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TITLE:

System Care of Patients With or Suspected of Having Ebola Virus Disease (EVD)

PURPOSE:

This plan defines the methods by which Harris Health will respond to and care for patients with or suspected of having been infected with Ebola virus.

GUIDELINE/PROCEDURES STATEMENT: Ebola Virus Disease (EVD) is a serious and highly contagious viral illness that is prevalent in West Africa. Human-to-human transmission of Ebola virus occurs via direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and/or with contaminated surfaces, materials, and objects (e.g. bedding, clothing, syringes, and needles). Individuals who have visited the affected countries (Guinea, Liberia, Sierra Leone, and Mali) or served as volunteer health workers in the affected regions may have been exposed to the virus and are at risk for infection. Health care workers including laboratory workers are at risk for infection with Ebola virus. Reduced exposure to those who have been infected is essential to the control of the spread of Ebola. In order to provide care for patients with, or suspected of having Ebola Virus Disease, as well as to control exposure to other patients, the following are Harris Health System’s general guidelines for treating suspected Ebola patients: •

Patients who access Harris Health System for care in all care locations (Ambulatory and acute care settings including the Emergency Centers) will be screened for risk of Ebola infection and be placed in contact and droplet isolation immediately the thredhold level of risk identified. Patients presenting in an ambulatory care setting with screening results high risks for Ebola will be transferred immediately to Harris Health acute hospitals (Ben Taub or Lyndon B. Johnson (LBJ)) for all diagnostic testing and care. All laboratory diagnostic evaluation for Ebola infection will be performed following the CDC testing guidelines.

• •

ELABORATION: I.

DEFINITIONS:

A.

Patient with Ebola Virus Disease: Patient with laboratory-confirmed diagnostic evidence of Ebola virus infection.

B.

Person Under Investigation: A person who has both (I) epidemiologic risk factors as follow AND (II) signs and symptoms consistent with Ebola Virus Disease: I.

Epidemiologic risk factors within the past 21 days before the onset of symptoms 1. Contact with blood or other body fluids or human remains of a patient known to have or suspected to have EVD; 2. Residence in, or travel to a Disease Endemic Area (defined below); or 3. Direct handling of bats or non-human primates from a Disease-Endemic Area.

Ebola Response Plan II.

C.

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Signs and Symptoms 1. Fever of greater than 38.0 degrees Celsius or 100.4 degrees Fahrenheit; OR 2. One of the following additional symptoms: a. Headache b. Weakness c. Muscle pain d. Vomiting e. Diarrhea f. Abdominal pain; OR g. Unexplained hemorrhage.

Disease Endemic Areas and CDC Travel Alert Countries • Countries with Widespread Transmission (As of November 6, 2014) o Guinea o Liberia o Sierra Leone http://www.cdc.gov/vhf/ebola/resources/distribution-map-guinea-outbreak.html#areas •

Countries with CDC travel advisory alert level 2 (Last updated November 19, 2014) o Mali http://wwwnc.cdc.gov/travel/notices/notices D.

Ebola Treatment Team (ETT): A team of healthcare professionals whose members are educated on Ebola Virus Disease risks, diagnosis, treatment and containment.

II.

PROCEDURE:

1.

Identification A. Initial Screening – Follow the Appendix 1A - Harris Health System EVD Screening and Appendix 1B - Ask My Nurse Screening Protocols. Every patient who presents to a Harris Health facility (including ambulatory care settings) will be immediately ask the exposure history using the following questions: 1. “In the past 21 days, have you: a. Been in the countries in West Africa - Guinea, Liberia, Sierra Leone or Democratic Republic of Congo?” b. Had contact with the blood, or body fluids of a person with suspected or known Ebola Virus Disease?” c. Had direct contact with bats, rodents, or primates from West Africa?”

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2. If the patient responds “YES” to any of these questions, further questions will be asked following the list of symptoms: a. Fever (subjective or ≥38.0 degrees Celsius or 100.4 degrees Fahrenheit); OR b. Headache c. Weakness d. Muscle pain e. Vomiting f. Diarrhea g. Abdominal pain h. Unexplained hemorrhage. 3. If the patient responds “YES” to any of these symptoms, the patient will be designated as “Person Under Investigation” (PUI) and the coordination of care and treatment is subject to the following plan. 4. If the patient responds “NO” to all of the questions asked above, proceed with the appropriate routine clinical diagnosis. B. Person Under Investigation (PUI) for Ebola – Continue to follow the Harris Health EVD Screening Protocol as referenced in Appendix 1A of this plan. 1. Inpatient Setting a. Place the PUI under contact and droplet isolation. Immediately contact Infectious Disease Physician, Infection Control Practitioner, House Supervisor, and Administrator on-call. The Administrator on-call will initiate hospital-wide communication following the Communication Decision Tree. Refer to Appendix 2A and 2B for telephone trees for Ben Taub, Quentin Mease and LBJ hospitals. b. Draw laboratory specimens for Ebola. Follow Appendix 3 - Harris Health System Laboratory Testing Protocol for Ebola Virus Disease and Appendices 3A and 3B for specimen handling and transport instructions for Ben Taub and LBJ hospital respectively. c. Limit contact with the PUI. Only essential personnel necessary to care for the patient should have contact. Utilize the Ebola Sign-in Logs for Ancillary and HCW and Lab Specimen Chain of Custody form (Refer to Appendices 4A, 4B and 4C) to record all personnel who care for the patient and who handle patient’s laboratory specimen.

2. Ambulatory Care & Other Outpatient Settings a. Community Health Centers i.

Place the patient in contact and droplet isolation. Immediately contact Infectious Disease Physician, Infection Control Practitioner, and Ambulatory Care Services (ACS) Administrator-on-call. Refer to Appendix 2C for telephone tree for ACS.

Ebola Response Plan ii.

iii.

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Contact Harris Health EMS to arrange for transfer to an acute care hospital (Ben Taub or LBJ) or a state designated Ebola treating facility. Refer to Appendix 10 – Harris Health System EMS Transport of Ebola Patients. Limit contact with the PUI. Only essential personnel necessary to care for the patient should be in contact with the patient. Utilize the Ebola Sign-in Logs for Ancillary and HCW and Lab Specimen Chain of Custody form (Refer to Appendices 4A, 4B and 4C) of this plan to record all personnel who care for the patient and who handle patient’s laboratory specimen.

b. Ask My Nurse Line i. If the patient is designated as PUI after the completion of the screening procedure, instructions will be provided to the patient that further work-up is necessary and transportation arrangement will be offered to the patient. Refer to Appendix 1B Ask My Nurse Screening Protocol. ii. Immediately contact Infectious Disease Physician, Infection Control Practitioner, Ambulatory Care Services (ACS) Administrator-on-call and Harris Health EMS team. Refer to Appendix 2C for telephone tree for ACS. c. Other Outpatient Settings (Hospital-based Outpatient Clinics) i.

ii.

2.

Place the PUI under contact and droplet isolation. Immediately contact Infectious Disease Physician, Infection Control Practitioner, House Supervisor, and Administrator on-call.

The Administrator on-call will initiate the hospital-wide communication following the Communication Decision Tree. Refer to Appendix 2A and 2B for telephone trees for Ben Taub, Quentin Mease and LBJ hospitals.

Activation, Communication & Incident Command A. Communication Upon identification of patients with or suspected of Ebola virus, staff will notify: 1. Infectious Disease Physician 2. Infection Control Practitioner 3. House Supervisor or Nurse Manager or Charge Nurse in ambulatory care setting 4. Laboratory Services, and 5. Administrator on-call (if applicable) The Administrator on-call will notify: 1. Pavilion Administrator, Chief Nurse Officer, Vice President of Operations and Chief of Staff 2. Harris Health System Chief Medical Officer 3. Harris Health System Chief Executive Officer 4. Harris Health System Corporate Communication 5. Harris Health System Office of Risk Management

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The Pavilion Administrator, Chief of Staff and Infectious Disease Physician will notify: 1. City of Houston Health and Human Services Office who will then notify the Centers for Disease Control & Prevention. B. Incident Command Under the direction and leadership of Harris Health System Chief Executive Officer, the Incident Command will be set up locally at the respective acute care hospital (Ben Taub or LBJ) to coordinate all response activities during the diagnostic and treatment phases of suspected EVD as specified in the System Emergency Operations Plan. 1.

Diagnostic Testing A. The CDC guideline for laboratory specimen handling and testing of Ebola virus will be followed. Refer to Appendix 3 - Harris Health System Ebola Testing Protocol for specific instruction and guidance. A confirmation test for Ebola virus also required to be performed by the Centers for Disease Control and Prevention. Refer to Appendix 5 - CDC guidelines for Packaging and Shipping Clinical Specimen for shipping instructions. B. Utilize the Lab Specimen Chain of Custody form referenced in Appendix 4C to record personnel handling patient’s laboratory specimen.

2.

Treatment

The Ebola Treatment Team will be the primary team to provide the medical management of the suspected or with EVD patient. During the treatment process, extra precautions must be taken. All personnel who provide care for the patient and those who handle patient’s laboratory specimen will be tracked and monitored for sign and symptoms for potential exposure. All healthcare workers must follow the indicated procedures: A. Wear Personal Protective Equipment (PPE). All staff who may come into contact with the PUI or any laboratory specimens of the PUI must use appropriate PPE. Refer to the instruction packet referenced in Appendix 6 for proper donning and doffing of PPE. 1. Double gloves, Tychem suit, full face shield, N95 mask, impervious gown, and knee high foot covers. 2. If the patient has been diagnosed with Ebola, or if the patient is grossly symptomatic, greater PPE will be required, including Powered Air Purifying Respirators (PAPR) and shroud, and water resistant coverall. 3. Each staff member and physician treating the patient must also dress and remove all such PPE in a buddy system, with the one person watching the other to ensure proper donning and removal of the PPE.

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B. Transferring Patients 1. Take extra precaution when transferring patients to nursing units, Diagnostic Imaging suite, and during transport of patient by ambulance. Appropriate PPE must be worn in accordance with the established procedures and guidelines. C. Handling of Contaminated Materials In any scenario, all materials used for patient care must be sequestered, and stored in a secure, locked environment, and remain untouched until after the diagnosis of the patient and definitive instructions for safe disposal and decontamination. Only staff who don appropriate PPE may handle the contaminated materials. Refer to Appendix 7 - Category A Waste Handling & Packaging Procedures and Guidelines for a Suspected or Confirmed Case of Ebola for specific instructions and Appendix 7A – EVD HazMat Handling Process Flow. D. Cleaning of Reusable Medical Equipment/Supplies Disposable medical equipment and supplies should be used during the care of the suspected Ebola patients. In cases where non-dedicated, non-disposable medical equipment was used for patient care, such equipment should be cleaned and disinfected according to the manufacturer’s instructions, and hospital policies. Any recommendations made from the CDC for cleaning and disinfecting of reusable medical equipment will be considered. E.

Cleaning and Disinfection of EVD Patient Room Daily cleaning and disinfection of hard, non-porous surfaces of patient room will be performed using the approved disinfectant and procedures.. Appropriate PPE is required when performing environmental cleaning and disinfection. Refer to Appendix 8 – Guidelines for Environmental Cleaning & Disinfection of EVD Patient Rooms.

F.

Limit Visitors Visitors are not allowed for patients who are being treated for EVD. The Ebola treatment team will determine if exceptions can be considered on a case by case basis. Appropriate PPE must be worn when entering the patient’s room.

3.

Discharge

Recovery from Ebola infection depends on good supportive care and the patient’s immune response. For the deceased patient, extra precaution should be considered during the post mortem care. Remains will be handled following the CDC guideline and protocol for post mortem care. All personnel who provide postmortem care of the patient’s remain will be tracked for potential exposure. Refer to Appendix 9 - CDC

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Guidance for Safe Handling of Human Remains of Ebola Patients in U. S. Hospitals and Mortuaries for further guidance.

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Appendix 1A Harris Health System EVD Screening Protocol

Harris Health System EVD Screening Protocol

ASSESS FOR SYMPTOMS:

IDENTIFY EXPOSURE HISTORY: In the past 21 days have you: 1) Been in the countries of Guinea, Liberia, Sierra Leone, or Mali? 2) Had contact with the blood, or body fluids of a person with suspected or known Ebola Virus Disease? 3) Had direct contact with bats, rodents or primates from West Africa? *Or travel to any country that is identified as an alert level 2 or higher by the CDC.

NO

Does the patient have fever (subjective or ≥ 100.4 F) now or in the past 24 hours +/YES headache, muscle pain, weakness, nausea or ALL NO vomiting, diarrhea, * Proceed with routine triage abdominal pain or questions hemorrhage? * Instruct patient to self monitor for fever & symptoms for 21 days and contact physician or Ask My Nurse if positive for symptoms ANY YES

Proceed with routine registration/triage questions PLACE PATIENT IN ISOLATION IN A SEPARATE ROOM Personal Protective Equipment

Implement Precautions: Droplet and Contact * Place surgical mask on patient * All medical providers to wear appropriate Personal Protective Equipment when entering room

Double gloves, impervious isolation gown, Tychem suit, knee high shoe covers, N95 mask, and face shield.

If patient vomiting or in respiratory distress, consider airborne precautions Determine level of risk by asking questions below. If patient in high/ medium risk will need room with private bathroom facilities. *ACS patients should be sent to their respective pavilion for work up.

HIGH RISK

MEDIUM RISK

1) Have you had direct skin or mucous membrane contact with an Ebola victim or suspected case? This includes needles sticks or fluids such as blood, vomit, urine, sweat or feces making contact with your skin.

1) Did you spend time in a hospital or other healthcare facility and used appropriate personal protective equipment or were not involved in patient or lab care?

2) Have you worked in a lab that processes Ebola samples and you weren’t wearing personal protective equipment? 3) Did you participate in a funeral or burial or have contact with human remains of a suspected Ebola victim?

ALL NO

2) Were you in a house with a suspected case of Ebola but had no contact? 3) Did you have direct, unprotected contact with bats or primates?

LOW RISK

ALL NO

1) Were you in the country only and not exposed to any sick person or animal? This includes flight layovers

YES

ANY YES Minimal possibility of Ebola

ANY YES High possibility of Ebola ADMIT TO ISO ROOM in SICU/ (MICU team primary) – BT-EC; LBJ-Flex Pod ACS – Isolate to Room in ACS 1. Call Harris Health EMT for transport. 2. Use Infectious Disease package to triage patients in centers.

Moderate possibility of Ebola Admit and destination will be determined in concert with ID/IP teams.

AND 1) Contact ID, Infection Prevention, House Supervisor, City of Houston Health Dept. 2) Work up should include test for malaria, typhoid, CBC, CMP, Coags, CRP, blood cultures, HIV. (Lab to be informed regarding patient status and samples should be carried to lab). 3) Minimize patient contacts. 4) Maintain log of entry into the isolation room.

1) Work up should include test for malaria, typhoid, CBC, CMP, Coags, CRP, Blood cultures, HIV. 2) Minimize patient contacts. 3) Maintain log of entry into the room. 4) Disposition will be determined in concert with ID/IP teams and Harris County Health Department.

IMPORTANT NUMBERS Infection Prevention BT/QM: 713-873-8812 LBJ/ACS: 713-566-4602 City of Houston Health Department Report diseases 24/7: Tel: 832-393-5080 Fax: 832-393-5232

Updated 11/19/2014

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Appendix 1B Ask My Nurse Screening Protocol

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Appendix 2A Notification Phone Tree Ben Taub & Quentin Mease Hospital First Tier Communication (To be activated by front-line staff) Function Telephone #

Person

Cell/Pager #

Charise Miltenberger

Infection Prevention

713-873-8812

832-427-0086

Dr. Robert Atmar

Infectious Disease

713-798-6849

281-952-4332

Laboratory Services

713-873-3230

713-873-3925

House Supervisor

713-873-7330

Administrator On-call

See schedule

See schedule

Person

Second Tier Communication (To be activated by the Administrator on-call or designee) Function Telephone #

See schedule

Cell/Pager #

Dr. Robert Trenschel

Pavilion Administrator

713-873-2300

713-876-2881

Maureen Padilla

Chief Nursing Officer

713-873-2300

832-228-7765

Michael Staley

VP of Operations

713-873-6120

281-782-7171

Dr. Kenneth Mattox

Chief of Staff

713-873-3440

888-471-7766

Office of Risk Management

713-566-6375

Dr. Fred Sutton

Chief Medical Officer

713-566-3810

281-952-0001

George Masi

Chief Executive Officer

713-566-6100

713-817-3304

Bryan McLeod

Corp Communications

713-566-6430

Communication to Health Department (To be activated by the Chief of Staff, the Administrator, and Infectious Disease physician only) Person

Function

Telephone #

Fax #

City of Houston

Health & Human Svcs.

832-393-5080

832-393-5232

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Appendix 2B Notification Phone Tree

Person Wanda Davis Dr. Charles Ericsson

LBJ Hospital First Tier Communication (To be activated by front-line staff) Function Telephone # Infection Prevention Infectious Disease Laboratory Services House Supervisor

713-566-4602 713-500-6732 713-566-5268 713-566-4896

Second Tier Communication (To be activated by the Administrator on-call or designee) Person Function Telephone # Dr. Jesse Tucker Pavilion Administrator 713-566-5103

Cell/Pager # 281-952-0377 713-608-8073 763-498-1409

Cell/Pager # 832-339-3345

Alan Vierling

Chief Nursing Officer

713-566-5700

740-319-4177

Chris Okezie

VP of Operations

713-566-4570

832-419-2863

Dr. Carmel Dyer

Chief of Staff Office of Risk Management

713-566-5566 713-566-6375

281-952-1223

Dr. Fred Sutton

Chief Medical Officer

713-566-3810

281-952-0001

George Masi

Chief Executive Officer

713-566-6100

713-817-3304

Bryan McLeod

Corp Communications

713-566-6430

Communication to Health Department (To be activated by the Chief of Staff, the Administrator, and Infectious Disease physician only) Person Function Telephone # Fax # City of Houston Health & Human Svcs. 832-393-5080 832-393-5232 Ebola Response Plan - Notification Tree

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Appendix 2C Notification Phone Tree Ambulatory Care Services First Tier Communication (To be activated by front-line staff) Function Telephone #

Person

Cell/Pager #

Notify designated Nurse Manager and Charge Nurse Wanda Davis

Infection Prevention

713-566-4602

281-952-0377

Dr. Charles Ericsson

Infectious Disease

713-500-6732

713-608-8073

EMS Transport

713-566-4398

Person

Second Tier Communication (To be activated by the Administrator on-call or designee) Function Telephone #

Cell/Pager #

Dr. Ericka Brown

Pavilion Administrator

713-566-6852

708-404-3102

Matthew Schlueter

Chief Nursing Officer

713-566-6850

281-262-2950

Tanya Stringer

VP of Operations

713-566-6850

708-359-6095

Dr. Mohammad Zare (UT)

Chief of Staff

281-837-2700

281-952-1205

Dr. Brian Reed (BCM)

Vice - Chief of Staff

713-547-1020

281-952-3336

Office of Risk Management

713-566-6375

George Masi

Chief Executive Officer

713-566-6100

Bryan McLeod

Corp Communications

713-566-6430

713-817-3304

Communication to Health Department (To be activated by the Chief of Staff, the Administrator, and Infectious Disease physician only) Person

Function

Telephone #

Fax #

City of Houston

Health & Human Svcs.

832-393-5080

832-393-5232

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Appendix 3

LABORATORY PROTOCOL FOR SUSPECTED VIRAL HEMORRHAGIC FEVER (EBOLA) 1. Prior to specimen collection, notify Lab to inform them there is a suspected Ebola patient. 2. Collect ALL of the following blood tubes: 2 Purple, 1 Green, and Blood culture if ordered following #5 below. 3. Nursing will perform ISTAT testing (5a and 5b below) in patient room 4. Specimens requiring testing other than those performed on ISTAT are transferred to Laboratory Personnel. Refer to Appendix 3A and 3B for Pavilion-specific specimen delivery process. 5. Limited tests available to be ordered: Refer to Appendix 3A and 3B for Pavilion-specific guidelines a. Point of Care Tests (POCT) available on ISTAT analyzer b. Malaria smear c. WBC and Platelet estimate from stained blood smear d. Blood Culture e. Refer to Appendix 3A and 3B for any additional tests offered per Pavilion 6. Collection a. Wipe each specimen tube with Oxiver after collection b. Label specimens and place “Patient under Investigation” label on each specimen tube and all paperwork c. Place specimen tube into double biohazard bags that contain absorbent pads soaked with 10% bleach solution. Then place double biohazard bags into biohazard rigid, leak proof transport container. SEAL CONTAINER PROPERLY. d. Initiate chain of custody form for specimens going to lab e. Place paperwork and chain of custody in separate sealable biohazard bag—NOT in bag with specimens. Wipe down bag with Oxiver before exiting patients room f. Deliver specimens to Laboratory personnel per Pavilion-specific guidelines in Appendix 3A and 3B. v. 11/5/2014

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Appendix 3A-1 Ben Taub Specimen Collection and Handling on Patient Under Investigation for Viral Hemorrhagic Fever (VHF)

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Appendix 3A-2 Ben Taub Specimen Collection and Handling on Patient Under Investigation for Viral Hemorrhagic Fever (VHF)

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Appendix 3B LBJ Specimen Collection and Handling on Patient Under Investigation for Viral Hemorrhagic Fever (VHF) Patient arrives at Hospital

Specimens delivered to laboratory entry door & given to techs

Clinician/Nursing Supervisor Calls Triage at 65268

Patient’s Location completes downtime form, chain of custody & prepares specimens to transport to lab

Triage Calls Microbiology at 65277 or Tech in charge Core Laboratory with patient’s name, location and Doctor’s name.

Tech in charge contacts Resident/Pathologist on call

Patient’s Location Collect Specimens & Performs ISTAT Testing Contacts patient’s location to discuss diagnosis and laboratory testing

Dr. Wanger 713-915-0315 Notifies lab testing team to proceed with VHF protocol

Laboratory personnel call the patient location when Tech is suited and ready to receive specimen.

LBJ Laboratory Test NOTES •

LB

•

Use Downtime Form to order Additional tests available:  Rapid Strep*  Rapid Flu*

Two techs suit up to receive specimen outside the laboratory entry door NOT in the drop off window.

*performed in TB Lab

v. 10/27/14

1. Testing team will take specimen to the TB lab 2. Remove TB supplies from under the hood. 3. Place red bucket testing supplies under hood for testing.

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Appendix 4A

EBOLA SIGN-IN SHEET - ANCILLARY ARRIVAL DATE

DATE

TIME IN

MRN / PATIENT STICKER

TIME OUT

NAME/TITLE

Ebola Response Plan – Ancillary Worker Exposure Log

EMP ID

SPOTTER

REASON (i.e. Transport pt.; Draw labs; EVS; etc.)

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Appendix 4B

EBOLA SIGN-IN SHEET - HEALTHCARE WORKER ARRIVAL DATE

DATE

TIME IN

MRN / PATIENT STICKER

TIME OUT

Ebola Response Plan – HCW Exposure Log

NAME/TITLE

EMP ID

SPOTTER NAME

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Appendix 4C Lab Specimen Chain of Custody

LABORATORY SPECIMEN CHAIN-OF-CUSTODY TRACKING FORM THIS FORM MUST BE COMPLETED ON SPECIMEN COLLECTED FROM PATIENT (Low, Moderate, AND High Risks) WITH SUSPECTED VIRAL HEMORRHAGIC FEVER (VHF)

Patient’s Name: Location: Specimen Type

MRN: Date: Description of Specimen Number of Date Tube/Bottle Collected

Time: Time Collected

Collected by:

(First & Last Name)

EDTA-Purple

Blood

Heparin - Green

Blood

Aerobic (Green-top)

Culture

Anaerobic (Purple-top)

Urine

CHAIN OF CUSTODY Ensure specimen(s) collected above received prior to signing Date / Time Submitted by Received in Lab by (Name and ID #)

Disposal Date

Final Disposal of Specimen Disposal Time Method of Disposition: Performed by:

(Name and ID #)

Witnessed by:

This Chain-of-Custody form shall be forwarded to Health Information Management Dept. for scanning as record in Patient’s Medical Record. Ebola Response Plan – Lab Specimen Chain of Custody v. 11/4/2014

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Appendix 5 CDC Guidelines for Packaging and Shipping of Clinical Laboratory Specimen

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Appendix 6 EVD PPE Donning and Doffing

Below are the reference materials for the proper technique for donning and removing Personal Protective Equipment. • Appendix 6 - EVD PPE Donning & Doffing instructions

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Appendix 7

Category A Waste Handling & Packaging Procedures Guidelines for a Suspected or Confirmed Case of Ebola •

With a suspected or confirmed Ebola case immediately contact the local/state health department and CDC.

•

All waste generated from a suspected/confirmed patient should be treated as special Category A DOT waste as follows: 1.

Make sure you are utilizing all PPE and following all applicable guidelines as directed by the following link from the CDC:

http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-inhospitals.html?mobile=nocontent 2.

Place soft waste or sealed sharps containers into a primary medical waste bag (1.5ml – ASTM tested; can be provided by Stericycle).

3.

Apply bleach or other virocidal disinfectant into the primary bag to sufficiently cover the surface of materials contained within the bag; securely tie the bag.

4.

Treat the exterior surface of the primary container with bleach or other virocidal disinfectant.

5.

Place the primary bag into a secondary bag and securely tie the outer bag.

6.

Treat the exterior surface of the secondary bag with bleach or other virocidal disinfectant.

If you HAVE Stericycle 55 gallon special Category A DOT Waste “GREEN DRUMS” on site go to Step 10 below. If you do NOT have special Stericycle 55 gallon special Category A DOT Waste “GREEN DRUMS” on site continue to Step 7 below. 7.

The double bagged waste should then be placed on a hard non-porous surface in a secure room close to the point of use. Make sure the collection area is clearly labeled special Category A DOT Waste.

8.

Contact your Stericycle representative who will arrange delivery of the special Category A DOT Waste containers (containers can be shipped for overnight delivery).

9.

As soon as your special Category A DOT Waste Containers arrive follow step 10 below.

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10.

The double bagged waste should then be place into special Category A DOT Waste packaging/drums provided by Stericycle with the liner tied securely and container closed per the packaging instructions provided. Label the special Category A DOT Waste with provided labels.

11.

Store the special Category A DOT Waste containers separate from other regulated medical waste in a secure area preferably isolated and with limited access.

•

Stericycle recommends using disposable sharps containers for suspected/confirmed Ebola cases. The disposable container should be sealed and disposed of as special Category A waste following the instructions above. If a reusable sharps container is inadvertently used that container should also be sealed and disposed of inside the bags with the Category A waste.

•

Contact your Stericycle representative who will begin the process with the DOT to acquire a “Special Permit” as required. •

Stericycle has been advised by the DOT and CDC that we must address each situation on a case by case basis until such time that they have an all-encompassing protocol.

•

Once the Special Permit has been granted, Stericycle will provide a current copy of the special permit to be maintained at the Generator’s site as per DOT regulations.

•

Contact your Stericycle representative should you need additional supplies to properly package Category A waste.

•

We will develop additional guidance for contingency planning as more information becomes available.

Additional information sources: CDC directly at CDC.gov

http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html?mobile=nocontent http://www.phmsa.dot.gov/portal/site/PHMSA/menuitem.6f23687cf7b00b0f22e4c6962d9c8789/?vgnextoid=4d180 0e36b978410VgnVCM100000d2c97898RCRD&vgnextchannel=0f0b143389d8c010VgnVCM1000008049a8c0RC RD&vgnextfmt=print

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Appendix 7A EVD HazMat Process Flow

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Appendix 8 Guidelines for Environmental Cleaning & Disinfection of EVD Patient Rooms Waste Management for Patient Room 1. 2. 3. 4. 5. 6. 7. 8.

R emove red biological hazard bag from the waste container Goose neck and tape loosely to secure bag. Disinfect the outside of the bag. Place bag into red biological hazard bag Goose neck and tape to secure bag. Disinfect the outside of the bag by spaying with Oxivir Store in bathroom (patient room) until removal Sanitize gloves

End of Shift Waste Management 1. Place waste into 2nd red bag 2. Bring waste into anteroom for Haz-Mat pick-up Spill Cleanup 1. Assist patient 2. Establish a spill parameter 3. Visual check of PPE and clean any visible contamination 4. Scoop cat litter on to the spill area 5. Pour disinfectant over the spill moving from outside in 6. Cover with Chux pad plastic side down and leave for 10 minutes 7. Clean up spill from outside-in and place in red bag 8. Sanitize gloves 9. Remove outer gloves 10. Don new outer gloves 19. Mop area using Oxivir 20. Sanitize gloves 21. Follow Waste Management for Patient Room protocol Changing Gloves 1. 2. 3. 4.

Sanitize gloves Remove outer gloves Sanitize inner gloves Don outer gloves

Needle Stick or Cut 1. Quickly sanitize gloves

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Remove inner and outer gloves and expose wound Express wound Flush wound with water for five minutes Cover wound by donning glove Doff PPE Report for medical assessment Log and report incident and notify Employee Health

Prior to Shift Change: Nursing 1. Empty all waste 2. Restock items needed for next shift (PPE, patient care items, etc.) 3. Wipe down equipment and furniture with disinfectant. In the following order: bed rails, headboard, footboard, over-bed table (use new cloth), equipment (IV pump & pole, suction, monitor, computer keyboard changing cloths as needed), and cleaning solution bottles. 4. Mop floor in bathroom, then mop patient room from patient to anteroom door 5. Exit room

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Appendix 9

CDC Guidance for Safe Handling of Human Remains of Ebola Patients in U. S. Hospitals and Mortuaries 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 PPE, 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. Definitions for Terms Used in this Guidance Cremation: The act of reducing human remains to ash by intense heat. Hermetically sealed casket: A casket that is airtight and secured against the escape of microorganisms. A casket will be considered hermetically sealed if accompanied by valid documentation that it has been hermetically sealed AND, on visual inspection, the seal appears not to have been broken. Leakproof bag: A body bag that is puncture-resistant and sealed in a manner so as to contain all contents and prevent leakage of fluids during handling, transport, or shipping. Personal protective equipment for postmortem care personnel • Personal protective equipment (PPE): Prior to contact with body, postmortem care personnel must wear PPE. • 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. Use caution when removing PPE as to avoid contaminating the wearer. Hand hygiene 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

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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 leakproof plastic bag not less than 150 μm thick and zippered closed The bagged body should then be placed in another leak-proof plastic 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 EPAregistered disinfectants which can kill a wide range of viruses. Follow the product’s label instructions. 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. Individuals driving or riding in a vehicle carrying human remains: PPE is not required for individuals driving or riding in a vehicle carrying human remains, provided that drivers or riders will not be handling the remains of a suspected or confirmed case of Ebola, and the remains are safely contained and the body bag is disinfected as described above.

Mortuary Care • Do not perform embalming. The risks of occupational exposure to Ebola virus while embalming outweighs its advantages; therefore, bodies infected with Ebola virus should not be embalmed. • Do not open the body bags. • Do not remove remains from the body bags. Bagged bodies should be placed directly into a hermetically sealed casket. • Mortuary care personnel should wear PPE listed above (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) when handling the bagged remains. • 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. Disposition of Remains • Remains should be cremated or buried promptly in a hermetically sealed casket. • Once the bagged body is placed in the sealed casket, no additional cleaning is needed unless leakage has occurred. • No PPE is needed when handling the cremated remains or the hermetically sealed closed casket.

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Transportation of human remains • Transportation of remains that contain Ebola virus should be minimized to the extent possible. • All transportation, including local transport, for example, for mortuary care or burial, should be coordinated with relevant local and state authorities in advance. • Interstate transport should be coordinated with CDC by calling the Emergency Operations Center at 770-488-7100. The mode of transportation (i.e., airline or ground transport), must be considered carefully, taking into account distance and the most expeditious route. • Although Ebola virus is a Category A infectious substance regulated by the U.S. Department of Transportation’s Hazardous Materials Regulations (HMR, 49 Code of Federal Regulations Parts 171-180), DOT has issued guidance that human remains contaminated with a category A infectious substance are excepted from the HMR. • Transportation of remains that contain Ebola virus outside the United States would need to comply with the regulations of the country of destination, and should be coordinated in advance with relevant authorities. References CDC. Medical Examiners, Coroners, and Biologic Terrorism A Guidebook for Surveillance and Case Management. MMWR 2004;53(RR08);1-27. (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5308a1.htm) Note: Copied from the CDC website on 10/31/2014 at 14:08 http://www.cdc.gov/vhf/ebola/hcp/guidance-safe-handling-human-remains-ebola-patients-us-hospitalsmortuaries.html

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Appendix 10 Harris Health System Transport of EVD Patient

Inter-facility Transfer The procedure to transfer a Person Under Investigation from a Harris Health System ambulatory clinic to one of the Harris Health hospitals for further work-up and treatment is indicated below: • • • •

Provider contacts Harris Health EMS and provides information. Harris Health EMS Communications Center contacts local 911 emergency service and requests transport. Harris Health EMS contacts appropriate facility staff and relays information received by 911. Sending facility will contact appropriate staff at receiving hospital with information regarding transport.

External facility Transfer Once the patient is serologically confirmed with having infected with Ebola virus or diagnosed with EVD, transferring of patient to a State designated Ebola Treating Center can be considered and determined by the Ebola Treating Team in concert with Infectious Disease Physician. •

The Ebola Treating Team will be in contact with the receiving facility to discuss transferring criteria. Transportation will be coordinated through the local Regional Advisory Councils office, (SETRAC), for patient transport to the treating facility.

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REFERENCES/BIBLIOGRAPHY: http://www.cdc.gov/vhf/ebola/hcp/index.html i. ii. iii. iv. v. vi. vii.

Infection Prevention and Control for Hospitalized Patients with Known or Suspected Ebola in U.S. Hospitals Environmental Infection Control in Hospitals for Ebola Virus Safe Handling of Human Remains of Ebola Patients in U. S. Hospitals and Mortuaries Medical Waste Management Specimen Collection, Transport, Testing, and Submission for Persons Under Investigation for Ebola in the U.S. Sequence for Putting On and Removing Personal Protective Equipment (PPE) Tools for Protecting Healthcare Personnel

EVD PPE Donning & Doffing instructions & Trained Observer & Caregiver Roles & responsibilities DNVGL Preparedness and Response Reference Harris Health System Emergency Operations Plan Harris Health System policy 1000 - Infection Prevention & Control Plan

DEPARTMENT OF PRIMARY RESPONSIBILITY: Harris Health System – Infection Prevention & Control

REVISION HISTORY: Effective Date

10/13/2014

Version # (If Applicable)

Review or Revision Date (Indicate Reviewed or Revised) 10/31/2014

Reviewed or Approved by: (Directors, Committees, Managers, and Stakeholders etc.) F. Sutton, MD – Chief Medical Officer