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Ebola Virus Disease (EVD)
Information available as of March 2016
Reservoir and transmission to
• Researchers believe that the virus is animal-borne
and that bats are the most likely reservoir
• Bats infect chimpanzees, gorillas, forest antelopes,
• Humans handle and eat bush meat (bats,
chimpanzees, gorillas)
• Infected human passes from person to person
• Ebola is not a new disease – discovered 1976
• Before the current situation, outbreaks have
appeared sporadically in Africa.
Source Pubic Health Ontario, Presentation Sept 2, 2014, www.publichealthontario.ca, and CDC
Areas Affected
West Africa
• Guinea
• Sierra Leone
• Liberia
Ebola in West Africa Outbreak
Distribution Map
Source: CDC accessed March 29 2016
www.mapsofworld.com Source accessed October 16 2014
Context for Outbreak in
Widespread on multiple fronts
• Affected large cities
• Weak and fragile infrastructure
• Lack of knowledge of the disease
• Distrust of government and foreigners
• Not seeking health care
• Social rituals / burial rituals
From Pubic Health Ontario, Presentation Sept 2, 2014, www.publichealthontario.ca
Key Facts
• Most infected individuals likely to have known exposures
(not unrecognized exposures)
• Other diseases associated with travel to these areas are
more likely. Examples are: malaria, influenza,
meningococcal, typhoid fever
Source: Ministry of Health and Long-Term Care & Public Health Ontario August 28, 2014
Transmission of EVD
• Incubation is 2 to 21 days (usually 8 – 10 days)
• Patients are only infectious when symptomatic
• Patients are increasingly infectious as they get sicker
Source: Ministry of Health and Long-Term Care & Public Health Ontario August 28, 2014
Transmission of EVD
EVD is associated with a high fatality rate. Although the risk in
Canada is low, those most at risk are individuals recently
returned from affected countries/areas in West Africa and
health care workers who manage patients with EVD.
Transmission of EVD can occur:
Directly through contact with blood and or body fluids or
droplets . Body fluids include: urine, saliva, stool, vomit,
sweat, tears, breast milk and semen.
Contact with patient care equipment or surfaces
contaminated with blood and/or body fluids, and
Possibly through generation of aerosols created during
aerosol generating procedures
Source MOHLTC Directive # 1 for Hospitals Revised August 27, 2015
Clinical Manifestations
The symptoms of EVD include:
• Fever
• Severe headache
• Muscle pain
• Diarrhea
• Vomiting
• Sore throat
• Abdominal pain
• Unexplained bleeding
Source MOHLTC Directive # 1 for Hospitals Revised August 27, 2015
WHCA Hospitals Designated as
Screening Hospitals
• The Ministry of Health and Long Term care has
implemented a 3 tier system of care for EVD or Suspect
1. Screening Hospitals
2. Testing Hospitals
3. Treatment Hospitals
• WHCA hospitals are designated as Screening Hospitals
• As Screening Hospitals we are expected to screen, isolate
and transfer any patient identified as being at risk for
EVD (no testing will be done at any of our sites)
Screening in Place - Passive
Signs are posted at
entrances asking
patients if they have
travelled or had
contact with someone
ill who has travelled
and if they feel unwell
to clean their hands,
put on a mask and go
to registration
Infection Prevention and
Control – Active Screening
All patients registering (emergency, admissions and clinics
including OBS) are asked regarding travel and if they answer yes
to travel to a country “of risk” they will be asked regarding any
After hours, nursing at NWHC will conduct screening via the
after hours phone
Screening at Registration Points,
After Hours Obstetrical and Emergency
Countries of Risk
•Sierra Leone
Symptoms of Risk
•Severe headache
•Muscle Pain
•Unexplained bleeding
•Sore throat
•Abdominal pain
This tool is available at registration areas, in the emergency
departments and in the inpatient areas as a resource for screening
for travel areas of risk and symptoms of risk
Active Screening – Process If An
Individual At Risk Is Identified
• If the patient has travelled but has no symptoms, they are not
considered at risk. Remember EVD can only be transmitted
when the patient is symptomatic
• If the individual registering the patient identifies a patient that
answers yes to travel and yes to symptoms, they will
immediately notify the emergency department to prepare a
room to further assess the patient. They will ask the patient to
put on a mask and clean their hands, continue the registration
process and ask the patient to remain at the registration area.
The patient will be informed that because of their travel
history and symptoms they will be moved to the emergency
department to be seen
Individual at Risk is Identified
• The emergency department will prepare the emergency room
removing non essential equipment as follows: Room 7 PDH,
Room 3 LMH, Room 3 GMCH and obtain the Ebola kit
• The emergency nurse will clear the transportation route of any
visitors, patients or other health care providers
• They will escort the patient to the emergency department
room wearing PPE (required PPE will be noted in another
• Routes for moving the patient to the ER department are
located in the Ebola policy and procedure and Ebola kit
• Housekeeping must be contacted to clean the registration and
transportation route once the patient leaves this area
Infection Prevention and
Control Practices – Patient
Placement Emergency
• As with all patient interactions HCW’s must
perform a risk assessment (to determine
exposure risk prior to patient contact).
• Place in a room by themselves using
Droplet + Contact Enhanced Precautions.
Place signage on the door and pull the
checklist in the Ebola kit for step by step
Hands must be cleaned before entering and after leaving this room.
remain closed
at all times.
Fluid Impervious Long-Sleeved Cuffed Gown + Lower Leg/Foot Coverings
 Apply gown and lower leg/foot coverings in corridor prior to entry to room.
N95 respirator
 Apply fit tested seal checked N95 respirator
Head covering and Full Face Shield
 Ensure no skin or hair is exposed and the face shield covers the front and sides of the face
Extended Cuff Double Nitrile Gloves
 One pair of gloves must go under the cuff and one pair over the cuff of the gown
 Ensure no skin is exposed
No Aerosol Generating Medical Procedures Will Be Performed
*Aerosol Generating Medical Procedures are medical procedures that generate droplets/aerosols
(e.g., nebulized therapy, BIPAP, CPAP, intubation, suctioning, CPR, etc.) .
Patient Transportation (Patient to remain in room)
 Place a mask on the patient covering nose and mouth.
 Person transporting patient receives patient in the hallway with new PPE. Person in room
removes PPE in anteroom/patient room, and applies new PPE if assisting in transport.
 Transport using most direct route. Remove other non -essential staff or patients/visitors from
the transport route
 No internal transportation except to transfer patient to a testing/treatment center
Equipment (use disposable whenever possible)
 Take only essential equipment into room.
 Equipment must stay in room.
 Use disposable dishes and utensils.
 Visitors are limited. Speak with the nurse
Remove and dispose of PPE in the anteroom or at the doorway (in the warm zone) prior to
exiting the patient room.
Patient Placement - Emergency
• Equipment must be dedicated to the patient - ideally use
disposable equipment when possible. Nothing leaves
the room unless it is appropriately cleaned and
• Close the door to the room (if able) – entry is limited to
essential care providers only. Volunteers or students
(except Senior Residents and Fellows) should not be
involved in the management of a suspect EVD patient
• The patient must not use the public bathroom. They
must use a dedicated commode – Hygie bags are
included in the Ebola kit. The patient should not leave
the room
Care of Patient – WHCA
Designated as Screening
Hospitals Only
• If after further assessment by a physician, the patient is deemed to
be a suspect case of Ebola Virus Disease, the following will be
notified immediately: Administration on call, Public Health, Public
Health Ontario, Infection Prevention and Control and an
Occupational Health and Safety Rep
• All persons entering room must sign entry log (in kit)
• Arrangements will be made through Criticall to transfer the patient
to a designated testing or treatment hospital
Care of Patient - Emergency
• No lab samples will be drawn or tested on site
• No aerosol generating medical procedures will be
performed. For example: no nebulized therapies, no
suctioning, no intubation, no bag mask ventilation
Patient Care
• The number of Health Care Workers in contact with the
patient should be minimized
• Two registered nurses are required for providing care at
all times; they must have no other duties. The two
nurses do not need to be in the room at the same time
and all of the time
• In addition, a trained observer must be present to
monitor health care worker activities and wellbeing.
They will ensure strict adherence to donning and doffing
of PPE procedures.
• A manager or supervisor must be available on site at all
• Visitors are limited to pediatric cases. These visitors
must be trained on PPE procedures
Personal Protective Equipment
as per Ministry Directive #1
Revised August 27, 2015
Screening (beyond registration point if no barrier
• Fit tested seal checked N95 respirator
• Full face shield
• Gloves (nitrile)
• Fluid resistant gown
Personal Protective Equipment
as per Ministry Directive #1
Revised August 27, 2015
Suspect/Confirmed Case and/or the patient environment
or touching anything that may be contaminated with the
patient’s blood or other body fluids
Fit tested seal checked N95 respirator
Fluid impermeable lower leg/foot coverings
Full length face shield
Fluid impermeable gown with cuffs
Full head covering
Double extended cuff nitrile gloves (one under and one
over gown cuff
** PPE should ensure no exposure of the skin, hair or clothing
Patient Care
Three Zones Designated
There are 3 zones designated for the care of a suspect Ebola
1. The cold (clean) zone which is the area outside of the
patient room or in the hallway
2. The warm zone is near the exit of the patient room or in the
anteroom if one is available and is potentially contaminated
3. The hot zone is the area within the patient room and is
considered contaminated
PPE will be put on in the cold zone and will be removed in the
warm zone at the doorway/exit of the room or in the anteroom
if one is available
Donning/Doffing PPE
A trained observer must be present to instruct health care
workers how to don (put on) and doff (remove) PPE. The
trained observer will follow a checklist and read aloud step by
step instructions
Trained observers will receive specific training on their role
Any health care worker required to wear PPE for EVD will be
trained on donning and doffing PPE and will have practice drills
to ensure they are competent in this task
If PPE becomes heavily contaminated with blood or other body
fluids, health care workers must remove PPE in the warm zone
and don fresh PPE as per hospital procedure
Patient Equipment
• Disposable dishes will be used
• No special cleaning agent is required – hospital approved
disinfectant is effective against the virus
• Environmental workers will wear the same PPE as other health
care workers entering the room
• Biohazardous waste pails will be used for all waste
• Special procedures for waste handling are required
• All linen of a suspect case will be discarded
Patient Equipment and Sharps
Disposable equipment will be used when possible. No
equipment will leave the room unless it is appropriately cleaned
and disinfected
• Extra care must be taken when handling sharps
• Safety engineered needles MUST be used
• Sharps must be disposed at the point of care by the individual
using it
• Perform essential procedures only. If initiating IV access the
most experienced individual should perform this task only if
deemed medically necessary
Patient Transportation
• The patient will be transported to a testing or treatment
facility in collaboration with Criticall
• Patient to remain in the room at all times – except for transfer
to a testing or treatment facility
• The person exiting the room must remove PPE in the
anteroom/patient room and applies new PPE if assisting in
• The person receiving/transporting the patient receives the
patient in the hallway wearing PPE
• The patient must wear a mask during transportation
Final note – things change
• The outbreak is evolving and new information continues to be
• Our goal is to keep everyone safe, informed and to be
• Watch for any e-mail updates
Contact Infection Prevention
and Control or your Manager

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