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Potential Ebola Virus Case Intake

Infection Containment Protocol

Wayne Voss

CEO, Methodist West Houston Hospital

 

Re: Potential Ebola Virus Case Intake

Infection Containment Protocol

 

Wayne,

I am writing out of concern over the Ebola virus epidemic currently raging in West Africa. This is such a serious problem that it is unlikely to be controlled for another 3-6 months. The longer the biological process of virus passage continues through human populations, the more the chances that this virus will evolve in its ability to reside in individuals (making them more capable living culture plates for transmission) and to pass more easily between individuals.

As director of the International Medicine Center, I know first-hand of the vigorous human traffic between Houston and the affected West African nations. The leading energy companies in our community refer me numerous cases of returning workers with illness following sojourns in those locales.

I have not seen any bulletins to our physician medical staff or across The Methodist Hospital System. The Centers for Disease Control currently has a Level 3 Travel Alert Status for those countries (Liberia, Guinea, and Sierra Leone), and so we should have a communiqué from infection control professionals on the practical steps clinicians must take in triaging patients to hospitals and what receiving hospital authorities and staff must do to protect themselves and the hospital community from risk of infection. In addition to that obvious issue, all diagnostic support departments, surgical staff, and ancillary services must be schooled in the strict protocols in handling such cases. The rule is to have a defined operational pathway in place prior to a potential case walking through the door. Case-dedicated isolation rooms and in-room equipment, Ebola-specific isolation barriers equipment and supplies, and entering and exit protocols must all be spelled out. It will be too late to have these questions arise as a staff physician diverts such a patient to the hospital Emergency Department. Private offices are not equipped to handle isolation and materials disposal consistent with CDC directives. So, it is inevitable that some U.S. hospitals will face what could be a medical and public relations disaster by lack of preparation. At cdc.gov there are excellent resource materials instructing hospitals in the details of handling such cases inpatient. With a disease with a 50-90% mortality and no specific treatment available, the hospital medical community and the community of patients must know that communicable risk has been minimized.

Our organization already has a protocol for intake of critical information by those who man our phones so that we proactively collect the information that will throw up warning flags on anyone heading our way from any of those countries with an acute infectious or febrile illness. We cannot have them show up in our waiting area or exposing our staff. The process starts below the physician level. We did this very effectively some years ago with the SARS epidemic threat from Asia as well as with pandemic flu. By awareness, top to bottom, in our organization we were able to shunt suspect cases into our facility through the back door, immediately giving them respiratory masks. This avoided exposure of other patients and staff. This type awareness must be cultivated in all hospitals and all healthcare professionals who refer to them, because that is where these cases will land. With an up to 21-day, symptom-free incubation period and an epidemic of this magnitude, it is only matter of time and a plane flight before what seems like a remote problem is at our doorstep.

Some considerations are as follows,

  1. Procedure for outpatient physicians notifying a hospital-based point-person that such a case is incoming; including having the hospital call the patient en route about how they are to enter the hospital
  2. Dedicated isolation room(s) for such cases – possibly negative pressure for aerosols
  3. Immediate standard, contact, and droplet isolation
  4. Fluid impermeable gowns, gloves; N-95 respiratory masks and goggles or faceshields
  5. CDC-compliant waste disposal procedures
  6. Clear, stepwise procedure for handling of such patients by staff and specimens in ER, surgery, lab, imaging
  7. Limited visitation with a traffic log maintained

This is merely a cursory outline; cdc.gov has much more detail.

In closing, this issue deserves immediate attention both at our hospital and at the system level. I have already had one case referred to me by a multi-national oil company anxious about Ebola virus as a possibility, obviously not turning out to be the case.

Please let me know what you think. I would be glad to participate if it would be of value.

 

Sincerely,

Edward R. Rensimer, FACP

Infectious Diseases

Director, International Medicine Center