[GCARC] Ebola Virus Disease Guidelines for 911 Centers & Emergency First Responders...
Tom Gorman
tom.gorman2178 at gmail.com
Sun Oct 5 10:35:21 EDT 2014
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Interim Ebola Virus Disease Guidance for 9-1-1 PSAPs, EMS and Medical
First Responders Now Available
<http://psc.apcointl.org/2014/10/03/interim-guidance-for-ems-systems-and-9-1-1-public-safety-answering-points-psaps-for-management-of-patients-with-known-or-suspected-ebola-virus-disease-in-the-united-states/>Information
on how to respond and stay safe
Agency Representative <http://psc.apcointl.org/author/agency/> on October
03, 2014
in Government Affairs <http://psc.apcointl.org/category/government-affairs/>,
News <http://psc.apcointl.org/category/news/>
*Who this is for*: Managers of 9-1-1 Public Safety Answering Points
(PSAPs), EMS Agencies, EMS systems, law enforcement agencies and fire
service agencies as well as individual emergency medical services providers
(including emergency medical technicians (EMTs), paramedics, and medical
first responders, such as law enforcement and fire service personnel).
*What this is for:* Guidance for handling inquiries and responding to
patients with suspected Ebola symptoms, and for keeping workers safe.
*How to use*: Managers should use this information to understand and
explain to staff how to respond and stay safe. Individual providers can use
this information to respond to suspected Ebola patients and to stay safe.
Key Points:
- The likelihood of contracting Ebola is extremely low unless a person
has direct unprotected contact with the blood or body fluids (like urine,
saliva, feces, vomit, sweat, and semen) of a person who is sick with Ebola
or direct handling of bats or nonhuman primates from areas with Ebola
outbreaks.
- When risk of Ebola is elevated in their community, it is important for
PSAPs to question callers about:
- Residence in, or travel to, a country where an Ebola outbreak is
occurring;
- Signs and symptoms of Ebola (such as fever, vomiting, diarrhea); and
- Other risk factors, like having touched someone who is sick with
Ebola.
- PSAPS should tell EMS personnel this information before they get to
the location so they can put on the correct personal protective equipment
(PPE) (described below
<http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html#ppe>
).
- EMS staff should check for symptoms and risk factors for Ebola. Staff
should notify the receiving healthcare facility in advance when they are
bringing a patient with suspected Ebola, so that proper infection control
precautions can be taken.
The guidance provided in this document is based on current knowledge of
Ebola. Updates will be posted as needed on the CDC Ebola webpage
<http://www.cdc.gov/vhf/ebola/index.html>. The information contained in
this document is intended to complement existing guidance for healthcare
personnel, Infection Prevention and Control Recommendations for
Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in
U.S. Hospitals
<http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html>
Background
The current Ebola outbreak in West Africa has increased the possibility of
patients with Ebola traveling from the affected countries to the United
States.1
<http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html#ftn1>
The likelihood of contracting Ebola is extremely low unless a person has
direct unprotected contact with the body fluids of a person (like urine,
saliva, feces, vomit, sweat, and semen) of a person who is sick with Ebola
or direct handling of bats or nonhuman primates from areas with Ebola
outbreaks.2
<http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html#ftn2>
Initial signs and symptoms of Ebola include sudden fever, chills, and
muscle aches, with diarrhea, nausea, vomiting, and abdominal pain occurring
after about 5 days. Other symptoms such as chest pain, shortness of breath,
headache, or confusion, may also develop. Symptoms may become increasingly
severe and may include jaundice (yellow skin), severe weight loss, mental
confusion, bleeding inside and outside the body, shock, and multi-organ
failure.3
<http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html#ftn3>
Ebola is an often-fatal disease and care is needed when coming in direct
contact with a recent traveler from a country with an Ebola outbreak who
has symptoms of Ebola. The initial signs and symptoms of Ebola are similar
to many other more common diseases found in West Africa (such as malaria
and typhoid). Ebola should be considered in anyone with fever who has
traveled to, or lived in, an area where Ebola is present. 2
<http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html#ftn2>
The incubation period for Ebola, from exposure to when signs or symptoms
appear, ranges from 2 to 21 days (most commonly 8-10 days). Any Ebola
patient with signs or symptoms should be considered infectious. Ebola
patients without symptoms are not contagious. The prevention of Ebola
includes actions to avoid exposure to blood or body fluids of infected
patients through contact with skin, mucous membranes of the eyes, nose, or
mouth, or injuries with contaminated needles or other sharp objects.
Emergency medical services (EMS) personnel, along with other emergency
services staff, have a vital role in responding to requests for help,
triaging patients, and providing emergency treatment to patients. Unlike
patient care in the controlled environment of a hospital or other fixed
medical facility, EMS patient care before getting to a hospital is provided
in an uncontrolled environment. This setting is often confined to a very
small space and frequently requires rapid medical decision-making and
interventions with limited information. EMS personnel are frequently unable
to determine the patient history before having to administer emergency care.
Coordination among 9-1-1 Public Safety Answering Points (PSAPs), the EMS
system, healthcare facilities, and the public health system is important
when responding to patients with suspected Ebola. Each 9-1-1 and EMS system
should include an EMS medical director to provide appropriate medical
supervision.
Case Definition for Ebola Virus Disease (EVD)
The CDC’s most current case definition for EVD may be accessed here:
http://www.cdc.gov/vhf/ebola/hcp/case-definition.html.
Recommendations for 9-1-1 Public Safety Answering Points (PSAPs)
State and local EMS authorities may authorize PSAPs and other emergency
call centers to use modified caller queries about Ebola when they consider
the risk of Ebola to be elevated in their community (e.g., in the event
that patients with confirmed Ebola are identified in the area). This will
be decided from information provided by local, state, and federal public
health authorities, including the city or county health department(s),
state health department(s), and CDC.
For modified caller queries:
It will be important for PSAPs to question callers and determine if anyone
at the incident possibly has Ebola. This should be communicated immediately
to EMS personnel before arrival and to assign the appropriate EMS
resources. PSAPs should review existing medical dispatch procedures and
coordinate any changes with their EMS medical director and with their local
public health department.
- PSAP call takers should consider screening callers for symptoms and
risk factors of Ebola. Callers should be asked if they, or someone at the
incident, have fever of greater than 38.6 degrees Celsius or 101.5 degrees
Fahrenheit, and if they have additional symptoms such as severe headache,
muscle pain, vomiting, diarrhea, abdominal pain, or unexplained bleeding.
- If PSAP call takers suspect a caller is reporting symptoms of
Ebola, they should screen callers for risk factors within the
past 3 weeks
before onset of symptoms. Risk factors include:
- Contact with blood or body fluids of a patient known to have or
suspected to have Ebola;
- Residence in–or travel to–a country where an Ebola outbreak is
occurring (a list of impacted countries can be accessed at
the following
link: http://www.cdc.gov/vhf/ebola/outbreaks/guinea/index.html); or
- Direct handling of bats or nonhuman primates from
disease-endemic areas.
- If PSAP call takers have information alerting them to a person with
possible Ebola, they should make sure any first responders and EMS
personnel are made confidentially aware of the potential for Ebola before
the responders arrive on scene.
- If responding at an airport or other port of entry to the United
States, the PSAP should notify the CDC Quarantine Station for the port of
entry. Contact information for CDC Quarantine Stations can be accessed at
the following link:
http://www.cdc.gov/quarantine/quarantinestationcontactlistfull.html
Recommendations for EMS and Medical First Responders, Including
Firefighters and Law Enforcement Personnel
For the purposes of this section, “EMS personnel” means pre-hospital EMS,
law enforcement and fire service first responders. These EMS personnel
practices should be based on the most up-to-date Ebola clinical
recommendations and information from appropriate public health authorities
and EMS medical direction.
When state and local EMS authorities consider the threat to be elevated
(based on information provided by local, state, and federal public health
authorities, including the city or county health department(s), state
health department(s), and the CDC), they may direct EMS personnel to modify
their practices as described below.
Patient assessmentInterim recommendations:
1. Address scene safety:
- If PSAP call takers advise that the patient is suspected of having
Ebola, EMS personnel should put on the PPE appropriate for
suspected cases
of Ebola (described below
<http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html#ppe>)
before entering the scene.
- Keep the patient separated from other persons as much as possible.
- Use caution when approaching a patient with Ebola. Illness can
cause delirium, with erratic behavior that can place EMS
personnel at risk
of infection, e.g., flailing or staggering.
2. During patient assessment and management, EMS personnel should
consider the symptoms and risk factors of Ebola:
- All patients should be assessed for symptoms of Ebola (fever of
greater than 38.6 degrees Celsius or 101.5 degrees Fahrenheit, and
additional symptoms such as severe headache, muscle pain, vomiting,
diarrhea, abdominal pain, or unexplained hemorrhage). If the patient has
symptoms of Ebola, then ask the patient about risk factors
within the past
3 weeks before the onset of symptoms, including:
- Contact with blood or body fluids of a patient known to have or
suspected to have Ebola;
- Residence in—or travel to— a country where an Ebola outbreak is
occurring (a list of impacted countries can be accessed at
the following
link: http://www.cdc.gov/vhf/ebola/outbreaks/guinea/index.html
<http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.html>);
or
- Direct handling of bats or nonhuman primates from
disease-endemic areas.
- Based on the presence of symptoms and risk factors, put on or
continue to wear appropriate PPE and follow the scene safety
guidelines for
suspected case of Ebola.
- If there are no risk factors, proceed with normal EMS care.
EMS Transfer of Patient Care to a Healthcare Facility
EMS personnel should notify the receiving healthcare facility when
transporting a suspected Ebola patient, so that appropriate infection
control precautions may be prepared prior to patient arrival. Any U.S.
hospital that is following CDC’s infection control recommendations
<http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html>
and can isolate a patient in a private room is capable of safely managing
a patient with Ebola.
Interfacility Transport
EMS personnel involved in the air or ground interfacility transfer of
patients with suspected or confirmed Ebola should wear recommended PPE
(described
below
<http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html#ppe>
).
Infection Control
EMS personnel can safely manage a patient with suspected or confirmed Ebola
by following recommended isolation and infection control procedures,
including standard, contact, and droplet precautions. Particular attention
should be paid to protecting mucous membranes of the eyes, nose, and mouth
from splashes of infectious material, or self-inoculation from soiled
gloves. Early recognition and identification of patients with potential
Ebola is critical. An EMS agency managing a suspected Ebola patient should
follow these CDC recommendations:
- Limit activities, especially during transport, that can increase the
risk of exposure to infectious material (e.g., airway management,
cardiopulmonary resuscitation, use of needles).
- Limit the use of needles and other sharps as much as possible. All
needles and sharps should be handled with extreme care and disposed in
puncture-proof, sealed containers.
- Phlebotomy, procedures, and laboratory testing should be limited to
the minimum necessary for essential diagnostic evaluation and medical care.
Use of Personal protective equipment (PPE)
Use of standard, contact, and droplet precautions is sufficient for most
situations when treating a patient with a suspected case of Ebola as
defined above. EMS personnel should wear:
- Gloves
- Gown (fluid resistant or impermeable)
- Eye protection (goggles or face shield that fully covers the front and
sides of the face)
- Facemask
- Additional PPE might be required in certain situations (e.g., large
amounts of blood and body fluids present in the environment), including but
not limited to double gloving, disposable shoe covers, and leg coverings.
Pre-hospital resuscitation procedures such as endotracheal intubation, open
suctioning of airways, and cardiopulmonary resuscitation frequently result
in a large amount of body fluids, such as saliva and vomit. Performing
these procedures in a less controlled environment (e.g., moving vehicle)
increases risk of exposure for EMS personnel. If conducted, perform these
procedures under safer circumstances (e.g., stopped vehicle, hospital
destination).
During pre-hospital resuscitation procedures (intubation, open suctioning
of airways, cardiopulmonary resuscitation):
- In addition to recommended PPE, respiratory protection that is at
least as protective as a NIOSH-certified fit-tested N95 filtering facepiece
respirator or higher should be worn (instead of a facemask).
- Additional PPE must be considered for these situations due to the
potential increased risk for contact with blood and body fluids including,
but not limited to, double gloving, disposable shoe covers, and leg
coverings.
If blood, body fluids, secretions, or excretions from a patient with
suspected Ebola come into direct contact with the EMS provider’s skin or
mucous membranes, then the EMS provider should immediately stop working.
They should wash the affected skin surfaces with soap and water and report
exposure to an occupational health provider or supervisor for follow-up.
Recommended PPE should be used by EMS personnel as follows:
- PPE should be worn upon entry into the scene and continued to be worn
until personnel are no longer in contact with the patient.
- PPE should be carefully removed without contaminating one’s eyes,
mucous membranes, or clothing with potentially infectious materials.
- PPE should be placed into a medical waste container at the hospital or
double bagged and held in a secure location.
- Re-useable PPE should be cleaned and disinfected according to the
manufacturer’s reprocessing instructions and EMS agency policies.
- Instructions for putting on and removing PPE have been published
online at http://www.cdc.gov/HAI/prevent/ppe.html and
http://www.cdc.gov/vhf/ebola/pdf/ppe-poster.pdf[PDF - 2 pages]
<http://www.cdc.gov/vhf/ebola/pdf/ppe-poster.pdf>.
- Hand hygiene should be performed immediately after removal of PPE.
Environmental infection control
Environmental cleaning and disinfection, and safe handling of potentially
contaminated materials is essential to reduce the risk of contact with
blood, saliva, feces, and other body fluids that can soil the patient care
environment. EMS personnel should always practice standard environmental
infection control procedures, including vehicle/equipment decontamination,
hand hygiene, cough and respiratory hygiene, and proper use of U.S. Food
and Drug Administration (FDA) cleared or authorized medical PPE. For
additional information, see CDC’s Interim Guidance for Environmental
Infection Control in Hospitals for Ebola Virus
<http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html>
.
EMS personnel performing environmental cleaning and disinfection should:
- Wear recommended PPE (described above) and consider use of additional
barriers (e.g., shoe and leg coverings) if needed.
- Wear face protection (facemask with goggles or face shield) when
performing tasks such as liquid waste disposal that can generate splashes.
- Use an EPA-registered hospital disinfectant with a label claim for one
of the non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus,
poliovirus) to disinfect environmental surfaces. Disinfectant should be
available in spray bottles or as commercially prepared wipes for use during
transport.
- Spray and wipe clean any surface that becomes potentially contaminated
during transport. These surfaces should be immediately sprayed and wiped
clean (if using a commercially prepared disinfectant wipe) and the process
repeated to limit environmental contamination.
Cleaning EMS Transport Vehicles after Transporting a Patient with Suspected
or Confirmed Ebola
The following are general guidelines for cleaning or maintaining EMS
transport vehicles and equipment after transporting a patient with
suspected or confirmed Ebola:
- EMS personnel performing cleaning and disinfection should wear
recommended PPE (described above) and consider use of additional barriers
(e.g., rubber boots or shoe and leg coverings) if needed. Face protection
(facemask with goggles or face shield) should be worn since tasks such as
liquid waste disposal can generate splashes.
- Patient-care surfaces (including stretchers, railings, medical
equipment control panels, and adjacent flooring, walls and work surfaces)
are likely to become contaminated and should be cleaned and disinfected
after transport.
- A blood spill or spill of other body fluid or substance (e.g., feces
or vomit) should be managed through removal of bulk spill matter, cleaning
the site, and then disinfecting the site. For large spills, a chemical
disinfectant with sufficient potency is needed to overcome the tendency of
proteins in blood and other body substances to neutralize the
disinfectant’s active ingredient.
- An EPA-registered hospital disinfectant with label claims for viruses
that share some technical similarities to Ebola (such as, norovirus,
rotavirus, adenovirus, poliovirus) and instructions for cleaning and
decontaminating surfaces or objects soiled with blood or body fluids should
be used according to those instructions. After the bulk waste is wiped up,
the surface should be disinfected as described in the bullet above.
- Contaminated reusable patient care equipment should be placed in
biohazard bags and labeled for cleaning and disinfection according to
agency policies. Reusable equipment should be cleaned and disinfected
according to manufacturer’s instructions by trained personnel wearing
correct PPE. Avoid contamination of reusable porous surfaces that cannot be
made single use.
- Use only a mattress and pillow with plastic or other covering that
fluids cannot get through. To reduce exposure among staff to potentially
contaminated textiles (cloth products) while laundering, discard all
linens, non-fluid-impermeable pillows or mattresses as appropriate.
The Ebola virus is a Category A infectious substance regulated by the U.S.
Department of Transportation’s (DOT) Hazardous Materials Regulations (HMR,
49 C.F.R., Parts 171-180). Any item transported for disposal that is
contaminated or suspected of being contaminated with a Category A
infectious substance must be packaged and transported in accordance with
the HMR. This includes medical equipment, sharps, linens, and used health
care products (such as soiled absorbent pads or dressings, kidney-shaped
emesis pans, portable toilets, used Personal Protection Equipment [e.g.,
gowns, masks, gloves, goggles, face shields, respirators, booties] or
byproducts of cleaning) contaminated or suspected of being contaminated
with a Category A infectious substance. 4
<http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html#ftn4>
Follow-up and/or reporting measures by EMS personnel after caring for a
suspected or confirmed Ebola patient
- EMS personnel should be aware of the follow-up and/or reporting
measures they should take after caring for a suspected or confirmed Ebola
patient.
- EMS agencies should develop policies for monitoring and management of
EMS personnel potentially exposed to Ebola.
- EMS agencies should develop sick leave policies for EMS personnel that
are non-punitive, flexible and consistent with public health guidance
- Ensure that all EMS personnel, including staff who are not directly
employed by the healthcare facility but provide essential daily services,
are aware of the sick leave policies.
- EMS personnel with exposure to blood, bodily fluids, secretions, or
excretions from a patient with suspected or confirmed Ebola should
immediately:
- Stop working and wash the affected skin surfaces with soap and
water. Mucous membranes (e.g., conjunctiva) should be irrigated with a
large amount of water or eyewash solution;
- Contact occupational health/supervisor for assessment and access to
post-exposure management services; and
- Receive medical evaluation and follow-up care, including fever
monitoring twice daily for 21 days, after the last known
exposure. They may
continue to work while receiving twice daily fever checks, based upon EMS
agency policy and discussion with local, state, and federal public health
authorities.
- EMS personnel who develop sudden onset of fever, intense weakness or
muscle pains, vomiting, diarrhea, or any signs of hemorrhage after an
unprotected exposure (i.e., not wearing recommended PPE at the time of
patient contact or through direct contact to blood or body fluids) to a
patient with suspected or confirmed Ebola should:
- Not report to work or immediately stop working and isolate
themselves;
- Notify their supervisor, who should notify local and state health
departments;
- Contact occupational health/supervisor for assessment and access to
post-exposure management services; and
- Comply with work exclusions until they are deemed no longer
infectious to others.
1 http://www.cdc.gov/vhf/ebola/hcp/patient-management-us-hospitals.html
2 http://www.cdc.gov/vhf/ebola/hcp/case-definition.html
3
http://www.cdc.gov/vhf/ebola/hcp/clinician-information-us-healthcare-settings.html
4
http://phmsa.dot.gov/portal/site/PHMSA/menuitem.6f23687cf7b00b0f22e4c6962d9c8789/?vgnextoid=4d1800e36b978410VgnVCM100000d2c97898RCRD&vgnextchannel=d248724dd7d6c010VgnVCM10000080e8a8c0RCRD&vgnextfmt=print
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