Publications by authors named "Angela L Hewlett"

51 Publications

Utility of repeat testing for COVID-19: Laboratory stewardship when the stakes are high.

Infect Control Hosp Epidemiol 2021 03 3;42(3):338-340. Epub 2020 Aug 3.

Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska.

As the coronavirus disease 2019 (COVID-19) continues to circulate, testing strategies are of the utmost importance. Given national shortages of testing supplies, personal protective equipment, and other hospital resources, diagnostic stewardship is necessary to aid in resource management. We report the low utility of serial testing in a low-prevalence setting.
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http://dx.doi.org/10.1017/ice.2020.397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7511838PMC
March 2021

Can You Catch It? Lessons Learned and Modification of ED Triage Symptom- and Travel-Screening Strategy.

J Emerg Nurs 2020 Nov 16;46(6):932-940. Epub 2020 Apr 16.

Introduction: Efficient identification and isolation of patients with communicable diseases limits exposure to health care workers, other patients, and visitors. In August 2014, our team developed and implemented an algorithm to triage suspected cases of Ebola virus disease in a midwestern United States emergency department and outpatient clinics based on patient travel history and symptoms. Here, we present the lessons learned and modifications to update the tool.

Methods: Two strategies were developed and utilized to properly identify, isolate, and inform on patients with suspected highly hazardous communicable diseases: 1) a robust electronic symptom and travel screen with decision support tools in the electronic medical record, and 2) the availability of workflow protocols for Ebola virus disease, Middle East Respiratory Syndrome (MERS), and coronavirus 2019 (COVID-19) once a person under investigation is identified. After action reports provided opportunities to modify the algorithm and improve the identification and isolation processes.

Results: Since our screening and travel electronic medical record inception 5 years ago, modifications changed iteratively to further enhance the screening process. Since 2018, staff have identified 5 patients at risk for MERS; in all cases, identification occurred during the check-in process. Exposure investigations in the emergency department decreased significantly after algorithm implementation in January 2019, from 30 in 2018 to 0 in 2019.

Discussion: Although highly hazardous communicable diseases like Ebola virus disease and MERS are of concern due to their mortality rates and limited treatment options, these same concepts may be applied to the early identification and isolation of patients suspected of having more common communicable diseases like measles and influenza, emphasizing the importance of protocol-based screening in the healthcare environment.
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http://dx.doi.org/10.1016/j.jen.2020.03.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7160057PMC
November 2020

Advanced Preparation Makes Research in Emergencies and Isolation Care Possible: The Case of Novel Coronavirus Disease (COVID-19).

Am J Trop Med Hyg 2020 05;102(5):926-931

University of Nebraska Medical Center/Nebraska Medicine, Omaha, Nebraska.

The optimal time to initiate research on emergencies is before they occur. However, timely initiation of high-quality research may launch during an emergency under the right conditions. These include an appropriate context, clarity in scientific aims, preexisting resources, strong operational and research structures that are facile, and good governance. Here, Nebraskan rapid research efforts early during the 2020 coronavirus disease pandemic, while participating in the first use of U.S. federal quarantine in 50 years, are described from these aspects, as the global experience with this severe emerging infection grew apace. The experience has lessons in purpose, structure, function, and performance of research in any emergency, when facing any threat.
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http://dx.doi.org/10.4269/ajtmh.20-0205DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204595PMC
May 2020

Update on Ebola Treatment Center Costs and Sustainability, United States, 2019.

Emerg Infect Dis 2020 05 17;26(5):1007-1009. Epub 2020 May 17.

We surveyed 56 Ebola treatment centers (ETCs) in the United States and identified costs incurred since 2014 ($1.76 million/ETC) and sustainability strategies. ETCs reported heavy reliance on federal funding. It is uncertain if, or for how long, ETCs can maintain capabilities should federal funding expire in 2020.
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http://dx.doi.org/10.3201/eid2605.191245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7181920PMC
May 2020

An update on US Ebola treatment center personnel management and training.

Am J Infect Control 2020 04 6;48(4):375-379. Epub 2020 Feb 6.

Department of Environmental and Occupational Health, Indiana University School of Public Health, Bloomington, IN.

Background: In 2014, 56 US hospitals were designated as Ebola treatment centers (ETCs). ETCs had minimum augmented capability requirements for Ebola virus disease care, including for staffing and training. We sought to identify current ETC staffing challenges and frequency of staff retraining.

Methods: In May 2019, an electronic survey was distributed to representatives of the 56 ETCs.

Results: Sixty-six percent (37/56) of ETCs responded. Registered nurses comprised the majority of ETC staff. All responding units required orientation training (average = 15.21 hours) and all but one required retraining. Among the top challenges that ETCs reported to maintaining high-level isolation capabilities were staff training time, staff recruitment, staff retention, and training costs.

Discussion: Five years after ETC designation, units face staffing challenges. Research is lacking on the effective number of hours and optimal frequency of staff training. ETCs reported smaller staffing teams compared to our 2016 assessment, but team composition remains similar. As units continue to maintain capabilities with decreasing external support and attention, the need for retraining must be balanced with logistical constraints and competing demands for staff time.

Conclusions: Our study shows that US preparedness capabilities are reduced. More research, support, and funding are needed to sustain the unique knowledge and proficiency acquired by ETC teams to ensure domestic preparedness for highly hazardous communicable diseases.
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http://dx.doi.org/10.1016/j.ajic.2019.12.005DOI Listing
April 2020

A Methodology for Determining Which Diseases Warrant Care in a High-Level Containment Care Unit.

Viruses 2019 08 22;11(9). Epub 2019 Aug 22.

Department of Medicine, Division of Infectious Diseases, College of Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA.

Although the concept of high-level containment care (HLCC or 'biocontainment'), dates back to 1969, the 2014-2016 outbreak of Ebola virus disease (EVD) brought with it a renewed emphasis on the use of specialized HLCC units in the care of patients with EVD. Employment of these units in the United States and Western Europe resulted in a significant decrease in mortality compared to traditional management in field settings. Moreover, this employment appeared to significantly lessen the risk of nosocomial transmission of disease; no secondary cases occurred among healthcare workers in these units. While many now accept the wisdom of utilizing HLCC units and principles in the management of EVD (and, presumably, of other transmissible and highly hazardous viral hemorrhagic fevers, such as those caused by Marburg and Lassa viruses), no consensus exists regarding additional diseases that might warrant HLCC. We propose here a construct designed to make such determinations for existing and newly discovered diseases. The construct examines infectivity (as measured by the infectious dose needed to infect 50% of a given population (ID)), communicability (as measured by the reproductive number (R)), and hazard (as measured by morbidity and mortality). Diseases fulfilling all three criteria (i.e., those that are highly infectious, communicable, and highly hazardous) are considered candidates for HLCC management if they also meet a fourth criterion, namely that they lack effective and available licensed countermeasures.
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http://dx.doi.org/10.3390/v11090773DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6784089PMC
August 2019

Ebola Virus Disease: Clinical Challenges, Recognition, and Management.

Nurs Clin North Am 2019 06 26;54(2):169-180. Epub 2019 Mar 26.

Division of Infectious Diseases, Nebraska Biocontainment Unit, Nebraska Medicine, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198, USA.

The 2014 to 2016 Ebola outbreak response resulted in many lessons learned about biocontainment patient care, leading to enhanced domestic capabilities for highly infectious and hazardous communicable diseases. However, additional opportunities for improvement remain. The article identifies and describes key considerations and challenges for laboratory analysis, clinical management, transportation, and personnel management during the care of patients infected with Ebola or other special pathogens. Dedication to maintaining preparedness enables biocontainment patient care teams to perform at the highest levels of safety and confidence.
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http://dx.doi.org/10.1016/j.cnur.2019.02.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7096726PMC
June 2019

Evaluation of the bacterial burden of gel nails, standard nail polish, and natural nails on the hands of health care workers.

Am J Infect Control 2018 12 6;46(12):1356-1359. Epub 2018 Jul 6.

College of Graduate Nursing, Western University, Pomona, CA.

Background: Acrylic nails harbor more bacteria than natural nails, and wear is not recommended for health care workers (HCWs). Little is known about the new and popular gel nail products. This study sought to evaluate the bacterial burden of gel nails, standard nail polish, and natural nails on the hands of HCWs.

Methods: The study was conducted at 3 health centers. Nails on the dominant hand of 88 HCWs were painted with gel polish and standard polish. Cultures were obtained on days 1, 7, and 14 of wear and before and after hand hygiene with alcohol hand gel.

Results: A total of 741 cultures were obtained. Bacterial burden increased over time for all nail types (P ≤ .0001). Reductions in the bacterial burden of natural nails and standard polish, but not gel polish, (P = .001, P = .0028, and P = .98, respectively) were seen after hand hygiene. All 3 nail types become more contaminated with bacteria over time. Standard polish and natural nails may be more amenable to hand hygiene than gel polish.

Conclusions: This study did not show an increased number of microorganisms on nails with gel polish; however, gel nails may be more difficult to clean using alcohol hand gel.
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http://dx.doi.org/10.1016/j.ajic.2018.05.022DOI Listing
December 2018

Personnel Management and Biosecurity of U.S. High-Level Isolation Units.

J Nurs Adm 2018 Nov;48(11):553-560

Author Affiliations: Program Coordinator (Ms Herstein) and Associate Professor (Dr Lowe), Department of Environmental, Agricultural, & Occupational Health; Associate Professor (Dr Hewlett), Department of Internal Medicine; Medical Student (Ms Jelden), University of Nebraska Medical Center, Omaha; Vice Chairman for Emergency Preparedness (Dr Biddinger), Department of Emergency Preparedness, Massachusetts General Hospital, Boston; Associate Professor (Dr Biddinger), Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Professor and Executive Associate Dean (Dr Gibbs) and Academic Specialist (Ms Le), Department of Environmental and Occupational Health, Indiana University School of Public Health, Bloomington; and Director of Research and Development (Dr Lowe) and Medical Director (Dr Hewlett), Nebraska Biocontainment Unit, Nebraska Medicine, Omaha.

Objective: To describe strategies used by US high-level isolation units (HLIUs) to recruit, train, and sustain a full team of multidisciplinary staff and identify how units are secured.

Background: Fifty-six US hospitals have been designated HLIUs, capable of providing safe care to patients with highly infectious disease.

Methods: An electronic survey was administered to the 56 HLIUs in spring of 2016. Responses were collected via a fillable PDF and analyzed using descriptive statistics.

Results: Thirty-six HLIUs (64%) responded; 33 completed surveys, and 3 reported no longer being a designated HLIU. HLIUs reported large numbers of multidisciplinary staff, primarily consisting of RNs and critical care clinicians. Nearly all HLIUs (94%) required orientation training, although hours varied.

Conclusions: Over a short period, HLIUs recruited and trained significant numbers of staff with little guidance. Costs of ongoing trainings are considerable, and it remains unclear how HLIUs will continue funding these activities.
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http://dx.doi.org/10.1097/NNA.0000000000000679DOI Listing
November 2018

Distinguishing Respiratory Features of Category A/B Potential Bioterrorism Agents from Community-Acquired Pneumonia.

Health Secur 2018 Jul/Aug;16(4):224-238. Epub 2018 Aug 10.

Differentiating between illness caused by community-acquired respiratory pathogens versus infection by biothreat agents is a challenge. This review highlights respiratory and clinical features of category A and B potential biothreat agents that have respiratory features as their primary presenting signs and symptoms. Recent world events make such a reminder that the possibility of rare diseases and unlikely events can occur timely for clinicians, policymakers, and public health authorities. Despite some distinguishing features, nothing can replace good clinical acumen and a strong index of suspicion in the diagnosis of uncommon infectious diseases.
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http://dx.doi.org/10.1089/hs.2018.0017DOI Listing
December 2018

Observed variation in N95 respirator use by nurses demonstrating isolation care.

Am J Infect Control 2018 05 9;46(5):579-580. Epub 2018 Jan 9.

University of Nebraska Medical Center College of Medicine, Omaha, NE.

Video review and scoring was used to evaluate the behaviors of nurses wearing N95 filtering face piece respirators while providing isolation care in a simulated patient care environment. This study yielded a detailed description of behaviors related to N95 respirator use in a health care setting. Developing a more robust and systematic behavior analysis tool for use in demonstration, simulation, and clinical care would allow for improved respiratory protection of health care workers.
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http://dx.doi.org/10.1016/j.ajic.2017.11.019DOI Listing
May 2018

US State Public Health Departments Special Pathogen Planning.

J Public Health Manag Pract 2018 Sep/Oct;24(5):E28-E33

Departments of Environmental, Agricultural & Occupational Health (Ms Herstein and Dr Lowe) and Internal Medicine, Division of Infectious Diseases (Dr Hewlett) and College of Medicine (Ms Jelden), University of Nebraska Medical Center, Omaha, Nebraska; Department of Emergency Medicine, Division of Emergency Preparedness, Massachusetts General Hospital, Boston, Massachusetts (Dr Biddinger); Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts (Dr Biddinger); Department of Environmental and Occupational Health, Indiana University School of Public Health, Bloomington, Indiana (Dr Gibbs and Ms Le); and Nebraska Biocontainment Unit, Omaha, Nebraska (Drs Hewlett and Lowe).

Context: US state public health departments played key roles in planning for and responding to confirmed and suspected cases of Ebola virus disease (EVD) during the 2014-2016 outbreak, including designating select hospitals as high-level isolation units (HLIUs) for EVD treatment in conjunction with the Centers for Disease Control and Prevention.

Objective: To identify existing guidelines and perspectives of state health departments pertaining to the management and transport of patients with EVD and other highly hazardous communicable diseases (HHCDs).

Design: An electronic 8-question survey with subquestions was administered as a fillable PDF.

Setting: The survey was distributed to publicly accessible e-mails of state health department employees.

Participants: State epidemiologists, emergency preparedness directors, or chief medical officers from each of the 50 states and the District of Columbia were contacted; a representative from 36 states and the District of Columbia responded (73%).

Main Outcome Measures: Descriptive statistics were used to identify the proportion of state health departments with various existing protocols.

Results: A majority of states reported that they would prefer patients confirmed with viral hemorrhagic fevers (eg, EVD, Marburg fever) and smallpox be transported to an HLIU for treatment rather than remain at the initial hospital of diagnosis. While most (89%) states had written guidelines for the safe transportation of patients with HHCDs, only 6 (16%) had written protocols for the management of accidents or other travel disruptions that may occur during HHCD transport within the state. Twenty-two state health departments (59%) had operationally exercised transport of a patient to an HLIU.

Conclusions: Nearly half of states in the United States lack an HLIU, yet most prefer to have patients with HHCDs treated in high-level isolation. Recent budget cuts and uncertainty of future funding threaten the abilities of health departments to devote the necessary resources and staff to prepare for and deliver the desired care to HHCD cases. The lack of HLIUs in some states may complicate transport to a geographically proximate HLIU. Moreover, limited guidance on diseases that warrant high-level isolation may cause disagreement in HHCD patient placement between health departments, diagnosing facilities, and HLIUs.
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http://dx.doi.org/10.1097/PHH.0000000000000714DOI Listing
November 2019

U.S. High-Level Isolation Unit Clinical Laboratory Capabilities Update.

J Clin Microbiol 2018 02 24;56(2). Epub 2018 Jan 24.

Department of Environmental, Agricultural, and Occupational Health, University of Nebraska Medical Center, Omaha, Nebraska, USA.

In late 2014, 56 hospitals in the United States were designated by state and federal public health authorities as specially designed high-level isolation units (HLIUs) equipped with advanced infrastructure, laboratory capabilities, and trained staff to care for patients with highly hazardous communicable diseases (HHCDs), such as Ebola virus disease. This survey describes the clinical laboratory support capabilities of U.S. HLIUs, including the specific test menus that HLIUs have identified to safely manage HHCD patients and the locations where such testing would be performed. In spring 2016, a survey was electronically distributed, as a fillable pdf file, to the 56 U.S. HLIUs. Site representatives completed the surveys, and data were coded and analyzed in an electronic spreadsheet, using descriptive statistics. Thirty-six HLIUs (64%) responded, and 33 completed the laboratory capabilities section. Thirty-one HLIUs (94%) had performed risk analyses for all laboratory procedures and equipment. Twenty-nine (88%) had decontamination procedures specified for all laboratory equipment used for patients with suspected or confirmed HHCDs. On-site laboratories in 27 HLIUs (81%) had the capacity to inventory and to securely store HHCD patient specimens. Ten HLIUs (31%) had at least one test they would conduct within the patient isolation room. The high-risk nature of HHCDs and the occupational exposures that may occur in clinical laboratories demand advanced preparation and risk assessment of work practices, laboratory equipment, and instrumentation by HLIU laboratories. Although risk analyses of clinical laboratory testing and equipment that HLIUs have conducted have likely focused on those for Ebola virus, HLIUs must be prepared to revise their current procedures for other HHCDs.
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http://dx.doi.org/10.1128/JCM.01608-17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5786736PMC
February 2018

Comment on "Ebola Virus Infection among Western Healthcare Workers Unable to Recall the Transmission Route".

Biomed Res Int 2017 20;2017:7458242. Epub 2017 Sep 20.

Division of Infectious Diseases and Nebraska Biocontainment Unit, University of Nebraska Medical Center, Omaha, NE, USA.

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http://dx.doi.org/10.1155/2017/7458242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5632492PMC
November 2018

High-Level Isolation Unit Infection Control Procedures.

Health Secur 2017 Sep/Oct;15(5):519-526

The 2014-2016 Ebola outbreak in West Africa prompted a select group of US hospitals to establish high-level isolation units equipped with advanced engineering controls, trained staff, and stringent protocols to safely treat highly infectious disease patients. This survey details the comprehensive infection control protocols developed by these units, including for decontamination of units, post-mortem management, liquid waste disposal, and personal protective equipment (PPE) use. In spring 2016, a survey was electronically distributed to the 56 original Centers for Disease Control and Prevention (CDC)-designated high-level isolation units. Responses were collected via a fillable PDF and analyzed using descriptive statistics. Thirty-six (64%) high-level isolation units responded; 33 completed the survey, and 3 reported they no longer maintained high-level isolation unit capabilities. Nearly all responding units had written procedures for decontamination, liquid waste disposal, and PPE use; however, infection control protocols varied between units. High-level isolation units implemented multiple strategies in promoting hand hygiene among staff and in monitoring correct PPE use. Maximum time allowed in full PPE was restricted in all but 2 units (average of 3.45 hours per shift). Almost all (94%) had written procedures for the management of human remains, although only 2 units had written protocols for an autopsy of a patient with a highly infectious disease. While the vast majority of high-level isolation units reported having written protocols for infection control practices, staff compliance and procedural application are the true indicators of the state of preparedness. Therefore, rigorous training and staff adherence to infection control practices is critical to minimizing exposure risks.
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http://dx.doi.org/10.1089/hs.2017.0026DOI Listing
June 2018

Sustainability of High-Level Isolation Capabilities among US Ebola Treatment Centers.

Emerg Infect Dis 2017 06;23(6):965-967

To identify barriers to maintaining and applying capabilities of US high-level isolation units (HLIUs) used during the Ebola virus disease outbreak, during 2016 we surveyed HLIUs. HLIUs identified sustainability challenges and reported the highly infectious diseases they would treat. HLIUs expended substantial resources in development but must strategize models of sustainability to maintain readiness.
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http://dx.doi.org/10.3201/eid2306.170062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5443454PMC
June 2017

Ultraviolet (UV)-reflective paint with ultraviolet germicidal irradiation (UVGI) improves decontamination of nosocomial bacteria on hospital room surfaces.

J Occup Environ Hyg 2017 06;14(6):456-460

a Department of Environmental , Agricultural & Occupational Health, University of Nebraska Medical Center , Omaha , Nebraska.

An ultraviolet germicidal irradiation (UVGI) generator (the TORCH, ClorDiSys Solutions, Inc.) was used to compare the disinfection of surface coupons (plastic from a bedrail, stainless steel, and chrome-plated light switch cover) in a hospital room with walls coated with ultraviolet (UV)-reflective paint (Lumacept) or standard paint. Each surface coupon was inoculated with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus faecalis (VRE), placed at 6 different sites within a hospital room coated with UV-reflective paint or standard paint, and treated by 10 min UVC exposure (UVC dose of 0-688 mJ/cm between sites with standard paint and 0-553 mJ/cm with UV-reflective paint) in 8 total trials. Aggregated MRSA concentrations on plastic bedrail surface coupons were reduced on average by 3.0 log (1.8 log Geometric Standard Deviation [GSD]) with standard paint and 4.3 log (1.3 log GSD) with UV-reflective paint (p = 0.0005) with no significant reduction differences between paints on stainless steel and chrome. Average VRE concentrations were reduced by ≥4.9 log (<1.2 log GSD) on all surface types with UV-reflective paint and ≤4.1 log (<1.7 log GSD) with standard paint (p < 0.05). At 5 aggregated sites directly exposed to UVC light, MRSA concentrations on average were reduced by 5.2 log (1.4 log GSD) with standard paint and 5.1 log (1.2 log GSD) with UV-reflective paint (p = 0.017) and VRE by 4.4 log (1.4 log GSD) with standard paint and 5.3 log (1.1 log GSD) with UV-reflective paint (p < 0.0001). At one indirectly exposed site on the opposite side of the hospital bed from the UVGI generator, MRSA concentrations on average were reduced by 1.3 log (1.7 log GSD) with standard paint and 4.7 log (1.3 log GSD) with UV-reflective paint (p < 0.0001) and VRE by 1.2 log (1.5 log GSD) with standard paint and 4.6 log (1.1 log GSD) with UV-reflective paint (p < 0.0001). Coating hospital room walls with UV-reflective paint enhanced UVGI disinfection of nosocomial bacteria on various surfaces compared to standard paint, particularly at a surface placement site indirectly exposed to UVC light.
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http://dx.doi.org/10.1080/15459624.2017.1296231DOI Listing
June 2017

Interagency cooperation is the key to an effective pandemic response.

Lancet Infect Dis 2017 01;17(1):21

College of Public Health, Omaha, Nebraska; Nebraska Biocontainment Unit University of Nebraska, Omaha, Nebraska.

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http://dx.doi.org/10.1016/S1473-3099(16)30549-7DOI Listing
January 2017

Containment Care Units for Managing Patients With Highly Hazardous Infectious Diseases: A Concept Whose Time Has Come.

J Infect Dis 2016 10 19;214(suppl 3):S137-S141. Epub 2016 Sep 19.

College of Public Health Nebraska Biocontainment Unit, University of Nebraska Medical Center, Omaha.

The concept of containment care for patients with highly hazardous infectious diseases originated in conjunction with the development of sophisticated biosafety level 4 laboratories at the US Army Medical Research Institute of Infectious Diseases in the late 1960s. Over time, the original containment facility served as a model for the development of other facilities in the United States at government and academic centers. The Ebola outbreak of 2014-2015 brought the issue of containment care into the mainstream and led to the development of such capabilities at strategic points around the country. We describe the original concepts behind development of such facilities, how the concept and acceptance has evolved over time, and how the guidelines for managing patients infected with viral hemorrhagic fevers have evolved as new information has been learned about protecting medical care providers from highly hazardous infectious pathogens.
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http://dx.doi.org/10.1093/infdis/jiw292DOI Listing
October 2016

Evaluating Isolation Behaviors by Nurses Using Mobile Computer Workstations at the Bedside.

Comput Inform Nurs 2016 Sep;34(9):387-92

Author Affiliations: University of Nebraska Medical Center (UNMC) College of Nursing, Omaha, NE (Dr Beam); Department of Environmental Health, Indiana University School of Public Health, Bloomington, IN (Dr Gibbs); Infectious Diseases, UNMC College of Medicine, Omaha, NE (Dr Hewlett); Pathology/Microbiology, UNMC College of Medicine, Omaha, NE (Dr Iwen); The Nebraska Medical Center, Omaha, NE (Dr Nuss); and Infectious Diseases, UNMC College of Medicine, Omaha, NE (Dr Smith).

This secondary analysis from a larger mixed methods study with a sequential explanatory design investigates the clinical challenges for nurses providing patient care, in an airborne and contact isolation room, while using a computer on wheels for medication administration in a simulated setting. Registered nurses, who regularly work in clinical care at the patient bedside, were recruited as study participants in the simulation and debriefing experience. A live volunteer acted as the standardized patient who needed assessment and intravenous pain medication. The simulation was video recorded in a typical hospital room to observe participating nurses conducting patient care in an airborne and contact isolation situation. Participants then reviewed their performance with study personnel in a formal, audio-recorded debriefing. Isolation behaviors were scored by an expert panel, and the debriefing sessions were analyzed. Considerable variation was found in behaviors related to using a computer on wheels while caring for a patient in isolation. Currently, no nursing care guidelines exist on the use of computers on wheels in an airborne and contact isolation room. Specific education is needed on nursing care processes for the proper disinfection of computers on wheels and the reduction of the potential for disease transmission from environmental contamination.
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http://dx.doi.org/10.1097/CIN.0000000000000248DOI Listing
September 2016

Use of Postexposure Prophylaxis After Occupational Exposure to Zaire ebolavirus.

Clin Infect Dis 2016 08 26;63(3):376-9. Epub 2016 Apr 26.

Centers for Disease Control and Prevention.

From September 2014 to April 2015, 6 persons who had occupational exposures to Zaire ebolavirus in West Africa received investigational agent rVSV-ZEBOV or TKM-100802 for postexposure prophylaxis and were monitored in the United States. All patients experienced self-limited symptoms after postexposure prophylaxis; none developed Ebola virus disease.
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http://dx.doi.org/10.1093/cid/ciw256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4946014PMC
August 2016

Infection Prevention in the Hospital from Past to Present: Evolving Roles and Shifting Priorities.

Curr Infect Dis Rep 2016 May;18(5):16

Division of Infectious Disease, Virginia Commonwealth University School of Medicine, Richmond, VA, 23219, USA.

Hospital epidemiologists are vital components of integrated health centers. This central place in the healthcare landscape has rapidly evolved over a half century. Early hospital epidemiologists possessed a visionary focus on patient safety many decades prior to the quality revolution of the 1990s. A systematic and scientific approach to infection prevention has facilitated the evolution of hospital epidemiology, along with advances in technology, and increasing public attention to infectious complications in the hospital. Currently, the growing expansion of tasks and moving regulatory targets strain existing resources. These challenges threaten to limit the effectiveness of some infection-prevention activities, while also providing important opportunities for improving care. It will be increasingly important to advocate for appropriate resources to address a diverse set of changing infection prevention priorities.
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http://dx.doi.org/10.1007/s11908-016-0523-zDOI Listing
May 2016

Comparison of hospital room surface disinfection using a novel ultraviolet germicidal irradiation (UVGI) generator.

J Occup Environ Hyg 2016 09;13(9):690-8

a Department of Environmental , Agricultural & Occupational Health, University of Nebraska Medical Center , Omaha , Nebraska.

The estimated 721,800 hospital acquired infections per year in the United States have necessitated development of novel environmental decontamination technologies such as ultraviolet germicidal irradiation (UVGI). This study evaluated the efficacy of a novel, portable UVGI generator (the TORCH, ChlorDiSys Solutions, Inc., Lebanon, NJ) to disinfect surface coupons composed of plastic from a bedrail, stainless steel, chrome-plated light switch cover, and a porcelain tile that were inoculated with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus faecalis (VRE). Each surface type was placed at 6 different sites within a hospital room and treated by 10-min ultraviolet-C (UVC) exposures using the TORCH with doses ranging from 0-688 mJ/cm(2) between sites. Organism reductions were compared with untreated surface coupons as controls. Overall, UVGI significantly reduced MRSA by an average of 4.6 log10 (GSD: 1.7 log10, 77% inactivation, p < 0.0001) and VRE by an average of 3.9 log10 (GSD: 1.7 log10, 65% inactivation, p < 0.0001). MRSA on bedrail was reduced significantly (p < 0.0001) less than on other surfaces, while VRE was reduced significantly less on chrome (p = 0.0004) and stainless steel (p = 0.0012) than porcelain tile. Organisms out of direct line of sight of the UVC generator were reduced significantly less (p < 0.0001) than those directly in line of sight. UVGI was found an effective method to inactivate nosocomial pathogens on surfaces evaluated within the hospital environment in direct line of sight of UVGI treatment with variation between organism and surface types.
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http://dx.doi.org/10.1080/15459624.2016.1166369DOI Listing
September 2016

Clinical Management of Ebola Virus Disease in the United States and Europe.

N Engl J Med 2016 Feb;374(7):636-46

From the Centers for Disease Control and Prevention (T.M.U., J.G.) and the Division of Infectious Diseases, Emory University School of Medicine (A.K.M.) - both in Atlanta; the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (R.T.D.); Texas Health Presbyterian Hospital Dallas, Dallas (A.M.L.); the Department of Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main (T.W.), the First Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg (S.S.), and Leipzig Treatment Center for Highly Contagious Diseases, Klinikum St. Georg, Leipzig (T.G.) - all in Germany; the Division of Infectious Diseases and Laboratory of Virology, Geneva University Hospitals, Geneva (P.V.); the Department of Infection, Royal Free London NHS Foundation Trust, London (M.J.); the Internal Medicine Department, Infectious Diseases Unit Madrid, Hospital La Paz-Carlos III IdiPAZ, Madrid (J.R.A.); New York University School of Medicine-Bellevue Hospital Center, New York (L.E.); University of Nebraska Medical Center, Omaha (A.L.H.); the Departments of Infectious Diseases and Acute Medicine, Oslo University Hospital, Oslo (A.B.B.); Lazzaro Spallanzani National Institute for Infectious Diseases, Rome (G.I.); the Infectious and Tropical Diseases Department, Bégin Military Hospital, Saint-Mandé, France (C.R.); and the Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, the Netherlands (A.I.M.H.).

Background: Available data on the characteristics of patients with Ebola virus disease (EVD) and clinical management of EVD in settings outside West Africa, as well as the complications observed in those patients, are limited.

Methods: We reviewed available clinical, laboratory, and virologic data from all patients with laboratory-confirmed Ebola virus infection who received care in U.S. and European hospitals from August 2014 through December 2015.

Results: A total of 27 patients (median age, 36 years [range, 25 to 75]) with EVD received care; 19 patients (70%) were male, 9 of 26 patients (35%) had coexisting conditions, and 22 (81%) were health care personnel. Of the 27 patients, 24 (89%) were medically evacuated from West Africa or were exposed to and infected with Ebola virus in West Africa and had onset of illness and laboratory confirmation of Ebola virus infection in Europe or the United States, and 3 (11%) acquired EVD in the United States or Europe. At the onset of illness, the most common signs and symptoms were fatigue (20 patients [80%]) and fever or feverishness (17 patients [68%]). During the clinical course, the predominant findings included diarrhea, hypoalbuminemia, hyponatremia, hypokalemia, hypocalcemia, and hypomagnesemia; 14 patients (52%) had hypoxemia, and 9 (33%) had oliguria, of whom 5 had anuria. Aminotransferase levels peaked at a median of 9 days after the onset of illness. Nearly all the patients received intravenous fluids and electrolyte supplementation; 9 (33%) received noninvasive or invasive mechanical ventilation; 5 (19%) received continuous renal-replacement therapy; 22 (81%) received empirical antibiotics; and 23 (85%) received investigational therapies (19 [70%] received at least two experimental interventions). Ebola viral RNA levels in blood peaked at a median of 7 days after the onset of illness, and the median time from the onset of symptoms to clearance of viremia was 17.5 days. A total of 5 patients died, including 3 who had respiratory and renal failure, for a mortality of 18.5%.

Conclusions: Among the patients with EVD who were cared for in the United States or Europe, close monitoring and aggressive supportive care that included intravenous fluid hydration, correction of electrolyte abnormalities, nutritional support, and critical care management for respiratory and renal failure were needed; 81.5% of these patients who received this care survived.
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http://dx.doi.org/10.1056/NEJMoa1504874DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4972324PMC
February 2016

U.S. Ebola Treatment Center Clinical Laboratory Support.

J Clin Microbiol 2016 Apr 3;54(4):1031-5. Epub 2016 Feb 3.

Department of Environmental, Agricultural, and Occupational Health, University of Nebraska Medical Center, Omaha, Nebraska, USA

Fifty-five hospitals in the United States have been designated Ebola treatment centers (ETCs) by their state and local health authorities. Designated ETCs must have appropriate plans to manage a patient with confirmed Ebola virus disease (EVD) for the full duration of illness and must have these plans assessed through a CDC site visit conducted by an interdisciplinary team of subject matter experts. This study determined the clinical laboratory capabilities of these ETCs. ETCs were electronically surveyed on clinical laboratory characteristics. Survey responses were returned from 47 ETCs (85%). Forty-one (87%) of the ETCs planned to provide some laboratory support (e.g., point-of-care [POC] testing) within the room of the isolated patient. Forty-four (94%) ETCs indicated that their hospital would also provide clinical laboratory support for patient care. Twenty-two (50%) of these ETC clinical laboratories had biosafety level 3 (BSL-3) containment. Of all respondents, 34 (72%) were supported by their jurisdictional public health laboratory (PHL), all of which had available BSL-3 laboratories. Overall, 40 of 44 (91%) ETCs reported BSL-3 laboratory support via their clinical laboratory and/or PHL. This survey provided a snapshot of the laboratory support for designated U.S. ETCs. ETCs have approached high-level isolation critical care with laboratory support in close proximity to the patient room and by distributing laboratory support among laboratory resources. Experts might review safety considerations for these laboratory testing/diagnostic activities that are novel in the context of biocontainment care.
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http://dx.doi.org/10.1128/JCM.02905-15DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4809931PMC
April 2016

Current Capabilities and Capacity of Ebola Treatment Centers in the United States.

Infect Control Hosp Epidemiol 2016 Mar 8;37(3):313-8. Epub 2015 Dec 8.

1Department of Environmental,Agricultural & Occupational Health,University of Nebraska Medical Center,Omaha,Nebraska.

Objective: To describe current Ebola treatment center (ETC) locations, their capacity to care for Ebola virus disease patients, and infection control infrastructure features.

Design: A 19-question survey was distributed electronically in April 2015. Responses were collected via email by June 2015 and analyzed in an electronic spreadsheet.

Setting: The survey was sent to and completed by site representatives of each ETC.

Participants: The survey was sent to all 55 ETCs; 47 (85%) responded.

Results: Of the 47 responding ETCs, there are 84 isolation beds available for adults and 91 for children; of these pediatric beds, 35 (38%) are in children's hospitals. In total, the simultaneous capacity of the 47 reporting ETCs is 121 beds. On the basis of the current US census, there are 0.38 beds per million population. Most ETCs have negative pressure isolation rooms, anterooms, and a process for category A waste sterilization, although only 11 facilities (23%) have the capability to sterilize infectious waste on site.

Conclusions: Facilities developed ETCs on the basis of Centers for Disease Control and Prevention guidance, but specific capabilities are not mandated at this present time. Owing to the complex and costly nature of Ebola virus disease treatment and variability in capabilities from facility to facility, in conjunction with the lack of regulations, nationwide capacity in specialized facilities is limited. Further assessments should determine whether ETCs can adapt to safely manage other highly infectious disease threats.
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http://dx.doi.org/10.1017/ice.2015.300DOI Listing
March 2016

Learning from Ebola: Interprofessional practice in the Nebraska Biocontainment Unit.

J Interprof Educ Pract 2015 Dec 17;1(3):97-99. Epub 2015 Aug 17.

Nebraska Biocontainment Unit, Nebraska Medicine, Omaha, NE 68198, USA.

Caring for patients with Ebola virus disease (EVD) in the Nebraska Biocontainment Unit (NBU) has necessitated and enabled extensive interprofessional relationships and the creation of a collaborative care model. Critical aspects of NBU functionality include a constructive leadership environment, staff inclusion and consideration during protocol development, and a culture of partnership and communication.
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http://dx.doi.org/10.1016/j.xjep.2015.07.071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7104021PMC
December 2015

Ebola virus disease: preparedness and infection control lessons learned from two biocontainment units.

Curr Opin Infect Dis 2015 Aug;28(4):343-8

aDivision of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska bDivision of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.

Purpose Of Review: This review details infection control issues encountered in the management of patients with Ebola virus disease (EVD), with emphasis on how these issues were confronted in two biocontainment patient care units in the United States.

Recent Findings: There is a notable paucity of medical literature to guide infection control policies and procedures when caring for patients with EVD. Thus, the experience of the Serious Communicable Diseases Unit at Emory University Hospital and the Nebraska Biocontainment Unit at the University of Nebraska Medical Center serves as the basis for this review. Facility issues, staffing, transportation logistics, and appropriate use of personal protective equipment are detailed. Other topics addressed include the evaluation of patients under investigation and ethical issues concerning the safe utilization of advanced life support.

Summary: This review intends to serve as a reference for facilities that are in the process of creating protocols for managing patients with EVD. Given the lack of literature to support many of the recommendations discussed, it is important to utilize the available referenced guidelines, along with the practical experiences of biocontainment units, to optimize the care provided to patients with EVD while strictly adhering to infection control principles.
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http://dx.doi.org/10.1097/QCO.0000000000000176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4743738PMC
August 2015

Administration of Brincidofovir and Convalescent Plasma in a Patient With Ebola Virus Disease.

Clin Infect Dis 2015 Sep 19;61(6):969-73. Epub 2015 May 19.

Infectious Diseases Division.

From 2014 to May 2015, >26 000 Ebola virus disease (EVD) cases were reported from West Africa. We present a patient with EVD who received brincidofovir and convalescent plasma. The relative contributions of supportive care, investigational therapies, and patient's immune-response on survival could not be determined. Randomized trials are needed.
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http://dx.doi.org/10.1093/cid/civ395DOI Listing
September 2015