Expecting the Unexpected: Preparing the ICU for Biothreats. Edgar Jimenez, MD, FCCM
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1 Expecting the Unexpected: Preparing the ICU for Biothreats Edgar Jimenez, MD, FCCM Past-President World Federation of Societies of Intensive and Critical Care Medicine Professor of Medicine and Critical Care Baylor Scott & White and Texas A&M COM VP, Critical Care Baylor Scott & White 12 th World Congress WFSICCM Seoul, Korea
2 Disclosures None Material was presented in October, 2014 at
3 Objectives Why do we do this? Obsolete recommendations from CDC What SARS taught us in 2003 Evidence of contamination Tricks of the trade in Dallas with Ebola
4 EBOLA and Western Africa
5 They are just an airplane away
6 In 1918
7 In 1918 It took 4 months for globalization of influenza
8 In 2009
9 In 2009 It took 4 days!!
10 Pandemic Flu
11 Pandemic Flu
12 H5N1
13 H1N1
14 H7N9
15 H3N2
16 MERS-CoV
17 H10N8
18 Mexico City May, 2009 Courtesy of Dr. Guillermo Dominguez
19 Courtesy of Dr. Guillermo Dominguez
20 Lack of Integrated Approach Miss any piece and the entire hospital medical response system fails DETECT TREAT PROTECT
21 How are we going to know?
22 How are we going to know?
23 WFSICCM s World
24
25
26
27
28 Obsolete Recommendations
29 Donning (1) CDC, DHHS. Sequence for Donning PPE for SARS, Accessed Oct 2014:
30 Donning (2) CDC, DHHS. Sequence for Donning PPE for SARS, Accessed Oct 2014:
31 Removal (1) CDC, DHHS. Sequence for Donning PPE for SARS, Accessed Oct 2014:
32 Removal (2) CDC, DHHS. Sequence for Donning PPE for SARS, Accessed Oct 2014:
33 Removal (3)
34 Areas of high risk for contamination Removal (3)
35 Removal (4) CDC, DHHS. Sequence for Donning PPE for SARS, Accessed Oct 2014:
36 Removal (4) CDC, DHHS. Sequence for Donning PPE for SARS, Accessed Oct 2014:
37 Removal (5)
38 Removal (5)
39 Removal (6)
40 Removal (7)
41 Areas of high risk for contamination Removal (7)
42 Removal (8) CDC, DHHS. Sequence for Donning PPE for SARS, Accessed Oct 2014:
43 Removal (8) CDC, DHHS. Sequence for Donning PPE for SARS, Accessed Oct 2014:
44 What SARS taught us
45 A SARS isolation case study 1. Open bay 2. Wrong masks by providers 3. No gloves (right provider holding bed rail) 4. No gowns (white coats go room to room) 5. No eye protection (right provider has blood on face mask) 6. Chart goes back to a central area for others to handle A SARS patient receives treatment at a hospital in Guangzhou, China, in April 2003
46 Fear: Real time evolution of PPE Bronchoscope present, but also 1. PAPR + N-95 masks 2. Face shield + goggles 3. Double gowned 4. Double gloved An ICU patient in Toronto during the 2 nd wave of the SARS outbreak of 2003
47 MMWR 52;
48 MMWR 52; HCW
49 HCW + Contacts MMWR 52;
50 Guangjou, China, 2007
51
52
53
54
55 Two Major Directives
56 Two Major Directives Force Protection
57 Two Major Directives Force Protection Facility Protection
58 Toronto, Canada, 2003 SARS
59 SARS Toronto, Cases 44 Deaths 95 HCW 37% 49 HCW contacts 19% HCW TOTAL 56%!!!! Infection Control Education Institute, 2004
60 SARS Toronto, Cases 44 Deaths 95 HCW 37% 49 HCW contacts 19% HCW TOTAL 56%!!!! Infection Control Education Institute, 2004
61 Reports of HCW s Contamination While Wearing PPE 1. MMWR May 16, 2003;52(19); Health Canada: Cluster of severe acute respiratory syndrome cases among protected health care workers Toronto, April Can Commun Dis Rep 2003;29: Christian MD, Loutfy M, McDonald LC, et al.: Possible SARS coronavirus transmission during cardiopulmonary resuscitation. Emerg Infect Dis 2004;10:
62 Contamination from Removing Personal Protective Equipment
63 Zamora J, et al: Contamination: a comparison of 2 personal protective systems CMAJ 2006;175(3):249-54
64 E RCP vs. PAPR n= Zamora J, et al: CMAJ 2006;175(3):249-54
65 E RCP vs. PAPR n= 23 Zamora J, et al: CMAJ 2006;175(3):249-54
66 E RCP vs. PAPR n= 27 Zamora J, et al: CMAJ 2006;175(3):249-54
67 E RCP vs. PAPR Contamination 4% (2) > Facial p< % (0) Zamora J, et al: CMAJ 2006;175(3):249-54
68 E RCP vs. PAPR Contamination 96% (48) > Neck - ant p< % (3) Zamora J, et al: CMAJ 2006;175(3):249-54
69 E RCP vs. PAPR Contamination 18% (9) > Neck - post p< % (1) Zamora J, et al: CMAJ 2006;175(3):249-54
70 E RCP vs. PAPR Contamination 76% (38) > Upper extr. p< % (9) Zamora J, et al: CMAJ 2006;175(3):249-54
71 E RCP vs. PAPR Donning 4% (2) < Errors P= % (15) Zamora J, et al: CMAJ 2006;175(3):249-54
72 E RCP vs. PAPR Removal 24% (12) > Errors ns 12% (6) Zamora J, et al: CMAJ 2006;175(3):249-54
73 Contamination E-RCP Zamora J, et al: CMAJ 2006;175(3):249-54
74 E RCP vs. PAPR Time < Donning p< Zamora J, et al: CMAJ 2006;175(3):249-54
75 E RCP vs. PAPR Time < Removal p< Zamora J, et al: CMAJ 2006;175(3):249-54
76 Conclusions (1) With aerosol risks: Ordinary gown, gloves and mask were inadequate barriers Editors CMAJ 2006;175(3):254
77 Conclusions (2) With aerosol risks: Breaches in technique can result in selfcontamination even with a highly protective system. Editors CMAJ 2006;175(3):254
78 Conclusions (3) With aerosol risks: Right kind of protective outfit and the correct technique for its use and removal will be critical to prevent disease transmission. Editors CMAJ 2006;175(3):254
79 Casanova L, et al.: Virus transfer from personal protective equipment to healthcare employees' skin and clothing. Emerg Infect Dis 2008;14:
80 Casanova L, et al.: Following the CDC protocol often resulted in virus transfer to hands and clothing. An altered protocol or other measures are needed to prevent healthcare worker contamination
81 Un-Natural Transmission In the ED and ICU we aerosolize with our interventions what would have been droplets
82 Safer techniques to deliver oxygen?
83 Safer techniques to deliver oxygen? May increase spread of virus through high-flow delivery of oxygen using conventional masks
84 Ventilators Should contain HEPA filters in exhalation circuit Batteries Compressor Basic modes Can give PEEP 20 minimum
85 Are we going to have enough ventilators?
86 ICU Triage
87
88 Critical Care Triage Tool (Initial Assessment) Color Criteria Priority/Action Exclusion Criteria Medical Mgmt Blue or +/- Palliate SOFA > 11 d/c from CC SOFA 7 Red or Highest Single organ failure Initial Yellow SOFA 8-11 Intermediate Green No significant organ failure Defer or d/c Reassess as needed Ontario Health Plan for an Influenza Pandemic (OHPIP) Working Group on Adult Critical Care Admission and Discharge Criteriia, April 2006
89 Critical Care Triage Tool (48 Hour Assessment) Color Criteria Priority/Action Exclusion Criteria or Blue SOFA > 11 Palliate and or d/c from CC SOFA 8-11 no SOFA < 11 Red and Highest decreasing 48 hrs Yellow SOFA < 8 no Intermediate Green No longer ventilator dependant d/c from CC Ontario Health Plan for an Influenza Pandemic (OHPIP) Working Group on Adult Critical Care Admission and Discharge Criteriia, April 2006
90 Critical Care Triage Tool (120 Hour Assessment) Color Criteria Priority/Action Exclusion Criteria or Blue SOFA > 11 Palliate and or d/c from CC SOFA < 8 no SOFA < 11 Red and Highest Decreasing progressively SOFA < 8 minimal decrease Yellow Intermediate (< 3 points in past 72 h) 120 hs Green No longer ventilator dependant Egreso de UCI Ontario Health Plan for an Influenza Pandemic (OHPIP) Working Group on Adult Critical Care Admission and Discharge Criteriia, April 2006
91 WHO May, 2006
92 WHO May, 2006
93 Tricks of The Trade
94
95 Avoid shoes made of absorbent material
96 Longitudinal taping of gloves
97
98
99
100
101 Gloves removed with gown
102 Clean side
103
104 PAPR PPE (Powered Air Purifier Respirator) HIGH RISK FOR AEROSOLIZATION
105 Supplies 105
106 PAPR Cart
107 Old beltporous New belt Nonabsorbent plastic
108 Face mask NOT RECOMMENDED
109 RECOMMENDED NO neck protection
110 HEPA Filter
111
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130 Incident Command System and Hospital Incident Command System HICS
131 Responsibilities of Command Incident command is organized around 5 major activity areas. Command OPERATIONS PLANNING LOGISTICS FINANCE
132 Protocols
133 CDC
134 CDC
135 PPE Staff Observer Coach Treatment
136 Centers Frontline - 3 Hours Assessment - 3 Days Treatment - 3 Weeks
137
138
139
140
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142 Checklist and buddy
143
144 Air pump and filter unit
145
146 Peeling visor protector
147 Peeling visor protector
148 Peeling visor protector
149
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152 Chin first, head second keep N-95 in place!
153 Chin first!
154
155 Second layer gown and gloves
156
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161 Longitudinal taping
162
163 Ready to go into high risk for aerosolization
164 Inside buddy getting ready
165
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168 Final checklist
169
170
171 Removal in ante-room
172 REVERSE ORDER Head first, chin second keep N-95 in place!
173 Dispose of hood and hose
174
175 Resources
176
177 Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement Ornelas J, et al. Task Force for Mass Critical Care Chest Oct;146(4 Suppl):35S-41S
178 IF YOU DON T OPEN I LL SNEEZE AND SNEEZE UNTIL I GIVE IT TO YOU!
179 Thank you!
180
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