Joint Commission Resources Quality & Safety Network (JCRQSN)

Transcription

1 Quality & Safety Network (JCRQSN) Resource Guide Ebola Preparedness: Infection Control, Protecting Staff, and Safely and Effectively Managing Contagious Patients December 16, 2014

2 About Joint Commission Resources Joint Commission Resources (JCR) is a client-focused, expert resource for healthcare organizations. It partners with these organizations, providing consulting services, educational services, and publications to assist in improving the quality, safety, and efficiency of healthcare services, and to assist in meeting the accreditation standards of The Joint Commission. JCR is a subsidiary of The Joint Commission, but provides services independently and confidentially, disclosing no information about its clients to The Joint Commission or others. Visit our web site at: Disclaimers Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of The Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation process. The information in this Resource Guide has been compiled for educational purposes only and does not constitute any product, service, or process endorsement by The Joint Commission or organizations collaborating with The Joint Commission in the content of these programs. NOTE: Interactivation Health Networks is the distributor of the Joint Commission Resources Quality & Safety Network series and has no influence on the content of the series Joint Commission Resources. The purchaser of this educational package is granted limited rights to photocopy this Resource Guide for internal educational use only. All other rights reserved. Requests for permission to make copies of this publication for any use not covered by these limited rights should be made in writing to: Department of Education Programs, Joint Commission Resources, One Renaissance Boulevard, Oakbrook Terrace, IL Joint Commission Resources 2 of 50

3 TABLE OF CONTENTS Program Summary...4 Program Outline...5 Continuing Education (CE) Credit...6 Joint Commission Standards Safely and Effectively Managing the Infectious Ebola Patient...7 Preparing for Ebola Response in U.S. Healthcare Facilities...8 Detailed Hospital Checklist for Ebola Preparedness...10 Health Care Facility Preparedness Checklist for Ebola Virus Disease (EVD)...16 Ebola 101 CDC Slides for US Healthcare Workers...18 Safe Management of Patients with Ebola Virus Disease (EVD) in U.S. Hospitals...31 Identify, Isolate, Inform: Emergency Department Evaluation and Management of Patients with Possible Ebola Virus Disease...33 Detailed Emergency Medical Services (EMS) Checklist for Ebola Preparedness...34 Ebola Virus Disease (EVD) Screening...39 Ebola Virus Disease (EVD) Screening for EMS...40 BULLETIN: HIPAA Privacy in Emergency Situations...41 Appendix A: Additional Resources...44 Appendix B: Faculty Biographies...45 Appendix C: Continuing Education (CE) Accrediting Bodies...46 Appendix D: Discipline Codes Instructions...47 Appendix E: Post-Test...48 Appendix F: JCRQSN Contact Information Joint Commission Resources 3 of 50

4 Program Summary This page provides an overview of the program content and learning objectives. Please refer to the Table of Contents and Program Outline for a detailed list of the topics covered. The information included in this Resource Guide is intended to support but not duplicate the video presentation content. There may be additional information available online for this topic. Program Description On September 30, 2014, the Centers for Disease Control and Prevention (CDC) confirmed the first case of the Ebola virus disease (EVD) in the United States (U.S.), and there are ongoing developments associated with the virus. There is an increased risk of people traveling from affected countries to the U.S. and subsequently seeking healthcare in American hospitals, clinics, and physician offices. Ebola is a highly virulent virus, and healthcare workers must use the utmost caution when treating patients who are suspected or confirmed to have EVD. Healthcare facilities must use the most currently available resources to ensure the safety of its patients and staff. This special episode from the Joint Commission Resources Quality and Safety Network (JCRQSN) features experts from The Joint Commission and case study organizations who share their experiences treating patients who are suspected as having EVD, including preparations for safely transferring confirmed or suspected patients with EVD, recommended use and removal of personal protective equipment (PPE), and training materials. Following the program, the faculty conducts an audio conference to answer the audience's questions for up to one hour. Program Objectives After completing this activity, the participant should be able to: 1. Identify effective infection control practices related to patients infected with Ebola. 2. Describe how to safely isolate and transfer patients suspected as being infected with Ebola. 3. Understand the techniques to keep staff safe when interacting with patients infected with Ebola. Target Audience This activity is relevant to infection control practitioners, emergency preparedness planners, all healthcare leaders, and the entire hospital and medical staff Joint Commission Resources 4 of 50

5 Program Outline Ebola Preparedness: Infection Control, Protecting Staff, and Safely and Effectively Managing Contagious Patients December 16, 2014 I. Introduction A. Program Content B. Objectives C. Faculty II. Treating a Patient Infected with Ebola III. Preparing to Treat Ebola Patients IV. Preparing to Identify and Transfer Suspected Patients V. Conclusion VI. Post-Program Live Question and Answer Session A. Audio only telephone seminar with program faculty for 30 minutes following the program. B. Call ; enter conference code: Or your questions or comments to: Questions@jcrqsn.com Program Broadcast Time Program Question and Answer Session Eastern: Central: Mountain: Pacific: 3:30 p.m. to 5:00 p.m. 2:30 p.m. to 4:00 p.m. 1:30 p.m. to 3:00 p.m. 12:30 p.m. to 2:00 p.m. During the live airing of this program on December 16, 2014, you may be able to talk directly with the faculty when prompted by the program s host. After this date, your message will be forwarded to the appropriate personnel. Immediately following the program, we invite you to join in a live discussion with the program presenters. Call and enter Conference Code: to be included in the teleconference. To submit your question ahead of time or for additional details, please send an to questions@jcrqsn.com. If you submit your questions after this date, your message will be forwarded to the appropriate personnel. You can also receive answers to your questions by calling The Joint Commission s Standards Interpretation Hotline at , option 6. Credit Is Available Only For Subscribers of the Joint Commission Resources Quality and Safety Network 2014 Joint Commission Resources 5 of 50

6 Continuing Education (CE) Credit After viewing the JCR Quality & Safety Network presentation and reading this Resource Guide, please complete the required online CE/CME credit activities (test and feedback form). The test measures knowledge gained and/or provides a means of self-assessment on a specific topic. The feedback form provides us with valuable information regarding your thoughts on the activity s quality and effectiveness. NOTE: Effective April 1, 2012, the Learning Management System web site URL changed as noted below. Prior to the Program Presentation Day 1. Login to the JCRQSN Learning Management System web site at 2. Enroll yourself into the program Note: Your administrator may have already enrolled you in the program Select All Courses from the courses menu. Select the course category for the current year, 2014 Programs. Select the course for this program, Ebola Preparedness: Infection Control, Protecting Staff, and Safely and Effectively Managing Contagious Patients When prompted, choose Yes to confirm that you would like to enroll yourself. 3. Display and print the desire documents (Resource Guide, etc.). Online Process for CE/CME Credit 1. Read the course materials and view the entire presentation. 2. Login to the JCRQSN Learning Management System web site at 3. Select Ebola Preparedness: Infection Control, Protecting Staff, and Safely and Effectively Managing Contagious Patients from the courses menu block. Note: This assumes you have already been enrolled in the program as described above. 4. If you didn t view the broadcast video presentation, view it online. 5. Complete the online post test (see Appendix E). You have up to three attempts to successfully complete the test with a minimum passing score of 80%. Physicians must take the post test to obtain credit. 6. Complete the program feedback form. 7. On the top right corner of the main course page, you will see your completion status in the Status block. 8. Select Print Certificate from within the Status block to print your completion certificate Joint Commission Resources 6 of 50

7 Joint Commission Standards Safely and Effectively Managing the Infectious Ebola Patient While surveying healthcare organizations readiness to receive a confirmed or suspected Ebola patient, the following highlighted accreditation chapters are focal to identifying strengths and/or gaps to safely and effectively managing the infectious Ebola patient within an organization, while minimizing the risk of transmission to self or others. Leadership (LD) , Complies with law and regulation, focus on patient safety, policies and procedures that support patient care, treatment, and services. Environment of Care (EC) , Manage risk to hazardous materials and waste; staff knowledge of roles/responsibilities. Emergency Management (EM) , , , , , , , Current implementation of organizational Emergency Operations Plan (EOP) specific to addressing Ebola (communication plan, management of resources/assets/hazardous waste/safety and security/staffing). Evaluate the effectiveness of implemented activities and the EOP. Human Resources (HR) , , , Staff orientation, education and training, and competency. Infection Control (IC) , , , , , , Identify risks for transmission of infection, IC Plan and implementation, use of personal protective equipment (PPE), response to an influx of infectious patients/ risks associated with medical equipment, devices, and supplies, prevention of transmission of infection to other patients, LIP s and staff, use of current national guideline. Evaluate the effectiveness of the IC Plan. Nursing (NR) , Delivery of nursing care, treatment, and services, implementing policy and procedure. NPSG Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. The Centers for Diseases Control and Prevention (CDC) remains a primary source of Ebola information Joint Commission Resources 7 of 50

8 Preparing for Ebola Response in U.S. Healthcare Facilities Issue: Due to the recent Ebola Virus Disease (EVD) outbreak in West Africa, there is an increased risk of individuals traveling from affected countries to the U.S. and subsequently seeking healthcare in American hospitals, clinics, and physician offices. Ebola is a highly virulent virus; health care workers must use utmost caution in treating patients suspected or confirmed with EVD, and a health care facility must use the most currently available resources to ensure the safety of its patients and staff. As of this writing, the Centers for Disease Control and Prevention (CDC) announced that EVD has been confirmed in at least two patients in Texas. Safety Actions to Consider: Now is the time to assess the readiness of your organization s Ebola response. The following information can help in preparing for Ebola (or any other highly infectious outbreak) response in your facility. Determine that all staff and clinicians who may care for or come into contact with EVD patients or persons under investigation for EVD are educated and trained on current Ebola guidance to safely care for patients, while minimizing the risk of transmission to themselves and others, including other patients and visitors. If the training provided previously to all staff did not include enough detail on handling EVD, initiate a mandatory educational overview of EVD, which would include the roles and responsibilities of staff. Consider phasing in additional education as more external guidelines and resources become available or are updated. Reevaluate the key domains in your current infection control plan to ensure your healthcare organization has ample guidelines, requirements, and components to deal with a potential EVD patient. Early recognition of any patient suspected of having EVD includes: Signs and symptoms, including: Fever greater than 38.0 C or F Severe headache Muscle pain Weakness Diarrhea Vomiting Abdominal (stomach) pain Unexplained hemorrhage (bleeding or bruising) Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola, but the average is 8 to 10 days. Travel history (residence in, or travel to, an area where EVD transmission is active) Isolation precautions (isolate the patient in a private room with their own bathroom and implement standard, contact, and droplet precautions) Proper use and careful removal of personal protective equipment (PPE); may use a buddy system to ensure that PPE is put on and removed safely. Signs and symptoms of Ebola Virus Disease (EVD) Fever greater than 38.0 C or F Severe headache Muscle pain Weakness Diarrhea Vomiting Abdominal (stomach) pain Unexplained hemorrhage (bleeding or bruising) Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola, but the average is 8 to 10 days. Safe and secure specimen collection, adequate labeling, transport and packaging (which includes sending specimens outside your laboratory for confirmation or additional analysis), testing, and submission Joint Commission Resources 8 of 50

9 Per CDC recommendations, infection prevention and control precautions to be implemented with a known or suspected EVD patient include but are not limited to the following: Isolate the patient Wear appropriate PPE Restrict visitors Avoid aerosol-generating procedures Implement environmental infection control measures Medical waste management In addition to reviewing the infection control mechanisms in your healthcare organization, review your organization s emergency operations plan (EOP). Consider whether an incident command should be activated if a possible EVD case is suspected. This could facilitate communication with other staff on elevating safe protocols and procedures. It is always good practice to review previous drills on EOP activation and how the organization responded to external situations. Verify that sufficient resources are available for handling special infectious disease situations. Your EOP review and actions to consider can also include touching base with your local governments to verify you are congruent with a community-wide approach, as a just in case scenario. Resources: Centers for Disease Control and Prevention: Ebola Virus Disease Information for Healthcare Workers Health Care Facility Preparedness Checklist for Ebola Virus Disease (EVD) Fact Sheet: CDC Ebola Surge 2014 How U.S. Clinical Laboratories Can Safely Manage Specimens from Persons Under Investigation for Ebola Virus Disease American Society of Microbiology: Interim Laboratory Guidelines for Handling/Testing Specimens from Cases or Suspected Cases of Hemorrhagic Fever Virus (HFV). September 10, Note: This is not an all-inclusive list. Legal disclaimer: This material is meant as an information piece only; it is not a standard or a Sentinel Event Alert. The intent of Quick Safety is to raise awareness and to be helpful to Joint Commission-accredited organizations. The information in this publication is derived from actual events that occur in healthcare. The Joint Commission, Division of Health Care Improvement Issue Seven, October 2014, SPECIAL EDITION 2014 Joint Commission Resources 9 of 50

10 Detailed Hospital Checklist for Ebola Preparedness The U.S. Department of Health and Human Services (HHS) Centers for Disease Control and Prevention (CDC) and Office of the Assistant Secretary for Preparedness and Response (ASPR), in addition to other federal, state, and local partners, aim to increase understanding of Ebola and encourage U.S. hospitals to prepare for managing patients with Ebola and other infectious diseases. Every hospital should ensure that it can detect a patient with Ebola, protect healthcare workers so they can safely care for the patient, and respond in a coordinated fashion. Many of the signs and symptoms of Ebola are non-specific and similar to those of many common infectious diseases, as well as other infectious diseases with high mortality rates. Transmission can be prevented with appropriate infection control measures. In order to enhance our collective preparedness and response efforts, this checklist highlights key areas for hospital staff especially hospital emergency management officers, infection control practitioners, and clinical practitioners to review in preparation for a person with Ebola arriving at a hospital for medical care. The checklist provides practical and specific suggestions to ensure your hospital is able to detect possible Ebola cases, protect your employees, and respond appropriately. Now is the time to prepare, as it is possible that individuals with Ebola in West Africa may travel to the United States, exhibit signs and symptoms of Ebola, and present to facilities. Hospitals should review infection control policies and procedures and incorporate plans for administrative, environmental, and communication measures, as well as personal protective equipment (PPE) and training and education. Hospitals should also define the individual work practices that will be required to detect the introduction of a patient with Ebola or other emerging infectious diseases, prevent spread, and manage the impact on patients, the hospital, and staff. The checklist format is not intended to set forth mandatory requirements or establish national standards. In this checklist, healthcare personnel refers to all persons, paid and unpaid, working in healthcare settings who have the potential for exposure to patients and/or to infectious materials, including body substances, contaminated medical supplies and equipment, or contaminated environmental surfaces. 1 This detailed checklist for hospitals is part of a suite of HHS checklists found on the CDC Ebola site ( CDC is available 24/7 for consultation by calling the CDC Emergency Operations Center (EOC) at or via at eocreport@cdc.gov. 1 Healthcare personnel includes, but is not limited to, physicians, nurses, nursing assistants, therapists, technicians, laboratory personnel, autopsy personnel, students and trainees, contractual personnel and persons not directly involved in patient care (e.g., house-keeping, laundry) Joint Commission Resources 10 of 50

11 C = Completed; IP = In Progress; NS = Not Started PREPARE TO DETECT C IP NS Review risks and signs and symptoms of Ebola, and train all front-line clinical staff on how to identify signs and symptoms of Ebola. Review CDC Ebola case definition for guidance on who meets the criteria for a person under investigation for Ebola and proper specimen collection and shipment guidelines for testing. Ensure EMS Crews at hospitals and other agencies are aware of Interim Guidance Emergency Medical Services Systems. Review Emergency Department (ED) triage procedures, including patient placement, and develop or adopt screening criteria (e.g. relevant questions: exposure to case, travel within 21 days from affected West African country) for use by healthcare personnel in the ED to ask patients during the triage process for patients arriving with compatible illnesses. Post screening criteria in conspicuous placements at ED triage stations, clinics, and other acute care locations (see suggested screening criteria). Designate points of contact within your hospital responsible for communicating with state and local public health officials. Remember: Ebola is a nationally notifiable disease and must be reported to local, state, and federal public health authorities. Ensure that all triage staff, nursing leadership, and clinical leaders are familiar with the protocols and procedures for notifying the designated points of contacts to inform 1) hospital leadership (infection prevention and control, infectious disease, administration, laboratory, others as applicable), and 2) state and local public health authorities regarding a person under investigation (PUI). Conduct spot checks and inspections of triage and ED staff to determine if they are incorporating screening procedures and are able to initiate notification, isolation, and PPE procedures for your hospital. Communicate with state and/or local health department on procedures for notification and consultation for Ebola testing requests. Ensure that laboratory personnel are aware of current guidelines for specimen collection, transport, testing, and submission for PUI. PREPARE TO PROTECT C IP NS Review and distribute the Guidelines for Environmental Infection Control in Healthcare Facilities. Treat all travelers with symptoms compatible with Ebola returning from affected West African countries as potential cases and obtain additional history. Ensure that PPE meets nationally recognized standards as defined by the Occupational Safety & Health Administration (OSHA), CDC, Food and Drug Administration (FDA), or Interagency Board for Equipment Standardization and Interoperability. Review plans, protocols, and PPE purchasing, with your community/coalition partners, that promote interoperability and inter-facility sharing if necessary. Ensure Ebola PPE supplies are maintained in triage, ED, and all patient care areas designated for evaluating and managing patients potentially infected with or confirmed to have Ebola Joint Commission Resources 11 of 50

12 Identify essential healthcare personnel for care of Ebola patients. Verify that all of these healthcare personnel involved in the care of Ebola patients: Meet all training requirements in PPE and infection control, Are able to use PPE correctly, Have proper medical clearance, Have been properly fit-tested on their respirator for use in aerosol-generating procedures or more broadly as desired, and Are trained on management and exposure precautions for suspected or confirmed Ebola cases. Ensure that the donning and doffing of PPE by healthcare personnel follows the guidelines in the CDC PPE guidelines found at: Ensure that there is a trained observer for all donning and doffing of PPE for all healthcare personnel as described in CDC PPE guidance: Ensure all healthcare personnel entering the room of a hospitalized patient with Ebola should be recorded and wear recommended PPE as described in: Implement observation of healthcare workers in the patient room, if possible (e.g., glass walled intensive care unit [ICU], video link) Limit the number of healthcare personnel who come into contact with PUI or confirmed Ebola patients. Ensure that non-clinical persons have limited access to PUI or confirmed Ebola patients rooms. Review and update, as necessary, hospital infection control protocols/procedures. Review policies and procedures for screening, minimizing healthcare personnel exposure, isolation, medical consultation appropriate for Ebola exposure and/or illness, and monitoring and management of potentially exposed healthcare personnel. Review and update, as necessary, all hospital protocols and procedures for isolation of PUI or confirmed infectious diseases. Review your hospital s infection control procedures to ensure adequate implementation for preventing the spread of Ebola. Review protocols for sharps injuries and educate healthcare personnel about safe sharps practices to prevent sharps injuries. Emphasize the importance of proper hand hygiene to healthcare personnel. Post appropriate signage alerting healthcare personnel to isolation status, PPE required, proper hygiene, and handling/management of infected patients and contaminated supplies. Develop contingency plans for staffing, logistics, budget, procurement, security, and treatment. Review plans for special handling of linens, supplies, and equipment from PUI or confirmed Ebola patients. Review environmental cleaning procedures and provide education/refresher training for healthcare personnel responsible for cleaning. Distribute guidelines concerning laboratory diagnostics and specimen handling to all laboratory personnel, and post the guidelines conspicuously in your hospital laboratory. Provide education and refresher training for healthcare personnel on sick leave policies Joint Commission Resources 12 of 50

13 Review policies and procedures for screening and work restrictions for exposed or ill healthcare personnel, and develop sick leave policies for healthcare personnel that are non-punitive, flexible and consistent with public health guidance. Ensure that healthcare personnel have ready access, including via telephone, to medical consultation. Conduct education and refresher training with healthcare personnel on Ebola or special pathogen handling in the laboratory. Ensure that all Airborne Infection Isolation Rooms (AIIR) are functioning correctly and are appropriately monitored for airflow and exhaust handling. Remember: CDC recommends an AIIR room be used if aerosol-producing procedures are absolutely necessary. PREPARE TO RESPOND C IP NS Review, implement, and frequently exercise the following elements with first-contact personnel, clinical providers, and ancillary staff: Appropriate infectious disease procedures and protocols, including putting on and taking off PPE, Appropriate triage techniques and additional Ebola screening questions, Disease identification, testing, specimen collection and transport procedures, Isolation, quarantine and security procedures, Communications and reporting procedures, and Cleaning and disinfection procedures. Review plans and protocols, and exercise/test the ability to share relevant health data between key stakeholders, coalition partners, public health, emergency management, etc. Review, develop, and implement plans to provide safe palliative care, adequate respiratory support, ventilator management, safe administration of medication, sharps procedures, and reinforce proper biohazard containment and disposal precautions. Review roles of the infection control practitioner to: Ensure appropriate infection control procedures are being followed, including for lab, food, environmental services, and other personnel, and Maintain updated case definitions, management, surveillance and reporting recommendations. Properly train healthcare personnel in personal protection, isolation procedures, and care of Ebola patients. Ensure that administrators are familiar with responsibilities during a public health emergency Joint Commission Resources 13 of 50

14 Identify a communications/public information officer who: Develops appropriate literature and signage for posting within the hospital (topics may include definitions of low-risk, high-risk and explanatory literature for patient, family members and contacts), Develops targeted public health risk communication messages for use in the event of a highly-suspected or confirmed Ebola case in your hospital, Develops internal messages for PUI and confirmed cases, and internal and external messages for confirmed Ebola cases, Contacts local- and state-identified Ebola subject matter experts, Requests Ebola-appropriate literature for dissemination to healthcare personnel, patients, and contacts, Prepares written and verbal messages ahead of time that have been approved, vetted, rehearsed and exercised, Works with internal department heads and clinicians to prepare and vet internal communications to keep healthcare personnel and volunteers informed, and Trains subject-matter experts to become spokespersons and practice sound media relations. Plan for regular situational briefs for decision-makers, including: PUI and confirmed Ebola patients who have been identified and reported to public health authorities, Isolation, quarantine and exposure reports, Supplies and logistical challenges, Personnel status, and Policy decisions on contingency plans and staffing. Maintain situational awareness of reported Ebola case locations, travel restrictions and public health advisories, and update triage guidelines accordingly. Incorporate Ebola information into educational activities, including physician Grand Rounds, nursing educational meetings, and other healthcare system and coalition healthcare personnel and management training opportunities Joint Commission Resources 14 of 50

15 Quick Resources List CDC has produced several resources and references to help you prepare, and more resources are in development. Information and guidance may change as experts learn more about Ebola. You should frequently monitor CDC s Ebola website and review CDC s Ebola response guide checklists for: Clinician and healthcare workers Healthcare facility information: Hospitals and Healthcare Settings Stay informed! Subscribe to the following sources to receive updates about Ebola: CDC Health Alert Network (HAN) CDC Clinician Outreach and Communication Activity (COCA) CDC National Institute for Occupational Safety and Health U.S. Department of Labor s Occupational Safety & Health Administration Newsletter Below are a few of the resources most relevant to healthcare preparedness: Ebola Virus Disease Information for Clinicians in U.S. Healthcare Settings Case Definition for Ebola Virus Disease. This case definition should be used for screening patients and should be implemented in all healthcare facilities. Safe Management of Patients with Ebola Virus Disease in US Hospitals Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals. This document provides a summary of the proper Personal Protective Equipment (PPE). Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Patients with Suspected Infection with Ebola Virus Disease Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing) National Guidance for Healthcare System Preparedness Capabilities, with particular emphases on Capability #6 (Information Sharing) and Capability #14 (Responder Safety and Health) Interim Guidance for Emergency Medical Services Systems and PSAPs. CDC is available 24/7 for consultation by calling the CDC Emergency Operations Center (EOC) at or via at eocreport@cdc.gov. Check CDC s Ebola website regularly for the most current information. State and local health departments with questions should contact the CDC Emergency Operations Center ( or eocreport@cdc.gov) Joint Commission Resources 15 of 50

16 Health Care Facility Preparedness Checklist for Ebola Virus Disease (EVD) All U.S. health care facilities need to be prepared for managing patients with infectious diseases such as Ebola virus disease (EVD). Facilities should review infection control policies and procedures and incorporate plans for administrative, environmental, and communication measures. Facilities should also define the individual work practices that will be required to detect the introduction of a patient with EVD or other emerging infectious disease, prevent spread, and manage the impact on patients, the facility, and staff. The following checklist highlights some key areas for health care facilities to review in preparation for a person with EVD arriving for medical care. The checklist format is not intended to set forth mandatory requirements or establish national standards. In this checklist health care personnel (HCP) refers to all persons, paid and unpaid, working in healthcare settings who have the potential for exposure to patients and/or to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air. HCP include, but are not limited to, physicians, nurses, nursing assistants, therapists, technicians, laboratory personnel, autopsy personnel, students and trainees, contractual personnel, and persons not directly involved in patient care (e.g., house-keeping, laundry, volunteers) Monitor the situation at CDC s EVD website: Assess and ensure availability of appropriate personal protective equipment (PPE) and other infection control supplies (e.g., hand hygiene supplies) to all health care personnel (HCP) Review facility infection control policies for consistency with the Centers for Disease Control and Prevention s Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected EVD in U.S. Hospitals ( Review environmental cleaning procedures and provide education/refresher training for cleaning staff ( Begin education and refresher training for HCP on EVD signs and symptoms, diagnosis, how to obtain specimens for testing, appropriate PPE use (including putting on and taking off PPE), triage procedures (including patient placement), HCP sick leave policies, how and to whom EVD cases should be reported, and procedures to take following unprotected exposures (i.e., not wearing recommended PPE) to suspected EVD patients at the facility Review triage procedures and ensure relevant questions (e.g., exposure to case, travel within 21 days from affected country) are asked during the triage process for patients arriving with compatible illnesses ( Ensure laboratories review procedures for appropriate specimen collection, transport, and testing of specimens from patients who are suspected to be infected with Ebola virus. ( ection-ebola.html) 2014 Joint Commission Resources 16 of 50

17 Review policies and procedures for screening and work restrictions for exposed or ill HCP, and ensure that HCP have ready access to medical consultation, including via telephone. Designate points of contact within the facility responsible for communicating with public health officials and providing internal updates for HCPs and volunteers. Confirm the local or state health department contacts for reporting EVD cases. EVD is a nationally notifiable disease and must be reported to local, state, and federal public health authorities Joint Commission Resources 17 of 50

18 Ebola 101 CDC Slides for US Healthcare Workers November 14, 2014 Presentation is current through November 14, 2014 and will be updated every Friday by 5pm. For the most up-to-date information, please visit Presentation contains materials from CDC, MSF, and WHO Ebola Virus Prototype Viral Hemorrhagic Fever Pathogen. Filovirus: enveloped, non-segmented, negative-stranded RNA virus. Severe disease with high case fatality. Absence of specific treatment or vaccine. >20 previous Ebola and Marburg virus outbreaks West Africa Ebola outbreak caused by Zaire ebolavirus species (five known Ebola virus species). Ebola Virus Zoonotic virus bats the most likely reservoir, although species unknown. Spillover event from infected wild animals (e.g., fruit bats, monkey, duiker) to humans, followed by human-human transmission Joint Commission Resources 18 of 50

19 Ebola Virus Disease (EVD) Cumulative Incidence* West Africa, October 18, 2014 * Cumulative number of reported EVD cases per 100,000 persons since December 22, MMWR 2014;63(43): Ebola Outbreak, West Africa WHO Ebola Response Team. N Engl J Med DOI: /NEJMoa Joint Commission Resources 19 of 50

20 EVD Cases and Deaths* Reporting Date Total Cases Confirmed Cases Total Deaths Guinea 9 Nov 14 1,878 1,612 1,142 Liberia 8 Nov 14 6,822 2,553 2,836 Sierra Leone 9 Nov 14 5,368 4,523 1,169 Nigeria** 15 Oct Spain 27 Oct Senegal** 15 Oct United States 24 Oct Mali 9 Nov TOTAL 14,098 8,715 5,160 Updated case counts available at *Reported by WHO using data from Ministries of Health **The outbreaks of EVD in Senegal and Nigeria were declared over on October 17 and 19, respectively. EVD Cases (United States) EVD has been diagnosed in the United States in four people, one (the index patient) who traveled to Dallas, Texas from Liberia, two healthcare workers who cared for the index patient, and one medical aid worker who traveled to New York City from Guinea. Index patient Symptoms developed on September 24, 2014 approximately four days after arrival, sought medical care at Texas Health Presbyterian Hospital of Dallas on September 26, was admitted to hospital on September 28, testing confirmed EVD on September 30, patient died October 8. TX Healthcare Worker, Case 2 Cared for index patient, was self-monitoring and presented to hospital reporting low-grade fever, diagnosed with EVD on October 10, recovered and released from NIH Clinical Center October 24. TX Healthcare Worker, Case 3 Cared for index patient, was self-monitoring and reported low-grade fever, diagnosed with EVD on October 15, recovered and released from Emory University Hospital in Atlanta October 28. NY Medical Aid Worker, Case 4 Worked with Ebola patients in Guinea, was self-monitoring and reported fever, diagnosed with EVD on October 24, recovered and released from Bellevue Hospital in New York City November 11. As of October 31, 2014, four U.S. health workers and one journalist who were infected with Ebola virus in West Africa were transported to hospitals in the United States for care. All the patients have recovered and have been released from the hospital after laboratory testing confirmed that they no longer have Ebola virus in their blood. Information on U.S. EVD cases available at Joint Commission Resources 20 of 50

21 Ebola Virus Transmission Virus present in high quantity in blood, body fluids, and excreta of symptomatic EVD-infected patients. Opportunities for human-to-human transmission. Direct contact (through broken skin or unprotected mucous membranes) with an EVD-infected patient s blood or body fluids. Sharps injury (with EVD-contaminated needle or other sharp). Direct contact with the corpse of a person who died of EVD. Indirect contact with an EVD-infected patient s blood or body fluids via a contaminated object (soiled linens or used utensils). Ebola can also be transmitted via contact with blood, fluids, or meat of an infected animal. Limited evidence that dogs become infected with Ebola virus. No reports of dogs or cats becoming sick with or transmitting Ebola. Detection of Ebola Virus in Different Human Body Fluids Over Time Human-to-Human Transmission Infected persons are not contagious until onset of symptoms. Infectiousness of body fluids (e.g., viral load) increases as patient becomes more ill. Remains from deceased infected persons are highly infectious. Human-to-human transmission of Ebola virus via inhalation (aerosols) has not been demonstrated Joint Commission Resources 21 of 50

22 EVD Risk Assessment **CDC Website to check current affected areas: Ebola Virus Pathogenesis Direct infection of tissues. Immune dysregulation. Hypovolemia and vascular collapse. Electrolyte abnormalities. Multi-organ failure, septic shock. Disseminated intravascular coagulation (DIC) and coagulopathy. Lancet. Mar 5, 2011; 377(9768): Early Clinical Presentation Acute onset; typically 8-10 days after exposure (range 2-21 days). Signs and symptoms: Initial: Fever, chills, myalgias, malaise, anorexia. After 5 days: GI symptoms, such as nausea, vomiting, watery diarrhea, abdominal pain. Other: Headache, conjunctivitis, hiccups, rash, chest pain, shortness of breath, confusion, seizures. Hemorrhagic symptoms in 18% of cases. Other possible infectious causes of symptoms: Malaria, typhoid fever, meningococcemia, Lassa fever, and other bacterial infections (e.g., pneumonia) all very common in Africa Joint Commission Resources 22 of 50

23 Clinical Features Nonspecific early symptoms progress to: Hypovolemic shock and multi-organ failure. Hemorrhagic disease. Death. Non-fatal cases typically improve 6-11 days after symptoms onset. Fatal disease associated with more severe early symptoms. Fatality rates of 70% have been reported in rural Africa. Intensive care, especially early intravenous and electrolyte management, may increase the survival rate. Clinical Manifestations by Organ System in West African Ebola Outbreak Organ System WHO Ebola Response team. NEJM Clinical Manifestation General Fever (87%), fatigue (76%), arthralgia (39%), myalgia (39%) Neurological Headache (53%), confusion (13%), eye pain (8%), coma (6%) Cardiovascular Chest pain (37%) Pulmonary Cough (30%), dyspnea (23%), sore throat (22%), hiccups (11%) Gastrointestinal Vomiting (68%), diarrhea (66%), anorexia (65%), abdominal pain (44%), dysphagia (33%), jaundice (10%) Hematological Any unexplained bleeding (18%), melena/hematochezia (6%), hematemesis (4%), vaginal bleeding (3%), gingival bleeding (2%), hemoptysis (2%), epistaxis (2%), bleeding at injection site (2%), hematuria (1%), petechiae/ecchymoses (1%) Integumentary Conjunctivitis (21%), rash (6%) 2014 Joint Commission Resources 23 of 50

24 Examples of Hemorrhagic Signs Hematemesis Gingival Bleeding Bleeding at IV Site Laboratory Findings Thrombocytopenia (50, ,000/μL range). Leukopenia followed by neutrophilia. Transaminase elevation: elevation serum aspartate amino-transferase (AST) > alanine transferase (ALT). Electrolyte abnormalities from fluid shifts. Coagulation: PT and PTT prolonged. Renal: proteinuria, increased creatinine Joint Commission Resources 24 of 50

25 EVD: Expected Diagnostic Test Results Over Time Ebola Virus Diagnosis Real Time PCR (RT-PCR): Used to diagnose acute infection. More sensitive than antigen detection ELISA. Identification of specific viral genetic fragments. Performed in select CLIA-certified laboratories. RT-PCR sample collection: Volume: minimum volume of 4mL whole blood. Plastic collection tubes (not glass or heparinized tubes). Whole blood preserved with EDTA is preferred. Whole blood preserved with sodium polyanethol sulfonate (SPS), citrate, or with clot activator is acceptable. Other Ebola Virus Diagnostics Virus isolation: Requires Biosafety Level 4 laboratory. Can take several days. Immunohistochemical staining and histopathology: On collected tissue or dead wild animals; localizes viral antigen. Serologic testing for IgM and IgG antibodies (ELISA): Detection of viral antibodies in specimens, such as blood, serum, or tissue suspensions. Monitor the immune response in confirmed EVD patients Joint Commission Resources 25 of 50

26 Laboratories CDC has developed interim guidance for U.S. laboratory workers and other healthcare personnel who collect or handle specimens. This guidance includes information about the appropriate steps for collecting, transporting, and testing specimens from patients who are suspected to be infected with Ebola. Specimens should NOT be shipped to CDC without consultation with CDC and local/state health departments. Information available at: Packaging and Shipping Clinical Specimens to CDC for Ebola Testing Interpreting Negative Ebola RT-PCR Result If symptoms started 3 days before the negative result: EVD is unlikely consider other diagnoses. Infection control precautions for EVD can be discontinued unless clinical suspicion for EVD persists. If symptoms started <3 days before the negative RT-PCR result: Interpret result with caution. Repeat the test at 72 hours after onset of symptoms. Keep in isolation as a suspected case until a repeat RT-PCR 72 hours after onset of symptoms is negative Joint Commission Resources 26 of 50

27 Clinical Management of EVD: Supportive, but Aggressive Hypovolemia and sepsis physiology: Aggressive intravenous fluid resuscitation. Hemodynamic support and critical care management, if necessary. Electrolyte and acid-base abnormalities: Aggressive electrolyte repletion. Correction of acid-base derangements. Symptomatic management of fever and gastrointestinal symptoms: Avoid NSAIDS. Multisystem organ failure can develop and may require: Oxygenation and mechanical ventilation. Correction of severe coagulopathy. Renal replacement therapy. Reference: Fowler RA et al. Am J Respir Crit Care Med Investigational Therapies for EVD Patients No approved Ebola-specific prophylaxis or treatment. Ribavirin has no in-vitro or in-vivo effect on Ebola virus. Therapeutics in development with limited human clinical trial data: Convalescent serum. Therapeutic medications. Zmapp chimeric human-mouse monoclonal antibodies. Tekmira lipid nanoparticle small interfering RNA. Brincidofovir oral nucleotide analogue with antiviral activity. Vaccines in clinical trials: Chimpanzee-derived adenovirus with an Ebola virus gene inserted. Attenuated vesicular stomatitis virus with an Ebola virus gene inserted. References: 1 Huggins, JW et al. Rev Infect Dis 1989; 2 Ignatyev, G et al. J Biotechnol 2000; 3 Jarhling, P et al. JID 2007 S400; 4 Mupapa, K et al. JID 1999 S18; 5 Olinger, GG et al. PNAS 2012; 6 Dye, JM et al. PNAS 2012; 7 Qiu, X et al. Sci Transl Med 2013; 8 Qiu, X et al. Nature 2014; 9 Geisbert, TW et al. JID 2007; 10 Geisbert, TW et al. Lancet 2010; 11 Kobinger, GP et al. Virology 2006; 12 Wang, D JV 2006; 13 Geisbert, TW et al. JID 2011; and 14 Gunther et al. JID Joint Commission Resources 27 of 50

28 Patient Recovery Case-fatality rate 71% in the 2014 Ebola outbreak. Case-fatality rate is likely much lower with access to intensive care. Patients who survive often have signs of clinical improvement by the second week of illness. Associated with the development of virus-specific antibodies. Antibody with neutralizing activity against Ebola persists greater than 12 years after infection. Prolonged convalescence. Includes arthralgia, myalgia, abdominal pain, extreme fatigue, and anorexia; many symptoms resolve by 21 months. Significant arthralgia and myalgia may persist for >21 months. Skin sloughing and hair loss has also been reported. References: 1 WHO Ebola Response Team. NEJM 2014; 2 Feldman H & Geisbert TW. Lancet 2011; 3 Ksiazek TG et al. JID 1999; 4 Sanchez A et al. J Virol 2004; 5 Sobarzo A et al. NEJM 2013; and 6 Rowe AK et al. JID Practical Considerations for Evaluating Patients for EVD in the United States CDC encourages all U.S. healthcare providers to: Ask patients with symptoms about a history of travel to West Africa in the 21 days before illness onset. Know the signs and symptoms of EVD. Know the initial steps to take if a diagnosis of EVD is suspected. CDC has developed documents to facilitate these evaluations: The EVD algorithm for the evaluation of a returned traveler. Available at The checklist for evaluation of a patient being evaluated for EVD. Available at Joint Commission Resources 28 of 50

29 EVD Algorithm for Evaluation of the Returned Traveler **CDC Website to check current affected areas: Algorithm available at Checklist available at Interim Guidance for Monitoring and Movement of Persons with EVD Exposure CDC has created guidance for monitoring people exposed to Ebola virus but without symptoms. RISK LEVEL PUBLIC HEALTH ACION Monitoring Restricted Pubic Activities Restricted Travel HIGH risk Direct Active Monitoring YES YES SOME risk Direct Active Monitoring Case-by-case assessment Case-by-case assessment LOW risk Active Monitoring for some; Direct No No Active Monitoring for others NO risk No No No Joint Commission Resources 29 of 50