4 Support services and documentation
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- Support services
- Procurement of provisions for infection control
- Decontamination of equipment
- Decontamination of patient care articles
- Decontamination of the environment
- Waste management
- Incident reporting
- Design of Ebola treatment units
- Case study
When you have completed this unit you should be able to:
- Understand the role of support services in Ebola outbreak management
- Know which essential infection control items must be obtained
- Be familiar with decontamination protocols for equipment and healthcare workers
- Know how to manage blood and body fluid spills
- Know how to render linen safe and manage healthcare waste
- Be familiar with outbreak documentation, including incident reporting and safety audits
- Understand the design, layout and workflow requirements for isolation areas
- Understand the environmental requirements (ventilation, water supply).
4-1 What are healthcare support services?
Support services work behind the scenes in healthcare to make sure that clinical staff, patients and visitors are safe and cared for. Unfortunately the staff working in support services are often neglected when training is provided. Infection prevention and control (IPC) programmes need simple but solid training programmes for these staff to ensure they are adequately informed and protected with knowledge and appropriate personal protective equipment (PPE). No healthcare delivery system can function without a well-organised infrastructure.
4-2 What is the role of support services in management of Ebola outbreaks?
The work of the support service teams is absolutely critical to the smooth operation and safety of patients and healthcare workers in outbreak settings. They essentially provide a safe environment in a busy and potentially highly infectious work setting. In Ebola outbreaks, there is excessive use of personal protective equipment (PPE), water, electricity, medical equipment, linen and disposal of infectious waste. Well-trained support staff will ensure a safer working environment for themselves, healthcare staff and patients, particularly when handling laundry and infectious waste.
Support staff provide essential services that ensure a safe working environment in a busy and potentially highly infectious healthcare setting.
4-3 Which support services are required?
In any healthcare facility, whether it is an Ebola Treatment Unit (ETU) or a regular healthcare facility dealing with possible suspected cases of Ebola, the following aspects must be considered:
- Obtaining PPE and IPC equipment to provide a consistent supply of quality products
- Essential supplies: ventilation, water and electricity for health and IPC needs
- Ensuring that patient care articles such as bedpan, jugs and urinals are safe
- Decontamination and sterilisation of medical devices
- Environmental cleaning and disinfection in high- and medium-risk areas
- Managing linen safely
- Managing both infectious and non-infectious waste with minimal risk
- Design, layout and workflow to ensure minimum transmission
- Essential documentation towards containing the outbreak.
Standard operating procedures (SOPs) must be in place as visual reminders to reduce occupationally acquired exposure in support services staff. They must understand the risk to themselves, know how to conduct their work safely and realise the critical role they play in the healthcare service. They should be recognised as an integral and essential part of the infection control (IPC) team and must be treated as such.
4-4 Who should co-ordinate the support services?
Ideally, the administration of the healthcare facility should ensure that these services are in place and are functioning properly. Each facility should appoint a technical co-ordinator, assisted by a multi-disciplinary team to manage and advise on technical issues.
In a crisis situation like an Ebola outbreak, there are often major shortages of PPE, IPC equipment and other essentials. There is also huge pressure on an already fragile healthcare infrastructure. Organisations supporting the Ebola epidemic should work together with the health administrators and facility technical co-ordinators to ensure that the correct amount of good-quality equipment is purchased and used. It is a team effort and needs to be based on trust and supply of accurate information. Ultimately, the responsibility lies with the government to ensure an uninterrupted supply of support services. Support services are part of the healthcare delivery team, the same as IPC.
Procurement of provisions for infection control
4-5 What is procurement of provisions?
Procurement is the buying of goods needed for healthcare service delivery. It is a complex business especially in countries where the supply chain is unreliable. In many outbreak settings or countries with weak healthcare systems, lack of essential stock items in hospitals is common. Additional challenges include inadequate quality control of items and absence of electronic stock control systems. In most of these settings, manual records are kept making it difficult to track which items are needed. A good procurement system should monitor usage and distribution of items, with a stock replacement system that can give accurate updates on current stock supplies.
Procurement is the buying of goods needed for the delivery of healthcare services.
4-6 Which essential items should be procured?
It is very difficult to estimate the exact needs of any particular unit in an outbreak setting, but certain essential items are required to ensure adequate infection control standards (based on the WHO guidelines, September 2014).
|Category of item||What is required||Comments|
|Hand hygiene supplies||Running water||Running water can be supplied from municipal services (if reliable) or water containers. If no disposable hand towels, can have personal use towels.|
|Alcohol handrub||If not available, chlorine solution at 0.05%, although this is not recommended by WHO.|
|Personal protective equipment (PPE)||Clothes or theatre scrubs||All staff must change out of their 'street' clothes. Each worker will need a pair of boots (preferably one size larger for easy removal). If boots are not available, slip-on shoes without laces that cover the full foot are an option, together with fluid-resistant shoe covers. Double gloving is required in all clinical areas. Domestic gloves are needed for burial, linen and waste management duties. Coveralls are preferred if working in Support Services. If using reusable aprons they must be robust to withstand repeated exposure to chlorine. Surgical masks are worn with face shields or can be 'off the face' fluid-resistant types worn with goggles. Face shields are less prone to fogging up and give more visibility to the worker.|
|Sets of PPE||PPE sets should include: non-sterile examination gloves, domestic (rubber) gloves, water-resistant gown or coverall, disposable plastic aprons or reusable ones, face covers or fluid-resistant surgical masks or respirators, face shields or goggles, head gear, e.g. hood to cover head and neck.|
|Waste management||Red bags and containers for infectious waste||Some facilities may use yellow bags for biohazardous waste, but red bags are preferred. For final waste disposal (after appropriate treatment) the simplest and cheapest method would be to use an incinerator. This, however, causes environmental pollution with health risks so better technologies, e.g. autoclaving, are being made available, at low cost, specifically designed for low-resource settings.|
|Robust sharps containers|
|Black bags for general waste|
|A method for final disposal of waste|
|A convenient place for storage, treatment and final disposal|
|Environmental cleaning and disinfectants (refer to WHO guidelines)||Supply of clean water||Chlorine liquid can be accurately diluted to give the correct concentration. The correct method for application is to use a cloth soaked in the correct dilution of chlorine and apply it evenly and allow to dry.|
|Chlorine liquid||Random spraying of the environment with disinfectants is not recommended. Quality control of detergents and disinfectants is important, especially in hot African climates, where some products may be unstable. Disinfectants should be stored in dry and cool areas.|
|Detergents (not washing up liquid!)|
|Ammonia-based cleaners for toilets and baths|
|Linen/mattresses||Linen for beds|
|Mattresses with impervious rubber covers|
|Sterilisation services||Indicators for sterilisers, Bowie Dick test, chemical and biological indicators|
|Clinical supplies||Laboratory sampling tubes and bottles||All essential items and equipment should be put into a dry, cool and secure store room.|
4-7 Which personal protective equipment is required for support services staff?
The table provides suggestions for appropriate PPE to be used in different support services areas.
|Procedure||Gloves||Gown or coverall||Apron||Face mask||N95 respirator||Face shield||Goggles||Hood or head cover||Boots|
|Direct clinical contact option 1||✓||✓||✓||✓||✓||✓||✓|
|Direct clinical contact option 2||✓||✓||✓||✓||✓||✓||✓|
|Body removal||Heavy duty||Coverall preferred||✓||✓||✓||✓||✓|
|Environmental cleaning||Domestic (rubber)||Coverall preferred||✓||✓||✓||✓||✓|
|Washing patient care articles||Domestic (rubber)||✓||✓||✓||✓||✓||✓|
|Burial of bodies||Heavy duty||Coverall preferred||✓||✓||✓||✓||✓|
4-8 Why is the quality of the items important?
Good-quality equipment is essential to protect healthcare workers and patients. However, purchases must be cost-effective. Ideally the procurement or logistics staff, together with someone with IPC experience, should review all items before ordering. The following issues should be considered:
- Developing an essential items lists, with minimum stock levels
- A method to ensure stock recording and control
- The lag-time for an order to be made and delivered (how long will it take)
- The minimum amount of essential stock needed (calculated as ‘one on the ward, one discarded off the ward and one on the way’)
- The product quality (items will need to withstand heavy use and constant application of disinfectants)
- Whether manufacturer’s instructions on how to use the item are clearly defined
- Whether the purchased items are ‘fit for use’ (i.e. appropriate for the task it was purchased for)
- Whether an adequate supply (for at least 6 months) can be ensured.
4-9 How is the amount of stock required estimated?
For smooth operation of an Ebola Treatment Unit (ETU) a constant supply of acceptable quality products must be ensured. In an Ebola outbreak, one will have to make certain assumptions or best guess estimates regarding the volume of usage, for example:
- A 10 bedded ETU located in a high humidity and temperature country
- At least 4 healthcare workers per shift
- A shift is usually 4 hours, but the ETU has no ventilation/cooling systems so each healthcare worker can only comfortably work for 60 minutes in the clinical areas when in full PPE
- Therefore, instead of using 4 sets of PPE per shift, the usage will be multiplied by 4 giving 16 sets of PPE per shift. One always assumes the need for extra sets of PPE (in case of damage or heavy soiling). So in fact it will require 20 sets of PPE per shift for a 10 bedded ETU.
- For each 24 hour period up to 120 sets of PPE may be needed!
- Gloves and plastic aprons should also be changed between patients (so the totals required will be more than the PPE sets).
If the quality of the PPE items is poor, this estimated number required could increase further. This potentially could lead to PPE shortages, in addition to generally increasing risk of healthcare worker contamination when using PPE of poor quality.
The amount of stock needed in each Ebola Treatment Unit must be carefully calculated.
4-10 What considerations are important when dealing with donated stock?
Everyone is trying to help with Ebola and making donations of equipment and materials which are not always appropriate to the local conditions. It is best to be specific about what donations are required and acceptable, otherwise large numbers of items that are unusable will be wasted. Countries in need do not want to appear ungrateful and often feel obliged to accept inappropriate donations. These items may be difficult to dispose of and may create an expectation of usefulness, but does not influence the outcome of the epidemic. Acceptable donations are disposable and/or single use items of good quality such as hand hygiene products, PPE or similar. Equally, good-quality linen, patient-care articles and ward-support articles can be accepted. Make sure that donated electric equipment has a service contract and that spare parts are available.
- For electrical machinery such as sterilisers, washer disinfectors, or other automated equipment make sure the following is also available and comes as part of the donation: What is the equipment to be used for and is it really needed? Will it reduce risk to staff, if so, how? Will the donor provide certified orientation to local staff on the use and maintenance of the donated equipment? What infrastructure is required to run the machines, such as 3-phase electricity, running water with sufficient pressure? What are the manufacturer’s guidelines and instructions on which chemicals are to be used with these machines and will these be supplied for 5 years? (If the wrong ones are used, the machines will not function.) Will the donor sign a contract to provide regular servicing of the equipment for at least 5 years? Will there be spare parts available for at least 5 years?
Decontamination of equipment
4-11 What is decontamination?
Decontamination is the process followed to ensure that reusable medical devices are safe to use on the next patient. Examples are the decontamination of a vaginal speculum between patients or surgical instruments between operations. In the case of outbreaks, particularly with viral haemorrhagic fevers, the risk of transmitting infection when sharing equipment is high (by indirect contact). Decontamination includes some or all of the following steps:
Decontamination is a process that ensures that reusable medical devices are safe to use on another patient.
4-12 What is cleaning?
Cleaning is the physical removal of all visible organic matter and dirt from the surfaces and crevices (hinges and serrated teeth) of any item that is to be disinfected or sterilised. Cleaning is essential before any disinfection of surfaces or disinfection and/or sterilisation of equipment which is reused, whether for patient care or surgery. In order for cleaning to be effective, detergents are added to the water. Detergents are cleaning substances which usually are sold as a powder or liquid and are similar to soaps.
Without cleaning, adequate disinfection cannot take place.
4-13 What is disinfection?
Disinfection is the use of heat or a chemical which will reduce the number of disease-producing microorganisms (bio-burden) of an item or surface. Disinfection will kill most bacteria, most viruses (including Ebola) and some fungi and parasites. It does not kill spores. Prior to disinfection, all items must be thoroughly cleaned as disinfectants can be inactivated by organic matter. Disinfection is used to make an item safe to handle and safe for use, but the items are not sterile. The best method of disinfection is heat because it is simple, inexpensive and can be controlled. However, in the current Ebola outbreak disinfectants such as chlorine (bleach) are widely used because of the ease of availability in shops across Africa.
Chlorine at a strength of 0.5% is used as an environmental or equipment disinfectant while a weaker dilution of 0.05% chlorine is often used for skin antisepsis (washing hands/body/hair) although this is not ideal.
Chlorine is corrosive to metal and can be inactivated by organic matter.
4-14 Why should the indiscriminate and incorrect use of chlorine be discouraged?
Items are often soaked in chemical disinfectants such as chlorine immediately after use in the belief that the virus will be destroyed. This is incorrect for the following reasons:
- Organic matter protects microbes
- Soil and organic matter will stick to the surfaces and will be difficult to clean
- Chemicals such as chlorine will destroy the smooth surface of the instrument and create pits and crevices which allow dirt and organic matter to remain. This makes the instrument impossible to clean in the future
- Chemicals such as chlorine are inactivated by organic matter so it is ineffective.
Putting items in liquid solutions also increases the risk of splashes to mucous membranes; while spraying with disinfectant also increases the risk of human exposure. Chlorine must always be used with caution as it is irritating to the skin and mucous membranes. Therefore, always wear protective equipment when using chlorine.
When handling chemicals always wear appropriate protective equipment: domestic gloves, plastic apron, face and eye cover to protect the skin and mucous membranes.
4-15 What is sterilisation?
Sterilisation means that all microbes are killed including bacterial spores. It is a process used mostly for surgical instruments (where sterility is essential). Since little or no invasive procedures are undertaken in Ebola Treatment Units, the need to sterilise items is limited, and it might be best to use disposable packs when necessary. Nonetheless, it is important to know what should be done in case sterilisation (a CSSD or Central Sterile Services Department) is required. The main method of sterilisation is steam with release of heat when it is in contact with items in the steriliser. Chemical sterilisation is possible but the equipment is expensive, the exposure time is long (hours) and has to be well controlled. It also does not work with all instruments.
- The Spaulding classification best defines the type of medical devices and the level of processing they require to be rendered safe for reuse.
Level Examples Critical Medical devices entering a sterile area of the body, e.g. surgical instruments, must be sterile. This means they must be sterilised under controlled conditions with quality indicators. Semi-critical Medical devices that enter areas of the body which have microbes in them such as the mouth and the respiratory tract; these items have to be cleaned and disinfected. Non-critical Items from the patient’s environment (not in direct contact with the patient) which can cause disease by indirect contact via hands. These must be clean and dry.
Sterilisation is a process that kills all microorganisms.
4-16 Which factors increase risk of transmission from inadequately decontaminated items?
The major risks are medical devices contaminated with blood and body fluids. Devices which have been damaged (lost integrity) due to pre-soaking in corrosive disinfectants such as 0.05% chlorine (bleach) are also a risk. If devices are poorly cleaned, organic matter will remain on the instruments, preventing proper disinfection and/or sterilisation. Staff must be well trained in proper reprocessing including cleaning, disinfection and sterilisation. The reprocessing of equipment must be functioning and the systems validated. The final risk is lack of proper storage of sterile items which become re-contaminated.
4-17 What steps should be followed when reprocessing devices?
Reprocessing is the action which makes reusable medical devices safe to use on other patients:
Make a list (an inventory) of the available medical devices which are reusable.
Evaluate the workload of the facility per week or month, e.g. how many procedures of which type take place on average. Then estimate the number of medical devices needed for these procedures. It is important to ensure that the staff dealing with medical devices is trained in handling equipment from Ebola facilities.
Pre-soak procedure (at the site of use). Wear PPE. Place clean water and detergent in a bucket with a lid, with a sieve (rack or tray) that can fit into it. The water level should be two thirds of the height of the container. The two handles of the rack or tray are outside on the lip of the bucket. The instruments are placed on this rack. After the surgical operation, the rack is lowered into the bucket and the instruments are soaked (completely covered) for 10 minutes to remove organic matter. Lift the rack and allow the medical devices to drain. Carry out a visual inspection to ensure most of the organic matter has been removed. If not, repeat the process. Throw the water from the bucket into the sluice (or patient toilet if nothing else is available). Place the rack in the bucket with the lid secured in place and carry these instruments to the sterilisation area. Disassemble and prepare for cleaning. No bleach or any other disinfectant is needed.
Soaking devices in bleach or any other disinfectant is not recommended or required.
Cleaning of medical devices. This is the most essential step in disinfection and/or sterilisation. Cleaning can be done with an automatic washer or manually:
- If an automated washer disinfector is available that can reach a temperature of 90 °C, use it! This is the safest system for most pathogens including viral haemorrhagic fever viruses. Once the cycle is complete, the medical devices are clean and safe to handle. Place the rack of instruments directly into the chamber with all medical devices disassembled and the hinges in the open position and run the cycle. The process has to be validated and the cycle completed. Automated systems are ideal as they allow minimal handling of contaminated devices.
- Where only manual cleaning is possible wear full protective PPE such as gloves (domestic), plastic apron, face cover and head cover, rubber boots. Dilute the medical device detergent (not to be confused with domestic detergent) according to the manufacturer’s guidelines. Measure the right amount of water and put a mark in the sink. Measure the detergent and pour it into the water-filled sink or basin. Put the medical devices into the sink and hold them under the water level to prevent splashing. Never wash such medical devices under running water. Use a soft nylon brush such as a toothbrush and clean in the grooves, hinges and serrated ends. Inspect to ensure the medical devices are clean. Remove carefully and lay into trays according to requirements on the checklist. Remove PPE. Wash hands thoroughly.
Most medical devices can be reprocessed safely if this is done by trained personnel.
- For manual cleaning refer to the WHO Decontamination Manual, 2nd Edition. 2014
4-18 What additional steps should be followed for devices that require sterilisation?
Inspection, Assembly, Packaging. Have a close look at the instruments for cleanliness, integrity and functionality. Disassemble all devices unless the manufacturer’s recommendations are to sterilise them while assembled. Place in trays and wrap with appropriate covers if a porous load steriliser is used. Place on trolley and load into the steriliser.
Sterilisation. There are either gravity (downward displacement) sterilisers or porous load (pre-vacuum) sterilisers. Careful placing and loading is important to allow good removal of air and circulation of steam!
- Gravity Sterilisers: validation is done by checking and recording readings from the gauges and physical indicators. Make sure the operators know how to use them and what the gauge readings mean. Porous Load sterilisers: these sterilisers will require 3 phase electricity and usually a constant water supply with clean water to provide high-quality steam. They are more sophisticated and the operators will require training. Minimum indicators are the daily Bowie Dick test and the chemical indicator is placed inside each pack, and ideally a biological indicator is run daily or at least weekly. There must be adequate space for steam to circulate and penetrate and that the vacuum will remove air consistently. Steam must be of the correct saturation to be most effective and penetrate each of the packs to ensure sterility.
Sterile storage and transportation. Once the sterilisation packages have been removed, they must be allowed to cool before being used. They must come out dry from the steriliser and be kept in a cool and dry environment ready for use. Sterile packs must be transported in a clean and dry manner. Sterile or cleaned items should be stored in a clean dry area away from heat.
Decontamination of patient care articles
4-19 Why do patient care articles pose a hazard?
A major source of transmission between patients and staff is poorly cleaned patient care articles such as bedpans, urinals, jugs, bowls and mattresses. These articles are often neglected because they have to be cleaned manually and proper provisions often do not exist. There is high risk of Ebola transmission from faeces, urine, vomitus and patient excretions. Therefore, it is best to assist the patient to get to the toilet. If available, adult nappies are another alternative. Cleaning is vital to reduce the transmission of Ebola. It is also the first step prior to disinfection or sterilisation.
It is important to manually clean bedpans, urinals, jugs, bowls and mattresses especially if soiled by stool or vomitus.
4-20 How should patient care articles be disinfected?
Automated bedpan washer disinfectors are best because these reduce the risk of exposure to the staff and also clean and disinfect the items using heat (90 °C for 1 minute). Where these are not available, manual cleaning should be done using the following method:
- Wear appropriate PPE covering all exposed skin and mucous membranes to avoid contamination with splashes
- Remove the used patient item and flush the contents down the patient’s toilet
- Rinse off the remaining contents with water until visibly clean
- Using a soft brush clean with water and detergent paying special attention to under the rim, and other difficult to reach areas
- Do not scrub under running water tap, it increases risk of splashes
- Rinse again and inspect for cleanliness
- Wipe over with 0.05% chlorine and allow to dry
- An alternative is to place upside down in the sun to dry, the bedpan will reach at least 85 °C in the sun (enough to kill Ebola virus)
- Do not soak bedpans, jugs or urinals in chlorine – it corrodes the metal and chlorine is inactivated by organic matter.
Ebola virus is highly sensitive to heat.
4-21 How should clinical items be handled?
Clinical items (such as thermometers) used in the confirmed Ebola section of the ETU may not be removed to other areas. These items should be cleaned with an alcohol wipe after each use. In West Africa, blood pressure apparatus is not used because of the risk of contamination. However, in high-income countries, disposable blood pressure cuffs and distance monitoring disposable finger probes are used. In almost all ETUs, no invasive procedures are carried out and therefore there are very few used medical devices which will require reprocessing.
4-22 How should patient’s crockery and cutlery be handled?
In Ebola, feeding utensils such as crockery (cups and plates) and cutlery (spoons, knives and forks), can get contaminated with saliva and patient secretions and will be treated as infectious. For this reason it is often simplest to supply food to inpatients in disposable containers. However, should the need arise to wash utensils (such as at home) the following method may be applied:
- Wear appropriate PPE (at home domestic gloves and aprons are sufficient if PPE is not available, while covering the face with a cloth).
- Fill a basin with clean warm water and detergent (washing-up liquid) and allow the items to soak for a couple of minutes. Sometimes chlorine is added to the water prior to washing. This has no additional disinfection value. However, it makes the carer feel safer.
- Using a cleaning brush or cloth, wipe over the surfaces carefully while holding the items under water to prevent splashing. Do not wash under running water!
- Remove and drip dry.
Decontamination of the environment
4-23 How should the patient environment be cleaned?
Environmental cleaning (cleaning the area around a patient) is a crucial part of infection control in ETU and must be done with special care and attention. In situations like Ebola, where high contamination of the environment is expected, cleaning and disinfection of all surfaces at least once a day is recommended.
The method for environmental cleaning and disinfection recommended by the World Health Organisation (WHO, 2014) is:
- Wear full protective PPE (domestic gloves, gown, face cover, head cover, rubber boots)
- Prepare a fresh solution of detergent in a clean bucket according to the manufacturer’s guidelines for dilution
- Prepare a separate bucket of disinfectant (i.e. 1000 parts per million of hypochlorite solution), (see the WHO guideline for chlorine solution preparation at the end of this chapter)
- Use these two buckets/containers (preferably of different colour) and two sets of clean dry clothes and mops; one for water and detergent, and the other for the disinfectant solution
- To minimise the spread of contamination on surfaces during cleaning, always start from clean areas first, such as the ward areas, and then move towards the dirtiest area last (toilets)
- Wipe the surfaces with water and detergent solution to remove organic matter and prevent inactivation of disinfectant
- Apply the disinfectant to the surfaces using a cloth (rather than spraying)
- Pay particular attention to frequently touched areas and horizontal surfaces
- Prepare clean, freshly made-up solution when the water in the bucket is dirty
- At the end of the cleaning session, discard the liquid in the buckets into the sluice (if sluice is not available, discard into the patient’s toilet)
- Clean and dry the containers and store them inverted
- Discard disposable clothes as infected waste
- Disposable mop heads are preferred for high contamination areas. If the mop heads are reused they should be washed thoroughly in water and detergent, then disinfected with hypochlorite, rinsed and allowed to dry before reuse.
Chlorine used as an environmental or equipment disinfectant is usually used at a strength of 0.5%. Chlorine used for skin antisepsis (washing hands/body/hair) is used at a weaker dilution of 0.05%.
4-24 What is terminal cleaning?
This is cleaning that is carried out when a patient is discharged or has died. The purpose of terminal cleaning is to make the room safe for the next patient to use (by reducing the chance of transmitting infection from contaminated surfaces). In ETU the rapid patient turnover makes it impossible to do this thoroughly. All disposable items or disposable equipment which have been in contact with an Ebola patient must be discarded as infectious waste. There are usually very few (if any) reusable items to be sent for decontamination.
High levels of environmental contamination occur in Ebola outbreaks, requiring that all surfaces are cleaned and disinfected at least once daily.
4-25 How should blood and body fluid spills be handled?
The following principles should be applied:
- Cover spillage with paper towels or an absorbent cloth
- Clean up using domestic gloves
- Glass and solids should be removed using a brush and pan, and discarded in a sharps container, or if too large, wrapped in newspaper before safely disposing
- The remaining fluids should be blotted using as many paper towels as needed; these should be discarded in the clinical waste
- Water and detergent should be used to remove all visible blood
- The area should be wiped over with a chlorine-based solution (at a concentration of 1000 parts per million) and allowed to dry
- Every healthcare facility and ETU requires a written, easily understandable and accessible standard operating procedure (SOP) for managing blood and body fluid spills.
An easily understandable protocol for handling blood or body fluid spills must be displayed.
4-26 How should used (soiled) linen be handled?
Linen is a potential source of Ebola transmission, particularly when contaminated with blood and body fluids. Disposable linen is ideal, but in most resource-constrained settings, linen will be reused. When handling contaminated linen:
- Protect yourself with appropriate PPE (see chapter 3 from 3-12)
- Remove the linen from the patient’s bed
- Remove gross contamination by scraping off into the patient’s toilet or waste pit
- Soak the linen in clean water and detergent for 30 minutes. Remove and inspect the linen, rub to remove dirt and discard the water
- Make up a fresh solution of 0.5% chlorine in water (bleach) and soak the linen in it for another 30 minutes
- Remove, rinse in clean water and wring out
- Spread in the sun to dry
- Wash the domestic gloves with soap and water before removing the PPE. Remove all the PPE safely. Carry out hand hygiene.
4-27 How should mattresses be disinfected?
While wearing full PPE, the mattress must be checked for any damage (there should be no tears or cracks). Fill a bucket with clean water and detergent. Use a cloth soaked in the bucket to wipe over the surface of the mattress. Wipe to dry. Wipe over with a disinfectant such as 0.05% chlorine solution and allow to dry (preferably in the sun).
0.05% chlorine (bleach) can be used to disinfect mattresses and 0.5% chlorine can be used for linen.
4-28 How should the home of a patient diagnosed with Ebola be decontaminated?
When entering a home, be respectful. Inform the senior member of the family of what you are about to do. Allow the family to tidy up the home if they want to. Put on the full set of personal protective equipment before entering the home. Go to the victim’s room to remove the body only after the prayers or other rites have been completed. Spray the home (surfaces, walls and floors) with a 0.5% chlorine solution, after thoroughly cleaning with detergent. There is no point in spraying the earth outside and no benefit in spraying humans directly with chlorine!
4-29 What is medical waste?
Medical waste is the waste discarded after patient care. Ebola Treatment Units and other healthcare facilities (not directly handling Ebola patients) produce a considerable amount of medical waste (up to 30 kg per day per bed). In the case of an ETU, all waste is classified as infectious. This simplifies matters because medical waste no longer needs to be separated into infectious (clinical) and non-infectious waste. Make sure that the ETU or facility has a clear policy stating who is responsible for collecting the waste, where containers will be stored, and how the waste will be finally disposed of.
4-30 How should medical waste be handled?
All areas where PPE is removed and patient care areas should have robust waste containers lined with red bags for infectious waste. If the outer containers are not disposable they have to be washed, cleaned, disinfected and relined with a red bag (some countries use yellow bags for infectious waste). During these processes the waste management worker should:
- Wear appropriate PPE
- Tie the neck of the bag and lift the bag gently, ensuring it does not spill
- Place it in another red bag
- Tie the neck of the bag, label it as ‘infectious’ or ‘Ebola’
- Place at a collection point just outside the clinical area
- Remove PPE and wash hands thoroughly.
Some people recommend spraying the outside of the bags with chlorine so that the handlers feel more comfortable that contamination is reduced. Make sure the chlorine does not drip all over the floor after spraying. For transportation of infectious waste, the bags will be collected in trolleys and taken to a point where they will be finally disposed. The trolley must be cleaned and disinfected daily or after each transportation session.
4-31 How should medical waste be disposed of?
Liquid waste can be disposed of down the patient toilets or double pit latrines. In some instances special pits can be dug to allow liquid waste disposal. All solid infectious waste must be disinfected before final disposal.
There are several methods available for disposal of solid waste:
- Pit fills: This method uses a large pit which is dug behind the facility. Waste is dumped into it and then covered with chlorine or soil. Both of these methods are not safe, since humans and animals have been known to scavenge at these sites. In some countries, approximately 5 cm or more of lime is applied over the waste to cover it completely to kill the virus. It is not a robust method of disposal but could be applied in rural villages.
- Drum burning: The waste is filled in drums and set alight to burn. The waste is usually incompletely burnt and has a high pollution effect.
- Pit burning: Currently the most common means of disposal is pit burning. This is where a large pit is dug and the waste is layered into it. A drum which is open on both sides is placed over the pit to act as a chimney or flu. The waste is ignited and burnt. This too, has problems with incomplete burning.
- Incinerators have been recommended by some, but the maintenance is a challenge.
- Automated systems such as autoclaving the waste before sending to land fill, and shredding and heat disinfection of waste are all techniques which are more appropriate for high-income countries with good infrastructure. However, affordable autoclaving technology for African settings is in development.
- For disposal of anatomical waste, e.g. placentas and human parts, burial appears to be the best method at present (although this method is also not ideal, as the water table levels may rise with run-off of infected fluids).
4-32 How should sharps be disposed of?
In an ETU the use of sharps should be kept to an absolute minimum to reduce the risk of needle-stick injury. Sharps are generally in the Ebola ‘suspect’ or triage areas where blood samples are drawn for laboratory tests. Recently, some ETUs have started using intravenous fluid replacement in the patient care areas. In such cases, it is essential that a robust sharps container is placed within arm’s length of each healthcare worker who is using sharps. The containers must be sealed and may be sprayed with chlorine before being placed in a red bag. The neck of the bag is tied and clearly labelled and taken to a place for removal.
4-33 What information should be documented?
There are many pieces of information that should be documented when containing an outbreak, but only the essential ones are mentioned here. A reasonable list of topics is as follows:
- Ebola preparedness. How prepared is the facility or country to deal with Ebola? A questionnaire has been produced by the Infection Control Africa Network (ICAN) and the International Society of Chemotherapy (ISC) (see Resources).
- What is the actual caseload? This is essential information which can only be gleaned from admission records and the confirmed laboratory cases. It is best to keep an electronic record at the patient arrival point (where cases are registered). There are national figures which could also be accessed via the non-governmental organisations.
- Set up links with the community to report suspected cases of Ebola. This could happen via peer counsellors but is not easy to set up.
- Infection control checklist. This is a list of items that must be in place at the beginning of each day with a 36 hour stock in the clinical areas. This includes hand hygiene products, PPE, detergents and disinfectants.
- Clinical activity audit. Behaviour of healthcare workers during clinical ward rounds to be observed by a colleague to ensure the right practices are followed including appropriate hand hygiene.
- Putting on and taking off PPE according to the prescribed method by the WHO – audit of practice.
4-34 Who should be responsible for documentation?
Various people are responsible for collecting data at each facility or ETU. It is best if one person is identified by the facility manager who can be held responsible for gathering and disseminating the information. The infection control (IPC) teams can collect information on clinical cases and IPC practices. They can also carry out audits to help with monitoring and evaluation of the programme. The information should be discussed at the daily or weekly clinical meetings, the administration meetings and meetings with the Department of Health.
4-35 What is incident reporting?
Any accidental exposure, occupational or otherwise, of a healthcare worker or patient should be reported immediately to the authorities. A register is set up which will record the incident. It will require laboratory testing (blood samples taken from source and victim) and the person will be put under observation for 21 days, which is taking one’s temperature twice a day. Ideally each Ebola treatment unit should have a physician appointed to deal with exposure incidents. All healthcare workers should be made aware of the risks and the requirement to report any exposure incidents.
Any accidental exposure by a healthcare worker must be reported immediately.
4-36 What action should be taken following an exposure incident?
Accidental exposure to blood via a needle-stick or splash exposure will require the following immediate actions:
- Wash the damaged area with copious amounts of running water (a mechanical and dilution effect) and make sure there is no chlorine in the water as this will damage the mucous membrane or skin and increase the risk of transmission
- Report the accident to your manager
- Record in the incident register exactly what happened and give details:
- Did anyone observe the incident?
- How did it happen?
- When did it happen? Date and time
- When was it reported? Date and time
- What was the action taken?
- Patient details: name, age, gender. How long has the patient had symptoms of Ebola? (less infectious in the early stages)
- Have blood samples taken from the patient (not necessary if known to have Ebola) and from the healthcare worker for testing and check the healthcare worker’s hepatitis B status
- Repeat the healthcare worker’s Ebola PCR on days 7, 14 and 21
- Record the healthcare worker’s body temperature every 12 hours each day for 21 days.
Design of Ebola treatment units
4-37 What is the preferred layout of an Ebola Treatment Unit?
In the countries with large Ebola outbreaks, several Ebola Treatment Units (ETUs) have been established by different non-governmental organisations. However, in all ETUs the design is covered by the same principles. There is clear definition of ‘clean or low-risk’ and ‘dirty or high-risk’ areas. The demarcation lines are never crossed from dirty to clean, i.e. there is one-way traffic from clean to dirty areas to reduce transmission and cross-contamination. Provision for hand hygiene and appropriate PPE must be available at each entry point and provision for safe removal of PPE must be clearly defined at each exit. Clinical notes and other materials will be kept outside the high-risk areas.
The demarcation lines are never crossed from dirty to clean, i.e. there is one-way traffic to reduce transmission and cross-contamination.
4-38 What is the preferred workflow for an Ebola Treatment Unit?
The ETU, like any other healthcare facility, should be well thought-out and constructed, whether it is make-shift with tents or a solid building structure. The ETU area is divided into separate staff and patient entry and exit areas (as shown in this diagrammatic sketch from MSF below).
|Area||Description of activity|
|1. Staff entry area||A clearly demarcated entry point for staff going into the clinical areas after putting on PPE. The area will hold enough PPE for two days for all those entering. There is a hand hygiene station. The changing area for men and women has to be clearly defined. Here the staff changes into scrubs and rubber boots.|
|2. Staff Exit area||Staff leaving the clinical area may only do so at this exit point. There will be no cross over into the entry section. Staff will remove their PPE according to the defined protocols which should be displayed on the walls. There must be at least 3 hand hygiene stations here since there will be more than one person exiting at any one time. The area will contain infectious waste containers for the PPE. There will be a bench to sit down and remove overshoes if used.|
|3. Patient entry point||Patients enter here, while the relatives go and wait at the visitors' area. A person must be present to receive the patients and talk to the relatives, take temperature and take a preliminary history before triaging. There must be good hand hygiene facilities available at all times.|
|4. Triage area||The patient will be placed here awaiting rapid diagnosis of suspected EVD. The area should be well ventilated and airy. The patients and relatives may meet over the wall separating the visitors' area.|
|5. Suspect area||Suspected Ebola cases are held here until results are returned. If the patient is found to be negative for Ebola but with suspicious clinical symptoms s/he remains there and is treated for malaria and other infectious diseases. This area needs good hand hygiene facilities, isolation areas or cohort areas and good toilet facilities.|
|6. Confirmed cases||For patients who test positive for Ebola and are transferred from the suspect area.|
|7. Ambulance entry||Entry of confirmed cases via ambulance – referral in from other ETUs.|
|8. Mortuary||For storage of bodies and preparation for safe burials|
|9. Support services||Support services, stores and other health facility infrastructure areas. Waste removal, laundry and other used item removal takes place via this area.|
|10. Visitors' area||Visitors' area where they can meet their families. This area should be covered and have seating for visitors to rest. There should be hand hygiene and toilet facilities. Information posters in at least two or three languages.|
Figure 4-1: Preferred workflow for an Ebola Treatment Unit
4-39 What is required for water supply?
A constant supply of clean water is essential for hand hygiene, domestic use, washing of patients, food preparation and most importantly cleaning the environment. Water supply is also required for steam sterilisers, laundry and in some areas, waste disposal. Ideally large tanks should be installed to contain up to three days usage of water. Piped water to the patient areas, kitchen and laundry would be ideal.
4-40 What are the power/energy requirements?
There should be a constant supply of electricity to all healthcare facilities. If power outages are common, a generator or two (possible donation) which runs on petrol or diesel would be essential. Some of the larger equipment such as sterilisers and operating theatre systems will require 3-phase electricity supply. If used as fuel, natural gas can either be piped or delivered in bottles or containers. It might be a cheaper alternative to electricity.
4-41 What are the ventilation requirements?
An essential but often neglected aspect of facility design is ventilation. Most of the ETUs do not have any type of ventilation. By following the recommendations of high-income countries and using coveralls without any ventilation in the facilities, healthcare workers have suffered from heat exhaustion and reduced capacity to work efficiently. This is cited as one of the reasons for healthcare workers getting infected, because they function less than optimally under these conditions. Good natural ventilation is important. In ideal circumstances, negative pressure ventilation of at least 6-12 air changes would be recommended.
A foreign country’s ministry of health has decided to assist in the West African Ebola crisis by building and staffing a 50-bed Ebola Treatment Unit (ETU) in Sierra Leone. They consult a team of healthcare facility designers, engineers, logistics managers and infection control specialists to determine what will be needed.
1. What are the basic requirements for setting up a field hospital or Ebola Treatment Unit?
The facility will require multiple temporary structures, e.g. tents, to accommodate patients and support service activities. A stable water and energy supply is needed. Provision of adequate natural or mechanical ventilation should be carefully considered, given the extremely hot and humid climate. Aside from medical and nursing staff, the ETU will require a host of other, very important workers to run the support services, e.g. engineers, supply managers, epidemiologists, decontamination experts, etc.
2. How should the Ebola Treatment Unit be laid out?
There should be separate entrances and exits for staff and patients. Patients should be separated into 3 groups: triage (awaiting assessment); suspect cases (compatible Ebola case history but pending laboratory result) and confirmed cases. There should be no movement from the confirmed area to other areas. There should be clear definition of ‘clean or low-risk’ and ‘dirty or high-risk’ areas. The demarcation lines should never be crossed from dirty to clean, i.e. there is one-way traffic to reduce transmission and cross-contamination. Provision for hand hygiene and appropriate PPE must be available at each entry point and provision for safe removal of PPE must be clearly defined at each exit.
3. Which support services should be present?
The work of the support service teams is critical to the smooth operation and safety of patients and healthcare workers in outbreak settings. They provide a safe environment in a busy and potentially highly infectious work setting. All ETUs need some or all of the following support services: Procurement/supply chain management; engineers (ventilation, water and electricity); decontamination services (to reprocess medical devices) and environmental cleaning; laundry; waste management; logistics and Information technology support.
4. How should waste be disposed of in Ebola Treatment Units?
Liquid waste can be disposed of down the patient toilets or double pit latrines. There are several methods available for disposal of solid waste, e.g. pit fills, drum burning, incineration and autoclaving. All staff handling waste should be wearing full PPE and should have received full training on the risks involved.
How to use chlorine (bleach) correctly
How to make chlorine solutions for environmental disinfection
Example 1: Using liquid bleach
Chlorine in liquid bleach comes in different concentrations. Any concentration can be used to make a dilute chlorine solution by applying the following formula:
% chlorine in liquid bleach ÷ % chlorine desired – 1 = Total parts water for each part bleach*
Example: To make a 0.5% chlorine solution from 3.5%** bleach:
3.5% ÷ 0.5% – 1 = 7 – 1 = 6 parts water for each part bleach
Therefore, you must add 1 part 3.5% bleach to 6 parts water to make a 0.5% chlorine solution.
* ‘Parts’ can be used for any unit of measure (e.g. ounce, litre or gallon), or any container used for measuring, such as a pitcher.
** In countries where French products are available, the amount of active chlorine is usually expressed in degrees chlorum. One degree chlorum is equal to 0.3% active chlorine.
Example 2: Using bleach powder
If using bleach powder,* calculate the amount of bleach to be mixed with each litre of water by using the following formula:
% chlorine desired ÷ % chlorine in bleach powder × 1000 = grams of bleach powder for every litre of water
Example: To make a 0.5% chlorine solution from calcium hypochlorite (bleach) powder containing 35% active chlorine:
0.5% ÷ 35% × 1000 = 0.0143 × 1000 = 14.3
Therefore, you must dissolve 14.3 grams of calcium hypochlorite (bleach) powder in each litre of water used to make a 0.5% chlorine solution.
* When bleach powder is used, the resulting chlorine mixture is likely to be cloudy (milky).
Example 3: Formula for making a dilute solution from a concentrated solution
Total Parts (TP) (H₂O) = % Concentrate ÷ % Dilute – 1
Example: To make a dilute solution (0.1%) from 5% concentrated solution
TP (H₂O) = 5% ÷ 0.1% – 1 = 50 – 1 = 49
Take 1 part concentrated solution to 49 parts boiled (filtered if necessary) water.
Source: AVSC International (1999). Infection Prevention Curriculum. Teacher’s Manual. New York. Page 267.