How to Contain the Ebola Virus in the Hospital: Lessons From Nebraska

Nebraska Biocontainment Unit Provides Illustrated Instructions

Laura A. Stokowski, RN, MS

Disclosures

October 17, 2014

In This Article

Biocontainment Units for Patients With Ebola

The United States is fortunate in having four specialized units capable of safely providing care for patients with contagious or deadly infectious diseases. These units are located at Emory University Hospital in Atlanta, Georgia; the National Institutes of Health (NIH) in Bethesda, Maryland; St. Patrick's Hospital in Missoula, Montana; and the Biocontainment Patient Care Unit at Nebraska Medical Center in Omaha, Nebraska.

Although their approaches differ slightly, both Emory University and Nebraska Medical Center have cared for patients with Ebola during the current outbreak, and so far, no staff member from either facility has acquired Ebola virus from a patient. Dallas nurses Nina Pham and Amber Vinson, who have tested positive for Ebola, are now receiving care at NIH and Emory, respectively. Although the average hospital can't duplicate the facilities, resources, and highly specialized care possible in these biocontainment units, some of their standard operating procedures and rigorous training models could be useful lessons to those working to establish Ebola preparedness plans.

The Nebraska Biocontainment Unit

The Biocontainment Unit at Nebraska Medical Center was designed as a facility for the treatment of patients affected by bioterrorism or such highly contagious and dangerous infectious diseases as Ebola, SARS, or monkeypox. Although the unit has five rooms with two beds each, Lead Nurse Kate Boulter, RN, reports that owing to the amount of autoclaving required when caring for a patient with a viral hemorrhagic disease, they can only care for two to three such patients at a time.

The facility in Nebraska has a unique arrangement. There is a separate "clean" room for clean equipment and supplies, a "dirty" staging room for collecting waste, a room with a pass-through autoclave, and an on-site satellite lab for running basic lab studies. Inside the patient room is a staff computer with Vidyo (a HIPAA-approved continuous Skype videoconferencing connection between the staff in the room and the staff outside the room), and another computer with Vidyo that allows the patient to communicate with his or her family members (who are barred from visiting in the Biocontainment Unit).

These resources are enviable, but what is really special about the Biocontainment Unit is its staff. Boulter believes in leading by example. "I never ask the nurses to do anything that I wouldn't do myself," says Boulter, who proves this by personally transporting patients with Ebola from the airport to the hospital, and by suiting up and assisting with admitting patients to the unit. The unit's 21 staff nurses (who are all based elsewhere in the hospital) choose to be part of the Biocontainment team and participate in routine education and training, including regular simulation drills on the unit. The nurses themselves developed the protocols that are followed in the Biocontainment Unit, revising and tweaking them to maximize safety.

The Biocontainment Unit also has respiratory therapists and patient care technicians. A typical day shift requires six staff members, including at least three nurses. Staff members fulfill different roles, all while suited up in full PPE. There is an autoclaver whose job is to autoclave all trash and laundry, a "doffer" who is always stationed outside the patient care area to assist staff (patient care providers and laboratory technicians) in doffing PPE, and a bedside nurse who remains in the room with the patient. Typically, nurses spend no more than four hours at a stretch in the patient's room, during which time they do not eat, drink, or use the restroom. If there is an emergency such as a code, other staff in full PPE will enter to assist, but as much as possible, actions are directed by the physician using the Vidyo conferencing system.

Whenever staff members in the patient's room make contact with the patient or items that the patient has used, they remove their outer gloves, wipe the middle-layer gloves with a bleach wipe, and then replace the outer gloves. "A lot of glove-changing goes on in that room," says Boulter. The doffer and the autoclaver perform the same process every time they touch a "dirty" item.

The attention to detail that prevents cross-contamination also extends to environmental cleanliness. Because environmental services personnel are not permitted in the biocontainment unit, the staff also cleans the unit and the patient rooms every night, using a checklist. Every surface is wiped with bleach and there are separate mop buckets for each area (nurse's station, hallway, patient room). New mop heads are used each night.

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