вирус эбола- взгляд о готовности "изнутри"
Приведу ниже статью, с автором которой я согласна в ее мнении.
Разумеется, это не для паники, а просто, как показатель текущего положения вещей в здравоохранении.
Да, стоит отметить, что госпитали не готовы к тому, чтобы масштабно работать с высокозаразными и при этом смертельно-опасными инфекциями, вроде лихорадки эбола. Нет помещений, нет тренированного персонала, и дорога экипировка и тренинги для персонала, которые являются ключевыми в том, чтобы предотвратить распространение инфекции.[далее английский]
Manoj Jain, MD, MPH | Physician | October 25, 2014
Recently at our community hospital, after we concluded a nearly two-hour standing room only Ebola preparedness meeting, I practiced donning and doffing the personal protective equipment (PPE) for Ebola cases.
PPE is the protective wardrobe health workers wear when examining a patient with a contagious infectious disease. Each disease has a different level of transmission and requires an appropriate level of protection. I wear gloves 25 times a day to examine each patient I see. (Not all doctors do this; in my specialty of infectious diseases, though, it is prudent.) I dress in a gown a dozen times when entering a room of a patient with antibiotic resistant bacteria like MRSA. I place on a mask a few times a day when I suspect that the patient has the flu or tuberculosis.
The risk of infection often times is to patients when health workers carry infectious agents like MRSA on their hands or clothes from one patient room to another or into the community leading to an outbreak of resistant bacteria. On other occasions the risk is to the health care workers of acquiring diseases such as flu, TB or meningitis from the patient.
Ebola poses both these risks. In fact, Ebola in America has completely overturned the thinking and practice of isolation precautions by its highly infectious nature. One billion Ebola virus particles are in two drops of blood, and it has a mortality rate of 70 percent.
In my hospital’s administrative boardroom, with guidance from my “buddy” the infection prevention nurse, I began my Ebola PPE practice. I first placed on the impervious booties and leg coverings, then the blue plastic impervious gown, then the N-95 mask, then the face shield, then head covering, and then two pairs of gloves.
A few weeks ago I thought that this was all overkill. But after I learned that Dallas nurses has contracted Ebola even with their protective gear, I wonder if this is sufficient. After a few minutes in the total body covering, I felt sweat on my neck. If I breathed heavily my face shield fogged up and when I walked across the room my boot and leg covers began to come off exposing my pants. A splash on them would mean that I could carry the virus home, putting my family at risk.
My “buddy” guided me through each step. Then I soaked my hands in water - as if I had a viral or blood exposure - and began the task of undoing the protective covering. First, removing the soiled gloves, replacing them with new ones, and then removing my head covering, gown, boot covers, face shield and mask, making sure to only touch the insides or backsides of the coverings. On three occasions the nurse stopped me from contaminating myself.
“It’s not easy,” another nurse who was on a hazardous material team remarked with a concerned look.
“So how can we do this better?” I asked. “We need practice.” While theoretically all hospitals should be able to manage an Ebola patient, in practice it is not possible. In my opinion, we cannot train hundreds of hospital staff including doctors, nurses, phlebotomists, and x-ray technician in meticulous isolation procedures.
I believe we need to treat every Ebola case under a hazardous material protocol, not as a hospital infectious disease isolation management protocol. A hazardous material management protocol requires a specialized team, specific equipment and trained practices. We need a local Ebola treatment center and a trained Ebola treatment team at one facility in each metro area, just as we have trauma centers and trauma teams.The Centers for Disease Control and Prevention is developing regional centers and will deploy rapid response teams however, we need to be prepared locally because Ebola will be a concern for months if not years and its course may be unpredictable.
One such team per metro area should be sufficient since we are unlikely to see thousands of cases of Ebola in America - as there are in Africa. Funding for training and preparing such a team could be shared by all the local hospitals because in large part it will save them tremendous internal resources to prepare for extensive hospital management of such patients and disruption if a patient has to be admitted to their facility.
However, with such a team, local hospitals and emergency rooms cannot drop their guard. All hospitals, primary care doctors and minor medical clinics would serve as triage units to help identify and isolate potential Ebola cases, because this is where patients will come first. Locally, health departments, hospital executives and infectious disease experts need to quickly meet and develop an Ebola management center and a team, if a case occurs in their city.
The past weeks has taught me an important lesson. Either we are underestimating the infectiousness of Ebola or overestimating our ability to protect our health care workers with our present protocol and training. Or what is more troubling - it may be both.
Manoj Jain is an infectious disease physician and contributor to the Washington Post and The Commercial Appeal. He can be reached at his self-titled site, Dr. Manoj Jain. This article originally appeared in the Huffington Post.
http://www.kevinmd.com/blog/2014/10/ebola-local-hospitals-prepared.html
и ряд комменатриев от медперсонала, которые дорисовывают картину:
52330173 •
Your comments are extremely practical and common sense based something lacking in the CDC and Federal government approach. If you go to Nurse.com the website of the head nurse at the Emory isolation unit you realize how much time (25 minutes) and steps it takes her experienced team going through 18 steps in pairs. It is also labor intensive requiring 2-3 nurses per patient working shorter shifts. We need regional centers while we gain experience with this pathogen and train the health care work force and give them time to practice and perfect their technique.
What are your thoughts on the NY and NJ quarantine of health care workers returning from working in hot zones? Is there a technology available to detect asymptomatic infected individuals ?
94359159
No, there is no such technology available. Presumably (i.e. it hasn't been reported in literature yet to my knowledge), RT-PCR should be able to catch cases just before they become symptomatic, but not necessarily in the couple of days immediately after exposure. I hope someone is working on this!
127315262 Eric Strong •
The 21 day quarantine is hyper-effective. Each person infected with the Ebola virus only infects two others on average, even in West Africa, where the funerary practice is for the entire family to pretty much bathe in the fluids of the victim. If 90% of infections are apparent by 21 days, then the infection rate is 10% * 2 = 20%. The outbreak will die out within a few cycles. This approach successfully took smallpox to extinction, and it was vastly more infectious.
There is the possibility that the virus will evolve to adapt to the quarantine period, but that is not necessarily a bad thing. Indolent viruses tend to lose their hazardousness. (Ebola's trick of blocking interferon signalling is not compatible with a 21 delay.) Selective breeding can turn a killer virus into a vaccine within a few viral generations
41423175
By recommending that community hospitals should be the forefront of fighting possible Ebola epidemic, CDC made a political decision to prevent panic related to Ebola over prevention of disease. This decision contradicts CDCs own rules of handling bio safety level 4 (BSL4) infections which Ebola is. Specifically, the standards for personal protective equipment (PPE), general security standards and the extent of training recommended to community facilities is much less stringent than that of BSL level 4 labs, CDCs bio containment units or their military equivalents. This move was supported by some nearsighted healthcare experts, who I am sure never have and never will deal with real Ebola patients. Healthcare professionals in tranches were thrown under the bus and blaimed for CDCs shortcomings. And hospital administrators were quick to announce their facilities readiness to handle Ebola cases as one more marketing ploy, playing Russian rulette and hoping they would never see real Ebola case.
57494404 Тhe military has the luxury of rotating soldiers out of combat (which is their job) and into less active settings where they have time to engage in intensive training, undistracted by having also to complete combat duties.
Our healthcare enterprise does not wish to rotate doctors and nurses out of their active jobs and into intensive training sessions, and so training for healthcare workers is rarely all that effective, since it is done on the fly, generally on the worker's own time, or in brief sessions that are squeezed into the worker's usual work day.
26910633
This, this and more this. Rapid comprehensive training of the entire healthcare workforce of the united states, of sufficient quality to ensure virtually no accidental transmission of Ebola in the event of a true epidemic, is a pipe dream.
Just ask yourself - how much training would you personally insist on, and how much practice, before you would don the space-suit, and walk into a room for 6-8 hours with a fluid-spewing ebola patient, in the terminal stages of their ilness, and know with near certainty that you won't contaminate yourself, or your family when you return home? Now imagine that time commitment, multiplied by 200,000, in a system that is already short on manpower, with sufficiently frequent retraining and practice to commit the protocols to muscle memory. You would also need to continue that degree of preparedness pretty much forever (never know when the next Ebola will strike).
So...follow that train of thought: it would cost a hospital hundreds of thousands of dollars to properly train all front-line workers to safely manage an Ebola patient. Do you think that your typical hospital CEO making a seven-figure salary is likely to approve a budget item which would adversely impact the hospital's ability to pay that salary? Highly unlikely.
At my hospital, there have been zero training sessions, at least for me and my peers. Instead, we were all forwarded a 45 minute video of an informational meeting (that we were not given time off to attend) and encouraged to "take a few minutes of your time" to watch the entire tape, presumably at home, at night, after all of our regular work was done for the day.
94359159
I agree with the previous responses. It is a virtual impossibility to prepare every hospital to be adequately prepared for Ebola. For training of adequate number of staff, providing adequate supply of PPE, and ward/room retrofitting, I would guess a minimum of half a million per hospital (yes, that kind of stuff is super expensive) x 5000+ hospitals = 2.5 billion dollars. Profound waste of money and resources. Plus, this isn't a one time cost. Training would need to be ongoing in order to prevent loss of knowledge and skills.
You think they can train Private Moron to reliably handle serious biohazards? You must be joking. Have you seen this story? http://www.nbcnews.com/news/us... Finally, the idea of putting an Ebola patient into a neonatal-type incubator is laughable. The amount of vomit and diarrhea produced during the peak of illness severity renders this completely implausible.
94773551One thing about the article bothers me. The author talks about washing the gloves before removing the rest of the suit. If I read the news stories from Liberia properly Medecins sans Frontieres (even under the conditions there) has staff step into a sealed shower where the entire suit is washed with a chlorine solution to sterilise it before disrobing begins. Why was this step skipped?
94359159
Hospitals aren't physically designed for this. Most isolation-specific rooms have an antechamber for putting on/taking off facemasks, gowns, and gloves. There is a sink present for washing hands. However, I've never seen an isolation antechamber with its own shower, and most of them are physically too small to retrofit them with one. This is yet another reason why it is implausible to make every hospital ready to handle an Ebola patient.
Разумеется, это не для паники, а просто, как показатель текущего положения вещей в здравоохранении.
Да, стоит отметить, что госпитали не готовы к тому, чтобы масштабно работать с высокозаразными и при этом смертельно-опасными инфекциями, вроде лихорадки эбола. Нет помещений, нет тренированного персонала, и дорога экипировка и тренинги для персонала, которые являются ключевыми в том, чтобы предотвратить распространение инфекции.[далее английский]
Manoj Jain, MD, MPH | Physician | October 25, 2014
Recently at our community hospital, after we concluded a nearly two-hour standing room only Ebola preparedness meeting, I practiced donning and doffing the personal protective equipment (PPE) for Ebola cases.
PPE is the protective wardrobe health workers wear when examining a patient with a contagious infectious disease. Each disease has a different level of transmission and requires an appropriate level of protection. I wear gloves 25 times a day to examine each patient I see. (Not all doctors do this; in my specialty of infectious diseases, though, it is prudent.) I dress in a gown a dozen times when entering a room of a patient with antibiotic resistant bacteria like MRSA. I place on a mask a few times a day when I suspect that the patient has the flu or tuberculosis.
The risk of infection often times is to patients when health workers carry infectious agents like MRSA on their hands or clothes from one patient room to another or into the community leading to an outbreak of resistant bacteria. On other occasions the risk is to the health care workers of acquiring diseases such as flu, TB or meningitis from the patient.
Ebola poses both these risks. In fact, Ebola in America has completely overturned the thinking and practice of isolation precautions by its highly infectious nature. One billion Ebola virus particles are in two drops of blood, and it has a mortality rate of 70 percent.
In my hospital’s administrative boardroom, with guidance from my “buddy” the infection prevention nurse, I began my Ebola PPE practice. I first placed on the impervious booties and leg coverings, then the blue plastic impervious gown, then the N-95 mask, then the face shield, then head covering, and then two pairs of gloves.
A few weeks ago I thought that this was all overkill. But after I learned that Dallas nurses has contracted Ebola even with their protective gear, I wonder if this is sufficient. After a few minutes in the total body covering, I felt sweat on my neck. If I breathed heavily my face shield fogged up and when I walked across the room my boot and leg covers began to come off exposing my pants. A splash on them would mean that I could carry the virus home, putting my family at risk.
My “buddy” guided me through each step. Then I soaked my hands in water - as if I had a viral or blood exposure - and began the task of undoing the protective covering. First, removing the soiled gloves, replacing them with new ones, and then removing my head covering, gown, boot covers, face shield and mask, making sure to only touch the insides or backsides of the coverings. On three occasions the nurse stopped me from contaminating myself.
“It’s not easy,” another nurse who was on a hazardous material team remarked with a concerned look.
“So how can we do this better?” I asked. “We need practice.” While theoretically all hospitals should be able to manage an Ebola patient, in practice it is not possible. In my opinion, we cannot train hundreds of hospital staff including doctors, nurses, phlebotomists, and x-ray technician in meticulous isolation procedures.
I believe we need to treat every Ebola case under a hazardous material protocol, not as a hospital infectious disease isolation management protocol. A hazardous material management protocol requires a specialized team, specific equipment and trained practices. We need a local Ebola treatment center and a trained Ebola treatment team at one facility in each metro area, just as we have trauma centers and trauma teams.The Centers for Disease Control and Prevention is developing regional centers and will deploy rapid response teams however, we need to be prepared locally because Ebola will be a concern for months if not years and its course may be unpredictable.
One such team per metro area should be sufficient since we are unlikely to see thousands of cases of Ebola in America - as there are in Africa. Funding for training and preparing such a team could be shared by all the local hospitals because in large part it will save them tremendous internal resources to prepare for extensive hospital management of such patients and disruption if a patient has to be admitted to their facility.
However, with such a team, local hospitals and emergency rooms cannot drop their guard. All hospitals, primary care doctors and minor medical clinics would serve as triage units to help identify and isolate potential Ebola cases, because this is where patients will come first. Locally, health departments, hospital executives and infectious disease experts need to quickly meet and develop an Ebola management center and a team, if a case occurs in their city.
The past weeks has taught me an important lesson. Either we are underestimating the infectiousness of Ebola or overestimating our ability to protect our health care workers with our present protocol and training. Or what is more troubling - it may be both.
Manoj Jain is an infectious disease physician and contributor to the Washington Post and The Commercial Appeal. He can be reached at his self-titled site, Dr. Manoj Jain. This article originally appeared in the Huffington Post.
http://www.kevinmd.com/blog/2014/10/ebola-local-hospitals-prepared.html
и ряд комменатриев от медперсонала, которые дорисовывают картину:
52330173 •
Your comments are extremely practical and common sense based something lacking in the CDC and Federal government approach. If you go to Nurse.com the website of the head nurse at the Emory isolation unit you realize how much time (25 minutes) and steps it takes her experienced team going through 18 steps in pairs. It is also labor intensive requiring 2-3 nurses per patient working shorter shifts. We need regional centers while we gain experience with this pathogen and train the health care work force and give them time to practice and perfect their technique.
What are your thoughts on the NY and NJ quarantine of health care workers returning from working in hot zones? Is there a technology available to detect asymptomatic infected individuals ?
94359159
No, there is no such technology available. Presumably (i.e. it hasn't been reported in literature yet to my knowledge), RT-PCR should be able to catch cases just before they become symptomatic, but not necessarily in the couple of days immediately after exposure. I hope someone is working on this!
127315262 Eric Strong •
The 21 day quarantine is hyper-effective. Each person infected with the Ebola virus only infects two others on average, even in West Africa, where the funerary practice is for the entire family to pretty much bathe in the fluids of the victim. If 90% of infections are apparent by 21 days, then the infection rate is 10% * 2 = 20%. The outbreak will die out within a few cycles. This approach successfully took smallpox to extinction, and it was vastly more infectious.
There is the possibility that the virus will evolve to adapt to the quarantine period, but that is not necessarily a bad thing. Indolent viruses tend to lose their hazardousness. (Ebola's trick of blocking interferon signalling is not compatible with a 21 delay.) Selective breeding can turn a killer virus into a vaccine within a few viral generations
41423175
By recommending that community hospitals should be the forefront of fighting possible Ebola epidemic, CDC made a political decision to prevent panic related to Ebola over prevention of disease. This decision contradicts CDCs own rules of handling bio safety level 4 (BSL4) infections which Ebola is. Specifically, the standards for personal protective equipment (PPE), general security standards and the extent of training recommended to community facilities is much less stringent than that of BSL level 4 labs, CDCs bio containment units or their military equivalents. This move was supported by some nearsighted healthcare experts, who I am sure never have and never will deal with real Ebola patients. Healthcare professionals in tranches were thrown under the bus and blaimed for CDCs shortcomings. And hospital administrators were quick to announce their facilities readiness to handle Ebola cases as one more marketing ploy, playing Russian rulette and hoping they would never see real Ebola case.
57494404 Тhe military has the luxury of rotating soldiers out of combat (which is their job) and into less active settings where they have time to engage in intensive training, undistracted by having also to complete combat duties.
Our healthcare enterprise does not wish to rotate doctors and nurses out of their active jobs and into intensive training sessions, and so training for healthcare workers is rarely all that effective, since it is done on the fly, generally on the worker's own time, or in brief sessions that are squeezed into the worker's usual work day.
26910633
This, this and more this. Rapid comprehensive training of the entire healthcare workforce of the united states, of sufficient quality to ensure virtually no accidental transmission of Ebola in the event of a true epidemic, is a pipe dream.
Just ask yourself - how much training would you personally insist on, and how much practice, before you would don the space-suit, and walk into a room for 6-8 hours with a fluid-spewing ebola patient, in the terminal stages of their ilness, and know with near certainty that you won't contaminate yourself, or your family when you return home? Now imagine that time commitment, multiplied by 200,000, in a system that is already short on manpower, with sufficiently frequent retraining and practice to commit the protocols to muscle memory. You would also need to continue that degree of preparedness pretty much forever (never know when the next Ebola will strike).
So...follow that train of thought: it would cost a hospital hundreds of thousands of dollars to properly train all front-line workers to safely manage an Ebola patient. Do you think that your typical hospital CEO making a seven-figure salary is likely to approve a budget item which would adversely impact the hospital's ability to pay that salary? Highly unlikely.
At my hospital, there have been zero training sessions, at least for me and my peers. Instead, we were all forwarded a 45 minute video of an informational meeting (that we were not given time off to attend) and encouraged to "take a few minutes of your time" to watch the entire tape, presumably at home, at night, after all of our regular work was done for the day.
94359159
I agree with the previous responses. It is a virtual impossibility to prepare every hospital to be adequately prepared for Ebola. For training of adequate number of staff, providing adequate supply of PPE, and ward/room retrofitting, I would guess a minimum of half a million per hospital (yes, that kind of stuff is super expensive) x 5000+ hospitals = 2.5 billion dollars. Profound waste of money and resources. Plus, this isn't a one time cost. Training would need to be ongoing in order to prevent loss of knowledge and skills.
You think they can train Private Moron to reliably handle serious biohazards? You must be joking. Have you seen this story? http://www.nbcnews.com/news/us... Finally, the idea of putting an Ebola patient into a neonatal-type incubator is laughable. The amount of vomit and diarrhea produced during the peak of illness severity renders this completely implausible.
94773551One thing about the article bothers me. The author talks about washing the gloves before removing the rest of the suit. If I read the news stories from Liberia properly Medecins sans Frontieres (even under the conditions there) has staff step into a sealed shower where the entire suit is washed with a chlorine solution to sterilise it before disrobing begins. Why was this step skipped?
94359159
Hospitals aren't physically designed for this. Most isolation-specific rooms have an antechamber for putting on/taking off facemasks, gowns, and gloves. There is a sink present for washing hands. However, I've never seen an isolation antechamber with its own shower, and most of them are physically too small to retrofit them with one. This is yet another reason why it is implausible to make every hospital ready to handle an Ebola patient.