Preparedness for Ebola Virus

Prepared by Infection PreventionOctober 13th, 2014

Sources

• Centers for Disease Control and Prevention• University of Nebraska Biocontainment Patient

Care Unit• University of Texas Medical Branch-Galveston

National Laboratory Biosafety Level 4• HCA: Clinical Services Group• World Health Organization

Real World Experience

Assumptions

• P/SL will only have 1 potential Ebola patient at a time– With more than 1 patient the plan would be altered

• Emergency Department is at highest risk to receive a patient with Ebola

• Ebola is transmitted through contact with infectious droplets and contact with body fluids

• Donning and doffing of PPE presents the highest risk of exposure to healthcare workers

• P/SL will restrict the number of healthcare workers that come in contact with patient– Physicians and nurses will perform all patient care and daily cleaning

of patient room

Key Personnel• Emergency Department

– Physicians and Nurses

• Intensive Care Unit (Adult & Peds)– Physicians and Nurses

• Infectious Disease Physicians– Adult and Pediatric Specialists

• Respiratory Therapy– Adult and Pediatric Therapists

• Security– First point- of-contact screening– Traffic control

• Radiology– Portable equipment, dedicated to a

single patient

• Environmental Services– Waste removal

• Laboratory– Laboratory assistant to transport

specimens to Colorado Department of Public Health

– Medical Technologists

• Infection Prevention– Coordination between our facility, the

health department, and the CDC

Preemptive Conversations

• With all key personnel• Are they willing to commit to care for a

patient that may have Ebola?• Address all fears• Educate on all processes• Keep lines of communication open

Infectious Disease Screening

• Emergency Department Screening 100% of patients and visitors – Security completes screening form • If positive, Security contacts ED staff– Patient is masked– Asked to wait in wheelchair for ED staff

• If negative, form is given to patient or visitor

Arrival by EMS

• If EMS notifies Emergency Department about possible or probable Ebola patient:– Staff will meet ambulance wearing PPE in

ambulance bay• PPE based on report from EMS

– Patient will be masked and covered with clean sheet to enter facility

– EMS will be directed to decontamination shower and provided scrubs as needed

Family Members and Visitors

• Family and visitors accompanying patient will be placed in private room– Will be asked to perform hand hygiene– If clothing is contaminated will be asked to

shower• Will be provided clothing or paper scrubs

– Family members and visitors will be asked to remain in the private room until released by the Colorado Department of Public Health

If, at any time, a patient is deemed high risk for Ebola Virus, initiate Level II Isolation immediately.

Patient’s Infectious Disease Screen positive for travel history, exposure, and/or

symptoms

Put Patient in Level I isolation (contact &

airborne)

Page Infection Prevention through PBX

Travel history, exposures, onset date, symptoms,

and any pertinent clinical information

Infection Prevention to Call CDPHE

CDPHE to determine index of suspicion and

initiate testing

Infection Prevention to notify ED

Infection Prevention to initiate Level II

Isolation

R/O Ebola Not Ebola

House Supervisor AOC Physician Leadership

Notify:Receiving Unit

LabRadiology

EVSFANSRT

Other Related Departments

Evaluate need to Incident Command

Notify Dr. Quach and Dr Terra

Provide

To Notify

If physician has high clinical

suspicion, initiate Level II Isolation

Levels of Isolation

• Level 1 ( Possible Ebola): – Airborne and Contact Isolation– Gown, gloves, N95

• Level 2 (Probable Ebola):– Impermeable gown– 3 layers of gloves– N95 or PAPR hood– Face shield– Surgical hood– Boot covers

Personal Protective Equipment

• Surgical hood• Impervious gown • Duct or Chem tape• 3 layers of gloves– 1st: exam gloves– 2nd: Long cuffed nitrile

surgical gloves– 3rd: exam gloves

• N95 or PAPR hood• Face shield• Boot/leg covers

Additional Equipment

• Hospital laundered scrubs

• Crocs- hospital issued• Doffing pad

• Dedicated or disposable equipment– Stethoscopes– Blood pressure cuff– Radiology equipment– Centrifuge– Medical equipment can be

cleaned but must be dedicated until discharge or no longer needed

– Disposable food tray and utensils

Donning PPEImpermeable Gown

1. Perform hand hygiene2. Put on washable footwear (Crocs)3. Put on leg/boot covers4. Put on head protection5. Put on gown6. Perform hand hygiene7. Put on N95 respirator8. Put on face shield9. Gloves– Three layers!

Doffing PPE: Impermeable Gown

1. Remove 3rd layer of gloves in patient room2. Remove duct or Chem tape and 2nd layer of gloves3. Remove gown4. Remove leg/boot covers5. Remove 1st layer of gloves6. Perform hand hygiene7. Put on clean pair of gloves8. Remove face shield9. Remove N95 respirator10. Wipe top and bottom of shoes with bleach

PPE:Gloves

Donning– 1st layer of gloves: standard

patient care gloves, bring cuffs of gown over gloves

– 2nd layer of gloves: nitrile long-cuff gloves secured to gown with Chem or duct tape

– 3rd layer of gloves: standard patient care gloves donned after entering patient room.

Doffing– Grasp outside of glove with

opposite gloved hand; peel off

– Hold removed glove in gloved hand

– Slide fingers of ungloved hand under remaining glove at wrist

– Peel glove off over first glove

– Discard gloves in waste container

PPE:Face Shield

Donning

• Place over face and eyes and adjust to fit

Doffing

– Grab rear strap and pull it over the head forward, gently allowing face shield to fall forward

– Dispose face shield in waste container

PPE:N95 respirator

Donning• Secure ties or elastic bands

at middle of head and neck• Fit flexible band to nose

bridge• Fit snug to face and below

chin• Fit-check respirator

Doffing• Front of respirator is

contaminated — DO NOT TOUCH!

• Grasp bottom, then top ties or elastics and remove

• Discard in waste container

Reminders:PPE Removal

• Remove the 3rd pair of gloves while in patient room. Wipe down second pair of gloves with bleach wipe prior to exiting patient room.

• Remove PPE on doffing pad in anteroom or directly outside patient room.

• Perform hand hygiene after removing PPE and if hands become contaminated between steps

Transportation

• Moving patients must be coordinated through Infection Prevention and the managers of both the sending and receiving units

• Transport of patient will be performed by 2 separate teams

Transportation- Team 1

• Team 1: Physician/Staff in the patient room– Prepare the patient– Staff must wear all required PPE– Put the patient in a surgical mask and drape with a

clean sheet– Disinfect the bed rails and equipment with 10%

bleach wipes– Transfer the patient to Team 2

Transportation- Team 2

• Team 2: ICU Staff members and security– Staff members involved in transport must wear all

required PPE– Additional team member will accompany transport

to push elevator buttons and open doors. Staff member will wear PPE but remain “clean”

– Security will be utilized for traffic control during transport

– Determine route of transport to limit exposure to public

Location of Care

• All patients will be cared for in ICU setting– Ideal location equipped with:• Negative pressure room • Sink outside door to patient room• Anterooms no longer required or needed for negative

air pressure rooms due to more efficient design.

– Location isolated from other patients if possible– Locations may vary within hospitals.• All PSL patients will be in room 15 in the ICU with

dedicated equipment stored in room 14

Patient Care

• Supportive care• Common complications include:– Sepsis– Coagulopathy– Secondary infections– Multi-organ failure

Ebola Treatment

• IRB will need to be prepared for immediate approval– Emergency investigational new drug application at

• http://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/ApprovalApplications/InvestigationalNewDrugINDApplication/ucm090039.htm

– Mapp Biopharmaceutical and contact information at• http://www.mappbio.com/

– ZMapp information at• http://www.mappbio.com/zmapinfo.pdf

– Chimerix brincidofovir information at • http://ir.chimerix.com/releasedetail.cfm?releaseid=87464

7

Laboratory

• The utilization of available point-of-care testing is required to decrease potential lab exposure

• The following tests can be performed on the iStat:– Arterial, venous, or capillary blood

gases (pH, pCO2, PO2,HCO3,TCO2, BE, O2 sat)

– Glucose– Sodium– Potassium– Hematocrit/calculated

hemoglobin– Ionized calcium– Bun/creatinine– PT /INR– ACT activated clotting time– Lactate– Troponin

Lab Specimen Handling Options

• Specimens can be centrifuged in laboratory – Care must be taken

when opening centrifuge after spin

• Centrifuge can be placed in negative airflow room near patient

Specimen Transport

• Clearly label specimen at the bedside with a sharpie• All specimens requiring centrifugation will be spun

prior to transport• Outside of specimen will be disinfected with 10%

bleach wipe and then placed in a clean plastic biohazard bag

• Biohazard bag will be placed in an impervious plastic container

• All specimens will be walked and hand delivered to the Chemistry lab for receiving and processing

Lab Specimen Handling

• All technologists processing the sample will wear:– Double gloves– Fluid resistant gowns– Full face shields or goggles– Mask to cover the nose and mouth

• Special care should be taken when removing lids of blood tubes to assure safe handling– Utilize BioSafety cabinet– Remove blood caps with gauze to contain any potential

spray and remove behind a shield

Ebola Testing

• All Ebola testing will be coordinated by Infection Prevention through the Colorado Department of Public Health– Testing can ONLY occur through this process

• Specimen requirements: – Minimum of 4mL of whole blood in EDTA (purple) plastic

tube is preferred but can be submitted in sodium polyanethol sulfonate (SPS) (light yellow), citrate (blue), or with clot activator (red with or without gel)

– Specimens cannot be submitted in glass or heparinized tubes (light green or dark green)

Daily Room Cleaning

• Only use 10% bleach wipes– Keep all surfaces wet for 4 minutes (contact time!)

• Clean all horizontal surfaces• Clean all high touch areas• Put any soiled linens in hazardous waste bins• EVS will not do routine cleanings

Initial Discharge Cleaning

• Only use 10% bleach wipes– Keep all surfaces wet for 4 minutes (contact time!)

• Clean all surfaces• Put all linens in hazardous waste bins• Put all disposable items in hazardous waste

bins

Discharge Cleaning for EVS

• Only enter after approval by Infection Prevention– Room will sit unoccupied for 24 hours– All PPE will be worn for cleaning

• Only use 10% bleach wipes– Keep all surfaces wet for 4 minutes (contact time!)

• Remove the privacy curtain and discard• Perform standard discharge terminal clean– Consider use of UV or Steriplex if facility standard

Waste

• Waste is an ongoing and unresolved issue• Class A waste is infectious/biohazardous waste as

defined by the Department of Transportation• All waste goes into Class A biohazardous bins

delivered by EVS. – If not available, waste should be collected in impervious

containers and secured

Sharps

• Sharps should be disposed of in a “normal” sharps container

• Contact EVS management for removal– EVS will treat as Class A waste• Place container in red bag• Dispose of in Class A container

Waste Removal• Contact EVS management to have container delivered and waste removed

– All waste will be handled as Category A waste and treated as follows:• Place soft waste or sealed sharps containers into a primary medical waste bag

(1.5ml – ASTM tested; can be provided by Stericycle).• Apply bleach or other virocidal disinfectant into the primary bag to sufficiently

cover the surface of materials contained within the bag; securely tie the bag.• Treat the exterior surface of the primary container with bleach or other virocidal

disinfectant.• Place the primary bag into a secondary bag and securely tie the outer bag.• Treat the exterior surface of the secondary bag with bleach or other virocidal

disinfectant.• The double bagged waste should then be place into special Category A packaging

provided by Stericycle with the liner tied securely and container closed per the packaging instructions provided.

• Store the Category A waste containers separate from other regulated medical waste and in a secure area preferably isolated and with limited access.

Disposal of Fluids

• All body fluids must be disinfected• After disinfection, all fluids can be flushed into the

sewer system• Contact EVS management to obtain the disinfectant

Drills

• Practice taking patient through process from ED to ICU– Will be able to identify additional issues or

processes that need to be addressed– Will increase the comfort level of staff