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DRTM - Contagious patient
- 1. Aeromedical Retrieval of the contagious patientAeromedical retrieval of the contagious patient
- 3. Intro… • Current situation • Clinical case • Risk Assessment • Infection control precautions/PPE • Minimising the transmission risk • Swine Flu 2009 – impact on NSW Ambulance Retrieval Service
- 5. Disease Outbreak News - WHO http://www.who.int/csr/don/archive/year/2017/en/
- 6. H7N9 Avian Flu • 1st human case March 2013 • Severe illness • No sustained human-to human transmission… YET
- 7. Clinical case 25 yo male with pneumonia and infective exacerbation of asthma – PMHx – Asthma – DHx - NKDA, PRN ventolin – PR 110 BP 105/74 RR 32 Sats 100% 15LHM T 37.8 GCS 15 BSL 9.0 Rx: IVABx, O2, IV crystalloid resuscitation, Bronchodilators and steroids
- 9. First actions • PPE!! • Precautions – Standard, Airborne, Contact • Reassess situation • Ask for help – complex mission
- 10. Considerations…. • Risk assessment – Patient – Disease – Transport – Aeromedical staff
- 11. The Patient
- 13. The Staff/Crew
- 14. The Disease
- 18. P2/N95 Mask • Fit Check • Fit testing - Qualitative – Aerosolised Saccharin Mist – Exercises – 1 minute each 1. Normal breathing 2. Deep breathing 3. Moving head side-to-side 4. Moving head up-down 5. Bending/jogging 6. Talking 7. Normal breathing again
- 19. High Risk Interventions • Advanced Airway management • Nebulised therapy • Invasive or ‘bloody’ procedures • Care within enclosed space • Post-response vehicle cleaning
- 20. Care within enclosed space
- 22. Ebola Specific
- 23. Challenges for the medical team • Confined treatment area • No handwashing facilities • Lack of ventilation • Prolonged PPE • Dehydration/Heat related illness
- 24. NSWA Vehicle decontamination Current unresolved issues: •Measles/Varicella - ? Allow particles to settle
- 25. Decontamination • Wipe down of equipment – NIV BP Cuffs, stethoscopes, sphygs • Fabric equipment: – Dr’s Thigh pouches – Medical packs – Loafs – Tourniquet
- 26. NSW Environmental Cleaning Policy
- 28. Swine Flu 2009 • Pre-2009 GSA-HEMS T/F 7 ECMO pts • ECMO service established 1/12 prior to H1N1 – Funded for 10 per yr • 1/6/09 – 31/8/09 – 722 patients with confirmed H1N1 admitted to ICU – 456 required mechanical ventilation – 24 ECMO – 19 patients retrieved on ECMO • During 2009 – 31 ECMO retrievals in total Jones, C. Hommers, C. Burns, B. Forrest, C. ECMO Retrieval in NSW and beyond. Current Anaesthesia
- 29. Take home points • Be vigilant • Risk assess • Phone a friend – SRC, DRC, PH, ID • Protect yourself and your colleagues • Follow up
- 31. References: • Jones, C. Hommers, C. Burns, B. Forrest, C. ECMO Retrieval in NSW and beyond. Current Anaesthesia and Critical Care react-text: 55 2 • MacIntyre, R., Dwyer, H., Seale, W., Quanyi, Z., Yi, P., Yang, S., Weixan. High risk procedures and respiratory infections in hospital healthcare workers – quantifying the risk. International Journal of Infectious Diseases 16S (2012) e317–e473 • Brouqui, P., Ippolitto, G. Clinical Management of Highly Infectious Diseases: European Network for Highly Infectious Diseases consensus guideline. Lancet ID. • Tran, K., Cimon, K., Severn, M., Oessoa-Silva, L., Conly, J. Aerosol Generating Procedures and Risk of Transmission of Acute Respiratory Infections to Healthcare Workers: A Systematic Review. PLoS ONE. April 2012/Vol 7/Iss 4/e35797 • ACB of Tranfser and Retrieval Medicine. A Law, J Hulme.Wiley Blackwell. 2015. • http://www.who.int/csr/don/archive/year/2017/en/ • http://www.who.int/influenza/human_animal_interface/influenza_h7n9/en/ • http://www.nipcm.hps.scot.nhs.uk/documents/tbp-environmental-decontamination-and-terminal-cleaning/ • https://www.cdc.gov/vhf/ebola/healthcare-us/emergency-services/interfacility-transport.html#care • https://idmic.net/2015/10/20/standard-precautions-infection-control-what-is-included/ • https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/diseases-infection/infection-prevention/transmissio mask • http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2012_061.pdf
- 32. Resources: • https://memegenerator.net/instance/66334797/i-will-find-you-meme-to- whoever-started-the-office-man-flu-i-will-find-you-and-i-will-kill-you • http://apcollege.edu.au/toll-air-ambulance/ • http://apcollege.edu.au/nsw-ambulance-jobs/ • http://www.16right.com/16R%20Main • https://www.whywesnore.com/cpap/ • https://www.backpackerdeals.com/australia/alice-springs/the-rock-tour-3d-2n- alice-springs-to-alice-springs • http://www.jervisbaywild.com.au/australian-backpacker-bucket-list-jervis-bay/ • http://qf1.info • https://au.pinterest.com/pin/130111876707797539/ • https://au.pinterest.com/lama201484/infection-control/?lp=true • http://thepreventionist.info/tag/contact-precautions/ • https://www.csiequipment.com/body-bag---heavy-duty_p31733.aspx • http://www.dailymail.co.uk/news/article-2204850/Portraits-famous-faces- created-petri-dishes-artist-using-bacteria.html
Notas do Editor
- In December 2015, WHO released this list of disease most likely to cause severe epidemics List includes respiratory viruses and viral haemorrhagic diseases http://www.who.int/medicines/ebola-treatment/WHO-list-of-top-emerging-diseases/en/
- http://www.who.int/csr/don/archive/year/2017/en/
- http://www.who.int/influenza/human_animal_interface/influenza_h7n9/en/
- Tasked to patient small hospital/medical centre in western NSW Scored fixed wing – what we all hope for at 1am in the morning Reasonably straightforward – on route prepare shopping list and consider actions you may need to take….
- First notice the patient has been commenced on NIV, and has deteriorated significantly Quick glance at settings PEEP 10 FiO2 0.7 Sats 100% RR 28 Increasing oxygen requirement Girlfriend in attendance – gain some collateral history – backpackers from the Uk, on a gap year, heading for the red centre Unwell 3 days with myalgias, fatigue, fevers, cough and SOB Arrived 4 days ago, on a road trip heading to Alice Springs Stopped off on route in United Arab Emirates Alarm bells start ringing https://www.whywesnore.com/cpap/ https://www.backpackerdeals.com/australia/alice-springs/the-rock-tour-3d-2n-alice-springs-to-alice-springs http://www.jervisbaywild.com.au/australian-backpacker-bucket-list-jervis-bay/ http://qf1.info
- Get some PPE, apply N95 mask immediately – biggest threat is airborne transmission, particularly as this patient is on NIV PROTECT yourself and your colleagues Precautions – Standard, Airborne, Contact Reassess the situation – situation has changed somewhat – now appears dealing with an infectious disease that is contagious, need to consider how we are going to approach this to mitigate the risk Re-evaluate patient management How to treat hypoxia on route - 02 via NRB, CPAP, intubation, ECMO Where should this patient be transferred to? Now suspect – MERS/Influenza -> speak to SRC, DRC, public health -> complex mission, need to consider best modality of transport ? Commence antiviral – no evidence for benefit of antiviral therapy in MERS, purely supportive Partner – does she need medical treatment ALSO THINK ABOUT PARTNER
- If we are lucky enough to know the patient has a cpntagious disease prior to being tasked, then what considerations do we need to make?
- Interhospital Distance Severity of disease/Stability of patient Team required – does this patient need ECMO Duration of transfer Impact of vehicle being ‘out of action’ for decontamination – impact on retrieval service http://apcollege.edu.au/toll-air-ambulance/ http://apcollege.edu.au/nsw-ambulance-jobs/ http://www.16right.com/16R%20Main%20Content%20More.htm
- Who are you going to send? WHO ARE WE GOING TO SACRIFICE ON THIS MISSION
- We need to be familiar with the disease, how its transmitted and expected clinical course, incubation and infectious periods What contagious diseases are we most likely to encounter in aeromedical retrieval - For registrars cycling through – unlikely to be exposed to an epidemic such as H1N1, but there may be odd sporadic cases of pertussis, measles (recently CBD/Chatswood), transfer of meningococcal sepsis, most of our sick ICU patients have MRSA, VRE, ESBL Who or what is this chap? A plague doctor, during the most devastating pandemics in human history – the black death, caused by yersinia pestis, killing up to 200million people in eurasia Costume – almost first attempt at PPE – protective suit – heavy, waxed fabric, leather hat/gloves/boots and a face mask with a glass eye opening and a beak shaped nose – this would be stuffed with aromatic – not just to block out the foul smelling odour of rotten flesh, but it was thought that disease spread through miasma theory – the smell alone could transmit the disease, this was finally dismissed in 1880 when germ theory came about Ref: http://blog.eleven-labs.com/fr/comprendre-le-ssltls-partie-4-handshake-protocol/ http://wonderopolis.org/wonder/why-do-you-sneeze
- Standard infection control precautions for all patients regardless of their presumed infection status This is the minimum acceptable level of practice in infection control – hand hygiene, safe work practices including sharps safety, use of PPE when in contact with bodily fluids, routine cleaning of equipment https://idmic.net/2015/10/20/standard-precautions-infection-control-what-is-included/
- Use PPE to behave as a barrier between HCW and patient – depending on level of contact anticipated with patient Usually gloves and disposable gown Droplet precautions Large droplets, > 5 micrometers in diameter Do not remain suspended in the air If inhaled, contact upper resp tract, not alveoli Influenza, rhinovirus, SARS, RSV, Pertussis, strept pharyngitis, ebola Protective eyewear/face shield and P2 masks to prevent breathing in respiratory droplets Airborne precautions Small droplet nuclei, < 5 micometers diameter Stay suspended in air When inhaled can reach alveoli and cause infection Measles, varicella, TB Protective eyewear, P2 mask, gloves Consider use of gown to minimise infectious particles being transmitted If in doubt, wear maximal PPE http://thepreventionist.info/tag/contact-precautions/
- Fit check– all staff including pilots/ACM Capable of filtering particles greater than 0.3 micometers in diameter Place on face Ties over head/neck Compress/Seal +ve pressure – exhale -ve press – inhale Inadequate seal – change mask Formal qualitative fit testing is available – but NSW health does not specific when this should be done, however it is done to ensure P2 mask is appropriate sized for individuals Place hood over head whilst wearing P2 mask A fine saccharin mist introduced If any sweetness detected – then failed Then need to perform 7 exercises for at least 1 min each, pass all of these without sweet taste in mouth
- Reducing risk of transmission to aeromedical staff Advanced airway management intubation, BVM, suctioning -> those that generate respiratory aerosols These interventions pose HCW a 3 fold increase of respiratory infections More specific to the SARS Cov – the risk of a HCW who is involved in endotracheal intubation being infected were 13 times higher than those who did not – high viral load Risk mitigation -> maximal PPE, optimise for FPS, most experienced intubator, consider NIV Nebulised therapy is obviously a concern NIV – is a contentious issue, unfortunately there is a lack of high quality evidence to regarding transmission of infectious disease when using NIV and this can be conflicting One particular paper reporting on the SARS- Cov outbreak in 2003, reports no evidence to support increased infection transmission to HCW with NIV, and that implementing NIV avoided –intubation in 2/3rds of patients in the SARS-Cov outbreak Other systematic reviews from the same outbreak indicated an increased risk (although numbers were small) Invasive/bloody procedures thoracostomies, thoracotomy, surgical airway, hysterotomy, GI haemorrhage Post exposure management strategy -> is there support for staff suffering needlestick
- Maintain appropriate PPE at all times Consider ‘fluid containment bag’ Closed In-line suction catheter Disposable ventilator hose Clamp ETT No vehicle ventilation
- Speaking to pilots/ACM -> generally guided by medical teams An unresolved issues at present is the management of patients with airborne disease on the aircraft (measles, varicella, TB) ? Pilots/ACM wear N2 masks when flying the aircraft – communication is paramount to their job, will masks hinder this, whats the risk/benefit ratio Partition curtain drawn down -> isolate cabin +ve pressure in cockpit No eating/drinking
- We do have NSW health guidelines for the management of a patient with Ebola, but we are yet to have a case of Ebola on our soil This picture demonstrates the isolation transfer units As you can imagine the coordination of transfer for such a patient is incredibly complex, with a huge amount planning, logistics and preparation involved From a clinical POV – there will be standard operating procedures for the management of Ebola, but they will be adjusted to respect local protocols and individualised to that patient being transferred Preparation is paramount Prior to departure with the patient, clinical care guidelines will be established number of specialists– transport agency’s medical director, state EMS, public health, hospital based teams -> this will determine what procedures could be performed and which will not be considered during transport (resucitation/intubation/invasive procedures) https://cilisos.my/first-ebola-now-mers-should-malaysians-worry-about-an-outbreak/
- Prolonged PPE Temperature control Perspiration Dehydration https://www.cdc.gov/vhf/ebola/healthcare-us/emergency-services/interfacility-transport.html#care
- One of the high risk exposure procedures Decontaminate vehicle in same PPE as required in transfer Airborne – close vehicle to allow particles to settle Viracidal disinfectant ++++ Time ‘offline’ – unclear at this stage Chlorine based disinfectant OR TGA approved disinfectant with viracidal claim against influenza Another unresolved issue in the infectious disease world at present is the decon of a vehicle after measles/varicella exposure How long do we leave the car closed up, to allow the particles to settle before cleaning with airborne precautions, and how long should the vehicle be off line. Public helath units are suggesting anything from 10mins to 2hours With regards to the aircraft – the TOLL manual advises decontamination protocols to be documented in local area supplements – which don’t exist at this stage
- Functional areas categorised according to risk of infection transmission The cleaning policy for each area depends on level of risk posed Retrieval service consider high risk in comparison to where we are taking patients from and to http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2012_061.pdf
- Out of interest, this is the CEC directions for how to complete a terminal clean following the discharge of an infectious patient t ensure a safe environment for the next patient http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0006/258666/ecsop-module-4-1.pdf
- I am told there were 2 ICPs and 1 Pilot who contracted Swine flu during this epidemic Jones, C. Hommers, C. Burns, B. Forrest, C. ECMO Retrieval in NSW and beyond. Current Anaesthesia and Critical Care react-text: 55 21(5):282-286/October 2010
- And your colleagues won’t thank you for it! https://memegenerator.net/instance/66334797/i-will-find-you-meme-to-whoever-started-the-office-man-flu-i-will-find-you-and-i-will-kill-you