Process of care guidelines for an infant, child or young person with an emerging viral disease. Draft June 2015

Transcription

1 Process of care guidelines for an infant, child or young person with an emerging viral disease. Draft June 2015 Information and guidelines pertaining to an emerging viral disease are in constant evolution. These guidelines are based on the World Health Organisation, New Zealand Ministry of Health and ADHB microbiology and infection prevention and control service recommendations. The specific personal protective equipment (PPE) will depend on the actual disease process and patient acuity and will be updated whenever an emerging viral disease is highlighted. Currently the recommended PPE is for the Ebola virus (EVD) contact and droplet precautions. In light of the lack of a safe and effective vaccine and a suspected high rate of morbidity and mortality among infected patients, the ADHB guidelines provide for a higher level of precaution. Presentation of a child directly to Starship The aim is to provide usual standards of care for all children. On initial presentation, all children, non-critical and critically ill will be managed in a designated room in the Adult Emergency Department (AED) with the appropriate staff, paediatric equipment and correct PPE. If a child with a suspected emerging viral disease is brought to hospital by ambulance, the Duty Manager will have been previously notified and commenced a modified incident management cascade. The child and family will be taken directly to the designated room in AED. If a child presents to triage who has symptoms of the emerging viral disease and a history of recent travel to the affected areas, the triage nurse will; o Don PPE from the Triage Ebola box o Put a surgical mask on the child and accompanying caregiver o The triage nurse calls the CED shift coordinator who ensures that the AED CCN and the most senior medical staff member on duty in CED are informed o Call security to clear path to the designated room in AED. o Escort the child and caregiver to the designated room in AED for further assessment and management. Once the child is confirmed as a suspected emerging viral disease patient, the CED shift coordinator will alert; the duty manager, who will initiate the modified incident management cascade, CED Clinical Service Director and NUM. A log will be kept of all staff members who enter the patient s room. This will be faxed to ADHB occupational health department by the CED NUM when the patient is transferred to the ward. Starship Emerging Viral Disease Process Of Care Guidelines Doc Page 1 of 12

2 Transfer to ward 7A On confirmation that ward 7A is ready to receive the patient, nursing and medical staff members from the admitting team, either ward 25AB or PICU, will go to the designated room in AED, receive patient handover, don PPE and accompany the patient to ward 7A with security staff assigned to manage any public en route Transport of a child to Starship Any child who presents to Northland, Waitemata and Waikato DHB hospitals will be transferred to ADHB if possible. For a non-critically ill child an initial clinical referral will be made to the General Paediatrician on-call. The referring team initiate an ambulance request as per usual process. The decision on whether and how to transport the child will be made by the Medical Officer of Health in collaboration with St John Medical Director ± Clinical Director of Air Ambulance service. The referring team is responsible for contacting Auckland City Hospital Duty Manager to initiate the incident management cascade and preparation of ward 7A for direct admission. Security staff will meet the ambulance and escort the child and accompanying family and St John staff directly to ward 7A. Where a child is being managed in CMDHB bio containment unit the decision on timing of transfer for a child who tests positive for Ebola but not unwell will require a clinical discussion via teleconference between ADHB General Paediatrician on call, Paediatric Infectious Disease Consultant on call, PICU Consultant on call and CMDHB Infectious Disease and Paediatric Consultants. For any critically ill child, an initial clinical referral will be made to the PICU Consultant oncall. The PICU team will initiate the usual transport request. The decision on whether it is possible to safely transport the patient and how will be made in consultation with the Medical Officer of Health, St John Medical Director ± Air Ambulance service Clinical Director and PICU Consultant. Once transport is confirmed, the PICU clinical team is responsible for contacting the Auckland City Hospital Duty Manager to initiate the incident management cascade and preparation of ward 7A for direct admission. Any PICU staff involved in transporting a child with a suspected emerging viral disease will follow the guidelines developed by the Air Ambulance service and St John. The designated PPE is obtained by contacting the Adult Emergency Department Charge Nurse and arranging to access the ADHB stock supply which is held there. Ensure that there is adequate staff on the transport for donning and doffing PPE safely. On arrival back at ADHB, security staff will escort the transport team directly to ward 7A. One asymptomatic adult family member may accompany the child. No symptomatic adult family members are to accompany the child. All adult symptomatic family members are to be managed as per the adult referral pathway (refer to Ministry of Health, Information for Health Professionals: EVD). Starship Emerging Viral Disease Process Of Care Guidelines Doc Page 2 of 12

3 Admission It is envisaged that all patients, non-critical and critically ill will be managed on ward 7A with appropriate staff and equipment moved from ward 25AB or PICU. It is important that all the more usual causes of illness in children are also considered and managed appropriately e.g. malaria, pneumococcal or meningococcal disease, and typhoid fever. As soon as a child is confirmed as a suspected emerging viral disease patient, the duty manager will be contacted (if not already done) and a modified Incident Management Cascade will be actioned. Ward 25AB or PICU nurse in charge will be informed as early as possible to facilitate staffing and equipment mobilisation. This notification should include the age/estimated weight of the child and the presence of family member/caregiver and their clinical status. The ward 25AB or PICU nurse in charge is responsible for contacting the Paediatrician or Intensivist on call and the Charge Nurse or Nurse Unit Manager. The Charge Nurse/Shift Co-ordinator of 7A will be informed by the ACH Duty Manager to commence decanting of patients from ward 7A, curtain removal and cleaning of patient rooms. Paediatric specific equipment; hardware and consumables will be stored in PICU storeroom and taken over to ward 7A by staff from either ward 25AB or PICU as appropriate. The nursing staff will set up the patient room, anteroom and PPE area, and admit the patient. This must be done in a timely manner liaising with Duty Manager /Charge Nurse/ Shift co-ordinator of ward 7A. Staffing Whenever staff members are in the room, there will be two staff members present irrespective of patient acuity as they will be responsible for monitoring each other for breaches in PPE. Therefore a nursing staff to patient ratio of 2:1 (one of the RNs should be level 3 or 4) is required with a third nurse available to swap out every 2 hours if constant nursing presence is required in the room. Assessment of the need for constant nursing presence in the room is required once the patient is stabilised and considering the length of time to don PPE before being able to go into the patient room. In addition, two appropriately trained nurses are required to fulfil the assistant and team leader roles to ensure correct putting on and taking off of PPE. These nurses will provide a communication link with the bedside nurses and the clinical team and can undertake other duties (ongoing organisation of supplies, waste management etc) in the ward but must be available at all times for anyone wishing to enter or leave the patient room. A paediatric medical staff member will be onsite on ward 7A also. The medical staff member may be from General Paediatrics, CED or PICU, depending on patient acuity and skills required. The Paediatric Infectious Disease team will consult as per usual practice. A record of nursing and medical staff trained in PPE will be maintained on the L drive. Starship Emerging Viral Disease Process Of Care Guidelines Doc Page 3 of 12

4 Staff should change into scrubs on their home ward (and leave personal belongings in their locker) before going to ward 7A. A room on ward 7A will be set up to facilitate staff showering and changing into clean scrubs at the end of the shift, prior to returning to home ward to change into own clothes. A log will be kept of all staff members who enter the patient s room. The log sheet will be faxed to ADHB occupational health department at 2pm each day by the designated team leader. A supply of personal protective equipment (PPE) and disposable linen will be maintained on ward 7A. Additional yellow bins and designated cleaning mops for each occupied room will be brought to ward 7A Laboratory tests Refer to laboratory guidelines. Restricted laboratory testing will be available. An initial laboratory specimen kit will be available on ward 7A and AED. Specimens will be processed outside of laboratory high acuity times at a time mutually agreed with the nursing staff looking after the child. The laboratory MUST be contacted prior to sending any specimens. Laboratory specimens are to be double bagged and put in to the bio-bottle in the room before being put into a designated transport chilli bin and walked over to the Labplus level 3 specimen reception area and given to a designated laboratory person (chain of custody approach). For a child requiring PICU management an Istat will be provided in the patient room to enable frequent electrolyte monitoring. Cross matching will not be undertaken and patients will receive O negative blood if required. Pharmacy Vigilance will be required if administering medications from ward 7A stock as these will generally be larger dose vials. Some additional medications may need to be provided from pharmacy (in hours) or ward 25AB or PICU stock or obtained from the pharmacy after hours cupboard. This is largely going to be medicines used for the more usual causes of illness in children e.g. malaria, pneumococcal or meningococcal disease, and typhoid fever or circulatory support medicines for children requiring intensive care. Care of the deceased child If the child dies, it is important that there is minimal contact with the body. It will be necessary to prepare the child s family that they will not be able to view or touch their child s body, spend any length of time with them or take their child home. The child s body should be removed in a double body bag and sealed coffin by a funeral director as soon as possible. Refer to the ADHB EVD plan for further information. Starship Emerging Viral Disease Process Of Care Guidelines Doc Page 4 of 12

5 Admission of a child with an emerging viral disease Depending on patient acuity and accepting team, either Ward 25AB or PICU nurse in charge, in liaison with the Duty Manager will ensure staffing of 3 nurses to care for the patient and 2 nurses to manage PPE (assistant and team leader role). If initial resuscitation in the emergency department is required, one of the identified PICU nurses will need to assist as per usual PICU practice. The role of assist and team leader may be shared between services if there are other emerging viral disease patients also on ward 7A. Contact the appropriate NUM and consider using the emergency staff call back cascade to ensure on-going functioning of clinical services. The appropriate NUM will liaise with the Duty Manager to develop a roster of staff to provide cover for at least 72 hours. If the patient requires intensive care support, enlist the PICU nurse technician to support. A collection of paediatric equipment to enable the initial set up of a paediatric room in ward 7A will be located in PICU. The assigned team of staff will collect this and take over to ward 7A to prepare the room for the admission of a child. Equipment The assigned nursing team are to collect the following equipment from the PICU store room Designated ventilator (as indicated) Designated Dash monitor (currently one with sticker that says this is the oldest monitor) Dash end tidal CO 2 cable and consumables Designated bedside trolley Paediatric resuscitation case 1 x IV pump (as required) 4 x syringe drivers and docking station (as required) Transport fridge drugs (as required) Central line insertion pack and appropriate size central line as indicated Case marked Emerging Viral Disease Equipment containing: Double outlet oxygen adapter Double outlet suction adapter 2 x suction regulators 1 x 4 multi-plug board with long extension Box of digital thermometers Range of disposable nappies X2 White board Magnifying glass Starship Emerging Viral Disease Process Of Care Guidelines Doc Page 5 of 12

6 Case marked Emerging Viral Disease Equipment containing: Monitoring bag: Airway bags: o Set of dash monitoring o T piece cables and appropriate monitoring leads o Paediatric and adult ambu bag/mask and range of facemasks o Paediatric size oxygen mask/tubing o Paediatric nasal oxygen cannula o Range of suction catheters Ventilator bag o X3 large and medium HME o Yankeur suction o Range of in-line suction catheters Adult dry ventilator circuit Paediatric dry ventilator circuit Medication bag Miscellaneous bag o Range of urinary catheters o Range of nasogastric tubes o Enteral feeding sets 500ml bags of IV 0.9% sodium chloride 500ml bags of dextrose/sodium chloride Set of ICU and ward patient notes 2 multicolour and 2 white board pens and pupil torch Snaplock bags for items within the room (patient cellphone, TV remote etc) Starship Emerging Viral Disease Process Of Care Guidelines Doc Page 6 of 12

7 Set up designated room in ward 7A (currently room 7 & 8 is first choice): Ensure all unnecessary equipment has been removed from the room (e.g. bedside locker) Ensure curtains have been removed from the room or disposable curtains are in situ Ensure large yellow waste bin with liner is in the room Ensure functioning oxygen and suction with appropriate consumables for age/weight of child. If required, ensure the T-piece and/or disposable ambubag have viral filter attached. Set up specific equipment for the patient (only take ventilator, physiological monitor, IV pump, syringe driver (s) into the room as needed) If Ventilator is needed (position to allow patient viewing through door window) Ensure double outlet oxygen adapter in situ Appropriate circuit (dry) for weight of patient with HME Set up in-line suction. Only medication chart and PICU flowchart or PEWS chart to be inside the patient room. All other notes to be outside in the corridor Ensure disposable linen is used (any non-disposable linen is disposed in the yellow waste bin) Put up putting on PPE instructions in the PPE donning area Put up taking off PPE instructions in the anteroom Set up infection prevention and control decontamination resources in anteroom. Ensure paediatric emergency trolley/storm case is placed within ward 7A emergency equipment bay. Ensure the cases with additional consumable supply are kept outside of the room and readily accessible in the ward. Starship Emerging Viral Disease Process Of Care Guidelines Doc Page 7 of 12

8 The following guidelines are split into 4 areas: Environment, Staff, Patient and Caregiver. Environment. The patient room is designated a red zone only staff in full PPE may enter this area. The ante-room is designated an orange zone only staff in assist or team leader PPE may enter this area. The ward corridor is designated a green zone all staff in this zone are to wear scrubs Patients will be nursed in a negative pressure room with ante-room. The doors are to remain closed and opened only for access. Patient room and ante room door should not be opened at the same time. Supplies and equipment within the patient room are to be kept to a minimum. Single use/disposable items are preferred. Minimise contact with environmental surfaces. Only the patient s medication chart and PICU 24 hour flowchart or PEWS chart should be kept within the patient room. These will be collected together at the end of the patients stay, double bagged in yellow bags and sent to CSSD for processing. All other clinical notes will remain outside the room. Laboratory specimens will be double bagged, put in a designated bio-bottle and transported in a designated chilli bin. A replacement specimen kit will be provided on a one for one basis on receipt of the specimen by the laboratory staff. Refer to laboratory specimen process guideline. Once occupied, the room will be cleaned and disinfected by the nursing staff within the room with Clinell wipes: o Clean and disinfect hard, non-porous surfaces (e.g. such as bed rails and housekeeping surfaces such as counters) each shift. o Clean and disinfect high touch areas (e.g. door handles, bedside trolley) regularly o Conduct environmental surface cleaning and disinfection following any procedure likely to result in aerosolisation of secretions o Blood or body fluid spills are to be disinfected with 1% bleach solution. o Use disposable cleaning cloths and mop cloths and dispose of these in leak-proof bags o Mop the floor daily. A large yellow waste bin will be situated in the patient room for immediate disposal of all waste. The outside of the bin will be cleaned with a clinell wipe before being removed from the room. A replacement yellow bin will be put into the patient room. The bin will be taken straight down to a locked area of the loading dock. Starship Emerging Viral Disease Process Of Care Guidelines Doc Page 8 of 12

9 Staff It is vital all health care workers have the correct PPE for the disease, patient acuity and duties being carried out. Refer to Infection Prevention and Control guidelines. Designated roles: healthcare worker refers to any person entering the room for direct patient care assist nurse is a trained nurse who assists the health care worker putting on and taking off PPE team leader who is a trained nurse who checks off the process. The assistant and team leader are responsible for ensuring all visiting staff members comply with the guidelines. The highest risk of exposure for healthcare staff is during removal of PPE which is a two person procedure. A buddy system will be in operation. Two staff members should be in the child s room at all times (initially this may be a doctor and a nurse). Each is responsible for ensuring their colleague does not contaminate themself. If PPE gets significantly soiled, wipe down with clinell wipe in the patient room, exit room to doff PPE as per standard procedure and don new PPE. If a breach in PPE results in significant soiling of scrubs, following removal of PPE, remove scrubs and change into a gown in the ante-room prior to exiting and going for shower. Staff members are to wear theatre scrubs. These are to be removed at the end of the shift and put into the hospital laundry system. Any scrubs which are heavily soiled should be double bagged and disposed in the yellow waste. A room on ward 7A will be set up as a staff change area and staff are to shower before putting on clean scrubs and returning to home unit to change into personal clothes to leave the hospital. PPE for team leader during doffing healthcare worker PPE procedure The team leader should maintain a distance of 1 meter from the doffing process. Scrubs Footware: socks, clogs and knee length shoe covers Gown: Yellow gown Head: head cover Visor: full face shield PPE for nurse assisting with doffing healthcare worker PPE Scrubs Footware: socks, clogs and knee length shoe covers Gown: purple impervious long gown Head: head cover Mask: N95 Mask Eye Protection: disposable eye glasses Visor: full face shield Gloves: High risk gloves, which are worn over the gown sleeves. Starship Emerging Viral Disease Process Of Care Guidelines Doc Page 9 of 12

10 Full body PPE for bedside staff (healthcare worker). Refer to Infection prevention and Control Guidelines. Prior to entering the anteroom all staff must be wearing scrubs and remove items of jewellery and personal items, perform hand hygiene and put on PPE. A second staff member will assist and a third staff member will check off the process. Foot ware: Patient Fall Prevention socks and clogs inside disposable knee length shoe covers. Coveralls: Full length impervious coveralls with hood. Mask: N95 mask Eye protection: disposable eye glasses Visor: disposable full face shield over the eye glasses and N95 mask. Gloves: 2 pairs of high risk gloves. One pair is worn under the coverall sleeve, use the thumb hook and second pair are worn over the coverall sleeve. It is vital all staff maintain thorough hand hygiene technique in the patient room. If the patient has a procedure likely to result in aerosolisation of secretions, the minimum number of staff required should be present in the room during the procedure with limited entry/ exit to the room during the procedure and for 20 minutes after the procedure. Removal of full body PPE All PPE except the designated footwear (clogs) are single use items and must be removed and disposed of in the yellow bin. Removal of PPE must be done correctly as per infection prevention and control guidelines. A trained assist nurse in PPE must help to avoid the risk of self contamination with a trained third person checking off the list. Clogs are inserted into large container for cleaning and disinfecting by assist nurse Assist nurse removes PPE and performs hand hygiene. Return cleaned clogs to clean PPE area When the specified PPE is worn and removed correctly the risk of a healthcare worker contracting Ebola is very low. Refer to Occupational Health and Safety staff management guidelines. Starship Emerging Viral Disease Process Of Care Guidelines Doc Page 10 of 12

11 Patient management Patients should be managed with due diligence and care to patient and staff safety. Limit the use of needles and other sharps as much as possible. All needles and sharps should be handled with extreme care and disposed in puncture-proof, sealed containers at point of care. Phlebotomy, laboratory testing and procedures should be limited to the minimum necessary for essential diagnostic evaluation and medical care. Unventilated: Patients will wear N95 mask if coughing Ventilated: The ventilator circuit will have dry humidification using a heat moisture exchange filter (HME). The HME is changed daily. Hand ventilation equipment should be used with an in line filter. To prevent further risk of contamination by breaking the ventilator circuit, closed suction will be used. The suction pressure is 100mmHg. The recommended use of ventilator tubing is 7 days, in these cases the tubing may be used for longer. All airway equipment is single use. The laryngoscope handle is not disposable and should be cleaned with clinell wipe if soiled. Avoid the use of nebulisers where possible and use an MDI on inspiration via a closed system if required. Starship Emerging Viral Disease Process Of Care Guidelines Doc Page 11 of 12

12 Caregivers In anticipation that a caregiver will wish to stay with a child for the duration of their admission, the following infection control measures are required: One or two asymptomatic family members (to relieve each other) are nominated as the child s caregiver to minimise potential contacts. Only one designated caregiver will be in the room at any one time. All symptomatic family members should be quarantined at home or may be admitted to ward 7A or other designated hospital. The caregiver is provided with similar personal protective equipment (PPE) as the healthcare worker; scrubs, N95 mask, disposable eyeglasses, full face visor, disposable coverall, and gloves. Nursing staff are to supervise correct use and removal of the protective attire and thorough hand washing technique. When leaving the patient room, the caregiver is to remove all protective attire with the nursing assistance as per healthcare worker. If the patient has a procedure likely to result in aerosolisation of secretions e.g. intubation, the caregiver should leave the room during the procedure. Meals are to be supplied to the caregiver from nutrition services using disposable crockery and cutlery. The small kitchen area on ward 7A will be used for caregivers need for rest breaks and a room on ward 7A can be designated for overnight accommodation. The caregiver should be monitored 12 hourly for signs of elevated temperature and/or symptoms. Should these occur in the hospital the caregiver is to be directed to another patient room on ward 7A to be assessed by a member of the adult Infectious Disease team. The caregiver is to be asked to notify the Auckland Regional Public Health Service (ARPHS) by phone if he or she becomes symptomatic in the community so that appropriate follow up can be arranged. Where patient death is highly likely, limitation to one caregiver may not be enforced. Caregivers should not touch a deceased patient without full PPE and contact should be limited. N.B. If a caregiver refuses to wear the required PPE in the room they should be advised to organise another caregiver who will wear PPE. If the caregiver insists on entering the room without PPE, they must be advised that they will be quarantined and CANNOT leave the room until the patient has been cleared. Security personnel may be used to ensure adherence. Starship Emerging Viral Disease Process Of Care Guidelines Doc Page 12 of 12