Donning and doffing: Emergency Department staffers train to protect themselves against Ebola

By Kristy Bleizeffer Oct 23, 2014

ER nurse Jill Hildner (from left), emergency physician Dr. William Selde, and ER nurse Jodi Kinder await the next step during PPE training Thursday in our ambulance bay. We will continue training emergency staff Friday and ICU staff beginning next week.

ER nurse Jill Hildner (from left), emergency physician Dr. William Selde, and ER nurse Jodi Kinder await the next step during PPE training Thursday in our ambulance bay. We will continue training staff through the upcoming weeks.

First, a little rumor control: Wyoming Medical Center has not treated anyone suspected of having Ebola, and we believe the chances of getting such a patient are low.

Second, an important request: We ask that anyone who suspects he has Ebola (exhibiting Ebola symptoms AND who has recently traveled to these West African countries) to call the hospital emergency room before showing up. That will give us time to implement our Ebola preparedness plan, protect the appropriate staff members and notify other necessary agencies. We’ll arrange with you the best way to get you to the hospital.

EMT John Bruno, from left, and Disaster Specialist Kaleigh Peil help ED staff don their PPE during training on Thursday.

EMT John Bruno, from left, and Disaster Specialist Kaleigh Peil help ED staff don their PPE during training on Thursday.

Third, a bit of background: Ebola is scary. We know that. Though there have been smaller outbreaks across Africa for more than 40 years, the virus is new to American hospitals.

“What’s going on is what I hate to call a media frenzy, but it is a media frenzy,” said Dr. Ghazi A. Ghanem, an infectious diseases specialist with Rocky Mountain Infectious Diseases. “You switch on the TV and what do you hear all day long? Ebola, Ebola, Ebola. People are scared and afraid because they think it’s going to hit here. This is very, very unlikely.”

America’s health system is different than those of the worst-hit countries in West Africa, and we know how to treat people with highly dangerous and highly transmittable infectious diseases. That said, most hospitals are preparing for a possible Ebola patient – no matter how unlikely the scenario. We are no different.

Wyoming Medical Center has been monitoring the Ebola outbreak through the Centers for Disease Control and Prevention since early this summer, and have been developing our own response plan for several weeks. (We’ll take a closer look at that plan tomorrow.)

This morning, we started training Emergency Department staff in the proper donning (putting on) and doffing (taking off) of the personal protective equipment (PPE) we will use in an Ebola response. Our ED nurses and physicians will use the same hazmat suits our paramedics and EMTs carry on every ambulance. They protect against all sorts of unknown hazards – including anthrax – since EMS routinely has to respond to unknown environments. “This PPE is above and beyond what the CDC is recommending,” said Mike Magee, Wyoming Medical Center emergency preparedness coordinator.

Below is a bird's-eye look at our PPE protocol, adopted from the CDC and hospitals that have successfully treated several Ebola patients without subsequent infections.

Putting it on

Step 1: Observation

A designated observer will lead caregivers through each step, watching for proper technique and making sure steps are completed in order. Observer will follow the visual checklist and ensure all caregivers complete each step before anyone is allowed to move on to the next one.

“This will be a slow, controlled process,” Magee said.

Steps 2-3: Hands and jewelry

EMT John Bruno tapes the cuffs of Dr. William Selde’s hazmat suit to seal the gap.

EMT John Bruno tapes the cuffs of Dr. William Selde’s hazmat suit to seal the gap.

Caregivers will wash hands and remove all jewelry, cell phones, pagers, extra belts and anything that could snag on PPE, which could be problematic when taking it off. All clothing, equipment and protective gear will be immediately incinerated after it is removed.

“Whatever you don’t want incinerated, take off,” Magee said.

Steps 4-5: Vitals and hydration

Wearing PPE suits for long periods will take a toll on caregivers. The suits are hot, and caregivers will sweat considerably. Vital signs will be taken to ensure caregivers are up to the task.

They will also be instructed to drink a bottle of water. Once the suit is on, protocol cannot be breached until it is time to remove it. Caregivers will not be able to eat or drink, so it is important they are properly hydrated.

Steps 6-12:  Personal Protective equipment

Caregivers will apply the following personal protective equipment in the listed order, as instructed by the observer:

  • Face mask
  • Hazmat suit
  • Rubber boots, worn over the suit’s foot covers; assistant will apply tape around the top of the boot, securing it to the suit leg and leaving a “tab” for easy removal
  • Latex gloves, pulled to elbow and worn under suit’s sleeves
  • Rubber gloves, worn over suit’s sleeves; assistant will apply tape around the top of each glove, securing it to the sleeve
  • Tape along the fulllength of suit’s front zipper

Step 13: PAPR (powered air-purifying respirators)

The hazmat suits in the ER use PAPRs with an FR-57 cartridge to triple-filter the air. (The surgical mask provides a fourth layer of filtration.)

Caregivers will apply the PAPRs in the following steps, according to observer’s instructions:

  • Add all three filters to cartridge
  • Add battery to PAPR unit; turn battery on
  • Connect PAPR hose to hazmat hood; verify air flow in the hood
  • Fasten PAPR around waist
  • Apply hood

 

Taking it off

Step 1: Observation

As with donning, observation is paramount in proper doffing technique. No one should leave the isolation room without an observer to walk them through the steps.

Careful technique is especially critical when removing PPE because it will almost certainly become contaminated during patient care. Caregivers will be reminded to go slow and follow observer instructions.

Ambulance Manager Eric Evenson, at left, pretends to spray trainees with bleach during PPE training this morning.

Ambulance Manager Eric Evenson, at left, instructs trainees to raise their arms so they can be "sprayed" with bleach during today's training.

Step 2: Hand hygiene

Caregivers will wipe down their outer rubber gloves with Clorox bleach wipes while still in the patient’s isolation room. Unlike some other viruses (like the Norovirus), the Ebola virus is actually very easy to kill outside the body, said Alice Lynch, infection specialist with Wyoming Medical Center.

Clorox bleach is highly effective in killing the virus and decontaminating surfaces; the trick is ensuring all surfaces have been sufficiently wiped down.

Step 3: Bleach spray

Caregivers will leave the isolation room and step onto the PPE “doffing station,” a designated area specially set up with all the tools needed for proper PPE removal. The station’s floor is protected by a sheet of plastic and several doffing pads to soak up dripping moisture and contain discarded equipment.

Caregivers will then step into tubs of bleach solution and raise their hands perpendicular to the floor. An assistant will thoroughly spray them with a bleach solution.

Steps 4-6: Removal

ER nurse Jill Hildner removes the tape from around her boots while learning to properly remove her hazmat suit.

ER nurse Jill Hildner removes the tape from around her boots while learning to properly remove her hazmat suit.

Everything used in the treatment of an Ebola patient, including all PPE and personal clothing, will be incinerated in our EPA-approved furnace at temperatures reaching 1,500 degrees. It is the only such furnace in the state. All Ebola waste will be double bagged in red biohazard bags and immediately escorted to the incinerator by two people, removing any need to store it.

Caregivers will let their equipment drop straight down to the doffing pad as they remove it, where it can be easily rolled up and disposed of at the end of the process.

Caregivers will step out of the bleach solution and onto the doffing pad. They will bend down to remove the tape from the top of their boots and remove the tape from the tops of their rubber gloves. They will peel down the gloves with the “glove-in-glove” technique.

Steps 7-15: PAPR and suit removal

Caregivers will doff the PAPRs in the following steps, according to observer’s instructions:

  • Bend forward facing floor; pull large hood back from head and drop to the doffing matt at feet; unbuckle belt at waist
  • Slowly remove zipper tape
  • Remove suit hood
  • Unzip the suit
  • Peal suit inside-out, rolling it down to the feet
  • Remove one boot (and suit foot) and step onto a new doffing pad; remove second boot and step completely onto the new doffing pad
  • Remove latex gloves with “glove-in-glove” technique
  • Wash hands and use hand sanitizer
  • Put on new pair of latex gloves

Steps 17-23: Disposal and last steps

  • Remove mask and hair cover and put in trash
  • Roll up doffing pad and trash, double-bag in red biohazard bags
  • Remove latex gloves and put in trash
  • Wash hands
  • Obtain vitals
  • Shower; all clothes will be incinerated and caregivers will be given WMC scrubs to wear home
  • Hydrate

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