EXAMPLE OF SITE-SPECIFIC GUIDELINES FOR FRONT LINE STAFF CARING FOR PATIENT WITH SUSPECTED EXOTIC INFECTIOUS DISEASE

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1 Patient arrives to the nurse first window and complains of any of the following symptoms - fever, cough, nausea, vomiting, diarrhea, influenza-like symptoms, headache, rash, difficulty breathing, abnormal bleeding, and/or altered level of consciousness. Yes Nurse to ASK: 1. Have you traveled outside of the United States within the last 30 days? 2. Have you come into contact with anyone sick who has traveled outside of the United States within last 30 days? If Yes to either question use handouts to investigate whether country visited is a country of risk for Ebola or MERS If yes-activate ED RESPONSE PLAN FOR PATIENTS UNDER INVESTIGATION FOR INFECTIOUS DISEASE Yes No ESI the Patient to appropriate care and room. 1. Have patient don a surgical mask. a. If family is present, have family/visitor(s) don a mask too. 2. Do Not touch the patient, do not obtain vital signs, do not continue with completing the arrival process at the window. 3. Alert the CN and immediately request a negative pressure room (room 1 or 2) for the a. CN/ PCRN will work collectively to clear Quiet Room (QR) & room 1 or 2 for the patient and family/visitor(s). b. If family is present with the patient, they will be placed in QR. c. If room 1 or room 2 cannot be cleared immediately, have patient and family stay in QR until alternate room(s) room 3, room 4 (any single room with door) is available. d. Do not transfer the patient to the Rapid Care (RC) area prior to transport to the treatment room. e. Charge RN/PCRN will notify that QR is ready to receive patient and family/visitor(s). f. Charge RN/PCRN will notify that treatment room is ready to receive patients 4. Assign ESI 2 (high risk situation). 5. Assign Physician via PASS. 6. When notified by CN/PCRN that QR is ready - Don mask (for Ebola surgical mask- Dropet) (for MERS-N95 Airborne) and gloves at a minimum based on patient presentation. Obtain key from CN desk, and return to waiting room towards QR door. 7. Triage Nurse to alert security to get the yellow tape/stanchions and secure the area where the patient has entered including entryway. Remind security to close QR door. 8. Open Quiet Room. Motion and call for patient and family/visitor(s) to follow you. 9. Instruct visitors to remain in QR, and continue with patient to room 1 or 2. (Primary RN will either go into negative pressure rooms or alternate single room with door). Do not stop anywhere else along the way (including a bathroom). 10. Receptionist calls EVS worker to reception area for STAT clean of needed areas e.g. Counter, waiting room, front bathroom. Anything the patient touched e.g. wheelchair, etc. must be sequestered in the Quiet Room and not used until terminally cleaned. 11. Surge Nurse will start triage of other waiting patients who have arrived to the ED from RC 1 until front area cleaned. Clerk will assist RN in banding other arriving patients in Rapid Care area, not at window, until front area has been cleaned. 12. The East side clerk will register the patient from arrival information and hand the ID armband to the primary nurse who will band the 1 P a g e

2 Charge Nurse: 1. Notify assigned ED physician for rapid response to patient location. 2. Notify ED Physician if there is family or visitors for patient in QR. 3. Turn on alarm system for negative pressure room. 4. Review infection control precautions (droplet and contact). 5. Assign the primary nurse and staff member who will be monitoring the entrance and exit from patient s room. Log is found in binder. 6. Call engineering to set up ante-room. 7. Have Infection Control cart and needed supplies moved to outside patient s room. 8. Page the EVS supervisor for APPROPRIATE BIOHAZARD waste and linen containers AND to assign an EVS worker to monitor and dispose of the waste. 9. Alert ED Manager on-call of potential infectious patient who will notify TPMG administrator on-call. 10. Alert the house supervisor to prepare for a potential transfer of the 11. Assist and trouble shoot other needs as arise. Triage Nurse Duties: 1. Give mask to patient and family/visitors if present. 2. Have the patient stand in front of window until notified that the QR is ready. In the meantime ask patient if anyone else is present. Ask if patient has vomited on the property or has used the restrooms in the entryway. 3. Give instructions to patient to wait at window until called to follow into QR. 4. Don mask, and gloves. DO NOT touch the 5. Coordinate with Security to cordon off area. If there is a possibility that bodily fluids have been left behind in entryway or restroom, have security post themselves at entry doors. Remind security to close Quiet Room door. 6. Have family/visitors stay in quiet room. Have patient follow you to RM 1 or 2. Have patient enter room. From the doorway instruct patient to undress, place gown on, and place clothes in patient belonging bag. Inform the patient that the nurse and MD will be into the room soon. 7. Accurately remove PPE and dispose in designated waste containers. 8. Wash your hands with soap and water and ensure door to room is closed. 9. Return to triage. Surge Nurse Duties. 1. Open Rapid Care door, call patients will go through this door to continue triaging. 2. Surge nurse monitors for arrival of additional patients to the ED and triages those waiting until relieved by returning assigned triage nurse. PCRN Duties: 1. Work with CN to assign nurse and clear rooms, QR first. 2. Work in assisting set up of PPE and infection control measures (Droplet and contact plus). 3. Place a STOP SIGN, Contact and Droplet isolation sign directly outside of door leading into the patient s room, as well as quiet room. 4. Ensure commode, and bucket with top are in room. 5. Anticipate additional assignment of personnel to support the assigned nurse. 2 P a g e

3 Primary RN: 1. Implement stringent infection control precautions (Droplet and contact plus). 2. Ensure infection control cart with PAPRs are readily available. 3. Don PPE outside the room prior to entering (Mask, face shield, impervious gown, shoe covers and gloves. Double gloving and shoe/leg covers for situations of copious blood or body fluids in the environment. Respiratory protection (PAPR) for use during aerosol-generating procedures. PPE must be put on prior to entering patient s room. 4. Place mayo stand near the door for placement of clean supplies for patient care. 5. Introduce yourself and relay to the patient that the physician will direct the care. 6. Positively identify the patient using two patient identifiers, then armband the 7. Using disposable monitoring equipment, place on pulse oximetry and NBP to obtain baseline VS. 8. DO NOT implement ESP or pre-orders, IV starts or lab draws. 9. If patient becomes unstable, work with the physician to implement condition specific care. Once in the room, the patient should be attached to appropriate cardiac and respiratory monitoring, as needed. a. If patient requires immediate fluid resuscitation start IV under strict contact & droplet precautions. b. If endotracheal intubation/neb treatment is needed=negative pressure room, N95, PAPR. c. No portable x-ray equipment 10. Any laboratory specimens must remain in the patient s room in a biohazard bag for required processing. Do not use glass tubes; do not send specimens to laboratory. Lab supervisor/director should be notified that specimens require collecting & processing. 11. All disposable IV equipment (sharps, tubing, etc.) must be disposed of within the patient s room. 12. All disposable monitoring and examination equipment (monitor leads, ear speculum, tongue depressors, etc.) must be disposed of within the patient s room in red bio- hazardous bin. 13. If patient uses commode or urinal, secure the top with tape. Leave in room until further instructions. 14. Provide patient with comfort measures using the assigned staff member to collect items and place on mayo stand. 15. Prior to exiting, ensure the patient s immediate needs have been provided for. 16. Doff (remove) PPE at the doorway (or anteroom if available) accurately and place in the designated waste container. 17. Wash hands with soap and water. 18. Prepare for possible admission. 19. If a piece of portable equipment is needed in the patient s room (e.g. portable ultrasound), this equipment must be carefully decontaminated in the patient s room prior to leaving the room. Whenever possible, use disposable covers for equipment. 20. No visitors are allowed. 3 P a g e

4 Monitoring RN: (stationed outside patient s room) 1. Restrict entries to the minimum number of personnel. 2. Log all personnel entering and leaving the isolation room to ensure all persons who come into contact with the patient are identified and to ensure appropriate PPE protocol is followed. 3. Observe personnel putting on PPE and ensure all required items are in place. 4. Observe personnel doffing (taking off) PPE and stop the action if self contamination noted and have person wash hands with soap and water and then continue. 5. Ensure all equipment/supplies remain in the isolation room until appropriate disinfection. 6. Wheelchair and equipment such as ultra sound machine, ekg machine after initial wipe down by bleach should be placed in Quiet Room for terminal clean. ED Physician: 1. Don surgical mask, face shield, gloves, impervious gown, shoe covers. Double gloving and shoe/leg cover for situations of copious blood or body fluids in the environment. Respiratory precaution (PAPR) for use during aerosol generating procedures. 2. Evaluate patient s travel history, complete examination to determine if the patient should be considered for possible Ebola or MERS case. 3. Routine labs or X-rays should not be ordered. 4. Anticipate the need for airway management and alert the nurse if suspected. (PAPR) airborne isolation protection will be placed by the room in the event of a procedure on the airway that may aerosolize the organism. 5. Accurately take off PPE at the doorway (or anteroom if available) and place PPE in designate receptacles. 6. Wash hands with soap and water. 7. Go to Quiet Room -Don surgical mask, face shield, gloves, impervious gown, shoe covers. 8. Evaluate family and visitor s travel history, complete examination to determine if they also should be considered for possible Ebola or MERS case. If this is the case, they will need to be registered as well and placed in an available room. 9. If there is a potential for Ebola or MERS, or any question, the ED physician contacts the on-call infectious disease physician. 10. Assists with expediting admission of patient to negative pressure room in ICU. Infectious Disease Physician: 1. If determined possible Ebola or MERS case, he/she contacts hospital administrator on-call to activate emergency command center. 2. Contacts Infection Control. 3. Review with ED physician what labs and procedures should be done. 4. Review case with HBS physician and expedite admission of patient to negative pressure room in ICU. 5. ID specialist contacts County Department of Public Health (DPH). 4 P a g e

5 Security responsibilities: 1. Alerted by triage nurse to secure the area. Calls security supervisor for additional security needs. 2. Walk over to the patients in line, open stanchions with gloved hand. Have them line up in front of rapid care door. Contain them in line until the flow nurse comes out to assist them. 3. If there is a possibility that bodily fluids have been left behind in the entryway, ensure an officer is posted at the temporarily closed doors. 4. Close off window area with caution tape/stanchions from window 3 to security desk to front door until cleared. Deactivate alarm on Emergency door. Ensure Security officer is assigned to direct patients through temporary new entryway into the ED. 5. Ensure door to Quiet Room has been closed. EVS responsibilities: 1. Immediately respond to clean and decontaminate areas touched by patient, e.g. in waiting room, bathroom. 2. Set up infectious specific waste containers as directed by the EVS supervisor. 3. Continually monitor the waste containers and resupply to ensure no transmission of infectious waste occurs. Manage process for disposal of lines and trash. 4. Monitor the exit from the room and clean with approved cleaner on the exit of ALL staff from the room. 5. Clean and decontaminate surface areas and equipment, as needed. 6. Monitor the transfer of the patient from the ED and alert the EVS supervisor of the transfer to ensure infection control procedures are initiated on the floor. 7. Terminal clean ALL areas of the ED with approved cleaning agents. Patients that arrive to the ED by EMS or/ through Ambulance Bay: When medics call report, and suspect that the patient may be a candidate for categorization as a Patient Under Investigation for Infectious Disease, inform medics that staff will be outside in the ambulance bay to meet them. Clear out room 2. Staff that has been called to ambulance bay to assist patient or direct ambulance must be in full PPE. Patients arriving in this manner should enter into room 2 via the outside door directly into room 2. Key is the same as QR door the CN desk Patients that want to sign out AMA: 1. Inform County Public Health 2. Inform the U.S. Centers for Disease Control and Prevention (CDC), available 24/7 at , or via the CDC Emergency Operations Center (EOC) or via at eocreport@cdc.gov 5 P a g e