County of Santa Clara Emergency Medical Services System Policy # 700-S01 Ebola Virus Prevention and Control EBOLA VIRUS PREVENTION AND CONTROL Effective: October 30, 2014 Replaces: October 8, 2014 (Version 1.2) Review: January 1, 2016 Resources: Attachment Healthcare Screening Questions and Care Guidelines Policy 700-S09: Infectious Disease Control Measures CDC - Interim Guidance for Emergency Medical Services (EMS) (dated October 28, 2014) I. Introduction This policy provides direction for EMS providers to identify and protect themselves from patients with symptoms consistent with Ebola viral hemorrhagic fever. As of October 8, 2014, Ebola is found in Sierra Leone, Guinea, and Liberia. This epidemic may spread beyond these countries at which time this policy will be immediately revised. This policy has been revised in accordance with the Center for Disease Control (CDC) Interim Guidance for Emergency Medical Services (EMS), dated October 28, 2014. II. Background A. Ebola is a viral hemorrhagic fever which has reached epidemic levels in the countries of; Sierra Leone, Guinea, and Liberia. The initial symptoms of Ebola appear suddenly and include: 1. Fever greater than 100.4 F 2. Body aches 3. Headache 4. Weakness 5. Vomiting and/or diarrhea 6. Abdominal pain 7. Unexplained hemorrhage B. Patients with these symptoms who have recently traveled, within the last twentyone (21) days, to or from the countries listed above, or are in close contact with persons who have recently visited these countries, are considered at high risk for Ebola. C. The Ebola virus incubation period ranges from 2 to 21 days, from time of exposure to when signs and symptoms appear. D. Ebola is spread through contact transmission, with infection resulting primarily from direct contact (through broken skin or mucous membranes) with blood, Page 1 of 6
secretions, sweat, emesis, diarrhea, or other bodily fluids of infected people, and indirect contact with environments contaminated with such fluids. E. Ebola does not enter intact skin, but those with breaks or cuts are more susceptible to infection. The Ebola virus cannot be spread via airborne transmission. The presence of upper respiratory symptoms (e.g. cough, sore throat, sneezing, nasal congestion, runny nose) lowers the clinical suspicion of Ebola. F. A patient with signs and symptoms should be considered infectious. A patient without signs or symptoms are not contagious. G. All prehospital providers involved in the care of a known Ebola patient must have received appropriate training and demonstrate competency in all Ebola related infection control practices and procedures; including but not limited to; donning and doffing personal protective equipment (PPE). H. All prehospital providers involved in the care of a suspected Ebola patient or a high risk patient must utilize all personal protective equipment prescribed in this policy, including but not limited to; covering all skin with appropriate impermeable devices. III. Patient Assessment Procedure A. Patient assessment begins with scene safety and proper personal protective equipment (PPE) on every patient encounter. B. The use of standard PPE precautions will be used on every patient contact, including; eye protection and nitrile gloves. C. All prehospital providers will ask the following two (2) Health Screening Questions at every patient contact: 1. Has the patient traveled to or had contact with anyone who has traveled to Sierra Leone, Guinea, or Liberia in the last twenty-one (21) days? 2. Does the patient have a fever? D. If Yes to both questions above, the prehospital provider will immediately: 1. Don High Risk PPE, ensuring that all exposed skin is covered as described in section IV B of this policy 2. Ensure other prehospital providers have donned High Risk PPE 3. Reduce unnecessary exposure of patient to others 4. Follow further instructions in Section IV below Page 2 of 6
E. If Yes to both questions above, does the patient have any additional symptoms: 1. Body aches 2. Headache 3. Weakness 4. Vomiting and/or diarrhea 5. Abdominal pain 6. Unexplained hemorrhage F. If No to either or both to the questions above, continue treating the patient per appropriate treatment protocol(s) and policy(s) as necessary. G. To minimize any potential exposures, prehospital personnel should perform the Health Screening Questions from at least three (3) feet away from the patient and immediately upon arrival, to prevent droplet transmission. H. The first arriving prehospital provider will initiate the Health Screening Questions on every patient contact and immediately report that the patient s Health Screening Questions are positive or negative to the next arriving prehospital provider. I. Upon arrival on scene, the prehospital transport provider will ask the first responding prehospital provider the results of Health Screening Questions, prior to arriving at patient s side or conducting any patient care. J. It is the responsibility of every prehospital provider to ensure that every patient is asked the Health Screening Questions. K. It is the responsibility of every prehospital transport provider to communicate the results of every patient s Health Screening Questions at the time of the field to hospital report. IV. Patient Treatment Procedure A. If the patient s Health Screening Questions are positive, the patient is considered to be at high risk for Ebola and the following must be followed at all times. B. All prehospital providers must don high risk PPE, including but not limited to: 1. Surgical hood, extending to the shoulders (exempt if coveralls or suit provides) 2. Face shield 3. Eye protection 4. N95 mask or P100 mask 5. Impermeable coveralls or suit 6. Impermeable gown 7. Double glove with high cuff 8. Leg and shoe coverings (exempt if coveralls or suit provides) Page 3 of 6
C. Prehospital providers should designate roles and responsibilities to each provider on scene, including: 1. Trained Observer to assist with donning high risk PPE 2. Communications to always remain readily available via phone and radio at all times D. Prehospital providers shall immediately notify the EMS Duty Chief via County Communications, if their patient s has Health Screening Questions are positive. Contact shall be made while on-scene over the phone, radio communication is NOT be used to transmit this information. E. The first arriving prehospital providers who have made patient contact and now have donned the appropriate high risk PPE should maintain patient care throughout the transport, in order to minimize potential provider exposure to patient. F. Treat the patient according to the appropriate protocol. Invasive procedures (e.g. intubation, IV placement, suction, chest compressions) should be limited whenever possible for patients considered to be high risk, unless clinically necessary. Base hospital contact shall be made to clarify any questions as needed. G. While Ebola is transmitted through bodily secretions, prehospital providers must be aware that some procedures such as nebulization treatments, the use of suction devices, and CPAP can aerosolize bodily fluid such as saliva, causing the virus to be transmitted through aerosols. If it is clinically necessary to perform these treatments, always wear a face shield and safety glasses, as well as an N95 or P100 particle respirator and fluid impermeable gown. H. Prepare the patient for transport to the hospital. I. The prehospital provider that will be operating the ambulance during the transport, shall not provide any patient care or assist with movement of the patient. The ambulance driver compartment should be as segregated as possible during the transport and clean standard PPE should be worn. J. Prehospital transport providers shall complete their field to hospital report via phone, as soon as practical after finding the patient s Health Screening Questions is positive and destination has been chosen. K. Prehospital transport providers shall ask the hospital for any special arrival instructions, such as; parking location. V. Arrival at Destination A. Upon arrival at the hospital prehospital transport providers shall maintain patient care in the closed vehicle until offload instructions are given to them by Emergency Department nursing personnel. Page 4 of 6
B. Prehospital transport providers shall follow all instructions given by the Emergency Department nursing personnel, until properly relieved. C. High risk PPE shall be carefully removed only after decontamination and when instructed to do so by Emergency Department nursing personnel and while under the observation of a Trained Observer, in an area designated by the hospital. D. If blood, body fluids, secretions, or excretions from a patient with suspected Ebola come into direct contact with the prehospital provider s skin or mucous membranes, then the prehospital provider should immediately stop working. E. The prehospital provider should wash the affected skin surfaces with soap and water and mucous membranes (e.g., conjunctiva) should be irrigated with a large amount of water or eyewash solution. F. The prehospital provider shall report exposure to their direct supervisor, and shall make notification to the EMS Duty Chief for follow-up. G. The transport ambulance shall be considered out of service and provide any further patient transportation until further notice by the EMS Duty Chief. VI. Vehicle Decontamination A. Non-transport prehospital providers that are exposed to a high risk patient will not reenter their vehicles. They shall isolate all exposed equipment and are to standby on-scene, until they receive notice from the EMS Duty Chief. If the scene is unsafe, they shall remain in their vehicle in a safe location but shall not exit the vehicle thereafter. The crew will remain out of service during this period. 1. The Public Health Officer will provide specific guidance to the prehospital non-transport provider, via the EMS Duty Chief. 2. This guidance is variable and will be determined on a case by case basis. 3. This guidance will be the minimum protective actions that crews are expected to follow and is based on the latest CDC and Cal-OSHA standards. B. Prehospital transport providers will secure the ambulance and its contents, after the patient transport is complete. Do not re-enter the vehicle and do not allow others to access the ambulance. Wait for notice from the EMS Duty Chief. 1. The Public Health Officer will provide specific guidance to the prehospital transport provider, via the EMS Duty Chief. 2. This guidance is variable and will be determined on a case by case basis. Page 5 of 6
3. This guidance will be the minimum protective actions that crews are expected to follow and is based on the latest CDC and Cal-OSHA standards. C. The prehospital provider agency is responsible for obtaining an appropriate medical waste decontamination service to properly clean their vehicle, according to CDC standards. Cal-OSHA recommends a professional cleaning company with the ability to clean Level A contaminates to disinfect transporting vehicles and equipment. Page 6 of 6
County of Santa Clara Emergency Medical Services System Healthcare Screening Questions and Care Guidelines HEALTHCARE SCREENING QUESTIONS AND CARE GUIDELINES Effective: October 30, 2014 Replaces: New Review: November 1, 2017 Resources: Santa Clara County Prehospital Care Policy 700-S01: Ebola Virus Prevention and Control Santa Clara County Prehospital Care Policy 700-S09: Infectious Disease Control Measures Healthcare Screening Questions 1. Use standard PPE precautions for every patient contact, including: Eye protection Nitrile gloves 2. For every patient contact the prehospital provider will ask the following Healthcare Screening Questions, it may be appropriate to maintain a three (3) foot radius from the patient during questioning 3. Has the patient traveled to or had contact with anyone who has Yes / No traveled to Sierra Leone, Guinea, or Liberia in the last twenty-one (21) days: 4. Does the patient have a fever? Yes / No 5. If YES to both questions above, ALL PROVIDERS WILL IMMEDIATELY PUT ON HIGH RISK PATIENT PPE (including): Surgical hood Face shield Eye protection N95 mask or P100 mask Impermeable gown or Impermeable leg and shoe covers Impermeable coveralls or suit Double glove with high cuff 6. If YES to both questions above, does patient have additional symptoms: Body aches Vomiting or Diarrhea Headache Abdominal pain Weakness Unexplained hemorrhage 7. If NO to questions above, treat patient appropriately per protocols Page 1 of 2
The following care guidelines will be immediately be followed for every patient that has a positive Healthcare Screening Questions. Care Guidelines 1. Mandatory use of High Risk PPE 2. Minimize unnecessary contact by EMS providers 3. Limit invasive treatment procedures 4. Restrict access of bystanders 5. Notify provider supervisor (via phone only) 6. Notify EMS Duty Chief (via County Communications phone only) 7. Notify hospital of a Positive Healthcare Screening Question Prior to departure from scene (via phone only) Ask for and follow arrival instructions 8. If the scene is unsafe: Retreat to a safe location Notify County Communications of retreat Stay in your vehicle Notify EMS Duty Chief and await instructions 9. If in the event the patient refuses treatment or transport notify EMS Duty Chief 10. Upon arrival at hospital: Remain in the ambulance until given instructions by Hospital Staff Keep ambulance doors secure Do not interact with others Keep High Risk PPE in use until instructed by ED staff 11. After patient transfer has occurred: Follow instructions by ED staff Secure all durable medical equipment and gurney used in ambulance Utilizing a properly trained Observer remove all contaminated PPE The hospital personnel will assist in decontaminating the crew Properly dispose of contaminated products in red biohazard bags Wash hands and all areas of skin that may have had contact with patient Secure and isolate the ambulance and its contents Do not re-enter ambulance for any reason Do not leave hospital premises Limit contact with other personnel Await instructions from EMS Duty Chief Page 2 of 2