Ebola Identification and Control Plan Effective Date: August 2014 Original Page 1 of 16. Revision WORKING DOCUMENT- LAST UPDATED 2/9/2015

Transcription

1 Table of Contents I. Purpose II. Objectives III. Background Information IV. Communication V. Exposure Prevention and Controls A. Common symptoms B. Less common symptoms C. Incubation period D. Transmission E. Case definition F. Treatment G. Triage H. Initiation of Special Precautions 1. Special Precautions 2. Airborne Infection Isolation (AII) Room 3. Personal Protective Equipment (PPE) 4. Public Health Reporting I. Admission of suspect or confirmed Ebola patient J. Staffing K. Laboratory Testing L. Portable Imaging M. Patient transport N. Waste disposal and Cleaning and Disinfection O. Dietary Requirements P. Pharmacy Q. Supplies R. Discontinuation of Special Isolation Precautions S. Handling of the Ebola patient body upon death VI. Exposure Surveillance VII. Known Employee Exposures VIII. References IX. Cross References X. Coordination Page 1 of 16 Appendix A: Special Precautions Isolation Sign Appendix B: Emergency Department Workflow for Screening of Patient for Ebola and MERS Appendix C: Signage for Triaging Patients for Travel History. Appendix D: Clinical Care Guidelines for Ebola (external to this document) Appendix E: Health Link Ebola Screening Process Map Appendix F: EMS Route for UW Hospital Direct Admits Appendix G: Floor Plan of F6/5 Isolation Unit Appendix H: PPE Donning and Doffing (external to this document) Appendix I: Room Entry Log Appendix J: Staff Signs and Symptoms Documentation form Appendix K: EHS Workflow for Screening Patients from Ebola Affected Countries Appendix R: Ebola Virus Disease (EVD) Biohazardous Exposure Avoidance, Recognition and Response

2 Page 2 of 16 I. PURPOSE This plan is designed as a protocol for preventing the transmission of Ebola virus (Ebola) within UWHC through prompt recognition of patients with suspected or confirmed Ebola and implementation of administrative, engineering and work practice controls. This plan is specifically focused on recognition of risk, initiation of isolation precautions and implementation of control measured in the hospital setting to prevent transmission. For ambulatory-specific plan, please refer to the Ambulatory Ebola Identification and Control Plan. II. III. OBJECTIVES A. To provide a background on Ebola B. To define a process for prompt identification of patients suspected to have Ebola C. To prevent the transmission of Ebola within the organization D. To outline the protocol for follow-up in the event of an occupational exposure to Ebola BACKGROUND INFORMATION Ebola virus disease (EVD) is caused by infection with a virus of the family Filoviridae, genus Ebolavirus. The natural reservoir for the virus is unknown; however, fruit bats are thought to be the most likely source. Based on past epidemics, the mortality of EVD ranges from 60 to 90%; there is no approved vaccine or previously identified specific treatment. Healthcare workers are at high risk for contracting illness through contact with infected blood or bodily secretions. Every effort must be made to limit transmission of EVD in healthcare facilities Emergence of EVD is most likely to occur in geographic areas with previously high incidence or prevalence. In the absence of EVD emergence within the United States or an outbreak of disease is occurring in a geographic area known to have an incidence of disease, only basic precautions will be taken to facilitate case finding and to minimize risk of spread. Details of current and past Ebola outbreaks can be found on the CDC website, IV. COMMUNICATION A. Infection Control personnel will be responsible for reporting suspect and confirmed Ebola cases to the Department of Public Health. B. Infection Control personnel will be responsible for staying abreast of changes in recommendations from CDC and state and local Public Health Agencies, and for promulgating these changes to affected clinicians, healthcare and ancillary workers by whatever means are deemed effective. ( C. The Hospital Epidemiologist or designee, may call for activation of the UWHC Biologic Event Plan if the impact of Ebola cases warrants such an institutional response for adequate management. Refer to UWHC Administrative policy, 12.20, Biological Event Plan for information on plan activation. **Activation of this plan is NOT overhead paged. D. The CDC s Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospital ( will serve as the basis of UWHCs response planning for Ebola. The most up to date version will be utilized.

3 Page 3 of 16 E. If the threat for an emerging pathogen related to international travel occurs, signage will be developed by Infection Control for posting at critical access points within UWHC instructing any patient with international travel within the past 30 days to don a surgical mask and report to a registration desk for further evaluation. F. All Ebola-related information will be posted onto an Ebola link on UConnect for ready access by all clinicians and healthcare workers. ( V. EXPOSURE PREVENTION AND CONTROLS A. Common symptoms 1. Fever 2. Headache 3. Joint and muscle aches 4. Weakness 5. Diarrhea 6. Vomiting 7. Stomach pain 8. Lack of appetite B. Less common symptoms 1. Rash 2. Cough 3. Sore throat 4. Chest pain 5. Difficulty breathing 6. Difficulty swallowing 7. Hiccups 8. Hemorrhage C. Incubation Period Symptoms may appear anywhere from 2-21 days after exposure though presentation between days 8-10 is most common. Individuals are NOT infectious until they are symptomatic. D. Transmission When infection occurs in humans, transmission can occur in the following ways: 1. Direct contact with the blood or bodily secretions of an infected symptomatic person. All secretions should be considered infectious. 2. Exposure to objects (such as needles) that have been contaminated with infected blood or secretions. 3. While is not spread through the airborne route, airborne precautions are indicated for aerosol-generating procedures such as intubation, extubation, BiPAP, bronchoscopy, sputum inductionand open airway suctions. For consistency, UWHC Infection Control recommends the use of Special Precautions which requires the use of an N-95 respirator or PAPR, Airborne Infection Isolation (AII) negative pressure room if available, as well as face shield, gown, gloves and/or other personal protective equipment (PPE) as needed.

4 Page 4 of 16 E. Case Definition 1. In the event that Ebola emerges within the United States or an outbreak of disease occurs in a geographic area known to have incidence of disease, the screening protocol developed by the CDC and the Department of Public Health will be implemented to identify suspect cases of EVD. This will be applied to all patients seeking care at UWHC. 2. A suspected Ebola case is defined as any patient who meets the current CDC definition for suspected Ebola ( or any patient for whom samples have been obtained for Ebola testing and are pending results. F. Treatment ( 1. EVD does not have a known, proven treatment. Standard treatment for EVD is limited to treating symptoms and providing supportive care. This consists of a. fluid and electrolytes administration b. monitoring and addressing cardiopulmonary status c. treating complicating infections d.. 2. Use of experimental drugs a. Questions and Answers on Experimental Treatments and Vaccines for Ebola (link). b. Experimental treatments may be requested by contacting the UWHC Pharmaceutical Research Center at (Pager ID 2877 or 2878). G. Triage All patients entering UW Health must be screened for EVD risk during registration, scheduling and presentation to ED, Urgent Care, and any clinic site (See attached Health Link EVD screening process map, Appendix E). If the patient presents with the following symptoms: 1. Travel in past 21 days to country where Ebola transmission is active OR contact with person with known Ebola infection AND 2. Fever of 99.5 or greater, headache, weakness, muscle pain, vomiting, diarrhea, abdominal pain or hemorrhage. Implement the following: 1. Registration and Greeter staff must don PPE to include face shield, mask, gloves and gown. 2. Instruct the patient to wear a yellow procedure mask 3. If patient must wait in waiting area, a separate waiting area at least 6 feet away from other patients and visitors must be designated. The use of a wheelchair is preferred. 4. Immediately initiate Special Precautions (see attached signage). 5. See section V.H.3 for use of PPE. 6. If available, move the patient to an Airborne Infection Isolation (AII) negative pressure room with a private bathroom as soon as possible. If an AII room is not available or is not preferred, a patient bathroom must be designated for use only by the patient suspected to have Ebola. 7. If there is any question as to the exclusion of Ebola as the illness in question CALL PAGING at and ask to page the Emerging Pathogen-MD Contact pager ID If a patient presents to a clinic with risk factors suspicious for Ebola, the patient should be

5 Page 5 of 16 masked and roomed immediately with use of PPE as directed under section V.H.3. An AII room shall be utilized if available. A designated patient bathroom shall be assigned. The clinician shall contact paging at and ask to page the Emerging Pathogen-MD Contact pager ID 4400 for further guidance. Refer to UW Health -Ambulatory Ebola Identification and Control Plan. 9. If the Emerging Pathogen MD deems that an Ebola risk exists, the patient will be admitted to UW Hospital F6/5 Isolation Unit and the Ebola List Page must be activated at pager 3500 by the Emerging Pathogen MD If a non-ebola diagnosis is established and the clinician deems Ebola to have been ruled out, the patient will be removed from Special Precautions and treated in accordance with precautions appropriate to the etiology identified. The Infection Control Practitioner on-call shall be notified at pager 2570 prior to discontinuing Special Precautions. 11. If no exclusionary diagnosis to explain the patient s symptomology has been made, Ebola testing, in consultation with the Wisconsin Department of Public Health, may be considered. If Ebola testing is ordered, the patient will be presumed to have Ebola and remain under Special Precautions isolation until testing proves otherwise, or an alternative diagnosis is eventually made. 12. If indicated for patients of patient contacts, the Infection Control Department will consult with the Department of Public Health regarding coordination of home quarantine or isolation. Initiation and enforcement of home quarantine and home isolation in order to minimize community exposure, falls under the purview of the Public Health Department. a. Home quarantine - Restriction of healthy persons exposed to, and therefore potentially incubating, Ebola to their home in order to minimize community exposure. b. Home isolation - Restriction of ill persons with suspect or confirmed Ebola who do not require hospitalization to their home in order to minimize community exposure. H. Initiation of Special Precautions 1. Special Precautions Any patients identified during the screening process as potential Ebola cases will be immediately placed under Special Precautions isolation (See attached signage). 2. Airborne Infection Isolation (AII) Room (negative pressure room) a. A designated negative pressure ventilation airborne infection isolation (AII) room with separate roofline exhaust is required, if available, for Special Precautions. b. These rooms are identified by signage stating that Negative Pressure Room, Suitable for Airborne Precautions. The Plant Engineering department will be responsible for verifying the pressure of AII rooms to ensure that they maintain proper airflow. c. If a pressure monitor alarms or questions arise regarding the proper function of monitors or room ventilation, Plant Engineering will investigate immediately. 3. Personal Protective Equipment (PPE) (Refer to Appendix H, PPE donning and Doffing Poster and PPE Matrix) a. Once PPE is donned, it shall not be adjusted while providing patient care. The choice of PPE must be risk based as follows: 1. If providing indirect patient assistance (i.e. Registration staff, Security Escorts, ambulatory clinics) in which no physical contact is made with the patient. The following PPE (Standard Equipment) must be worn if within 6 feet of the patient: a. Double Gloves b. Fluid resistant gown (optional if risk of vomiting)

6 Page 6 of 16 c. Yellow procedure mask d. Face shield 2. If providing direct patient care, the following PPE (multi-component) must be worn at minimum. PPE MUST BE WORN SO THERE IS NO EXPOSED SKIN OR MUCOUS MEMBRANES WHEN PROVIDING DIRECT PATIENT CARE, WORKING WITH LABORATORY SPECIMENS OR CLEANING AREAS WITH THE POTENTIAL FOR HEAVY VIRUS CONTAMINATION: a. N-95 mask b. Face shield c. Fluid resistant gown d. Gloves (triple) i. Short cuff nitrile ii. Long cuff nitrile iii. Short cuff nitrile (patient care) e. Fluid resistant boot covers f. Surgical hood 3. In some situations, use of the following PPE for procedures involving large volumes of blood or body fluids (patient is vomiting, is incontinent, blood draws, aerosol generating procedures) or for when long periods of patient contact are anticipated will be more practical than multi-component PPE. i. Fluid resistant coverall ii. PAPR with long disposable hood Use of the coveralls requires the external disinfection of the suit using a bleach solution prior to removal of the coverall. Competency for multi-component and coverall/ PAPR donning and doffing must be established prior to use. b. Remove PPE in accordance with Appendix H, taking great care to not contaminate your body during the removal process. All PPE must be removed in the designated PPE Removal Area. This area must be designated prior to patient care. If PPE is designated to be removed within the patient room, there must be at least 6 feet between the patient and the PPE removal area if risk for significant exposure exists (i.e., vomiting). The N-95 respirator must be removed after leaving the patient room. Competency for PPE removal must be established prior to patient care. A poster depicting sequence for PPE removal shall be placed in the designated PPE removal area. (Appendix H) c. A PPE removal buddy will assist with PPE removal 1. The PPE removal buddy must don complete PPE during the removal process as described in IV.H.3.A.2 above for those having direct contact with patients. 4. Public Health Reporting The Infection Control Practitioner on call will be immediately notified of all suspect, probable or confirmed Ebola cases in order to facilitate reporting to Public Health Agencies for appropriate follow-up. I. Admission of Suspect or Confirmed Ebola patient

7 Page 7 of Patients entering UW Hospital through the Emergency Department must be screened for Ebola exposure risk (See V.G.). If after screening questions and consult with Emerging Pathogen-MD, the patient is deemed to be at risk for Ebola infection, they will be admitted to F6/5 for further testing and medical management. 2. If the patient presents to a clinic or from an outside facility, they will preferably be admitted to F6/5 bypassing the ED. 3. Direct admits will be coordinated by the Access Center per usual protocol. The Access Center will implement the same screening questions as registration staff and will consult with the Emerging Pathogen MD (pager #4400) and the admitting physician about activation of the Ebola protocol for admission to F6/5. 4. All direct admits should be instructed to enter the facility, preferably by EMS, at the loading dock for entry at the E2 core (see map of EMS Route for Direct Admits, Appendix F). 5. Activation of the Ebola isolation unit, F6/5, will be designated as the first Ebola isolation unit set aside exclusively for the admission and care of suspect or confirmed Ebola cases. The F6/5 isolation unit will be utilized for all ages and level of care. Healthcare personnel appropriate for the age and level of care will be assigned to the patient. a. Current patients in F6/5 will be relocated to F6/4 through coordination with the Nursing Coordinator and unit nursing management. b. Refer to the floor plan of F6/5 Isolation Unit, Appendix G, in this plan for layout of unit. 1. F6/56 Point of Care Lab 2. F6/562 Point of Care Lab Doffing (PPE Removal) Room 3. F6/58 Patient Room 4. F6/560 Doffing Room c. At minimum, the following persons will be involved in the transfer of the patient from the ED to F6/5: 1. Two inpatient nurses assigned to the patient 2. Security (refer to Job Action Sheet) 3. Two Environmental Services personnel (refer to Job Action Sheet) d. Isolation precautions must be maintained during transfer e. The transfer route must be secure and restricted from entry by visitors or nontransport staff. f. Patient relations will be apprised of this transfer in order to be able to respond to questions from patients or their families. 6. Specific requests from public health agencies to admit an individual patient under extenuating circumstances will be considered by the Emerging Pathogens MD (pager 4400). The Emerging Pathogens MD will have ultimate decision making authority in these circumstances. Refer to Communication and Transfer Plan. 7. The Director of Plant Engineering will be asked to set aside sufficient material and personnel resources to enable conversion of an inpatient unit wing to negative pressure within 90 minutes (large HEPA filtered evacuation fan, material to block recirculation of unit air), and also to procure ventilation materials needed to permanently convert a unit to negative pressure with 100% exhaust for installation.. J. Staffing 1. The Hospital Epidemiologist, or designee, will have broad authority to implement restrictions on entry of nonessential persons, dependent upon the number of potential or confirmed Ebola cases, the pattern of community or nosocomial transmission and other

8 Page 8 of 16 epidemiologic parameters. Final decisions will be made in conjunction with Hospital Administration. 2. Volunteers to form a multi-disciplinary treatment team will be solicited in advance if possible. If adequate staff is not available, then duty to treat policies would be implemented. 3. A log shall be maintained of all persons entering an isolation area (refer to floor plan of F6/5 isolation unit, Appendix G). On F6/5 there will be a log for entry onto the isolation wing as well as entry beyond the red line to the patient room, doffing rooms and the point of care lab. Personnel will be posted outside the room to ensure that appropriate use of PPE is observed for all who enter the patient room. Only individuals essential to care of the patient should enter the patient s room. Visitors are not allowed. Only essential blood draws and radiology should be performed on the patient to minimize entry of ancillary support personnel in the room. 4. A staff member will be assigned to secure the patient room entry to ensure proper PPE and limited room access. On F6/5 a staff member will also be assigned to secure the entry to the Isolation Unit. This assignment will initially go to a Security Officer and then be transferred as appropriate. 5. If possible, staff assigned to care for potential or confirmed Ebola patients will be cohorted to minimize the number of employees with potential exposure. 6. Nursing teams assigned to the care of the patient will work 12 hour shifts. Ideally each nurse will share patient care duties with 4 hour care assignments each. (Refer to Nursing Care Ebola Plan). 7. Cohort staff will work only with suspect or confirmed Ebola cases and will not be permitted to provide care to non-suspect Ebola patients. 8. Patient care staff who typically cover multiple hospital areas must also be cohorted. 9. Infection Control personnel or designee will serve as the Ebola Protocol Managers and will provide targeted education to personnel on the unit housing the suspect or confirmed Ebola case and to other staff who enter the unit to care for the patient or perform housekeeping of the patient s room. This targeted education will be in addition to housewide educational efforts and will include descriptions of currently understood routes of Ebola transmission, engineering and work practice controls to avoid infection, symptoms of Ebola, what to do in the event of unprotected exposure to Ebola or if symptoms compatible with Ebola develop in the employee. K. Laboratory Testing 1. Specimen for Ebola Virus Disease testing must be approved by Wisconsin Department of Public Health. i. During business hours (M-F 7:45 am 4:30 pm) - Call ii. After hours and weekends - Call Specimen should be collected in the isolation unit and packaged in the Emerging Pathogen POC Lab following procedures developed for specimen transport on that unit. 3. Specimen for testing of Ebola will be sent directly to the CDC or designated State Health Laboratory for testing as Category A. Only trained personnel may package and send Category A. Lab maintains a list of trained personnel. ( 4. Diagnostic specimens from suspected Ebola cases will be collected and handled in accordance with current CDC recommendations Staff

9 Page 9 of 16 working in the EP POC Lab will use PPE following the instructions given in V. H. 3. above. As always, any laboratory procedure which may spatter blood, body fluids, or any solution or reagent containing patient materials must be performed in a biological safety cabinet or behind a splash shield. 5. As laboratory testing occurring within the laboratory cannot be limited to performance within a biological safety cabinet and is performed on open systems, testing will be limited to the following POC menu. i. Blood gases ii. Electrolytes, whole blood iii. CBC with three part differential iv. Glucose, whole blood v. Lactate, whole blood vi. BUN, whole blood vii. Creatinine, whole blood viii. Amylase, whole blood ix. AST, whole blood x. ALT, whole blood xi. Total Calcium, whole blood xii. Ionized Calcium, whole blood xiii. GGT, whole blood xiv. Total Bilirubin, whole blood xv. Total Protein, whole blood xvi. Uric Acid, whole blood xvii. Urine dipstick xviii. Urine pregnancy xix. INR, whole blood xx. Malaria screen, whole blood xxi. HIV Screen, whole blood xxii. Influenza A/B Antibody, nasopharyngeal swab xxiii. Respiratory syncytial virus (RSV), nasopharyngeal swab xxiv. ABO typing if experimental plasma treatment is considered, whole blood 6. The laboratory can perform the complete POC menu above once per day. Daily test menu may be adjusted based on consultation with clinical team. Any additional testing will be performed by nursing personnel caring for the patient and will be limited to glucose, blood gases, sodium, potassium, ionized calcium, lactate and hematocrit. 7. Any testing performed will be collected using preassembled collection kits. The Laboratory Patient Services Manager will assist Nursing in preparation of the collection kits. Instructions for use of collection supplies and order of draw are available on the isolation unit. 8. All POC instrumentation and equipment required to do testing within the isolation area will be transported to F6/562 by plant engineering. Laboratory personnel must accompany plant engineering as equipment is moved. 9. All instrument and specimen waste from testing should be included in the patient waste stream described in O. When the unit is dismantled, instrumentation should be cleaned following manufacturers guidelines. 10. Any request for additional testing, please contact laboratory Medical Director, pager # L. Portable Imaging

10 Page 10 of Radiology imaging specialist will bag the imaging arm of the portable imaging machine. 2. Radiology imaging specialist will advance the portable imaging machine to the red line. 3. Radiology imaging specialist will bag and securely tape the imaging receptor, then place into an additional clear bag that is not taped. 4. Patient s nurse will don lead apron located in the patient s restroom (where it is stored and not to leave the patient room). 5. Patient s nurse will position the covered imaging receptor with direction from the imaging specialist standing behind the red line. 6. Patient nurse will advance portable imaging machine into the patient room. Radiology imaging specialist will maintain possession of the imaging exposure button. 7. Patient nurse will finalize positioning of receptor and tube and take exposure. 8. Once the imaging has been completed, the nurse will doff the apron and put aside to clean. 9. Patient s nurse will remove imaging receptor from behind the patient. 10. Patient s nurse will clean the outside bag covering the imaging receptor with a bleach wipe. 11. Patient s nurse will take the imaging receptor to the red line and hold the outside bag to allow the resource nurse to remove the imaging receptor from the bag. 12. The resource nurse will clean the inner bag covering the receptor then remove the tape and bag while cleaning the receptor. The plate should be handed to the imaging specialist for additional cleaning and is then taken to process. 13. Once the imaging is confirmed, patient s nurse or resource nurse will relocate the imaging machine from the patient room to the doffing room. The resource nurse will disinfect and remove the bag from the imaging arm. The resource nurse will then proceed to clean the portable imaging machine. The portable imaging machine may be disinfected with UV light and bleach wipes. 14. The resource nurse will use bleach wipe mops to wipe the floor outside of the doffing room. 15. The resource nurse will relocate the portable imaging machine from the doffing room to in front of the red line. The cleaned/disinfected imaging machine will be stored on the unit in F6/556 M. Patient Transport 1. Transport outside the room should be avoided if possible. Infection Control must be contacted at pager 2570 prior to any patient transport. 2. Patient must wear a yellow procedure or a surgical mask. It will be the responsibility of the patient s primary nurse to ensure that the patient s mask is secured correctly prior to transport. 3. If use of the elevator is required, the elevators will be used only for the patient and the transport team and the elevator will be commandeered to the necessary floor and cleaned/disinfected by EVS after use. 4. Special Precautions must be maintained during transport. 5. All routes of transport must be secured and traffic outside the transport team restricted. N. Waste Disposal and Cleaning/Disinfection 1. The CDC s Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus ( will be followed.

11 Page 11 of All waste generated from a suspect or confirmed Ebola patient should be placed in red biohazard containers, bags for non-sharp items and sharps containers for needles and other sharp objects.. All bags should be double bagged and disinfected between bagging. Sharps containers, once closed, should also be double bagged in red biohazard bags and disinfected between bagging. 3. The patient toilet shall be treated with bleach for 5 minutes prior to flushing. 4. All waste generated from suspect or confirmed Ebola must be segregated from other biohazard waste and must be packaged in accordance with DOT category A requirements. The waste with then be sent to a Thermal Destruction Facility in collaboration with MERI. Contact Jim Fitzpatrick, MERI, ( ). 5. To reduce exposure among staff to potentially contaminated textiles (cloth products) while laundering, discard all linens, non-fluid-impermeable pillows or mattresses, and textile privacy curtains as a regulated medical waste. Pillows and mattresses should be discarded after patient discharge as regulated medical waste. 6. To minimize contamination of hard to clean surfaces, cloth covered furniture and cloth window dressings are restricted from the room. 7. Body fluids may be disposed into the normal sewer system after being treated with bleach. 8. Diligent environmental cleaning and disinfection and safe handling of potentially contaminated materials is essential, as blood, sweat, emesis, feces and other body secretions represent potentially infectious materials. 9. For surfaces with visible contamination of blood and body fluids, it is critical to first apply disinfectant to the surface to clean the surface and then reapply disinfectant a second time to disinfect the surface. 10. Use a U.S. Environmental Protection Agency (EPA)-registered hospital disinfectant with a label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus) to disinfect environmental surfaces in rooms of patients with suspected or confirmed Ebola virus infection. The regular hospital disinfectant detergent will kill it. 11. Daily cleaning will be performed by nursing staff caring for the patient. 12. Discharge cleaning will be performed by environmental services staff. 13. Any staff member performing cleaning and disinfection practices should wear the following PPE. a. N-95 respirator b. Surgical hood c. Face shield d. Disposable fluid resistant gown e. Fluid resistant shoe covers f. Fluid resistant leg covers g. Triple gloving 1. Short cuff nitrile 2. Long cuff nitrile 3. Short cuff nitrile O. Dietary Requirements 1. Disposable plates, cups and silverware should be used whenever possible. 2. Food service workers should not deliver food trays to suspect or confirmed Ebola patients. This task should be performed by the nursing staff caring for the patient.

12 Page 12 of 16 P. Pharmacy 1. Pharmacy staff should not enter the patient room. Consultation with the patient may occur via phone. 2. A runner should be utilized to pass medications from pharmacy to the primary nurse. Q. Supplies 1. The Director of Materials Management will be asked to order and stock PPE as needed. Supplies and quantity needed will be determined in consultation with the Infection Control Department and the Safety Director. Depending on current supply on hand and general vendor availability, items to stock may include: a. N-95 respirators b. surgical masks and/or procedure masks c. face shields d. disposable fluid resistant gowns e. long and short cuff gloves f. fluid resistant shoe covers g. fluid resistant leg covers h. Fluid resistant head covers-surgical hoods i. Fluid resistant coveralls TyChem j. Fluid resistant PAPR hood k. Duct tape l. PAPR hose clamps m. 2 Adhesive waterproof tape n. Bleach wipes o. Quat #23 spray p. Red biohazard bags q. Clorox toilet bowl cleaner R. Discontinuation of Special Precautions Duration of precautions should be determined on a case-by-case basis, in conjunction with the local, state and federal health authorities, Infection Control and the Hospital Epidemiologist. S. Handling of the Ebola patient body upon death 1. The CDC Guidance for Safe Handling of Human Remains of Ebola Patients in U. S. Hospitals and Mortuaries ( will be followed. 2. In all cases of suspected or confirmed Ebola patient death: i. The body will remain in the patient room under video surveillance until the Medical Examiner is contacted and allowed to view the body. ii. Nursing staff will assume responsibility for appropriate packaging of the body as follows: i. Leave any medical devices such as urinary catheters, intravenous lines or endotracheal tubes that may be present in place. ii. Avoid washing or cleaning the body. iii. Obtain plastic shroud and two leak-proof body bags not less than 150 μm thick from the morgue Ebola Kit. iv. While in the Ebola isolation unit, the body should be first wrapped in a

13 Page 13 of 16 plastic shroud. v. After wrapping in a shroud, the body should be immediately placed in a leakproof plastic bag not less than 150 μm thick and zippered closed. vi. The bagged body surface is then decontaminated with EPA-registered hospital disinfectant, prior to being placed in another leak-proof plastic bag that is not less than 150 μm thick and zippered closed. vii. The surface of the second body-containing bag should also be decontaminated with an EPA-registered hospital disinfectant. viii. Nursing shall then tape a Special Precautions isolation sign to the outside of the second body bag. iii. Nursing and Security will assume responsibility for transporting the body to the morgue cooler. Two nurses wearing freshly donned full PPE (Multi-component at minimum) will transport the body of a patient with confirmed or suspected Ebola to the morgue. A security office will escort the transit team and will be donned in standard equipment PPE (Gown, double gloves, mask, and face shield). The security officer will have no physical contact with the body. iv. A log will be kept of all morgue personnel entering the room/cooler in which there is a decedent with suspected or confirmed Ebola. The log will be submitted to Employee Health Services to arrange daily monitoring of staff for signs and symptoms of Ebola. v. All morgue personnel will wear standard equipment PPE (Gown, double gloves, mask, and face shield)when in the room with body of a suspected or confirmed Ebola patient. vi. The body bag(s) should not be opened once closed unless the patient is ultimately confirmed NOT to have Ebola. 3. In cases of suspected Ebola: i. The body will be stored in the morgue cooler until antemortem blood can be sent for confirmative testing; the body should not be released for funeral services until Ebola ii. testing is finalized to minimize community infection risk. If no appropriate antemortem sample exists, a postmortem EDTA blood sample in a plastic tube will be obtained on the isolation unit prior to transferring body to the morgue. 4. In cases of confirmed Ebola: i. Autopsy will not be performed. If an autopsy is deemed absolutely necessary, the state health department and CDC will be consulted regarding additional precautions, and the exam will be performed by autopsy personnel trained in handling infected human remains. The CDC can be reached for consultation at ii. Prior to releasing the body for funeral arrangements, morgue staff will confirm that the funeral home is familiar with CDC recommendations for mortuary care. iii. Multi-component PPE should be donned at least until the body is in a sealed coffin or cremated. iv. The funeral home should be contacted to provide the casket or cremation container. Morgue staff will seal the body in the container if staff are available to do so. v. Cremation is preferred to burial. For burial, a Ziegler case that can be hermetically sealed with screws is preferred. vi. Embalming should be avoided. VI. EXPOSURE SURVEILLANCE

14 Page 14 of 16 The CDC Interim Guidance for Monitoring and Movement of Persons with Ebola Virus Disease Exposure will serve as the basis for the guidance for the below recommendations. ( A. Continuous surveillance for early symptoms of Ebola will be required of all staff cohorted to care for potential or confirmed Ebola patients, and those who have otherwise had potential contact with an Ebola patient. If there is evidence that nosocomial transmission of Ebola has occurred within UWHC, this surveillance may be expanded to include additional employee groups, at the discretion of the Hospital Epidemiologist. B. A log shall be maintained of all persons entering the F6/5 isolation unit and/or the patient s room and personnel will be posted outside the room to ensure that appropriate use of PPE is observed for all who enter the patient room. C. Self-surveillance will consist of taking one s temperature and monitoring for other symptoms (Refer to Appendix J) at designated times, at least two times each day in the am and pm and at least 6 hours apart in addition to: 1. Immediately, if the employee begins to feel feverish or chilled, develops headache, muscle aches, diarrhea, or feels otherwise ill. 2. Self-surveillance will continue for at least 21 days after the last possible exposure to Ebola. 3. Fever reducers such as acetaminophen and ibuprofen should be avoided as much as possible when monitoring temperature and should not be taken in the 4 hours prior to taking temperature D. Any employee required to perform self-surveillance for Ebola will be excluded IMMEDIATELY from their job duties and evaluated by a physician if they develop a fever. Employees who develop a fever at home will be required to contact the Emerging Pathogen-MD by calling paging at and ask to page Any employee who develops fever or symptoms shall call ahead of presenting to a medical facility. VII. KNOWN EMPLOYEE EXPOSURES A. Any employee required to perform self-surveillance for Ebola who develops a fever greater than 99.5 F or other symptoms of Ebola (Refer to Sign and Symptom Documentation Form, Appendix J)) must be immediately excluded from duty and medically evaluated. If the fever is discovered while at home, the employee is to remain at home and contact The Emerging Pathogens MD by calling paging at and ask to page Emerging Pathogen MD Contact pager ID B. The Emerging Pathogen MD will provide medical guidance and will notify the on call Infection Control Practitioner.. C. The on call Infection Control Practitioner will notify WI DPH of the exposure. D. The employee will remain excluded from duty until directed to return by WI DHP. E. The WI DPH, in consultation with UWHC Infection Control Department and Employee Health Services, will have authority to exclude any employee from duties. F. If there is any question about the appropriateness of exclusion from duty or the duration of such exclusion, the WI DPH will have ultimate discretion and authority to define the exclusion parameters for potentially infectious employees. G. The Infection Control Department will have responsibility for providing the names, addresses and contact information of excluded employees to the state and local Health Department with jurisdiction over the employee s county of residence in order to facilitate follow-up with regard to home quarantine or home isolation. H. Any employee who believes that they have incurred an exposure to Ebola, but who has not been identified as part of a Communicable Disease Exposure follow-up, should report the exposure to the Infection Control Practitioner on call via the paging operator ( ). After normal business

15 Page 15 of 16 hours, call paging at and ask to page Emerging Pathogen MD Contact pager ID I. Refer to the Ebola Virus Disease Biohazardous Exposure Avoidance, Recognition and Response plan for more information regarding exposure management (Appendix K). VIII. REFERENCES A. Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals ( document contains a number of topic-specific Supplements, the most relevant to the hospital environment are described below: B. Ebola Virus Disease Information for Clinicians in U.S. Healthcare Settings ( provides guidance to clinicians regarding clinical presentation and clinical course for patients with Ebola. C. Safe Management of Patients with Ebola Virus Disease (EVD) in U.S. Hospitals ( provides an overview of managing patients with Ebola. D. Interim Guidance for Monitoring and Movement of Persons with EVD Exposure ( provides guidance for preventing Ebola transmission in moving persons with Ebola virus disease. E. Interim Guidance for Specimen Collection, Transport, Testing and Submission ( provides guidance for specimen collection, transport, testing and submission or patients suspected or confirmed to have Ebola. F. Ebola Infection Control Resources ( Infection-Control-Resources.aspx) provides guidance from the Society of Healthcare Epidemiology of America (SHEA). G. Information for Health Care Workers ( H. Viral hemorrhagic disease provides guidance for preventing Ebola transmission from the Wisconsin Department of Public Health. ( I. Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus ( J. Guidance for Safe Handling of Human Remains of Ebola Patients in U. S. Hospitals and Mortuaries ( K. Questions and Answers on Experimental Treatments and Vaccines for Ebola ( IX. CROSS REFERENCES A. UWHC Administrative Policy #13.08, Hand Hygiene. B. UWHC Administrative Policy #13.07, Standard Precautions and Transmission Based Precautions (Isolation) for Inpatient Settings. C. UWHC Administrative Policy# 13.28, Precautions & Transmission-based Precautions (Isolation) for Ambulatory Settings. D. UWHC Administrative Policy #13.04, Communicable Disease Reporting. E. UWHC Administrative Policy #13.11, Guidelines for Investigation of a Potential Epidemic within UWHC. F. UWHC Administrative Policy #13.21, Communicable Disease Exposure Response

16 Page 16 of 16 G. UWHC Administrative Policy #12.17, External Disaster Plan H. UWHC Administrative Policy #12.20, Biologic Event Plan X. COORDINATION Sr. Administrative Sponsor: Senior Vice President, Medical Affairs Author: Infection Control Practitioner Review/Approval Committees: Hospital Epidemiologist Infection Control Committee Administrative Policy and Procedures Committee UWHC Medical Board Nasia Safdar, M.D. Hospital Epidemiologist Ron Sliwinski, CEO