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North Shore LIJ Health System, Inc.Policy & Procedure Manual

GENERAL STATEMENT OF PURPOSE:

The purpose of this policy is to:1) Provide guidance on identification of Ebola Virus Disease (EVD).2) Outline infection prevention management of patients with suspected or confirmed EVD.3) Provide guidance on internal and external notification of a suspected case. 4) Clarify which specimens should be obtained and how to submit for diagnostic testing.5) NOTE: This policy applies to adult and pediatric patients.

POLICY:

This policy provides guidelines:1) For recognition and transmission prevention of EVD within healthcare settings.2) To allow healthcare personnel (HCP) to provide safe care during the treatment of patients with EVD.

SCOPE:

This policy applies to faculty and students of the Hofstra North Shore-LIJ School of Medicine (“School ofMedicine”) conducting work or research on behalf of the School of Medicine or at any North Shore-LIJ HealthSystem facility; and all members of the North Shore – LIJ Health System workforce including, but not limitedto, employees, medical staff, volunteers, students, physician office staff, and other persons performing workfor or conducting research at or on behalf of the North Shore – LIJ Health System.DEFINITIONS:

EVD is an infection characterized by sudden onset of fever and malaise, accompanied by other nonspecific signs and symptoms, such as fever, myalgia, headache, vomiting, and diarrhea. Patients with severe forms of the disease may develop hemorrhagic symptoms and multi-organ dysfunction, including hepatic damage, renal failure, and central nervous system involvement, leading to shock and death. The fatality rate can vary from 40-90%.

of 72 INF.1156 10/23/15*© 2014 North Shore-Long Island Jewish Health System

POLICY TITLE: Ebola Virus Disease Recognition and Management

CLINICAL POLICY AND PROCEDURE MANUAL

POLICY #: INF.1156 CATEGORY: Infection PreventionSystem Approval Date: 10/23/15*

Site Implementation Date:

Effective Date: 08/22/14

Last Revised: 11/5/14Prepared by:Donna Armellino, RN, DNP, CIC, Vice President Infection Prevention and Site Specific Infection Prevention Committee Members

Exceptions/Alternate Policy(s)/#:N/A


In outbreak settings, EVD virus is typically first spread to humans after contact with infected wildlife and is then spread person-to-person through direct contact with bodily fluids such as, but not limited to, blood, urine, feces, emesis, sweat, semen, and breast milk. The incubation period is usually 8–10 days (ranges from 2–21 days). Patients can transmit the virus while symptomatic and through later stages of disease. The virus can be transmitted postmortem, when persons touch the body during funeral preparations.

1) “Confirmed Case”, consistent with current guidance from the Centers for Disease Control and Prevention (CDC), means a case with laboratory-confirmed diagnostic evidence of EVD virus infection.

2) “Suspect Case”, means a person who has both consistent symptoms and risk factors consistent with EVD.

PROCEDURE/GUIDELINES:



This document outlines prevention guidelines within a number of sections as follows:

Link Section Title

I. EBOLA VIRUS DISEASE (EVD) CASE DEFINITION

II. NOTIFICATION OF SUSPECTED EVD CASE TO THE DEPARTMENT OF HEALTH

III. TRIAGE OF A SUSPECT\CONFIRMED EVD PATIENT IN VARIOUS HEALTH CARE ENVIRONMENTS

IV. PATIENT POINT OF ENTRY AND TRANSPORTATION OF A SUSPECT\CONFIRMED EVD PATIENT FROM POINT OF ENTRY TO DESIGNATED EVD TREATMENT AREA, REGISTRATION, DOCUMENTATION, AND SECURITY

V. SUSPECT\CONFIRMED EVD PATIENT CONTACT PRIOR TO PLACEMENT IN AN ISOLATION ROOM AND MANAGEMENT OF VISITORS

VI. SUSPECT\CONFIRMED EVD ACUTE CARE FACILITY PRECAUTION, ISOLATION, AND PATIENT PLACEMENT

1. Health Care Personnel (HCP) Monitoring LogVII. EVD PERSONAL PROTECTIVE EQUIPMENT (PPE) AND PROCEDURES FOR DONNING AND

DOFFING1. Observer Role and Documentation of PPE Donning and Doffing

VIII. SUSPECT\CONFIRMED EVD PATIENT MANAGEMENTIX. MONITORING HCP’s AND EVD EXPOSURE MANAGEMENTX. EVD LABORATORY AND LABORATORY SAFETYXI. EVD ENVIRONMENTAL INFECTION PREVENTION AND CONTROLXII. EVD MANAGEMENT OF WASTE, DAILY ROOM CLEANING, AND DISCHARGE ROOM

DISINFECTIONXIII. EVD EQUIPMENT REPROCESSINGXIV. COMMUNICATIONSXV. EVD MANAGEMENT OF THE DECEASEDXVI. STAFFING OF EVD PATIENT CARE TEAMXVII. EVD FACILITY PREPAREDNESS



SECTION I: Ebola Virus Disease (EVD) CASE DEFINITION

A. IDENTIFICATION OF A PATIENT WITH SUSPECTED EVD:1. Healthcare personnel (HCP) should evaluate patients for EVD who have signs and symptoms

and risk factors as follows:i. Clinical criteria, which includes:

1. Fever of greater than 38.0° Celsius or 100.4° Fahrenheit, OR2. Additional symptoms such as severe headache, muscle pain, vomiting, diarrhea,

abdominal pain, or unexplained hemorrhage; AND3. Epidemiologic risk factors within the past 21 days before the onset of symptoms,

such as:a. Contact with blood or other bodily fluids of a patient known to have or

suspected to have EVD.b. Residence in or travel to an area where EVD transmission is active.

i. Up-to-date travel notices can be viewed at:http://wwwnc.cdc.gov/travel/notices

ii. A current outbreak distribution map of the EVD outbreak in Western Africa can be viewed at: http://www.cdc.gov/vhf/ebola/resources/distribution-map-guinea-outbreak.html.

iii. Note: Suspect EVD should be considered in patients from areas with widespread transmission and symptoms consistent with EVD.

c. Direct handling of bats, rodents, or primates from disease-endemic areas.d. Individuals who eat bush meat or are involved with animal rituals within

endemic areas.e. Individuals who participated in funeral rites or other direct exposure to

human remains in the geographic area where the outbreak is occurring without appropriate personal protective equipment (PPE).

f. Percutaneous or mucous membrane exposure, or direct skin contact with body fluids of a person with a confirmed or suspected case of EVD without appropriate PPE.

g. Laboratory processing of body fluids of suspected or confirmed EVD case with or without appropriate PPE or standard bio-safety precautions.

i. NOTE: Malaria diagnostics should also be a part of initial testing because it is a common cause of febrile illness in persons with a travel history to the affected countries.

4. For persons with a high-risk exposure, but without a fever, testing is recommended only if there are other compatible clinical symptoms present and blood work findings are abnormal (i.e., thrombocytopenia <150,000 cells/μL and/or elevated transaminases) or unknown.

5. Refer to the enclosed link for additional information on the EVD case definition at http://www.cdc.gov/vhf/ebola/hcp/case-definition.html.


http://www.cdc.gov/vhf/ebola/hcp/case-definition.html

http://www.cdc.gov/vhf/ebola/resources/distribution-map-guinea-outbreak.html

http://www.cdc.gov/vhf/ebola/resources/distribution-map-guinea-outbreak.html

http://wwwnc.cdc.gov/travel/notices


ii. Testing is recommended for all persons with onset of fever within 21 days of having a high-risk exposure. Notify the Local Health Department and refer to the section “Laboratory and Laboratory Safety” before obtaining specimens.

2. Patients that present to any setting with a significant travel history and are asymptomatic should be advised to perform temperature checks twice a day for 21 days after returning from travel. Any temperature increase, or signs and symptoms consistent with EVD should be communicated to their primary care provider at the first indication of illness via telephone and medically evaluated.



SECTION II: NOTIFICATION OF SUSPECTED EVD CASE TO THE DEPARTMENT OF HEALTH

A. NOTIFICATION OF A SUSPECTED EVD CASE:1. Internal Notification: Contact Network Emergency Management (NEM) at 516-719-5000,

Infection Prevention, and an Infectious Disease physician when a suspected case is identified. Establish off hour and weekend communication. Use Attachment A “Ebola Virus Disease (EVD) Evaluation Tool” to guide collection of patient information.

2. External Communication:i. Outside New York City (NYC): When considering EVD in the differential diagnosis of

patients, immediately contact the Local Health Department in the county where the facility/provider is located to discuss the case and to seek approval for testing at CDC, if appropriate. Providers who are unable to reach their Local Health Department can contact the New York State Department of Health (NYSDOH) Bureau of Communicable Disease Control.

ii. The NYSDOH Bureau of Communicable Disease Control can be contacted at (518) 473-4439 during business hours or the NYSDOH Public Health Duty Officer at (866) 881-2809 evenings, weekends, and holidays. NYSDOH’s Wadsworth Center will assist with testing logistics between the healthcare facility and the CDC. NOTE: Testing for EVD can only occur at CDC laboratories.

iii. Local Health Department Contact Information:1. Nassau County Department of Health:

a. Monday through Friday – (516) 227-9639b. After hours, weekends, and holidays – (516) 742-6154

2. Suffolk County Department of Health: a. Monday through Friday - (631) 854-0333b. After hours, weekends, and holidays – (631) 852-4820

iv. Within NYC: Providers and facilities located in NYC (regardless of the jurisdiction of the patient’s usual residence) should immediately contact the New York City Department of Health and Mental Hygiene (NYCDOHMH) at (866) 692-3641 to discuss the case and to seek approval for testing at CDC, if appropriate. In these situations, the NYCDOHMH Public Health Lab will assist with testing logistics between the healthcare facility and the CDC.

3. When you call the Local Health Department, be prepared to: i. Describe the patient’s risk factors and travel history, including dates and locations of

travel and any contact with sick patients, healthcare facilities, or animals in areas with ongoing EVD transmission.

ii. Describe the patient’s presenting symptoms, signs, and duration of illness. 4. When you call the Local Health Department, you can expect to:

i. Discuss the case and possible recommendations for testing.ii. Be provided consultation on the need to refer the patient to a hospital for further workup

and testing.iii. Receive assistance to arrange transport to another medical facility if needed.



5. Refer to Attachment A “Ebola Virus Disease (EVD) Evaluation Tool” to guide the assessment.

6. Internal Communication:i. Follow process as outlined within the policy. Triage the patient and place the patient on

isolation when the individual meets case definition. ii. The physician should discuss the case with the Local Health Department. When the case

meets case definition and a specimen for EVD testing is requested by the Local Health Department, this information should be communicated to the NEM at (516) 719-5000. This call will trigger the senior leadership team and a scheduled call to outline inpatient management of the patient. A plan will be outlined and executed.



SECTION III: TRIAGE OF A SUSPECT\CONFIRMED EVD PATIENT IN VARIOUS HEALTH CARE ENVIRONMENTS

(Emergency Department, Extension Clinics, and Facilities External to an Acute Care Facility)A. AMBULATORY SERVICES:

1. Ambulatory Services personnel should assess symptoms of EVD, travel history, and exposure.2. If the patient has a significant travel history (refer to the following web link for areas with

ongoing transmission - http://wwwnc.cdc.gov/travel/notices) within 21 days and a fever, the patient should be instructed to stay home and wait for a call from a Licensed Independent Practitioner (LIP).

3. The patient’s information should be provided to the LIP and the LIP should call the patient to obtain additional information regarding their illness.

i. If symptoms are consistent with EVD and the patient traveled to an area with diagnosed EVD cases:

1. Contact NEM at (516) 719-5000, state you have a suspected EVD case, and provide your name plus telephone number. NEM will coordinate an immediate conference call with the Senior Clinical Leadership Team and mobilize Center for Emergency Management Services (CEMS) if necessary.

ii. If the case meets the definition for suspected EVD, the Local Health Department in which your facility is located will be called for consultation.

iii. The Local Health Department and other external support such as the NYSDOH will assist with case management and approval for EVD testing at the CDC.

4. If a patient presents to the ambulatory setting and EVD is suspected the patient should be placed in an exam room with the door closed. Ambulatory personnel should adhere to the following:

i. Screen upon presentation and immediately place patient in a private room with a closed door, preferably with a bathroom. If not available, have a bedpan and urinal available for use.

ii. Provide the patient with a surgical mask and demonstrate its proper use.iii. Minimize the number of HCP who interact with the patient and maintain a contact log,

refer to Attachment C. iv. HCP who interact with the patient should follow Standard, Droplet, and Contact

Precautions. v. Appropriate PPE should be worn upon entry to the patient’s room to include gloves,

gown (fluid resistant or impermeable), eye protection (goggles or face shield), and a facemask. Refer to Attachment D and Attachment D1 for donning and doffing of PPE and the donning and doffing of PPE observer checklist.

vi. The patient should remain within the exam room unless movement is essential.vii. Transportation to an alternative level of care should be coordinated with Infection

Prevention and the Local Health Department.viii. If the patient is categorized as a suspect case of EVD, identify the patents in the waiting

room and anyone who accompanied them. Each individual’s name and contact information should be obtained and should be provided to the site manager. The information should be faxed to (516) 472-3598.

ix. Ambulatory HCP should follow the guidelines outlined within this document.




x. For more information on transporting a patient refer to the CEMS “Operational Response to Ebola Exposed Patients.”

B. AMBULANCE:1. Ambulance personnel should assess travel at the time of pick up for travel to endemic areas and

symptoms of infection. Ambulance personnel will notify the facility prior to arrival of the suspect case and remain in the ambulance until the patient’s room is ready for immediate occupancy and Emergency Department personnel are donned with PPE. Patients with a significant travel history, or exposure and symptoms consistent with EVD should be placed into isolation immediately upon arrival to the facility. Note: When the patient is categorized as suspect EVD, the patient should remain within the ambulance until the patient’s room is ready for immediate occupancy.

2. The ambulance stretcher should remain outside the facility. When the patient is brought into the facility, a clean stretcher should be used to enter the facility.

3. The receiving facility should notify NEM at (516) 719-5000 and request to be connected with CEMS. They will activate the Senior Clinician Leadership Team telephone tree and set up a conference call to discuss the action plan.

4. Ambulance personnel should follow guidelines outlined within this document.

C. EMERGENCY DEPARTMENT:1. Emergency Department personnel should assess the patient’s travel history, risk for exposure,

and symptoms upon arrival for all patients to identify suspect/confirmed cases of EVD.2. A patient that arrives via their car and communicates a significant travel history or contact with

signs and symptoms should have their car placed within a designated location until a diagnosis is made. Management of the car will be coordinated with the Local Health Department.

3. If the patient has a significant travel history (refer to the following web link for areas with ongoing transmission - http://wwwnc.cdc.gov/travel/notices) within 21 days plus signs and symptoms consistent with EVD, the following should be initiated:

i. Provide the patient with a surgical mask and demonstrate its proper use.ii. Place in a single room (preferably negative pressure) and place the patient on the

following precautions: Standard, Airborne, and Contact Precautions. iii. A room with an anteroom is preferred. When a room with an anteroom is not available,

designate areas (or additional rooms) adjacent to the isolation room to serve as donning area (“Green” or “Cold” Zone), doffing area (“Yellow” or “Warm” Zone), and patient treatment area (Isolation room= “Red” or “Hot” Zone). Mark these areas accordingly with signage and/or tape to clearly delineate the green (Cold Zone), yellow (Warm Zone), and red (Hot Zone).

iv. The HCP should wear gloves, a gown (fluid resistant or impermeable), eye protection (goggles or face shield), and face mask when there is contact with the patient. Refer to Attachment D and Attachment D1 for donning and doffing of PPE and the donning and doffing of PPE observer checklist. Level 1 is recommended, unless there is visible body fluid then Level 2 is recommended.




v. Emergency Department personnel should follow guidelines outlined within this document.

vi. NOTE: The patient is placed in an isolation room in the event the level of care changes and aerosolized procedures may be performed. When the level of care changes, then Level II PPE should be worn.

vii. Refer to Attachment B1 for the EVD Patient Management Algorithm.viii. When a patient has a significant travel history or exposure and symptoms, evaluate

individuals that accompany them to the Emergency Department for signs and symptoms consistent with EVD, isolate individual(s) as outlined within this guideline.

ix. The physician should discuss care with the Local Health Department. When the case meets the case definition and a specimen for EVD testing is requested by the Local Health Department, this information should be communicated to NEM at (516) 719- 5000. This call will trigger the Senior Leadership Team and a scheduled call to outline inpatient management of the patient. A plan will be outlined and executed.

x. If the patient is categorized as a suspect case of EVD, identify the patients in the waiting room and anyone who accompanied them. Each individual’s name and contact information should be obtained and should be provided to the facility’s Infection Prevention Department.

xi. When a patient is categorized as a suspect case and is transported to a designated unit, the hallway and elevator should be closed to the public. The area should be cleaned and then decontaminated prior to resuming normal functioning.

D. HOME CARE:1. Home Care personnel should assess symptoms of EVD, travel history, and exposure prior to the

start of a home visit. 2. If the client has a significant travel history (refer to the following web link for areas with

ongoing transmission – http://wwwnc.cdc.gov/travel/notices) within 21 days, instruct client to stay home until further notice. Reassure the client they will be contacted shortly.

3. Notify the nursing supervisor immediately. The nursing supervisor should:i. Contact the client to assess symptoms, travel, and contact information.

ii. If symptoms are consistent with EVD and the patient traveled to, or had direct contact with someone who traveled to, an area with diagnosed EVD case:

1. Notify NEM at (516) 719-5000 and request to be connected to Emergency Management. They will activate the Senior Clinical Leadership Team telephone tree and set up a conference call to discuss the action plan.

4. If the client meets the definition for suspected EVD, the Local Health Department in which your facility is located will be called for consultation, refer to SECTION II: NOTIFICATION OF SUSPECT EVD CASE TO THE DEPARTMENT OF HEALTH.

i. The Local Health Department and other external support such as the NYSDOH will assist with case management and approval for testing at the CDC.

ii. If the client requires another level of care, contact NEM at (516) 719-5000.




E. LONG TERM CARE FACILITIES, BEHAVIORAL HEALTH FACILITIES, AND INPATIENT HOSPICE CARE:

1. Patients within the facility at the time of the initial assessment:i. Individuals within the facility should be assessed for travel to areas with ongoing

transmission, refer to the following web link for areas with ongoing transmission - http://wwwnc.cdc.gov/travel/notices. Patients with a positive travel history should have temperature monitoring conducted twice a day for 21 days post potential travel exposure.

2. Admissions into the facility:i. Individuals admitted into the facility should be assessed for pertinent travel history and/

or exposure to individuals from areas with ongoing transmission, refer to the following web link for areas with ongoing transmission -http://wwwnc.cdc.gov/travel/notices.

ii. An individual with a significant travel history and/or exposure should be discussed with senior leadership prior to admission.

iii. A patient with a pertinent travel/exposure should have temperature monitoring conducted twice a day for 21 days post exposure.

iv. If the individual is asymptomatic, admit and monitor their temperature twice a day for 21 days post exposure.

3. Response to temperature elevation or symptoms consistent with EVD:i. Any increase in temperature and/or flu-like symptoms:

1. Isolate the patient with Standard, Droplet, and Contact Precautions2. Contact the Medical Director and Health System Infection Prevention3. The Medical Director should call the Local Health Department to discuss the

case. 4. If the Local Health Department does not consider this a case, then discontinue

precautions and continue to provide services. 5. If the Local Health Department considers this a case, call NEM at (516) 719-5000

to arrange for transport to the designated facility

F. OBSTETRICAL:1. If symptoms are consistent with EVD and the patient traveled to an area with diagnosed EVD

cases, the following guidelines should be followed:i. Ambulatory patient presenting to the obstetrician’s office should follow the Ambulatory

Services process listed under “A” in SECTION III: TRIAGE OF A PATIENT IN VARIOUS HEALTH CARE ENVIRONMENTS.

ii. Obstetrical patient presenting to the Emergency Department should follow the Emergency Department process listed under “C” in SECTION III: TRIAGE OF A PATIENT IN VARIOUS HEALTH CARE ENVIRONMENTS.

iii. Scheduled/elective obstetrical patient should be discussed with the Senior Clinical Leadership Team prior to admitting the patient and performing the procedure.

1. Notify NEM at (516) 719-5000 and ask to activate the Senior Clinical Leadership Team telephone tree and call into a conference call to discuss the case.

2. An obstetrical patient admission or walk-in evaluated in a practice setting within the acute care facility displaying signs and symptoms with a significant travel history and/or exposure should:





i. Follow the facility’s site specific management plan and place within the designated isolation room in the Emergency Department. Care, including a vaginal delivery or caesarean section, is performed within the room until EVD is ruled out or isolation is discontinued.

3. If the patient is categorized as a suspect case of EVD identify the patients in the waiting room and anyone who accompanied them. Each individual’s name and contact information should be obtained and should be provided to the site manager. The information should be faxed to (516) 472-3598.



SECTION IV: PATIENT POINT OF ENTRY AND TRANSPORTATION OF A SUSPECT/CONFIRMED PATIENT FROM POINT OF ENTRY TO DESIGNATED EVD

TREATMENT AREA, REGISTRATION, DOCUMENTATION, AND SECURITY

A. SIGNS AT POINT OF ENTRY:1. Post signs prominently at all entrances, at reception, and at triage locations, in at least English,

French, Spanish, Chinese, Russian, Italian, Korean and Haitian Creole asking all persons presenting for care to provide their international travel history. Refer to Attachment B for an image of the sign.

B. PATIENT ALGORITHM FORM THE POINT OF ENTRY:1. Refer to Attachment B1 for the Patient Management Algorithm.

C. POINT OF ENTRY INTO THE FACILITY:1. Patient transport route:

i. Identify the point(s) of entry into hospital is(are) designated for suspect or confirmed EVD patients arriving by ambulance, and transportation routes from entry point to designated EVD patient care area are pre- identified. The entry points should be:

1. Separate from main thoroughfares2. Clear of all traffic (e.g., security escort)3. Access to service elevators

D. INTERNAL TRANSPORTATION OF THE PATIENT:1. HCP PPE during transport:

i. HCP who transport personnel should wear appropriate PPE during transport of EVD patients. Such personnel must receive competency-based training on proper procedures for donning and doffing of PPE. Refer to Section VII for more information on PPE utilization, Attachment D and Attachment D1 for donning and doffing of PPE and the donning and doffing of PPE observer checklist.

2. Management of the patient during transport:i. Minimize patient dispersal of droplets by placing a mask on the patient prior to transport.

ii. The patient should be wrapped within a fluid resistant material prior to transportation to the receiving location to prevent leakage or spillage of body fluids.

3. Management of the environment during transport:i. Blood and body fluid contamination is cleaned and decontaminated as Section IX.

ii. Post-transport cleaning and disinfection of the route will be done when there is contamination.

iii. Equipment used during transport will be cleaned and disinfected within the “Warm Zone” with an Environmental Protection Agency (EPA)-approved disinfectant and allowed to air dry before bringing it into the “Cold Zone”.

4. Movement of the patient:i. Limit the movement and transport of the patient from the room to essential purposes

only.



ii. If a patient requires a test or procedure that cannot be performed within the room contact Infection Prevention to outline a plan for safe transport.

1. The route of transport should be through the least traveled areas of the hospital. 2. Security or designated staff should be notified to assist in transport by clearing

hallways, securing and clearing elevators. 3. Necessary equipment that will accompany the patient at the time of transport

should be considered and their continuation determined prior to transport.

E. TRANSPORTATION OF A HIGHLY SUSPECT OR CONFIRMED PATIENT FROM THE AMBULANCE TO DESIGNATED ISOLATION ROOM:

1. Transport the patient in a wheelchair or a stretcher from the ambulance to designated isolation room.

2. Patient protective barriers:i. If the patient is ambulatory have the patient fluid resistant suite, mask, and gloves.

ii. When the patient is not able to ambulate use the fluid resistant sheet and wrap the patient on the stretcher.

F. EMERGENCY MANAGEMENT PERSONNEL:1. The ambulance fiver, within the cab that is separated from the back of the ambulance with an

impervious barrier does not require PPE.2. The ambulance staff within the transport bay of the ambulance should wear Level 3 PPE.3. PPE decontamination should be as outlined, Attachment D and Attachment D1 for donning

and doffing of PPE and the donning and doffing of PPE observer checklist.

G. REGISTRATION, CONSENT, AND DOCUMENTATION:1. All consents should be verbally obtained. There should not be any exchange of paper and pen

between staff and the patient. If paper is contaminated place in a bag, seal, and label “Biohazard”.

H. SECURITY:1. The entrance area must be secured to prevent access by unauthorized individual (staff and

public), with either locking doors or the continuous presence of security personnel at the hospital/site.

2. Security staff within the hallways to eliminate traffic when a patient is being transported does not require PPE. If the patient is agitated, at minimum Level 1 PPE is recommended.



SECTION V: SUSPECT/CONFIRMED EVD PATIENT CONTACT PRIOR TO PLACEMENT IN AN ISOLATION ROOM AND MANAGEMENT OF VISITORS

A. PATIENT CONTACTS PRIOR TO PLACEMENT IN ISOLATION:1. Create a list of all persons who came into contact with a patient before they were placed in

isolation, including direct physical contact or coming within six (6) feet of a patient. The list shall be provided to the Local Health Department where the hospital is located. Refer to Attachment C for the document to record person who came into contact with the patient prior to placement into isolation.

B. MONITORING, MANAGEMENT, AND TRAINING OF VISITORS: 1. Visitors should not be allowed within the patient care room/area. Exceptions may be considered

on a case by case basis for those who are essential for the patient's wellbeing, e.g., parent of a child.

2. Visitors should wear Level I PPE while in the patient’s room/area and wash their hands or use hand sanitizer after patient contact and upon exiting the patient’s room.

3. Instruct visitors on how to apply and remove PPE.4. Visitors should be screened for signs and symptoms of EVD, and evaluated and reported to the

Local Health Department if infection is suspected. Arrange for LIP follow-up with Infection Prevention.

i. Visitors accompanying patient should not be allowed to be checked in with the patient unless visitors are symptomatic. If symptomatic, then follow the above guidelines and isolate.

ii. Visitors that are not symptomatic should be informed to stay home and the Medical Team or Local Health Department will contact them for further information and update of patient status.

5. Essential visitors that enter the room “Hot Zone” should be monitored record the name and contact number for those essential visitors that enter the room. Refer to Attachment C1.



SECTION VI: SUSPECT/CONFIRMED EVD ACUTE CARE FACILITY PRECAUTION, ISOLATION, AND PATIENT PLACEMENT

A. PRECAUTIONS:1. Place on Standard, Airborne, and Contact Precaution and place the sign in a visual location.

B. IDENTIFICATION OF THE ISOLATION ROOM1. Identify an isolation room for patients who present with symptoms with a travel history or

contact with a suspect/confirmed EVD case for evaluation and ongoing care.

C. ISOLATION ROOM FEATURES:1. Patient care space:

i. Place the patient in a single patient room, preferably with an anteroom (containing a private bathroom) with the door closed.

ii. Anticipate the need for aerosolizing procedure and the need for negative pressure (airborne) isolation room prior, when available.

iii. When an anteroom is not available there needs to be a designated area for donning (Cold Zone) and doffing (Warm zone).

iv. The room should be within a low traffic area, when possible.v. The room should have puncture-proof, sealed sharps container within the room.

vi. Bathroom: 1. The toilet should have a lid and the lid should be shut prior to flushing the toilet

or cover with impervious material prior to flushing.2. When a patient is admitted, based on the facility’s protocol, the water may be pre-

treated prior to flushing.2. PPE:

i. The PPE should be available outside of the “Hot Zone”.

D. HCP MOVEMENT IN AND OUT OF THE ISOLATION ROOM:1. Limit movement in and out of the room.

E. ROOM MONITORING LOG:1. A log of all persons entering the patient's room “Hot Zone” should be maintained. Refer to

Attachment C1 for the log to record entries into the patient room. i. All persons entering the room should wear recommended PPE as outlined by this

guideline.



SECTION VII: EVD PERSONAL PROTECTIVE EQUIPMENT (PPE) AND PROCEDURES FOR DONNING AND DOFFING

A. PPE1. Dress Code for Staff wearing level PPE:

i. Remove personal items such as jewelry, watches, cell phone, pagers, pens, etc… ii. Shoulder length hair must be pulled back with hair tie behind neck.

iii. Shoes should be washable.2. PPE:

i. PPE should be worn based on the clinical presentation of the patient.ii. It is important to slowly and systematically put on your PPE so that you are focused on

covering your clothes, skin, face, eyes, and mouth.iii. It is VERY important to slowly and systematically remove your PPE so that you do not

contaminate yourself during removal.iv. PPE removal should be voice command directives read from a checklist from a dedicated

observer.v. Consider adding a mirror within the “Warm Zone” for proper donning and doffing.

vi. An observer should be present to assist in verbally walking you through the donning and doffing process and provide assistance if needed. PPE worn by the observer will be based on the guidance the potential for contamination.

vii. PPE utilization should include:1. Donning PPE when entering the room/area. 2. Upon exiting the patient room/area, care should be taken not to contaminate the

eyes, mucous membranes, or clothing with potentially infectious materials.3. In Level 3 PPE the suit is visibly contaminated, the suit is decontaminated with an

EPA-approved disinfectant before the doffing procedure starts.4. PPE inventory is monitored by Procurement to ensure at least a 30-day supply and

makes alternative arrangements for alternative products. When products are changed, staff is trained on the PPE.

viii. All persons entering the patient room should wear at least from triage to the isolation room:

1. Gloves (nitrile)2. Gown (fluid resistant or impermeable)3. Eye protection (goggles or face shield)4. Facemask5. Additional PPE might be required in certain situations (e.g., presence of blood,

other body fluids, such as urine, feces, emesis, sweat, semen, and breast milk present in the environment), including but not limited to:

a. Double gloving-nitrileb. Impermeable foot and leg coverc. Fluid resistant head and neck coverd. Goggles and face shield



e. National Institute of Occupational Safety and Health (NIOSH) certified fit-tested N95 respirator

f. Protective suitg. Powered air purifying respirator (PAPR)

6. Donning and doffing of PPE should be followed as outlined by the CDC, Refer to Attachment D.

a. For donning and doffing there should be a dedicated observer

B. OBSERVER ROLE: 1. Trained observer will assist with PPE donning and doffing process along with providing

guidance to the staff. 2. Visually inspect all PPE is donned and doffed successfully utilizing the PPE observer checklist

and making sure that no skin is exposed. Refer to Attachment D1 the donning and doffing of PPE observer checklist “Ebola Donning and Doffing of Personal Protective Equipment Observer Checklist”.

3. Observer will be knowledgeable in the exposure management plan in the event of an unintentional break in procedure.

4. Attachment D2 is the PPE donning and doffing d posters that should be posted within the donning and doffing areas.

C. ENGINEERING AND MAINTENANCE1. When repairs are made within the room the individuals should wear the same level of protection

as the clinical staff entering the room.

D. HAND HYGIENE: 1. Strict adherence to hand hygiene prior to entering and exiting the patient’s room/area. If you’re

gloved hands become contaminated while caring for the patient, decontaminate the glove with an alcohol-based hand sanitizer. Refer to the procedures for doffing for additional procedures for decontaminating the glove during the doffing process. Refer to the Hand Hygiene policy within the Infection Control Manual.

2. After removing PPE perform hand hygiene prior to exiting the anteroom.3. If possible have hands-free operated sink and alcohol-base hand sanitizer.

E. ANTEROOM:1. The anteroom, including the chair should be cleaned and disinfected with an EPA-approved

disinfectant following doffing of PPE. Spot clean the walls and the floor with a disposable microfiber mop and allow to air dry.



SECTION VIII: SUSPECT/CONFIRMED EVD PATIENT MANAGEMENT

As the disease progresses the following should be considered:

A. MONITORING AND EQUIPMENT:1. Continuous electrocardiographic monitoring for associated arrhythmias.2. Automated blood pressure device for blood pressure monitoring, there should be stethoscope use

only as appropriate(electrical one on unit)3. Central temperature monitoring or thermal temperature, i.e. temperature scanning device4. Pulse oximetry5. Portable radiography device

i. A portable device will remain within the designated area.ii. The film cartridge will be placed within a plastic bag in the cold zone, passed to the RN

in the warm zone, and the RN in the hot zone will place it behind the patient.iii. The portable machine will be distanced from the patient and the image will be taken.iv. The film will be removed from behind the patient by the nurse in the hot zone and the bag

will be opened the film will be removed and passed to the individual in the cold zone. The portable device will be disinfected within the anteroom, air dried, and then removed to the designated storage area.

v. Mechanical ventilation machinevi. Portable ultrasound

vii. Hemodialysis machine

B. NURSING:1. All patients will have the following minimum orders as part of the admission protocol, unless the

units protocol’s frequency exceeds the following standards: i. Vital signs every 4 hours

ii. A weight as prescribed by physician orderiii. Intake and output (without urinary catheterization)iv. Nursing assessment each shift with particular attention to presence of rash; mental status;

lung and heart assessment; and presence of nausea, vomiting or diarrhea

C. FLUID REPLACEMENT: 1. Large amounts of fluid replacement with crystalloids will be required. Monitor for development

of hyperchloremia which may necessitate alternative fluid choices (e.g. lactated ringers). 2. Hemodynamic support, 5 to 10 liters/day may be required.3. Electrolyte replacement with at least daily (likely 2-4 times a day) monitoring of basic metabolic

panel (BMP), magnesium, etc… 4. Use of platelets or fresh frozen plasma (FFP) to be determined on an individual patient’s state.5. Packed red blood cell (PRBC) transfusion as per the emergency protocol and recommendations

by the clinical team.

D. NUTRITIONAL SUPPORT:1. Total nutritional support (TPN) may be likely, enteral feeds are preferred if tolerated.



E. PHLEBOTOMY:1. Patient Care Considerations with Needles and Sharps:

i. Phlebotomy, procedures, and laboratory testing should be limited to the minimum necessary for essential diagnostic evaluation and medical care.

ii. Laboratory testing should be coordinated with the laboratory.iii. All needles and sharps should be handled with extreme care and disposed in puncture-

proof, sealed containers.1. Once patient discharged, the sharps container should be removed and managed as

“Category A” waste. Refer to Section XII for more information on the management of waste.

F. RESPIRATORY FAILURE:1. Mechanical intubation via endotracheal intubation:

i. Mechanically vented patients should be placed in an Airborne Infection Isolation Room (AIIR), negative pressure on Standard, Airborne and Contact Precautions.

ii. Consults with Infection Prevention and Respiratory Therapy regarding the management of the respirator and reusable components of the ventilator prior to use on another patient. The ventilator should remain within the patient’s room until it is decontaminated.

G. RENAL FAILURE:1. Patients receiving dialysis:

i. Renal failure can be treated with temporary dialysis.ii. Refer to the CDC guidelines for management of an EVD patient receiving dialysis at

http://www.cdc.gov/vhf/ebola/hcp/guidance-dialysis.html.iii. Clean and disinfect the dialysis machine as outlined for hepatitis B patients.

H. AEROSOL GENERATING PROCEDURES:1. Avoid aerosolizing generating procedures for a suspected and confirmed case.2. Visitors should not be present during aerosol-generating procedures.3. Limit the number of HCP present during the procedure to only those essential for patient-care

and support.4. Conduct the procedures in a private room and ideally in an AIIR when feasible. Room doors

should be kept closed during the procedure except when entering or leaving the room, and entry and exit should be minimized during and shortly after the procedure.

5. HCP should wear gloves, a gown, disposable shoe covers, and either a face shield that fully covers the front and sides of the face or goggles, and respiratory protection that are at least as protective as a NIOSH certified fit-tested N95 filtering face piece respirator during aerosol generating procedures. Refer to Section VII for more information on donning and doffing of PPE.

6. Conduct environmental surface cleaning following procedures. Refer to Section VII for more information.

7. Management of respiratory therapy:


http://www.cdc.gov/vhf/ebola/hcp/guidance-dialysis.html


i. Inhaled Medications: Metered Dose Inhalers (MDI) with an attached holding chamber is the first choice to reduce exposure from contaminated aerosol. If appropriate MDI and holding chamber is not available secondary options include small volume nebulizers incorporating both an inspiratory reservoir and expiratory filter or a breath actuated nebulizer.

ii. Manual Resuscitation: Resuscitation bags must be disposable and include an appropriately rated filter.

iii. Oxygen Therapy: For patients requiring > 40%, a mask with a good seal and appropriately rated expiratory filter must be used.

iv. Tracheostomy Humidification: Use heat and moisture exchanger in spontaneously breathing patients. Aerosol therapy must be avoided to prevent environmental contamination.

v. Suctioning Artificial Airways: Only use closed system suctioning. Open system suctioning must be avoided.

vi. Non-invasive ventilation will not be used for these patients given the potential to aerosolize respiratory secretions.

vii. Invasive Ventilation: The ventilator circuit must include inspiratory/expiratory lines to prevent condensation or use a heat and moisture exchanger. An appropriately rated expiratory filter must be used.

viii. High Frequency Oscillatory Ventilation (HFOV) will not be used.ix. Limit the number of health care personnel present during the procedure to only those

essential for patient-care and support.

I. LABOR OR OBSTETRICAL RELATED COMPLAINTS:1. A pregnant woman requiring obstetrical or gynecology interventions will be admitted to the

designated containment unit and all elements of the Ebola Recognition and Management protocol will be followed.

2. A patient in labor or with obstetrical complains will be monitored with external fetal heart monitoring.

3. Cesarean Section or any surgical intervention should be in consultation with the Senior Leadership Clinical Team.

J. PEDIATRIC GUIDELINES:1. Based on the child’s age and acuity consider utilizing a regular bed, crib, or radiant warmer.2. Monitoring will include ECG waveforms, respiratory rate, oxygen saturation, and end tidal CO2

if on a ventilator with a monitor capable for 2 invasive waveforms to be displayed.3. A pediatric and neonatal Emergency Cart will be available in the room. The full array of

endotracheal tubes, nasogastric tubes, suction catheters and a glidescope available.4. A Kangaroo pump for NG feeding will be available.5. A defibrillator with pediatric and neonatal pads as well as for external pacing will be in the room.6. Pharmaceuticals as listed (coming) will be in the pharmacy with both pediatric neonatal TPN

formulations (coming).



7. A refrigerator for breast milk storage will be immediately available for neonates, if the mother is healthy or the breast milk comes from an approved breast milk bank.

8. Nursing staffing per recommendations.

K. INVASIVE DEVICES: 1. Consider the insertion of a triple lumen central line and/or lumen midline catheter for infusion of

fluids, medication, and other intravenous therapy early in the course of the disease. The device should also be used for blood drawing.

2. Designated competent individuals to place the intravenous or central line device within the isolation room.

3. Confirmation of the central line placement should be done by a portable radiography machine.4. The end of the intravenous and/or central line should have needleless connectors.5. Indwelling urinary catheter to be used only as essential for care6. Nasogastric tube7. Rectal tube:

i. Rational: Patients who are having copious diarrhea should consider having a rectal tube considered and attached to a closed drainage bag which can discarded. Patients that are not having diarrhea can use a portable commode that has a disposable drainage can.

L. RADIOLOGY GUIDELINES:1. Radiology personnel required to perform a radiology procedure should be identified and receive

training on donning and doffing of PPE and the following X-ray and Ultra-Sound processes.2. Use wireless transmitting devices whenever possible.3. Only necessary imaging procedures should be performed. If the patient is a “rule out” EVD case and

the procedure can be delayed, delay the procedure until test results are available.4. The number of technologist/radiology personnel involved should be limited. 5. Radiology personnel entering the room should have a dedicated donning and doffing observer.6. The following outlines the portable X-ray and ultra-sound procedures:

i. Preparation of the X-ray process prior to entering the room: It is recommended that the below supplies be gathered. X-ray process should be coordinated with the care providers to ensure that the patient has a clean gown and sheets prior to performing an x-ray.

ii. Staff required:1. 2 staff members: Direct resource caregiver (LIP that competencies in radiography) and

1 indirect resource caregiver (RN or technician) iii. Supplies required:

1. 1 C-arm mobile x-ray drape2. 1 Steri-Drape Ioban 2 (or a second C-arm mobile drape)3. 2 x-ray cassette drapes (as used in the operating room)4. 2 nitrile glove to cover the exposure switch

iv. Preparation:1. The digital x-ray portable machine will be prepped in advance with 2 impermeable

covers. The C-arm mobile x-ray drape will cover the x-ray tube, telescope and the arm of the machine. The control panel and drive handle will be covered with a drape. The



plastic cover will also be wrapped around the front of the machine so that all parts of the machine are covered. Excessive plastic covering will be taped to avoid touching the floor.

2. One glove should be placed over the exposure switch and another over the switch holder.

3. The detector should be placed in the x-ray cassette drape and wrapped closed. Then place the wrapped detector in a second cassette drape, opening side first. Note: Do not tape the bag closed.

4. Confirm the patient’s identity and procedure with the provider.5. The direct resource caregiver will select patient information and set exam technique

before entering the room.6. Both the direct resource caregiver (LIP) and indirect resource caregiver (RN or

technician) will don appropriate level of personal protective equipment (PPE).v. Isolation Room (Hot Zone):

1. The direct resource caregiver (LIP) will enter the isolation room via the anteroom or the designated door with the portable machine and confirm pt identity.

2. Place the imaging detector behind the patient and sanitizes gloves.3. Position the x-ray tube over the patient and sanitizes gloves.4. Pick up the exposure switch and move 6 feet away from the x-ray machine. If needed,

the staff can step out of the room into the anteroom.5. Perform the exposure, and then place the exposure switch back into the holder.6. Retrieve the detector from behind the patient’s back.7. Sanitize gloves then open the anteroom’s door.

vi. Anteroom (Warm Zone):1. Top cassette drape will be partially rolled back and the direct resource care giver will

hand the indirect resource caregiver (who is donned in PPE) in the anteroom the single bagged side of the detector while not touching the soiled bag.

2. Cassette drape will be placed in the red biohazard bag by the direct resource caregiver. 3. The indirect resource caregiver (RN or technician) will then remove the remaining bag

from the detector, will dispose of it in the red biohazard bag and will clean the detector with the orange top EPA-approved impregnated disposable wipes and places the clean detector on a designated (table/rack) inside the clean side of the anteroom and allow to dry.

4. The indirect resource caregiver will sanitize gloves and doffs PPE according to EVD policy.

5. The direct resource caregiver (LIP) sanitizes outer gloves and removes the top layer of gloves and then dons a second layer of gloves. Direct Caregiver will (LIP) then perform the following:

a. Removes all of the equipment covers and places them in red biohazard bags as per EVD policy.

b. Clean the equipment with an EPA-approved disposable wipes and sanitize gloves.

c. Doff level PPE as per EVD policy.



d. A large pad should be saturated with EPA-approved disinfection solution will be placed at the door. The pad should extend from the warm zone to the cold zone.

e. Exit the room with the x-ray machine; slowly be driven over the saturated pad. vii. Outside the Anteroom (Cold Zone):

1. X-ray machine and the detector will be cleaned again EPA-approved disposable wipes. 2. Digital x-ray portable machine and detector will be placed aside in a designated

location for at least thirty (30) minutes before next use. 7. Portable Ultra-Sound Process for the EVD Patient:

i. Preparation of the ultra-sound process prior to entering the room: It is recommended that the below supplies be gathered in a location in the radiology department. Ultra-sound process should be coordinated with the patient care providers to ensure that the patient has a clean gown and sheets prior to performing a ultra-sound exam.

ii. Staff required:1. LIP with competencies in ultra-sound imaging

iii. Supplies required:1. Small portable ultra-sound machine2. 1 C-arm mobile x-ray drape3. 1 transducer cover4. 1 package of ultra-sound gel

iv. Preparation:1. Remove all unnecessary probes from the probe holders and utilize only identified

probe. Don the remaining probe with the transducer cover. Don the probe and wire extending from the probe to the ultra-sound machine with the long transducer cover. Don the ultra-sound machine with the equipment cover (or C-arm mobile x-ray drape). Ensure that the remaining covered ultra-sound probe is mounted on the probe holder external to the equipment cover (or C-arm mobile x-ray drape). Excessive plastic covering will be taped to avoid touching the floor. This will prevent any fluids from contacting any openings in the equipment.

2. Select patient information and set exam technique before the machine enters the room.3. Don appropriate level of personal protective equipment as per EVD Policy.

v. Isolation Room (Hot Zone):1. Enter the isolation room via the anteroom (if available) or the designated door with the

ultra-sound portable machine and confirm patient identity.2. Prepare the patient and perform the ultra-sound procedure.3. Place the covered probe back into the probe holder.4. Discard the package of ultra-sound gel.

vi. Anteroom (Warm Zone):1. Sanitize gloves then open the anteroom’s door. 2. Removes the top layer of gloves and then don a second layer of gloves.3. Remove all of the equipment covers and probe covers and places them in red biohazard

bags as per EVD policy.



4. Clean the equipment, including the probe and wire, with orange top EPA-approved disposable wipes and sanitize gloves.

5. Doff PPE as per EVD Policy.6. A large pad saturated with an EPA-approved solution should be placed at the door. The

pad should extend from the warm to cold zone as you exit the anteroom, equipment should be slowly rolled over this pad so that the wheels are covered with the disinfectant before exiting the room.

7. Staff will exit the room with ultra-sound machine. vii. Outside the Anteroom (Cold Zone):

1. Don clean gloves and cleans the ultra-sound machine with an EPA-approved disposable wipe(s).

2. Then place the ultra-sound machine aside in a designated location for at least 30 minutes before next use.

M. OTHER CLINICAL CONSIDERATIONS:1. Treat secondary infections and minimize specimens sent for laboratory testing.2. If available, investigate available experimental therapies such as Zmapp; convalescent sera;

BCX4430 and other therapies available through the CDC. A compassionate use protocol for the use of investigational agents has been approved by the institutional Review Board (IRB) for the Health System.

3. Consider supportive symptomatic therapy with analgesics, antipyretics, anti-emetics, and consider anti-diarrheal agents.

4. Maintain communication with the Local Department of Health and external resources regarding ongoing laboratory testing to monitor the progression of the disease.

5. If a patient arrests have a predetermined plan on the management of the patient, do not resuscitate (DNR).

N. DISCONTINUING PRECAUTIONS:1. Duration of precautions should be determined on a case-by-case basis, in conjunction with local,

state, and federal health authorities. Precautions for EVD may be discontinued if an alternative diagnosis for the patient’s symptoms is established.

2. Note: For cases in which the diagnosis of EVD is confirmed recommendation is to isolate until no longer viremic. Guidance may be provided by the external agencies.

i. Discontinuing of isolation will be in consultation with the Local Department of Health. 3. If a patient’s rapid testing is negative within the first 48 hours of symptoms but clinical suspicion

is high, repeat testing is warranted. The patient would remain on isolation and all outlined procedures will be followed.

O. DISCHARGE INSTRUCTIONS FOR PATIENTS WITH CONFIRMED EVD:1. Male patients should be informed that their sperm may still be contagious for a period of three

months after leaving hospital and it is transmitted during sexual intercourse. During this period, the patient must either abstain from sex or use condoms.



2. Female patients that are breast feeding must be informed that breast milk is contagious for three months.

3. If available use discharge instructions from the NYSDOH, CDC, and or Local Department of Health



SECTION IX: MONITORING HCP’s AND EVD EXPOSURE MANAGEMENT

A. MANAGEMENT OF POTENTIALLY EXPOSED EMPLOYEES:1. Staff members that anticipate having contact with patient with suspected/confirmed EVD should

bring a complete change of clothing to work with them.2. HCPs with percutaneous or mucocutaneous exposures to blood, body fluids, secretions, or

excretions from a patient with suspected EVD should:i. Complete the task and then wipe the outer glove with a bleach-based impregnated wipe.

When exiting the room follow the outlined doffing protocol, and ensure the affected skin surfaces are washed with soap and water.

ii. In the event there is a mucous membrane (e.g., conjunctiva) exposure, irrigate the affected area with water or eyewash solution.

iii. Immediately follow-up in the Emergency Department or designated location. Following the assessment in the Emergency Department or designated location contact occupational health/supervisor for assessment and access to post exposure management services for all appropriate pathogens (e.g., Human Immunodeficiency Virus (HIV) , hepatitis B, hepatitis C, etc.). Seek prompt medical evaluation and testing as per Employee Health Service guidance documents.

3. HCPs who develop fever greater than 38.0° Celsius or 100.4° Fahrenheit, weakness or muscle pains, vomiting, diarrhea, or any signs of hemorrhage after exposure to an EVD patient, whether or not it was unprotected should:

i. Not report to work or should immediately stop working.ii. Notify their supervisor.

iii. Seek prompt medical evaluation and testing.iv. The facility will notify the Local Health Department.v. Comply with work exclusion until they are deemed no longer infectious to others.

4. For an asymptomatic HCP who cared and/or had an unprotected exposure (i.e. not wearing recommended PPE at the time of patient contact or through direct contact to blood or body fluids) to a patient with EVD:

i. HCPs who cared for the patient should check their temperature twice daily for 21 days after the last known exposure. Any temperature elevation should be evaluated through the Emergency Department. Employees who report to the Emergency Department for follow-up should be managed as per the Health System’s EVD protocol and communication as outlined within the protocol.

ii. Unprotected exposures should be discussed by a group of Health System representatives that includes the Employee Health Service physician or designee, Infectious Disease physician, Infection Preventionist, and site specific representative(s) familiar with the exposure. Based on the employee’s exposure and determination made by the Health System group, restrictions from work with specific monitoring guidelines may be recommended.

iii. Refer to the Employee Health Service policy and procedure titled “Ebola Employee Management” located on Intranet under Employee Health Service.



SECTION X: EVD LABORATORY AND LABORATORY SAFETY

A. LABORATORY TESTING:1. If testing is indicated, obtaining and submission of specimens should be coordinated with the

Local Health Department or NYSDOH. i. NOTE: Do not send any specimens to a reference laboratory. Management of specimens

should be coordinated with the Local Health Department.2. All laboratory specimens should be labeled “Suspected Ebola” or “Confirmed Ebola” and

placed in plastic collection containers when possible and then placed within a double-bagged biohazard bag. The double bagged specimen should be placed in a transport container at the patient’s doorway. The specimens should be placed in one bag within the room and within a secondary bag at the doorway. The specimen label is placed on the secondary bag. Specimens should be hand delivered to the laboratory (rigid container with secured top). They should not be sent by pneumatic tube. The following outlines the procedure:

i. Staff will label the tubes, draw the blood, and place the tubes into a biohazard bag. The tubes should be wiped before they are placed in the bag.

ii. Bring the biohazard bag to the patient’s doorway. The bag should be wiped before it is placed into the second bag.

iii. Another staff member holds open a biohazard bag, the staff that draws the blood folds the biohazard bag and places it into another biohazard bag. A label “Suspected Ebola” or “Confirmed Ebola” should be placed on the pouch of the outer biohazard bag.

iv. Then, place that double specimen bag into the biohazard laboratory container, close the top of container and then place on the transport cart.

v. Transport within the designated transport container.vi. A nurse or designated staff member will then transport the specimen to the processing

area and inform staff that it’s a “Suspect or Confirmed Ebola Specimen” and communicate to the laboratory the specimen is suspect or confirmed EVD. There will be direct handoff to a staff member within the laboratory.

vii. Laboratory will then activate their internal Ebola ProcessNOTE: Testing should be minimized.

3. The specimen within the laboratory should be handled under a hood and the staff member should wear a gown, gloves, full face protection or goggles, mask to cover all of the nose and mouth, and gloves when manipulating the specimen, i.e. splitting of specimens. The hood should be a certified class II Biosafety cabinet or splash guard. Instruments used to process specimens should include manufacture-installed safety features.

4. For specimens sent and processed within the Core Laboratory, refer to the Core Laboratory guidelines for transport and management of specimens from suspected or confirmed EVD. The transport container used to transport the specimen should be decontaminated with 10% bleach or an EPA-approved disinfectant once the specimen has been removed.

5. Refer to Attachment E for laboratory guidance for specimen procedure. 6. Upon completion of the testing the area of testing should be decontaminated with a 10% bleach

solution that is EPA- approved.7. EVD specimens:



i. HCPs should collect serum, plasma, or whole blood. A minimum sample volume of 4 mL into two (2) lavender-top tubes for the NYSDOH and another two (2) for the CDC if requested, should be shipped refrigerated, or frozen on ice pack or dry ice (no glass tubes), in accordance with International Air Transporters Association (IATA) guidelines as a Category B diagnostic specimen. Refer to http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-specimen-collection-submission-patients-suspected-infection-ebola.html for detailed instructions and a link to the specimen submission form for CDC and prevention laboratory testing. Follow the manufacturer’s guidelines for disinfect contact times.

ii. Coordinated submission of the specimen with the receiving laboratory, as directed by the Local Health Department or NYSDOH.NOTE: The specimen may be picked up by the Local Department of Health or NYSDOH from the Emergency Department or laboratory; this will be determined by the Local Health Department prior to the pick-up.

B. Refer to the Laboratory Manual for more information on management of a suspect or confirmed EVD specimen.


http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-specimen-collection-submission-patients-suspected-infection-ebola.html

http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-specimen-collection-submission-patients-suspected-infection-ebola.html


SECTION XI: EVD ENVIRONMENTAL INFECTION PREVENTION AND CONTROL

A. PATIENT BELONGINGS:1. Clothing will be discarded in red biohazard bag. 2. Other personal belongings e.g. wallet and purse should be double red bagged and itemized.

These items should stay in the patient room.3. Upon discharge, patient will be provided with clothing by the family. Their wallet and purse will

be wiped with approved cleaning product and returned to patient.

B. UTENSILS AND FOOD TRAYS:1. A patient meal should be provided to the patient on a disposable tray with disposable plates and

utensils. Dispose the tray and utensils in a red bag within the room.

C. LINEN: 1. All linen within the patient room should be immediately discarded into an impervious linen

hamper lined with a red plastic bag removed when ¾ full, and discard as regulated medical waste (red bag). Transported to a designated area to be processed as “Category A” waste. Use disposable linen if available and discard as regulated medical waste (red bag).

D. WASTE WATER TREATMENT FOR DESIGNATED INPATIENT CENTER(S):1. PPE should be donned to minimize skin and mucous membrane contamination while in the

patient’s room and performing this task.2. Prior to the patient utilizing the toilet or emptying the contents of a commode or bedpan, pour

one cup of a bleach-based product into the clean toilet water.3. Let the waste stand within the toilet for ten (10) minutes, cover the toilet with the lid, and then

flush.



SECTION XII: EVD MANAGEMENT OF WASTE, DAILY ROOM CLEANING, AND DISCHARGE ROOM DISINFECTION

A. PPE:1. The hospital has identified a dedicated waste management team with special training and

standard procedures for wearing appropriate PPE (the same PPE used for direct patient care). Refer to Section VII for more information.

B. WASTE MANAGEMENT:1. All waste should be discarded as regulated medical waste (red bag). Refer to Attachment F for

management of waste. The process for management in the Hot, Warm, and Cold Zone is within Attachment F1.

2. All waste is placed in leak-proof bags, using a rigid waste receptacle designed to support the bag and help minimize contamination of the bag’s exterior.

3. Sharps waste is placed in appropriate disposable sharps containers, and EPA- registered solution is added prior to disposal. Sharps containers ready for disposal are sealed and placed into primary medical waste bags (1.5 mil) that is American Society for Testing and Materials (ASTM) tested.

4. “Category A” waste should be transported by designated staff to the designated waste holding room until pick-up by the contracted waste management company.

5. Waste or other potentially contaminated materials are not stored in the clean area.6. Wastes contaminated or suspected to be contaminated with EVD virus must be packaged and

transported in accordance with U.S. Department of Transportation Hazardous Materials Regulations.

7. A contract with a waste contractor should be in place.

C. CLEANING AND DISINFECTION OF A PATIENT CARE ROOM:1. Refer to Attachment F2 for routine cleaning within a room when a patient has a diagnosis of

suspected/confirmed EVD. This includes the frequency of anteroom cleaning.2. Refer to Attachment F3 for Terminal cleaning of a room following discharge or transfer of a

patient “Cleaning Procedure for a Room Occupied with a Suspected/Confirmed Case of EVD (Discharged/Expired/Transferred)”. The room shall be cleaned by an individual trained to don and doff Level 3 PPE.

3. Refer to Attachment F4 for management of a spill and Attachment F5 for guidelines for decontamination and cleaning of contaminated surfaces/area.

4. The room is NOT TO BE cleaned with a dry mop, duster or sweeper.5. Avoid using spray bottles; use disposable clothes moistened with EPA-approved disinfectant.

HCPs performing environmental cleaning and disinfection should wear PPE based on the potential for exposure. An inpatient room should be cleaned and disinfected in Level 3 PPE.

6. The anteroom or the designated area outside the room will be cleaned by a different HCP who will don PPE and clean behind the HCP responsible for cleaning the room as they exit.

7. Liquid medical waste such as feces and vomitus can be disposed of in the sanitary sewer following local sewage disposal requirements. Inpatient unit waste should be treated.



SECTION XIII: EVD EQUIPMENT REPROCESSING

A. EQUIPMENT MANAGEMENT:1. Equipment that is in use remains in the patient’s room, and is subject to regular cleaning in the

room as per the manufacturer’s recommendations. Under no circumstances should used dialyzers be reprocessed or reused.

B. NON-CRITICAL EQUIPMENT CLEANING AND DISINFECTION:1. PPE and required training for personnel performing cleaning and disinfection is the same as for

providers performing direct patient care.2. Use a disposable wipe impregnated with an EPA- approved disinfectant with a label claim of

potency at least equivalent to that for a non- enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus).

3. Routinely clean all environmental surfaces with an EPA-approved disinfectant daily (e.g., 1:10 bleach or quaternary ammonium) and when the patient is discharged. This includes bedrails, chart, carts, doorknobs, bed controls, call bells, telephones, faucet handles, commodes, curtains, etc. Focus on areas potentially contaminated with materials such as blood, sweat, emesis, feces, and other body secretions which represent potentially infectious materials.

4. Dedicate the use of non-critical items, such as a stethoscope, thermometer, blood pressure cuff, an intravenous (IV) pole, etc.

5. When used, all personal and non-dedicated stethoscopes shall be wiped with an EPA approved disinfectant before it is used on another patient.

6. Any equipment taken into the room (e.g. EKG machines, x-ray machines, ultrasound machines, etc.) should be cleaned and disinfected with EPA-approved disinfectant as soon as they are removed from the room. Follow manufacturer’s guidelines for disinfect contact times. Once the equipment has been cleaned and disinfected with an EPA-approved disinfectant and air dries, it can go back into circulation.

7. A large pad should be saturated with EPA-approved disinfectant and placed at the door. The pad should extend from the dirty to clean area as you exit the room. Equipment should be slowly rolled over this pad so that the wheels are covered with the disinfectant before exiting the room.

8. Consider having tongs available for staff to pick up items that may have fallen on the floor.

C. CRITICAL AND SEMI-CRITICAL EQUIPMENT:1. Instruments requiring sterilization:

i. When possible utilize disposable instruments.ii. Critical (e.g. surgical instruments) and semi-critical (e.g. laryngoscope blade, endoscope)

items shall be discarded within the patient’s room. iii. Any item that is categorized as semi-critical and critical will be wrapped within the room

and discarded as regulated medical waste within the patient room.



SECTION XIV: COMMUNICATIONS

A. COMMUNICATIONS:1. The organization has a plan in place to inform and educate staff and patients of plans to care for

EVD patients, and to notify staff and patients upon arrival of an EVD patient in the facility.2. The organization has a process in place for dissemination of every new or changed plan,

procedure, and protocol to appropriate groups within hospital to ensure understanding, proficiency, and comfort among HCPs.

3. The organization has a plan in place to handle media inquiries related to EVD patient care.4. The organization has a plan in place for protecting the privacy of the EVD patient, controlling and

monitoring access of HCPs to the EVD patient record so that unauthorized access does not occur.



SECTION XV: EVD MANAGEMENT OF THE DECEASED

A. POST-MORTEM CARE:1. If the patient dies, handling of the body should be minimized. Remains should be wrapped in

sealed leak-proof material and handled as per the guidance of the Local Health Department or NYSDOH. If an autopsy is necessary, the Local Health Department, NYSDOH, and CDC should be consulted regarding appropriate precautions. Refer to Attachment G.



SECTION XVI: STAFFING OF EVD PATIENT CARE TEAM

A. STAFFING RECOMMENDATIONS:1. Students, volunteers, and residents should not be assigned to care for suspected/confirmed EVD

patients or enter the room. 2. A dedicated, pre-identified, and trained EVD patient care team has been identified and trained for

the management of the EVD patient.3. The facility has identified team members involved in consultation but who should avoid entering

EVD patient room (e.g., audio/video conferencing may be used to communicate with patients or team members in room).

4. A schedule of staffing for EVD patient care is created in advance of an EVD patient arriving so that individuals on call are determined and training can be prioritized.

5. Staffing schedules include the following considerations:i. Enough team members to provide care for an EVD patient for at least one month

ii. Planning to ensure a minimum number of staff in roomiii. Minimum number of LIPs, RNs, and observers on unit at any timeiv. Adequate time to rest between shiftsv. On-call schedule for consultants 24 hours/7 days/week

vi. Maximum duration HCP can be providing direct patient care (e.g., 2-4 hours) and maximum duration of an EVD patient care unit shift (e.g., 12 hours)

6. Policies are in place for movement, monitoring, and patient care responsibilities while serving on an EVD patient care unit.

7. Team members receive competency-based, job- specific training on infection control practices, policies, and procedures for caring for EVD patient.

8. A single staff member is designated as primary point of contact for communicating information to public health authorities on a daily basis.

9. A plan for ongoing support and evaluation of team members is in place, including process for HCP to provide feedback to leadership.

10. Protocols are in place for meals to be delivered by members of the patient care team wearing all appropriate PPE.

11. An on-site manager is identified and available to coordinate and oversee all activities related to the care delivered to the patient(s), coordination of staffing, supplies and promoting safety.



SECTION XVII: EVD FACILITY PREPAREDNESS

A. EDUCATION:1. Training requires HCPs to be trained and receive repeat training to maintain competencies to

perform donning and doffing, plus observation of their co-workers properly donning and doffing PPE.

2. HCPs will receive repeated training and are required to demonstrate competency through testing and assessment on proper procedures for donning and doffing of PPE.

3. Training on the observer role will be incorporated into the training and ongoing training.4. Refer to the Health System Education and Training Plan and information on employees who

completed the education and applicable training for details on initial and ongoing training, plus their competencies.



CLINICAL REFERENCES/PROFESSIONAL SOCIETY GUIDELINES

1. Centers for Disease Control and Prevention Health Alert – Guidelines for Evaluation of US Patients Suspected of Having Ebola Virus Disease. The Ebola Virus Disease alert is available at http://emergency.cdc.gov/han/han00364.asp.

2. Centers for Disease Control and Prevention Ebola hemorrhagic fever. Further information is available at http://www.cdc.gov/vhf/ebola/ or http://www.cdc.gov/vhf/ebola/hcp/index.html.

3. Centers for Disease Control and Prevention Ebola hemorrhagic fever precautions. Further information is available at http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html.

4. New York State Department of Health. Health Advisory: Ebola Guidance Document. August 8, 2014. Further information is available at http://emergency.cdc.gov/han/han00364.asp.

5. 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).

6. New York State Department of Health: In the Matter of Infection Prevention and Control of Ebola Disease, Order for Summary Action, October 16, 2014.

7. New York State Department of Health: Health Advisory; CDC Guidance on Personal Protective Equipment To Be Used By Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, October 28, 2014.

REFERENCES to REGULATIONS and/or OTHER RELATED POLICIES 1. Joint Commission Surveillance, Prevention and Control of Infections 2. New York State Department of Health 405.113. Joint Commission Emergency Management4. Joint Commission Environment of Care

FORMSAttachment A: Ebola Virus Disease (EVD) Evaluation ToolAttachment B: Sign at Point of EntryAttachment B1: Ebola Virus Disease (EVD) Patient Management AlgorithmAttachment C: Contact With Patient Prior to Isolation LogAttachment C1: Patient and Visitor Encounter LogAttachment D: Ebola (suspect and confirmed) Donning and Doffing of Personal Protective Equipment (PPE)Attachment D1: Ebola (suspect and confirmed) Donning and Doffing of Personal Protective Equipment (PPE) Observer ChecklistAttachment D2: PPE Donning and Doffing Signs and PostersAttachment E: Laboratory Guidance for Specific Procedures Attachment F: Category “A” Waste Handling & Packaging ProcedureAttachment F1: Category “A” Waste Handling & Packaging Step-by-Step Procedure Attachment F2: Environmental Maintenance of a Suspect/Confirmed Ebola Patient’s RoomAttachment F3: Cleaning Procedure for a Room Occupied with a Suspect/Confirmed Case of Ebola (Discharged/Expired/Transferred)


http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5308a1.htm

http://emergency.cdc.gov/han/han00364.asp

http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html

http://www.cdc.gov/vhf/ebola/hcp/index.html

http://www.cdc.gov/vhf/ebola/

http://emergency.cdc.gov/han/han00364.asp


Attachment F4: Guidance for Safe Handling of Spill from Patient with EbolaAttachment F5: Guidance for Management of Contaminated Environmental Surfaces Attachment G: Guidance for Safe Handling of Human Remains of Ebola Patients

APPROVAL:System Clinical P&P Committee 10/23/15 (electronic vote)System PICG/Clinical Operations Committee 10/23/15*

*Expedited Approval by System PICG Co-Chairpersons

Versioning History: 11/5/14 – Expedited review by the Health System Clinical Leadership10/29/14 – Expedited review by the Health System Clinical Leadership10/22/14 – Expedited review by the Health System Clinical Leadership10/19/14 – Expedited review by the Health System Clinical Leadership10/18/14 – Expedited review by the Health System Clinical Leadership08/20/14 – Expedited



ATTACHMENT A

Ebola Virus Disease (EVD) Evaluation Tool

When you call the Department of Health, be prepared to: 1) Describe the patient symptoms (place an X before the presenting symptoms):

___ fever of greater than 38.0° Celsius or 100.4° Fahrenheit ___ severe headache ___muscle pain ___ vomiting ___ diarrhea ___ abdominal pain ___ unexplained hemorrhage ___ weakness

2) Describe the duration of illness:___________________________________________________________

3) Describe the patient’s travel history or known contact with a person who has suspect or confirmed Ebola regardless of travel. Include the following (note – patients who traveled but do not have symptoms should monitor their temperature twice a day and notify the Department of Health if they develop a fever greater than 38.0° Celsius or 100.4° Fahrenheit within 21 days of travel to identified area):

a. Travel:i. Residence in or travel to an area where EVD transmission is active.

1. Identify the locations: ______________________________________________________ii. Identify the dates within the affected country: ___________________________________

iii. Identify date entered into the United States:______________________________________b. Identified risk:

i. Known contact with someone with suspect or confirmed Ebola; Describe contact: __________________________________________________________________________________________________________________________________________________________________________________________________________

4) Discuss epidemiologic risk factors within the past 21 days before the onset of symptoms (place an X before potential risk factors):

___ Contact with blood or other body fluids of a patient known to have or suspected to have EVD.___ Direct handling of bats, rodents, or primates from disease-endemic areas. ___ Eat bush meat or are involved with animal rituals within endemic areas.___ Participated in funeral rites or other direct exposure to human remains without appropriate personal protective equipment

(PPE). ___ Percutaneous or mucous membrane exposure or direct skin contact with body fluids of a person with confirmed or suspected

EVD without appropriate PPE.___ Laboratory processing of body fluids of suspected or confirmed EVD cases without appropriate PPE or standard biosafety

precautions.NOTE: Evaluate family members and individuals that accompany the patient

5) Contact numbers (add the information based on the facility’s location):a. CALL INFECTIOUS DISEASE PHYSICIAN or FELLOW IMMEDIATELY, if available

i. Telephone number:______________________________b. CALL INFECTION PREVENTION IMMEDIATELY

i. Telephone number:________________________________ii. Off hours and weekends:__________________________

c. Local Department of Health should be called by Infectious Disease and/or Infection Prevention if the case meets criteria:

i. Telephone number:________________________________ii. Off hours and weekends:__________________________



ATTACHMENT B



ATTACHMENT B1



ATTACHMENT C

Contact With Patient Prior to Isolation Log

Name of Facility: __________________________________

1. List all individuals who came into contact with a patient before they were placed in isolation, including direct physical contact or within six (6) feet of a patient.

2. The list shall be provided to the Local Health Department where the hospital is located.


Exposure date

Time EVD case initials

First Name Last Name Phone number

Address Describe exposure


ATTACHMENT C1 FAX to the site specific Infection Prevention Department: Enter Fax numberSample Log for Hospital Personnel Involved In Caring for EVD Patient and Visitor Encounter Log (use the electronic version of the form)

Date: Date/Time Started: / / ____:_____ AM/PM

Facility name: Observer name: Date/Time Completed: / / ____:_____ AM/PMInstructions: Complete one line for each person entering the patient room, anteroom, or laboratory, or performing lab courier duties. If a person enters multiple times during a shift, that person will have multiple entries on the Observer Log. Fill in each field for each person, do not leave fields blank.

Recorder Name:CONTACT INFORMATION. EACH PERSON

COMPLETES ONCE.

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ATTACHMENT D

Ebola (suspect and confirmed) Donning and Doffing of Personal Protective Equipment (PPE)

** Prior to removal of PPE and entering the PPE removal area (warm zone) inspect PPE for cuts and tears and disinfect (using an EPA registered disinfectant wipe) any visible contamination on the PPE. As a final step, disinfect outer-gloved hands with alcohol-based hand sanitizer and allow to air dry.

Level I PPE (Low risk contact and no visible blood or body fluid) To be worn in the ambulatory setting and at minimum from triage to designated isolation room and when obtaining additional information from the patient while within the isolation room:

Note: Street clothes can be worn under PPE.Donning (putting on) PPE:

1)GOWN (impervious)a) fully cover torso and fasten in

the back of neck OPTIONS: Mask and Goggles OR Face shield OR Mask with Face shield

a) place mask over mouth and nose Secure the ties of the mask behind head Secure the bridge of nose and pinch the top clip

b) place goggles over eyesc) If a face shield is used instead of

mask and goggles, place over face and eyes and adjust to fit

d) If a mask with face shield is used place the mask over nose and mouth with the visor covering the eyes

2)GLOVES (nitrile)a) place the gloves on and extend to

cover your wrist and the isolation gown

* Single gloves

Doffing (removing) PPE:

1) GLOVES (nitrile)a) disinfect gloves with an alcohol based sanitizer and allow to air dryb) grasp the outside of the glove with opposite gloved hand, peel off and

hold the removed glove in gloved handc) slide fingers of ungloved hand under remaining glove at wristd) peel glove off over first glove and then discard

2) GOGGLES or FACE SHIELD or MASK with FACESHIELDa) handle by head and/or ear pieces and removeb) if a face shield or face shield with mask is used remove by handling the

ties or ear piecesc) discard

3) GOWNa) pull away from neck and shoulders, touching inside only, turn gown

inside out; fold or roll into bundle and discard4) HAND HYGIENE (using soap and water or an alcohol-based hand sanitizer)5) MASK, if applicable

a) grasp bottom, then top ties or elastics and remove; discard in waste container

6) HAND HYGIENE (using soap and water or an alcohol-based hand sanitizer)Note: The outside is contaminated! Place ALL items in Red Bag Waste

Removal of PPE:o Zone 1(hot) this is within the patient’s room: PPE remain ono Zone 2 (warm) is at the patient’s doorway or designated dirty area within the anteroom: remove gloves, goggles or face shield,

and gown, perform hand hygiene, then remove mask, perform hand hygiene. o Zone 3(cold) outside the patient room/anteroom: no PPE are worn



ATTACHMENT D

Level II PPE (visible blood or body fluid or low risk contact in the isolation room) To be worn when there is contact with a patient with visible blood and/or body fluid from the triage area walking into the isolation room and when caring for the patient within the isolation room and there is low-risk contact with the patient. In high-risk situations follow Level III PPE.

If the patient is at high risk and brought in by ambulance, the patient should be triaged within the ambulance prior to being transferred to a designated isolation room.

Note: Disposable scrubs can be worn under PPE.Donning (putting on) PPE:

1) Prior to donning observer ensures that staff member has no personal items and are wearing washable shoes

2) Trained Observer assists with donning, making sure NO SKIN OR HAIR IS EXPOSED

3) Observer completes this procedure by checking each step on the competency.

4) FOOT and LEG COVERa) slip foot and leg into leg

cover and pull the leg covering up until in position

5) GLOVES (nitrile)a) place on the “inner gloves”

and extend to cover the wrist

6) GOWN (impervious)a) fully cover torso, fasten in

back of neck and waist7) N95 Respirator

a) put on the N95 respirator as per protocol and fit-check respirator prior to entering the room

8) GOGGLESa) place over face and eyes

and adjust to fit9) FLUID RESISTANT HEAD

and NECK COVERa) place head and neck cover

over your head making sure your neck is covered

Doffing (removing) PPE:

1) Trained Observer will inspect PPE prior to doffing for visible contamination, cuts or tears before the doffing process starts

2) Observer will supervise doffing process and read the doffing sequence to the healthcare worker in a step-by step fashion during doffing

3) GLOVES (nitrile)a) disinfect outer-gloved hands with alcohol based sanitizer and allow to air dryb) remove the“ outer gloves” by grasping the outside cuff of one “outer gloved”

hand with opposite “outer gloved” handc) then peel off “outer glove” only ; hold removed “outer glove” in remaining

“outer gloved” handd) slide fingers of “inner gloved” hand under remaining “outer gloved hand and

wriste) peel “outer glove” off over first “outer glove”; discard

4) FACE SHIELDa) disinfect gloves with alcohol based sanitizer and allow to air dryb) handle and remove by the headband

5) FLUID RESISTANT HEAD and NECK COVERa) disinfect gloves with alcohol based sanitizer and allow to air dryb) place your hand at the top of head grasping & pulling the head & neck cover

back and away from head; discard6) GOWN (impervious)

a) disinfect gloves with alcohol based sanitizer and allow to air dryb) untie neck and waist, pull away from neck and shoulders, touching inside of

gown only, turn gown inside outc) fold or roll into bundle; discard

7) FLUID RESISTANT FOOT and LEG COVERa) disinfect gloves with alcohol based sanitizer and allow to air dryb) using both hands slip second & third fingers inside of the foot & leg coverc) fold & roll cover down towards ankle & foot (never touch the outside of the

foot & leg cover)d) lift foot up and slide out pulling the foot & leg cover away from bodye) discard

8) GLOVES (nitrile)a) disinfect inner gloves with alcohol sanitizerb) “ inner gloves”- grasp outside with opposite gloved hand, roll into ball

ATTACHMENT D



tie in a bow

10)FACE SHIELDa) place over face and eyes

and adjust to fit11)GLOVES (nitrile)

a) place on the “outer gloves” and extend to cover wrist of the isolation gown

* Double gloves

c) peel off; hold removed glove in gloved handd) slide fingers of ungloved hand under remaining glove at wrist, peel glove off

over first glove; discard9) HAND HYGIENE use soap and water or alcohol-based hand sanitizer10) GOGGLES and N95 RESPIRATOR

a) remove the goggles: handle the head strap and removeb) without touching the respirator, slowly lift the bottom strap from around your

neck up over head; lift off the top strap and discard11) Don gloves; sitting in a chair, disinfect washable shoes using an EPA-approved

disinfectant to wipe every external surface of the washable shoes. Remove and discard gloves.

12) HAND HYGIENE use soap and water or alcohol-based hand sanitizer13) Observer must report any break in procedure and record on patient encounter log see

attachment E.Note: The outside is contaminated! Place ALL items in Red Bag Waste

The observer should be wearing at least Level I PPE.

Removal of PPE:o Zone 1(hot) this is within the patient’s room: PPE remain ono Zone 2 (warm) is at the patient’s doorway or designated dirty area within the anteroom: remove gloves, face shield, head &

neck cover, gown, foot/leg covers, 2nd pair of gloves, perform hand hygiene, then remove N95 mask and goggles – then perform hand hygiene

o Zone 3(cold) outside the patient room/anteroom: no PPE are worn



ATTACHMENT D

Level III PPE (high risk exposure related to secretions, long periods of contact due to care needs, or performing an invasive procedure or admitted to an in-patient unit) PPE for suspect or confirmed Ebola case with presence of blood, other body fluids such as blood, urine, feces, emesis, sweat, semen, and breast milk present in the environment, staff with long periods of contact with the patient due to care needs, or involvement with an invasive procedure. Once the patient has been admitted to an inpatient unit Level III PPE should be worn.

Note: Disposable scrubs can be worn under PPEDonning (putting on) PPE:1) Prior to donning, trained

observer ensures that staff member has no personal items and is wearing scrubs with washable shoes.

2) Trained Observer to assist with donning, making sure no skin or hair is exposed.

3) Observer completes this procedure by checking each step on the list.

4) PROTECTIVE SUITa) while seated place suit onb) only place the suit to the

waist5) FOOT and LEG COVER

a) slip foot and leg into leg cover and pull the leg covering up until it is in position

b) Optional: tape the leg covers to the protective suit (50% on the suit and 50% on the leg cover)

6) GLOVES (nitrile)a) place on the “inner gloves”

and extend to cover the wrist

7) PROTECTIVE SUITa) now cover the upper body

part8) GLOVES (nitrile)

a) place the outer gloves onb) pull over suit wrists and

secure with chemical tapec) zip the suit, close the storm

flap; Optional secure the flap with tape (*

Doffing (removing) PPE:1) Observer dons in Level II PPE and completes doffing utilizing the competency checklist2) Check all protective equipment prior to doffing3) If self-doffing, step into appropriate sized red biohazard bag. All material removed is

placed into bag except PAPR.4) Body splashes in the room can be wiped away with an EPA-approved disinfectant5) Remove Apron (if used) (Could perform doffing in the patient’s room if PPE is soiled)

a) remove apron by rolling the apron from inside to outside6) Decontaminate the protective suit with an EPA-approved disinfectant, when possible.7) PAPR Unit (PAPR unit should remain on)

a) disinfect gloves with alcohol based sanitizerb) remove the PAPR unit; The PAPR unit should be held by Observer (in level 2 PPE)

or secured on a counter or a wall mounted hook.c) If held, always hold the PAPR unit away from body.

8) GLOVES (nitrile) – 1st pair “outer glove”a) disinfect “outer glove” with alcohol based sanitizerb) Remove chemical tape from wrist. If applicable remove from center and leg of the

suit.c) Remove the“ outer gloves” and discard the gloves

9) PAPR HOODa) the observer in Level II PPE will disinfect outer gloves, then roll the back outer cowl

(external hood barrier) from clean to dirty and secure with tape so it can remain in place, then wash hands

b) The outer cowl in the front of the suite will be rolled by the individual wearing the suit; roll from clean portion of cowl upward and tape

10) PROTECTIVE SUITa) disinfect gloved hands, open suit flaps, pull zipper down, and roll suit off starting at

shoulders and rolling the suit into itself, only touching the outside of the suitb) roll suit past the kneesc) sit in chair

11) FLUID RESISTANT FOOT and LEG COVERa) if necessary, the observer should assist in removal of foot and leg coverb) fold and roll cover down towards ankle and foot (never touch the outside of the foot

& leg cover)c) lift foot up and slide out pulling the foot & leg cover away from bodyd) repeat with other leg and foot

12) PROTECTIVE SUITa) Remove the rest of the suitb) If self doffing, leave inside red biohazard bag



ATTACHMENT D

(50% on the suit and 50% on the flap)

9) **PAPR (Powered Air Purifying Respirator) unita) place on waist and turn onb) fold and wrap extra waist

band and insert into the side of the waist band that’s around the waist.

10)PAPR HOOD with covera) place over head and adjust

to fit11) APRON (optional)

a) Put on full-body apron over gown for significant vomiting and diarrhea and at the discretion of the Observer. Double gloves are on at this time.

13) GLOVES (nitrile)a) Disinfect “inner gloves” with alcohol based sanitizerb) Remover the “ inner gloves”- grasp outside with opposite gloved handc) peel off; hold removed glove in gloved handd) slide fingers of ungloved hand under remaining glove at wrist and peel glove

off over first glove; discard14) PAPR HOOD

a) tilt head slightly backward, reach under hood, lift off and discard.b) step away from the dirty area

15) HAND HYGIENE use soap & water or hand sanitizer16) Don gloves; sitting in a chair, disinfect washable shoes using an EPA-approved

disinfectant to wipe every external surface of the washable shoes17) HAND HYGIENE use soap and water or alcohol based hand sanitizer18) Observer performs final inspection of healthcare worker for any indication of

contamination of the scrubs or disposable garments. If contamination identified, record on patient encounter log (see Attachment E).

A shower should be taken following removal of the PPE.Note: When there is a tear or hole identified in the suit while within the room, use the

extra tape that is taped to the suit.*Optional = suggested to use tape for the center of the suit over the zipper and leg

covers when entering an environment that is heavily soiled.

Note: The outside is contaminated! Place ALL items in Red Bag Waste.** Powered Air Purifying Respirator

1) Donning and doffing of PPE must always be observed by a qualified observer. PPE should be donned in a clean area outside the patient care room.

2) The observer should be wearing at least a Level II PPE.

In an emergency the individual within the suit will be removed from the hot zone and the suit will be removed by cutting from the back and rolled off within the yellow zone.

Removal of PPE:o Zone 1(hot) this is within the patient’s room: PPE remain ono Zone 2 (warm) is at the patient’s doorway or designated dirty area within the anteroom: remove PAPR motor, outer gloves,

protective suit, foot/leg covers, inner gloves, then remove PAPR hood and perform hand hygieneo Zone 3(cold) outside the patient room/anteroom: no PPE is wornNote: This process may change based on additional guidance from external regulatory and guidance agencies.

Decontamination of the PAPR:1) The PAPR should be cleaned and decontaminated within the warm zone prior to entering the cold zone2) Disinfectant: Disinfectant wipe – PDI Sani-Cloth Plus (Germicidal Disposable Cloth – purple top container):

a. Use cloth to thoroughly wet surface and let air dry



ATTACHMENT D

b. Treated surface must remain visibly wet and allowed to dry as per manufacturer guidelines3) All decontamination procedures will be conducted in the warm zone under direction of a decontamination team leader:

a. Disconnect the breathing tube from the hoodb. Disposable hoods will be discardedc. Remove the PAPR air filter unit from the waist belt

4) Decontamination of the breathing tube, PAPR unit and waist belt:a. Using the Germicidal Disposable Cloth clean and disinfect the PAPR unit and components and allow to air dryb. Filter:

i. Remove and replace filters after the unit has been decontaminated, as necessary and defined by protocolii. Discard the filter as regulated medical waste and replace with a new filter



ATTACHMENT D1

EBOLA Donning and Doffing of Personal Protect Equipment Observer Checklist

EMPLOYEE NAME: _____________________________________ OBSERVER NAME: _____________________________________ DATE: ______________________

Level I PPE

*NOTE: Street cloths can be worn under PPE *Check appropriate box and initialWhen DONNING Level I PPE, did the HCP: C=Completed NC = Not

Completed1) GOWN:

a) fully cover torso and fasten in the back of neck2) MASK and GOGGLES OR FACE SHIELD or MASK or FACE SHIELD:

a) place the mask and goggles over eyes, nose, and mouth and adjust to fitb) if a face shield is used, place over eyes, nose, and mouth and adjust to fitc) if the mask with face shield is used place the mask over nose and mouth with the visor covering the eyes

3) GLOVES (nitrile):a) place the gloves on and extend to cover wrist and the isolation gown

*Single gloves are on at this timeWhen DOFFING Level I PPE, did the HCP: C=Completed NC = Not

Completed1) GLOVES (nitrile):

a) disinfect gloves with an alcohol-based sanitizer and allow to air dryb) grasp the outside of the glove with your opposite gloved hand, peel off and hold the removed glove in gloved

handc) slide fingers of ungloved hand under the remaining glove at wristd) peel glove off over first glove and then discard

2) GOGGLES OR FACE SHIELD or MASK or FACE SHIELD:a) handle by head or ear pieces and remove; if a face shield with mask is used remove by handling the ties or ear

pieces3) GOWN:

a) pull away from neck and shoulders, touching inside only, turn gown inside out; fold or roll into bundle and discard

4) HAND HYGIENE using soap and water or alcohol-based sanitizer



ATTACHMENT D1

When DOFFING Level I PPE, did the HCP (continued): C=Completed NC = Not Completed

5) MASK (if utilized):a) grasp bottom, then top ties or elastics and remove; discard in waste container

6) HAND HYGIENE using soap and water or alcohol-based sanitizerNote: The outside is contaminated! Place ALL items in Red Bag Waste.

Removal of PPE:o Zone 1(hot) this is within the patient’s room: PPE remain ono Zone 2 (warm) is at the patient’s doorway or designated dirty area within the anteroom: remove gloves, face shield, head & neck cover, gown, foot/leg covers, 2nd pair of

gloves, perform hand hygiene., then remove N95 mask and goggles - then perform hand hygieneo Zone 3(cold) outside the patient room/anteroom: no PPE are worn



ATTACHMENT D1 EBOLA Donning and Doffing of Personal Protect Equipment Observer Checklist


Level II PPE


*NOTE: Street clothes or disposable scrubs can be worn under PPE *Check appropriate box and initialWhen DONNING Level II PPE, did the HCP: C=Completed NC = Not

Completed1) Prior to donning, trained observer ensures that have no personal items and are wearing scrubs with washable

shoes2) Observer assists with donning making sure NO SKIN OR HAIR IS EXPOSED3) Observer complete the procedure by checking each step on the competency4) FOOT and LEG COVER

a) slip foot and leg into cover and pull the leg covering up until in its position5) GLOVES (nitrile):

a) place on the “inner gloves” and extend to cover the wrist6) GOWN (impervious):

a) fully cover torso and fasten in the back of neck7) N95 RESPIRATOR:

a) put on the N95 respirator as per protocol and fit-check respirator prior to entering the room8) GOGGLES:

a) place over face and eyes and adjust to fit9) FLUID RESISTANT HEAD and NECK COVER:

a) place head and neck cover over your head making sure your neck is covered10) FACE SHIELD:

a) place over face and eyes and adjust to fit11) GLOVES (nitrile):

a) place on the “outer gloves” and extend to cover wrist of the isolation gown. Double gloves are on at this time



ATTACHMENT D1

When DOFFING Level II PPE, did the HCP: C=Completed NC = Not Completed

1) Observer will inspect PPE prior to doffing for visible contamination, cuts or tears before the doffing process starts2) Observer will supervise the doffing process3) Observer verbally repeats the steps of the process during doffing4) GLOVES (nitrile):

a) disinfect outer gloves with alcohol-based hand sanitizer and allow to air dryb) remove the“ outer gloves” by grasping the outside cuff of one “outer gloved” hand with opposite “outer gloved” handc) peel off “outer glove” only; hold removed “outer glove” in remaining “outer gloved” handd) slide fingers in “inner gloved” hand under remaining “outer gloved” hand and wriste) peel “outer glove” off over first “outer glove”; discard

5) FACE SHIELD:a) disinfect gloves with alcohol-based hand sanitizer and allow to air dryb) remove by handling by the headband

6) FLUID RESISTANT HEAD and NECK COVER:a) disinfect gloves with alcohol-based sanitizer and allow to air dryb) place hand at the top of head grasping and pulling the head and neck cover back and away from head and discard

7) GOWN (impervious):a) disinfect gloves with alcohol-based sanitizer and allow to air dryb) untie at neck and waist ties, pull away from neck and shoulders, touching inside of gown only, turn gown inside outc) fold or roll into bundle and discard

8) FLUID RESISTANT FOOT and LEG COVER:a) disinfect gloves with alcohol-based sanitizer and allow to air dryb) using both hands slip second & third fingers inside of the foot & leg coverc) fold and roll cover down towards ankle and foot (never touch the outside of the foot & leg cover)d) lift foot up and slide out pulling the foot and leg cover away from bodye) discard

9) GLOVES (nitrile):a) disinfect “inner gloves” with alcohol-based hand sanitizerb) “ inner gloves ”- grasp outside with opposite gloved hand, roll into a ball



ATTACHMENT D1

When DOFFING Level II PPE, did the HCP (continued): C=Completed NC = Not Completedc) peel off; hold removed glove in remaining gloved handd) slide fingers of ungloved hand under remaining glove at wrist, peel glove off over first glove; discard

10) HAND HYGIENE use soap and water or an alcohol-based hand sanitizer11) GOGGLES and N95 RESPIRATOR:

a) remove the goggles: handle the head strap and removeb) without touching the respirator, slowly lift the bottom strap from around neck up over head; lift off the top strap

and discard12) Disinfect Washable Shoes

a) put on clean pair of glovesb) sitting in chair, disinfect washable shoe as using an EPA approved disinfectant to wipe all external surfaces of

the washable shoes.c) remove and discard gloves

13) HAND HYGIENE use soap and water or an alcohol-based hand sanitizer14) Observer must record any break in procedure on the patient encounter log (Attachment E)

Note: The outside is contaminated! Place ALL items in Red Bag Waste.

Removal of PPE:o Zone 1(hot) this is within the patient’s room: PPE remain ono Zone 2 (warm) is at the patient’s doorway or designated dirty area within the anteroom: remove gloves, face shield, head & neck cover, gown, foot/leg covers, 2nd pair of

gloves, perform hand hygiene, then remove N95 mask and goggles – then perform hand hygiene o Zone 3(cold) outside the patient room/anteroom: no PPE are worn



ATTACHMENT D1

EBOLA Donning and Doffing of Personal Protect Equipment Observer Checklist


Level III PPE


*NOTE: Street cloths can be worn under PPE *Check appropriate box and initialWhen DONNING Level III PPE, did the HCP: C=Completed NC = Not Completed1) Prior to donning, observer needs to make sure staff have no personal items and are wearing scrubs with

washable shoes2) Observer must assist with donning and making sure NO SKIN OR HAIR IS EXPOSED3) Observer will complete the procedure by checking each step on the competency4) PROTECTIVE SUIT:

a) while seated place suit onb) only place the suit to the waist

5) FOOT and LEG COVERa) slip foot and leg into leg cover and pull the leg covering up until it is in positionb) Optional*: tape the leg covers (*optional) to the protective suit (50% on the suit and 50% on the leg cover)

6) GLOVES (nitrile):a) place on the “inner gloves” and extend to cover the wrist

7) PROTECTIVE SUIT:a) now cover the upper body part

8) GLOVES (nitrile):a) place the outer gloves onb) pull over suit wrists and secure with chemical tapec) now zip the suit, close the storm flap, Optional*: secure the flap with tape (50% on the suit and 50% on the

flap- *optional)9) **PAPR (Powered Air Purifying Respirator) unit on waist:

a) place on waist and turn onb) fold and wrap extra waist band and insert into the side of the waist band that’s around the waist



ATTACHMENT D1

When DONNING Level III PPE, did the HCP (continued): C=Completed NC = Not Completed

10) PAPR HOOD with cover:a) place over head and adjust to fit

11) APRON (optional):12) put on full-body apron for significant vomiting and diarrhea at the discretion of the Observer. Double gloves are on at this time.When DOFFING Level III PPE, did the HCP: C=Completed NC = Not

Completed1) Observer dons in Level II PPE and completes doffing utilizing the competency checklist2) Step into appropriate size red biohazard bag if self doffing; body splashes in the room can be wiped away with an EPA-

approved disinfectant3) APRON:

a) if used, remove apron by rolling the apron from the inside to outside; may have been removed in patient room and placed into the red biohazard bag within the room

4) Decontaminate the protective suit with an EPA-approved disinfectant when possible5) PAPR UNIT (PAPR unit remains powered on):

a) disinfect glovesb) Remove the PAPR unit. PAPR unit should be held by Observer (in level 2 PPE) or secured on a counter or a wall mounted hookc) If held, always hold the PAPR unit away from body

6) GLOVES (nitrile) – 1st pair “outer glove”a) disinfect “outer glove” with alcohol based hand sanitizerb) remove chemical tape from the wrist, center, and leg of the suit, if used on the center and leg of the suitc) then, remove the “outer gloves” and discard the gloves

7) PAPR HOODa) The observer in Level 2 PPE will disinfect outer gloves, then roll the back outer cowl (external hood barrier) from clean to dirty,

and secure with tape so it can remain in place; then wash hands.b) The outer cowl in the front of the suit will be rolled by the individual wearing the suit; roll from clean portion of cowl upward

and tape.8) PROTECTIVE SUIT:

a) disinfect gloved hand, open suit flaps, pull zipper down, roll suit off starting at shoulders and rolling the suit into itself only touching the outside of the suit

b) roll suit past knees9) FLUID RESISTANT FOOT and LEG COVER:

a) if necessary, the assistant should assist in removal of foot and leg cover



ATTACHMENT D1

When DOFFING Level III PPE, did the HCP (continued): C=Completed NC = Not Completed

b) fold and roll cover down towards ankle and foot (never touch the outside of the foot & leg cover)c) lift foot up and slide out pulling the foot & leg cover away from bodyd) repeat with other leg and foot

10) PROTECTIVE SUIT:a) Remove rest of the suitb) If self doffing, leave inside red biohazard bag

11) GLOVES (nitrile):a) disinfect “inner gloves” with alcohol-based hand sanitizerb) “inner gloves”- grasp outside with opposite gloved handc) peel off; hold removed glove in gloved handd) slide fingers of ungloved hand under remaining glove at wrist, peel glove off over first glove; discard

12) PAPR HOOD:a) tilt head slightly backward, reach under hood, lift off and place PAPR into the red, plastic lined receptacle, (if necessary an

individual in Level II PPE can assist)b) step away from the dirty area

13) HAND HYGIENE use soap and water or an alcohol-based hand sanitizer; a shower should be taken following removal of PPE14) Washable Shoes:

a) Don gloves; sitting in a chair, disinfect washable shoes using an EPA-approved disinfectant to wipe every external surface of the washable shoes

b) Remove gloves and perform HAND HYGIENE; use soap and water or alcohol based hand sanitizer15) Observer performs final inspection of healthcare worker for any indication of contamination of the scrubs or disposable

garments; if contamination identified, record on patient encounter log (Attachment C1); a shower should be taken following removal of PPE

Note: The outside is contaminated! Place ALL items in Red Bag Waste.*Optional = suggested to use tape for the center of the suit over the zipper and leg covers when entering an environment that is heavily soiled

1) Donning and doffing of PPE must always be observed by a qualified observer; PPE should be donned in a clean area outside the patient room

Removal of PPE:o Zone 1(hot) this is within the patient’s room: PPE remain on



o Zone 2 (warm) is at the patient’s doorway or designated dirty area within the anteroom: remove gloves, face shield, head & neck cover, gown, foot/leg covers, 2nd pair of gloves, perform hand hygiene, then remove N95 mask and goggles – then perform hand hygiene

o Zone 3(cold) outside the patient room/anteroom: no PPE are wornATTACHMENT D1

Note: This process may change based on additional guidance from external regulatory and guidance agencies.

Decontamination of the PAPR:1) The PAPR should be cleaned and decontaminated within the warm zone prior to entering the cold zone2) Disinfectant: Disinfectant wipe – PDI Sani-Cloth Plus (Germicidal Disposable Cloth – purple top container):

a. Use cloth to thoroughly wet surface and let air dryb. Treated surface must remain visibly wet and allowed to dry as per manufacturer guidelines

3) All decontamination procedures will be conducted in the warm zone under direction of a decontamination team leader:a. Disconnect the breathing tube from the hoodb. Disposable hoods will be discardedc. Remove the PAPR air filter unit from the waist belt

4) Decontamination of the breathing tube, PAPR unit and waist belt:a. Using the Germicidal Disposable Cloth clean and disinfect the PAPR unit and components and allow to air dryb. Filter:

i. Remove and replace filters after the unit has been decontaminated, as necessary and defined by protocolii. Discard the filter as regulated medical waste and replace with a new filter



ATTACHMENT D2



ATTACHMENT E

Laboratory Guidance for Specific Procedures

ATTACHMENT F


Procedure Recommendations for facility laboratory

Recommendations for the Core Laboratory

Centrifugation The specimen should be processed within a closed specimen tube/container. If the device has a top it should be closed when being spun. Once testing is completed the area should be cleaned and decontaminated with 10% bleach,

Chemistry and hematology Perform the test under the certified class II Biosafety cabinet or Plexiglas splash guard wearing PPE. If the specimen is transported to the Core Laboratory - label each specimen container or tube, double bag, and place within a separate transport container.

Malaria testing A specimen ordered for Malaria testing should be processed. If the test is performed at the Core Laboratory - label each specimen container or tube, double bag, and place within a separate transport container.

Blood Cultures Performed on a case by case basis as per discussion with the Licensed Healthcare Provider and Infectious Disease physician or their designee. The location for testing will be discussed with the Laboratory Director.

Other specimens for bacterial culture

Performed on a case by case basis as per discussion with the Licensed Healthcare Provider and Infectious Disease physician or their designee. The location for testing will be discussed with the Laboratory Director.

Wet preps Not to be performed.Viral cultures Performed on a case by case basis as per discussion with the Licensed

Healthcare Provider and Infectious Disease physician or their designee. The location for testing will be discussed with the Laboratory Director.

Viral or bacterial antigen tests Not to be performed.Molecular testing for infectious agents

Performed on a case by case basis as per discussion with the Licensed Healthcare Provider and Infectious Disease physician or their designee. The location for testing will be discussed with the Laboratory Director.

Cross-matching for blood transfusion

The test should be avoided and if necessary performed on a case by case basis as per discussion with the Licensed Healthcare Provider and Infectious Disease physician or their designee. The location for testing will be discussed with the Laboratory Director.

Tissue Pathology The test should be avoided and if necessary performed on a case by case basis as per discussion with the Licensed Healthcare Provider and Infectious Disease physician or their designee. The location for testing will be discussed with the Laboratory Director.

Post-mortem examinations Not to be performed – Refer to Attachment HSpecimen storage: Place within a secondary container, label as “Quarantined” and store in

a designated location. The storage container should be decontaminated with 10% bleach once the specimen has been removed.

Specimen decontamination and disposal

Follow current procedures.


Category “A” Waste Handling & Packaging Procedures

PURPOSETo maintain stringent guidelines for a suspected/confirmed case of Ebola as it relates to waste handling and packaging procedures for Environmental Service workers.

EQUIPMENT Protective Equipment (PPE): Level 2 as outlined in Attachment A Environmental Protection Agency (EPA) Registered hospital disinfectant with a label claim for non-

enveloped virus ( e.g. norovirus, rotavirus, adenovirus) Regulated Medical Waste bags Rigid leak proof Waste Receptacle

PROCEDUREThe following are recommendations that should be followed by Environmental Service workers or designated staff to perform this type of work:

1) Environmental Service workers or designated staff performing this type of works staff don (put on) and doff (take off) Level 2 as outlined in Attachment A of this document.

2) Any free flowing fluid should be solidified with isolyzer.3) Bags should be within a holder that allows decontamination of the outer bag, i.e. linen bag holder.4) Minimize the weight of the bag by using medium size bags and fill no more than ¾ full.5) Management of waste from a suspect/confirmed Ebola room wearing Level 2 PPE the following should

be performed:a. Place waste or sealed sharps containers into a primary medical waste bag that is at least 1.5 milliliters

in thickness bag as recommended by the American Society for Testing and Materials (ASTM). The ASTM recommended bag will be provided by the contracted regulated medical waste company that removes waste from health care facilities.

b. Apply an EPA disinfectant into the primary medical waste bag to cover the surface of materials contained within the bag; securely tie the bag. This should be done within the isolation room.

c. Treat the exterior surface of the primary container with EPA registered hospital disinfectant.d. Place the primary bag into a secondary bag and securely tie the outer bag.e. Treat the exterior surface of the secondary bag with EPA registered hospital disinfectant.f. The double bagged waste should then be placed into a special Category “A” packaging with the liner

tied securely and container closed per the packaging instructions provided. The container will be provided by contracted regulated medical waste company that removes waste from health care facilities.

g. Remove the Level 2 PPE and do the following: Remove and deliver the “Category A” waste container from the anteroom and store the Category “A” waste containers separate from other regulated medical waste and in a secure area preferably isolated and with limited access.

h. Contact the contracted regulated medical waste company representative and the representative will arrange delivery of the special Category “A” waste containers as well as begin the process with the U.S. Department of Transportation who has a “Special Permit” to transport this type of waste.



i. Refer to Environmental Service management and transport plans.

ATTACHMENT F1Category “A” Waste Handling & Packaging Procedures


HOT AREA:

All waste should be placed in a red bag in the hot zone (patient room) The red bag should:be within a holder that allows the outer bag to be wiped with an Environmental Protection Agency (EPA) approved impregnated wipe;prior to starting, don a utility glove over the nitrile gloves;pour a sufficient amount of an EPA-approved disinfectant over the contents within the bagwipe the red bag with an EPA-approved disinfectantthen, tie the top of the bag;place the red bag into a secondary red bag at the entrance of the patient’s doorway;remove and discard utility gloves in red receptacle.Reline the waste receptacle with a red bag.

WARM AREA:

Wearing utility gloves within the warm zone (anteroom), all the surfaces of the red bag will be wiped with an EPA-approved disinfectant and allowed to air dry.The secondary red bag will be tied following disinfection with the EPA-approved disinfectant and the red bag has dried.Following completion of this process discard the utility gloves into a red receptacle.


ATTACHMENT F2

Environmental Maintenance of a Suspect/Confirmed Ebola Patient’s Room

PURPOSE

Outline the general maintenance of a patient’s environment with a diagnosis of suspect/confirmed Ebola, daily and when there is a spill or visible blood and your body fluid.

EQUIPMENT Level 3 Personal Protective Equipment (PPE) as outlined in Attachment D Disposable microfiber mop, already pre-moistened with an EPA-registered disinfectant Disposable toilet bowl brush Environmental Protection Agency (EPA) registered hospital disinfectant Disposable wipes pre-moistened with an EPA approved disinfectant Dispenser refills as needed – paper towels, toilet paper, hand soap, red bags

PROCEDURE1) Only individuals wearing Level 3 PPE shall perform the following activities daily.2) Pre-moisten container lid in the room should be closed at all times to prevent drying.3) Wipe down surface of patient furniture with pre-moistened wipe, i.e. bedside table, chair, side table,

bedrails.4) If patient is able to be out of the chair, wipe down bed surface with pre-moistened wipe and allow to air

dry before making the bed. All bed linen is discarded in the waste receptacle.5) Disinfect sink surface and counter using pre-moistened wipe.6) Disinfect toilet, place disinfectant into toilet bowl and clean with the disposable brush, close the lid and

flush. Wipe all surfaces of seat and outer bowl with pre-moistened disposable wipe.7) Spot clean areas as needed on walls, windows, etc. with pre-moistened wipe.8) Using pre- moisten wipes to remove gross decontamination of body fluid splashes.9) Place all used cleaning wipes into a biohazard waste receptacle. Only fill bag to ¾ to be able tie the liner

before discarding.


COLD AREA:

At the doorway of the warm zone (anteroom), place the double wrapped red bag into the “Category A” container that is on a dolly in the corridor. The corridor is considered the cold zone (hallway). The “Category A” container should have the lid replaced and stored within the soiled utility room or designated location until it is ¾ full.When the container is ¾ full, seal the container and move it to the designated location for pick-up by the contracted waste management company.


a. Waste should be removed when ¾ full; refer to Attachment F for management of waste.10) Empty the room waste receptacle by removing the liner, tie and place into biohazard waste receptacle.

Wipe outside of receptacle with disinfectant. Install new liner.11) Mop the floor with the pre-moistened microfiber mop and dispose of mop head into biohazard waste

receptacle.12) Check and refill any needed dispenser.

Note: If cleaning items enter the room they remain in the room and when empty discarded.Note: The anteroom should be cleaned once each shift and when there is contamination.



ATTACHMENT F3

Cleaning Procedure for a Room Occupied with a Suspect/Confirmed Case of Ebola (Discharged/Expired/Transferred)

PURPOSE

To clean the room of a suspect/confirmed case of Ebola when a patient is discharged, expires, or is transferred before another patient is admitted to the room. Note: Allow the EPA-solution to air dry.

EQUIPMENT Level 3 Personal Protective Equipment (PPE) as outlined in Attachment D Wet floor sign Bio hazard waste receptacle Dispenser refills; paper towels, toilet paper, hand soap, red trash, alcohol-based hand sanitizer Disposable cloths Environmental Protection Agency (EPA) disinfectant Disposable microfiber mop and disposable cleaning cloths, already pre-moistened with an EPA-

registered disinfectant PROCEDURE

1) Trained personnel on Level 3 donning and doffing shall clean the room.2) Gather waste within the room, i.e. waste within the wastebasket, linen, sharps containers, curtains and

disposable products shall be placed within a bio-hazardous waste receptacle. If there are curtained within the room; remove and discard. Refer to Attachment F for waste management processes.

3) Clean and disinfect the items within the room with a disposable cloth saturated with an EPA approved disinfectant, do not spray. Clean surfaces if visibly soiled with blood and/or body fluid with a disposable cloth, then disinfect and allow the solution to remain moist on the surface for the time identified by the manufacturer’s guidelines. Allow to air dry.

i. wash equipment within the room such as intravenous pump(s), pole, portable suction, oxygen flow meter, commode, etc., clean and disinfect as per manufacturer guidelines

ii. wash all lamps, cords, cables, switches, telephones, call buttons, monitors, keyboards and thermostats; allow to air dry

iii. wash cabinets, storage closets, inside, top, bottom and sides and shelves of bedside cabinets, over-bed tables and telephone stand

iv. wash top, sides, arms, and legs of chairsv. wash foot board, frame, bedside rails, legs, and casters

vi. clean the toilet and bath area an EPA-approved disinfection:1. wash all porcelain and metal, sink, tub, shower exterior of toilet bowl, pipes, toilet seat and

fixtures with cleaner; wash all walls and remember to wipe behind the toilet2. clean interior of toilet bowl with bowl cleaner, flush to rinse3. replace hand soap, paper towels and toilet paper

vii. wash all wall surfaces and clean baseboards



viii. clean and disinfect all waste receptaclesix. wash windows with glass cleaner on a pre-moistened paper towel and dryx. Note:

1. inspect mattress, chairs cushion if holes or ripped, make arrangements to discard 2. discard any fabric cords or items within the patient room

4) Using the microfiber mop clean the floor and allow the floor to air dry.



ATTACHMENT F4

Guidance for Safe Handling of Spill from Patient with Ebola

For large, gross spills, an Environmental Protection Agency (EPA)-approved disinfectant should be used for cleaning and decontaminating surfaces or objects contaminated with blood and/or body fluids. Some EPA-approved disinfectant may cause harm to the patient by the vapors they produce. If unsure which disinfectant does NOT create a hazardous environment for the patient please contact NEM Hazardous Material Team at 516-719-5000.

Spill cleanup procedures for the ambulatory and inpatient setting:

Alert the appropriate cleanup/mitigating team; the Hazardous Material Team at 516 719-5000.

1. Assess the spill and involved area(s).2. Assemble a barrier around the spill.3. Upon arrival of the Hazardous Material Team the team members will don at least Level 2 personal

protective equipment (PPE). May be Level 3dependent on the situation. Refer to Attachment D for the procedures for donning and doffing.

4. Pour an EPA-approved disinfectant, i.e. bleach-based product on clean disposable absorbent material near the spill (now referred to as a mat).

5. Soak clean disposable absorbent material with an EPA-disinfectant, i.e. bleach-based product on a clean towel and cover the spill.

6. Allow for at least contact time as per manufacture’s guidelines.7. Clean up the spill from the outside-in and discard the contents of the spill into a red waste receptacle and

follow the guidelines outlined in Attachment F.8. Doff PPE as outlined in Section IV and Attachment D and disinfect the area as outlined above.9. Spill cleanup procedures for the Special Treatment Center:10. Alert the appropriate clean-up team.11. Assess the spill and involved area(s).12. At least Level 2 PPE should be donned by the personnel involved in the clean-up. Refer to Attachment

D for the procedures for donning and doffing.13. Pour an EPA-approved disinfectant on clean disposable absorbent material near the spill (now referred

to as a mat).14. Sanitize gloves, remove outer gloves, sanitize inner glove.15. Don outer gloves, then booties, sanitize outer gloves.16. Soak clean disposable absorbent material with an EPA-disinfectant clean towel and cover the spill.17. Allow for at least contact time as per manufacture’s guidelines.18. Clean up the spill from the outside-in and discard the contents of the spill into a red waste receptacle and

follow the guidelines outlined in Attachment F.19. Doff PPE as outlined in Section IV and Attachment D and disinfect the area as outlined above.



ATTACHMENT F5

Guidance for Management of Contaminated Environmental Surfaces

Blood or other body fluid contamination must be cleaned and decontaminated as soon as possible when the patient is transported from one area to another to decrease the risk of exposure to others. The following outlines the procedure.

Procedure

1. Upon identification of environmental contamination, immediately clean and disinfected with an Environmental Protection Agency (EPA)-approved disinfectant within a disposable disinfectant cloth.

2. Discard the cloth in a red receptacle and discard as per Attachment F.3. If significant contamination, refer to the spill protocol in Attachment F4.4. Personal protective equipment (PPE) should be donned and doffed as outlined in Section IV.



ATTACHMENT G

Guidance for Safe Handling of Human Remains of Ebola Patients

Purpose:

To give guidance on the safe handling of human remains that may contain Ebola virus. 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 of contaminated instruments, through direct handling of human remains without appropriate PPE, and through splashes of blood or other body fluids.

1. Only trained personnel, wearing Level 3 Protective Equipment (PPE), should touch, or move Ebola-infected remains.

2. Handling of remains should be kept at a minimum.3. Autopsies on patients who die of Ebola should be avoided. If autopsy is necessary. New York State

Department of Health (NYSDOH) and Centers for Disease Control and Prevention (CDC) should be consulted regarding additional precautions.

PPE Equipment: Refer to the Level 3 PPE in Section IV

1. Postmortem Preparation:a. Preparation of the Body:

i. Leave any type of intravenous or central line, indwelling catheters, nasogastric tube or endotracheal tubes in place.

ii. At site of death: unwrap the sheet that is under the patient from the four corners of the bed, pulled it over the body and then wrap body in the plastic shroud in a way that prevents contamination of outside of shroud. Do not tape the eye, tie hands and legs etc...

iii. Do not wash or clean the body.iv. After wrapping, the body should be immediately placed in a leak-proof plastic bag not less

than 150µm thick and zippered close. Then place in a second bag. The body should be in three (3) leak proof bags (triple). Label the bag as “INFECTIOUS”.

v. The bags should be used as follows: 1. primary bag should be secured and wiped with an EPA-approved disinfectant 2. secondary bag should be secured and wiped with an EPA-approved disinfectant 3. third bag, outer shipping bag should be labeled with the decedent’s name, medical

record number, date of birth, and facility identification. The bag should be secured and wiped with an EPA-approved disinfectant.

vi. Keep the body within the room until the body is removed by the licensed funeral parlor for post-mortem cremation.

2. Surface Decontamination:



a. Prior to transport, perform surface decontamination of the corpse-containing body bags by removing all visible soil on outer bag surfaces with Environmental Protection Agency (EPA)-registered disinfectant.

b. Follow the product’s label instructions.c. After visible soil has been removed, reapply the disinfectant to the entire bag surface and allow to

air dry.d. Following removal of the body, the patient room should be cleaned and disinfected.e. Reusable equipment should be cleaned and disinfected according to standard procedures.

3. Communication:a. Communicate suspect/confirmed Ebola case to the funeral director prior to pick-up.b. Communication from the facility to the Local Department of Health and NYSDOH prior to

transport of the body to the designated mortuary.c. Follow the facility process for communicating and recording a death.

4. Transportation of human remains:a. The triple bagged body should be placed in the funeral facility’s vehicle.b. All transportation, for mortuary care or burial, should be coordinated with Local Health

Department and/or NYSDOH in advance.c. Individuals driving or riding in a vehicle carrying human remains do not required PPE provided

they will not be handling the remains, and the remains are safely contained and the body bag is disinfected as above.

Note: The same process should occur with a death occupying in the field or outside the hospital.


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