CDC Posts Ebola Guidelines for EMS

The Centers for Disease Control and Prevention (CDC) has posted Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola Virus Disease in the United States.

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The information is for managers of 9-1-1 Public Safety Answering Points (PSAPs), emergency medical service (EMS) agencies, EMS systems, law enforcement agencies, fire service agencies, and individual EMS providers (including emergency medical technicians (EMTs), paramedics, and any other medical first responders. EMS responders are offered guidance in handling inquiries, responding to patients with suspected Ebola symptoms, and keeping workers safe.

Among its key messages are the following:

• The likelihood of contracting Ebola is extremely low unless a person has direct unprotected contact with the blood or body fluids (like urine, saliva, feces, vomit, sweat, and semen) of a person who is sick with Ebola or direct handling of bats, rodents, or nonhuman primates from areas with Ebola outbreaks.

• When risk of Ebola is elevated in their community, it is important for PSAPs to question callers about the following:
  • Do they have residence in, or travel to, a country where an Ebola outbreak is occurring?
  • Do they have signs and symptoms of Ebola, such as fever, vomiting, or diarrhea?
  • Do they have other risk factors, such as having touched someone who is sick with Ebola?
• PSAPS should tell EMS personnel this information before they get to the location so they can put on the correct personal protective equipment (PPE) (described below).

• EMS staff should check for symptoms and risk factors for Ebola. Staff should notify the receiving healthcare facility in advance when bringing in a patient with suspected Ebola, so that proper infection control precautions can be taken.

Updates will be posted as needed on the http://www.cdc.gov/vhf/ebola/index.html. The information contained in this document is intended to complement existing guidance for healthcare personnel, Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals

The current Ebola outbreak in West Africa has increased the possibility of patients with Ebola traveling from the affected countries to the United States.¹ Ebola is an often-fatal disease; be careful when coming in direct contact with a recent traveler from a country with an Ebola outbreak who has symptoms of Ebola. Consider Ebola in anyone with fever who has traveled to, or lived in, an area where Ebola is present. ² The incubation period for Ebola, from exposure to the appearance of signs or symptoms, ranges from 2 to 21 days (most commonly 8-10 days). Consider any Ebola patient with signs or symptoms infectious. Ebola patients without symptoms are not contagious. To prevent Ebola, avoid exposure to blood or body fluids of infected patients through contact with skin; mucous membranes of the eyes, nose, or mouth; or injuries with contaminated needles or other sharp objects.

Emergency medical services (EMS) personnel and other emergency services staff have a vital role in responding to requests for help, triaging patients, and providing emergency treatment to patients. Unlike patient care in the controlled environment of a hospital or other fixed medical facility, EMS patient care before getting to a hospital is provided in an uncontrolled environment. This setting is often confined to a very small space and frequently requires rapid medical decision-making and interventions with limited information. EMS personnel are frequently unable to determine the patient history before having to administer emergency care.

Coordination among 9-1-1 Public Safety Answering Points (PSAPs), the EMS system, healthcare facilities, and the public health system is important when responding to patients with suspected Ebola. Each 9-1-1 and EMS system should include an EMS medical director to provide appropriate medical supervision. (Italics added.)

Recommendations for EMS and Medical First Responders, Including Firefighters and Law Enforcement Personnel

“EMS personnel” in this section refers to prehospital EMS, law enforcement, and fire service first responders. These EMS personnel practices should be based on the most up-to-date Ebola clinical recommendations and information from appropriate public health authorities and EMS medical direction.

When state and local EMS authorities consider the threat to be elevated (based on information provided by local, state, and federal public health authorities, including the city or county health department(s), state health department(s), and the CDC), they may direct EMS personnel to modify their practices as described below.

Patient assessment

Interim recommendations:

1. Address scene safety:
   • If PSAP call takers advise that the patient is suspected of having Ebola, EMS personnel should put on the PPE appropriate for suspected cases of Ebola before entering the scene.
   • Keep the patient separated from other persons as much as possible.
   • Use caution when approaching a patient with Ebola. Illness can cause delirium, with erratic behavior that can place EMS personnel at risk of infection, e.g., flailing or staggering.

1. During patient assessment and management, EMS personnel should consider the symptoms and risk factors of Ebola:
   • All patients should be assessed for symptoms of Ebola (fever of greater than 38.6˚C or 101.5˚F, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage). If the patient has symptoms of Ebola, ask the patient about risk factors within the past three weeks before the onset of symptoms.
   • Based on the presence of symptoms and risk factors, put on or continue to wear appropriate PPE and follow the scene safety guidelines for suspected case of Ebola.
   • If there are no risk factors, proceed with normal EMS care.

EMS Transfer of Patient Care to a Healthcare Facility

Notify the receiving healthcare facility when transporting a suspected Ebola patient so that the facility may prepare appropriate infection-control precautions prior to patient arrival. Any U.S. hospital that is following CDC’s infection control recommendations and can isolate a patient in a private room‎ is capable of safely managing a patient with Ebola.

Interfacility Transport

If you are involved in the air or ground interfacility transfer of patients with suspected or confirmed Ebola, wear the recommended PPE.

Infection Control

You can safely manage a patient with suspected or confirmed Ebola by following recommended isolation and infection-control procedures, including standard, contact, and droplet precautions. Pay particular attention to protecting mucous membranes of the eyes, nose, and mouth from splashes of infectious material or self-inoculation from soiled gloves. It is critical to recognize and identify Ebola patients early. If managing a suspected Ebola patient, follow these CDC recommendations:

• Limit activities, especially during transport, that can increase the risk of exposure to infectious material (e.g., airway management, cardiopulmonary resuscitation, use of needles).
• Limit the use of needles and other sharps as much as possible. Handle all needles and sharps with extreme care and dispose of them in puncture-proof, sealed containers.
• Limit phlebotomy, procedures, and laboratory testing to the minimum necessary for essential diagnostic evaluation and medical care.

Use of Personal Protective Equipment (PPE)

Use of standard, contact, and droplet precautions is sufficient for most situations when treating a patient with a suspected case of Ebola.  EMS personnel should wear the following?

• Gloves
• Gown (fluid resistant or impermeable)
• Eye protection (goggles or face shield that fully covers the front and sides of the face)
• Face mask
• Additional PPE might be required in certain situations (e.g., large amounts of blood and body fluids present in the environment), including but not limited to double gloving, disposable shoe covers, and leg coverings.

Prehospital resuscitation procedures such as endotracheal intubation, open suctioning of airways, and cardiopulmonary resuscitation frequently result in a large amount of body fluids, such as saliva and vomit. Performing these procedures in a less controlled environment (e.g., moving vehicle) increases risk of exposure. Perform these procedures under safer circumstances (e.g., stopped vehicle, hospital destination).

During prehospital resuscitation procedures (intubation, open suctioning of airways, cardiopulmonary resuscitation), do the following:

• In addition to donning the recommended PPE, add  respiratory protection that is at least as protective as a National Institute for Occupational and Safety Health (NIOSH) Administration -certified fit-tested N95 filtering face piece respirator or higher instead of a face mask.
• Consider additional PPE (including but not limited to) the following for these situations because of the potential increased risk for contact with blood and body fluids: double gloving, disposable shoe covers, and leg coverings.

If blood, body fluids, secretions, or excretions from a patient with suspected Ebola come into direct contact with your skin or mucous membranes immediately stop working, and wash the affected skin surfaces with soap and water. Report the exposure to an occupational health provider or supervisor for follow-up.

Observe the following recommendations:

• Wear PPE when entering the scene, and continue to wear it until you are no longer in contact with the patient.
• Carefully remove the PPE without contaminating your eyes, mucous membranes, or clothing with potentially infectious materials.
• Place the PPE into a medical waste container at the hospital, or double-bag it and hold in a secure location.
• Clean and disinfect reusable PPE according to the manufacturer’s reprocessing instructions and EMS agency policies.
• Instructions for putting on and removing PPE have been published online at http://www.cdc.gov/HAI/prevent/ppe.html and http://www.cdc.gov/vhf/ebola/pdf/ppe-poster.pdf[PDF – 2 pages].
• Perform hand hygiene immediately after removing the PPE.

Environmental Infection Control

Environmental cleaning and disinfection and safe handling of potentially contaminated materials is essential to reduce the risk of contact with blood, saliva, feces, and other body fluids that can soil the patient care environment. Always practice standard environmental infection-control procedures, including vehicle/equipment decontamination, hand hygiene, cough and respiratory hygiene, and proper use of U.S. Food and Drug Administration (FDA)-cleared or authorized medical PPE. For additional information, see CDC’s Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus.

When performing environmental cleaning and disinfection, do the following:

• Wear recommended PPE (described above,) and consider use of additional barriers (e.g., shoe and leg coverings) if needed.

• Wear face protection (facemask with goggles or face shield) when performing tasks such as liquid waste disposal that can generate splashes.

• Use an Environmental Protection Agency (EPA)-registered hospital disinfectant with a label claim for one of the non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus) to disinfect environmental surfaces. Alternatively, use a freshly prepared (i.e., within 12 hours) 1:50 dilution of household bleach (final working concentration of 100 parts per million or 0.1% hypochlorite solution) that is prepared fresh daily. Disinfectant should be available in spray bottles or as commercially prepared wipes for use during transport.

• Spray and wipe clean any surface that becomes potentially contaminated during transport. Immediately spray and wipe these surfaces clean if using a commercially prepared disinfectant wipe; repeat the process to limit environmental contamination.

Cleaning EMS Transport Vehicles after Transporting a Patient with Suspected or Confirmed Ebola

The following are general guidelines for cleaning or maintaining EMS transport vehicles and equipment after transporting a patient with suspected or confirmed Ebola:

• When cleaning and disinfecting, wear the recommended PPE (described above) and consider use of additional barriers if needed. Wear face protection (face mask with goggles or face shield).
• Clean and disinfect patient-care surfaces (including stretchers, railings, medical equipment control panels, and adjacent flooring, walls and work surfaces) after transport.
• For a blood spill or spill of other body fluid or substance (e.g., feces or vomit), remove the bulk of the spill matter, clean the site, and then disinfect the site. For large spills, use a chemical disinfectant with sufficient potency to overcome the tendency of proteins in blood and other body substances to neutralize the disinfectant’s active ingredient.
• Use an EPA-registered hospital disinfectant with label claims for viruses that share some technical similarities to Ebola (such as, norovirus, rotavirus, adenovirus, poliovirus) and instructions for cleaning and decontaminating surfaces or objects soiled with blood or body fluids should be used according to those instructions. Alternatively, a 1:10 dilution of household bleach (final working concentration of 500 parts per million or 0. 5% hypochlorite solution) that is prepared fresh daily (i.e., within 12 hours) can be used to treat the spill before covering with absorbent material and wiping up. After the bulk waste is wiped up, the surface should be disinfected as described in the bullet above.
• Place contaminated reusable patient care equipment in biohazard bags and labeled for cleaning and disinfection according to agency policies. Trained personnel wearing correct PPE can clean and disinfect reusable equipment according to manufacturer’s instructions. They should avoid contamination of reusable porous surfaces that cannot be made single use.
• Use only a mattress and pillow with plastic or other covering that prevent fluids from getting through. To reduce exposure among staff to potentially contaminated textiles (cloth products) while laundering, discard all linens and non-fluid-impermeable pillows or mattresses as a regulated medical waste.

Follow-Up and/or Reporting Measures by EMS Personnel after Caring for a Suspected or Confirmed Ebola Patient

• EMS personnel should be aware of the follow-up and/or reporting measures they should take after caring for a suspected or confirmed Ebola patient.

• EMS agencies should develop policies for monitoring and management of EMS personnel potentially exposed to Ebola.

• EMS agencies should develop sick leave policies for EMS personnel that are non-punitive, flexible, and consistent with public health guidance.

• Ensure that all EMS personnel, including staff who are not directly employed by the healthcare facility but provide essential daily services, are aware of the sick leave policies.

• EMS personnel with exposure to blood, bodily fluids, secretions, or excretions from a patient with suspected or confirmed Ebola should immediately:
  • Stop working and wash the affected skin surfaces with soap and water. Irrigate mucous membranes (e.g., conjunctiva) with a large amount of water or eyewash solution;
  • Contact occupational health/supervisor for assessment and access to post-exposure management services; and
  • Receive medical evaluation and follow-up care, including fever monitoring twice daily for 21 days after the last known exposure. They may continue to work while receiving twice daily fever checks, based on the EMS agency’s policy and discussion with local, state, and federal public health authorities.
• EMS personnel who develop sudden onset of fever, intense weakness or muscle pains, vomiting, diarrhea, or any signs of hemorrhage after 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 suspected or confirmed Ebola should
  • Not report to work or immediately stop working and isolate themselves;
  • Notify their supervisor, who should notify local and state health departments;
  • Contact their  occupational health/supervisor for assessment and access to post-exposure management services; and
  • Comply with work exclusions until they are deemed no longer infectious to others.

¹http://www.cdc.gov/vhf/ebola/hcp/patient-management-us-hospitals.html

²http://www.cdc.gov/vhf/ebola/hcp/case-definition.html

³http://www.cdc.gov/vhf/ebola/hcp/clinician-information-us-healthcare-settings.html