New and Emerging Threats: From A to Zika

Robin Manke, RN, CCMC, MSHL2016 MHA Emergency Preparedness Conference

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Objectives

1. Examine the recent history and need for a Unique Pathogen Unit 2. Explain the activities and challenges of preparing a highly infectious

disease program3. Understand how Ebola preparedness efforts have improved the

infection prevention programs and disease preparedness4. Understand the strategic design of a Unique Pathogens Unit, Team,

and Training regimen

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December 6, 2013 4

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Ground Zero

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Ebola Hemorrhagic Feveraka Ebola Virus Disease (EVD)

Filoviridae family (also includes Marburg)

Lipid-enveloped, non-segmented, negative-stranded RNA virus with characteristic filamentous particles

First discovered in Democratic Republic of Congo (now Zaire) 1976 and named Ebola Hemorrhagic Fever (EHF)• Zaire Ebolavirus • Sudan Ebolavirus• Tai Forest Ebolavirus• Reston Ebolavirus• Bundibugyo Ebolavirus

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How did one case turn into the worst ebolaepidemic in history?

First introduction into West AfricaUnprecedented scale and pace of transmission

-simultaneous multi-country outbreaks-high population mobility across porous boarders-disease transmission within highly populated urban slums

Weak, damaged local health systems and infrastructure– Severe shortage of healthcare workers– Lack recognition, surveillance, contact tracking– Lack basic infection-control essentials

Cultural beliefs and practicesInadequate and delayed international aid and leadership (WHO and others)

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WHO declares Ebola epidemic an international health emergency

“This outbreak is moving faster than our efforts to control it. If the situation continues to deteriorate, the consequences can be catastrophic in terms of lost lives but also severe socioeconomic disruption and a high risk of spread to other countries.”

Margaret Chan, WHO, 8/8/14

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“Individuals who have traveled to and returned from the countries of Sierra Leone, Liberia or Guinea in the past 21 days, or have had contact with a known EVD patient in that time period, should NOT travel to New Orleans to attend the conference…we see no utility in you traveling to New Orleans to simply be confined in your room.”

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Just how infectious is EBOV?

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Clinical suspicion

Clinical suspicionSudden onset fever plus possible exposure?• Travel history• Sick contacts• Sick or dead animalIn epidemic areas, also include any person with sudden onset high fever and at least 3 of following: HA, vomiting, anorexia, SOB, hiccups; or any person with unexplained bleeding or any sudden, unexplained death

EBV laboratory diagnosis• Real time PCR (RT-PCR)• Confirm negative at least 72 hours after onset symptoms

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Signs and symptoms

Fever (87%)Fatigue (76%)Vomiting (68%)Diarrhea (66%)Anorexia (65%)Headache (53%)Abdominal pain (39%)Myalgias (39%)Other—maculopapular rash, hiccups, delirium, conjunctival injectionHemorrhage distinctly less frequent than previous outbreaks

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Treatment

• Supportive care• Specific treatments• Infection control

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DDX

MalariaTyphoid feverCholeraLeptospirosisRickettsiosisTrypanosomiasisLassa feverDengue feverChickungunuya

Other viral, bacterial, and parasitic causes of gastroenteritisUsual systemic bacterial infections, hepatitis, influenza

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Local impact

Unique history

The Awkward Phase

Fully Functional

Maintaining Readiness

Multifunctional ( VCU Health)

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August 2014

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Personal protective equipment or PPE

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Unique History

1958 2012 2008 Oct ‘14 Nov ‘14

Jan ‘15

North Hospital BuiltBurn Unit / ICU

MCV Medical Simulation

Center

2014 Feb ‘15Jul ‘15

May ‘15Apr ‘15

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Abby Williams, RN

Stephen Ankiel, RNLaurel Crane, RN

Olivia Damico, RN

Special Thanks to the Caregivers

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School of Medicine

Simulation Center

NICU Physicians & Nursing

Pharmacy

Plant Operations

Adult Critical Care Physicians &

Nursing

Pediatric Critical Care Physicians &

Nursing

Labor & Delivery

Physicians & Nursing

Education & Professional Development

Security & VCU Police

Emergency Department Physicians &

Nursing

Hospital & Nursing

Administration

Dialysis

Radiology

Infection Prevention

Physicians & Team

VCUMC Emergency

Preparedness

Respiratory Therapy

Environmental Services

Central Supply

Information Technology

Quality & Safety

Unique Pathogens

Unit

Unique Pathogens Unit Interdisciplinary Team

Virginia Department

of Health

Regional & Local EMS

Laboratory Services

Food & Nutrition Services

Clinical Engineering

Human Resources

Employee Health

Marketing & Public

Relations

Chaplain

Care Coordination

Hospital & Nursing Finance

Bed Management

Central Sterile

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(Photo courtesy of Dr. Ellen Brock)

The Awkward Phase

• Temporary Walls

• Departmental Silos• PPE• Training• Procedures

• Packaging and Shipping Trash

• Laboratory Limitations

• Standards of Practice Development

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Multifunctional: Utilization of High-Demand Real Estate

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Fully Functional: Flow

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Fully Functional: Emergency Department Readiness

• All staff PPE trained

• EMS and UPU Coordination

• Remodeled

• Ambulance decontamination bay direct entrance

• Defined travel path to N2

• Mobile Communications

( Photos courtesy of Amy Dean, RN)

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Fully Functional: Team

All VOLUNTEER (80-109 members)

• Attending Level Physicians• Adult & Pediatric Critical Care• Infectious Disease• Hospitalists• OBGYN• Emergency Medicine

• Registered Nurses• Certified Central Sterile Technicians• Care Partners• Safety Officers• Laboratory Technicians• Infection Preventionists• Nursing Clinical Leader• Employee Monitoring RNs• Education and Professional Development Educators

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Unique History

1958 2012 2008 Oct ‘14 Nov ‘14

Jan ‘15

North Hospital BuiltBurn Unit / ICU

MCV Medical Simulation

Center

2014 Feb ‘15Jul ‘15

May ‘15Apr ‘15

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Fully Functional: Activation

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Donning & Doffing

“Provider understands importance of properly donning PPE to ensure personal safety by following checklist and agrees to use an assistant each and every time they don PPE”

(Photos courtesy of Erin Nowlin, RN)

Fully Functional: Personal Protective Equipment (PPE)

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We have competed simulations for the following care pathways:

• Venipuncture

• Central lines

• Intubation

• Ventilation with ETT

• Chest and abdominal radiographs

• Dialysis

• Precipitous Delivery

• Lab Handling

• Waste Handling

• Post Mortem Care

• Transfer of patient in Isochamber

• Spill Management

(Photo courtesy of Erin Nowlin, RN)

(Photo courtesy of VCU Health)

Maintaining Readiness : Ongoing Training

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• New Member Training

• PPE Blitz

• Quarterly Training Teams

• Hospital-wide Activation Drill

(Photo courtesy of Erin Nowlin, RN)

Maintaining Readiness : Ongoing Training

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WHO: LOCATION: ROLE:Provider 1 (PV1) Nurse or Physician Hot Room Provide direct patient care and

any Hot Room activities.

Provider 2 (PV2) Nurse or Physician Warm Room – Dirty Side Actively aids PV1 in doffing PPE, assists with trash

management, and any Warm Room dirty-side activities.

Reader Observer Nurse or Physician Warm Room – Clean Side Direct and observe doffing and trash management instructions and any Warm Room clean-side activities.

Runner / Trash Helper

Nurse or Physician Runner – in Comm Room when not as Trash Helper

Trash Helper - Warm Room –Clean Side

Aids in waste management flow from Warm room to Autoclave Room.

Autoclave Operator Certified Central Sterile Technician Autoclave Room Processes waste generated from Hot and Warm rooms through Autoclave process.

Safety Observer Epidemiology Infection Prevention Nurse

Communication Room Actively monitors PV1 for infection prevention methods, communicates instructions, records time in PV1, and acts as communication center.

Lab Provider 1 Lab Technician Laboratory – Hot Lab Performs all UP Lab point of care laboratory testing and any Hot Lab room activities.

Lab Provider 2 Lab Technician Laboratory – Warm Room Actively aids Lab Prov 1 in doffing PPE, assists with trash management, and any Warm Room dirty-side activities.

Care Partner Care Partner Supply areas-Does NOT enter Warm

or Hot Rooms -

Stocks and reorders unit, patient, and provider supplies.

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Abby

Olivia

Fully Functional: On-site Laboratory

• Extensive Lab Menu

• Specialized Training in PPE

• Cross Training

• Certified Shippers

• State of the art dedicated equipment

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Abaxis Piccolo Chemistry AnalyzerComprehensive profiles for metabolic, kidney and liver

function analyses.

SysmexpocHi-100i

Rapidly performs a CBC with 3-part

differential.

BioFire FilmArrayPCR-based microbiological analyzer for the detection of viral, bacterial and parasitic respiratory and enteric pathogens.

GEM 4000 PlusPerforms a full Blood Gas panel on venous and arterial samples.

Unique Pathogens Laboratory

Testing at the Point of Care by a Dedicated Team of Technologists

HemochronElite

aPTT/PT/INR

BinaxNOWMalariaQualitative detection of Plasmodium antigens

Additional Tests• Urine Beta hCG• Rapid HIV ½ Antibody• Urinalysis by dipstick• ABO Blood Grouping

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Unique Pathogens LaboratoryTesting at the Point of Care by a Dedicated Team of

Technologists

Abaxis PiccoloComprehensive and Basic Met

PanelsAlbumin BUNALP CalciumALT ChlorideAmylase CreatinineAST GlucoseGGT PotassiumTotal Bilirubin SodiumTotal Protein PhosphorustCO2 Magnesium

Sysmex pocHi-100iComplete Blood Count w/ 3-part Diff

WBC MCVRBC MCHHGB MCHCHCT PLT

NeutrophilsLymphocytes

Mixed Cells (Eos, Basos, Monos)

Respiratory PanelAdenoviruscoronavirus 229Ecoronavirus HKU1coronavirus NL63coronavirus OC43human metapneumovirusinfluenza Ainfluenza A subtypes H1, H3, and 2009 H1influenza Bparainfluenza viruses 1-4rhinovirus/enterovirusrespiratory syncytial virusBordetella pertussisChlamydophila pneumoniaMycoplasma pneumoniae

GEM 4000 PlusBlood Gas Panel

pHpCO2pO2

Ionized CalciumLactateBE ecf

sO2HCO3

Hemochron EliteaPTT

PTINR

POC DevicesBinaxNOW Malaria Antigen DetectionRapid HIV 1/2 Antigen DetectionDipstick UrinalysisUrine beta hCG pregnancy testABO Blood Grouping

GI Panel Campylobacter E. coli 0157Clostridium difficile toxin A/B SalmonellaPlesiomonas shigelloides VibrioYersinia enterocolitica Vibrio choleraEnteroaggregative E. coli (EAEC)Enteropathogenic E. coli (EPAC)Enterotoxigenic E. coli (ETEC) lt/stShiga-like toxin producing E. coli (STEC) stx1/stx2Shigella/ Enteroinvasive E. coli (EIEC)

Cryptos[poridium] CyclosporacayetanensisGiardia lamblia Entamoebahistolytica

Adenovirus F 40/41 Norovirus GI/GIIAstovirus Rotavirus A Sapovirus

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Unique Pathogens Unit Essential Skills Training Model

PPE Training Session 1

1. Review PowerPoint module on the Learning Exchange

2. Tour of unit3. Describe process flow of

receiving patient from ED to UPU

4. Sizing Tychem® suit to ensure proper fit

5. Practice donning & doffing PPE

PPE Training Session 2

Trainer-the-Trainer Session 1

1. Practice donning & doffing PPE

2. Perform patient care activities while wearing PPE, such as starting IV, changing linens, spill clean-up, drawing & packaging labs, etc. Physician skills include supporting nurses with patient care activities as well as practicing central line placement & intubation.

Observe trainer during session & have opportunity to participate in coaching participant

Trainer-the-Trainer Session 2

Teach training session while being observed by trainer.

Ongoing Training will occur at least every 3-6 months and include donning/doffing PPE, patient care activities, patient care scenarios and any additional needs identified during unit activations and through collaboration with other unique pathogens unit experiences.

For unit activation, trainers provide just-in-time training on donning/doffing PPE before providing any patient care.

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Waste management

UNMC experience• ~ 500 cu feet or >1000 lbs of waste per patient• If disposed as is, i.e. Category A waste, cost $500K-1.5 million• Utilized pass-through autoclave to convert to Category B waste• Room sat idle 48 hours after discharge; then disinfected with UV light

robot, and then every surface area bleach wipedEmory• Autoclaved 3058 lbs of regulated waste for 2 patients• Packaged 218 boxes of regulated waste• Hydrogen peroxide robot

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MISC: Bleach wipes, clear trash bags, extra

boot covers

Extended-cuff PURPLE Chemo Gloves: 2 boxes of each size (Sm,M,Lg,XL)

Standard Precaution gloves: 2 boxes of each size (Sm,M,Lg,XL)

1 box Face Shields2 boxes Contact

Gowns2 Lab Kits

1 Flashlight

1 Bx Shoe Covers

1 Bx Boot Covers

4 Tychem M

6 Tychem Lg

1 Bx Bouffant Caps

5 Tychem 4x5 Tychem

5x

7 Tychem 2X

6 Tychem XL

12 Regular Hoods 3 Large Hoods

12 PAPRs (with hose and belt)

BIN:• 4 Rolls Chemtape• 2 Rolls DuctTape• 10 Lanyards• Hair bands

1 box of each N95 (4 total)• 3m regular• 3m small• Duckbill regular• Duckbill small

1 box Surgical Mask

Extended-cuff BLUE Chemo Gloves: 2 boxes of each size (Sm,M,Lg,XL)

6 Tychem 3X

Maintaining Readiness

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Is it over when it’s over?

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Maintaining Readiness: You ?

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