Download Press CLINICAL ISSUES Ebola Hemorrhagic Fever: Precautions in the OR

EBOLA: PERIOPERATIVE CONSIDERATIONS
CLINICAL ISSUES AHEAD OF PRINT
CLINICAL ISSUES
Editor’s note: The following is an excerpt from the “Clinical Issues” column appearing online ahead of
print. The complete column will be published in the January 2015 issue of the AORN Journal.
© AORN, Inc, 2014
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Ebola Hemorrhagic Fever: Precautions in the OR
QUESTION:
What precautions should the perioperative team take in the OR when caring for a patient
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with known or suspected Ebola hemorrhagic fever (HF)?
ANSWER:
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Perioperative team members should take standard, contact, droplet, and airborne precautions
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when caring for a patient with known or suspected Ebola HF in the OR. Based on the Centers for
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Disease Control and Prevention (CDC) Infection Prevention and Control Recommendations for
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Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in US Hospitals,1
standard, contact, and droplet precautions should be taken for patients with known or suspected
Ebola HF. However, when an aerosol-generating procedure (eg, bilevel positive airway pressure
[BiPAP]®), bronchoscopy, sputum induction, intubation and extubation, open suctioning of
airways) is performed on a patient with Ebola HF, airborne precautions also should be taken.
This includes the use of an airborne infection isolation room and respiratory protection that is at
least as protective as a National Institute for Occupational Safety and Health (NIOSH)-certified,
fit-tested N95 filtering face piece respirator.1 Airborne precautions are necessary in the OR
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because most invasive procedures involve an element of airway management, and an aerosolgenerating procedure is highly likely to occur.1
AORN’s “Recommended practices for prevention of transmissible infections in the
perioperative practice setting”2 provide guidance for interventions and activities to implement
standard, contact, droplet, and airborne precautions in the OR. The CDC guidance for Ebola HF1
provides precautions to implement in addition to the AORN recommendations2 that are specific
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to patients with known or suspected Ebola HF. According to the CDC, heightened precautions
for Ebola HF are recommended because of the “high rate of morbidity and mortality among
infected patients, risk of human-to-human transmission, and lack of a FDA-approved vaccine
and therapeutics.”1 Table 1 describes recommendations for personal protective equipment (PPE)
for perioperative team members caring for a patient with known or suspected Ebola HF in the
(OSHA)7 recommendations.
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OR, as based on the CDC,1,3 AORN,2,4-6 and Occupational Safety and Health Administration
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The CDC advises health care personnel to wear respiratory protection that is “at least as
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protective as a NIOSH-certified, fit-tested N95 filtering face piece respirator or higher (eg,
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powered air purifying respiratory, elastomeric respirator)”1 when caring for patients known or
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suspected to have Ebola HF during aerosol-generating procedures. Because positive airway
pressure respirators (PAPRs) and elastomeric respirators are not approved for use as a surgical
mask, perioperative team members should take an abundance of caution when considering the
use of PAPRs or elastomeric respirators in the OR. Use of PAPRs or elastomeric respirators,
which are designed to protect the wearer and may not filter exhaled air, may contribute to air
contamination in the OR by exhausting unfiltered air.8 This is an unresolved issue and further
research is necessary to investigate this concern. Air contamination in the OR could increase the
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risk of a patient developing a surgical site infection from a contaminated sterile field or surgical
wound. Wearing surgical masks under a PAPR or elastomeric respirator in the OR to reduce the
concern of air contamination invalidates the function of the respirator and may jeopardize the
respiratory protection provided by these types of respirators. Therefore, the proposed benefits of
respiratory protection to the health care workers may be in question and the patient is possibly at
an increased risk of surgical site infection.9
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Table 1. Personal Protective Equipment (PPE) for Perioperative Team Members Caring for a Patient with Ebola
hemorrhagic fever.
PPE for non-scrubbed team members should include
 Clean gloves, double.1
 Gown, fluid resistant or impermeable.1,2
 Either a face shield that fully covers the front and sides of the face or goggles. 1-3
 Respiratory protection that is at least as protective as a National Institute for Occupational Safety and Health
(NIOSH)–certified, fit-tested N95 filtering face piece respirator.1,2
 Disposable shoe covers.1
 Leg covers or boots, depending on the risk for exposure to blood/body fluids. 1-4
 Fluid-resistant head covering or hood, depending on the risk for exposure to blood, body fluids, or other potentially
infectious material.1,2,4*
PPE for scrubbed team members:
 Sterile gloves, double.5,6
 Sterile gown.5
 Either a face shield that fully covers the front and sides of the face or goggles. 1-3
 Respiratory protection that is at least as protective as a NIOSH-certified, fit-tested N95 filtering face piece
respirator.1-3
 Disposable shoe covers.1
 Leg covers or boots, depending on the risk for exposure to blood, body fluids, or other potentially infectious
material.1-4*
 Fluid-resistant head covering or hood, depending on the risk for exposure to blood, body fluids, or other potentially
infectious materials.1,2,4
PPE for environmental services (EVS) team members:
 Clean gloves,8 doubled depending on the risk for exposure to blood, body fluids, or other potentially infectious
materials.2
 Fluid-resistant or impermeable gown.2,7
 Either a face shield that fully covers the front and sides of the face or goggles. 1-3,7
 Respiratory protection that is at least as protective as a NIOSH-certified, fit-tested N95 filtering face piece
respirator1 or a facemask,7 depending on the time and air exchanges after the patient leaves the OR. 2**
 Disposable shoe covers.1,7
 Leg covers or boots, depending on the risk for exposure to blood, body fluids, or other potentially infectious
materials.1-4*
 Fluid-resistant head covering or hood, depending on the risk for exposure to blood, body fluids, or other potentially
infectious materials.1,3,4*
PPE for sterile processing team members:
 Gloves, heavy-duty.4,8
 Fluid-resistant or impermeable gown.4,8
 Either a face shield that fully covers the front and sides of the face or goggles. 4,8
 Mask.4,8
 Leg covers or boots.4
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*According to OSHA Bloodborne Pathogens 1910.1030,4 “Surgical caps or hoods and/or shoe covers or boots shall be
worn in instances when gross contamination can reasonably be anticipated (e.g., autopsies, orthopaedic surgery).” Note:
According to the AORN Recommended Practices for Surgical Attire,3 “head coverings commonly used in the perioperative
setting (eg, bouffant caps) are worn for hair and skin containment and are not considered PPE. The Occupational Safety
and Health Administration requires that PPE not permit blood, body fluids, or other potentially infectious materials to pass
through or reach the employee's clothing, skin, eyes, or other mucous membranes under normal conditions of use.”
** If the EVS team member enters the OR before “adequate time has passed for air exchanges per hour to clean 99% of
airborne particles from the air (eg, 15 air exchanges per hour for 28 minutes to remove 99.9% of airborne
contaminants),”2(p 392) a N95 respirator should be worn according to airborne precautions. 1 If the EVS team member enters
the room after “adequate time has passed for air exchanges per hour to clean 99% of airborne particles from the air” 2(p 392),
a facemask should be worn to protect against skin and mucous membrane exposure of cleaning chemicals or contamination
during environmental cleaning activities.7
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References
1.
Infection prevention and control recommendations for hospitalized patients with known or suspected Ebola
hemorrhagic fever in U.S. hospitals. Centers for Disease Control and Prevention.
http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html. Updated October 6, 2014.
Accessed October 9, 2014.
2.
Recommended practices for prevention of transmissible infections in the perioperative practice setting. In:
Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc.; 2014:385-417.
3.
Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO:
AORN, Inc;2014:49-60.
4.
Occupational Safety and Health Administration. Toxic and hazardous substances: bloodborne pathogens. 29
CFR§1910.1030. Occupational Safety and Health Administration.
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS. Updated April 3,
2012. Accessed September 19, 2014.
5.
Recommended practices for sterile technique. In: Perioperative Standards and Recommended Practices. Denver, CO:
AORN, Inc.; 2014:89-118.
6.
Recommended practices for sharps safety. In: Perioperative Standards and Recommended Practices. Denver, CO:
AORN, Inc.; 2014:351-374
7.
Interim guidance for environmental infection control in hospitals for Ebola virus. Centers for Disease Control and
Prevention. http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html. Updated October 3,
2014. Accessed October 9, 2014.
8.
Recommended practices for Cleaning and Care of Surgical Instruments and Powered Equipment. In: Perioperative
Standards and Recommended Practices. Denver, CO: AORN, Inc.; 2014:541-560.
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Individual facilities should conduct a risk assessment with a multidisciplinary team (eg,
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infection preventionists, perioperative nurses, occupational health practitioners) and guidance
from local and state health officials, when deciding on use of respirators in the OR. As part of the
risk assessment, the team should assess the benefits of respirator protection to health care
workers versus the harm of the patient developing a surgical site infection from air
contamination. The issue of PAPRs and elastomeric respirators in the OR is being evaluated by
OSHA and NIOSH, but this issue remains unresolved because of lack of evidence. Some states,
such as California, require the use of a PAPR for health care personnel when performing aerosol
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generating procedures on patients with influenza, which underscores the importance of working
closely with local and state health departments to ensure that regulations are followed.
Although there have been no documented instances of transmission of Ebola HF from
environmental surfaces, the CDC advises higher levels of precaution toward potentially
contaminated surfaces because of “the apparent low infectious dose, potential of high virus titers
in the blood of ill patients, and disease severity”3 of Ebola HF. According to the CDC, health
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care personnel should use “a US Environmental Protection Agency (EPA)-registered hospital
disinfectant with a label claim for a non-enveloped virus (eg, norovirus, rotavirus, adenovirus,
polio virus)”3 for cleaning environmental surfaces during the care of patients with known or
suspected Ebola HF. The disinfectant should be selected by a multidisciplinary team (eg,
infection preventionists, environmental services personnel, perioperative nurses) at the health
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care organization.10 If a surface cannot be disinfected (eg, sensitive electronic equipment), the
perioperative team should cover the surface with a protective barrier that can be discarded after
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the procedure.10 To apply disinfectants, perioperative team members should use disposable
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cleaning materials because the CDC advises that all contaminated textiles be discarded as
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regulated medical waste to reduce exposure risks.3 Additionally, all linens, nonfluid-
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impermeable pillows or mattresses, and textile privacy curtains should be discarded as regulated
medical waste per the CDC guidance and should be handled in accordance with local, state, and
federal regulations.3 The US Department of Transportation’s (DOT) Hazardous Materials
Regulations has classified Ebola HF as a Category A infectious substance, and as such the
handling of this waste (eg, sharps, linens, PPE, cleaning byproducts, used health care products)
must comply with regulations for Category A infectious substances.3 To further reduce the risk
of Ebola HF exposure among personnel, the perioperative team should limit the amount of
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surface contamination of with blood, body fluids, or other potentially infectious materials from
the patient during the procedure and follow recommendations for sharps safety.6,7
Because of rapid advances in the medical sciences in particular, independent verification
of diagnoses and medication dosages should be made. The CDC’s Ebola Hemorrhagic Fever
guidelines are changing rapidly and clinicians are advised to consult the most recent CDC update
for infection prevention and control recommendations
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(http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html).
Editor’s notes: BiPAP is a registered trademark of Phillips Respironics, Murrysville,
Pennsylvania.
To receive continuing education credit for this content, you must read the entire
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“Clinical Issues” column in the January 2015 issue of the AORN Journal and complete the
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References
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online Learner Evaluation at http://www.aorn.org/CE.
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1. Infection prevention and control recommendations for hospitalized patients with known or
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suspected Ebola virus disease in US Hospitals. Centers for Disease Control and Prevention.
http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html.
Updated October 6, 2014. Accessed October 10, 2014.
2. Recommended practices for prevention of transmissible infections in the perioperative
practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO:
AORN, Inc; 2014:385-417.
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3. Interim guidance for environmental infection control in hospitals for Ebola virus. Centers for
Disease Control and Prevention. http://www.cdc.gov/vhf/ebola/hcp/environmental-infectioncontrol-in-hospitals.html. Updated October 3, 2014. Accessed October 10, 2014.
4. Recommended practices for surgical attire. [In Press] In: Perioperative Standards and
Recommended Practices. Denver, CO: AORN, Inc; 2015:541-560.
5. Recommended practices for sterile technique. In: Perioperative Standards and
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Recommended Practices. Denver, CO: AORN, Inc; 2014:89-118.
6. Recommended practices for sharps safety. In: Perioperative Standards and Recommended
Practices. Denver, CO: AORN, Inc; 2014:351-374
7. Occupational Safety and Health Administration. Toxic and hazardous substances: bloodborne
pathogens. 29 CFR§1910.1030. Occupational Safety and Health Administration.
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https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STAND
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ARDS. Updated April 3, 2012. Accessed September 19/2014.
8. Implementing Respiratory Protection Programs in Hospitals: A Guide for Respirator Program
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Administrators. California Department of Public Health.
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http://www.cdph.ca.gov/programs/ohb/Documents/HCResp-CARPPGuide.pdf. Accessed
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October 10, 2014.
9. Institute of Medicine Board on Health Sciences: The Use and Effectiveness of Powered AirPurifying Respirators in Health Care. [Workshop Agenda]. Presented at the Institute of
Medicine Workshop; August 6-7, 2014: Washington, DC.
10. Recommended practices for environmental cleaning. In: Perioperative Standards and
Recommended Practices. Denver, CO: AORN, Inc; 2014:255-276.
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Amber Wood, MSN, RN, CNOR, CIC, CPN, is a perioperative nursing specialist in the nursing
department at AORN, Denver, CO. Ms Wood has no declared affiliation that could be perceived
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as posing a potential conflict of interest in the publication of this article.
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