Patient care and sampling; experiences from Madrid, lesson ... · When patient is recovered, RT-PCR...

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ECDC Training Course – Ebola and Marburg Diagnostic 24th February to 27th February 2015

Robert Koch Institute, Berlin

Patient care and sampling; experiences from Madrid, lesson learned

Fernando de la Calle Prieto Tropical Infectious Disease Unit (Internal Medicine) La Paz-Carlos III Hospital. Madrid. Spain Wednesday 25th February 2015.

Organization in an Isolation Unit.

Patient cares. General treatment in our Unit.

Management of samples and residues.

Security measures.

What have we learned?

Security measures.

Organization in an Isolation Unit

• Isolation Unit Facilities. • Isolation Unit Team.

Hospital

Due to the limited number of biocontainment units it is important to prepare other types of isolation units.

It’s possible another optimal treatment of patients with EVD in the developed world.

Hospital

La Paz-Carlos III Hospital is located in the center of Madrid City.

It is a hospital complex with several buildings. Carlos III and La Paz is really close.

Carlos III is a small building with six floors.

The Isolation Unit (IU) is on the top of them.

You can walk this way. And you take only about ten minutes.

Isolation Unit La Paz-Carlos III There is a direct route to 6th floor.

All access controlled with electronic identity card.

There is an exclusive back door access for patient.

Direct access by its own lift. The rest of lifts in the hospital cant’t go up to 6th floor.

Entrances/exits of patient and residues are only carried by this circuit.

Residues’ way-out is directly to the endpoint avoiding intermediate handling.

Isolation Unit facilities IU has six individual rooms with airlock anterooms.

Each one with restroom.

Rooms are equipped with oxygen, medicinal air and vacuum intakes, mechanical ventilator and wireless stethoscope.

All utensils are disposable.

No porous material.

Sprays and desinfectant sensor dispenser.

A full-body spray in case of gross PPE contamination is available.

Isolation Unit facilities Negative pressure system prevents opening both doors

simultaneously and in-out air circulation.

Both airlock-room doors have a window to monitor patients and health care workers.

Airlock has body-mirrors to facilitate Personal Protective Equipment (PPE) doffing.

TV circuit.

Rigid cubes placed inside for waste disposal.

Disinfectant product is available into airlock. New rooms with decontamination shower.

Isolation Unit facilities

Nurse station is in front of the rooms.

Nurse station has room-intercoms and a TV circuit for monitoring patient and Health Care Workers (HCW) inside room and anteroom

Continuous patient monitoring system is available.

Log of room entries and incidences.

Isolation Unit facilities

Portable X-Ray All the time inside the patient room.

If portable X-ray can not be permanently in the room, it must be covered with three plastic layers.

Information is transmitted to the external computer through wifi.

Portable ultrasound.

Bluetooth stethoscope.

Isolation Unit Laboratory IU has a laboratory

Located in the same floor, close to the room. New laboratory is directly connected to airlocks.

Laboratory instruments were housed within a laminar flow safety containment, in a negative pressure room.

Laboratory worker use the same PPE.

Infectious Diseases

Emergency

Intensive Care

Microbiology Departament

Laboratory

Public Health Department

Prevention of Laboral Risks Departament

Nurses & Physicians

Cleaners

Logistician

Private & Public Security

Communication Media

Infection Prevention & Control

Emergency Operation System

La Paz-Carlos III Hospital

Psycho. Departament

Isolation Unit Team Everyday there is a multidisciplinar team on call: Infectious diseases specialist.

Intensive care specialist.

Nurse.

Nurse-assistants.

Occupational health supervisor for PPE. Laboratory specialist.

And a delegate from the hospital administration.

If there is a case or suspected case, the team will be activated.

CLINICAL CRITERIA

• Tª > 38,6ºC (RETURN FROM HOT ZONE) or Tª < 37,7ºC (CONTACTS).

• SYMPTOMS.

EPIDEMIOLOGY CRITERA

• STAYING/RETURNING EVD ZONE.

• CONTACT WITH EVD PATIENT.

SUSPECT CASE CONTACT TRACING HOSPITALIZED

IMMEDIATE NOTIFICATION TO HEALTH AUTHORITIES

SAMPLES ARE TESTED ON MICROBIOLOGY NATIONAL CENTER OF MAJADAHONDA

(MADRID)

- SYMPTOMS FOR MORE THAN 72

HOURS AGO

SYMPTOMS FOR LESS THAN 72 HOURS AGO

EVD IS RULED OUT MICROBIOLOGICAL

CRITERIA TEST IS

REPEATED CASE

Isolation Unit Team Nurse and physician must check medication,

equipements, room-intercoms, mechanical ventilator, etc previously patient arriving.

First medical evaluation should be inmediately after patient arrives at the UI. Physician. Nurse.

Isolation Unit Team Tropical Infectious disease specialist and intensive

care specialist, both in 24h shift.

At least 1-2 entrance per shift.

4 nurses and 4 nurse-assistants 8h shifts.

At least 2 entrance per shift.

8:00 am and 16:00 pm team meeting

Physician on guard must meet with every nurse shift.

But it is very important to minimize the

number of entries

Security measures.

Objectives Saving life. Paliative care.

Appropriate care.

Preventing infection.

Ensuring worker safety.

Basic management Continuous Hemodynamic monitoring.

O2 monitoring.

Peripheral/central venous catheter.

Replacement of fluid and electrolytes. Crystalloid solutions.

Nutrition.

Source Water

contribution (ml/day)

Source Water loss (ml/day)

Oral fluids 400 Urine 500 Water in foods 850 Stools 200

Oxidation 350 Skin 500 Respiratory tract 400

Balance + 1600 Balance - 1600

Management of fluids and electrolytes

Source Water

contribution (ml/day)

Source Water loss (ml/day)

Oral fluids 400 Urine 500 Water in foods 100 Stools 2.000

Oxidation 350 Skin 500 Respiratory tract 600

Vomiting 1.500 Sweat 1.500

Temperature 100 * (Tª-37ºC) Balance + 850 Balance

Management of fluids and electrolytes

- 7.000

DRUGS Oral intake Clinical situation

Drugs available

Imported vs local Case

Analgesic drugs

Acetaminophen. Metamizole. Tramadol 50 mg/4-6h. Morphine 0.1 mg/kg/4h.

Metoclopramide. 10 mg/6-8h. Omeprazole 20-40 mg/24 h

Antiemetics

Antipsychotics drugs

Haloperidol 5-10 mg /8-12 h Clorpromazine 25 mg/8h.

Ansiolitic drugs

Diazepam 5 mg /8-12 h

Thrombotic prophylaxis

Transfusion

Antipyretics

Acetaminophen. Metamizol. Avoid use of aspirin or NSAIDs.

Symptoms care

Staph or Strept infection

Typhoid fever

Leptospirosis

Meningococcus

Sepsis Gram -

Toxic Shock Syndrome

Malaria

Yellow fever

Dengue

Measles

Chicken pox

Ceftriaxone Levofloxacin Doxycycline Vancomycin

Atovaquone-proguanil. Artemether-lumefantrine. Quinidine gluconate+Doxycycline. Artesunate.

Intensives care Conditioned room from the beginning of the case.

Intensive care specialist must go to the IU. Patient must be remaind in his room.

Two physician are needed if invasive procedures are required.

The best PPE in this situation is PPE equiped with powered air purifying respirators.

The advantages of more aggressive therapeutic measures have to be weighed against biosafety risks

Convalescence. Follow-up Patients who survive often have signs of clinical improvement by

the second week of illness Associated with the development of virus-specific antibodies

Antibody with neutralizing activity against Ebola persists greater than 12 years after infection

Prolonged convalescence Includes arthralgia, myalgia, abdominal pain, extreme fatigue, and

anorexia; many symptoms resolve by 21 months

Significant arthralgia and myalgia may persist for >21 months

Skin sloughing and hair loss has also been reported

References: 1WHO Ebola Response Team. NEJM 2014; 2Feldman H & Geisbert TW. Lancet 2011; 3Ksiazek TG et al. JID 1999; 4Sanchez A et al. J Virol 2004; 5Sobarzo A et al. NEJM 2013; and 6Rowe AK et al. JID 1999.

Security measures.

What have we learnt?

Management of samples and

residues

• 1 nurse inside room • 1 nurse asistant inside airlock • 1 HCW out the room (green

• 2 nurses inside room • 1 nurse assistant inside airlock • 1 HCW out the room (green

Management of samples

PRIMARY CONTAINER (hermetic bag) SECUNDARY CONTAINER (leakproof container) OUTER CONTAINER (rigid plastic)

Management of samples

PATIENT ROOM AIRLOCK

Laboratories IU Laboratory Really close to room.

New lab directly connected with airlock.

National Center of Microbiology Biosafety level III.

Laboratory BSL-4, Bernhard Nocht Institute for Tropical Medicine. Virus culture.

Hamburg (Germany)

RT-PCR EBOV RT-PCR testing blood for EBOV everyday.

Patiente can be considered recovered of EVD when two consecutive blood samples are negative by PCR. Two samples separated a minimum of 48

hours.

RT-PCR EBOV

When patient is recovered, RT-PCR testing of fluids was performed and repeated every 48-72 hours.

Saliva, conjunctival, axillary- region sweat, vaginal swabs, stool and urine.

We discharged patient from the isolation unit when all surveillance samples were negative by PCR in at least two consecutive samples separated a minimum of 48 hours.

Other tests. Septifast Molecular technique (it only detects genetic material)

Clostridium difficile toxin (stool)

Malaria antigen

Inactivated samples

Security measures.

What have we learnt?

Security measures

Hospital Carlos III building is not surrounded by residential area or

another public buildings.

Crossing gates.

Exclusive access controlled with electronic identity card (back entrance door, lifts, etc)

It’s necessary to dial a password to leaving room and airlock. Open security system is available on nurse station.

Security staff at every entrance.

Biosecurity Warning signal.

Edmond MB et al. JAMA Published Online First: 28 October 2014. doi:10.1001/jama.2014.15497

1.Be impervious to fluid

2.Cover all skin and all underclothing (ie, surgical scrubs)

3.Be easy to don

4.Be easy to remove while minimizing the risk for self contamination,

5.Provide maximal comfort for health care workers,

6.Be easy to dispose of while minimizing contamination of health care workers or environmental services workers and be environmentally friendly

Personal Protective Equipement

The PPE employed in our unit was more complete than the one originally recommended by OMS, CDC, ECDC and Spanish Ministry of Health.

Staff members working in our isolation unit used PPE certified according to Spanish and European directives.

PPE included an impermeable coverall, hood, triple nitrile gloves, two impermeable waterproof legs coverings, FFP 3 masks and goggles.

PPE: Dupont Tychem C

“Although PPE is effective at decreasing exposure to infected bodily fluids among health care workers, its presence is simply not enough”

PPE itself can introduce risk. Proper training and competency in donning and doffing of PPE key for safety

Preparations

Instruction donning/doffing posters.

You can’t wear any jewellery, wristwatch, hairgrip, etc

Close-toed and no porous shoes.

No lens.

If you need glasses they might be firmly attached.

Work clothes disposable.

Inside the room You shouldn’t exceed 20 minnutes inside.

We always working in pairs.

You must move slowly and safely.

If you aren’t doing anything your hands must be up and separated from you body.

You cant’t sit on the patient bed.

You shouldn’t force the situation if you feel tired or dizzy, etc. Then you must warn by room-intercoms and go out.

Inside the room-patient Patient wear mask while health care working with. On

the condition that health patient allow it.

Not manipulated the bedding. Dispose directly.

Urine and faeces can be disposed in the restroom. Pour bleach previously.

Inside the room-time/incidences

When a HCW stays inside room, outside supervisor warning about time.

It is registred time spend in the room after leaving.

All possible incidences are registred too.

All this information are written whith the dates and telephone number of the HCW.

At the time of leaving PPE doffing is always supervised A supervisor who has only this ocupation every shift.

TV circuit.

Both airlock-room doors have a big window.

Inside airlock: Keep calm.

Listen to your supervisor.

Look at your supervisor and at yoursefl in the mirror.

Be conscientious on your body, your movements, etc.

At the time of leaving

When HCW leaves the airlock: Hands cleaning. Shoes cleaning. HCW take a shower inmediately after leaving the

room. All clothes are removed.

Follow-up of HCW The follow-up protocol consists in passive surveillance

of body temperature.

HCW were instructed to take their temperature twice a day.

Occupational health keep an active surveillance with daily contacts with HCW.

Temperature threshold is 37.7 ºC for HCW.

Follow-up of contacts Hihg-risk contacts were admitted to our hospital for

active surveillance.

According to Public Health authorities and to contact.

Take temperature three time per day.

Visits once a day and temperature is checked previously.

Disinfection Disinfectation of gloves, PPE (if necessary): Virkon solution 1% (perpotassium sulfate 49,8%) There is a full-body spray in every room. New rooms are equiped with decontamination shower.

Spilled fluids: Sprint H-100 10% (sodium hypochlorite)

Every day trained cleaning service clean the room with Sprint H-100 5% (sodium hypochlorite)

Two cleaning service workers: one for cleaning patient room and one to evacuate residues containers.

Ambient surveillance testing for EBOV.

Biosafety cans Biological residues.

Needles.

Security measures.

What have we learnt? Previous slides are our learning…but I would like add….

Treatment

Case-fatality rate is likely much lower with access to intensive care

Working with new drugs and vaccines.

But…where Can I look for answers??

Crucial point: management of fluids.

Physician-patient interaction

Limitations on physical examination.

Limitations on complementary tests.

Human touch is difficult.

Work as a team

ORGANISATION

RESPECT THE WORK OF EACH

TEAMWORK

Contagion risk

Doffing of the PPE is one of the riskier moments. Always in pairs.

Always supervision.

Appropriate equipement.

Trained personel.

Low risk of transmission of EVD before patients become fully symptomatic (multiple contacts during one week, none became infected).

Facilities

Ebola response has to be prepared before the first case occurs.

Treatment of EVD in hospitals without biocontainment has significant challenges.

It is required a large investment in physical and human resources.

Specialized units are needed.

The Unit worker must receive regular and intense training, supervision and drills to care for EVD patients and other highly infectious diseases

What is stress ? Stress is the state that you experience when you are

faced with a challenge, a threat, or a change, and you perceive there is a possible imbalance between demands and resources.

Acknowledge that humanitarian work is inherently stressful.

Other sources of stress

Physically demanding working and living conditions

Lack of privacy and personal space.

Separation from family.

Lack of time, resources.

Conflicts within work team.

Difficulties with local authorities.

What can I do?

Accept your limits and those of the organization you work for.

Do something about the problems you can change and accept those which you cannot change.

Take care of your health (healthy eating, exercise, enjoy the landscapes, enough rest and sleep, etc.)

Taking short breaks in the work

What can I do?

S Stop T Take a breather O Observe P Proceed

The media Professional journalist team.

Transparent and clear information.

Avoiding panic (social & HCW) and stigmatization.

You are a HCW… you are not a TV character. We must

avoid fear

Thank you so much!

Patient care and sampling; experiences from Madrid, lesson ... · When patient is recovered, RT-PCR...

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