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Lessons Learned: Critical Care Management of Patients With Ebola in the United States* Daniel W. Johnson, MD1; James N. Sullivan, MD1; Craig A. Piquette, MD2; Angela L. Hewlett, MD3; Kristina L. Bailey, MD2; Philip W. Smith, MD3; Andre C. Kalil, MD3; Steven J. Lisco, MD, FCCM1

Objective: This report will describe the preparations for and the provision of care of two patients with Ebola virus disease in the biocontainment unit at the University of Nebraska Medical Center. Data Sources: Patient medical records. Study Selection: Not applicable. Data Extraction: Not applicable. Data Synthesis: Not applicable. Conclusions: Safe and effective care of patients with Ebola virus disease requires significant communication and planning. Adherence to a predetermined isolation protocol is essential, including proper donning and doffing of personal protective equipment. Location of the patient care area and the logistics of laboratory testing, diagnostic imaging, and the removal of waste must be considered. Patients with Ebola virus disease are often dehydrated and need adequate vascular access for fluid resuscitation, nutri*See also p. 1326. 1 Division of Critical Care, Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE. 2 Division of Pulmonary, Critical Care, Sleep, and Allergy, ­D epartment of Internal Medicine, University of Nebraska Medical Center, Omaha, NE. 3 Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE. This work was performed at University of Nebraska Medical Center, Omaha, NE. Supported, in part, by the University of Nebraska Medical Center. Dr. Piquette has disclosed government work. Dr. Hewlett’s institution received grant support from Pfizer (orthopedic infections research grant). Dr. Lisco served as a board member for the University of Nebraska Medical Center Physicians and the Association of Midwest Academic Anesthesiology (Chairman); is employed by the University of Nebraska Medical Medical Center and the University of Nebraska Medical Center Physicians; was employed in the past by the University of Cincinnati and the University of Cincinnati Physicians; and has patents with RADLyn, LLC (US 2008/0066746 A1: Nelson LA; Lisco SJ: Method and Device for Placing an Endoctracheal Tube. Patent approved 11/2010). He provided expert testimony for Calderhead, Lockemeyer & Peschke; ROTHBERG LOGAN & WARSCO; PROCHASKA, GIROUX, AND HOWELL; Williams, Hall & Latherow; McGOWAN & JACOBS; Wellman, Nichols & Smith; Martin F. White, Co, LPA; and Dellecker, Wilson, King, McKenna, Ruffier, & Sos. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: [email protected] Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000000935

Critical Care Medicine

tion, and phlebotomy for laboratory sampling. Advanced planning for acute life-threatening events and code status must be considered. Intensivist scheduling should account for the significant amount of time required for the care of patients with Ebola virus disease. With appropriate precautions and resources, designated hospitals in the United States can safely provide care for patients with Ebola virus disease. (Crit Care Med 2015; 43:1157–1164) Key Words: disease management; Ebola virus; intensive care; isolation; protective clothing; United States

A

s the West African Ebola epidemic persists, critical care physicians in the United States must accept that this “far-away” disease is finding its way to American ICUs. In September and October 2014, governmental and nongovernmental agencies collaborated to transport two U.S. citizens with confirmed Ebola virus disease (EVD) from Liberia to the biocontainment unit (BCU) at the University of Nebraska Medical Center (UNMC). The purpose of this article is to communicate the lessons learned by the critical care physicians during these patients’ ICU courses so that insights gained will positively impact the future care of patients with EVD.

FACILITIES UNMC is home to a unit specifically designed for patients with diseases or exposure to pathogens that represent an exceptional risk to the general public. The Nebraska Biocontainment Patient Care Unit opened in 2005 with support from the federal government and is an ongoing joint project involving UNMC and the Nebraska Department of Health and Human Services. The BCU is purposely located on the same campus as the Nebraska Public Health Laboratory, a Biosafety Level-3 Laboratory. The BCU is a locked unit controlled by a security access system. It is equipped with a special air handling system, high-level filtration, a dunk tank for laboratory specimens, a pass-through autoclave, and a decontamination area. Hepa-filtered individual isolation units are available for safe transport and transfer of an infected patient to the unit. A large conference room adjacent to the BCU is converted to a command center in the event of patient admission (Fig. 1). www.ccmjournal.org

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higher risk procedures such as tracheal intubation were oriented to advanced PPE including powered air purifying respirators (PAPR). Throughout the course of both patients, healthcare workers benefitted from the supervision of an experienced user of PPE during each donning and doffing process. In the BCU, donning and doffing of PPE as an individual without a supervising partner only occurs when absolutely necessary. Lack of a donning and doffing partner is thought to potentially increase the risk of contamination. Detailed explanations of procedures for donning and doffing different types of PPE are posted on the walls of the BCU for easy reference. Figure 1. Command center of the biocontainment unit 1 day after a patient was admitted. Note the boxes of personal protective equipment stacked on the right.

PREPARATION FOR PATIENT ARRIVAL The Medical Director (P.W.S.) and Associate Medical Director (A.L.H.) of the BCU lead a volunteer team of 40 registered nurses, respiratory therapists, and patient care technicians with members on-call 24 hr/d. Several of the BCU nurses and respiratory therapists are also on staff in the adult ICUs at UNMC. All BCU staff members regularly receive specialized training and participate in drills throughout the year. In the years leading up to the 2014 Ebola epidemic, critical care physicians were not included in these drills. Upon the news that the State Department intended to transport patient 1 from Liberia to UNMC, the medical directors of the BCU communicated immediately with critical care leaders within the hospital. BCU staff members provided orientation to the critical care physicians, including instruction in the proper methods for donning and doffing of personal protective equipment (PPE) (Fig. 2). The decision was made to absorb the first patient into the existing Critical Care Medicine (CCM) service, as opposed to designating a separate attending intensivist specifically for the BCU. At UNMC, the nontrauma adult critical care service is shared between the Department of Anesthesiology (Division of Critical Care) and the Department of Internal Medicine (Division of Pulmonary, Critical Care, Sleep, and Allergy) and intensivists from both departments volunteered to work in the BCU.

PPE Prior to the arrival of the first patient, BCU staff members provided orientation sessions on PPE for all healthcare workers at UNMC who had significant potential to enter the room of a patient with EVD. Providers who might be required to perform 1158

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VASCULAR ACCESS

Patients arrived with peripheral IV catheters in the upper extremity. Because of an anticipated need for ongoing fluid resuscitation and frequent laboratory sampling, central venous access was deemed necessary. Arterial catheterization was not indicated. For the first patient, a peripherally inserted central catheter (PICC) was attempted, but the guide wire could not be successfully threaded beyond a few centimeters. For the second patient, a PICC was not attempted. The attending intensivist on duty for the CCM service placed a right internal jugular (IJ) catheter. Trainees were not involved in the procedure, as the initial policy of the BCU excluded trainees from entering the patient room. A 4 lumen, 16 cm, 8.5F catheter with antimicrobial surface treatment was selected, as it would most likely terminate in the superior vena cava, reducing the likelihood of an additional procedure to pull the line back in the event that the tip terminated in the right atrium or ventricle. An ultrasound-guided approach to the right IJ vein was selected, given the high likelihood of thrombocytopenia and/or coagulopathy. The intensivists systematically donned the following PPE under close supervision by an experienced BCU nurse: surgical gown, surgical cap, bouffant cap, face shield, standard patient gloves, impermeable washable shoes, surgical boot covers (over the calf), N-95 respirator mask, long-cuffed nitrile gloves (duct taped to the surgical gown), and splash protection apron (1, 2). Outer garments consisted of a sterile surgical gown and sterile gloves to ensure adherence to the Centers for Disease Control and Prevention (CDC) Guidelines for the Prevention of Intravascular Catheter-Related Infections (3). The outer sterile gloves were upsized by one half size to account for the two pairs of gloves underneath. A nurse and a respiratory therapist were in the room to assist. June 2015 • Volume 43 • Number 6

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it eliminated the need for traditional phlebotomy. Accordingly, the catheter remained in situ until patients required neither total parenteral nutrition (TPN) nor frequent laboratory sampling. Considering the potential risk for severe acute kidney injury in EVD and the possible need for renal replacement therapy, the Nephrology service has requested that for future patients with EVD, the left IJ vein be used for primary venous access. This would allow the right IJ vein to be cannulated for temporary hemodialysis access. The CCM service intends to use the left IJ for future patients with EVD.

NEUROLOGIC/MUSCULOSKELETAL MANIFESTATIONS Both patients arrived to the BCU with severe fatigue and mild delirium. Delirium improved each day. Standard delirium prevention measures were performed, with avoidance of benzodiazepines and opioids, frequent reorientation by nursing staff, and exposure to sunlight during daytime hours (4). Profound fatigue improved slightly with each day. Initially patients were unsteady on their feet and required assistance to move around the room. A stationary bicycle was placed in the room to aid in physical therapy, reduce boredom, and improve mood.

Figure 2. Intensivist in personal protective equipment just prior to entering room of patient 1.

In both cases, ultrasound imaging of the right IJ vein demonstrated near complete collapse with tidal inspiration despite Trendelenburg position, likely due to significant dehydration. After ultrasound confirmation of venous and not arterial location of the guide wire, the site was dilated and the catheter was placed over the wire. A small amount of blood pooled on the drape during the change from the dilator to the catheter, and this blood was immediately absorbed by sterile gauze to minimize risk of splash. In both cases, up to the point of inserting the catheter over the wire, handling the components of the central catheter kit with three pairs of gloves was not challenging. However, suturing the catheter to the skin was challenging with three pairs of gloves on. Chest radiographs were obtained after the procedure and confirmed appropriate location. The central venous catheter site was monitored frequently for external signs of infection and the nursing staff adhered strictly to institutional protocol with regard to cleansing, accessing, and dressing the device. The first patient had a set of blood cultures drawn from the central catheter on hospital day 6 due to an increasing leukocytosis. The second patient had a set of blood cultures drawn from the central catheter on hospital day 3 due to an increasing leukocytosis and then on hospital days 6 and 7 due to a worsening fever. All blood cultures resulted in no growth. The availability of the central venous catheter for laboratory sampling conferred a major reduction in risk for needle-stick injury for the nursing staff, as Critical Care Medicine

RESPIRATORY/AIRWAY COURSE AND CONSIDERATIONS Initially, patient 1 was on oxygen 2 L/min via nasal cannula and maintaining Spo2 in the mid-90s (Table 1). After 12 hours of IV fluids (total infused 1,200 mL), the oxygen requirement rose to 6 L/min to maintain Spo2 in the low-90s. This worsening A-a gradient prompted a change from gentle rehydration to gentle diuresis with a single dose of furosemide. The patient’s oxygenation improved from that point forward. Work of breathing appeared normal throughout the course. Noninvasive positive pressure ventilation was not an option due to ongoing nausea and vomiting and concern regarding aerosolization of secretions. Patient 2 developed a dry cough but had no clinical manifestations of impaired oxygenation and did not require diuretic therapy (Table 2). A predetermined plan for nonemergency intubation was created prior to patient arrival. The main issues considered were the need for an expert in airway management, accommodation for the time necessary for donning PPE, and ensuring that all necessary equipment would be available. The anesthesiologist responsible for hospital airway emergencies (postanesthesia care unit attending during the day, on-call attending during the night) would be called to the BCU in the event of progressive respiratory failure. The plan for PPE for intubation would be enhanced precaution PPE as recommended by the American Society of Anesthesiologists: PAPR with full face piece mask, disposable hood that extends to the shoulders, coverall without one-piece hood, triple gloves (with extended cuff nitrile gloves as outer layer duct taped to coverall), impermeable washable shoes, and impermeable www.ccmjournal.org

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Table 1. Physiologic Variables and Laboratory Data for the First 10 Days of Hospitalization of Patient 1 Variable

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Day 8

Day 9

Day 10

95

94

95

98

97

99

98

97

98

100

0.28

0.32

0.28

0.28

0.28

0.28

0.21

0.21

0.21

0.21

16

18

28

22

22

22

14

20

22

18

 Heart rate

77

77

62

69

75

91

78

88

90

85

 Mean arterial pressure (mm Hg)

75

93

86

90

94

93

97

98

94

93

 Central venous pressure (mm Hg)

3

6

6

6

5

3

4

 Urine output (mL/kg/hr)

1.15

0.57

0.78

0.83

1.9

0.95

1

1.1

2.3

2.3

 Daily urine output (mL)

2,225

1,100

1,500

1,600

3,720

1,825

2,020

2,185

4,465

4,455

 Daily stool output (mL)

2,220

2,285

205

950

0

0

501

0

0

0

0

400

30

0

0

0

0

0

0

0

 Daily total fluid output (mL)

4,425

3,785

1,735

2,550

3,720

1,825

2,521

2,185

4,465

4,455

 Daily IV fluids (mL)

1,957

2,282

1,942

887

2,350

1,277

213

40

2,033

1,984

260

355

1,090

1,130

645

1,438

360

1,041

1,887

4,234

 Daily total fluid input (mL)

2,217

2,637

3,032

2,017

2,995

2,715

573

1,081

3,920

6,218

 Net balance (mL)

–2,207

–1,148

–533

1,552

–725

890

–1,948

–1,104

–545

1,763

 Serum potassium (mmol/L)

3.1

3.5

3.7

3.8

3.8

4

4.1

3.8

4

3.7

 Potassium administered (mEq)

40

40

40

80

54

54

54

 Serum magnesium (mg/dL)

2.1

2.6

1.9

2.1

2.3

2.2

2.3

2.2

2

1

1

1

1

 Serum phosphorus (mg/dL)

0.8

1.8

2.9

 Phosphate administered (mmol)

67.5

30

30

Respiratory  Spo2 (%)  Fio2  Respiratory rate Hemodynamics

Fluids

 Daily emesis output (mL)

 Daily oral fluids (mL)

Electrolytes

 Magnesium sulfate administered (g)

shoe covers (5). The most likely plan for intubation would be rapid sequence induction including neuromuscular blockade followed by video laryngoscopy to allow the anesthesiologist to keep his/her face away from the patient’s airway. The combination of rapid-onset neuromuscular blockade (with succinylcholine or high-dose rocuronium) with the indirect laryngoscopy provided by a video laryngoscope should reduce the likelihood of exposure by coughing or vomiting of body fluids. An airway cart resides in the BCU and contains essentially all equipment that could be required for airway management. Devices include a variety of laryngoscopes (Macintosh and Miller) of different sizes, a video laryngoscope, gum elastic bougies, stylettes, and a variety of different sized masks, endotracheal tubes, oral airways, and laryngeal mask airways. 1160

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30

30

A fiberoptic bronchoscope is not included on the airway cart due to the risk of aerosolization associated with bronchoscopy.

CARDIOVASCULAR COURSE Aside from well-compensated hypovolemia, the patients’ cardiovascular systems were essentially normal on initial presentation (Tables 1 and 2). Heart rate was normal, rhythm was sinus, and the patients were normotensive. The patients never developed a severe derangement of hemodynamics suggestive of a profound systemic inflammatory response syndrome (SIRS)-like loss of vascular tone or SIRS-induced cardiomyopathy. Both patients experienced mild vasoplegia manifesting as orthostatic hypotension, but mild hypertension was the most common finding when patients were in the sitting position. Random cortisol levels were checked to evaluate for June 2015 • Volume 43 • Number 6

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Table 2. Physiologic Variables and Laboratory Data for the First 10 Days of Hospitalization of Patient 2 Variable

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Day 8

Day 9

Day 10

98

99

96

95

97

97

97

97

98

98

0.21

0.21

0.21

0.21

0.21

0.21

0.21

0.21

0.21

0.21

30

26

32

38

32

24

22

24

24

20

 Heart rate

93

91

83

95

89

64

67

73

88

72

 Mean arterial pressure (mm Hg)

95

93

96

104

103

97

98

90

92

92

 Central venous pressure (mm Hg)

5

3

5

5

8

 Urine output (mL/kg/hr)

0.66

1.65

0.91

1.54

2.01

1.52

1.32

0.62

1.08

0.66

 Daily urine output (mL)

1,350

3,525

1,950

3,305

4,325

3,255

2,795

1,310

2,225

1,350

 Daily stool output (mL)

3,375

2,265

1,325

0

0

0

0

200

50

0

 Daily emesis output (mL)

1,425

200

0

0

0

0

0

0

0

0

 Daily total fluid output (mL)

6,150

5,990

3,275

3,305

4,325

3,255

2,795

1,510

2,275

1,350

 Daily IV fluids (mL)

4,863

7,429

4,066

3,155

3,043

2,161

1,117

60

80

110

90

756

300

660

1,050

1,415

1,495

1,685

2,280

1,740

 Daily total fluid input (mL)

4,953

8,185

4,366

3,815

4,093

3,576

2,612

1,745

2,360

1,850

 Net balance (mL)

–1,197

2,195

1,091

510

–232

321

–183

235

85

500

 Serum potassium (mmol/L)

4.0

3.9

3.7

3.6

3.8

3.8

4.1

4.3

4.3

4.1

 Potassium administered (mEq)

40

40

20

60

20

20

20

 Serum magnesium (mg/dL)

1.4

1.7

1.8

2.1

2.1

2.2

1.9

1.8

2.0

1.9

3

3

3.5

1.5

1.5

1.5

1

4.0

2.0

2.0

2.5

2.8

3.8

3.5

4

3.4

3.9

25

35

20

50

50

Respiratory  Spo2 (%)  Fio2  Respiratory rate Hemodynamics

Fluids

 Daily oral fluids (mL)

Electrolytes

 Magnesium sulfate administered (g)  Serum phosphorus (mg/dL)  Phosphate administered (mmol)

adrenal insufficiency and were found to be normal. Orthostatic hypotension resolved prior to discharge.

GASTROINTESTINAL, HEPATIC, AND NUTRITION MANAGEMENT Prior to admission, both patients had multiple liquid stools per day with inadequate oral intake. Serum albumin was low at admission, indicating a moderate state of protein malnutrition likely related to poor oral intake of calories and protein and enteral losses due to gastroenteropathy. Nausea and diarrhea were the predominant symptoms and caloric intake was self-limited. Antidiarrheal agents were not used. A nutritional therapist was consulted in both cases and assisted the intensivists in creating goals of caloric and protein intake. All early attempts at oral intake were unsuccessful as they induced nausea and emesis, despite aggressive treatment with antiemetic agents. TPN was started on hospital day 3 for the initial patient, and based on this experience, Critical Care Medicine

TPN was started on hospital day 1 for the second patient. An ICU pharmacist assisted in managing the daily TPN orders based on current laboratory values. When patients had improved enough to tolerate a moderate to high calorie diet, TPN was stopped and constant encouragement of oral intake was provided (Tables 1 and 2). The patients had moderately elevated transaminases upon arrival that corrected to normal over the hospital stay. After initiation of TPN, mild hyperglycemia developed. The risks of frequent glucose monitoring were felt to outweigh the benefits of maintaining normoglycemia, so insulin therapy was not initiated. When oral intake was adequate, TPN was discontinued and blood glucose levels returned to normal levels.

RENAL, FLUID, AND ELECTROLYTE MANAGEMENT Upon presentation, patients appeared dehydrated with dry mucous membranes and had multiple electrolyte www.ccmjournal.org

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derangements including hypokalemia and mild metabolic acidosis with respiratory compensation. The critical care team was unable to ascertain whether there was a renal component to electrolyte losses as urine electrolyte analysis was deemed unsafe due to the potential for splash exposure. Both patients complained of extreme thirst, yet they were unable to tolerate adequate fluids by mouth. Fluid and electrolyte therapy was immediately begun with lactated Ringer’s solution. Patient 1 received an infusion at 100 mL/hr. Despite this modest administration of fluid, the patient developed a significant A-a gradient and a chest radiograph suggestive of pulmonary edema within 12 hours of arrival. This development, along with constantly normal blood pressure, adequate urine output, and resolution of metabolic acidosis, led the critical care team to utilize fluids sparingly throughout the remainder of the early course (Table 1). Patient 2 received an initial bolus of 30 mL/kg, a continuous infusion, and subsequent 500 mL boluses in response to large liquid stools or when the urine output diminished to 0.5 mL/kg/hr (Table 2). The second patient never required supplemental oxygen to maintain a normal Spo2. Initially, consistent laboratory analysis was difficult for the first patient due to the complex nature of handling samples known to contain Ebola virus and a lack of point-of-care testing within the unit. This problem was addressed by the Department of Pathology and the College of Public Health, resulting in point-of-care availability for nearly all necessary critical care laboratory assays. Daily parenteral doses of potassium and magnesium were given based on the daily laboratory values and electrolytes were included in TPN. With the addition of point-of-care laboratory testing, more frequent assays were possible. Several doses of potassium and magnesium were required to maintain serum potassium within a normal range. Upon initiation of TPN, the patients exhibited refeeding syndrome and inorganic phosphorus fell to low levels. Phosphorus was replaced with parenteral potassium phosphate. Renal function was adequate throughout both patients’ courses, with normal creatinine levels and urine output. Patient 1 arrived with a mild metabolic acidosis and a normal lactic acid level, whereas patient 2 arrived with a mild metabolic acidosis and elevated lactic acid. In both cases, the acidosis resolved within 24 hours. Both patients had received fluid replacement prior to transport, and they arrived in the BCU within 6 days of the onset of EVD. These factors likely helped the patients avoid the profound acute kidney injury suffered by some other victims of the disease (6). In both cases, a Foley urinary catheter was considered but not placed, as both patients were capable (with nursing assistance) of reliably collecting urine for measurement.

HEMATOLOGIC COURSE Initial laboratory values for both patients revealed anemia, thrombocytopenia, and mild coagulopathy. With the exception of convalescent plasma infusion (the purpose of which was provision of antibodies), the teams agreed to adhere to the Society of CCM guidelines for transfusion (7) and avoided administration of any blood products unless the patient 1162

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exhibited a clinically significant need for RBCs, plasma, or platelets. Neither patient required the transfusion of blood products, besides convalescent plasma, during the hospital stay. Anemia, thrombocytopenia, and coagulopathy all resolved over the hospital course. While neither patient developed a transfusion requirement, preplanning was done for this possibility. Blood type was performed, but an antibody screen could not be performed due to the risk of splash exposure during open centrifugation in the evaluation of agglutination. After extensive consultation between the critical care team and the Assistant Director of Transfusion and Tissue Services, the following plan was made for possible transfusion: administration of type-specific, Rh-negative, Kell-negative packed RBCs and administration of type compatible plasma and platelets. This strategy would prevent transfusion reactions related to the three most potent antigen systems with regard to triggering severe hemolytic transfusion reaction: ABO, Rh, and Kell (8). Chemical prophylaxis against deep venous thrombosis was avoided due to thrombocytopenia and concern for possible hemorrhage. Mechanical prophylaxis against deep venous thrombosis was provided with sequential compression devices. More importantly, patients were standing and ambulating with assistance throughout the course.

INFECTIOUS DISEASE CONSIDERATIONS The details of the patients’ infectious disease issues will be described elsewhere in the literature. Both patients received a combination of experimental therapies for EVD and both tolerated these treatments well. The medical directors of the BCU were in daily contact with the CDC with updates on the conditions of each patient. Serial blood samples were sent to the CDC to ensure that patients’ blood was free of Ebola virus prior to discharge.

CODE STATUS The Medical Director of the BCU and the critical care team made an agreement that any patient with confirmed EVD would not receive chest compressions. The rationale was that the likelihood of a patient with EVD surviving to hospital discharge after pulseless cardiac arrest would be very small, while the risk of transmission of Ebola to a healthcare worker during chest compressions or emergency tracheal intubation would be high. The Medical Director of the BCU explained this code status to the patients and their families immediately upon arrival, and the families expressed understanding of the policy. Semi-elective, nonemergency tracheal intubation for support of a failing respiratory system was always considered an option. Initially, defibrillation was considered a nonoption, but given each patient’s condition, the team agreed that cardioversion and defibrillation should be considered in case of dangerous or lethal arrhythmia. Vasopressors, inotropes, and antiarrhythmic agents were always considered options. The hospital ethics committee was not consulted to assist with the dilemma of advanced cardiac life support for cardiac arrest in patients with EVD. June 2015 • Volume 43 • Number 6

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DEDICATION OF EQUIPMENT Multiple teams agreed that dedicating typically reusable and sterilizable equipment to the BCU was in the best safety interest of staff members and other patients at UNMC. Prior to patients’ arrival, the following equipment had been placed in a clean ante room in the BCU for the duration of the epidemic: ultrasound machine with high-frequency linear transducer, video laryngoscope, airway cart, portable radiograph machine, and a ventilator with a sterilizable exhalation port. For auscultation, a new disposable stethoscope was used by each examining physician, with the earpieces placed in the ears prior to entering the patient’s room to avoid facial contamination after contact with the patient.

INTENSIVIST STAFFING MODELS The first patient was placed on the census of one of the two critical care teams. This meant that the attending intensivist for that team was required to enter the BCU each morning prior to normal ICU rounds, don the necessary PPE, coordinate decision making with the Infectious Diseases team, doff PPE, and perform all of the normal duties of the attending intensivist on duty while remaining available to BCU at any time for assistance. If the intensivist was in PPE and engaged in the care of a patient with EVD when an emergency arose for a different ICU service, the service was instructed to call the attending intensivist on duty for the other critical care team. This situation did not arise. This staffing model placed a strain on the attending physician and on the larger critical care team and was not considered sustainable given the time required for care of these isolated patients. Before the arrival of the second patient, a separate call schedule, minimizing handoffs, was created to cover the BCU. Intensivists without any clinical conflicts were scheduled in blocks of 4–7 days in a row in the BCU and took overnight call from home. BCU staff were provided with a call list to facilitate rapid communication with the critical care team. The first call was to the CCM fellow on duty, who is available within the hospital 24 hr/d. The second call was to the CCM attending assigned to the BCU, who is in the hospital from 7 am to 5 pm and then is available to return from home from 5 pm to 7 am. This communication model is the same as for other patients on the UNMC CCM service. Critical care fellows and attendings were either from the Department of Anesthesiology or from the Department of Internal Medicine, depending on the date and the call schedule.

INVOLVEMENT OF STUDENTS, RESIDENTS, AND FELLOWS Leaders of the BCU and of the Graduate Medical Education Committee discussed, at length, the role of students, residents, and fellows in the care of patients with EVD. All parties agreed that no trainee should be forced to enter the BCU as a requirement of a clinical rotation. For the initial two patients, it was decided that fellows would be allowed to enter the BCU and assist in medical decision making, but they would not be allowed to enter the patient room or participate in invasive procedures. This initial policy was adopted to eliminate the risk of Ebola infection for trainees and to promote the most efficient Critical Care Medicine

provision of optimal clinical care. The institutional policy has recently changed, in response to requests by the residents and fellows, to allow for volunteer participation of residents and fellows in all aspects of patient care within the BCU. The new policy will promote the training of future experts in the care of diseases with exceptional risk to the general public.

IMPLICATIONS FOR STAFF AFTER THE CARE OF PATIENTS WITH EVD All healthcare workers who entered the patient room were in full PPE and had no known breach in PPE, which placed them at low but not zero risk of contracting EVD. To appropriately monitor and care for BCU workers, UNMC utilizes protocols that are in compliance with the policies of local health departments and that satisfy the recommendations of the CDC. As these policies and recommendations change over time, UNMC continually re-evaluates its protocols to ensure the safety of its employees, its non-BCU patients, and the community at large.

CONCLUSIONS AND CONSIDERATIONS FOR OTHER CENTERS PREPARING FOR EVD Planning for patients with EVD requires significant communication between all service areas of the hospital including environmental services, security, and materials management. A large amount of PPE should be procured. Examples of recommended PPE may be found at the Nebraska BCU website or in the Nebraska Ebola Method App available on iTunes U (1, 9). Early communication is essential among physicians from Infectious Diseases, Critical Care and Pathology to discuss what laboratory tests can be performed at the point-of-care, what tests require processing in the main laboratory, and how samples will be handled if they need to leave the unit. Nurses, respiratory therapists, and other key team members must be engaged in the planning and training for management of patients with EVD. Although some centers are fortunate to have dedicated space for patients with EVD, other hospitals need to plan now and establish care areas for these patients. Specific plans must be made for the safe transfer of patients to the specialized unit, cleaning of the receiving area, and proper isolation practices during the transfer. Special attention must be paid to training in the appropriate donning and doffing of PPE. Care of these patients is time intensive and absorbing them into an existing critical care service is challenging. Trainees can be involved in the care of patients with EVD but only after appropriate orientation. Attending physicians from Critical Care and Infectious Diseases must be responsible for the direct care of the patient. The BCU at UNMC adheres firmly to a policy of risk reduction to healthcare workers, patients, and others in the facility. From the time a patient is admitted to the BCU until the physicians in conjunction with the CDC deem the patient safe to be discharged, the patient remains in his/her hospital room. BCU policy states that patients will not, for any reason, travel outside of the BCU. This type of policy is currently the topic of debate at many hospitals worldwide. www.ccmjournal.org

Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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The complex logistics of caring for patients with EVD present large challenges to hospitals in the United States, including large academic tertiary care centers. It is neither practical nor necessary for every hospital in the United States to prepare for the comprehensive care of patients with EVD. Instead, leaders at every hospital should consider the role that their center ought to play. A significant number of hospitals will need to be designated as destinations for comprehensive care of patients with EVD, but the vast majority of hospitals will instead receive patients suspected of having EVD and will need to have a preplanned strategy for safe testing and transfer of such patients. Large centers that are designated for the comprehensive care of EVD need to engage in extensive preplanning, be willing to modify normal critical care practices, and formulate a meticulous strategy for waste management. Upon the arrival of a patient with EVD, these centers will benefit from frequent communication with the CDC and peer institutions with prior EVD experience. The optimal care of patients with EVD requires a significant collaborative effort by many different teams of professionals at many levels. This article focuses on issues most pertinent to critical care physicians who would provide direct patient care. The authors hope that the lessons learned with the initial Ebola patients at UNMC will help healthcare providers in other parts of the country and around the world.

ACKNOWLEDGMENTS We thank all the members of the University of Nebraska Medical Center Biocontainment Unit (BCU) team, the BCU patients

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and their families, and all healthcare workers worldwide who are providing care for patients with Ebola. Your courage is utterly inspiring.

REFERENCES

1. University of Nebraska Medical Center: Ebola resources and protocols. Available at: http://www.nebraskamed.com/biocontainmentunit/ebola. Accessed October 30, 2014 2. Centers for Disease Control: Ebola information for healthcare workers and settings. Available at: http://www.cdc.gov/vhf/ebola/hcp/index. html. Accessed December 11, 2014 3. Marschall J, Mermel LA, Fakih M, et al: Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014; 35:753–771 4. Brummel NE, Girard TD: Preventing delirium in the intensive care unit. Crit Care Clin 2013; 29:51–65 5. Recommendations from the American Society of Anesthesiologists Ebola Workgroup. Available at: https://www.asahq.org/resources/ clinical-information/ebola-information. Accessed February 26, 2015 6. Bah EI, Lamah MC, Fletcher T, et al: Clinical presentation of patients with Ebola virus disease in Conakry, Guinea. N Engl J Med 2015; 372:40–47 7. Napolitano LM, Kurek S, Luchette FA, et al; EAST Practice Management Workgroup; American College of Critical Care Medicine (ACCM) Taskforce of the Society of Critical Care Medicine (SCCM): Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care. J Trauma 2009; 67:1439–1442 8. Reid M, Lomas-Francis C, Olsson ML: The Blood Group Antigen FactsBook. Third Edition. New York, Academic Press Elsevier, 2012 9. Nebraska Ebola Method for Clinicians. 2014. (Version 1.0) [Mobile application software]. Available at: https://itunes.apple.com/us/ course/nebraska-ebola-method-for/id933439277. Accessed October 30, 2014

June 2015 • Volume 43 • Number 6

Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Lessons learned: critical care management of patients with Ebola in the United States.

This report will describe the preparations for and the provision of care of two patients with Ebola virus disease in the biocontainment unit at the Un...
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