New: Revised Directive #1 for Hospitals — EVD
On August 27, 2015, a revised directive to all Hospitals in Ontario was issued by Public Health Ontario.
Please see the summary of changes in the revised directive.
If you have questions or concerns which cannot be addressed by your JHSC and your employer, please contact Terri Aversa (firstname.lastname@example.org), Health and Safety Officer at OPSEU Head Office.
New: Resources Issued August 27, 2015
On August 27, 2015, David C. Williams, Acting Chief Medical Officer of Health released new resources to support Ontario's health system readiness for ebola virus disease (EVD).
New Resource: A Three-Tier Approach to Ebola Virus Disease Management in Ontario
The Three-Tier Approach to EVD designates 4 hospitals for treating EVD, 7 hospitals for testing, and the remaining hospitals for screening.
Click here to see the summary of the Three-Tier Approach
New: Directive #5 Regarding Laboratory Services in Designated Hospitals–Aug 27, 2015
This directive is addressed to testing and training hospitals. It mandates that each main and satellite laboratory must conduct a risk assessment in consultation with the JHSC or health and safety representative to assess the risk of exposure to EVD and to establish control measures. Workers who handle, process, or test specimens from confirmed or suspect cases shall wear solid-front, fluid-resistant, long-sleeved gowns, double gloves, full face shields, and fitted, tested N95 masks. A trained observer shall observe donning and doffing in the lab and in training sessions. The directive also provides guidance regarding transporting, handling, and managing specimens.
New: Management of Cases of Ebola and their Contacts in Ontario: Guidance for Public Health Units–August 27, 2015
If EVD is diagnosed in Ontario, Public Health Units may be involved in the following activities: identifying, assessing, assigning exposure risk levels, and managing contacts of a confirmed case, managing a contact who develops symptoms compatible with EVD, or managing a confirmed case, convalescent or deceased case. The document provides guidance for managing and advising contacts, outlines reporting requirements for Public Health Units regarding EVD, and provides various worksheets.
Training resources for Screening, Testing and Treatment Hospitals
On January 30, 2015, the MOHLTC released a memo providing information about new training resources for Screening, Testing and Treatment hospitals as well as a number of useful checklists for donning and doffing personal protective equipment. Links to information about the training workshops as well as to the checklists and other information are at the link below:
Directive #3 – Precautions and Procedures for Primary Care Settings
On December 9, 2014, a Directive was issued by the Chief Medical Officer of Health.
The Directive is issued to all primary care providers in ambulatory care settings that deliver primary care to patients that present with acute illnesses. The Directive applies in sites such as physician’s offices, walk-in clinics and nurse practitioner offices. In addition, the Directive states that the guidance provided can be implemented in principle in settings such as pharmacies, midwifery practice groups and dental offices.
The guidance provided in the Directive is similar to that given in the Directive #1 for Acute Care settings. It requires employers to provide staff with education on EVD symptoms, transmission and level of risk, as well as the process to screen patients by phone and at reception desks. It provides advice on measures to stop transmission of EVD in primary care settings and the requirement to notify Public Health and contact Paramedic Services to transfer a patient suspected of having EVD.
This guidance provided in this Directive is weak in two key areas. The first substantive problem is found in the section, Results of In-Person Screening, which describes actions to take when patient screening finds a patient with a positive travel history and symptoms compatible with EVD. Following direction to isolate the suspect patient, the Directive states, “if PPE is available and direct contact with the patient is necessary…” and then goes on to describe required PPE. This is not acceptable. In any workplace where there is a risk of direct contact exposure to patients with infectious illnesses (not only EVD), appropriate PPE must be available to workers who need it.
The list of required PPE for workers who have to have contact with the patient includes: gown, gloves, surgical mask and eye protection. This is in direct contradiction to the guidance in Acute Care Directive #1 which requires workers who have contact with a suspect EVD case to wear a fluid-resistant gown, gloves with extended cuffs, full face shield and a fit-tested N95 respirator.
Directive #3 provides no explanation as to why recommended PPE for workers in one setting dealing with a suspect EVD case would be different than another.
However, in the section on “Cleaning, Disinfection and Waste Management,” Directive #3 requires PPE that is similar to what is required in Directive #1: impermeable gown, two pairs of gloves (one under and one over cuff) and face shield. However, unlike Directive #1, only a surgical mask is recommended.
OPSEU advises that workers in primary care settings covered by this Directive, challenge this particular advice and review the list of PPE provided in Directive #1. We recommend that Health & Safety Representatives and Joint Health & Safety Committees in primary care settings, review the Directive closely and make recommendations to your employer to increase PPE to include N95 respirators, impermable gowns, appropriate gloves and face shields.
The other substantive problem in the document is found in the short section, Education and Training. The Directive contains no requirement for workers to be trained on donning and doffing PPE used when in contact with a patient with suspect EVD. While Directive # 1 (acute care settings) and Directive #2 (paramedic services) make repeated references to the need for workers to be fully trained, tested and drilled on procedures for donning and doffing of PPE, this Directive is silent on that requirement. In addition, the other Directives call for a “trained observer” to watch donning and doffing of PPE in order to prevent protocol breaches which could expose workers to EVD. OPSEU recommends that Health & Safety Representatives and Joint Health & Safety Committees in primary care settings, review the Directive closely, compare it to Directive # 1 and make recommendations to your employer for appropriate training and supervision of donning and doffing.
OPSEU will be challenging the direction regarding PPE and lack of guidance on training requirments in Directive #3 in meetings with the Ministry of Health and Ministry of Labour.
When the CMOH released Directive #3 for primary care, it also released and posted a screening tool, “Ebola Virus Disease Screening Tool for Primary Care Settings” which should be implemented in all primary health care sites.
Directive #2 to Paramedic Services (pre-hospital care) – Ebola Virus Disease
On December 9, 2014, a revised Directive to All Paramedic Services Land and Air Ambulance was issued by the Chief Medical Officer of Health.
In addition to the changes to the Directive, the MOHLTC has posted the Ebola Virus Disease Screening Tool for Paramedic Services as a separate document. There is one small change to one question concerning fever, which now includes a question about “feeling feverish” in addition to the question about fever of 38 C or greater.
Please see the summary of changes to the revised Directive.
The revised document is better organized, has less repetition and offers more detail than the previous version. It also contains a glossary of terms which is helpful. As with the earlier version, this Directive provides guidance on transporting suspect and confirmed EVD patients, the role of Designated ambulance services to transport confirmed EVD cases, patient screening procedures, Personal Protective Equipment (PPE) (which now provides the option of Positive Air Pressure Respirators (PAPR)), cleaning and decontamination, and management of potentially or exposed paramedics.
Unfortunately, as with the previous Directive it is still left for local ambulance service providers to develop PPE requirements for ambulance drivers when transporting suspect and confirmed EBV cases. Although some guidance is given in the Directive, it is not specific. OPSEU encourages Joint Health and Safety Committees (JHSC) to meet with employers to discuss this issue and to provide input on all decisions concerning PPE.
As with the previous Directive, this one calls for “deep environmental cleaning and decontamination of the ambulance” after transport of a suspect or confirmed EVD case. The advice about cleaning in this Directive is somewhat more detailed than before but continues to refer to a future “CMOH Waste Management Directive” leaving it up to local services to develop their own procedures. No timeframe has been provided for the development of the CMOH Waste Management Directive. OPSEU encourages JHSCs to meet with employers to review cleaning and decontamination procedures to ensure they are appropriate and well understood.
The other area of concern is an acknowledgement that cleaning and decontamination services may be contracted to an “external agency.” If cleaning services are being contracted out, it is important for JHSCs to question their own employers about the contracted service’s worker training program and availability of appropriate PPE.
In two places in the Directive, there is a reference to Designated ambulances which do not have an available “land ambulance radio package.” In that case, the Directive requires a portable FleetNet capable radio and/or cell phones to be provided with additional support from an escort unit. OPSEU is concerned about the possibility of paramedic workers fully suited up in PPE having to use portable radios or cell phones. We advise JHSC members in Designated ambulance services to review this direction and make recommendations to ensure that Designated ambulances have an installed radio communication system.
The Directive has two appendices: Appendix 1 describes the elements necessary for paramedic training. Appendix 2 provides guidance for Designated Paramedic Services on three issues: the use of negative pressure containment vessels; the configuration and use of Designated vehicles; and, inter-facility transfers of suspect EVD cases. It should be noted that although direction has been provided about the use of negative pressure containment vessels, to date, only Ornge has identified an isolation vessel which meets their requirements for use in a Designated ambulance.
OPSEU advises all paramedic JHSCs to meet soon to review the revised Directive and to ensure that their employers are in compliance with it.
If you have questions or concerns which cannot be addressed by your JHSC, please contact either Terri Aversa (email@example.com), Health and Safety Officer at OPSEU Head Office, or Brad Thomson (firstname.lastname@example.org). Brad is the Health & Safety Representative on OPSEU’s Ambulance Divisional Executive.
Other Directives from Public Health Ontario
Infection Prevention and Control Guidance for Patients with Suspected or Confirmed Ebola Virus Disease (EVD) in Ontario Health Care Settings, August 29, 2014 http://www.publichealthontario.ca/en/eRepository/EVD_IPAC_Guidance.pdf
Decision Guide on Selection of Personal Protective Equipment for Ebola Virus Disease – Isolation Gowns or Suits October 14, 2014 http://www.publichealthontario.ca/en/eRepository/EVD_PPE_Decision_Guide.pdf
Interim Risk Assessment and Evaluation of Returning Travelers, updated August 29, 2014 http://www.publichealthontario.ca/en/eRepository/EVD_Risk_Assessment_Evaluation_Returning_Travellers.pdf