HEAD TO TOE A healthcare professional removes her face shield during a demonstration of personal protective equipment procedures at Toronto Western Hospital.

In surgical facilities across the country, doctors and nurses are running drills to practice how to don and doff what they refer to as the Ebola spacesuit: double gloves (the first pair taped around the wrist), gowns impervious to liquid and viral penetration, booties, full face shields and surgical hoods that tuck neatly into the gowns. These dress rehearsals are in preparation for a horror show you pray the curtain never rises on: an infected patient showing up at your registration desk.

For many, these donning-and-doffing drills are unsettling, especially when you consider the odds of an Ebola patient showing up in any given facility. "We've had to do so much for something that seems so remote," says Genevieve Holody, RN, the nurse educator at the Buffalo Surgery Center in Amherst, N.Y. "It seems like we're overreacting."

A surgeon was puzzled by the e-mail he received from his hospital saying he had to go to a class to learn how to don and doff personal protective equipment (PPE) in case of an Ebola patient. "I don't remember ever having to do this with a patient who had the flu, HIV, or hepatitis B or C," says the surgeon, who wishes to remain anonymous.

To those who say the drills are excessive, the Centers for Disease Control and Prevention says every U.S. healthcare facility needs to have the capability to initially handle a case. "Even if the patient is going to be transferred to another facility, they need to be able to handle the first moments," says Abbigail Tumpey, a CDC spokeswoman.

This is only a drill
The goal of these PPE drills is simple: to leave no skin exposed, as the Ebola virus is only transmitted through direct contact with bodily fluids after a patient exhibits symptoms.

"Head-to-toe personal protection is alien to the perioperative nurse," says a nurse who works in a surgery center that sits in the shadow of Texas Health Presbyterian Hospital Dallas, ground zero in the Ebola scare, where a patient died of Ebola and 2 nurses contracted the virus. "We know about exposure risks, but we're not accustomed to placing the isolation-type equipment on."

When nurses and doctors practice putting on and removing protective equipment, they're encouraged to pair up with a co-worker or "buddy" to watch them do so, making sure they remember such important details as removing protective equipment by grasping it from behind, because the front is contaminated. "It's actually very hard to do," says the nurse from Dallas. "Taking it off is especially hard. I don't know what to touch first or what to take off first."

Is your facility prepared to handle Ebola? Only 19% of surgical facilities are well-prepared to receive a patient with the Ebola virus, according to an online survey of 180 OR managers Outpatient Surgery Magazine conducted last month. Most (43%) feel they're "somewhat prepared" and 38% say they're "not at all prepared."

Only a flight away
The infection prevention team at West Virginia University Hospital has been working for months to develop a plan and educate staff on Ebola. Dawn Yost, MSN, RN, BSDH, RDH, CNOR, manager of nursing operations, says that the ease of international travel means that hospitals are only a flight away from an Ebola patient coming through the front door.

"It's not if it occurs, it's when," says Ms. Yost. "In this day and age, you're only 24 hours away for something (like Ebola) to come into your hospital."

Educating staff is key to the hospital's preparations. The infection control team distributed a PowerPoint presentation that reviews the basics: incubation time, signs and symptoms, how the lab confirms it, early recognition, isolation and treatment.

Mary Wilson, BSN, RN, CNOR, West Virginia University's clinical nurse preceptor/educator, says the hospital has met with different departments to discuss how each would respond to an Ebola patient, from administration to the emergency room. The hospital also has volunteers — many from the ER but some from the OR — who've been undergoing intense training to learn how to care for an Ebola patient, says Ms. Wilson.

While the hospital has decided patients won't stay at the facility for treatment, it is equipped to identify and isolate infected patients before transferring them to a local hospital with the resources to care for the patient long-term.

The hospital actively monitors patients before they arrive for surgery. The most important question is about recent travel, says Ms. Wilson. The hospital is also finishing up minor renovations to create a quarantine space in the ER that would house suspected Ebola patients. The room, previously a vertical treatment room, has its own bathroom, is self-contained, has an area for staff to change into PPE and will be a negative pressure room.

Another key aspect of preparation involves training staff on the PPE worn when treating infected patients. At the hospital, staff would wear PAPRs (powered air-purifying respirators) with a hood that completely covers the worker's head, neck and shoulders, and can then be tucked into an impermeable suit. Staff also would wear a "bunny suit" on top of that, and protective plastic foot covers. Finally, staff would wear 2 pairs of gloves, with the first pair taped around the wrist. "The goal is no exposed skin," says Ms. Wilson.

Educating the staff has been important not only to train the workers on the proper care of an Ebola-stricken patient, but also to help them and their families alleviate fears.

"Back in the early '80s, when AIDS became very prevalent, healthcare workers were afraid to take care of patients," says Ms. Yost. "When people have a lack of knowledge, they are very fearful."

EBOLA READINESS Genevieve Holody, RN, the nurse educator at the Buffalo Surgery Center in Amherst, N.Y., holds her facility's Ebola policy and a package of surgical hoods.

Pre-screening patients
At the Buffalo Surgery Center, Ms. Holody says they've doubled their pre-operative screening efforts for Ebola. A pre-op nurse asks patients if they've traveled to or been in contact with a person from an Ebola-infected area within the past 21 days. The admitting nurse asks patients those same questions again when they arrive at the center. The ASC of Spartanburg (S.C.) has also added Ebola-specific questions to its pre-op phone screening. Patients who've traveled to a country with active Ebola can't be on the surgical schedule for 21 days after they've left that country. In addition to travel, a nurse asks about fevers. "Even with no travel history, if patients have a fever over 100 degrees, we do not want them to come to the facility," says Mike Pankey, RN, MBA, the administrator of the ASC of Spartanburg. "You don't want flu in your facility either."

The Riddle Surgical Center in Media, Pa., added questions pertaining to the signs and symptoms of Ebola as well as the patient's recent travel, to its online patient portal where patients fill out health histories, says Kristin Thompson, RN, BSN, CNOR, RNFA, the director of nursing. Riddle has also attached an addendum to its emergency management policy to specifically deal with Ebola. The addendum has 3 phases, says Ms. Thompson.

• If there's a confirmed case in the United States the center will educate staff on Ebola signs and symptoms, establish a "buddy system" for staff to use PPE properly and assign key staff members to monitor the national Ebola situation.

• If there's a confirmed Ebola patient in the state the center will conduct drills, review PPE stock and lab processes, and establish tighter patient screening.

• If there's an Ebola patient confirmed within 100 miles of the center the center will put more specific plans in place, including screenings at each of the entry points of the center.

What about disposing of Ebola-associated waste? It may be incinerated or inactivated through the use of appropriate autoclaves, says the CDC, adding that other methods such as chemical inactivation have not been standardized.

"We don't have an incinerator on site, so we'd have to autoclave the waste on site to make it inert," says Mr. Pankey, "and then put it into red bag waste and send it off as though it were biohazardous."

Who's your infection preventionist?
The Ebola scare and its demand for intense, in-person training and drilling have drawn attention to the dearth of full-time infection preventionists.

"We know that many hospitals do not have enough staff dedicated to infection prevention and control," says Jennie Mayfield, BSN, MPH, CIC, president of the Association for Professionals in Infection Control and Epidemiology. "Facilities that are inadequately staffed to begin with are stretched beyond capacity at a time like this. The current crisis demonstrates our lack of surge capacity and should concern everyone. Because our infection preventionist members are having to focus so much attention on Ebola, they are very worried about what other infectious diseases we might be missing. The infection preventionist's skills have never been in more demand."

An unlikely visitor
While Ebola isn't likely to make an appearance at your surgical facility, experts still recommend that you be prepared to treat and transport a patient.

"It's highly unlikely someone would come in for ambulatory surgery," says Linda Greene, RN, MPS, CIC, a member of APIC's regulatory review panel, noting that it's still important to "be able to quickly screen and isolate the patient" if it happens.

Staff should have a "high level of awareness," says Ms. Greene. If they come across a patient who has traveled recently and is exhibiting signs and symptoms, they should immediately change into an Ebola spacesuit, isolate the patient, contact the proper organizations, like the CDC, and arrange for transport to the nearest hospital accepting infected patients.

So much to do for an invisible enemy that will probably never rear its ugly head. "There's such a big hype," says Ms. Holody.

"Yes," says Mr. Pankey, "all of these precautions are just-in-case, but you don't want to figure out what you're going to do when [an infected patient] walks in the door."