This module will provide guidance to
Emergency Departments for the development of hospital specific plans
and procedures to screen patients under investigation for Ebola virus
disease. It is important to know that all travelers from Ebola affected countries
are currently screened upon entry to the United States for Ebola signs and symptoms
and potential exposures by airport personnel.
and potential exposure by airport personnel. Returning travelers are also monitored by public health authorities for the 21 day incubation period.
Because of this screening process, the risk of an unidentified patient
presenting to your emergency department without prior notification is low.
That being said, health care organizations offering urgent
or emergent care services through emergency departments are key first
points of contact for patients who may be at risk for Ebola.
Therefore, it is important to be vigilant and screen all patients presenting
to your emergency department for relevant travel history,
potential risk factors and signs and symptoms of Ebola.
All US acute health care facilities have an important role in preparing to identify,
isolate and evaluate persons under investigation for Ebola
and promptly informing public health authorities.
However, the roles and preparations required to perform these tasks will differ by facility.
Acute health care facilities can serve one of three roles:
As a front-line health care facility, Ebola assessment hospital
or Ebola treatment center. In some cases,
a hospital may be prepared to serve in more than one role. It is important
to know which roles your facility will be prepared to serve.
Front-line facilities, including most US acute care facilities that are equipped for
emergency care, need to be prepared to identify, isolate
and care for patients under investigation for Ebola for a limited period of time
and should contact local public health authorities to initiate
plans to transfer the patient to an Ebola Assessment Hospital
or Ebola Treatment Center as soon as possible. Frontline facilities must
also be prepared to ensure there is no delay in the care of these patients.
By being prepared to evaluate, manage and treat alternative etiologies
of febrile illness, as clinically indicated.
Ebola Assessment Hospitals are facilities prepared to receive and isolate
persons under investigation for Ebola and care for the patient
until the diagnosis can be confirmed or ruled out, and until discharge
or transfer is completed. This means that the facility
may care for a patient under investigation for Ebola up to 96 hours.
In collaboration with public health officials, Ebola assessment hospitals also
should be prepared to coordinate Ebola testing, which may involve transferring
specimens to a laboratory capable of Ebola testing.
If your facility is preparing to be an Ebola Assessment Hospital, also ensure that
you have plans for safe limited lab testing and waste management.
In general, the vast majority of patients with symptoms arriving at the
emergency department do not have the Ebola virus or any risk factors for the infection.
Nevertheless, because early symptoms of Ebola are similar to other illness,
it is critical to properly screen and evaluate all patients
for the possibility of Ebola. All staff should aim to provide
patient and family centered respectful care. Be mindful
of the situation and the patients needs during the screening process.
Always respect the patients right to privacy and conduct the screening process
in a private area whenever possible.
If the patient is unable to provide answers to the screening questions due to their medical condition
or another communication barrier, the history should be elicited from the next most reliable source
available, such as a family member, friend or EMS personnel.
Prominent signage posted at entrances and
registration areas helps to inform and prompt patients to report any history
of recent travel to the countries with widespread Ebola transmission.
Immediately upon entrance to the ED, or in advance of entry, if possible,
patients should be asked if they have traveled outside of the United States
or had contact with an individual with confirmed Ebola virus
within the previous 21 days. If the patient answers yes to travel outside
the United States, follow up to ask whether they have traveled to any country
with widespread Ebola transmission. The list of affected countries changes over time
and therefore the screening process will need to be updated and revised.
Please check the CDC website regularly for the most current information
and have plans in place to update signage and screening procedures accordingly.
Whether a patient arrives by ambulance or through the main
registration area, how they are safely evaluated and cared for in the
emergency department depends upon the results of a preliminary screening assessment
performed by the first point of contact. We will now go through three scenarios.
In the following scenario, a patient arrives in the emergency department
showing no visible signs or symptoms of Ebola.
"Hi, can I help you?" "Yeah, I was in a car accident yesterday
"and I think I hurt my neck. I'd like to see a doctor." "Have you been out of the United States
"in the last 21 days?" "Nope." "And have you had any contact with any individuals with
"confirmed Ebola in the last 21 days?" "No."
Because this patient has not reported any relevant travel or exposure history,
they can be directed to the waiting room, where normal triage and assessment
procedures can be followed. "Okay if you want, you can just have a seat right over there
"and somebody will be with you shortly." "Okay, thank you."
In the next scenario, a patient arrives in the emergency department
with no apparent signs or symptoms of Ebola. However, this time
the patient does report a relevant travel history or possible exposure
which prompts further assessment. "Hi, can I help you?"
"Hi, I actually tripped over some camera equipment and I think I hurt my ankle pretty bad."
"I'd like to see a doctor." "Okay, have you been out of the United States in the last
"21 days?" "Yes, I was out of the States, I was in Liberia. I'm a jounalist
"and I was shooting a story there." "Gotcha." As you've just heard, the patient has in fact
recently traveled to one of the countries identified as having widespread Ebola
transmission. At this point, staff should maintain a safe distance
of at least 3 feet of the patient at all times and avoid any physical contact.
"Have you had any contact with any individuals with confirmed
"Ebola?" "To my knowledge, I have not been in contact with anyone with Ebola."
"Okay. Just hold on one second for me please."
"I need a triage nurse please."
"Okay. Thank you." The triage nurse now
continues the screening process by confirming the reported travel and exposure history
and then assessing the patient for symptoms that might indicate possible Ebola.
"Can you please tell me what country or countries you've visited and when did you return
"to the United States?" "Yes, I was in Liberia
"about two and a half weeks ago, and I got back about a week ago." "Have you had any
"contact with any person having Ebola within the last 21 days?"
"No. Actually, I was checked at the airport when I got back
"and they cleared me and I've been checking my temperature daily." "So have you had any abdominal
"pain, nausea, vomiting or diarrhea?" "No."
"Any muscle ache fatigue?" "Nope, just the pain in my ankle."
"Any unexplained bleeding?" "No, not at all." If the patient
does not report any of the relevant signs or symptoms, finish with the initial triage
process and register the patient for care, following normal procedures.
The patient may go back to the waiting room, if necessary.
"Well can you please just follow me this way?" "Sure."
All patients who report a travel
or exposure history should be assessed for relevant risk factors, based on the most
recent CDC guidance. Notify your public health authorities that you have
identified a patient with recent travel history to a country with widespread
Ebola transmission so the patient is appropriately monitored by public health authorities
for the duration of the 21 day monitoring period.
In the next scenario, we encounter a patient who reports a relevant travel and exposure
history, as well as symptoms that might be consistent with Ebola.
As with the previous scenarios, providers should maintain a distance of at least
3 feet and avoid any physical contact with the patient during the initial
screening process. "Hi, can I help you?"
"Yeah, I'm not actually sure what's wrong, but I really don't feel well."
"Have you been out of the United States in the last 21 days?"
"Um yeah, actually I was in Sierra Leone for a funeral."
"Okay. And do you know if you've had any contact with anyone
"who has confirmed Ebola in the last 21 days?" "No, I don't think so."
If the patient has traveled in the last 21 days to a country with widespread
Ebola transmission, and reports any symptoms that might be consistent with
Ebola, immediately notify the triage or charge nurse.
"Okay, just hold on for one second please."
"Hi, I need a triage nurse."
"Can you please tell me what country or countries you've visited
"and when did you return to the United States?"
"Yeah, I was in Sierra Leone a couple weeks ago
"and I got back about a week ago." "Have you had any contact with
"any person having Ebola within the last 21 days?" "No, I don't think so."
"So, have you had any abdominal pain, nausea, vomiting or
"diarrhea?" "Yeah." "Any muscle ache fatigue?"
"Mhm." "Any unexplained bleeding?" "No."
"Okay. We're sorry that you don't feel well and we'll definitely get someone to
"take care of you as soon as possible." The patient has reported relevant travel
and potential exposure history and is exhibiting symptoms that might be consistent with Ebola.
Alert the charge nurse immediately that you have identified
a patient who reports a relevant travel or exposure history and
who has possible Ebola symptoms so they can place the patient in the
designated isolation room. The provider should maintain a distance of at least
3 feet if not in PPE from any patient until escorted back
to an isolation room. A patient who presents to an emergency department
and reports relevant recent travel and potential exposure history
as well as symptoms possibly consistent with Ebola, must be placed
into a private room or separate enclosed area with a private bathroom
or covered bedside commode. It is important that all providers adhere
to procedures and precautions designed to prevent transmission by
direct or indirect contact. Wait until the charge nurse or
other staff has ensured that the isolation room and the transport pathway
is free of other patients and personnel. Escort the patient to the isolation room,
free of other patients and personnel not wearing PPE, not touching the patient,
maintaining at least 3 feet distance. Once you have alerted the ED staff of the patient
with possible risk factors or symptoms of Ebola and the
isolation room is prepared, escort the patient to the designated isolation room.
"Would you follow me to this room please? We are just going to put you here just
temporarily. We're going to ask you a few more questions." "Okay, thank you." We're going to take care of you."
The triage or charge nurse will inform the physician and
other ED staff that a patient with relevant recent travel or exposure
history, as well as symptoms possibly consistent with Ebola, is being brought
to the designated isolation room for further screening and evaluation.
If the patient cannot walk on their own to the isolation
patient room, wait until the charge nurse or other staff has ensured that the
isolation room and the transport pathway is free other patients and personnel.
Don PPE and then transport the patient to the isolation room in
a wheelchair wearing PPE. In the event a patient arrives at your hospital
by ambulance and EMS already notified the ED that the patient
reports travel to the affected countries or exposure and symptoms of Ebola
the ED should receive the patient in a designated area away from
other patients and implement appropriate isolation precautions at the time
of arrival. A process should be in place for safely transporting the patient
on the stretcher to the isolation room with minimal contact with non-essential
health care workers or the public. Please review the isolation training
module for more information regarding isolation room preparation.
After arranging for the patient to be placed into the designated isolation room,
activate your institution's Ebola plan and notify appropriate
designated staff, such as infection prevention or other staff, and
the local public health authorities that your institution is evaluating a patient with a
relevant travel or exposure history and symptoms that may be consistent with Ebola.
For further information and recommendations regarding preparedness,
isolation, evaluation and management of a patient with a relevant travel or
exposure history, who is exhibiting symptoms consistent with Ebola,
see the modules in the next sections.