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PROCEDURE FOR THE MANAGEMENT OF INFECTIOUS DISEASES DATE APPROVED: 28 January 2016 APPROVED BY: Infection Prevention and Control Committee IMPLEMENTATION DATE: 06 February 2016 REVIEW DATE: February 2018 LEAD DIRECTOR: Deputy Director of Nursing & Quality IMPACT ASSESSMENT STATEMENT: No adverse impact on Equality or Diversity. Policy Reference Number: CLN – Procedure – 022 (Version 3) WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Change Control Document Number Document Version Owner Distribution list Issue Date Next Review Date File Reference Impact Assessment Author CLN – Procedure – 022 Management of Infectious Diseases Three Deputy Director of Nursing & Quality All staff and relevant NHS Partners 28 January 2016 February 2018 PR-022 No Impact Infection, Prevention and Control Lead Document History Date 26.01.12 28.01.12 07.02.12 Feb 2012 Feb 2012 14 Feb 12 January 14 February 14 June 14 August 14 15th January 15 20th January 15 January 2016 February 2016 Page 2 of 131 Change Infection Prevention and Control Working Group for comments Requested minor changes applied No changes requested No changes requested No changes requested Approved (v1) Updated re changes from HPA to PHE Approved by PHE and IPC Working Group Revised due to up-dates in Category Four diseases from DoH and resistant bacteria Additions to Cat 4 process added, so changes made to Appendix 14 and 15 Additions and changes to Appendix 15 Above additions and changes to Appendix 15 Updated as required Taken to Policy Group Authorised/Comments Some minor changes requested by HPA Darryl Pennells HPA approved Sent to Staff side for comments CPGMs Clinical team CQGC IPC Lead Carolyn Gregory PHE approved changes Approved by IPC committee on 30.07.14 published while still awaiting confirmation of some additions to Cat 4 process Approved by S. Green. IPC Lead and Emergency Planning Approved IPC committee and EP Approved by Public Health England, HPU West Approved by PHE, Emergency Planning and IPC Committee Approved 04.02.16 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE CONTENTS 1 Statement ...................................................................................................................... 4 2 Introduction and Scope .................................................................................................. 4 3 Aims and Objectives ...................................................................................................... 4 4 Standard Precautions .................................................................................................... 4 5 References ................................................................................................................... 6 Appendix Two - Measles ................................................................................................... 23 Appendix Three - Scarlet Fever ......................................................................................... 24 Appendix Four - Chickenpox and Shingles – Varicella Zoster ........................................... 26 Appendix Five - Creutzfeldt Jakob Disease – CJD ............................................................ 28 Appendix Six - Clostridium difficile ..................................................................................... 29 Appendix Seven – Antimicrobial Resistant Organisms ...................................................... 30 Appendix Eight - Methicillin Resistant Staphylococcus Aureus (MRSA) ............................ 33 Appendix Nine - Norovirus – Winter vomiting disease ....................................................... 34 Appendix Ten - Respiratory Diseases ............................................................................... 36 Appendix Eleven - Tuberculosis - TB................................................................................. 39 Appendix Twelve - P.V.L. Staphylococcus aureus ............................................................ 42 Appendix Thirteen - Meningitis .......................................................................................... 44 Appendix Fourteen - Viral Haemorrhagic Diseases ........................................................... 47 Appendix Fifteen – Category Four Diseases – Transport of Cases ................................... 51 Page 3 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE 1 Statement 1.1 2 3 Introduction and Scope 2.1 In any situation where numbers of people are brought together as providers or receivers of health care, the risks of both acquiring infection from others and/or spreading infection can be high. Ambulance personnel have transitory contact with large numbers of people and provide a variety of services ranging from outpatient services to emergency response. In such circumstances, the risks of cross-infection are high unless Infection Prevention and Control measures are taken to reduce these risks. 2.2 This procedure has been developed to provide staff with a robust framework to enable them to effectively control and manage infectious diseases: To ensure there is a reference source for all staff to access To ensure infectious cases are treated appropriately to reduce the risk of spread to others. Aims and Objectives 3.1 4 West Midlands Ambulance Service NHS Foundation Trust (the Trust) is committed to addressing the risks of healthcare associated infection and serious communicable diseases, through a strategy aimed at dealing proactively with the outcomes and continually developing safer working practices. This procedure aims to provide advice on the working practices that need to be adopted in order to manage all cases of infectious disease effectively. Standard Precautions 4.1 The spread of infections that are dealt with on a day to day basis can be prevented by adherence to hygiene standards known as ‘Standard Precautions’, these precautions are: Hand Hygiene Use of appropriate Personal Protective Equipment Cleaning all possible contaminated items Disposal of waste including body fluid spillages Handling of Linen and laundry Safe handling of sharps and injuries Aseptic No Touch Technique 4.2 The level and amount of these standard precautions sometimes varies dependant on the mode of spread of the infection being dealt with, for instance respiratory or touch spread. 4.3 The list of diseases in appendix One gives an ‘at a glance’ quick overview of Page 4 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE what is required. For further information on specific diseases: 4.4 There is a list of infections in appendices Two to Fifteen, (referenced on the PHE (formerly HPA) A to Z list of diseases and the World Health Organisation). Other information can be found on the Public Health England/HPA Website, A to Z list of diseases www.gov.uk/topic/healthprotection/infectious-diseases And the NHS Choices website where there is further guidance www.nhs.uk/conditions/Pages/hub.aspx Category 3 diseases Category 3 diseases – the definition is they are caused by organisms that may cause severe human disease and present a serious hazard to laboratory workers and may spread to the community, however, there is usually effective prophylaxis or treatment available. An example of a category 3 disease is Tuberculosis (TB) These patients can be carried on a normal Ambulance, utilizing the relevant Personal Protective Equipment and standard precautions – see table of diseases in Appendix One for information. 4.5 Category 4 Diseases – See Appendix Fourteen and Fifteen Category 4 diseases – the definition is that they are caused by an organism that causes severe human disease, presents a serious hazard to laboratory workers and may present a high risk of spread in the Community, but there is usually no effective prophylaxis or treatment available. Examples of category 4 diseases are Viral Haemorrhagic fevers such as Marburg and Ebola, other category four diseases are Small Pox, Rabies and Plague. The procedure for transferring CONFIRMED High Risk Category 4 patients involves using 6 HART team members, one to drive and two wearing enhanced level of PPE to be with the patient with a further 3 staff following with decontamination equipment. An escorting Officer will also follow the vehicle and liaise with all concerned to ensure all goes smoothly and safely. Action Card Three gives full instructions for these transfers. Transfers many require transport to a High Security Infectious Disease Unit (HSIDU) – which currently the only one is the Royal Free Hospital in London. North East are due to have a new HSIDU built at the Royal Victoria Hospital, Newcastle-upon-Tyne, however until this is built, only London has this facility. Category 4 patients are extremely rare in the United Kingdom. Any vehicle that transports a suspected, low, high, very high or Confirmed category 4 disease must have a specific cleaning regime followed after the patient has been handed over to the receiving hospital – Action Cards in Appendix 15 have the cleaning instructions for each level of risk. Page 5 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Follow up for any member of staff who has transported a confirmed case will be by either WMAS Occupational Health Nurse (OHN) Manager or the Infection Prevention and Control (IPC) Lead. There is no requirement to stay away from work. The member of staff will have to take their own temperature twice each day from day two to day twenty one from contact with the confirmed case. Any rise in temperature >37.5°C must be reported to the local Public Health England Health Protection Unit (HPU), and either the Occupational Health Nurse Manager or IPC Lead. For any suspected or confirmed category Four case, liaison with the Infection Prevention and Control team will be required at the earliest possible opportunity. Appendix Fifteen deals with Category Four transport in more detail. Further guidance is found on the Health and Safety Executive website - Health and Safety Executive, Advisory Committee on Dangerous Pathogens. www.hse.gov.uk/pubns/misc208.pdf VHF Guidance DoH - Management of Hazard Group Four viral haemhorragic and similar human infectious diseases of high consequence 5 References Public Health England www.gov.uk/topic/health-protection/infectious-diseases World Health Organisation: www.who.int/publications/guidelines/en/index.html NHS Choices: www.nhs.uk/conditions/Pages/hub.aspx Health and Social Care Act 2008 (update 2015): Code of practice on the prevention and control of infections and related guidance Health and Safety Executive and Advisory Committee on Dangerous Pathogens publications www.hse.gov.uk/pubns/misc208.pdf www.hse.gov.uk/biosafety/diseases www.hse.gov.uk/pubns/indg342.pdf www.hse.gov.uk/pubns/infection.pdf Page 6 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE INFECTION Acinetobacter Anthrax Release can be a deliberate act Contact with any visible powder must be avoided. Mode of Transmission Can live harmlessly on the skin of healthy people, highest risk is to immune compromised and those who have invasive procedures or injuries and hospitalized patients. Poor hygiene and IP&C procedures can spread the infection Incubation period Usually poses no risk to healthy people. Required PPE Gloves changed regularly. Can be colonized on the skin without an infection. Apron should be worn if the infected wound is open Inhalation, ingestion or direct contact with infected soil and animal products such as bone meal and untreated leather. With inhalation Anthrax, symptoms usually develop within 48 hours Person to person airborne transmission does NOT occur – airborne transmission can be by breathing in the spores for instance in the tanning industry. Infection occurs when the bacteria enters a injury or cut With other types of Anthrax symptoms may not appear for up to a week Page 7 of 131 Eating or breathing in the toxin produced by the organism Clostridium botulinum – spores found in soil. There is also ‘wound’ botulism Gloves changed regularly and Apron as a minimum. Can be treated with anti-biotics if successfully recognized early enough. Avoid any powder – wear mask if necessary or call for HART if suspected deliberate act. Usually 12-36 hours after exposure to the toxin Cover wounds with waterproof dressing. Direct contact with a lesion – skin to skin – can cause transmission though is rare Botulism PPE must be worn where there is potential for splashes or inoculation injuries. Wear gloves if performing invasive procedures. Additional Advice Acinetobacter Baumani is a strain that has become resistant to many antibiotics, and is often found in patients returning from abroad - MRAB Cleaning Required All patient touch items, flat surfaces and wall by patient wiped clean using sanitizing wipes. Cutaneous – skin lesion, starts as small bump, then goes into an ulcer with black centre, untreated can cause blood poisoning. Inhalation – Flu like illness – respiratory difficulties, then shock after 2-6 days Injection – Recently some drug users from contaminated heroin Intestinal – from eating contaminated meat (ie. animal has died from anthrax) All patient touch items, flat surfaces and wall by patient wiped clean using sanitizing wipes. Symptoms are blurred vision, difficulty swallowing, speaking, diarrhoea, vomiting and can lead to paralysis All patient touch items and change all used linen. Change all used linen. For blood and body fluid spills use the ‘Spill Pack’ Change all used linen. For blood and body fluid spills use the ‘Spill Pack’. For blood and body fluid spills use ‘Spill pack’ WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE INFECTION Campylobacter Mode of Transmission Eating raw or undercooked meat, especially poultry, unpasturised milk, untreated water, domestic pets with watery diarrhoea, person to person if hygiene is poor Incubation period 1 to 11 days (usually 2 to 5 days) Required PPE Gloves changed on a regular basis and apron to protect uniform if necessary. Additional Advice Symptoms are abdominal pain, profuse diarrhoea, malaise. (vomiting is uncommon) Chickenpox Varicella Zoster Direct person to person contact, airborne droplets and contact with infected articles such as clothing or bedding. 10 to 21 days after contact Gloves changed regularly, apron to protect uniform and face mask if patient has cold symptoms if immune status is not known or negative Symptoms may initially begin with cold like symptoms, followed by high temperature and intensely itchy rash NB. Can be caught from someone with shingles Clostridium difficile Spores can be passed from infected people into the environment, which are then ingested – faecal oral route. Infectious only when patient is symptomatic See appendix Six for further information Page 8 of 131 Infectious 2 days before the lesions appear and until the lesions have crusted over (usually 5 to 6 days after they have appeared) Depends on strain and health of patient. NB. Staff should know their own immune status to Chicken Pox – vaccination is recommended for non-immune Healthcare workers Gloves changed on a regular basis and apron and sleeve protectors to protect uniform if necessary. NB. Alcohol gel does not kill the spores, use soap and water or wipes and gel Cleaning Required All patient touch items and change all used linen. For faecal contamination use a ‘Spill pack’ if appropriate or use sanitizer wipes to clean followed by disinfectant as per cleaning procedures All patient touch items, flat surfaces and wall by patient wiped using sanitizer wipes. Change all used linen. High risk groups for complications are immunocompromised, adults, neonates and pregnant women, who can develop pneumonia, secondary infections and encephalitis The spores do not always cause infection, those at risk are hospitalized, immune compromised, elderly, recent antibiotics and taking PPI’s (eg. omeprazole) Thorough cleaning of the environment is required, preferably using detergent and water. Sanitizing wipes can be used if water is not available, followed by a sporicidal agent or chlorine based disinfectant. Change all used linen. WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE INFECTION Mode of Transmission Incubation Period Required PPE Additional Advice Cleaning Required Creutzfeldt-Jakob Encephalopathy Brain, blood, nervous tissue or pituitary extracts from infected people, by transfusion, transplant or contaminated medical equipment. Many years – not fully known Gloves if performing invasive procedures – changed on a regular basis Seek advice from receiving hospital re any additional measures required All patient touch items, flat surfaces and wall by patient wiped. Change all used linen. Dispose of any metal surgical items used eg. Laryngoscope blades in designated Yellow container for surgical items Eating beef or beef products from BSE infected cattle is thought the most likely cause of Vcjd Diarrhoea Infections Mainly Ingestion by faecal oral route. Some are from infected meat, water or seafood Can be airborne – generally if patient also suffering from projectile vomiting Diptheria C.diff is an anaerobic bacterium – see appendix Six for further information Respiratory droplets or direct contact with respiratory discharge or skin lesions – very close contact. If you have been fully vaccinated, you are protected from the bacteria, but could be a carrier of the bacteria Page 9 of 131 Can be within a few hours depending on the micro-organism causing the infection, usually between 6 and 48 hours. For suspected infectious Diarrhoea and vomiting staff must be advised they have to be 48 hours free of symptoms before returning to work. May develop up to 7 days after contact with the bacteria Apron, sleeve protectors and gloves should be worn where there is a potential for contamination of uniform by faecal matter or vomit. Wear face mask with eye protection for close contact with patient who is actively vomiting. Gloves for any invasive procedures, changed on a regular basis. Apron if necessary. If patient is actively coughing, wear a face mask with eye protection Good hand hygiene is required using soap and water when available – NB. Alcohol does not work on diarrhoeal infections, use wipes followed by gel if soap and water are not available Majority of population are immunized. Usually begins with sore throat and fever and can quickly develop into severe breathing problems, it can also damage the heart and nervous system. All patient touch items, flat surfaces and wall by patient wiped thoroughly with sanitizing wipes. Change all used linen. For any body fluid spillage, first clean, then disinfect with chlorine releasing agent for instance Chlorclean All patient touch items, flat surfaces and wall by patient thoroughly wiped with sanitizing wipes. Change all used linen. WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE INFECTION Mode of Transmission Mosquito-borne infection that causes a flu like infection Dengue Fever It is not spread from person to person Escherichia coli – Including Extended Spectrum Beta Lactamase (ESBL) Ingestion of contaminated food or water (can cause travellers diarrhoea). Incubation period Approximately 5 to 8 days from the bite, though could be sooner. Depends on site of infection Person to person transmission is by faecal – oral route Hepatitis A Hepatitis B Hepatitis C Page 10 of 131 Faecal/oral, contaminated food and water Blood borne, sexual contact and vertical transmission from infected mother to baby Blood borne, vertical transmission from infected mother to baby, small risk of sexual transmission Required PPE Gloves for invasive procedures If patient is bleeding – full PPE is required Gloves for invasive procedures, changed on a regular basis. Apron should be worn if there is a risk of contamination from body fluid. Additional Advice Symptoms include fever and headache, flu like symptoms. Can lead to complications of dengue haemorrhagic fever and dengue shock syndrome E coli causes urinary tract infections, gastric infections and can cause bacteraemia. Good hand hygiene is required to avoid spread, especially on farms – also avoid under cooked meat and unpasteurised milk, and drink safe water when abroad Cleaning Required If patient is not bleeding - Standard precautions – clean all patient touch items and change all linen Patient bleeding – use Chlor Clean disinfectant All patient touch items, flat surfaces and wall by patient thoroughly wiped with sanitizer wipes and change all used linen Blood spills use ‘Spill pack’, use absorbent cloth for urine spills followed by chlorine based disinfectant Around 28 days (15-50 days) 40 to 160 days In many cases, infection will not be apparent for many years. All patient touch items, flat surfaces and wall by patient wiped Gloves for invasive procedures, changed on a regular basis. Apron should be worn if there is a risk of contamination from body fluids Majority of staff are inoculated against Hep B Blood and body product spill - use the spill pack Good hand hygiene procedures are required to prevent spread WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE INFECTION Human Immunodeficiency virus (HIV) Mode of Transmission Sexually transmitted and exposure to blood and body fluids Incubation period Long silent period without any symptoms Required PPE Gloves for invasive procedures, changed at regular intervals. Wear an apron if there is a risk of contamination to uniform from blood and body products Impetigo Influenza Page 11 of 131 Highly infectious by direct contact or by using items touched by someone infected – such as a towel or face cloth Transmitted easily from person to person via respiratory droplets from coughs and sneezes – which can be either airborne or by touching items that have been contaminated by respiratory droplets Healthcare workers with Impetigo must be referred to Occupational Health – generally they can return to work following 48 hours of treatment. Gloves for invasive procedures, changed at regular intervals. Infection to illness approximately 2 days. Wear gloves for invasive procedures, changed at regular intervals. If patient is unable to use a tissue to catch respiratory droplets, request they wear a mask, if that is not possible or they refuse, staff should wear a mask Sudden onset of high fever, dry cough, headache, muscle and joint pain, severe malaise, sore throat and runny nose – which lasts approximately 1 to 2 weeks and can lead to complications. Do not touch the rash. Additional Advice Following sharps injury or blood contamination of member of staff, post exposure prophylaxis needs to be started within 24 hours of the contamination with anti-viral drugs Cleaning Required Clean all patient touch items, flat surfaces and wall by patient thoroughly wiped clean with sanitizing wipes. Change all used linen Use ‘Spill pack’ for blood and body fluid spills Bacterial skin infection – caused by same bacteria that causes sore throats (Group A streptococci or pyogenes and also by Staphylococcus aureus). Infection occurs when bacteria enters a break in the skin through such as a cut or bite Clean all patient touch items with sanitizing wipes. Staff immunization is recommended. Clean all patient touch items, flat surfaces and wall by patient thoroughly wiped clean with sanitizing wipes Some specific strains eg. Swine and Avian require FFP3 masks to be worn -especially if the patient is actively coughing and sneezing and unable to wear a mask or use a tissue themselves Change all used linen. Change all used linen WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE INFECTION Legionnaires Disease Mode of Transmission By inhaling aerosolised bacteria from a contaminated water source Incubation period 2 to 19 days from exposure, (normally around 6 to 7 days) It cannot be passed from person to person Leptospirosis (Weills disease) Leprosy Malaria Page 12 of 131 Direct or indirect contact with infected animal urine (usually rats and cattle in the UK), the bacteria mainly enter the body through cuts or damaged skin and mucous membranes, but can also pass through intact mucous membrane and the eyes. Person to person spread extremely rare. Not highly infectious, requires prolonged close contact with an untreated person suffering from an infectious form, combined with an inherent immunological susceptibility Caused by the protozoan parasite, transmitted by bite of a female Anopheles mosquito Required PPE Gloves for any invasive procedure, changed on a regular basis. Wear an apron if there is a risk of blood or body fluid contamination to the uniform Symptoms usually appear 7 to 21 days after exposure, though have been reported as short as 2 or 3 days or as long as 30 days. Gloves for any invasive procedure changed on a regular basis. Often in excess of 5 years – it can take as long as 20 years for symptoms to appear Gloves for any invasive procedure changed on a regular basis. Wear an apron if there is a risk of blood of body fluid contamination to uniform Gloves for any invasive procedure changed on a regular basis Depends on the type of malaria – can be anything from 7 days to months or years Wear an apron if there is a risk of blood or body fluid contamination to uniform. Additional Advice Legionnaires disease a severe pneumonia – symptoms include flu like illness and fever which leads to pneumonia, diarrhoea and confusion can also occur. A less severe disease caused by the same bacteria is Pontiac disease Can cause a flu like illness, or severe illness which is called Weils disease with jaundice and kidney failure. Sometimes has a two phases – flu like, followed by remission and relapse with a return of fever and jaundice. Can take up to 3 months to recover. Cleaning Required Standard precautions clean all patient touch items using sanitizer wipes. Affects the skin, peripheral nerves, respiratory mucosa and eyes. Standard precautions clean all patient touch items using sanitizer wipes. Change all used linen. Standard precautions clean all patient touch items using sanitizer wipes. Change all used linen. Change all used linen. Not spread from person to person Standard precautions – clean all touch items and change all used linen WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE INFECTION Measles (Notifiable disease) Mode of Transmission Respiratory from airborne droplets and touching items that have been contaminated. Significant contact = in same room for 15 minutes or longer Highly contagious MMR vaccination can be given as Post Exposure Prophylaxis within 72 hours of exposure Meningitis – Meningococcal Disease (Bacterial) From person to person by inhaling respiratory secretions from the mouth or throat or by direct contact (kissing) – Close contact. The bacteria do not live long outside the body PHE can advise regarding required actions Page 13 of 131 Incubation period Contagious from 5 days after contracting the infection Symptoms of respiratory type illness usually starts from day 6 to 14 and can last 4 days before onset of the rash – patient remains infectious for 4 days after rash has appeared Infection has been known to incubate for 21 days before rash appears Usually 3 to 5 days Required PPE Gloves for any invasive procedure changed on a regular basis. Wear an apron if there is a risk of blood or body fluid contamination to uniform If patient is coughing and/or sneezing and unable to tolerate a mask themselves or use a tissue to catch the droplets, staff should wear face mask Gloves for invasive procedures changed on a regular basis. Wear an apron if risk of blood or body fluid contamination, face masks for any close contact or aerosol generating procedure Do not perform mouth to mouth Additional Advice Staff should know their own immunity – either by 2 x MMR vaccination or have had measles in the past and blood test positive. Contact tracing is required, with a priority to trace all immunocompromised, pregnant, infants, and healthcare workers. Cleaning Required Clean all patient touch items, flat surfaces and wall by side of stretcher using sanitizer wipes. Change all used linen. Exposed Healthcare workers without definite evidence of immunity should be excluded from work from day 5 of exposure – urgent referral to Occupational Health required If mouth to mouth resuscitation has taken place, member of staff must be referred immediately to OH for risk assessment regarding need for PEP. Occupational Health can also advise regarding vaccination if appropriate Standard precautions – clean all patient touch items using sanitizer wipes and change all used linen WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE INFECTION Mode of Transmission Incubation period Required PPE Additional Advice Cleaning Required Methicillin Resistant Staphylococcus Aureus (MRSA) Staphylococcus aureus colonizes healthy skin – infections occur when bacteria enters the body through for example broken skin or a medical procedure 4-10 days and person remains infectious to others as long as infection or carrier status persists Gloves for any invasive procedures changed on a regular basis. MRSA is a strain of Staph aureus that has become resistant to certain anti-biotics Clean all patient touch items with sanitizing wipes. Wear an apron if there is a risk of blood or body fluid contamination of uniform. Strict adherence to hand hygiene procedures is required and the use of alcohol hand sanitiser MRSA is no more virulent or pathogenic than sensitive strains, but may be more difficult to treat Change all used linen See also Staph aureus and PVL Mumps (Notifiable) Direct contact with saliva or droplets of saliva from an infected person 14 to 21 days and person is contagious for several days before the swelling appears to several days after. Gloves for any invasive procedures changed on a regular basis. As many as 30% of cases of Mumps do not have any symptoms Standard precautions – clean all patient touch items with sanitizing wipes Change all used linen None immunized exposed staff should be considered infectious from day 12 to 25 days after exposure Wear an apron if there is a risk of blood or body fluid contamination of uniform. Wear a mask if patient is actively coughing/sneezing and unable to wear one themselves Page 14 of 131 Illness starts with headache and a fever for a few days, followed by swollen parotid glands Urgent Occupational Health referral required for none immunized exposed staff WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE INFECTION Mode of Transmission Incubation period Required PPE Additional Advice Cleaning Required Pertussis (Whooping Cough) Respiratory spread by droplets of saliva from the infected person Incubation period 7-10 days. Gloves for any invasive procedures changed on a regular basis. Staff should be appropriately vaccinated - may still develop disease but may reduce severity. Clean all patient touch items, flat surfaces and wall by stretcher using sanitizing wipes. Infectious from 7 days to three weeks – can last for up to 3 months (Notifiable) Change all used linen Wear an apron if appropriate Pneumococcal Pneumonia Respiratory infection, usually caused by patients own flora. Not applicable Not usually passed person to person Gloves for any invasive procedures changed on a regular basis. Wear a mask if patient is actively coughing Streptococcus pneumoniae causes diseases such as pneumonia, meningitis and bacteraemia Clean all patient touch items, flat surfaces and wall by stretcher using sanitizing wipes. Change all used linen Wear an apron if appropriate Wear a mask if patient is actively coughing Poliomyelitis Faecal oral route and respiratory droplets (Staff should ensure they are up to date with vaccination) 3 to 35 days Highly infectious virus – Now rarely seen due to effective vaccination programme Gloves for any invasive procedures changed on a regular basis. Virus enters the blood stream and central nervous system and can lead to muscle weakness and paralysis. Wear an apron if appropriate 90-95% of cases do not have any symptoms Page 15 of 131 Clean all patient touch items, flat surfaces and wall by stretcher using sanitizing wipes. Change all used linen WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE INFECTION Mode of Transmission Incubation period Required PPE Additional Advice Cleaning Required PVL Staphylococcus aureus Pantene-Valentine leukocidin (PVL) is a toxic substance produced by some strains of Staph Aureus and is associated with an increased ability to cause disease. 4-10 days and person remains infectious to others as long as infection or carrier status persists Gloves for any invasive procedures changed on a regular basis Strict adherence to hand hygiene procedures is required and the use of alcohol hand sanitiser Clean all patient touch items with sanitising wipes Wear an apron if there is a risk of blood or body fluid contamination of uniform Can be MSSA or MRSA strain Rabies Saliva from the bite of an infected animal Two to twelve weeks Gloves for any invasive procedures changed on a regular basis. Wear an apron if appropriate Resistant Enterococci:Carbapenem CRE Vancomycin VRE Gentomycin GRE Enterococci – found in the gut, can be in faeces or urine - patients can be colonised by the resistant strains of Enterococci Change all used linen Not applicable Apron, Gloves and strict hand hygiene Control of any loss of urine or faeces Most recent UK case was in London in 2012, previous was in Northern Ireland in 2008 Bat bites – patient may require Post exposure vaccination – contact PHE Patient may know they are a carrier who is colonised by these resistant bacteria – any infections caused by these resistant bacteria can be difficult to treat, may cause severe infections, sepsis and even death Clean all patient touch items, flat surfaces and wall by stretcher using sanitizing wipes. Change all used linen Strict hand hygiene at all times. Clean all patient touch items with vehicle based wipes and change all used linen. Any body fluid contamination must be cleaned using chlorclean or spill pack if necessary Any uniform contamination uniform will have to be changed Page 16 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE INFECTION Mode of Transmission Incubation period Required PPE Additional Advice Cleaning Required Rubella Direct contact and respiratory droplet spread 2 to 3 weeks from contact with the infection Contagious 1 week before rash appears up to 6 days after rash Gloves for any invasive procedures changed on a regular basis. Advise to avoid pregnant women. Clean all patient touch items, flat surfaces and wall by stretcher using sanitizing wipes. (Notifiable) Wear an apron if appropriate Normally fit patients with Rubella do not need medical attention Change all used linen Wear a mask if patient is actively coughing Scarlet Fever (Notifiable) Caused by Group A Streptococci bacteria – commonly found on the skin or in the throat (also causes impetigo) Usually 2 to 5 days, but can be 1 day to 1 week Strict hand hygiene procedures are required Spread by coughing, sneezing – respiratory droplets Severe Respiratory Infections – ie. China Flu and MERS.CoV See latest notices for updates regarding emerging new diseases Page 17 of 131 Airborne viruses mainly spread by coughing and sneezing, though can survive on surfaces for some time if not cleaned effectively Wear gloves and apron – changed at regular intervals Each disease has different incubation, China Flu is 2 days up to 10 days, MERS.CoV is 2 days up to 14 days For all suspected severe respiratory diseases – wear an FFP3 mask if within 1 metre of patient – remember to wear safety glasses as well. Or Surgical mask with visor for above 1 metre First symptoms are fever, sore throat, headache, nausea, vomiting, 12 to 48 hours later a fine ‘sand paper’ red rash appears Clean all patient touch items, flat surfaces and wall by stretcher using sanitizing wipes. Patient can be asked to wear a SURGICAL mask if they are able to tolerate one to help to lower the risk of spread. Clean all patient touch items, flat surfaces and wall by stretcher using sanitizing wipes. For MERS.CoV Level 2 PPE is required (overall and apron) For suspected MERS.CoV patient who is symptomatic/nebulised return to base to have a Chlorclean done on vehicle Strict hand hygiene at all times Change all used linen Change all used linen WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE INFECTION Mode of Transmission Group A Streptococcal Infections Can cause a range of diseases, such as Scarlet Fever, Impetigo, GAS Gangrene, Necrotising Fasciitis Shingles Shigella Can spread Chicken Pox to non immune person/s Chicken pox can be caught by direct contact with the fluid from the spots Bacillary dysentery – acquired by drinking water contaminated by human faeces or eating food washed with contaminated water Incubation period Incubation depends on where the infection is – can live harmlessly on skin or in throat. Necrotising Fasciitis is caused by bacteria entering a cut or damaged skin – GAS is known to cause a severe form of Necrotising Fasciitis Can be many years – Chicken pox virus lays dormant and is reactivated Between 12 and 96 hours Required PPE Additional Advice Wear Gloves and apron – changed at regular intervals For a severe Strep infection such as Necrotising Fasciitis – AFA clean required utilising Chlor-Clean and full PPE Use face mask with visor for respiratory infections or any risk of splash Wear gloves for any invasive procedures, which must be changed at regular intervals Wear an apron if appropriate. Wear gloves for any invasive procedures, which must be changed at regular intervals Wear an apron if appropriate. Staphylococcus aureus (MSSA) Staph aureus is a bacterium that commonly colonises human skin and mucosa (inside the nose), without causing any problems. It causes disease if there is an opportunity for the bacteria to enter the body, for example through broken skin or a medical procedure Page 18 of 131 Approximately 2 to 10 days depending on the site of infection Food poisoning 2 to 6 hours Gloves for any invasive procedures changed on a regular basis. Wear an apron if there is a risk of blood or body fluid contamination of uniform Cleaning Required Clean all patient touch items, flat surfaces and wall by stretcher using sanitising wipes. Change all used linen Re-activation of the Chicken Pox virus (Herpes zoster) in someone who has had chicken pox in the past Clean all patient touch items, flat surfaces and wall by stretcher using sanitizing wipes. Shigella may survive for up to 20 days in the environment, so strict adherence to hand hygiene and cleanliness is required Clean all patient touch items, flat surfaces and wall by stretcher using sanitizing wipes. Strict adherence to hand hygiene procedures is required and the use of alcohol hand sanitiser Clean all patient touch items with sanitising wipes Change all used linen Change all used linen Change all used linen WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE INFECTION Mode of Transmission Incubation period Required PPE Additional Advice Cleaning Required Tetanus Not passed from person to person Usually between 3 and 21 days, though could be from 1 day to several months Wear gloves for any invasive procedures, which must be changed at regular intervals Ensure your protection is up to date. Clean all patient touch items, flat surfaces and wall by stretcher using sanitizing wipes. Spores are widespread in the environment. Wear an apron if appropriate. First symptoms are stiff muscles by the injury site, followed by stiffening of other muscles until ‘lock jaw’ occurs Wear gloves for any invasive procedures, which must be changed at regular intervals Contact Occupational Health. Staff should have had vaccination and be immune to most types. Transmission occurs when the spores are introduced into the body via a wound Tuberculosis (TB) Respiratory – coughing respiratory droplets. Varied depending on different factors. Prolonged close contact with an infected case (8 hours plus) – only infectious in ‘open’ or ‘sputum smear positive’ cases A small number of people contract primary disease usually within 8 weeks of exposure, this can go unnoticed and they do not get full infection for many years – diagnosed by xray as a scar Bovine TB mainly transmitted via ingestion of untreated milk Typhoid Fever Contaminated food and water and faecal oral route 7 to 14 days but can be longer or shorter depending on number of bacteria ingested Wear an apron if appropriate. Wear a mask if patient is actively coughing and unable to wear one themselves Wear gloves for any invasive procedures, which must be changed at regular intervals Wear an apron if appropriate. Page 19 of 131 Change all used linen Clean all patient touch items, flat surfaces and wall by stretcher using sanitizing wipes. Change all used linen Resistant strains have emerged. These are more difficult to treat. Strict adherence to IPC standards The bacteria are passed in the urine and faeces of infected people – who then handle food without adequate hygiene, or by drinking water contaminated by sewerage Clean all patient touch items, flat surfaces and wall by stretcher using sanitizing wipes. Change all used linen WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE INFECTION Viral Haemorrhagic Fevers Ie. Ebola, Marburg, etc See Appendices 14 and 15 for full procedure to follow Mode of Transmission Incubation period Required PPE Additional Advice Cleaning Required Very close contact with someone who has got the disease or an animal who is carrying this – dead or alive Up to 21 days from contact with the known source Dependant on the severity of the patients symptoms Follow the action cards in Appendix 15 in the Management of Infectious Diseases Always ask if patient has had any foreign travel in last 21 days – if so, check the Pro med Mail website for recent outbreaks of disease:- Low risk symptoms wear Level One PPE See Action Cards in Appendix 15 for full information on decontamination of the vehicle – Deep Clean can be done by the AFAs Specialist Decon Team http://www. promedmail.org/ High risk symptoms (ie. Loosing body fluids) this is a HART transfer Up to 8 weeks after infection Wear gloves for close personal contact and for any invasive procedures, which must be changed at regular intervals Caused by the mite Sarcoptes scabei. Clean all patient touch items, flat surfaces and wall by stretcher using sanitizing wipes. Spread by direct contact with blood and all body fluids Could be laboratory worker Not normally endemic in the UK – however it could be brought here by a traveller – so very important to ask regarding Foreign Travel within last 21 days Medium risk symptoms wear Level Two PPE Infestations:Scabies Very close person to person contact, for example holding hands for a length of time Very slight risk from bedding - transfer will only occur on bed linen or clothing if they have been contaminated immediately before contact as the mites can not live for long away from their host Page 20 of 131 Wear an apron if appropriate. Sarcoptes scabiei mites die very soon after they leave the skin, they do not survive well in the environment Once treatment has been completed for scabies, there is no risk of spread, though itch may remain Change all used linen WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE INFECTION Mode of Transmission Incubation period Required PPE Norwegian or Crusted Scabies Highly contagious and can be spread through minimal contact with a person with the crusted areas. Can be up to 8 weeks after infection Wear gloves and apron for any contact. Strict hygiene practices required. Jump from animal to human or human to human. Flea bites are often not felt until a short time later, when the area goes red and itches Animal fleas will feed on humans but live on the animal host. Very difficult to protect against if patient visibly has them – use hair protector, coveralls and gloves if appropriate They can also live for example in carpets, soft furnishings and pet bedding Lice - Head Page 21 of 131 Head to head contact Caught the same way as normal scabies. The crusting is linked to the hosts immune response. Cleaning Required Clean all patient touch areas and flat surfaces. Change all used linen. Others acquiring infection from a case of Norwegian will develop normal scabies There is an increased risk of spread of crusted scabies on bed linen and clothing Flea’s Additional Advice Household flea spray can be used to stop and prevent further infestations for a length of time. Fleas can lay dormant for up to 2 years Specialist clean if infestation confirmed. Clean all items that can be removed from the vehicle, and dispose of used linen as contaminated. Human fleas are extremely rare – infestation usually due to cat fleas Eggs are pinhead size, normally found by scalp, take 7 to 10 days to hatch (called Nits). They then feed by biting the scalp and sucking the blood, they are fully grown after 6 to 8 days, they can now breed, lay more eggs and move from head to head. Keep long hair tied back, do not let hair drop on to or touch anyone else’s hair. Wear relevant PPE for patients underlying medical condition Head lice crawl from head to head – They do not jump or fly (ALWAYS keep long hair tied back as per Uniform Policy, IPC procedures and code of conduct) Avoid head to head contact where possible Standard precautions – clean all patient touch items. Change all used linen. WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Infestation Mode of Transmission Incubation Period Required PPE Additional Advice Cleaning Required Ticks Opportunistic - they attach themselves to skin, can be from leaning on a tree or walking in long grass or many other scenario’s Larvae, nymph and adult, feed on blood – they can carry disease, which is spread when they bite – incubation of the disease depends on what they are carrying Be aware if walking through undergrowth and keep skin covered. Useful document on the Lyme disease website: www.lymedisease action.org.uk Standard precautions – clean all patient touch items. Check afterwards for small black dots If reddening occurs around the wound – like a ‘target’ medical attention is required urgently Page 22 of 131 Change all used linen. WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Appendix Two - Measles Measles is highly infectious, and is transmitted by airborne droplets – inhaled directly via coughs or sneezes, or touching surfaces contaminated with respiratory secretions, then transferred to the mouth – The virus can survive for up to 2 hours on surfaces. At risk groups include non immune individuals (ie. Not had the disease or not been vaccinated) the immune compromised, and children under 6 months. None immune pregnant staff should contact Occupational Health or GP/Midwife for advice if exposed. If you have had measles in your lifetime then the immunization is said to be permanent. West Midlands Ambulance Service advises all staff to check their vaccination/immunity status to Measles (MMR) if they do not already know, via a telephone call to their GP or Occupational Health provider. Most patients with measles can be managed at home, with fluid and control of fever; however, complications can include pneumonia, ear infections, and encephalitis which require medical assessment. If you are taking a patient to hospital that you suspect has measles, the receiving hospital department will have to be informed on route. On arrival at the receiving hospital, the driver must go into the department to advise arrival and obtain instructions regarding where the patient is to be taken. This is to enable the receiving department to prepare isolation facilities for the patient. Walk in centres will also have to be informed as they will need to prepare a side room to prevent exposure to others in the waiting area. Relevant PPE should be worn, as per procedures for respiratory infections. After patient discharge patient touch items and equipment used must be cleaned as per Trust IPC procedures – Strict adherence to hand hygiene is required, with wipes, gel, and soap and water whenever possible. Please inform EOC if you have been in contact with a suspected case. Measles Information: Highly infectious communicable disease Incubation period = 7 - 18 days (average 10 days) Period of infectivity = 4 days before to 4 days after onset of rash Early stage symptoms = 3 - 4 days; high fever, cough, conjunctivitis, runny nose Rash: maculopapular erythematous (flat red area with small raised lumps), – initially on hairline, spreading rapidly to face, trunk, and limbs Koplik’s spots (similar to grains of salt on red background) : may be seen on gums: start 1 -2 days before skin rash appears, and for 1 -2 days after Mild cases may occur in vaccinated child (usually after 1 dose) as a low grade fever and transient rash Information obtained from the PHE, WHO and NHS Choices January, 2016. Page 23 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Appendix Three - Scarlet Fever Scarlet Fever is an infectious disease caused by bacteria called Streptococcus pyogenes or group A streptococcus, this same bacteria also causes Impetigo, and are commonly found on the skin or in the throat, where they can live without causing problems, however under some circumstances, they can also cause disease. The infection is easily treated with antibiotics. The bacteria are carried in the mucus and saliva, and the disease is spread by coughing and sneezing, or direct contact with the mucus or saliva. The disease tends to be most common in the winter and spring, and the usual treatment is a 10 day course of anti-biotics, the fever will normally subside within 24 hours of starting antibiotic treatment. Current guidance advises that children should not return to nursery or school and adults to work until a minimum of 24 hours after starting treatment. Symptoms The first symptoms often include a sore throat, headache, fever, nausea and vomiting. After 12 to 48 hours the characteristic fine red rash develops (feels like sandpaper when touched). Typically it first appears on the chest and stomach, rapidly spreading to other parts of the body. Fever – 38.3 C (101F) or higher is common White coating on tongue, which peels a few days later, leaving the tongue looking red and swollen Swollen glands in the neck Feeling tired and unwell Flushed red face, but pale around the mouth Peeling skin on finger tips, toes and groin area as the rash fades How is it caught? It is spread by contact with the mucus or saliva of an infected person – this can be airborne when coughing or sneezing – and also contact with surfaces touched by the mucus and saliva. Complications Most cases of Scarlet Fever have no complications at all, however in the early stages, there is a small risk of the following: Ear infection Throat abscess Pneumonia Sinusitis Meningitis On rare occasions, at a later stage in the disease (in the first few weeks after the main infection has cleared up) there is a risk of the following: Bone or joint problems Liver damage Kidney damage Acute rheumatic fever Page 24 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Transporting Patient with Known or Suspected Scarlet Fever Wear apron and gloves if there is a risk of contact with patient’s body fluid/mucus/saliva. Change PPE when contaminated. Do Not drive wearing PPE – dispose of, then wear new on arrival at hospital If patient is coughing or sneezing, encourage them to use a tissue, and wear a face mask if they are able to tolerate one – if not, it is acceptable for staff to wear a face mask if in close contact Inform receiving hospital of estimated time of arrival of known or suspect case so that a suitable cubicle or area can be made ready Driver enter department to let them know you have arrived and to find out where to go Dispose of any PPE used as Clinical Waste Vehicle Cleaning If possible leave all used linen at the hospital, either with patient or in hospital contaminated linen skip Any used linen that has to be transported back to station, first put into a red alginate bag, seal bag, then place sealed red alginate bag into a white laundry bag, seal bag – place this double bagged laundry into the contaminated laundry bin on station when next there Use sanitiser wipes to clean all relevant patient touch items and any items liable to have been contaminated by crew (eg. PRF board/tablet, pen), and the wall by the side of the stretcher – dispose of wipes as clinical waste Dispose of PPE and wash hands – the stretcher can now be made up and the vehicle is ready to use Information obtained from the PHE, WHO and NHS Choices January, 2016. Page 25 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Appendix Four - Chickenpox and Shingles – Varicella Zoster Chickenpox is an acute, infectious disease caused by the varicella-zoster virus and is most commonly seen in children under 10 years old. Reactivation of this virus causes shingles (herpes zoster), which tends to be more prevalent in adults. It is not possible to develop shingles from exposure to a person with chickenpox. It is possible however, for a none immune person to develop chickenpox as a result of exposure to a person with shingles. Transmission Chickenpox is highly contagious, infecting up to 90% of none immune people who come into contact with the disease. Transmission is through direct person to person contact, airborne droplet infection or through contact with infected articles such as clothing and bedding. The incubation period (time from becoming infected to when symptoms first appear) is from 10 to 21 days. The most infectious period is from 1 to 2 days before the rash appears but infectivity continues until all the lesions have crusted over (commonly about 5 to 6 days after onset of illness). Symptoms of Chickenpox Chickenpox may initially begin with cold-like symptoms followed by a high temperature and an intensely itchy, vesicular (fluid-filled blister-like) rash. Clusters of vesicular spots appear over 3 to 5 days, mostly over the trunk and more sparsely over the limbs. The severity of infection varies and it is possible to be infected but show no symptoms. Shingles (Herpes Zoster) Following chickenpox infection, the virus can lay dormant in the nervous tissue for several years but may reactivate later in life or when the immune system is challenged, for example due to stress or conditions that depress the immune system such as old age, immunosuppressive therapy and HIV infection. The first sign of herpes zoster is usually pain in the area of the affected nerve - most commonly in the chest. A rash of fluid-filled blisters then appears in the affected area, typically only on one side of the body. This rash is usually present for about 7 days but the pain may persist for longer. Persistent pain is more common in elderly people and is termed 'postherpetic neuralgia'. On average this lasts for 3 to 6 months although it can continue for years. As mentioned above, people with shingles are contagious to those people who have not had chickenpox. However, it is not possible to catch shingles from a person who has chickenpox. Page 26 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Possible Complications and High Risk Groups Chickenpox is usually a mild illness and most healthy children recover with no complications. Certain groups of people however, such as neonates (infants within the first four weeks of life), adults, pregnant women and those who are immunocompromised due to illness or treatments such as chemotherapy or high-dose steroids, may experience more serious complications. These include viral pneumonia, secondary bacterial infections and encephalitis. Varicella infection in pregnant women can cause severe chickenpox with increased risks for the mother from varicella pneumonia and other complications. It also carries the risk of congenital varicella syndrome for the foetus. Congenital varicella syndrome can cause a range of problems including shortened limbs, skin scarring, cataracts and growth retardation. Treatment There is no specific treatment for chickenpox. It is a viral infection that will therefore not respond to antibiotics. Treatment should be based on reducing symptoms such as fever and itchiness. Shingles can be treated with oral antiviral drugs such as acyclovir. People at higher risk of developing serious complications from chickenpox or shingles may be given antiviral drugs such as acyclovir and/or immunoglobulin (a specialised preparation of antibodies taken from the plasma of blood donors), which may prevent severe illness developing. Immunity and Prevention In December 2003, the Chief Medical Officer announced a new varicella vaccination policy for health care workers. Following advice from the Joint Committee on Vaccination and Immunisation, varicella vaccination is now recommended for non-immune healthcare workers who work in primary care and in hospitals (both NHS and private). This recommendation covers all non-immune staff who have direct patient contact including ambulance drivers, ward cleaners, catering staff and GP receptionists. Those without a previous history of chickenpox or shingles infection and who are then found to be seronegative to varicella following antibody testing should be offered varicella vaccine. Information obtained from the PHE, WHO and NHS Choices January, 2016. Page 27 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Appendix Five - Creutzfeldt Jakob Disease – CJD Creutzfeldt-Jakob disease (CJD) is a rare and ultimately fatal degenerative brain disease. It is one of a group of diseases called Transmissible Spongiform Encephalopathies (TSEs) that affect humans and animals. TSEs are thought to be caused by the build up in the brain of an abnormal form of the naturally occurring 'prion' protein. CJD was initially described in its classical, or sporadic form, in 1920. A new variant known as variant CJD (vCJD) was first identified in 1996. Variant CJD is strongly linked to exposure, probably through food, to a TSE of cattle called Bovine Spongiform Encephalopathy (BSE). Most (85%) cases of CJD are sporadic, with no known cause, and occur worldwide at a rate of about 1 case per million population per year. There are also inherited forms of CJD (10-15%) and those which have been acquired from another source. Acquired CJD includes iatrogenic CJD and vCJD. Iatrogenic CJD is very rare, and occurs when CJD is accidentally transmitted during medical or surgical procedures. Although there have been no reported cases of vCJD having been transmitted as a result of surgical procedures, the possibility cannot be ruled out. Precautionary measures have been taken to reduce such a risk by improving the standards of decontamination services for surgical instruments. This is why in the Ambulance service we now use single use metal surgical items, which are disposed of as clinical waste, so destroyed. CJD is not spread by direct contact with patients or person to person, so no specific IP&C precautions are required. Standard precautions are sufficient to transport this type of patient. Information obtained from the PHE, WHO and NHS Choices January, 2016. Page 28 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Appendix Six - Clostridium difficile Clostridium difficile infection is the most important cause of hospital-acquired diarrhoea. Clostridium difficile is an anaerobic bacterium (unable to survive in oxygen atmosphere) that is present in the gut of up to 3% of healthy adults and 66% of infants. However, Clostridium difficile rarely causes problems in children or healthy adults, as it is kept in check by the normal bacterial population of the intestine. When certain antibiotics disturb the balance of bacteria in the gut, Clostridium difficile can multiply rapidly and produce toxins which cause illness. Clostridium difficile infection ranges from mild to severe diarrhoea to, more unusually, severe inflammation of the bowel (known as pseudomembranous colitis). People who have been treated with broad spectrum antibiotics (those that affect a wide range of bacteria), people with serious underlying illnesses and the elderly are at greatest risk – over 80% of Clostridium difficile infections reported are in people aged over 65 years. Clostridium difficile infection may be spread on the hands of healthcare staff and other people who come into contact with infected patients or with environmental surfaces (e.g. floors, bedpans, toilets) contaminated with the bacteria or its spores. Spores are produced when Clostridium difficile bacteria encounter unfavourable conditions, such as being outside the body. They are very hardy and can survive on clothes and environmental surfaces for long periods. In most patients the treatment for Clostridium difficile infection is treatment with a specific antibiotic. To prevent the spread of the disease requires the implementation of strict infection control measures: Patients with the infection should be cared for in side rooms. All patients should be encouraged to wash hands after visiting the toilet and before eating food. Staff should wear disposal gloves and aprons when caring for a patient with the infection and wash their hands after contact. Visitors should be encouraged to wash hands before leaving the ward. Maintain a high standard of cleaning For Ambulance staff the important things to remember are: To clean thoroughly following discharge of patient at the hospital To wear PPE – gloves and apron – when treating the patient Change all used linen Inform receiving hospital department if the patient has diarrhoea so they are able to make an isolation cubicle ready for the patient – once asymptomatic, cases are no longer considered to be infectious Information obtained from the PHE, WHO and NHS Choices January, 2016. Page 29 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Appendix Seven – Antimicrobial Resistant Organisms Antimicrobial resistance describes the ability of a micro-organism to resist the action of antimicrobial drugs. In a few instances some micro-organisms are naturally resistant to particular antimicrobial agents, however a more common problem is when microorganisms that are normally susceptible to the action of a particular antimicrobial agent become resistant. This resistance often arises as a result of changes in the genetics of the micro-organism – in some cases, the gene’s causing the resistance can be transferred between different strains of micro-organisms, which gives them the ability to also ‘resist’ the antimicrobial usually used to kill it – so the resistance spreads. The resistance to antimicrobials (antibiotics) has been described as an ‘Urgent Threat to Health’ by the Centre for Disease Control, as the powerful antibiotics used for the more serious infections are also being rendered useless to fight them. Ambulance staff may be informed that their patient is known to have CPE, CRE, GRE, VRE, ESBL or could be suspected, has been colonised or had this in the past, however, many patients present with infections and in the Ambulance environment we do not know what the specific infection is – the risk of these multi resistant organisms reinforces the requirement for STRICT Infection Prevention and Control standard precautions to be followed for ALL patients at all times, so the following must be followed: Strict hand hygiene – regular use of sanitiser gel and wipes and using soap and water when they are available Wear PPE – Apron and gloves – changed on a regular basis Clean ALL touch items using vehicle based wipes when the patient is discharged from your care Change ALL used linen ensuring the stretcher is wiped clean after use The receiving hospital will need to be informed, so that an isolation cubicle can be made available for the patient with any infectious disease The following is an overview of some of the resistant organisms – further information can be found on Public Health England and HPA website. Carbapenem Resistant Enterobacteriaceae (CRE) Carbapenems are a powerful group of broad spectrum beta-lactam (penicillin related) antibiotics which, in many cases are our last effective defence against multi-resistant bacterial infections, they are used to fight the more serious infections, such as multiresistant strains of Klebsiella pnuemoniae and Escherichia coli – unfortunately a number of the organisms that cause the multi-resistant infections have been able to form a resistance to this anti-biotic. There is concern that resistance is developing and increasing, which means new antibiotics will need to be developed to counter these resistant micro-organisms. Page 30 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE There has been a yearly increase in these multi drug resistant bacteria since 2000, with a rapid increase over the last five years. In 2014, there are now reports of 25 per week across the country. NHS England has produced a Toolkit for Acute Trusts for the early detection, management and control of Carbapenemase Producing Enterobacteriaceae (CPE) to ensure this threat to health does not get out of control. The toolkit is mainly Acute focused and involves communication of any positive CPE so that it can be contained by use of isolation and enhanced cleaning. As this is a new emerging problem in the UK, there are many questions still to be answered. These resistant bacteria were first found in other countries – One of these bacteria is New Delhi metallo beta lactamase (NDM-1) – this is currently most widespread in the Indian subcontinent, though it has spread to various other countries around the world, including the UK, often via patients previously hospitalized in India or Pakistan. Most of the bacteria with the NDM-1 enzyme do remain susceptible to two types of antibiotic - Colistin and Tigecycline – neither of these are suitable for general use, and a few of the NDM-1 are completely resistant to all currently produced antibiotics. Glycopeptide Resistant Enterococci Enterococci are bacteria that are commonly found in the bowels of most humans. There are many different species of enterococci, but only a few have the potential to cause infections in humans. More than 95% of infections due to enterococci are caused by just two species, Enterococcus faecium and Enterococcus faecalis. Glycopeptide-Resistant Enterococci (GRE) are enterococci that are resistant to glycopeptide antibiotics (vancomycin and teicoplanin). GRE were first detected in the United Kingdom (UK) in 1986 and have subsequently been found in many other countries. GRE are sometimes also referred to as VRE (Vancomycin-Resistant Enterococci). The most common type of GRE is Enterococcus faecium, and the second most common type is Enterococcus faecalis. In rare instances, infections may also be caused by other GRE such as Enterococcus casseliflavus or Enterococcus gallinarum. GRE commonly cause wound infections, bacteraemia (blood poisoning) and infections of the abdomen and pelvis. GRE may also occasionally cause infections in the bile duct (cholangitis), heart valves (endocarditis) or the urinary tract. Who is at risk of infection? Infections caused by GRE mainly occur in hospital patients, particularly those who are immuno-compromised, those who have had previous treatment with certain other antibiotics (particularly cephalosporins and glycopeptides), those who are on a prolonged hospital stay, or those in specialist units such as intensive care or renal units. However, GRE are sometimes found in the faeces of people who have never been in hospital or have not recently been given antibiotics. Page 31 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE How do people contract it? There are two routes by which patients tend to contract GRE infections. The first is by cross-infection, which occurs when bacteria causing infection in one patient are passed to another patient, who also becomes infected. The second involves the spread of GRE bacteria that reside harmlessly in a person's gut to other areas of the body where they are not normally found. Is it treatable? GRE are not particularly virulent bacteria, but they are difficult to treat because of limitations in the range of antibiotics which are effective against them. ESBL – Extended Spectrum Beta Lactamase Extended Spectrum Beta Lactamase are enzymes that can be produced by bacteria making them resistant to cephalosporins (eg. Cefuroxime, Cefotaxime and Ceftazidime) – which are antibiotics used widely across the UK. They were first discovered in the mid 1980’s and mostly found in Klebsiella species, mainly in hospitals and often in intensive care units treating the most vulnerable patients. A new class of ESBL – called CTX-M enzymes – has emerged and has been widely detected among Escherichia coli (E. coli) bacteria. E. coli bacteria are very common bacteria that normally live harmlessly in the gut. The ESBL producing strains makes them harder to treat when they produce infections in other parts of the body. These ESBL E. coli are able to resist penicillins and cephalosporin antibiotics, they are found most often in urinary tract infections – though not in simple cystitis – A patient with ESBL E. coli urinary infection can develop blood poisoning and sepsis. Information obtained from the PHE, WHO and NHS Choices June, 2016. Page 32 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Appendix Eight - Methicillin Resistant Staphylococcus Aureus (MRSA) Staphylococcus aureus is a bacterium that commonly colonises human skin and mucosa (e.g. inside the nose) without causing any problems. It can also cause disease, particularly if there is an opportunity for the bacteria to enter the body, for example through broken skin or a medical procedure. Staphylococcus aureus causes abscesses, boils, and it can infect wounds -- both accidental wounds such as grazes and deliberate wounds such as those made when inserting an intravenous drip or during surgery. These are called local infections. It may then spread further into the body and cause serious infections such as bacteraemia (blood poisoning). Staphylococcus aureus can also cause food poisoning. Infections caused by many antibiotic-sensitive varieties of Staphylococcus aureus are usually successfully treated with antibiotics such as some types of penicillin and erythromycin. Some S. aureus bacteria are resistant to the antibiotic methicillin, and they are termed MRSA. MRSA stands for methicillin-resistant Staphylococcus aureus - They are varieties of Staphylococcus aureus that are resistant to methicillin (a type of penicillin) and usually to some of the other antibiotics that are normally used to treat Staphylococcus aureus infections. There are different types of MRSA Treatment It is not generally necessary to treat MRSA colonisation or carriage, only the Infections need to be treated. MRSA infection is no more dangerous or virulent than infection with other varieties of Staphylococcus aureus, but it is more difficult to treat depending on whether it is resistant to any other antibiotics. Some of the antibiotics used to treat MRSA however can on occasion be more difficult to use or may cause side effects. How is MRSA spread? MRSA is most commonly spread via hands, equipment, and sometimes the environment. It is important that healthcare workers wash their hands before and after treating a patient. Provided hands are not soiled (when they should be washed with soap and water), rapid acting alcohol and other hand hygiene solutions are now advocated in healthcare: they are easier and faster to use than hand washing. Equipment must also be cleaned after use. Information obtained from the PHE, WHO and NHS Choices January, 2016. Page 33 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Appendix Nine - Norovirus – Winter vomiting disease Noroviruses are a group of viruses that are the most common cause of gastroenteritis (stomach bugs) in England and Wales. In the past, noroviruses have also been called ‘winter vomiting viruses’, ‘small round structured viruses’ or ‘Norwalk-like viruses’. How does norovirus spread? The virus is easily transmitted from one person to another. It can be transmitted by contact with an infected person; by consuming contaminated food or water or by contact with contaminated surfaces or objects. The infectious dose is very low, swallowing as few as 10 - 100 virus particles may be enough to cause illness. What are the symptoms? The most common symptoms are nausea, vomiting and diarrhoea. Symptoms often start with the sudden onset of nausea followed by projectile vomiting and watery diarrhoea. However, not all of those infected will experience all of the symptoms. Some people may also have a raised temperature, headaches and aching limbs. Symptoms usually begin around 12 to 48 hours after becoming infected. The illness is self-limiting and the symptoms will last for 12 to 60 hours. Most people make a full recovery within 1-2 days, however some people (usually the very young or elderly) may become very dehydrated and require hospital treatment. Why does norovirus often cause outbreaks? Norovirus often causes outbreaks because it is easily spread from one person to another and the virus is able to survive in the environment for many days. There are many different strains of norovirus, immunity is short-lived and infection with one strain does not protect against infection with another strain. Outbreaks commonly occur in semi-closed environments such as hospitals, nursing homes, schools and on cruise ships, where people are in close contact with one another for long periods. How can these outbreaks be stopped Outbreaks can be difficult to control because norovirus is easily transmitted from one person to another, its low infectious dose and because the virus can survive in the environment for lengthy periods. The most effective way to respond to an outbreak is to institute good hygiene measures such as strict adherence to hand-washing especially when handling food, after contact with infected people, and after using the toilet; disinfecting contaminated areas promptly; not allowing infected people to prepare food until 48 hours after symptoms have elapsed and isolating ill people for up to 48 hours after their symptoms have ceased. How is norovirus treated? There is no specific treatment for norovirus apart from letting the illness run its course. It is important to drink plenty of fluids to prevent dehydration. Page 34 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE If I am suffering from norovirus, how can I prevent other from catching it? Good hygiene is important in preventing others from becoming infected – this includes thorough hand washing after using the toilet. Food preparation should also be avoided until 48 hours after the symptoms have subsided. Who is at risk of getting norovirus? There is no one specific group who are at risk of contracting norovirus – it affects people of all ages. The very young and elderly should take extra care if infected, as dehydration is more common in these age groups. Outbreaks of norovirus are reported frequently anywhere that large numbers of people congregate for periods of several days. This provides an ideal environment for the spread of the disease. Healthcare settings tend to be particularly affected by outbreaks of norovirus. A recent study by the Agency shows that outbreaks are shortened when control measures at healthcare settings are implemented quickly, such as closing wards to new admissions within 4 days of the beginning of the outbreak and implementing strict hygiene measures. How common is norovirus? The vast majority of people who are infected with norovirus will not have any contact with medical services. This makes formal identification of cases difficult. PHE does obtain information on outbreaks of norovirus from hospitals and from food borne outbreaks. The number of outbreaks varies each year. Recent research suggest that around two million cases of norovirus occur in the community each year. Are there any long term effects? No, there are no long-term effects from norovirus. What can be done to prevent infection? It is impossible to prevent infection, however, good hygiene measures (such as frequent hand washing) around someone who is infected is important. Certain measures can be taken in the event of an outbreak, including the implementation of basic hygiene and food handling measures and prompt disinfection of contaminated areas, and the isolation of those infected for 48 hours after their symptoms have ceased. FOR INTERNAL OUTBREAKS OF NOROVIRUS – SEE THE OUTBREAK PROCEDURE . Information obtained from the PHE, WHO and NHS Choices January, 2016. Page 35 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Appendix Ten - Respiratory Diseases Respiratory viruses can infect any age group although the severe complications of such infection are often restricted to children and the elderly. These viruses are most commonly transmitted by airborne droplets or nasal secretions and can lead to a wide spectrum of illness. In the UK many of these viruses are seasonal in their activity and tend to circulate at higher levels during the winter months. In this section there is a short description of: Influenza Respiratory Syncytial Virus Human parainfluenza viruses (HPIVs SARS MERS-CoV Adenoviruses Influenza or 'flu' Is a respiratory illness associated with infection by influenza virus. Symptoms frequently include headache, fever, cough, sore throat, aching muscles and joints. There is a wide spectrum of severity of illness ranging from minor symptoms through to pneumonia and death. Respiratory Syncytial Virus (RSV) causes respiratory infection. It is the commonest cause of severe respiratory illness such as bronchiolitis (inflammation of the bronchioles) in young children aged under 2 years. It is also the commonest cause of hospital admissions due to acute respiratory illness in young children. RSV infections may be overlooked in older children and adults. Several studies have shown that RSV causes severe respiratory illness in elderly people and that outbreaks are associated with higher death rates. Peak numbers of RSV infections are reported in December and January every winter, although the size of the peak varies from winter to winter. The virus is an enveloped RNA virus, in the same family as the human parainfluenza viruses and mumps and measles viruses. The virus is transmitted by large droplets and by secretions, so you may catch it if you touch an infected person and then touch your own eyes, nose or mouth. The virus can survive on surfaces or objects for about 4-7 hours. Transmission can be prevented through standard infection control practices such as hand washing. The incubation period - the delay between infection and the appearance of symptoms - is short at about three to five days. In temperate climates such as the United Kingdom, RSV occurs regularly each year. Epidemics generally start in November or December and last for four to five months, peaking over the Christmas and New Year period. The sharp winter peak varies little in Page 36 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE timing or magnitude, in contrast to influenza virus infection which is much less predictable in its timing. For most people, RSV infection causes a respiratory illness that is generally mild. For a small number of people who are at risk of more severe respiratory disease, RSV infection might cause pneumonia or even death. RSV infection causes symptoms similar to a cold, including rhinitis (runny nose, sneezing or nasal congestion), cough, and sometimes fever. Ear infections and croup (a barking cough caused by inflammation of the upper airways) can also occur in children. Human parainfluenza viruses (HPIVs) Are one of the most important causes of upper and lower respiratory tract diseases, especially in young children. HPIVs can cause repeated infections throughout life, mostly causing mild disease, such as the common cold and croup, with symptoms including malaise, fever, cough, and such sore throats. HPIV infections may also cause more severe respiratory diseases especially among the elderly and among patients who are immunocompromised These viruses are unstable in the environment and are readily inactivated with soap and water. HPIV1-4 infection is one of the common causes of upper and lower respiratory tract disease, especially in young children. Similar to respiratory syncytial virus (RSV), HPIVs 1-4 can cause repeated infections throughout life, and HPIV types 1-4 can cause a full spectrum of respiratory illness, including the common cold, croup, and severe lower respiratory tract illness, such as bronchitis, bronchiolitis and pneumonia. Disease association with HPIV5 is not well established, although it has been implicated in a range of chronic diseases outside the respiratory tract. Among adults, most HPIV 1-4 infections cause mild disease showing as upper respiratory tract symptoms. However, HPIV infections may also cause more severe diseases especially among the elderly and among patients who are immunocompromised. HPIV infections are important causes of mortality among immunocompromised patients (1-3). The incubation period is from 1-7 days. SARS Is a severe respiratory disease caused by SARS coronavirus (SARS CoV). It was first recognised in Guangdong Province in China in November 2002, and spread worldwide before being contained by 5 July 2003. Between July 2003 and May 2004, four small and rapidly contained outbreaks of SARS have been reported; three of which appear to have been linked to laboratory releases of SARS-CoV. The source of the fourth outbreak remains unclear, although epidemiological investigations focused on an animal source. The possibility of SARS re-emergence remains and there is a need for continuing vigilance. Page 37 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Clinicians and other healthcare professionals should remain vigilant to the possibility of SARS, even though the threat to the UK remains low at this time. Refer to guidance documents for the current/inter-epidemic period MERS-CoV Middle East Respiratory Syndrome Coronavirus – MERS-CoV – Was first identified in 2012. Symptoms include a cough and fever that progresses to a severe pneumonia causing shortness of breath and breathing difficulties. In some cases diarrhoeal illness has been the first symptom to appear. Most cases currently (January 2016) have been in the Arabian Peninsula, particularly the Kingdom of Saudi Arabia. Dromedary camels are an identified host and said to be the likely source of primary infection in some cases, though now, most cases are human to human transmission. South Korea had an outbreak in 2015 caused by one person who had been in Saudi Arabia, who travelled back to South Korea and it was not identified as MERS for some time, this lead to multiple contacts infected with the disease, of which 34% died. Many of these contacts were healthcare workers. It is very important in the Ambulance service for any person with a fever or breathing problems to be asked if they have had any recent foreign travel – if they have been to one of the ‘at risk’ countries in the last 14 days, then MERS must be considered, the list of ‘at risk’ countries is updated regularly with the Emergency Operational Control Clinical Support Desk and on a Clinical Notice. Adenoviruses Are a group of viruses that infect the membranes of the respiratory tract, the eyes, the intestines, and the urinary tract. There are several different types of adenovirus and different types cause different symptoms. Adenoviruses usually cause respiratory illness, they can also cause diarrhoea, conjunctivitis, cystitis, and rashes. Adenoviral infections affect young children more frequently than adults. Information obtained from the PHE, WHO and NHS Choices January, 2016. Page 38 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Appendix Eleven - Tuberculosis - TB Tuberculosis, or TB, is a disease caused by a germ (called the tubercle bacterium or Mycobacterium tuberculosis). TB usually affects the lungs, but can affect other parts of the body, such as the lymph nodes (glands), the bones and (rarely) the brain. Infection with the TB germ may not develop into TB disease. This disease used to be common in England and Wales. For example, in the mid-1930s, over 50,000 cases of TB were notified each year. These days it is much less common. Around eight thousand people develop TB in England and Wales each year. TB is curable with a full course of treatment. What are the symptoms? TB disease develops slowly in the body, and it usually takes several months for symptoms to appear. Any of the following symptoms may suggest TB: Fever and night sweats Persistent cough Losing weight Blood in your sputum (phlegm or spit) at any time If you are concerned that you might have TB because you develop any of these symptoms, visit your family doctor for advice. How do you catch it? The TB germ is usually spread in the air. It is caught from another person who has TB of the lungs. The germ gets into the air when that person coughs or sneezes. But only some people with TB in the lungs are infectious to other people. Such cases are called 'sputum smear positive' (or "open"). Even then, you need close and prolonged contact with them to be at risk of being infected. Sputum smear positive cases stop being infectious after a couple of weeks of treatment. Mycobacterium bovis from contaminated milk was once common in the UK prior to pasteurisation of milk (older people may remember this as a route of transmission). Pasteurisation of milk removes this risk from milk. Can anyone get it? Anyone can get TB. But it is difficult to catch. You are most at risk if someone living in the same house as you catches the disease, or a close friend has the disease. The following people have a greater chance of becoming ill with TB if exposed to it: Those in very close contact with infectious people Page 39 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Children Elderly people Diabetics People on steroids People on other drugs affecting the body's defence system People who are HIV-positive People in overcrowded, poor housing People who are dependent on drugs or alcohol People with chronic poor health How is TB treated? For many years now, we have had good treatment for TB. You have to take the treatment (usually tablets) for around six months. But it is worth it. Without treatment, many people used to die of this disease. How important is treatment? Treatment is vital. If you have TB disease, or if you have been infected with the germ but have not yet become unwell, you must take the treatment as directed. It is very important to complete the full course of treatment, as it will stop you being infectious, and it will remove the risk of you developing drug-resistant TB. We must not forget that TB used to kill many people before we had modern treatments. What should I do if I think I might have TB? Visit your family doctor for advice. He or she may then refer you to a chest clinic for some simple tests. If you don't have a family doctor, visit your local casualty (A&E) department. They will refer you to a specialist in TB if they think you may have TB. But you should register with a family doctor as soon as possible. What if I have been in contact with someone with TB? Discuss this with your family doctor. Only close contacts are at risk of catching TB. You may be asked to make an appointment with your local chest clinic. Sometimes a TB nurse or chest diseases health visitor will contact you first (they will have a list of close contacts). The nurse will arrange a skin test and/or chest x-ray. This does not mean that you have TB, but it is a chance to check for any symptoms, so it is very important that you do attend, if asked. Can TB be prevented? Yes it can. Most important is early detection, especially of infectious cases, and complete treatment. Early case detection reduces onward transmission of the disease and a full course of treatment is vital to prevent the disease relapsing, to prevent the development of drug-resistant strains of TB, to prevent prolonged infectiousness and preventable death. Identifying cases who have been infected through screening contacts and offering preventive treatment to reduce the risk of infected persons developing TB also contributes Page 40 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE to preventing TB. In hospitals and institutional settings infection control measures to identify and isolate infectious cases is important. In some high-risk groups and especially among infants and young children at risk of exposure to TB, BCG vaccination can offer some protection against TB but overall, BCG vaccination plays a limited role in TB control. What is the BCG vaccination programme? The BCG immunisation increases a person's immunity to TB and protects against the most severe forms of disease such as TB meningitis. The schools' programme nationally has been replaced by targeted immunisation of children at increased risk of TB. The main recommendations for routine BCG vaccination of children are now: infants (aged 0 to 12 months) living in areas with a high incidence of TB (40/100,000 or greater), and any children with a parent or grandparent born in a high incidence country. Local arrangements exist to opportunistically identify, test and immunise those children at increased risk of TB who will no longer be offered BCG immunisation through the schools' program. What is the difference between TB disease and TB infection? In most people who breathe in TB bacteria and become infected, the body is able to fight the bacteria to stop them from growing. The bacteria become inactive, but they remain alive in the body and can become active later. This is called TB infection. People with TB infection: Have no symptoms Don't feel sick Can't spread TB to others Usually have a positive skin test reaction Can develop TB disease later in life Most people who have TB infection will never develop TB disease. In these people, the TB bacteria remain inactive for a lifetime without causing disease. But in other people (for example, those who have weak immune systems), the bacteria may become active and cause TB disease. What is extensively drug resistant TB (XDR-TB)? Multi-drug resistant (MDR) TB describes strains of TB that are resistant to at least isoniazid and rifampicin, two of the first line drugs used in the treatment of TB. Extensively drug resistant TB (XDR-TB) refers to MDR-TB that is also resistant to any of a group of drugs called fluoroquinolones and at least one of three injectable second line anti-TB drugs (capreomycin, kanamycin or amikacin). This revised definition of XDR-TB was agreed by the World Health Organization (WHO) Global Task Force on XDR-TB in October 2006. In the UK in 2005, only 1.1% of all TB isolates were classed as MDR, only a very small proportion of which may now be classed as XDR-TB using the new definition. In 2012 there were 8,751 cases of TB in England, of which 1085 were in the West Midlands. This is an increase from 18 cases for every 100,000 population in 2011 to 19.3 in 2012 in West Midlands. The TB rates in West Midlands are higher than the national average. Information obtained from the PHE, WHO and NHS Choices January, 2016. Page 41 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Appendix Twelve - P.V.L. Staphylococcus aureus Panton-Valentine Leukocidin (PVL) is a toxic substance produced by some strains of Staphylococcus aureus which is associated with an increased ability to cause disease. The incidence of PVL related disease in the UK is low at present but it is important that healthcare professionals and the public are aware of the infections it can cause and precautions which should be taken. PVL can be produced by both meticillin sensitive and meticillin resistant strains of Staph aureus. Most of the PVL positive Staph aureus strains identified in the UK are sensitive to many antibiotics. How common is PVL S. aureus? The PVL toxin is carried by less than 2% of S. aureus and can be carried by both MRSA (meticillin resistant Staphylococcus aureus) and MSSA (meticillin sensitive Staphylococcus aureus ). During 2005 and 2006, a total of 720 cases of PVL-SA were identified from isolates referred to the HPA (PHE) Staphylococcus Reference Unit for testing and characterization. Of these, 224 were in 2005 and 496 in 2006, representing a two-fold increase, possibly the result of increased awareness and reporting. Provisional data for 2007 show 1361 PVL-SA were identified, representing a 2.7-fold increase over the 2006 figures. Of the 1361, 845 (62%) were PVL-MSSA and 516 (38%) were PVL-MRSA. We are aware of isolated cases and clusters of disease, occurring predominantly in the community across the United Kingdom (UK). Microbiology laboratories across the UK are vigilant and have been requested to send any suspicious samples to the PHE for further analysis. What are the symptoms? Infections caused by PVL strains of S. aureus normally cause cellulitis (inflammation of layers under the skin) and pus-producing skin infections (eg abscesses, boils and carbuncles). They can, however, on very rare occasions, lead to more severe invasive infections, such as septic arthritis, bacteraemia (blood poisoning) or necrotising pneumonia (a severe, life-threatening form of pneumonia). Why do people get PVL S. aureus infections? Not all patients with PVL S. aureus will suffer an infection. When these occur they are usually associated with the presence of other risk factors such as overcrowding, skin abrasions resulting from close contact sports such as wrestling or rugby, or using contaminated articles such as sharing towels, razors, poor hand hygiene and damaged skin from other conditions such as eczema. What should people do to protect themselves? The risk to the general public of becoming infected with PVL S. aureus is small but it is always good practice to maintain appropriate hygiene measures which include proper cleansing and disinfection of cuts and minor wounds. Wounds should be covered with a Page 42 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE bandage until healed and individuals should avoid contact with other peoples' bandages and lesions. If the infection spreads or recurs go to your GP or Accident and Emergency for further investigation and/or treatment. Such spreading infection should not be ignored. Other simple measures are regular bathing/showering, regular changing of linen and underwear, hand washing, avoiding sharing personal items (eg toothbrushes, face cloths, towels) and keeping wounds covered. Chances of contracting all types of S. aureus infections are reduced by maintaining good hand hygiene and not sharing personal items. In shared facilities (for instance, in gyms) it is good practice to use liquid soap and disposable towels, to place a towel on the bench before sitting, and to ensure the facilities are cleaned frequently and that there is good ventilation to the locker room and showers. Information obtained from the PHE, WHO and NHS Choices January, 2016. Page 43 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Appendix Thirteen - Meningitis Meningitis is the inflammation of the linings of the brain and spinal cord, septicaemia is the blood poisoning form of the disease – these two conditions have different sets of symptoms and may occur separately or together. Additionally they may be caused by a variety of different organisms, including bacteria, viruses and fungi. When caused by meningococcal bacteria it is known as meningococcal disease. Meningococcal meningitis and Meningococcal septicaemia (Bacterial Meningitis) Meningococcal meningitis and Meningococcal septicaemia are systemic infections caused by the bacteria Neisseria meningitidis. Humans are the only known reservoir for these bacteria. It is commonly found in the back of the throat or nose and only occasionally causes disease, it is said that 10% of the population will carry Neisseria meningitidis, with the highest carriage (around 25%) in 15-19 year olds - It is not known why some people develop the disease while others are carriers only. The infection is not easily spread, it is transmitted from person to person by inhaling respiratory secretions from the mouth and throat or by direct contact (kissing or mouth to mouth). Close prolonged contact is usually required to transmit the bacteria. They do not live long outside the body. Early signs and symptoms of meningococcal disease may be non-specific and therefore difficult to distinguish from influenza or other diseases. Early symptoms include fever, vomiting, malaise and lethargy. Someone with the disease will become very ill, though not all the symptoms will occur at once, in children and adults symptoms can include: Sudden onset of a high fever A severe headache Dislike of bright lights (photophobia) Vomiting Painful joints Fitting Drowsiness that can deteriorate into a coma Symptoms are harder to identify in babies but include: A fever while the hands and feet are cold High pitched moaning or whimpering Blank staring, inactivity, hard to wake up Poor feeding Neck retraction with arching of the back Pale and blotchy complexion Septicaemia occurs if the bacteria enter the bloodstream – a characteristic rash develops and may start as a cluster of pinprick blood spots under the skin, spreading to form bruises. The rash can appear anywhere on the body. It can be Page 44 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE distinguished from other rashes by the fact that is does not fade when pressed under the bottom of a glass – (the tumbler test) Symptoms can develop within hours If the disease is diagnosed early and treated promptly most people make a full recovery however, about 1 in 8 people who recover experience some long term effects, which can include headaches, stiffness in the joints, epileptic fits, deafness and learning difficulties. Antibiotics are used to treat meningococcal disease. The earlier the treatment, the better the prospect of recovery. Very close contacts of people with Bacterial Meningitis will sometimes be given prophylactic antibiotics. This is done on a risk assessment basis. Chemoprophylaxis is only recommended for those whose mouth or nose is directly exposed to large particle droplets/secretions from the respiratory tract of a probable or confirmed case of meningococcal disease during acute illness until the patient has completed 24 hours of antibiotics. This type of exposure will only occur among staff who are working in close proximity to the face of the patient without wearing a face mask – performing for example airway management such as suction, intubation, inserting an airway, and can occur if the patient coughs or sneezes in your face. General medical or nursing care of cases is not an indication for prophylactic treatment. The recommended prophylaxis is one stat dose of Ciprofloxacin 500mg or Rifampicin 600mg orally twice daily for 2 days. Viral Meningitis Viral meningitis is caused by a range of different viruses and is milder than the meningitis caused by bacteria. These viruses are common in the community and usually cause mild respiratory infections but can occasionally cause a person to develop meningitis. The viruses that can cause meningitis are passed from person to person by coughing and sneezing and by contaminated hands that have not been washed (catch it, bin it, kill it then sanitise your hands) The symptoms are: Headache Neck stiffness Photophobia Fever Vomiting Diarrhoea Aching joints and muscle pain Page 45 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE In the early stages there is very little to distinguish viral meningitis from other common viral infections such as flu-like illnesses. The treatment for Viral Meningitis is pain-killers and lots of rest. Occasionally in more severe cases when people are admitted to hospital, anti-viral drugs may be given. Sometimes people with viral meningitis may be given a course of antibiotics while waiting for a confirmed diagnosis, just in case they have meningococcal disease (caused by bacteria). Antibiotics do not have any effect on viral infections. Contacts of people with viral meningitis are NOT usually at any increased risk of developing the illness themselves. This applies to the closest contact, including family and household members and healthcare workers. There is no need for the contacts of a person with VIRAL meningitis to be given antibiotics as these are not effective against viruses. There is no need for contacts to be excluded from school or work. Personal Protective Equipment for any type of meningitis is the same as for any respiratory spread disease: Face mask if in close proximity or aerosol producing procedure taking place – surgical with visor will normally suffice, though an FFP3 mask with goggles can be worn if there is any suspicion of one of the Severe Acute Respiratory diseases Gloves – changed on a regular basis and relevant hand hygiene using hand gel and wipes Apron if there is a risk of body fluid splash All PPE used must be disposed of as clinical waste. Information obtained from the PHE, WHO and NHS Choices June, 2016. Page 46 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Appendix Fourteen - Viral Haemorrhagic Diseases Viral haemorrhagic fevers are a group of illnesses that are caused by several distinct families of viruses: arenaviruses, filoviruses, bunyaviruses and flaviviruses. Some of these cause relatively mild illnesses, whilst others can cause severe, life-threatening disease. Examples of these viruses and the diseases they cause are shown in the table below. Table: Haemorrhagic fever viruses and the diseases they cause Family Virus Arenaviruses Lassa virus Junin virus Machupo virus Sabia virus Guanarito virus Lujo virus Filovirus Bunyavirus Flavivirus Ebola virus Marburg virus Disease Lassa fever Argentinian haemorrhagic fever Bolivian haemorrhagic fever Brazilian haemorrhagic fever Venezuelan haemorrhagic fever Caused an outbreak in South Africa, ex-Zambia in 2008 These two viruses cause the most severe forms of haemorrhagic fever Crimean-Congo Crimean-Congo haemorrhagic fever haemorrhagic fever virus Haemorrhagic fever with renal syndrome, Hanta virus Hantavirus pulmonary syndrome Rift Valley fever virus Rift Valley fever Yellow fever virus Dengue virus Yellow fever Dengue and dengue haemorrhagic fever Where are viral haemorrhagic fevers found? Because the viruses depend on their animal hosts for survival, they are usually restricted to the geographical area inhabited by those animals. The viruses are endemic in areas of Africa, South America and Asia. Human cases or outbreaks of viral haemorrhagic fever occur sporadically and irregularly, and cannot easily be predicted. Recent outbreaks of Ebola infection have occurred in Western Africa. Occasionally, humans may acquire infection from animal hosts that have been exported from their native habitats, as occurred when laboratory workers in Germany handled imported monkeys infected with Marburg virus. Environmental conditions in England and Wales do not support the natural reservoirs of infection. How do you catch viral haemorrhagic fever? Humans are not the natural host for these viruses which normally live in wild animals. Rodents are the main reservoirs of haemorrhagic fever viruses - examples include the multimammate rat, cotton rat and house mouse. Humans may acquire infection when they come into close contact with animal hosts, their carcasses during slaughtering, or their droppings. Some of the viruses, such as yellow and Crimean-Congo fever are transmitted Page 47 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE between animal species, including humans, by the bites of tick or mosquito vectors. For some of the viruses, for example Ebola, the animal host is not known, but contact with monkeys has been implicated in some cases of infection. Lassa, Ebola, Marburg and Crimean-Congo viruses can be transmitted from person-to-person through close contact with symptomatic patients or contaminated body fluids. How long can you have the infection before developing symptoms? This varies according to the type of virus, but is rarely longer than 21 days. If symptoms occur more than 21 days after contact with a potential source of infection, then they are unlikely to be due to viral haemorrhagic fever. What are the symptoms of viral haemorrhagic fever? Symptoms also vary according to the type of virus, but initial symptoms generally include fever, fatigue, dizziness, muscle aches and weakness. Patients with severe disease may show signs of bleeding under the skin, from body orifices like the mouth, eyes and ears, or into internal organs. Severely ill patients may also show signs of shock, kidney failure and nervous system malfunction including coma, delirium and seizures. How can VHF be treated? Some viral haemorrhagic fevers can be treated with anti-viral drugs, however other infections can only be managed supportively. How can VHF be prevented or treated? A vaccine is available to protect against yellow fever, and is recommended for travellers to endemic areas. No vaccines are available against other types of haemorrhagic fever viruses. Therefore, prevention measures concentrate on avoiding contact with host species. Because many of the hosts that carry haemorrhagic fever viruses are rodents, disease prevention efforts include controlling rodent populations and keeping rodents away from homes and workplaces. For haemorrhagic fever viruses spread by vectors, prevention measures also include controlling the population of ticks and mosquitoes, and preventing bites by using screens, wearing proper clothing and using repellent spray. For haemorrhagic fever viruses that can be transmitted from person-to-person, great care needs to be taken when nursing patients, including isolation and the wearing of gloves, gowns and masks, in order to prevent the spread of infection. There have been several documented instances when health care staff contracted Ebola and Marburg viruses from infected patients. Does viral haemorrhagic fever occur in the UK? Environmental conditions in England and Wales do not support the natural reservoirs of infection, thus cases do not occur here, except as an imported disease. Such imported cases in travellers returning from endemic areas are rare: for instance, there were 2 cases of Lassa Fever imported in to the UK in 2009, one from Nigeria and one form Mali, which is 12 cases since 1971. In 2015, 2 cases of Ebola affecting aid workers dealing with the Page 48 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE large West African outbreak in Sierra Leone were treated in the UK, one developed the disease on return to this country, the other person was flown back known to have the disease. The main person to person spread of Ebola is said to be caused by direct contact with blood and body fluids entering none intact skin or mucous membranes. Incubation between contact and symptoms is 2 to 21 days. Symptoms of Ebola are that of a severe acute viral illness often characterised by the sudden onset of fever, intense weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhoea, rash, impaired kidney and liver function, and in some cases internal and external bleeding. People are infectious as long as their blood and secretions carry the virus. Ebola virus was isolated from semen 61 days after onset of illness in a laboratory worker in 1976, very little was known about the disease until the outbreak in Guinea, Sierra Leone and Liberia in 2014/15. Following this outbreak, there has been reoccurrence of the virus in patients who have survived the disease, as it appears to be able to lie dormant. The use of strict IPC precautions, hand hygiene and full PPE is required for any SUSPECTED cases – confirmed cases will be transported using special Category Four Procedures (see Appendix 15 Confirmed Case Transport/transfer) The Table below is a list of the Viral Haemhorragic Fevers with transmission routes:Virus Disease Geographical distribution Transmission routes/vectors Further information West and Central Africa Contact with excreta, or materials contaminated with excreta, of infected multimammate rat (Mastomys spp). ARENAVIRIDAE Old World arena viruses Lassa Lassa fever In particular: Guinea, Liberia, Sierra Leone, Nigeria Lujo Unnamed Also consider: Central African Republic, Mali, Senegal, Burkina Faso, Cote D’Ivoire, Ghana, Gabon, Uganda Inhalation of aerosols of excreta of multimammate rat. Southern Africa Transmission to the index case unknown. One outbreak to date (5 cases) in South Africa, ex-Zambia Public Health England website A to Z of diseases Contact with blood or body fluids from infected patients, or sexual contact. Direct contact with infected patient, blood or body fluids. First identified in October 2008 following a nosocomial outbreak in South Africa involving five people, four of whom died. New World arena viruses (Tacaribe complex) Chapare Unnamed Bolivia One outbreak to date in Cochabamba, Bolivia Page 49 of 131 Direct contact (e.g. bite) with infected rat or mouse. See Public Health England website WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Guanarito Junín Machupo Venezuelan haemorrhagic fever Argentine haemorrhagic fever Central Venezuela Bolivian haemorrhagic fever North eastern Bolivia Argentina Pampas region Beni department Direct contact with excreta of infected rat or mouse. Contact with materials (e.g. food) contaminated with excreta from infected rat or mouse. Inhalation of aerosols of excreta (often in dust) of rat or mouse. Machupo and Guanarito Sabiá Brazilian haemorrhagic fever Brazil only: One case to date Contact with blood or body fluids from infected patients. Crimean Congo haemorrhagic fever Central and Eastern Europe, Central Asia, the Middle East, East and West Africa. Bite of an infected tick (most commonly Hyalomma ticks). BUNYAVIRIDAE Nairoviruses Crimean Congo haemorrhagic fever Recent outbreaks in Russia, Turkey, Iran, Kazakhstan, Mauritania, Kosovo, Albania, Pakistan and South Africa Virus See Public Health England website Contact with infected patients, their blood or body fluids. Contact with blood or tissues from infected livestock Disease Geographical distribution Transmission routes/vectors Further information Ebola haemorrhagic fever Western, Central and Eastern Africa Transmission to the index case probably via contact with infected animals. See Public Health England website Outbreaks have occurred in the Democratic Republic of the Congo, Sudan, Uganda, Gabon, Republic of Congo and Côte D’Ivoire Contact with infected blood or body fluids. Fever, headache, joint and muscle aches, weakness, diarrhea, vomiting, stomach pain, lack of appetite. FILOVIRIDAE Ebola - Ebola Zaïre - Ebola Côte d’Ivoire Ebola Sudan - Ebola Bundibu gyo - Ebola Reston and Siena Marburg Some patients may experience: A rash, red eyes, hiccups, cough, sore throat, chest pain, difficulty breathing, difficulty swallowing bleeding inside and outside of the body Symptoms can occur from 2 - 21 days from contact, though most common is 8 – 10 days Marburg haemorrhagic fever Central and Eastern Africa Outbreaks have occurred in Angola, the Democratic Republic of Congo, Kenya, Uganda and South Africa exZimbabwe Page 50 of 131 Symptoms typically include: Transmission to the index case probably via contact with infected animals (?fruit bats). Contact with infected blood or body fluids. See Public Health England website Symptoms are very similar to those listed above in Ebola with Jaundice, delirium, shock, liver failure and inflammation of the pancreas WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE FLAVIVIRIDAE Kyasanur forest disease Kyasanur forest disease India Western districts of Karnataka state Bite of an infected tick, most commonly Haemaphysalis spinigera. Contact with an infected animal, most commonly monkeys or rodents. Alkhurma (Al Khumrah) haemorrhagic fever Alkhurma haemorrhagic fever Omsk haemorrhagic fever Omsk haemorrhagic fever Saudi Arabia Makkah (Mecca), Jeddah, Jizan, Najran regions Russian Federation Novosibirsk region of Siberia Contact with an infected animal (sheep, camels). Bite of an infected tick or mosquito (principal vector species not yet identified). Bite of an infected tick, most commonly Dermacentor reticulatus. Person-to-person Common in young adults exposed in the forests of western Karnataka – approximately 100-500 cases per year. Case fatality rate is estimated at 2-10%. Cases have been reported outside Saudi Arabia, but have had contact with animals that likely originated in Saudi Arabia e.g. case in an Italian tourist in 2010 who visited a camel market in southern Egypt. Virus circulates in muskrats, and other animals, in the forest Steppe regions of Russia. Infection most common in farmers and their families. To transport any patient with symptoms of any of the Viral Haemhorragic Fevers, the process in Appendix Fifteen MUST be followed. (Information from the US Centers for Disease Control and Prevention CDC July 2015 Page 51 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Appendix Fifteen Category Four Diseases – Transport of cases The definition of a category four infectious disease - Caused by an organism that causes severe human disease, which presents a serious hazard to laboratory workers and may present a high risk of spread in the Community, there is usually no effective prophylaxis or treatment available. HAZARD GROUP 4 BIOLOGICAL AGENTS:Hazard Group 4 Biological agents as defined by the ACDP (Advisory Committee on Dangerous Pathogens) - Health and Safety Executive. Biological agents: Managing the risks in laboratories and healthcare premises; 2005 Lassa Fever Kyasanur Forest Disease Guanarito Haemorrhagic Fever Omsk Haemorrhagic Fever Argentinean Haemorrhagic Fever (Junin) Russian Spring Summer Encephalitis Bolivian Haemorrhagic Fever (Machupo) Nipah Brazilian Haemhorrhagic Fever (Sabia) Hendra Crimean/Congo Haemhorrhagic Fever Smallpox Ebola Herpesvirus simiae infection (B virus) Marburg Many of the Category Four diseases are Viral Haemhorrhagic Fevers (VHF) (see Appendix Fourteen) - these are normally restricted to the geographical area where their animal hosts live, as they depend on these for their survival – however with the large amount of foreign travel and ease of moving from one side of the world to the other, it is now very possible for someone to arrive in the UK who either already has or is incubating one of these infections. The incubation for these is said to be up to 21 days – so anyone who presents with severe symptoms that could be a VHF who has history of travel to one of the ‘at risk’ countries within the last 21 days, must be treated as SUSPECTED infectious Category Four disease with strict procedures adhered to for the safety of staff and all contacts until proved otherwise by a blood test and advice from Public Health England. Other Category Four diseases are:Small Pox – This disease is believed to have been eradicated by use of vaccination There is still a small risk it could return, or be an action of deliberate release or accidental release in a laboratory. Symptoms are acute onset of fever >38.3 degrees centigrade, followed by a rash characterized by firm, deep seated vesicles or pustules in the same stage of development with no other apparent cause. Page 52 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Hendra and Nipah Virus - These disease’s were identified in horses and people in these areas in Australia – the symptoms are respiratory illness with severe flu like signs and symptoms, in some cases this progresses to encephalitis Yellow Fever – The majority of people infected with Yellow Fever have no illness or only mild illness, initial symptoms include sudden fever, chills, severe head ache, back pain, general body aches, nausea, vomiting, fatigue and weakness, most people improve after the first initial presentation, then after a brief remission of hours to a day, roughly 15% of cases progress to a more severe form of the disease characterised by high fever, jaundice, bleeding, and eventually shock and failure of multiple organs. Rabies – This affects the central nervous system, ultimately causing disease in the brain and death. The early symptoms are similar to that of many other illnesses including fever, headache, and general weakness or discomfort. As the disease progresses, more specific symptoms appear and may include insomnia, anxiety, confusion, slight or partial paralysis, excitation, hallucinations, agitation hypersalivation, difficulty swallowing and hydrophobia. Death usually occurs within days of the onset of symptoms. Plague – This has been removed from the category four list as it is very curable with antibiotics – it is caused by the Yersinia pestis bacteria. It can however cause severe illness and death if not promptly treated, and outbreaks still occur Western United States, Africa and Asia. Main risk for the Ambulance Service regarding V.H.F.’s or the other category four diseases is that a person who has just returned from one of the High Risk countries could ring 999 – with no mention of a category four disease. Staff must be aware that any patient who presents with the following could be a possible case of V.H.F. or Imported Infectious Disease:High fever >37.5 degrees C with at least one of the following: Recent history of travel to a high risk country – within last 21 days Contact with a known or SUSPECTED case within the last 21 days Contact with samples from a SUSPECTED or known case within the last 21 days The following may or may not be present at the time for VHF: Severe symptoms of viral disease – muscle aches and pains, sore throat Bruising or bleeding – (contact EOC to call Public Health on Call) In the early stages of these diseases, they are said to pose a much lower risk of spread, as the patient is not usually losing blood or body fluid at this stage. Scrupulous hand hygiene must be adhered to (as normal standard procedures), with a minimum of gloves, apron and face masks considered and risk assessed regarding the need for further PPE. This case must be followed by cleaning of all patient touch items and change of all linen and clean of stretcher using the double clean of detergent in the first instance, followed by Chlorclean to disinfect. Suspected cases could also be booked from Doctors Surgeries and home addresses. For these, specific advice will be required as to the severity of the patient’s condition. General Page 53 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE advice is that if the patient is very low risk and has not got bruising, bleeding, vomiting or diarrhoea then they can be carried on a normal Ambulance with crew wearing level one PPE which is Apron, Gloves and surgical face mask with safety spectacles or with visor – FFP3 and eye protection must be worn for aerosol generating procedures, if the risk is higher, but no loss of blood or body fluid, level two PPE should be worn, if the patient has any loss of blood or body fluid, this immediately makes the patient a Level three risk patient, which are transported by HART in a specially prepared vehicle. The following is recommended for Low risk symptoms of VHF eg. Ebola:LEVEL ONE – LOW Risk - Infection control measures for Suspicion of/Possibility of VHF Patients Symptoms Staff protection Fever >37.5°C Standard Precautions: AND Hand hygiene History of travel to high risk country within last 21 days Gloves Plastic apron The following may or may not be present: Mild viral infection symptoms – sore throat, joint and muscle aches and pains, weakness, chest pain, rash, red eye hiccups, difficulty breathing and/or swallowing Symptoms not known to be associated with any other illness No Bleeding or Bruising NB. Any bleeding, vomiting or diarrhea will require special precautions regarding extra PPE and HART transport in specially prepared vehicle Consider wearing mask for any aerosol generating procedure Fluid repellent surgical mask with safety spectacles Fluid repellent surgical mask with visor is available in the level 2 PPE pack All of the items required for Level One PPE can be found in the red pouch in the vehicle response bag. Action Cards 1a, b, c, d and e refer to the process to follow for this category of patient Page 54 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE The following is recommended for High Risk of VHF eg. Ebola:LEVEL TWO – High Risk - Infection control measures for High Possibility of VHF Patient’s symptoms Staff protection Fever >37.5c Hand hygiene AND Gloves History of travel to high risk country Fluid repellent white Tyvek overall Plastic apron Contact with known case/s or samples from known case/s The following may or may not be present: Viral infection symptoms - sore throat, joint and muscle aches and pains, weakness, chest pain, rash, red eye hiccups, difficulty breathing and/or swallowing NO Loss of Blood or Body Fluid FFP3 Mask with safety spectacles for any close contact or aerosol generating procedure – or Fluid repellent surgical facemask with visor. A mask with visor can be worn over the top of an FFP3 to protect eyes Shoe or boot covers and sleeve protectors ANY bleeding, vomiting or diarrhoea in the community In addition, for use of any sharp: must be reported to EOC before moving, as special Double glove – extra care precautions have to be taken, with specialist PPE from taken to dispose of the either ASO or NILO car pack, and HART involvement in sharp – ensure sharps box the patient movement as this move the patient in to a is closed following disposal LEVEL THREE of sharp All of the PPE required for a Level Two High Risk patient is in the vehicle based PPE pack Action Cards 2a, b, c, d and e refer to the process to follow for this category of patient Page 55 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE If the suspected patient has symptoms of any bleeding, vomiting and/or diarrhoea in the Community, Control will have to be contacted immediately, the Regional Command Centre will co-ordinate response, and will immediately contact the Infectious Disease Consultant on call at Heartlands Hospital on 0121 424 2000 and Public Health England as this case may have to be treated as Very High Risk awaiting Confirmation of VHF which requires extra P.P.E. and specialist transport arrangements involving the HART team. Any member of staff who believes they have identified a patient with very high risk symptoms in the community must withdraw to put on the highest level PPE that is available at that time to treat the patient and contact EOC, who will respond the nearest officer with a Specialist PPE pack and the HART team. Action Card Three refers to the process to follow for Very High risk/Confirmed patients The following is recommended for Very High Risk/Confirmed VHF eg. Ebola LEVEL THREE – VERY HIGH Risk - Infection control measures for Confirmed/VERY High Possibility of VHF Patient’s symptoms Staff protection Hand hygiene Fever >37.5c Double glove – Nitrile and heavy duty AND HART/NARU Overall History of travel to high risk country or contact with known case/s or samples from known case/s Plastic apron May be confirmed or very high risk awaiting confirmation – the following may be present:- FFP3 Mask Face Shield Water repellent knee length boot covers or Wellington boots o Crew of 3 – Driver does not come in to contact with the patient, plus rest of team to escort to decon o Escorting officer required o Follow Action Cards Three a, b, c, d and e o All items of relevant equipment must be sealed inside plastic bags – including the Airwave Radio Severe viral infection symptoms Vomiting, diarrhoea, bruising, bleeding – this could be uncontrollable Confirmed packs are held in 25 locations – a list of these is held in the Regional Command Centre (RCC). Action Card Three a, b, c, d and e refers to the process to follow for any patients who come in to the category of Very High Risk/Confirmed – either in the community or as a hospital transfer. Page 56 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE The HART base has designated VHF cages which contain the items in Action 3a for Vehicle Preparation, and items required in Action cards 3b, 3c, and 3d to perform and complete the case. Transfers could be from hospitals in the Region to the High Security Infectious Disease Unit (HSIDU) - currently there is only one in the UK – The Royal Free Hospital in London. Newcastle HSIDU is currently under construction (January 2016). There are other units that can accept Very High Risk/Confirmed patients in Manchester, Liverpool, Sheffield and Newcastle – the addresses of these hospitals will be given to the crew transporting the patient, as this will have been arranged by the transferring hospital. The HART team of 6 is required to do the confirmed/very high risk transfers, 3 in the patient transporting vehicle (1 driver not in PPE plus 2 in PPE in back with patient), the other 3 in the crew will follow in the vehicle containing spare kit and decontamination items. An Officer is also required to escort. EOC and NHS111 The 111, 999 and ambulance bookings systems have questions incorporated in to the pathways system to ensure that as many suspected cases are flagged as possible and the process for reporting, informing and crew risk assessment is followed for every possible case. There is always the possibility that a case may not be identified on a call, for instance due to language difficulties, so all staff must be aware that any patient with suspicious symptoms must be asked regarding their foreign travel when the crew or RRV arrive, a call to the Clinical Support Desk (CSD) to confirm whether the country the patient has visited is a high risk for any infection is required. Calls that are identified as a risk will be forwarded to the CSD who will ask extra questions regarding contact and travel to high risk areas, as per the flow carts in Annex I. If a case is suspected, this will then be passed to the Regional Command Centre, where it will be managed directly by the Trauma desk through to closure. EOC flow charts follow in this document, with the Action Cards 9 to 11 in Annex 4. Actions on Arrival at Scene following 999 call:As soon as there is a suspicion of a V.H.F. 1. Contact CSD to confirm whether the country that the patient has travelled to has any known infection risks (CSD can look on www.promedmail.org for up to date information on infectious diseases) advice can then be given regarding the level of PPE required 2. If risk is confirmed, inform EOC and ask for further support from the on call Area Support Officer or National Interagency Liaison Officer (NILO) 3. Don the relevant P.P.E. explaining to the patient and the family that there is no need to be alarmed, however your procedures state these items have to be worn just in case there is an infection present Page 57 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE 4. Follow the process in the relevant Action Cards for vehicle preparation and PPE use. 5. Make patient safe, and comfortable on the vehicle if they are going to be transported on this vehicle – ensure it is safe to carry the patient on your vehicle - if the patient is losing any blood or body fluid, this moves the patient in to a Level Three risk, so they should not be transported on a normal ambulance without special preparation and actions taken. 6. RCC will call the local Accident and Emergency unit to ensure they are able to accept the patient as per National Guidelines regarding every A&E to accept the high risk patients in an isolation cubicle 7. If patient requires Cannulation, ensure the sharps box is in close proximity, double glove for the insertion, be exceptionally careful with the used sharp, dispose of in the sharps box immediately, shut the lid securely and ensure the entire container is disposed of after the case, with the box marked as ‘Infectious – for Incineration’ 8. For any personal contact with blood or body fluids, ensure the area is washed immediately, utilising soap and water if available or saline solution, also any contact with mucous membranes must be washed out with a copious amount of saline – referral to the receiving hospital immediately and to Occupational Health. 9. For any blood or body fluid spillage, use the ‘spill pack’ on the vehicle to make the spill safe. 10. If there is any blood or body fluid in the community – inside or outside the address, inform Police, so that the area can be quarantined until PHE have been contacted to arrange to send a cleaning and decontamination team. 11. When ready to leave scene, driver remove PPE outside vehicle, roll up the PPE and place in a Clinical waste bag, seal the bag, then this must be left in the back of the vehicle – Driver use own individual hand sanitiser, once rear ambulance doors are closed. NB. Do not drive in PPE. An alternative to this, is for any available extra person to drive the vehicle, then both members of staff wearing PPE can travel in the back with the patient. 12. If On Call officer has arrived, they can remove any equipment from the vehicle that is not required for the case, and take charge of any staff belongings and bags, these can be placed securely in the Officers vehicle. They will escort the crew to the relevant hospital – no contact with the patient is necessary for the on call officer unless they are the only Paramedic on scene, then they may need to change place’s with the attendant depending on the patient’s condition, care must be taken NOT to contaminate the Officers car. 13. On arrival at hospital, the driver (or escorting on call officer) will need to go into the receiving department to announce their arrival, and obtain details of the isolation room for the patient. 14. Driver if still part of the ‘crew’ must don further relevant clean P.P.E. obtained from either the escorting officer or the hospital staff Page 58 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE 15. Once patient is handed over, remove all used linen – leave with patient, or ask advice regarding whether to place in the hospital ‘contaminated laundry bag’ or a red incinerator bag. 16. Ensure all clinical waste produced on the case is left with the receiving hospital 17. Ensure the vehicle is secured as soon as the patient is taken out of the ambulance, to prevent anyone entering a possible infectious vehicle. 18. Remove P.P.E. very carefully following Action Card 1c, 2c or 3c depending on the level of risk Remember the Importance of Hand Hygiene throughout the process of removing PPE, and when it has all been removed. 19. Wear clean PPE to wipe the stretcher and any patient touch areas in the vehicle, and any equipment used using the vehicle based wipes – or Chlorclean depending on level of risk – the crew clean is to make the vehicle safe for return to base 20. Mop the vehicle out using disposable mop with Chlorclean. NB. Any body fluid spills must be cleaned using Haztabs at 10,000ppm chlorine and a ‘spill pack’ 21. Ensure Logistics desk are aware vehicle is being taken back to the Hub for a clean, so they can inform the relevant AFA team 22. The vehicle once safe to drive can be taken to the Hub for an AFA clean – Follow AFA instructions regarding where to park – there should be a designated place ready for the vehicle – and AFA will give crew a ‘quarantine’ notice to place the in the windscreen where it can be seen. 23. Ensure the AFAs are aware they will have to wear relevant PPE to perform the clean and follow action cards 1d, 2d or 3d whichever is the level of risk 24. Crew can change uniform and shower if necessary – if full decontamination is required, some hospitals have this facility, if not, the HART team can be contacted to perform this. NB. Full PPE is very warm to wear, so a shower may be required due to this. 25. Contact Infection Prevention and Control and/or N.I.L.O. for any further advice For Doctors removal case:NB. Qualified Crew is required, not HCRT 1. EOC to obtain as much information as possible from the person booking the ambulance – call the GP if not enough information is given 2. EOC to respond the on-call National Interagency Liaison Officer (NILO) and/or Area Support Officer and relevantly informed crew 3. Liaise with GP regarding where the patient is going and full patients history 4. Follow all relevant steps from 2 to 25 above (full details in Action Cards). Page 59 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE For Hospital to Hospital Transfers:NB. Qualified Crew is required, not HCRT If a local hospital is unable to keep a patient with suspected or high possibility symptoms, a transfer could be booked to Heartlands Ward 28 – this has to be arranged by the transferring hospital. Heartlands is the Regional Infectious Disease Unit, so they would have to be contacted on the number below by the transferring hospital, to speak to the Infectious Disease Consultant on call. Instructions will be given regarding where to take the patient – this is usually directly to ward 28 – instructions for admissions to Heartlands are on Action Card 4, as the vehicle has to go to a barrier to wait for the hospital team to escort the patient up to the ward. If there are no High Risk symptoms (ie. no Bruising, Bleeding, Diarrhoea and Vomiting) the patient can be transported wearing PPE as described in either Level one or Level two - though Very high risk/Confirmed cases must be transported utilising the HART team members utilising the designated VHF Cages from the HART base and Level three. As these transfers should be ‘planned’, this gives time for any not required equipment to be removed from the vehicle as per Action Card 1a, 2a or 3a, if there is somewhere safe to leave the equipment – either with the escorting National Interagency Liaison Officer (NILO), Area Support Officer, left at base or another vehicle could be sent to collect the equipment. Address for Heartlands is:Bordersley Green East, Birmingham. B9 5SS Telephone number: 0121 424 2000 – ask for the On-Call Infectious Diseases Consultant or On Call Virologist Long distance transfers could also be arranged for any confirmed cases – these could be to any of the ‘surge’ hospitals, though the main one would be to the Royal Free Hospital in London. A full HART team of 6 staff and an escorting officer are required for these cases following action cards 3a, b, c, d and e. Due to the location of the ‘surge’ units, it may be necessary for crews from other areas to stop at pre-arranged premises within WMAS region, and also for WMAS HART crew to stop at premises in other areas. This will be to change the crew and vehicle due to the length of time in the PPE. List of these addresses is in Annex VII. Specialist P.P.E. packs are held around the region, these are ready to be deployed if required. They are at each main Hub – the AFA teams are responsible for the packs on Hubs with Make Ready, the Area Manager is responsible for the packs at Hubs without Make Ready. All of the NILOs (National Interagency Liaison Officers) also have packs, the HART team and IPC Lead. The content of these packs is in Annex II of this appendix. EOC Actions are in Annex I and Action Cards 10 to 14:- Page 60 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE 1. On receipt of a call where a GP or Member of the public states the patient has a possibility/suspected Viral haemorrhagic Fever/VHF/Ebola/Lassa/Imported Infectious disease/Rabies – the on-call NILO, ASO and Regional Command Centre must be informed in case there is a requirement for an escorting officer – the IPC Lead can also be contacted if necessary for advice and must be informed by e mail. 2. Trauma desk must be informed as soon as any Suspected case is received by 999, Doctors removal or transfer. 3. Duty Officer and Trauma desk to keep in contact with crew and Officer on scene. 4. Inform crew of the need to wear PPE as stated for the assessed risk 5. Contact local hospital to ask if they are able to accept the patient – if not, hospital Consultant MUST contact Heartlands hospital on 0121 424 2000 to see if they will accept the patient instead, however National Guidelines are for every A&E to accept patients in their own area. 6. If patient is a hospital to hospital transfer – Ascertain the patient’s condition, if this is a Very High Risk/Confirmed patient, these transfers must be done by the HART team as per Action card 3. If this is a low risk suspected case that a local hospital cannot accommodate so they are sending to Heartlands, then a normal vehicle and crew (wearing relevant level of PPE) can attend following full liaison with the transporting ward to ascertain there are no high risk symptoms. National Interagency Liaison Officer/Area Support Officer actions (Full details on Action Cards 1e, 2e and 3e in Annex IV):1. Contact crew, give your Estimated time of arrival either at scene or at the receiving hospital 2. Keep in contact with EOC via Trauma desk on 0121 307 9119 3. Ensure there is a copy of this procedure available for reference purposes 4. Ensure crew are wearing the correct PPE for the case 5. Ask if there is any possibility that member of crew is pregnant – if so, they should not be in contact with the patient. 6. Ensure safety of crew and patient at all times. 7. Ensure relevant Action Cards are followed 8. If there is time, remove unnecessary equipment from the transporting vehicle, and the crew belongings. 9. Liaise with Infection Prevention and Control Lead and complete the VHF Incidents Record – forward the information from the record to [email protected] and [email protected] Page 61 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE 10. Follow Action Cards 1e, 2e and 3e and relevant other action cards depending on circumstances. Vehicle Cleaning – Full details are on Action Cards 1d, 2d and 3d – A full Procedure is also available – Make Ready VHF Cleaning Procedure:1. Following crew quick clean to make vehicle safe, vehicle must go back to a Hub for a deep clean 2. The vehicle needs to be quarantined until the Specialist Cleaning Team (SCT) is available for level 2 and 3 cleans – this could mean movement of an AFA from another unit to help and support, and contact made with the On-call AFA Supervisor or Make Ready Manager 3. When informed a vehicle is coming to the Hub for an VHF specialist clean – clear a part on the carpark for the vehicle to be placed into quarantine, and get the ‘quarantine’ notice ready to give to the crew when they arrive 4. AFA or SCT to ensure all items are ready by the vehicle before starting the clean for instance: Clean Mop and Bucket containing cold water and Chlor clean (1 tablets per 1 litre for 1,000ppm solution) Clean Mop and Bucket containing cold water and Haztab solution (4 tablets per 1 litre for 10,000ppm solution) for blood and body fluid spillages (check pack of Haztab details for confirmation of number of tablets required for strength of solution) Approximate number of cloths required for the job, plus at least 2 large yellow bags and ties Bucket or bowl containing cold water and Chlorclean for the disinfectant stage of the clean following case without body fluid spills Bucket of detergent wipes Full PPE of White fluid repellent overall, plastic apron, fluid repellent face mask with visor – make sure enough of these masks are available so they can be changed when required, and a box of relevant sized gloves 5. Once items are ready, and AFA is fully ready – remember - do not eat or drink during this clean, or leave the vehicle to go to the other facilities unless all PPE is taken off and hands washed – clean PPE will need to be put on when the vehicle clean re-commences. 6. Any equipment removed must be placed separately to any other items and kept to one side until vehicle cleaning has taken place. 7. Start at the front of the vehicle using detergent and follow the process for a Deep Clean, disposing of all cloths as Clinical Waste. Page 62 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE 8. Once at the back of the vehicle, the front should be dry, change all PPE, and start the process again using Chlorclean (use Action Card for removal of PPE) 9. Finish the process by mopping the floor with Chlorclean. 10. The equipment must then be cleaned using the detergent and Chlorclean process, it can then be put into the drying room to fully dry before replacing on the vehicle. 11. Any disposable items must be disposed of as clinical waste– Sharps containers that have been used must be locked and thrown away as Clinical Waste. 12. If a vehicle returns from a Confirmed/Very High Risk case, where there has been body fluid spillage, ensure the crew or Officer inform the AFA of the treatment that area has had regarding use of Chlorine 10,000ppm (Haztabs – 4 tablets per 1 litre of cold water) 13. If the vehicle has been used on a Very high risk transfer or there has been any body fluid loss, SCT must be contacted to perform the clean. 14. If there is any evidence of Blood or Body Fluid spillage, the area will have to be cleaned first with a solution of 10,000ppm using Haztabs – Ensure this disinfectant solution is used in a very well ventilated vehicle. 15. Clinical Waste produced on confirmed VHF case’s MUST be segregated, and sent to the Incinerator in a separate large bin, identified to the collector and disposer of the waste as confirmed VHF waste. 16. For further advice contact the Infection Prevention and Control team. NB. If the vehicle is very badly contaminated – advice will be required from the IPC Lead regarding decontamination. Confirmed/Very High Risk Case of VHF/Category Four Disease (See Action Card 3) Confirmed and very high risk cases of VHF/category four may need to be transported to the High Security Infectious Disease Unit – which currently, there is only one in the UK – at the Royal Free Hospital in London. As these cases are generally pre-planned, there is time for the case to be prepared for. The HART team on duty will transport the patient with an escorting officer, and take a car and one of the HART vehicles to hold equipment required for disrobing and cleaning. There must be an Escorting Officer (as per Action Card 3e) – the escorting Officer will need to carry a Specialist PPE pack for spare items and all of the crew personal belongings. Page 63 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE There are specially prepared cages at the HART base that contain the kit required to prepare a vehice, PPE and decontaminate following a case. A normal vehicle can be prepared following Action card 3a. Any essential equipment must be either very easy to clean using Haztab Chlorine 10,000ppm solution, disposable, or covered and sealed in plastic bags to protect it. See Action Card 3 for full details The Crew One crew member will undertake the driving of the ambulance only and must not take any part in patient handling procedures. The driver will not need any PPE until the case is complete as they will not have any contact with the patient. The 2 crew members will perform patient handling and treatment procedures. The crew will have to rendezvous with the Escorting Officer. The other 3 members of the HART team will need to be allocated their roles, which are the dressing and undressing support, Clinical Waste operative or cleaning at the hospital operative. The PPE required for Very High Risk/Confirmed V.H.F. are in boxes at the HART base: Wellington Boots/knee high boot covers Water repellent overalls in boxed packs Face shield FFP3 mask Disposable gloves - double glove at all times – heavy duty gloves as the top pair Apron The designated VHF cages contain all relevant items to prepare and complete a VHF case. The Escorting Officer will not require PPE, as they will be supervising the disrobing and using the script to ensure all items are removed safely. Vehicle preparation (Action cards 1a, 2a and 3a refer to the full process for preparation of vehicles for each level of risk.) Page 64 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Level Three risk is the highest risk, as these patients are confirmed or very high risk, so there is a risk of loss of blood and/or body fluid, this means the vehicle equipment has to be removed or protected – follow Action Card 3a for vehicle preparation. Additional equipment may be necessary and will be agreed with EOC and the escorting officer depending on the case. If a medical team is to accompany the patient, they may wish to bring items of their own equipment – this can be bagged using the bags from the ‘specialist’ packs. Crew Personal Preparation: Consideration should be given to the distance required to travel to collect the patient and the most appropriate place to undertake the personal preparation – it is advisable to put on the PPE at the last safest point before collection of the patient. The HART crew PPE boxes have disposable scrubs in that must be worn by the HART crew. All items of top clothing, shoes and personal items, including jewelry must be given to the escorting officer, placed in to bags which can be found in the specialist pack or in designated cages. The bags, with the member of staffs name written on, can then be given to the Escorting Office to be placed in the officer’s car for safe keeping. A comfort visit and refreshments will be required just before putting on the PPE and collecting the patient – this is best done at the transferring hospital. Ambulance Control When a Category 4 disease transfer is requested, Ambulance Control will take the detailed particulars and any special instructions regarding the patient and the journey. A full HART team will be required – this could mean calling in extra staff to back fill. The crew should be given sufficient time to have a rest break, complete their preparations and be at the patient’s pick up point within the time allocated by the hospital. Ambulance control should brief the crew and the Officer with the fullest information available and regularly update them as further information is received. A police escort is required, local police need to be contacted to arrange this with the other services along the way. The escorting Officer must be able to escort the crew throughout the journey. If the journey is going to take longer than 2 hours, there needs to be liaison with Ambulance services on the way to the receiving hospital, as the crew and vehicle may need to be changed to complete the journey. There is a list of possible Ambulance stations for crew exchanges in Annex VII Page 65 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Ambulance Escorting Officer (see Action Card 3e) The officer allocated to escort the crew has the following duties: Rendezvous with the crew at an agreed station/location prior to the patient pick up Ensure that the crew are correctly attired and are fully conversant with the confirmed patient transport procedures Confirm with the crew the route to be taken Collect the clothing and personal belongings of the crew, in bags with their names on, and put them in the escort vehicle Leave the rendezvous point at the same time as the crew and proceed to the pickup point Do not come in to contact with the patient – Escorting Officer is there to make sure everyone is safe and follows the process laid out in Action Card 3a, b, c, d and e for confirmed/very high risk awaiting confirmation patients COLLECTING THE PATIENT Crew Before entering the patient’s location, the crew will don the full PPE from the HART PPE boxes and wellington boots. Reassurance may be necessary as the appearance of a fully protected crew may result in some anxiety for the patient and relatives. Ideally the patient will have been prepared in advance for the journey and any necessary clinical interventions such as cannulation and commencement of intravenous fluids will have been initiated by the referring clinician. This reduces any risk to ambulance staff in undertaking invasive procedures en route to the HSIDU. The patient should be provided with and asked to wear a facemask – surgical mask without visor. There is a white body bag in the Specialist pack and cages, this can be used to protect the stretcher – it can be used as a sort of sleeping bag – with one of the Ultrasorb Stretcher size incontinent pads inside. The patient can have blankets over them and the zip pulled part way to protect the vehicle and stretcher from spillage of body fluid. If the body bag does not have any handles, a carry sheet can be placed underneath the body bag to enable safe transfer of the patient. The crew will transfer the patient to the ambulance using any necessary manual handling aids. Care should be taken to ensure that all ambulance equipment used is taken with the patient before leaving the site. This will include any materials used for cleaning spillages of bodily fluids, which must be treated carefully as clinical waste – if at a hospital site, clinical waste must be left at the hospital. The driver, 3 other HART team members and escorting officer will not become involved in any aspect of patient care or handling but will attempt to keep bystanders, onlookers, etc. at a safe distance. Page 66 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE When the patient is secured in the vehicle, the crew should carry out a communication check with the escorting officer. If satisfactory, they should then contact Ambulance Control. Relatives will not be conveyed with the patient and will be expected to make their own way to the HSIDU. Escorting Officer Do not engage in any aspect of patient contact or care Assist the ambulance driver and HART team to ensure that onlookers and bystanders are kept well away when the patient is transferred to the ambulance When the patient is loaded and the doors are closed, drive the escorting vehicle into position behind the ambulance with the rest of the HART team in the other escorting vehicle behind Complete a communications check with the ambulance crew and EOC before moving off DURING THE JOURNEY Crew REMEMBER Other than for emergency evacuation purposes members of the crew who have been in contact with the patient must not leave the vehicle under any circumstances – unless it is at a designated premises to swap the crew In the event of a breakdown, the crew will notify Ambulance Control and the escorting officer. If the escorting officer cannot repair defects at the roadside, arrangements will be made to tow the vehicle, if possible to its destination. The escorting officer will co-ordinate this. If the vehicle cannot be towed or repaired, another vehicle will be summoned and the patient will be transferred. Any necessary patient care procedures should be carried out, but the crew should avoid unnecessary patient handling. If respiratory resuscitation is necessary the crew must not attempt mouth to mouth – a BVM must be used – a DNAR may accompany the patient. The crew should make steady progress to the HSIDU under emergency conditions. Escorting Officer Throughout the journey, drive behind the ambulance, endeavoring to keep it in sight at all times. If it becomes impractical to follow the planned route, communicate alternatives to the ambulance crew and relevant Ambulance Control centre(s); Page 67 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE If a breakdown occurs, prevent anyone from approaching the vehicle. If possible carry out roadside repairs or alternatively arrange for the ambulance to be towed to its destination. If towing is not possible, arrange with the relevant local Ambulance Service for the provision of another vehicle which must be prepared for a Category 4 transfer as previously described. Prevent the exposure of other ambulance staff and the public to any avoidable risks during the transfer. ON ARRIVAL AT THE HSIDU: Royal Free Hospital London or other Surge unit Crew Proceed as directed by hospital staff and the escorting officer and hand over the patient. All ambulance blankets and other linen should be placed in to a clinical waste bag and labelled ‘Infectious for incineration’ along with a patient identifier. The bag should be handed to hospital staff for subsequent incineration. The stretcher should be decontaminated in the High Security Infectious Disease Unit if the patient is taken to the Royal Free in London – if badly contaminated it may have to be left there. If the body bag has kept all of the body fluids inside, then the stretcher can be cleaned and taken back to the ambulance. Vehicle decontamination procedure at London Royal Free Hospital: The driver will be directed to drive the vehicle to a decontamination area where the vehicle can be treated as per Action Card 3d: Driver to wear same level of PPE as crew to clean the vehicle – though should not require a face shield – face mask and goggles should be sufficient Open all doors and windows and remove all unfixed items of equipment from the saloon of the vehicle Any body fluid spills to be cleaned using spill kits and Haztab solution of 10,000ppm chlorine – 4 tablets per 1 litre of cold water – this must be used in a well ventilated area All interior surfaces of the vehicle, fixtures and fittings are to be mopped using the disposable mop heads, mop handles, buckets and Haztab solution, as per Action Card 3d All items removed from the vehicle also need to be cleaned. All items in plastic bags – put the equipment still in the bags on to an incontinent/absorbent sheet – mop the bags as per Action Card 3d and leave for 2 minutes. The bags can be removed using a 2 person process – one clean, one ‘dirty’ – ‘dirty’ member of staff cut through the bags revealing the clean equipment, ‘clean’ member of staff disconnect the tubing or wiring from the piece of equipment inside the bags, and remove the equipment to a clean Page 68 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE area – ‘Dirty’ member of staff dispose of the plastic bag with the leads or tubing still taped to the bag as clinical waste – leave these bags at the receiving hospital Any disposable equipment is to be placed in clinical waste bags along with all tissues and items used during the cleaning and disinfection procedure. Clinical waste bags should be secured and labelled ‘infectious for incineration’ and the labels endorsed with the patient identifier. All waste bags should be handed to hospital staff for subsequent disposal; Leave the vehicle doors and windows open to aid drying Once the vehicle is dry, the clean equipment can be placed in clean plastic bags for transport back to base The vehicle will then be safe for return to base, and should undergo a deep clean on return to eradicate all risk. Crew decontamination NB. A Disrobing process is required before this takes place to remove the top layer of PPE – follow Action Card 3c for the disrobing process. If at the Royal Free in London, there is a decontamination suite where the crew can shower - enter the suite and proceed to the ‘dirty’ changing room Undress and place all disposable items into a clinical waste bag labelled ‘infectious for incineration’ along with the patient identifier Any recoverable items such as spectacles, contact lenses etc. should be placed in the clear plastic bags provided Proceed to the shower room; wash thoroughly and shampoo hair Clean the shower after use and throw back towels and paper foot mats into the dirty changing room Proceed to the clean changing area. Ensure that all doors are left unlocked when progressing through the shower suite On arrival in the clean changing area, retrieve clothing and personal items from the storage containers and get dressed Leave the unit by the designated exit and return the storage container to the officer Reusable items such as spectacles and personal clothing will be processed by hospital staff and returned at a later date. Non-washable items will be destroyed by incineration Page 69 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Crew Decontamination if not at the Royal Free: See Action Card 3c – the 3 members of HART who followed with the equipment must designate themselves a ‘task’ either as a safe un-dresser, clinical waste assistant, or cleaner. The Safe Undressing Assistant (SUA) wearing a water repellent gown, double gloves, face protection and wellington boots or CR1 boots will help to remove the PPE. The crew will then proceed to shower area at the hospital wearing the disposable scrubs that have been worn underneath the PPE. The Escorting Officer will take the crew clothing from car and place in the clean dressing area, so that the crew have clothing to wear for the return journey. The Safe Undressing Assistant will also assist the driver or member of staff who has cleaned the vehicle to remove their PPE Another member of staff will assist the SUA with their undressing procedure – they can wear level one PPE – apron, gloves, water repellent surgical mask with visor and disposable boot covers The area where the undressing has taken place will have to be cleaned and made safe – the Clinical Waste assistant will make sure all items are disposed of in the clinical waste bins and bags, all bags and bins are wiped outside with wipes or chlorclean solution to ensure the outer bags are clean. All bags to be sealed and marked up as Clinical Waste for Incineration, with a patient identifier written on the bag – this waste is to be given to the receiving hospital for disposal. The Escorting Officer Follow the vehicle to the decontamination area: Ensure that decontamination processes have been fully completed and that staff have the required facilities available to them to complete this Act as a supervisor and narrator of the Disrobing Process to ensure all actions take place in the correct order When the crew have completed their decontamination, liaise with them and undertake a hot debrief of the incident to identify any issues Inform Ambulance Control of their status. AIR TRANSPORTATION WITHIN THE UK Where necessary, isolator transfers of non-ambulant or incontinent patients may be arranged with the RAF who have specific arrangements and facilities to ensure the safe removal of the patient and protection of the aircraft and crew. Local Air Ambulances MUST NOT be used as they cannot be decontaminated. Page 70 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE MEDICAL SURVEILLANCE (See Action Card 9) All transfers must generate the VHF Incident Record – which must be sent to the Emergency Planning Manager and Infection Prevention and Control Lead. Infection Prevention and Control (IPC) Lead will maintain records of any confirmed Category 4 transfers or transport from the returned VHF Incident Records returned. Public Health England will inform the IPC Lead if a positive diagnosis is made of a Category four patient, this information will then be passed to the Occupational Health Nurse (OHN) Manager. Members of staff in contact with confirmed cases will need to check their own temperature twice a day for 21 days, informing their GP, PHE and OHN manager if their temperature rises to 37.5 degrees C. Information for Appendix 15 from:Management of Hazard Group 4 viral haemhorragic fevers and similar human infectious diseases of high consequence – H.S.E. – Department of Health – Advisory Committee on Dangerous Pathogens -2012 updated 2014 Interim Infection Control Recommendations for Care of Patients with Suspected or Confirmed Filovirus (Ebola, Marburg) Haemorrhagic Fever – March 2008 – World Health Organisation Rapid Risk Assessment – Outbreak of Ebola virus disease in West Africa – second update, 9 June, 2014 – European Centre for Disease Prevention and Control Public Health England website and documents Ambulance Service Basic Training Manual – Institute of Healthcare Development – IHCD November 2011 update Communicable Disease Control and Health Protection Handbook – Third Edition – Hawker, Begg, Blair, Reintjes, Weinberg, Ekdahl. NARU guide for confirmed Category Four disease transfers Page 71 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE The Following Annexes contain:Annex I EOC Flow Charts Annex II Specialist PPE Pack Contents Annex III Map of West Africa Annex IV Action Cards for Category Four Calls Annex V How to Self-Fit Check an FFP3 Annex VI VHF Incident Record Annex VII List of Premises for Crew swaps on transfers Annex VIII Flow Chart for AFAs and Specialist Cleaning Team Page 72 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Page 73 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE EOC/111 Actions–SUSPECTED IMPORTED INFECTIOUS DISEASE’S RISK ASSESSMENT V14 (Viral Haemorrhagic Fevers (VHFs), for example Ebola, Marburg, Lassa and Crimean Congo Fever) Trauma Desk:All SUSPECTED cases will be taken to the nearest Emergency Department (ED) where they will be isolated in a side room. Trauma Desk will alert the receiving ED. If any of these SUSPECTED cases are CONFIRMED by laboratory results the patient will be transferred by HART to the High Security Infectious Disease Unit (HSIDU) at the Royal Free Hospital in London or one of the ‘Surge’ units, utilising the procedure and PPE as per Action Card 3 of this instruction. SUSPECTED cases going to Heartlands will bypass the ED department and go directly to the Infectious Diseases Unit (Ward 28) The Single Point of Contact (SPOC) for ADMISSIONS to Heartlands is the On Call Infectious Diseases Consultant, who can be contacted on 0121 424 2000. Crew to go to liaison point to be escorted through to Ward 28 – Trauma desk to inform on 0121 424 0354 stating incoming patient ‘Suspected VHF Outbreak’ and child or adult, which will trigger actions at the hospital to meet crew at barrier by Maternity unit. Trauma Desk:To make a full risk assessment of the case the following links will help and advise regarding where the latest ‘outbreaks’ are:ADDITIONAL QUESTIONS:a./ Has the patient travelled to any area where there is a current VHF outbreak? http://www.promedmail.org/ b./ Has the patient lived or worked in basic rural conditions in an area where Lassa Fever is endemic? https://www.gov.uk/guidance/lassa-fever-origins-reservoirs-transmission-and-guidelines c./ Has the patient visited caves OR mines, or had contact with primates, antelopes or bats in a Marburg / Ebola endemic area? https://www.gov.uk/guidance/ebola-and-marburg-haemorrhagic-feversoutbreaks-and-case-locations d./Has the patient travelled in an area where Crimean‐Congo Haemorrhagic Fever is endemic AND sustained a tick bite* or crushed a tick with their bare hands OR had close involvement with animal slaughter? https://www.gov.uk/guidance/crimean-congo-haemorrhagic-fever-origins-reservoirstransmission-and-guidelines Refer to Management of Infectious Diseases procedure – Appendix 15 Category Four Diseases Other useful numbers to contact:Public Health England - 0344 225 3560 then press relevant options for the area required Imported Fever Unit - 0844 778 8990 part of Public Health England Heartlands Hospital Infectious Disease Unit – 0121 424 0228 for Ward 28 Royal Stoke University Hospital Infectious Disease Unit - 01782 672904 for Ward 117 On Call Infectious Disease Consultant 0121 424 2000 On Call Virologist 0121 424 2000 – Ask for the On Call Virologist Ensure On-Call NILO has been informed of any Suspected, Possible, High Risk or Confirmed cases – and also the IPC Lead [email protected] or telephone 07979 700436 if necessary Page 74 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE CONFIRMED EOC/111 Actions –CONFIRMED IMPORTED INFECTIOUS DISEASE’S (Viral Haemorrhagic Fevers (VHFs), for example Ebola, Marburg, Lassa and Crimean Congo Fever) Is there any uncontrolled bleeding, bruising, diarrhoea and/vomiting? YES Has a hospital requested transfer to either Heartlands Ward 28 or the Royal Free Hospital London following confirmation of VHF by laboratory result? Confirmed/Very High Possibility VHF YES Transfers to be done by HART following WMAS Action Cards 3a, 3b, 3c, 3d and 3 e Escorting Officer Identified Ambulance will be crewed by three HART Operatives and supervised by an Escorting Officer Further 3 members of the HART team to travel in escorting vehicle Send Nearest ASO/NILO with CONFIRMED Level PPE Do not have any contact with patient Supervise and ensure safety of crew and patient Follow Action Cards 3a, 3b, 3c, 3d and 3e Complete VHF Incident Record Inform On-Call NILO Inform IPC Lead Vehicle Preparation CONFIRMED/VERY HIGH POSSIBILITY OF VHF Crew P.P.E. to examine and transport patient NARU PPE Face Shield and head cover Wellington boots/Knee length Shoe covers Double glove – Nitrile and heavy duty FFP3 mask NB. Third member of HART team is to drive the vehicle only – this does not require PPE as the driver must not have any direct contact with the patient or other HART operatives, only voice contact. Patient PPE Fluid Shield mask Cover stretcher with o Body Bag o Full Length Inco Pad o Any blankets used are to be treated as disposable o Vomit bags with solidifying crystals x 6 Follow WMAS Action Card 3 Page 75 of 131 See Action Cards 1a, 2a and 3a Vehicle and Crew Decontamination Crew – Action Cards 1c, 2c and 3c Vehicle – Action Cards 1d, 2d and 3d Case to be fully co-ordinated by the ICD and Trauma Desk: Inform HART Cat 4 Transfer request and full details of case Inform relevant Escorting Officer – NILO on call or ASO Liaise with transporting hospital regarding location of patient and their condition Liaise with the receiving hospital regarding the receiving unit Inform all involved to use a specific chosen channel Inform Police of High Risk transfer case and request an escort if necessary WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Other useful numbers to contact:Public Health England - 0344 225 3560 then press relevant options for the area required Imported Fever Unit - 0844 778 8990 part of Public Health England Heartlands Hospital Infectious Disease Unit – 0121 424 0228 for Ward 28 or 0121 424 2000 for on call Infectious Disease Doctor Ensure On-Call NILO (Via Incident Command Desk) has been informed of any Suspected, Possible, High Risk or Confirmed cases – and also the IPC Lead [email protected] Page 76 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE 999 Call Is The Patient Breathing? Complete Case Entry What’s the Reason for the Call? Illness Injury Complete call as normal Call to 999: Viral infection symptoms with fever >37.5° Viral Infection Symptoms: - Sore throat, joint and muscle aches and pains, weakness, chest pain, rash, red eye, hiccups, difficulty breathing and/or swallowing – And these symptoms are not known to be associated with any other particular illness Ask the following questions: 1. Has the patient been to one of the High Risk Countries in the last 21 Days i.e. West Africa – Guinea, Sierra Leone or Liberia? 2. Has the patient been in contact with/cared for someone or been in contact with specimens of blood, urine, faeces, tissues, laboratory cultures from an individual or animal strongly suspected or known to have VHF Yes A only Yes to B or A+B Complete module 0. On reaching the body map: Early Exit Transfer to a clinician Complex call Pass onto Dispatch Page 77 of 131 No Complete call as normal WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE 111 Call Patients Demographics What’s the Reason for the Call Illness Injury Complete call as normal Call to 111: Viral infection symptoms with fever >37.5° Viral Infection Symptoms: - Sore throat, joint and muscle aches and pains, weakness, chest pain, rash, red eye, hiccups, difficulty breathing and/or swallowing – And these symptoms are not known to be associated with any other particular illness Ask the following questions: 3. Has the patient been to one of the High Risk Countries in the last 21 Days i.e. West Africa – Guinea, Sierra Leone or Liberia? 4. Has the patient been in contact with/cared for someone or been in contact with specimens of blood, urine, faeces, tissues, laboratory cultures from an individual or animal strongly suspected or known to have VHF Yes Complete module 0. On reaching the body map: Early Exit Transfer to a Clinician Complex call Page 78 of 131 Yes to B or A+B Pass onto Clinician No Complete call as normal WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Warm Transfer Confirm Demographics Confirm 5. Has the patient been to one of the High Risk Countries in the last 21 Days i.e. West Africa – Guinea, Sierra Leone or Liberia? 6. Has the patient been in contact with/cared for someone or been in contact with specimens of blood, urine, faeces, tissues, laboratory cultures from an individual or animal strongly suspected or known to have VHF Further Questions Required: a) Has the patient travelled to any area where there is a current Viral Haemorrhagic Fevers (VHF) outbreak? b) Has the patient lived or worked in basic rural conditions in an area where Lassa fever is endemic? c) Has the patient visited caves or mines or had contact with primates, antelopes or bats in Marburg or Ebola endemic areas? d) Has the patient travelled to an area where Crimean Congo Fever is endemic and suffered a tick bite or crushed a tick with bare hands or had close involvement with animal slaughter e) Symptoms of bleeding internal and/or external, vomiting, diarrhoea of bruising. No to ALL Yes to ANY Warm Transfer Warm Transfer Low Possibility of sfer VHF Pass to Dispatch sfer High Possibility of VHF Pass to Dispatch FOLLOWING AMULANCE DISPATCH VERBALLY UPDATE DISPATCH sfer TEAMS WITH RELEVANT INFORMATION TO ENSURE CREW SAFETY. sfer ENSURE ALL NOTES AND FLAGS ARE IN PLACE HIGH OR LOW POSSIBLITY. IN THE SCENE SAFETY SELECTION OF CLERIC THERE IS A VHF SELECTION WHICH SHOULD BE SELECTED ON EVERY VHF CASE REGARDLESS OF RISK LEVEL. Page 79 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE DISPATCH ACTIONS – SUSPECTED IMPORTED INFECTIOUS DISEASES (Viral Haemorrhagic Fevers including Ebola, Marlburg, Lassa and Crimean Congo Fever) Call received with symptoms of severe viral infection reported A fever >37.5°C or history of fever in the previous 24 hours Joint and muscle pain Sore throat, intense weakness and chest pain Some patients may develop a rash, red eye and hiccups Difficulty with breathing and/or swallowing A Has the patient been to one of the High Risk Countries in the last 21 Days where there is a current VHF outbreak– i.e. West Africa – Guinea, Sierra Leone or Liberia recent large outbreak of Ebola in these countries 2014/15 N.B. If any other area of Africa is documented in the notes, please check if it is in West Africa B Has the patient been in contact with/cared for someone or been in contact with specimens of blood, urine, faeces, tissues, laboratory cultures from an individual or animal strongly suspected or known to have VHF NO to A and B Dispatch as per normal EOC Dispatch Protocol CSD SUSPECT LOW POSSIBILITY OF VHF Dispatch and notify RCC through save & notify function LOW POSSIBILITY OF VHF CASE WILL BE MANAGED BY REGIONAL TRAUMA DESK Page 80 of 131 YES to A No to B Case will be passed to CSD for further questioning CSD SUSPECT HIGH POSSIBILITY OF VHF YES to B or A and B Dispatch and notify RCC through save & notify function HIGH POSSIBILITY OF VHF CASE WILL BE MANAGED BY REGIONAL TRAUMA DESK WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Annex II Specialist PPE Pack for V.H.F – Contents list:- Item Quantity Used Replaced Water Repellent Tyvek Suits 2 Roll of Aprons 1 roll Surgical Masks with Visor 4 Surgical Masks 4 FFP3 Masks 4 Safety Glasses 2 Shoe Covers 4 pairs Sleeve Protectors 1 box Heavy Duty Gloves 2 pairs XL Gloves 1 box L Gloves 1 box M Gloves 1 box S Gloves 1 box Hair nets 4 Clinical waste bags, labels and ties 2 of each Red and White Laundry bags 2 of each Spare Vernagel Sachet Absorbent granules Pack of 10 Chlorclean 1 Pot Haztabs 1 Pot Stretcher Size Incontinent Pad 1 Scissors 1 Pair CONFIRMED/HIGH RISK CASE ITEMS – (Sealed blue plastic pack) Water Proof Tyvek Suits - XXL 3 Water Repellent Tyvek Suit - XXL 1 FFP3 Masks 6 Aprons 4 Goggles 2 Surgical Masks with Visors 3 Safety Glasses 2 Pairs Over Boots 3 Pairs Water Repellent Over Shoes 3 Pairs Stretcher size Incontinent sheet 1 Box of Tissues 1 Vomit Bowls containing Vernagel sachets 6 Roll of Gaffa tape to seal any gaps 1 Roll Clear plastic bags for equipment 2 Packs Clear plastic bag for staff belongings 5 Bags Clear plastic bag for Airwave radio 1 Bag Clinical Waste bags 7 Clinical Waste ties and labels 4 White Body Bag 1 Spill Pack 1 Pack Urine pot and collection bag 1 PAPERWORK AND INSTRUCTIONS Copy of Procedure (Appendix 15) 1 Set Copy of IMARC plan 1 Set Set of Laminated Action Cards 1Set FFP3 Self-Fit Test instructions 1 Map of West Africa 1 Chinagraph pen 1 Page 81 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Annex III Map of Africa Guinea Sierra Leone Liberia Recent Outbreak of Ebola was in WEST AFRICA 2014/15 Specifically – GUINEA, SIERRA LEONE and LIBERIA Page 82 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Annex IV ACTION CARDS FOR TRANSPORT OF VHF CASES Card Action Card 1a Level One – Vehicle Preparation 1b Level One – Crew Actions and PPE requirements 1c Level One – PPE Removal 1d Level One – Vehicle Cleaning 1e Level One – Officer Actions 2a Level Two – Vehicle Preparation 2b Level Two – Crew Actions and PPE requirements 2c Level Two – PPE Removal 2d Level Two – Vehicle Cleaning 2e Level Two – Officer Actions 3a Level Three – Vehicle Preparation 3b Level Three – Crew Actions and PPE requirements 3c Level Three – PPE Removal 3d Level Three – Vehicle Decontamination 3e Level Three – Officer Actions 4 Heartlands Hospital instructions for crews 5 Patient from Birmingham Airport 6 Birmingham Children’s Entrance 7 Community First Responder on scene 8 P.T.S., High Dependency and H.C.R.T staff – road and control 9 Occupational Health Follow up after CONFIRMED Case 10 Dispatch Team Actions 11 Trauma Desk Actions 12 Logistics Desk Actions 13 EOC Duty Manager Actions 14 111 Call Handler Flow Chart 15 999 Call Handlers Flow Chart Page 83 of 131 MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST ACTION WEST CARD 1a – Level ONEDISEASE – Vehicle Preparation MANAGEMENT OF INFECTIOUS PROCEDURE 1 2 3 4 5 ACTIONS Level one patients are very low risk, there is no necessity to strip the vehicle completely Remove any crew personal belongings, and place in front cab Ensure there are vomit bowls and incontinent sheets close to hand Close any cupboards Do not transport as a Level One patient if there is any suspicion of body fluid loss Page 84 of 131 WEST MIDLANDS SERVICE NHS FOUNDATION TRUST ACTION CARD 1b – AMBULANCE Level ONE – Crew Actions and PPE MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE requirements Suspicion of VHF may or may not have already been recognised from 999 call or Doctors call Symptoms: Fever >37.5°C AND History of travel to high risk country within last 21 days – recent outbreak of Ebola was in Guinea, Sierra Leone and Liberia 2014/15 – ask CSD to check on www.promedmail.org/ The following may or may not be present: MILD viral infection symptoms – sore throat, joint and muscle aches and pains, weakness, chest pain, rash, red eye hiccups, difficulty breathing and/or swallowing NB. ANY bleeding, vomiting or diarrhoea will require special precautions regarding extra PPE from ‘specialist packs’ available from the ASO or other local officer and transport of the patient by HART in specially prepared vehicle ACTIONS 1 2 3 3a Confirm that support has been requested from the on call Area Support Officer or other local officer if not already sent by EOC Confirm that patient is level One Risk – VERY Low risk – with EOC Low Level P.P.E. to be worn for the patient’s condition: Strict Hand Hygiene at all times Apron Gloves Sleeve Protectors Surgical Mask with safety glasses The above are available in the small red pouch in the response bag. If a surgical mask with visor is required – these are in the Green and Yellow vehicle based IPC PPE pack Ensure the PPE is donned BEFORE patient contact – withdraw to put on if risk 4 discovered after arrival – Remember do not touch your face or any other part of your skin or clothing once you have been in contact with the patient Ensure that the patient and the family have been told that there is no need to be 5 alarmed, however procedures state these items have to be worn just in case there is an infection present Any blood or body fluid loss MUST be reported to EOC immediately for the risk to be 6 upgraded to a level three. Ensure any IV insertions are carried out safely, utilising double gloves and sharps 7 safety at all times Ensure Patient has been made safe and comfortable on the vehicle. 8 Ensure a vomit bowl and incontinence sheets are available 9 10 When ready to leave scene, driver must remove PPE outside vehicle – Leave one door open. 10a For full instructions on removal of PPE, see Action Card 1c Page 85 of 131 Remove gloves, hand to attendant for disposal and use hand sanitiser Break loop at the neck of the apron, behind your neck and fold the top part down carefully – use hand gel Break the waist ties, at the back as close together as your hands will reach, then fold the apron in on itself, so that it is inside out Roll or fold up the inside out apron, and hand to the attendant Use hand sanitiser again before removing any facial PPE Remove facial PPE by leaning forwards, and taking each item off away from Yes/No WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE 11 12 13 14 15 16 17 18 your face and body – hand the items to the Attendant to dispose of Use hand sanitiser again, and close the doors DO NOT DRIVE IN PPE Ensure ICD/Trauma/Hospital desk have informed local hospital regarding SUSPECTED case of V.H.F. confirming that there is an isolation cubicle available at the hospital you are travelling to If crew have to travel to Heartlands, ensure the full instructions regarding which department at the hospital is accepting the patient, and directions to the department are clear (Action Card 4) or if travelling to Birmingham Children’s hospital, follow Action Card 6 Arrival at hospital - Driver (or escorting on call officer) to go into the receiving department to announce the arrival, and obtain details of the isolation room for the patient. Driver must don further relevant clean P.P.E. obtained from either the escorting officer or the hospital staff before contact with patient at the hospital – Ensure vehicle is secured and locked when patient has been moved. Once patient is handed over - all used linen must be removed – leave with patient, or ask advice regarding whether to place in the hospital ‘contaminated laundry bag’ or a red incinerator bag. All clinical waste must be in sealed bags and left with the receiving hospital department. Go to Action Card 1c for instruction on PPE removal Go to Action Card 1d for vehicle cleaning instructions Page 86 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE ACTION CARD 1c – Level ONE – PPE removal ACTIONS 1 2 3 4 5 6 7 PPE should be removed in the following Order with Hand Hygiene in between each of the actions – Remember to use Soap, Water and paper towels whenever they are available:For First level of PPE (SUSPECTED Low Risk)– Firstly remove Gloves: Grasp the outside of the glove with the opposite gloved hand; peel off turning the glove inside out. Hold the removed glove in your gloved hand. Slide the fingers of the ungloved hand under the remaining glove at the wrist Peel the second glove off over the first glove and discard as clinical waste NB. If wearing sleeve protectors, these must be removed at the same time as gloves Now use Hand Sanitiser or wash and dry hands Remove Apron: Unfasten or break the loop at the back of your neck, Pull apron front down, away from the neck and shoulders, touching the inside of the apron only – use hand gel Break the ties at the back Bring the apron forwards, folding it in half, only touching the inside, fold or roll into a bundle and discard as clinical waste Now use Hand Sanitiser or wash and dry hands If wearing Safety Spectacles: Handle by the ears, taking away from your face and discard as clinical waste Now use Hand Sanitiser or wash and dry hands If wearing a Face Mask: Untie or break the bottom ties, followed by the top ties or stretch the elastic. Tilt head forwards Handle only using the ties if possible, and take the mask away from your face forwards – Do NOT take over your head Now use Hand Sanitiser or wash and dry your hands REMEMBER THE IMPORTANCE OF HAND HYGIENE THROUGHOUT THE PROCESS OF REMOVING PPE, AND WHEN IT HAS ALL BEEN REMOVED Clean PPE must now be worn to clean the stretcher, any equipment used and the vehicle, to ensure it is safe to return to the Hub – see Action Card 1d Page 87 of 131 Yes/No WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE ACTION CARD 1d – Level ONE – Vehicle Cleaning ACTIONS 1 2 3 4 4 5 Clean PPE must be worn to clean the vehicle – Change gloves at a regular intervals and always if contaminated. Wear clean apron and gloves to wipe the stretcher, any patient touch areas in the vehicle, and any equipment used, using the vehicle based wipes to make the vehicle safe for return to base If there has been any body fluid spillage – though this is not expected for a Level One Risk case – the spill must be cleaned up using a Spill Pack and 10,000ppm Chlorine – NB. Level Two PPE is required for any body fluid spill cleaning The vehicle now needs to be taken to the Hub for an AFA Chlor-clean wipe of all Flat Surfaces – ensure the AFAs are aware they will have to wear Level One PPE to clean, also fully inform AFAs what you have done to make the vehicle safe. The crew can return to base for a change of uniform and shower if necessary, though this is not normally necessary for a Level One risk patient unless there was an unexpected loss of body fluid – if full decontamination is required, some hospitals have this facility, if not, the HART team can be contacted to perform this For any queries, IPC Lead can be contacted via control, or the On Call NILO, alternatively e mail [email protected] Page 88 of 131 Yes/No WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE ACTION CARD 1e – Level ONE – Officer Actions ROLE: Ensure safety at all times of the crew, patient and other members of the public Suspicion of VHF may or may not have already been recognised from 999 call or Doctors call Symptoms: Fever >37.5°C AND History of travel to high risk country within last 21 days – recent large outbreak of Ebola was in West Africa – Guinea, Sierra Leone and Liberia 2014/15 – ask CSD to check on www.promedmail.org/ for any recent outbreaks The following may or may not be present: MILD viral infection symptoms – sore throat, joint and muscle aches and pains, weakness, chest pain, rash, red eye hiccups, difficulty breathing and/or swallowing NB. ANY bleeding, vomiting or diarrhoea will require special precautions regarding extra PPE from ‘specialist packs’ available from the ASO or other local officer and transport of the patient by HART 1 2 3 4 5 6 7 8 8a 9 10 ACTIONS Full liaison with EOC – ICD/Trauma/Hospital desk is required to ensure all actions are completed. Confirm the level of Risk is a Level One Low risk case – escalate risk level if necessary If necessary arrange a transporting vehicle if one not already on scene Contact crew, give estimated time of arrival either at scene, or at the receiving hospital if Officer is required Ensure no member of staff is pregnant, if so, they should not be in contact with the patient If required on scene Do Not come in to direct contact with the patient or crew, prepare transferring vehicle prior to the loading of the patient Remove any loose equipment from the vehicle that is not required for the case, with staff belongings and bags, these can be placed securely in the Officer’s vehicle, or if possible, secured in the passenger side of the cab. If there is no room for some equipment, another vehicle can be called to take the equipment to the Hub, to be kept safe and clean ready to be re-kitted later. Ensure all cupboard doors are closed. Ensure Crew are wearing the correct PPE for the Level One Risk case Low risk – (Ensure there is No risk of Bleeding, Vomiting, Diarrhoea or any body fluid loss) : Strict Hand Hygiene at all times Apron Gloves, Sleeve Protectors, Surgical Mask with safety glasses The above items are available in the small red pouch in the response bag If a surgical mask with visor is required, these are in the Level two IPC PPE packs Keep in contact with EOC via ICD/Trauma desk and crew Ensure Driver removes all PPE before driving to the hospital For full instructions on removal of PPE, see Action Card 1C Remove gloves, hand to attendant for disposal and use hand sanitiser Break loop at the neck of the apron, behind your neck and fold the top part down Page 89 of 131 Yes/No WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 carefully – use hand gel Break the waist ties, at the back as close together as your hands will reach, then fold the apron in on itself, so that it is inside out Roll or fold up the inside out apron, and hand to the attendant Use hand sanitiser again before removing any facial PPE Remove facial PPE by leaning forwards, and taking each item off away from your face and body – hand the items to the Attendant to dispose of Use hand sanitiser again, and close the doors Ensure ICD/Trauma desk have informed local hospital regarding SUSPECTED case of V.H.F. confirming that there is an isolation cubicle available If necessary, the officer can escort the crew to the relevant hospital – no contact with the patient is necessary for the on call officer If crew have to travel to Heartlands, ensure the full instructions regarding which department at the hospital is accepting the patient, and directions to the department are clear – See Action Card Four If Officer has followed crew to the hospital, go in to the department and obtain details of the isolation room for the patient, then meet crew – Do Not come in to contact with the patient or crew. Driver must don further relevant clean P.P.E. obtained from either the escorting officers specialist PPE pack or the hospital staff before contact with patient at the hospital Ensure vehicle is closed and secure when crew and patient have gone in to hospital Ensure when patient is handed over - all used linen has been removed and left with patient, or ask advice regarding whether to place in the hospital ‘contaminated laundry bag’ or a red incinerator bag. Ensure all clinical waste has been sealed in bags and left with the receiving hospital department. Ensure PPE is removed in the order as listed in Action Card 1c Ensure Hand Hygiene has been performed in between each piece of PPE removal, using Soap, Water and paper towels if they are available or Hand Sanitiser if not available Ensure crew wear clean PPE to clean the vehicle to make it safe for return to base and the PPE is again removed following the process in 1c If there has been any unexpected body fluid loss – this must be cleaned using a ‘spill pack’ and 10,000ppm chlorine – crew need to be wearing Level 2 PPE for body fluid spill cleaning The vehicle now needs to be taken to the Hub for an AFA Chlorclean of all flat surfaces– ensure the AFAs are aware they will have to wear Level One PPE to perform the clean Crew can return to base for a change of uniform and shower if this is necessary, though it is not expected that body fluid spills will occur for a level one low risk patient – if full decontamination is required, some hospitals have this facility, if not, the HART team can be contacted to perform this for the crew Leave Equipment that has been removed from vehicle with AFA for return to vehicle once it has been cleaned, and return Staff belongings if any were removed. Ensure safety of crew and patient at all times If advice is required – Contact on Call NILO or IPC Lead Complete VHF Incident Record Annex VI and return to [email protected] Page 90 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS PROCEDURE ACTION CARD 2a – Level TWODISEASE – Vehicle Preparation 1 2 3 4 5 6 7 8 9 10 ACTIONS Level two patients are a slightly higher risk, so all unnecessary items must be removed from the vehicle If possible, a vehicle ready prepared for a VHF case can be brought to scene by an AFA, Officer or any available person – this vehicle will only contain the necessary items for use on the patient – all cupboards will have been stripped and all unnecessary items left at the Hub The AFA, Officer or available person can then take the crews vehicle back to the nearest Hub, ready for collection and use later If the crew vehicle has been contaminated while awaiting the prepared vehicle – no person can enter the rear of the contaminated vehicle without full Level 2 PPE on, and it must be quarantined at the Hub for a full clean by the ‘Specialist Cleaning Team’ If the original vehicle has to be used to move the patient, an Officer or AFA with the special Plastic covering can attend scene if this is available, otherwise the vehicle will need to be stripped of all unnecessary items – kit placed in a spare vehicle taken to scene for this purpose. All staff belongings to be removed and placed in a spare vehicle/officers car All loose equipment to be removed – including spinal board Monitor if required to be placed in to a plastic bag – with leads for pads ready to be connected to record heart rhythm, and sats probe – all taped to protect the monitor (bags in Specialist PPE Pack) Suction unit and Para pac can be placed into a plastic bag as per the monitor Only leave out items that are necessary for the patients treatment, such as: Spare Gloves and other PPE – though make sure these are away from any ‘splash’ risk area Surgical mask for patient to wear Tissues Vomit bowls Incontinent sheets Clinical waste bag Sharps box and any items required for cannulation if required Oxygen masks – one of each type and nebuliser acorn Any drugs, fluids, syringes and giving set that could be required 11 12 13 If the Plastic Sheeting is available, the vehicle can then have the cupboards covered in this - otherwise, ensure all cupboard doors are closed Ensure stretcher is covered by incontinent sheets, and a sheet, with blankets available or the white body bag used as a sleeping bag Do NOT transport as a Level Two Patient if there is any suspicion there could be loss of body fluid – This would have to be escalated to a Level Three Page 91 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE ACTION CARD 2b – Level TWO – Crew Actions and PPE required Crew – Suspicion of VHF may or may not have already been recognised from 999 call or Doctors call Symptoms: Fever >37.5°C AND History of travel to high risk country within last 21 days – recent large outbreak in West Africa – Guinea, Sierra Leone and Liberia 2014/15 – contact CSD so they can check on www.promedmail.org/ may have had contact with known cases or samples from known cases The following may or may not be present: Viral infection symptoms – sore throat, joint and muscle aches and pains, weakness, chest pain, rash, red eye hiccups, difficulty breathing and/or swallowing NB. ANY bleeding, vomiting or diarrhoea will require special precautions regarding extra PPE from ‘specialist packs’ – Loss of body fluids moves the patient in to a LEVEL THREE transport by HART in specially prepared vehicle 1 2 3 4 ACTIONS Confirm that support has been requested from the on call Area Support Officer or other local officer if not already sent by EOC Confirm with EOC that patient has Level Two symptoms and requires Level Two PPE Level Two P.P.E. is in the Green and Yellow IPC PPE bag on every front line vehicle and there is spare in the Specialist Packs – Level Two Risk PPE – Severe viral infection symptoms (NO loss of body fluid – any loss of body fluid moves patient into a Level Three risk): Water Repellent Overall Apron Gloves – Double glove Surgical Mask With Visor – can be worn over the top of the overall hood and an FFP3 mask Sleeve Protectors Shoe/boot Protectors FFP3 mask for any aerosol generating procedure with safety glasses or surgical mask with visor over the top of FFP3 mask. NB. FFP3 masks need to be worn underneath the overall hood to ensure they ‘fit’ 5 6 7 Strict Hand Hygiene at all times – Remember – Do not touch your face or any other part of your skin or clothing once you have been in contact with a patient Ensure that the patient and the family have been told that there is no need to be alarmed, however procedures state these items have to be worn just in case there is an infection present NB - Any person in contact with blood or body fluids, the area must be washed immediately, utilising soap and water if available or saline solution, any contact with mucous membranes must be washed out with a copious amount of saline – with referral to the receiving hospital immediately and Occupational Health. Blood spills must be treated with a Spill Pack contents and 10,000ppm chlorine using Haztab solution – and Contact EOC to move to a Level Three Response Ensure any IV insertions are carried out safely, utilising double gloves and extreme sharps safety at all times Page 92 of 131 Yes/No WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE 8 9 10 11 12 13 14 15 16 17 18 19 Ensure Patient has been made safe, and comfortable on the vehicle – utilise large incontinent sheets from specialist pack if felt necessary. Ensure a vomit bowl, tissues and incontinent pads are readily to hand Do not drive in PPE – this means it has to be removed prior to driving or for both members of staff in PPE to stay in the back of the ambulance, and another member of staff to drive the vehicle who is not in PPE. If there is no one available to drive, when ready to leave scene, leave one door open, driver must then remove PPE outside vehicle, following the process in Action Card 2c for safe removal of PPE – handing the used PPE to the Attendant for disposal in the clinical waste bag – Ensure hands are thoroughly cleaned using wipes and hand sanitiser, then close door. Use hand sanitiser again after closing door, ready to drive the vehicle. Ensure ICD/Trauma desk have informed local hospital regarding SUSPECTED case of V.H.F. confirming that there is an isolation cubicle available If travelling to Heartlands, ensure the full instructions regarding which department at the hospital is accepting the patient, and directions to the department are clear – Action Card 4 has instructions for direct admission to Ward 28. Birmingham Children’s instructions are on Action Card 6 Arrival at hospital - Driver (or escorting on call officer) to go into the receiving department to announce the arrival, and obtain details of the isolation room for the patient. Driver if part of the crew, must don further relevant clean P.P.E. obtained from either the escorting officer or the hospital staff before contact with patient at the hospital ensure vehicle is secured when patient is taken off the vehicle Once patient is handed over - all used linen must be removed – leave with patient, or ask advice regarding whether to place in the hospital ‘contaminated laundry bag’ or a red incinerator bag. All clinical waste must be in sealed bags and left with the receiving hospital department. For instruction on PPE removal use Action Card 2c Some hospital may have an area for safe removal of PPE – ensure whoever is supervising the ‘undressing’ process has Action Card 2c For instruction on Vehicle Cleaning use Action Card 2d Page 93 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST OF INFECTIOUS ACTION CARDMANAGEMENT 2c – Level TWO –DISEASE PPE PROCEDURE Removal 1 2 3 4 5 6 7 ACTIONS For Level Two PPE (Medium risk with NO Bleeding, vomiting, diarrhea): PPE is removed in the following Order:FIRSTLY Change the Top pair of gloves (Double Glove Process) Remove Apron: Break loop at the back of the neck Pull apron down, away from the neck and shoulders, touching the inside of the apron only Break the ties at the back, holding the ties with hands as close to each other as possible to keep the apron ties under control Bring the apron forwards, folding it in half, only touching the inside, fold or roll into a bundle and discard as clinical waste – or drop in to waste bin Change top pair of gloves as per double gloving process – or use alcohol gel to clean top pair of gloves If wearing Safety Spectacles: Tilt head forwards Handle by the sides of the glasses, taking away from your face and discard as clinical waste Change top pair of gloves as per double gloving process – or use alcohol gel to clean top pair of gloves If wearing a surgical Face Mask: Tilt Head forwards Untie or break the bottom ties, followed by the top ties Handle only using the ties if possible, and take the mask away from your face forwards – Do NOT take over your head Change top pair of gloves as per double gloving process – or use alcohol gel to clean top pair of gloves Then remove White Overall carefully turning inside out: Unzip Fold hood backwards and start to turn the overall inside out, only touching the inside of the overall Change top pair of gloves at any time where there has been contamination with outside of the overalls Remove Sleeve and Shoe protectors with the overalls as the overalls are turned inside out If gloves come off as the sleeves are removed, allow this to happen, use hand sanitizer, then put on 2 pairs of clean gloves When the overall is fully inside out, carefully roll up and discard as clinical waste Change top pair of gloves as per double gloving process or use alcohol gel to clean top pair of gloves if still wearing a mask If wearing an FFP3 mask: Wearing clean top gloves, grasp bottom elasticated strap at the back of head, and put on the top of your head Lean slightly forwards, so your face is facing down Then grasp the original top strap with both hands and bring it over the strap on the top of your head – ensure the mask then comes off forwards away from your face Page 94 of 131 Yes/No WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE 8 Remove Gloves: Grasp the outside of the glove with the opposite gloved hand; peel off turning the glove inside out. Hold the removed glove in your gloved hand. Slide the fingers of the un-gloved hand under the remaining glove at the wrist Peel the second glove off over the first glove and discard as clinical waste Use Soap and Water to wash hands and paper towels to dry them if they are available – if not available, use Hand wipes and Sanitiser 9 REMEMBER THE IMPORTANCE OF HAND HYGIENE THROUGHOUT THE PROCESS OF REMOVING PPE, AND WHEN IT HAS ALL BEEN REMOVED 10 Clinical Waste – if at hospital, place all items directly in to the hospital yellow bins/bags. If at side of road place all items in to a heavy duty large clinical waste bag – this bag will need to be wiped clean with vehicle based wipes – then the bag placed in to another heavy duty large clinical waste bag, which is securely tied and tagged. All waste from suspected VHF cases must be identified as such, as it has to be segregated. 11 Clean PPE must be worn to clean the vehicle and stretcher 12 Wear clean overall, apron, surgical mask with visor and gloves to wipe the stretcher and any patient touch areas in the vehicle, to make the vehicle safe for return to base Page 95 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE ACTION CARD 2d – Level TWO – Vehicle Cleaning ACTIONS 1 2 3 4 4 5 6 7 8 8a 8b 8c 8d 8e 9 9a 9b 9c 9d Crew - Clean Level 2 PPE must be worn to make the vehicle safe for return – Change gloves at regular intervals and always if contaminated. Wear clean Overall, surgical mask with visor, apron and gloves to wipe the stretcher, any patient touch areas in the vehicle, and any equipment used, using the vehicle based wipes to make the vehicle safe for return to base If there has been any body fluid spillage – though this is not expected for a Level Two Risk case – the spill must be cleaned up using a Spill Pack and 10,000ppm Chlorine The vehicle now needs to be taken to the Hub for an AFA Deep Clean – ensure the AFAs are aware they will have to wear Level TWO PPE to clean or move the vehicle to a quarantine area – the Specialist Cleaning Team can be requested to attend the Hub to supervise or clean the vehicle The crew can return to base for a change of uniform and shower if there has been any breach in PPE, though this is not always necessary for a Level Two risk patient unless there was an unexpected loss of body fluid, or the crew have worn the full PPE for a length of time, as this can be very hot to wear – if full decontamination is required, some hospitals have this facility, if not, the HART team can be contacted to perform this or give advice regarding this At the Hub, the vehicle may need to be quarantined until the Specialist Cleaning team are available – AFAs must ensure that the vehicle is appropriately labelled and secured so that no one can enter while it is in Quarantine NB. When using Chlorine releasing agents, the vehicle MUST be well ventilated To prepare the vehicle for the disinfection – place all of the plastic bagged equipment and stretcher outside the vehicle (ensure they are in a safe place) If the vehicle has the Plastic Sheeting in place - the Specialist Cleaning Team will need wear Water Proof PPE in the first instance to use the decontamination spray The Specialist Cleaning Team will use 10,000ppm chlorine in a spray to ensure the vehicle is safe – the stretcher and bagged equipment also need to be sprayed – ensure there are incontinent pads around the edge to absorb the fluid The vehicle will need to be left for a minimum of 2 minutes for the Chlorine ‘contact time’ – the vehicle can then be mopped using dry disposable mop heads to absorb any excess water The Specialist Cleaning Team will need to remove the water proof PPE as per Action Card 2c The Specialist Cleaning Team will then need to don Water Repellent PPE – as per Level Two PPE to complete the cleaning process The plastic sheeting can then be removed and disposed of as Clinical Waste (yellow bag), and a full vehicle clean using Chlorclean – 1,000 ppm used to finish the full cleaning process of the vehicle as per a Deep Clean procedure If no plastic sheeting was used, the vehicle will need to be mopped using Haztabs 10,000ppm (walls, cupboards, doors etc) – do not place the mop back in to the cleaning fluid – change mop head each time, ensure it is rung out well so it is not dripping Split the vehicle in to sections to clean – starting with the side door – mop this area, all over the inside of the door – then open the door to ensure there is a good air flow to ventilate the vehicle – change the mop head – dispose of as yellow bag clinical waste Then mop the top end of the vehicle – change the mop head dispose of as yellow bag clinical waste Using clean, rung out mop, clean the left side of the vehicle – change mop head and dispose of as yellow clinical waste Using another clean, rung out mop, clean the right side of the vehicle – change mop Page 96 of 131 Yes/No WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE 9e 9f 9g 9h 10 11 12 head and dispose of as yellow clinical waste Stretcher and all equipment in bags should be at the side of the vehicle – outside – using another clean mop head, rung out, clean all of the items placed at the side of the vehicle – change mop head and dispose of as yellow clinical waste Use another clean mop head – mop the floor of the ambulance – dispose of the mop head as yellow bag clinical waste Leave the vehicle for minimum of 2 minutes for the Chlorine contact time – Dry mop heads can then be used to mop up any excess fluid The vehicle can then be fully cleaned using Chlorclean at 1,000ppm hypochlorite following the Deep Clean procedure The equipment in plastic bags – plastic bags must be carefully removed, with a ‘clean’ person handling the part of the equipment that has been protected by the plastic bags – the plastic bags and any leads that have been exposed, can then be disposed of as yellow bag clinical waste Once completed, the removed equipment can be replaced and the vehicle can go back on the road if it is an operational vehicle – or if this was a designated Infectious vehicle, then the plastic lining can be replaced and equipment for next case will need to be bagged and boxed so the vehicle is ready for use if there is another case For any queries, IPC lead can be contacted by EOC. Or e mail [email protected] Page 97 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS PROCEDURE ACTION CARD 2e – Level TWO DISEASE – Officer Actions ROLE: Ensure safety at all times of the crew, patient and other members of the public Symptoms: Fever >37.5°C AND History of travel to high risk country within last 21 days – Recent large outbreak of Ebola in West Africa – Guinea, Sierra Leone and Liberia 2014/15 – Contact CSD for them to check www.promedmail.org - may have had contact with known cases or samples from known cases The following may or may not be present: Viral infection symptoms – sore throat, joint and muscle aches and pains, weakness, chest pain, rash, red eye hiccups, difficulty breathing and/or swallowing NB. ANY bleeding, vomiting or diarrhoea requires special precautions regarding extra PPE from ‘specialist packs’ - Loss of any body fluids moves the patient in to a Level THREE transport by HART in a specially prepared vehicle 1 2 3 4 5 6 7 8 9 Yes/No ACTIONS Full liaison with EOC – ICD/Trauma desk is required to ensure all actions are completed. If necessary arrange a transporting/transferring vehicle if one not already on scene Contact crew, give estimated time of arrival at scene Ensure no member of staff is pregnant, if so, they should not be in contact with the patient Do Not come in to direct contact with the patient or crew, prepare transferring vehicle prior to the loading of the patient Any person in contact with blood or body fluids, the area must be washed immediately, utilising soap and water if available or saline solution, any contact with mucous membranes must be washed out with a copious amount of saline – with referral to the receiving hospital immediately and Occupational Health. Blood spills must be treated with a Spill Pack contents and 10,000ppm chlorine using Haztab solution – Any Body Fluid loss immediately triggers a LEVEL THREE response Ensure a relevant vehicle is sent to scene to transport the patient – or prepare the vehicle on scene as per Action Card 2a Ensure Crew are wearing the correct PPE for the case – Level Two Level Two PPE – Viral infection symptoms – NO loss of Blood or Body Fluid (this triggers an immediate LEVEL THREE response utilising the HART team) Water Repellent Overall Apron Gloves (double gloves) Surgical Mask With Visor – to be worn over the top of the overall hood, and can be worn over the top of an FFP3 mask for extra face protection Sleeve Protectors Shoe Protectors FFP3 mask for any aerosol generating procedure, with safety glasses or a surgical mask with visor over the top of the FFP3 mask – NB. FFP3 mask MUST be worn underneath the overall hood to ensure it ‘fits’ correctly 10 11 Keep in contact with EOC via ICD/Trauma desk When ready to leave scene, ensure driver removes PPE outside vehicle, following process in Action Card 2c, rolls up the PPE and hands to the attendant to dispose of in the Clinical waste bag on the vehicle – Driver use own individual hand sanitiser, Page 98 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 when rear ambulance doors are closed. Driver MUST NOT drive in PPE that has been in contact with the patient. An alternative to the driver removing the PPE, is for someone who has not been in contact with the patient to drive, then both staff who are wearing PPE can travel in the back, removing PPE in a controlled environment at the hospital Ensure ICD/Trauma desk have informed local hospital regarding SUSPECTED case of V.H.F. confirming that there is an isolation cubicle available The officer will escort the crew to the relevant hospital – no contact with the patient is necessary for the on call officer If crew have to travel to Heartlands, ensure the full instructions regarding which department at the hospital is accepting the patient, and directions to the department are clear (see action card 4) if Birmingham Children’s see action card 6 At hospital, go in to the department and obtain details of the isolation room for the patient, then meet crew – Do Not come in to contact with the patient crew or transferring vehicle. Driver, if part of the crew, must don further relevant clean P.P.E. obtained from either the escorting officer Specialist PPE pack or the hospital staff before contact with patient at the hospital Ensure vehicle is secured when crew and patient leave the vehicle Ensure once patient is handed over - all used linen has been removed – leave with patient, or ask advice regarding whether to place in the hospital ‘contaminated laundry bag’ or a red incinerator bag. Ensure all clinical waste has been sealed in bags and left with the receiving hospital department. Ensure All PPE is removed as per Action Card 2c – supervise and advise crew on what to remove next Ensure clean Level Two PPE is worn to clean the vehicle at the hospital to make it safe to return Ensure Crew make the vehicle safe for return to base, and remove the PPE as per Action Card 2c again The vehicle can now be taken to the Hub for the Specialist Cleaning Team – Ensure the vehicle is quarantined at the Hub to await the cleaning team – The keys must be given to an AFA, who will move the vehicle to a safe place, Lock the vehicle, placing signage around regarding do not enter. All sets of keys for that vehicle to be locked in the AFA office, with the Fleetwave system fully updated to ensure no-one is allocated or given the vehicle to use. Crew can return to base for a change of uniform and shower if necessary – if full decontamination is required due to loss of body fluid, some hospitals have this facility, if not, the HART team can be contacted to perform this and advise on this Ensure any removed Equipment from vehicle is left with AFAs at the Hub for return to vehicle once it has been cleaned Ensure safety of crew and patient at all times If advice is required – Contact on Call NILO or IPC Lead Complete VHF Incident Record (Annex VI) and return to [email protected] Page 99 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE ACTION CARD 3a – Level THREE – Vehicle Preparation 1 2 3 4 5 6 7 8 ACTIONS Level Three patients are Very High risk awaiting confirmation or could already be Confirmed, so all unnecessary items must be removed from the vehicle and all items required need to be disposable or protected with plastic covers A vehicle will need to be prepared for VHF cases utilising the designated caged equipment from the HART base, AFA, Officer or any available person can start the process by stripping a vehicle at whichever Hub the vehicle is going to be collected from If the HART crew to bring the designated cages to the relevant Hub, kit placed on to the vehicle and PPE put ready for the attending crew, rest of the kit to stay in the escorting vehicle These cases will usually be a transfer from a local hospital to one of the Infectious Disease units either in London, Liverpool, Sheffield or Newcastle, so a time will be given to get to the patient with a fully prepared Ambulance and crew – PHE advise is a one hour response. If this is a case identified in the Community by the first crew/person to attend – their vehicle must NOT be used for the patient unless it is fully stripped and prepared on scene A fully prepared vehicle for a Level Three case will have been stripped – with all cupboards empty and all Lifting aids removed – Only the Oxygen to remain – enough for the journey – if HART designated cages are available, use the vehicle kit from these and equipment protection bags Only equipment necessary for the case will be placed back on to the vehicle – protective plastic bags for the equipment are available in the specialist PPE pack. I. Strip all equipment from cupboards and remove all lifting aids that are not required for the case II. If plastic protective covering is available, this can be used to cover cupboards, using it in strips from top to bottom of the vehicle, ensuring a 2 inch overlap for each sheet. Hand grab rails also need to be covered with the plastic protective covering. III. Place a white body bag on the stretcher – unzipped, with a large stretcher sized incontinent sheet inside the body bag – a large carry sheet can be placed underneath the body bag for ease of transfer IV. Put 3 blankets on the stretcher and pillow V. A carry chair may be required – ask the person booking the case – if not required, this can be left off VI. Any equipment required must be placed in a plastic bag, with the leads hanging out of the bag, sealed around the leads, so nothing can get on the piece of equipment – NB. Confirmed VHF Patients may have a DNR so resuscitation equipment may not be necessary – confirmed patients will be transported by HART as a Level Three patient VII. Oxygen flow meter and one of each type of mask and tubing – either adult or paediatric depending on patient VIII. Radio bag and Airwave Radio IX. Heavy Duty Clinical Waste bags x 4 X. Spill packs x 2 Page 100 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE XI. XII. XIII. XIV. XV. XVI. XVII. XVIII. XIX. XX. XXI. 9 Sharps box x 2 Cannulation equipment if necessary with giving set, fluids and any drugs required for pain relief and anti-emetic (Drugs pack) Tissues x 2 boxes Incontinent pads – small x 6 and spare large one Vomit bowls with absorbent crystal pouches in x 6 Urine collection pot and blue absorbent bag Spare gloves the correct size’s for crew of vehicle (full boxes), spare aprons x 4 and heavy duty gloves x 6 pairs – placed away from stretcher area so they are not in close vicinity to the patient 4 surgical masks for patient to wear Vehicle wipes - Clinell Alcohol Hand Sanitiser x 6 Small individual pots of water for Patient x 6 In the HART designated cages, all items in number 8 are in packs as below:Patient Clinical Items – Box ONE:2 of each type of O2 mask with tubing and nebuliser: 2 x Adult O2 masks 2 x Paed O2 masks 2 x Adult Trauma masks 2 x Paed Trauma masks 2 nebuliser acorns 2 tubing 6 sealed packs containing: Syringes, needles, drawing up devices and ampoule breakers x 10 Cannula packs x 2, tourniquets x 4, sterets x 10 and Chloraprep x 8 Cannula’s x 7 (2 x pink, 2 x green, 1 x grey, 1 x brown, 1 x blue) Bandages, tape and scissors Dressings and plasters Airways Patient Clinical Items – Box TWO: Sharps Box Giving Sets x 2 Page 101 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Sodium Chloride 500ml x 8 Paracetamol 1000mg in 100ml x 1 Patient Drugs and spares – Box THREE – NB. will need to be utilised from a normal vehicle Drug Pack Patient Consumable Items – Box FOUR Spare box of Tissues (One box on side ready to use) Spare Urine Collection Pot (One box on side ready to use) Spare Surgical masks for patient use x 5 (One on side ready to use) Spare Vomit Bowls with absorbent granules (One on side ready to use) Incontinent pads x 2 large and 6 small (One of each on side ready to use) Spare Bottles of Water x 5 (One on side ready to use) Vehicle Kit Out Ready to Use: White Body Bag Black Body Bag Large carry sheet 2 full Stretcher size Incontinent Sheets 3 Blankets (Disposable or woollen which are disposed of after case) 1 Pillow (Disposed of after case) and pillow case Monitor with 3 lead capability, BP cuff and Sats probe attached – wrapped in plastic bag Airwave Radio bag and Radio – Radio to go in bag (bag can be chlorine cleaned) Pack of Wipes (spare pack in large box) Spill pack Alcohol Gel Sanitiser x 1 (6 spares in large box) Roll of paper towel x 1 (plus spare in large box) Heavy Duty Large Clinical waste bags x 1 (3 in large box) Heavy Duty Small Clinical waste bags x 2 in vehicle (roll in large box) Page 102 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Box of tissues Vomit bowl with absorbent gel in Spares box for Crew in back of Ambulance: Full box of gloves of relevant size for members of staff attending Spare FFP3 masks x 6 – separately wrapped Spare surgical masks with visors x 6 Spare goggles x 2 Spare aprons x 4 separately wrapped Heavy duty gloves x 6 pairs Alcohol gel x 6 tottles Tape for quick repair of any rips – emergency use only Spill pack Sleeve protectors Slider Sheets Items for in the Cab of the vehicle: Map book PRF board and pack of PRFs Pen Sat Nav Bags for crew belongings (for their clothing and shoes etc – to be handed to the escorting officer) Patient Equipment on vehicle: Monitor with sats probe and BP cuff – Charging lead to keep monitor charged (protected with plastic bag and taped to wires and tubes) Suction Unit with suction catheters and connecting tubing (protected with plastic bag and taped to wires and tubes) BVM 2 large Oxygen cylinders connected and a flow meter 1 small Oxygen cylinder for transferring the patient 10 HART Designated VHF Cages Checks are required monthly to ensure items are not dusty and all are still in place. Cage of kit for the disrobing and cleaning of a vehicle after a case – This cage must contain the following: 2 buckets Page 103 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE 2 mop handles Minimum 10 disposable mop heads Pot of Haztabs and pot of Chlorclean Pack of cleaning cloths 2 rolls of paper towelling 2 Spill packs 8 x 60 litre Clinical waste bins and lids Box of absorbent granule packs to go in the clinical waste bins Roll of large heavy duty Clinical Waste bags, 10 ties and 10 labels 6 packs of wipes (Clinell) Alcohol gel (either 24 small tottles or 12 large dispensers) Pack of PPE for the staff who will be cleaning and helping disrobe – this kit will contain 3 Tyvek suits, 2 waterproof suits, 2 goggles, 1 safety glasses, 4 aprons, 2 pairs over boots, sleeve protectors, 4 surgical masks with visors 1 spare box of each size of PPE (M, L, XL and XXL) 1 spare box of each size of gloves (S, M, L and SL) 6 Pairs of Heavy Duty gloves 6 large incontinent sheets to use as absorbent floor covers when disrobing Roll of heavy duty aprons Box of sleeve protectors 4 surgical masks with visors 2 pairs of goggles 1 pair safety glasses 2 pairs of shears Rolls of tape – micro-pore and duct tape Tarpaulin for disrobing process Laminated set of Disrobing Action Cards NARU PPE kit spares must be in the designated VHF cages :NARU PPE kits – sizes M, L, XL and XXL Wellington boots – sizes from 5 to 12 The HART team of 6 who are going to a case, must ensure the correct sizes of Wellington boots and a box of PPE is available for them. Page 104 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST ACTION CARD 3b – Level THREE – Crew Actions and PPE MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE requirements Symptoms: Fever >37.5°C AND History of travel to high risk country within last 21 days – recent large outbreak of Ebola in West Africa 2014/15 – Guinea, Sierra Leone and Liberia – and has had contact with known case or samples from a known case – Contact CSD for them to check www.promedmail.org/ for the latest outbreak information The following may or may not be present: SEVERE Viral infection symptoms – sore throat, joint and muscle aches and pains, weakness, chest pain, rash, red eye hiccups, difficulty breathing and/or swallowing, with internal and/or external bleeding, diarrhoea and vomiting – which could be uncontrollable These cases will generally be transfers from a hospital in the West Midlands to go to a HSIDU elsewhere in England – though there is potential for this to be from a GP surgery, private address or in the community 1 2 3 4 5 6 7 8 9 10 11 12 Yes/No ACTIONS HART team of 6 staff contacted and mobilised – taking the designated VHF cages of kit with them. Equipment from the cages used to kit up the transporting vehicle – team to designate who are the 2 attendants and 1 driver Attendants x 2 ensure the correct sized wellington boots and PPE box is available for them to wear, 2 other members of the team must also ensure the correct size wellington boots and box of PPE is available for them to take the role of Safe Undresser and vehicle cleaner – with level 1 PPE for the Clinical Waste attendant Team of 6 liaise with Escorting Officer (probably the NILO) and meet at rendezvous point/Hub with vehicle to prepare Vehicle prepared as per Action Card 3a with the kit from the designated VHF cages Case could be from the community or a transfer from a hospital unit Additional equipment might be necessary; this will be agreed by the escorting officer and transferring hospital. HART staff designated as 2 Attendants, 1 driver, 1 drivers ‘mate’, 2 in escorting vehicle Escorting Officer will contact the transferring department for full instructions and details of patient which will be passed on to crew– ensuring only required correct equipment is being carried ONLY the 2 attendants need to don PPE at this stage, and ONLY the 2 attendants to come into contact with the patient. Don PPE at the latest time possible before collecting the patient to ensure attendants are wearing PPE for the least time possible – crew to have comfort break and a drink before the PPE is put on. Checklist for Dressing the Attendants:a) Collect bag for belongings and clothing from vehicle, box of PPE and wellington boots b) Remove ALL jewellery – Tie back hair – Cover any minor cuts with waterproof plasters – wash hands and put on scrubs c) Place all belongings in the crew belongings bag and give to the escorting officer for safe keeping d) Adjust/put together face shield to ensure it is ready to put on Page 105 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE 13 14 15 e) Put trouser legs of scrubs into socks f) Put on coverall – zip nearly up to neck, turn neck flap back on to itself as this is not required, and roll up legs to knees (NB. Do not use the adhesive strip over the zip) g) Put on wellington boots, roll the legs of the overall down over the top of the wellington’s h) Put on apron, ensure the top of the apron is high up by the neck – this means tying a knot in the neck strap. Ensure the back of the apron is tied securely i) Put on surgical cap – ensure all hair and ears are inside cap j) Put on FFP3 mask – cross the straps at top of head – use Buddy system for this k) Put on face shield l) Put on inner nitrile gloves underneath the cuffs of the overall – if finger loop is on the sleeves, put this over the middle finger over the back of hand m) Put on outer heavy duty gloves over the suit cuff n) Buddy check everything is on correctly, and write on the front of the apron in permanent marker name and role Escorting officer and the rest of the HART team will not have any direct touch contact with the patient or with the 2 members of staff attending once the patient has been collected Team and Escorting Officer will clear the way for the 2 attendants and the patient, control onlookers and secure the vehicle for the crew members attending to the patient. To collect patient who requires a stretcher – the patient can be placed into the WHITE body bag on top of the ultrasorb pad (large ultrasorb pad fitted in the bottom of the White Body bag – body bag used as a sort of sleeping bag, with blankets on if required, bag zipped part way to hold in as much body fluid as possible. If body bag does not have carrying handles, a carry sheet can be placed under the body bag for ease of patient transfer 16 Ensure Strict Hand Hygiene at all times – Do not touch any part of your face or body once wearing PPE and in contact with the patient 17 Crew check radio to ensure in contact with driver, Escorting Officer and Control 18 For patients with Confirmed VHF, in the Haemorrhagic stage there may be a DNR with the patient, as resuscitation is usually futile at this stage due to multiple organ failure, if DNR in place, do not assist with respirations or do cardiac compressions as these processes are high risk of aerosol spread of the infection. Care is focused on comfort, compassion and dignity at all times with fluid replacement therapy, pain relief and anti-emetics. NB. Vehicle must be stationary to perform any cannulation or to give any IM or IV drugs. 19 On arrival at hospital, crew prepare to leave the vehicle with the patient, wait until the doors have been opened by team or escorting Officer, as they will have confirmed the route to take at the receiving department 20 Team and escorting Officer will clear the way and open any doors for the crew 21 Driver ensure no person is able to enter the vehicle before a preliminary clean Page 106 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE takes place – lock vehicle if necessary. 22 Leave all used disposable items with the patient including body bag, blankets and any clinical waste produced on journey at the receiving hospital 23 Hand patient over to receiving staff, if at the Royal Free Hospital, London, they have a decontamination suite – Follow Action Card 3c for removal of PPE process Page 107 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE ACTION CARD 3c – Level THREE – PPE Removal 1 2 3 ACTIONS The driver will position the vehicle in a suitable area with easy access to washing and cleaning facilities. 2 members of escorting staff will prepare the area for the crew to disrobe – the hospital may have an area that can be utilised – Officer to check as to the viability of any area to be used To prepare the scene utilise the items taken from the designated cages for disrobing and cleaning: 4 5 6 7 Place tarpaulin on floor Designate/mark the tarpaulin to ensure there is a clear line for red, amber and green areas Place Clinical waste bins in each area on left hand side Place upturned clinical waste bin in second area on right hand side Place absorbent sheet in red area and amber area Place pack of wipes in red and amber area Place roll of paper towels in Amber area Place bottles of alcohol gel – 1 in red area, 4 in amber area and 1 in green area Extra gloves – marigold heavy duty and nitrile of the correct size will be required for each member of staff Safe Undressing Assistant to wear PPE – Overall, apron, face shield/mask, double gloves, wellington boots Safe Undressing Narrator will not require PPE – Laminated copy of the undressing procedure is required, and this person will remain in a place of safety where their instructions can be heard Clinical waste lead – will require minimum of Apron, face shield/mask and heavy duty gloves, their role is to secure the clinical waste bins and to clean the area using the mop handles, buckets, mop heads, cloths and Chlorine solution Any excess contamination on crew must be removed before any PPE is removed. This can either be done in the patient’s cubicle or in the first zone on the tarpaulin, while standing on an absorbent sheet. Take some wipes and clean gloves – dispose of the wipes, use alcohol gel on gloves. If gloves are damaged, exchange for new gloves Use wipes on face shield – followed by paper towels to ensure sight is not impaired Use wipes on apron to remove any excess contamination Use wipes on wellington boots to remove any excess contamination Clean gloves again with wipes and gel Once any gross contamination has been removed, move in to next area on tarpaulin Page 108 of 131 Yes/No WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Alcohol must be applied to the attendants hands by the Undressing assistant between each removal action 9 Attendants and assistant must follow the instructions fully from the Safe Undressing Lead – commentary is below 10 Repeat the process for the second attendant 11 Repeat the process for removal of PPE for the assistant 12 Clinical waste lead – ensure each bin is locked, and the outside of the bin is wiped clean, to ensure none of the bins are contaminated in anyway. Fold and dispose of the tarpaulin as clinical waste, and ensure the area is fully cleaned and decontaminated 8 ACTION CHECKLIST: UNDRESSING THE CLINICAL WORKER SAFE UNDRESSING ASSISTANT Seal used bin, move it out of the way and replace with empty bin CLINICAL WORKER In isolation room, use clinical wipes to remove obvious contamination from PPE Move to Red undressing station Apply alcohol gel to CW’s hands Perform hand hygiene Remove and discard apron Apply alcohol gel to CW’s hands Perform hand hygiene Remove and discard outer gloves Apply alcohol gel to CW’s hands Perform hand hygiene Remove CW’s coverall and boots Unzip coverall Face SUA and tilt head back Step backwards one pace Turn 180º. Put arms straight and backwards Grasp coverall at shoulders Pull arms free of sleeves Roll down coverall to ankles Clasp hands together Grasp ankle of right boot Step out of right boot Grasp ankle of left boot Step out of left boot Put coverall and boots in bin Move to Amber undressing station Remove and discard outer gloves Apply alcohol gel to own and CW’s hands, and perform hand hygiene Perform hand hygiene Put on replacement outer gloves if a second CW requires undressing assistance Remove and discard face shield Apply alcohol gel to CW’s hands Page 109 of 131 Perform hand hygiene WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Remove and discard FFP3 respirator Remove and discard surgical cap Apply alcohol gel to CW’s hands Perform hand hygiene Remove and discard inner gloves Replace bin if required for second CW Go to sink to wash hands in soap and water If no second CW requiring undressing, remain in decontamination room to assist SUA ACTION CHECKLIST: UNDRESSING THE ASSISTANT SAFE UNDRESSING ASSISTANT CLINICAL WORKER Clean upturned bin and alcohol gel bottle Move to Red undressing station Perform hand hygiene Apply alcohol gel to SUA’s hands Remove and discard gown Perform hand hygiene Apply alcohol gel to SUA’s hands Step out of clogs into Amber area Move to Amber undressing station Remove and discard face shield Discard clogs into waste bin (optional*) Perform hand hygiene Apply alcohol gel to SUA’s hands Remove and discard inner gloves Go to sink to wash hands in soap and water Put on clean gloves Put lid on bin Visual check of equipment available in Red Zone (bins, wipes, gel and gloves) Discard gloves and perform hand hygiene Exit decontamination room/area Page 110 of 131 Exit decontamination room/area WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE ACTION CARD 3d – Level THREE – Vehicle Cleaning ACTIONS EOC have been informed crew and vehicle are off call for decontamination 1 clean Following case, crew have disposed of all waste at the receiving hospital in 2 the correct waste stream for the hospital Following case, crew have disposed of all used linen at the receiving hospital 3 in the Infected laundry stream Following case, designated vehicle cleaner will don clean PPE – overall, 4 surgical mask with visor, wellington boots, heavy duty marigold gloves, to clean the stretcher and vehicle using mop, bucket, chlorine, the vehicle wipes and spill kit if necessary to make the vehicle safe for return to base NB. Any use of Chlorine releasing agent requires a well ventilated area 4a Any body fluid spillage must be absorbed using the contents of a ‘spill pack’ 4b Make a solution of Chlorclean – 4 tablets per 1 litre of cold water to make a solution of 1,000ppm if there is no obvious body fluid spill 4c If there has been a body fluid spill – a Haztab solution must be made up, which is 1 tablet per 1 litre of cold water to make a solution of 10,000ppm 4d Split vehicle into at least 6 sections to mop – starting firstly with the side door – squeeze out mop, wipe all over the side door and window – then open the side door to ensure there is a good air flow throughout the vehicle 4e Change the mop head and dispose of the used mop head as clinical waste after each use – do not put a used mop head back in to any chlorine solution, as this may stop the chlorine from working 4f With last but one mop head, mop the plastic bags covering the equipment 4g With last mop head, clean the floor and leave for a minimum of 2 minutes to ensure the chlorine is in contact for the required time to kill any microorganisms 4h The vehicle can then be wiped dry using clean, dry mop heads or paper towels 4i Strict hand hygiene standards must be followed at all times while cleaning When vehicle is safe and dry, replace the stretcher and equipment 5 Remove PPE following the relevant parts of the safe disrobing process 6 The vehicle can then be driven back to the relevant base to await a specialist 7 clean. The Specialist Cleaning team on call Supervisor must be contacted by I.C.D. 8 to ensure they are aware that a vehicle will need to be quarantined when it arrives at any base. On arrival at base, driver to secure the vehicle in a relevant safe place – lock 9 all doors and place signage on vehicle ‘Do Not Use’ – Keys must be locked securely away, and Fleetwave updated that the vehicle is off call awaiting specialist clean 10 The vehicle can then be left in a safe place to await the results of any blood tests if the patient is a ‘suspected’ case – if the case is already confirmed, the specialist cleaning team will have to be mobilised to clean the vehicle. If the case is negative and the tests have not shown any infectious risk, the vehicle Page 111 of 131 Yes/No WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE 11 12 12a 12b 12c 12d 12e 12f 12g 13 14 15 16 17 18 19 20 can be taken out of quarantine, cleaned and made ready as normal – any infection risk, the vehicle will require a deep clean by the AFAs If the case is already confirmedVHF – the Specialist Cleaning team (SCT) will be required to do the full clean on the vehicle SCT will need to prepare all required items by the vehicle before starting the deep clean Clean Mop and Bucket containing cold water and Chlor clean for the floor Bucket or bowl containing cold water and Chlorclean for the disinfectant stage of the internal clean Bucket or pack of detergent wipes Approximate number of cloths required for the job Large yellow bags and ties x 2 PPE - white fluid repellent overall, plastic apron, wellington boots, fluid repellent face mask with visor and gloves – with spare set to use once detergent clean has finished Ensure a comfort break is taken before the clean starts – do not eat or drink while cleaning the vehicle or leave the vehicle to go to the other facilities unless all PPE is taken off and hands washed – clean PPE will need to be put on when the vehicle clean re-commences. SCT have the equipment to spray the vehicle if it was badly contaminated – to use the spray, waterproof overalls, FFP3 mask and surgical mask with visor or goggles must be worn The vehicle must then be left for 2 minutes then the vehicle dried with paper towels and dry disposable mop heads. All PPE will then need to be removed following the safe disrobing process in Action Card 2c Clean PPE will then be required to complete the deep clean of the vehicle – water repellent overall can be used with marigold gloves, apron, surgical mask with visor and over boots. Any equipment removed must be placed separately to any other items at the Hub and kept to one side until vehicle cleaning has taken place. Vehicle deep clean must start at the front of the vehicle (Cab then saloon), working the way to the back, firstly using detergent wipes and follow the process for a Deep Clean, disposing of all cloths as Clinical Waste. Disposable items should have already been removed by the crew, any remaining can be disposed of as clinical waste – any sharps containers used, must be locked and disposed of. All sharps and clinical waste from a confirmed VHF patient must be kept separately, and identifiable to the incinerator – use 60 litre sharps bins as per the safe disrobing process for HART crews. Once a full deep clean has taken place, the vehicle can be re-kitted, made ready and re-used. Page 112 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE ACTION CARD 3e – Level THREE – Officer Actions 1 2 3 3a 3b 3c 3d 3e ACTIONS HART team of 6 staff contacted and mobilised with the relevant PPE and cleaning items as in the designated cages from HART base Crew of 6 liaise with Escorting Officer and meet at rendezvous point in vehicle containing designated VHF cages of kit, which includes PPE, Disrobing and cleaning kit cage Vehicle at Hub can start to be stripped to await arrival of the HART team and designated VHF cages Remove all unnecessary equipment and staff belongings at base if possible, if not, should be placed safely in one of the escorting vehicle’s Vehicle kit minimum list:– Stretcher Carry chair and any other relevant lifting aids – carry sheet and slide sheet 3 blankets (either disposable or normal ones that must be disposed of following case) 6 vomit bowls and Vernagel sachets 2 Stretcher sized incontinent sheets and 4 normal sized ones Body bag for on stretcher Contents of a specialist IPC pack containing spare FFP3 masks for crew on journey, surgical face masks for patient, clinical waste bag, laundry bag, aprons Spill kit 2 boxes of tissues and a roll or pack of paper towels Boxes of gloves of relevant sizes for members of staff treating patient Disposable urine collecting device Disposable suction – or vehicle based Suction unit with clear plastic bag fully over, taped to disposable tubing Sharps boxes x 2 Drinking water for patient if long journey Alcohol hand sanitiser – 6 on vehicle, with 20 carried in escorting vehicle ready for the disrobing process Pack of sanitising wipes – 1 on vehicle, plus extra 6 packs carried in escorting vehicle for disrobing process 1 Airwave radio inside plastic protective bag Any equipment must be inside plastic bags secured with tape Ensure the vehicle is in a road worthy condition and is fully fuelled Ensure there is enough oxygen cylinders for the patient on the journey with enough of the relevant masks to use Officers car and escorting vehicle to contain the following items: Respirator and disposable tubing (Parapac) and clear plastic bag to hold the Parapac with the top of the bag taped securely around the disposable tubing Page 113 of 131 Yes/No WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Response bag – fully kitted – though only relevant items would be placed in to the back of transporting vehicle BVM Torch Airwave Radio with spare batteries and spare protective bag PRF and pen’s – can go in the cab of the transporting vehicle Map book or specific instructions for the journey – can go in the cab of the transporting vehicle Cleaning and disrobing items in designated VHF cages Additional equipment might be necessary; this will be agreed by the transferring hospital. Members of HART team to decide who is driver, 2 attendants, Safe undressing assistant, safe undressing lead and Clinical waste lead PPE boxes are required from the designated VHF cages for both attendants, plus spare boxes and wellington boots for both attendants and Safe Undressing Assistant – ensure correct sizes are available for all staff in the team Driver, undressing assistant and lead, clinical waste lead and escorting officer will not have any direct touch contact with the 2 members of staff attending once the patient has been collected. The escorting Officer will contact the transferring department for full instructions and details of patient to ensure the correct equipment is being carried HART team and escorting officer will clean the way for the crew and patient, to control on lookers and secure the vehicle 4 5 6 7 8 9 10 To collect patient who requires a stretcher – place Body Bag unzipped on to the stretcher, with a full length Ultrasorb sheet inside the bag, and a pillow at the head end, the patient can be placed in to the body bag, then have blankets over with the zip pulled half way round over patient and blankets to use like a plastic sleeping bag – this should contain many of the body fluid loss – a carry sheet can be placed under the body bag for ease of transfer 11 Escorting Officer to ensure communication is possible between all members of staff and control – Airwave Radio in with crew and patient must be contained in a plastic bag provided by the Escorting Officer from the specialist pack. Open Talk Group to be assigned by ICD 12 Escorting Officer to confirm details of receiving hospital and person accepting the patient. With full instructions on route to the hospital and receiving department 13 Escorting Officer to follow the vehicle all of the way to receiving hospital 14 Escorting Officer ensure ICD/Trauma desk have contacted the police forces and ambulance services on way to the receiving hospital so they are aware just in case of vehicle breakdown or accident – a police escort may be required 15 If the journey is likely to take longer than 2 and a half to 3 hours, a pre-planned change of crew may be required – this will have to be arranged with the relevant service HART team on way to the receiving hospital 16 At the completion of the case or if the attending crew have to be changed for any reason, they will need to be decontaminated utilising a designated decontamination area and safe disrobing process – Ensure this takes place Page 114 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE effectively 17 Ensure no person is able to enter the vehicle before a preliminary clean takes place – lock vehicle if necessary. 18 Leave all used disposable items with the patient including body bag and blankets 19 Dispose of all unused disposable items that have been on the back with the patient in to a clinical waste bag 20 Any items of equipment in plastic bags – follow cleaning process – carefully remove any disposable wires or tubing – then peel off the ‘contaminated’ bag, removing the ‘clean’ item of equipment – these items of equipment can then be placed in to the Escorting vehicle or car for return to base. 21 Ensure any blood spillage is cleaned using a Spill Kit 22 Ensure vehicle is ‘aired’ once any blood spillage has been removed due to chlorine use 23 Ensure vehicle is made safe for return to base following Action Card 3d 24 If crew need to shower – use towels from receiving hospital and borrow set of scrubs for each member of staff – or utilise items held in the escorting vehicles 25 Following comfort break, all members of staff can return to base. 26 Ensure EOC ICD are kept informed throughout regarding progress during the case 27 On return to the Hub where the vehicle is based, ensure the AFAs are aware that the vehicle will need to be cleaned by the Specialist Cleaning team – Vehicle must be placed in to Quarantine until the clean has been done – utilising signage and locking away of keys. Page 115 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Action Card 4 – Admission to Heartlands Hospital Chief Executive/Deputy CEO or Locality Director – onYes/No call ACTIONS 1 2 3 Should a patient require conveyance to Heartlands Hospital Ward 28, EOC will have discussed with the ID Consultant that admittance is appropriate Before the crew arrive at Heartlands Hospital WMAS Trauma Desk or Clinical Support desk will contact Heartlands Hospital on 0121 424 0582 to give an estimated ETA of the vehicle and must state the incoming patient is suffering from ‘suspected Ebola/VHF outbreak’ in addition they must state if the patient is an adult or child On arrival at Heartlands the ambulance will be met at point A on the map at 5 below, by an arrivals team. Then escorted to Ward 28. The arrivals team will consist of security and porters providing a progressive lockdown in addition cleaners will follow the crew to mop floors, and clean all touch points and the lift on route to the ward. 4 All PPE worn by the crew will be taken off on the ward and disposed of by Heartlands staff. Showers may be available for WMAS crew use. The ambulance trolley will be cleaned appropriately prior to going back to the ambulance. Route back from ward will be as normal. 5 Point A Conveying Ambulance awaits Heartlands Arrival Team at the barrier Page 116 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Action Card 5 – Collecting Patient from Birmingham Airport Chief Executive/DeputyACTIONS CEO or Locality Director – on call Yes/No 1 Screening at Birmingham Airport for Ebola has now finished by Public Health England regarding the large outbreak in 2014/15 – however, a patient on a plane could be identified as a risk, so a 999 call could be made advising of the risk 2 The responding crew will proceed to the Birmingham Airport Airside RVP point on Ramp Road 3 The responding crew will be provided with a vehicle escort from Ramp Road to go airside and park up at an appropriate parking location, Don appropriate level of PPE as directed by EOC and then pedestrian escort (short distance) to the Port Health Room, which is located within the North International Baggage Hall. 4 Upon patient assessment, should conveyance be required the crew will be escorted back to the RVP for onward transportation to the appropriate health care facility following existing operating procedures 5 Ramp Road RVP Page 117 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Action Card 6 – Birmingham Children’s Hospital Entrance Chief Executive/DeputyACTIONS CEO or Locality Director – on Yes/No call 1 2 3 4 Should a patient require conveyance to Birmingham Children’s Hospital (BCH), EOC will have discussed with the ID Consultant that admittance is appropriate to the isolation room in PICU Before the crew arrive at BCH WMAS Trauma Desk or Clinical Support desk will contact BCH, to give an estimated ETA of the vehicle and must state the incoming patient is suffering from ‘suspected VHF outbreak’ in addition to patient details On arrival at BCH the ambulance will go to point A on the map at 5 below, and not to the main A&E entrance to be escorted to the isolation room in PICU All PPE worn by the crew will be taken off on the ward and disposed of by BCH staff. Showers may be available for WMAS crew use. The ambulance trolley will be cleaned appropriately prior to going back to the ambulance. Route back from ward will be as normal. 5 Point A Conveying Ambulance enters at front of BCH and await escorting team, do not go via A&E Page 118 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Action Card 7 – Community First Responder First on Scene Chief Executive/Deputy CEO or Locality Director – on call 1 2 ACTIONS If the 999 call flags up any risk of VHF disease, the Community First Responder (CFR) will receive a stand down from the case by E.O.C. If a CFR arrives at scene and finds that the patient has:High Temperature >37.5°Cwith symptoms of a viral infection AND History of travel to a high risk country – contact CSD for them to check on www.promedmail.org/ for latest outbreak in formation 3 4 5 6 Withdraw from scene and call control immediately Inform control that you have a suspicion that the patient could have VHF. Control will need to know what symptoms the patient has so they can ascertain the level of risk. If patient has No Symptoms other than a high temperature and slight viral symptoms, and has travel history to a high risk country, this is classed as a Level ONE risk – PPE required is: Apron Gloves Surgical mask with visor Strict Hand Hygiene at all times – use of hand gel and wipes If these items are available, you may go back in to the patient to explain a crew is on the way, and they will be wearing PPE so they should not be alarmed, it is part of the procedure – Have as little patient contact that is possible If patient has more severe viral symptoms such as a sore throat, joint and muscle aches and pains, weakness, chest pain, rash, red eyes, hiccups, difficulty breathing and/or swallowing and travel history to a high risk VHF country as identified by CSD and/or contact with known case, this is called a Level TWO risk – PPE required is: Water Repellent Overall Apron Double Gloves Surgical Mask with visor or FFP3 mask and safety glasses Shoe protectors If these items are available, you may go back to the address to let the family know a crew is on the way, and they will be wearing PPE so they should not be alarmed, it is part of the procedure – Have little or NO patient contact if that is possible – If there is any loss of blood or body fluid do not go back in to the address If patient has more severe viral symptoms as in 5, travel history or contact AND there is ANY loss of blood or body fluid – this is a Level Three Risk - these cases require Specialist PPE and transport by HART crew in specially prepared vehicle – DO NOT return to the house if you will come in to contact with the patient, advise family to isolate patient and there will be a crew there as soon as possible. Withdraw from scene. Page 119 of 131 Yes/No WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Action Card 8 – Patient Transport Services, High Dependency and H.C.R.T. – Road and Control Ensure you use STRICT HAND HYGIENEStaff at all times 7 Chief Executive/DeputyACTIONS CEO or Locality Director – on call Yes/No 1 2 2a Patient Transport Services staff, including High Dependency Crews and Healthcare Referral teams MUST NOT be sent to any SUSPECTED or known cases of VHF – For example: Ebola If a PTS driver or crew are sent for a patient for a routine journey who displays signs and symptoms of an infection such as those in box 2a below, the patient must not be collected or touched by the members of staff – they must contact control immediately to pass on their suspicions Symptoms: Fever >37.5°C (fever symptoms could be: feeling hot and cold, sweating, headache and the shivers) AND History of travel to high risk country within last 21 days – recent outbreak in West Africa of Ebola 2014/15 was in Guinea, Sierra Leone and Liberia – contact CSD for information on the most up to date outbreaks as they can check on www.promedmail.org/ or the patient may know they have been in contact with a known case of VHF or samples from a known case The following may or may not be present: Viral infection symptoms – sore throat, joint and muscle aches and pains, weakness, chest pain, rash, red eye hiccups, difficulty breathing and/or swallowing 3 4 5 6 7 8 9 Explain to the patient that you are gaining advice regarding their condition from your colleagues in control and they will be arranging for someone else to call them – Do Not Have ANY contact with the patient Obtain the telephone number for the address if possible and WITHDRAW FROM SCENE. Inform PTS control that you believe the patient may have an infection that has been brought in from Abroad due to the fact they have returned from one of the high risk areas within the last 21 days or been in contact with a known patient/sample On return to the Ambulance vehicle, dispose of any PPE worn in a Yellow Clinical Waste – sealing the top of the bag with a tie or secure knot, then use the vehicle based wipes to clean your hands, and follow this with the hand sanitiser Depending on contact with the patient, a return to base to wash hands and clean any equipment may be required. If a member of staff has come in to direct contact with a SUSPECTED case, advice will be required from the On-Call NILO and/or IPC Lead regarding the follow up required, which will depend on the amount of contact with the patient PTS Control staff who receive a call to say staff believe they have been sent to a possible case of VHF must pass the information immediately to the Emergency Operations Centre (EOC). PTS Control must ring 01384 246035 and ask for the EOC Supervisor, explaining that a PTS crew believe they have identified a SUSPECTED case of VHF. Page 120 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Action Card 9 – Occupational Health Follow Up after a CONFIRMED Case Yes/No ACTIONS All staff are expected to follow strict Infection Prevention and control standards 1Chief Executive/Deputy CEO or Locality Director – on call at all times, and wear the appropriate PPE as stated for the relevant risk in Action Cards One, Two and Three. Following transport of a SUSPECTED VHF case, who when tested is found to 2 be positive to VHF disease, Public Health England will inform WMAS via the Infection Prevention and Control Lead and Occupational Health Nurse Manager The Infection Prevention and Control (IPC) Lead will liaise with WMAS 3 Occupational Health Nurse (OHN) Manager, who will arrange for any relevant follow up Members of staff who have transported a CONFIRMED case will follow the 4 instructions from Public Health England regarding taking their temperature twice per day if necessary and reporting any rise above 37.5°C There are no restrictions on Healthcare workers continuing with work following 5 exposure to a SUSPECTED or CONFIRMED case of VHF whilst on their normal daily duties The incubation period following exposure to a confirmed case is approximately 6 2 to 21 days – a confirmation of the diagnosis for any cases will normally be known by day 2 of contact. If a patient is found to be positive to VHF disease – the members of staff who 7 have transported the patient will be contacted by Public Health England to arrange for them to monitor their own temperature twice daily for 21 days – this is not optional – and must also be recorded by the member of staff. The member of staff will have to report any increase in their temperature above 8 37.5°C to Public Health England and their own GP For Voluntary Aid Workers – please see H.R. Information Sheet for Managers 9 of Voluntary Aid Workers 10 For any further information please contact Debbie Glasgow Occupational Health Nurse Manager [email protected] Page 121 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Action Card 10 – Dispatch Actions Chief Executive/Deputy CEO or Locality Director – on call Yes/No ACTIONS 1 2 3 4 5 Inform responding vehicles of SUSPECTED or CONFIRMED case of VHF. Escalate to the Duty Manager. Inform ASO RCC to Trauma Desk When the vehicle clears at hospital- place on downtime - unavailable Inform Logistics and Duty Manager the vehicle that the vehicle is clear and returning to the Hub. DISPATCH ACTIONS – SUSPECTED IMPORTED INFECTIOUS DISEASES V3 (Viral Haemorrhagic Fevers including Ebola, Marlburg, Lassa and Crimean Congo Fever) Call received with symptoms of severe viral infection reported A fever >37.5°C or history of fever in the previous 24 hours Joint and muscle pain Sore throat, intense weakness and chest pain Some patients may develop a rash, red eye and hiccups Difficulty with breathing and/or swallowing A Has the patient been to one of the High Risk Countries in the last 21 Days where there is a current VHF outbreak– recent large outbreak of Ebola in West Africa 2014/15 in Guinea, Sierra Leone and Liberia N.B. If any other area of Africa is documented in the notes, please check with CSD re recent outbreaks (www.promedmail.org/ ) B Has the patient been in contact with/cared for someone or been in contact with specimens of blood, urine, faeces, tissues, laboratory cultures from an individual or animal strongly SUSPECTED or known to have VHF NO to A and B Dispatch as per normal EOC Dispatch Protocol CSD SUSPECT LOW POSSIBILITY OF VHF YES to A No to B Case will be passed to CSD for further questioning CSD SUSPECT HIGH POSSIBILITY OF VHF Dispatch and notify RCC through save & notify function LOW POSSIBILITY OF VHF CASE WILL BE MANAGED BY REGIONAL Page 122 of 131 TRAUMA DESK YES to B or A and B Dispatch and notify RCC through save & notify function HIGH POSSIBILITY OF VHF CASE WILL BE MANAGED BY REGIONAL TRAUMA DESK WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Action Card 11 – Trauma Desk Actions Chief Executive/DeputyACTIONS CEO or Locality Director – onYes/No call 1 2 3 4 5 6 7 8 9 10 Confirm Case meets criteria for SUSPECTED or CONFIRMED utilising the flow charts. Confirm the responding resource has the relevant PPE on the vehicle, and inform crew of the Level of PPE required. Any suspicion of loss of Blood or Body Fluid in a High Risk Case is a Level Three case which generates a HART response and specially prepared vehicle for transport or transfer Assign a TG in consultation with ICD Alert receiving Emergency Department with details and confirm patient to be isolated in a side room If Heartlands - contact Infectious Diseases Consultant On Call who is the SPOC for admission of SUSPECTED cases, who will bypass the ED Department and follow Action Card 4 as the crew will be escorted through the hospital, following liaison at the barrier. Queries about patients already admitted should be addressed to the on-call Virologist Ensure correct level of PPE is to be used and corresponds with patients symptoms and risk Inform NILO Inform Infection Control Lead (OOH by email) Page 123 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Action Card 12 – Logistics Desk Chief Executive/DeputyACTIONS CEO or Locality Director – onYes/No call 1 2 2 3 4 5 Confirm what level of case the crew have transported (Level One, Level Two or Level Three) Inform ASO crew returning to station following Level One or Two VHF case if the ASO is not on scene Contact AFAs to advise the vehicle is on the way back to the Hub and will require a Level one or Two clean and to make area ready for a quarantined vehicle See Action Cards 1d, 2d and 3d Level One Clean – AFA clean of all flat surfaces wearing Level One PPE (Apron and Gloves) Level Two Clean – Specialist Cleaning Team will need to be informed they are required to clean or spray the interior of the vehicle and remove the plastic sheeting if it is in place Level Three Clean – Specialist Cleaning Team will need to be informed they are required to do the full clean of the vehicle Crew may need to have a shower and change of uniform depending on what they have been in contact with: Level One – Low risk of requiring full decon unless they have been in contact with body fluid Level Two – May be needing a shower as the level two PPE is very warm to wear – if there has been a breach in PPE and body fluid spillage, then the crew may need to be de-contaminated by HART crew Level Three – Should only be transported by HART crews, who should already be decontaminated at the receiving hospital, though will require a return to base for full change of clothing and to collect their original vehicle Identify a replacement vehicle if necessary for the crew to use once they have showered and changed Action Card 13 – EOC Duty Manager Actions Yes/No ACTIONS Chief Executive/Deputy CEO or Locality Director – on call 1 2 3 Ensure Job has been RCC’d Ensure Escalation Policy has been followed Ensure NILO and Infection Control Lead have been informed Page 124 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Action Card 14 – 111 Call Handler Chief Executive/Deputy CEO or Locality Director – on call 111 Call Patients Demographics What’s the Reason for the Call Illness Injury Complet e call as normal Call to 111: Severe viral infection symptoms with fever >37.5° Viral Infection Symptoms: - Sore throat, joint and muscle aches and pains, weakness, chest pain, rash, red eye, hiccups, difficulty breathing and/or swallowing – And these symptoms are not known to be associated with any other particular illness Ask the following questions: 7. Has the patient been to one of the High Risk Countries in the last 21 Days check with CSD who can check www.promedmail,org/ 8. Has the patient been in contact with/cared for someone or been in contact with specimens of blood, urine, faeces, tissues, laboratory cultures from an individual or animal strongly SUSPECTED or known to have VHF Yes Complete module 0. On reaching the body map: Early Exit 125 Transfer Page of 131 to a Clinician Complex call Yes to B or A+B Pass onto Clinician No Complet e call as normal WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Action Card 15 – 999 Call Handler Chief Executive/Deputy CEO or Locality Director – on call CALL ASSESSING ACTIONS – SUSPECTED IMPORTED INFECTIOUS DISEASES (VERSION 3) (Viral Haemorrhagic Fevers including Ebola, Marlburg, Lassa and Crimean Congo Fever) Call received with a fever and any symptom of severe viral infection (see below) DECLARED by the patient/caller Symptoms of severe viral infection: Joint and muscle pain Sore throat, intense weakness and chest pain Some patients may develop a rash, red eye and hiccups Difficulty with breathing and/or swallowing ASK BOTH OF THESE QUESTIONS AHas the patient been to one of the High Risk Countries in the last 21 Days where there is a current VHF outbreak– recent outbreak of Ebola in West Africa 2014/15 – Guinea, Sierra Leone or Liberia N.B. If any other area of Africa is documented in the notes, please check with CSD if there is a current outbreak, as they can check on www.promedmail.org/ B Has the patient been in contact with any person, animal or specimen of blood, urine, faeces, tissues or laboratory culture from a suspected case of any viral haemorrhagic fever? NO to A and B or unknown to both YES to A No to B YES to B or A and B Case to be passed to CSD Process as per normal protocol Complete module 0. On reaching the body map: Early Exit Transfer to a clinician Complex call A clinician from our service will call the individual back immediately to assess the problem Case to be passed to dispatch Complete module 0. On reaching the body map: Early Exit Transfer to a clinician Complex call An emergency ambulance is being arranged YOU MUST SAVE AND NOTIFY ANY POSITIVE ANSWER TO QUESTION A OR B Page 126 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Annex V – How to Self-Fit Check an FFP3 Mask Page 127 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Annex VI VHF Incident Record Date of incident Time of incident Case Number Name of Officer/Manager in attendance at scene Crew/s RRV Base Crew/s RRV call signs Area/hospital Patient collected from? 999/111/transfer/Doctors call Fever? History of travel? What country? Suspected/low, high risk or confirmed? What level of PPE worn? Receiving Hospital Name Doctor Accepting patients name Any contact with blood or body fluids? Crew Welfare check? Any learning from incident? Please forward completed record to [email protected] Page 128 of 131 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Annex VII List of Premises for HART crew to Exchange crew and vehicle on Transfers TRUST Station Postcode Near to NWAS Penrith Broughton Sandbach Manchester HART Liverpool HART CA11 8HY PR3 5LN CW11 1FJ M17 1EH L11 9AP M6 M6 M6 M6 NEAS Berwick Alnwick Hexham HART Coulby Newham Darlington TD15 2XF NE66 2NN NE46 4DQ NE31 2JZ TS8 0TQ DL1 5LN A1 A1 A69 A1 A19 A1 YAS HART Bentley Magna LS11 8LQ DN5 9SL S60 1FD M62/M621 WMAS HART Stoke Hub Warwick Hub Worcester Hub B69 4LH ST4 6RR CV34 6LG WR5 2NL M5 M6 M40 M50 EMAS HART Loughborough Narborough Mereway NG18 5BU LE11 3GE LE19 3EQ NN4 8BE M1 Jn 28 M1 Jn 23 M1 Jn 21 M1 Jn 15 EEAT Peterborough PE1 5UA SG8 6EN or SG8 6NA LU1 1XL A1(M) A1(M)/ M11 M1 AL7 4HL A1(M) CM77 7AH M11 Melbourn HART Luton Welwyn Garden City Great Notley HART Page 129 of 131 M1 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE LAS HART East HART West E16 4TL TW7 6DT M4 SWASFT HART South HART North EX5 2FL BS34 7QH M5 Jn 29 M5/M4 SCAS Nursling HART Basingstoke Kidlington SO16 0YU SO50 4ET RG24 9LY OX5 IUD M27 HART East HART West TN24 0GN RH11 0TG SECAmb Page 130 of 131 A303, M3 M40 WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST MANAGEMENT OF INFECTIOUS DISEASE PROCEDURE Annex VIII Flow Chart for vehicle returning for cleaning Incident Command Desk Inform Logistics where the vehicle is returning to Level One Low risk – NO body fluid spills: All flat surfaces wiped clean using Chlorclean at 1,000ppm (4 tablets Chlorclean in 1 litre of cold water) in well ventilated area PPE – Overall, apron, double gloves AFA clean Level Two High Risk – NO Body fluid spills: Contact On-Call AFA Supervisor to mobilise the Specialist Cleaning Team Organise a replacement vehicle for crew Partition off part of the car park with bollards for vehicle to be kept in quarantine and get sign ready to go on vehicle Logistics desk contact relevant AFA unit:Willenhall 01384 266723 Dudley 01384 215631 West Bromwich 0121 525 9720 Erdington 01785 237164 Hollymoor 01785 237157 Tollgate 01785 237332 Lichfield 01785 237176 Stoke 01782 338670 Coventry 01785 237151 Warwick 01785 237170 Shrewsbury 07584 999867 Donnington 01384 215767 / 07584 999865 Bromsgrove 01384 266792 / 07825 720905 Worcester 01384 215876 / 07920 278390 Hereford 01384 215884 Inform Vehicle Number has been to a Level 1, 2 or 3 VHF patient, ETA at the Hub or HART unit so that a quarantine area can be arranged Level Three VERY High Risk/Confirmed – could have been body fluid spills Contact On-Call Supervisor to mobilise the Specialist Cleaning Team (S.C.T.) Inform S.C.T. where the vehicle is going to be kept in quarantine (could be HART base) When Vehicle Arrives back at Hub: Show crew where the vehicle needs to be placed, and give them the sign to go on windscreen Crew lock and secure vehicle Crew hand keys to AFA AFA take all keys for that vehicle into AFA office Put keys in envelope – mark envelope ‘Quarantine Vehicle keys – vehicle number’ Page 131 of 131 If on Hub – Partition off part of the car park with bollards for vehicle to be kept in quarantine, and get sign ready to go on vehicle AFA ensure NO-ONE can access the vehicle Put notes on Fleetwave regarding vehicle off call in quarantine Inform Duty ASO Await instructions from S.C.T.
