1
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
SH CP 164
Standard Operating Procedure
for Ebola Identification
Version: 4
Summary:
The IP&C Lead has developed a Standard Operating Procedure, SOP (Appendix A) to help guide staff to identify and manage patients who present with a high index of suspicion of Ebola. This SOP is specific for MAU and MIU at Lymington New Forest Hospital and MIU at Petersfield but should also be used in other areas in the Trust if clinically indicated in line with the Viral Haemorrhagic Fever (VHF) Risk Assessment flow chart. To escalate any potential case please see the Escalation Flowchart at Appendix B.
Keywords (minimum of 5): (To assist policy search engine)
Ebola, Viral Haemorrhagic Fever (VHF), virus disease, Ebola virus.
Target Audience:
All staff of all disciplines, particularly MAU, MIU and FAC at Lymington and MIU at Petersfield
Next Review Date:
November 2019
Approved & Ratified by: IPC& Decontamination Group
Date of meeting: 03.11.15
Date issued:
November 2015
Author:
Theresa Lewis, Lead Nurse Infection Prevention and Control.
Sponsor:
Della Warren, Director of Nursing.
2
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
Version Control
Change Record
Date Author Version Page Reason for Change
Oct 2014
Theresa Lewis 2 Update
Nov 2014
Theresa Lewis 3 Updated guidance received from Department of Health Nov 2014 to include
Increased level of PPE required for patient management
Changes in Risk Assessment Algorithm (temp ≥37.5c)
More detail added for waste management
Nov 2015
Theresa Lewis 4 Review required one year post initial publication
Reviewers/contributors
Name Position Version Reviewed & Date
Theresa Lewis, Lead Nurse Infection Prevention and Control August 2014
Julia Lake Deputy Head of Professions August 2014
Paul Mundy Clinical Nurse Manager August 2014
Della Warren, Director of Nursing August 2014
Chris Gordon Chief Operating Officer & Integrated Care August 2014
Martyn Diaper Medical Director August 2014
Lesley Stephens Director of MH & LD August 2014
Public Health England August 2014
Theresa Lewis Lead Nurse Infection Prevention and Control Nov 2014
Jacky Hunt IP&C Nurse – North Nov 2014
Angela Roberts IP&C Nurse – West Nov 2014
Nicky Bartlett Interim Matron – Lymington New Forest hospital
Nov 2014
Shelly Mason Modern Matron Nov 2014
Sandra Grimes
Commercial Contract Manager & Project manager
Nov 2014
Darren Hedges Area Health & Safety Officer Nov 2014
Fiona Richey Head of Risk and Business Continuity Nov 2014
EPRR Working Group Members of this Group Dec 2014
Angela Roberts IPCN West Sept 2015
Louise Piper IPCN East Sept 2015
Robert Harris Estate Services Contract and Project Manager
Oct 2015
Lesley Chandler Public Health England (Wessex) Oct 2015
IPC& Decontamination Group Members of the Group Nov 2015
3
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
For risk assessment and management of potential cases please go
straight to SOP (Appendix A) on page 6
To escalate potential cases in any healthcare setting please go
straight to Appendix B on page 19
CONTENTS
Subject Page
Number
Background 4
Appendix A Standard Operating Procedure 6
Risk Assessment 6
Isolation 7
Standard Precautions 7
Personal Protective Equipment 9
Hand Hygiene 10
Equipment 11
Decontamination 11
Waste 13
Linen 14
Diagnostic Investigations 15
Staff exposure to potentially infectious material 15
Staff exposure to confirmed case of VHF 16
Communications 18
Department of Health VHF Guidance 18
Appendix B: Escalation Flow Chart 19
Appendix C: Communication Algorithm LNFH 22
Appendix C: Communication Algorithm MIU Petersfield 23
Appendix D: Ebola Boxes (Hazardous Material Box) 24
Appendix E: Donning and Doffing of PPE 25
Appendix F: Timeline of actions taken by Southern Health NHS
Foundation Trust
28
4
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
SOP for Ebola Identification, Personal Protective Equipment and Fit
Testing
Background
Ebola virus disease is a severe disease which affects humans and other primates,
and is form of viral haemorrhagic disease. The incubation period of Ebola virus
disease ranges from 2-21 days. The onset of illness is sudden with fever, headache,
joint and muscle pain, sore throat and intense weakness. This is then followed by
diarrhoea, vomiting, rash, impaired kidney and liver function and stomach pain.
Some patients may develop a rash, red eyes, hiccups, internal and external
bleeding. Ebola haemorrhagic fever is fatal in between 50-90% of cases. No
specific treatment or vaccine has yet been developed.
The Ebola virus is thought to come from fruit bats, and it affects other animals such
as chimpanzees, gorillas, monkeys and porcupines. Humans can be infected
through contact with the blood or body fluids of an infected animal. Once this has
occurred, the infection can be passed from person to person through direct contact
with blood or other body fluids from an infected person, including contact with objects
such as needles or soiled clothing that have been contaminated with infected body
fluids. The disease can also be transmitted via sexual contact with a person who is
infected or who is recovering from the disease, as the virus is present in semen for
up to 7 weeks after recovery. Experts agree that there is no circumstantial or
epidemiological evidence of an aerosol transmission risk from VHF patients.
This SOP is a summary a based on the ‘Management of Hazard Group 4 viral
haemorrhagic fevers and similar human infectious diseases of high consequence’
(DH November 2014).
The aim of this SOP is to help guide staff to identify and manage patients who
present with a high index of suspicion of Ebola. This SOP is specific for MAU, MIU
and Forest Assessment Centre (FAC) at Lymington New Forest Hospital and MIU at
Petersfield but should also be used in all other areas in the Trust if clinically indicated
in line with the Viral Haemorrhagic Fever (VHF) Risk Assessment flow chart. This
assessment flow chart can be found within the main document (Management of
Hazard Group 4 VHF) embedded on page 18 of this SOP.
Risk Assessment
Risk assessment is a legal obligation
The patient’s risk assessment determines the level of staff protection and the
management of the patient
The risk to staff may change over time, depending on the patients symptoms
Patients with VHF can deteriorate rapidly
5
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
In preparation for the updated guidance in November 2014, ACDP undertook a new
assessment of the risks of transmission of VHF infection. Evidence from outbreaks
strongly indicated that the main routes of transmission of VHF infection are direct
contact (through broken skin or mucous membranes) with blood or body fluids, and
indirect contact with environments contaminated with splashes or droplets of blood
or body fluids.
VHFs are severe and life-threatening viral diseases that are endemic in parts of
Africa, South America, the Middle East and Eastern Europe. Environmental
conditions in the UK do not support the natural reservoirs or vectors of any of the
haemorrhagic fever viruses. All recorded cases of VHF in the UK have been
acquired abroad, with the exception of a laboratory worker who sustained a needle
stick injury. There have been NO cases of person-to-person transmission of a VHF
in the UK to date of publication of the revised guidance (DH Nov 2014).
VHF’s are of particular public health importance because:
They can spread readily within a hospital setting
They have a high case-fatality rate
They are difficult to recognise and detect rapidly
There is no effective treatment
CURRENT (Nov 2015)
There remains an expectation that a small number of cases may occur in the UK in
the coming months. These people could become infected in a VHF endemic country
and arrive in the UK while incubating the disease and develop symptoms after their
return
Individuals may present in several different ways to healthcare facilities: referral by
primary care, self-presentation at Minor Injuries Unit or self-presentation at local
inpatient facility. Triage mechanisms need to be able to quickly identify patients at
risk so that they can be isolated and a risk assessment completed.
Please follow the Standard Operating Procedure (SOP) for the management of
suspected cases of VHF including Ebola Virus Disease (EVD) – Appendix A, page 6
Version 4. This procedure should also be read in conjunction with the SHFT
Lockdown Policy
It is the responsibility of the Professional Leads to ensure dissemination and
implementation of this SOP and documentation is viewed in accessible areas.
6
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
APPENDIX A: SOP for the Identification and Management of Patients with
suspected Viral Haemorrhagic Fever including Ebola* (version 4)
*For further guidance including the risk assessment flowchart, please refer to Management of Hazard
Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence (Dept
of Health November 2014), embedded at the end of this SOP, page 18.
VHFs are severe and life-threatening diseases for which there is currently no proven
treatment or prophylaxis. Patients with confirmed VHF infection should be managed in a
specialist high level isolation unit eg Royal Free in London.
For patients who present with a high index of suspicion of Ebola or any other infectious
disease please follow the Viral Haemorrhagic Fevers Risk Assessment.
Please note that SHFT does not have the facilities to accept/manage a confirmed case of
VHF including Ebola.
RISK ASSESSMENT
A. Does the patient have a fever (≥ 37.5°C) or history of fever in the previous 24hrs and
has developed symptoms within 21 days of leaving a VHF endemic country
OR
B. Does the patient have a fever (≥ 37.5°C) or history of fever in the previous 24hrs and
cared for/come into contact with body fluids of/handled clinical specimens (blood,
urine, faeces, tissues, laboratory cultures) from an individual or laboratory animal
known or strongly suspected to have VHF within the past 21 days
If the answer to either of the above is YES please:
1. Isolate in a single room immediately to limit contact
2. Follow the instructions as per the VHF Risk Assessment algorithm which can be
accessed from the full document embedded on page 18 of this SOP
3. Follow instructions as per Appendix B: Escalation Flowchart for Management of
Suspected Cases, page 22
4. For Lymington and Petersfield, staff to also follow instructions as per Appendix C:
Communication Algorithm, page 25
5. For community staff visiting patients in their own home who fall into this category,
avoid direct contact with the patient and seek urgent advice from the duty GP.
If the answer to either of the above is NO then VHF (Ebola) is unlikely and manage patient
locally using normal standard precautions.
Patients will be categorised as either: ‘unlikely to have VHF’, or ‘high possibility of VHF’.
Please contact the Duty Consultant Microbiologist at your nearest acute Trust if you need
7
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
support with the risk assessment. If further advice is needed, please contact the Imported
Fever Service at Porton 0844 7788990 (manned 24hrs).
VHF is a notifiable disease under Schedule 1 of the Health Protection (Notifications)
Regulations 2010 and notification of VHF is classified as urgent. The Registered Medical
Practitioner (RMP) attending the patient must notify the highest possible risk by telephone to
the Proper Officer of the local authority in which the patient currently resides, within 24hours.
Written notification should be followed up within three days. The Proper Officer is usually
the Consultant in Communicable Disease at the local Public Health England (PHE).
Risk assessment is a legal obligation. The patients risk assessment determines the level of
staff protection and the management of the patient. Standard precautions and good infection
control are paramount to ensure staff are not put at risk whilst the initial assessment is
carried out. It is assumed throughout this guidance that staff will be following standard
precautions. If these measures are not already in place, they must be introduced
immediately when dealing with a patient in whom VHF is being considered.
PATIENT MANAGEMENT OF SUSPECTED CASES OF EBOLA (VHF)
ISOLATE
Isolate patient in a side room immediately to limit contact. The side room should
have dedicated ensuite facilities or at least a dedicated commode.
For ‘HIGH POSSIBLE’ VHF infection identify a side room which has an adjacent
contained space in which appropriate infection control can be carried out eg removal
and disposal of PPE. If possible ensure the patient isolation room is minimally
furnished and equipped with items which are disposable or can be cleaned with a
chlorine (bleach) agent.
For ‘HIGH POSSIBLE’ VHF infection, restrict the number of staff in contact with the
patient. Only named staff wearing appropriate PPE and trained in its use should
enter the patient’s room
MINIMUM STANDARD PRECAUTIONS REQUIRED ‘HIGH POSSIBILITY VHF’:
Hand Hygiene
Double gloves
Fluid repellent disposable coverall
Full length plastic apron
Head cover eg surgical cap
Fluid repellent footwear eg long boot covers
Full face shield
Fluid repellent FFP3 respirator*
Staff member to be wearing surgical scrubs (worn as single use items under PPE)
Isolation in a side room with dedicated ensuite facilities or dedicated commode
8
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
For staff delivering care to the patient, contact with body fluids should be avoided,
taking care to minimise contamination of the environment, and ensure safe
containment of contaminated fluids and materials.
NB: Appendix 8 can be found in the full ACDP guidance embedded in this SOP, page 18
All of the standard precautions required to care for a patient with ‘HIGH POSSIBILITY VHF’
can be found in dedicated Ebola Boxes (also labelled as Hazardous Material Box -
HAZMAT). The contents of each box have been procured centrally from NHS Supplies.
Please see Appendix D, page 27 for a full list of the contents of each box.
Ebola boxes (HAZMAT boxes) will be located in the following locations*:
9
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
X1 MIU Petersfield Community Hospital
X1 MIU Lymington New Forest Hospital
X1 MAU Lymington New Forest Hospital
*These sites have been identified as potentially being our high risk areas.
X1 Spare: East Division (held in MIU Petersfield)
X1 Spare: Trust (held centrally in Moorgreen hospital). This can be accessed by contacting
the Duty Estates Manager on 0701 0072 516 in working hours. The duty engineer will be
contacted and instructed to deliver the HAZMAT box where needed. Out of hours, please
contact the Director on Call (070 1703 1107).
X1 Training box for IP&C team held at Elms, Tatchbury.
FFP3 RESPIRATORS
FFP3 respiratory protection must be worn for any ‘high possibility’ case as splash protection.
If using the mask for respiratory protection during aerosol generation procedures, please
ensure that any staff wearing a FFP3 respirator have been Fit Tested and trained to wear
this – please see FFP3 Fit Check poster attached to this SOP. Potential aerosol generating
procedures include;
Endotracheal intubation
Bronchoscopy
Airway suctioning
Positive pressure ventilation via face mask
High frequency oscillatory ventilation
Central line insertion
Diagnostic sputum induction
PERSONAL PROTECTIVE EQUIPMENT (PPE)
The PPE should provide a suitable barrier protection for staff. The barrier function will need
to be maintained throughout all clinical/nursing procedures including the decontamination of
potentially contaminated equipment by the wearer
The PPE should provide adequate coverage of all exposed skin
The materials from which the PPE is made should resist penetration of relevant
liquids/ suspensions and aerosols.
The various components (body clothing, footwear, gloves, respiratory/face/eye
protection) should be designed to fit the user well enough to maintain a barrier eg
sleeves long enough to be adequately overlapped by glove cuffs.
10
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
DONNING AND DOFFING (REMOVING) OF PPE
A detailed and pre-defined sequence for donning and doffing of items must be followed.
Please see Appendix E, page 28 for the full donning and doffing procedure. A laminated
copy of this will also be available in each Ebola Box (HAZMAT box).
The expiry dates and integrity of PPE should be checked prior to donning
PPE should be put on over single use disposable scrubs
Donning and doffing must always be done in pairs using the ‘buddy – buddy’ system
After use it should be assumed that PPE may be contaminated and an appropriate removal
procedure is essential to prevents risks of exposure to the wearer.
Staff should be trained* in procedures to don and especially doff PPE, including the correct
order to avoid cross contamination, and to check that the FFP3 with which they are provided
fits properly. Staff who have not received training in the wearing of this level of PPE, should
not be involved in the care / decontamination of areas of patients with ‘HIGH POSSIBILITY
VHF’.
PPE should be donned before starting procedures likely to cause exposure and only doffed
after moving away from a source of exposure eg moving into an adjacent changing area.
PPE should not be a source of further contamination. Please ensure that following removal
PPE is not left on environmental surfaces.
Following removal disposable PPE will need to be placed into suitable disposable
receptacles and treated as clinical infectious waste – see Waste section
PPE should be stored off the floor in a designated clean and dry storage area to ensure they
are not contaminated prior to use.
*Training in PPE will be provided for staff working in areas which are considered higher risk
areas. 3 sites will be targeted to receive this training – MIU at Petersfield Community
Hospital and MIU, MAU and FAC at Lymington New Forest Hospital.
HAND HYGIENE
Before donning gloves and wearing PPE on entry to isolation room
Before any clean/aseptic procedure being performed on the patient
After any exposure risk or actual exposure with the patient’s blood or body fluids
After touching (even potentially) contaminated surfaces/items in the patient’s
surroundings
Before leaving the patient isolation room and moving to the room identified to remove
PPE
11
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
When caring for ‘HIGH POSSIBLITY VHF’ hand hygiene must be performed in-
between the removal of each different part of PPE
EQUIPMENT
If possible ensure the isolation room is minimally furnished and equipped with items
which are disposable or can be cleaned with a chlorine (bleach) agent.
Single use (disposable) equipment and supplies should be used where possible
The use of needle-free sharps systems to eliminate the risk of needle-stick injuries
should also be used if possible.
Disposable crockery and cutlery should be used where possible for those patients
categorised with ‘HIGH POSSIBILITY VHF’. These items should be disposed of as
Category A waste (yellow bag)
DECONTAMINATION
VHF viruses have been shown to be susceptible to a broad range of disinfectants including
chlorine and alcohol. It is also inactivated with soap and water
VHF viruses can survive for several hours when dried onto surfaces such as
doorknobs and worktops and up to several days in body fluids such as blood at room
temperature
VHF viruses have also been known to survive for two weeks or even longer on
contaminated fabrics and equipment
Staff involved in decontamination and cleaning must wear appropriate PPE and use
suitable disinfectants.
For surfaces where there is no visible contamination with blood or body fluids and
general environmental cleaning, a hypochlorite solution containing 1,000ppm
available chlorine should be used
Blood/body fluid spillages (eg; urine, vomit, diarrhoea): Contamination should firstly
be covered with absorbent chlorine granules (Sodium dichloroisocyanurate –
NaDCC). The area should then be disinfected with freshly prepared hypochlorite
solution containing 10,000ppm available chlorine ensuring a contact time of two
minutes before wiping with disposable towels. Please refer to manufacturer’s
instructions. The surface should then be washed with warm water and detergent.
Please note this is a clinical staff NOT housekeeping responsibility.
Full PPE must be worn whilst disinfecting.
All waste, including gloves and paper towels should be disposed of as Category A
waste (yellow bag)
When using chlorine products please ensure there is adequate ventilation (open
windows), and follow manufacturers instructions.
12
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
Terminal clean of room upon patient discharge/transfer.
INITIALLY CLOSE THE ISOLATION ROOM / TOILET & PPE REMOVAL ROOM TO
ADMISSIONS
Keep these areas closed until all decontamination is complete and ensure these rooms are
clearly identified as ‘Out of Use’. Hazard tape (from the Ebola box) can be used across the
doors to identify these as closed rooms.
For ‘HIGH POSSIBILITY VHF’ do not use the room until test results are known from potential
cases – NB: this can be 8-12 hours for the results to be known.
For ‘CONFIRMED CASES OF VHF’ rooms will need to be decontaminated via fumigation
following discussions with PHE. The process for fumigation is outlined on page 76 of the
ACDP guidance embedded at the end of this SOP, page 18. Fumigation can only be
undertaken by staff fully trained in this procedure. Contact Wessex Health Protection team
on 0344 225 3861 for further advice.
Public areas where the suspected case has passed through and spent minimal time in eg
corridors, but which are not visibly contaminated with bodily fluids, do not need to be
specially cleaned and disinfected.
If the VHF test is negative, usual cleaning methods can be used.
TOILETS
Toilets or commodes may be used by patients categorised as ‘HIGH POSSIBILITY
VHF’.
Where commodes are used it must be dedicated for that patient and used with a
disposable bedpan insert. The contents of the bedpan must be solidified with a high
absorbency gel / granules and then disposed of as Category A waste (yellow bag)
Toilets and commodes should be disinfected with hypochlorite containing 10,000ppm
available chlorine at least daily, preferably after each use and upon patient
discharge.
For non-ambulant patients, disposable bedpans should be used and the contents
solidified with high-absorbency gel / granules and then disposed of as Category A
waste (yellow bag).
13
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
WASTE
Waste for ‘HIGH POSSIBILITY’ VHF infection
For ‘high possibility’ all waste is classified as Category A infectious waste on the
basis that it is known or contaminated with pathogens presenting the most severe
risk of infection. All waste including gloves and paper towels should be autoclaved or
incinerated – place waste in YELLOW bag. These waste bags must be double
bagged.
Inside Isolation Room: Patient Waste
1. Staff caring for patients in isolation must be wearing full PPE as outlined in Standard
Precautions section
2. HCW inside the room must line a yellow clinical waste sack with an absorbent liner /
cushion from the Ebola box.
3. Place waste and linen into yellow clinical waste sack ensuring the sack is only half
full (this is the primary sack)
4. Securely tie the clinical waste sack at the neck with a yellow tag
5. Before transferring waste sack to an adjacent area which has been identified to store
waste, place waste sack inside a second heavy duty clinical waste bag. Securely tie
this sack at the neck with a yellow tag.
6. HCW must then perform hand hygiene by rubbing alcohol hand rub into gloved
hands before leaving the patient isolation room and moving to the room designated
to remove PPE and manage waste
1. For sharps waste, including disposable cutlery, place waste inside the sharps bin
2. When sharps reach the fill line, lock shut and then date and sign
3. Wipe down the exterior of the sharps bin with a clinell sanitising wipe before moving
into the adjacent area
Adjacent Single Room Identified to Store Waste and Remove PPE:
1. Ensure an empty heavy duty yellow clinical waste sack is placed into a rigid leak
proof 60 litre burn bin with half of the sack folded over the opening of the container
2. The 1st HCW (who has brought waste from patient isolation room), places the waste
sack / or sharps container into the lined bin ensuring the bag will fit into the container.
1st HCW then moves away from bin without touching the bag lining the bin
3. The 2nd HCW (wearing gloves and apron) securely ties the waste sack lining the bin
at the neck (with a yellow tag) and then attaches post coded tape or numbered tag.
The bag is then placed in the bin leaving approx. 3-4 inch gap at the top and the lid of
the container. Fill any dead space at the top of the bin with packaging to prevent any
excess movement.
4. The 2nd HCW places the lid on the rigid bin and seals it shut
5. The 2nd HCW then wipes down the exterior of the bin with a clinell wipe
6. Attach a completed waste label to the front of each bin.
7. Contact Veolia Helpdesk on 0845 606 0460 or by email
([email protected]) for a 770 litre lockable clinical
14
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
waste wheelie bin to be brought direct to the ward/dept. This 770 bin must remain in
the corridor outside of the room where the waste is packaged.
8. The 60 litre bins are then placed into the 770 litre bin, which will then be taken
directly to the secure quarantined storage area
Removal of PPE:
Hand hygiene must be performed by rubbing alcohol hand rub into gloved hands,
before leaving the patient isolation room to the room designated to remove PPE
Once in this designated room, PPE will be removed under the supervision of a buddy
to ensure the correct procedure is followed. See Appendix E, page 28 for full details
of doffing of PPE
On removal PPE must be disposed of directly into a double lined 60 litre burn bin
Scrubs worn to provide care must also be removed after each contact and disposed
of as Category A waste.
Transportation of Waste
A reputable and licenced waste contractor must undertake transport to the
incinerator. Prior to collection by the contractor waste must be stored securely and
access restricted to authorised and trained personal.
To arrange a Category A waste collection please contact:
Veolia Helpdesk on 0845 606 0460 or
[email protected] (working hours)
Simon Hull 44(0) 7554 115080 or Andy Higgins 07425 620954 (out of hours
for Ebola waste only)
Staff at Lymington hospital and Fordingbridge should contact the SCRL
helpline to arrange collection on 0333 240 4400. NB this number is only
manned during working hours. Out of hours or at weekend please ensure
waste is stored as outlined above and contact the Veolia Helpdesk using the
telephone number above.
For any queries regarding waste please contact Rob Harris on mobile 07717 652 317
LINEN
For patients with a ‘HIGH POSSIBILITY’ VHF infection, the use of disposable linen
should always be considered. This linen must be treated and disposed of as
Category A waste (yellow bag). If re-usable linen is used, it must be disposed of in
yellow waste bags and treated as Category A waste and sent for incineration.
15
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
DIAGNOSTIC INVESTIGATIONS
The main risk of infection to the health care worker when collecting the specimens is
direct contact with blood or body fluids from the patient.
Specimens should only be taken if absolutely essential following discussion with the
Microbiologist at the Acute Hospital, and there are systems in place to transport
these high risk specimens safely
For patients with a ‘HIGH POSSIBILITY’ of VHF infection, specimens must be
transported to the lab in suitably sealed containers and labelled with a ‘Danger of
Infection’ sticker. It is important to inform the lab prior to sending to ensure the
appropriate laboratory containment is in place for specimen handling. Healthcare
waste generated as a result of specimen collection from patients categorised as
‘HIGH POSSIBILITY’ of VHF infection, must be securely stored pending laboratory
results. In the event that VHF infection is confirmed this would require disposal as
Category A infectious waste (yellow bag – double bagged), otherwise it can be
treated as Category B infectious waste (orange bag).
Category A specimens must only be transported using couriers who are licenced to
transport this type of specimen. Please contact the SHFT courier - ERS Medical
on 0333 240 4999 to arrange collection. Please note this number is available 24/7
STAFF EXPOSED TO POTENTIALLY INFECTIOUS MATERIAL
Following percutaneous or muco-cutaneous exposure to blood, body fluids,
secretions or excretions from a patient with suspected VHF infection the HCW should
immediately and safely stop any current tasks, safely remove PPE, clean hands and
leave the patient area.
Accidental exposures that need to be dealt with promptly are:
Percutaneous injury eg needlesticks: Immediately wash the affected part with
soap and water. Encourage bleeding.
Contact with broken skin: Immediately wash the affected part with soap and
water
Contact with mucous membranes: Immediately irrigate the area with water or
emergency wash bottles, which should be accessible in case of such an
emergency.
Report incident to Occupational Health Advisor using Sharps Emergency Hotline
0845 371 0572
Contact Wessex Health Protection Team 0344 225 3861. Out of hours 0844 967
0082
Report incident on Trust Internal reporting system
In the event that VHF is confirmed in the source patient, the exposed individual
should be followed up as a Category 3 contact – see section below for further details.
16
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
STAFF EXPOSED TO CONFIRMED CASE OF VHF
A contact is defined as a person who has been exposed to an infected person or their blood
or body fluids, excretions or tissues following the onset of fever in the infected person. As
soon as a patient has been categorised as confirmed VHF all those who have had contact
with the patient should be identified as far as possible.
Public Health are responsible for the management of contacts and will have an overview of
the contact tracing. However Occupational Health will be asked to identify the contacts in
the area affected. Once contacts have been identified PHE will monitor them.
Each potential contact should be individually assessed for risk of exposure and categorised
according to the categories listed in the table below
Categorisation of Contacts
17
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
Contacts should be managed as outlined it the table below. There should be no restrictions
on work or movement of contacts unless disease compatible symptoms develop. PHE will
monitor contacts and provide advice on an individual basis
Management of Contacts
18
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
COMMUNICATIONS
For all patients who screen YES (HIGH POSSIBILITY VHF) to either of the two screening question on the Risk Assessment (Appendix B, page 22) please ensure the Communications team are contacted
This applies for all patients regardless of the healthcare environment to which they present – inpatient, outpatient or in their own home
The Comms team can be contacted via their on call number: 07017 029 238 Please see Appendix B, page 22 and Appendix C, pages 25 & 26 for further details
VISITORS
Asymptomatic relatives or carers who present to the department with a patient who
screens YES (HIGH POSSIBILITY VHF) should ideally be separated from the patient
with symptoms
Please contact Wessex Health Protection Team 0344 225 3861 / Out of hours 0844
967 0082 to discuss any actions that may be required
AFTER DEATH CARE
If a patient who screens YES (HIGH POSSIBILITY VHF) and suddenly dies in your
department, please refer to Appendix 12: After Death Care in the full VHF guidance
embedded below
Theresa Lewis
Lead Nurse IP&C
Southern Health NHS Foundation Trust
26.10.15
Management of Hazard Group 4 Viral Haemorrhagic Fevers (DH Nov 2014) is embedded
below. Please use this version to open the links in the Risk Assessment Algorithm
VHF guidance document updated 19112014
References:
Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of
high consequence (Department of Health Nov 2014).
WHO (2014) Interim Infection Prevention and Control Guidance of Patients with Suspected or
Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola. World Health
Organisation 2014.
19
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
Appendix B: Escalation Flowchart for Management of Suspected
Cases of Ebola
Health care facilities should clearly display information requesting that patients/relatives tell the healthcare worker or receptionist on arrival if they are unwell and have returned from an Ebola-affected area within the last 21 days
For all unplanned admissions or individuals reporting to any SHFT site please check
RISK ASSESSMENT
A. Does the patient have a fever (≥ 37.5°C) or history of fever in the previous 24hrs and has
developed symptoms within 21 days of leaving a VHF endemic country
OR
B. Does the patient have a fever (≥ 37.5°C) or history of fever in the previous 24hrs and
cared for/come into contact with body fluids of/handled clinical specimens (blood, urine,
faeces, tissues, laboratory cultures) from an individual or laboratory animal known or
strongly suspected to have VHF within the past 21 days
IF YES to either question on risk assessment and patients presents to MIU Petersfield,
MIU, MAU or FAC at Lymington
1. Individuals should be isolated in a side room straight away. They should not sit in a
general waiting room before being assessed.
2. Contact the Duty Consultant Microbiologist at your nearest acute Trust to arrange
transfer to dedicated isolation facility
3. Following discussions with Consultant Microbiologist ring 999 (inform them of the risk of
Ebola) to arrange transfer
4. Contact Wessex Health Protection Team 0344 225 3861. Out of hours 0844 967 0082
5. Contact a member of the Infection Prevention & Control team (IP&C) / out of hours
contact your On Call Manager
6. IP&C or On Call Manager (if weekend or out of hours) to contact Director on Call (070
1703 1107) who will inform CCG as per Director on Call pack (1B, page 2).
7. IP&C/Ward or Team Manager or On Call Manager (if weekend or out of hours) to contact
Trust Comms Team on 07017 029 238.
IF YES to either question on risk assessment and patient presents to healthcare
setting with no access to Ebola boxes
1. In areas where there is no access to Ebola boxes and staff have not been trained in the wearing of high level PPE, immediately isolate the patient in a single room without any direct contact with the patient.
20
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
2. Where possible the side room should be cleared of removable items to reduce cleaning requirements later if the patient is diagnosed with Ebola
3. The patient should be clinically assessed without any physical contact
4. Even though contact with the patient should be avoided single use gloves and apron are
still recommended to reduce contamination from the environment. In the event of
mucosal membrane exposure to potentially infectious bodily fluids, the affected
individual should contact the Wessex Health Protection Team 0344 225 3861 in the
first instance, who will advise and arrange appropriate assessment and follow up
where necessary
5. Follow steps 2- 7 above
6. Discard PPE into a yellow bag in the room
7. Use alcohol hand rub immediately after removal of PPE and after leaving the room
Actions needed for all sites whilst waiting for patient to be transferred
1. Keep patient in isolation with own ensuite.
2. If no ensuite available and patient is mobile, allocate a toilet to be used solely by this
patient
3. If no ensuite available and patient is not mobile, a commode can be used
4. Restrict number of staff in contact with the patient
5. On discharge/transfer close the room and do not use until it has been fully decontaminated. If there is waste present in the room, do not remove, and keep room quarantined out of use until results of ebola testing are known.
6. The full risk assessment and investigations may rapidly exclude Ebola and specific
decontamination of the room will not be required
7. For ‘HIGH POSSIBILITY’ cases quarantine the isolation room / toilet until results of
Ebola testing are known – this may take up to 24hours
8. If Ebola is confirmed specific decontamination advice will be provided by Wessex Health
Protection Team. The Health Protection Team will also identify and organise any follow
up for contacts
9. Public areas where the suspected case has passed through and spent minimal time in
eg corridors, but which are not visibly contaminated with bodily fluids, do not need to be
specially cleaned and disinfected.
IF YES on risk assessment when patients are seen in their own home
1. For community staff visiting patients in their own home who fall into this category, avoid
direct contact with the patient and seek urgent advice from the duty GP
2. Even though contact with the patient should be avoided single use gloves and apron are
still recommended to reduce contamination from the environment
3. GP will seek urgent advice from either the Consultant Microbiologist at local acute trust or
Wessex Health Protection Team
4. If transfer to hospital is required, an ambulance will be arranged, alerting them to the
possibility of ebola in advance
5. Contact Comms via the on call tel number 07017 029 238.
21
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
VHF is a notifiable disease under Schedule 1 of the Health Protection (Notifications)
Regulations 2010 and notification is classified as urgent. The registered medical practitioner
(RMP) attending the patient must notify the highly possible case by telephone to the Proper
Officer of the local authority in which the patient usually resides within 24 hours. The Proper
Officer is usually the Consultant in Communicable Disease Control at local PHE – 0344 225
3861. Verbal notification should be followed up with a written notification within three days.
The RMP should not wait for laboratory confirmation in order to notify suspected cases.
The Proper Officer must disclose the content of the notification received from the RMP by
telephone within 24hrs to:
1.Public Health England – negated if Proper Officer is employee of institution
2.Local Director of Public Health
3.The Department of Health
For further advice contact the IP&C team: 02380 874658 or 02380 874291
22
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
APPENDIX C: Communication Algorithm
Ebola Virus Haemorrhagic Fever(EBVH): LNFH
Communication Algorithm
High Risk Suspected EVHF
Implement full isolation procedures
(Refer to SOP, algorithm,
LNFH-‘Ebola boxes’ on MAU & MIU)
Bleep 1
(LNFH only )
Inform Infection, Prevention &
Control on 02380 874291/
02380 874658 or
On Call Manager out of hours:
07017 031615
On Call Medical
Consultant
(LNFH only)
(LNFH)
UHS Consultant
Microbiologist UHS
main no:
023 8077 7222
Hospital /ISM Manager/
Matron/Head of Professions
On Call Manager-mobile no.
07017 031615
ISD Director
On Call Director-mobile:
07017 031107
CCG
On call CCG Director-
OOH
Trust Comms
Team via on call
number:
07017 029238
On call Medical Consultant
(LNFH) to contact:
Wessex Health Protection
Team: 0344 225 3861.
Out of hours 0844 967 0082
Following discussions with Microbiologist
ring 999, inform of risk of Ebola and
arrange transfer
23
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
APPENDIX C: Communication Algorithm
Ebola Virus Haemorrhagic Fever(EVHF): MIU Petersfield
Communication Algorithm
Contact Consultant
Microbiologist via QAH
switchboard:
02392 286000
High Risk Suspected
EVHF
Implement full isolation procedures
(Refer to SOP, algorithm,
‘Ebola boxes’ on MIU)
Contact Matron/On
call manager out of
hours
07017 031911
Inform IPC team (Infection,
Prevention & Control):
02380 874291 or
02380 874658
Following
discussions with
Microbiologist
arrange transfer
Site Manager /ISM Manager/
Head of Professions
On Call Manager-mobile no.
07017 031911
ISD Director
On Call Director-mobile
07017 031107
CCG
On call CCG Director-
OOH
Trust Comms
Team via on call
number:
07017 029238
MIU to contact:
Wessex Health Protection
Team: 0344 225 3861.
Out of hours:
0844 967 0082
Contact SCAS Duty Control
999
24
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
Appendix D: Ebola Boxes (HAZMAT Box)
Following collaboration between IP&C Lead and Head of Procurement X5 Ebola boxes have
been ordered centrally using a combination of the national Ebola PPE order line and the
normal procurement route for NHS supplies.
Each Ebola / HAZMAT box will contain:
Product Size Number
Faceshield - 12
Full body coverall M, L, XL 4 of each size
Surgical cap - 12
Long cuff gloves (outer glove)* M, L, XL 12 pairs
Nitrile gloves (inner glove) (from existing stock) M, L, XL
3M FFP3 masks (from existing stock)
Ankle length apron - 12
Scrubs (or equivalent) – single use M, L, XL 4 of each size
Long boot covers – knee length - 12
Heavy duty yellow clinical waste bags (outer) - Roll
Yellow clinical waste bags (inner) Roll
Waste labels - 12
60 litre yellow clinical waste bin - 12
Absorbent sheets/cushion to line clinical waste bin - 12
Absorbent granules and scoop - 1
Alcohol hand pump dispenser - 1
Actichlor Plus tablets - 1 tub
Dilution bottles for Actichlor 2
Disposable clothes - 5
Disposable cutlery / crockery various
Hazard tape X1 roll
Tape to mark clean / dirty areas X1 roll
Large wipeable storage container - X1 to store all supplies
*double glove with normal size nitrile if none available
Boxes will be held at:
X1 box at MIU Petersfield Community Hospital
X1 box at MIU Lymington New Forest Hospital
X1 box at MAU, Lymington New Forest Hospital
X1 spare for East Division – held at Petersfield
X1 spare for the Trust – held at Moorgreen hospital. This can be accessed by contacting the
Duty Estates Manager on 0701 0072 516 in working hours. The duty engineer will be
contacted and instructed to deliver the HAZMAT box where needed. Out of hours, please
contact the Director on Call (070 1703 1107).
X1 Training box for IP&C team – held at Elms, Tatchbury
25
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
Appendix E: Procedure for Putting on and Taking off PPE for
Suspected or Confirmed Ebola Patients
PPE should be put on over single use scrubs.
The putting on and removal of PPE must be completed in pairs using
the “buddy – buddy” system.
*At all times check on your buddy for correct PPE application*
To put on PPE:
1. Step into the full body suit – take care not to damage it. Zip the body
suit up – do NOT tear off the sticky panel but ensure the flap is folded
over to cover the zip.
2. Put on over boots and ensure they are over suit with ties in a loose
bow.
3. Place theatre cap on head – ensure all hair is within the hat. Females
with long hair may need to tie it up into a bun.
4. Put on the FFP3 mask – mould it around the nose. DO NOT
SQUEEZE. Buddy to check mask is on correctly.
5. Put on the visor with a knot in the strap.
6. When ready pull your buddy’s hood over their head – make sure the
cap and visor remain in place and that it covers all around the head and
face. Once fitted ensure the suit zip is to the top.
7. Put the apron on – split the neck and take it in turns for each buddy to
tie the apron on to the other.
8. Put on the inner gloves – ensure the finger loop on the suit is in place if
fitted.
9. Put on the outer gloves – these MUST go on top of the suit sleeve.
10. To finish complete a 360* check of your buddy to ensure there are no
breaches of exposed skin.
*At all times check on your buddy for correct PPE application*
26
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
Prior to leaving the isolation room and moving to the PPE removal room,
staff must decontaminate their gloved hands with alcohol hand rub
To remove PPE.
The safe undressing procedure must take place in an area identified
close by to the isolation room, ideally with a hand wash sink.
The room will need a clean and dirty area clearly marked – tape can be
used fixed to the floor to demarcate between these areas.
Alcohol gel will be dispensed from a pump bottle direct onto gloved
hands, by a 3rd person who is ‘clean’. This person will wear gloves and
apron and will remain in the ‘clean’ area.
Removal – continuing with the buddy system:
1. Clean gloves with alcohol hand rub
2. Pinch the top of the apron, making sure you do not touch the suit. Rip
the ties of the apron off from the neck; allow top part to fold down. Then
pinch the sides and pull the apron off, folding it on itself so the
contaminated side is on the inside of the fold. Put in the clinical waste
bin.
3. Clean gloves with alcohol hand rub
4. Use your buddy to remove your hood by peeling it back and folding it on
itself so that it is rolled inside out down to the neck.
5. Clean gloves with alcohol hand rub
6. Buddy to untie over boot ties.
7. Remove outer gloves using pinch method and put in clinical waste
8. Use your buddy to unzip the suit. From behind take hold of the shoulder
of the suit and fold down to waist level. Buddy to take care not to
contaminate self or inside of buddy’s suit.
9. Clean inner gloves with alcohol hand rub
10. Step in to clinical waste bag rolled on the floor.
11. Pull suit down until you can step forward from the boots across the
clean/dirty line ensuring the boots and suit remain in the clinical waste
bag. (Ensure you only touch the inside of the suit).
27
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
12. Remove the visor by tipping head forward with eyes closed and
allowing it to drop forward into the clinical waste bin.
13. Clean gloves with alcohol hand rub
14. Use your buddy to locate straps of FFP3 mask. Remove by pulling
straps forward and allowing mask to come away from face. Place in the
clinical waste bin.
15. Clean gloves with alcohol hand rub.
16. Take hold of the top of the theatre cap and pull off. Place in the clinical
waste bin.
17. Clean gloves with alcohol hand rub
18. Remove inner gloves by pinching the top of the glove and pulling it
down so that it turns inside out. Place in the clinical waste bin.
19. Wash hands using soap and water.
20. Proceed to clean area to remove disposable scrubs and dispose of in
clinical waste bin, shower (if able) and dress in normal uniform.
If a breach occurs, decontaminate straight away and report the breach.
28
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
Appendix F: Timeline of actions taken by Southern Health NHS
Foundation Trust
8.8.14 NHS England circulated a letter in response to the current outbreak of
Ebola in West Africa and the heightened international response requesting
assurance on points a-d below
Requirement
Action by SHFT
a) SHFT is assured that there are
systems and processes in
place to identify and isolate a
patient who presents with a
high index of suspicion of
Ebola
SOP written by IPC Lead nurse and
circulated to IPC Links and their Managers,
topic for Sept IPC Link meetings, displayed
on Trust Intranet, in Trust Bulletin
b) SHFT has sufficient supplies of
Personal Protective Equipment
(PPE) and FFP3 facemasks
In version 2 of the Ebola SOP, all
community hospitals were asked to keep
an Ebola Box ready with the required PPE
as stated by the IP&C team (to be
available for community teams if needed).
c) SHFT has a robust Fit-Testing
programme in place, which
complies with FFP3 guidance
19/5/14 The IP&C team (X4 IP&C Nurses),
and X3 staff from LNFH attended a half
day fit testing workshop on the use of the
Fit Testing Kit organised by 3M
End Sept 2014 –
All SHFT staff including Junior Doctors,
Consultants and physio’s who work
working in MAU and MIU in LNFH, or at
MIU Petersfield hospital were fit tested.
On completion of Fit Test training a copy of
the Fit Test record will remain locally with
the staff member, a copy sent to HR to
ensure staff records are updated centrally,
a copy will be sent to occupational health,
and a copy held by the IP&C team.
By the end of 2014 the IP&C team with
support as stated above will aim to Fit Test
other key staff who work within physical
health teams. Aiming for a minimum of 2
members of staff from each ICT and ward
(physical health)
Following a risk assessment and
29
Standard Operating Procedure for Ebola Identification
Author: Theresa Lewis, Lead Nurse Infection Prevention and Control
Version: 4
November 2015
consultation with Senior Managers in
December 2014 it was agreed that OPMH
staff would not be Fit Tested. This will be
reviewed if necessary
d) SHFT is aware of our local
Infectious Diseases Unit and
how they can be contacted
to provide a source of expert
information and to support
clinical discussions
SHFT does not have Infectious Diseases
Unit within the organisation. Patients who
require this facility will be transferred to
their local acute trust if this is required
following discussions with Consultant
Microbiologist at Acute Trust. Staff can
also contact a member of their IP&C team
for further support and advice. If further
advice is needed please contact the
Imported Fever Service at Porton on 08447
788990 (manned 24/7).
NB: Patients with confirmed VHF including
Ebola must be cared for in dedicated High
Level Isolation Units such as Royal Free in
London
November 2014 Department of Health changes the Management of Hazard
Group 4 viral haemorrhagic fevers and similar human infectious diseases of
high consequence’ (DH November 2014).
Higher level of personal
protective clothing required
(PPE)
The Ebola PPE boxes prepared in October
2014 do not contain the level of PPE
outlined in (DH Nov 2014). They can still
be used to manage other incidents, but for
the purposes of potential Ebola patients
they have now been superseded as higher
levels of PPE are now required which
include coveralls, face visors and shoe
covers. PPE is covered in the SOP
(Appendix A, page 8 and Appendix E,
page 28). 5 ‘Ebola kit boxes’ have been
purchased via Ebola NHS Supplies line on
behalf of the Trust.
The boxes will be held at:
X1 MIU, Petersfield
X1 MIU, Lymington
X1 MAU, Lymington
X1 spare East Division, Petersfield
X1 spare Trust, Moorgreen hospital