Presented by the COTEP Subcommittee on Ebola
Committee on Trauma and Emergency Preparedness
Committee on Occupational Health
Committee on Ethics
Additional ASA Members
Posted: October 24, 2014
- Background: 2014 Ebola outbreak
- Prevention of Transmission
- Surgical Procedures for Ebola Patients
- AMA Statement on Physician Obligation, Ethical commentary
- Additional Ethical Commentary
1. Purpose: To provide guidance and education to anesthesia providers with regard to contact with patients who have suspected OR confirmed Ebola virus.
2. Background: 2014 Ebola outbreak
- Filoviridae family (filovirus), enveloped, single-stranded RNA virus, one of several hemorrhagic viral families, Genus Ebolavirus, first identified in the 1976 outbreak near the Ebola River in the Democratic Republic of the Congo, 2014 West Africa species: Zaire.
- Transmission: direct contact, droplet contact, possibly contact with short range aerosols
- Blood and body fluids of infected patient (urine, feces, saliva, vomit, breast milk, sweat, and semen)
- Percutaneous contaminated sharps injury
- Contaminated fomites
- Infected animals
- Diseased primates (monkeys, gorillas, chimpanzees)
- Bats (probable natural reservoir)
- Broken skin or mucous membranes
- Case definition:
- Clinical criteria (fever and one or more of the symptoms below), and
- Epidemiologic risk factor
- Signs and symptoms of suspected Ebola virus disease (EVD):
- Suspect: elevated temperature (any)
- Diagnostic criteria: >38.6° C (101.5° F)
- Severe headache, muscle pain, vomiting, diarrhea, stomach pain, or unexplained bleeding or bruising.
- Appear anywhere from 2 to 21 days after exposure, 8 to 10 days most common.
- Maculopapular rash
- Multi-organ failure
- symptomatic management: fluid status, electrolytes, oxygenation, hemodynamics
- Vaccines and antiviral medications in development
- Convalescent serum has been used with some success on a limited number of patients
Additional information about the virus can be obtained from many sources including:
Centers for Disease Control
New England Journal of Medicine
Journal of the American Medical Association
Additional CDC information for Healthcare Providers
Additional WHO information for Healthcare Providers
3. Prevention of Transmission
Principles of PPE
- PPE donning must be performed in the proper order and monitored by a trained observer using a donning checklist.
- Check range of motion in the PPE and make necessary adjustments in accordance with the observer prior to entering the patient care area.
- During Patient Care:
- Do not make adjustments to or remove PPE.
- Frequently disinfect gloved hands with alcohol-based hand rub (ABHR) or EPA-registered disinfectant wipes, especially after contact with body fluids. Know the appropriate wet contact time for the disinfectant product to be used prior to entering the room (see below).
- During this phase, if a partial or total breach in PPE (i.e. gloves separate from sleeves exposing skin, tear in outer glove, needlestick) occurs, move immediately to the doffing area to assess the exposure. Implement the facility exposure plan, if indicated by assessment.
- PPE removal is a high risk process that requires a structured procedure, a trained observer (also in PPE), and a designated removal area.
- Doffing needs to be a slow and deliberate process and must be performed in the correct sequence using a doffing checklist.
- A stepwise process should be developed and used during training and daily practice.
(Modified from CDC website)
- Personal Protective Equipment (PPE) (routine) must include the following (when properly garbed, there should be no exposed skin). If this PPE is not available, a higher level of protection (PAPR) should be used (N.B. additionally, some state and local health departments are mandating higher levels of protection for EVD. It is imperative that individuals be aware of local requirements):
- Surgical hood to ensure complete coverage of head and neck
- Single-use face shield (goggles are no longer recommended due to issues with fogging and difficulty cleaning)
- N95 mask
- Impermeable gown (with sleeves) that extends at least to mid-calf or coverall without a one-piece integrated hood; Gowns or coveralls should ideally have a thumb hook. If not, then the use of duct tape will be required as well over the gown and inner gloves. Consideration should be given to wearing a protective coverall layer under the impermeable gown. This allows for layered protection and progressively less contaminated layers when doffing.
- Double gloves (i.e., disposable nitrile gloves with a cuff that extends beyond the cuff of the gown), the cuff of the first pair is worn under the gown and the second cuff should be over the gown
- Impermeable shoe covers that go to at least mid-calf or leg covers (there must be overlap of the impermeable layers)
- Impermeable and washable shoes
- Apron that is waterproof and covers the torso to the level of the mid-calf should be used if Ebola patients have vomiting or diarrhea
There is extensive guidance from the CDC regarding PPE including step-by-step donning and doffing procedures, training, and information on designated donning and doffing areas.
- Enhanced precaution PPE (Advised for aerosol generating procedures such as intubation, extubation, BiPAP, CPAP, bronchoscopy, sputum induction, airway suction, and surgery) This is the recommended level of PPE for anesthesiologists.
- Personal Air-Purifying Respirator (PAPR) with full face piece mask
- Disposable hood that extends to the shoulders and is compatible with the selected PAPR
- Coverall without one-piece hood
- Triple gloves (i.e., disposable nitrile with a cuff that extends beyond the cuff of the gown), the cuff of the first pair is worn under the gown and the second cuff should be over the gown and taped, and a third pair of disposable extended cuff nitrile gloves
- Impermeable and washable shoes
- Impermeable shoe covers
- Duct Tape (make tabs for easier removal)
Video for donning PAPR
Video for doffing PAPR
Video for donning routine PPE
Video for doffing routine PPE
Detailed donning and doffing procedure for PAPR and PPE from the CDC
Extensive article on PAPR in Anesthesia & Analgesia
- Recommended PPE for Trained Observer during Observations of PPE Doffing
- Surgical hood to ensure complete coverage of head and neck
- N95 mask
- Single-use (disposable) fluid-resistant or impermeable gown that extends to at least mid-calf or coverall without integrated hood
- Single-use (disposable) full face shield.
- Single-use (disposable) nitrile examination gloves with extended cuffs. Two pairs of gloves should be worn. At a minimum, outer gloves should have extended cuffs.
- Single-use (disposable) fluid-resistant or impermeable shoe covers. Shoe covers should allow for ease of movement and not present a slip hazard to the worker.
- Alternatively, enhanced precaution PPE may be used
The trained observer should not enter the room of a patient with Ebola, but will be in the PPE removal area to observe and assist with removal of specific components of PPE, as outlined below. The observer should not participate in any Ebola patient care activities while conducting observations. Trained observers should don and doff selected PPE according to same procedures outlined above. Of note, if the trained observer assists with PPE doffing, then the trained observer should disinfect outer-gloved hands with an *EPA-registered disinfectant wipe or alcohol-based hand rub (ABHR) immediately after contact with healthcare worker’s PPE.
Important Points about PPE: Training, practice, competence, and observation are essential in correct donning and doffing of PPE. Facilities should select and standardize for themselves the training and equipment necessary to accomplish this task.
There should be separate designated areas for storage and donning of PPE (an adjacent patient care area), one-way movement to the patient’s room, and an exit to a separate room or anteroom for doffing procedures and disposal. Donning and doffing should occur in two separate areas. Clean and contaminated areas need to be clearly delineated. Be well-stocked with bleach, alcohol solutions, EPA-registered disinfectant wipes, and of course, PPE.
Prior to donning, all personal items including phones and pagers should be secured and not on their person. PPE donning and doffing should always include a checklist and a trained additional individual (spotter) to assist. During doffing, the spotter is in the recommended PPE (above). An additional precaution would include a third trained individual who could monitor donning and doffing. Steps on donning and doffing are referenced above. Disinfect visibly contaminated PPE using an EPA-registered disinfectant wipe prior to taking off equipment. An important concept concerning pre-moistened disinfectant wipes is wet contact time which the EPA defines as "the surface must remain ''visibly wet'' for the prescribed contact time in order to produce disinfection." Additional application of wipes may be required to meet the minimum wet contact time. This time will vary depending on manufacturer and on the pathogen to be disinfected (bacteria vs. viruses). The wet contact time should be listed on the label. Immediate hand sanitization is to follow the completion of doffing PPE and a shower should be taken before the end of the shift.
All personnel should have undergone an N95 test fitting or respirator test fitting and select the appropriate size mask or respirator. A properly fitting N95 mask filters 95% of particles 0.1-0.3 microns, the most penetrating size. It attains up to 99.5% for particles outside this size range. However, it can be difficult to maintain a tight seal for prolonged periods of time under working conditions. Therefore, in environments where it is anticipated that the worker may be exposed to aerosols for extended periods, the use of a Personal Air-Purifying Respirator (PAPR) suit may be indicated. The usage of electrocautery, intubation, extubation, CPAP, BiPAP, bronchoscopy, and suctioning can aerosolize viable DNA/RNA. Evacuation suction should be used if available. PAPR usage needs to include practice donning and doffing with a spotter for all personnel that will contact an Ebola-suspected patient prior to any contact. The safe use of PAPRs requires initial and periodic training. It should be noted that unless properly executed, the risk of self (or buddy) contamination, and hence transmission, when removing PAPR may exceed that of lower levels of PPE.
WARNING: An orthopedic surgical “space suit” (SS) commonly used during total joint procedures is NOT equivalent to PAPR and accompanied hood. In the SS, air is drawn into the suit from the outside environment, unfiltered by anything other than the material in the suit itself. It is then blown down the helmet into the inside of the suit. This could potentially expose the user to a higher volume of pathogens and is not recommended.
4. Surgical Procedures on Ebola Patients
American College of Surgeons on Surgical Protocol for Possible or Confirmed Ebola Cases
Elective surgical procedures should not be performed in cases of suspected or confirmed Ebola (EVD). Emergency operations can be considered in cases as defined by the CDC: Persons Under Investigation, Probable Cases, and early Confirmed Cases. Patients with severe active disease would not likely tolerate an operation due to the severity of their disease. Any decision to operate should weigh all risks and benefits; specifically the risk of death from the current severity of their EVD, risk of death from their surgical disease, and risk of exposure to the OR team against the likelihood of potential benefit of emergency surgery. Choice of operative approach (open or MIS) should take into consideration minimizing potential hazards to all members of the OR team.
Operating Suite Precautions for Suspected Ebola Patients (only urgent/emergent procedures should be performed)
Every effort should be given to keeping the patient in their own isolation room and moving surgical and anesthetic equipment to the bedside.
- The anesthesia floor manager or coordinator must be notified of all suspected Ebola patients requiring anesthesia. Additionally, any cases involving the operating rooms (OR) or operating room personnel require OR charge nurse notification.
- A preoperative briefing with all members of the surgical and perioperative team as well as hospital leadership should take place and a plan for the case should be established.
- Intubated patients requiring anesthesia: If possible, all procedures should be performed in the patient’s room. Every effort should be given to keeping the patient in their own isolation room and moving surgical and anesthetic equipment to the bedside. If not feasible, an OR should be designated for the patient. Preferably, this OR should be away from traffic flow, have an anteroom, and not be connected to a clean core (sterile core). There have been reports that some hospitals have modified air flow in an operating room to change the normally positive pressure of the OR into a negative pressure airborne isolation room for surgery on patients on respiratory isolation. Portable negative pressure antechambers may be utilized.
- Non-intubated patients requiring anesthesia for procedures will be assessed on an individual basis by the anesthesia floor manager or coordinator to determine whether the procedure can be safely and adequately performed at the bedside. Again, every effort should be given to keeping the patient in their own isolation room and moving surgical and anesthetic equipment to the bedside. If not, the floor manager or coordinator will designate the operating room for the case (same locations as mentioned above).
Transportation to and from the OR
- Hallways near the designated operating room will be cordoned off. Adjacent operating rooms will be closed. Traffic flow must be limited to only essential personnel involved with the case.
- Designate personnel to provide a clear pathway from the patient’s room to the designated operating room to minimize exposure.
- PPE must be donned prior to entering the patient’s room.
- PPE should be removed as outlined above. Additionally, PPE will remain on while transporting the patient.
- There must be a designated person on the transport team wearing the same requisite PPE who is not involved in patient care or bed transport (i.e., has not touched infected surfaces or patient) whose responsibility it is to open doors and push elevator call buttons.
- Non-intubated patients must have a surgical mask placed prior to transport from their isolation room.
- Ideally, the patient should be transported in an isopod or equivalent negatively pressured, HEPA-filtered transport isolation unit.
- Recovery from anesthesia will occur in the operating room or the patient’s hospital room, and NOT PACU.
- Following recovery in the operating room, the patient should be transported to their isolation room by a new team with clean PPE and with similar security measures as mentioned above.
Operating Room Set-Up
- Anesthesia machine with all additional items from atop the machine removed.
- Drawers of the anesthesia machine should be emptied except for the bare minimum of supplies. Additionally, the drawers should not be accessed unless absolutely necessary.
- All paperwork/laminated protocols and non-essential items must be removed from the machine.
- The anesthesia cart should be removed from the room and will not be directly accessible once the patient enters.
- An isolation cart (stainless steel or other easily cleanable table) should be stocked with all anticipated medications, emergency medications, syringes, needles, I.V. fluids (multiple), I.V. supplies, arterial line supplies, tubing, suction catheters, NG tubes, endotracheal tubes of appropriate size, additional ECG electrodes, gauze, chlorhexidine or alcohol pads, saline flushes, an extra BP cuff, a sharps container, additional gloves, and any additional equipment and supplies which the anesthesia attending for the cases requests.
- It is the responsibility of the anesthesia provider (preferably attending anesthesiologist) to double check the setup prior to transporting the patient and make additions as necessary. Keep in mind that once a patient enters the OR, additional supplies, equipment, and medications may be unavailable.
- Cabinets should be emptied, closed and sealed.
- Once the patient enters the OR, absolutely no entry or exit from the OR will occur without following PPE protocols.
- As such, bathroom and personal needs should be attended to prior to transporting the patient. Therefore, excessive fluid intake by OR personnel should be avoided prior to transport as well.
- All anesthesia personnel should remain in the room for the duration of the case except for absolute emergencies (PPE protocol will continue to be enforced in such cases).
- The attending anesthesiologist should have no additional rooms or responsibilities during the case.
- Special effort is required to avoid opening any cabinets or drawers in the operating room.
Bedside Cases and Intubation Consults
- Intubation and suctioning may aerosolize the pathogens.
- Bedside cases will require notification of both the anesthesia floor manager/coordinator and charge nurse.
- PPE precautions remain as previously listed.
- Stat intubations or procedures are not to be attempted until properly donned in PPE and that necessitates significant time. There are no shortcuts. Full PPE precautions are to be adhered to regardless of an emergency status or acute deterioration in patient status.
- Fiberoptic bronchoscopes are not recommended for most facilities as aerosolization will occur and adequate cleaning is difficult.
- Keep in mind, all equipment brought into the patient’s room must remain there and will be unusable for an indefinite period of time.
- Due to the extended time necessary to properly don and doff PPE, anesthesia provider backup should be called in if anesthetic coverage of other patients is concurrently required. An intubation of an Ebola patient could potentially take ninety minutes or longer when accounting for proper donning and doffing procedures.
- Room and Equipment decontamination will be conducted according to hospital protocols. All disposable items that have been in the OR during the case should be discarded.
- Decontamination and removal of PPE should be performed as above in a designated doffing area. This includes the use of a checklist and a trained spotter who is also in appropriate PPE.
- A shuffle pit (tray with disinfectant soaked towels) is helpful to prevent shoes, etc. from tracking material on floors.
- Personnel who have had contact with a patient suspected to have Ebola must contact their Infection Control director for further instructions, precautions, and possible surveillance following the encounter.
- Additionally, the anesthesia floor manager or coordinator and OR charge nurse should submit names of all involved personnel to their Infection Control director.
- A post-operative debriefing with all members of the perioperative team should occur to develop lessons learned.
- Certain states are now specifying restrictions on caregivers, even with enhanced PPE, after they have provided care to Ebola patients. This may involve no care of other patients, mandatory sick leave, no use of public transportation no distant travel, and other measures. Be aware that your facility and local/state health departments may have these and other restrictions following contact.
Perioperative Staff Exposure
- Persons with a violation of PPE should arrange for relief and begin PPE doffing procedures in the designated doffing area immediately.
- Persons with mucous membrane or percutaneous exposure to a known or suspected Ebola patient should:
- Stop working and immediately wash the affected skin surfaces with soap and water.
- Mucous membranes (e.g., conjunctiva) should be irrigated with copious amounts of water or eyewash solution
- Immediately contact Infectious Disease consultant in your hospital for post exposure evaluation.
(From CDC website)
5. AMA Statement on Physician Obligation in Disaster Preparedness and Response
National, regional, and local responses to epidemics, terrorist attacks, and other disasters require extensive involvement of physicians. Because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters. This ethical obligation holds even in the face of greater than usual risks to their own safety, health or life. The physician workforce, however, is not an unlimited resource; therefore, when participating in disaster responses, physicians should balance immediate benefits to individual patients with ability to care for patients in the future.
In preparing for epidemics, terrorist attacks, and other disasters, physicians as a profession must provide medical expertise and work with others to develop public health policies that are designed to improve the effectiveness and availability of medical care during such events. These policies must be based on sound science and respect for patients. Physicians also must advocate for and, when appropriate, participate in the conduct of ethically sound biomedical research to inform these policy decisions. Moreover, individual physicians should take appropriate advance measures to ensure their ability to provide medical services at the time of disasters, including the acquisition and maintenance of relevant knowledge.
6. Additional Ethical Commentary
Patient autonomy is a hallmark of care in the United States, but this is not absolute. Among other principles, autonomy must be balanced with futility, safety, and limited resources. With respect to Ebola, open and honest discussions with patients early in their presentation regarding the possible course and prognosis would be of great value. This includes a discussion of advance directives. Of note, in these patients an emergency airway intervention is an impossibility, since that health care provider needs to safely and fully don PPE, which is a time-consuming endeavor. Furthermore, it may be inappropriate for that person to resume duties for routine patient care due to the chance of cross-infection. Despite these caveats, this does not preclude patients with Ebola from requiring anesthetic care, whether urgent airway intervention or semi-elective procedural anesthesia. However, there are unique issues which must be addressed on a case by case basis.
Due to the nature of the disease, all invasive procedures should be performed by those who are very experienced in doing them. It is never appropriate for medical, nursing, or other health provider students to perform invasive or aerosol producing procedures on a patient with a known or suspected diagnosis of Ebola.
Residents or fellows providing care to patients should have the same training and ongoing practice in infection control procedures as attending staff, and operate under the direct supervision of trained faculty members.
Updates to the protocols may be rapidly and dramatically altered due to changing circumstances and as new information is obtained.
CDC Main Ebola Page: http://www.cdc.gov/vhf/ebola/
CDC Ebola virus disease Information for Clinicians in U.S. Healthcare Settings: http://www.cdc.gov/vhf/ebola/hcp/clinician-information-us-healthcare-settings.html
CDC information for Health Care Workers (list of available resources): http://www.cdc.gov/vhf/ebola/hcp/index.html
Specific CDC recommendations for safe patient management: http://www.cdc.gov/vhf/ebola/hcp/patient-management-us-hospitals.html
Specific CDC infection control recommendations: http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html
Specific CDC guidance on PPE: http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html
Specific CDC environmental cleaning recommendations: http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html
CDC Health Alert Network: http://emergency.cdc.gov/han/index.asp
PAPR donning information and video from University of Nebraska Medical Center: http://app1.unmc.edu/nursing/heroes/mpv.cfm?updateindex=52&src=yt
PAPR doffing information and video from University of Nebraska Medical Center: http://app1.unmc.edu/nursing/heroes/mpv.cfm?updateindex=53&src=yt
ASA Emergency Preparedness Resources and Departmental Emergency Preparedness Chapter: http://www.asahq.org/about-asa/governance-and-committees/asa-committees/committee-on-trauma-and-emergency-preparedness/emergency-preparedness
Ebola Preparedness Protocols from Emory Healthcare: http://www.emoryhealthcare.org/ebola-protocol/ehc-message.html
Ebola Outbreak from The New England Journal of Medicine:http://www.nejm.org/page/ebola-outbreak
The 2014 Ebola Outbreak from JAMA: http://jama.jamanetwork.com/article.aspx?articleID=1911333&
Infection prevention and control guidance for care of patients in health-care settings, with focus on Ebola from WHO: http://www.who.int/csr/resources/publications/ebola/filovirus_infection_control/en/
Tompkins BM. Antoine JA. Personal Protective Equipment in Pandemic/Avian Influenza/SARS: N95 or PAPR for Intubation? American Society of Anesthesiologists 2008, 8, accessed at January2008/personal-protective-equipment-in-pandemic-avian-influenza.aspx accessed on October 22, 2014
Chee VW, Khoo ML, Lee, SF, Lai, YC, Chin NM. Infection Control Measures for Operative Procedures in Severe Acute Respiratory Syndrome-related Patients. Anesthesiology. 2004;100: 1394-8, accessed at http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1974243 accessed on October 22, 2014
San Francisco General Hospital Infection Prevention & Control: Ebola Virus Disease Guidance
Ebola Preparedness Plan from Mayo Clinic Division of Infectious Diseases
The 2014 Ebola Outbreak. JAMA. 2014;312(14):1388.
Surgical Protocol for Possible or Confirmed Ebola Cases by Sherry M. Wren M.D., F.A.C.S., F.C.S. (ECSA) and Adam L. Kushner M.D., M.P.H., F.A.C.S., accessed at https://www.facs.org/ebola/surgical-protocol accessed on October 22, 2014
Lau, A C-W, et al, “Response to SARS as a Prototype for Bioterrorism: Lessons in a Regional Hospital in Hong Kong,” in McIsaac, JH., Ed., Hospital Preparation for Bioterror: A Medical and Biomedical Systems Approach, Academic Press, 2006.
McIsaac, JH, “Decontamination and Personal Protection,” in McIsaac, JH., Ed., Hospital Preparation for Bioterror: A Medical and Biomedical Systems Approach,Academic Press, 2006.
AMA Statement on Physician Obligation in Disaster Preparedness and Response: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion9067.page accessed on October 22, 2014
ACGME Guidance Statement on Ebola Virus Infection and Resident/Fellow Training in the United States: http://www.acgme.org/acgmeweb/Portals/0/PDFs/Nasca-Community/ACGME-GME-Ebola-Final1.pdf accessed on October 22, 2014
Wood, A. Ebola Hemorrhagic Fever: Precautions in the OR. AORN Journal. (Article in Press), accessed at http://www.aornjournal.org/pb/assets/raw/Health%20Advance/journals/aorn/EbolaPerioperativeConsiderations.pdf accessed on October 22, 2014
Use of convalescent whole blood or plasma collected from patients recovered from Ebola virus disease: Empirical treatment during outbreaks from WHO: http://www.who.int/csr/resources/publications/ebola/convalescent-treatment/en/
Mupapa K, Massamba K, Kibadi K, Kuvula A,Bwaka, M, Kipasa R, Colebunders R, Muyembe-Tanfum JJ. Treatment of Ebola Hemorrhagic Fever with Blood Transfusions from Convalescent Patients. Journal of Infectious Diseases. 1999;179: 18-23.
Wagner, J. Disinfectant Surface Wipes: Effective or Simply Convenient? Becker’s Infection Control and Clinical Quality, accessed at http://www.beckersasc.com/asc-quality-infection-control/disinfectant-surface-wipes-effective-or-simply-convenient.html accessed on October 22, 2014
Brosseau LM, Jones, R. COMMENTARY: Health workers need optimal respiratory protection for Ebola. CIDRAP, accessed at http://www.cidrap.umn.edu/news-perspective/2014/09/commentary-health-workers-need-optimal-respiratory-protection-ebola accessed on October 23, 2014
This committee work product has not been reviewed or approved by ASA’s Board of Directors or House of Delegates and does not represent an ASA Policy, Statement or Guideline.