DEPARTMENT OF HEALTH
RESEARCH INSTITUTE FOR TROPICAL
MEDICINE
Transport of EVD
cases
Rick Speare, Miguel Dorotan, Julian Donald
December 2-4, 2014
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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
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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)
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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
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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
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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
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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
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Community cases – Sierra Leone
Image - http://www.ctvnews.ca/health/unicef-doubling-staff-in-west-africa-to-better-fight-ebola-1.2083968
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Abandoned EVD cases - Liberia
Image - http://www.nydailynews.com/life-style/health/calls-emergency-meeting-ebola-article1.1893501
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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?
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List of topics relevant to the ambulance
service at a hospital
1.
2.
3.
4.
5.
6.
Planning and preparation
Screening cases and calls
Preparing to transport an EVD case
Transporting an EVD case
Immediate post-transport activities
Post-transport evaluation
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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
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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
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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
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Pickup as ambulance - Liberia
Cover
protects
patients
and crew
Image - http://blog.usaid.gov/2014/11/recapturing-growth-in-ebola-stricken-west-africa/
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Ambulance for EVD cases - Liberia
Driver
separated
from patients
•
Image - http://www.zimbio.com/pictures/ge7n5YUMy12/Liberia+Battles+Spreading+Ebola+Epidemic/J_xjxLBe8jw
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Ambulance for EVD cases - USA
Image - http://www.telegraph.co.uk/news/worldnews/ebola/11153745/Ebola-outbreak-inpictures.html
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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?
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Ambulance with separated driver’s
compartment
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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-ejeepney.html
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Interesting possibilities!
Separate driver’s
compartment
Patient
compartment well
ventilated; easy to
disinfect
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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 / confirmed
Severity 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
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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)
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Preparing to transport
a particular case
•
•
•
•
•
Personal protection
Preparation of the ambulance
Preparation of the stretcher
Equipment for attending HCW
Supplies for driver
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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
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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?
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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
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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
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Ambulance lined with plastic sheeting
Image - Lowe et al. Prehospital Emergency Care (2014)
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RITM Ambulance: connection between
driver and patient now closed
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RITM ambulance 2: plastic sheeting
covers cupboards
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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
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This mattress can be decontaminated with
0.5% chlorine – no plastic cover needed
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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
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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?
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Backup ambulance – USA – EVD case
Airport to Emory Hospital, Georgia
Image - http://www.georgianewsday.com/news/regional/273806-ebola-escort-roads-in-georgia-remain-open-as-american-doctorinfected-with-incurable-ebola-virus-is-taken-to-hospital-in-specially-fitted-ambulance-after-landing-in-us-for-treatment.html
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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?
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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
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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
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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
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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?
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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-ebolamust-not-be-underminned/
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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
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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
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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
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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
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Almost finished:
still attached on right wall
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Ready to be decontaminated and
discarded
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MSF technique for ambulance
decontamination
Note: The person in this video should be wearing full PPE
when cleaning the ambulance
Image captured from MSF video on ambulance decontamination vimeo.com/110485075
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Post-transport evaluation
• Evaluation of performance
– Did it work?
– Can it be improved
• Modification of SOPs if indicated
SOPs would make the transfer
just described safer and less
stressful for all involved
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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-medicaltransport-patients.html
• Isopod may be used
Image http://www.releases.gov.nl.ca/releases/2014/health/1113n04.aspx
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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)
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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
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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?
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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/guidanceair-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
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