Validation of Autoclave Protocols for Successful Decontamination of Category A Medical Waste Generated from Care of Patients with Serious Communicable Diseases.

In response to the Ebola outbreak in 2014, many hospitals designated specific areas to care for patients with Ebola and other highly infectious diseases. The safe handling of category A infectious substances is a unique challenge in this environment. One solution is on-site waste treatment with a steam sterilizer or autoclave. The Johns Hopkins Hospital (JHH) installed two pass-through autoclaves in its biocontainment unit (BCU). The JHH BCU and The Johns Hopkins biosafety level 3 (BSL-3) clinical microbiology laboratory designed and validated waste-handling protocols with simulated patient trash to ensure adequate sterilization. The results of the validation process revealed that autoclave factory default settings are potentially ineffective for certain types of medical waste and highlighted the critical role of waste packaging in successful sterilization. The lessons learned from the JHH validation process can inform the design of waste management protocols to ensure effective treatment of highly infectious medical waste.

The Creation of a Biocontainment Unit at a Tertiary Care Hospital. The Johns Hopkins Medicine Experience.

In response to the 2014-2015 Ebola virus disease outbreak in West Africa, Johns Hopkins Medicine created a biocontainment unit to care for patients infected with Ebola virus and other high-consequence pathogens. The unit team examined published literature and guidelines, visited two existing U.S. biocontainment units, and contacted national and international experts to inform the design of the physical structure and patient care activities of the unit. The resulting four-bed unit allows for unidirectional flow of providers and materials and has ample space for donning and doffing personal protective equipment. The air-handling system allows treatment of diseases spread by contact, droplet, or airborne routes of transmission. An onsite laboratory and an autoclave waste management system minimize the transport of infectious materials out of the unit. The unit is staffed by self-selected nurses, providers, and support staff with pediatric and adult capabilities. A telecommunications system allows other providers and family members to interact with patients and staff remotely. A full-time nurse educator is responsible for staff training, including quarterly exercises and competency assessment in the donning and doffing of personal protective equipment. The creation of the Johns Hopkins Biocontainment Unit required the highest level of multidisciplinary collaboration. When not used for clinical care and training, the unit will be a site for research and innovation in highly infectious diseases. The lessons learned from the design process can inform a new research agenda focused on the care of patients in a biocontainment environment.

Clinical nurse specialist as change agent: delirium prevention and assessment project.

PURPOSE/OBJECTIVES: The objective of this article is to address the role of the clinical nurse specialist (CNS) as a change agent in the implementation of a quality improvement program designed to prevent and assess delirium in ventilated patients at a community hospital. BACKGROUND: Delirium is both a common condition that is not well recognized among patients in the intensive care unit (ICU) setting and a challenging problem to manage. Patients remain ventilated in ICU settings longer, and often, physical/occupational therapy is not started until after the patient is extubated; thus, the risk for delirium is high. RATIONALE: The quality improvement program was implemented to recognize and decrease delirium in the critically ill patient. An understanding of the role of the CNS as the change agent provides a reference for other CNSs. The CNS's roles of communication, collaboration, and education in fulfilling the core competencies across the spheres of patient, nurse, and system are crucial when implementing lasting change. DESCRIPTION: A review of the literature supports the use of the ABCDE Bundle to better manage pain, sedation, and delirium. The CNS uses Kurt Lewin's 3-step model of change to implement the quality improvement program. OUTCOME: A CNS successfully implemented the ABCDE Bundle in a community hospital to improve the prevention and assessment of delirium in the ICU patient. CONCLUSION: This project demonstrates the CNS's ability to implement a program to aid in the prevention and assessment of delirium in critically ill patients in the ICU. IMPLICATIONS: The CNS's involvement as the change agent to implement the ABCDE Bundle is effective in the prevention and assessment of delirium in ventilated patients. The goal of the ABCDE Bundle is to extubate patients sooner and transfer them out of the ICU faster.