As the worlds most deadly Ebola virus outbreak continues to spread throughout Western Africa, EDs in many U.S. hospitals are on heightened alert for any patients who report travel histories and symptoms that indicate they may be at risk of carrying the disease.
If a patient has traveled to Guinea, Sierra Leone, Liberia or Nigeria and also has symptoms such as a fever, headache, joint and muscle aches, diarrhea or vomiting, then we are recommending that the triage nurses move forward with isolating the patient immediately and putting on protective barriers, Donna Armellino, RN, DNP, CIC, vice president of infection prevention at North Shore-LIJ Health System in New York, said.
Hospital organizations such as North Shore-LIJ are stressing the importance of early assessment in part because the current Ebola virus situation in West Africa is surpassing previous outbreaks of the disease. Not only is it the most deadly outbreak, but it also is spreading rapidly to a wider geographic area than in the past, which makes containment more difficult, according to an article published by the Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston. During the first week of August, two infected American aid workers were flown to Emory University Hospital in Atlanta, where they are being treated in special isolation units.
At North Shore-LIJ hospitals, if a patient is moved to isolation the ED staff contacts the hospitals infection control department, an infectious disease specialist and the local and state health departments, which perform a case review with the clinical staff to determine if the patient meets the criteria for Ebola virus infection, Armellino said.
When a patient is put into isolation, we have personal protective equipment available for anyone who enters the room, she said. We have made sure that we have gowns, gloves, masks and face shields available in the triage area. For patients with more severe symptoms such as bleeding inside and outside of the body, we have protective jumpsuits for caregivers.
According to the Centers for Disease Control and Prevention, the incubation period before the onset of symptoms for Ebola is two to 21 days, though eight to 10 days is the most common. The virus is passed from human to human through contact with blood or bodily fluids, such as urine, feces, sweat or saliva.
The medical staff at Carolinas Medical Center in Charlotte, N.C., implemented isolation procedures at the end of July when a patient was admitted to the ED. The patient had traveled to West Africa and demonstrated symptoms including a fever.
Infection prevention and the hospital epidemiologist were paged to evaluate the patient, Maureen Titus-Hinson, RN, MHA, CIC, assistant vice president of infection prevention at the Carolinas HealthCare System, said. We had a team of healthcare workers assembled and ready to [begin isolation and treatment if that had been deemed necessary].
Later the same day doctors and public health officials ruled out the risk of Ebola, and the patient tested positive for malaria, according to news reports.
We have to take into consideration that we have an international airport in our city, so that is always something in the back of our minds, but we have a plan in place to deal with infectious diseases, and that reduces the level of worry, Titus-Hinson said.
Patients with malaria and Ebola virus can present with similar symptoms in the early stages, and for this reason false alarms are bound to happen during the current outbreak, Audrey Adams, RN, MPH, CIC, director of infection prevention and control at Montefiore Medical Center in the Bronx, N.Y., said.
At Childrens Hospital at Montefiore in early August, Adams was speaking to a group of ED staff about the Ebola virus when a nurse asked about a newly admitted patient from Gambia. The patient had a fever and general malaise, so we decided to put the patient in isolation until a viral workup could be done, Adams said. We have to be cautious because the risk of disease associated with travel is real, especially in New York City, where we see so many people from all over the world.
The testing revealed that the patient did not have the Ebola virus. Later the same week, the hospital admitted a pediatric patient who had returned from Nigeria, and the patient was placed in isolation until further testing could be completed. With the heightened level of caution, Adams predicts this scenario may become more common until the Ebola virus situation in Africa is under control.
The good news
Although modern globalization can increase the opportunities for viruses to cross continents, advancements in healthcare are making it easier to contain these diseases when they enter the U.S., according to nurses who work in infection control.
Now we have better communication structures in place to share information more quickly within the hospital and with the [states] Department of Health, Armellino said. At North Shore-LIJ Health System, there is a lead emergency physician Armellino can call if there is a new alert that needs to be shared with 17 EDs within the system. In the past, she would have contacted an emergency physician at each of the hospitals to share the same information.
This improved communication among the hospitals also increases the chances of identifying trends in symptoms among patients, which can be critical when trying to isolate infectious diseases, she said.
During the H1N1 outbreak [in 2009], the staff at one of our facilities started noticing several younger patients who were suffering from more acute respiratory symptoms, and we would normally expect to see that in the older population, Armellino said. We started to see a trend in their travel histories and recognized that it was H1N1. If we had not had good communication processes in place between the nurses, doctors, hospital infection control and the states Department of Health, we would not have recognized this trend.
Although the Ebola virus is difficult to contain in Africa, nurses such as Armellino are confident that it will not be transmitted to caregivers in the U.S. if they use standard precautions and wear protective barriers to minimize contamination from blood or body fluid. Cultural practices are one of the reasons the disease can spread in countries within Africa. Mourners who have direct contact with the body of a victim can contract the disease. Humans also can contract the Ebola virus by handling infected chimpanzees, gorillas, fruit bats, monkeys, forest antelope or porcupines.
Although the mortality rate for the disease can be as high as 90%, data from the CDC suggests that the overall rate for this outbreak is about 55%, though it varies by country. The death rate in Guinea is the highest at about 74%. Death typically occurs about nine to 10 days after the onset of symptoms, but for patients who survive to two weeks, the chances of survival increase, to Barbara Knust, DVM, MPH of the CDC, said during a CDC conference call Aug. 5.
This is something that we know exists throughout the world, and although there is a lot of concern, it is not a new disease, Adams said. We are very fortunate in that we understand the transmission of this disease and have the proper equipment in this country to prevent transmission.