1 1 RESEARCH INSTITUTE FOR TROPICAL MEDICINE DEPARTMENT OF HEALTH RESEARCH INSTITUTE FOR TROPICAL...

1 1RESEARCH INSTITUTE FOR TROPICAL MEDICINE

DEPARTMENT OF HEALTHRESEARCH INSTITUTE FOR TROPICAL MEDICINE

Transport of EVD cases

Rick Speare, Miguel Dorotan, Julian Donald

December 2-4, 2014

2RESEARCH INSTITUTE FOR TROPICAL MEDICINE

Objectives

• Review Ebolavirus transmission routes and identify those relevant to transport of EVD cases

• Review EVD case definitions and what they mean for transportation

• Highlight the need to have systems and resources in place prior to deployment

• List and describe the components of the service needed to transport EVD cases safely pre-hospital and between facilities

• Highlight the need for a national policy that guides and supports safe and timely transport of EVD patients


Transmission of Ebolavirus:in the community

• In the community transmission typically requires direct physical contact with – i) a dead body of a EVD case or – ii) an EVD case or – iii) possibly items contaminated by body

fluids from an EVD case

• Ambulance crews have a community role with EVD even now in the Philippines (different from most other HCWs)


Transmission of Ebolavirus:in the hospital

• In the hospital the same applies, but transmission may also occur:– i) by needlestick– Ii) by droplet infection (within 0.5-1 m of

a patient) or – Iii) in theory by procedures that

generate aerosols of infected fluid (e.g., intubation, ventilation, etc.)

• Ambulance crews face the same risks as other HCWs and must follow the same protocols to keep themselves safe


EVD case definitions

• Person under investigation (PUI) = a person who has been in a country with ongoing ebola transmission within the last 21 days

• Suspect case = a PUI who has signs and symptoms consistent with EVD

• Probable case = a suspect case with an epidemiological link to a confirmed EVD case

• Confirmed case = a person who has a positive ebola laboratory test


Relevance of the EVD case definitions

• PUI = no symptoms, not infectious• Suspect case = If the person truely has EVD, the

case is infectious; most suspect cases in the Philippines will likely not be Ebola, but falciparum malaria

• Probable case = much more likely to be a true case of EVD; infectious

• Confirmed case = definitely infectious• Suspect, probable and confirmed cases have to

be managed using EVD infection control protocols


Reasons for transporting EVD cases

Moving EVD cases between health facilities• Case can not be safely managed at current location• Better care available at receiving hospital– Current referral hospitals are RITM and St Lazaro

• Hospital that diagnoses EVD case “refuses” to accept the case

Moving EVD cases from community to hospital• PUI in home quarantine develops symptoms (ie,

becomes a suspect EVD case) and needs safe management

• EVD case identified at home, needs hospitalisation• Suspect case abandoned on street; called out by

public


Community cases – Sierra Leone

Image - http://www.ctvnews.ca/health/unicef-doubling-staff-in-west-africa-to-better-fight-ebola-1.2083968


Abandoned EVD cases - Liberia

Image - http://www.nydailynews.com/life-style/health/calls-emergency-meeting-ebola-article-1.1893501

1010

RESEARCH INSTITUTE FOR TROPICAL MEDICINE

Where is an EVD case best treated?• Cases do better with specialized and

experienced support• Will an EVD case have a better outcome

treated in a local hospital with imported specialized support or if moved to a specialized hospital remote from the case?

• Will the negatives of transport be outweighed by the benefits of specialized treatment?

• Role for a Rapid Response Team to go to peripheral hospitals to provide support where the patient is?

11


List of topics relevant to the ambulance service at a hospital

1. Planning and preparation2. Screening cases and calls3. Preparing to transport an EVD

case4. Transporting an EVD case5. Immediate post-transport

activities6. Post-transport evaluation

12


Planning and Preparation

• Development of protocols and Standard Operating Procedures (SOPs)

• Identifying vehicles and crew• Obtaining and prepositioning supplies• Training crews– Infection control for EVD– Transporting EVD patients– Preparation for transport– Decontamination of ambulance

1313


Identifying vehicles

• Does each hospital need to identify its own transport vehicle or will DOH or groups of hospitals identify a vehicle to be used across a region?

• Essential characteristic:– Driver is separated from patient– Permanent (structural) or temporary (plastic sheet)

• Assume vehicle will be not available for routine use for at least 1 day after transporting an EVD patient

• This is not for infection control reasons, but because of the time involved in all procedures

1414


Possible types of vehicles

• Pickup – used in West Africa– Add cover to protect patients and staff in back

• Ambulance– Basic– Sophisticated

Image captured from MSF video on decontamination of ambulance - vimeo.com/110485075

1515


Pickup as ambulance - Liberia

Image - http://blog.usaid.gov/2014/11/recapturing-growth-in-ebola-stricken-west-africa/

Cover protects patients and crew

1616


Ambulance for EVD cases - Liberia

• Image - http://www.zimbio.com/pictures/ge7n5YUMy12/Liberia+Battles+Spreading+Ebola+Epidemic/J_xjxLBe8jw

Driver separated from patients

1717


Ambulance for EVD cases - USA

Image - http://www.telegraph.co.uk/news/worldnews/ebola/11153745/Ebola-outbreak-in-pictures.html

1818


What could be used in Philippines?• Pickup – yes• Ambulance – Basic – yes– Sophisticated – probably misuse of a

scarce resource since complex procedures will not be performed on EVD cases and the ambulance is better used for other cases

• Other – Jeepney?

1919


Ambulance with separated driver’s compartment

2020


Jeepney as an ambulance for EVD case • Easy to disinfect• Could be a dedicated vehicle• Needs to have barrier between driver and

patient compartments

http://www.boardinggate101.com/2012/08/jeepney.html

http://cheekeegirl.blogspot.com/2014/04/philippines-e-jeepney.html

2121


Interesting possibilities!

Separate driver’s

compartment Patient compartment

well ventilated; easy to

disinfect

22


Screening cases and calls

Routine cases• Determine the likelihood of a routine case having EVD• Travel history – Been in a country with EVD in last 21

days?Ebola cases• Determine the category (only 2 in practice) – PUI, OR

suspect / probable / confirmedSeverity of case• Too ill to move? Refuses to be transported?• Wet = liable to contaminate ambulance (e.g., diarrhea,

vomiting, bleeding)• Dry = low risk of contamination

2323


To move EVD case or not?

• Should be based on expert clinical assessment of risk factors

• Will the patient benefit?• Is the patient too ill?• Will transfer take too long (>2 hrs)?– Heat stress is a safety issue in PPE– Patient welfare

• Is the transfer too hazardous to staff?

Who decides and how ? Good to have this clearly established prior to transport (SOP)

24


Preparing to transport a particular case

• Personal protection• Preparation of the ambulance• Preparation of the stretcher• Equipment for attending HCW• Supplies for driver

2525


PPE for transport

• Paramedics (2 per trip) (if possible)– Full PPE for both– Have at least 2 spare sets available for both

• Driver (1 per trip)– Does not need full PPE while driving– However, have spare set of full PPE available– Driver can act as Trained Observer; so needs Trained Observer’s

PPE when supervising donning/doffing

• Patient– Should wear surgical mask to stop droplets– If “wet” case, may consider putting patient in coverall to limit

environmental contamination

• Ancillary items– All items needed to ensure safety when donning/doffing PPE– Cleaning up visible contamination– Decontamination of ambulance

2626


Preparation of the ambulance

• Essential – Separate driver’s compartment from patient’s compartment

• Put up plastic sheeting as minimum temporary measure

• Remove unnecessary items• Does the patient compartment need to be

lined with plastic sheeting?

2727


Plastic sheeting: To line or not to line?

• The reason for lining with plastic sheeting is if the ambulance has a complex interior that would be difficult to disinfect; i.e., inbuilt cupboards, seats with non-washable material, many nooks and crannies

• If the ambulance has a simple interior (like an empty box) and can be easily disinfected, no need to line with plastic sheeting

• Lining takes time to put up (an hour or more); time to remove safely (30 mins); adds cost

2828


Lining with plastic sheeting

• Line the patient compartment with plastic sheeting (impermeable to liquid)

• Try to make the floor and 10 cm up wall a single sheet (to contain fluids on the floor)

• Fix in place with duct tape – double tape all seams – inside and on the other side

• Let floor structures (for stretcher) protrude through plastic• Do not cover entry door• Consider including vertical slits at windows to allow

ventilation (plastic will need to be taped to front and back of window space)

• Put medical items that may be required into plastic bags that can be decontaminated if not used

2929


Ambulance lined with plastic sheeting

Image - Lowe et al. Prehospital Emergency Care (2014)

3030


RITM Ambulance: connection between driver and patient now closed

3131


RITM ambulance 2: plastic sheeting covers cupboards

3232


Prepare the stretcher

• If stretcher is basic, no preparation needed• If it has a mattress, cover with plastic

sheeting

Image - http://www.ctvnews.ca/health/unicef-doubling-staff-in-west-africa-to-better-fight-ebola-1.2083968

3333


This mattress can be decontaminated with 0.5% chlorine – no plastic cover needed

3434


Preparing to transport an EVD case: crew• Three crew (two paramedics, one driver)• Skills and experience– Clinical experience for paramedics– Driver – must have been trained as a Trained

Observer

• Training– Infection control for EVD– Transporting EVD patients– Preparation for transport– Decontamination of ambulance

3535


Preparing to transport an EVD case: logistics• Inform and collaborate

– Have medical supervisor involved in decision to move a EVD case

– Ensure that there is communication between sending and receiving medical teams

– Follow the SOPs (if there are some)

• Back up ambulance– Decide if this is needed– Incidents, including accidents, have health and

reputational risks

• Police assistance – Needed to help with traffic?

3636


Backup ambulance – USA – EVD caseAirport to Emory Hospital, Georgia

Image - http://www.georgianewsday.com/news/regional/273806-ebola-escort-roads-in-georgia-remain-open-as-american-doctor-infected-with-incurable-ebola-virus-is-taken-to-hospital-in-specially-fitted-ambulance-after-landing-in-us-for-treatment.html

3737


Prepare for the worst!

Backup ambulance should have:• Additional paramedics• Full sets of PPE• Equipment to decontaminate a crash

scene• Items to cordon off area• Maybe an attending physician

What is the role for police or security?

38


Transporting an EVD case

• Collection of patient• Assessment of likelihood of

contamination of crew and vehicle (wet / dry case)

• Containment of excretions• Safety of crew during transport• Clinical activities during transport• Communications during transport• Arrival at receiving facility• Handover

3939


Collecting EVD patient

• The route to the ambulance area from the patient’s location at the dispatch hospital must be able to be controlled and secured, and wide enough to permit transfer of patient, staff, and equipment

• Usually do not use Emergency Department but collect from Isolation Unit

• Receive patient with paramedic involved wearing full PPE

• If mobile case, use one paramedic• If stretcher case, will need two• Any person who had direct contact with the case,

should not enter the driver’s compartment, but should stay with patient

4040


Safety of crew

• One paramedic needs to be with patient• If patient’s condition is unstable, two paramedics

may be needed with patient• Other paramedic could be on standby in driver’s

cab, but should not have had any patient contact• No major interventions should be done• No procedures involving sharps• Clean up visible contamination as soon as it

occurs if possible• Paramedic with patient needs to be able to

communicate with others

4141


Driver – what PPE?

• Driver’s compartment is separate from patient compartment

• Risk of exposure is minimal• Prime requirement – Any PPE worn by

driver must not reduce safety of driving• More of a psychological issue than a

biological one• Coveralls, one pair of gloves, mask?

4242


Handover at receiving facility

• For suspect/confirmed EVD case only handover patient to staff wearing full Ebola PPE

Image - http://www.theadvocate.org.au/msf-australia-hard-won-gains-in-fight-against-ebola-must-not-be-underminned/

43


Immediate post-transport activities

• Safe doffing of PPE–Where?– At receiving facility?– Follow the doffing protocol – driver as Trained

Observer

• Managing wastes– At receiving facility?– To return in ambulance?

• Ambulance decontamination– At depot or at receiving facility?

• Debriefing of crew

4444


Sequence of decontamination

• Doff PPE used during transport• Use plastic sheeting as a high risk area for

doffing• Dispose of used PPE safely• Disinfect or dispose of sheet• Don new PPE• Clean and decontaminate ambulance• Dispose of waste• Doff PPE• Dispose of used PPE safely

4545


Decontamination vehicle

• Wear full Ebola PPE• Soak visible contamination with 0.5% bleach or

other approved disinfectant• Wipe this up after 10 minutes• Clean the plastic sheeting with 0.5% bleach or other

approved disinfectant• Remove the plastic sheeting and put into waste

bags or onto an impermeable waste sheet that is folded and secured

• Clean the interior of the ambulance with 0.5% bleach or other approved disinfectant

• Clean the outside of the ambulance with 0.5% bleach or other approved disinfectant

4646


Removing the plastic sheeting

• Interior of plastic sheeting is decontaminated

• In removal the aim is to roll the sheeting in on itself (clean side out; side that had contact with patient inside)

• Start at the edges near the back entry door

• Remove from walls and roof, rolling them inwards

4747


Almost finished: still attached on right wall

4848


Ready to be decontaminated and discarded

4949


MSF technique for ambulance decontamination

Image captured from MSF video on ambulance decontamination - vimeo.com/110485075

Note: The person in this video should be wearing full PPE when cleaning the ambulance

50


Post-transport evaluation

• Evaluation of performance– Did it work?– Can it be improved

• Modification of SOPs if indicatedSOPs would make the

transfer just described safer and less stressful for

all involved

5151


Transport by air

• When will patients be transported by air?• CDC have developed a protocol• Guidance on Air Medical Transport for

Patients with Ebola Virus Disease. http://www.cdc.gov/vhf/ebola/hcp/guidance-air-medical-transport-patients.html

• Isopod may be used

Image - http://www.releases.gov.nl.ca/releases/2014/health/1113n04.aspx

5252


Guiding Principles for Transport of EDV cases• The decision to transport an EVD patient must be

based on expert clinical risk assessment• The appropriate transport mode and vehicle type

should be determined by expert risk assessment• Staff and others who might be exposed to the patient

during the journey should wear appropriate PPE, and should be subject to health surveillance after the journey if the patient is a confirmed EVD case

• The ambulance and any fixed equipment used must be able to be effectively decontaminated with an approved disinfectant

• The ambulance crew must be trained in the protocol for transport of EVD patients

Based on Bannister et al (2009)

5353


Guiding Principles for Transport of EDV cases (cont.)• The ambulance should have an external, securable,

area for parking and decontamination, and procedures for safe decontamination of ambulance equipment, including safe storage before decontamination

• The route from the ambulance area to the unit entrance at both dispatch and receiving hospitals must be able to be controlled and secured, and wide enough to permit transfer of patient, staff, and equipment

• An ambulance used to transport an EVD patient should not be returned to normal use until the vehicle has been decontaminated

54


Operational questions: DOH policy and guidelines in preparation

• Who is in overall control of transporting EVD cases?

• Who decides if a patient should or should not be transported?

• Who organises the transport?• Who pays the cost?• Who organises police escort to assist

with travel in heavy traffic?

5555


References• American Medical Response. AMR Guidance for Ebola Patient

Transport Preparation For Transport, Patient Movement and Decontamination Procedures. 3 October 2014. (http://www.amr.net/Ebola/October-3-Update, accessed 27 November 2014).

• Bannister B et al. Framework for the design and operation of high-level isolation units: consensus of the European Network of Infectious Diseases. Lancet Infectious Diseases 2009;9:45–56

• Centers for Disease Control. Guidance on Air Medical Transport for Patients with Ebola Virus Disease. Altanta; Centers for Disease Control and Prevention. 23 October 2014. (http://www.cdc.gov/vhf/ebola/hcp/guidance-air-medical-transport-patients.html, accessed 27 November 2014).

• Lowe JJ et al. Considerations for safe EMS transport of patients infected with Ebola virus. Prehospital and Emergency Care epub 7 November 2014. doi:10.3109/10903127.2014.983661

http://www.amr.net/Ebola/October-3-Update

http://www.cdc.gov/vhf/ebola/hcp/guidance-air-medical-transport-patients.html

http://www.cdc.gov/vhf/ebola/hcp/guidance-air-medical-transport-patients.html

1 1 RESEARCH INSTITUTE FOR TROPICAL MEDICINE DEPARTMENT OF HEALTH RESEARCH INSTITUTE FOR TROPICAL...

Documents

Transcript of 1 1 RESEARCH INSTITUTE FOR TROPICAL MEDICINE DEPARTMENT OF HEALTH RESEARCH INSTITUTE FOR TROPICAL...