Planning as a tool to create Harm Free Health Care Dr Jeannette Young PSM Chief Health Officer & Deputy Director General Prevention Division Queensland Health 13 October 2016 RACMA Conference Brisbane

Background - EVD • Ebola virus disease (EVD) – Average Case Fatality Rate 50% (Range 25-90%) – Incubation 2-21 days – Transmission by contact with body fluids – “Dry phase” - sudden onset of generic febrile symptoms – “Wet phase” - usually 3-5 days post symptom onset

2013-2016 Outbreak • • • •

December 2013 – Patient Zero – Guinea Rapid spread to Liberia & Sierra Leone 8th August 2014 - WHO Declaration Sporadic cases in returning travellers and aid workers, with limited onward transmission – – – –

Spain: August 2014 United States: Sept and Oct 2014 United Kingdom: December 2014 Italy: May 2015

Domestic Preparedness • • •

Gap analysis identified special requirements of this event for Queensland Activation of SHECC EVD-IMT 14 Oct 2014 “To prepare, exercise and implement plans for managing suspect cases and contacts and related issues such as treatment and the implications for Queensland.” – – – –

Proactive public engagement and messaging Production of clinical guidelines Establishment of chains of communication Receiving hospitals – Royal Brisbane and Women's Hospital & Lady Cilento Children's Hospital

Queensland • •

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No direct flights from West Africa to Qld so potential for any portal of entry Proactive assessment of system capability to deal with a potential case within our borders seemed prudent Plan based on scenario –

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Rural presentation of returned traveller in “Dry” phase

Importance emphasised by presentation of three potential cases in Qld • Gold Coast: 11 Sept 2014 • Cairns: 9 Oct 2014 • Brisbane: 26 Oct 2014

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All subsequently tested negative

Exercise Uplift • • •

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5 November 2014 Proof of concept Simulate retrieval of febrile traveller presenting to Roma Hospital within incubation timeframe Utilising QAS & appropriate aeromedical asset Ebola Virus Disease Retrieval Team - Senior Medical Officer - Senior Flight Nurse - Infection Control Nurse as spotter

Exercise Objectives 1. 2. 3.

4.

5. 6. 7. 8.

Exercise the transfer by road and by air of a suspected case of EVD from a regional hospital to the closest designated EVD hospital in accordance with appropriate infection control procedures. Test the timely recognition, notification and transfer of a suspected case of EVD. Validate existing coordination and communication pathways, processes and activities in response to a suspected case of EVD between local and state-wide health coordination units and relevant hospitals. Provide individual participants with the opportunity to evaluate the responsiveness of their unit’s coordination and communication processes and activities to ensure future ability to respond to suspected cases of EVD. Identify factors that may affect the ability to retrieve a suspected case of EVD. Exercise preparation of a suspected case of EVD for transfer by ambulance and aircraft. Test infection control requirements and instructions for donning and doffing personal protective equipment (PPE). Exercise the use of PPE during the assessment of a patient who presents with a suspected case of EVD.

Route - Air

Route - Road

Communication Pathways •

First IMT - expert panel to – – –

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Second IMT – expert panel to –

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discuss EVD status determine the most suitable means of transferring the patient if required Identify key logistical requirements Determine if patient clinically suitable for retrieval

Members of expert panel: – – – – – – –

Public Health Physician Local hospital EDMS/DEM SMO IDP (if available) Designated hospital EDMS IDP lead SHECC - SHIC(CHQO/SDCDU) QCC RSQ Senior Director (for actual case Senior Second on Call SSOC)

Communication Needs •

Multiple key stakeholders – – – – – –

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Requirement to maintain – –

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Local facility Receiving facility Public Health SHECC RSQ EVDRT Single point of truth Situational awareness

HIGHLY dynamic situation Across multiple geographic locations During movement using varying transport modalities

Communication platform • • • • • • •

Private group set up within messaging app Key stakeholders access only “End to End” encryption for privacy Usable on smartphones, tablets and PC’s Totally transparent communication in real time Reliant on integrity of 3G/4G networks Worked extremely well

Patient Isolation: The ISO-POD • • • •

Isolation module and filtration system Draws in ambient air using two particulate filters Service ports allow IV and oxygen lines Integrated long gauntlet gloves enable basic patient handling and assistance

Patient Isolation: The ISO-POD • • •

Device had been purchased by WA but never utilised in Australia Never previously used for aeromedical transfer QH & CASA worked collaboratively to identify & resolve issues with – Adequate fixing of the ISO-POD to aircraft interior – Adequate restraint of occupant

Clinical Care in the ISO-POD • •

Very limited ability to do anything procedurally Comfort Pack – – – – – – –

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Bottle of water Snack Travel John Antiseptic wipes Disposable pillow Tissues Emesis Bag

Self-treatment Pack – – – – – –

Hudson Mask Nasal Prongs Non-Rebreather mask Paracetamol Ibuprofen Ondansetron Wafers

ISO-POD Patient Limitations • • • • • • • • •

Claustrophobic / Anxious Mental Health issues Altered LOC or Agitation Non English Speaker Children ?Pregnant Too tall Too wide Too heavy

PPE •

EVDRT utilised PPE as per Queensland Health SHECC EVD IMT guidelines – – – – –

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a P2/N95 fluid resistant respirator a pair of goggles two pairs of non-sterile long cuff nitrile gloves a Tychem coverall with integrated head covering fluid resistant/impermeable boot covers that extend to at least mid-calf.

Physiological monitoring for safety and quality control

Exercise Sequence

Exercise Sequence

Exercise Sequence

Challenges – 1. The ISO-POD

Challenges – 2. PPE

Core Body Temperature in PPE

PPE Solutions • •

Rehydration and toilet breaks Cooling Methods • Cold water/slushies • Minimise time in PPE • Enforcement Strategy

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Use of PAPR with integral hood Potential use of 3 teams for long transfers – Forward – Flight – Reception

In Conclusion •

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Innovative development of – Access to dedicated trained EVDRT – Access to specialised equipment, tailored to aeromedical retrieval, in support of above – Defined procedures / processes / communication pathways in support – Assessing and ensuring staff health and safety Confirmation of concerns about management of “wet” phase patients System enhancements based on exercise experience Principles also generically applicable to other emerging infectious diseases of global significance