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Canberra Hospital and Health ServicesOperations ManualInfectious ThreatsContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................3

Alerts.........................................................................................................................................3

Scope........................................................................................................................................ 3

Section 1 - Communication.......................................................................................................3

Section 2 - Presentation at Triage.............................................................................................9

Section 3 - Presentation by Ambulance..................................................................................13

Section 4 - Presentation at Triage with Vomiting or Bleeding.................................................13

Section 5 - Presentation of Patients Referred by External Sources.........................................14

Section 6 - Management on 7B...............................................................................................14

Section 7 - Management in ICU...............................................................................................15

Section 8 - Management of Patients who are Violent, Aggressive or wanting to leave..........16

Section 9 - Staff Requirements................................................................................................17

Section 10 - Management of Pathology Specimens................................................................18

Section 11 - Management of Body Fluids................................................................................21

Section 12 - Cleaning Services.................................................................................................21

Section 13 - Stores.................................................................................................................. 22

Section 14 - Management of Waste........................................................................................22

Section 15 - Support Services..................................................................................................23

Section 16 - Management of Deceased..................................................................................23

Section 17 - Management of Staff Collapse or Fainting in the Red or Yellow Zone................25

Section 18 - Management of Potentially Exposed Personnel..................................................26

Section 19 - Staff Support....................................................................................................... 27

Implementation...................................................................................................................... 28

Related Policies, Procedures, Guidelines and Legislation.......................................................28

References.............................................................................................................................. 28

Search Terms.......................................................................................................................... 29

Attachments............................................................................................................................29Doc Number Version Issued Review Date Area Responsible PageCHHS16/091 1.2 05/07/2016 01/07/2019 Clinical Support

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Attachment 1: Log of health care worker/visitors to the patient room..............................30

Attachment 2: Log of equipment in and out of the patient room.......................................31

Attachment 3: Emergency Department EBOLA Patient Pack..............................................32

Attachment 4: EVD Staff Temperature Monitoring Chart...................................................33

Attachment 5: Waste Management from Red Zone through to Green Zone......................34

Attachment 6: SteriHealth Ebola Waste Packaging Protocol for Healthcare Facilities........35

Attachment 7: Contaminated Staff Member – Emergency Department.............................37

Attachment 8: Risk Assessment and Initial Management of Suspected EVD for ACT Emergency Departments.................................................................................................... 38

Attachment 9: Log for visitors to the patient room/ those assisting in transportation/ carriage of specimens/ procedures in other departments..................................................40

Attachment 10: The ‘HOW TO’ for PPE and Hand Hygiene.................................................41

Attachment 11: Donning and Doffing Within Zones- Applying / Donning of PPE for Confirmed, Probable or Suspected EVD WITH marked bleeding, bruising, diarrhoea &/or vomiting.............................................................................................................................. 45

Attachment 12: Public Messaging Fact Sheets....................................................................50

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Purpose

To describe the process of managing a patient who presents with a suspected or confirmed cases of Infectious Threats at Canberra Hospital and Health Services.

Back to Table of Contents

Scope

Alerts

First principles Protect staff and other patients from potential exposure by appropriate management

and wearing of personal protective equipment (PPE). Isolate the patient with suspected Infectious Threats in appropriate hospital

accommodation. Immediately notify senior staff for risk assessment and correct management of a

suspected or confirmed case of Infectious Threats such as Ebola Virus Disease: Ebola virus is transmissible through contact of non-intact skin and mucosa with

body fluids from an infected person. People at risk of Ebola will also be at risk of malaria and other transmissible diseases

which may be life threatening but are readily treated, therefore need appropriate assessment and treatment.

Privacy Every patient’s rights to privacy and confidentiality must be maintained. All personal health information, clinical records, and clinical information systems are to

be protected against loss, misuse, modification, unauthorised access or disclosure.


Scope

All Health Directorate staff involved in the management of a patient with suspected or confirmed Infectious Threats.


Section 1 - Communication

The Public Health Act (1997) allows the Chief Health Officer (CHO) to make Public Health Directions (Direction) or Public Health Orders (Order) to require a person to take appropriate action to avoid spreading the infectious disease.

The CHO should be contacted for further advice regarding this.

The CHO can be contacted during business hours on (02) 6205 0883 or via the hospital switchboard after hours/weekends.Doc Number Version Issued Review Date Area Responsible PageCHHS16/091 1.2 05/07/2016 01/07/2019 Clinical Support

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High Level Infectious threats cases Communication Plan at a Glance

COMMUNICATION OBJECTIVESThis at a glance communication plan aims to: - Provide clear advice on the internal and external key messages relating to Infectious Threats such as Ebola Virus disease, Viral Haemorrhagic Fevers. - Outline the planned internal and external communication initiatives.- For EVD cases, provide reassurance to staff and the community that the risk of contracting Ebola is extremely low, and the risk of Ebola in Australia is also low – however in the unlikely event that a case does present, ACT Health is prepared and well equipped to deal with this.

COMMUNICATION GOALS1. PROVIDE CLEAR, REASSURING

INFORMATION TO STAFF Ensure CHHS staff are well informed

about Infectious Threats. Ensure CHHS staff have up to date

information about our preparedness.

2. PROVIDE CLEAR, REASSURING INFORMATION TO THE PUBLIC

Ensure the public are well informed about Infectious Threats such as Ebola and the low risk it poses.

Reassure the public that the ACT is prepared, in the unlikely event that we should see a suspected or confirmed case.

KEY MESSAGES FOR EBOLA VIRUS DISEASE (EVD)1. THE RISK OF TRANSMISSION OF

EBOLA IS EXTREMELY LOW Contact Infection Prevention and

Control regarding countries that are currently identified as having Ebola

Only people that have been in direct contact with body fluids of people who are unwell with Ebola or infected animals are at risk of contracting the disease.

Ebola is not infectious in people without symptoms of the disease, and therefore, well people pose no risk of infection to others.

Ebola cannot be spread by casual social contact with a person during the incubation period.

2. THE RISK OF EBOLA COMING TO THE ACT IS VERY LOW

There remain no cases of Ebola in Australia.

Very few people travel to Australia from West Africa and therefore the risk to Australia remains low.

Australia has in place, robust border protection systems to enable early detection of any potential cases entering the country.


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1. IF YOU HAVE TRAVELLED TO AN AFFECTED COUNTRY IN THE LAST 21 DAYS

and are concerned that they may have been exposed to the Ebola virus, they should call ACT Communicable Diseases on 6205 2155 (24/7).

2. WE HAVE PREPARED The ACT has undertaken intensive

planning in the unlikely event that a case should present in the ACT.

Canberra Hospital is equipped to deal with a suspected or confirmed case and has plans to ensure a high level of preparedness and response is available.

The CHO would work closely with GP’s to ensure they are also prepared and informed in the event of EVD.

TACTICAL INITIATIVESThis is a high level at a glance strategy that is complimented by a larger, broader strategy. This strategy separates the internal, CHHS communications plan and the public communication plan. This strategy outlines key communication milestones as well as the likely response, should the ACT have a suspected or confirmed case. This strategy has overlaying key messages that are suitable, irrespective of the target audience.

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PUBLIC MESSAGINGWhere possible, ACT Health, through the CHO will promote messages to the public through the media. Use of digital and social media to reiterate the 4 key messages.

The below are the current, approved key talking points (and can be used for media requests):

Disease Information Infectious Threats are severe acute viral illnesses often characterized 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, this progresses to internal and external bleeding.

The incubation period, that is, the time interval from infection with the virus to onset of symptoms, is usually 2 to 21 days.

Infectious threat such as Ebola is a very serious disease, it is not highly contagious. It is only caught through direct contact with the bodily fluids of an infected person or animal. This is most likely to occur where people are living with a person who is very unwell with Ebola, handling bodies for burial without appropriate protective measures, or providing medical care to a person who is very unwell with Ebola without appropriate protective equipment.

There is currently no proven safe and effective specific treatment for EVD, care is largely supportive. High quality supportive care does, however, reduce the mortality of infection.

ACT Preparedness activities ACT Health regularly communicates with other jurisdictions and the Federal

Department of Health on Infectious Threats preparedness as part of the Communicable Diseases Network of Australia (CDNA) and the Australian Health Protection Principal Committee (AHPPC).

ACT Health has met with and continues to work with ACT airport and airline authorities to review preparedness for Infectious Threats and other communicable diseases.

ACT Health has communicated information about Infectious Threats with hospital clinicians, Medicare Local and Ambulance service.

ACT Health has met with and continues to work with the hospitals to review Infectious Threats planning and preparedness activities.

There are National Guidelines, which ACT Health will follow in the event of an Infectious Threats case, to manage suspect and confirmed Ebola cases.

The Cabinet has been briefed on the preparedness and plans in place nationally and locally.

Canberra Hospital is in the process of finalising its preparedness response plans and this is being managed through an expert working group.


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INTERESTED STAKEHOLDER COMMUNICATIONCanberra ConnectA Fact Sheet is at Attachment 8 for Canberra Connect calls. This information is derived from the approved key messages.Canberra Hospital SwitchboardA Fact Sheet is at Attachment 9 for Canberra Hospital switchboard calls.Unions & peak bodiesUnions and peak bodies (HCCA etc) will be invited to attend a briefing on CHHS preparedness during week 4.General PracticeInformation about what to do in the event of a case presenting to GP’s to be sent to all GP’s from the CHO in week 2.

A follow up education session will be offered to interested GP’s, by the Chief Health Officer in week 4.

RESPONSE TO A SUSPECTED OR CONFIRMED CASE OF INFECTIOUS THREATSThe following outlines the actual communication steps that would be taken, should a genuine suspected or confirmed case of Infectious Threats present in the ACT. This plan assumes that at the point of notification to the CHO, notification would also be given to the Senior Manager, Communications & Marketing. At the point of notification to the Senior Manager, Communications & Marketing,

notification would also be given to the Public Information Control Centre Manager for assistance in managing likely media and community interest. Simultaneously, notification to the Department of Health communications centre will also occur.

The Senior Manager, Communications & Marketing will liaise with the treating team, who will in turn advise the patient that the CHO will be making a statement confirming that we are investigating a suspected case of Infectious Threats. The patient is to be advised of likely national and international media interest following release of the alert. The treating team will be asked to seek consent from the patient for the following information to be provided:o Their age and gender;o Their method of contact (ie. Aid worker, returning traveller etc);o That they presented with fever (if applicable);o Their current condition (stable, serious, critical).o A further pubic update to confirm that their condition is considered Infectious

threats, or not. Following this discussion, a Public Health Notice from the CHO would be issued

(Attachment 10). There are likely to be no further updates available for 12 hours whilst test results are

pending. However, during this time, the agreed spokesperson (the CHO, delegate of the CHO, or an Infectious Diseases Physician from Canberra Hospital) will be required to do television media & radio. Due to the likely level of interest, two spokespeople may be required.


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If the tests confirm positive Infectious threats such as Viral Haemorrhagic Fevers, a further notice will be issued (Attachment 11). Accompanying media interviews will also be required through the approved spokespersons.

If the tests are negative, a statement will be issued advising of this and media will be informed that no further updates on the patient will be provided.

Public Messaging Fact Sheets see Appendix: Attachment 12

Contact NumbersAdmitting Officer Via Switch Infectious Diseases Consultant Via SwitchICU Outreach Via Switch Microbiologist Via SwitchIntensive care Unit 62443300 After Hours Hospital Managers 62442560Ward 7B 62444994 Access Unit 62443247Security 6244 2141 Public Health 62050883Infection Control 6244 3695


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Section 2 - Presentation at Triage

Assess immediately (aim <5 minutes) for:1. Recent travel to affected countries as outlined by WHO; Refer to link for latest

outbreak information.2. Fever/history of fever in pas t 24 ho u rs (if not known, give patient thermometer for

them to take temperature, tell staff the number, and the patient keeps the thermometer).

3. Ask patient to place a face mask on. 4. Staff member in triage to put on face mask and give potential infectious threat pack to

patient (Attachment 3)5. Escort or wheel the patient out into covered area immediately outside the ED

department in the ambulance waiting bay.6. Member of nursing staff to stay at least 2 metres from patient to provide reassurance

regarding process.7. DO NOT take any observations or other physical examination directly at this stage.8. Immediate notification of ED consultant and perform risk assessment.


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Note (EVD cases):For a Person Under investigation (fever plus recent (within 21 days) travel to West Africa}, use the risk assessment and initial management of Suspected EVD flow chart to determine EVD risk and required PPE.

If there is ANY delay in risk assessment (language barrier requiring access to interpreter, lack of reliable information, concern regarding veracity of information obtained), the patient should be moved to an isolation area within 10 minutes where further assessment takes place.


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1. Route for transferring the well patient to 7B is via the staff hospital lifts as per any ward transfer.

2. Route for transferring the unwell patient to ICU is via the lift level 2 building 12.


Section 3 - Presentation by Ambulance

Immediate actions:1. Patient should remain in the ambulance2. Immediate notification of ED consultant should be done to perform risk

assessment. It should be done outside the ambulance but with the visualisation of the patient. Maintain a distance of 2 metres from the patient.

3. In cases of positive risk assessment or unable to be completed without direct access to patient, then the patient is to be transferred to one of the isolation areas (7B if well, ICU if unwell).

4. Route for transferring the well patient to 7B is via the staff hospital lifts as per any ward transfer.

5. Unwell patient must be transferred via building 12 carpark. Patient is transported through the car park, to the lift and then transported up to the lift to ICU.


Section 4 - Presentation at Triage with Vomiting or Bleeding

All staff in the area (triage, clerical, any other) that is not exposed to the suspected person are to immediately exit through the kitchenette located in administration area of ED.

1. Clerical staff notifies ED consultant and stands at back entrance to triage to limit exposure. Maintain 2 metre distance from patient at all times

2. Notification of internal disaster must be done.3. Enactment of internal disaster plan for closure of triage.4. Patient remains briefly in contaminated area, then transferred ASAP to ICU as per risk

assessment5. Any staff or patients immediately within the contaminated area follow the

contaminated person pathway (Attachment 7). Staff / patients with direct body fluid exposure should remain in the area while urgent advice sought from Infection Control (contact via the switch board) on any decontamination or clean up required.

6. If staff in the immediate area maintain no body fluid contamination, they should apply appropriate PPE and distance themselves from the patient whilst still observing the patient.

7. Contaminated area is CLOSED until further advice from Infection Prevention and Control Department.

8. Enact management of a spill – see Management of Body Fluids.


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Internal Disaster plan for Triage Closure

NOTE: This is expected to be brief, but given the critical physical area involved, a brief activation of an internal disaster is warranted.

Admitting Officer phone to be given to ED consultant with no direct clinical load.1. ACT Ambulance Service diverted to Calvary temporarily2. Capital Region Retrieval Service to be notified of internal disaster3. Additional triage staff deployed with clerical staff to set up temporary triage in the

annex area.4. Waiting room patients moved to most easily identified space for assessment: this will

depend on day of week, time of day and activity levels of hospital: consider radiology, HITH, discharge lounge etc within 5 -10 minutes

5. Access unit to urgently move all patients waiting for ward beds to another area in the hospital: ward services re-directed to aid in transfers

6. Communications to be notified7. Walk-in patients to ED to be re-directed to alternative region in hospital for assessment

and management: ED to send partial B side team to urgently assess and treat:i. Consider using disaster packs to help with communication when normal computers

not functional (no access to EDIS) depending on level of ED activityii. Manual use of triage collection of information if required


Section 5 - Presentation of Patients Referred by External Sources

Suspected known patients referred via external sources such public health/GP’s/Walk-in Centres/Calvary Hospital present to the Emergency department triage and the above processes are put into place.


Section 6 - Management on 7B

Patients arriving at triage or by ambulance and assess as being “well” will then move to Ward 7B, Room 7 (single negative pressure room with anteroom).

1. Admitting officer only contacts 7B CNC during business hours and team leader after hours.

2. CNC/Team leader decants patient from Room 7 to allow for “well” patient.3. ED medical/ED nursing staff transports the patient to 7B wearing designated PPE as per

the risk assessment and initial management of Suspected Infectious threats such as EVD flow chart.

4. All possible information should be sought verbally without entry into the room of the person under investigation for Infectious threats via voice, prepaid mobile phone, and collateral sources.


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5. Room 6 ward 7B decanted, ensuite Room 6 available for staff use. 6. Commencement of high security isolation principles.

Non essential staffs are not permitted to enter the high security isolation area.7. Initial assessment will be handled by ED medical/nursing staff on 7B, includes.

Blood tests (need to contact microbiologist on call before blood taken) Observations If Cannulation is required patient must be taken to ICU

8. Care, including medical review is handed over to the Infectious Diseases Consultant on-call.

9. Security will maintain a log of all persons entering the high security isolation area ( Attachment 1).

10. A log of all equipment entering the high security isolation area must be maintained (Attachment 2).

11. Please refer to Appendix 1 for High Security and Donning and Doffing Principles.


Section 7 - Management in ICU

Patient/Patients arriving at triage or by ambulance and assess as being “unwell” or patients become unwell whilst on 7B will then move to ICU, Brindabella South

Criteria for “unwell” patient with potential Infectious threats would be a positive travel history, fever and any one of the following:1. Vomiting and/or diarrhoea2. Any evidence of haemorrhage3. Hypotension4. Abnormal mental status

Procedure1. When transferring patients to another area, referral should be done via phone only.2. ICU outreach doctor contacts ICU CNC/ Unit coordinator and most senior ICU medical

personnel on-site to activate communication and action plan in ICU

Preparation of dedicated space in ICU Move patients from Brindabella South - decant to beds 1-2, 30-31 (contact

Executive Director responsible to consider other decanting areas in hospital). Close doors to Brindabella South to create RED Zone and mark off area

around nurses station, balcony entrance and corridor to form YELLOW Zone as per High Security Isolation Principles

pull curtains across corridor to beds 20-21 for plastic sheet across gap between bed 23 and window to create GREEN Zone as per High Security Isolation Principles

Move PPE to beds 20-21; clear bed 14 when possible to allow utilisation of this space for staff rest area.


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Arrange for collection of appropriate additional PPE supplies from emergency storage

3. ED medical/nursing staff transports the patient to ICU in designated PPE as per the risk assessment and initial management of Suspected Infectious Threats such as EVD flow chart.

4. Non-essential staff are not permitted to enter the high security isolation area.5. Initial assessment will be handled by ICU medical/nursing staff in ICU, including the

bloods, observations and cannulation.6. Security will maintain a log of all persons entering the high security isolation area

(Attachment 1).7. A log of all equipment entering the high security isolation area must be maintained

(Attachment 2).8. Please refer to Appendix 1 for High Security and Donning and Doffing Principles.


Section 8 - Management of Patients who are Violent, Aggressive or wanting to leave

Remove yourself from the situation and contact Public Health on 62050883. Also refer to the Violence and Aggression by Patients, Consumers or Visitors SOP 2 Managing an Incident

Section 9 - Staff Requirements Back to Table of Contents

Work shifts should be limited to a maximum of 8 hours. a. Nursing of moderately ill patients requires less staff, and in many instances, it is not

necessary to maintain a constant presence in the red or yellow isolation areas. This should be reviewed by Infection Prevention and Control.

b. The risk of a personnel member fainting in the red isolation area does exist. Therefore, the availability of immediate assistance in the area is important to avoid unnecessary exposure.

c. Medical Rosters will be collated by ED Deputy Director Nursing Rosters will be collated by Nurse Manger.

d. All staff drawn from the Infectious threats Response Team.

Number of Staff required to care for one patient on ward 7BNursing 3RN’s per 8hr shift, maximum 3 days in a row.

Assume: 3rd RN as a supervisor who is responsible for making sure the area is controlled and can assess PPE donning and doffing.

Number of Staff required to care for one patient in ICUNursing 3RN’s per 8hr shift to rotate every 2 hours, maximum 3 days in a row. Doc Number Version Issued Review Date Area Responsible PageCHHS16/091 1.2 05/07/2016 01/07/2019 Clinical Support

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http://inhealth/PPR/Policy%20and%20Plans%20Register/Violence%20and%20Aggression%20by%20Patients%20Consumers%20or%20Visitors%20SOP%202%20-%20Managing%20an%20Incident.docx

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Medical 2 medical Officers per 8hr shift to rotate every 2 hours, maximum 5 days in a row.Assume: 1RN and 1 medical officer in red rotating with one RN and one doctor in the green every 2 hours, with RN in yellow to manage transfer of waste/equipment/observe donning/doffing


Section 10 - Management of Pathology Specimens (EVD only)



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Pathology Specimen Reception – TCH. When taking specimen on paedatric patients please use brown top paedatric collection

tube with a minimum collection up to the first line. Pathology Specimens are transported to pathology by the staff member in the green

zone.



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Section 11 - Management of Body Fluids

Please see Appendix 1 Disinfection and Management of Body Fluids Management of all spills requires full PPE wear to be worn. Cleaners should at all times

well full PPE.Back to Table of Contents

Section 12 - Cleaning Services

The correct strength of the correct disinfectant is essential in managing Infectious Threats patients. It should be remembered that mechanical cleansing is an integral part of proper disinfection. Excess organic matter rapidly reduces the efficacy of most disinfectants.

ISS can be contact through the help desk 24/7 on (02) 6244 2598 or Ext 42598 ISS will clean the Green Zone only twice daily Healthcare staff in the patient’s room will be responsible for the daily cleaning

requirement of Yellow and Red zones. Achtichlor™, a combined detergent & Sodium hypochlorite product, is to be used for all

cleaning. Preparation instructions including dilution instructions are available. A fresh solution should be prepared every 24 hours.

Bedroom floors should be mopped and drains flushed with sodium hypochlorite 1,000 ppm solution twice a day.

The toilet is to be cleaned at twice a daily using Sodium hypochlorite 5,000 ppm solution.

Used mop heads require management in a similar way as used linen. Dispose cleaning cloth and mop head into clinical waste.

The dedicated PPE doffing section of the patient room and the Yellow zone should be cleaned following doffing procedure.

Terminal/ Discharge clean will be undertaken by appropriately trained ISS cleaning staff Discharge/terminal cleaning of room of confirmed or probable, or suspected case of

Infectious threats prior to confirmation of results: rooms should be washed thoroughly including ceilings, walls, floor and fittings with sodium hypochlorite 1,000 ppm solution. The room is kept sealed overnight and heated if possible for 24 hours. Maximum sunlight should be let into the room. After 24 hours windows should be opened (if possible) and the room well ventilated before it is entered again. Ceilings, walls, floor and fittings are then re-washed with Sodium hypochlorite 10,000 ppm solution. Cleaning equipment should be disposed of into clinical waste after terminal clean.

The same procedures can be applied to mortuaries and laboratories.



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Section 13 - Stores

Spare PPE supplies are located in level 8B store.

The Supply Section located on Level 1, Building 1 of the Canberra Hospital is a sub-section of Supply Services Mitchell, and provide support for the hospital's internal customers. This support includes: Replenishment of all clinical areas' storeroom stocks; Input of inventory requisitions into the computer system; Receipt and internal distribution of goods from other commercial suppliers

Canberra Hospital customers should initially direct their enquiries to personnel from the Supply Section Canberra Hospital, prior to contacting the Supply Services Mitchell.

Supply Services TCH Stores Supervisors Tel: (02) 6244-3280 orTel: (02) 6244-2979

Afterhours through the afterhours CNC via switch.


Section 14 - Management of Waste

When discarding clinical waste contaminated with blood or other body fluids from patients who poses infectious threats, contain the waste with minimal agitation during handling.

Sharps should be discarded into a rigid-walled sharps container in the patient’s room. The full sharps container must be sealed, external surface disinfected and removed from the red area using the same steps as for a clinical waste bag.

The location of the space identified for the temporary storage of Infectious threats contaminated waste awaiting pick up from the campus is; Brick shed/garage currently housing the loading dock fork lift, At the main loading dock, B1 Level 1.

Please see Attachment 5 for waste management in High Security Isolation Rooms Please see Attachment 6 for SteriHealth Ebola Waste Packaging Protocol for Healthcare

Facilities



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Section 15 - Support Services

Linen Disposable linen is preferable for patient clothing and bed linen. Linen should be placed into clinical waste bags and not into fabric linen bags. In

unconfirmed Infectious threats cases, these bags need to be clearly labelled as linen. For suspected Infectious threats cases, the linen may be securely quarantined until the

results of further testing have been finalised. If suspected cases is excluded then the linen can be processed as per usual practice.

For probable and confirmed Infectious threats cases, contaminated linen is disposed of via the same process as clinical waste.

Food Services Food services are contacted via Ext 43930 Out of food services operating hours emergency food packs can be sourced from the

MediHotel. Crockery and cutlery used for feeding patients and staff in the Isolation unit should be of

disposable type and incinerated along with food wastes.


Section 16 - Management of Deceased

1. Unnecessary handling of the body, including embalming should be avoided for patients with EVD.

2. Persons who dispose of the deceased person must take the same precautions outlined for healthcare staff in the red zone.

3. Notify mortuary of patient’s death so that arrangements can be made for funeral director to be present to receive body on its arrival at the mortuary. Deceased bodies will not be routinely stored in the mortuary.

4. For death occurring afterhours contact Senior Scientist, Anatomical Pathology via switchboard and they will arrange for a staff member from the mortuary to be available to receive the body and to contact the funeral directors.

5. Family members should have pre-decided what funeral arrangements are to be made and what Funeral Directors they wish to use. This will allow preliminary discussion with the funeral directors so that they know to expect the body should death occur.

6. Ensure patient does not have a pacemaker present, as this will not be removed and the body will require burial and not cremation.

7. Ensure appropriate medical staff are present to ensure the correct legal paperwork is completed i.e. Government Medical Officer required if cremation is to occur. These staff are not required to enter the Red zone.

8. Remains should not be sprayed, washed or embalmed. Any practice of washing the remains in preparation for “clean burials” should be discouraged.


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9. The deceased person is placed in the first body bag with absorbent material placed all around the body. The external surface of the bag is washed in fresh Sodium hypochlorite 10,000 ppm solution.

10. A patients identification tag is placed into the clear pocket on the front of the bag. 11. An additional label, signed by a Dr, is secured to the outside of the blue bag near the ID

label, stating “This patient does / does not have a pacemaker.” If a pacemaker is present the label must also state “ The pacemaker has NOT been removed”

12. Absorbent material must be placed between the first bag and a second body bag.13. The body is then secured in a clear sealed body bag. 14. The outer bag is disinfected with 10,000 ppm solution. 15. The outer bag must be clearly indelibly labelled with ‘INFECTIOUS DISEASE- HANDLE

WITH CARE 16. The deceased person is transported to the mortuary for collection by the Funeral

directors.17. If the nominated funeral home is interstate there may be a requirement to store the

deceased in the Mortuary at CH&HS.18. At the funeral Directors, the coffin should be packed with additional absorbent material.

Post-mortem examination A post-mortem examination on a suspected, probable or confirmed case should not be carried out unless considered absolutely essential by either the medical or legal authority responsible for the case. A post-mortem examination on a person known to have died of Infectious threats such as EVD exposes staff to unwarranted risk and should not be performed.

Where a patient suspected of having Infectious threats dies prior to a definitive diagnosis being made, it may be necessary on public health grounds to conduct limited diagnostic testing after death to establish or eliminate the diagnosis of Infectious threats cases.

In the event that a post-mortem examination is required it should be performed by operators using the highest level PPE appropriate for high risk infectious diseases, as per accepted forensic medicine procedures. Aerosol formation must be avoided (e.g. electrically powered cutting instruments must not be used). All solid and liquid waste must be decontaminated with disinfectant solution or autoclaved, then incinerated. After the post-mortem has been completed the room must be thoroughly cleaned with disinfectant solution.



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Section 17 - Management of Staff Collapse or Fainting in the Red or Yellow Zone

Collapse in the Red zone Other staff in Red zone immediately ensure staff member is safe and not at risk of breach in PPE

Staff member in Yellow zone dons additional PPE and enters Red zone to assist collapsed staff member. Actions: Hold staff members hands to prevent facial exposure as collapsed staff member wakes

up Do not remove any PPE from collapsed staff member When able, assist recovering staff member to red doffing area Assist recovering staff member to remove PPE as per standard protocol Do not allow recovering staff member to doff themselves Record incident in Staff log

Staff member in green zone dons PPE and proceeds to the yellow zone to assist with doffing of staff member needs to be ready to enter Red zone if additional help is required with the collapsed

staff member

Collapse in the yellow zone Staff member in Green zone dons PPE and enters Yellow zone to assisted collapsed staff member. Actions: Hold hands to prevent facial exposure as collapsed staff member wakes up Do not remove any PPE from collapsed staff member When able, assist recovering staff member to yellow doffing area Assist recovering staff member to remove PPE as per standard protocol Record incident in Staff log



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Section 18 - Management of Potentially Exposed Personnel


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Section 19 - Staff Support

Training De-Briefing Employee Assistance Program ph: 1300 361 008 (24/7)



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Implementation

Education about this manual will be provided to staff via forums, educational sessions and departmental briefings. Practical education through an education program will be provided to staff from the Emergency Department, ICU and 7B as well as NICU.


Related Policies, Procedures, Guidelines and Legislation

PoliciesInfectious Threats Clinical Procedure


References

Alfred Health. (Draft). Infection Prevention Management of a patient presenting with Viral Haemorrhagic Fever.

CDC. (2005). Interim Guidelines for Managing Patients with Suspected Viral Hemorrhagic Fever in U.S. Hospitals.

CDC. (2014). Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals .

CDNA National Guidelines for Public Health Units Ebola Virus Disease (EVD) 2014. Department of Health, W. A. (2007). Contingency Plan for Public Health Management of

Cases of Viral Haemorrhagic Fever within Western Australia. Department of Health. (2014). National guidelines for management of patients with

suspected, probable or confirmed Ebola. Australian Government. Sighted 07/10/2014 http://www.health.gov.au Ligthelm, T. (2007). Management of Viral Haemorrhagic Fevers. South African Military

Health Services. Military Health Support Doctrine (2014). Viral Haemorrhagic Fevers Management in the

SANDF. South African Military Health Service.

WHO (2014) Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola http://www.who.int/csr/resources/publications/ebola/filovirus_infection_control/en/



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http://www.who.int/csr/resources/publications/ebola/filovirus_infection_control/en/

http://www.health.gov.au/

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Search Terms

EbolaEbola virusEVDEmergency DepartmentHaemorrhagic fever

Infectious ThreatsIntensive CareCritical CareNeonatal Intensive CarePPE

Donning and Doffing7BCleaning LinenSpills


Attachments Attachment 1: Log of health care worker/visitors to the patient roomAttachment 2: Log of equipment in and out of the patient roomAttachment 3: Emergency Department EBOLA Patient PackAttachment 4: EVD Staff Temperature Monitoring ChartAttachment 5: Waste Management from Red Zone through to Green ZoneAttachment 6: SteriHealth Ebola Waste Packaging Protocol for Healthcare FacilitiesAttachment 7: Contaminated Staff Member – Emergency DepartmentAttachment 8: Risk Assessment and Initial Management of Suspected EVD for ACT

Emergency DepartmentsAttachment 9: Log for visitors to the patient room/ those assisting in transportation/

carriage of specimens/ procedures in other departments Attachment 10: The ‘HOW TO’ for PPE and Hand HygieneAttachment 11: Donning and Doffing Within Zones- Applying / Donning of PPE for

Confirmed, Probable or Suspected EVD WITH marked bleeding, bruising, diarrhoea &/or vomiting

Attachment 12: Public Message Fact Sheets

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved By15 May 2017 Updated Attachment 11 CHHSPC03 July 2018 Updated throughout to

reference “infectious threats” instead of “Ebola and other VHF”

Executive Director, Clinical Support Services


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Attachment 1: Log of health care worker/visitors to the patient room


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Attachment 2: Log of equipment in and out of the patient room


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Attachment 3: Emergency Department EBOLA Patient Pack1. Ondansetron wafer 4 mg in case of nausea2. Bottle of Water x 23. Paracetamol 1gm for symptomatic relief of fever4. Prepaid Mobile Phone: number to be placed on outside of pack for

collection by treating team once patient identified as requiring Ebola pack.

5. Map of Africa with affected countries clearly identified6. Detailed map of each affected country so that actual location can be identified7. Pen and Paper8. Travelogue for the last 21 days including flights (date of arrival and

airline) and modes of transport over last 21 days9. Contact details for family10. Key questions for the patient to think about:

a. Contact with bush meat/ eating at traditional ceremoniesb. Contact or care of person with known ebolac. Contact /involvement in burial ceremoniesd. Immunisation status for other e. Malarial prophylaxis – type and duration


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Attachment 4: Staff Temperature Monitoring Chart (e.g. EVD)


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Attachment 5: Waste Management from Red Zone through to Green Zone


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Attachment 6: SteriHealth Ebola Waste Packaging Protocol for Healthcare FacilitiesThe recent Australian CDNA Infectious threats guideline requires Ebola waste to be double-bagged and handled as normal Clinical Waste (CW)1. However, three healthcare workers have inexplicably contracted Ebola while wearing personal protective equipment and this has alarmed healthcare workers, waste contractors and the public.

It is apparent that Infectious threats is transmitted more easily than thought and until all aspects of transmission are known, hospitals and handlers are requesting a higher level of containment to allay their fears and cater for potential slips, breaches or accidents. Under Australian Dangerous Good (ADG) regulations2, substances known or suspected of containing Category A organisms (e.g. Ebola) must utilise certified Infectious Substance triple-packaging. However, such packaging for Ebola waste is unavailable.

To resolve this, SteriHealth has developed an alternative, ADG-equivalent, triple-pack Ebola Waste Kit.

SteriHealth’s Ebola Waste Packaging Kit is a self-contained, triple-package system using SteriHealth’s highly-certified, tamper-proof, PG2-rated Clinismart collector with added risk controls to match ADG “leakproof primary + leakproof secondary + rigid outer” requirements. WorkCover approval is being sought.

Contents of SteriHealth Ebola Waste Kit I64 Infectious Clinismart as rigid PG2-rated outer (to be used with SteriHealth foot-pedal

bin)Inside I64 3 x 30L and 2 x 50L 50micron Primary (10)plastic clinical waste bags 1 x 55micron 80L Secondary (20)plastic clinical waste bag Zip bag containing 100g Super Absorbent Powder (SAP) (will absorb 2.5L blood) 11 x cable ties.

Healthcare facility to supply hypochlorite disinfectant solution (minimum 1,000ppm)PROTOCOL

At all times, institutional protocols and procedures for PPE and glove changing must be followed.A. Primary bagging

1. Remove bags, and cable ties from I642. Place 80L 20 bag in I64, open and fold top around rim of I64. Empty contents of SAP

bag into 20 bag3. As waste is generated, place immediately into appropriate-sized 10 plastic bag 4. When 10 bag 2/3 full, twist top, fold over and cable-tie tightly5. Wipe entire exterior of bag with min 1,000ppm hypochlorite using instrument sponge

or similar.6. Repeat with 10 bags of waste until lined I64 is 2/3 full.


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7. Sharps Containers if certified -leakproof must be sealed, disinfected and placed directly into 20 bag. If not certified-leakproof, must be sealed in 10 bag which is disinfected and placed in 20 bag.

8. Keep lid of I64 closed between uses.

B. Removing PPE1. Remove PPE as per intuitional protocol2. Place gently into appropriate-size10 bag, seal as above, disinfect exterior, and place

in 20 bag.

C. Closing and sealing 20 bag and I641. Gently twist top of 20 bag, fold over and cable-tie tightly 2. Wipe entire exterior of bag with hypochlorite using instrument sponge or similar3. Close lid of I64 and fully-activate front catch and two side locks4. Wipe entire external surface of with hypochlorite.

D. Transport and collection by SteriHealth1. Transport I64 to bio-waste holding area and place in SteriHealth dedicated I64

Transporter.2. SteriHealth drivers will re-disinfect all I64 and transport for incineration of intact I64.


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Attachment 7: Contaminated Staff Member – Emergency Department


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Attachment 8: Risk Assessment and Initial Management of Suspected EVD for ACT Emergency Departments


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EBOLA RISK/Transmission Risk

Mask Eye/Face Protection

Full body suit

Gown Gloves Shoes covers RoomWith door

closedPerson Under Investigation

WITHOUT exposure riskSurgical(P2/N95

aerosolising procedures)

Goggles NO Yellow Single NO Single with ensuite

Suspected Case EVDWITHOUT marked bleeding, bruising,

diarrhoea or vomiting

Surgical(P2/N95


Goggles NO Impervious Single NO Single with ensuite

(restrict access)

Confirmed or Probable or Suspected case EVD WITH marked bleeding, bruising,

diarrhoea or vomiting

Surgical(P2/N95


Goggles and face visor

YES Impervious Double OR booties & plastic leg

covers

Single with ensuite

(restrict access)


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Attachment 9: Log for visitors to the patient room/ those assisting in transportation/ carriage of specimens/ procedures in other departments

Date Name & Surname (Please print your name)

Contact number Time in Time out Signature


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Attachment 10: The ‘HOW TO’ for PPE and Hand Hygiene

HOW TO PERFORM HAND HYGIENE:Prior to application of PPE hand hygiene must be performedHand Hygiene by hand washing or using alcohol based hand rub1. Hand Washing Technique

Wet hands first with water.Apply product to hands.Rub hands together vigorously for 15 seconds covering all surfaces of hands and fingers.Rinse hands with water.Dry hands thoroughly with disposable towel.

2. Hand Decontamination Technique using alcohol based hand rubApply product to palm of one hand and rub hands together vigorously, covering all surfaces of hands and fingers until hands are dry.

HOW TO PUT ON A GOWNSelect appropriate type of gownOpening is in the backSecure at neck and waist


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HOW TO FIT AN N95/ P2 RESPIRATOR AND PERFORM A ‘FIT TEST’Place the mask over nose, mouth and chin1. Fit flexible nose piece over nose bridge2. Secure on head with elastic ties3. Adjust to fit4. Move head around to ensure the mask is

secure5. Perform a User Seal Check:– Inhale – mask should collapse– Exhale – check for leakage around face

A User Seal Check should be performed each time a mask is fitted.

Masks must be replaced when they become wet, soiled or if the mask begins to leak.

HOW TO PUT ON PROTECTIVE EYEWEARPosition protective eyewear over eyes and secure the ear piecesPosition face shield over face and secure on brow with headbandAdjust protective eyewear or face shield to fit comfortably

HOW TO PUT ON GLOVESSelect correct type and sizePerform Hand hygieneInsert hands into glovesIf wearing a gown extend gloves over gown cuffs


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HOW TO REMOVE GLOVESGrasp outside edge of the glove near the wristPeel away from hand, turning glove inside-outHold in opposite gloved hand

Slide ungloved finger under the wrist of the remaining glovePeel off from inside, creating a bag for both glovesDiscard

HOW TO REMOVE GOWNSGown front and sleeves are ‘dirty’; handle by inside/back of gownUnfasten tiesPeel gown away from neck and shoulderTurn contaminated outside surface toward the insideFold or roll into a bundleDiscard


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HOW TO REMOVE A N95/ P2 RESPIRATORThe front of the mask is ‘dirty’ , handle by the elastic straps/ ear loopsRemove from face in a downward direction using straps/ ear loopsDiscard


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Attachment 11: Donning and Doffing Within Zones- Applying / Donning of PPE for Confirmed, Probable or Suspected INFECTIOUS THREATS WITH marked bleeding, bruising, diarrhoea &/or vomiting

Applying/DonningIN THE GREEN ZONE

1Engage trained safety supervisor.

The safety supervisor oversees the whole donning process and provides verbal guidance on the sequence of doffing.

2Remove all jewellery. No nail polish or long nails. Intact skin?

No contact lenses to be worn.Toilet stop and hydrate.

3 Change into theatre scrub suit clothing. Own shoes can be worn if impervious and washable.

4Prepare and inspect PPE prior to donning

ensure that it is correct size, complete, & in serviceable condition Check PAPR battery and function


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5 If wearing own glasses tape glasses to side of forehead

6 Ensure long hair tied up with hair band

7 Apply overshoes covers.

8 Perform hand hygiene - ABHR or wash.

9Apply plastic shoe covers.

Ensure plastic leg covers are worn under coverall legs.(Sit on a chair if required to provide stabilisation during donning).


11Put on full body suit/coverall, secure flap or zip to leave no skin exposed

around neck. Hair tucked in.Put ‘Sleek’ tape tag on zip


13 Apply first pair of long cuffed inner gloves (Ensure cuffs of inner gloves are tucked under the sleeve of the coverall).

14 Secure cuff of coverall to glove with tape. Leave folded over flap to aid with easy removal of the tape

15

Apply PAPR. Secure external belt-mounted blower unit around waist and then place hood on head. Be sure that the hood extends past the neck to the

shoulders.Assistant to connect hose and turn on power

IN THE YELLOW ZONE

16 Apply second pair of overshoe covers (or booties)

17 Apply long sleeve impervious disposable gownEnsure PAPR hood is inside of gown

18 Apply second pair of long cuffed (outer) gloves (extend gloves over gown cuffs)

19 Secure cuff of glove to disposable gown with tape. Leave folded over flap to aid with easy removal of the tape


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20Verify. The integrity of the ensemble is verified by safety supervisor. Move around freely. No exposed skin or hair of the healthcare worker should be

visible.

ENTER THE RED ZONE

21 Disinfect outer-gloved hands with ABHR. Allow to dry prior to patient contact.


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Removal / Doffing of PPEIN THE RED ZONE

1Engage trained safety supervisor.

The safety supervisor oversees the doffing process and provides verbal guidance on the sequence of doffing.

2 Inspect the PPE to assess for visible contamination, cuts, or tears before starting to remove. Report abnormalities to safety supervisor.

3 Wipe gloved hands with disinfectant wipe. Wipe away from body

4 Remove 1st pair of overshoes

5Wipe gloved hands with disinfectant wipe.

6 Remove tape that secure cuff of the glove to the gown

7 Remove outer-gloves

8 Inspect inner gloves for contamination, then disinfect using a disinfectant wipe.

9Remove disposable gown

Pull gown away from body, rolling inside out and touching only the inside of the gown.

10 Wipe gloved hands with disinfectant wipe.

11 Inspect and disinfect all outer surfaces of remaining PPE using a disinfectant wipe.Work from head to feet. Report any cuts or tears to the safety supervisor.

12 Wipe gloved hands with disinfectant wipe if they appear contaminated.

13Step into shallow container of bleach solution to disinfect plastic boot covers.

Step onto drying mat (fluid absorbent), ensure soles are dry before proceed into ‘dirty’ area of yellow zone.

IN THE YELLOW ZONE

14 Remove tape that secure cuff of the glove to the coverall.

15

Observer / Assistant to assist with PAPR removalTurn off power and disconnect tubing from hood and power unit and dispose into

clinical wasteRemove power unit and belt and place in an area or container for disinfection.

16Remove disposable hood.

Tilt the head slightly forward and grab the hood from the back of the head and pull upwards away from head. Discard into clinical waste.

17 Disinfect inner gloved hands with disinfectant wipe


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18 Remove the top of the coverall. Sit on chair to remove bottom section.Roll inside out ensuring contaminated side is folded to inside.

19 Remove plastic leg/shoe covers.Grasp from the heel and pull away from body. Do not flick

20 Remove overshoes.

21 Disinfect gloved hands with disinfectant wipe.

22 Remove inner gloves and perform hand hygiene.

23Perform a final inspection for contamination of the surgical scrubs.

Report any abnormalities to safety supervisor.

IN THE GREEN ZONE

24 Wash hands with antimicrobial soap and water

25 Staff member & safety supervisor meet to review the patient care activities performed to identify and document any concerns about care protocols

26 Remove theatre scrubs, shower and change into normal uniform / clothes at end of shift and before leaving the area.


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Attachment 12: Public Messaging Fact Sheets for EVD

Canberra Connect Fact Sheet

THE RISK OF TRANSMISSION OF EBOLA IS EXTREMELY LOW Ebola is causing disease in the countries of Guinea, Sierra Leone and Liberia. Only people that have been in direct contact with body fluids, blood or secretions of

people who are unwell with Ebola or contaminated environments are at risk of contracting the disease.

Ebola is not infectious in people without symptoms of the disease and airborne transmission is not known to occur.

Ebola cannot be spread by casual social contact with a person during the incubation period.

Traditional burial ceremonies conducted in affected areas of Africa are a known high risk activity for transmission.

THE RISK OF EBOLA COMING TO THE ACT IS VERY LOW There remain no cases of Ebola in Australia. Very few people travel to Australia from West Africa and therefore the risk to

Australia remains low. Australia has in place, robust border protection systems to enable early detection of

any potential cases entering the country.

IF YOU HAVE TRAVELLED TO AN AFFECTED COUNTRY IN THE LAST 21 DAYS If people have travelled to the affected countries in the last 21 days and are

concerned that they may have been exposed to the Ebola virus, they should contact the Health Protection Service, ACT Communicable Diseases on 6205 2155 or page 02 9962 4155 after hours.

Canberra Hospital Switchboard Fact Sheet

CALLS FROM GP’S ADVISING OF A PATIENT THAT MAY BE A SUSPECTED EBOLA CASE Put them through to the Infectious Diseases (ID) physician on call. Advise them that they must also contact Health Protection Service on 6205 2155 or Page

02 9962 4155 after hours. If unable to make contact with either of these, contact the Chief Health Officer on call.


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Public Health Notice

The ACT Chief Health Officer, Dr Paul Kelly/Dr Andrew Pengilley has confirmed that a suspected case of Ebola Virus Disease is currently being investigated at Canberra Hospital.

“[The patient, who is a [xx] year old [male/female] is a returning aid worker from one of the affected countries] or [the patient recently travelled to an affected country] and is currently being investigated for suspected Ebola Virus Disease, however this diagnosis is not confirmed”, the Chief Health Officer said.

“The patient has known contact [treating] or [in an Ebola affected area] within the past 21 days and has presented with a fever. The patient is currently in a [stable/serious/critical] condition.

“Ebola Virus Disease is a severe acute viral illness, often characterised by the sudden onset of fever, intense weakness, muscle pain, headache and sore throat. The disease is then followed by vomiting, diarrhoea, rash, impaired kidney and liver function, and in some cases, this progresses to internal and external bleeding.

“However, I would like to take this opportunity to reassure the community that the risk of transmission remains extremely low. Ebola is not infectious in people without symptoms of the disease and is only transmissible through direct contact with body fluids of people who are unwell with Ebola,” the Chief Health Officer said.

The Chief Health Officer confirmed that contact with the family of the patient who reside in the same residence is occurring and these household members will now remain in isolation.

If people have travelled to Sierra Leone, Liberia, or Guinea in the last 21 days and are concerned that they may have been exposed to the Ebola virus, they should call ACT Communicable Diseases on 6205 2155 (24/7).


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Public Health Notice

The ACT Chief Health Officer, Dr Paul Kelly/Dr Andrew Pengilley has confirmed that the patient being treated for suspected Ebola is now confirmed as having Ebola.

“Blood tests have confirmed that the patient has tested positive for the Ebola Virus Disease,” the Chief Health Officer said.

“There is no known treatment for Ebola, however the patient will be treated with a number of supportive measures, including intense fluid management, pain management and medications to manage any onset of further symptoms. The patient is currently in a [stable/serious/critical] condition.

“There is a specialised treatment team managing the care of this patient and there is no reason for anyone else within the hospital to be concerned. Transmission of Ebola Virus Disease is only through direct contact with the bodily fluids of an infected patient. The treatment team are a highly specialised and specifically trained team to manage Ebola patients.

“The treatment teams are wearing specialised Personal Protective Equipment (PPE) at all times and they have been specially trained in the effective use of this equipment,” the Chief Health Officer said.

“There are specific management plans in place for the management and disposal of Ebola bio-hazard waste throughout the hospital. These plans are well thought out and considered plans to ensure that there is no risk of contamination to any parts of the hospital,” the Chief Health Officer said.


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Documents

Infectious Threats Operations Manual€¦ · Web viewEbola virus is transmissible through contact of non-intact skin and mucosa with body fluids from an infected person. People at