Viral haemorrhagic fever (VHF) including Ebola virus disease

This  training video will cover:

• the   steps to safely put on and remove personal protective equipment.

suspected or confirmed cases of VHF are managed using the following strategies;

• Placement in a single room
• Restricted patient transportation
• Minimised use of needles and other sharps
• Avoidance of aerosolising procedures
• Effective cleaning
• Careful Hand Hygiene, and
• Use of the prescribed PPE.

There are two different levels, or tiers, of PPE that are applied in the care of a suspected or confirmed case of VHF. Tier selection is based on a risk assessment and depends on:

• the clinical status of the patient and
• whether they are suspected of or confirmed   to have VHF.

Tier 1 is to be used only for clinically stable patients who are under investigation, with early, or Dry, symptoms such as:

• fever, aches, pains, sore throat, loss of appetite, and fatigue.

Tier 2 - referred to as the Wet Phase is initiated for all patients with confirmed VHF.

It is also used for patients who are still under investigation who are clinically unstable or with wet symptoms.

Wet symptoms include vomiting, diarrhoea, or bleeding.

In the event that there is uncertainty regarding the clinical status of the patient, Tier 2 PPE should be used.

Let’s have a look at the PPE required now.

The PPE for Tier 1 includes:

• a long-sleeved, single-use, disposable,   fluid-resistant or impermeable gown that extends to at least mid-calf and   overlaps to cover the back.
• two pairs of non-sterile, long cuff gloves
• a particulate filter respirator, also   known as a P2 or N95 respirator
• a single-use full-length face shield

The PPE for Tier 2 is intended to further protect the worker when there is an increased chance of uncontained body fluids.

It includes all of the PPE for Tier 1, PLUS

• fluid   resistant or impermeable boot covers that extend to at least mid-calf, and

* a hood that covers all hair and the ears and exposed skin of the neck secured at the rear.

Additionally, if the patient has wet symptoms the worker may wear a single use fluid resistant apron over the gown.

Follow a consistent sequence each time PPE is put on and removed, using a trained observer and a checklist.

Take your time, and don’t rush.

Following these steps will help keep you safe and protected.

The trained observer must:

• use a checklist to ensure that all steps are completed in sequential   order
• stop and check that the worker has put on all items as intended, and
• check that the worker is comfortable and can perform the ranges of   motion required for patient care before entering the patient zone.

When the worker exits the patient zone, the trained observer must carefully direct and observe the worker taking off the PPE, again using a checklist.

The Donning process

The PPE donning zone is a designated area, separate from the doffing zone. A chair and mirror may assist the worker in donning their PPE.

The worker should ensure that all required equipment for the care bundle or activity is assembled and ready to take into the patient zone.

Before the worker starts putting on the PPE, it is important that they have recently eaten, hydrated and visited the bathroom.

The worker should wear hospital scrubs and fluid-resistant shoes. Long hair must be tied up and fingernails must be short. Ensure that all jewellery, and personal equipment, such as a stethoscope, pen, and ID badge are removed. Secure prescription glasses to the face with tape.

The observer and the worker must both review the donning sequence before starting to put on the PPE. The observer reads the donning sequence aloud to the worker step by step as each item of PPE is applied.

The observer visually inspects the PPE ensemble to ensure that all required items are present and in the correct size and serviceable condition.

To begin, the worker performs hand hygiene with alcohol-based hand rub and allows the hands to dry.

For Tier 2 PPE, the worker applies boot covers. The worker may use a chair or stool as required. Then, perform hand hygiene with alcohol-based hand rub and allow hands to dry.

The observer instructs the worker to put on the first pair of long-cuffed gloves.

Next, put on the gown ensuring the cuffs of the inner gloves are under the sleeves of the gown. Secure the gown at the neck and waist. Ensure the gown is large enough to allow unrestricted freedom of movement without gaping.

Put on the respirator and perform a fit check according to the manufacturer’s instructions, to ensure a good seal.

For Tier 2 PPE, the worker next puts on the hood. Carefully, place the hood over the respirator, covering all of the hair and the ears. If the respirator has moved, fit-check it again.

If the worker is using a plastic apron, it should be put on at this stage.

Then put on the face shield. This provides additional protection to the front and sides of the face, including skin and eyes. Ensure the face shield does not disturb the fit of the respirator. Re-fit check as required.

The worker will need to disinfect the inner gloves with alcohol-based hand gel or a disinfectant wipe, and allow them to dry.

Once the inner gloves are dry, put on the second pair of gloves, known as the “outer gloves”, ensuring that the cuffs of the gloves are pulled up over the cuffs of the gown.

After completing the process to put on the PPE, the trained observer and the worker must stop and check the integrity and placement of all items. The worker should be comfortable, and able to extend their arms, bend over at the waist, and go through a range of motions to ensure there is sufficient range of movement without dislodging the PPE.

The doffing process for PPE is conducted under the supervision of a trained observer who reads aloud each step of the procedure and confirms visually that the PPE has been removed correctly.

When the worker is ready to leave the patient zone, they must attract the attention of the observer, who will indicate when they can commence doffing. The first part of this process starts in the patient zone.

The following items are needed in the PPE doffing area:

• a chair or stool
• alcohol-based hand rub
• disinfectant wipes
• a supply of long-cuff gloves
• a large clinical waste receptacle   and
• a large absorbent mat secured to the   floor.

The trained observer must put on the following PPE to assist the worker exiting the patient zone:

• a long-sleeved fluid-resistant or   impermeable gown that extends to at least mid-calf
• a surgical mask
• a full-length face shield
• two pairs of non-sterile long cuff   gloves, and
• for Tier 2 PPE, bootie or shoe   covers.

Before the worker exits the patient zone, the observer must remind the worker to work slowly and avoid reflexive actions, such as touching their face or adjusting their hair. It is useful to repeat this instruction during PPE removal.

• Although the observer should   minimise touching the worker or their PPE during the removal process, they   may assist with removing specific components of the PPE if required.
• If the trained observer assists in   any way, they must immediately disinfect their outer gloves before continuing   to observe the removal process.

While in the patient zone, the worker disinfects their outer gloves with alcohol-based hand rub or disinfectant wipe. Discard used wipe into a clinical waste bin in the patient zone.

The worker removes the outer apron if worn, by first breaking the neck and waist straps, and then rolling the apron inside out. Work from the outside edge towards the middle of the apron, taking care not to touch the outer surface, which may have been in contact with the patient or their environment. Discard the apron into a clinical waste bin in the patient zone.

The worker disinfects their outer gloves.

The observer instructs the worker to exit the patient zone onto an absorbent mat in the doffing area.

The observer and worker inspect the PPE for visible contamination, cuts, or tears before starting the removal process. The observer must record any breaches of PPE and make a note to action this after doffing is complete. If any PPE is visibly contaminated, the healthcare worker or observer disinfects the contaminated area using a disinfectant wipe.

The worker disinfects their outer gloves and removes them.

The observer inspects the inner gloves for cuts, damage, or visible contamination.

If there is no visible contamination, disinfect the gloves and leave them in place for the next step.

If there is visible contamination, the inner gloves are disinfected and removed. The worker then performs hand hygiene on their bare hands and applies a new pair of gloves.

If there is a cut or tear in the inner gloves this is a PPE breach and further action is required for potential occupational exposure.

Next, the worker removes the face shield by tilting the head slightly forward, grasping the rear strap, and pulling it over their head. Gently allow the face shield to fall forward and discard it.

Avoid touching the front surface of the face shield.

Disinfect the gloves and leave them in place for the next step.

This step only applies to the use of a hood for Tier 2 PPE. The worker unfastens the surgical hood for removal. The observer may assist with unfastening the hood if required. The worker will be instructed to carefully remove it, making sure not to drag the outer surface over the face or dislodge the respirator. Discard the hood.

The worker then disinfects their gloves.

The worker is then instructed to remove and discard their gown.

• Depending on the gown design and the   location of the fasteners, the worker can either untie or break the   fasteners. Assistance from the trained observer may be required.
• Remove the gown by pulling it away   from the body and rolling it in on itself.
• At all times, the worker should take   care to avoid contact with their clothing or skin during the gown removal.

The worker will now disinfect their gloves.

The following step only applies when boot covers are worn. To remove the boot covers, the worker will:

• Sit on a chair or stool
• Avoid touching the boot covers with their   forearms, while untying them.
• Disinfect   and remove gloves. Perform hand hygiene on bare hands and apply a new pair of   gloves for the next steps.
• Place both hands inside the top of   one boot cover and grasp the inside of some of the material.
• Without touching the outer material   of the boot cover, roll the top down to form a clean cuff.
• With both hands inside the clean   cuff, push the boot cover down to the shoe, then push the cover off the foot.   Be careful not to touch the outside of the boot cover, or contaminate your   leg or scrub pants.
• Place in the clinical waste bin.
• Disinfect   and remove gloves. Perform hand hygiene on bare hands and apply a new pair of   gloves for the second boot cover.
• Repeat the process for the second boot cover.

Again disinfect and remove gloves. Perform hand hygiene on bare hands and apply a new pair of gloves for the next step.

The final piece of PPE to be removed is the respirator.

• The worker should be instructed to   tilt the head slightly forward, grasping first the bottom elastic strap, then   the top elastic strap. Then carefully remove the respirator without touching   its front.
• Immediately discard it into the   clinical waste bin.

Disinfect gloves.

Next, the outer surfaces of the fluid-resistant shoes are disinfected using a disinfectant wipe. Sit down to complete this step.

Disinfect, remove and discard the gloves, and perform hand hygiene.

The observer and the worker will both, inspect the scrubs, shoes and person of the worker for any sign of contamination with blood or body fluids. If contamination is identified the worker should move to a designated space where garments can be carefully removed and they can shower immediately. Further action is required in this instance to assess for potential occupational exposure.

Once inspected, the worker can now leave the PPE removal area wearing their scrubs and shoes. The worker can then remove the tape securing prescription eyewear in front of a mirror for comfort.

The observer cleans the chair with a disinfectant wipe and disposes of wipe into the clinical waste bin.

If contamination has been identified at any point in the PPE removal process, the healthcare worker must follow the facility’s exposure process and immediately inform their supervisor.

That’s the end of the demonstration.

Here are some take-away points to remember:

• The PPE recommended for VHF is highly protective for   workers
• It’s important to work slowly, carefully and deliberately   to ensure the PPE is put on correctly and to avoid self-contamination when   taking it off
• There should always be a trained observer supervising the   process for putting on and taking off the PPE
• Always use a checklist– these can be found in the Queensland   Health VHF guideline
• Report any PPE breaches to your supervisor

These steps are designed to help keep you safe.

Thanks again for undertaking this training.