Special Pathogen Patient Care: 9/14/2016 Ensuring a Unit ... · PDF fileSARS Monkeypox Plague...

Special Pathogen Patient Care: Ensuring a Unit That Works

9/14/2016

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Special Pathogens Patient Care: Ensuring a Unit That Works

September 20, 2016 4:15‐5:15 pmSession B08

Presenters: PATRICIA LENAGHAN RN, MSN, NE‐BC, FAAN Healthcare Operations AnalystLEO A DALY

ROBERT COUNTER AIALos Angeles Office Director of HealthcareLEO A DALY

SHARON VANAIRSDALEMS, APRN, ACNS‐BC, NP‐C, CENDirector Serious Communicable DiseasesEmory University Hospital

• Evolution of Infectious Diseases

• Ebola Crisis / Special Pathogen Unit Development

• Building a Collaborative Professional Team to Maximize Engagement and Safety

• Best Practices in Design

• Adapting Existing Spaces and Challenges

• Ideal Safe Staff and Waste Traffic Patterns

• Best Practices in Operations

• Operational Challenges and Solutions (Lessons Learned)

Learning Objectives

• 100‐year history of full‐service Architecture‐Engineering and Planning• Headquartered in Omaha, Nebraska• 32 offices worldwide • 800+ staff

• HealthCare Designo Hospitals: Academic, Trauma, Community, Critical Access, Specialty, Regionalo Special Pathogen Centers (2 of 9 Regional Centers) o Clinics and Outpatient Centers o Clinical and Bio Safety Laboratories (BSL)o SPECIAL PATHOGEN UNITS: retrofitting existing and new

• Ranked #7 Among Healthcare Design Firms in Modern Healthcare

LEO A DALY


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Serious Communicable Diseases Unit • Located at Emory University Hospital in Atlanta, GA• Serious Communicable Disease Unit was developed in 2002• Activated twice prior to 2014• Specialty trained physicians, nurses, lab personnel through didactic and scenario based learning

• Lead Institution for the National Ebola Training and Education Center (with Nebraska Medicine and Bellevue Hospital)

The Evolution of Infectious Diseases

Ebola

Smallpox

SARS

Monkeypox

Plague

MDR TB

• Cause 25 – 30% of all deaths worldwide• 20‐30 diseases have been newly identified/reemerged since 1973 • US Death rates: doubled to over 170,000/yr• Antibiotic Overuse: 2 million resistant infections/yr• US Influenza (annual)

o 5‐20% of populationo 8,000‐ 49,000 dieo 220,000 hospitalized

• Borderless Disease Transmission o International travelers/immigrants o US military personnel o Animals & foodstuffs

• Index Case Risk (Examples) o AIDS:Gaeten Dugas (US flight attendant) 1984o Typhoid Mary (2000)o Ebola (1976)o SARS (2003) o Cholera (1854)o Swine Flu (2009)

“New and re‐emerging infectious diseases will pose a rising global health threat and will complicate US and global security over the next 20 years.” (National Intelligence Council)

Infectious Diseases


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Ebola Crisis / Special Pathogen Unit Development

Severity and Lethality of EVD• 28,616 infected & 11,310 deaths; resurgence: 25 deaths in the last year

• ONLY 1 Ebola virus causes illness highly lethal o 37‐74% fatality rateo In contrast, it takes 1,000 Influenza viruses illness

Index Case Transmission• Ebola transmission is relatively LOW 1.3 to 1.8 secondary cases• In contrast, Measles 17 secondary cases (up to 1963)

Current EVD Research (survivors)• Infection persists over 282 days post disease • Eye, CNS (CSF), Testes, urinary tract

The 2014‐16 Ebola (EVD) Outbreak

CDC2014‐2016 Ebola Case Counts (8.1.16)

Country Total Cases Laboratory‐Confirmed Cases

Total Deaths

Guinea 3,814 3,358 2,544Liberia 10,678 3,163 4,810

Sierra Leone 14,124 8,706 3,956Nigeria 20 19 8Mali 8 7 6US 4 4 1

Europe :UK, Spain, Italy 3 3 0

Senegal 1 1 0

Total 28,616 15,227 11,310

Hospital Origin of Disease

Dates Profession Final Disposition

Bellevue NYC Guinea Oct 23‐Nov 11 2014 Medical Aid Worker

Discharged

Emory Monrovia August 21 2014 MD DischargedEmory Monrovia August 21 2014 Volunteer DischargedEmory Dallas Oct 15‐28 2014 RN DischargedEmory Africa Sept 9, 2014 MD Discharged NIH Dallas Oct 10‐24 2014 RN Discharged NIH Serra Leone Mar 10‐April 9 2015 MD Discharged NIH Africa Sept 28 MD Discharged Texas Presbyterian

Liberia (Index Pt)

Sept 24‐Oct 8 2014 Patient Expired

Nebraska Liberia Sept 4‐25 2014 MD DischargedNebraska Liberia Oct 6‐21, 2014 Photojournalist Discharged Nebraska Serra Leone Nov 15‐17 2014 MD Expired

US Ebola Cases


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10 Hospital Beds Available Prior to 2014 Crisis

National Agenda & Goals

• After 9/11, Homeland Security Funding Each State –increase # hospital negative pressure rooms

• Events alarmed US healthcare and US governmento Monkey Pox (2003) 71 patients in Midwest

o SARS (2002‐2004) 8,098 patients/774 deaths Infected healthcare providers

• Metropolitan Medical Response Systems (2009)o Prepare largest cities (120) for NBC agents o Coordination of healthcare and local response

National Agenda & Goals • Public institutions and public health agencies working together beforeand during the crisis

• Vigilance/Monitoring of Symptoms

• PPE Availability and Guidelines for Proficiency

• Quarantine policies (research based)

• Strategies for screening & quarantine of international travelers

• Modernize public and health care reporting of diseases

• Risk communication and information sharing

• Vaccination and treatment: distribution of resources

Outbreaks: Protecting Americans From Infectious Diseases (2015) RWJ Report: Trust for America’s Health

National Agenda & Goals


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Units designed to minimize nosocomial transmission of highly contagious and hazardous diseases by incorporating engineering and safety measures in patient care facilities

GoalTreat serious communicable diseases (Infectious pathogens) • Bioterrorist Act • Laboratory Event • Accident

Partnership• State and local health departments (regulatory agencies) • Hospitals – clinical care and space • University Systems

o Infectious Disease Departmento Educational Institutions' – simulation and videoso Research protocols

• Community agencies with emergency response plans o MMRS (city plans)o Emergency Management Agencies – local and stateo Emergency Medical Services

Special Pathogens Units • Separate Patient Rooms • Anterooms (donning)• Doffing shower adjacent to patient room• Contaminated waste storage adjacent to patient room• Waste storage direct access to pass through autoclave (s)• Pass though autoclave (s) clean side accessible from outside the unit

Hot zones (room contaminated) • Patient rooms• Waste storage• Dirty side of autoclave• Laboratory• Doffing

Warm zones (potential for contamination)• Passages • Donning (ideally cold zone) • Nursing work station

Clean/cold zones (not contaminated) • Staff and patient entry and exit• Family Space • Office and Command Center• Clean side of autoclave

Special Pathogen Unit Conceptual Designs

Best Practices in Design

Robert Counter AIA

• PRESENTATION FOCUS:“Architectural, Planning and Engineering of Special Pathogens Units”

• PRESENTATION AGENDA:

o Special Pathogens Unit Plan Different Isolation Zones

o Dual Use Special Pathogens Unit Plans Operational Readiness Training Additional Isolation Beds

o Patients, Providers & Materials Flows Processes

o Engineering Concerns


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• Isolated zone: dedicated, non recirculating air • Sequential exit: dirty clean • Airlock entry, negative air pressure to surrounding areas• Emergency power: Exhaust & ventilation systems Alarms/monitors Life support systems Lighting Entry & exit controls Security systems

• Redundant air handling units (supply and exhaust)• Pass through autoclave & dunk tank• Sealed internal shell • Decontamination of waste, liquids, gases, materials

• Protective clothing and equipment

Biosafety Microbiology/Biomedical Laboratories Safety and Leak Proof Environment

• Scrubbable epoxy paint on walls• Sealed light fixtures, outlets, switches• Gasketed entry and exit doors • Impact‐resistant glass windows (local threats)

• Solid surface materials

• Air handling system with negative pressure, ≥ 20 air exchanges per hour

• No recirculated air• Exhaust air >25 feet from the building air intake areas • All exhaust air HEPA filtered• Emergency power

High plume dilution type exhaust fans

• Roof mounted directly above unit• Two high velocity fans, each fan can produce required negative air flow

• Operate simultaneously • Each can accommodate 100% of exhaust air • Pressure monitors for each space in unit

HVAC SystemSpecial Pathogens UnitPrimary Use:Hemorrhagic Fever (Ebola)

Boundary of Primary Hot Containment Zone

Boundary of Secondary Cold Containment Zone

Boundary of entire Special Pathogens Unit

Shw F. Lk /

Dress

Shw M Lk /

Dress

Staff Lounge

SPU Vestibule

Doff / Shw

Ante & Donn

Nursing SupportEVS

Hot WasteHolding

& Process

Auto‐clave

Off

Passway

S.T.

Doffing

Doff / ShwHot

Patient Room

Toilet / Shw

Doffing

Doff / Shw Hot

Patient Room

Toilet / Shw

Ante & Donn

Doff / Shw

Ante & Donn

8’ Warm Corridor

Nursing Support

Hot WasteHolding

& Process

Auto‐clave

Shwr &

Doff

Ante & Donn

SPU Vestibule Hot

LabSoiled

Clean

Nou

r

Equip

Med


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SPECIAL PATHOGENS UNIT ISOLATION ICU

Patients, Providers & MaterialsFlow Processes

• Easiest way to accomplish a task is also the safest way

• Validate uni‐directional provider flows

• Access points and security variance with two patient populations

• Locations of zone boundaries and red‐lines

• Locations of Anterooms, Airlocks & Containment Zones

• Locations of donning & doffing PPE

• Locations of provider showering out

• Verify Code compliance

Planning Issues


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Special Pathogens UnitProcess MapsProviders Entering SPU

Provider obtains correct size scrubs and Croc shoes from

supply shelves. Then removes street clothes, places them in locker and changes into scrubs and

Crocs

Provider then

proceeds to their

assigned area in the

SPU

Provider enters to the appropriate gender Locker & Dressing Room

Provider leaves the

Staff Lockers & Dressing Room and enters the Staff Passway

Provider crosses the red‐line into the Warm

Containment Zone

Provider arrives at the SPU and enters SPU Vestibule

with authorized card key

1 2 3 4 5 6

Shw F. Lk /

Dress

Shw M Lk /

Dress

Staff Lounge

SPU Vestibule

Doff / Shw

Ante & Donn

8’ Warm Corridor

Nursing SupportEVS

Hot Waste

Holding & Process

Auto‐clave

Off 34

5

2

1

6

Passway

S.T.

Doffing

Doff / ShwHot

Patient Room

Toilet / Shw




Provider removes their PPE with the assistance of a second provider (spotter)

Provider showers with soap and water and then steps onto 4x4 mat and dries off

HotPatient Room

Doff / Shw

Doffing

Staff Lounge

SPU Vestibule

Doff / Shw

Ante & Donn

8’ Warm Corridor

Nursing SupportEVS

Hot WasteHolding & Process

Auto‐ clave

Off

1 2

8

7

Shw F. Lk /

Dress

Shw M Lk /

Dress

Passway

3 4 65

S.T.

Toilet / Shw

Donn

Special Pathogens UnitProcess MapsProviders Exit Patient Room

Provider completes their assignment in the Special Pathogens Patient Room

1

Provider first enters the Patient Toilet & Shower Room followed by the Doffing & Shower Room

2

3

Contaminated PPE & gloves are placed in red bag waste bin in the Doffing & Shower

Room

4

Second provider leaves the room. Provider then

removes scrubs and places in red bag waste bin.

5Provider dons a fresh set of scrubs and then crosses the red‐line and enters the Ante

& Donning Room

6 7

Provider then exits to corridor

8




Provider showers with soap and water and then dries

off with a towel

Shw F. Lk /

Dress

Shw M Lk /

Dress

Staff Lounge

SPU Vestibule

Doff / Shw

Ante & Donn

8’ Warm Corridor

Nursing SupportEVS


Auto‐ clave

Off

1

2

3 7 86

2

Passway

S.T.

4 5

Doffing

Doff / ShwHot

Patient Room

Toilet / Shw

Donn

Special Pathogens UnitProcess MapsProviders Exiting SPU




Provider completes their shift in the Special Pathogens Unit

1

Provider enters the Staff Lounge and proceeds to and available Toilet & Shower

Room2

Provider enters the Toilet & Shower Room and removes scrubs and places them in a

red bag waste bin

3

4Provider in towel crosses

red‐line into Staff Passageway and proceeds to appropriate gender Staff

Locker Room

5

Provider removes street clothes from their locker and

dresses

6

Provider then leaves the Staff Lockers & Dressing and enters the SPU Vestibule

7

Provider leaves the SPU Vestibule and Special Pathogens

Unit

8

Doffing

Doff / Shw Hot

Patient Room

Toilet / Shw

Ante & Donn

Doff / Shw

Ante & Donn

8’ Warm Corridor

Nursing Support


Auto‐clave

Shwr & Doff

Ante &

DonnP

7

89

SPU Vestibule

HotLab

Soil Cl Nou EqMed

1

2

5

D3

4

5 6

Special Pathogens UnitProcess MapsMaterial Enter SPU




Supply carts are taken to the SPU by Materials Management staff

1

Materials Management staff access the SPU Vestibule via

card key2

Materials Management staff bring the supply carts into the SPU Vestibule within the

Cold Zone3

Materials staff call the SPU staff via a wall phone to notify them that supply carts are in the SPU

vestibule

4

Materials staff push the supply carts to the Red‐Linewithin the Cold Zone side

without crossing and return to their department

5

SPU staff put down a 4x4 mat across the red‐line and offload supplies into the Warm Zone and a

SPU cart

6

SPU staff take supplies to Supply Storage Room

7

yesSPU staff takes the supplies to the Supply

Storage Room

noSPU staff takes the supplies to the

Patient Room for immediate use

8

9


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Doffing

Doff / Shw

Ante & Donn

8’ Warm Corridor

Nursing SupportEVS


Auto‐ clave

Doff / Shw

1 2 4

5

6

7

Shw F. Lk /

DressStaff

Lounge

SPU Vestibule

Off

Shw M Lk /

Dress

Passway

S. T.

HotPatient Room

Toilet / Shw

Donn

3

8

9

Special Pathogens UnitProcess MapsHot Solid Waste Disposal




Bio‐contaminated solid waste is created in the Patient Room or

Staff Doffing & Shower Room

1

A provider in PPE places the hot waste into a red bag inside the Patient Room or Staff Doffing &

Shower room2

The red bag is then seated & placed into a second red bag that is

held by a second provider in the Doffing

Room

3

The second provider in PPE then seals & takes the double bagged hot waste to the Hot Waste

Processing Room

4

The provider in PPE assigned to the Hot Waste Processing Room receives and stages the double bagged hot waste

5

The hot waste provider loads the double bagged hot

waste into an available pass‐

through autoclave

6

The hot waste is processed in the autoclave and sterilized

7

An EVS service member in the SPU

Vestibule removes the sterilized waste from the pass‐through

autoclave

8

EVS service member places the sterilized waste in a cart to be taken to the Loading Dock

for disposal

9

Doffing

Doff / Shw

Ante & Donn

8’ Warm Corridor

Nursing Support


Auto‐ clave

Doff / Shw

Shwr & Doff

Ante &

DonnP

1110

9

DSPU Vestibule

HotLab

Soil Cl Nou EqMed

HotPatient Room

Toilet / Shw

Ante & Donn

1 2 3 4

Special Pathogens UnitProcess MapsHot Fluid Waste Disposal




Bio‐contaminated fluid waste is created in the Patient Room or

Patient Toilet & Shower Room

1

A provider in PPE measures the waste and records the observations in the patient’s chart2

The fluid waste is taken to the Patient Toilet & Shower and placed into the water closet bowl, treated, closed and

flushed.

3

4

The provider then places the bedpan or urinal into the MeikoTopLine 30 WC (or

equal) for disinfection

Patient Waste:

Bio‐contaminated fluid waste is created after being tested in the Hot Laboratory

Laboratory provider in PPE takes the fluid waste to the laboratory clinic sink, treated, closed and

flushed

Any bio‐contaminated specimen containers that are not re‐used are placed in the red

bag waste bin

Laboratory Waste:

5 6 7

Special Pathogens UnitProcess MapsPatient Discharge




Patient is determined to be virus free and eligible

for discharge1

Patient proceeds to Doffing & Shower Room and removes patient gown and places in red‐bag waste

container2

Patient takes a 15 minute shower with hot water and soap and then steps onto 4x4 mat and dries off

3

5

Patient leaves the Ante & Donning Room and enters the Warm Zone

Corridor

Patient enters to the Staff Lounge and proceeds to an

unoccupied Toilet & Shower Room

Patient enters the Toilet & Shower Room and removes scrubs and

places them in a red bag waste bin

Patient takes a second shower and then dries

off with a towel

Patient wrapped in towel crosses red‐line into the Passageway connected to Staff Lockers & Dressing

Room

Patient then selects and enters the

gender appropriate Staff Lockers & Dressing Room

Patient takes provided

street clothes and dresses

Patient then leaves the Staff Lockers & Dressing and enters the Staff Vestibule

Patient enters the SPU

Vestibule and leaves the

SPU

A

A

6 7 8

Patient dons a set of scrubs and Crocs and then crosses the red‐lineand enters the Ante & Donning

Room.

4

9 10 11 12 13

Shw F. Lk /

Dress

M Lk / Dress

Doffing

Staff Lounge

SPU Vestibule

Doff / Shw

Ante & Donn

8’ Warm Corridor

Nursing SupportEVS

Hot WasteHolding

& Process

Auto‐clave

Doff / Shw

Off

1

2

3

4

6 7

9

11 12106

S.T.

Shw

7 8

8

HotPatient Room

Toilet / Shw

Donn

5

Engineering Concerns


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Exhaust Air Treatment and Waste Treatment Issues:

• Solid waste disposal• Effluent waste disposal• Room Exhaust

– Dilution Rates– Facility Management Safety– Air Entrainment

• Toilet waste venting• Redundancy on all systems, all on emergency power• Dedicated HVAC systems• Sealing of all penetrations

Best Practices:Clinical Operations

Sharon Vanairsdale

Front Line Response: Hospitals• Frontline Facilities

–Must be able to manage a patient for 12‐24 hours–Must have enough PPE for clinical care

• Ebola Assessment Hospitals–Receive, isolate and provide care (96 hours) –Confirm/rule out disease –Discharge or transfer to treatment center

• Ebola Treatment Center–Provide comprehensive care for the entirety of illness –Decision to designate: state and local health officials, hospital officials –Accept patients referred by public health authorities or other hospitals

• Regional Ebola Treatment Center–10 regional ETCs–Funded by the Office of the Assistant Secretary for Preparedness and Response

• Minimum Requirements for Hospital for Ebola

• Represents the “infancy stage” of developing Special Pathogen Units (SPUs) System

CDC Response Plan Levels: Accountabilities


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Front Line Response: Hospitals • Identify person under investigation (PUI)• Immediately isolate if relevant exposure, history

or symptoms • Private room• Route to Isolation Room

• Protect hospital staff: PPE, limit access • Inform

• Infection control • State and local health department • Hospital Leadership

• Plan for admission or transfer • Track staff exposure (document)

Emergency Department Evaluation and Management of PUI for EVD (CDC) 2016Interim US Guidance for monitoring and movement of people with potential EVD (CDC) 2016

Personal Protective Equipment

Personal Isolation Unit (PIU)

Heat‐sealer system

Specialized Equipment


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Waste Managment

•Volume of waste generated–Acuity –Length of stay (1‐21 days)

• Processing and storage of contaminated waste

• Location of waste removal and storage

• Safe passage during transport to holding area

Video Conferencing

• Decreases staff and family exposure • Remote professional consultations• Staff support in room • Behavioral health support • Digital family visitation• Patient support by significant others

Behavioral Health: Staff, Patient and Family

Staff• Fears of family, friends and co-workers • Anxiety of caring for novel disease with

challenging diagnosis• Media • Patients were very ill • Infected health care staff in Texas

Patient • Known fatalities where they were working• Unknown healthcare system• Gravity of illness

Family• No direct patient access• Concerns about possible outcome • Away from home and support systems

Lessons Learned From Patient with EVD

• Adequate space to: ‒ Provide patient care‒ Safely work in personal protective equipment

• Utilize materials that are not porous and can be easily cleaned • Ability to visualize patient and staff‒ Patient room‒ Patient restroom

• Remove equipment that is not essential (minimize blinds, curtains, etc.)


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Resources and Regulations http://www.cdc.gov/vhf/ebola/healthcare‐us/preparing/treatment‐centers.html.hlthyamericans.org

CDC Guidance on Personal Protective Equipment to be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease (EVD) in U.S. Hospitals

Outbreaks: Protecting Americans from Infectious Disease (2015) RWJF

National Ebola Training and Education Center http://netec.org

https://www.osha.gov/law‐regs.html/message.html

http://www.emoryhealthcare.org/

http://www.cdc.gov/niosh/about/default.html

http://leoadaly.com/

"Fortune favors the prepared mind." ~ Louis Pasteur

For more information on Special Pathogen Units or planning and design services contact:

Patricia A. Lenaghan, RN, MSN, NE-BC, FAANSenior Healthcare Clinical and Operations [email protected]

Robert Counter, AIADirector of Healthcare Leo A Daly Los Angeles Office [email protected]

Sharon VanairsdaleProgram Director for Serious Communicable Diseases, Emory University [email protected]

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