Ebola

Patient management

Infection Prevention and Control – March 2015

Ebola

• Background• Case definition• Signs & Symptoms• Transmission• PPE

• Donning/ doffing order with goggles and mask• N95 mask fit test• Jupiter hood• Donning/ doffing order with Jupiter hood

• Patient management• Resources

Background• Ebola Virus Disease (EVD) – previously called

Ebola haemorrhagic fever - is one of several Viral Hemorrhagic Fevers.

• Fruit bats are considered to be the natural hosts with outbreaks identified amongst chimpanzees, gorillas, monkeys.

• Since first being identified in 1976, there have been numerous outbreaks in Central and East Africa.

BackgroundThe 2014/15 outbreak is the first in West Africa. Countries with widespread transmission • Guinea • Liberia • Sierra Leone

Localised transmission and travel associated cases have been identified in other countries.Please refer to:CDC - http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html or WHO - http://www.who.int/csr/don/archive/disease/ebola/en/

for the latest numbers and affected areas.

Background

• The risk of an outbreak in Australia is very low

• There is no evidence that Ebola is present in Australian bats

• Should a case be identified in Victoria, the Royal Children's & Royal Melbourne Hospitals are the designated Ebola receiving hospitals

RCH process

• A guideline has been developed to managed identified cases within RCH.

• Relevant staff are being trained in correct donning and doffing of PPE.

Case definitionSuspected Case Definition

• Fever ≥ 380C, documented or reported, in the last 24 hours

WITH OR WITHOUT additional symptoms such as

• severe headache, • muscle pain, • vomiting, • diarrhoea, • abdominal pain, or • unexplained haemorrhage

AND

Case definitionIn the 21 days prior to symptoms:

• Residence in—or travel to—an area where EVD transmission is active

OR

• A high risk exposure OR

• A low risk exposure

High Risk ExposureAny contact or exposure to blood and body fluid of a confirmed EVD patient without appropriate PPE

Processing blood or body fluids of a confirmed EVD patient without appropriate PPE / biosafety precautions

Direct contact with a dead body without appropriate PPE where EVD transmission is active

Direct contact with bats or primates (alive or dead) or consumption of bush meat in EVD endemic areashttp://docs.health.vic.gov.au/docs/doc/F379C2BD968364E8CA257D540008B3CA/$FILE/Victorian%20Ebola%20Virus%20Disease%20Response%20Plan_September

%202014.pdf

Low Risk Exposure• Household contacts with a confirmed case of

EVD

• Being in the same room as an EVD patient with active vomiting/ diarrhoea/ coughing/ aerosol generating procedure without appropriate PPE

• Having direct brief contact –eg shaking hands with an EVD patient without appropriate PPE

http://docs.health.vic.gov.au/docs/doc/F379C2BD968364E8CA257D540008B3CA/$FILE/Victorian%20Ebola%20Virus%20Disease%20Response%20Plan_September%202014.pdf

Active EVD areas

• CDC and WHO provide updated lists of areas where EVD transmission is active.

• This can be accessed from: • CDC http://www.cdc.gov/vhf/ebola/index.html• WHO http://www.who.int/csr/disease/ebola/en/

Case definitionMalaria diagnostics should also be a part of initial testing because it is a common cause of febrile illness in persons with a travel history to the affected countries.

Source: http://emergency.cdc.gov/han/han00364.asp

Signs and Symptoms• Symptoms may appear anywhere from 2 to 21

days after exposure to EVD8-11 days is most common.

•Initially symptoms may have a sudden onset of•Fever•Headache•Joint and muscle aches•Stomach pain

Signs and SymptomsLater symptoms can include

•Diarrhoea•Rash•Vomiting•Stomach pain•Unexplained bleeding or bruising

Transmission

TransmissionTransmission can only occur when a case has symptoms.

In healthcare settings, transmission occurs through contamination of the HCWs mucous membranes or broken skin with • Direct contact of blood or body fluids of an

infected person• Contact with a contaminated environment and

equipment

Transmission

If after 21 days an exposed person does not develop symptoms, they will not become ill with EVD

Personal Protective Equipment- PPEPPE requirements vary with:

• the patients condition• the length of time the HCW is in the patient room• procedures to be undertaken• confirmation of EVD

PPEMinimum PPE requirements include:

• Overshoes• Coveralls or disposable scrubs• Gloves• Gown (fluid resistant)• Balaclava• Eye protection (goggles)• Facemask

Additional PPE is required in the presence of copious blood or body fluids and includes:

• Powered Air Purifying Respirator (PAPR) with Jupiter hood

PPEA PAPR with Jupiter hood may be worn to protect the HCW

• during aerosol generating procedures (AGPs)• for comfort if the HCW will be in the room for

prolonged periods of time• if the HCW cannot perform an adequate fit check

with a face mask• if the standard PPE does not provide adequate head

coverage

PPE Rules• Collect all items before starting• Perform hand hygiene prior to donning PPE

NEVER rush the removal of PPE

N95 mask rules• Perform Hand Hygiene prior to donning &

doffing mask• Handle mask by edges and ties • HCWs with facial hair may not be able to

achieve a good fit test and should consider a PAPR for AGPs

• A fit check should be carried out every time a mask is applied

N95 mask rules• Masks should never be re-used• Wet or damaged masks should be discarded

immediately• Masks should be discarded when no longer

required and NEVER allowed to dangle on front of uniform

N95 mask – prior to donning

• Hold mask upside down by the sides• Push sides together to separate the mask

edges• Bend nose piece slightly• Loosen and separate elastic ties

N95 – donning• Place the mask under chin and bring elastic

ties over head• Fit flexible nose piece over nose bridge and

across cheeks to create a snug fit• Adjust elastics ties for comfort and fit over the

crown of the head and at the base of the neck.

Picture courtesy of QLD health

N95 – mask fit test• Perform a fit test:

• Inhale – mask should collapse• Exhale – check for leakage around face

• Note:• Air should not leak around the mask• Glasses or goggles should not fog up

• If necessary, repeat donning of mask to achieve a good fit

Picture courtesy of QLD health

N95 mask – doffing• Perform hand hygiene• Handle mask ONLY by elastic ties• Lift the bottom elastic over head first• Lift off top elastic• Discard into bin• Perform hand hygiene

Picture courtesy of QLD health

PPE –Donning a Jupiter hood

• Ensure belt has filters attached• Fasten belt and adjust to fit

• Belt should sit on hips

• Remove belt• Insert charged battery and ensuring it clicks

into place• Attach respirator hose to belt by lining up

metal nibs with holes in belt attachment, twist to secure

• Attach hose to hood and ensure clicks in place• Turn on with one short press of button

PPE –Donning a Jupiter hood

• Allow hood to inflate• Roll up back of hood to open• Place chin in hood and pull hood over head• Ensure grey head band sits horizontal on

forehead• Hood collar should sit under the gown when

entering patient room• Make sure hood is comfortable before entering

patient room

PPE – donning and doffing• Refer to the Infection Prevention and Control

website for EVD PPE donning and doffing instructions

http://webedit.rch.org.au/uploadedFiles/Main/Content/infection_control/EVD-PAPR-PPE-Donning-and-doffing-text.pdf

PPE donning Jupiter hood & coveralls

PPE Instructions

Overshoes Sit down and place overshoe covers over scrubs. Note: These go under coveralls Perform Hand Hygiene

Sterile Gloves Select the correct glove size and put on 1st pair of gloves

Coverall Put on and zip up coveralls, excluding hood.The sleeve cuffs should extend over the cuffs of the 1st pair of gloves

Belt & Jupiter hood

Fit beltInsert battery and attach hosesInflate hoodDon PAPR hoodSecure belt

Gown Secure gown at neck and waist to ensure both front and back is covered.  

Gloves Select correct sizeInsert gloved hands into 2nd pair of glovesExtend glove cuffs over gown cuff

Plastic apron Place over gown before entering the patient roomBuddy to assist

PPE doffing Jupiter hood & coveralls

PPE Instructions

In patient roomReplace or gel and allow to dry, 2nd pair of gloves so doffing occurs with clean gloves

Plastic apron Tear apron tie at neck and allow top to fold down on itselfTear waist tie and fold apron in on itself

Gown & gloves Have buddy untie gownRoll gown down arms, folding in on itself. Remove slowly so gloves are peeled off with gown and so only the clean side of the gown is exposedDiscard into bin

In anteroomJupiter hood & belt

Place hands under hood collarPinch chin strap and pull up over face and allow to drop backwards onto ground.Buddy should disconnect hose from the belt with gloved handsUndo belt and pass to buddy to place on plastic sheet

Coverall, gloves& overshoes

Buddy with clean gloves to undo zip and assist in removing coveralls from behind, touching the outside only.Slowly peel arms out of sleeves, removing 1st pair of gloves with sleeves.Peel coveralls off to below bottom and sit down.Peel coveralls down the legs to expose overshoe ties and untie overshoe covers.Pinch outside of covers at top and peel downwards in on itself until outside is enclosed.Slowly remove legs so overshoes are peeled off with coveralls and only the clean inside of coveralls are exposed

Wash hands

Patient management Management of:• Traffic management• Room supplies• Food• Linen• Waste• Room cleaning• Patient transfer• Handling of deceased patient• Specimen collection

Patient managementTraffic Management

• A log of all HCWs entering the room must be maintained

• Limit room access to essential staff only

• Family/ visitors should be restricted to essential carers only

Patient managementRoom supplies

• Limit equipment taken into the room to what is required for that shift

• Any item that can not be adequately decontaminated on patient discharge WILL be discarded

Patient management

• Food• Meals should be ordered with disposable crockery and

cutlery.• All leftover food/items should be discarded into yellow

clinical waste bags and treated as waste

• Linen (including curtains if present)• Should be discarded into yellow clinical waste bags

and treated as waste

Patient management• Waste

• Place an anatomical sulo bin outside the patient room• Carps through Support Services

• Waste generated in the patient room should be placed directly into a yellow clinical waste bag

• Room waste bags should be double bagged at the anteroom door using a buddy before being placed directly into the anatomical sulo bin

• If excess fluid is present a third clinical waste bag may be required prior to placing waste in the sulo bin

Patient management• Room cleaning

• Daily cleaning of horizontal surfaces and spills to be undertaken by nurse caring for patient• Refer to procedure for detailed instructions

• Cleaning equipment• single use only or • cleaned after use and kept in the room until the patient is

discharged

• Discharge clean – request Infectious clean EVD via CARPS

Patient managementTransfer of patient• Emergency to Rosella

• Director of Operation (7am to 16.30pm Monday to Friday) Nursing Hospital Manager (after hours) to facilitate

Handling of deceased patient• Contact Anatomical Pathologist on call via

switchboard

Initial Diagnostic Specimen Collection

Notify and collect specimen collection kit from Laboratory Services ext 55904

When specimens have been collected they must be hand delivered to Laboratory Services

Do NOT use the pneumatic tube

Initial Diagnostic Specimen Collection

Collect the following specimens into tubes labelled with patient details:

• EDTA blood for Ebola virus PCR• Serum gel tube• Flocked throat swab

Refer to specimen collection guide in EVD Kit• Video -

Remember: Hand deliver to Laboratory Services Do NOT use the

pneumatic tube

Additional Pathology testingAvoid unnecessary pathology testing

• If required -the iSTAT device will be used at the patient bedside for the following assays:

Na, K, Cl, Ca, Glucose, Urea, Creatinine, lactate, Haematocrit, Haemoglobin, blood gases (pH, pCO2, pO2, Bicarbonate, BE, sO2), INR, ACT.

• Obtain iSTAT from on call Clinical technologist via switchboard

• Additional tests may be submitted to the laboratory using the specimen collection and transport kit ONLY AFTER consultation with the Medical Microbiologist on call.

ResourcesSeries of National Guidelines –SoNGhttp://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-ebola.htm/$File/EVD-SoNG.pdf

Chief Health Officer, Victoria - http://health.vic.gov.au/chiefhealthofficer/alerts/alert-2014-07-ebola-virus-disease.htm

CDC http://www.cdc.gov/vhf/ebola/index.html?s_cid=cdc_homepage_feature_001

WHO http://www.who.int/csr/disease/ebola/en/

Department of HealthEbolavirus Disease Information for Travellers, Patients and ConsumersInformation about Ebola virus disease, outbreaks and preparedness