There is a strong probability that sporadic cases of Ebola virus disease will be seen in the UK over the coming months. Primary care guidance has changed, taking a different direction and risk assessment to previous versions,1 particularly in respect to the management of patients who self-present to services. All services require a safe system of working to protect staff (Box 1). Staff engaged in briefing and rehearsing what might happen and how a patient would be received and cared for, will feel more confident and it will help to alleviate their anxieties in dealing with a challenging situation.2
Box 1. Features of a safe system of working.
Notices at entrances instructing patients concerned about Ebola how to act.
A pre-identified isolation room.
GPs and staff briefed about how to direct and assess patients.
Planned route through the premises for a suspected patient.
Plans to manage any contaminated part of the GP premises.
Ready access to current algorithm and action cards.
Integrated plans within multi-occupancy buildings.
Business-continuity arrangements in the event of part, or all of the building, being out of action.
Rehearsal and practice of arrangements.
This article supports the implementation of the recent Public Health England (PHE)1 guidance, particularly on how a self-presenting patient would be managed in general practice or walk-in services.
The English guidance no longer recommends personal protection equipment (PPE) for GPs or their staff; instead, potential patients presenting to services must be isolated and assessed without examination, in an appropriate room with all physical contact avoided (Box 2). The ‘no contact’ approach may be concerning to clinicians as it potentially delays a patient’s examination by a few hours. The expert view accepts that very sick patients may not appear to receive any care and that care for conditions other than Ebola (for example, malaria, flu, and sepsis) may be delayed slightly. This has to be balanced against the potential risk to healthcare workers posed by this group of patients. Isolation and remote care must continue until the risk of Ebola has been assessed using the most recent algorithm.
Box 2. Features of an ideal isolation room.
Minimally furnished and equipped, with items which are disposable or can be cleaned with bleach.
Washable flooring, not carpeted.
Adjacent or en-suite toilet.
Has containers for vomit, thermometer, patient explanation leaflet and telephone.
Located in a part of the building that could be cordoned off if required.
Has a planned route out that minimises contamination.
If the possibility of Ebola can be ruled out, then normal procedures and standard infection control policies should be observed. The level of protection provided by standard PPE is not sufficient for a pathogen such as Ebola and the complexity of donning, working in, and removing of higher levels of PPE makes it inappropriate in GP and walk-in services. To reiterate, protection comes from a safe system of working rather than use of PPE. This still applies in the event of the patient’s condition appearing to deteriorate.
Updates on guidance and news
https://www.gov.uk/government/collections/ebola-virus-disease-clinical-management-and-guidance
If a patient is suspected of having a possible case of Ebola and presents as a gross contamination threat due to vomiting, profuse sweating, bleeding, or diarrhoea, secondary care services should be contacted for onward referral based on local referral recommendations. The patient will need to be collected by a specialist ambulance team and there may be a delay of several hours depending on geography and availability.
Those parts of the premises where the patient has had contact will need to be isolated until the diagnosis can be proven; this may take more than 12 hours due to the need to transport samples to specialist laboratory services. Primary care services must ensure they have appropriate business-continuity arrangements in place to manage this.
Finally, standard infection control and decontamination procedures following a negative result should then take place.
REFERENCES
- 1.Public Health England Information for Primary Care: Managing patients who require assessment for Ebola virus disease. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/364858/PHE_Ebola_guidance_for_primary_care_v3_October_17_2014.pdf (accessed 3 Nov 2014)
- 2.Qureshi K, Gershon RR, Sherman MF, et al. Health care workers’ ability and willingness to report to duty during catastrophic disasters. J Urban Health. 2005;82(3):378–388. doi: 10.1093/jurban/jti086. [DOI] [PMC free article] [PubMed] [Google Scholar]