Once again, the medical community is taking notice of a highly contagious pathogen arising in Africa and potentially threatening all of mankind. The Ebola virus has now caused a very real pandemic that is wiping out villages and rapidly crossing borders in African nations. Those nations’ public health and social resources are challenge by this dangerous, aggressive killer.
As I write, Ebola has killed more than 3,000 people with thousands more infected. The United Nations estimates that $1 billion will be needed to fight the epidemic and President Obama has pledged 3,000 U.S. military personnel and many more military medical staff to train the thousands of healthcare providers who will be required to care for patients and prevent disease transmission. We know now that the viral agent has arrived in the United States via evacuated medical personnel and that the first U.S. case has been diagnosed in Texas. That patient died yesterday.
While all the medical personnel were treated successfully, our heightened awareness about Ebola has provoked discussion of its challenge to our patient and provider safety environment.
Some of the recent news reporting—much of which breeds confusion and near panic—reminds me of the worldwide fear and panic that took place nearly 30 years ago when another African virus came onto the world’s medical stage: HIV. Back then there was a 60 Minutes segment in which a well-known San Francisco-based surgeon was interviewed talking about how she refused to expose her surgical team to the then perceived high risk of cross infection from HIV-positive patients.
Ultimately, knowledge, experience, and relearning and applying basic care techniques, won the day. Yes, the HIV/AIDS patient still poses a risk of infection, but we have developed protocols, policies, procedures, and even the specialized medical devices that help minimize and manage the healthcare environment safely for both patients and their providers.
The fact is that healthcare has proven itself to be a highly adaptable, ever-evolving industry, constantly incorporating new materials and technology to enhance infection control and advance patient care and safety. I personally have practiced through many operating room changes. As a surgical resident, gowns, masks, and hats all were made of cloth and required a trip to the laundry, followed by an autoclave bake. Any small holes found during inspection were patched. At the time, most surgical devices also were reprocessed. Tracheostomy tubes, which were usually metal with a slip-on balloon, were cleaned and used on another patient when needed. It’s hard to believe, but that was the “standard of care.”
The good news is that industry and material advances are making it possible to eliminate the expensive and imperfect in-house reprocessing of devices and trays, reduce the risk of cross contamination and make the patient care environment safer. I can remember clearly donning my first paper mask and hat and thereafter a paper gown. Soon, all the cloth OR patient drapes were replaced. Today, advances have led us to entirely disposable (single-use) devices and procedure trays and the timing couldn’t be better.
In light of the Ebola outbreak, hospitals in this country are tasked with making sure that they’re prepared to contain the virus. In an effort to assist, the Centers for Disease Control (CDC) in August released infection prevention and control guidance for U.S. hospitals treating “known or suspected” Ebola victims. Among their recommendations, the CDC suggests that “dedicated medical equipment (preferably disposable, when possible) should be used for the provision of patient care” and “all non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer’s instructions and hospital policies.” This all makes sense, but even single-use innovations pose some infection control challenges.
Take, for example, medical devices requiring the use of an external light source—laryngoscopes, anoscopes, vaginal speculums, etc. These pieces of equipment are often hard to effectively clean. In most cases, they have internal wiring or light-conducting tube that attaches to either a large battery in the handle or to a threaded fiber optic cable (with broken fibers), which, itself, attaches to a light source that can cost several hundred dollars. The disassembly and careful cleaning and reprocessing of these pieces can be expensive, time consuming, and often imperfect. Reprocessing can take up to 24 hours and delays often limit procedure volume. A busy OR, ED, or clinic using these devices would have to purchase multiple sets in order to keep up with the demand. And several studies of laryngoscope handles, as an example, have found that even those that have been reprocessed and deemed “ready to use” still have bacteria on them.
Over time, the science and engineering of plastic materials, light emitting diodes (LED) and battery technology have all advanced and innovation has led to products capable of meeting clinicians’ needs while eliminating reprocessing costs and, most importantly, reducing (or eliminating) the risk of device-based cross contamination. These disposable devices cost much less to shelve, use, and then discard compared to the previous complex cleaning, reprocessing and repackaging cycle.
For an excellent example of this product evolution one can study the evolution of the vaginal speculum and laryngoscope. Many healthcare facilities are moving from reusable metal to disposable plastic versions of these devices because of cost, convenience and elimination of reprocessing and cross contamination concerns. Some disposable models, however, still make use of add-on plug-in or rechargeable light sources that can get dirty and become sources of cross contamination if not properly cleaned between cases.
Newer, more advanced disposable single-use options actually can have an integral built-in light and power sources.This integration is possible because the very low power requirement of the LED light allows for much smaller batteries. This means that everything, including the light source and batteries, comes out of the package pre-assembled and ready to use and is thrown away after a single procedure. The great benefit of an “all-in-one” integrated device as compared devices requiring a reusable light source is that the device-light assembly time cost (hunting and gathering), the light source cleaning and reprocessing cost, and the possible risk of cross contamination are all eliminated.
During the more than 30 years since the HIV virus challenged healthcare, many advances in the patient care environment have occurred. Our profession first reemphasized and enforced standard care and isolation procedures on all patients and we have benefitted from improved care devices and supplies. Now, single-use procedure trays, safer needles, central line placement standardization, enhanced policy and procedures to protect patients and care-givers, and a whole new class of truly disposable instruments all combine to arm our profession as we face the newest virus challenge coming out of Africa.
About the Author:
Douglas H. McConnell, M.D., F.A.C.S., is Medical Director at OBP Medical, the leading global developer of single-use, self-contained, illuminating medical devices. Trained at Stanford University and the University of California at Los Angeles (UCLA) School of Medicine, Dr. McConnell is board certified in Thoracic Surgery and currently serves as Director of Cardiac Surgery at Shasta Regional Medical Center, a 246-bed acute care, medical and surgical facility in Northern California.