Tasmanian Department of Health and Human Services
Tasmanian Health Organisation-South
Clinical Protocol
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MANAGEMENT OF EBOLAVIRUS DISEASE ID-1-0009
Custodian: RHH IPCU service
Authorised by: Medical Advisor, RHH IPCU
Effective Date: October 2014
Review Date: October 2015
Document File Name: ID-1-0009 _EVD_2014v7 final.docx Page 1 of 26
Background
Objective
Definitions
Initial management of patients
presenting to the RHH ED
Initial management of patients
presenting external to the RHH ED
Laboratory testing
Infection Control Management for
Patients within the Emergency
Department or Inpatient Ward
Clinical assessment and management
Management of exposed persons
References
Stakeholders
Key Words
Related Documents
Appendix 1- Ebolavirus disease
patient risk assessment
Appendix 2- Visitor and Staff
Log
Appendix 3 - Quarantine
Signage
Appendix 4 - Donning PPE
Appendix 5 - Doffing PPE
Appendix 6 - EVD Case Report
Form
Background
EBOLAVIRUS DISEASE
Ebolavirus disease (EVD) is caused by an Ebolavirus. Ebolaviruses are part of the family Filoviridae, which
also includes Marburg virus.
EVD is a quarantinable disease in Australia and is nationally notifiable. As such it can be controlled through
a range of quarantine measures including the enforcement of appropriate quarantine measures if suspected
or confirmed cases are identified.
The largest outbreak of EVD ever reported commenced in West Africa in early 2014 and is continuing in
Guinea, Liberia and Sierra Leone as of the 3rd October 2014.
TRANSMISSION
Ebolavirus spreads person-to-person via contact with the blood, secretions, organs or other bodily fluids of
infected people, and indirect contact with environments contaminated with such fluid, including in
healthcare settings. Airborne transmission, as occurs for measles or smallpox, has never been
documented.
Tasmanian Department of Health and Human Services
Tasmanian Health Organisation-South
Clinical Protocol
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MANAGEMENT OF PATIENTS WITH SUSPECTED
OR CONFIRMED EVD
ID-1-0009.
Custodian: RHH IPCU service
Authorised by: Medical Advisor, RHH IPCU
Effective Date: October 2014
Review Date: October 2015
Document File Name: ID-1-0009 _EVD_2014v7 final.docx Page 2 of 26
The risk for infection in healthcare settings can be significantly reduced through the appropriate use of
infection control precautions and adequate barrier procedures and given the high mortality, infection
control precautions are to be rigorously applied.
INCUBATION PERIOD
The incubation period is considered to be from 2 up to 21 days; most commonly 8-10 days.
INFECTIOUS PERIOD
People are not infectious until the onset of symptoms of EVD. People are infectious as long as their blood
and secretions contain the virus.
Objective
The objective of this guideline is to provide guidance for the infection prevention and control management
of any person who has suspected, probable or confirmed EVD, within THO-South, in the context of the
2014 West African outbreak.
The principles of this management guideline could be used for the management of patients with suspected
or confirmed Marburg haemorrhagic fever outside this context..
Definitions
The definitions within this document are aligned to the EVD Communicable Diseases Network of Australia
(CDNA) Set of National Guidelines (SoNG) (v1.2 3 October 2014).
PERSON UNDER INVESTIGATION
This refers to a person who meets broad criteria that requires clinicians to consider the possibility of EVD
and to manage the person in an appropriate manner.
A ‘person under investigation’ with possible EVD is defined to have clinical evidence of EVD
(i.e. fever of 38°C or greater or history of fever within the last 24 hours) AND limited
epidemiological evidence (i.e. travel to an EVD affected area).
*Guinea, Sierra Leone and Liberia as of the 3rd October 2014. Please refer to www.who.int/csr/don/en for
up to date country information.
Tasmanian Department of Health and Human Services
Tasmanian Health Organisation-South
Clinical Protocol
Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer.
MANAGEMENT OF PATIENTS WITH SUSPECTED
OR CONFIRMED EVD
ID-1-0009.
Custodian: RHH IPCU service
Authorised by: Medical Advisor, RHH IPCU
Effective Date: October 2014
Review Date: October 2015
Document File Name: ID-1-0009 _EVD_2014v7 final.docx Page 3 of 26
SUSPECTED EBOLAVIRUS DISEASE (EVD) CASE
EVD should be suspected in the following circumstances:
Clinical evidence (i.e. fever of 38°C or greater or history of fever within the last 24 hours)
o AND
Epidemiological evidence (lower risk or higher risk exposure as defined below)
o Lower risk exposure includes any of the following:
Household contact with an EVD case
Being within approximately 1 metre of an EVD patient or within the patient’s room or
care area for a prolonged period of time (e.g. healthcare workers, household members)
while not wearing recommended personal protective equipment (PPE)
Having direct brief contact with an EVD patient while not wearing recommended PPE
o High risk exposure criteria include any of the following;
Percutaneous (e.g. needle stick) or mucous membrane exposure to blood or body fluids
of an EVD patient (either suspected, probable or confirmed)
Direct skin contact with blood or body fluids of an EVD patient without appropriate PPE
Laboratory processing of blood or body fluids of suspected, probable, or confirmed EVD
cases without appropriate PPE or standard biosafety precautions
Direct contact with a dead body without appropriate PPE in a country where an EVD
outbreak is occurring
Direct handling of sick or dead animals from disease-endemic areas or consumption of
“bushmeat” in a country where EVD is known to occur
PROBABLE EBOLAVIRUS DISEASE (EVD) CASE
EVD should be considered a probability in the following circumstances:
Clinical evidence (i.e. fever of 38°C or greater or history of fever within the last 24 hours)
AND
Epidemiological evidence (see above)
AND
Laboratory suggestive evidence of EVD.
NOTE: No diagnostic tests are to be collected until after discussion with the On-Call
Infectious Disease Physician and others as specified within the “Early Communication”
section of this guideline.
Tasmanian Department of Health and Human Services
Tasmanian Health Organisation-South
Clinical Protocol
Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer.
MANAGEMENT OF PATIENTS WITH SUSPECTED
OR CONFIRMED EVD
ID-1-0009.
Custodian: RHH IPCU service
Authorised by: Medical Advisor, RHH IPCU
Effective Date: October 2014
Review Date: October 2015
Document File Name: ID-1-0009 _EVD_2014v7 final.docx Page 4 of 26
CONFIRMED EBOLAVIRUS DISEASE (EVD) CASE
Requires laboratory definitive evidence only.
Please refer to the http://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-ebola.htm for up to
date information relating to the public health case definitions for EVD.
INITIAL MANAGEMENT OF PATIENTS WITH POSSIBLE EVD
PRESENTING EXTERNAL TO THE RHH ED
EARLY RECOGNITION
Patients who are presenting with ‘clinical evidence and limited epidemiologic evidence’ (see definitions
above) raising the possibility of EVD become a ‘person under investigation’ should be recognized as early as
possible, preferably prior to presentation to the ED. Prior to the transfer of any patient meeting any of the
case definition criteria for EVD, appropriate communication must be undertaken with the RHH Infectious
Diseases Physician on-call (via the RHH switchboard) and if EVD remains a possibility, the patient should be
transferred to the RHH as soon as practicable. The admission destination will be determined by clinical
severity and bed availability. To minimize bed movements, optimally the patient will be transferred directly
to either the Quarantine room on 1BN or a negative pressure room within intensive care, depending on
the clinical severity of the patient’s illness. The RHH Infectious Diseases Physician on-call will liaise directly
with the RHH to inform them of the transfer.
PATIENT ISOLATION
Implementation of transmission-based precautions should occur immediately on recognition of someone
meeting the ‘person under investigation’ criteria for EVD. This will include:
Application of a surgical mask onto the patient
Donning of personal protective equipment (PPE) by staff accompanying patient
o Long sleeved fluid impervious gown o Hat
o P2 (N95) mask
o Approved single use eye protection
o Gloves
o Boots or closed shoes with overshoes (booties)
Transfer patient into physically separate area whilst awaiting transfer
Visitors/family members accompanying the patient on presentation should be accommodated with the
patient whilst further advice is sought. These accompanying persons should also don PPE as per the
staff recommendations above.
Dedicated staff should be assigned to the patient
Tasmanian Department of Health and Human Services
Tasmanian Health Organisation-South
Clinical Protocol
Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer.
MANAGEMENT OF PATIENTS WITH SUSPECTED
OR CONFIRMED EVD
ID-1-0009.
Custodian: RHH IPCU service
Authorised by: Medical Advisor, RHH IPCU
Effective Date: October 2014
Review Date: October 2015
Document File Name: ID-1-0009 _EVD_2014v7 final.docx Page 5 of 26
Non-essential staff and visitors should be restricted
A visitor log will be maintained for all persons having contact with the patient (refer to Appendix 2).
EARLY COMMUNICATION
Contact the following people directly as soon as practicable:
On-call Infectious Diseases Physician (available via RHH switchboard); this person will contact
the Chief Human Quarantine Officer (0418 123 265) (or the On-call Communicable Diseases
Prevention Unit clinician (0408 532 708)) and the Director of Microbiology. They will also liaise
directly with the RHH if transfer is deemed necessary (Patient Flow Co-ordinator and either 1BN
(NUM) or DCCM (Medical Director and NUM)) regarding their transfer and their admission
destination – i.e. Quarantine room on 1BN (clinically stable patient) or negative pressure room in
DCCM (if clinically unstable or deteriorating patient)
RHH IPCU in normal business hours (0407 175 022 or 62228658) or the Clinical Manager/Patient Flow Manager (CM/PFM) after hours
If the patient is to be transferred to the RHH for further investigation and management, depending on the
mode of transport required, Ambulance Tasmania may need to be contacted.
PATHOLOGY TESTING
No specimens are to be collected from the patient until the patient has been reviewed by the on-call
Infectious Diseases Physician at the RHH. The RHH laboratory is the only state laboratory with the
capacity to manage any specimens from patients with suspected, probable or confirmed EVD.
If the patient is being transferred to the RHH, pathology testing can be deferred until they reach the RHH.
INITIAL MANAGEMENT OF PATIENTS WITH POSSIBLE EVD
PRESENTING TO THE RHH ED
EARLY RECOGNITION
Patients who are presenting with ‘clinical evidence and limited epidemiologic evidence’ (see definitions
above) raising the possibility of EVD become a ‘person under investigation’. These individuals should be
recognized as early as possible, preferably prior to presentation to the ED or at triage. Please refer to
Appendix 1 to assist triage. These patients must be isolated. Once they are isolated, further information
can be obtained and the decision to continue isolation will be determined by the RHH Infectious Diseases
Physician on-call.
Tasmanian Department of Health and Human Services
Tasmanian Health Organisation-South
Clinical Protocol
Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer.
MANAGEMENT OF PATIENTS WITH SUSPECTED
OR CONFIRMED EVD
ID-1-0009.
Custodian: RHH IPCU service
Authorised by: Medical Advisor, RHH IPCU
Effective Date: October 2014
Review Date: October 2015
Document File Name: ID-1-0009 _EVD_2014v7 final.docx Page 6 of 26
PATIENT ISOLATION
Rigorous application of standard precautions is critical. Implementation of transmission-based precautions
should occur immediately on recognition of suspected EVD. This will include:
Application of surgical mask onto patient
Donning of personal protective equipment (PPE) by staff accompanying patient o Long sleeved fluid impervious gown
o Hat
o P2 (N95) mask
o Approved single use eye protection
o Gloves
o Boots or closed shoes with overshoes (booties)
Transfer patient into a negative pressure room; Quarantine room on 1BN as soon as practicable or if
this room is not immediately available, Resuscitation room 4 in ED
Visitors/family members accompanying the patient on presentation should be accommodated with the
patient whilst further advice is sought. These accompanying persons should also don PPE as per the
staff recommendations above
Dedicated staff will be assigned to the patient
Non-essential staff and visitors should be restricted
A visitor log will be maintained for all persons entering the room (refer to Appendix 2)
EARLY COMMUNICATION
The following people should be contacted directly as soon as practicable:
ED Medical Co-ordinator (6166 6101)
ED Nursing Clinical Co-ordinator (6166 6109)
RHH IPCU in normal business hours (0407 175 022 or 62228658) or the Clinical
Manager/Patient Flow Manager (CM/PFM) after hours
On-call Infectious Diseases Physician (available via RHH switchboard); this person will contact the Chief Human Quarantine Officer (0418 123 265) (or the On-call Communicable Diseases
Prevention Unit clinician (0408 532 708)) and the Director of Microbiology
The Executive Director of Medical Services (or the Chief Executive Officer) and the Executive Director of
Nursing should also be contacted.
PATHOLOGY TESTING
No specimens are to be collected from the patient until the patient has been reviewed by the on-call
Infectious Diseases Physician. Management of all laboratory testing will be determined by the Department
of Microbiology.
Tasmanian Department of Health and Human Services
Tasmanian Health Organisation-South
Clinical Protocol
Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer.
MANAGEMENT OF PATIENTS WITH SUSPECTED
OR CONFIRMED EVD
ID-1-0009.
Custodian: RHH IPCU service
Authorised by: Medical Advisor, RHH IPCU
Effective Date: October 2014
Review Date: October 2015
Document File Name: ID-1-0009 _EVD_2014v7 final.docx Page 7 of 26
CLINICAL REVIEW
The patient will be reviewed by the On-call Infectious Diseases Physician as soon as practicable.
Laboratory Testing: Key principles
Specimens for laboratory testing must not be collected without approval of the Director of Microbiology
(or their delegate), as Ebolavirus has the potential to contaminate laboratory instruments and infect
laboratory staff. Non-microbiological specimens require deactivation by an experienced senior scientist in a
PC2 laboratory prior to processing.
General principles are, Testing should be restricted to minimum essential tests
Wherever possible testing should be performed in “routine” hours
Any testing must be approved by the Director of Microbiology (or their delegate) as above prior to
specimen collection
A Designated Receiving Area (DRA) will be established in microbiology, Samples should be
delivered directly to the DRA by hand
Samples must not be placed in the ferret system or taken to specimen reception
Instructions and containers for transport of the specimen in the hospital will be provided when a
specimen is to be collected
Confirmed Ebolavirus is a Tier 1 Security Sensitive Biological Agent. As a result increased security
requirements are required if infection is confirmed, including maintaining a log of all staff who handle the
specimen.
If the patient is at the RHH, the Director of Microbiology (or their delegate) will be contacted by the
Infectious Diseases Physician on-call to prepare the laboratory for receipt of specimens.
After approval by both the Infectious Diseases Physician on-call and the Director of Microbiology, the
following specimens will be collected for testing:
Green top (haemoglobin, haematocrit, urea, electrolytes, creatinine, liver function tests)
Blue top (coagulation profile and arterial blood gases)
Pink top (Ebolavirus PCR)
Pink top (malaria ICT)
Blood cultures
Serology
The Director of Microbiology will arrange for specific EVD testing to be performed at the Victorian
Infectious Diseases Reference Laboratory (VIDRL).
Tasmanian Department of Health and Human Services
Tasmanian Health Organisation-South
Clinical Protocol
Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer.
MANAGEMENT OF PATIENTS WITH SUSPECTED
OR CONFIRMED EVD
ID-1-0009.
Custodian: RHH IPCU service
Authorised by: Medical Advisor, RHH IPCU
Effective Date: October 2014
Review Date: October 2015
Document File Name: ID-1-0009 _EVD_2014v7 final.docx Page 8 of 26
Infection Control Management for Patients within the Emergency
Department or Inpatient Ward
STANDARD AND TRANSMISSION-BASED PRECAUTIONS
Rigorous application of standard precautions is critical, particularly hand hygiene. Please refer to the
Transmission Based Precautions Protocol IC1-04 for detailed information about the application of
combined contact, droplet and airborne precautions. Specific Quarantine Disease Signage is to be used
(refer to Appendix 3).
ADDITIONAL RECOMMENDATIONS
To minimize the risk of transmission of EVD, it is recommended that additional strategies to optimize
transmission-based precautions are implemented as outlined below:
1. PATIENT ACCOMMODATION
The patient will be accommodated in a single negative pressure room. If required, security may need to be
employed at the entry of the room.
2. STAFFING
All non-essential staff should be restricted from the patient care area.
Nursing staffing
The patient will be managed by dedicated nursing staff i.e. the patient will be ‘specialed’. 3 suitably
experienced nursing staff who are able to provide all requisite nursing care will be allocated to the patient
for each shift to allow for both direct supervision (or observation) of donning and doffing PPE for each
entry and exit as well as shift breaks. It is recommended that the staff providing care to this patient are
allocated exclusively to the patient and do not provide care to other patients in the unit.
The nursing staff will additionally directly supervise (or observe) other healthcare workers’ practice of donning and doffing PPE for each entry and exit also.
Medical staffing
The patient will be managed by nominated senior medical staff; the staff member will vary according to
where the patient is accommodated but at the commencement of each shift, there should be clear clinical
handover and allocation of which medical staff member will be the most appropriate person to provide
patient care.
Tasmanian Department of Health and Human Services
Tasmanian Health Organisation-South
Clinical Protocol
Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer.
MANAGEMENT OF PATIENTS WITH SUSPECTED
OR CONFIRMED EVD
ID-1-0009.
Custodian: RHH IPCU service
Authorised by: Medical Advisor, RHH IPCU
Effective Date: October 2014
Review Date: October 2015
Document File Name: ID-1-0009 _EVD_2014v7 final.docx Page 9 of 26
The patient will be admitted under the Infectious Diseases Unit. The on-call Infectious Diseases Physician
will review the patient as soon as practicable. Ongoing patient care will be provided by either the Infectious
Diseases Physician or Registrar.
Additional medical care may need to be provided by other senior medical staff depending on the
circumstances and the location of the patient;
If the patient is within the Emergency Department, additional medical care will be provided by
either an Emergency Department Physician or a Senior Emergency Department Registrar.
If the patient has been admitted to ward 1BN, additional medical care, particularly after-hours, may
need to be provided by the Senior Medical Registrar.
If the patient has been admitted to the Department of Critical Care Medicine (DCCM), additional
medical care will be provided by either an Intensive Care Physician or a Senior Intensive Care
Registrar.
Other healthcare worker staffing
If other healthcare workers are required for the care of the patient, they should be made aware of the risk
of the patient having EVD and the appropriate transmission-based precautions required for the care of the
patient.
A visitor log will be maintained for all persons (including staff and visitors) entering the room (refer to
Appendix 2).
3. CLOTHING AND PPE
Careful and vigilant use of PPE is a critical risk mitigation strategy. Personal clothing should not be worn
for working in the patient area. Scrubs should be provided by the hospital for donning each shift. Refer to
‘Linen Management’ in this guideline for further advice on clothing.
Please refer to Appendix 4 and Appendix 5 for signage relating to donning and doffing PPE.
Direct supervision (or observation) of donning and doffing PPE for each entry and exit including
appropriate hand hygiene will be undertaken by a second trained staff member. PPE is donned outside the
anteroom and removed within the patient room, immediately prior to exiting. The P2 (N95) mask may be
retained in place in certain circumstances including: aerosol generating procedures within room, when the
mask would be removed in the anteroom and placed in the clinical waste.
Tasmanian Department of Health and Human Services
Tasmanian Health Organisation-South
Clinical Protocol
Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer.
MANAGEMENT OF PATIENTS WITH SUSPECTED
OR CONFIRMED EVD
ID-1-0009.
Custodian: RHH IPCU service
Authorised by: Medical Advisor, RHH IPCU
Effective Date: October 2014
Review Date: October 2015
Document File Name: ID-1-0009 _EVD_2014v7 final.docx Page 10 of 26
Recommended PPE for routine care includes:
o Long sleeved fluid impervious gown
o Hat
o P2 (N95) mask
o Approved single use eye protection
o Gloves
o Boots or closed shoes with overshoes (booties)
Consideration should be given to enhanced PPE if prolonged patient care, aerosol generating procedures
undertaken (such as caring for an intubated/ventilated patient) or close contact with blood and body fluids
is likely including the following:
o Addition of a plastic apron over the fluid impervious gown
o Double gloving
o Long fluid impervious boots
o Powered air purifying respirator (PAPR) (trained personnel only)
Non-soiled scrubs are to be laundered by the hospital laundry. Soiled scrubs should be removed as soon as
possible and managed as clinical waste (as per soiled linen). If scrubs are visibly contaminated with blood
or body fluids or there is a high risk that this has occurred, then the scrubs should be removed with caution within the ante-room and whilst retaining the P2 (N95) mask in place. Immediately after leaving
the patient care area in the event of an exposure, wash the affected skin surfaces or the percutaneous
injury site with soap and water, a shower should be considered. Accordingly, irrigate mucous membranes
(e.g. conjunctivae) with copious amounts of water or eyewash solution. If a percutaneous or
mucocutaneous exposure to blood or body fluids has occurred refer to Management of Exposed
Person (contacts) in this guideline.
Additional support and training to be provided to the healthcare workers providing direct patient care
including:
Unit-based in-services
Assessment of appropriate donning and doffing technique
Ensuring only those staff that have been successfully fit-tested for a P2 (N95) mask provide care
Tasmanian Department of Health and Human Services
Tasmanian Health Organisation-South
Clinical Protocol
Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer.
MANAGEMENT OF PATIENTS WITH SUSPECTED
OR CONFIRMED EVD
ID-1-0009.
Custodian: RHH IPCU service
Authorised by: Medical Advisor, RHH IPCU
Effective Date: October 2014
Review Date: October 2015
Document File Name: ID-1-0009 _EVD_2014v7 final.docx Page 11 of 26
4. PATIENT MOVEMENT
Patients should not be transferred from their room to other areas for treatment or investigation without
prior approval from the on-call Infectious Diseases Physician. As EVD is a quarantinable disease in Australia,
additional measures may be considered to support maintaining a patient within a designated area.
When it is required for the patient to be moved from one area to another, prior planning is required to
minimize contact with other people. The patient will be transferred with a surgical mask donned and the
people accompanying the patient should wear PPE as previously described.
5. VISITORS
Visitors should be limited to include only those necessary for the patient’s well-being and care, such as a
child’s parent. As EVD is a quarantinable disease in Australia, advice from the Communicable Diseases
Prevention Unit will be provided in relation to the management of visitors. Ensure all visitors use PPE (as
described above) and perform hand hygiene according to standard precautions and are provided with
related instructions prior to entry into and on leaving the isolation room.
6. EQUIPMENT AND SUPPLIES
Patient-dedicated equipment or single-use non-critical patient-care equipment must be used. Items and
equipment should not be moved between isolation room and other areas of the healthcare facility unless
they are appropriately cleaned and disinfected or discarded and disposed of (refer to ‘Environmental
Cleaning’ in this guideline). Moving medical equipment into the room must be done with regard for the difficulty in removing equipment from the room. It is strongly recommended that all equipment that enters
the room is either discarded to Clinical Waste after use or retained until the patient is discharged. This
includes procedural and emergency trolleys.
Patient charts and records must be kept OUTSIDE the isolation rooms/areas to avoid their contamination.
Any pen or paper taken into the room will ultimately need to be discarded into clinical waste.
Upon patient discharge or transfer, liaison with the RHH IPCU should occur for specific advice regarding
cleaning and disinfection. All medical supplies, patient-dedicated equipment and patient-care equipment that
cannot be cleaned, must be discarded including items packaged in paper or cardboard.
7. LINEN MANAGEMENT
All linen used in the care of the patient must be regarded as having a high infection transmission potential
and should be considered as Clinical Waste and handled accordingly (see below).
The patient should be encouraged to wear hospital clothing and gowns and not their own clothes. This
should be treated as Clinical Waste.
Tasmanian Department of Health and Human Services
Tasmanian Health Organisation-South
Clinical Protocol
Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer.
MANAGEMENT OF PATIENTS WITH SUSPECTED
OR CONFIRMED EVD
ID-1-0009.
Custodian: RHH IPCU service
Authorised by: Medical Advisor, RHH IPCU
Effective Date: October 2014
Review Date: October 2015
Document File Name: ID-1-0009 _EVD_2014v7 final.docx Page 12 of 26
8. WASTE MANAGEMENT (including urine, faeces and vomit)
Patients may use the toilet in the ensuite and toilet waste may be flushed as usual.
Clinical waste such as faecal material, urine, vomitus and other human blood or body fluids or items that
have been in contact or likely to be contaminated with these substances, must be disposed of in the
macerator in a disposable pan within the anteroom if macerator compatible. If there is concern that
disposal of waste may present a risk for splash, spray or spatter or if there are items associated with the
waste to be macerated which cannot be placed in the macerator, then high absorbency gel (e.g. Vernagel)
may be added to any liquid waste and the item disposed of into the Clinical Waste bag.
All other waste created in the care of a patient with suspected or confirmed EVD must be categorised as
Clinical Waste. All waste must be placed directly into a Clinical Waste bag or rigid sharps container
(depending on nature of waste). The bags must be tied off prior to removal from the patient room. In the
anteroom, it will be placed into a second Clinical Waste bag and tied off. The waste bag will be retained in
the anteroom and only removed following discussion with Infection Prevention and Control. Whilst
properly bagged waste may be handled as per standard Clinical Waste, it is important that all waste is
handled cautiously to minimise the risk of a spill and inadvertent exposure to EVD for staff collecting such
waste.
9. FOOD SERVICES
Disposable cutlery and crockery are required for these patients.
Food Services staff must not enter the patient room but are to give the meal to a ward staff member to deliver to the patient. Reusable meal trays should not be used.
10. ENVIRONMENTAL CLEANING
Diligent environmental cleaning and disinfection is an essential component of safe patient management.
Routine environmental cleaning of the patient room and associated environs, including ensuite and
anteroom, will be undertaken by the IPCU Environmental Services Staff. Divercleanse (1000 ppm available
free chlorine) will be used for cleaning and disinfecting all environmental surfaces and items. Any items to
be removed from the room must be carefully considered for its ability to be cleaned and disinfected. If an
item cannot be cleaned then it must be considered as Clinical Waste and handled as per waste
management requirements. Staff caring for the patient may undertake additional cleaning of items in the
room as required to minimise the burden of Ebolavirus on items and surfaces.
Tasmanian Department of Health and Human Services
Tasmanian Health Organisation-South
Clinical Protocol
Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer.
MANAGEMENT OF PATIENTS WITH SUSPECTED
OR CONFIRMED EVD
ID-1-0009.
Custodian: RHH IPCU service
Authorised by: Medical Advisor, RHH IPCU
Effective Date: October 2014
Review Date: October 2015
Document File Name: ID-1-0009 _EVD_2014v7 final.docx Page 13 of 26
Recommended PPE for environmental cleaning includes:
o Long sleeved fluid impervious gown o Addition of a plastic apron to the fluid impervious gown
o Hat o P2 (N95) mask o Approved single use eye protection or full face shield (preferred) o Heavy duty rubber gloves o Long fluid impervious boots
For cleaning up a spill of blood or body fluid, soak the spill with a sodium hypochlorite solution made up to
5000 ppm and cover with absorbent paper towel; leave to soak for 30 minutes before wiping up. Discard
the towels into the Clinical Waste bags. Following the removal of the initial material, the area of
contamination should be liberally covered with sodium hypochlorite solution made up to 5000 ppm and left
for a further 30 minutes before rinsing.
Terminal cleaning should occur once the patient has left the room. The entire room should be cleaned
with Divercleanse made up to 1000 ppm, this includes cleaning the walls. Items that cannot be cleaned and disinfected should be classified as Clinical Waste and discarded accordingly. Items used to support cleaning
should be discarded into Clinical Waste; this includes rags, mops heads and buckets.
11. CADAVERIC MANAGEMENT
After the death of a patient with EVD, the body remains highly infectious and close contact by family and
other visitors must be limited and PPE must continue to be utilised after death of the patient.
Staff wearing PPE (as specified above) must place the body of a confirmed or suspected EVD patient in a
leak-proof double body bag. Absorbent material must be placed between each bag, and the bag sealed and
disinfected with a 1,000 ppm sodium hypochlorite solution. Normal measures must be undertaken to
ensure that the identification of the deceased person is possible. Special arrangements are to be made prior
to transfer to the Mortuary. The body bag should not be opened except by a designated person after
consultation with the on-call Communicable Diseases Prevention Unit clinician.
CLINICAL ASSESSMENT AND MANAGEMENT
Clinical assessment of a patient with suspected EVD will be undertaken by the on-call Infectious Diseases
Physician and may be assisted by the use of the EVD Case Report Form (refer to Appendix 5.)
There are no specific therapeutic options available to treat human infections and care is largely supportive.
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Exclusion of treatable conditions is important but management will be guided by the on-call Infectious
Diseases Physician. Empirical therapy for conditions such as malaria and bacterial sepsis may be considered,
particularly if there are delays in the availability of laboratory tests.
MANAGEMENT OF EXPOSED PERSONS (CONTACTS)
Persons, including healthcare workers, with percutaneous or mucocutaneous exposure to blood or body
fluids, secretions or excretions from a patient with suspected or confirmed EVD should immediately and
safely stop any current tasks, leave the patient area and safely remove PPE. If scrubs are contaminated with
blood or body fluids, these should be removed with caution within the ante-room and whilst retaining the
P2 (N95) mask in place. Immediately after leaving the patient care area, wash the affected skin surfaces or
the percutaneous injury site with soap and water, a shower should be considered. Accordingly, irrigate
mucous membranes (e.g. conjunctivae) with copious amounts of water or eyewash solution.
Immediately report the incident to the Occupational Exposure coordinator. Exposed persons should be
evaluated according to the Occupational Exposure Protocol. In addition, the on-call Infectious Diseases
Physician should be contacted and they should receive follow-up care including fever monitoring, twice
daily for 21 days after the incident. Exclusion from work may need to be considered. Immediate isolation and consultation with the on-call Infectious Diseases Physician is recommended for any exposed person
who develops fever within 21 days of exposure.
References
WHO Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or
Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola. September 2014
Management and Control of Viral Haemorrhagic Fevers. ENIVD Scientific Advisory Committee. May 2001
CDNA. EVD outbreaks in West Africa. Important information for clinicians in secondary or tertiary care.
11 August 2014
EVD. CDNA National Guidelines for Public Health Units. SoNG endorsed by CDNA. 3 October 2014
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MANAGEMENT OF PATIENTS WITH SUSPECTED
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Stakeholders
Director, Infectious Diseases and Microbiology
Medical Advisor, Infection Prevention and Control, RHH
NUM, Infection Prevention and Control Unit, RHH
Senior Medical Advisor, Public and Environmental Health Services
Medical Director, Emergency Department
NUM, Emergency Department Medical Director, Department of Critical Care Medicine
NUM, Department of Critical Care Medicine
NUM, 1BN Medical
ADON, Medical Services
Key Words - Intranet Search Function
1. Ebola 2. EVD
3. Viral haemorrhagic fever
4. VHF
5. Quarantine 6. Infection
Related Documents
Transmission Based Precautions Protocol IC1-04
Tasmanian Department of Health and Human Services
Tasmanian Health Organisation-South
Clinical Protocol
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MANAGEMENT OF PATIENTS WITH SUSPECTED
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ID-1-0009.
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Review Date: October 2015
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APPENDIX 1
EBOLAVIRUS DISEASE (EVD) PATIENT RISK ASSESSMENT
Does the patient:
Have a fever (≥ 38°C) or history of fever in the past 24 hours AND
Report returning from an EVD affected *country in the 21 days prior to the illness
onset
NO
EVD highly unlikely
YES
Don a surgical mask onto the patient
Place the patient into a negative pressure room
(resuscitation room 4 in ED or quarantine room on 1BN)
Quarantine transmission based precautions
Contact key personnel:
o ED Medical Co-ordinator and Nursing Clinical Co-ordinator
(6166 6101 and 6166 6109)
o RHH IPCU (0407 175 022 or 62228658) or the Clinical
Manager/Patient Flow Manager (CM/PFM)
o ID physician on-call (available via RHH switchboard); this
person will contact the Chief Human Quarantine Officer
(0418 123 265) ( or the CDPU clinician on-call (0408 532
708) and the Director of Microbiology
EVD possible
*Affected countries (3/10/2014): Sierra Leone, Liberia, Guinea.
Refer to www.who.int/csr/don/en/ for up to date information.
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APPENDIX 2
VISITOR AND STAFF LOG
Name Staff Y/N
Date Time in e.g. 08:10
Time out e.g. 08:20
Contact number
(mobile
preferable)
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APPENDIX 3
QUARANTINE SIGNAGE
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APPENDIX 4
DONNING PPE
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APPENDIX 5
DOFFING PPE
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APPENDIX 6
EVD CASE REPORT FORM
1 NOTIFICATION Date notified __/__/____ dd/mm/yyyy
Notifier name
Notifier organisation Telephone
Treating Doctor
Telephone Fax
2 INTERVIEW Was the case interviewed
Yes No N/A
If case not interviewed, state who was interviewed and their relationship to the case
Date of first interview __ /__ /____ dd/mm/yyyy
Name of interviewer
Telephone number of interviewer
3 CASE DETAILS Name (first name, surname)
Date of birth __ /__ /____ dd/mm/yyyy
Age (yrs / months) __ Yrs __ Mths
Sex Male Female
Occupation - specify
English preferred language
Yes If no specify language….
Address (permanent)
Telephone (home)
Telephone (mobile)
Temporary address (if different from permanent address
Telephone (temporary home)
Telephone (mobile)
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CASE DETAILS Indigenous Status Aboriginal
origin
Torres Strait
Islander origin
Both
Aboriginal and Torres Strait Islander
origin Not
Aboriginal or Torres Strait Islander
Unknown
Ethnicity – specify
Country of birth – specify
4 CLINICAL DETAILS
Date of symptom onset __ /__ /____ dd/mm/yyyy
Febrile phase fever malaise myalgia
headache pharyngitis conjunctival injection
vomiting diarrhoea bloody
diarrhoea abdominal
pain
rash petechiae
Other symptoms –specify
Complications Hypotension
Spontaneous
bleeding
Oedema
Shock Neurologic
involvement
Multi-
organ failure Other complications – specify
5 HOSPITAL and TREATMENT DETAILS
Hospitalised Yes No Unknown
Date admitted __ /__ /____ Date discharged __ /__ /____
Name of hospital – specify
Isolated in single room Yes No Unknown
Admitted to ICU or HDU ICU HDU Unknown
Date admitted to ICU/HDU __ /__ /____ Date discharged __ /__ /____
6 OUTCOME Patient outcome Alive Dead Unknown
Date outcome information
sought
__ /__ /____
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7 LABORATORY CRITERIA
Testing must be organised according to the SoNG Laboratory Testing Guidelines in discussion with jurisdictional public health laboratory
Specimens collected Blood /
serum
Throat swab Urine
Date collected __ /__ /____ __ /__ /____ __ /__ /____
Laboratory that received specimens
Specimens transferred to Jurisdictional PH lab (if relevant e.g. NSW, QLD)
Yes No Unknown
Detection of virus by PCR in Jurisdictional PH lab (if relevant e.g. NSW, QLD)
PCR
Specimens transferred to NHSQL Yes No Unknown
Isolation of virus Yes No Unknown
Detection of virus by PCR Antigen
detection
Electron
microscopy IgG Titre Single
high titre
Titre ___ Date __ /__ /____
Four fold
rise
1st titre --- Date __ /__ /____
2nd titre --- Date __ /__ /____
IgM positive Yes No
Unknown/ Not done
Confirmation by Special pathogens
lab Atlanta CDC
National Institute of
Virology, Johannesburg Lymphopaenia Yes No Unknown
Thrombocytopaenia Yes No Unknown
8 EXPOSURE
PERIOD
Between dates:
__ /__ /____ (onset of symptoms minus 21 days)
TO __ /__ /____ (onset of symptoms minus 1 day)
During this time was there contact with a confirmed/probable case/s?
Yes No Unknown
Case Contact 1 name
Case Contact 1 type Living patient Deceased patient
Specify type of contact Visit sick
patient
Care for sick
patient – specify type of care
Bury
deceased patient
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EXPOSURE PERIOD
Exposed to blood,
saliva, urine, vomit or faeces of sick
patient
Exposed to
blood, saliva, urine, vomit or faeces of
deceased patient Case Contact 2 name
Case Contact 2 type Living patient Deceased patient
Specify type of contact Visit sick
patient
Care for sick
patient – specify type of care
Bury
deceased patient
Exposed to
blood, saliva, urine, vomit or faeces of sick patient
Exposed to blood,
saliva, urine, vomit or faeces of deceased patient
Recent residence or travel in an area with active Ebola disease/outbreak
Yes No Unknown
If yes, specify country, region
Specify dates of travel __ /__ /____ To __ /__ /____
Animal exposures
Contact with bats primates or other animals from disease-endemic area?
Yes Details:
No Unknown
Contact with people who are in close contact with bats or
primates from disease-endemic areas b/c of their work?
Yes Details:
No Unknown
Laboratory exposure Yes Details:
No Unknown
Did the case visit a healthcare facility or hospital during their exposure period?
Yes Specify including date last attended:
No Unknown
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EXPOSURE
PERIOD
Other high risk settings (e.g. funeral / burial of suspected/confirmed EVD patient) -Specify
For any exposure
Location of possible exposure
Nature of possible exposure- specify
Dates of possible exposure __ /__ /____ To __ /__ /____
7 PLACE INFECTION ACQUIRED
Australian state or territory Specify
Country - specify
8 INFECTIOUS PERIOD
Between dates __ /__ /____ (onset of symptoms)
To __ /__ /____ (10
weeks after onset or as long as blood/
secretions contain virus) Isolation commenced Yes No Unknown
If yes, date isolation commenced __ /__ /____
Details of isolation
Did case travel during their infectious period?
Yes No Unknown
PLACE VISITED Arrival date Departure Date
Flight no. or mode of transport
1
2
3
4
Did the case attend any of the following places during their infectious period?
Name Telephone Date attended
Childcare
Preschool / School
Educational/residential facility
Hospital/healthcare facility
9 CASE
CLASSIFICATION Confirmed Probable Suspected Rejected
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10 CONTACT
MANAGEMENT Contact setting No. of
casual contacts*
No. of low risk close contacts*
No. of high risk close contacts*
Household
Ambulance staff
Medical/healthcare staff
Laboratory staff
Work
Other - specify
Contact surveillance No. of casual contacts
No. of low risk contacts
No. of high risk contacts
No temperature monitoring but advice to seek information and health care if symptoms develop
Twice daily self-monitoring of temperature for 21 days and reporting to PHU if fever > 38 C temp or other symptoms develop
Details of contacts hospitalized with temperature >38 degrees
Name DOB UR no. Telephone
APPENDIX 4
DOFFING PPE APPENDIX 4
DOFFING PPE