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Instructions to Complete the
Ebola Preparedness Plan
1. The attached Core Policy sets forth the minimum standards that must be met at each BJC
entity with respect to Ebola Virus Disease (EVD) Preparedness Plan. Each entity must
adopt an entity specific written plan that meets these requirements. The adopted plan may
contain provisions beyond the minimum requirements of the attached plan, so long as the
additional provisions in no way conflict with or abrogate the terms of the Core Plan.
2. The purpose of this plan is to provide guidelines for prevention of nosocomial transmission
of Ebola to patients and employees.
3. This policy applies to all staff who may come in contact with known or suspected cases of
Ebola.
4. Each BJC entity is responsible for the annual review and revision as necessary, of their
individual Ebola Preparedness Plan.
5. The core plan for the Ebola Plan must be customized to the unique features of each BJC
entity. Areas which require customization are indicated by:
A. parentheses, and
B. bold face type, and
C. underlining
D. Each BJC entity must designate an individual responsible for the Ebola Plan. These
individuals must then customize their site-specific plan to correctly include all of its
unique features.
6. Change the customized font so it is no longer bold, in parentheses, and underlined.
7. Include fact sheets related to Ebola.
8. Once steps 1-7 are completed, delete this instruction page from the plan.
Ebola Plan © 2014, BJC Health Care. All Rights Reserved. Reproduction is strictly prohibited without written consent of BJC HealthCare
BJC HealthCare
CORE POLICY
EBOLA PREPAREDNESS PLAN
Original Document Approved: October 2014
Ebola Plan © 2014, BJC Health Care. All Rights Reserved. Reproduction is strictly prohibited without written consent of BJC HealthCare
BJC HEALTHCARE CORE POLICY
EBOLA PREPAREDNESS PLAN – CORE POLICY
Table of Contents
Ebola Preparedness Plan…………………………………………………………..………………………….2-16
Appendix A: Stop Sign for Points of Entry……………………………………………………………………...17
Appendix B: Patient Room and PPE Removal Designation…………………………….…………..……..…18
Appendix C: Isolation Sign for Patient Room ………………………………………………………..…….…..19
Appendix D: Stop Sign for Patient Room ……………………………………………………………..………..20
Appendix E: Healthcare Worker and Patient / Visitor Log ………………………………………….….…21-22
Appendix F: Sequence for Donning and Removal of PPE……………………………………….……..…23-24
Appendix G: Ebola Communication Interim Guidance.............................................................................25
Appendix H: Algorithm for the Evaluation of the Returned Traveler....................................................26-28
Appendix I: Laboratory Personnel Guidance for Ebola………………………………………………………..29
Appendix J: Occupational Exposure to Ebola……………………………………………...……………….30-32
Appendix K: Fact Sheet for Employees…………………………………………………………………………33
Appendix L: Just-in-Time (JIT) Training for Employees………………………………………………..…..34-35
Appendix M: Fact Sheet for Patients and Visitors…………………………………………..………..…...…..36
Appendix N: Stericycle Waste Handling Procedures…………………………………………….…………….37
Appendix O: Ebola Frequently Asked Questions……………………………………………………..….…….38
Appendix P: Hospital Preparedness Checklist (Stoplight Gap Analysis)…………………………….…..39-44
Appendix Q: Safe Handling of Human Remains of Ebola Patients…………………………………….…45-46
NOTE: All appendices in full-version format are available separately on the BJC Ebola Intranet Site:
http://bjcnetnew.carenet.org/sites/riskmanagement/evdpage/default.aspx
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1
CORE POLICY
I.
NUMBER:
II.
TITLE:
EBOLA PREPAREDNESS PLAN
III.
APPLICABILITY:
This policy applies to BJC HealthCare Member locations.
IV.
PURPOSE:
This Core Policy sets forth the minimum standards that must be met at each BJC
member hospital with respect to the prevention of nosocomial transmission of Ebola
Virus Disease (EVD). Each hospital must adopt a written policy that meets these
requirements. The adopted policy may also contain provisions beyond these minimum
requirements, so long as the additional provisions in no way conflict with or abrogate the
terms of the Core Policy. The minimum requirements are set forth below.
V.
STATEMENT OF POLICY:
A.
Introduction
Ebola is one of numerous Viral Hemorrhagic Fevers (VHFs). It is a severe, often
fatal disease in humans and nonhuman primates (such as monkeys, gorillas, and
chimpanzees). Ebola is caused by infection with a virus of the family Filoviridae,
genus Ebolavirus. The first Ebolavirus species was discovered in 1976 in what is
now the Democratic Republic of the Congo near the Ebola River. The natural
reservoir host of Ebolaviruses remains unknown, however it is thought to be
zoonotic (animal-borne) with bats being the most likely reservoir.
The virus initially is spread to the human population after contact with infected
wildlife and is then spread person-to-person through direct contact with body
fluids such as, but not limited to, blood, urine, sweat, semen, and breast milk.
The incubation period is 2–21 days. Patients can transmit the virus while febrile
and through later stages of disease, as well as postmortem, when persons
contact the body during funeral preparations. It is extremely important to note
that Ebola is only spread through symptomatic infected persons.
For additional information on Ebola, see Employee Fact Sheet on Appendix K.
B.
Responsibility
This policy applies to all staff that might come in contact with suspected or
confirmed Ebola patients, their environment, and/or their blood or body fluids.
VI.
PROCEDURE:
A.
Patients in emergency rooms, outpatient settings and those admitted to hospitals
should be screened for risk factors and signs and symptoms of Ebola.
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2
B.
Ebola “stop” signage must be displayed at key points of entry, (primarily the
Emergency Department), (Appendix A)
C.
Ebola should be considered in patients with signs and symptoms of Ebola who
have had a known exposure to a confirmed or suspected ebola case or with a
recent travel history (within 21 days) to outbreak-associated West African
countries.
D.
A Person Under Investigation (PUI) is an individual who has both consistent risk
factors and symptoms consistent with Ebola.
1.
Risk factors include:
 Known exposure to a confirmed or suspected Ebola case
 Recent travel history (within the previous 21 days) to an outbreakassociated West African country
2.
Signs and Symptoms may include:







3.
Probable Case:
a.
3.
Fever >101.5F (>38.60C)
Severe headache
Joint pain / muscle aches
Vomiting
Diarrhea
Abdominal pain
Unexplained hemorrhage
A PUI whose epidemiologic risk factors include high or low risk
exposure(s) (see below)
Confirmed Case:
a.
A case with laboratory-confirmed diagnostic evidence of Ebola
virus infection
High risk exposures include any of the following: Percutaneous (e.g., needle
stick) or mucous membrane exposure to blood or body fluids of Ebola patient; Direct
skin contact with, or exposure to blood or body fluids of, an Ebola patient without
appropriate personal protective equipment (PPE); Processing blood or body fluids of
a confirmed Ebola patient without appropriate PPE or standard biosafety
precautions; Direct contact with a dead body without appropriate PPE in a country
where an Ebola outbreak is occurring.
Low risk exposures include any of the following: Household contact with an
Ebola patient; Other close contact* with Ebola patients in health care facilities or
community settings; Having direct brief contact (e.g., shaking hands) with an Ebola
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
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3
No known exposure includes having been in a country in which an Ebola
outbreak occurred within the past 21 days and having had no high or low risk
exposures
Refer to Appendix H for Mandatory Screening Questions for Patient Presenting
to the Hospital and an Ebola Algorithm for Returned Travelers
*Close contact is defined as 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).
E.
Ebola Infection Prevention Precautions
When a suspected Ebola patient is identified, infection prevention precautions
must be implemented immediately:
1.
An surgical/isolation mask must be immediately placed on the
patient, if tolerable. The patient should be placed in a private room with
the door closed. Critically ill or unstable patients should be placed in
negative pressure ventilation if aerosol generating procedures are
anticipated.
2.
Suspect patients should not be transported from the room except for
medical reasons only. A surgical/isolation mask must be worn by patient
during transport.
3.
A private room with the door closed and an anteroom or staging area
for personal protective equipment (PPE) removal (i.e. adjacent patient
room, zip walls, construction tent) is required for suspect Ebola patients.
(Patient room designation including assigned PPE removal location)
is defined in Appendix B. Patients occupying, but not requiring a private
room with these accommodations, must be immediately relocated to allow
for placement of the suspect Ebola patient.
4.
The designated Ebola isolation sign with droplet and contact categories
marked, including eye protection (Appendix C) along with the Ebola stop
sign (Appendix D) must be placed outside the patient’s door.
5.
All persons entering the patient room must be recorded on a healthcare
worker log (Appendix E-1) and Patient/Visitor log (Appendix E-2) outside
the patient room (Appendix E).
6.
Per Centers for Disease Control and Prevention (CDC) guidelines for
Ebola, required isolation precautions include: Standard + Droplet +
Contact + EYE PROTECTION:




Impervious or impermeable gown (not the yellow isolation gown)
(Gown description and product number(s): X######)
Disposable gloves – two pairs or “double gloving”
Full eye protection (goggles or full face shield)
Surgical/isolation mask to cover nose and mouth
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4
7.
Boot covers or leg covers must be available for extensive bleeding or
uncontrolled secretions and for all spill / room cleaning. (Boot and leg
cover product number(s): X######).
8.
Don bouffant hair covers if needed to contain hair.
9.
Eye protection to prevent exposure to eyes - Regular prescription
eyeglasses are not considered adequate eye protection. Sidepieces,
goggles, face shields, or eye protection covering eyeglasses must be
worn.
10.
Personal Protective Equipment (PPE) including surgical/isolation masks,
gowns, gloves and eye protection are required for all persons entering the
room of an Ebola patient.
11.
Clean PPE should be stored outside the patient’s room. Regulated
medical biohazardous waste receptacles for used/contaminated PPE
should be located near point of use but separate from clean PPE
(Appendix B).
12.
Don PPE (Appendix F) prior to entering patient room. Doffing / removal of
PPE must be limited to the anteroom or staging area designated for PPE
removal and disposal.
13.
Sequence for removal of PPE is as follows (Appendix F):






Gown AND first pair / outer of gloves
Boot or leg covers (if applicable)
Second pair / inner gloves
Goggles or face shield
Surgical / isolation mask
Hand hygiene must be performed between steps if hands are
visibly contaminated and immediately after removal of all PPE
14.
All PPE doffing/removal must be observed by another staff member.
15.
Hand hygiene may be performed with alcohol-based hand sanitizer; or
soap and water when hands are visibly soiled.
16.
For aerosol generating procedures such as bronchoscopy, intubation,
manual ventilation, non-invasive ventilation (i.e. BiPAP, BPAP), or
tracheostomy insertion: N-95 mask or PAPR (powered air purifying
respirator) are required to be worn by all healthcare workers (HCW)
during the procedures.
a) Refer to the facility Respiratory Protection Plan as needed for appropriate
fit-testing, medical evaluation, and use of respiratory protection.
b) Conduct all aerosol generating procedures in an Airborne Infection Isolation
Room (AIIR) when feasible.
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5
c) Limit the use of aerosol-generating procedures on Ebola patients to those
that are deemed medically necessary.
d) Use clinically appropriate sedation during intubation and bronchoscopy to
minimize resistance and coughing during the procedure.
e) If the patient is mechanically ventilated, an expiratory filter must be placed on
the circuit.
F.
Immediate Notification
1.
Upon identification of a suspected Ebola patient, the (insert title of
person responsible who will conduct the notification) will contact the
(Infectious disease physician or other entity appointed bioterrorism
authority), (Infection Prevention Department), and the (Nursing
Supervisor) on duty.
2.
The (Infectious disease physician or other entity appointed
bioterrorism authority Infection Prevention Department ) must
ascertain that all appropriate individuals have been notified that a
suspected Ebola patient has been identified in the facility. Ebola
Communication Interim Guidance has been collated from the BJC
Management of Biological Agents core policy (Appendix G).
3.
The identification of a suspected Ebola patient should automatically
trigger the initiation of the Hospital Incident Command Structure (HICS).
This will be a key element to facilitate the coordination necessary to
ensure continuity of communication and processes both internally and
externally.
4.
The establishment of a HICS should also trigger the emergency
notification process which has been established by the hospital.
a.
In the event that it is determined that HICS should be activated,
hospitals should refer to their respective HICS Plan to initiate the
command center and identify core responsibilities in the command
center.
NOTE: Notify the BJC HealthCare – Director of Emergency Preparedness
that HICS has been activated.
H.
Testing and Transportation
Limit the use of testing and diagnostic procedures on Ebola patients to those that
are deemed medically necessary.
All procedures must be performed in the patient’s room unless physically
impossible and medically necessary for treatment (i.e., CT scan, MRI, etc.).
1.
If the patient requires transport to another department, the patient’s nurse
is responsible for notifying the receiving department of the patient’s Ebola
isolation status.
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6
I.
2.
At least two clinical care providers (not patient transport staff) must travel
with the patient to ensure isolation precautions are maintained.
3.
One provider should remain “clean”, not touching the patient or patient
equipment during transport. This provider’s sole function is to open doors,
push elevator buttons, etc.
4.
When a patient is required to travel the patient must wear a
surgical/isolation mask.
5.
Prior to leaving room patient should don a clean gown and perform hand
hygiene or be completely covered with a clean sheet if on stretcher/bed.
6.
The required test should be the last case of the day, if medically feasible.
7.
The patient should be transported by a designated route.
8.
The elevator used to transport patient should only be occupied by patient
and transport team during the transportation of the patient.
9.
The patient should not go to or be held in waiting areas.
Hand Hygiene
A vigorous 15-second hand wash with soap and water or the use of alcohol foam
is required before and after each patient contact and prior to leaving the room.
J.
Duration of Isolation
Duration of precautions should be determined on a case-by-case basis, in
conjunction with local, state, and federal health authorities.
K.
Staffing
Limit the number of healthcare workers (HCW) caring for Ebola patients to those
who are essential for patient care and support. This should include restriction of
all ancillary personnel including but not limited to phlebotomy,
physical/occupational therapy, and dietary staff.
1.
Staffing assignments must be made to minimize the number of HCWs
assigned to care for the patient identified with Ebola.
2.
Infection Prevention will provide consultative assistance to Nursing in
determining the appropriate location and staffing for the Ebola patient’s
care.
3.
Non-essential staff students, and volunteers will not be allowed in the
patient’s room.
4.
The staffing assignment goals are to limit HCW exposure to the Ebola
patient and limit the assigned HCW contact with other non-Ebola patients.
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7
5.
L.
Examples of limited staff assigned to Ebola patient care:
a.
ICU patient assigned 1 RN per shift, dedicated to one or more
Ebola patients and the RN is not available for routine, nonemergent assistance to other patients in the unit.
b.
One or more Ebola patient assigned to one RN per shift, who also
has a lighter assignment and other patients in his/her assignment
are not immunocompromised.
6.
Pregnant employees do not need to be restricted from caring for Ebola
patients.
7.
Environmental Services (EVS) assignments remain unchanged; however,
if possible the housekeeper should clean the Ebola room last clean of the
day.
8.
Additional ancillary staff such as dietary, or phlebotomy, will not be
allowed to enter the room unless the nurse is not qualified to complete the
task.
9.
All employees entering the patient’s room must sign in on a log posted
outside the patient’s room (Appendix E). It is only necessary to sign the
log once each shift.
10.
Upon discharge, the Clinical Manager or designee will forward the log to
Occupational Health.
11.
Removal of all PPE must be observed using the buddy system and/or
compliance officer.
12.
(Infection prevention, clinical education or other designated
personnel) must be positioned outside the room of an Ebola patient at all
times to ensure compliance with isolation precautions.
13.
(The compliance officer or buddy) will be trained on the use of personal
protective equipment and isolation precautions.
14.
This may also be referred to as the “buddy system” or ensuring that HCW
don and remove PPE appropriately to avoid cross contamination (refer to
Appendix F for sequence for PPE removal).
15.
It is recommended that (the compliance officer or buddy) wear required
PPE (as listed in E-6) for assisting HCW from patient rooms with grossly
contaminated or visibly soiled PPE.
Visitors
Visitation policy should minimize the number of visitors exposed to Ebola and
decrease the potential of transmission of Ebola within the facility.
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8
1.
Adult patients will not be allowed visitors. Infection Prevention and
(Infectious disease physician or other entity appointed bioterrorism
authority) must be consulted and may approve exceptions to the
visitation rule for extenuating circumstances.
2.
If a visitation exception is made, nursing must screen the visitor by phone
for signs and symptoms of Ebola before the visitor arrives at the facility.
3.
Pediatric patient visitors:
a. One parent who has been screened by nursing for signs and
symptoms of Ebola will be allowed for pediatric patients, but must
be restricted to the patient’s room at all times.
b. The parent must don a new surgical/isolation mask and perform
hand hygiene prior to leaving the patient’s room and will be
escorted in and out of facility.
M.
4.
Close contacts of Ebola patients must be educated about signs and
symptoms of Ebola and must be instructed that they are not allowed to
visit.
5.
Visitors who arrive with suspected Ebola patients should be screened for
symptoms and segregated from other visitors.
6.
The local public health agency (LPHA) must be consulted in all close
contacts and visitors with signs and symptoms of Ebola prior to exiting of
the facility.
Surveillance
1.
(Insert department responsible for conducting patient/employee
illness surveillance) must perform routine ongoing surveillance to
identify employees and hospitalized patients with Ebola signs and
symptoms of an unknown etiology.
2.
Since Ebola transmission has been identified outside of the outbreakassociated West African countries, all patients presenting to the
emergency room or clinics with Ebola signs and symptoms should be
screened for Ebola risk factors.
3.
HCW or volunteers traveling from outbreak-associated West African
countries must immediately report any signs and symptoms of Ebola.
4.
HCWs that care for Ebola patients should be screened twice daily for
fever and other Ebola signs and symptoms.
5.
Employees must notify Occupational Health if they have had unprotected
close contact (refer to Appendix J) with an Ebola case.
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9
N.
6.
All employees with an unprotected occupational exposure (refer to
Appendix J) to a suspected case of Ebola will be evaluated on a case by
case basis.
7.
Employees with exposure to Ebola must be furloughed from duty for 21
days following exposure as outlined in Appendix J.
Laboratory Procedures
Limit the use of sharps, blood draws, and other laboratory testing on Ebola
patients to those that are deemed medically necessary.
P.
1.
Specimens should be collected in accordance with the following to
maximize the use of plastic containers and not glass.
2.
Double bag any samples in plastic biohazard bags and hand-carry to
(designated laboratory and drop-off site).
3.
DO NOT place samples in pneumatic tube system
4.
Minimize the use of courier services for laboratory specimen transport.
5.
(The designated courier service that has been pre-approved for
Ebola specimen transfer for facility must be listed)
6.
Alert (appropriate laboratory personnel) to expect samples from a
suspect Ebola patient prior to delivery.
7.
For additional laboratory specifications related to Ebola specimen
collection and transport, refer to Appendix I.
Cleaning / Disinfection
1.
Full PPE as outlined in section E-6 must be utilized for all cleaning and
disinfection, including after the patient is discharged from the room.
2.
All environmental services personnel must also wear boot covers to
protect against direct skin and mucous membranes exposure to cleaning
chemicals, contamination, and splashes/splatters.
3.
All horizontal surfaces in the patient’s room will be cleaned (bedrails,
doorknobs, faucets, and all bathroom surfaces) daily or more often when
visible soiling or spills occur.
4.
Use a U.S. Environmental Protection Agency (EPA)-registered hospital
disinfectant with a label claim for a non-enveloped virus (i.e. norovirus,
rotavirus, adenovirus, poliovirus) to disinfect environmental surfaces in
rooms of patients with suspected or confirmed Ebola virus infection.
Approved hospital disinfectant includes:(List hospital disinfectants with
appropriate label claim such as 1:10 bleach solution).
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10
Q.
5.
Ensure appropriate use of disinfectants according to the manufacturer’s
instructions for contact time.
6.
The room of the Ebola patient should be the last room cleaned for the
day.
7.
Avoid utilizing non-disposable cleaning cloths. Cleaning cloths used in the
isolation room should not be used to clean any other area of the facility
and/or equipment, but should be bagged for disposal as regulated
medical or biohazardous waste.
8.
Disinfect surfaces with disposable wipes whenever possible including:
(List hospital wipes ,such as, Sani Plus wipes (purple top) or (Sanibleach wipes (gold top).
9.
Dispose of all contaminated equipment as regulated waste in red
biohazard bags. This includes linen and privacy curtains in room.
10.
Discard all linens, non-fluid-impermeable pillows or mattresses, and
textile privacy curtains as a regulated medical or biohazardous waste.
Visually inspect all otherwise impermeable pillows and mattresses for rips
and tears prior to re-use.
11.
Mop bucket water must be changed before cleaning any other areas of
the hospital, and mop heads must be discarded as regulated medical or
biohazard waste.
12.
At discharge, terminal cleaning of all horizontal surfaces of the isolation
room including, bedrails, doorknobs, faucets, bathroom surfaces, and bed
curtains should occur.
Patient Care Equipment
Ebola patients should have dedicated equipment (i.e. stethoscopes, blood
pressure cuffs, thermometers, etc.). No electronic equipment should be used if it
cannot be designated to the patient and stay in the patient’s room. (List
hospital-specific equipment that will stay in the patient’s room).
1.
After use, patient equipment that is routinely terminally cleaned in (insert
name of department responsible for cleaning and disinfection
equipment) (i.e.; IV pumps, IV poles, Mini-infusers, enteric tube feeding
pumps) should be cleaned with a hospital-approved disinfectant (refer to
section P-4) according to the manufacturer’s instructions for contact time
before removal from the isolation room. All previously recommended PPE
must be worn for cleaning equipment (section E-6). Thorough, terminal
disinfection will be performed in (insert name of department
responsible for cleaning and disinfection equipment), versus the
location of the existing equipment cleaning process.
2.
The person responsible for the equipment will clean shared/community
equipment (i.e.; portable x-ray machines, EKG machines, physical
therapy equipment) with a hospital-approved disinfectant according to the
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11
manufacturer’s instructions for contact time (i.e., x-ray machine will be
cleaned by the radiology tech).
R.
3.
Whenever possible, prior to admission of an Ebola patient, a minimal
amount of supplies should be placed in the room’s supply cabinet or in
patient’s room.
4.
Upon discharge, all supplies or linens in the nurse server or patient room
will be removed prior to admission of another patient. Linens and all
supplies will be discarded as regulated medical biohazardous waste. The
empty nurse server will be disinfected using the same process as for
equipment.
5.
All patient meals must be served with disposable equipment (i.e. trays,
plates, bowls, cups, utensils).
6.
Use only a mattress and pillow with plastic or other covering that fluids
cannot get through.
7.
Do not place patients with suspected or confirmed Ebola virus infection in
carpeted rooms and remove all upholstered furniture and decorative
curtains from patient rooms before use.
Monitoring negative pressure rooms for aerosol-generating procedures
1.
Nursing will notify (Facilities Management or the department
responsible for monitoring negative pressure) regarding the location
of an Ebola patient where aerosol-generating procedures will be
performed.
2.
(Facilities Management or the department responsible for
monitoring negative pressure) should monitor the negative pressure
status of the room during all aerosol-generating procedures or daily, if
warranted.
3.
(Facilities Management or the department responsible for
monitoring negative pressure) will immediately notify nursing if the
negative pressure ventilation is not functioning properly and/or the system
alarms.
4.
Checks of function using a titanium-tetrachloride smoke stick or another
approved device, i.e., (Flowchecker) can be performed, as needed by
(name of department specifically responsible for monitoring
ventilation).
5.
All evaluations and monitoring results will be documented. Documentation
is maintained in the (insert name of department responsible, such as
Facilities or Maintenance) department.
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12
S.
Reporting
1.
All patients identified with suspected Ebola (a PUI with epidemiologic risk
factors that include high or low risk exposures, refer to section D-2) will be
reported to:
 LPHA at (insert phone number of the LPHA) AND
 The Missouri Department of Health and Senior Services 1-800392-0272/ Illinois Department of Health 1-217-785-2080 or 1/312814-5171.
 The State Health Department will contact the CDC.
T.
OR/PACU recommendations
Surgery should not be performed on suspect or confirmed Ebola patients.
The (Infectious disease physician or other entity appointed bioterrorism
authority) and Infection Prevention should be contacted for critical concerns.
U.
Post-mortem procedures
Autopsies should not be performed for all suspect or confirmed Ebola patients.
For instructions on Safe Handling of Human Remains of Ebola Patients refer to
Appendix Q.
V.
Outpatient Recommendations
1.
Patients in outpatient settings should be screened for symptoms and risk
factors for Ebola when community transmission of Ebola is present. The
presence of community transmission will be based travel alerts issued by
the Centers for Disease Control and Prevention and/or the World Health
Organization.
2.
It is essential for all healthcare workers and all medical settings to take
Ebola exposure histories and/or travel histories from patients as well as to
ask about signs and symptoms of Ebola during periods when community
transmission has been identified (Appendix H).
3.
If the patient reports exposure, or is exposed, to a confirmed Ebola case,
screening for the early symptoms of Ebola such as subjective fever, chills,
joint/muscle pain, and headache should be done.
4.
If a patient meets the criteria and has symptoms, immediately place a
surgical/isolation mask on the patient, and move the patient to a separate
room.
5.
If it is essential that a patient with suspected Ebola visit an outpatient
setting, the patient must don a surgical/isolation mask prior to entering the
facility. The patient must be placed in a separate room and be
immediately seen and evaluated.
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13
W.
6.
HCWs must wear impermeable gowns, gloves, surgical/isolation masks,
and protective eyewear when in the room with the patient.
7.
A patient with suspected Ebola will not be allowed to visit or be treated at
any outpatient physical/occupational therapy setting until 21 days after
resolution of fever and symptoms.
8.
If advance notification about an Ebola patient has not occurred,
immediately place a surgical/isolation mask on the patient and place the
patient in a separate room until evaluation occurs, and have the patient
leave the facility as soon as possible.
9.
All patients who visit an outpatient facility should be educated about good
respiratory and hygiene practices. Patient should be taught to cover
mouth and nose with tissue when coughing and sneezing. The patient
should be taught to dispose of tissue in appropriate container after use
and to perform hand hygiene with alcohol based product or soap and
water.
10.
Tissues and hand hygiene products should be available in the waiting
area.
Disposal of infectious waste:
Infectious waste should be stored and disposed of in accordance with Stericycle
and the Department of Transportation (DOT). Refer to Appendix O for permit
instructions. A 1:10 bleach solution should be used in accordance with their
instructions.
X.
Y.
Transfer to another Facility
1.
For Ebola patients who require higher level of care than can be provided
at the presenting facility, transfer may be medically necessary.
2.
Facility transfers must be minimized to avoid unnecessary exposure to
emergency medical services personnel.
3.
Contact and droplet precautions with eye protection must be maintained
during the patient’s transfer or discharge.
4.
The patient must wear a surgical/isolation mask during transfer/discharge.
5.
The primary care physician, case coordinator and/or nurse should
coordinate patient discharge with local health department.
6.
If patient attempts to leave against medical advice (AMA) notify the local
public health agency (LPHA) at (insert phone number of LPHA) and
detain the patient at the facility until arrangements for discharge can be
made.
Work Restrictions for Health Care Workers
Ebola Plan © 2014, BJC Health Care. All Rights Reserved. Reproduction is strictly prohibited without written consent of BJC HealthCare
14
Z.
AA.
1.
Healthcare Workers with unprotected exposure to Ebola patients will be
reviewed on a case-by-case basis and 21-day furlough from duty with
twice-daily fever checks may be initiated for exposures. Refer to
Appendix J for employee exposures.
2.
LPHA must be consulted for all employee exposures and educate
employees on the procedures for home quarantine.
Education and Training
1.
(Infection Prevention and/or the Nursing Supervisor) will coordinate
staff and patient education.
2.
Refer to Appendix L for Just-In-Time (JIT) training for employees.
3.
Infection Prevention will educate the healthcare team on the
epidemiological significance of Ebola, infection prevention precautions,
and this Ebola Preparedness Plan.
4.
All of the staff will reinforce education at the change of shift.
Available Resources
1.
Internal resources for additional information and guidance on Ebola
include:
a.
Infection Prevention Department (insert phone number)
b.
BJC Ebola Intranet Site:
http://bjcnetnew.carenet.org/sites/riskmanagement/evdpage/
default.aspx.
c.
2.
Hospital preparedness checklist for gap analysis (Refer to
“stoplight” document - Appendix P)
External resources for additional information and Ebola guidance:
a.
Departments of Health:
Local Department of Health: (insert phone number)
County Department of Health: (insert phone number)
Missouri Department of Health and Senior Services:
1-800-392-0272
Illinois Department of Public Health:
Call Local Health Department
b.
Web Sites:
Centers for Disease Control and Prevention:
http://www.cdc.gov/vhf/ebola/hcp/index.html
Ebola Plan © 2014, BJC Health Care. All Rights Reserved. Reproduction is strictly prohibited without written consent of BJC HealthCare
15
World Health Organization:
http://www.who.int/csr/don/2014_09_04_ebola/en/
Missouri Department of Health and Senior Services:
http://health.mo.gov/index.php
Illinois Department of Public Health:
http://www.idph.state.il.us/
c.
Appendices:
All appendices without titles and page numbers are available on
the BJC intranet site for printing.
BB.
References
1.
DD.
Centers for Disease Control and Prevention: Ebola Virus Disease:
Information for Healthcare Workers and Settings (2014).
Review of Policy
The plan will be reviewed not less than annually and revised as needed.
VII.
ORIGINAL EFFECTIVE DATE:
October 2014
VIII.
AUTHORIZED BY:
Infection Prevention and Healthcare Epidemiology
Consortium (IPEC)
Council for Occupational Health Professionals
(COHP)
BJC Emergency Preparedness
IX.
DATE OF REVISION:
October 2014
Ebola Plan © 2014, BJC Health Care. All Rights Reserved. Reproduction is strictly prohibited without written consent of BJC HealthCare
16
Appendix A: Stop Sign for Points of Entry
17
Appendix B: Designated Patient Rooms for Ebola Patients
Designated Patient Rooms for Ebola Patients
Including location for removal of PPE (i.e. anteroom, adjacent room)
Department
Patient Room #’s
PPE removal location
(Emergency Department) ###
(Treatment room #)
(Medical/Surgical Floor)
###
(Anteroom)
(Intensive Care Unit)
###
(Anteroom)
Include pictures or diagrams of patient care areas whenever possible to
ensure appropriate location of clean and contaminated areas (i.e. PPE cart,
PPE donning, PPE doffing, waste receptacles) to eliminate cross
contamination.
18
Appendix C: Isolation Sign for Patient Room
19
Appendix D: Stop Sign for Patient Room
20
Appendix E-1: Entry Log
Employee Entry Sign-In-Log
for Biological Agents
ALL EMPLOYEES ARE REQUIRED TO SIGN IN
BEFORE ENTERING THIS ROOM #________
Sign the log once each shift
#
1
Date
Name
Department
Work Phone #
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Forward the completed log to the Occupational Health Department: _______________
21
Appendix E-2: Entry Log
Patient and Visitor Entry Sign-In-Log
for Biological Agents
ALL PERSONS ARE REQUIRED TO SIGN IN
BEFORE ENTERING THIS ROOM #________
Sign the log once each shift
#
1
Date
Name
Department
Work Phone #
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Forward the completed log to the Occupational Health Department: __________
22
Appendix F-1: Donning / Putting on Personal Protective Equipment
23
Appendix F-1: Doffing / Removing Personal Protective Equipment
24
Appendix G: Ebola Communication Interim Guidance
Ebola Communication Interim Guidance
Adapted from BJC Management of Biological Agents Policy
F.
Initial Communication
b.
The (Infectious disease physician or other entity appointed
bioterrorism authority) will notify the following persons that a
potential bioterrorist event occurred:
1)
2)
3)
c.
Infection Prevention Specialists
President or SEO
Local City or County Department of Health, if applicable,
who will contact:
 State Health Department - MO: 1-800-392-0272 /
IL: 1-800-782-7860 or 217-782-7860
 Centers for Disease (CDC) Emergency Response Office (1-800-232-4636) or (770-488-7100)
The (entity appointed administrative authority/on-scene
commander) for the hospital will initiate the entity specific
Communication Matrix or manager-call down through
telecommunications. These individuals must report to the
designated Command Center immediately for briefing by the onscene commander. (List titles of all entity specific persons to
be contacted. Examples of persons to contact may include
but are not limited to the following:
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
16)
17)
18)
19)
20)
Chief Operating Officer of facility
Infection Prevention Specialist
Safety Manager
Critical Care Committee Chair
Admitting Director
Disaster Team Members
Facilities Management, Vice President
Medical and Nursing Directors of the Emergency
Department, Department of Medicine, Pediatrics,
OB/GYN, Psychiatry, Anesthesia and Surgery
Human Resources, Vice President
Chief Medical Officer
Medical Executive Committee, Chair
Chief Nursing Executive
Operations, Director
Pharmacy, Director
Pathology, Director
Microbiology, Director
Public Affairs, Director
Risk Management and General Counsel
Security, Director
Occupational Health, (Supervisor)
25
Appendix H-1: Ebola Algorithm for Returned Travelers
26
Appendix H-2: Mandatory Screening Questions for Patients
Presenting to the Hospital
Mandatory Screening Questions for Patients Presenting to the Hospital
A. Have you recently traveled to or from a country that is an Ebola-affected area in West
Africa (Guinea, Sierra Leone, Liberia, Nigeria, Benin, Burkina Faso, Cape Verde, Cote
D’Ivoire [Ivory Coast], Gambia, Ghana, Guinea-Bissau, Mali, Mautitania [Maghreb],
Niger, Saint Helena, Senegal, and Togo), or from the Democratic of Congo?
Yes
No
B. Have you had a fever (≥101.5°F or 38.6°C) or other signs and symptoms such as
headache, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or hemorrhage
within the last 21 days?
Yes
No
If the answer is “Yes” to A, but the patient is asymptomatic, report this patient to the
local and state health department, and continue with the standard of care.
If the answer is “Yes” to BOTH A and B, consider Ebola and immediately place the
patient on precautions using steps 1 – 5 below. Continue with question C.
1. A surgical mask must be immediately placed on the patient. The patient should be
placed in a private room with the door closed. Critically ill or unstable patients should
be placed in negative pressure ventilation if aerosol generating procedures are
anticipated.
2. A private room with the door closed and an anteroom or staging area for personal
protective equipment (PPE) removal (i.e. adjacent patient room, zip walls,
construction tent) is required for suspect Ebola patients. (Patient room designation
including assigned PPE removal location) is defined in Appendix B. Patients
occupying, but not requiring a private room with these accommodations, must be
immediately relocated to allow for placement of the suspect Ebola patient.
3. Per Centers for Disease Control and Prevention (CDC) guidelines for Ebola, required
isolation precautions include: Standard + Droplet + Contact + EYE PROTECTION:
a.
b.
c.
d.
Impervious or impermeable gown (not the yellow isolation gown)
Disposable gloves – two pairs or “double gloving”
Full eye protection (goggles or full face shield)
Surgical or isolation mask to cover nose and mouth
4. The designated Ebola isolation sign with droplet and contact categories marked,
including eye protection (Appendix C) along with the Ebola stop sign (Appendix D)
must be placed outside the patient’s door.
5. Notify Infection Prevention.
C. Did the patient have a high-risk exposure?
Yes
No
 A high-risk exposure is defined as the following:
o Percutaneous (e.g. needle stick) or mucous membrane contact with blood or
body fluids from an Ebola patient
27
o Direct skin contact with, or exposure to blood or body fluids of, an Ebola
patient
o Processing blood or body fluids form an Ebola patient without appropriate
PPE or biosafety precautions
o Direct contact with a dead body (including during funeral rites) in an Ebola
affected area without PPE
If the answer is “Yes” to C, testing for Ebola is indicated. The health department will
arrange specimen transport and testing at a Public Health Laboratory and CDC. The
health department, in consultation with CDC, will provide guidance to the hospital on
all aspects of patient care and management.
If the answer is “No” to C, continue with questions D and E.
D. Did the patient have a low-risk exposure?
Yes
No
 A low-risk exposure is defined as the following:
o Household members of an Ebola patient and others who had brief direct
contact (e.g. shaking hands) with an Ebola patient without appropriate PPE
o Healthcare personnel in facilities with confirmed or probable Ebola patients
who have been in the care area for a prolonged period of time while not
wearing recommended PPE
E. Did the patient reside in, or travel to or from an Ebola-affected area in West Africa or the
Democratic Republic of Congo within the last 21 days and having had no high- or lowrisk exposure?
Yes
No
If the answer is “Yes” to EITHER D or E, review the case with the health department,
including severity of illness, laboratory findings (e.g. platelet counts), and alternative
diagnoses.
If, after reviewing the case with the health department, Ebola is suspected, testing for
Ebola is indicated.
If Ebola is not suspected, testing is NOT indicated.
If the patient requires in-hospital management, please refer to steps 1 – 2 below.
1. Decisions regarding infection prevention precautions should be based on the
patient’s clinical situation and in consultation with Infection Prevention and the health
department
2. If patient’s symptoms progress or change, re-assess need for testing with the health
department
If the patient does not require in-hospital management, please refer to steps 1 – 2
below.
1. Alert the health department before discharge to arrange appropriate discharge
instructions and to determine if the patient should self-monitor for illness
2. Self-monitoring includes taking their temperature twice a day for 21 days after their
last exposure to an Ebola patient
28
Appendix I: Laboratory Guidance
Guidance for Specimen Collection, Transport, Testing, and Submission for Patients with
Suspected Infection with Ebola Virus Disease
Laboratory Procedures
1. Limit the use of sharps, blood draws, and other laboratory testing on Ebola patients to those that
are deemed medically necessary.
2. Specimens should be collected in accordance with the following to maximize the use of plastic
containers and not glass:
Specimen
Blood
Blood Culture
CSF
Stool
Urine
Collection Device
(plastic tube)
(List plastic bottle type if available)
(plastic tube)
(plastic tube)
(plastic cup)
3. Double bag any samples in plastic biohazard bags and hand-carry to (designated laboratory
and drop-off site).
a. DO NOT place samples in pneumatic tube system.
b. Minimize the use of courier services for laboratory specimen transport.
4. Personnel collecting specimens should place the specimen tube/cup in the first plastic biohazard
bag while still in the room. A clean, designated person should be waiting outside the room with
the second biohazard bag, which is designated as “clean”. The tube and first biohazard bag will
be carefully placed into the second biohazard bag, and sealed securely
5. Alert (appropriate laboratory personnel) to expect samples from a suspect Ebola patient prior
to delivery.
6. Personnel collecting specimens must wear the recommended personal protective equipment
(PPE) including disposable gloves, fluid-resistant/impermeable gown, eye protection (goggles or
face shield), and fluid-resistant surgical/isolation mask.
7. Laboratory personnel performing testing on specimens must wear PPE including disposable
gloves, fluid-resistant/impermeable gown, eye protection (goggles or face shield), and fluidresistant surgical/isolation mask AND use of a certified Class II Biosafety cabinet or plexiglass
splash guard, as well as manufacturer-installed safety features for instruments.
Testing for Suspected Ebola Virus Disease
1. Testing a patient for suspected Ebola virus disease requires consultation with the state health
department
a. The Department of Health and Human Services (DHHS) is consulted to determine if a
patient meets criteria for testing.
b. If criteria are met, the medical provider will contact the state laboratory for further
guidance on specimen collection and shipping considerations.
c.
The Centers for Disease Control and Prevention (CDC) cannot accept any specimens
without prior consultation.
i. Specimens other than blood may be submitted upon consult with the CDC.
29
Appendix J: Occupational Exposure to Ebola Virus Disease (EVD)
A.
Nosocomial transmission of Ebola from patients to healthcare workers after occupational
exposure has been documented.
B.
The definition of an occupational exposure is any employee exposed to an individual with
Ebola without proper isolation precautions, proper respiratory protection (either patient or
employee), and/or proper personal protective equipment (gown, gloves, mask, eye
protection, and N-95 respirator or PAPR, if applicable).
C.
High risk exposures include any of the following: Percutaneous (e.g., needle stick) or
mucous membrane exposure to blood or body fluids of Ebola patient; Direct skin contact
with, or exposure to blood or body fluids of, an Ebola patient without appropriate personal
protective equipment (PPE); Processing blood or body fluids of a confirmed Ebola patient
without appropriate PPE or standard biosafety precautions; Direct contact with a dead body
without appropriate PPE in a country where an Ebola outbreak is occurring.
D.
Low risk exposures include any of the following: Household contact with an Ebola patient;
Other close contact* with Ebola patients in health care facilities or community settings;
Having direct brief contact (e.g., shaking hands) with an Ebola 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
E.
No known exposure includes having been in a country in which an Ebola outbreak occurred
within the past 21 days and having had no high or low risk exposures
*Close contact is defined as 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).
F.
Management of occupational exposures to Ebola patients should occur as follows:
1.
The employee must immediately report any occupational exposures to Ebola patients
to their supervisor and notify Occupational Health and Infection Prevention. Failure to
notify their supervisor of an Ebola exposure may result in disciplinary action.
2.
A line list of all exposed employees must be developed by the department manager
and Occupational Health (see Table 1).
3.
All employees with an unprotected occupational exposure to a known case of Ebola
must be furloughed from duty for 21 days following the last date of exposure.
a.
The (Infectious disease physician or other entity appointed bioterrorism
authority) will make a determination about whether an unprotected exposure
as defined above has occurred.
b.
Occupational Health shall be notified of all employee furloughs.
c.
The exposed employee must watch closely for and immediately report any
symptoms of illness to Occupational Health by taking their temperature twice
a day and monitoring for the presence of the other symptoms (subjective
fever, chills, myalgia, headache, abdominal pain, vomiting, and diarrhea).
d.
Furloughed employees will be paid in accordance with the BJC HealthCare
Earned Time Off (ETO) policy (#4-1).
30
4.
G.
1)
Furloughed employees who do not develop signs and symptoms
consistent with Ebola will be reimbursed for any ETO/EIB (extended
illness benefit) used during the furlough period, provided they return
to work when requested.
2)
Furloughed employees who develop signs and symptoms consistent
with Ebola will be paid in accordance with the BJC HealthCare
Workers Compensation Policy (#4-6).
Passive surveillance (e.g., review of occupational health or other sick leave records)
should be conducted among all healthcare workers in a facility with a Ebola patient,
and all healthcare facility workers should be educated concerning the symptoms of
Ebola.
Non-occupational exposure: Employees may be exposed to Ebola during activities such as
international travel to and from areas with community transmission or exposure to persons
identified as a result of a public health investigation.
1.
The Centers for Disease Control and Prevention recommends that persons planning
elective or non-essential travel to areas with community transmission postpone their
trips until further notice.
2.
Employees who may have traveled to areas with community transmission of Ebola
should watch closely for fever and the presence of the other symptoms (subjective
fever, chills, myalgia, headache, vomiting, and diarrhea). Those who develop fever
or other Ebola symptoms should not report for duty and should seek health-care
evaluation. Employees must notify occupational health of their travel and before
returning to work.
3.
At this time, in the absence of fever or other Ebola symptoms, employees who
traveled to areas with community transmission of Ebola need not limit their activities
outside the home and should not be excluded from work.
4.
All employees with an unprotected exposure or close contact to a known case of
Ebola outside of work must be furloughed from duty for 21 days following exposure.
5.
a.
The exposed employee must immediately notify their supervisor of the
exposure. Failure to notify their supervisor of an Ebola exposure may result
in disciplinary action.
b.
The exposed employee must watch closely for any symptoms of illness by
taking their temperature twice a day and monitoring for Ebola symptoms;
those who develop fever or other Ebola symptoms should not report for duty
and should seek health-care evaluation.
c.
Employees who may have been exposed to Ebola patients outside of work
will be reimbursed in accordance with the BJC HealthCare Earned Time Off
(ETO) policy (#4-1).
Infection Prevention and Occupational Health must be notified of any employees that
develop fever or other Ebola symptoms consistent with suspected Ebola.
31
Appendix J: Occupational Exposure to Ebola Virus Disease (EVD) (TABLE 1)
Patient Name:
DOB:
Adate:
Disease of Exposure: Ebola
Employee Name
Last, First
Page _______ of _______
Ddate:
Exposure Date:
Location:
Job Title
Department
Type of
Exposure
Date of Isolation:
Fever
Headache
Myalgia
Vomiting
Diarrhea
Other
Symptom
onset
High / Low
Social Security Number
Employee Name
Last, First
Home Phone
Job Title
Date:
No known
Date of furlough / quarantine
Department
Type of
Exposure
Fever
Headache
Myalgia
Vomiting
Diarrhea
Other
Symptom
onset
High / Low
Social Security Number
Employee Name
Last, First
Home Phone
Job Title
Date:
No known
Date of furlough / quarantine
Department
Type of
Exposure
Fever
Headache
Myalgia
Vomiting
Diarrhea
Other
Symptom
onset
High / Low
Social Security Number
Employee Name
Last, First
Home Phone
Job Title
Date:
No known
Date of furlough / quarantine
Department
Type of
Exposure
Fever
Headache
Myalgia
Vomiting
Diarrhea
Other
Symptom
onset
High / Low
Social Security Number
Employee Name
Last, First
Home Phone
Job Title
Date:
No known
Date of furlough / quarantine
Department
Type of
Exposure
Fever
Headache
Myalgia
Vomiting
Diarrhea
Other
Symptom
onset
High / Low
Social Security Number
Home Phone
No known
Date of furlough / quarantine
Date:
32
Appendix K: Employee Fact Sheet
33
Appendix L-1: Just In Time (JIT) Employee Training
34
Appendix L-2: Ebola Checklist for Employees
35
Appendix M: Patient and Visitor Education
36
Appendix N: Stericycle Waste Handling Procedures
37
Appendix O: Frequently Asked Questions
Which countries in Africa are affected by the Ebola outbreak?
The 2014 outbreak is currently affecting three countries in West Africa: Guinea, Liberia and Sierra
Leone.
How is Ebola transmitted?
Ebola is not easily transmitted, and people are only infectious if they have symptoms. There is no
risk of transmitting the virus by people who have been exposed to Ebola but do not yet have
symptoms. Unlike the flu and other respiratory infections, the virus does not spread readily through
the air. The virus is transmitted through direct contact with bodily fluids (blood, sweat, stool, etc.) of
another infected individual, including through contact with objects that have been contaminated by
infected fluids such as needles.
Do we expect to see more cases in the United States?
Due to the public health crisis in West Africa, it is likely there will be additional cases imported to the
U.S. It is important to remember our health care system is prepared and much better equipped to
contain the virus. The U.S. Centers for Disease Control and Prevention is working with other U.S.
government agencies, the World Health Organization, and other domestic and international partners
on an international response.
Is our hospital prepared if we receive an infected patient?
Throughout BJC HealthCare, infection prevention protocols for Ebola have been reviewed, revised
and tested. If a suspected case is identified, the patient’s treatment and movements have already
been planned and practiced.
What do I need to do to be prepared?
Health care workers are the first line of detection in the U.S. and it is important for frontline staff to
be vigilant, particularly at the first point of contact such as the emergency department. It is essential
that any patient presenting with a fever be asked immediately about travel history.
What do I need to do if I am caring for a patient under investigation?
Health care workers need to take precautions to protect themselves by following meticulous
infection prevention protocols. Any staff member involved in direct care of a patient with known or
suspected Ebola virus will receive additional training.
Why do responders in Africa wear so much personal protective equipment (that can include
full body suits) for this Ebola outbreak when CDC says hospitals here could safely manage
the care of an Ebola patient without a full body suit?
There are important differences between providing care or performing public health tasks in Africa
versus in a U.S. hospital. In field medical settings, additional PPE may be necessary to protect
healthcare workers. In some places in Africa, workers may not have the ability to prepare for
potential exposures. For example, in some places, care may be provided in clinics with limited
resources (e.g., no running water, no climate control, no floors, inadequate medical supplies), and
workers could be in those areas for several hours with a number of Ebola infected patients.
Additionally, certain job responsibilities and tasks, such as attending to dead bodies, may also
require different PPE than what is used when providing care for infected patients in a hospital.
For more information, visit the BJC Ebola Intranet Site:
http://bjcnetnew.carenet.org/sites/riskmanagement/evdpage/default.aspx.
38
Appendix P: Stoplight Gap Analysis for Ebola Preparedness
Detailed Hospital Checklist for Ebola Preparedness
The U.S. Department of Health and Human Services (DHHS), Centers for Disease Control and
Prevention (CDC), and Office of the Assistant Secretary for Preparedness and Response (ASPR), in
addition to other federal, state, and local partners, aim to increase understanding of Ebola virus
disease (EVD) and encourage U.S. hospitals to prepare for managing patients with EVD and other
infectious diseases. Every hospital should ensure that it can detect a patient with ebola, protect
healthcare workers so they can safely care for the patient, and respond in a coordinated fashion.
Many of the signs and symptoms of EVD are non-specific and similar to those of many common
infectious diseases, as well as other infectious diseases with high mortality rates. Transmission can
be prevented with appropriate infection control measures.
In order to enhance our collective preparedness and response efforts, this checklist highlights key
areas for hospital staff -- especially hospital emergency management officers, infection control
practitioners, and clinical practitioners -- to review in preparation for a person with EVD arriving at a
hospital for medical care. The checklist provides practical and specific
suggestions to ensure your hospital is able to detect possible EVD cases, protect your
employees, and respond appropriately.
While we are not aware of any domestic EVD cases (other than two American citizens who were
medically evacuated to the United States), now is the time to prepare, as it is possible that
individuals with EVD in West Africa may travel to the United States, exhibit signs and symptoms of
EVD, and present to facilities.
Hospitals should review infection control policies and procedures and incorporate plans for
administrative, environmental, and communication measures, as well as personal protective
equipment (PPE) and training and education. Hospitals should also define the individual work
practices that will be required to detect the introduction of a patient with EVD or other emerging
infectious diseases, prevent spread, and manage the impact on patients, the hospital, and staff.
The checklist format is not intended to set forth mandatory requirements or establish national
standards. In this checklist, healthcare personnel refers to all persons, paid and unpaid, working in
healthcare settings who have the potential for exposure to patients and/or to infectious materials,
including body substances, contaminated medical supplies and equipment, or contaminated
1
environmental surfaces.
This detailed checklist for hospitals is part of a suite of HHS checklists currently in development. CDC
is available 24/7 for consultation by calling the CDC Emergency Operations Center
(EOC) at 770-488-7100 or via email at [email protected].
1
Healthcare personnel includes, but is not limited to, physicians, nurses, nursing assistants, therapists, technicians, laboratory personnel,
autopsy personnel, students and trainees, contractual personnel and persons not directly involved in patient care (e.g., house-keeping,
laundry).
39
Stoplight Gap Analysis for Hospital Preparedness:
C=Completed (RED); IP=In Progress (YELLOW); NS=Not Started (GREEN)
PREPARE TO DETECT
Review risks and signs and symptoms of EVD, and train all front-line clinical staff on how
to identify signs and symptoms of EVD:
http://www.cdc.gov/vhf/ebola/symptoms/index.html;
http://www.cdc.gov/vhf/ebola/exposure/index.html
C
IP
NS
Review CDC EVD case definition for guidance on who meets the criteria for a person
under investigation for Ebola Virus Disease, http://www.cdc.gov/vhf/ebola/hcp/casedefinition.html and proper specimen collection and shipment guidelines for testing:
http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-specimen-collectionsubmission-patients-suspected-infection-ebola.html
Ensure EMS Crews at hospitals and other agencies are aware of current
guidance: http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergencymedical-services-systems-911-public-safety-answering-points-managementpatients-known-suspected-united-states.html
Review Emergency Department (ED) triage procedures, including patient placement,
and develop or adopt screening criteria (e.g. relevant questions: exposure to case,
travel within 21 days from affected West African country) for use by healthcare
personnel in the ED to ask patients during the triage process
for patients arriving with compatible illnesses.
Post screening criteria in conspicuous placements at ED triage stations, clinics, and
other acute care locations (see suggested screening criteria in Attachment
A).
Designate points of contact within your hospital responsible for communicating with state
and local public health officials. Remember: EVD is a nationally notifiable disease and
must be reported to local, state, and federal public health authorities.
Ensure that all triage staff, nursing leadership, and clinical leaders are familiar with the
protocols and procedures for notifying the designated points of contacts to inform 1)
hospital leadership (infection prevention and control, infectious
disease, administration, laboratory, others as applicable), and 2) state and local
public health authorities regarding a suspected EVD case.
Conduct spot checks and inspections of triage staff to determine if they are incorporating
screening procedures and are able to initiate notification, isolation, and PPE procedures
for your hospital.
Communicate with state and/or local health department on procedures for
notification and consultation for EVD testing requests.
Ensure that laboratory personnel are aware of current guidelines for specimen
collection, transport, testing, and submission for patients with suspected EVD.
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PREPARE TO PROTECT
Review and distribute the Guidelines for Environmental Infection Control in
Health-Care Facilities:
http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_hcf_03.pdf.
Treat all symptomatic travelers returning from affected West African countries as
potential cases and obtain additional history.
Conduct a detailed inventory of available supply of PPE suitable for
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STANDARD, contact and droplet precautions. Ensure an adequate supply, for all
healthcare personnel, of:
 Impermeable gowns (fluid resistant or impermeable),
 Gloves,
 Shoe covers, boots, and booties, and
 Appropriate combination of the following:
o Eye protection (face shield or goggles),
o Facemasks (goggles or face shield must be worn with
facemasks),
o N95 respirators ( for use during aerosol-generating procedures)
 Other infection control supplies (e.g. hand hygiene supplies).
Ensure that PPE meets nationally recognized standards as defined by the Occupational
Safety & Health Administration (OSHA), CDC, Food and Drug Administration (FDA), or
Interagency Board for Equipment Standardization and Interoperability:
https://iab.gov/SELint.aspx.
Review plans, protocols, and PPE purchasing, with your community/coalition
partners, that promote interoperability and inter-facility sharing if necessary.
Ensure EVD PPE supplies are maintained in triage, ED, and all patient care areas.
Verify that all of your healthcare personnel:
 Meet all training requirements in PPE and infection control,
 Are able to use PPE correctly,
 Have proper medical clearance,
 Have been properly fit-tested on their respirator for use in aerosolgenerating procedures or more broadly as desired, and
 Are trained on management and exposure precautions for suspected or
confirmed EVD cases: http://www.cdc.gov/vhf/ebola/hcp/infectionprevention-and-control-recommendations.html.
Encourage healthcare personnel to use a “buddy system” when caring for patients
and when putting on and removing PPE: http://www.cdc.gov/vhf/ebola/pdf/ppeposter.pdf and
http://www.cdc.gov/hicpac/2007IP/2007ip_part2.html
Spot-check frequently to be sure standard, contact and droplet infection control and
isolation guidelines are being followed, including safe putting on and
removing PPE.
Ensure all healthcare personnel entering the patient room should wear at least: gloves,
gown (fluid resistant or impermeable), eye protection (goggles or face shield), and a
facemask.
Ensure that non-clinical persons have limited access to suspected or confirmed
EVD patients’ rooms.
Review and update, as necessary, hospital infection control
protocols/procedures.
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Review policies and procedures for screening, minimizing healthcare personnel
exposure, isolation, medical consultation appropriate for EVD exposure and/or illness,
and monitoring and management of potentially exposed healthcare
personnel.
Review and update, as necessary, all hospital protocols and procedures for
isolation of patients with suspected or confirmed infectious diseases.
Review your hospital’s infection control procedures to ensure adequate
implementation for preventing the spread of EVD
Review protocols for sharps injuries and educate healthcare personnel about
safe sharps practices to prevent sharps injuries.
Emphasize the importance of proper hand hygiene to healthcare personnel.
Post appropriate signage alerting healthcare personnel to isolation status, PPE
required, proper hygiene, and handling/management of infected patients and
contaminated supplies.
Develop contingency plans for staffing, logistics, budget, procurement, security, and
treatment.
Review plans for special handling of linens, supplies, and equipment from
suspected or confirmed EVD patients.
Review environmental cleaning procedures and provide education/refresher training
for cleaning healthcare personnel: http://www.cdc.gov/vhf/ebola/hcp/infectionprevention-and-control- recommendations.html.
Distribute guidelines concerning laboratory diagnostics and specimen handling to all
laboratory personnel, and post the guidelines conspicuously in your
hospital laboratory: http://www.cdc.gov/vhf/ebola/hcp/interim-guidancespecimen-collection-submission-patients-suspected-infection-ebola.html and
http://www.cdc.gov/ncezid/dhcpp/vspb/specimens.html.
Provide education and refresher training for healthcare personnel on sick leave policies.
Review policies and procedures for screening and work restrictions for exposed or ill
healthcare personnel, and develop sick leave policies for healthcare personnel that are
non-punitive, flexible and consistent with public health guidance.
Ensure that healthcare personnel have ready access, including via telephone, to
medical consultation.
Conduct education and refresher training with healthcare personnel on EVD for special
pathogen handling in the laboratory.
Ensure that all Airborne Infection Isolation Rooms (AIIR) are functioning correctly
and are appropriately monitored for airflow and exhaust handling.
Note: CDC recommends an AIIR room be used if aerosol-producing procedures
are absolutely necessary.
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PREPARE TO RESPOND
Review, implement, and frequently exercise the following elements with first- contact
personnel, clinical providers, and ancillary staff:
 Appropriate infectious disease procedures and protocols, including PPE
donning/removal,
 Appropriate triage techniques and additional EVD screening questions,
 Disease identification, testing, specimen collection and transport
procedures,
 Isolation, quarantine and security procedures,
 Communications and reporting procedures, and
 Cleaning and disinfection procedures.
Review plans and protocols, and exercise/test the ability to share relevant health
data between key stakeholders, coalition partners, public health, emergency
management, etc.
Review, develop, and implement plans to provide safe palliative care, adequate
respiratory support, ventilator management, safe administration of medication,
sharps procedures, and reinforce proper biohazard containment and disposal
precautions.
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Review roles of the infection control practitioner to:
 Ensure appropriate infection control procedures are being followed,
including for lab, food, environmental services, and other personnel, and
Maintain updated case definitions, management, surveillance and
reporting recommendations.
Properly train healthcare personnel in personal protection, isolation
procedures, care of EVD patients.
Ensure that administrators are familiar with responsibilities during a public health
emergency.
Identify a communications/public information officer who:
 Develops appropriate literature and signage for posting within the
hospital (topics may include definitions of low-risk, high-risk and
explanatory literature for patient, family members and contacts),
 Develops targeted public health risk communication messages for use in the
event of a highly-suspected or confirmed EVD case in your hospital,
 Develops internal messages for suspected and confirmed cases, and internal
and external messages for confirmed EVD cases,
 Contacts local- and state-identified EVD subject matter experts,
 Requests EVD-appropriate literature for dissemination to healthcare
personnel, patients, and contacts,
 Prepares written and verbal messages ahead of time that have been
approved, vetted, rehearsed and exercised,
 Works with internal department heads and clinicians to prepare and vet internal
communications to keep healthcare personnel and volunteers
informed, and
 Train subject-matter experts to become spokespersons and practice sound
media relations.
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Plan for regular situational briefs for decision-makers, including:
 Suspected and confirmed EVD patients who have been identified and
reported to public health authorities,
 Isolation, quarantine and exposure reports,
 Supplies and logistical challenges,
 Personnel status, and
 Policy decisions on contingency plans and staffing.
Maintain situational awareness of reported EVD case locations, travel
restrictions and public health advisories, and update triage guidelines
accordingly.
Incorporate EVD information into educational activities, including physician Grand
Rounds, nursing educational meetings, and other healthcare system and coalition
healthcare personnel and management training opportunities:
http://emergency.cdc.gov/coca/.
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Appendix Q: Safe Handling of Human Remains of Patients with Ebola
Safe Handling of Human Remains of Patients with Ebola
(Guidance from Centers for Disease Control and Prevention, Guidance for Safe Handling of
Human Remains of Ebola Patients in U. S. Hospitals and Mortuaries, October 8, 2014)
These recommendations give guidance on the safe handling of human remains that may
contain Ebola virus and are for use by personnel who perform postmortem care in U.S.
hospitals and mortuaries. In patients who die of Ebola virus infection, virus can be detected
throughout the body. Ebola virus can be transmitted in postmortem care settings by laceration
and puncture with contaminated instruments used during postmortem care, through direct
handling of human remains without appropriate personal protective equipment, and through
splashes of blood or other body fluids (e.g. urine, saliva, feces) to unprotected mucosa (e.g.,
eyes, nose, or mouth) which occur during postmortem care.



Only personnel trained in handling infected human remains, and wearing personal
protective equipment as described in the Ebola Preparedness Plan should touch, or move,
any Ebola-infected remains.
Handling of human remains should be kept to a minimum.
Autopsies on patients who die of Ebola should be avoided. If an autopsy is necessary,
the state health department and CDC should be consulted regarding additional precautions.
Personal protective equipment for postmortem care personnel

Personal protective equipment (PPE): Prior to contact with body, postmortem care
personnel must wear PPE consisting of: surgical scrub suit, surgical cap, impervious gown
with full sleeve coverage, eye protection (e.g., face shield, goggles), facemask, shoe covers,
and double surgical gloves. Additional PPE (leg coverings, apron) might be required in certain
situations (e.g., copious amounts of blood, vomit, feces, or other body fluids that can
contaminate the environment).

Putting on, wearing, removing, and disposing of protective equipment: PPE should
be in place BEFORE contact with the body, worn during the process of collection and
placement in body bags, and should be removed immediately after and discarded
appropriately (see Interim Guidance for Environmental Infection Control in Hospitals for Ebola
Virus(http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html)).
Follow appendix F when removing PPE as to avoid contaminating the wearer. Hand hygiene
(washing your hands thoroughly with soap and water or an alcohol based hand rub) should
be performed immediately following the removal of PPE. If hands are visibly soiled, use soap
and water.
Postmortem preparation

Preparation of the body: At the site of death, the body should be wrapped in a plastic
shroud. Wrapping of the body should be done in a way that prevents contamination of the
outside of the shroud. Change your gown or gloves if they become heavily contaminated with
blood or body fluids. Leave any intravenous lines or endotracheal tubes that may be present
in place. Avoid washing or cleaning the body. After wrapping, the body should be immediately
placed in a leak-proof plastic body bag not less than 150 μm thick and zippered closed. The
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bagged body should then be placed in another leak-proof plastic body bag not less than 150
μm thick and zippered closed before being transported to the morgue.

Surface decontamination: Prior to transport to the morgue, perform surface
decontamination of the corpse-containing body bags by removing visible soil on outer bag
surfaces with EPA-registered disinfectants which can kill a wide range of viruses. Follow the
product’s label instructions. After the visible soil has been removed, reapply the disinfectant to
the entire bag surface and allow to air dry. Following the removal of the body, the patient
room should be cleaned and disinfected. Reusable equipment should be cleaned and
disinfected according to standard procedures. For more information on environmental
infection control, please refer to “Interim Guidance for Environmental Infection Control in
Hospitals for Ebola Virus(http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-inhospitals.html)” (http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-inhospitals.html(http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-inhospitals.html)).

Communicate with any mortuary personnel in a timely manner that the body may be
contaminated with Ebola and they will need to use proper precautions in coordination with
State Health Department and the CDC.

In the event of leakage of fluids from the body bag, thoroughly clean and decontaminate
areas of the environment with EPA-registered disinfectants which can kill a broad range of
viruses in accordance with label instructions. Reusable equipment should be cleaned and
disinfected according to standard procedures. For more information on environmental
infection control, please refer to “Interim Guidance for Environmental Infection Control in
Hospitals for Ebola Virus(http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-inhospitals.html)” (http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-inhospitals.html(http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-inhospitals.html)).
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