Viral Haemorrhagic Fever (VHF) RHC initial assessment & patient pathway guidance

If presenting with a child with a fever, ED reception staff should ask if they have visited one of the countries highlighted on the VHF and CCHF maps within the last 21 days.

Areas with endemic haemorrhagic fever include-

• If there is a positive travel history to any of the above countries in that time frame AND history of fever, reception staff to ask patient to wait in the breast feeding room across from reception desk for the triage nurse.
• Reception staff to inform triage nurse and ED coordinator immediately.
• Reception staff to take screen shot identifying list of patients in the ED waiting room
• If a high risk of haemorrhagic fever is identified at triage nurse assessment then the decontamination of the breast feeding room should be discussed with infection control, and it must remain out of use until this is complete.   

• If informed re a child with a potential haemorrhagic fever by reception staff risk assessment should be undertaken  in the breast feeding room wearing apron and gloves, and if risk of body fluid splashing onto face a surgical mask. At this stage, and until the assessment has been completed, the patient would remain low risk
• If patient is now deemed potentially high risk, then patient and family must be informed of this suspicion and informed that the patient is now in isolation, and that from this point staff wearing full Ebola PPE will attend to the patient’s needs
• If patient identified in triage as high risk they should be instructed to remain in that triage room to avoid contamination of multiple rooms, and informed that the next staff in attendance will be in full PPE.
• The patient should be transferred to room 18 (negative pressure room) in CDU once preparation is complete.

There is currently a poorly controlled outbreak of the ebola virus (viral haemorrhagic fever) in the DR Congo (July 2019). If presence of fever >37.5 or positive history of  fever in the last 24 hrs AND of travel to VHF endemic area in the last 21 days (see maps) AND:

the patient has travelled to any area where there is a current VHF outbreak

OR

has been living in basic rural conditions where Lassa fever endemic

OR

visiting caves/mines, or having contact with/eating primates, antelopes or bats in a Marburg/Ebola endemic area

OR

travelling in an area where Crimean-Congo fever is endemic AND sustaining a tick bite or crushing a tick with their bare hands OR had close involvement with animal slaughter

OR

the patient has active bleeding or extensive bruising- then they are at high risk of VHF, appropriate PPE should be donned and the patient moved safely to isolation rooms in CDU. Investigation for the possibility of malaria should proceed concurrent to VHF investigations.

If these criteria are not met then there is a low possibility of VHF, malaria investigation should be prioritised and the patient managed as usual within RHC ED.

Seehttp://www.staffnet.ggc.scot.nhs.uk/Info Centre/PoliciesProcedures/GGCClinicalGuidelines/GGC Clinical Guidelines Electronic Resource Direct/Possible Viral Haemorrhagic Fever (VHF) Management in Adults and Children.pdf or search for VHF on staffnet

• If a patient identified as high risk has vomited or had diarrhoea or active bleeding (i.e. spills bodily fluids) in triage, the door to the waiting area should be closed, and the senior nurse in ED and infection control should be informed.
• Only staff in full PPE should re-enter contaminated room, to clean patient and bodily fluid spill, and transfer to room 18 (negative pressure room) in CDU.
• If the patient spilt bodily fluids in the waiting area, that area must be closed. Inform Public health and ID, take screen shots as above, public health will deal with monitoring of contacts.
• Patients present in the waiting area should be moved through to the other side of triage rooms and dealt with in a timely fashion. Until blood results confirmed or refuted we are advised NOT to tell members of public in waiting room that they have possible exposure.  They are not infectious at this point.
• New patients arriving should be directed to the CDU via the ambulance entrance if the waiting area is closed, and booked in and triaged in this area temporarily.
• If a patient undergoing risk assessment has vomited in the waiting area, then the area should be cordoned off until the risk assessment is complete.  If patient is high risk, the area should be closed and the area decontaminated as per Ebola IC Guidance (HPS). If low risk patient vomits in waiting area, then area should be cordoned off and cleaned by cleaning up as per Body Fluid spillage policy.

• PPE should be donned by 2 nurses with assistance of buddy. Long hair should be tied up, consider using a surgical cap.
• Laminated instructions for donning are beside the trolleys containing PPE, located adjacent to the triage rooms.  PPE is donned in room 1 in CDU.
• Radio walkie talkies should be sourced from the ED seminar room.  Clocking in / clocking out board should also be collected from decontamination area for use by senior nurse to monitor staff in PPE.
• Those in PPE should be in communication with their buddy and the senior nurse on the ED floor.
• A large yellow waste bin should be placed inside room 18 (negative pressure room) in CDU from the area adjacent to the triage rooms. Yellow waste bags should be available inside the room. Vernigel sachets and bed pans / vomit bowls should be made available along with a commode (if required) which should stay in the room until patient has been transferred out. Actichlor Plus tablets, diluter bottle and Actichlor granules should be sourced to deal with body fluid spills. A disposable commode is presently on order.
• Monitoring equipment already in Room 18 should be used.
• If additional equipment/drugs needed, consider use of basin for clean individuals to place relevant equipment in then the buddy in their PPE to hand to person in full PPE.

• 0900-0000 ED consultant to be informed to decide best placed member of medical staff to don initial PPE and assess.  This must be a senior decision maker. 
• When no ED consultant on site this role will fall to ED registrar, but ED consultant must be informed and called to attend.
• Following medical assessment, or before it is complete, if requested via radio communication, the ID consultant on call should be informed of the attendance.
• Auscultation is not possible without breeching PPE. Work of breathing can be visualised and saturation assessed. Cap refill can be assessed, pulse unlikely through 2 gloves. BP will be available.
• Do not take High Risk Specimen transport box into room 18 (negative pressure room) in CDU. Take only blood bottles, parafilm and cannulation equipment into room 18 (negative pressure room) in CDU.  Grab Bags with the required blood bottles are in the trolley in the area adjacent to triage rooms ( EMC-097)
• See further instructions on “Management of patients with possible VHF in GGC” on staffnet.  Search for VHF.
• Buddy should source a yellow bin for the de-robing area at the entrance to room 18 (negative pressure room) in CDU and a drape for derobing, and alcogel.

• In the event of a breech in PPE within room 18 (negative pressure room) in CDU, the buddy should be informed over the radio and the person in PPE should then exit the room and derobe with the assistance of the buddy.
• If a breech occurs in the derobing area, continue to derobe with assistance from buddy
• IC should advise on immediate management of breech, and public health on follow up of individual who has breeched PPE.
• All potential and actual exposures should be reported to OH for follow-up.  All staff looking after this patient become contacts whose names should be provided to OH.

• For a planned removal of PPE the person in room 18 (negative pressure room) in CDU should inform the buddy and nurse via walkie talkie, with an already robed member of staff standing by.  If heavily contaminated outer gloves, visor and apron should be removed in room 18 (negative pressure room) in CDU before exiting to complete derobing in the antechamber with buddy assistance.
• Senior nurse should allocate the next 2 nurses to care for the patient if they are in the ED department for  for >2 hrs.    

• High risk children will likely be more safely nursed without their accompanying adult carers and this will be a stressful position for children and their families to understand. This must be approached and communicated sensitively to families. 
• If parents are made aware of the risk of remaining in contact and are still insistent it may be possible for them to remain for a time in physical proximity in room 18 (negative pressure room) in CDU, with discussion with ID and infection control.
• Symptomatic siblings may have to be managed adjacent to the initial presenting child. 
• Asymptomatic siblings should return home in the care of an appropriate adult and be monitored by public health.
•  Asymptomatic adults will also be monitored at home by public health.
• Symptomatic adults must be transferred to QEUH.  They should remain in room 18 (negative pressure room) in CDU awaiting transfer.

CCHF distribution map (WHO 2008) (pdf)