Download Ebola - HealthONE

Ebola
HCA Continental Division Response
October 13, 2014
Prepare
to
Detect
Prepare
to
Protect
Prepare
to
Respond
Information Sources
• Centers for Disease Control and Prevention
• University of Nebraska Biocontainment
Patient Care Unit
• University of Texas Medical Branch-Galveston
National Laboratory Biosafety Level 4
• HCA: Clinical Services Group
• World Health Organization
Presenters
• Gary Winfield MD
– Division Chief Medical Officer
• Lindy Garvin RN, CPHRM
– Division Vice President of Quality and Patient Safety
• David Markenson, MD
– CMO Sky Ridge Medical Center
• Steve Quach MD
– CMO PSL Medical Center
• Paul Hancock MD
– CMO Swedish Medical Center
• Dianne McCallister MD
– CMO The Medical Center of Aurora
Agenda
•
•
•
•
•
•
Introduction
Ebola History and Overview
Prepare to Detect
Prepare to Protect
Prepare to Respond
Division Response and Communication
Ebola History and Overview
David Markenson, MD
Chief Medical Officer
Sky Ridge Medical Center
Overview
• Ebola hemorrhagic fever or EVD
– Viral Hemorrhagic Fever
– Rare and deadly disease
– Caused by infection with one of the Ebola virus strains.
• Named after the Ebola River in the Democratic Republic of
the Congo (formerly Zaire)
• First outbreak (Zaire 1976)
– 318 human cases
– 88% mortality
– Disease spread by close personal contact in hospital setting
• Five types
– Zaire, Sudan, Tai Forrest, Bundibugyo and Reston
Viral Hemorrhagic Fevers
• Cases in the United States are extremely rare
– Have occurred multiple times
– Yearly there are possible cases as well as actual
• Dengue probably most common
– Recently have visited endemic areas
– Potential occupational exposure
Viral Hemorrhagic Fevers (cont.)
• Vascular Damage and hemorrhage
• Fatality < 10% (Dengue) to 90% (Ebola)
• Five families of viruses
– Arenaviruses (Lasa, Junin Virus)
– Bunyaviruses (Nariovirus, Hanta Virus)
– Flaviviruses (Dengue, Yellow Fever)
– Filoviruses (Marburg & Ebola)
– Paramyxoviruses (Hendra, Nipah but also Measles
and Mumps)
Ebola Past Outbreak – Key Points
• Predominantly Africa
• Many index cases are people who ate bush meat
• Only one sub-type (reston) had possible airborne
transmission
– Only transmitted to non-human primates
– Evidence for airborne is weak
– Not common species of Ebola
• Spread has been due to healthcare sites, burial
rituals and close family contact with ill patient's
– Most cases found no PPE
Overview-Current Outbreak
•
West Africa
– Guinea, Liberia, Sierra Leone, Nigeria
and Senegal
– 8397 cases (probable, suspected and
confirmed) with 4032 deaths
•
Democratic Republic of Congo
– 71 cases with 43 deaths
– The index case was a pregnant woman
who butchered a bush animal.
– She became ill with symptoms of EVD,
reported to a private clinic in Isaka
Village, and died on August 11, 2014.
– Local customs and rituals associated
with death meant that several
healthcare workers were exposed to
Ebola virus.
•
United States
– 2 confirmed and 1 death
•
Spain
– 1 confirmed
Transmission
•
•
Contagiousness
– Not during early stages
– As the illness progresses, bodily fluids represent an extreme biohazard
Methods of Transmission
–
Direct contact
• Blood , secretions , organs
–
–
–
•
•
Unsterilized needles
Burial ceremonies
Infected animal
Airborne transmission
– Only circumstantial evidence is in non-human primates
Highest risk has been
– Healthcare providers in Africa
– Family and friends in close contact
– Burial Rituals
Transmission
• Because the natural reservoir is unknown, the manner in which the
virus first appears in a human is unknown
– Researchers believe that the first patient becomes infected through
contact with an infected animal
• Not spread through the air or by water, or in general, by food.
– May be spread by handling bushmeat and contact with infected bats
– There is no evidence that mosquitos or other insects can transmit
Ebola
• Only mammals (for example, humans, bats, monkeys, and apes) have shown
the ability to become infected with and spread Ebola virus.
• If someone recovers from Ebola, can no longer spread virus.
– Ebola virus has been found in semen for up to 3 months. People who
recover from Ebola are advised to abstain from sex or use condoms for
3 months.
Pathogenesis
Symptoms
• Symptoms may appear from 2 to 21 after exposure
– Average is 8 to 10 days.
• Initial Signs
– Fever (at least 102°F)
– Weakness & exhaustion
– Pain
• Severe headache
• Muscles & joints
• Abdominal pain
– Sore throat
– Nausea
– Dizziness
Symptoms (cont.)
Progressed Symptoms
• Vomiting
• Diarrhea
• Extensive bleeding
– Red eyes
• hemorrhage of sclerotic arterioles
– From mouth, nose, eyes, rectum & mucosa membranes
• Maculopapular rash
– Spreads over the body (often hemorrhagic)
• Other secondary symptoms
– Hypotension , Hypovolemia , Tachycardia
– Organ damage
– Internal and external bleeding
Clinical Course (cont.)
Recovery
• 10 to 12 days after the
onset
– sustained fever may break,
with improvement and
eventual recovery of the
patient.
• Recovery from Ebola depends
on good supportive clinical
care and the patient’s immune
response
• People who recover from
Ebola infection develop
antibodies that last for at least
10 years
Death
• 1-2 weeks after onset
– Death often preceded by
hemorrhagic diathesis, shock,
multi-organ system failure
Diagnosis
• Diagnosing Ebola in an person who has been
infected for only a few days is difficult
– Early symptoms, such as fever, are nonspecific to
Ebola infection
– Same symptoms often seen in patients with more
commonly occurring diseases
• Malaria
• Typhoid fever
• Dengue
– Not common but more so than Ebola
CDC Case Definition
• Person Under Investigation
– Clinical Criteria - fever of greater than 38.6 degrees Celsius, and
additional symptoms such as severe headache, muscle pain,
vomiting, diarrhea, abdominal pain, or unexplained hemorrhage
– Epidemiologic Criteria (21 days before the onset of symptoms) –
• Contact with blood or other body fluids or human remains of a patient
known to have or suspected to have EVD
• Residence in—or travel to—an area where EVD transmission is active
• Direct handling of bats or primates from disease-endemic areas
• Probable Case
– PUI with High or Low Risk Exposures
• Confirmed Case
– Laboratory confirmation
CDC Case Definition (cont.)
• High Risk Exposure
– Percutaneous (e.g., needle stick) or mucous
membrane exposure to blood or body fluids of EVD
patient
– Direct skin contact with, or exposure to blood or body
fluids of, an EVD patient without PPE
– Processing blood or body fluids of a confirmed EVD
patient without PPE or standard biosafety precautions
– Direct contact with a dead body without appropriate
PPE in a country where an EVD outbreak is occurring
CDC Case Definition (cont.)
• Low risk exposure
– Household contact with an EVD patient
– Close contact with EVD patients in health care facilities or
community settings
• 3 feet of an EVD patient or within the patient’s room or care area for a
prolonged period of time while not wearing PPE
• Direct brief contact (e.g., shaking hands) with an EVD patient while
not wearing PPE
– Brief interactions, such as walking by a person or moving
through a hospital, do not constitute close contact
• No known exposure
– Having been in a country in which an EVD outbreak occurred
within the past 21 days and having had no high or low risk
exposures
Diagnostic Testing
Timeline of Infection
Within a few days after symptoms begin
Diagnostic tests available
•Antigen-capture enzyme-linked
immunosorbent assay (ELISA) testing
•IgM ELISA
•Polymerase chain reaction (PCR)
•Virus isolation
Later in disease course or after recovery
•IgM and IgG antibodies
Retrospectively in deceased patients
•Immunohistochemistry testing
•PCR
•Virus isolation
Preparedness for Ebola Virus
Steve Quach MD
CMO, PSL Medical Center
Sources
• Centers for Disease Control and Prevention
• University of Nebraska Biocontainment
Patient Care Unit
• University of Texas Medical Branch-Galveston
National Laboratory Biosafety Level 4
• HCA: Clinical Services Group
• World Health Organization
Real World Experience
Assumptions
• Facilities will only have 1 potential Ebola patient at a time
– With more than 1 patient the plan would be altered
• Emergency Department is at highest risk to receive a
patient with Ebola
• Ebola is transmitted through contact with infectious
droplets and contact with body fluids
• Donning and doffing of PPE presents the highest risk of
exposure to healthcare workers
• Facilities will restrict the number of healthcare workers that
come in contact with patient
– Physicians and nurses will perform all patient care and daily
cleaning of patient room
Key Personnel
• Emergency Department
– Physicians and Nurses
• Intensive Care Unit (Adult & Peds)
– Physicians and Nurses
• Infectious Disease Physicians
– Adult and Pediatric Specialists
• Respiratory Therapy
– Adult and Pediatric Therapists
• Security
– First point- of-contact screening
– Traffic control
• Radiology
– Portable equipment, dedicated to a
single patient
• Environmental Services
– Waste removal
• Laboratory
– Laboratory assistant to transport
specimens to Colorado
Department of Public Health
– Medical Technologists
• Infection Prevention
– Coordination between our facility,
the health department, and the
CDC
Preemptive Conversations
With all key personnel:
• Are they willing to commit to care for a
patient that may have Ebola?
• Address all fears
• Educate on all processes
• Keep lines of communication open
Infectious Disease Screening
• Screening of patients at all points of access.
• Emergency Department Screening 100% of
patients.
– Security completes screening form
• If positive, Security contacts ED staff
– Patient is masked
– Asked to wait in wheelchair for ED staff
• If negative, form is given to patient or visitor
Arrival by EMS
• If EMS notifies Emergency Department about
possible or probable Ebola patient:
– Staff will meet ambulance wearing PPE in
ambulance bay
• PPE based on report from EMS
– Patient will be masked and covered with clean
sheet to enter facility
– EMS will be directed to decontamination shower
and provided scrubs as needed
Family Members and Visitors
• Family and visitors accompanying patient will
be placed in private room
– Will be asked to perform hand hygiene
– If clothing is contaminated will be asked to
shower
• Will be provided clothing or paper scrubs
– Family members and visitors will be asked to
remain in the private room until released by the
Colorado Department of Public Health
If, at any time, a patient is deemed high risk for Ebola Virus, initiate Level II Isolation immediately.
Patient’s Infectious Disease
Screen positive for travel
history, exposure, and/or
symptoms
Put Patient in Level I
isolation (contact &
airborne)
If physician has
high clinical
suspicion, initiate
Level II Isolation
Page Infection
Prevention through PBX
Provide
Infection Prevention to
Call CDPHE
CDPHE to determine
index of suspicion and
initiate testing
R/O Ebola
Infection Prevention
to initiate Level II
Isolation
Not Ebola
Infection Prevention
to notify ED
To Notify
House Supervisor
AOC
Physician Leadership
Notify:
Receiving Unit
Lab
Radiology
EVS
FANS
RT
Other Related
Departments
Evaluate need to
Incident Command
Notify Dr. Quach and
CMO
and ID
Dr Terra
Notify Facility
Physician
Travel history, exposures,
onset date, symptoms,
and any pertinent clinical
information
Levels of Isolation
• Level 1 ( Possible Ebola):
– Airborne and Contact Isolation
– Gown, gloves, N95
• Level 2 (Probable Ebola):
–
–
–
–
–
–
Impermeable gown
3 layers of gloves
N95 or PAPR hood
Face shield
Surgical hood
Boot covers
Personal Protective Equipment
•
•
•
•
Surgical hood
Impervious gown
Duct or Chem tape
3 layers of gloves
– 1st: exam gloves
– 2nd: Long cuffed nitrile
surgical gloves
– 3rd: exam gloves
• N95 or PAPR hood
• Face shield
• Boot/leg covers
Additional Equipment
• Hospital laundered scrubs
• Crocs- hospital issued
• Doffing pad
• Dedicated or disposable
equipment
–
–
–
–
–
Stethoscopes
Blood pressure cuff
Radiology equipment
Centrifuge
Medical equipment can be
cleaned but must be
dedicated until discharge
or no longer needed
– Disposable food tray and
utensils
Donning PPE
Impermeable Gown
1.
2.
3.
4.
5.
6.
7.
8.
9.
Perform hand hygiene
Put on washable footwear (Crocs)
Put on leg/boot covers
Put on head protection
Put on gown
Perform hand hygiene
Put on N95 respirator
Put on face shield
Gloves
–
Three layers!
Doffing PPE:
Impermeable Gown
1. Remove 3rd layer of gloves in patient room
2. Remove duct or Chem tape and 2nd layer of
gloves
3. Remove gown
4. Remove leg/boot covers
5. Remove 1st layer of gloves
6. Perform hand hygiene
7. Put on clean pair of gloves
8. Remove face shield
9. Remove N95 respirator
10.Wipe top and bottom of shoes with bleach
PPE:
Gloves
Donning
– 1st layer of gloves:
standard patient care
gloves, bring cuffs of
gown over gloves
– 2nd layer of gloves: nitrile
long-cuff gloves secured
to gown with Chem or
duct tape
– 3rd layer of gloves:
standard patient care
gloves donned after
entering patient room.
Doffing
– Grasp outside of glove
with opposite gloved
hand; peel off
– Hold removed glove in
gloved hand
– Slide fingers of
ungloved hand under
remaining glove at wrist
– Peel glove off over first
glove
– Discard gloves in waste
container
PPE:
Face Shield
Donning
• Place over face and
eyes and adjust to fit
Doffing
– Grab rear strap and
pull it over the head
forward, gently
allowing face shield
to fall forward
– Dispose face shield in
waste container
PPE:
N95 respirator
Donning
Doffing
• Secure ties or elastic bands
at middle of head and neck
• Fit flexible band to nose
bridge
• Fit snug to face and below
chin
• Fit-check respirator
• Front of respirator is
contaminated — DO NOT
TOUCH!
• Grasp bottom, then top ties
or elastics and remove
• Discard in waste container
Reminders:
PPE Removal
• Remove the 3rd (external) pair of gloves while
in patient room. Wipe down second pair of
gloves with bleach wipe prior to exiting
patient room.
• Remove PPE on doffing pad in anteroom or
directly outside patient room.
• Perform hand hygiene after removing PPE and
if hands become contaminated between steps
Transportation
• Moving patients must be coordinated through
Infection Prevention and the managers of
both the sending and receiving units
• Transport of patient will be performed by 2
separate teams
Transportation- Team 1
• Team 1: Physician/Staff in the patient room
– Prepare the patient
– Staff must wear all required PPE
– Put the patient in a surgical mask and drape with a
clean sheet
– Disinfect the bed rails and equipment with 10%
bleach wipes
– Transfer the patient to Team 2
Transportation- Team 2
• Team 2: ICU Staff members and security
– Staff members involved in transport must wear all
required PPE
– Additional team member will accompany transport to
push elevator buttons and open doors. Staff member
will wear PPE but remain “clean”
– Security will be utilized for traffic control during
transport
– Determine route of transport to limit exposure to
public
Location of Care
• All patients will be cared for in ICU setting
– Ideal location equipped with:
• Negative pressure room
• Sink outside door to patient room
• Anterooms no longer required or needed for negative
air pressure rooms due to more efficient design.
– Location isolated from other patients if possible
– Locations may vary within hospitals.
• Facilities should designate rooms and equipment for
these patients.
Patient Care
• Supportive care
• Common complications include:
– Sepsis
– Coagulopathy
– Secondary infections
– Multi-organ failure
Ebola Treatment
• IRB will need to be prepared for immediate
approval
– Emergency investigational new drug application at
• http://www.fda.gov/Drugs/DevelopmentApprovalProcess/H
owDrugsareDevelopedandApproved/ApprovalApplications/I
nvestigationalNewDrugINDApplication/ucm090039.htm
– Mapp Biopharmaceutical and contact information at
• http://www.mappbio.com/
– ZMapp information at
• http://www.mappbio.com/zmapinfo.pdf
– Chimerix brincidofovir information at
• http://ir.chimerix.com/releasedetail.cfm?releaseid=874647
Laboratory
• The utilization of available
point-of-care testing is
required to decrease
potential lab exposure
• The following tests can be
performed on the iStat:
– Arterial, venous, or capillary
blood gases (pH, pCO2,
PO2,HCO3,TCO2, BE, O2 sat)
– Glucose
– Sodium
– Potassium
– Hematocrit/calculated
hemoglobin
– Ionized calcium
– Bun/creatinine
– PT /INR
– ACT activated clotting time
– Lactate
– Troponin
Lab Specimen Handling Options
• Specimens can be
centrifuged in
laboratory
– Care must be taken
when opening centrifuge
after spin
• Centrifuge can be
placed in negative
airflow room near
patient
Specimen Transport
• Clearly label specimen at the bedside with a
sharpie
• All specimens requiring centrifugation will be
spun prior to transport
• Outside of specimen will be disinfected with 10%
bleach wipe and then placed in a clean plastic
biohazard bag
• Biohazard bag will be placed in an impervious
plastic container
• All specimens will be walked and hand delivered
to the Chemistry lab for receiving and processing
Lab Specimen Handling
• All technologists processing the sample will wear:
–
–
–
–
Triple gloves
Fluid resistant gowns
Full face shields or goggles
N-95 Mask to cover the nose and mouth
• Special care should be taken when removing lids
of blood tubes to assure safe handling
– Utilize BioSafety cabinet
– Remove blood caps with gauze to contain any
potential spray and remove behind a shield
Ebola Testing
• All Ebola testing will be coordinated by Infection
Prevention through the Colorado Department of
Public Health
– Testing can ONLY occur through this process
• Specimen requirements:
– Minimum of 4mL of whole blood in EDTA (purple)
plastic tube is preferred but can be submitted in
sodium polyanethol sulfonate (SPS) (light yellow),
citrate (blue), or with clot activator (red with or
without gel)
– Specimens cannot be submitted in glass or
heparinized tubes (light green or dark green)
Daily Room Cleaning
• Only use 10% bleach wipes
– Keep all surfaces wet for 4 minutes (contact time!)
•
•
•
•
Clean all horizontal surfaces
Clean all high touch areas
Put any soiled linens in hazardous waste bins
EVS will not do routine cleanings
Initial Discharge Cleaning
• Only use 10% bleach wipes
– Keep all surfaces wet for 4 minutes (contact time!)
• Clean all surfaces
• Put all linens in hazardous waste bins
• Put all disposable items in hazardous waste
bins
Discharge Cleaning for EVS
• Only enter after approval by Infection
Prevention
– Room will sit unoccupied for 24 hours
– All PPE will be worn for cleaning
• Only use 10% bleach wipes
– Keep all surfaces wet for 4 minutes (contact
time!)
• Remove the privacy curtain and discard
• Perform standard discharge terminal clean
– Consider use of UV or Steriplex if facility
standard
Waste
• Waste is an ongoing and unresolved issue
• Class A waste is infectious/biohazardous waste as
defined by the Department of Transportation
• All waste goes into Class A biohazardous bins
delivered by EVS.
– If not available, waste should be collected in impervious
containers and secured
Sharps
• Sharps should be disposed of in a “normal”
sharps container
• Contact EVS management for removal
– EVS will treat as Class A waste
• Place container in red bag
• Dispose of in Class A container
Waste Removal
•
Contact EVS management to have container delivered and waste removed
–
All waste will be handled as Category A waste and treated as follows:
• Place soft waste or sealed sharps containers into a primary medical waste bag (1.5ml –
ASTM tested; can be provided by Stericycle).
• Apply bleach or other virocidal disinfectant into the primary bag to sufficiently cover
the surface of materials contained within the bag; securely tie the bag.
• Treat the exterior surface of the primary container with bleach or other virocidal
disinfectant.
• Place the primary bag into a secondary bag and securely tie the outer bag.
• Treat the exterior surface of the secondary bag with bleach or other virocidal
disinfectant.
• The double bagged waste should then be place into special Category A packaging
provided by Stericycle with the liner tied securely and container closed per the
packaging instructions provided.
• Store the Category A waste containers separate from other regulated medical waste
and in a secure area preferably isolated and with limited access.
Disposal of Fluids
• All body fluids must be disinfected
• After disinfection, all fluids can be flushed into the
sewer system
• Contact EVS management to obtain the disinfectant
Drills
• Practice taking patient through process from
ED to ICU
– Will be able to identify additional issues or
processes that need to be addressed
– Will increase the comfort level of staff
If you have:
• Fever (greater than 38.6°C or 101.5°F)
• Muscle pain
• Diarrhea
• Unexplained bleeding or bruising
Attention Patients
• Severe headache
• Vomiting
• Stomach pain
AND
You have traveled to any of the following areas in the past 3 weeks
Democratic Republic of the Congo (DRC)
South Sudan
Uganda
South Africa
Liberia
Senegal
Gabon
Ivory Coast
Republic of the Congo (ROC)
Guinea
Sierra Leone
Nigeria
Please put on a mask and notify Emergency
Department Personnel Immediately
Employee Health Guidance
Paul Hancock MD
CMO Swedish Medical Center
Employees who have travelled
to West African or Central African countries
• Should be screened by phone by an Infection Prevention nurse prior to
returning to work.
• Employees who are deemed to be at low risk for Ebola exposure should:
• self-monitor for fever and other signs of illness and
• report to Employee Health for a temperature check and brief review
of systems at the beginning of every shift until the 21-day incubation
period has passed. (Nursing Supervisor during off-hours)
• Employees who are considered high-risk based on travel to areas of Ebola
breakouts or contact with Ebola patients should not return to work until
the 21 day incubation period has passed.
• Discussion: pay for employees who are asked not to work because of
their high-risk status
Employees to provide care
for Ebola patients
• Consider developing a list of staff who are
willing to participate in the care of an Ebola
patient
• Exclude employees who are pregnant or who
are on immunosuppressive therapy for
autoimmune disease or other conditions
Accessing The HealthONE Division
Ebola Website
HealthONE Division Ebola Website
www.healthonecares.com
Concerns or questions can be directed to
[email protected]
Questions?