Patient safety in managing Ebola in resource-rich and poor settings

Transcription

1 Patient safety in managing Ebola in resource-rich and poor settings Stephen Mepham Consultant in Microbiology and Infectious Diseases Royal Free London NHS Foundation Trust Colin Brown Infectious Diseases Lead Kings Sierra Leone Partnership

2 Ebola: Patient safety in a Resource Rich setting Stephen Mepham Consultant in Microbiology and Infectious Diseases 23 April 2015

3 UK VHF: an uncommon event 1976 Ebola Ebola, Porton microbiologist; NSI 2012 CCHF (2014 CCHF-not transferred to RFH) 2014 Ebola 2014 Ebola 2015 Ebola HLIU Coppetts Wood Hospital North London (until 2006)

4 High Level Isolation Unit, Royal Free London NHSFT (2006-) Self contained unit 2 Patient isolators Confirmed cases only, via RAF, or Ambulance Service

5 Isolators are not standalone 3 Autoclaves Category 3+ laboratory Air handling unit One way ward flow Changing rooms Nurses station

6 Biological containment strategies Trexler isolator Risk of personal contamination Low High Risk of environmental contamination Low High Staff movement around unit Easier Harder Staff shift length Longer Limited Cost High Cost Lower Interventions More difficult Easier 1 Personal Protective Equipment Scalability Specialist facility Transferable between sites (in principle) Centralised versus decentralised Centralised Both

7 Varying PPE models

8 How do you ensure quality healthcare when the primary concern is HCW safety?

9 HLIU Multidisciplinary approach Non-Clinical team Executive-led; Estates team; Communications; Bed manager Clinical team - HLIU team -Infectious Diseases -Nurse specialists -Microbiology BMS -ICU/PAART -Pharmacy -Physiotherapy -Nutrition -As required - Haematology - Dermatology - Psychology - Massage Rx! -Volunteers from other hospitals

10 A+E risk assessment: Health care worker safety v patient needs Side room

11 Patient safety during aeromedical transfer RAF Medical team Repatriation options Closed isolator HCW in scrubs Start to end isolation Interventions harder Closed Isolator: system: RAF RAF Open system Interventions easier requires PPE Open system: Phoenix Air (US)

12 Experimental Ebola specific management Patient Aug 14 Dec 14 Mar 15 Monoclonal antibodies - ZMapp (3 monoclonals) X X - ZMab (2 monoclonals; animal grade) X - MIL77(3 monoclonals) X Convalescent Sera X Favipiravir X Small interfering RNA - Tekmira (Brincidofovir) X

13 Viral load (log), temperature and ZMapp administration RFL data, used with patient consent

14 The challenge of providing Level 3 Care in a Trexler Isolator 24 patients treated in resource-rich settings Level 3 Care provided in PPE Germany, US 1, 2 1 Kreuls et al. A Case of Severe Ebola Virus Infection Complicated by Gram-Negative Septicemia. NEJM 22 Oct Wolf et al. Severe Ebola virus disease with vascular leakage and multiorgan failure: treatment of a patient in intensive care. NEJM 19 Dec 2014

15 Limitation of a small Lab footprint: Point of care tests Blood culture bottle -agar slope istat Piccolo Should we use closed loop auto-analysers in level 2 facilities?

16 Conclusion Patient safety in Resource-rich settings Primacy of HCW safety Patient risk Initial patient assessment Limited laboratory repertoire Level 3 care challenges: Trexler v PPE Experimental Drugs Quality care MDT approach Innovation: Trexler Isolator redesign

17 Patient safety when managing Ebola West African perspective Colin Brown Oliver Johnson Marta Lado Infectious Diseases Lead Country Director Clinical Lead

18 December 6 th 2013 Index case March 19 th 2014 Guinea March 31 st 2014 Liberia May 26 th 2014 S. Leone July 25 th 2014 Nigeria August 29 th 2014 Senegal September 29 th 2014 U.S.A October 25 th 2014 Mali December 30 th 2014 U. K. MSF WHO EU 40% ZMapp given UK & USA West African trail: Mar 2015 CP given USA West African trails: Dec 2015 Vaccine trail discussions Start date: Feb-Apr 2015 Maps: Maia Majumder, 2015

19 EVD Progression Symptom Stages 1 - Bodi wam Intermittent fever, no pattern, not very high Headache, LOA Back pain, joint pain, myalgia Intense fatigue, severe progressive weakness Malarial symptoms late presentation 2 - De kaka fast fast Vomiting, diarrhoea, abdominal & chest pain Liver tenderness Hiccups? paralytic ileum 3 - De torment Conjunctivitis Cognitive slowing Ebola stare, startled, disorientated, confused, falling over, lying on floor Bleeding rare from gums, cannula sites, IM injections, epistasis, vaginal bleeding Photos: Michael Duff/KSLP

20 SL Case Management Committee National Ebola Taskforce, June 2014

21 Photo : Colin Brown

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23 Photos: Michael Duff/KSLP

24 Connaught Hospital Holding Unit

25 HTD/UCLH 700 CONSULTANTS/ ATTENDING PHYSICIANS Liberia 51 Guinea 46 Sierra Leone 136 ~250 WEST AFRICAN TOTAL DOCTORS Sources: Afri-Dev, Geraldine O Hara

26 Modupeh Cole, 56, consultant physician Martin Salia, 44, consultant surgeon Sheikh Khan, 39, consultant physician And many others

27 % of all infections represented by HCW HCW infections as a proportion of all infections in VHF declined Onset month, 2014 CDC, WHO, MoHS SL

28 Wider Team in UK Photos: Michael Duff/Jo Dunlop/KSLP

29 Photos: Michael Duff/KSLP

30 Photos: Plan International/Neil Brandvold

31 Public health mainstays Photos & Images: Jeff Trahir/Alex Koloskov/Sam Pearce/John Moore/Getty

32 Novel diagnostics & therapeutics Photos: AP/Kazuhiro Noi/AFP/Getty

33 Photo: Colin Brown

34 Photo: KSLP