Command

Figure 1

Figure 1. Planned command structure for potential admission of a patient with viral hemorrhagic fever, Major Incident Hospital (MIH), University Medical Centre of Utrecht, the Netherlands, 2014.

The chain of command was demarcated in 4 levels (Figure 1). First, the crisis management team would be responsible for external communication and coordination with the adjoining hospitals. Second, the crisis coordination team would operate between the crisis management team and the command team to ascertain continuity of care at UMC Utrecht. Third, the command team would oversee the admission of a patient to the MIH. Finally, the treatment team would provide medical treatment for the patient.

Scenario Description and Routing

Flowcharts were developed that described 3 scenarios for routing a patient with suspected or confirmed VHF: 1) self-referral, 2) external referral, and 3) in-hospital referral from another ward. Security staff and a nurse would guide the patient to the MIH via a designated cleared route. Meanwhile, an emergency department nurse would open the MIH, activate the negative pressure system, and alert a team of trained nurses and an infectious disease specialist, all of whom would perform triage and assess the need to scale up the response.

Figure 2

Figure 2. Entrance of isolation unit with demarcated zones, Major Incident Hospital, University Medical Centre of Utrecht, the Netherlands, 2014. Markings on the floor indicate a safe zone and potentially contaminated zones and...

VHF patients arriving by ambulance would enter the MIH through a separate entrance in the MIH. At this entrance, a 3-zone area was drawn on the floor to indicate the safe zone and potentially contaminated zones and to delineate doffing zones (where potentially contaminated clothing and gear are removed) for ambulance and disinfection personnel (Figure 2). Personnel from the appointed ambulance services also were trained in accordance with the revised protocols.

Infection Prevention Measures

Working Procedures

Figure 3

Figure 3. A buddy nurse demonstrates reading instructions in front of the isolation unit glass window for healthcare personnel working inside the unit, Major Incident Hospital, University Medical Centre of Utrecht, the Netherlands,...

To ensure the safety of personnel, the “buddy system,” an extended version of the trainer-observer method (4), was introduced. In this system, a specialized nurse (buddy) guides and monitors all activities of the staff who are wearing PPE, starting with the donning of clothing and gear and ending with discarding all PPE. The buddy would be seated outside the unit in front of the glass window looking into an isolation room (Figure 3) and would guide the care provider in the room by reading aloud every step of the protocol being used, ensuring the minimization of risk behaviors arising from haste, stress, and the uncomfortably warm conditions felt while wearing PPE. The buddy and care provider would communicate by speakerphone inside the room connected to a mobile telephone. The glass windows would also facilitate monitoring of and communication with the patient. The maximum number of medical personnel present in an isolation unit was set to 1 at a time to ensure maximum safety. The maximum time spent in PPE was set at 45 minutes to minimize the loss of concentration caused by discomfort.

While a patient is in an isolation room, the nurses would work 8-hour shifts in teams of 3 persons (i.e., a bedside nurse, a buddy nurse, and a coordinating nurse). All procedures were summarized in task cards that would be used by the buddy to guide the bedside nurse. All protocols and task cards were made available through the hospital intranet.

Personnel

The required number of personnel was calculated for the admission of multiple patients to guarantee successful upscaling. During preparations, it proved necessary to activate the crisis coordination team to guarantee the availability of personnel from the hospital for frequent training sessions to ensure maximum availability during the admission of a patient. Flowcharts directed the alerting of in-house staff by team leaders during the acute phase; as necessary, a computerized alarm system would be activated to warn personnel by telephone.

Figure 4

Figure 4. Results of a post-training survey conducted among staff indicating whether they felt competent and safe in caring for patients with Ebola, Major Incident Hospital, University Medical Centre of Utrecht, the Netherlands,...

Some personnel were excluded from participation because of certain conditions (e.g., claustrophobia). Personnel were repeatedly trained in sessions of 1.5 hours, during which the donning and doffing of PPE, the buddy system, and other procedures were rehearsed (e.g., waste management, cleaning, and diagnostic procedures). These sessions were repeated every 10 weeks and resulted in a noticeable increase in the quality and safety of working conditions. The nursing staff of the MIH were prepared to fulfill the roles of buddy and trainer. A total of 126 staff members were trained (Table 1). After 2 training sessions, a survey conducted among personnel indicated that they felt sufficiently prepared (Figure 4).

Occupational health and safety service guidelines were developed for staff. All employees whose work involved contact with a VHF patient under protected conditions would be registered and required to monitor their temperature. In the event of unprotected contact with a VHF patient, personnel would be excluded from activities in the hospital and closely monitored by the public health service. If onset of VHF-associated symptoms occurred, personnel would be requested to contact the hospital’s occupational health and safety service and would be admitted to the isolation unit.

Diagnostics

PCR testing for VHF was to be performed in 2 reference centers (the Erasmus Medical Center, Rotterdam, the Netherlands, and the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany), which were appointed in accordance with national regulations and are in compliance with safety protocols (6,7). PCR testing was to be performed for EBOV, Marburg virus, Lassa virus, Crimean-Congo hemorrhagic fever virus, HIV, Plasmodium spp., and Leptospira spp. All materials were to be stored in plastic safety bags, placed in plastic containers, and then placed in cardboard shipping boxes (i.e., the “box-in-box” method).

Point-of-care laboratory tests were to be performed in the isolation unit by using I-STAT portable clinical analyzer (Abbott Point of Care, Inc., Princeton, NJ, USA). More extensive testing would be possible in one of the appointed external diagnostic centers.

A stethoscope equipped with a Bluetooth connection was acquired for auscultation of patients without physical contact. The radiology department was consulted to explore the possibilities of imaging in certain circumstances, such as the localization of a central venous catheter. However, these possibilities were limited by the confined space in the isolation rooms and by the need to decontaminate the equipment. It was then decided that the use of conventional radiography would not be possible. The option of a small portable ultrasound device was explored; however, the quality of the imaging was insufficient.

Isolation Department and Adaptations

Figure 5

Figure 5. Schematic overview of the isolation department, Major Incident Hospital, University Medical Centre of Utrecht, the Netherlands, 2014. U, isolation unit; N, nursing station; A, access valve.

Only small adaptations to the isolation units were necessary. To prevent spread of the virus, running water taps were shut off, and sinks were disconnected from the sewage system. To ensure safety in cases of patient delirium and to enforce involuntary quarantine, the units were equipped with locks and safety glass. A schematic overview of the isolation department is shown in Figure 5.

Medical Treatment Protocol

A medical protocol was developed to describe the standard diagnostic procedures and medical treatment according to the available guidelines. The protocol included preemptive treatment for malaria and administration of antimicrobial drugs for possible bacterial sepsis.

Communication and Information

Flyers and banners were posted in the outpatient departments and in hospital entryways, requesting that patients, visitors, and personnel who had recently traveled to a high-risk area for EBOV infection inform hospital staff. Additionally, information was broadcast on a television screen in the emergency department entryway and waiting room. Staff at the emergency department and hospital wards were instructed to enquire actively about risk factors for VHF for patients with fever.

Local hospitals and other external partners were informed and advised about VHF procedures and referral to the MIH. Meetings to inform noninvolved hospital staff about EVD and the precautions taken by the hospital were organized and, before the arrival of an actual patient, repeated for the relatives of involved staff.

Transfer and Admission

Before arrival of the patient, the transfer procedures were rehearsed twice with the involved ambulance and MIH personnel. Some changes had to be made to the infrastructure of the hospital entrance because of the differing PPE doffing procedures used by the designated ambulance services. It was then decided to involve no more than 2 ambulance services for future transport of VHF patients to the MIH.

At the time of patient admission, the command team, 4 trained nurses, and an infectious disease specialist were present, and intensive care unit (ICU) personnel and a cleaning team were on standby. Security personnel were present to prevent unauthorized persons from entering the unit and to prevent members of the news media from entering the hospital grounds.

The command team was continuously updated about the progress of the ambulance en route to the hospital. At 15 minutes before expected arrival, the first team of nurses started PPE donning procedures. The transfer of the patient at the hospital entrance was time-consuming because the patient was enveloped in a body bag, which resulted in more time required for triage by the first crew in PPE. The initial triage indicated no need for ICU admission. The initial diagnostics and medical treatment proved to be more time-consuming than expected. Cleaning and disinfection of the hospital entrance took >1 hour instead of the planned 45 minutes.

Treatment

All necessary medical and nonmedical activities (e.g., food delivery) were bundled to minimize the number of entries into the isolation room, resulting in 2–3 entries per 8-hour shift. Diagnostic blood samples were collected from an intravenous line to avoid high-risk procedures. Microbiological diagnostic procedures and sample transport to the diagnostic centers were supervised by the attending virologist and proceeded without incident. The results became available the same day. Coagulation tests were not available at the time; however, they were not required in this particular case.

Daily physician visits, except for replacement of the intravenous tube, were primarily conducted through the glass window by telephone. Spiritual counseling was provided at the request of the patient, and a tablet computer was provided for distraction and contact with family. The continuous presence of 3 nurses proved necessary during all 3 daily shifts. The availability of a coordinating nurse ensured that the interaction between the buddy and the bedside nurse was never disturbed. No safety incidents occurred. The limited working time of 45 minutes in PPE proved to be appropriate; however, an additional 20 minutes for recovery seemed to be warranted. PPE stock levels were always adequate.

Waste production was lower than expected because of the relatively stable condition of the patient. The maximum number of 60-L barrels used was 8 on the first day and 3 on every following day. Guided transport of the barrels to the external facility was necessary only twice weekly. A complicating factor was the difficulty of appropriately closing the barrels in 5 instances, which necessitated the resealing of boxes inside other boxes before further transport.

Discharge

After 6–7 days, all signs and symptoms of EVD in the patient had disappeared; however, the patient was dismissed from isolated treatment another 7 days later, after 2 PCR blood test results were negative for EBOV. The discharge procedure had been described only minimally in protocols and was developed in the days before dismissal. The isolation unit was sealed awaiting decontamination of the room by hydrogen peroxide gassing, which was performed 1 day after discharge. The isolation room was not made available until 14 days later because of the mandatory incubation period, the time required to interpret biostrips used to monitor the space, and the unavailability of staff from the external company during the end-of-year holidays. The entire isolation unit was unavailable for the admission of patients on the day of gassing because of interconnected air systems.

Evaluation

All involved personnel were monitored daily for 3 weeks after their last shift, and none experienced onset of symptoms. The experiences of the admission were shared with other medical centers and the National Institute for Public Health. Revisions to the design of the isolation unit are under way and include the installation of automatic sliding doors and improvement of the communication equipment.