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Reflections on Interprofessional Team-based Clinical Care in the Ebola Epidemic: The Nebraska Medicine Experience
Abstract
Smoothly functioning interprofessional teams are critical to provision of safe and effective health care and particularly in high-risk situations that contain multiple ambiguities and uncertainties such as the ebola epidemic. This paper describes reflections on the experience of interprofessional team care in the Nebraska Biocontainment Unit, with particular emphases on selected characteristics of teamwork, including training, expertise, creativity, learning, and courage.
... Most students in our study believed that representatives of every profession had the same goal during their voluntary work. The experience of interprofessional collaboration at the time of the Ebola outbreak shows that working toward a common goal in challenging situations fosters partnership and teamwork between different medical professions, as members have a sense their contribution is equally valued [42]. ...
... Additionally, healthcare team members and other students were also the sources of the most support felt by the respondents. Patient care in pandemic conditions facilitates intergroup cooperation, as it requires attention to the patient's welfare while mitigating risk for the healthcare team [42]. It is also worth noting that during the recruitment process, each volunteer had the opportunity to choose his placement to best match his qualifications and preference with the assigned team. ...
Students’ volunteering is an effective way to manage health crises, including pandemics. Due to the limited capacity of the healthcare system at the time of the COVID-19 outbreak, the engagement of students in volunteering services seemed invaluable. Based on different teaching–learning theories, in this survey study, we aimed to evaluate the potential of the volunteering service project launched by the Poznan University of Medical Sciences during the COVID-19 pandemic as a learning opportunity for undergraduate healthcare students. The results indicate the potential of involving students in volunteering activities for educational purposes, as well as other values, including attitudes and professional identity development, which could be difficult to realize using traditional teaching methods. However, stimulating students’ reflectiveness seems necessary to reach its full educational effectiveness. Medical teachers should provide students with more opportunities for volunteering and service learning and consider making these a constant element of the curriculum beyond the COVID-19 pandemic.
... 27 Multidisciplinary teamwork is critical to address the unique problem solving challenges of caring for patients infected with Ebola or other special pathogens, and dedication to maintenance of preparedness allow these teams able to perform at the highest levels of safety and confidence. 28 ...
The 2014 to 2016 Ebola outbreak response resulted in many lessons learned about biocontainment patient care, leading to enhanced domestic capabilities for highly infectious and hazardous communicable diseases. However, additional opportunities for improvement remain. The article identifies and describes key considerations and challenges for laboratory analysis, clinical management, transportation, and personnel management during the care of patients infected with Ebola or other special pathogens. Dedication to maintaining preparedness enables biocontainment patient care teams to perform at the highest levels of safety and confidence.
... coronaviruses, viral hemorrhagic fever viruses, Bacillus anthracis, Yersinia pestis) are frequently cited as requiring advanced resources, protocols, and training to minimize risk of disease transmission and mortality [1][2][3]. The 2014-2016 West Africa Ebola virus disease (EVD) outbreak, for example, challenged the capabilities, capacities, and efficacy of healthcare facilities in caring for patients with a highly infectious pathogen both abroad and in the United States [4][5][6][7][8][9][10][11][12]. In addition to the direct clinical care provided to patients with confirmed and suspected EVD, public health departments and other affiliated sectors including emergency management, clinical and research laboratories, medical waste management, and mortuary services collaborated with medical providers to optimize and support patient care while reducing the risks to environmental and public safety [13][14][15][16][17]. ...
In the United States of America, Medical Examiners and Coroners (ME/Cs) investigate approximately 20% of all deaths. Unexpected deaths, such as those occurring due to a deceased person under investigation for a highly infectious disease, are likely to fall under ME/C jurisdiction, thereby placing the ME/C and other morgue personnel at increased risk of contracting an occupationally acquired infection. This survey of U.S. ME/Cs′ capabilities to address highly infectious decedents aimed to determine opportunities for improvement at ME/C facilities serving a state or metropolitan area. Data for this study was gathered via an electronic survey. Of the 177 electronic surveys that were distributed, the overall response rate was N = 108 (61%), with 99 of those 108 respondents completing all the questions within the survey. At least one ME/C responded from 47 of 50 states, and the District of Columbia. Select results were: less than half of respondents (44%) stated that their office had been involved in handling a suspected or confirmed highly infectious remains case and responses indicated medical examiners. Additionally, ME/C altered their personal protective equipment based on suspected versus confirmed highly infectious remains rather than taking an all-hazards approach. Standard operating procedures or guidelines should be updated to take an all-hazards approach, best-practices on handling highly infectious remains could be integrated into a standardized education, and evidence-based information on appropriate personal protective equipment selection could be incorporated into a widely disseminated learning module for addressing suspected or confirmed highly infectious remains, as those areas were revealed to be currently lacking.
... The 2014-2016 West Africa Ebola virus disease (EVD) outbreak resulted in best practices on patient care and supplemental clinical activities within health care settings to be widely disseminated. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] Highly infectious diseases (HIDs) like EVD tend to have high case fatalities; are easily transmissible from human to human; and require intensive medical, public health, and community control measures. 17 Consequently, the EVD outbreak underscored the lack of consistent guidelines, training, and education for workers outside of traditional hospital settings who might also encounter potential HID scenarios, and subsequently respond to these hazards. ...
Background:
The Ebola virus disease outbreak highlighted the lack of consistent guidelines and training for workers outside of hospital settings. Specifically, emergency medical services (EMS) workers, who are frequently the first professionals to evaluate patients, often do not have advanced notice of patient diagnosis, and have limited time in their national curricula devoted to highly infectious disease (HID) identification and containment. All of these can place them at increased risk. To explore the depth of US EMS practitioners' HID training and education, a pilot gap analysis survey was distributed to determine where the aforementioned can be bolstered to increase occupational safety.
Methods:
Electronic surveys were distributed to EMS organization members. The survey collected respondent willingness to encounter HID scenarios; current policies and procedures; and levels of knowledge, training, and available resources to address HIDs.
Results:
A total of 2,165 surveys were initiated and collected. Eighty percent of frontline personnel were aware that their agency had an HID standard operating guideline. Almost 85% of respondents correctly marked routes of exposure for select HIDs. More than half of respondents indicated no maximum shift times in personal protective equipment.
Discussion:
This research suggests EMS practitioners could benefit from enhanced industry-specific education, training, and planning on HID mitigation and management.
Conclusion:
Strengthening EMS preparedness in response to suspected or confirmed HID cases may not only improve patient outcomes, but also worker and community safety.
... Institutions that have successfully cared for a patient with EVD within the walls of high-level isolation units (HLIUs) have published their methods in an array of areas: teambased care, training, infection prevention measures, environmental decontamination, waste management, CONTACT medical treatment, personal protective equipment (PPE) donning/doffing, cleaning procedures, and staffing models. [1][2][3][4][5][6][7][8][9][10][11][12][13] Furthermore, the Centers for Disease Control and Prevention (CDC) and U.S. Department of Health and Human Services (DHHS) issued interim guidance on how hospitals-ergo health care workers-should assess and address patients presenting with symptoms and exposure history aligning with EVD, or manage the care of a patient confirmed to have EVD. [14] Few national organizations, associations, or societies for non-healthcare worker industries have issued official, standardized guidelines or protocols on how workers in their field should address highly infectious pathogens, nor has a comprehensive survey before been distributed to assess industry-specific capacity or needs. ...
Purpose: A United States industry-specific gap analysis survey of the death care sector—which comprises organizations and businesses affiliated with the funeral industry and the handling of human remains— was developed, the results analyzed, and training and education needs in relation to highly infectious disease mitigation and management were explored in an effort to identify where occupational health and safety can be enhanced in this worker population.
Methods: Collaborating national death care organizations distributed the 47-question electronic survey. N = 424 surveys were initiated and results recorded. The survey collected death care sector-specific information pertaining to the comfortability and willingness to handle highly infectious remains; perceptions of readiness, current policies and procedures in place to address highly infectious diseases; current highly infectious disease training levels, available resources, and personal protective equipment.
Results: One-third of respondents have been trained on how to manage highly infectious remains. There was a discrepancy between Supervisor/Management and Employee/Worker perceptions on employees' willingness and comfortability to manage potentially highly infectious remains. More than 40% of respondents did not know the correct routes of transmission for viral hemorrhagic fevers.
Conclusions: Results suggest death care workers could benefit from increasing up-to-date industry-specific training and education on highly infectious disease risk mitigation and management. Professional death care sector organizations are positioned to disseminate information, training, and best practices.
... We strive to learn all we can about the human body so that we may help heal others, to provide not only physical healing but emotional support, and above all else, to do no harm. As healthcare providers who volunteer to work in the NBU, those desires drive us to go one step further, to provide that same level of care to patients for whom no one else can [3]. ...
... The NBU utilizes a collaborative model with a minimized hierarchical structure. 7 Every individual involved in the NBU team, regardless of profession, is responsible for the health and safety of his or her co-workers, particularly during procedures such as donning and doffing (i.e., putting on and removing) personal protective equipment (PPE). Thus, all staff are encouraged and expected to immediately notify their coworkers if they notice any potential breach in protocol or PPE during patient care. ...
Caring for patients with Ebola virus disease (EVD) in the Nebraska Biocontainment Unit (NBU) has necessitated and enabled extensive interprofessional relationships and the creation of a collaborative care model. Critical aspects of NBU functionality include a constructive leadership environment, staff inclusion and consideration during protocol development, and a culture of partnership and communication.
Perioperative nurses use aseptic and sterile technique along with standard cleaning and disinfection practices to prevent surgical site infections. At our hospital, OR team members identified a clinical problem: the lack of a systematic approach to determine the type of postprocedure cleaning required between procedures involving patients with multi‐drug resistant organisms or Clostridium difficile. Facility leaders developed a project to design and implement an evidence‐based decision‐making algorithm to help perioperative nurses rapidly identify the appropriate environmental cleaning procedures for these ORs. After the perioperative nurses were taught how to use the algorithm, it was put into use. Nineteen months later, the nurses completed a postimplementation survey. The results of the survey were generally positive, and the cleaning process was more standardized. We found that a decision‐making algorithm was an effective tool to determine the proper postprocedure environmental cleaning between surgical procedures for patients with multi‐drug resistant organisms or C difficile.
Staffing a facility for bioemergencies is one of the more complicated issues in high containment care. The unique challenges of this environment demand a multidisciplinary team with experience from all aspects of healthcare delivery. At the same time, the goal is to minimize the number of individuals who are potentially exposed to highly infectious pathogens. As a result, the team must consist of engaged individuals who are willing to take on responsibilities above and beyond their normal duties in the hospital. Each healthcare facility must take into account their unique strengths and circumstances when designing a staffing model that is appropriate for that institution. Healthcare worker and patient safety are the ultimate measures of success for a staffing model. Provider engagement in protocol design, training, administration, and team building activities will help to ensure the successful operation of the team during times of activation. Future research and experience with new bioemergencies will continue to inform the practical and ethical issues of staffing units for the care of patients with highly hazardous communicable diseases.
Background:
Fear surrounds Ebola Virus Disease (EVD) because it is highly infectious. Yet members of the Serious Communicable Diseases Unit (SCDU) at Emory University Hospital (EUH) had to overcome that fear when caring for patients with EVD.
Purpose:
The analysis reported here illustrates how the members of EUH's SCDU tacitly enacted high reliability (HR) principles while caring for patients with EVD.
Methods:
A qualitative study was conducted to describe the experience of members of the EUH SCDU who worked with EVD patients in 2014. We completed 17 semi-structured interviews involving registered nurses, physicians, and support personnel (eg, laboratory technicians). Interview recordings were transcribed and analyzed using conventional content analysis. Exploring HR principles was not among the questions guiding this exploration, but the participants repeatedly described concepts related to HR.
Results:
The goal of the SCDU team was to save patients' lives while protecting their own lives. Rigorous training and meeting high standards were required to make the team. The fear surrounding EVD set in motion the enactment of HR principles. HR principles served to alleviate failures or breakdowns in infection prevention and control, thus keeping patients and staff safe.
Conclusions:
These findings illustrate that it is possible to move HR principles from theory to practice in high-risk situations. HR principles were essential to safety and to infection prevention and control.
Preparing for Serious Communicable Diseases in the United States: What the Ebola Virus Epidemic Has Taught Us, Page 1 of 2
Abstract
The largest and deadliest outbreak of Ebola virus disease (EVD) began on 2 December 2013 when a 2-year-old child developed an illness characterized by fever, black stools, and vomiting in a town called Meliandou, Guinea—a remote and sparsely populated village of 31 households approximately 20 miles from the borders of Liberia and Sierra Leone ( 1 ). The exact source of infection is unclear but likely involved contact with an infected animal. The child died on the 5th day of his illness ( 2 ).
This review details infection control issues encountered in the management of patients with Ebola virus disease (EVD), with emphasis on how these issues were confronted in two biocontainment patient care units in the United States.
There is a notable paucity of medical literature to guide infection control policies and procedures when caring for patients with EVD. Thus, the experience of the Serious Communicable Diseases Unit at Emory University Hospital and the Nebraska Biocontainment Unit at the University of Nebraska Medical Center serves as the basis for this review. Facility issues, staffing, transportation logistics, and appropriate use of personal protective equipment are detailed. Other topics addressed include the evaluation of patients under investigation and ethical issues concerning the safe utilization of advanced life support.
This review intends to serve as a reference for facilities that are in the process of creating protocols for managing patients with EVD. Given the lack of literature to support many of the recommendations discussed, it is important to utilize the available referenced guidelines, along with the practical experiences of biocontainment units, to optimize the care provided to patients with EVD while strictly adhering to infection control principles.
Planning and design of a unique biocontainment unit specifically for care of patients with rare and highly infectious diseases presented an opportunity for nurse leaders to engage staff in crucial groundbreaking decisions. The Magnet® philosophy and framework were used to structure committees with key stakeholders and staff to ensure best and safe practices. Members of the biocontainment unit are engaged in active research and outreach training.
The science of team training in healthcare has progressed dramatically in recent years. Methodologies have been refined and adapted for the unique and varied needs within healthcare, where once team training approaches were borrowed from other industries with little modification. Evidence continues to emerge and bolster the case that team training is an effective strategy for improving patient safety. Research is also elucidating the conditions under which teamwork training is most likely to have an impact, and what determines whether improvements achieved will be maintained over time. The articles in this special issue are a strong representation of the state of the science, the diversity of applications, and the growing sophistication of teamwork training research and practice in healthcare. In this article, we attempt to situate the findings in this issue within the broader context of healthcare team training, identify high level themes in the current state of the field, and discuss existing needs.
Background:
Effective teamwork facilitates collective learning, which is integral to safety culture. There are no rigorous evaluations of the impact of team training on the four components of safety culture-reporting, just, flexible and learning cultures. We evaluated the impact of a year-long team training programme on safety culture in 24 hospitals using two theoretical frameworks.
Methods:
We used two quasi-experimental designs: a cross-sectional comparison of hospital survey on patient safety culture (HSOPS) results from an intervention group of 24 hospitals to a static group of 13 hospitals and a pre-post comparison of HSOPS results within intervention hospitals. Dependent variables were HSOPS items representing the four components of safety culture; independent variables were derived from items added to the HSOPS that measured the extent of team training, learning and transfer. We used a generalised linear mixed model approach to account for the correlated nature of the data.
Results:
59% of 2137 respondents from the intervention group reported receiving team training. Intervention group HSOPS scores were significantly higher than static group scores in three dimensions assessing the flexible and learning components of safety culture. The distribution of the adoption of team behaviours (transfer) varied in the intervention group from 2.8% to 31.0%. Adoption of team behaviours was significantly associated with odds of an individual reacting more positively at reassessment than baseline to nine items reflecting all four components of safety culture.
Conclusions:
Team training can result in transformational change in safety culture when the work environment supports the transfer of learning to new behaviour.
Serious events within healthcare occur daily exposing the failure of the system to safeguard patient and providers. The complex nature of healthcare contributes to myriad ambiguities affecting quality nursing care and patient outcomes. Leaders in healthcare organizations are looking outside the industry for ways to improve care because of the slow rates of improvement in patient safety and insufficient application of evidenced-based research in practice. Military and aviation industry strategies are recognized by clinicians in high-risk care settings such as the operating room, emergency departments, and intensive care units as having great potential to create safe and effective systems of care. Complexity science forms the basis for high reliability teams to recognize even the most minor variances in expected outcomes and take strong action to prevent serious error from occurring. Cultural and system barriers to achieving high reliability performance within healthcare and implications for team training are discussed.
Objective:
Minimizing healthcare worker exposure to airborne infectious pathogens is an important infection control practice. This study utilized mathematical modeling to evaluate the trajectories and subsequent concentrations of particles following a simulated release in a patient care room.
Design:
Observational study.
Setting:
Biocontainment unit patient care room at a university-affiliated tertiary care medical center.
Methods:
Quantitative mathematical modeling of airflow in a patient care room was achieved using a computational fluid dynamics software package. Models were created on the basis of a release of particles from various locations in the room. Computerized particle trajectories were presented in time-lapse fashion over a blueprint of the room. A series of smoke tests were conducted to visually validate the model.
Results:
Most particles released from the head of the bed initially rose to the ceiling and then spread across the ceiling and throughout the room. The highest particle concentrations were observed at the head of the bed nearest to the air return vent, and the lowest concentrations were observed at the foot of the bed.
Conclusions:
Mathematical modeling provides clinically relevant data on the potential exposure risk in patient care rooms and is applicable in multiple healthcare delivery settings. The information obtained through mathematical modeling could potentially serve as an infection control modality to enhance the protection of healthcare workers.
This study assessed the efficacy of gaseous chlorine dioxide for inactivation of Bacillus anthracis, Francisella tularensis, and Yersinia pestis in a hospital patient care suite. Spore and vegetative cells of Bacillus anthracis Sterne 34F2, spores of Bacillus atrophaeus ATCC 9372 and vegetative cells of both Francisella tularensis ATCC 6223 and Yersinia pestis A1122 were exposed to gaseous chlorine dioxide in a patient care suite. Organism inactivation was then assessed by log reduction in viable organisms postexposure to chlorine dioxide gas compared to non-exposed control organism. Hospital room decontamination protocols utilizing chlorine dioxide gas concentrations of 377 to 385 ppm maintained to exposures of 767 ppm-hours with 65% relative humidity consistently achieved complete inactivation of B. anthracis and B. atrophaeus spores, as well as vegetative cells of B. anthracis, F. tularensis, and Y. pestis. Decrease in exposure (ppm-hours) and relative humidity (<65%) or restricting airflow reduced inactivation but achieved >8 log reductions in organisms. Up to 10-log reductions were achieved in a hospital room with limited impact on adjacent areas, indicating chlorine dioxide concentrations needed for decontamination of highly concentrated (>6 logs) organisms can be achieved throughout a hospital room. This study translates laboratory chlorine dioxide fumigation studies applied in a complex clinical environment.
Given the potential for the transfer of infectious diseases among patients in isolation, health care workers (HCWs), and other patients in the hospital environment, the proper use of personal protective equipment (PPE) is paramount. The literature is limited regarding studies of HCWs' use of PPE in patient care tasks.
A pilot study was conducted to examine the feasibility of using a simulated health care environment to assess HCWs' technique when implementing standard airborne and contact isolation precautions. The participants (n = 10) were assigned patient care tasks based on their specific professional roles. The encounters were digitally recorded during donning and doffing of PPE, as well as during interactions with the simulated patient. Powdered fluorescent marker was used as a measure of contamination.
The pilot data show various inconsistencies in the HCWs' PPE technique. Each of the 10 participants committed at least one breach of standard airborne and contact isolation precautions.
An expanded research study of HCW behaviors is needed to properly examine these contamination and exposure pathways. Training programs should be developed that emphasize the common errors in HCWs' PPE technique.
Serious events within healthcare occur daily exposing the failure of the system to safeguard patient and providers. The complex nature of healthcare contributes to myriad ambiguities affecting quality nursing care and patient outcomes. Leaders in healthcare organizations are looking outside the industry for ways to improve care because of the slow rates of improvement in patient safety and insufficient application of evidenced-based research in practice. Military and aviation industry strategies are recognized by clinicians in high-risk care settings such as the operating room, emergency departments, and intensive care units as having great potential to create safe and effective systems of care. Complexity science forms the basis for high reliability teams to recognize even the most minor variances in expected outcomes and take strong action to prevent serious error from occurring. Cultural and system barriers to achieving high reliability performance within healthcare and implications for team training are discussed.
Medical Director of the Nebraska Biocon-tainment Unit Professor and Associate Dean for Student Affairs, UNMC College of Public Health
- M D Smith
- M D Angela Hewlett
- Director
- Nbu
- G Shawn
- Gibbs
- C D I H Ph
Smith, M.D., Medical Director of the Nebraska Biocon-tainment Unit; Angela Hewlett, M.D., Associate Medi-cal Director, NBU; Shawn G. Gibbs, Ph.D., C.I.H., Professor and Associate Dean for Student Affairs, UNMC College of Public Health; John J. Lowe, Ph.D., Assistant Professor, UNMC College of Public Health;
Building high reliability teams: Progress and some reflections on teamwork training Quality and Safety in Health Care The Nebraska Biocontainment Unit Staff The Nebraska Ebola Method for Clinicians
- E Salas
- M A Rosen
Complexity science, high reliability organizations, and implications for team training in healthcare. Clinical Nurse Specialist, 20, 298e304. Salas, E., & Rosen, M. A. (2013). Building high reliability teams: Progress and some reflections on teamwork training. Quality and Safety in Health Care, 22, 369e373. Schwedhelm, S., & Boulter, K. (2014). The Nebraska Biocontainment Unit Staff. Module in Gold, J.P. (editor-in-chief), The Nebraska Ebola Method for Clinicians. Omaha, NE: University of Nebraska Medical Center College of Public Health. Retrieved from http://www.unmc.edu/publichealth/ news/ebola-community.html. Also on itunes university.
Behavioral health considerations for hospitals responding to ebola Module in goldeditor-in-chief) The Nebraska Ebola Method for Clinicians
- R Zagurski
Zagurski, R. (2014). Behavioral health considerations for hospitals responding to ebola. Module in gold, J.P. (editor-in-chief) The Nebraska Ebola Method for Clinicians. Omaha, NE: University of Nebraska Medical Center College of Public Health. Retrieved from http://www.unmc.edu/publichealth/news/ebola-community.html. Also on itunes university.