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 - 2015
Disclosures None Material was presented in October, 2014 at
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
EBOLA and Western Africa
They are just an airplane away
In 1918
In 1918 It took 4 months for globalization of influenza
In 2009
In 2009 It took 4 days!!
Pandemic Flu
Pandemic Flu
H5N1
H1N1
H7N9
H3N2
MERS-CoV
H10N8
Mexico City May, 2009 Courtesy of Dr. Guillermo Dominguez
Courtesy of Dr. Guillermo Dominguez
Lack of Integrated Approach Miss any piece and the entire hospital medical response system fails DETECT TREAT PROTECT
How are we going to know?
How are we going to know?
WFSICCM s World
Obsolete Recommendations
Donning (1) CDC, DHHS. Sequence for Donning PPE for SARS, 2004 - Accessed Oct 2014: http:// www.cdc.gov
Donning (2) CDC, DHHS. Sequence for Donning PPE for SARS, 2004 - Accessed Oct 2014: http:// www.cdc.gov
Removal (1) CDC, DHHS. Sequence for Donning PPE for SARS, 2004 - Accessed Oct 2014: http:// www.cdc.gov
Removal (2) CDC, DHHS. Sequence for Donning PPE for SARS, 2004 - Accessed Oct 2014: http:// www.cdc.gov
Removal (3)
Areas of high risk for contamination Removal (3)
Removal (4) CDC, DHHS. Sequence for Donning PPE for SARS, 2004 - Accessed Oct 2014: http:// www.cdc.gov
Removal (4) CDC, DHHS. Sequence for Donning PPE for SARS, 2004 - Accessed Oct 2014: http:// www.cdc.gov
Removal (5)
Removal (5)
Removal (6)
Removal (7)
Areas of high risk for contamination Removal (7)
Removal (8) CDC, DHHS. Sequence for Donning PPE for SARS, 2004 - Accessed Oct 2014: http:// www.cdc.gov
Removal (8) CDC, DHHS. Sequence for Donning PPE for SARS, 2004 - Accessed Oct 2014: http:// www.cdc.gov
What SARS taught us
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
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
MMWR 52; 241-248.
MMWR 52; 241-248. HCW
HCW + Contacts MMWR 52; 241-248.
Guangjou, China, 2007
Two Major Directives
Two Major Directives Force Protection
Two Major Directives Force Protection Facility Protection
Toronto, Canada, 2003 SARS
SARS Toronto, 2003 251 Cases 44 Deaths 95 HCW 37% 49 HCW contacts 19% HCW TOTAL 56%!!!! Infection Control Education Institute, 2004
SARS Toronto, 2003 251 Cases 44 Deaths 95 HCW 37% 49 HCW contacts 19% HCW TOTAL 56%!!!! Infection Control Education Institute, 2004
Reports of HCW s Contamination While Wearing PPE 1. MMWR May 16, 2003;52(19);433-436 2. Health Canada: Cluster of severe acute respiratory syndrome cases among protected health care workers Toronto, April 2003. Can Commun Dis Rep 2003;29:93-7 3. Christian MD, Loutfy M, McDonald LC, et al.: Possible SARS coronavirus transmission during cardiopulmonary resuscitation. Emerg Infect Dis 2004;10:287-93.
Contamination from Removing Personal Protective Equipment
Zamora J, et al: Contamination: a comparison of 2 personal protective systems CMAJ 2006;175(3):249-54
E RCP vs. PAPR n= Zamora J, et al: CMAJ 2006;175(3):249-54
E RCP vs. PAPR n= 23 Zamora J, et al: CMAJ 2006;175(3):249-54
E RCP vs. PAPR n= 27 Zamora J, et al: CMAJ 2006;175(3):249-54
E RCP vs. PAPR Contamination 4% (2) > Facial p<0.001 0% (0) Zamora J, et al: CMAJ 2006;175(3):249-54
E RCP vs. PAPR Contamination 96% (48) > Neck - ant p<0.001 6% (3) Zamora J, et al: CMAJ 2006;175(3):249-54
E RCP vs. PAPR Contamination 18% (9) > Neck - post p<0.001 2% (1) Zamora J, et al: CMAJ 2006;175(3):249-54
E RCP vs. PAPR Contamination 76% (38) > Upper extr. p<0.001 18% (9) Zamora J, et al: CMAJ 2006;175(3):249-54
E RCP vs. PAPR Donning 4% (2) < Errors P=0.003 30% (15) Zamora J, et al: CMAJ 2006;175(3):249-54
E RCP vs. PAPR Removal 24% (12) > Errors ns 12% (6) Zamora J, et al: CMAJ 2006;175(3):249-54
Contamination E-RCP Zamora J, et al: CMAJ 2006;175(3):249-54
E RCP vs. PAPR Time < 1 58 6 17 Donning p<0.0001 Zamora J, et al: CMAJ 2006;175(3):249-54
E RCP vs. PAPR Time < 2 15 7 32 Removal p<0.0001 Zamora J, et al: CMAJ 2006;175(3):249-54
Conclusions (1) With aerosol risks: Ordinary gown, gloves and mask were inadequate barriers Editors CMAJ 2006;175(3):254
Conclusions (2) With aerosol risks: Breaches in technique can result in selfcontamination even with a highly protective system. Editors CMAJ 2006;175(3):254
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
Casanova L, et al.: Virus transfer from personal protective equipment to healthcare employees' skin and clothing. Emerg Infect Dis 2008;14:1291 1293
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
Un-Natural Transmission In the ED and ICU we aerosolize with our interventions what would have been droplets
Safer techniques to deliver oxygen?
Safer techniques to deliver oxygen? May increase spread of virus through high-flow delivery of oxygen using conventional masks
Ventilators Should contain HEPA filters in exhalation circuit Batteries Compressor Basic modes Can give PEEP 20 minimum
Are we going to have enough ventilators?
ICU Triage
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
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
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
WHO May, 2006
WHO May, 2006
Tricks of The Trade
Avoid shoes made of absorbent material
Longitudinal taping of gloves
Gloves removed with gown
Clean side
PAPR PPE (Powered Air Purifier Respirator) HIGH RISK FOR AEROSOLIZATION
Supplies 105
PAPR Cart
Old beltporous New belt Nonabsorbent plastic
Face mask NOT RECOMMENDED
RECOMMENDED NO neck protection
HEPA Filter
Incident Command System and Hospital Incident Command System HICS
Responsibilities of Command Incident command is organized around 5 major activity areas. Command OPERATIONS PLANNING LOGISTICS FINANCE
Protocols
CDC
CDC
PPE Staff Observer Coach Treatment
Centers Frontline - 3 Hours Assessment - 3 Days Treatment - 3 Weeks
Checklist and buddy
Air pump and filter unit
Peeling visor protector
Peeling visor protector
Peeling visor protector
Chin first, head second keep N-95 in place!
Chin first!
Second layer gown and gloves
Longitudinal taping
Ready to go into high risk for aerosolization
Inside buddy getting ready
Final checklist
Removal in ante-room
REVERSE ORDER Head first, chin second keep N-95 in place!
Dispose of hood and hose
Resources
www.cdc.gov
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. 2014 Oct;146(4 Suppl):35S-41S
IF YOU DON T OPEN I LL SNEEZE AND SNEEZE UNTIL I GIVE IT TO YOU!
Thank you!