Patient with fever >38 (or history of fever in last 24 hours)
AND either been in a VHD endemic country
OR has been in contact with person/body fluids/lab samples or
handled/eaten animals known or strongly suspected to have VHF
Ysbyty Gwynedd Emergency Department
Ask patient to wait outside whilst decontamination room is
emptied of all equipment (except a trolley & designated
commode) and PPE is fetched: there are sets in the decontamination
room, in triage, and in Matron Lynns office
Put patient into the emptied decontamination room
Minimise contact to one doctor (most senior available) +/- one
nurse who must both wear PPE. A 3rd staff member must supervise the
process of putting on and taking off PPE.
Take bloods for FBC, U&Es, LFTs, Coag screen, CRP, glucose,
and malaria screen plus at least one spare yellow and purple-topped
bottles.
Keep samples in room with patient till they are collected and do
not take a venous or arterial blood gas for analysis in the ED!
Get history Treat as clinically indicated
v1.1 - 21st Sept 2014 Dr Linda Dykes (Consultant EM, YG) based
on Welsh Public Health Guidance for Acute Hospital Staff and the UK
VHF Risk Assessment Algorithm (HPA & ACDP)
Then do exactly what the consultant in microbiology or
infectious diseases tells you.
S/he will organise any necessary VHF testing & decide
ongoing management - not you!
Your own safety is
paramount, but even in patients we have to treat
as at high risk of VHF. the most likely diagnosis is still
malaria, and this must be ruled in or out
urgently.
ED Nurse In Charge to alert the microbiology consultant on-call,
who will arrange for all initial laboratory specimens to be
collected from the ED & provide further advice. Do not use the
chute!
Based on local infection control advice, in Bangor we will be
using the higher level of PPE for all
contacts with possible VHF patients: Hand hygiene, double
gloves, fluid repellant disposable gown/suit, eye protection,
mask/FFP3 respirator,
and boots
The 2014 Ebola outbreak in Sierra Leone, Guinea & Liberia
The incubation period for Ebola Virus Disease is 2-21 days Apart
from fever, symptoms may include headache, sore throat,
general malaise, diarrhoea, vomiting, bleeding & bruising
(late). Ask whether there has been any contact with persons
known/
suspected of having Ebola, or a history of caring for anyone
with a severe illness (or who has died of unknown cause), attended
any funerals, had any contact with dead bodies, visited any
traditional or spiritual healers, or been admitted to hospital in
the affected areas.
Dehydration & electrolyte disturbances have been predominant
features in many of the deaths in Africa during current
outbreak.
Admit
VIRAL HAEMORRHAGIC FEVERS RISK ASSESSMENT (Version 3:
11.08.2014) A) Does the patient have a fever [>38oC] or history
of fever in past 24 hours AND has returned from (or is currently
residing in) a VHF endemic country
(http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/ViralHaemorrhagicFever/VHFMaps/)
within 21 days? OR B) Does the patient have a fever [>38oC] or
history of fever in past 24 hours AND has 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?
NO to A AND B YES to A only
VHF Unlikely; manage locally
ADDITIONAL QUESTIONS: Has the patient travelled to any area
where there is a current VHF outbreak? (http://www.promedmail.org/)
Has the patient lived or worked in basic rural conditions in an
area where Lassa Fever is endemic?
(http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1191942150101)
Has the patient visited caves OR mines, or had contact with
primates, antelopes or bats in a Marburg / Ebola
endemic area?
(http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1254510365073)
Has the patient travelled in an area where Crimean-Congo
Haemorrhagic Fever is endemic
(http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1195733776241)
AND sustained a tick bite* or crushed a tick with their bare hands
OR had close involvement with animal slaughter?
NO
YES
YES to B
No to ALL additional questions
CLINICAL QUESTION TO DETERMINE INFECTION CONTROL BEHAVIOUR AND
PROTECT STAFF: does the patient have extensive bruising or active
bleeding?
HIGH POSSIBILITY OF VHF ISOLATE PATIENT IN A SIDE ROOM Urgent
Malaria investigation Full blood count, U&Es, LFTs, Clotting
screen, CRP, glucose, blood cultures Inform laboratory of possible
VHF case (for specimen waste disposal
purposes if confirmed)
Clinical concern OR continuing fever after 72 hours?
No
Malaria Negative
LOW POSSIBILITY OF VHF Urgent Malaria investigation Urgent local
investigations as normally
appropriate, including blood cultures
VHF Unlikely; manage locally
Yes
Alternative diagnosis confirmed?
No
Yes
CLINICAL QUESTION TO DETERMINE INFECTION CONTROL BEHAVIOUR AND
PROTECT STAFF: does the patient have extensive bruising OR active
bleeding OR uncontrolled diarrhoea OR uncontrolled vomiting?
Is the patient fit for outpatient management?
Inform/update Local Health Protection Unit Ensure patient
contact details recorded Patient self isolation Follow up VHF
screen result Review daily
Discuss with Infection Consultant (Infectious
Disease/Microbiology/Virology)
Infection Consultant to arrange VHF screen with Imported Fever
Service (0844 7788990)
Notify Local Health Protection Unit Consider empiric
antimicrobials
Discuss with Infection Consultant (Infectious
Disease/Microbiology/Virology) Possibility of VHF; Infection
Consultant to consider discussion of VHF screen with Imported Fever
Service (0844 7788990)
YES to ANY ADDITIONAL QUESTION
Malaria Positive: Manage as Malaria; VHF unlikely
Malaria Negative
No
Positive
Yes No
Yes
Negative CONFIRMED VHF Contact High Level Isolation Unit for
transfer
(020 7794 0500: Royal Free) Launch full public health actions,
including
categorisation and management of contacts Inform lab if other
lab tests are needed Manage locally
VHF Result
INFECTON CONTROL MEASURES
MINIMAL RISK Standard precautions apply: Hand hygiene, gloves,
plastic apron (Eye protection and fluid repellent surgical facemask
and for splash inducing procedures)
STAFF AT RISK Hand hygiene, gloves, plastic apron, fluid
repellent surgical facemask, eye protection (FFP3 respirator for
aerosol generating procedures ) Patients that have extensive
bruising, active bleeding, uncontrolled diarrhoea, uncontrolled
vomiting: Hand hygiene, double gloves, fluid repellent disposable
gown/suit, eye protection, FFP3 respirator
STAFF AT HIGH RISK Hand hygiene, double gloves, fluid repellent
disposable gown or suit, plastic apron (over disposable gown/suit)
eye protection, FFP3 respirator
Continuing fever after 72 hours?
* If an obvious alternative diagnosis has been made e.g. tick
typhus, then manage locally Please note this algorithm is a guide
designed to aid early diagnosis of VHF cases
These features would mean patient is deemed high risk of VHF on
the UK risk assessment tool (left & PTO)
Find the latest version within HPA document
at bit.ly/1A7geGO
Management of clinical waste/decontamination of room Keep
everything that has touched patient in the room, and bar
access to it until advice obtained Keep a record of all staff
who have had contact with the patient
What to do if someone might haveEbola Virus Disease (or other
VHFs)
If patient is sick enough to need
resus room care, use Room 4 instead
What to do if someone might have Ebola Virus Disease (or other
VHFs)
Ysbyty Gwynedd Emergency Department
Below is the September 2014 Advisory Committee on Dangerous
Pathogens (ACDP) Risk Assessment flowchart. It is included here as
a thumbnail, to help ED staff recognise which document they need to
be using. In the event of needing to use it in anger, you must
download the latest version by looking at the Public Health
England/UK guidance at bit.ly/1pKLzNW (this is a shortcut web link)
or by Googling HPA Ebola. Do not try to read this thumbnail!
v1.1 - 21st Sept 2014 Dr Linda Dykes (Consultant EM, YG) based
on Welsh Public Health Guidance for Acute Hospital Staff and the UK
VHF Risk Assessment Algorithm (HPA & ACDP)
Admit
VIRAL HAEMORRHAGIC FEVERS RISK ASSESSMENT (Version 4:
10.09.2014) A) Does the patient have a fever [>38oC] or history
of fever in past 24 hours AND has returned from (or is currently
residing in) a VHF endemic country
(https://www.gov.uk/viral-haemorrhagic-fevers-origins-reservoirs-transmission-and-guidelines
or see VHF in Africa map at
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/354636/VHF_Africa_2014_update.jpg)
within 21 days? OR B) Does the patient have a fever [>38oC] or
history of fever in past 24 hours AND has 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?
NO to A AND B YES to A only
VHF Unlikely; manage locally
ADDITIONAL QUESTIONS: Has the patient travelled to any area
where there is a current VHF outbreak? (http://www.promedmail.org/)
Has the patient lived or worked in basic rural conditions in an
area where Lassa Fever is endemic?
(https://www.gov.uk/lassa-fever-origins-reservoirs-transmission-and-guidelines#epidemiology)
Has the patient visited caves OR mines, or had contact with
primates, antelopes or bats in a Marburg / Ebola
endemic area?
(https://www.gov.uk/ebola-and-marburg-haemorrhagic-fevers-outbreaks-and-case-locations)
Has the patient travelled in an area where Crimean-Congo
Haemorrhagic Fever is endemic
(http://www.who.int/csr/disease/crimean_congoHF/Global_CCHFRisk_20080918.png?ua=1
AND sustained a tick bite* or crushed a tick with their bare hands
OR had close involvement with animal slaughter?
NO
YES
YES to B
No to ALL additional questions
CLINICAL QUESTION TO DETERMINE INFECTION CONTROL BEHAVIOUR AND
PROTECT STAFF: does the patient have extensive bruising or active
bleeding?
HIGH POSSIBILITY OF VHF ISOLATE PATIENT IN A SIDE ROOM Urgent
Malaria investigation Full blood count, U&Es, LFTs, Clotting
screen, CRP, glucose, blood cultures Inform laboratory of possible
VHF case (for specimen waste disposal
purposes if confirmed)
Clinical concern OR continuing fever after 72 hours?
No
Malaria Negative
LOW POSSIBILITY OF VHF Urgent Malaria investigation Urgent local
investigations as normally
appropriate, including blood cultures
VHF Unlikely; manage locally
Yes
Alternative diagnosis confirmed?
No
Yes
CLINICAL QUESTION TO DETERMINE INFECTION CONTROL BEHAVIOUR AND
PROTECT STAFF: does the patient have extensive bruising OR active
bleeding OR uncontrolled diarrhoea OR uncontrolled vomiting?
Is the patient fit for outpatient management?
Inform/update Local Health Protection Unit Ensure patient
contact details recorded Patient self isolation Follow up VHF
screen result Review daily
Discuss with Infection Consultant (Infectious
Disease/Microbiology/Virology)
Infection Consultant to arrange VHF screen with Imported Fever
Service (0844 7788990)
Notify Local Health Protection Unit Consider empiric
antimicrobials
Discuss with Infection Consultant (Infectious
Disease/Microbiology/Virology) Possibility of VHF; Infection
Consultant to consider discussion of VHF screen with Imported Fever
Service (0844 7788990)
YES to ANY ADDITIONAL QUESTION
Malaria Positive: Manage as Malaria; VHF unlikely
Malaria Negative
No
Positive
Yes No
Yes
Negative CONFIRMED VHF Contact High Level Isolation Unit for
transfer
(020 7794 0500: Royal Free) Launch full public health actions,
including
categorisation and management of contacts Inform lab if other
lab tests are needed Manage locally
VHF Result
INFECTON CONTROL MEASURES
MINIMAL RISK Standard precautions apply: Hand hygiene, gloves,
plastic apron (Eye protection and fluid repellent surgical facemask
and for splash inducing procedures)
STAFF AT RISK Hand hygiene, gloves, plastic apron, fluid
repellent surgical facemask, eye protection (FFP3 respirator for
aerosol generating procedures ) Patients that have extensive
bruising, active bleeding, uncontrolled diarrhoea, uncontrolled
vomiting: Hand hygiene, double gloves, fluid repellent disposable
gown/suit, eye protection, FFP3 respirator
STAFF AT HIGH RISK Hand hygiene, double gloves, fluid repellent
disposable gown or suit, plastic apron (over disposable gown/suit)
eye protection, FFP3 respirator
Continuing fever after 72 hours?
* If an obvious alternative diagnosis has been made e.g. tick
typhus, then manage locally Please note this algorithm is a guide
designed to aid early diagnosis of VHF cases
Putting on and taking off PPE Needs an additional member of
staff,
standing outside the room, to supervise Use these WHO PPE
guidelines as a
checklist - there are copies inside the PPE kits, and in
strategic locations in the ED.
Remember this is the stage where HCW in Africa have been
infected: so do not hurry, take care, and it is ok to be a bit
paranoid!
1Always put on essential required PPE when handlingeither a
suspected,probable orconfirmed case of viralhaemorragic fever.
2The dressing and undressing of PPE shouldbe supervised by
another trainedmember of the team.
3 Gather all the necessary items of PPE beforehand. Put on the
scrub suit in the changing room.
4 Put on rubber boots. If not available, make sure you have
closed,puncture and fluid resistant shoes and put on overshoes.
Steps to put on personal protective equipment (PPE)
5 Place theimpermeablegown over the scrubs.
6 Put on face protection:6a Put on a medical mask. 6b Put on
goggles or a face shield.
OR, IF BOOTS UNAVAILABLE
7If available, put a head cover on at this time.
8 Perform hand hygiene. 9 Put on gloves* (over cuff).
While wearing PPE: Avoid touching or adjusting PPE Remove gloves
if they become torn or damaged Change gloves between patients
Perform hand hygiene before putting on new gloves
10 If animpermeable gown is not available,placewaterproof apron
over gown.
All reasonable precautions have been taken by the World Health
Organization to verify the information contained in this
publication. However, the publishedmaterial is being distributed
without warranty of any kind, either expressed or implied. The
responsibility for the interpretation and use of the material lies
with thereader. In no event shall the World Health Organization be
liable for damages arising from its use.
* Use double gloves if any strenuous activity (e.g. carrying a
patient or handling a dead body) or tasks in which contact with
blood and body fluids are anticipated. Use heavy duty/rubber
glovesfor environmental cleaning and waste management.
All reasonable precautions have been taken by the World Health
Organization to verify the information contained in this
publication. However, the publishedmaterial is being distributed
without warranty of any kind, either expressed or implied. The
responsibility for the interpretation and use of the material lies
with thereader. In no event shall the World Health Organization be
liable for damages arising from its use.
3 Remove gown and gloves and rollinside-out anddispose of
safely.
4 If wearing rubber boots, remove them (ideally using the boot
remover) withouttouching them with your hands.Place them in a
container with disinfectant.
6 If wearing a head cover,remove it now (frombehind the
head).
7b Remove mask from behindthe head. When removingmask, untie the
bottom stringfirst and the top string next.
Source: Modified from Clinical Management of Patients with Viral
Haemorrhagic Fever: A pocket Guide for the Front-line Health
Worker.World Health Organization, 2014
8 Perform hand hygiene.
5 Perform handhygiene.
1 Remove waterproof apron and dispose of safely. If the apron is
to be reused, place it in a container with disinfectant.
2 If wearing overshoes,remove them with your gloves still on (If
wearing rubberboots, see step 4).
7 Remove face protection:7a Remove face shield or goggles
(from behind the head). Placeeye protection in a
separatecontainer for reprocessing.
Steps to remove personal protective equipment (PPE)
WHO instructions on have to safely put on & take off
PPE.
