Emory’s Ebola Experience Held Logistical Surprises

WASHINGTON – When two Ebola-infected patients were airlifted to Emory University Hospital in Atlanta in early August, dedicated staffers were prepared to care for the patients. But those staffers had to act quickly to deal with unanticipated challenges that came from regulators and some of the hospital’s contractors, who initially refused to dispose of the mountains of medical waste generated by the patients and the clinicians who cared for them, according to Dr. Aneesh Mehta.

Dr. Mehta, associate chief of Emory’s infectious disease service, was one of the primary attending physicians for Nancy Writebol and Dr. Kent Brantly, who recovered from their Ebola infections and were discharged from Emory’s isolation unit on Aug. 19 and Aug. 21.

The lessons learned from caring for these initial patients are now being applied to Emory’s latest Ebola-infected patient, who arrived at the facility from West Africa on Sept. 9, said Dr. Mehta, who spoke on the logistics, successes, and challenges of caring for Ebola-infected patients at Emory at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The local civil authorities asked that the Emory unit not introduce any untreated patient waste into the municipal waste stream. The staff disinfected with bleach or detergents all of the patients’ liquid wastes for more than 5 minutes before flushing them down the toilet.

And there was plenty of other potentially hazardous and infectious material that had to be addressed. At the peak of the patients’ illness, up to 40 bags a day of medical waste were being produced, said Dr. Mehta.

Initially, the hospital’s waste management contractor refused to pick up the medical waste for several days. To manage the situation temporarily, the Emory staff "went to Home Depot and bought up every large trash can and sealed canister that we could get," said Dr. Mehta. The filled cans were kept in a containment room until the hospital completed negotiations with the contractor to pick up the waste.

Even the commercial courier company that the hospital had always used to transport infectious and potentially lethal samples to the labs at the Centers for Disease Control and Prevention "suddenly said ‘no,’ " Dr. Mehta said. "If the label said ‘CDC’ on it, they refused to touch it."

Even some Emory staffers who had previously handled and packed dangerous samples for shipping refused to come to the isolation unit’s lab, said Dr. Mehta. The hospital’s safety officers had to train some of the dedicated Ebola staff to pack samples appropriately for shipping.

But even as the hospital dealt with these issues and the growing media circus, the Ebola staff stayed focused, Dr. Mehta said. "It was very chaotic outside, but very calm in the hospital and with our team."

The hospital spent a lot of time on communications – with the public, with staff, and with other patients in the hospital and their families. Emory held twice-daily town halls with staff to give information and answer questions, and also sent regular e-mail updates about the Ebola patients. Every inpatient and new admission was given a letter explaining why Emory had taken the patients, and physician and administrative leaders rounded throughout the hospital to answer questions.

Emory already had a "serious communicable diseases" unit, which it created in 2002 as a place to receive any CDC workers who might be exposed to pathogens on the job. The six-room unit has a patient room on each end, with a private bathroom in each, a staff dressing area, and an anteroom that was used as a staging area for nurses.

After the decision to accept the Ebola-infected patients, a new point-of-care lab facility was built in less than 72 hours in an adjoining office space, said Dr. Mehta. Having this kind of dedicated unit was not absolutely necessary, but it allowed the staff to more conveniently perform chemistry, hematology, blood gas, urinalysis, coagulation, and malaria tests and get immediate results. Having a dedicated lab space also limited the exposure fears of staff elsewhere in the hospital.

To prevent transmission of the virus, the unit followed the CDC’s recommendations, which included keeping a detailed log of anyone who entered and exited a patient room, using disposable equipment whenever possible, and using personal protective equipment that included gloves, fluid-resistant or impermeable gowns, and goggles or face shields. Initially, the Emory caregivers had leg and foot coverings because the patients had vomited blood before arriving, and one of the patients had fulminant diarrhea, up to four liters per day, said Dr. Mehta.

Because the disease can be transmitted from protective gear, all staff had a refresher course on appropriate use of the gear, everyone was observed by another team member when putting on or taking off the gear, and reminders about appropriate use of the gear were placed on the walls of the unit and in the changing area.

The clinical care team met every day to review plans and protocols and to answer staff questions. Twice daily, all personnel had to enter into an online registry their body temperatures and any symptoms. Dr. Mehta told the ICAAC audience that he had just completed his 21-day observation period.

The patient care itself was far from clear cut, as there is no proven treatment and Emory officials initially were not clear on the availability of any experimental therapy, said Dr. Mehta. The CDC helped to monitor the patients’ viral load, and both patients had marked electrolyte imbalances, including hypokalemia, hypocalcemia, and hyponatremia, as well as severe nutritional deficiencies. Both required significant potassium replacement.

Both patients received a three-dose course of Zmapp, which consists of three monoclonal antibodies and is under development by Mapp Biopharmaceutical. While in Africa, Dr. Brantly also had received a transfusion of plasma from a patient who was recovering from the Ebola virus.

High-level, one-on-one nursing care also was noted as a significant factor in patient recovery, said Dr. Mehta.

"It’s hard to derive a lot of meaningful data from the care of those two patients," Dr. Mehta said. It’s not clear yet which of these factors – Zmapp, the transfusion, the supportive care, or the combination – was responsible for the patients’ recovery.

Emory will publish its experiences in Ebola care, but "the real front line is in West Africa," Dr. Mehta added.

[email protected]

On Twitter @aliciaault

WASHINGTON – When two Ebola-infected patients were airlifted to Emory University Hospital in Atlanta in early August, dedicated staffers were prepared to care for the patients. But those staffers had to act quickly to deal with unanticipated challenges that came from regulators and some of the hospital’s contractors, who initially refused to dispose of the mountains of medical waste generated by the patients and the clinicians who cared for them, according to Dr. Aneesh Mehta.

Dr. Mehta, associate chief of Emory’s infectious disease service, was one of the primary attending physicians for Nancy Writebol and Dr. Kent Brantly, who recovered from their Ebola infections and were discharged from Emory’s isolation unit on Aug. 19 and Aug. 21.

The lessons learned from caring for these initial patients are now being applied to Emory’s latest Ebola-infected patient, who arrived at the facility from West Africa on Sept. 9, said Dr. Mehta, who spoke on the logistics, successes, and challenges of caring for Ebola-infected patients at Emory at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The local civil authorities asked that the Emory unit not introduce any untreated patient waste into the municipal waste stream. The staff disinfected with bleach or detergents all of the patients’ liquid wastes for more than 5 minutes before flushing them down the toilet.

And there was plenty of other potentially hazardous and infectious material that had to be addressed. At the peak of the patients’ illness, up to 40 bags a day of medical waste were being produced, said Dr. Mehta.

Initially, the hospital’s waste management contractor refused to pick up the medical waste for several days. To manage the situation temporarily, the Emory staff "went to Home Depot and bought up every large trash can and sealed canister that we could get," said Dr. Mehta. The filled cans were kept in a containment room until the hospital completed negotiations with the contractor to pick up the waste.

Even the commercial courier company that the hospital had always used to transport infectious and potentially lethal samples to the labs at the Centers for Disease Control and Prevention "suddenly said ‘no,’ " Dr. Mehta said. "If the label said ‘CDC’ on it, they refused to touch it."

Even some Emory staffers who had previously handled and packed dangerous samples for shipping refused to come to the isolation unit’s lab, said Dr. Mehta. The hospital’s safety officers had to train some of the dedicated Ebola staff to pack samples appropriately for shipping.

But even as the hospital dealt with these issues and the growing media circus, the Ebola staff stayed focused, Dr. Mehta said. "It was very chaotic outside, but very calm in the hospital and with our team."

The hospital spent a lot of time on communications – with the public, with staff, and with other patients in the hospital and their families. Emory held twice-daily town halls with staff to give information and answer questions, and also sent regular e-mail updates about the Ebola patients. Every inpatient and new admission was given a letter explaining why Emory had taken the patients, and physician and administrative leaders rounded throughout the hospital to answer questions.

Emory already had a "serious communicable diseases" unit, which it created in 2002 as a place to receive any CDC workers who might be exposed to pathogens on the job. The six-room unit has a patient room on each end, with a private bathroom in each, a staff dressing area, and an anteroom that was used as a staging area for nurses.

After the decision to accept the Ebola-infected patients, a new point-of-care lab facility was built in less than 72 hours in an adjoining office space, said Dr. Mehta. Having this kind of dedicated unit was not absolutely necessary, but it allowed the staff to more conveniently perform chemistry, hematology, blood gas, urinalysis, coagulation, and malaria tests and get immediate results. Having a dedicated lab space also limited the exposure fears of staff elsewhere in the hospital.

To prevent transmission of the virus, the unit followed the CDC’s recommendations, which included keeping a detailed log of anyone who entered and exited a patient room, using disposable equipment whenever possible, and using personal protective equipment that included gloves, fluid-resistant or impermeable gowns, and goggles or face shields. Initially, the Emory caregivers had leg and foot coverings because the patients had vomited blood before arriving, and one of the patients had fulminant diarrhea, up to four liters per day, said Dr. Mehta.

Because the disease can be transmitted from protective gear, all staff had a refresher course on appropriate use of the gear, everyone was observed by another team member when putting on or taking off the gear, and reminders about appropriate use of the gear were placed on the walls of the unit and in the changing area.

The clinical care team met every day to review plans and protocols and to answer staff questions. Twice daily, all personnel had to enter into an online registry their body temperatures and any symptoms. Dr. Mehta told the ICAAC audience that he had just completed his 21-day observation period.

The patient care itself was far from clear cut, as there is no proven treatment and Emory officials initially were not clear on the availability of any experimental therapy, said Dr. Mehta. The CDC helped to monitor the patients’ viral load, and both patients had marked electrolyte imbalances, including hypokalemia, hypocalcemia, and hyponatremia, as well as severe nutritional deficiencies. Both required significant potassium replacement.

Both patients received a three-dose course of Zmapp, which consists of three monoclonal antibodies and is under development by Mapp Biopharmaceutical. While in Africa, Dr. Brantly also had received a transfusion of plasma from a patient who was recovering from the Ebola virus.

High-level, one-on-one nursing care also was noted as a significant factor in patient recovery, said Dr. Mehta.

"It’s hard to derive a lot of meaningful data from the care of those two patients," Dr. Mehta said. It’s not clear yet which of these factors – Zmapp, the transfusion, the supportive care, or the combination – was responsible for the patients’ recovery.

Emory will publish its experiences in Ebola care, but "the real front line is in West Africa," Dr. Mehta added.

[email protected]

On Twitter @aliciaault

WASHINGTON – When two Ebola-infected patients were airlifted to Emory University Hospital in Atlanta in early August, dedicated staffers were prepared to care for the patients. But those staffers had to act quickly to deal with unanticipated challenges that came from regulators and some of the hospital’s contractors, who initially refused to dispose of the mountains of medical waste generated by the patients and the clinicians who cared for them, according to Dr. Aneesh Mehta.

Dr. Mehta, associate chief of Emory’s infectious disease service, was one of the primary attending physicians for Nancy Writebol and Dr. Kent Brantly, who recovered from their Ebola infections and were discharged from Emory’s isolation unit on Aug. 19 and Aug. 21.

The lessons learned from caring for these initial patients are now being applied to Emory’s latest Ebola-infected patient, who arrived at the facility from West Africa on Sept. 9, said Dr. Mehta, who spoke on the logistics, successes, and challenges of caring for Ebola-infected patients at Emory at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The local civil authorities asked that the Emory unit not introduce any untreated patient waste into the municipal waste stream. The staff disinfected with bleach or detergents all of the patients’ liquid wastes for more than 5 minutes before flushing them down the toilet.

And there was plenty of other potentially hazardous and infectious material that had to be addressed. At the peak of the patients’ illness, up to 40 bags a day of medical waste were being produced, said Dr. Mehta.

Initially, the hospital’s waste management contractor refused to pick up the medical waste for several days. To manage the situation temporarily, the Emory staff "went to Home Depot and bought up every large trash can and sealed canister that we could get," said Dr. Mehta. The filled cans were kept in a containment room until the hospital completed negotiations with the contractor to pick up the waste.

Even the commercial courier company that the hospital had always used to transport infectious and potentially lethal samples to the labs at the Centers for Disease Control and Prevention "suddenly said ‘no,’ " Dr. Mehta said. "If the label said ‘CDC’ on it, they refused to touch it."

Even some Emory staffers who had previously handled and packed dangerous samples for shipping refused to come to the isolation unit’s lab, said Dr. Mehta. The hospital’s safety officers had to train some of the dedicated Ebola staff to pack samples appropriately for shipping.

But even as the hospital dealt with these issues and the growing media circus, the Ebola staff stayed focused, Dr. Mehta said. "It was very chaotic outside, but very calm in the hospital and with our team."

The hospital spent a lot of time on communications – with the public, with staff, and with other patients in the hospital and their families. Emory held twice-daily town halls with staff to give information and answer questions, and also sent regular e-mail updates about the Ebola patients. Every inpatient and new admission was given a letter explaining why Emory had taken the patients, and physician and administrative leaders rounded throughout the hospital to answer questions.

Emory already had a "serious communicable diseases" unit, which it created in 2002 as a place to receive any CDC workers who might be exposed to pathogens on the job. The six-room unit has a patient room on each end, with a private bathroom in each, a staff dressing area, and an anteroom that was used as a staging area for nurses.

After the decision to accept the Ebola-infected patients, a new point-of-care lab facility was built in less than 72 hours in an adjoining office space, said Dr. Mehta. Having this kind of dedicated unit was not absolutely necessary, but it allowed the staff to more conveniently perform chemistry, hematology, blood gas, urinalysis, coagulation, and malaria tests and get immediate results. Having a dedicated lab space also limited the exposure fears of staff elsewhere in the hospital.

To prevent transmission of the virus, the unit followed the CDC’s recommendations, which included keeping a detailed log of anyone who entered and exited a patient room, using disposable equipment whenever possible, and using personal protective equipment that included gloves, fluid-resistant or impermeable gowns, and goggles or face shields. Initially, the Emory caregivers had leg and foot coverings because the patients had vomited blood before arriving, and one of the patients had fulminant diarrhea, up to four liters per day, said Dr. Mehta.

Because the disease can be transmitted from protective gear, all staff had a refresher course on appropriate use of the gear, everyone was observed by another team member when putting on or taking off the gear, and reminders about appropriate use of the gear were placed on the walls of the unit and in the changing area.

The clinical care team met every day to review plans and protocols and to answer staff questions. Twice daily, all personnel had to enter into an online registry their body temperatures and any symptoms. Dr. Mehta told the ICAAC audience that he had just completed his 21-day observation period.

The patient care itself was far from clear cut, as there is no proven treatment and Emory officials initially were not clear on the availability of any experimental therapy, said Dr. Mehta. The CDC helped to monitor the patients’ viral load, and both patients had marked electrolyte imbalances, including hypokalemia, hypocalcemia, and hyponatremia, as well as severe nutritional deficiencies. Both required significant potassium replacement.

Both patients received a three-dose course of Zmapp, which consists of three monoclonal antibodies and is under development by Mapp Biopharmaceutical. While in Africa, Dr. Brantly also had received a transfusion of plasma from a patient who was recovering from the Ebola virus.

High-level, one-on-one nursing care also was noted as a significant factor in patient recovery, said Dr. Mehta.

"It’s hard to derive a lot of meaningful data from the care of those two patients," Dr. Mehta said. It’s not clear yet which of these factors – Zmapp, the transfusion, the supportive care, or the combination – was responsible for the patients’ recovery.

Emory will publish its experiences in Ebola care, but "the real front line is in West Africa," Dr. Mehta added.

[email protected]

On Twitter @aliciaault