In this module, we will
cover the basic concepts for how to evaluate and briefly manage a patient
under investigation for Ebola. While all US
facilities need to provide screening and triage for Ebola virus disease,
the tiered system encourages various capacities amongst different facilities.
If your facility is a frontline facility,
you will be working closely with public health authorities to arrange for prompt
transport of patients to an Ebola Assessment Hospital for further
testing and evaluation. The content of this module is primarily
for Ebola Assessment Hospitals. If your facility is an Ebola Assessment
Hospital, you will need to be capable of initial evaluation
and care of the patient for up to 96 hours and the patient is transferred to
an Ebola treatment facility. Ebola assessment hospitals must be
prepared to identify, isolate, evaluate and
briefly manage a patient under investigation for Ebola until the diagnosis
can be confirmed or ruled out and until discharge
or transfer of the patient is complete. Ebola Assessment Hospitals
should be prepared to safely transfer patients with confirmed Ebola to an
Ebola treatment center. The CDC provides guidance on the minimum
capabilities that Ebola Assessment Hospitals should have in place before
receiving any patients under investigation. This module summarizes the
guidance, but it is not an exhaustive list. Refer to the CDC
website for more detailed information on safely caring for,
and managing patients under investigation for Ebola at Ebola
Assessment Hospitals. Ebola Assessment Hospitals must be prepared
to receive, isolate and care for a patient under investigation for Ebola
up to 96 hours. To confirm or rule out an
Ebola diagnosis in a patient under investigation may take up to 72 hours
or longer and potentially require an additional 12 to 24
hours for specimen transport, testing and identification of
another facility for transfer. Ebola Assessment Hospitals must have
plans in place for transporting patients with possible or confirmed Ebola,
both internally, within the facility, and externally, to an Ebola
Treatment Hospital. Intrafacility plans should be in
place for transporting a patient from the point of entry or from the ED
to the designated treatment area and isolation room.
Interfacility plans include plans to transfer a confirmed Ebola patient
to a designated Ebola treatment center. Transport plans
and procedures should be well developed and practiced in drills to ensure the transport
mechanisms are understood by all staff who will be involved in the process.
Proper staffing, training and worker safety
plans should be in place at Ebola assessment hospitals. Staffing plans
should be developed to support 96 consecutive hours of clinical care.
At a minimum, staff should be trained and available to care for patients
and a trained observer should be present at all times to supervise safe
infection control practices, including donning and doffing
of personal protective equipment. The facility should have a process to
ensure availability of continuous staff input from a multidisciplinary group
including those who may or may not be directly involved in Ebola
patient care. Staff who are involved in or supporting patient care
must be appropriately trained for their roles and should demonstrate proficiency
in the activities in which they will be involved, including the donning and doffing
of PPE, proper waste management,
infection control practices, "Hello, infection prevention?"
"We have a possible Ebola patient in the ED", and specimen
transport to the laboratory. "So good morning, thanks for
"coming today. We're going to learn about donning PPE." Ongoing
training should be provided, competency assessed and
breaches should be addressed through retraining and practice sessions.
Worker safety programs must also be in place. The hospital should be in
compliance with all federal or state occupational safety and health regulations
applicable to reducing employee exposure to the Ebola virus
and direct active monitoring for all health care workers involved
in direct patient care should occur for 21 days since the last known exposure.
Because Ebola Assessment Hospitals must be prepared to care for patients
under investigation for up to 96 hours, it is important that the facility
have the proper infrastructure in place to care for these patients.
The hospital must have a private room with an interim dedicated bathroom or
covered bedside commode equipped with dedicated patient care equipment.
There should be separate areas for donning and doffing of PPE
that allow for the supervision of donning and doffing activities by a
trained observer. After a patient under investigation for Ebola is safely
isolated, several key actions should be taken to manage care.
First, the detailed risk factor and symptom screening as described
by the CDC should be performed by a clinician.
Second, the institution's Ebola preparedness plan should be activated and
key staff, including the laboratory and public health authorities should be informed.
All laboratory tests for Ebola should be done in consultation
with the local public health authorities. They will provide guidance on what testing
should be performed. It is important to consider other, more likely conditions
including influenza and malaria. Plans for how to safely
pursue other diagnostic considerations should be made with the laboratory team
in order to minimize any risk of contamination in collecting,
transporting and processing potentially infectious samples.
Diagnostic laboratory procedures and protocols should be in place for
specimen testing for Ebola by the nearest Laboratory Response Network
capable of testing for Ebola, addressing dedicated space,
possible point of care testing, equipment
selection and disinfection, staffing, reagents,
training and specimen transport for routine clinical diagnostic testing
at the facility. Protocols for lab personnel PPE use and
training should also be in place. Staff should notify the laboratory
prior to sending any samples to the lab and all samples must be
clearly labeled to identify that they are from a patient under investigation for Ebola.
All specimens should be hand-carried to the lab. Do not
transport specimens through a pneumatic tube system.
Plan and distinguish which tests can be safely performed in your facility.
Ebola testing itself is always performed in consultation with the public
health authorities. All waste from patients with possible Ebola
must be treated as highly infectious until Ebola is ruled out.
Ebola is classified as a Category A Infectious substance according to the Department
of Transportation Hazardous Material's regulations. It is important
that all waste from patients under investigation for Ebola is handled
according to the CDC and local or state Department of Transportation guidelines.
Ebola Assessment Hospitals should have in place the services of a waste
management vendor, capable of managing and transporting
Category A infectious substances, have appropriate containers and procedures
for the safe temporary storage of Category A infectious waste,
and ensure that staff are trained in the correct use of PPE,
personal protective equipment and in the proper handling and storage
of Category A waste. If a vendor capable of
transporting Category A infectious substances has not been arranged,
hospitals may consider sequestering medical waste until the patients
Ebola test result becomes known. At that time, if a
patient is confirmed to have Ebola, arrangements should be made to transport the waste by a vendor
who services who have been procured for this purpose.
If the patient is determined not to have Ebola, waste can be handled according to normal
procedures in compliance with local waste management ordinances.
Ebola Assessment Hospitals should have plans in place to clean and disinfect
patient care areas and equipment, including the use of an EPA registered
hospital disinfectant with a label claim at least equivalent to that
for a non-enveloped virus and safe practices for use of the disinfectant
in accordance with the manufacturer's instructions for use.
In managing the care of a patient under investigation for Ebola,
it is important that to be deliberate and efficient with your interactions.
One key strategy for minimizing risk to staff is to plan for clustering
care, specifically you can use a log to help plan patient care activities
so you can bundle tasks to minimize the number of trips into and out of
room. Before entering the isolation room, plan the tasks that
will be completed in the room and ensure all supplies needed to accomplish the
planned tasks are available. If you happen to need additional medication or supplies
while in the patient room, you may ask another staff member to supply
these in a way that would prevent contamination, such as using a tray.
Use a method of passing that would prevent you contaminating yourself.
Consider using various communication devices to minimize the
time in the room, such as an intercom or telephone.
In addition, the communication devices can be used to allow the patient to communicate
with their family and visitors. The proper use of personal protective equipment,
or PPE, is critical in preventing transmission of Ebola virus disease.
Ensure that PPE is readily available and the appropriate sizes
are available for all health care workers who will enter the room. CDC
guidance calls for two different types of PPE. The first type of
PPE is recommended for care of patients under investigation for Ebola
and who are clinically stable and not having bleeding, vomiting or diarrhea.
There is a low risk of splashes and contamination in these
situations. The first type of PPE consists of a
fluid resistant gown, or coverall, surgical mask,
full face shield
and two pairs of gloves with extended cuffs.
The second type of PPE is for health care workers caring for patients with confirmed
Ebola, or to health care workers caring for patients with possible
Ebola, who have obvious bleeding, vomiting, diarrhea or
a clinical condition that warrants invasive or aerosol generating procedures.
The PPE, personal protective equipment ensemble includes
use of a PAPR or N95 respirator with boot covers,
a fluid impermeable gown or coverall, two pairs of gloves with extended cuffs,
and full head piece or N95 respirator plus
a surgical hood, extending to the shoulders and a full face shield.
Training on the use of PPE is critical. Ensure all health care
workers who enter the room are trained on how to don and doff personal protective
equipment safely. Practice is required to gain competence.
Consider checking staff's ability to demonstrate PPE
donning and doffing to ensure they are competent in the process.
Each step of every PPE donning and doffing event must be supervised
by a trained observer to ensure proper completion of established PPE
protocols. Any breaches should be identified immediately.
Refer to the CDC website for PPE training videos for additional
information on the donning and doffing of PPE. Ebola
Assessment Hospitals should select appropriate Ebola PPE and have
at least a 4 to 5 day supply of PPE in stock and should have identified
a vendor capable of providing resupply.
In the event that a facility does not have sufficient PPE, the facility
should work with local health care coalitions, emergency management services,
and local and state public health authorities to identify
additional PPE resources. Refer to the CDC website for more
information on PPE. In addition to clearly defined clinical
protocols for Ebola, your facility should define expectations
and protocols for internal and external communication. Make sure you are
familiar with each protocol and have have the necessary contact information.
The hospital should follow its emergency management structure for communication.
It is critical to maintain open and efficient lines of communication
between care providers and the patient using electronic communication
when possible, care providers and patients families, keeping them updated.
Care providers during handoffs, critical
services of the hospital involved in safe Ebola patient management, such
as lab and Environmental Services, the hospital and the Health Department
and the patient and their family and visitors. Ebola is
a serious disease and the emotional stress it produces can be damaging.
The patient, family members and health care workers alike
may be in need of counselors or peer support. Leaders at all levels
should work to ensure that these resources are made available and accessible.
We recommend having a process in place to connect patients, their families,
and staff to support services, such as a list of contacts
and appropriate educational materials.
In this module, we have covered the basic considerations for how to evaluate and briefly manage a patient
with suspected or confirmed Ebola at an Ebola assessment hospital.
Additional information can be found on the CDC website.
Your health department is available for assistance.
The CDC is also available 24/7 for consultation by calling the
CDC Emergency Operations Center.