Beyond Traditional Biosafety

Abstract

Applied BiosafetyVol. 21, No. 1 Special FeaturesFree AccessBeyond Traditional BiosafetyNanette E. Moss and Steven B. BloomNanette E. MossEnvironmental Health & Engineering, Inc., Needham, MA, USASearch for more papers by this author and Steven B. BloomBrigham and Women’s Hospital, Boston, MA, USASearch for more papers by this authorPublished Online:1 Mar 2016AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Biosafety professionals have ever-expanding roles at their institutions. In this Beyond Traditional Biosafety column, we focus on topics that may fall outside the scope of the traditional biosafety role but where the expertise of the biosafety professional may be called on to provide a valuable contribution to his or her institution. Please e-mail any comments, suggestions, or insights to Bryan Connors at bconnors@eheinc.com.Preparing for Ebola and Emerging Diseases with Medical Simulation TrainingBackgroundOne of the major public health concerns today is that of emerging infectious diseases (EIDs). EID is a term that applies to a disease that is newly recognized as occurring in humans, one that is appearing in a new population or geographic area, one that is affecting many more people than previously observed, or one that has developed new attributes, such as increased virulence or antibiotic resistance. Because EIDs are commonplace, health care, laboratory, and support personnel may be at increased risk of occupationally acquired infections from highly pathogenic organisms such as Ebola virus, Severe Acute Respiratory Syndrome (SARS) coronavirus, Middle Eastern Respiratory Syndrome (MERS) coronavirus, and continually evolving influenza strains.Several factors may contribute to EIDs worldwide, including human population growth and movement, encroachment on wildlife habitat causing more frequent contact with wild animals, changes in land use, substandard animal husbandry practices, natural mutation of organisms, and inadequate public health systems. Combine these factors with improved laboratory detection methods and the ease of international travel and trade, and what may have been a localized epidemic can become a serious pandemic in a very short time.1The Ebola Epidemic and Occupational IllnessA “perfect storm” scenario played out in the 2014 Ebola virus disease (EVD) outbreak. The outbreak was the largest in history and marked the first time that EVD cases have come to the United States. Hospitals and government agencies responded by rushing to produce and refine guidance materials on operational safety strategies for all aspects of care, including but not limited to the following: obtaining, handling, and transporting specimens; donning, doffing, and disposing of personal protective equipment (PPE); and managing infectious patients and waste. Numerous educational and instructional resources were made available by these agencies and organizations via the Internet and teleconferences in the form of videos, webinars, slide presentations, handouts, and posters.2–5The first laboratory case of EVD in the United States was confirmed on September 30, 2014, in Dallas, Texas. While caring for this patient, 2 registered nurses subsequently acquired EVD. These 2 cases generated great concern among health care workers (HCWs) when it was becoming known that EVD could be potentially transmitted by improper removal of contaminated PPE, inadvertent contact with contaminated gloves, or mucous membrane exposure to infectious droplets. Concerns further escalated when a nurse who became infected with EVD in Spain recalled that she had touched her face with her gloves as she removed her protective suit after leaving the isolation room where the patient with EVD was being treated. This event highlighted the critical importance of selecting proper PPE, thoroughly training staff on its use, and utilizing a trained observer or monitor to assist in PPE donning and doffing.6Medical Simulation TrainingBrigham and Women’s Hospital (BWH) in Boston, Massachusetts, is a Level 1 trauma center and teaching affiliate of Harvard Medical School. In the fall of 2014, while the Ebola epidemic was raging in Africa, BWH assembled a multidisciplinary team led by the Department of Environmental Affairs, the Center for Nursing Excellence, and the Infection Control Department to address the challenge of training staff to care for patients infected with EVD. They recognized the difficulties inherent in caring for patients while wearing high-level PPE, as well as the detailed care required to safely remove and handle the used PPE. The result was a novel “hands-on” training program at BWH’s Neil and Elise Wallace STRATUS Center for Medical Simulation (henceforth, STRATUS), where the program was developed for HCWs who might be tasked with caring for a patient infected with EVD.STRATUS houses 1 fully equipped operating room, 2 full-scale patient simulation suites with a dedicated control room to emulate the actual environment, a video recording and observation area, procedure rooms, several life-sized computer-programmed mannequins, and a classroom area. This facility is typically used for training physicians, including residents and fellows, nurses, and other clinicians in the techniques utilized in anesthesiology, surgery, obstetrics, critical care, and emergency medicine. Much of this advanced technology was used for simulating care when managing a patient with EVD.Personal Protective EquipmentMost facilities identified by the Centers for Disease Control and Prevention as “Ebola treatment centers,” as well as some “Ebola assessment hospitals,” have chosen to protect their HCWs by requiring use of protective suits, double gloves, boots or shoe covers, and powered air-purifying respirators to care for patients with EVD.3,7 Working in this high-level PPE is cumbersome and presents a number of challenges, such as heat, stress, difficulty conducting tasks that require manual dexterity, coordination of clinical manipulations with other clinicians, working in a restricted space, and clear communication. To address these issues, STRATUS created a training area with a realistic environment and a specially prepared training team. According to Dr. Charles Pozner, medical director for STRATUS, “It is important to create realistic conditions and work in that environment, find the problems, then deconstruct the process, make corrections, and improve.”8 In the simulation center, staff were able to practice both standard and emergency medical procedures on the mannequins, such as starting intravenous cannulae, taking vital signs, inserting Foley catheters, drawing blood samples, opening an airway, and resuscitating a patient—all while wearing the full PPE. Staff also practiced cleanup of biological material spills and handling of medical waste.The simulations allowed BWH to assess stress and fatigue of HCWs in this realistic environment and to further evaluate how long staff could work effectively while wearing the PPE. Based on observations of the training simulations and input from clinical staff, 4-hour shifts appeared to be the optimal limit for maintaining effective care.According to staff who completed the simulation training, communication with the patient and other staff was a significant challenge, as well as coordinating movements within a small area. After using traditional powered air-purifying respirators with large hoods and belt-mounted fans for most of the training, lighter-weight quieter units were identified that improved the situation markedly. The input of senior microbiologists from the BWH clinical laboratories with long-term experience in working with highly virulent organisms was critical in the selection of these improved powered air-purifying respirators, as well as other PPE products.In addition to the clinical tasks, emergency scenarios were practiced, such as a breach in containment and a rupture in PPE. Staff also learned how to remove protective suits, respirators, shoe covers, and gloves without inadvertently contaminating themselves. “It’s complicated,” says Patrick Macdonald, laboratory safety manager of the BWH Department of Environmental Affairs, who conducted many of the training sessions. “Just the proper way of holding a zipper and rolling off the suit and gloves correctly were challenging to develop and implement. With repeated practice, staff became highly proficient in these detailed techniques.” (Personal communication with authors)TeamworkTeams of up to 4 were trained by faculty members at STRATUS. Training in this setting helped staff feel confident that their clinical care team could work as a cohesive unit. Dr. Pozner explained that training as an interdisciplinary team was imperative (Personal communication with authors): In this case, it was critical to mix doctors, nurses, and respiratory therapists together to create a realistic team situation in a setting where staff must do things that are not part of their normal activities. For example, a small number of staff will be working in protective suits, and it will not be possible to call in other specialized staff for help in performing tasks such as linen changes, cleaning a patient, turning a patient, monitoring a patient, or cleaning up a body fluid spill, as would be done under normal conditions. The objective of training as a team was to create a “shared mental model” where individuals learn in a different role and practice doing unfamiliar tasks.Training ComponentsThis particular program involved training >300 people. The training sessions were 4 hours long and divided into multiple sections. Each team was assigned to a faculty member and was first shown proper procedures for donning and doffing of PPE. The team then practiced these procedures while being observed and coached by instructors. The trainees then circulated in their PPE to work at 3 skill stations using mannequins: Station 1: Clinical skillsSubstation 1: Airway managementSubstation 2: Dressing care and intravenous infusion managementSubstation 3: Foley catheter insertion and careStation 2: Cleaning a biological spill and treating and removing waste from the roomStation 3: Human patient simulation, Ebola scenario—general care provision with a mannequin (eg, moving the patient, taking vital signs)Dr. Pozner emphasized, “We didn’t just concentrate on technical proficiency but on other skills which prove to be critical to successful patient management, including leadership, decision making, and situational awareness. These skills underpin the technical skills.” (Personal communication with authors)An additional training program, entitled “EVD Monitor Training,” prepared other staff members to function as “monitors.” The monitor is often a clinician who does not provide direct care to the patient but rather guides the staff while they don and doff PPE, ensures adherence to checklists, looks for defects or breaches in equipment or PPE during procedures, anticipates risks (eg, watching for signs of heat stress or fatigue), and ensures that communications are received and acknowledged (“closed loop”). Selected staff who had taken the basic 4-hour course went through this training. The role of the monitor cannot be underestimated. This individual plays a critical role in ensuring the safety and efficacy of the HCWs in the patient room and in the overall success of the operation.According to Patrick Macdonald, “The STRATUS training was well received by staff, who said that after the training they felt much more comfortable donning and removing PPE and were more confident in their ability to perform the clinical tasks, while sometimes dressed in multiple layers of PPE.” (Personal communication with authors). Pre- and post-training surveys clearly showed this improvement in their self-assurance.Future ApplicationsThe value of medical simulation was demonstrated in the case of training HCWs for management of patients with EVD. It can clearly play a role in preparing for future epidemics of highly infectious diseases that will require comparable levels of PPE. Since other diseases may have different modes of transmission, the specific PPE requirements for each disease will have to be reassessed on the basis of the mode of transmission and virulence of the infecting organism.Understandably, not all hospitals have access to such high-technology facilities for training. BWH was fortunate to have STRATUS available. However, a highly sophisticated medical simulation center is not a requirement for each health care institution. An alternative strategy includes utilizing regional medical simulation centers where selected staff may be sent for in-depth training and who would return to their facilities to share that knowledge and experience. Utilization of regional centers would require standardization in procedures among facilities in each region. STRATUS and other medical simulation centers in the United States currently train staff from other health care facilities, both national and international. Another possibility is to use mobile units. The University of Nebraska Medical Center has a mobile simulation unit that provides education and training throughout the state.9 Alternatively, a hospital could create its own simulation area for training. The core elements include a dedicated space, appropriate equipment (eg, mannequins, medical supplies, PPE), and qualified staff to conduct training.According to Dr. Pozner, BWH will soon be publishing the curriculum “Ebola Virus Disease Targeted Inter-professional Training for Safe Patient Management,” which will include an instructors’ guide, a PowerPoint presentation, checklists, resources, a debriefing form, and facilitator information. Detailed programs have also been published by Emory University and the University of Nebraska Medical Center to supplement hospital training programs.4,5 These resources can be used as references or adapted to meet site-specific requirements by other medical facilities.AcknowledgmentsCharles Pozner, MD, medical director of the Neil and Elise Wallace STRATUS Center for Medical Simulation in the Department of Emergency Medicine at Brigham and Women’s Hospital, Boston, Massachusetts. Patrick Macdonald, laboratory safety manager, Department of Environmental Affairs, Brigham and Women’s Hospital, Boston, Massachusetts.Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this special feature article.FundingThe author(s) received no financial support for the research, authorship, and/or publication of this special feature article.