear to consumers and providers. Healthcare organizations now are challenged with Ebola’s jump to the U.S. Reports now are surfacing that nurses do not feel prepared or safe to handle/treat Ebola patients. And as per this article Nurses: On the Front Line Against Ebola are in positions of major risk.
Healthcare providers have successfully isolated and treated Tuberculosis, AIDS/HIV, and Avian Bird Flu. Ebola is deadly with a very short latency period. While transmission modalities and routes of exposure (airborne-inhalation/contact-skin, mucous membranes/injection-sharps, needles, IV’s/ingestion) are being hotly debated, when aerolized treatment occurs (patient is on a respirator), nurses and other front line/ancillary staff may require level 3/Level B (See: OSHA PPE Protective Levels) Hazmat gear. Healthcare organizations and staff should be maximizing their protective measures to prevent further transmission.
^Disclaimer, the information contained in this article is based on best practice experience from a safety/risk management perspective and may not align with the current recommendations set forth by the CDC. Please consult the CDC guidelines for compliance with their recommendations and check back weekly for updated information.
From a risk, safety, nursing, human resources, quality, and industrial hygiene perspective, there was lack of clarity from government officials on effective protocols for triaging potentially Ebola infected patients from Emergency Room presentation to admission and isolation.
Because of this confusion and lack of clarity on protocols, healthcare organizations and staff were limited to the basic prevention of the spread of disease transmission commonly known as Universal Precautions. In examining the risk/hazard control principles from the IH/Safety point of view, each group of healthcare providers require protection. From first responders (EMS/AMBULANCE), Triage (ED), Holding (CDU), Treatment (Med/Surg), to Intervention (OR’s/Outpatient/Special Procedure), OSHA’s hierarchy of controls consists of elimination/substitution/isolation of the hazard/risk, engineering controls, administrative controls/work practices and personal protective equipment. Speaking from one experience of many while preparing our surgical team and staff to admit a TB/HIV positive patient, we utilized isolation techniques (i.e. protecting staff/patient with the appropriate PPE, i.e. elevated beyond Standard/Universal Precautions), while maximizing engineering controls (negative pressure isolation suites with ante-room), and administrative/work practice controls: (Policy/Procedure, Training, Inspecting/Donning/Doffing PPE, and Decon Procedures). An infection control protocol is an integral part of any hospital’s Safety, Infection Prevention and Emergency Management Plan!
Let’s begin with isolating and controlling the hazard first and move through the various stages:
Isolate/Control: Regardless of scenario (e.g., outpatient, emergency responder, triage, admission) the patient is isolated from the general population and environment via personal protective equipment/isolation chamber. Supply/provide impervious/moisture resistant outer garment(s) to all potentially affected/impacted parties covering head to toe, minimum N95 respirator, however HEPA Filtered Air Purifying Respirators/PAPR hood is preferred for maximum protection of transport personnel prior to transport/transfer of patient. Secure the environment and personnel. Protect patient/staff via PPE and/or mobile isolation chambers prior to movement, and cover all means of transport via protective poly or other protective impervious barriers/enclosure and alert receiving parties of precautions. Proceed to isolation. Negative pressure isolation is preferred once a patient is received. Other parties to assess immediately secured-impacted environment & person(s).
Personal Protective Equipment: Healthcare professionals are highly trained in the utilization of PPE as it relates to Standard/Universal Precautions, and again, this is not Level 3/Level B HazMat protection. These PPE guidelines are unique in the sense that not all hospitals are equipped with the appropriate types of PPE and types of procedures/policies and training required to handle an Ebola patient. In addition, these guidelines have evolved since the first known transmission from patient to staff recently. Of particular concern is, and will continue to be, the management of the decontamination process of treating clinicians, the proper doffing or safe removal of the PPE, appropriate staffing (buddy system with donning and doffing), and how materials will be disposed as per current CDC Guidelines. (Also see CDC Guidance on PPE r/t Ebola)
*Illustration examples only
Changes to Ebola Protection Worn by U.S. Hospital Workers
After two nurses in Dallas tested positive for Ebola after helping to care for Thomas Eric Duncan, the Liberian who died of the disease last week, federal health officials decided to tighten the guidelines for American hospitals with Ebola patients. Many hospitals, including those in the North Shore Long Island Jewish Health System and the Nebraska Medical Center in Omaha — one of four facilities in the country with biocontainment units equipped to isolate patients with dangerous infectious diseases — have long had more stringent guidelines than the C.D.C. OCT. 15, 2014-Additional Source: CDC
Engineering Controls: Once the patient has been safely isolated and transported, the next preferred destination is a negative pressure isolation suite/room equipped with an ante room. This isolation suite shall have appropriate air pressure relationships with very specific air exchange rates. These rates should be validated/confirmed by Facilities Management, HVAC Techs, and/or an independent 3rd party I.H. HVAC contractor prior to placing the patient in the room. The room should be equipped with an audio/visual device indicating that the pressure relationships are appropriate and can be constantly monitored by clinical staff to ensure optimal safety for the patient and staff. Constant visual testing and verification can be confirmed utilizing non-toxic/non-irritant smoke/vapor generators. Most hospitals have, or should have Building Automation Systems (BAS) to constantly monitor HVAC operation and functionality.
Administrative/Work Practice Controls: Organizational guiding principles and compliance measures dictate standard versus best practices in accredited healthcare organizations. In most facilities, policies are developed, approved, and adjusted once every three years according to The Joint Commission requirements. Best and evidenced based practices indicate a more robust adjustment process is needed for most facilities. Policies based on change in work practice could be as frequent as monthly. In the case of adjusting to the Ebola virus, organizations may develop a new policy and training protocol based on current lessons learned, and adjust as new lessons emerge. Orientation and annual training for healthcare organizations are designed as an overview of topics and do not provide detailed information designed to protect staff specifically. Computer Based Training (CBT) is the standard model of training in healthcare.
This may be an opportunity for organizations to revisit one on one, hands on competency training for all departments and staff specific to their roles in response to receiving a suspected or confirmed Ebola patient. Not all hospital departments will be equipped to handle a suspect Ebola patient arriving to the facility through the ED after traveling from Africa, or after exposure to an Ebola host. For high risk departments such as Physicians, Nursing, Imaging Services, Lab, Respiratory, Lab, Environmental Services, Facilities, and staff in the ED, OR’s, ICU, Med/Surge Floors, there should be provided extensive hands on training, not pamphlets, information flyers, intranet postings, YouTube videos, and the like. It has been suggested that a Buddy System be incorporated into specific practices such as inspecting, donning/doffing PPE. The buddy system is utilized through healthcare facilities and is an integral part of many OSHA compliant programs. We strongly encourage the buddy system, now called trained observer, be part of any isolation program when donning and doffing is part of the isolation routine.
Laboratory requirements and functions also should be evaluated to ensure appropriate management of samples in biocontainment fashion and can adhere to the stringent above Level 1 requirements for cleaning and waste management protocols as well as other protocol requirements. Respirator fit testing beyond the standard N95 may be required. Healthcare facilities must adopt best and evidence based practices that ensure the safety and health of all patients and staff, which also includes psychological safety and health. All safety concerns must be addressed and no healthcare employee should feel unsafe to challenge a safety practice or unsafe practice.
The Importance of “Soft Skills”
Given the persistence of human factors, leadership, and communication factors in root causes of sentinel events to date, it is essential to keep in mind how complicated individual and organizational behaviors may impact prevention efforts. These are important to consider because speaking up about deficiencies such as inadequate PPE or problems, saying “No” to unsafe practices or “I need more practice to feel confident donning and doffing this PPE”, asking for, offering, or refusing to help, setting limits around fatigue, rushing, interruptions or other limitations, and working in a buddy system all involve assertiveness for patients, self, and colleagues, respectful listening, and healthy relationships. All of these are “soft skills” that can make the different between exposure and prevention at every step of the way and the following guidelines will contribute to optimal prevention:
1. Understand that “soft skills” like assertiveness and listening are complicated. They involve core emotional intelligence such as self-esteem, self- and other-awareness, and an ability to validate other perspectives even when emotionally charged differences exist. Nurses are often much better at advocating for patients than for themselves and this is often exploited by organization leaders or perhaps not understood. Training should include facilitated practice and ongoing opportunities for more practice. Encouraging nurses to ‘speak up’ isn’t about intellectual learning that must take place, it is about changing behaviors! Crew Resource Management, TeamSTEPPS, and Medical Improv are all strategies that can help.
2. Respectful listening by administrative and physician leaders is absolutely essential to create and sustain cultures where speaking up (by nurses, patients and others) is nurtured. And it should be nurtured. Inviting nurses to voice concerns about Ebola and listening to them is an effective way leaders can help build this skill set.
3. Undoing long histories of ignoring or dismissing input from nurses must be addressed IF toxic cultures are present and they often are. This requires an apology for old and a vision of new ways of being. This is critical for building trust. Imagine how frontline professionals might feel about CDC regulations or MD videos about PPE that were woefully inadequate. We need and want to trust our leaders, but it is understandable why we might be reluctant.
4. Recognize that 1-3 above are key for creating collaborative healthcare teams and that from this, we can create a healthier vision of what we want USA healthcare to be and then act on it. It will be safer (for patients and providers), more cost-effective, and more rewarding to work in.
In closing, we can prevent more painful and unnecessary lessons from the Ebola virus IF we are vigilant with the science of safety and truly collaborative in our practices.
Randall Charpentier is a 20 year experienced, safety and risk management consultant specializing in healthcare compliance and best practice management. Project experience ranges from leading teams on the construction of the west coast space shuttle project, working internationally & domestically for leading environmental engineering firms conducting real estate assessments involving occupational and environmental risks, assessing business operational risks concerning commercial insurance policies, and reducing/eliminating exposures/hazards, to leading world renowned, top ten/one hundred community based & BioMedical Research/Teaching hospitals, with development and execution of best practices with EOC, Fire/Life Safety, Infection Prevention in Healthcare Construction, and Emergency Management programs. HSNE’s/Randall’s passion is keeping patients, staff and visitors safe in a healthcare setting. CMS is measuring safety and quality in healthcare facilities basing reimbursement on healthcare outcomes. Does your facility measure up? If not, you should conduct a risk assessment. Is your facility compliance or results driven? To find out, contact firstname.lastname@example.org or www.hsnellc.com, or LinkedIn profile.
Peggy Berry, MSN, RN is a PhD candidate with the University of Cincinnati and consultant in occupational health and environmental health. She is studying workplace bullying in healthcare with her dissertation focus on what nurses do to work through, cope, and support each other when bullying occurs. She is certified as a Senior Human Resource Professional, Certified Occupational Health Nurse Specialist, and Professional Legal Nurse Consultant. She has presented programs on benchmarking in occupational health, migraines in the workplace, on pandemic preparedness, communicable diseases, and workplace violence. Peggy has volunteered her time as an examiner with the Baldrige National Quality Program and Ohio Partnership for Excellence and as a volunteer with the Dayton Chapter of the American Red Cross as a Disaster Health Services and Emergency Services leads. Peggy is past president of Ohio Association of Occupational Health Nurses and past national director with American Association of Occupational Health Nurses. Contact Peggy: email@example.com or through her LinkedIn profile.
Beth Boynton RN, MS is a national speaker, consultant, and the author of “Confident Voices: The Nurses’ Guide to Improving Communication and Creating Positive Workplaces”. She specializes in communication, collaboration, & emotional intelligence for healthcare professionals and organizations and is trained in the Professor Watson Curriculum for Medical Improv through Northwestern University Feinberg School of Medicine. Her video, “Interruption Awareness: A Nursing Minute for Patient Safety” and blog, “Confident Voices in Healthcare” have drawn audiences from all over the world. She is currently writing a core text on communication for nursing students with F.A. Davis Publishing Co. which is tentatively scheduled for publication in the Spring of 2015.
* Sources to consult include: CDC, OSHA, NIOSH, NIH, APIC, ASHE, AHA, AIA, ASHRAE, TJC, CMS, DPH, DHHS, WHO, etc. Not all sources are included in this reference. The information contained in this article is for general use only and is not intended to provide regulatory guidance. Please consult with all regulatory requirements prior to implementing any prevention efforts.