Ken’s Take on the World


Healthcare: Privilege or Right?

As Republicans struggle to obtain enough votes in the US Senate to pass their version of a bill (Better Care Reconciliation Act) that was originally brought forward to repeal, and replace, the Affordable Care Act (ACA) much focus has been placed upon the economic costs and the personal costs to those who would be affected should this legislation become enacted into law.  As one who has paid attention to the debate over healthcare access for the past three decades, I have been thinking of a much deeper question that we should be asking of ourselves as it would, perhaps, better drive the debate over this legislation.  The question that each of us should ask is this:  Should healthcare be considered a privilege, a commodity, that should be available only to those who can afford such care or, should it be considered a necessary right for every person that must be protected, and assured by government?

 

When I have posed this question to those who express opposition to the ACA, the most common response that I receive is that healthcare should be treated as any other service that a person would seek out.  The most common support offered for this position is that every person receiving services should be required to pay for such services.  To bolster this claim, these critics argue that it is not fair to expect others to pay for services that they receive.  On its face this appears to be a reasonable argument that must be considered.  After all, you wouldn’t take your car to a mechanic and not be expected to pay for repairs or maintenance on your vehicle.  You don’t take your family to a restaurant and expect to receive free food, do you?  You wouldn’t call an air conditioning repair person and expect to not receive a bill for the parts and services provided, would you?  These criticisms appear to suggest that healthcare services and products are no different than whether or not your vehicle or your heating and cooling systems at home are functional.  This is a false and illogical argument.

 

When one dines out at a restaurant, one knows what they can afford and if they are unable to afford to dine at a certain establishment they simply eat dinner at home or at a less expensive restaurant.  When your air conditioner is on the fritz, if you do not have the money available for repairs, you will need to open your windows, use fans, or other methods of staying cool.  For those with underlying health conditions in which extreme heat is dangerous, communities provide cooling centers, or family and friends are often able to step in to provide temporary shelter until the air conditioning is repaired.  Even if a new central air system must be installed, the cost is almost always going to be less than $5,000 USD.  Many heating and cooling companies will also finance this amount to keep costs manageable.  Similarly, if you need repairs on your automobile, you can determine what are the most crucial and pay for those and defer other repairs until later.  Or, your community may have decent public transportation available.  Or, you may be able to car-pool to work or use a ride-sharing service.

 

Healthcare, unlike these other services, is not a commodity that can simply be delayed in many cases.  I have frequently likened the provision of healthcare as an essential service that must be available to every single person.  Similar to a community that provides fire departments and trained personnel to operate this life-saving equipment.  Or, law enforcement agencies that respond to safety or criminal complaints.  Or, military agencies like the Coast Guard who respond to emergencies on our nation’s waterways.  We don’t bat an eye when we are asked to fund these critical services.  As a society, we have come to realize these are critical pieces of infrastructure that exist for the benefit of each of us even if we never need to directly use these services.  Why, then, do we look at healthcare differently?

When I have attempted to discern how so-called conservatives continue to maintain the position that healthcare is a commodity, and not a right, in addition to the arguments about paying for services and the burdens of having to pay for those who cannot afford these services, they remind me that healthcare services are already provided to people in the nation’s Emergency Departments (ED) regardless of one’s ability to pay for such care.  This, then, implies there is, in fact, some existential right to healthcare.  When I point out this inconsistency in logic, one person actually mentioned that fewer (uninsured) people seek medical care as if this implies lower costs to taxpayers.  The problem with this (il)logic is that while uninsured individuals are far less likely to present to a primary care physician in the community setting, they are far more likely to present to an ED for treatment of conditions that can be much more effectively, and economically, managed in a community setting by a primary care physician.  This translates into significantly increased healthcare costs for all of us.  The average cost of an ED visit in the United States is nearly $2,200 based on a study described in “The Atlantic.”  Compare this to the average cost to a primary care provider (PCP) in the US which is only $100 based on an Agency for Healthcare Research and Quality (ARHQ) study by the Department of Health and Human Services (HHS).

 

A review of multiple studies has demonstrated that access to health insurance is correlated with significantly improved health outcomes.  The review, published recently in the “New England Journal of Medicine” (NEJM), documents that improved healthcare outcomes are especially notable among pediatric patients.  Further, this review notes that not only are healthcare outcomes improved, but other measures of quality of life, including educational achievement, are improved with access to health insurance.  Other studies have demonstrated the significant economic consequences associated with illness.  I am not only speaking of the direct costs associated with providing medically-necessary care, but the impacts that illness and preventable injury have on individual and societal economic stability and growth.

 

I believe we must frame the debate over access to health insurance as one of a necessary right that must be protected by government actions.  Only then, will we be able to determine the most effective means of financing healthcare in the United States.



Healthcare: Commodity or Essential Right

The recently, spectacularly, failed American Healthcare Act (AHCA), once again, brought to the forefront the debate on whether healthcare access should be considered a commodity, much like an automobile, subject to the whims of a free market and made available to those who can afford it or, rather, that healthcare is an essential right of all Americans that must be guaranteed by government.  Democrats appear united behind the concept that healthcare access is crucial to society and must be available to every US citizen regardless of their economic status.  As the debate over the AHCA progressed, it became obvious that Republicans are divided over this central question.  Polling shows that overwhelming majorities of Americans believe every citizen should have access to high-quality, affordable, healthcare.  In this, it appears the GOP is at odds with the majority of Americans.

 

This week, President Trump signaled the AHCA is not actually dead and that his campaign pledge to repeal and replace the Patient Protection and Affordable Care Act, also known simply as the Affordable Care Act (ACA) or, “Obamacare” continues onward.  The problem with this position is that the President has not articulated what this would look like.  Even with Republican majorities in both chambers of Congress, and without input from Democrats, a coherent plan that would meet the President’s promises of providing affordable health insurance to even more Americans, and at lower costs than the ACA, was not presented.  Competing factions within the Republican Congress ensured that no bill put forth would garner a majority of votes or even entice moderate Democrats to join in support.  Party leadership attempted to rush the bill through the House even prior to scoring by the nonpartisan Congressional Budget Office (CBO) which ultimately decided that, although ten-year cost projections would reduce the budget, the result would be more people without health insurance than prior to enactment of the ACA.

 

After the AHCA was pulled prior to a vote, the President commented, “Who would have known that healthcare would be so complicated?”  What?!?!  Besides anyone who has ever studied this topic?  This point underlies a central problem within the Trump Administration.  There is a serious lack of competent Administration leadership that might be able to shepherd complicated proposals through a Congress that is itself lacking in effective leadership that is committed to promoting and implementing legislation that will serve to actually benefit the American people.  Basically, Republicans have demonstrated that, since at least 2010, they lack the ability, or desire, to govern in the best interests of the people.

 

The failure of the AHCA effectively leaves the Republican leadership in Congress with two choices.  They can continue in their efforts to undermine the ACA which will lead to its eventual collapse, or, they can work with Democrats to strengthen the law which is what a majority of Americans currently favor.  It should be noted that the ACA has been effective and would continue to remain viable for at least the next decade but for efforts of the Republican Party over the past seven years.  Elected Republicans, and right-wing talking heads on radio and television, have spent the last seven years misleading the American public.  This has resulted in ballot box gains, however, it has not actually helped the American people.  While the ACA did not seriously further the debate on whether healthcare was an essential right versus a commodity available to the highest bidder, it did suggest that access to insurance to provide for healthcare expenses was a necessary thing that should be promoted by government.  In contrast, the debate among Republicans since 2009 has brought into the open the role of government in healthcare access at all levels.  It should be noted that prior to 2010, there was no question that government should ensure the availability of some access to healthcare for all Americans.  In 1986, President Ronald Reagan signed the bipartisan Emergency Medical Treatment and Active Labor Act (EMTALA) into law.  Likewise, COBRA was enacted under the Reagan Administration which provided individuals with a continuity of health insurance coverage.

 

The most recent debate between Republicans over the AHCA has placed a focus on whether government has any role in determining access to health insurance or healthcare itself.  This debate also served to highlight a disconnect between elected Republicans in Congress and their constituents.  Had the AHCA passed, the harms would have been felt significantly more among rural voters who overwhelmingly voted Republican over the past several election cycles.  The more extreme members of the GOP who make-up the Libertarian-wing (aka the Freedom Caucus formerly known as the Tea Party caucus) believe healthcare should be left to the winds of a completely free market.  Health insurers should be let alone to serve only the customers they desire and to charge whatever rates the free market might bear.  Let the buyer beware lest they procure a policy only to find out it lacks the protections necessary when they are needed, or worse, they are dis-enrolled when they become ill or seriously injured.  Somewhat more moderate Republicans seek to provide competition among insurers by removing obstacles to the sale of health insurance policies across state lines.  Theoretically, this appears to be reasonable, however, there are a significant number of realities that make this an unattractive proposal.  The biggest one is that insurance companies establish provider networks where they operate.  Healthcare providers are not likely to want to participate in a network that is out-of-state, perhaps in a different time zone, when they need to have their billing issues resolved or if they need to seek authorization for patient care.  This is inefficient and costly.  Another major issue affecting consumers is relating to the need to, perhaps, sue an insurance company for denial of a claim.  Consumers would be subjected to the laws of a particular state which might be much more favorable to the insurance company in a classic David and Goliath tale.

 

I doubt there is anyone who disagrees with the idea that society functions better when people are healthier.  Employee productivity is increased, chronic healthcare expenditures are decreased, and individual satisfaction is improved.  The United States outspends every other developed nation on healthcare but has significantly lower health outcomes on almost every measure.  Civilized societies throughout the world recognize this.  In promoting the well-being of their respective nations, leaders have already debated whether healthcare should be construed as a basic right to be assured by government.  It has been unanimously affirmed by economically- advanced societies that some level of healthcare must be provided for each person as by doing so it benefits every person.  The United States continues to be an outlier.  If, by independent measures, it was demonstrated that our status as an outlier made the health of our nation’s citizens better it would make perfect sense to continue our current system of healthcare delivery.  Unfortunately, this is not the case on ANY measure of national health.  Republicans continue to refuse to acknowledge this and continue to permit healthcare to consume ever-larger amounts of spending and an ever-growing share of our gross domestic product (GDP).

 

It is obvious the Republican Party is incapable, or unwilling to, of addressing this.  We, the people, must continue to demand healthcare access for all.  GOP-led efforts to undo the most significant healthcare reform in a generation is harmful to patients, providers, and insurers.  These efforts undermine the healthcare infrastructure and will lead to a significant collapse that would cause all of us to suffer.  If we recognize that a healthy citizenry makes for a more robust society, we must not maintain the idea of healthcare as a commodity to be enjoyed only by those who can afford it.  Essential healthcare must be available for all people.  This must be ensured by government.



On Guns and Sense

In the wake of the latest mass shooting event in San Bernardino that killed 14 and wounded 21, including at least two police officers, my Twitter and Facebook feeds lit up with calls to enact more vigorous gun control measures.  This is a recurring theme in this country.  There is a mass shooting that captures the attention of the public, there are calls for more gun control, the calls go, mostly, unheeded, and the nation moves on until the next day or next week when the next mass shooting event rivets the nation’s focus on gun violence.

 

In the aftermath of the latest shooting, which baffled investigators for nearly four days before determining this was an act of terrorism, albeit, one of the more convoluted episodes I can recall, Congress finally attempted to take action.  Senator Dianne Feinstein introduced a measure that would close a loophole that currently permits suspected terrorists to legally purchase firearms in the United States.  This measure failed on a mostly party-line vote with all but one Republican voting against the measure and all but one Democrat voting in favor of the measure.  Following the vote, there was condemnation from gun-rights proponents that the measure would have stripped away due process rights from those seeking to purchase handguns.  This was the first time I had heard this suggestion made, and from my Twitter feed, this line of conversation picked up a bit of steam.

 

First off, let me say that Twitter is a difficult environment to try and have a coherent and reasonable debate with anyone on any issue, let alone one as complex and controversial as access to firearms.  Nonetheless, I engaged in conversations with several folks who supported the view that barring people on a consolidated FBI watch-list from legally procuring firearms was a violation of due process rights established under the 5th Amendment of the US Constitution.  I admit that I was baffled at this suggestion as this is the text of the amendment:

 

“No person shall be held to answer for a capital, or otherwise infamous crime, unless on a presentment or indictment of a Grand Jury, except in cases arising in the land or naval forces, or in the Militia, when in actual service in time of War or public danger; nor shall any person be subject for the same offence to be twice put in jeopardy of life or limb; nor shall be compelled in any criminal case to be a witness against himself, nor be deprived of life, liberty, or property, without due process of law; nor shall private property be taken for public use, without just compensation.” – See more at: http://constitution.findlaw.com/amendment5.html#sthash.VZehsmyM.dpuf

 

The gist of the Twitter conversation is that, as the right to, “bear arms” is an enumerated right within the Bill of Rights, being, “…deprived of life, liberty, or property without due process of law…,” means that blocking specific individuals from obtaining a firearm infringes upon their Constitutional rights.  The focus of this discussion, left unspoken by proponents of this position, is on the word, “liberty” suggesting that not being able to buy a gun deprives an individual of her or his liberty.  Now, I am not besmirching any of the participants of this line of thought as I am certain they are each patriotic Americans.  However, their line of reasoning is flawed.  Being limited to 140 characters, I was unable to effectively explain the errors associated with this line of thought.  It is clear, however, that their focus on depriving a person of, “due process” BEFORE denying a fundamental right is un-Constitutional.  This is an incorrect interpretation of due process as related to the purchase of firearms by an individual who has had their name placed on a watch-list of suspected terrorists.

 

It has been publicly recognized that this list compiled by the Department of Justice is flawed and there are names on the list that, most likely, should not appear on the list.  Other names, like at least one of the suspected shooters in San Bernardino, should probably be on this list.  Some elected US officials, children and infants, and deceased individuals names appear on this list as has been reported by numerous media outlets.  See: http://www.wired.com/2007/09/700000-name-ter/  http://dailycaller.com/2015/12/04/san-bernardino-shooting-suspect-not-on-terrorist-watch-list/

 

Critics of this list complain that due to flaws, the list should not be a bar to legally obtaining a firearm.  They state that the list is arbitrary and that people are not informed their name is on a watch-list until they attempt to engage in activity (such as attempting to board a commercial airliner) that would cause the person’s name to appear.  Prior to September 11, 2001, several federal agencies maintained lists of individuals who were subjected to heightened scrutiny.  After the horrible terrorist attacks of that day, President George W Bush signed a Presidential Directive requiring the FBI to consolidate and maintain these listings.  There are currently nearly a million names in this database.  If your name is on the list, you can expect to be subjected to enhanced scrutiny in certain circumstances (boarding a commercial aircraft, being pulled over for speeding, attempting to purchase a firearm, etc.).  A number of reasons exist why a person’s name may appear on this list.  One reason, is that you are, in fact, suspected of being a terrorist.  Often, an individual’s name will appear because it is either identical to, or similar enough to, a name used by a known or suspected terrorist.  Senator Ted Kennedy’s name appeared on the watch-list because a suspected terrorist was using, “Edward Kennedy” as an alias.  Representative John Lewis had his name on the list for the same reason as did at least one Roman Catholic nun.  The list is hardly arbitrary as you have to be, “nominated” by someone in the intelligence community in order to be evaluated, promoted, and finally, placed on the list.  Additional information on being on this list, and how to remove your name on the list may be found here:  http://people.howstuffworks.com/government-watch-list.htm

 

In any case, the folks I attempted to carry on a debate with via Twitter, are incorrect that denying or, most likely deferring, the purchase of a firearm violates their due process rights under the US Constitution.

 

What, exactly, is, “due process?”

 

As the name implies, it is a method, or process, that is owed to another person.  This may be established within the framework of organizational policies or, as used in this discussion, a requirement that is established within the framework of our nation’s founding document, the US Constitution.  Due process provides a means for an individual, or group of individuals to seek relief, or a redress, of a grievance.  The process involves those steps put into place for that appeal.  Under the US Constitution, due process, especially as recognized under the 5th and 14th Amendments is recognized as two separate entities.  There is procedural due process and there is substantive due process.  Procedural due process requires that a process for redress of potential harms be provided for the person who has suffered.  Substantive due process requires that this process be sufficient to resolve the issue at hand.

 

The folks in the Twitter universe invoking the 5th Amendment due process provisions as a reason to not block actual or suspected terrorists from obtaining firearms are actually missing the entire point about both, procedural and substantive, due process.  A number of these folks have suggested that by not providing due process BEFORE denying a fundamental right, a person’s fundamental rights have been violated.  This is not the case.  My counterargument to this flawed assertion is that while procedural due process may exist prior to a “harm” being inflicted, substantive due process begins AFTER a fundamental right has been infringed upon.  Furthermore, none of the recognized, “enumerated,” or, “fundamental” rights is absolute.

 

An example of procedural due process would be if I intended to stage a protest rally in a certain location.  It should be noted that not all speech is protected under the 1st Amendment.  For example, a person cannot yell, “Fire!” in a crowded theatre because he or she feels like causing a commotion.  Politically protected speech, though, is recognized as an essential, or fundamental, right.  However, even politically-motivated speech is subject to certain restrictions.  Namely, the time and the place of such protest may be limited for specific reasons, including safety.  If I failed to obtain the appropriate permits prior to engaging in this protest, I could be arrested and denied permission to exercise what has been recognized as a fundamental right—the right to engage in politically-protected speech.

 

Additionally, a person must be legally capable of exercising the particular right.  Would any logical person suggest that a five year-old child has the legal capacity to purchase a firearm with their allowance money?  This is why those persons who have been adjudicated as being mentally-unfit are banned from possessing firearms.  The same goes with certain convicted felons even after they have served their prison sentences.  Aren’t we denying these individuals their fundamental rights?  Yes.  Again, no right established in the US Constitution is considered absolute!

 

Now, to the point recent Twitter postings allude to:  Denying a person the legal opportunity to purchase a firearm violates their 5th Amendment due process rights.  Never mind that this right generally refers to an individual who has been formally accused of committing a serious crime.

 

If I was to enter a gun store, or any other environment that sells firearms, and attempt to purchase a firearm, I may be required to provide certain information which is supposed to be checked against a database that includes names that are on the consolidated terrorist watch-list.  Suppose my name flags as being on this list.  I will assume I would be informed this is the reason that I was being denied the opportunity to purchase said firearm(s) as this has not happened to me before.  If nothing else, I would be informed that there is a process that I may follow to address and correct any information that I believe is erroneous and what that process is for doing so.  After all, the gun seller wants to make a sale and would like me to return to purchase the gun(s) I wanted, right?

 

If the folks I was conversing with through Twitter were able to catch on to what I was pointing out, they might have a viable claim that the placement of their name on a list of suspected terrorists violated their 5th and 14th Amendment due process rights.  I would suggest that an individual might want the ability to be notified PRIOR to their name being placed on the list.  There is no process for this, however.  This is where the folks I was having a dialogue with should have their grievance.  There is a process for having your name removed from this list.

 

The process for purchasing a firearm, as I stated before, requires that a purchaser be eligible to exercise this action.  One additional point regarding the folks I was conversing with is that I am surprised that folks who claim to be so patriotic are so sympathetic to the needs and desires of actual terrorists.  Perhaps, that was a bit snarky, however, that is what the Senate vote was designed to address—the ability of terrorists who WANT to legally purchase firearms.  Why would patriotic Americans want to, even inadvertently, facilitate the efforts of a terrorist?

 



I live only 2 hours from the Ebola hospital in Dallas. Here’s what I’m doing to protect my family.

I live only 2 hours from the Ebola hospital in Dallas. Here’s what I’m doing to protect my family..

Thanks, Jennifer Raff, for this snag!!  Knowledge is power!!



Preparing the Central Sterile Processing Department for Ebola

Ebola electron photograph Photo MD Health

The Ebola virus is something that has been on the mind of virtually every American these days.  In addition to becoming a formal public health concern within the past month and a half, it has managed to become a political issue.  The fact this has become a political issue is disappointing and a topic for a different post.  This post is to inform readers of preparations that must be made to protect healthcare providers from the very real possibility of providing medical care to a patient who presents with symptoms that are consistent with the Ebola virus.

Hospitals in the United States have already provided care for at least seven individuals who have become infected with Ebola virus.  This includes two missionary medical aid workers who contracted the virus while working with Africa, a man from Liberia who arrived in the Dallas Texas area, two nurses who cared for the Texas patient, and a cameraman for a media outlet that was covering the epidemic in west Africa.  The infections involving the two nurses who provided care for Thomas Duncan, the Texas patient, are troubling and put on display flaws with the Centers for Disease Control and Prevention (CDC) response to the currently unfolding public health situation.  While I have great respect and admiration for the CDC, and especially the work of Dr. Anthony Fauci who I personally admire a great deal, I am disappointed with their response to the current situation unfolding in the US with regards to Ebola.  Dr. Fauci has been the single beacon of confidence in the current conversation on this major public health concern.

It is important to note that not a single healthcare worker involved in the treatment of the two missionary workers contracted Ebola during their care of these patients.  It is also wise to note that no healthcare worker who provided care to Mr. Duncan during his initial visit to Dallas Presbyterian Hospital nor the Emergency Medical Technicians (EMT’s) who transported Mr. Duncan to the hospital a couple of days later have contracted the virus.  None of Mr. Duncan’s personal contacts on the area in which he was staying prior to his admission to the hospital were infected either.  These bits of news should provide some reassurance to an American public that seems to thrive on fear and conspiracy.

This brings us to the two nurses who, apparently, provided care to Mr. Duncan after he was admitted into the hospital.  By all accounts, these two nurses, as well as other nurses, technicians and physicians who cared for him until his demise in the hospital from multiple-organ failure, were wearing at least the level of personal protective equipment (PPE) that had been recommended by the CDC.  Guidance on donning (putting on) and doffing (removal) of PPE has been made available on the CDC website here: http://www.cdc.gov/sars/downloads/ppeposter1322.pdf  I have found this document to be flawed in regards to the acceptable level of PPE required for the safe and effective care of a patient in the most contagious stages of Ebola virus infection and, in particular, with the sequence for removal of PPE in any case.  However, until now, this is what healthcare workers have had for a resource.  In defense of the CDC, they have stated that the PPE guidelines provided are the minimum levels of protection for healthcare workers caring for a patient with confirmed or suspected Ebola virus infection.  This is not very reassuring.

Donning PPE

It is believed that the two nurses that have become infected with Ebola following the care of their patient may have inadvertently contaminated themselves during removal of their contaminated PPE.  This, in itself, is a tragedy.  It is likely that additional healthcare workers caring for Ebola patients using the same measures could become infected based on the selection of PPE and if they are removing their PPE using the steps outlined by the CDC.

Part of the rationale behind the CDC’s guidance is an awareness that very few American hospitals currently have the capacity to provide enhanced forms of PPE for significant numbers of their healthcare providers.  Full protective suits and gear are limited and stockpiled in small quantities for acute, transient, emergencies and quantities necessary to provide extended care for a patient requiring such gear is not on hand in most facilities.  I have learned this at my own facility as I began researching to prepare a policy for, specifically, Central Sterile Processing Department (CSPD) staff members who will be on the front lines of cleaning, decontaminating, disinfecting and sterilizing items used in the care of a patient with Ebola.

To date, no patient hospitalized for treatment of Ebola in the United States has required surgical intervention in the course of their treatment or recovery.  This is great news, because there is currently no guidance from the CDC on how to handle surgical intervention on such a patient.  The American College of Surgeons has issued guidance on surgical intervention for a patient with Ebola virus infection here: https://www.facs.org/ebola/surgical-protocol  This is a good resource for Operating Room (OR) team members including surgeons, nurses, anesthesia providers and surgical technologists.  It does not, however, address the concerns related to the reprocessing of items used in surgical procedures for these patients.  In my contacts with other CSPD managers, including at US hospitals that have treated patients with Ebola, there are no policies in place and the comments are that they are, essentially, relying on current CDC guidance if necessary.

Below is the first draft of a policy specifically addressing the needs of CSPD staff members who will bear the responsibility of cleaning, decontaminating, disinfecting, and sterilizing items used in the care of a patient with Ebola virus infection.  I am also attaching two of the appendices that address donning and doffing of PPE.  Perhaps someone at the CDC might incorporate these into a poster format!

While the vast majority of US hospitals are currently unprepared to handle an onslaught of Ebola cases, I have extreme confidence that most hospitals can safely and effectively care for a patient infected with the Ebola virus if they are given the proper resources and training.  It is critical to tamp down the hysteria and fear surrounding Ebola and base our actions on a scientific understanding and using evidence-based measures for providing care that is safe and effective for both our patients and our healthcare workers.

The Policy:

Handling and Processing of Items Exposed, or Potentially Exposed, to Ebola or Other Hemorrhagic Fever Patients

Purpose:

To provide guidance and direction for Central Sterile Processing personnel on the handling of instruments and durable medical equipment (DME) exposed, or potentially exposed, to the blood or other body fluids of a confirmed, or suspected, patient with Ebola, other hemorrhagic fever viruses.

Rationale:

XXXXXXXXXXX serves as the primary quarantine facility for travelers arriving through Detroit Metropolitan Airport.  The possibility exists for a disembarking passenger to present to airport officials with symptoms that may be consistent with suspected infection with Ebola, or other hemorrhagic fever, viruses.

To ensure that all proper infection control practices are implemented in order to protect staff members, patients, visitors and others who may be exposed to surgical instrumentation or durable medical equipment (DME) that has been used on a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses.

Policy:

All Central Sterile Processing personnel must follow specific guidelines when handling surgical instrumentation and durable medical equipment (DME) that has been exposed, or potentially exposed, to the blood, or other bodily fluids, of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses.

Procedure:

It is the responsibility of the attending physician to notify the Infection Control (IC) Director, or her/his designee, anytime a patient presents with symptoms consistent with exposure to, or infection with, Ebola, or other hemorrhagic fever, viruses.

The Infection Control (IC) Director, or her/his designee will notify, in addition to other appropriate Managers, the Manager of the Central Sterile Processing Department (CSPD), that a patient with confirmed, or suspected, Ebola, or other hemorrhagic fever, viruses has been admitted to the facility.

The Manager of the Central Sterile Processing Department (CSPD), or her/his designee, will work with other appropriate Managers to ensure that items necessary for the cleaning, decontamination, disinfection and/or sterilization of items used in the care of patients with confirmed, or suspected, Ebola, or other hemorrhagic fever, viruses are readily available for staff members within CSPD.  (See Appendix A)

The Manager of the Central Sterile Processing Department (CSPD) will ensure that appropriate education and training has been conducted for all staff members responsible for the cleaning, decontamination, processing, disinfection and/or sterilization of surgical instrumentation, or durable medical equipment (DME), used on a patient with confirmed, or suspected, Ebola, or other hemorrhagic fever, viruses.

The Manager of the Central Sterile Processing Department (CSPD) will maintain documentation of the qualifications of CSPD staff members with regard to the cleaning, decontamination, processing, disinfection and/or sterilization of surgical instrumentation, or durable medical equipment (DME), used on a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses.  The Manager of CSPD, or her/his designee, will be responsible for conducting annual in-service education and training for addressing Ebola, or other hemorrhagic fever, viruses.

The Nurse Manager, or her/his designee, of a unit providing care for a patient with a confirmed, or suspected, diagnosis of infection with Ebola, or other hemorrhagic fever, viruses will immediately notify the Central Sterile Processing Department (CSPD) Manager, or her/his designee, when an item used in the care of the patient is to be transported for processing by the CSPD.

Items transported to the Central Sterile Processing Department (CSPD) must be contained within a sealed, impervious, barrier.  Small items should be transported within an enclosed, or covered cart and not carried by hand.  Durable medical equipment (DME) should be contained within a large plastic bag, or similar impervious containment device, and transported on a cart that is also covered, where possible. Isolation carts, crash carts and other wheeled carts or equipment that have been used in the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses are to be covered with a large plastic bag, or similar impervious containment device, for transportation to the decontamination area.  Fluids are to be contained within sealed suction canisters.  Linen and trash must be contained within autoclaveable, leak resistant bags.  These bags must then be contained in impervious bags for transport to the CSPD.  Items that cannot be autoclaved must be segregated and discarded in red biohazard containers that are leak-proof and puncture-proof.

Items transported from a patient care area to the decontamination area must be constantly attended.  Items are not to be placed on an elevator or left in hallways awaiting transportation.  Contaminated items are not to be transported through the pneumatic tube system.  The person delivering the item(s) to the decontamination area must immediately notify the Sterile Processing Technician on duty that an item has been delivered to the decontamination area.  The Sterile Processing Technician on duty must immediately notify the Central Sterile Processing Department (CSPD) Supervisor on duty or on call.  The CSPD Supervisor will designate qualified individuals to perform the cleaning and decontamination of items associated with the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses.  The CSPD Supervisor will directly supervise the cleaning and decontamination of such items.

The Central Sterile Processing Department (CSPD) Supervisor will ensure the decontamination area is prepared and appropriately stocked for the decontamination process.  (See Appendix B)

Central Sterile Processing Department (CSPD) staff members assigned to the cleaning and decontamination of items used in the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses are to wear specific personal protective equipment (PPE). (See Appendix D)  CSPD staff members are to work in pairs as assigned by the CSPD Supervisor.  One staff member is designated as the “Primary” Technician and the other is designated as the “Secondary” Technician.  Both staff members shall wear the specific personal protective equipment (PPE) required for this process.  All other staff members are to be removed from the decontamination area for the duration of the cleaning and decontamination process of items associated with the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses.

The cleaning and decontamination process for surgical instrumentation used in the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses is consistent with established cleaning and decontamination processes recommended by the Association for the Advancement of Medical Instrumentation (AAMI), the Association of Professionals in Infection Control (APIC) and the Association of Perioperative Registered Nurses (AORN) regarding the cleaning and decontamination of any surgical instrumentation.  In all cases, manufacturer instructions for use (IFU’s) must be followed consistently.  NOTE:  Surgical instrumentation that cannot be processed using immersion, automated cleaning processes, ultrasonic cleaning, or high-temperature sterilization methods should not generally be used in the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses.

The Primary Technician will be responsible for performing all tasks associated with the cleaning, decontamination and disinfection of surgical instrumentation and durable medical equipment (DME) associated with a patient with confirmed, or suspected, Ebola, or other hemorrhagic fever, viruses.  The Secondary Technician will be responsible for ensuring no other personnel enter the decontamination area during this process, as well as directly observing the Primary Technician to identify any compromise in the personal protective equipment (PPE) and ensuring that the process for removal of PPE by the Primary Technician is performed properly.

Durable medical equipment (DME) used in the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses is to be cleaned using an appropriate, hospital-grade, disinfectant that is capable of inactivating non-enveloped viruses.  Adherence to wet times is to be strictly enforced.  Wheeled equipment, including IV poles, crash carts, isolation carts, stretchers, wheelchairs, etc are to have all surfaces, including wheels, wiped down with approved, hospital-grade disinfectants that are capable of inactivating non-enveloped viruses.

Donning Specialized PPE:

Appendix D—Donning of personal protective equipment (PPE) for the cleaning, decontamination, disinfection and sterilization of items involved in the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses

 

The employees who are assigned as “Primary” or “Secondary” Technician will be identically attired for the duration of the cleaning and decontamination process.

  1. The employees will don disposable scrub tops and pants.
  1. The employees will remove all jewelry including earrings, bracelets, necklaces, finger

            rings, and wristwatches.

  1. The employees will apply standard shoe covers over shoes.
  1. The employees will wear a hair cover and a surgical mask (if they will be wearing a

completely enclosed hood) or N95 high-filtration disposable respirator mask.

  1. The employees will don a pair of surgical-grade gloves ensuring adequate fit.
  1. The employees will don a Tyvek® biohazard suit hood. Ensure flaps of hood are

fully extended down the front and the back.  NOTE:  This is for a suit with a

separate hood/face-shield.  Attire must comply with ASTM: F1671.

  1. The employees will don a Tyvek® biohazard suit with attached booties. If the suit

does not have attached booties (one-piece), the employees will need to don water-

proof, disposable, knee-high booties.  The employees will ensure that the hood

flaps are completely contained within the suit.  Attire must comply with ASTM: F1671.

  1. The employees will use Duct tape to completely seal the sleeve to the inner gloves

making sure to leave a one (1) inch flap of tape for removal after the cleaning and

decontamination process.  Duct tape will also be used to seal knee-high booties if

these are worn leaving a one (1) inch flap of tape for removal.

  1. The employees will use Duct tape to completely seal the collar of the suit and the

body of the suit making sure to leave a one (1) inch flap of tape for removal after

the cleaning and decontamination process.  NOTE:  This is for a suit with a separate

hood/face-shield.

  1. The employees will use Duct tape to completely seal the zippers of the Tyvek® suit

making sure to leave a one (1) inch flap of tape for removal after the cleaning and

decontamination process.

  1. If the Tyvek® suit does not have an enclosed hood with face-shield, the employees

will don fully-enclosed goggles that secure with an elastic band AND a full face-shield.

  1. The employees will don a second pair of gloves that must be at least surgical-grade or

thicker-ply.

  1. The employees will use Duct tape to completely seal the outer glove and sleeve

making sure to leave a one (1) inch flap for removal after the cleaning and

decontamination process.

  1. The Central Sterile Processing Department (CSPD) Supervisor will verify that all

steps of the PPE donning process have been followed before permitting the

Technicians to enter the decontamination area.  This includes ensuring all areas

have been taped/sealed properly.

Removal of PPE:

Appendix E—Doffing (Removal of) personal protective equipment (PPE) used in the cleaning, decontamination, disinfection and/or sterilization of items involved in the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses

The employees who are assigned as “Primary” or “Secondary” Technician will be identically attired for the duration of the cleaning and decontamination process.  Personal protective equipment (PPE) is to be removed in a specific order in order to reduce the risk of inadvertent contamination of self during the removal of this gear.  The Central Sterile Processing Department (CSPD) Supervisor will directly observe the removal of PPE to ensure there are no breaks in technique.

  1. Verify the decontamination area has been properly cleaned and all items exposed,

or potentially exposed, to any contamination resulting from the cleaning and

decontamination process have been correctly disposed of.

  1. Position waste hamper with empty, autoclaveable, waste bag near tarpaulin that

has been positioned on the floor near the entry vestibule.

  1. Step onto tarpaulin to be sprayed off with approved, hospital-grade, disinfectant

ensuring that all surfaces of the PPE has been wetted.

  1. After the established wet-time criteria has been met, PPE may be removed in the

following order:

  1. Face-shield (if worn) is removed by grasping strap at back of head and pulling

up and over the head.  NOTE:  Applies if a separate hood/face-shield was not

worn.  Discard in waste hamper.

  1. Goggles (if worn) are removed by grasping strap at back of head and pulling

up and over the head.  NOTE:  Applies if a separate hood/face-shield was not

worn.  Discard in waste hamper.

  1. Remove each strip of Duct tape by pulling on tab left during donning of PPE.

Exercise care to not tear Tyvek® suit material.  Roll tape between hands into

a ball and discard into waste hamper.

  1. Remove booties (if used) and discard in waste hamper.
  2. Unzip Tyvek® suit exercising care to not let gloves touch scrubs.
  3. Remove outer gloves and discard in waste hamper.
  4. Remove Duct tape from inner glove/sleeve by pulling on tab left during

donning of PPE.

  1. One-piece suit—Grasp back of hood and pull back and downwards rolling

suit down back and arms ensuring outside of suit does not come into

contact with skin or scrubs.  Carefully step out of suit and off tarpaulin onto

clean floor.  Carefully roll suit up, ensuring suit does not come into contact with

skin or scrubs, and discard into waste hamper.

  1. Two-piece suit—Grasp suit at shoulders and pull back and downwards rolling

suit down back and arms ensuring outside of suit does not come into contact

with skin or scrubs.  Remove hood by grasping material of hood and pulling up

and over the head, ensuring outside of hood does not come into contact with

skin or scrubs, and discard in waste hamper.  Carefully step out of suit and off

tarpaulin onto clean floor.  Carefully roll suit up, ensuring suit does not come

into contact with skin or scrubs, and discard in waste hamper.

  1. Remove first inner glove by grasping palm of second glove and pulling downward

and off hand and discard in waste hamper.

  1. Remove second inner glove by sliding finger under cuff and rolling glove down

and off fingers and discard in waste hamper.

  1. The Primary and Secondary Technician will each don a pair of gloves then an impervious

gown and a pair of outer gloves to roll up and discard the tarpaulin, secure the waste

hamper and place hamper on autoclave cart.  The waste hamper is to be

decontaminated as other pieces of equipment.  These items will then be removed as

described above and discarded in a regular waste hamper along with shoe covers,

hair covers, masks, and disposable scrub tops and pants.  Clean scrub tops and pants will

be immediately available in the vestibule to change into.

  1. Remove mask by untying strings, or by grasping band, and pulling up and over

head and away from face.

  1. Remove hair cover by grasping top and pulling up and over head.
  2. Remove shoe covers by grasping shoe cover at heel and pulling down and

toward toes.

  1. Remove first glove by grasping palm of second glove and pulling downward

and off hand.

  1. Remove second glove by sliding finger under cuff and rolling glove down and

off fingers.

  1. The Primary and Secondary Technician will be escorted to an area where they are to

perform hand-washing and be permitted the opportunity to shower.