Resources and other articles

A comprehensive and systematic search for published literature as well as grey literature and other resources was conducted. Learn more about the search for published literature and access our strategy for identifying grey literature and other resources. All information included here is searchable using keywords relevant for infection prevention, management and control, as well as by the type of resource (article, video, etc).

Ebola clinical care guidelines: A guide for clinicians in Canada

This resource is informed by systematic review(s) and published single studies, one of which is a randomized controlled trial.  The evidence in this resource has been assessed for quality.

These clinical care guidelines were developed by the Canadian Critical Care Society (CCCS) and the Association of Medical Microbiology and Infectious Disease Canada (AMMI) to help clinicians faced with the potential of treating a case of Ebola Virus Disease (EVD). The authors recognize that due to the lack of high quality evidence on the pathophysiology and optimal specific clinical management of EVD a large portion of this guidance has been based on expert opinion.

http://www.canadiancriticalcare.org/_assets/Ebola%20Clinical%20Care%20Guidelines_ENG.pdf

 Guidance
Author: Public Health Agency of Canada
Resource Date: Aug 24, 2014
Categories: Disease information Paramedics Diagnosis and management Health Care Professionals Surveillance and monitoring Infection prevention and control measures Transportation Environmental cleaning Waste management Post-mortem care Waste Management Professionals Laboratory Professionals Ambulatory Care Public Health Agency of Canada Federal
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This guidance document was developed in collaboration by the Canadian Critical Care Society, the Canadian Association of Emergency Physicians and the Association of Medical Microbiology & Infectious Diseases Canada, and was coordinated by the Public Health Agency of Canada.

Much of the guidance within the document derives from expert opinion as there is little high grade evidence regarding the clinical management of Ebola Virus Disease (EVD).

The purpose of these clinical care guidelines is to support clinicians in Canada who may be required to treat a patient with EVD.

Overview of Ebola Virus Disease: The epidemiology, transmission, clinical picture, diagnosis and treatment of EVD are described.

Clinical Leadership: Leadership should ensure that the facility has the ability to detect and provide initial appropriate levels of care for all diseases, including rare and severe diseases. The facility should be prepared for these diseases as a part of routine care and ensure that a team is in place to coordinate the overall response.

Point of First Contact – Emergency Department (ED): This section discusses preparedness: developing plans to screen patients and the corresponding response should the patient screen positive. Risk factors in the ED, such as overcrowding and increased wait times, can lead to high numbers of patients and family being exposed and consequently tracked by public health. EMS (emergency medical services) should also screen for EVD and notify the ED should a patient screen positive. Triaging the patient with risk factors for EVD includes maintaining a distance of 1–2 metres, putting on the facility’s recommended personal protective equipment (PPE) and isolating the patient. When examining the possible Ebola case in an ED isolation room, the level of personal protection required must be carefully considered according to the patient’s symptom presentation. Early identification of potential EVD cases is based on clinical presentation AND epidemiologic risk. Preparation for potential EVD cases requires a specific plan that is unique to each hospital. The plan needs to focus on protecting hospital staff, patients and visitors. Implementing the plan requires practice for the staff as well as exercising the systems and processes.  

Where to Provide Care for an Admitted Patient with Suspected or Confirmed Ebola: When selecting potential areas to care for an Ebola patient, consideration should be given to a number of factors, including:

  • access to a single patient room and anteroom
  • body fluid disposal
  • communication with staff/visitors outside of the room
  • ability to restrict access
  • ability to provide dedicated patient equipment
  • ability to provide critical care
  • sufficient space to put on and take off PPE
  • storage for medical equipment and PPE
  • ability to clean or dispose of contaminated equipment or waste outside the patient room
  • access to point of care equipment
  • access to a work area outside of the room
  • Intelligence Technology (IT) and communication requirements
  • physical separation from other non-EVD patients
  • access to elevators and diagnostic suites

General Considerations for Clinical Care: Key considerations to guide the clinical care of confirmed or suspected EVD patients include: safety (patient, health care worker (HCW), community); minimizing the number of contacts to patients; minimizing the amount of time a HCW is exposed to a patient; and the ability to increase the staffing ratio to allow for a buddy care system or safety officer.                                                    

Personal Protective Equipment Considerations: Minimum standards of PPE are beyond the scope of this document, but it presents some points that clinicians may find useful to consider. Infection protection and control (IPAC) professionals and clinicians working together can select the appropriate PPE and the process for putting on and taking off PPE based on the clinical tasks that need to be performed. Open discussions about risk of exposure, variance in PPE from different manufacturers, heat stress, physical comfort and the role of the buddy/safety officer will aid in the appropriate use of PPE.

Waste Management: The infection control issues related to waste management are provided in other documents, but are included here to highlight to clinicians and hospital leadership that waste management may present logistical challenges and potential significant safety risk. Hospital policies must align with existing regulations and legislation from municipal to federal jurisdictions.

Care of the Suspect Ebola Patient: Point of care testing in the investigation of suspect EVD patients is insufficient to appropriately evaluate illness in most hospitals. The use of portable x-ray and ultrasound can minimize the need for the patient’s movement within the hospital. Consultation with an infectious disease specialist is suggested as empiric therapies may be warranted if clinical risk factors exist and diagnostic investigations are delayed. Limiting the number of staff participating in resuscitation is suggested. Life support and resuscitation present logistical challenges, as the degree of PPE required will create significant delay in response as staff put on the PPE, which in turn may significantly decrease the effectiveness of resuscitation. Hospitals should develop and practice a protocol for responding to a code blue situation with a suspect EVD patient.

Clinical Care of Confirmed Ebola Infected Patients: Clinical examination and assessment of a patient with EVD is discussed. Specific considerations about patient monitoring, body fluid control, airway management, fluid resuscitation and electrolytes, vasopressors, use of antibiotics and antivirals organ support, CPR, symptom management, prophylaxis and preventative measures, nutrition, experimental antiviral medications and vaccinations, discharge decisions, palliative, pregnancy, obstetrics and pediatrics, are discussed in detail. Discussion about the impact on health care workers caring for EVD patients and psychological support are also included. HCWs are understandably concerned about the risk of becoming infected themselves and transmitting the infection to their family and friends. Hospitals should develop policies to support their HCWs and plan to provide psychological support to help cope with the anxiety and fear.

Inter-facility Transport of Patients with EVD: Principles of aeromedical evaluation apply and consideration should be given to aircraft selection, keeping potential crew exposure to a minimum, emergency procedures, waste management and cleaning and disinfection, all in accordance with Transport Canada regulations. Flight safety must remain the primary consideration for the aircrew, medical staff and patient, including response to in-flight emergencies and disembarking the aircraft.

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