standard operating procedure for ebola identification · standard operating procedure for ebola...

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



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



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



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



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



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



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



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



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



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



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



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



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

mailto:[email protected]

14



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.

mailto:[email protected]

15



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



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



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



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



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



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



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



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



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



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



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



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.


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.


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



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.


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.


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



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



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

standard operating procedure for ebola identification · standard operating procedure for ebola...

Documents