1. Ebola Ebola Virus Disease (EVD) Prevention Guidelines All content based on available data from the CDC as of 10/17/14

2. Acknowledgements Presented By: Debbie Territ RN,BSN In Cooperation With: Kathleen Rosatti RN, BSN Mary Jo Bellush MSN,CIC Joan Grote, BS, MT(ASCP) Suzanne Mamrose-Hunt, MPH, MT (ASCP) Debbie Schotting, RN, MSN

3. Click the links below to jump to selected “chapters” in the course. Introduction Objectives What is Ebola Ebola Exposure Components for Prevention of Ebola PPE Recommendations Aerosol Generating Procedures Summary References Menu

4. Introduction The Centers for Disease Control and Prevention (CDC) has released Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals. Standard, Contact and Droplet Precautions are recommended for any patients with known or suspected Ebola hemorrhagic fever.

5. Objectives  Healthcare workers are able to recognize the signs and symptoms of Ebola Virus Disease (EVD).  Define the key components of Standard, Contact and Droplet precautions recommended for Prevention of EVD Transmission.  Describe how EVD is transmitted and the Personal Protective Equipment (PPE) that needs to be used when caring for patients infected with EVD.  Healthcare workers will be able to identify key POINTS OF CONTACT for any suspect case of EVD.

6. What is Ebola Ebola virus is the cause of a viral hemorrhagic fever disease: Symptoms of Ebola include: - Fever (greater than 38.6 C or 101.5 F) - Severe Headache - Muscle pain - Weakness - Diarrhea - Nausea and vomiting - Abdominal pain - Unexplained hemorrhage (bleeding or bruising)  Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola, although 8-10 days is most common.

7. Transmission of Ebola  Ebola is transmitted through direct contact with the blood or bodily fluids of an infected symptomatic person. (Body fluids include saliva, mucus, vomit, feces, sweat, tears, breast milk, urine, and semen.)  It can also be transmitted through exposure to objects (such as needles) that have been contaminated with infected secretions.  Individuals who are not symptomatic are not contagious. In order for the virus to be transmitted, an individual would have to have direct contact with an individual who is experiencing symptoms.

8. Ebola Exposure The level of exposure for EVD is important to know: High Risk Exposure  Percutaneous or mucous membrane exposure to fluids of affected patients.  Direct care of affected patient without PPE.  Handling lab specimens of affected patient without PPE.  Exposure to remains of affected patient without PPE. Low Risk  Household member or **casual contact with affected patient (no contact with body fluids).  Patient care or **casual contact without high risk exposure with affected patient in healthcare facilities.  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. **Casual contact is defined as >3 feet from patient and no exposure to body fluids.

9. Screening for Ebola Screening all patients at any entry point within Excela Health is key! All clinicians are to screen patients when they present for services. EVD should be suspected in persons who have BOTH consistent symptoms AND risk factors within 21 days of symptom onset as follows. Screening consists of two key components:  Symptoms  Travel History / Risk Factors

10. Screening for Ebola Patients should be screened for symptoms associated with EVD. SYMPTOMS INCLUDE:  Fever (subjective or > 101.5 degrees F or 38.6 degrees C)  Severe headache  Muscle pain  Vomiting  Diarrhea  Stomach pain  Unexplained bleeding or bruising

11. Screening for Ebola If a patient presents with ANY of the aforementioned symptoms, a travel history should be obtained, particularly as it relates to travel to West Africa in the last three weeks (21days) or if the patient has had direct contact with blood, other body fluids, secretions, or excretions of a person with EVD or who has traveled to one of the areas listed below:  Guinea  Sierra Leone  Liberia  Nigeria  Democratic Republic of the Congo Areas of concern will be updated/included as recommended by the CDC

12. Screening for Ebola Screening tools have been created. Whenever possible, the screening information is being added to the electronic medical record.  Outpatient settings will use a paper tool  Inpatient settings will use the EMR

13. Screening for Ebola For ANY suspect case of Ebola Virus Disease (EVD), staff must follow these very important steps:  Isolate the patient in a single room with a private bathroom and negative airflow (if possible).  Immediately suspend any further physical exam and/or diagnostic testing at this time.  Implement standard, contact and droplet precautions for any individuals who have contact with the patient.  Contact the Infection Control Preventionist ON CALL for Excela Health. Call the Excela Health Switchboard Operator at 724-832-4000. Request the On-Call Infection Control Preventionist.  The Infection Control Preventionist will provide you with further guidance and information.  The Infection Control staff are accountable for immediately contacting the Department of Health and CDC for direction and management of potential patients.

14. Components for Prevention of Ebola CDC Recommendations for Patient Placement:  Single patient room (containing a private bathroom ) with door closed.  Standard, Contact and Droplet Precautions should be put in place.  Facilities should maintain logs of all persons entering the patient’s room.  Consider posting personnel at the patient door to ensure appropriate and consistent use of PPE by all persons entering the patient room.

15. PPE Recommendations The CDC recommends: (The recommendations will be revised as new information comes from the CDC)  All persons entering the patient rooms should wear at least: - Double Gloves - Gowns (fluid resistant or impermeable) - Eye Protection (goggles or face shield) - Facemask & Hood to include full neck coverage - Disposable Leg/ Shoe coverings  Additional PPE MAY be required in certain situations(e.g., copious amounts of blood, other body fluids, vomit or feces present in the environment). Infection Control Practitioner will provide guidance based the clinical presentation.

16. PPE Recommendations Excela Health will begin:  Training on the additional PPE requirements for EVD including proper application and removal.  In the case of a suspect EVD case, the buddy system will be implemented and an Infection Control Preventionist or designated individual will be assigned to the area to assist and assure proper application and removal is occurring.

17. PPE Recommendations  CDC recommends PPE should be worn by healthcare providers upon entry into the patient rooms or care areas. When exiting the patient room, PPE should be carefully removed without contaminating one’s eyes, mucous membranes, or clothing with potentially infectious materials and discard it in the appropriate container in the room.  Follow procedure for donning and removing PPE as published by the CDC. Educational Materials found on: EH Intranet/Featured News/Learn More About Ebola  Hand Hygiene should be performed immediately after removal of PPE.

18. Patient Care Equipment  Dedicated equipment (preferably disposable, when possible) should be used for the provision of patient care.  All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to the manufacturer’s instructions and hospital policies.  Use only a mattress and pillow with plastic or coverings that fluids cannot get through.

19. Patient Care Considerations CDC recommendations:  Limit use of needles and other sharps as much as possible. - Any injection equipment or parenteral medication container that enters the patient treatment area should be dedicated to that patient and disposed of at the pointof use.  Phlebotomy, procedures and laboratory testing should be limited to the minimum necessary for essential diagnostic evaluation and medical care.  All needles and sharps should be handled with extreme care and disposed in puncture-proof, sealed containers.

20. Aerosol Generating Procedures The CDC recommends avoiding Aerosol Generating Procedures (AGP) for Ebola patients.  AGPs are procedures that include use of BIPAP, open suctioning of airways, bronchoscopy, intubation and extubation of patients.  However, if APGs are needed, use a combination of measures to reduce exposures. - Limit number of healthcare providers (HCP’s) present during the procedure. - Conduct the procedure in an Airborne Infection Isolation Room. - Keep room doors closed during procedure and minimize entry and exit during and shortly after the procedure. - HCP’s during the procedure should wear PPE recommended by CDC with the addition of respiratory protection (N95 respirator or higher filtering facepiece respirator).

21. Hand Hygiene  The healthcare provider must perform hand hygiene frequently: - Before and after all patient contact - Contact with potentially infectious waste - Before putting on and after removal of PPE  Hand hygiene can be performed by washing with soap and water or using alcohol-based handrubs. If hands are visibly soiled use soap and water only.

22. Environmental Infection Control Measures  Diligent environmental cleaning and disinfection and safe handling of potentially contaminated material is of paramount importance, as blood, sweat, vomit, feces, urine and other body secretions represent potentially infectious materials.  Environmental service staff performing cleaning should wear recommended PPE and consider additional barriers such as shoe and leg coverings, if needed.

23. Additional Ebola Facts On the Excela Health Intranet Featured News at Excela Health Section Learn More About Ebola Click on links for additional information

24. Summary  Key components of standard, contact and droplet precautions are recommended by the CDC for prevention of transmission of the Ebola virus.  Appropriate PPE (i.e. gown, gloves, eye protection and facemask) is essential in the care of Ebola patients.  Aerosol Generating Procedures, if needed, require additional measures to reduce exposure risks.  Symptoms of Ebola include fever, headache, nausea, vomiting, diarrhea, abdominal pain, weakness, muscle pain and excessive bleeding and bruising.

25. http://www.cdc.gov/vhf/ebola References

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