Edward Ebola Plan. Published: 10/3/2014 Last updated: 10/3/2014

Transcription

1 Edward Ebola Plan Published: 10/3/2014 Last updated: 10/3/2014 Emergency Department Triage 1. Signage will be posted at triage desks instructing patients to self-report travel history. 2. On initial assessment, ask all patients about international travel in the past month. If a patient reports history of travel, ask about specific countries/regions visited. 3. If the patient has history of recent travel to Ebola-affected areas: a. Immediately place a mask on the patient b. Escort the patient to a treatment room for immediate medical evaluation (see patient placement below) c. Initiate CONTACT + AIRBORNE Isolation Precautions Patient Placement in ED 1. If the patient has severe respiratory illness or is critically ill and likely to require intubation while in the ED, place the patient in a negative pressure airborne isolation room (A0 or A1 in Naperville ED; Room 2 in Plainfield ED). 2. If the patient is stable, place the patient in an exam room with a bathroom (B8/B9 or C5/C6 in Naperville ED; Room 6 in Plainfield ED). Block the adjacent room to discourage sharing of the bathroom and to allow additional space for PPE, point-of-care lab testing, etc. 3. Post room entry log at entrance to patient room. All people entering the isolation room must sign in. 4. Follow all procedures and precautions described below. Case Identification and Reporting Case Finding Ask the patient detailed questions about travel history, symptoms and exposure risks, including: 1. Dates and exact locations of travel? 2. Date of onset of symptoms? 3. Exposure risks in the 21 days prior to symptom onset? (see also Ebola screening algorithm): a. Had any contact with a person with known or suspected Ebola Virus Disease (EVD)? b. Had known exposure to blood or body fluid from a person with known or suspected EVD? c. Worked or spent time in a health care facility where EVD patients were being treated? d. Worked in a laboratory where specimens from EVD patients were being analyzed or processed? e. Participated in funeral rites or have other exposure to human remains in the EVD outbreak affected area? 4. Evaluate level of exposure based on CDC criteria below. NOTE: Additional information available on CDC Ebola case definition. HIGH-RISK EXPOSURE Percutaneous (e.g., needle stick) or mucous membrane contact with blood or body fluids from an EVD patient OR Direct skin contact with, or exposure to blood or body fluids of, an EVD patient OR Direct contact with a dead body (including during funeral rites) in an Ebola affected area without appropriate PPE LOW-RISK EXPOSURE Household members of an EVD patient and others who had brief direct contact (e.g., shaking hands) with an EVD patient without appropriate PPE OR Healthcare personnel in facilities with confirmed or probable EVD patients who have been in the care area for a prolonged period of time while not wearing recommended PPE NO KNOWN EXPOSURE Residence in or travel to affected areas** without HIGH- or LOW-risk exposure For current information on affected areas, see CDC Ebola website. Edward Ebola Plan Page 1

2 5. Based on exposure risk category, determine appropriate testing strategy as follows: Exposure Category Testing Strategy HIGH-RISK EXPOSURE LOW-RISK EXPOSURE NO KNOWN EXPOSURE (With symptoms of EVD) 1. Continue AIRBORNE + CONTACT Isolation as described below 2. Consult with Public Health regarding testing for Ebola 3. Limit other Laboratory testing to: a. Point of Care Testing (I-Stat testing, done by Respiratory Therapy in room) b. Blood cultures c. Malaria smear 4. Limit imaging testing to portable in-room techniques Notify Lab, Radiology prior to testing. For specimens sent to Lab: Place biohazard label on each specimen. Use Chain of Custody form. Do not send specimens via tube system. NO KNOWN EXPOSURE (No symptoms of EVD) 1. Continue AIRBORNE + CONTACT Isolation as described below 2. Normal laboratory testing permitted 3. Limit transport to essential purposes only. Utilize in-room imaging techniques when possible. Mask patient during transport. Reporting of a Suspect Case Initial Notification Any suspected EVD patient (regardless of exposure risk category) must be reported immediately to the Local Health Department. Clinicians should be prepared to discuss clinical findings and exposure details with Health Department representatives. As soon as Ebola is suspected or pertinent travel history noted, notify the following: DuPage County Health Department (DCHD) Daytime number: Communicable Disease Hotline (ask for person on call): (630) (630) Edward Infection Control Pager: 2121 or (630) Dr. Pinsky (Medical Director, Infection Control) Pager: 8589 Additional Notifications (as needed) 1. If additional Public Health consultation is desired, clinicians may also notify the following as needed: Illinois Department of Public Health (IDPH) Communicable Disease Division: Crisis Line (ask for IDPH duty officer): (217) (800) CDC Emergency Operations Center: (770) If DCHD categorizes the patient as a Person Under Investigation (PUI), notify the following: Administrator On-Call Dr. Brent Smith, CMO X73773 Patti Ludwig-Beymer, CNO Pager: 2247 or x Lynn Cochran, AVP Spectralink: x68283 Pager: 2290 or x Notify each of the following departments as needed and prior to their involvement with the patient: Central Distribution (for additional PPE supplies) Laboratory (prior to collecting ANY specimens for ANY type of testing) Respiratory Therapy (for I-Stat testing or other needs) Housekeeping (prior to cleaning the room) x68742 x73451 X68869 x If the patient requires admission to the hospital, notify the following: Edward Nursing Supervisor Spectralink: x68800 Pager: 2304 ICU Charge Nurse X68285 ICU Charge Nurse to notify ICU Nursing Director and Dr. Nemivant (ICU Medical Director) Edward Ebola Plan Page 2

3 PPE for Ebola Isolation Inpatient Admission and Room Set-up Inpatient Room Placement If the patient will be admitted, admit to ICU Airborne Infection Isolation Room (AIIR) preferably room 474. Room Set-up 1. Post isolation signs (Airborne and Contact) outside patient room. 2. Post room entry log at entrance to patient room. All persons entering the isolation room must sign in. 3. Obtain supply of PPE (see below) from Central Distribution and station immediately outside the isolation room. 4. Post CDC Flyer Sequence for putting on PPE with the PPE supplies. 5. Post CDC Flyer Sequence for removing PPE in the ante-room. 6. Place large Biohazard waste containers inside patient room (1-2 containers) and in the ante-room (1 container). Containers should be sturdy and leakproof. They should be lined with two layers of Biohazard bags. 7. Ensure that the sharps disposal container is empty or nearly empty. Replace as needed. 8. Assemble needed supplies in patient room. a. Utilize disposable equipment and supplies whenever possible (i.e., disposable blood pressure cuff, pulse ox) b. If re-usable equipment must be used, dedicate it to the isolation room (i.e., thermometer, glucometer) 9. Remove window curtains. 10. Remove excess furniture, including any upholstered furniture. 11. Replace privacy curtain with curtain from PPE cart. 12. Block patient room adjacent to the isolation room for point-of-care testing. 13. Contact Respiratory Therapy to set up I-Stat point-of-care testing station. 14. Order Safety Tray in Epic for disposable dietary tray and service items. 15. If imaging testing is ordered, request portable X-ray machine from Radiology, to be dedicated for the patient and stored in adjacent vacant room. Infection Prevention Strategies Isolation Precautions Order AIRBORNE + CONTACT Isolation Precautions for the patient. The patient will remain in isolation until cleared by Infection Control and Public Health. Personal Protective Equipment (PPE) 1. Staff entering the isolation room should be trained in use and removal of PPE and have been fit tested prior to using an N95 respirator. 2. If possible use a buddy-system to observe and critique PPE donning and removal. 3. Use PPE as indicated in box below. When putting on PPE, adhere to CDC guidelines for sequence for putting on PPE 4. Store and don PPE outside the isolation room. 5. Remove PPE at doorway of isolation room, or in the ante-room. 6. Remove N95 respirator in the ante-room. 7. In order to prevent contamination during PPE removal, adhere to CDC guidelines for methods of PPE removal. 8. Dispose of all used PPE as regulated (biohazard) waste. Gown (blue, impervious) Polypropylene coverall (bunny suit) under impervious gown N95 respirator Disposable full-face face shield Double gloves Disposable shoe covers Edward Ebola Plan Page 3

4 Hand Hygiene Perform hand hygiene frequently, including before and after all patient contact, contact with potentially infectious material, and before putting on and upon removal of PPE, including gloves. Change gloves as needed, and if visibly soiled. - Wash hands with soap and water if hands are visibly soiled - Wash hands or use hand sanitizer for all other uses - Wash hands or use hand sanitizer as needed between steps of and after PPE removal in the ante-room - Wash hands thoroughly with soap and water upon exit from ante room Other Infection Prevention Strategies 1. Limit use of needles and other sharps; handle sharps with extreme caution. 2. If multi-dose or multi-use medications (including insulin pens, inhalers) must enter the patient room, they must be stored and disposed of in the patient room or vacant adjacent room. 3. Anything that enters the room must be either disinfected upon removal or disposed of as biohazard waste. 4. Equipment cleaning must be performed by trained staff using appropriate PPE. Consider quarantining used, soiled equipment until a definitive diagnosis is made. Staff Education All staff assigned to work with a suspect EVD case will receive training from Infection Control staff or their designee regarding: - Modes of transmission of Ebola Virus - Appropriate PPE use, including safe methods for removing and disposing of PPE - Hand Hygiene requirements - Other Infection Prevention Strategies (as outlined above) - Housekeeping Strategies (as outlined below) - Occupational Health procedures Care of the Patient Staffing 1. Limit the number of staff assigned to care for a patient with suspected EVD. 2. Consider dedicating staff to the care of a patient with suspected EVD. 3. Ensure that staff are adequately trained and experienced in the care of critically ill patients with infectious diseases. 4. Limit use of ancillary and support staff to the extent possible. 5. Limit use of consulting physicians to the extent possible. 6. Hospital-laundered scrubs will be made available to staff, and may be worn when entering the isolation room. Upon exit from the isolation area or at the end of shift, remove scrubs and place in designated hamper. If scrubs are visibly soiled, dispose as biohazard waste. Visitors 1. Restrict visitors. 2. Work with ISS if needed to arrange skype visitation (visitor to access connection from home) as needed. 3. Exceptions to visitor restrictions will be made on a case-by-case basis only for individuals deemed essential for the patient s well-being. Exceptions must be approved by Public Health authorities. 4. If a visitor is permitted, additional precautions must be taken, including: a. Visits must be scheduled and limited in duration b. Screen visitor for Ebola symptoms upon arrival to the hospital c. Evaluate risk to the health of the visitor and ability to comply with precautions d. Provide instruction, before entry into the patient care area, on hand hygiene, limiting surfaces touched, and use of PPE while in the patient s room e. Restrict visitor movement within the facility to the patient care area Edward Ebola Plan Page 4

5 Laboratory Testing for Ebola 1. Prior to collecting specimens for Ebola testing, notify Edward Lab and DCHD and/or IDPH for approval to submit specimen. Testing will be performed at CDC Laboratories. 2. It may take up to 3 days after symptoms appear for the Ebola virus to reach detectable levels. Virus is generally detectable by RT-PCR from 3-10 days after symptoms appear. Specimens should be taken when a PUI reports to a healthcare facility. However, if the onset of symptoms is <3 days, a later specimen may be needed to completely rule-out Ebola virus, if the first specimen tests negative. 3. Preferred specimens include: Minimum 4mL whole blood in plastic collection tubes EDTA (pink top) preservative preferred Specimens other than blood may be submitted upon consult with Public Health Specimens should be immediately stored or transported at 2-8 C or frozen on cold-packs to IDPH 4. Lab staff will package specimens for shipping to IDPH Lab in accordance with published guidelines. (Refer to specimen transport and handling information below.) Laboratory Testing, Other 1. Limit phlebotomy and laboratory testing to tests essential for clinical care. 2. If a specimen must be taken to the Laboratory, place a biohazard sticker on each specimen/blood tube. 3. Maintain a log of all personnel handling any specimens from suspected or confirmed EVD patients, including dates and times when specimens were handled by each staff member and the identity of the patient (i.e., MRN). 4. Wherever possible, testing should be performed inside the patient s isolation room or in an adjacent room, using point-of-care instruments and testing methods. 5. Testing that requires transport of samples to the Lab should be kept to a minimum. Specimens should be doublebagged and placed in a biohazard transportation container. The container should be wiped down with 10% bleach or Super Sani-Cloth, hand carried to the laboratory and opened inside a biosafety cabinet. Specimens from a suspected EVD patient must never be transported via the pneumatic tube station. 6. Laboratory staff will follow established Laboratory procedures for handling, testing, storing and disposal of specimens from EVD patients. Aerosol-Generating Procedures (AGP) AGPs include, but are not limited to: BiPAP, Bronchoscopy, sputum induction, intubation, open suctioning of airways. 1. Avoid AGPs for suspect Ebola patients. 2. Visitors should not be present during AGPs. 3. Limit the number of HCP present during AGPs. 4. HCP will wear full PPE as described above. 5. Conduct AGP in the patient s AIIR if possible; keep door closed; restrict traffic. 6. Clean/disinfect environmental surfaces after AGP. Environmental Cleaning and Disinfection Cleaning and Disinfection 1. Housekeeping staff will use PPE described above. 2. Clean and disinfect hard, non-porous surfaces daily and as needed (e.g., high-touch surfaces such as bed rails and over bed tables, housekeeping surfaces such as floors and counters). 3. Use an EPA-registered hospital disinfectant with a label claim for a non-enveloped virus (e.g. norovirus, rotavirus, adenovirus, poliovirus). Edward disinfectants considered appropriate for use include: a. Super Sani-Cloth (Purple top) b. Dispatch (Stabilized bleach solution) c. Oxycide 4. Dispose of cleaning cloths, mop cloths and wipes as biohazard waste in the isolation room or ante-room. Edward Ebola Plan Page 5

6 Linen and Waste Management 1. To reduce exposure among staff to potentially contaminated textiles while laundering, discard all linens, non-fluidimpermeable pillows or mattresses, and textile privacy curtains as biohazard waste. NOTE: during initial period of isolation, before Ebola diagnosis has been confirmed, place linen in a separate biohazard container and sequester until diagnosis is confirmed and disposal method determined. 2. Dispose of the following products in leak-proof bags with secondary rigid container, as biohazard waste: a. Single-use PPE b. Cleaning cloths, wipes, microfiber cloths c. Food service items d. Disposable medical supplies 3. Ensure adequate supply of large biohazard waste containers in room (Recommend 1-2 in patient room and 1 in anteroom). 4. Infection Control and Environmental Safety will consult with Public Health authorities and Waste Disposal contractor for instructions on storage and transport of waste. 5. Prior to removal by the waste contractor, all biohazard waste associated with a potential EVD patient will be stored in a secured location and clearly labeled as high risk waste. NOTE: during initial period of isolation, before Ebola diagnosis has been confirmed, waste may be sequestered until diagnosis is confirmed and disposal requirements determined. Remediation after Patient Discharge 1. Ensure that staff continues to use appropriate PPE until room is terminally cleaned and disinfected. 2. Room should remain vacant for at least one hour prior to cleaning to ensure an appropriate number of air changes. 3. Dispose of items (including linen) in biohazard waste as indicated above. 4. Remove privacy curtain and dispose as biohazard waste. 5. Clean and disinfect any used equipment that will not be disposed of. 6. Perform terminal clean of patient room using bleach solution. 7. Repeat terminal clean of patient room using bleach solution. 8. Use Xenex UV-C disinfection device per manufacturer recommendations for sporicidal cleaning. Post-Mortem Care Preparation of the Body 1. Staff working with the body will wear full PPE as described above. 2. At the site of death, the body should be wrapped in a plastic shroud. Wrapping of the body should be done in a way that prevents contamination of the outside of the shroud. Change gown or gloves if they become heavily contaminated with blood or body fluids. 3. Leave any IV lines or endotracheal tubes that may be present in place. 4. Avoid washing or cleaning the body. 5. After wrapping, the body should be immediately placed in a leak-proof plastic bag not less than 150 µm thick and zippered closed. The bagged body should then be placed in another leak-proof plastic bag not less than 150 µm thick and zippered closed before being transported to the morgue. 6. Prior to transport to the morgue, perform surface decontamination of the corpse-containing body bag by cleaning twice with disinfectant. Allow to air dry. Other Considerations 1. Transportation of the body to the mortuary must be coordinated in advance with local and state authorities. 2. Avoid autopsy. If an autopsy is necessary, consult IDPH and CDC regarding appropriate precautions. Edward Ebola Plan Page 6

7 Occupational Health Health care personnel (HCP) are at risk for exposure to Ebola virus through contact with blood, body fluids, excretions and secretions. Any HCP caring for or entering the room of a suspect EVD patient (prior to or after initiation of isolation precautions) will be required to follow the precautions described below. Any HCP with known percutaneous/mucocutaneous exposure to blood or body fluid (e.g. needle stick, cut, splash of fluid to eye/nose/mouth/non-intact skin) will receive post-exposure evaluation in accordance with Edward policy INFC_021. Asymptomatic HCP: 1. HCP will follow up with Occ. Health for initial evaluation, counseling, instructions. 2. HCP will provide personal contact information to Occ. Health. 3. HCP will be instructed to self-monitor twice daily for fever and symptoms for 21 days post-exposure. 4. Occ. Health, in cooperation with Public Health officials, will contact exposed HCP twice daily for 21 days postexposure to ask about symptoms and fever. 5. Work restrictions will be enforced as needed per Public Health recommendations. HCP with symptoms: 1. Stop work or do not report to work. 2. Notify manager or Nursing Supervisor. 3. Go to the Edward ED for prompt medical evaluation/testing. Put on a mask upon entry into the facility and notify triage nurse or first point of contact of your exposure history. 4. Edward ED will notify Infection Control and Occ. Health. 5. Infection Control/ED will notify DuPage County Health Department. 6. Remain off work until cleared by Public Health. Edward Recommendations are based on guidance from CDC and IDPH published through 10/2/2014, including: 1. CDC: Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals Published 8/1/14; Updated 8/19/14; Accessed 10/1/14 2. CDC: Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus Published 8/19/14; Accessed 10/1/14 3. CDC: Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Persons Under Investigation for Ebola Virus Disease in the United States Published 8/19/14; Updated 8/26/14; Accessed 10/1/14 4. CDC: Interim Guidance for EMS Systems and Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola Virus Disease in the U.S. Published 8/26/14; Accessed 10/1/14 5. CDC: Guidance for Safe Handling of Human Remains of Ebola Patients in U.S. Hospitals and Mortuaries Published 8/25/14; Accessed 10/1/14 6. IDPH: Memo - Evaluating Patients for Ebola Virus Disease in Illinois Received 8/20/14 7. IDPH: Health Alert Notice Interim IDPH Laboratory Guidelines for Submitting Specimens from Cases or Suspected Cases of Ebola Virus Disease Received 8/20/14 Edward Ebola Plan Page 7