Donning PPE
1st Lt. Tiffany Mendez watches as Spc. Jonathan Whitford dons his personal protective equipment as they prepare for COVID-19 patients at Madigan Army Medical Center on Friday, March 20, on Joint Base Lewis-McChord in Tacoma, Wash. Madigan Army Medical Center is a level II trauma center providing primary and specialty medical care to more than 100,000 service members, retirees, and families. (Photo Credit: John Wayne Liston) VIEW ORIGINAL

MADIGAN ARMY MEDICAL CENTER, Joint Base Lewis-McChord, Wash. – Infectious diseases, by their very definition, present risk of illness to anyone within the vicinity of a pathogen – a contagious agent.

The Centers for Disease Control and Prevention identified that nearly 1.7 million hospitalized patients annually acquire healthcare-associated infections while being treated for other health issues and that more than 98,000 of these patients (one in 17) die due to HCAIs.

“Putting on PPE (personal protective equipment) and taking it off is not a new concept at all. We have our signage for all the various types of PPE and the little things that go along with it, depending on what the pathogen is,” noted Deborah McMillin, infection control manager at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash.

At any given time, Madigan may have one or more patients in isolation under strict precautions. That means entry into their negative pressure room, which does not allow air to leave the room, is severely limited and only allowed with proper PPE use.

But the novel coronavirus that has become known as COVID-19 is just that – novel. Though it is part of a family of viruses that are quite familiar to us, to include the common cold, this particular strain is new.

“There is so much that is unknown with this particular illness,” said McMillin. “I think they’re still learning how this is transmitted,” she added regarding the level of understanding the CDC and others in the medical community have about COVID-19, putting them at the forefront of this fight.

Medicine has been an important part of any fight the military has been engaged in since the Army’s inception in 1775. In the battle against this global pandemic, however, Army Medicine is playing a different role than it usually does.

“Medical is historically a support element,” commented Madigan Commander Col. Thomas Bundt. “But now, we are fully out front.”

Town halls conducted by the garrison and the I Corps Commander Lt. Gen. Randy George have relied heavily on the medical advice of Bundt and other Madigan subject matter experts.

One of those experts, Maj. Leanna Gordon, Madigan’s chief of epidemiology and disease control, is on the very front edge of the expanding knowledge of this disease.

“We don’t know if this is more transmissible from surfaces not being cleaned well enough, from actual patient care or from asymptomatic spread; there are just so many factors that we don’t know right now,” Gordon concluded.

Madigan has seen some of its care providers test positive for COVID-19.

As much as people might wish that infection be entirely controllable and those providing medical care can avoid exposure and infection altogether, that is not a realistic view, according to Gordon.

“Look at things as whether each was a preventable infection or non-preventable; I suspect most of these are non-preventable. But, again, we don’t know yet,” she said.

In a short span of time – mere months – the general understanding of this illness has encompassed a belief that it is just like the flu and that the highest risk would come from being in a patient’s room with them coughing, explained Gordon.

“But, really as every day goes by, we are learning more from seeing is happening in other places in the country and realizing that it’s much more complicated than that,” she corrected. “While the symptoms of this are super similar to the flu, the way it’s transmitted is not the same.”

The reality is that this disease is presenting Army Medicine with a new battlefront.

Unlike with the flu, there is no preventive measure – no vaccine – to inoculate clinicians against infection. That leaves medical professionals, and everyone else, learning as they go.

“We don’t know for certain how people are getting infected with COVID-19. It can be transmitted from person to person, but also from surfaces to people. In many situations, it is very difficult to determine how someone may have been exposed,” Gordon noted.

That said, she is confident that Madigan, its commander and staff are reacting appropriately.

“As we see these cases happen and we find potential problems, we are reacting very quickly to those problems,” Gordon added.

It would be inaccurate to assume that a clinician becoming infected is necessarily due to exposure during care, both Gordon and McMillin noted.

Some nurses and providers have been put into isolation who were not in a room with an infected patient.

Given that a person can be a vector spreading disease without having any symptoms oneself, a clinician could have been exposed in the community, by family, from touching a contaminated surface, or in some other way that is yet unknown.

“This is not just unique to Madigan. This is happening at hospitals across the country,” said Gordon about clinicians testing positive without obvious sources of infection.

Madigan has enlisted not only specialists in infection and disease control, but clinical nurse scientists and educators, housekeeping, provost marshal and every other staff member, patient and visitor to the facility in its efforts to stop the spread of this virus.

Everyone coming to the facility will find just three points of entry with screening personnel asking health questions and requiring hand hygiene. All are now encouraged to add using face coverings to the heightened protocol of washing their hands and not touching their faces.

From the outset, everyone in a patient care role was given additional training in donning and doffing PPE; this training is ongoing as stricter requirements have been put in place over time.

The infection control program and the clinical nurse scientists created an algorithm for modified precautions to offer staff guidance on PPE use and avoiding contamination.

McMillin described the two-person donning and doffing process that is now being implemented where, as one person puts their gear on, the other is watching the entire time to ensure no step, however small, is missed. As a nurse or provider is ready to come out of a patient room, they let their partner know and the process of removing the gear is watched carefully as well.

“The steps are a little different from what you would normally do. We’ve done everything we can to try to mitigate any potential self-cross contamination,” stated McMillin. “Having a second person there to assist helps make sure, very sure, of that.”

This protocol is akin to what was used for Ebola, said Gordon.

She also pointed out that other diseases where these precautions are used have not proven as transmissible on surfaces.

That fact has led to a noticeable increase in Environmental Services disinfecting all commonly touched surfaces throughout the facility, with a significantly heightened frequency of disinfection in the intensive care unit, which has seen the most concentration of COVID-19 patients so far.

“The biggest thing we’ve been trying to stress recently is that that is not just a function of housekeeping,” said Gordon, noting that this is everybody’s fight.

Madigan has consolidated care into a single ward for COVID-19 patients only, turning a floor that was partially in use for administration into a full-fledged, isolation ward within 48 hours.

Additionally, to funnel potentially positive patients into limited areas, the Winder Soldier-Centered Medical Home has relocated its standard care appointments to the McChord Clinic so that it can serve as a site to triage ill patients.

Typically, nurses in the inpatient units will rotate the patients they care for throughout their work week. For COVID-19 care, these rotations have stopped; a single nurse sees the same patient for all their shifts now. This is just another step to minimize exposure.

While it is all hands on deck, it is also well-experienced eyes on the problem set as well.

“I’m going to the critical care unit pretty much on a daily basis to try to do some observations and see their processes. Just to see what we can improve there,” said McMillin.

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