Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola virus, although 8-10 days is most common.

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1 Introduction: This protocol is intended to address the transport and PPE requirements of patients with a positive Ebola screen. The 2014 Ebola outbreak is one of the largest Ebola outbreaks in history and the first in West Africa. It is affecting four countries in West Africa: Guinea, Liberia, Nigeria, and Sierra Leone. Although Ebola does not pose a significant threat to the United States at the time of this publication, the CDC has reported documented Ebola cases that have been treated in the U. S. Ebola, also known as Ebola virus disease, is a rare and deadly disease caused by infection with one of the Ebola virus strains (Zaire, Sudan, Bundibugyo, or Tai Forest virus). Ebola was discovered in 1976 near the Ebola River in what is now the Democratic Republic of the Congo. Since then, outbreaks have appeared sporadically in several African countries. Signs and Symptoms of Ebola: Fever Severe headache Muscle pain Weakness Diarrhea Vomiting Abdominal (stomach) pain Unexplained bleeding Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola virus, although 8-10 days is most common. Transmission: When an infection does occur in humans, the virus can be spread in several ways to others. The virus is spread through direct contact (through broken skin or mucous membranes) with: a sick person's blood or body fluids (urine, saliva, feces, vomit, and semen) objects (such as needles) that have been contaminated with infected body fluids infected animals

2 Healthcare workers and the family and friends in close contact with Ebola patients are at the highest risk of getting sick because they may come in contact with infected blood or body fluids. Emergency Calls: Upon receiving a call, the Communications Center will attempt to screen the caller to determine if the patient has any identified medical complaints. If it is determined the patient has signs, symptoms, and a travel history which would put them at risk for having Ebola, the ambulance crew will be notified. The EMS crew should also screen the patient prior to making any physical patient contact. Screening questions that should be asked are: 1. What symptoms is the patient having? If the patient is not having any symptoms consistent with Ebola, proceed with patient contact and treatment as usual. If the patient is having any signs and symptoms consistent with Ebola, ask about travel history. 2. Did the patient travel to or have any physical contact, within the past 21 days, with anyone exhibiting symptoms Ebola or from areas where there is a known Ebola outbreak such as the following W. African countries? Guinea, Liberia, Nigeria, or Sierra Leone If the patient has a positive screen, the Communications Center will contact the HSE Department to provide further guidance and the local ODS to bring additional PPE to the scene. The EMS crew should then prepare the ambulance for transport and explain to the patient what they are doing. If the patient does not have any of the signs and symptoms or a positive travel history, the EMS crew should proceed with normal patient care and/or contact. Call Pre-Screening/Planning: It is possible that Acadian or other EMS organizations might be asked to transfer a patient with a positive screen for Ebola between healthcare facilities. To assure patient, public and employee safety, such a transport must be carefully planned.

3 Scheduled Ebola Patient Transport: The steps below describe the process local practices should follow: Upon receiving a call for a scheduled Ebola transport, the Communications Center will discuss the following with the sending facility: 1. The exact pick up location and where the ambulance should be parked. 2. As with any inter-facility transport, confirm the treatment that the patient will need to receive during transit (medications, ventilator, etc.) and assure that it is within the scope of practice. If necessary, request that the hospital provide an appropriately trained clinician to provide "out of scope" care during transport. 3. Assure that the receiving facility is aware of the patient's status and has the appropriate team to receive the patient. Confirm the timing of the transport. 4. Prior to arrival at the sending facility, assure the HSE representative has been notified and discussions have taken place to assure additional PPE is on hand and will be donned. PPE Requirements: Upon coming in contact with a patient that has a positive Ebola screen, the following PPE shall be worn: Eye protection (Goggles) N 95 Respirator Exam gloves (double gloving required) Tyvek suit with hood Booties (Shoe covers) Preparing the Ambulance for Transport: Ambulance preparation will be done with the purpose of segregating the cab from the patient compartment and covering the cabinetry/shelving, ceiling, seating and floor with an impermeable barrier.

4 Supplies needed: Plastic sheeting (visqueen) Duct tape Scissors Procedures: All sheeting should overlap prior sheets of plastic by a minimum of 1 inch. All seams should be sealed completely by duct tape. 1. Remove all unnecessary medical equipment and place in the cab of the ambulance. 2. Cover the ceiling of the patient compartment with plastic sheeting and affix with duct tape. 3. Place sheeting on the floor of the rig and affix to bench seat, jump seat and walls to create a bowl affect in an effort to channel any body fluids toward the center of the floor causing fluids to collect in one area. 4. Place plastic sheeting over the walls (sides and bulkhead) by affixing it to the edges of the sheeting for the ceiling and floor with duct tape to enable any flow of fluid to be captured on the sheet on the floor. 5. Wall sheeting should overlap with the upper portion over the lower portion to prevent any body fluid from leaking between sheets by gravity. 6. The gurney antlers and clamp will need to be accessible through the plastic sheeting for safe transport of the gurney and patient. Seal these openings generously with duct tape so that all fluids flow to the sheeting on the floor. 7. Leave openings around ventilation ports to allow proper airflow and exchange. 8. Continue to overlap sheeting down and over seating to the floor. Cover rear doors with plastic sheeting and duct tape. Stretcher Preparation: Supplies needed:

5 Impermeable Mattress Cover Cover mattress pad with fitted impermeable mattress cover. If no impermeable mattress is available then use plastic sheeting and seal with duct tape. Crew Preparation: If the patient is able to walk to the ambulance, have them do so and have the patient don PPE as is required for EMS personnel. This will only require one crew member to have to don additional PPE and the other crew member to drive the ambulance and supervise the donning and doffing of PPE. If the patient is unable to walk to the ambulance, Communication Center will dispatch a second ambulance to the scene to provide a third crew member. The third crewmember, Driver, will assume no patient contact nor enter the patient compartment. Their sole purpose will be to remain uncontaminated during the transport, supervise the donning and doffing of PPE, and to drive the ambulance to the destination. Prior to patient contact, each patient caregiver will don the PPE while the other crewmember assists by both checking for integrity issues or exposed body parts. Transport to Hospital and Patient Care: 1. Patient care during transport should be limited to supportive care and the on call medical director should be notified for guidance if further treatment is required. If any at risk procedure is required, it should not be done in a moving ambulance. The ambulance must stop until the procedure is completed and used sharps and other waste are properly disposed of. 2. Family or friends of the infected patient should not ride in the ambulance and should be instructed to stay home. 3. When calling the receiving facility, make them aware you are transporting a patient with positive screen for Ebola and ask for specific instructions as to where to unload the patient. 4. Preplan the unloading procedure with the receiving facility.

6 5. Patients with a positive screen for Ebola should be isolated away from public areas as designated by the facility staff. They also should not be moved through or temporarily left in waiting rooms. 6. Upon arriving at the receiving facility, make contact with the staff and do not unload the patient until they are ready to receive them. After patient care has been transferred, doff PPE as indicated in donning and doffing procedures and dispose of properly. Notification Guidelines: 1. Any communications or notifications need to be done by the crew member not participating in patient care. 2. The transporting crew must notify the Communications Center of a transport with a positive screen for Ebola as soon as possible if they were not already aware. 3. Acadian Communications Center will contact the HSE Representative on call to provide assistance and further guidance and will also notify the respective OM, DOO, and VPO. 4. When the HSE representative is contacted, he/she will consult with the on call Medical Director as needed for further guidance. 5. For Louisiana Operations only, the ambulance crew must notify the Louisiana Department of Health and Hospitals as soon as feasible to report a patient with a positive screen for Ebola. The phone numbers the EMS crew must call are: , or At the time of this publication, there are no numbers to report transports for the Texas or Mississippi markets. If this changes, these numbers will be provided. 6. Any other notifications to local entities or agencies shall be handled by the local Operations Management. Environmental Infection Control/Decontamination Procedures: 1. The transporting ambulance and crew will immediately be placed out of service until appropriate decontamination of equipment can be completed. 2. Diligent environmental cleaning and disinfection and safe handling of potentially contaminated materials is paramount, as blood, sweat, emesis, feces, and other body secretions represent potentially infectious material.

7 3. Only one person that provided patient care should be used to doff and disinfect the ambulance module. The other person should be used to watch over and supervise the process looking for any at risk behaviors. 4. The person performing environmental cleaning and disinfection should wear the recommended minimum PPE as described above for gross decontamination of mass body fluids. 5. For decontamination without the presence of mass body fluids, it is acceptable to wear the following PPE: N 95 mask, impermeable gown, booties/shoe covers, eye protection (fluid shield wrap around and safety glasses), and disposable exam gloves. 6. Dispatch disinfectant, which is a bleach solution, should be used to clean all equipment and environmental surfaces. 7. When decontaminating the module, mist Dispatch disinfectant on all plastic sheeting surfaces and let it sit for 5 minutes. 8. Carefully and slowly un-tape the plastic sheeting from the walls, floor, and ceiling, roll in a ball, and place in a red bio hazard bag. 9. When the plastic sheeting is removed, spray all other surfaces with Dispatch and let soak for 5 minutes then wipe off thoroughly. Discard used towels immediately in bio hazard container prior to wiping other surfaces. 10. Following this, mist all affected with Dispatch disinfectant and let it dry on the surface (usually 8-10 minutes). 11. All infectious waste, which consists of but not limited to soiled absorbent pads or dressings, impermeable covers, used PPE (Tyvex suits, masks, gloves, goggles, respirators, booties, etc.) emesis basins, and any byproducts of cleaning, must comply with the packaging requirements for infectious substances as indicated in CFR Any potentially infectious waste must be packaged separately and disposed of at the receiving facility. Upon doing so, the receiving facility must be notified we are disposing of potentially Ebola infectious (Class A) waste. The receiving facility will need to follow their internal procedures in place for packaging and handling of Class A infectious material. Any deviation from this procedure requires specific approval from the HSE Department. 12. When decontamination is complete, the EMS crew should doff their PPE in accordance with the donning and doffing procedures and wash hands thoroughly with soap and water for a minimum of 20 seconds.

8 13. The ambulance and crew may be placed back in service only after decontamination is completed and the crew has been sent to a local station to shower. Donning Procedure: When donning PPE, it is important to have an additional person not involved in patient care watch over and supervise the donning procedure to assure PPE is donned appropriately. The PPE required shall be donned in this order: 1. One pair of booties (shoe covers) 2. One pair of inner gloves 3. N 95 face mask 4. Tyvex suit with hood 5. Goggles outside of hood 6. Outer pair of gloves 7. Disposable gown Doffing procedures: When doffing PPE, an additional person not involved in patient care shall watch over the doffing procedure to assure it is doffed appropriately minimizing the risk for contamination. The order and procedure in which PPE should be doffed is as follows: 1. Lay disposable sheet on surface to stand on 2. Have someone mist gown, gloves, and booties with Dispatch or bleach solution and wait 5 minutes 3. Remove gown by pulling forward 4. Remove outer pair of gloves 5. Remove goggles by grabbing sides. 6. Remove Tyvex suit making sure to avoid outer surface 7. Remove inner gloves. 8. Don a new pair of gloves 9. Remove N 95 face mask 10. Remove booties 11. Remove last pair of gloves

9 12. After the last pair of gloves are removed, don another impermeable gown, a fluid shield wrap around, and another pair of gloves to pick up and discard any used PPE or any byproducts of cleaning. When doffing is complete, make sure hands and other exposed body parts are washed thoroughly with soap and water for a minimum of 20 seconds.