Repeated training, more protective gear: Inside the new Ebola guidelines

Some hospitals are preparing to become 'Ebola centers,' CDC says

CDC on Monday evening issued new guidelines for health care providers caring for patients with Ebola that Director Tom Frieden says represent a "consensus" by workers who have already treated Ebola patients in the United States.

Why were new guidelines needed?

The new guidelines come a little over one week after two Texas Health Presbyterian Hospital nurses treating the first U.S. Ebola patient contracted the disease, heightening concerns about the U.S. health system's ability to contain its spread.

Why health care workers are so susceptible

While the direct cause of the nurses' exposure is still unknown, Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases, in a statement last week said "an inadvertent, innocent breach of the protocol of taking care of a patient within the personal protective equipment" was to blame. He says CDC is working to identify the breach in question.

However, some health care workers—including some colleagues of the infected nurses—say that the case doesn't highlight a protocol breach so much as a lack of adequate training for hospital workers. Infection control experts say hospital workers must be coached through treating Ebola cases.

Moreover, many health care experts took issue with the CDC guidelines for hospitals, saying they were too lax. They said the original guidelines did not outline adequate protective gear for health workers. For example, CDC recommended only a minimum of gloves, a fluid-resistant gown, and eye protection for workers dealing with Ebola patients.

Experts also said the CDC guidelines did not include important steps used by Doctors Without Borders (globally known as Medecins Sans Frontieres, or MSF) and other groups to prevent infections, such as the presence of a "site supervisor" watching for errors.

Sean Kaufman—who oversaw infection control at Emory University Hospital—says that that the original CDC guidelines issued to hospitals were "absolutely irresponsible and dead wrong."

Last week, CDC issued preliminary changes to its guidelines to address the concerns.

Fauci acknowledged that the existing guidelines were intended for field workers who were not doing "very invasive procedures," like those carried out by Texas Health Presbyterian workers.

Similarly, Frieden says the two infections in Texas showed that the existing protocols were not stringent enough. "We may never know exactly [how two health workers became infected], but the bottom line is [the guidelines] didn't work for that hospital," he says. He adds, "Even one health care worker infection is too many."

Who is Tom Frieden? Meet the man behind the U.S. Ebola response

Details of new guidelines

According to Frieden, the new guidelines were created with input from medical personnel who have already treated Ebola patients in the United States. They are based on the strict protocols that MSF has been using for years and were reviewed by that organization.

The new guidelines are voluntary, not mandated by law, according to the New York Times.

Broadly, the guidelines recommend three main changes to previous guidelines:

  • "Repeatedly training" health care workers treating Ebola patients, especially in how to properly dress and undress in protective gear;
  • Personal protective equipment (PPE) that leaves no skin exposed; and
  • A "trained observer" or site manager should watch each employee put on and take off their PPE.

The specific recommendations for PPE include:

  • Wearing two pairs of gloves;
  • Wearing waterproof boot covers that go to at least the middle of a worker's calf;
  • Single-use impermeable or fluid-resistant gowns that go down to at least the middle of the calf and do not include an integrated hood;
  • Using respirators;
  • A full-face, disposable shield;
  • Surgical hoods that provide full coverage of the worker's head and neck; and
  • A waterproof apron that should be used if a patient is vomiting or suffering from diarrhea

In addition, workers will be required to wipe down their PPE with a virucidal wipe before they begin undressing and will be required to shower after they take off their equipment.

Frieden says, "All patients treated at Emory University Hospital, Nebraska Medical Center, and the NIH Clinical Center have followed the three principles [and] [n]one of the workers at these facilities have contracted the illness."

Dedicated Ebola treatment centers?

Meanwhile, Frieden says that the agency is planning to designate hospitals as Ebola centers where patients would be transferred for treatment. Frieden said various facilities have begun preparations to become an Ebola center, but he did not say how many centers would be designated.

Officials have said that any further Ebola cases in Dallas will be transferred to one of the four top-level biocontainment units in the country.

However, there are only seven remaining beds in such units (Peralta, "The Two-Way," NPR, 10/20; Fox, NBC News, 10/20; Yan/Fantz, CNN, 10/20; Johnson, Modern Healthcare, 10/20; McNeil, New York Times, 10/20).

How to make complex guidelines more usable

One of the major challenges of adopting evidence-based practice is coping with the length and complexity of guidelines. 

For example, faced with an effective—but unwieldy—set of sepsis guidelines, some organizations have identified the subset of elements that have greatest direct impact on outcomes, focusing first on adherence to those. Read more.

What you need to know about Ebola

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The Daily Briefing has been tracking the Ebola outbreak since early 2014, and the Advisory Board's experts have created myriad resources for hospitals to help them prepare for the potential cases and reassure their communities about the disease.

Here's an overview of our top coverage and resources.

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