In the United States we have escaped the brunt of these epidemics thus far because SARS, MERS, and Ebola have had a much greater impact on other countries and have primarily only entered the United States through infected travelers coming from Asia and Africa. The positive side of this coin is that our population is spared a widespread impact. The negative side of this coin is that because the viruses did not originate in the United States, health care providers are typically slow to ramp up to address the outbreak, and care providers have limited knowledge about how to treat and/or contain the viruses. So far, mostly due to well-coordinated public health efforts and a little luck, the few cases that have occurred in the United States have been quickly isolated preventing widespread outbreaks. But we are not out of the proverbial woods yet with these viruses, because even as I write this article, MERS is making headlines in South Korea and the fight against Ebola continues in Guinea and Sierra Leone. Then, of course, there is the new Bourbon Virus, a tick-borne illness causing lung failure, kidney failure, and shock that recently killed a previously healthy man in Kansas.
If we are all honest with ourselves, we will fully admit that there is no organization, agency or team that is fully prepared for the next epidemic. Yes, those of us on the frontlines of health care help patients with highly contagious infectious diseases on a regular basis. And, yes we have been trained on using standard PPE to protect ourselves and those around us, but it is a game changer when that infectious disease has a high rate of mortality among otherwise healthy individuals. These deadly infectious diseases cause panic in the general population and have the potential to strike fear in the hearts of even the most well trained, well-educated health care provider. We fear for ourselves, our families and our communities, but we face our fears head on because it is our life’s work and mission to care for the patients who need us.
How do we make sure we are prepared? How do we make sure we do the best thing for our patients and protect ourselves in the process? We learned a lot from the two brave nurses who treated the patient in Texas who had returned from Africa infected with Ebola. These nurses and their peers faced the deadly virus head-on, even in the face of having inadequate PPE and training. These brave Texas caregivers adapted the best they could, creating their own PPE in an effort to provide the best possible care for their patient. The experience, exposure, and ultimately infection these two nurses endured actually changed the U.S. Center for Disease Control guidelines for how caregivers in the United States were instructed to respond to the Ebola epidemic.
We learn something from the response to every single epidemic. In the case of Ebola, we learned through the two Texas nurses who became infected with the virus that our lack of preparedness and equipment created potentially deadly consequences for care providers. This is not acceptable in one of the world’s richest countries with the best health care resources. We can do better. We have to do better. Patients and the community should expect and deserve competent care from well-trained health care professionals. Health care professionals should expect and deserve to have the training and resources they need to treat patients with infectious diseases.
Health care organizations and first responders must rise to the challenge or face serious repercussions and potentially dire consequences. Although the two Texas nurses who ultimately became infected with and treated for Ebola survived, the exposure has already resulted in a lawsuit brought by one of the nurses, Nina Pham, against Texas Health Presbyterian Hospital’s parent company. In the lawsuit, she claims that she was “a casualty of a hospital system’s failure to prepare for a known and impending medical crisis.” The fact is her case is pretty strong. They did not have adequate equipment, fashioning homemade neck guards and such out of duct tape and found items. There are also conflicting reports about the training provided and whether or not care providers at Texas Health were required to demonstrate competency using the required PPE. Both the Federal and Texas Occupational Safety and Health Administration (OSHA) require that PPE donning and doffing training include demonstration and competency proof — not just training on paper.
What are health care providers to do?
Follow the lead of decontamination teams and require yearly training for proper PPE usage. Truth be told, there are major similarities among all epidemics because the illnesses are either in one of two categories — respiratory or gastrointestinal. The PPE for treating patients with infectious diseases should not change that much between illnesses and PPE training ultimately needs to be incorporated into other mandatory annual training.
This all sounds right and logical but the reality is that training is expensive and labor intensive. So, where do you start?
Training Plan Broken Down
Step 1 – Training is Three-fold
Many assume that training is simple. After all, we can beg, borrow, steal, or simply design a training program that meets our needs. Besides, developing a training program takes no more time than delivering the training itself, right? Educational programs can be amazingly complex. They involve educators working with subject matter experts (SME) to ensure the content and the processes are appropriate for the audience and the medical ailment or disease process. In the case of viruses, the education must focus on ensuring the participants understand the differences in the PPE and the limitations both the PPE and the providers may have. (Yes, there are PPE limitations.) Just like any other profession, we must use the right equipment for the right disease.
As health care professionals, we often overlook these limitations and take for granted that not all types of gloves will provide an adequate barrier. Even worse, the level of protection provided by turnout gear or a surgical gown may not be enough. The key to understanding the limitations of PPE is to understand and practice with the equipment you would likely use.
Start with an online or in-person education program. Provide relevant and easy-to-understand information to anyone who may have contact with the various viruses that exist today. Yes, that could and should be everyone! Knowledge is power and the more that all responders understand, the better they will be able to respond to and manage these incidents. For example, a communications specialist is the first point of contact for a patient needing help. A communications specialist is an integral member of the response team. They coach, guide, provide reassurance and provide education to the panicking patient. Knowledge helps the team work together to take care of even the sickest individual and it helps the entire team develop a plan of action. Keep the online education simple and short. We must learn to provide a lot of information using the most succinct method possible. Why? This same training model can eventually become a “Just-in-Time Training” program.
With the core training program developed, distributed, and completed, it is important to bring those tasked with utilizing the PPE in for a practical scenario-based training program. Having individuals practice and demonstrate the sequence PPE is donned and doffed sounds silly. But, something as simple as accidently touching the top of your bare hand while changing gloves can kill you. Consider how concentrated the Ebola virus is in one drop of blood when compared to HIV. It is amazingly potent and amazingly deadly. Donning and doffing MUST be perfect every time! The only way to ensure individuals understand what PPE is needed, is to have facilitated dedicated practice sessions and scenario-based training where providers can learn and practice these critical steps.
At the absolute least, you have to complete a mass competency-based training session, possibly utilizing a “Just in Time Training” video made available digitally. “Just in Time Training” video resources are easy to create — they do not need to be fancy or highly produced, but they do need to be accurate and accessible. Every single smartphone has the ability to capture decent video and these smartphones are easily accessible and easy to use. Getting a checklist and this video tutorial out immediately can save countless lives.
Step 2 – Identify Your Resources
Waiting until a crisis hits to figure out the resources available to you is too late. Figure out whom in your community offers specialty resources for health care providers. Make a point to meet these individuals. Create a contact list complete with cell phone numbers and email addresses. Examples of helpful resources both internal and external to your organization may include occupational health, infection prevention and emergency services professionals. Do some research on the training resources available. Can you piggyback off a training already provided by a community health organization? Is there a simulation program in your area that you could call upon to provide realistic training?
Step 3 — Incorporate the Training into Annuals
PPE training is not rocket science, but it is critically important. Knowing what you have and what you need to treat different illnesses is critical. Knowing how to put the equipment on and, more importantly sometimes, how to take it off is critical. Make this part of normal mandatory annual training and drill, drill, drill. During this training make sure that providers are required to validate competency. And, did I mention drill? Drilling is the best way to ensure the training you are providing is going to be effective because providers are actually practicing donning and doffing during a real-life scenario. Nothing is closer until the real thing actually walks through the door.
Step 4 – Develop an Action Plan or Response Guide When a Risk Is Identified
Do not wait for there to be an immanent risk. The next disease is always right around the corner. Make a point to know what the disease is and develop an action plan or response guide where there is a potential risk. Share this information with your team and be prepared to create that “Just in Time Training” video or to reach out to your community resources.
Better preparation on the front end through training, advance preparation and to some degree just taking the time to pay attention can be the difference between life and death for our care providers. When treating a patient with an infectious disease, we literally have one chance to get it right. Let us make sure we do everything in our power to invest the time and resources necessary to respond.
Health care organizations and first responder agencies also have to focus on making sure our care providers have the right resources. Order that PPE! Source those eye shields, gowns, gloves, boot covers, and respirators with shrouds. Keep them in stock, updated and ready to use at a moment’s notice. If we are requiring our employees to come to work and face deadly diseases, the least they should expect from us is access to the proper training and the proper equipment. It is our duty and obligation not to let them down.
Amar Patel is the Director of the Center for Innovative Learning at WakeMed Health and Hospitals. Dr. Patel is responsible for integrating technology-based educational programs to include human patient simulation, healthcare gaming and hybrid education. Dr. Patel works with patient safety and risk management teams to make changes to processes in healthcare that directly improve patient and provider safety.