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CDC Updates Health Care Worker Protection for Safe Handling of Ebola Patients

Due to the October 2014 cases of Ebola reported in Dallas, TX, the CDC has updated their infection prevention and control recommendations for hospitalized patients with Ebola Virus Disease. In the health care setting, the risk for a health care worker (HCW) becoming ill from Ebola is higher since the disease is spread through direct contact (e.g. through broken skin, mucous membranes, eyes, mouth) of body fluids contaminated with the virus.  Following the model of Doctors Without Borders, the CDC now recommends that no skin be visible while working in PPE to lessen the likelihood of Ebola exposure in HCWs.

The new guidelines set a firmer standard, calling for full-body garb and hoods that protect worker’s necks; setting rigorous rules for removal of equipment and disinfection of hands; and calling for a “site manager” to supervise the putting on and taking off of equipment.

They also call for health workers who may be involved in an Ebola patient’s care to repeatedly practice and demonstrate proficiency in donning and doffing gear — before ever being allowed near a patient.

 

Principle #1: Rigorous and repeated training

Focusing only on PPE gives a false sense of security of safe care and worker safety. Safety wise, this is considered the last line of defense. Training is a critical aspect of ensuring infection control. Facilities need to ensure all healthcare providers practice numerous times to make sure they understand how to appropriately use the equipment, especially in the step by step putting on and taking off of PPE. CDC and partners will ramp up training offerings for healthcare personnel across the country to reiterate all the aspects of safe care recommendations.

 

Principle #2: No skin exposure when PPE is worn

Given the intensive and invasive care that U.S. hospitals provide for Ebola patients, the tightened guidelines are more directive in recommending no skin exposure when PPE is worn. 

CDC is recommending all of the same PPE included in the August 1, 2014 guidance, with the addition of coveralls and single-use, disposable hoods.  Goggles are no longer recommended as they may not provide complete skin coverage in comparison to a single-use, disposable full-face shield.  Additionally, goggles are not disposable, may fog after extended use, and healthcare workers may be tempted to manipulate them with contaminated gloved hands.  PPE recommended for U.S. healthcare workers caring for patients with Ebola includes:

  • Double gloves
  • Boot covers that are waterproof and go to at least mid-calf or leg covers
  • Single-use fluid resistant or impermeable gown that extends to at least mid-calf or coverall without integrated hood.
  • Respirators, including either N95 respirators or powered air purifying respirator (PAPR)
  • Single-use, full-face shield that is disposable
  • Surgical hoods to ensure complete coverage of the head and neck
  • Apron that is waterproof and covers the torso to the level of the mid-calf (and that covers the top of the boots or boot covers) should be used if Ebola patients have vomiting or diarrhea

The guidance describes different options for combining PPE to allow a facility to select PPE for their protocols based on availability, healthcare personnel familiarity, comfort and preference while continuing to provide a standardized, high level of protection for healthcare personnel. 
The guidance includes having:

  • Two specific, recommended PPE options for facilities to choose from. Both options provide equivalent protection if worn, put on and removed correctly.
  • Designated areas for putting on and taking off PPE. Facilities should ensure that space and layout allows for clear separation between clean and potentially contaminated areas
  • Trained observer to monitor PPE use and safe removal
  • Step-by-step PPE removal instructions that include:
    • Disinfecting visibly contaminated PPE using an EPA-registered disinfectant wipe prior to taking off equipment (PPE)
  • Disinfection of gloved hands using either an EPA-registered disinfectant wipe or alcohol-based hand rub between steps of taking off PPE.

 

Principle #3: Trained monitor

CDC is recommending a trained monitor actively observe and supervise each worker putting PPE on and taking it off. This is to ensure each worker follows the step by step processes, especially to disinfect visibly contaminated PPE. The trained monitor can spot any missteps in real-time and immediately address.

PPE is Only One Aspect of Infection Control

It is critical to focus on other prevention activities to halt the spread of Ebola in healthcare settings, including:

  • Prompt screening and triage of potential patients
  • Designated site managers to ensure proper implementation of precautions
  • Limiting personnel in the isolation room
  • Effective environmental cleaning
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