Ebola Virus Disease (EVD) VHA Safety and Health …c.ymcdn.com/sites/ Virus Disease (EVD) VHA Safety...

Ebola Virus Disease (EVD)VHA Safety and Health Education and Training Plan

November 2014

VETERANS HEALTH ADMINISTRATION

EBOLA VIRUS DISEASE SAFETY AND HEALTH BLUEPRINT

• Goal: Veterans, employees, and family members are protected from Ebola Virus exposure while in VHA Medical Facilities– Ebola Virus is an Infectious Disease and an occupational hazard for health

care workers in facilities caring for Ebola Virus Disease patients.– It is transmitted by mucous membrane contact (eyes, mouth, broken skins,

GI track) and by needle stick/sharps exposure– OSHA Bloodborne Pathogen Standard, 29 CFR 1910.1030– OSHA Respiratory Protection Standards, 29 CFR 1910.134– OSHA Personal Protection Standards, 29 CFR 1910.132– OSHA Hazard Communication Standard, 29 CFR 1910.1200– CDC Ebola Virus Disease Guidelines– VHA Ebola Virus Disease Guidance, Emergency Management Operations

Plan 01-2015FY


TRAINING OBJECTIVES

• EVD epidemiology, symptoms, and modes of transmission

• Recognizing tasks and activities involving exposure to EVD

• Methods that reduce exposure to EVD

• Procedures for exposure incidents and emergencies

• Selection of personal protective equipment (PPE)

• Designating areas for PPE donning and doffing

• Reporting an exposure incident and post exposure evaluation 2


2014 West Africa Outbreak

• The 2014 Ebola outbreak is the largest Ebola outbreak in history and the first in West Africa.

• The current outbreak is affecting multiple countries in West Africa.

Current as of 10/2/20143


EPIDEMIOLOGY & SYMPTOMS OF EVD

• Symptoms typically appear abruptly, within 2-21 days (8-10 days is most common) following exposure to the virus.

• Individuals exposed while living, working, or traveling in areas experiencing an ongoing outbreak or where EVD is endemic could develop symptoms up to three weeks after exposure.

• EVD is contagious when an individual begins to show symptoms.

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EPIDEMIOLOGY & SYMPTOMS OF EVD

• Individuals with EVD generally have symptoms typical of viral illnesses, including fever, fatigue, muscle pain, headache, and sore throat.

• The illness progression includes nausea, vomiting, diarrhea, and impaired organ function. In some cases, rash, internal and/or external bleeding, and death may occur.

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MODES OF TRANSMISSION OF EVD

• The most common routes of transmission of Ebola viruses are:– Contact of the eyes or other mucous membranes with

blood or body fluids of a person or animal with EVD,– Contact with contaminated equipment or other objects– Ingestion of infectious blood or body fluids.– Percutaneous exposure to sharps/needle stick

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VHA TIERED APPROACH TO EVD CASE MANAGEMENT

VA Medical Centers and Clinics have different capabilities due to size, staffing, and equipment. The extent of activity a facility is expected to provide to a patient presenting with suspected EVD follow a Tiered System: • Tier 3 – VA facilities lacking infrastructure to care for EVD

patients• Tier 2 – Designated regional VA referral facilities for suspected

EVD patients• Tier 1 – VA facilities capable of providing definitive care for

confirmed EVD patients. BSL 3 Lab with certified hood, autoclave, mortuary plan to manage EVD cadavers.

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EVD SITE MANAGER ROLE AND RESPONSIBILITIES

• Designate an EVD site manager, responsible for overseeing the implementation of precautions for healthcare workers and patient safety, based on the complexity/tier of your facility.

• Site managers are responsible for all aspects of Ebola infection control including monitoring and evaluating supplies, and direct observation of care before, during, and after staff enter an isolation and treatment area.

• At least one site manager should be on-site at all times in the location where the Ebola patient is being cared for.

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EVD SITE MANAGER ROLES

• Key roles of the Designated Site Manager:

– Identify critical patient care functions and essential healthcare workers for care of Ebola patients, for collection of laboratory specimens, environmental management , and waste handling.

– Ensure healthcare workers have been trained in all recommended protocols for safe care of Ebola patients before they enter the patient care area.

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PRINCIPLES OF PPE

• Healthcare workers must understand the following basic principles to ensure safe and effective PPE use, which include that no skin may be exposed while working in PPE:– Donning

• PPE must be donned correctly in proper order before entry into the patient care area,

• PPE cannot be later modified while in the patient care area• PPE donning activities must be directly observed by a

trained observer.

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PRINCIPLES OF PPE

– During Patient Care • PPE must remain in place and be worn for the duration of exposure

to potentially contamination. PPE should not be adjusted during patient care.

• Healthcare workers should perform frequent disinfection of gloved hands using an ABHR, particularly after handling body fluids. If visibly contaminated, use an EPA approved disinfectant.

• If during patient care a partial or total breach in PPE (e.g., gloves separate from sleeves leaving exposed skin, a tear develops in an outer glove, a needlestick) occurs, the healthcare worker must move immediately to the doffing area to assess the exposure. Implement the facility exposure plan, if indicated by assessment.

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PRINCIPLES OF PPE

– Doffing • The removal of used PPE is a high-risk process that requires a

structured procedure, a trained observer, and a designated area for removal to ensure protection.

• PPE must be removed slowly and deliberately in the correct sequence to reduce the possibility of self-contamination or other exposure to Ebola virus.

• A stepwise process should be developed and used during training and daily practice.

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CDC PPE GUIDANCE FOR HCWsCARING FOR PATIENTS WITH EVD

• Double gloves. Single-use nitrile examination gloves with extended cuffs• Boot covers that are fluid-resistant or impermeable and go to at least

mid-calf or leg covers • Single-use fluid resistant or impermeable gown that extends to at least

mid-calf or coverall without integrated hood • Respirators, including either N95 respirators or powered air purifying

respirator (PAPR) • Single-use, full-face shield that is disposable (if N-95 is used) • Surgical hoods that completely covers the head and neck (if N-95 is

used) • Apron that is fluid-resistant or impermeable and covers the torso to the

level of the mid-calf http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html

http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html


CDC PPE GUIDANCE FOR HCWsSCREENING PATIENTS FOR EVD

• PPE for Healthcare Workers involved in the Tier 3 process of screening patients for EVD – Double gloves. Single-use nitrile examination gloves – Single-use fluid resistant or impermeable gown that extends to at

least mid-calf – Surgical Mask– Single-use full-face shield Centers for Disease Control and Prevention (CDC) Identify, Isolate, Inform: Emergency Department Evaluation and Management for Patients Who Present with Possible Ebola Virus Disease http://www.cdc.gov/vhf/ebola/hcp/ed-management-patients-possible-ebola.html

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http://www.cdc.gov/vhf/ebola/hcp/ed-management-patients-possible-ebola.html


CDC RECOMMENDED PPE EXAMPLES

• Different PPE procurements at Facility and VISN levels are inevitable.

• Equivalent PPE options/choices must be considered. • Selections based on many factors including but not limited to;

– Most current CDC recommendations– General availability – Sizing availability – Lead time delivery

• This guidance must be modified to meet the facility’s specific PPE training needs.


N-95 FILTERING FACE PIECES

• N-95 Respirator: Single-use (disposable)

• NIOSH-certified and fit-tested

• If N95 respirators are used careful observation is required to ensure healthcare workers are not inadvertently touching their faces under the face shield during patient care.


POWERED AIR PURIFYING RESPIRATOR

• A PAPR with a full face shield, helmet, or headpiece.

• Follow manufacturer’s instructions for decontamination of all reusable components

• PAPR with a self-contained filter and blower unit integrated inside the helmet is preferred.

• A PAPR with external belt-mounted blower unit requires adjustment of the sequence for donning and doffing (See Competency Checklist)


POWERED AIR PURIFYING RESPIRATORS

• PAPR Components – Fluid resistance PAPR Head Covers – Breathing Tube

– PAPR protective covers


FLUID-RESISTANT OR IMPERMEABLE COVERALLS W/O INTEGRATED HOOD

• Coveralls with or without integrated socks are acceptable.

• Consideration should be given to selecting gowns or coveralls with thumb hooks to secure sleeves over inner glove.

• Personnel may consider taping the sleeve of the gown or coverall over the inner glove to prevent potential skin exposure from separation between sleeve and inner glove during activity. Care must be taken to remove tape gently. Taping of outer gloves is not recommended


FLUID RESISTANT OR IMPERMEABLE GOWN

• Single use (disposable) • Extends to at least mid-calf • Consider selecting gowns or coveralls with thumb

hooks to secure sleeves over inner glove. • If gowns with thumb hooks are not available,

consider taping the sleeve of the gown or coverall over the inner glove to prevent potential skin exposure from separation between sleeve and inner glove during activity. Care must be taken to remove tape gently. Taping of outer gloves is not recommended


BOOT COVERS

• Single-use (disposable), fluid-resistant or impermeable boot covers that extend to at least mid-calf

• Boot and shoe covers should allow for ease of movement and not present a slip hazard to the worker

• Single-use (disposable) fluid-resistant or impermeable shoe covers are acceptable only if they will be used in combination with a coverall with integrated socks.


DOUBLE GLOVES

• Single-use (disposable) nitrile examination gloves with extended cuffs.

• Two pairs of gloves should be worn (consider different color gloves).

• At a minimum, outer gloves should have extended cuffs.


SURGICAL HOODS

• Single-use (disposable), surgical hood extending to shoulders

• Ensure complete coverage of the head and neck


SINGLE-USE, FULL-FACE SHIELD

• Disposable, head mounted – 14”+ 180 degree coverage

• Used with N-95 Respiratory and Surgical Hood


APRON

• Fluid-resistant or impermeable apron that covers the torso to the level of the mid-calf should be used if Ebola patients have vomiting or diarrhea.

• An apron provides additional protection against exposure of the front of the body to body fluids or excrement. If a PAPR will be worn, consider selecting an apron that ties behind the neck to facilitate easier removal during the doffing procedure


EVD TIER 3 SCREENING PPE TRAINING

• PPE training for HCW screening patients for EVD.

• Training must include specific modifications of tasks or procedures that affect the employee's occupational exposure to EVD.

• The training must include the conditions when to don the recommended PPE.

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EVD COMPREHENSIVE PPE COMPETENCY TRAINING

• EVD PPE training is a collaborative effort at VA Medical Centers

• Recommended make-up of VA Medical Center trainer/observer pools– Infection Control Staff – Nursing / Nursing Education Staff – Occupational Safety and Health (OSH) Staff – First Receiver Decontamination Certified Trainers (Clinical/Non-clinical) – Other Qualified Job Specific Trainers/Observers

• Specialized job classifications e.g. Lab, EMS, VA Police

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• Ensure healthcare workers have been trained in all recommended protocols for safe care of Ebola patients before they enter the patient care area.

• Use trained observers to monitor for correct PPE use and adherence to protocols for donning and doffing PPE, and guide healthcare workers at each point of use using a checklist for every donning and doffing procedure.

• Document training of observers and healthcare workers for proficiency and competency in donning and doffing PPE, and in performing all necessary care-related duties while wearing PPE.

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• PPE itself can introduce potential risks – Training and competency in donning and doffing of PPE

– Monitoring of activities by other team members

– Evaluate for and to mitigate fatigue, exhaustion and complacency

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USE OF A TRAINED OBSERVER

• The trained observer is a dedicated individual with the sole responsibility of ensuring adherence to the entire donning and doffing process.

• Because the sequence and actions involved in each donning and doffing step are critical to avoiding exposure, the trained observer will read aloud to the healthcare worker each step in the procedure checklist and visually confirm and document that the step has been completed correctly.

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USE OF A TRAINED OBSERVER• The trained observer will be knowledgeable about all PPE

recommended in the facility’s protocol and the correct donning and doffing procedures, including disposal of used PPE, and will be qualified to provide guidance and technique recommendations to the healthcare worker.

• The trained observer will monitor and document successful donning and doffing procedures, providing immediate corrective instruction if the healthcare worker is not following the recommended steps.

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RECOMMENDED PROCEDURES & PPE FOR TRAINED OBSERVERS

• The trained observer should know the exposure control management plan in the event of an unintentional break in procedure.

• The trained observer should not enter the room of a patient with Ebola, but will be in the PPE removal area to observe and assist with removal of specific components of PPE.

• The observer should not participate in any Ebola patient care activities while conducting observations.

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• The following PPE are recommended for trained observers:– Single-use (disposable) fluid-resistant or impermeable gown that

extends to at least mid-calf or coverall without integrated hood.– Single-use (disposable) full face shield.– Single-use (disposable) nitrile examination gloves with extended

cuffs. Two pairs of gloves should be worn. At a minimum, outer gloves should have extended cuffs.

– Single-use (disposable) fluid-resistant or impermeable boot covers. Boot covers should allow for ease of movement and not present a slip hazard to the worker.

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DESIGNATING AREAS FOR PPE DONNING AND DOFFING

• Facilities should ensure that space and layout allow for clear separation between clean and potentially contaminated areas.

• It is critical that physical barriers (e.g., plastic enclosures) be used where necessary, along with visible signage, to separate distinct areas.

• Ensure a one-way flow of care moving from clean areas (e.g., area where PPE is donned and unused equipment is stored) to the patient room and to the PPE removal area (area where PPE is removed and discarded).

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• Post signage to highlight key aspects of PPE donning and doffing, including;– Designating clean areas vs. potentially contaminated areas– Reminding healthcare workers to wait for a trained observer

before removing PPE– Reinforcing need for slow and deliberate removal of PPE to

prevent self-contamination– Reminding healthcare workers to perform disinfection of gloved

hands in between steps of the doffing procedure

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• PPE Storage and Donning Area– This is an area outside the Ebola patient room (e.g., a nearby vacant

patient room, a marked area in the hallway outside the patient room) where clean PPE is stored and where healthcare workers can don PPE before entering the patient’s room.

– Do not store potentially contaminated equipment, used PPE, or waste removed from the patient’s room in this area.

– If waste must pass through this area, it must be properly contained.

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• Patient Room– This is a single-patient room. The door is kept closed. Any

item or healthcare worker exiting this room should be considered potentially contaminated.

– Some steps of the PPE removal process may be performed in a clearly designated area of the patient’s room near the door, provided these steps can be seen and supervised by a trained observer (e.g., through a window such that the healthcare worker doffing PPE can still hear the instructions of the trained observer).

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• PPE Removal Area– This is an area in proximity to the patient’s room (e.g., anteroom or

adjacent vacant patient room that is separate from the clean area) where healthcare workers leaving the patient’s room can doff and discard their PPE. Do not use this clearly designated area within the patient room for any other purpose. Stock gloves in a clean section of the PPE removal area accessible to the healthcare worker while doffing.

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• PPE Removal Area– If a facility must use the hallway outside the patient room as the PPE

removal area, construct physical barriers to close the hallway to through traffic and thereby create an anteroom. In so doing, the facility should make sure that this hallway space complies with fire-codes.

– Restrict access to this hallway to essential personnel who are properly trained on recommended infection prevention practices for the care of Ebola patients.

– Facilities should consider making showers available for use by healthcare workers after doffing of PPE.

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REPORTING AN EXPOSURE INCIDENT ANDPOST EXPOSURE EVALUATION

• If during patient care a partial or total breach in PPE (e.g., gloves separate from sleeves leaving exposed skin, a tear develops in an outer glove, a needlestick) occurs, the healthcare worker must move immediately to the doffing area to assess the exposure. – Report any break in protocol or exposure incident immediately to the

designated EVD site manager– Follow procedures in the facility’s EVD exposure control plan

• Post-exposure evaluation will be accomplished using local Public Health, CDC, and VHA guidance

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• EVD HCW PPE Donning and Doffing PPE Competency Verification Checklist

• Employee Occupational Health Clearance Exams for PPE EOH Guidebook Chapter 10 Section 10.2.2

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https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/ebola/Shared%20Documents/EVD%20Operations%20Plan%20Guidance%20Annexes/EVD_Annex_F_Appendix_3_Attchment_2_EVD%20HCW%20PPE%20Competency%20Checklist%20Template_2014_Final.docx

http://vaww.ceosh.med.va.gov/01HP/02HP_Guidebooks/03_Collections/04HP_OccupationalHealth/NetHelp/EOHGB.htm


PERSONAL PROTECTIVE EQUIPMENT

• Approved EVD PPE Donning and Doffing Training Tools and Videos

• Guidance on PPE To Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures on Donning & Doffing

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https://vaww.vha.vaco.portal.va.gov/sites/PublicHealth/ebola/SitePages/Training%20Videos.aspx

http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html


For Additional Information

For general information: • Centers for Disease Control and Prevention (CDC)

http://www.cdc.gov/vhf/ebola/index.html

• World Health Organization (WHO)http://www.who.int/csr/disease/ebola/en/

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http://www.cdc.gov/vhf/ebola/index.html

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


QUESTIONS

• An opportunity for interactive questions and answers with the person conducting the training session.

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