GHS details extensive Ebola response plan

GREENVILLE, S.C. –The Greenville Health System has developed detailed plans to help manage Ebola patients both at GHS hospitals and throughout the Upstate as part of a statewide Ebola regional referral system.

More details about the regional system are expected to be released later this week.

“While the likelihood of an Ebola patient coming to GHS is very small, hospitals must be prepared for everything – including Ebola,” said Angelo Sinopoli, M.D., Greenville Health System’s vice president of clinical integration and its chief medical officer. “As an academic health center, GHS brings unique expertise in everything from infectious-disease management to advanced-care nursing and laboratory diagnostics. And being a community leader means meeting the community’s needs. We stand ready to do that.”

Far-reaching protocols, preparation and training also mean that safeguards are in place to ensure that GHS is able to provide sequestered state-of-the-art care to those patients while continuing to care for patients in its emergency departments, physician offices and all hospitals, he said.

Extensive protocols in place

GHS already had extensive protocols in place to safely treat patients with communicable infectious diseases such as Ebola, but those protocols were significantly strengthened in the wake of additional guidance from the Centers for Disease Control and Prevention and peer hospitals. GHS staff who volunteered to provide intensive care to Ebola patients are already receiving additional safety training on the use of special personal protective equipment (PPE) that is beyond CDC-recommended levels. Staff throughout GHS who may be first point-of-contacts with less-ill patients are also receiving additional information on utilizing appropriate personal protective equipment.

Meanwhile, all GHS employees are now required to complete computer-based training that provides an overview of the illness or, for clinical volunteers, includes specific instruction about the donning and removing of personal protective equipment and supplemental information such as minimizing the use of sharps. Information forums for employees are also being held.

All points of entry, such as physician offices, emergency departments and urgent-care centers, are receiving special instruction on how to isolate any potential Ebola patient and transport to Greenville Memorial Hospital. Additional triage measures have been in place since August at GHS emergency departments and physician offices to screen for potential Ebola patients. That protocol, which includes warning signs on doors, includes checking for flags such as fever, recent travel in an area where Ebola transmission is active or patient contact with someone believed to have Ebola.

Employees who screen suspected Ebola patients will be required to wear a CDC-approved PPE. Employees who deal with advanced-illness Ebola patients will wear an enhanced-level PPE: a Tyvek suit; three sets of gloves with the bottom two layers taped to the suit to ensure no exposed skin; a procedure mask or N 95 respirator and a powered air-purifying respirator with neck skirt and a full face piece, breathing tube, battery-operated blower and HEPA particulate filter. The gear would include leg/shoe covers and a cover gown to protect the zipper in the front of the Tyvek suit to reduce possible contamination during the removal process.

GHS will also use a buddy system to ensure that a trained observer is closely monitoring the putting on or removingof PPE to ensure that safety is maintained.

Staff involved in treatment of a potential Ebola patient would be notified of the Ebola diagnosis so that all proper precautions would be taken immediately.

Waste management will also be a critical element in keeping the community safe. All patient waste materials will be triple bagged in viricide-treated biological hazard bags before being stored in special drums in the isolation unit until removed by a U.S. Department of Transportation-certified waste-management company.

Upholstered furniture and decorative curtains would be removed from the isolation room prior to use, with used linens, pillows and mattresses discarded as hazardous medical waste. All non-disposable equipment, such as portable X-ray or EKG equipment, would undergo CDC-recommended levels of cleaning and disinfecting.

Any material not immediately removed by certified handlers after being taken out of the room would be stored in special locked containers inside secured areas that would include 24-7 security.

Facts about contagion risks

“It’s important for everyone to remember that Ebola patients are only contagious when they’re symptomatic,” said Scott Sasser, MD., chair of GHS’ emergency medicine department and a national leader in disaster preparedness and planning. “You can’t get Ebola from standing next to someone in the grocery store line or even if you used the grocery store cart after that person if they don’t have symptoms.

Ebola is only transmitted by contact with body fluids, such as vomit, blood or diarrhea of people who have the disease. Those symptoms occur later in the disease progression, which is why it’s so important to provide additional layers of protection for healthcare workers caring for advanced Ebola patients,” he said. “The risk of contagion increases as people get sicker and have a higher viral load in their bodily fluids.”

Public health agencies’ aggressive contact tracing of suspected cases and U.S. healthcare availability and expertise make a West Africa-like Ebola scenario in the U.S. extraordinarily unlikely, said Rhett Shirley, M.D., a GHS infectious disease physician with tropical medical training who worked in Kenya for several years.

“We will likely continue to get occasional patients in the U.S. who may have brought the disease with them, but aggressive intervention and contact tracing won’t allow it to spread the way it has in those pockets in West Africa,” he said.

Ironically, the U.S.’s aggressive contact tracing, which involves backtracking on a patient’s activities and notification of those even considered low risk and possible self-isolation of those considered to be higher risk, may have inadvertently raised the fear level on the recent Ebola cases – when, in fact, it helped keep the nation safe.

“Surveys show that people continue to think they can get Ebola from casual contact or that they think their chances of contracting Ebola are high,” said Shirley. “We could save thousands of lives in the U.S. if people were as worried about the flu as they are about Ebola.” Half of Americans are still failing to get vaccinated against influenza, even though it kills thousands every year. Flu kills an average of 23,000 people in the U.S. annually across all demographics, including otherwise healthy children and even young adults.

Said Shirley, “Even with the concern about Ebola, the best health advice I can give anyone – especially this year – is to get a flu vaccine early.”

Safely transporting and treating patients

At GHS, potential Ebola patients would be evaluated at the hospital where they sought initial treatment but then would have appropriate PPE placed on them and be transported immediately by a dedicated specially-outfitted Mobile Care ambulance and crew to Greenville Memorial Hospital. The vehicle, which has been ‘wrapped’ with plastic completely on the inside, segregated from the ambulance cab and equipped with special supplies, would be sanitized following CDC protocols after each use.

As an academic, referral and Level I trauma center, GHS has established relationships and a strong history of collaboration with the Emergency Medical Services community in Greenville County, said Sasser.

“This has enabled work closely with EMS on Ebola planning to ensure our plans mesh well and to provide the best care for our patients – both in the hospital and before they arrive,” he said.

GHS protocols are exceptionally detailed and move the suspected patient quickly but securely to either a special holding room in the emergency department or immediately up to an isolation ward by trained protected staff. All plans feature specific direction regarding routes of transportation and movement of masked or specially-enclosed patients.

An isolation unit at Greenville Memorial Hospital has the capacity to house up to three patients. The completely walled-off unit features negative-pressure capabilities, HEPA filters on the air supply and an on-site point-of-care lab that will help speed lab results and safely process any patient samples away from other samples. As an additional precaution, the unit will be controlled access and feature 24-7 security.

GHS continues to work with state officials and local hospitals to ensure appropriate safe patient care through the statewide referral system.

GHS will also work with any physician office – regardless of affiliation with GHS – to help work with staff and provide guidance about guidelines.

Extraordinary response by volunteer clinical staff

To help minimize the number of caregivers involved, specially trained volunteer nursing, physician and respiratory staff will care for patients in the isolation unit.

Unit volunteers will not care for any other patients, and, as an added precaution, will be monitored and self-isolate themselves during that time. They will remain quarantined until 21 days after their last encounter with an Ebola patient.

The majority of day-to-day care will come from nursing staff. Nurses will not only provide clinical care but provide meals to the patients and ensure that any waste material is safely contained.

“I couldn’t be more proud of our nursing staff,” said Michelle Taylor-Smith, GHS’ chief nursing officer and vice president of patient services. “Many have stepped forward without hesitation to do whatever is needed to provide care in the event they’re needed.”

“Compassionate care is the core of nursing practice – and not just in potential emergency situations but in every-day care. It’s what we do.”