Standard Operating Procedure for Ebola Identification

Transcription

1 SH CP 164 Standard Operating Procedure for Ebola Identification Summary: The IP&C Lead has developed a Standard Operating Procedure, SOP (Appendix A) to help guide staff to identify and manage patients who present with a high index of suspicion of Ebola. This SOP is specific for MAU and MIU at Lymington New Forest Hospital and MIU at Petersfield but should also be used in other areas in the Trust if clinically indicated in line with the Viral Haemorrhagic Fever (VHF) Risk Assessment flow chart. Keywords (minimum of 5): (To assist policy search engine) To escalate any potential case please see the Escalation Flowchart at Appendix B. Ebola, Viral Haemorrhagic Fever (VHF), virus disease, Ebola virus. Target Audience: All staff of all disciplines, particularly MAU, MIU and FAC at Lymington and MIU at Petersfield Next Review Date: November 2019 Approved & Ratified by: IPC& Decontamination Group Date issued: Date of meeting: Author: Sponsor: Theresa Lewis, Lead Nurse Infection Prevention and Control. Della Warren, Director of Nursing. 1

2 Version Control Change Record Date Author Version Page Reason for Change Oct 2014 Nov 2014 Nov 2015 Theresa Lewis 2 Update Theresa Lewis 3 Updated guidance received from Department of Health Nov 2014 to include Increased level of PPE required for patient management Changes in Risk Assessment Algorithm (temp 37.5c) More detail added for waste management Theresa Lewis 4 Review required one year post initial publication Reviewers/contributors Name Position Version Reviewed & Date Theresa Lewis, Lead Nurse Infection Prevention and Control August 2014 Julia Lake Deputy Head of Professions August 2014 Paul Mundy Clinical Nurse Manager August 2014 Della Warren, Director of Nursing August 2014 Chris Gordon Chief Operating Officer & Integrated Care August 2014 Martyn Diaper Medical Director August 2014 Lesley Stephens Director of MH & LD August 2014 Public Health England August 2014 Theresa Lewis Lead Nurse Infection Prevention and Control Nov 2014 Jacky Hunt IP&C Nurse North Nov 2014 Angela Roberts IP&C Nurse West Nov 2014 Nicky Bartlett Interim Matron Lymington New Forest Nov 2014 hospital Shelly Mason Modern Matron Nov 2014 Sandra Grimes Commercial Contract Manager & Project Nov 2014 manager Darren Hedges Area Health & Safety Officer Nov 2014 Fiona Richey Head of Risk and Business Continuity Nov 2014 EPRR Working Group Members of this Group Dec 2014 Angela Roberts IPCN West Sept 2015 Louise Piper IPCN East Sept 2015 Robert Harris Estate Services Contract and Project Oct 2015 Manager Lesley Chandler Public Health England (Wessex) Oct 2015 IPC& Decontamination Group Members of the Group Nov

3 For risk assessment and management of potential cases please go straight to SOP (Appendix A) on page 6 To escalate potential cases in any healthcare setting please go straight to Appendix B on page 19 CONTENTS Subject Page Number Background 4 Appendix A Standard Operating Procedure 6 Risk Assessment 6 Isolation 7 Standard Precautions 7 Personal Protective Equipment 9 Hand Hygiene 10 Equipment 11 Decontamination 11 Waste 13 Linen 14 Diagnostic Investigations 15 Staff exposure to potentially infectious material 15 Staff exposure to confirmed case of VHF 16 Communications 18 Department of Health VHF Guidance 18 Appendix B: Escalation Flow Chart 19 Appendix C: Communication Algorithm LNFH 22 Appendix C: Communication Algorithm MIU Petersfield 23 Appendix D: Ebola Boxes (Hazardous Material Box) 24 Appendix E: Donning and Doffing of PPE 25 Appendix F: Timeline of actions taken by Southern Health NHS 28 Foundation Trust 3

4 SOP for Ebola Identification, Personal Protective Equipment and Fit Testing Background Ebola virus disease is a severe disease which affects humans and other primates, and is form of viral haemorrhagic disease. The incubation period of Ebola virus disease ranges from 2-21 days. The onset of illness is sudden with fever, headache, joint and muscle pain, sore throat and intense weakness. This is then followed by diarrhoea, vomiting, rash, impaired kidney and liver function and stomach pain. Some patients may develop a rash, red eyes, hiccups, internal and external bleeding. Ebola haemorrhagic fever is fatal in between 50-90% of cases. No specific treatment or vaccine has yet been developed. The Ebola virus is thought to come from fruit bats, and it affects other animals such as chimpanzees, gorillas, monkeys and porcupines. Humans can be infected through contact with the blood or body fluids of an infected animal. Once this has occurred, the infection can be passed from person to person through direct contact with blood or other body fluids from an infected person, including contact with objects such as needles or soiled clothing that have been contaminated with infected body fluids. The disease can also be transmitted via sexual contact with a person who is infected or who is recovering from the disease, as the virus is present in semen for up to 7 weeks after recovery. Experts agree that there is no circumstantial or epidemiological evidence of an aerosol transmission risk from VHF patients. This SOP is a summary a based on the Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence (DH November 2014). The aim of this SOP is to help guide staff to identify and manage patients who present with a high index of suspicion of Ebola. This SOP is specific for MAU, MIU and Forest Assessment Centre (FAC) at Lymington New Forest Hospital and MIU at Petersfield but should also be used in all other areas in the Trust if clinically indicated in line with the Viral Haemorrhagic Fever (VHF) Risk Assessment flow chart. This assessment flow chart can be found within the main document (Management of Hazard Group 4 VHF) embedded on page 18 of this SOP. Risk Assessment Risk assessment is a legal obligation The patient s risk assessment determines the level of staff protection and the management of the patient The risk to staff may change over time, depending on the patients symptoms Patients with VHF can deteriorate rapidly 4

5 In preparation for the updated guidance in November 2014, ACDP undertook a new assessment of the risks of transmission of VHF infection. Evidence from outbreaks strongly indicated that the main routes of transmission of VHF infection are direct contact (through broken skin or mucous membranes) with blood or body fluids, and indirect contact with environments contaminated with splashes or droplets of blood or body fluids. VHFs are severe and life-threatening viral diseases that are endemic in parts of Africa, South America, the Middle East and Eastern Europe. Environmental conditions in the UK do not support the natural reservoirs or vectors of any of the haemorrhagic fever viruses. All recorded cases of VHF in the UK have been acquired abroad, with the exception of a laboratory worker who sustained a needle stick injury. There have been NO cases of person-to-person transmission of a VHF in the UK to date of publication of the revised guidance (DH Nov 2014). VHF s are of particular public health importance because: They can spread readily within a hospital setting They have a high case-fatality rate They are difficult to recognise and detect rapidly There is no effective treatment CURRENT (Nov 2015) There remains an expectation that a small number of cases may occur in the UK in the coming months. These people could become infected in a VHF endemic country and arrive in the UK while incubating the disease and develop symptoms after their return Individuals may present in several different ways to healthcare facilities: referral by primary care, self-presentation at Minor Injuries Unit or self-presentation at local inpatient facility. Triage mechanisms need to be able to quickly identify patients at risk so that they can be isolated and a risk assessment completed. Please follow the Standard Operating Procedure (SOP) for the management of suspected cases of VHF including Ebola Virus Disease (EVD) Appendix A, page 6 Version 4. This procedure should also be read in conjunction with the SHFT Lockdown Policy It is the responsibility of the Professional Leads to ensure dissemination and implementation of this SOP and documentation is viewed in accessible areas. 5

6 APPENDIX A: SOP for the Identification and Management of Patients with suspected Viral Haemorrhagic Fever including Ebola* (version 4) *For further guidance including the risk assessment flowchart, please refer to Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence (Dept of Health November 2014), embedded at the end of this SOP, page 18. VHFs are severe and life-threatening diseases for which there is currently no proven treatment or prophylaxis. Patients with confirmed VHF infection should be managed in a specialist high level isolation unit eg Royal Free in London. For patients who present with a high index of suspicion of Ebola or any other infectious disease please follow the Viral Haemorrhagic Fevers Risk Assessment. Please note that SHFT does not have the facilities to accept/manage a confirmed case of VHF including Ebola. RISK ASSESSMENT A. Does the patient have a fever ( 37.5 C) or history of fever in the previous 24hrs and has developed symptoms within 21 days of leaving a VHF endemic country OR B. Does the patient have a fever ( 37.5 C) or history of fever in the previous 24hrs and cared for/come into contact with body fluids of/handled clinical specimens (blood, urine, faeces, tissues, laboratory cultures) from an individual or laboratory animal known or strongly suspected to have VHF within the past 21 days If the answer to either of the above is YES please: 1. Isolate in a single room immediately to limit contact 2. Follow the instructions as per the VHF Risk Assessment algorithm which can be accessed from the full document embedded on page 18 of this SOP 3. Follow instructions as per Appendix B: Escalation Flowchart for Management of Suspected Cases, page For Lymington and Petersfield, staff to also follow instructions as per Appendix C: Communication Algorithm, page For community staff visiting patients in their own home who fall into this category, avoid direct contact with the patient and seek urgent advice from the duty GP. If the answer to either of the above is NO then VHF (Ebola) is unlikely and manage patient locally using normal standard precautions. Patients will be categorised as either: unlikely to have VHF, or high possibility of VHF. Please contact the Duty Consultant Microbiologist at your nearest acute Trust if you need 6

7 support with the risk assessment. If further advice is needed, please contact the Imported Fever Service at Porton (manned 24hrs). VHF is a notifiable disease under Schedule 1 of the Health Protection (Notifications) Regulations 2010 and notification of VHF is classified as urgent. The Registered Medical Practitioner (RMP) attending the patient must notify the highest possible risk by telephone to the Proper Officer of the local authority in which the patient currently resides, within 24hours. Written notification should be followed up within three days. The Proper Officer is usually the Consultant in Communicable Disease at the local Public Health England (PHE). Risk assessment is a legal obligation. The patients risk assessment determines the level of staff protection and the management of the patient. Standard precautions and good infection control are paramount to ensure staff are not put at risk whilst the initial assessment is carried out. It is assumed throughout this guidance that staff will be following standard precautions. If these measures are not already in place, they must be introduced immediately when dealing with a patient in whom VHF is being considered. PATIENT MANAGEMENT OF SUSPECTED CASES OF EBOLA (VHF) ISOLATE Isolate patient in a side room immediately to limit contact. The side room should have dedicated ensuite facilities or at least a dedicated commode. For HIGH POSSIBLE VHF infection identify a side room which has an adjacent contained space in which appropriate infection control can be carried out eg removal and disposal of PPE. If possible ensure the patient isolation room is minimally furnished and equipped with items which are disposable or can be cleaned with a chlorine (bleach) agent. For HIGH POSSIBLE VHF infection, restrict the number of staff in contact with the patient. Only named staff wearing appropriate PPE and trained in its use should enter the patient s room MINIMUM STANDARD PRECAUTIONS REQUIRED HIGH POSSIBILITY VHF : Hand Hygiene Double gloves Fluid repellent disposable coverall Full length plastic apron Head cover eg surgical cap Fluid repellent footwear eg long boot covers Full face shield Fluid repellent FFP3 respirator* Staff member to be wearing surgical scrubs (worn as single use items under PPE) Isolation in a side room with dedicated ensuite facilities or dedicated commode 7

8 For staff delivering care to the patient, contact with body fluids should be avoided, taking care to minimise contamination of the environment, and ensure safe containment of contaminated fluids and materials. NB: Appendix 8 can be found in the full ACDP guidance embedded in this SOP, page 18 All of the standard precautions required to care for a patient with HIGH POSSIBILITY VHF can be found in dedicated Ebola Boxes (also labelled as Hazardous Material Box - HAZMAT). The contents of each box have been procured centrally from NHS Supplies. Please see Appendix D, page 27 for a full list of the contents of each box. Ebola boxes (HAZMAT boxes) will be located in the following locations*: 8

9 X1 MIU Petersfield Community Hospital X1 MIU Lymington New Forest Hospital X1 MAU Lymington New Forest Hospital *These sites have been identified as potentially being our high risk areas. X1 Spare: East Division (held in MIU Petersfield) X1 Spare: Trust (held centrally in Moorgreen hospital). This can be accessed by contacting the Duty Estates Manager on in working hours. The duty engineer will be contacted and instructed to deliver the HAZMAT box where needed. Out of hours, please contact the Director on Call ( ). X1 Training box for IP&C team held at Elms, Tatchbury. FFP3 RESPIRATORS FFP3 respiratory protection must be worn for any high possibility case as splash protection. If using the mask for respiratory protection during aerosol generation procedures, please ensure that any staff wearing a FFP3 respirator have been Fit Tested and trained to wear this please see FFP3 Fit Check poster attached to this SOP. Potential aerosol generating procedures include; Endotracheal intubation Bronchoscopy Airway suctioning Positive pressure ventilation via face mask High frequency oscillatory ventilation Central line insertion Diagnostic sputum induction PERSONAL PROTECTIVE EQUIPMENT (PPE) The PPE should provide a suitable barrier protection for staff. The barrier function will need to be maintained throughout all clinical/nursing procedures including the decontamination of potentially contaminated equipment by the wearer The PPE should provide adequate coverage of all exposed skin The materials from which the PPE is made should resist penetration of relevant liquids/ suspensions and aerosols. The various components (body clothing, footwear, gloves, respiratory/face/eye protection) should be designed to fit the user well enough to maintain a barrier eg sleeves long enough to be adequately overlapped by glove cuffs. 9

10 DONNING AND DOFFING (REMOVING) OF PPE A detailed and pre-defined sequence for donning and doffing of items must be followed. Please see Appendix E, page 28 for the full donning and doffing procedure. A laminated copy of this will also be available in each Ebola Box (HAZMAT box). The expiry dates and integrity of PPE should be checked prior to donning PPE should be put on over single use disposable scrubs Donning and doffing must always be done in pairs using the buddy buddy system After use it should be assumed that PPE may be contaminated and an appropriate removal procedure is essential to prevents risks of exposure to the wearer. Staff should be trained* in procedures to don and especially doff PPE, including the correct order to avoid cross contamination, and to check that the FFP3 with which they are provided fits properly. Staff who have not received training in the wearing of this level of PPE, should not be involved in the care / decontamination of areas of patients with HIGH POSSIBILITY VHF. PPE should be donned before starting procedures likely to cause exposure and only doffed after moving away from a source of exposure eg moving into an adjacent changing area. PPE should not be a source of further contamination. Please ensure that following removal PPE is not left on environmental surfaces. Following removal disposable PPE will need to be placed into suitable disposable receptacles and treated as clinical infectious waste see Waste section PPE should be stored off the floor in a designated clean and dry storage area to ensure they are not contaminated prior to use. *Training in PPE will be provided for staff working in areas which are considered higher risk areas. 3 sites will be targeted to receive this training MIU at Petersfield Community Hospital and MIU, MAU and FAC at Lymington New Forest Hospital. HAND HYGIENE Before donning gloves and wearing PPE on entry to isolation room Before any clean/aseptic procedure being performed on the patient After any exposure risk or actual exposure with the patient s blood or body fluids After touching (even potentially) contaminated surfaces/items in the patient s surroundings Before leaving the patient isolation room and moving to the room identified to remove PPE 10

11 When caring for HIGH POSSIBLITY VHF hand hygiene must be performed inbetween the removal of each different part of PPE EQUIPMENT If possible ensure the isolation room is minimally furnished and equipped with items which are disposable or can be cleaned with a chlorine (bleach) agent. Single use (disposable) equipment and supplies should be used where possible The use of needle-free sharps systems to eliminate the risk of needle-stick injuries should also be used if possible. Disposable crockery and cutlery should be used where possible for those patients categorised with HIGH POSSIBILITY VHF. These items should be disposed of as Category A waste (yellow bag) DECONTAMINATION VHF viruses have been shown to be susceptible to a broad range of disinfectants including chlorine and alcohol. It is also inactivated with soap and water VHF viruses can survive for several hours when dried onto surfaces such as doorknobs and worktops and up to several days in body fluids such as blood at room temperature VHF viruses have also been known to survive for two weeks or even longer on contaminated fabrics and equipment Staff involved in decontamination and cleaning must wear appropriate PPE and use suitable disinfectants. For surfaces where there is no visible contamination with blood or body fluids and general environmental cleaning, a hypochlorite solution containing 1,000ppm available chlorine should be used Blood/body fluid spillages (eg; urine, vomit, diarrhoea): Contamination should firstly be covered with absorbent chlorine granules (Sodium dichloroisocyanurate NaDCC). The area should then be disinfected with freshly prepared hypochlorite solution containing 10,000ppm available chlorine ensuring a contact time of two minutes before wiping with disposable towels. Please refer to manufacturer s instructions. The surface should then be washed with warm water and detergent. Please note this is a clinical staff NOT housekeeping responsibility. Full PPE must be worn whilst disinfecting. All waste, including gloves and paper towels should be disposed of as Category A waste (yellow bag) When using chlorine products please ensure there is adequate ventilation (open windows), and follow manufacturers instructions. 11

12 Terminal clean of room upon patient discharge/transfer. INITIALLY CLOSE THE ISOLATION ROOM / TOILET & PPE REMOVAL ROOM TO ADMISSIONS Keep these areas closed until all decontamination is complete and ensure these rooms are clearly identified as Out of Use. Hazard tape (from the Ebola box) can be used across the doors to identify these as closed rooms. For HIGH POSSIBILITY VHF do not use the room until test results are known from potential cases NB: this can be 8-12 hours for the results to be known. For CONFIRMED CASES OF VHF rooms will need to be decontaminated via fumigation following discussions with PHE. The process for fumigation is outlined on page 76 of the ACDP guidance embedded at the end of this SOP, page 18. Fumigation can only be undertaken by staff fully trained in this procedure. Contact Wessex Health Protection team on for further advice. Public areas where the suspected case has passed through and spent minimal time in eg corridors, but which are not visibly contaminated with bodily fluids, do not need to be specially cleaned and disinfected. If the VHF test is negative, usual cleaning methods can be used. TOILETS Toilets or commodes may be used by patients categorised as HIGH POSSIBILITY VHF. Where commodes are used it must be dedicated for that patient and used with a disposable bedpan insert. The contents of the bedpan must be solidified with a high absorbency gel / granules and then disposed of as Category A waste (yellow bag) Toilets and commodes should be disinfected with hypochlorite containing 10,000ppm available chlorine at least daily, preferably after each use and upon patient discharge. For non-ambulant patients, disposable bedpans should be used and the contents solidified with high-absorbency gel / granules and then disposed of as Category A waste (yellow bag). 12

13 WASTE Waste for HIGH POSSIBILITY VHF infection For high possibility all waste is classified as Category A infectious waste on the basis that it is known or contaminated with pathogens presenting the most severe risk of infection. All waste including gloves and paper towels should be autoclaved or incinerated place waste in YELLOW bag. These waste bags must be double bagged. Inside Isolation Room: Patient Waste 1. Staff caring for patients in isolation must be wearing full PPE as outlined in Standard Precautions section 2. HCW inside the room must line a yellow clinical waste sack with an absorbent liner / cushion from the Ebola box. 3. Place waste and linen into yellow clinical waste sack ensuring the sack is only half full (this is the primary sack) 4. Securely tie the clinical waste sack at the neck with a yellow tag 5. Before transferring waste sack to an adjacent area which has been identified to store waste, place waste sack inside a second heavy duty clinical waste bag. Securely tie this sack at the neck with a yellow tag. 6. HCW must then perform hand hygiene by rubbing alcohol hand rub into gloved hands before leaving the patient isolation room and moving to the room designated to remove PPE and manage waste 1. For sharps waste, including disposable cutlery, place waste inside the sharps bin 2. When sharps reach the fill line, lock shut and then date and sign 3. Wipe down the exterior of the sharps bin with a clinell sanitising wipe before moving into the adjacent area Adjacent Single Room Identified to Store Waste and Remove PPE: 1. Ensure an empty heavy duty yellow clinical waste sack is placed into a rigid leak proof 60 litre burn bin with half of the sack folded over the opening of the container 2. The 1 st HCW (who has brought waste from patient isolation room), places the waste sack / or sharps container into the lined bin ensuring the bag will fit into the container. 1 st HCW then moves away from bin without touching the bag lining the bin 3. The 2 nd HCW (wearing gloves and apron) securely ties the waste sack lining the bin at the neck (with a yellow tag) and then attaches post coded tape or numbered tag. The bag is then placed in the bin leaving approx. 3-4 inch gap at the top and the lid of the container. Fill any dead space at the top of the bin with packaging to prevent any excess movement. 4. The 2 nd HCW places the lid on the rigid bin and seals it shut 5. The 2 nd HCW then wipes down the exterior of the bin with a clinell wipe 6. Attach a completed waste label to the front of each bin. 7. Contact Veolia Helpdesk on or by (uk.veolia.solentandsouthernnhs.mailbox@veolia.com) for a 770 litre lockable clinical 13

14 waste wheelie bin to be brought direct to the ward/dept. This 770 bin must remain in the corridor outside of the room where the waste is packaged. 8. The 60 litre bins are then placed into the 770 litre bin, which will then be taken directly to the secure quarantined storage area Removal of PPE: Hand hygiene must be performed by rubbing alcohol hand rub into gloved hands, before leaving the patient isolation room to the room designated to remove PPE Once in this designated room, PPE will be removed under the supervision of a buddy to ensure the correct procedure is followed. See Appendix E, page 28 for full details of doffing of PPE On removal PPE must be disposed of directly into a double lined 60 litre burn bin Scrubs worn to provide care must also be removed after each contact and disposed of as Category A waste. Transportation of Waste A reputable and licenced waste contractor must undertake transport to the incinerator. Prior to collection by the contractor waste must be stored securely and access restricted to authorised and trained personal. To arrange a Category A waste collection please contact: Veolia Helpdesk on or uk.veolia.solentandsouthernnhs.mailbox@veolia.com (working hours) Simon Hull 44(0) or Andy Higgins (out of hours for Ebola waste only) Staff at Lymington hospital and Fordingbridge should contact the SCRL helpline to arrange collection on NB this number is only manned during working hours. Out of hours or at weekend please ensure waste is stored as outlined above and contact the Veolia Helpdesk using the telephone number above. For any queries regarding waste please contact Rob Harris on mobile LINEN For patients with a HIGH POSSIBILITY VHF infection, the use of disposable linen should always be considered. This linen must be treated and disposed of as Category A waste (yellow bag). If re-usable linen is used, it must be disposed of in yellow waste bags and treated as Category A waste and sent for incineration. 14

15 DIAGNOSTIC INVESTIGATIONS The main risk of infection to the health care worker when collecting the specimens is direct contact with blood or body fluids from the patient. Specimens should only be taken if absolutely essential following discussion with the Microbiologist at the Acute Hospital, and there are systems in place to transport these high risk specimens safely For patients with a HIGH POSSIBILITY of VHF infection, specimens must be transported to the lab in suitably sealed containers and labelled with a Danger of Infection sticker. It is important to inform the lab prior to sending to ensure the appropriate laboratory containment is in place for specimen handling. Healthcare waste generated as a result of specimen collection from patients categorised as HIGH POSSIBILITY of VHF infection, must be securely stored pending laboratory results. In the event that VHF infection is confirmed this would require disposal as Category A infectious waste (yellow bag double bagged), otherwise it can be treated as Category B infectious waste (orange bag). Category A specimens must only be transported using couriers who are licenced to transport this type of specimen. Please contact the SHFT courier - ERS Medical on to arrange collection. Please note this number is available 24/7 STAFF EXPOSED TO POTENTIALLY INFECTIOUS MATERIAL Following percutaneous or muco-cutaneous exposure to blood, body fluids, secretions or excretions from a patient with suspected VHF infection the HCW should immediately and safely stop any current tasks, safely remove PPE, clean hands and leave the patient area. Accidental exposures that need to be dealt with promptly are: Percutaneous injury eg needlesticks: Immediately wash the affected part with soap and water. Encourage bleeding. Contact with broken skin: Immediately wash the affected part with soap and water Contact with mucous membranes: Immediately irrigate the area with water or emergency wash bottles, which should be accessible in case of such an emergency. Report incident to Occupational Health Advisor using Sharps Emergency Hotline Contact Wessex Health Protection Team Out of hours Report incident on Trust Internal reporting system In the event that VHF is confirmed in the source patient, the exposed individual should be followed up as a Category 3 contact see section below for further details. 15

16 STAFF EXPOSED TO CONFIRMED CASE OF VHF A contact is defined as a person who has been exposed to an infected person or their blood or body fluids, excretions or tissues following the onset of fever in the infected person. As soon as a patient has been categorised as confirmed VHF all those who have had contact with the patient should be identified as far as possible. Public Health are responsible for the management of contacts and will have an overview of the contact tracing. However Occupational Health will be asked to identify the contacts in the area affected. Once contacts have been identified PHE will monitor them. Each potential contact should be individually assessed for risk of exposure and categorised according to the categories listed in the table below Categorisation of Contacts 16

17 Contacts should be managed as outlined it the table below. There should be no restrictions on work or movement of contacts unless disease compatible symptoms develop. PHE will monitor contacts and provide advice on an individual basis Management of Contacts 17

18 COMMUNICATIONS For all patients who screen YES (HIGH POSSIBILITY VHF) to either of the two screening question on the Risk Assessment (Appendix B, page 22) please ensure the Communications team are contacted This applies for all patients regardless of the healthcare environment to which they present inpatient, outpatient or in their own home The Comms team can be contacted via their on call number: Please see Appendix B, page 22 and Appendix C, pages 25 & 26 for further details VISITORS Asymptomatic relatives or carers who present to the department with a patient who screens YES (HIGH POSSIBILITY VHF) should ideally be separated from the patient with symptoms Please contact Wessex Health Protection Team / Out of hours to discuss any actions that may be required AFTER DEATH CARE If a patient who screens YES (HIGH POSSIBILITY VHF) and suddenly dies in your department, please refer to Appendix 12: After Death Care in the full VHF guidance embedded below Theresa Lewis Lead Nurse IP&C Southern Health NHS Foundation Trust Management of Hazard Group 4 Viral Haemorrhagic Fevers (DH Nov 2014) is embedded below. Please use this version to open the links in the Risk Assessment Algorithm VHF guidance document updated 19 References: Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence (Department of Health Nov 2014). WHO (2014) Interim Infection Prevention and Control Guidance of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola. World Health Organisation

19 Appendix B: Escalation Flowchart for Management of Suspected Cases of Ebola Health care facilities should clearly display information requesting that patients/relatives tell the healthcare worker or receptionist on arrival if they are unwell and have returned from an Ebola-affected area within the last 21 days For all unplanned admissions or individuals reporting to any SHFT site please check RISK ASSESSMENT A. Does the patient have a fever ( 37.5 C) or history of fever in the previous 24hrs and has developed symptoms within 21 days of leaving a VHF endemic country OR B. Does the patient have a fever ( 37.5 C) or history of fever in the previous 24hrs and cared for/come into contact with body fluids of/handled clinical specimens (blood, urine, faeces, tissues, laboratory cultures) from an individual or laboratory animal known or strongly suspected to have VHF within the past 21 days IF YES to either question on risk assessment and patients presents to MIU Petersfield, MIU, MAU or FAC at Lymington 1. Individuals should be isolated in a side room straight away. They should not sit in a general waiting room before being assessed. 2. Contact the Duty Consultant Microbiologist at your nearest acute Trust to arrange transfer to dedicated isolation facility 3. Following discussions with Consultant Microbiologist ring 999 (inform them of the risk of Ebola) to arrange transfer 4. Contact Wessex Health Protection Team Out of hours Contact a member of the Infection Prevention & Control team (IP&C) / out of hours contact your On Call Manager 6. IP&C or On Call Manager (if weekend or out of hours) to contact Director on Call ( ) who will inform CCG as per Director on Call pack (1B, page 2). 7. IP&C/Ward or Team Manager or On Call Manager (if weekend or out of hours) to contact Trust Comms Team on IF YES to either question on risk assessment and patient presents to healthcare setting with no access to Ebola boxes 1. In areas where there is no access to Ebola boxes and staff have not been trained in the wearing of high level PPE, immediately isolate the patient in a single room without any direct contact with the patient. 19

20 2. Where possible the side room should be cleared of removable items to reduce cleaning requirements later if the patient is diagnosed with Ebola 3. The patient should be clinically assessed without any physical contact 4. Even though contact with the patient should be avoided single use gloves and apron are still recommended to reduce contamination from the environment. In the event of mucosal membrane exposure to potentially infectious bodily fluids, the affected individual should contact the Wessex Health Protection Team in the first instance, who will advise and arrange appropriate assessment and follow up where necessary 5. Follow steps 2-7 above 6. Discard PPE into a yellow bag in the room 7. Use alcohol hand rub immediately after removal of PPE and after leaving the room Actions needed for all sites whilst waiting for patient to be transferred 1. Keep patient in isolation with own ensuite. 2. If no ensuite available and patient is mobile, allocate a toilet to be used solely by this patient 3. If no ensuite available and patient is not mobile, a commode can be used 4. Restrict number of staff in contact with the patient 5. On discharge/transfer close the room and do not use until it has been fully decontaminated. If there is waste present in the room, do not remove, and keep room quarantined out of use until results of ebola testing are known. 6. The full risk assessment and investigations may rapidly exclude Ebola and specific decontamination of the room will not be required 7. For HIGH POSSIBILITY cases quarantine the isolation room / toilet until results of Ebola testing are known this may take up to 24hours 8. If Ebola is confirmed specific decontamination advice will be provided by Wessex Health Protection Team. The Health Protection Team will also identify and organise any follow up for contacts 9. Public areas where the suspected case has passed through and spent minimal time in eg corridors, but which are not visibly contaminated with bodily fluids, do not need to be specially cleaned and disinfected. IF YES on risk assessment when patients are seen in their own home 1. For community staff visiting patients in their own home who fall into this category, avoid direct contact with the patient and seek urgent advice from the duty GP 2. Even though contact with the patient should be avoided single use gloves and apron are still recommended to reduce contamination from the environment 3. GP will seek urgent advice from either the Consultant Microbiologist at local acute trust or Wessex Health Protection Team 4. If transfer to hospital is required, an ambulance will be arranged, alerting them to the possibility of ebola in advance 5. Contact Comms via the on call tel number

21 VHF is a notifiable disease under Schedule 1 of the Health Protection (Notifications) Regulations 2010 and notification is classified as urgent. The registered medical practitioner (RMP) attending the patient must notify the highly possible case by telephone to the Proper Officer of the local authority in which the patient usually resides within 24 hours. The Proper Officer is usually the Consultant in Communicable Disease Control at local PHE Verbal notification should be followed up with a written notification within three days. The RMP should not wait for laboratory confirmation in order to notify suspected cases. The Proper Officer must disclose the content of the notification received from the RMP by telephone within 24hrs to: 1.Public Health England negated if Proper Officer is employee of institution 2.Local Director of Public Health 3.The Department of Health For further advice contact the IP&C team: or

22 APPENDIX C: Communication Algorithm Ebola Virus Haemorrhagic Fever(EBVH): LNFH Communication Algorithm High Risk Suspected EVHF Implement full isolation procedures (Refer to SOP, algorithm, LNFH- Ebola boxes on MAU & MIU) On Call Medical Consultant (LNFH only) Bleep 1 (LNFH only ) Inform Infection, Prevention & Control on / or On Call Manager out of hours: UHS Consultant Microbiologist UHS main no: Hospital /ISM Manager/ Matron/Head of Professions On Call Manager-mobile no Trust Comms Team via on call number: Following discussions with Microbiologist ring 999, inform of risk of Ebola and arrange transfer On call Medical Consultant (LNFH) to contact: Wessex Health Protection Team: Out of hours ISD Director On Call Director-mobile: CCG On call CCG Director- OOH 22

23 APPENDIX C: Communication Algorithm Ebola Virus Haemorrhagic Fever(EVHF): MIU Petersfield Communication Algorithm High Risk Suspected EVHF Implement full isolation procedures (Refer to SOP, algorithm, Ebola boxes on MIU) Contact Consultant Microbiologist via QAH switchboard: Contact Matron/On call manager out of hours Inform IPC team (Infection, Prevention & Control): or Following discussions with Microbiologist arrange transfer Site Manager /ISM Manager/ Head of Professions On Call Manager-mobile no Trust Comms Team via on call number: Contact SCAS Duty Control 999 MIU to contact: Wessex Health Protection Team: Out of hours: ISD Director On Call Director-mobile CCG On call CCG Director- OOH 23

24 Appendix D: Ebola Boxes (HAZMAT Box) Following collaboration between IP&C Lead and Head of Procurement X5 Ebola boxes have been ordered centrally using a combination of the national Ebola PPE order line and the normal procurement route for NHS supplies. Each Ebola / HAZMAT box will contain: Product Size Number Faceshield - 12 Full body coverall M, L, XL 4 of each size Surgical cap - 12 Long cuff gloves (outer glove)* M, L, XL 12 pairs Nitrile gloves (inner glove) (from existing stock) M, L, XL 3M FFP3 masks (from existing stock) Ankle length apron - 12 Scrubs (or equivalent) single use M, L, XL 4 of each size Long boot covers knee length - 12 Heavy duty yellow clinical waste bags (outer) - Roll Yellow clinical waste bags (inner) Roll Waste labels litre yellow clinical waste bin - 12 Absorbent sheets/cushion to line clinical waste bin - 12 Absorbent granules and scoop - 1 Alcohol hand pump dispenser - 1 Actichlor Plus tablets - 1 tub Dilution bottles for Actichlor 2 Disposable clothes - 5 Disposable cutlery / crockery various Hazard tape X1 roll Tape to mark clean / dirty areas X1 roll Large wipeable storage container - X1 to store all supplies *double glove with normal size nitrile if none available Boxes will be held at: X1 box at MIU Petersfield Community Hospital X1 box at MIU Lymington New Forest Hospital X1 box at MAU, Lymington New Forest Hospital X1 spare for East Division held at Petersfield X1 spare for the Trust held at Moorgreen hospital. This can be accessed by contacting the Duty Estates Manager on in working hours. The duty engineer will be contacted and instructed to deliver the HAZMAT box where needed. Out of hours, please contact the Director on Call ( ). X1 Training box for IP&C team held at Elms, Tatchbury 24

25 Appendix E: Procedure for Putting on and Taking off PPE for Suspected or Confirmed Ebola Patients PPE should be put on over single use scrubs. The putting on and removal of PPE must be completed in pairs using the buddy buddy system. *At all times check on your buddy for correct PPE application* To put on PPE: 1. Step into the full body suit take care not to damage it. Zip the body suit up do NOT tear off the sticky panel but ensure the flap is folded over to cover the zip. 2. Put on over boots and ensure they are over suit with ties in a loose bow. 3. Place theatre cap on head ensure all hair is within the hat. Females with long hair may need to tie it up into a bun. 4. Put on the FFP3 mask mould it around the nose. DO NOT SQUEEZE. Buddy to check mask is on correctly. 5. Put on the visor with a knot in the strap. 6. When ready pull your buddy s hood over their head make sure the cap and visor remain in place and that it covers all around the head and face. Once fitted ensure the suit zip is to the top. 7. Put the apron on split the neck and take it in turns for each buddy to tie the apron on to the other. 8. Put on the inner gloves ensure the finger loop on the suit is in place if fitted. 9. Put on the outer gloves these MUST go on top of the suit sleeve. 10. To finish complete a 360* check of your buddy to ensure there are no breaches of exposed skin. *At all times check on your buddy for correct PPE application* 25

26 Prior to leaving the isolation room and moving to the PPE removal room, staff must decontaminate their gloved hands with alcohol hand rub To remove PPE. The safe undressing procedure must take place in an area identified close by to the isolation room, ideally with a hand wash sink. The room will need a clean and dirty area clearly marked tape can be used fixed to the floor to demarcate between these areas. Alcohol gel will be dispensed from a pump bottle direct onto gloved hands, by a 3 rd person who is clean. This person will wear gloves and apron and will remain in the clean area. Removal continuing with the buddy system: 1. Clean gloves with alcohol hand rub 2. Pinch the top of the apron, making sure you do not touch the suit. Rip the ties of the apron off from the neck; allow top part to fold down. Then pinch the sides and pull the apron off, folding it on itself so the contaminated side is on the inside of the fold. Put in the clinical waste bin. 3. Clean gloves with alcohol hand rub 4. Use your buddy to remove your hood by peeling it back and folding it on itself so that it is rolled inside out down to the neck. 5. Clean gloves with alcohol hand rub 6. Buddy to untie over boot ties. 7. Remove outer gloves using pinch method and put in clinical waste 8. Use your buddy to unzip the suit. From behind take hold of the shoulder of the suit and fold down to waist level. Buddy to take care not to contaminate self or inside of buddy s suit. 9. Clean inner gloves with alcohol hand rub 10. Step in to clinical waste bag rolled on the floor. 11. Pull suit down until you can step forward from the boots across the clean/dirty line ensuring the boots and suit remain in the clinical waste bag. (Ensure you only touch the inside of the suit). 26

27 12. Remove the visor by tipping head forward with eyes closed and allowing it to drop forward into the clinical waste bin. 13. Clean gloves with alcohol hand rub 14. Use your buddy to locate straps of FFP3 mask. Remove by pulling straps forward and allowing mask to come away from face. Place in the clinical waste bin. 15. Clean gloves with alcohol hand rub. 16. Take hold of the top of the theatre cap and pull off. Place in the clinical waste bin. 17. Clean gloves with alcohol hand rub 18. Remove inner gloves by pinching the top of the glove and pulling it down so that it turns inside out. Place in the clinical waste bin. 19. Wash hands using soap and water. 20. Proceed to clean area to remove disposable scrubs and dispose of in clinical waste bin, shower (if able) and dress in normal uniform. If a breach occurs, decontaminate straight away and report the breach. 27

28 Appendix F: Timeline of actions taken by Southern Health NHS Foundation Trust NHS England circulated a letter in response to the current outbreak of Ebola in West Africa and the heightened international response requesting assurance on points a-d below Requirement Action by SHFT a) SHFT is assured that there are systems and processes in place to identify and isolate a patient who presents with a high index of suspicion of Ebola b) SHFT has sufficient supplies of Personal Protective Equipment (PPE) and FFP3 facemasks c) SHFT has a robust Fit-Testing programme in place, which complies with FFP3 guidance SOP written by IPC Lead nurse and circulated to IPC Links and their Managers, topic for Sept IPC Link meetings, displayed on Trust Intranet, in Trust Bulletin In version 2 of the Ebola SOP, all community hospitals were asked to keep an Ebola Box ready with the required PPE as stated by the IP&C team (to be available for community teams if needed). 19/5/14 The IP&C team (X4 IP&C Nurses), and X3 staff from LNFH attended a half day fit testing workshop on the use of the Fit Testing Kit organised by 3M End Sept 2014 All SHFT staff including Junior Doctors, Consultants and physio s who work working in MAU and MIU in LNFH, or at MIU Petersfield hospital were fit tested. On completion of Fit Test training a copy of the Fit Test record will remain locally with the staff member, a copy sent to HR to ensure staff records are updated centrally, a copy will be sent to occupational health, and a copy held by the IP&C team. By the end of 2014 the IP&C team with support as stated above will aim to Fit Test other key staff who work within physical health teams. Aiming for a minimum of 2 members of staff from each ICT and ward (physical health) Following a risk assessment and 28

29 d) SHFT is aware of our local Infectious Diseases Unit and how they can be contacted to provide a source of expert information and to support clinical discussions consultation with Senior Managers in December 2014 it was agreed that OPMH staff would not be Fit Tested. This will be reviewed if necessary SHFT does not have Infectious Diseases Unit within the organisation. Patients who require this facility will be transferred to their local acute trust if this is required following discussions with Consultant Microbiologist at Acute Trust. Staff can also contact a member of their IP&C team for further support and advice. If further advice is needed please contact the Imported Fever Service at Porton on (manned 24/7). NB: Patients with confirmed VHF including Ebola must be cared for in dedicated High Level Isolation Units such as Royal Free in London November 2014 Department of Health changes the Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence (DH November 2014). Higher level of personal protective clothing required (PPE) The Ebola PPE boxes prepared in October 2014 do not contain the level of PPE outlined in (DH Nov 2014). They can still be used to manage other incidents, but for the purposes of potential Ebola patients they have now been superseded as higher levels of PPE are now required which include coveralls, face visors and shoe covers. PPE is covered in the SOP (Appendix A, page 8 and Appendix E, page 28). 5 Ebola kit boxes have been purchased via Ebola NHS Supplies line on behalf of the Trust. The boxes will be held at: X1 MIU, Petersfield X1 MIU, Lymington X1 MAU, Lymington X1 spare East Division, Petersfield X1 spare Trust, Moorgreen hospital 29