Download EbolaprocedureEHS1

COMMUNICABLE DISEASES EXPOSURE
INITIAL QUESTIONNAIRE
EBOLA
INTERVIEW DATE:
/
INTERVIEW METHOD:
/
20
IN PERSON
INTERVIEW TIME:
(24-HOUR CLOCK)
BY PHONE
EMPLOYEE DEMOGRAPHIC INFORMATION
EMPLOYEE NAME:
CONTACT NUMBERS:
DOB:
HOME:
/
/
WORK:
AGE:
CELL:
LAST 4 DIGITS SSN:
EMPLOYEE IDENTIFICATION NUMBER (EIN):
DEPT. NAME:
DEPT NUMBER:
PRIMARY WORK LOCATION:
SUPERVISOR:
LOCATION LAST WORKED:
DATE LAST WORKED:
/
/
*SEE PATIENT ASSESSMENT ALGORITHM
SOURCE – SPECIFIC
DOES THE PATIENT HAVE A CONFIRMED EBOLA INFECTION?
DOES A COWORKER HAVE A CONFIRMED EBOLA INFECTION?
DO YOU HAVE A FAMILY MEMBER WITH A CONFIRMED EBOLA INFECTION?
YES
YES
YES
NO
NO
NO
/
DATE OF SYMPTOM ONSET (IF KNOWN):
UNSURE
UNSURE
UNSURE
/
HAVE YOU BEEN USING PPE?
HAS YOUR COWORKER BEEN USING PPE?
HAS YOUR PATIENT BEEN IN PPE SINCE YOUR INITIAL CONTACT?
IS THE PATIENT STILL HOSPITALIZED?
IS YOUR COWORKER STILL HOSPITALIZED OR ON LEAVE?
IS THE PATIENT CURRENTLY ISOLATED?
IF EMPLOYEE, IS HE/SHE AT HOME?
WAS THE PATIENT ISOLATED PROPERLY SINCE ADMISSION?
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
DISPOSITION OF EMPLOYEE
IS THIS EMPLOYEE ACUTELY ILL OR SYMPTOMATIC?
CAN THIS EMPLOYEE WORK?
ARE DROPLET PRECAUTIONS REQUIRED?
YES
YES
YES
NO
NO
NO
EHS TO CONTACT INFECTION CONTROL ASAP IF:

EMPLOYEE HAS ANY OF THE ABOVE ACUTE SYMPTOMS OR DIAGNOSIS AND PERSONAL TRAVEL HISTORY, OR HAS HAD
CONTACT WITH TRAVELERS FROM UP TO 21 DAYS BEFORE THE ONSET OF SYMPTOMS TO THE PRESENT.
INSTRUCTIONS TO EMPLOYEE
IF EXPOSED TO EBOLA:




EMPLOYEE SHOULD MONITOR AND RECORD THEIR TEMPERATURE TWICE A DAY FOR 21 DAYS POST-EXPOSURE
AND
NOT COME TO WORK IF THEY DEVELOP A FEVER (100.4°F /38ºC OR GREATER) AND SYMPTOMS OF EBOLA. (E.G., SUDDEN ONSET OF FEVER AND
WEAKNESS, HEADACHE, VOMITING AND DIARRHEA).
EMPLOYEES WHO HAVE HAD A CONFIRMED EXPOSURE AND BECOME ILL WITH SYMPTOMS (FEVER, WEAKNESS, VOMITING AND DIARRHEA) WILL BE
MASKED AND PLACED IMMEDIATELY IN A PRIVATE ROOM UNDER DROPLET/CONTACT PRECAUTIONS. INFECTIOUS DISEASE CONSULTANT WILL BE
CONTACTED USING WAKE ON-CALL AND INFECTION PREVENTION (413-8199).
EMPLOYEES THAT ARE WITHOUT FEVER ARE TO WEAR A SURGICAL MASK WHEN PERFORMING PATIENT CARE.
NOTE: IMMEDIATELY FOLLOWING THIS CONTACT, THE INTERVIEWER/CLINICIAN IS TO CONTACT THE EMPLOYEE’S MANAGER/SUPERVISOR
ADVISING OF THE EMPLOYEE’S STATUS TO WORK. (EMAIL)
Revised 09/2014
COMMUNICABLE DISEASES EXPOSURE
INITIAL QUESTIONNAIRE
EBOLA
IF INSTRUCTED TO GO HOME/ STAY AT HOME:


1.
2.
3.
EMPLOYEE IS TO NOTIFY THEIR MANAGER/SUPERVISOR IMMEDIATELY FOLLOWING THIS CONTACT.
(SEE NEXT PARAGRAPH SHARE WITH EMPLOYEE); THEN,
EMPLOYEE SHOULD GO HOME/STAY AT HOME UNTIL AFEBRILE (WITHOUT FEVER – BELOW 100.4°F/38ºC [ORAL]) FOR A MINIMUM OF 21 DAYS.
FURTHER, INSTRUCT THE EMPLOYEE TO CONTACT EHS PRIOR TO RETURNING TO WORK.
NOTE: IMMEDIATELY FOLLOWING THIS CONTACT, THE INTERVIEWER/CLINICIAN SIGNING OFF IS TO CONTACT (EMAIL) THE MANAGER/SUPERVISOR
APPRISING THEM OF THE FOLLOWING (CC: EMPLOYEE)
INSTRUCTIONS TO SUPERVISOR
EMPLOYEE CONTACTED EHS AND HAS BEEN ADVISED TO GO HOME/STAY AT HOME OR CLEARED TO WORK; THEREFORE, THE EMPLOYEE IS NOT
SUBJECT TO DISCIPLINARY ACTION FOR BEING OUT OF WORK FOR THIS ISSUE.
EMPLOYEE HAS CONTACTED EHS FOR WORK DETERMINATION AS PER PROCEDURE. THE EMPLOYEE IS NOT SUBJECT TO DISCIPLINARY ACTION FOR
BEING OUT OF WORK FOR THIS ISSUE.
ENCOURAGE MANAGER/SUPERVISOR TO CONTACT EHS WITH ANY QUESTIONS OR CONCERNS.
NAME OF INTERVIEWER/CLINICIAN: (PRINT)
NAME OF INTERVIEWER/CLINICIAN: (SIGNATURE)
DATE:
/
/
20
INTERVIEW TIME:
(24-HOUR CLOCK)
RETAIN THIS FORM IN EHS FOR DATA COLLECTION AND ANALYSIS, AND SCAN INTO THE EMR (ELECTRONIC MEDICAL RECORD).
TIP SHEET:
Case Definition for Ebola Virus Disease (EVD)
Early recognition is critical for infection control. Health care providers should be alert for and
evaluate any patients suspected of having Ebola Virus Disease (EVD).
Person Under Investigation (PUI)
A person who has both consistent symptoms and risk factors as follows:
1. Clinical criteria, which includes fever of greater than 38.6 degrees Celsius or 101.5 degrees
Fahrenheit, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea,
abdominal pain, or unexplained hemorrhage; AND
2. epidemiologic risk factors within the past 21 days before the onset of symptoms, such as contact
with blood or other body fluids or human remains of a patient known to have or suspected to have
EVD; residence in—or travel to—an area where EVD transmission is active*; or direct handling of
bats or non-human primates from disease-endemic areas.
Probable Case
A PUI whose epidemiologic risk factors include high or low risk exposure(s) (see below)
Confirmed Case
A case with laboratory-confirmed diagnostic evidence of Ebola virus infection
Exposure Risk Levels
Levels of exposure risk are defined as follows:
Revised 09/2014
COMMUNICABLE DISEASES EXPOSURE
INITIAL QUESTIONNAIRE
EBOLA
High risk exposures
A high risk exposure includes any of the following:
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Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or body fluids of EVD
patient
Direct skin contact with, or exposure to blood or body fluids of, an EVD patient without
appropriate personal protective equipment (PPE)
Processing blood or body fluids of a confirmed EVD patient without appropriate PPE or standard
biosafety precautions
Direct contact with a dead body without appropriate PPE in a country where an EVD outbreak is
occurring.
Low risk exposures
A low risk exposure includes any of the following



Household contact with an EVD patient
Other close contact with EVD patients in health care facilities or community settings. Close contact
is defined as
a. being within approximately 3 feet (1 meter) of an EVD patient or within the patient’s room or
care area for a prolonged period of time (e.g., health care personnel, household members)
while not wearing recommended personal protective equipment (i.e., standard, droplet, and
contact precautions; see Infection Prevention and Control Recommendations)
b. having direct, brief contact (e.g., shaking hands) with an EVD patient while not wearing
recommended personal protective equipment.
Brief interactions, such as walking by a person or moving through a hospital, do not constitute
close contact
No known exposure
Having been in a country in which an EVD outbreak occurred within the past 21 days and having had
no high or low risk exposures
ALL HIGH AND LOW RISK EXPOSURES SHOULD BE REPORTED TO THE North Carolina Board of
Health at:
DHHS switchboard
919-855-4800
DHHS Mailing Address
2001 Mail Service Center
Raleigh, NC 27699-2001
Revised 09/2014