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Lukowski J, Vasa A, Arguinchona C, ElRayes W, Frank MG, Galdys AL, Garcia MC, Garland JA, Kline S, Persson C, Ruby D, Sauer LM, Vasistha S, Carrasco S, Herstein JJ. A narrative review of high-level isolation unit operational and infrastructure features. BMJ Glob Health 2023; 8:e012037. [PMID: 37423621 DOI: 10.1136/bmjgh-2023-012037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/29/2023] [Indexed: 07/11/2023] Open
Abstract
High-level isolation units (HLIUs) are specially designed facilities for care and management of patients with suspected or confirmed high-consequence infectious diseases (HCIDs), equipped with unique infrastructure and operational features. While individual HLIUs have published on their experiences caring for patients with HCIDs and two previous HLIU consensus efforts have outlined key components of HLIUs, we aimed to summarise the existing literature that describes best practices, challenges and core features of these specialised facilities. A narrative review of the literature was conducted using keywords associated with HLIUs and HCIDs. A total of 100 articles were used throughout the manuscript from the literature search or from alternate methods like reference checks or snowballing. Articles were sorted into categories (eg, physical infrastructure, laboratory, internal transport); for each category, a synthesis of the relevant literature was conducted to describe best practices, experiences and operational features. The review and summary of HLIU experiences, best practices, challenges and components can serve as a resource for units continuing to improve readiness, or for hospitals in early stages of developing their HLIU teams and planning or constructing their units. The COVID-19 pandemic, a global outbreak of mpox, sporadic cases of viral haemorrhagic fevers in Europe and the USA, and recent outbreaks of Lassa fever, Sudan Ebolavirus, and Marburg emphasise the need for an extensive summary of HLIU practices to inform readiness and response.
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Affiliation(s)
- Joseph Lukowski
- College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Christa Arguinchona
- Special Pathogens Program, Providence Sacred Heart Medical Center, Spokane, Washington, USA
| | - Wael ElRayes
- College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Global Center for Health Security, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Maria G Frank
- School of Medicine, University of Colorado, Denver, Colorado, USA
- Biocontainment Unit, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Alison L Galdys
- Division of Infectious Disease and International Medicine - Department of Medicine, University of Minnesota Medical School Twin Cities Campus, Minneapolis, Minnesota, USA
| | - Mary C Garcia
- Department of Laboratory Services, The University of Texas Medical Branch, Galveston, Texas, USA
| | - Jennifer A Garland
- Department of Hospital Epidemiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Susan Kline
- Division of Infectious Disease and International Medicine - Department of Medicine, University of Minnesota Medical School Twin Cities Campus, Minneapolis, Minnesota, USA
| | - Caroline Persson
- Biocontainment Unit, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Darrell Ruby
- Special Pathogens Program, Providence Sacred Heart Medical Center, Spokane, Washington, USA
| | - Lauren M Sauer
- College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Global Center for Health Security, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sami Vasistha
- Global Center for Health Security, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sharon Carrasco
- Serious Communicable Disease Program, Emory University, Atlanta, Georgia, USA
| | - Jocelyn J Herstein
- College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Global Center for Health Security, University of Nebraska Medical Center, Omaha, Nebraska, USA
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2
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Mulkey SB, Ansusinha E, Cristante C, Russo SM, Biddle C, Kousa YA, Pesacreta L, Jantausch B, Hanisch B, Harik N, Hamdy RF, Hahn A, Chang T, Jaafar M, Ambrose T, Vezina G, Bulas DI, Wessel D, du Plessis AJ, DeBiasi RL. Complexities of Zika Diagnosis and Evaluation in a U.S. Congenital Zika Program. Am J Trop Med Hyg 2021; 104:2210-2219. [PMID: 33872214 DOI: 10.4269/ajtmh.20-1256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/23/2020] [Indexed: 12/31/2022] Open
Abstract
The objective of the study was to describe the complexity of diagnosis and evaluation of Zika-exposed pregnant women/fetuses and infants in a U.S. Congenital Zika Program. Pregnant women/fetuses and/or infants referred for clinical evaluation to the Congenital Zika Program at Children's National (Washington, DC) from January 2016 to June 2018 were included. We recorded the timing of maternal Zika-virus (ZIKV) exposure and ZIKV laboratory testing results. Based on laboratory testing, cases were either confirmed, possible, or unlikely ZIKV infection. Prenatal and postnatal imaging by ultrasound and/or magnetic resonance imaging (MRI) were categorized as normal, nonspecific, or as findings of congenital Zika syndrome (CZS). Of 81 women-fetus/infant pairs evaluated, 72 (89%) had confirmed ZIKV exposure; 18% of women were symptomatic; only a minority presented for evaluation within the time frame for laboratory detection. Zika virus could only be confirmed in 29 (40%) cases, was possible in 26 (36%) cases, and was excluded in 17 (24%) cases. Five cases (7%) had prenatal ultrasound and MRI findings of CZS, but in only three was ZIKV confirmed by laboratory testing. Because of timing of exposure to presentation, ZIKV infection could not be excluded in many cases. Neuroimaging found CZS in 7% of cases, and in many patients, there were nonspecific imaging findings that warrant long-term follow-up. Overall, adherence to postnatal recommended follow-up evaluations was modest, representing a barrier to care. These challenges may be instructive to future pediatric multidisciplinary clinics for congenital infectious/noninfectious threats to pregnant women and their infants.
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Affiliation(s)
- Sarah B Mulkey
- 1Division of Fetal and Transitional Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,2Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,3Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Emily Ansusinha
- 4Division of Pediatric Infectious Diseases, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Caitlin Cristante
- 1Division of Fetal and Transitional Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Stephanie M Russo
- 1Division of Fetal and Transitional Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Cara Biddle
- 2Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,5Division of General and Community Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Youssef A Kousa
- 2Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,6Division of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Lindsay Pesacreta
- 1Division of Fetal and Transitional Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Barbara Jantausch
- 2Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,4Division of Pediatric Infectious Diseases, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Benjamin Hanisch
- 2Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,4Division of Pediatric Infectious Diseases, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Nada Harik
- 2Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,4Division of Pediatric Infectious Diseases, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Rana F Hamdy
- 2Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,4Division of Pediatric Infectious Diseases, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Andrea Hahn
- 2Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,4Division of Pediatric Infectious Diseases, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Taeun Chang
- 2Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,3Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,6Division of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Mohamad Jaafar
- 2Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,7Division of Ophthalmology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Tracey Ambrose
- 8Division of Audiology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Gilbert Vezina
- 2Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,9Division of Radiology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Dorothy I Bulas
- 2Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,9Division of Radiology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - David Wessel
- 2Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,10Division of Chief Medical Officer, Children's National Hospital, Washington, District of Columbia
| | - Adre J du Plessis
- 1Division of Fetal and Transitional Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,2Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,3Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,6Division of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Roberta L DeBiasi
- 2Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,4Division of Pediatric Infectious Diseases, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,11Department of Microbiology, Immunology and Tropical Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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The Isolation Communication Management System. A Telemedicine Platform to Care for Patients in a Biocontainment Unit. Ann Am Thorac Soc 2021; 17:673-678. [PMID: 32357069 PMCID: PMC7258411 DOI: 10.1513/annalsats.202003-261ip] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Kiiza P, Adhikari NKJ, Mullin S, Teo K, Fowler RA. Principles and Practices of Establishing a Hospital-Based Ebola Treatment Unit. Crit Care Clin 2020; 35:697-710. [PMID: 31445614 DOI: 10.1016/j.ccc.2019.06.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Outbreaks of Ebola virus disease and high-risk transmissible infections are increasing and pose threats to health care workers and global health systems. Previous outbreaks offer lessons for health system preparedness and response, including establishment of hospital-based high-risk pathogen treatment units. Their creation demands early preparation and interprofessional coordination; infection prevention and control; case management training; prepositioning of supplies; conversion of existing structures to treatment units; and strengthening communication and research platforms. Hospital-based Ebola and high-risk pathogen treatment units may improve case detection, interrupt transmission, and improve staff safety and patient care.
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Affiliation(s)
- Peter Kiiza
- Sunnybrook Research Institute, Sunnybrook Hospital, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada
| | - Neill K J Adhikari
- Sunnybrook Research Institute, Sunnybrook Hospital, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Mullin
- Sunnybrook Research Institute, Sunnybrook Hospital, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada
| | - Koren Teo
- Canadian Forces Health Services Group, Toronto, 10 Yukon Ln, North York, Ontario M3K 0A1, Canada
| | - Robert A Fowler
- Sunnybrook Research Institute, Sunnybrook Hospital, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.
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Nuzzo JB, Meyer D, Snyder M, Ravi SJ, Lapascu A, Souleles J, Andrada CI, Bishai D. What makes health systems resilient against infectious disease outbreaks and natural hazards? Results from a scoping review. BMC Public Health 2019; 19:1310. [PMID: 31623594 PMCID: PMC6798426 DOI: 10.1186/s12889-019-7707-z] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 09/30/2019] [Indexed: 11/24/2022] Open
Abstract
Background The 2014–2016 Ebola outbreak was a wake-up call regarding the critical importance of resilient health systems. Fragile health systems can become overwhelmed during public health crises, further exacerbating the human, economic, and political toll. Important work has been done to describe the general attributes of a health system resilient to these crises, and the next step will be to identify the specific capacities that health systems need to develop and maintain to achieve resiliency. Methods We conducted a scoping review of the literature to identify recurring themes and capacities needed for health system resiliency to infectious disease outbreaks and natural hazards and any existing implementation frameworks that highlight these capacities. We also sought to identify the overlap of the identified themes and capacities with those highlighted in the World Health Organization’s Joint External Evaluation. Sources of evidence included PubMed, Web of Science, OAIster, and the websites of relevant major public health organizations. Results We identified 16 themes of health system resilience, including: the need to develop plans for altered standards of care during emergencies, the need to develop plans for post-event recovery, and a commitment to quality improvement. Most of the literature described the general attributes of a resilient health system; no implementation frameworks were identified that could translate these elements into specific capacities that health system actors can employ to improve resilience to outbreaks and natural hazards in a variety of settings. Conclusions An implementation-oriented health system resilience framework could help translate the important components of a health system identified in this review into specific capacities that actors in the health system could work to develop to improve resilience to public health crises. However, there remains a need to further refine the concept of resilience so that health systems can simultaneously achieve sustainable transformations in healthcare practice and health service delivery as well as improve their preparedness for emergencies.
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Affiliation(s)
- Jennifer B Nuzzo
- Johns Hopkins Center for Health Security, 621 East Pratt Street, Suite 210, Baltimore, MD, 21202, USA
| | - Diane Meyer
- Johns Hopkins Center for Health Security, 621 East Pratt Street, Suite 210, Baltimore, MD, 21202, USA.
| | - Michael Snyder
- Johns Hopkins Center for Health Security, 621 East Pratt Street, Suite 210, Baltimore, MD, 21202, USA
| | - Sanjana J Ravi
- Johns Hopkins Center for Health Security, 621 East Pratt Street, Suite 210, Baltimore, MD, 21202, USA
| | - Ana Lapascu
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Jon Souleles
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Carolina I Andrada
- Johns Hopkins Center for Health Security, 621 East Pratt Street, Suite 210, Baltimore, MD, 21202, USA
| | - David Bishai
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
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Hamele M, Neumayer K, Sweney J, Poss WB. Always ready, always prepared-preparing for the next pandemic. Transl Pediatr 2018; 7:344-355. [PMID: 30460186 PMCID: PMC6212382 DOI: 10.21037/tp.2018.09.06] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A future global pandemic is likely to occur and planning for the care of critically ill children is less robust than that for adults. This review covers the current state of federal and regional resources for pediatric care in pandemics, a strategy for pandemic preparation in pediatric intensive care units and regions focusing on stuff, space, staff and systems, considerations in developing surge capacity and triage protocols, special circumstances such as highly infectious and highly lethal pandemics, and a discussion of ethics in the setting of pediatric critical care in a pandemic.
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Affiliation(s)
- Mitchell Hamele
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI, USA
| | - Katie Neumayer
- Division of Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jill Sweney
- Division of Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - W Bradley Poss
- Division of Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
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Toyokawa T, Hori N, Kato Y. Preparedness at Japan's Hospitals Designated for Patients with Highly Infectious Diseases. Health Secur 2017; 15:97-103. [PMID: 28192052 DOI: 10.1089/hs.2016.0056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In 2015, in order to assess the preparedness of Japan's special hospitals that have been designated to admit and treat patients with highly infectious diseases, we conducted a cross-sectional study of all 47 hospitals with this designation, using a self-report questionnaire that addressed 5 issues: (1) hospital characteristics and the occupation of the respondents; (2) the availability and content of the hospital guidelines for managing patients with suspected or confirmed viral hemorrhagic fever; (3) the implementation of preparedness activities in the context of the recent Ebola crisis; (4) characteristics of admission rooms for patients; and (5) human resources and occupational issues. Although our study found that most of Japan's designated hospitals were well-equipped, several areas of concern were also identified, including the lack of an effective clinical protocol, problems with management of human resources, and occupational issues. Developing a more feasible response protocol to any possible outbreak of new or reemergent infectious diseases is essential not only for Japan but for the global community in view of the threat posed by highly infectious diseases.
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Costs Associated with Ebola Preparedness at a Freestanding Pediatric Assessment Center. Infect Control Hosp Epidemiol 2017; 38:1367-1369. [PMID: 28874225 DOI: 10.1017/ice.2017.193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The 2014-2016 West Africa Ebola outbreak led US hospitals to prepare to treat Ebola patients, with significant attributable costs. A nationwide preparedness transition to a tiered approach allowed regional allocation of preparedness resources for Ebola frontline, assessment, and treatment hospitals. Preparedness costs for assessment centers were significant and largely uncompensated. Infect Control Hosp Epidemiol 2017;38:1367-1369.
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Abstract
The recent Ebola virus disease outbreak highlighted the need to build national and worldwide capacity to provide care for patients with highly infectious diseases. Specialized biocontainment units were successful in treating several critically ill patients with Ebola virus disease both in the United States and Europe. Several key principles underlie the care of critically ill patients in a high-containment environment. Environmental factors, staffing, equipment, training, laboratory testing, procedures, and waste management each present unique challenges. A multidisciplinary approach is key to developing effective systems and protocols to maintain the safety of patients, staff, and communities.
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Affiliation(s)
- Brian T Garibaldi
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, 1830 East Monument Street, 5th Floor, Baltimore, MD 21205, USA
| | - Daniel S Chertow
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, 10 Center Drive, Room 2C-145, Bethesda, MD 20892-1662, USA.
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Affiliation(s)
- Lisa Saiman
- Columbia University Medical Center, New York, New York,New York–Presbyterian Hospital, New York
| | - Amy S. Arrington
- Baylor College of Medicine, Houston, Texas,Texas Children’s Hospital, Houston
| | - Michael Bell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia,National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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Grein JD, Murthy AR. Preparing a Hospital for Ebola Virus Disease: a Review of Lessons Learned. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2016. [DOI: 10.1007/s40506-016-0087-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Davies HD, Byington CL. Parental Presence During Treatment of Ebola or Other Highly Consequential Infection. Pediatrics 2016; 138:peds.2016-1891. [PMID: 27550981 DOI: 10.1542/peds.2016-1891] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This clinical report offers guidance to health care providers and hospitals on options to consider regarding parental presence at the bedside while caring for a child with suspected or proven Ebola virus disease (Ebola) or other highly consequential infection. Options are presented to help meet the needs of the patient and the family while also posing the least risk to providers and health care organizations. The optimal way to minimize risk is to limit contact between the person under investigation or treatment and family members/caregivers whenever possible while working to meet the emotional support needs of both patient and family. At times, caregiver presence may be deemed to be in the best interest of the patient, and in such situations, a strong effort should be made to limit potential risks of exposure to the caregiver, health care providers, and the community. The decision to allow parental/caregiver presence should be made in consultation with a team including an infectious diseases expert and state and/or local public health authorities and should involve consideration of many factors, depending on the stage of investigation and management, including (1) a careful history, physical examination, and investigations to elucidate the likelihood of the diagnosis of Ebola or other highly consequential infection; (2) ability of the facility to offer appropriate isolation for the person under investigation and family members and to manage Ebola; (3) ability to recognize and exclude people at increased risk of worse outcomes (eg, pregnant women); and (4) ability of parent/caregiver to follow instructions, including appropriate donning and doffing of personal protective equipment.
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