INFECTION PREVENTION POLICY AND … PREVENTION POLICY AND PROCEDURE MANUAL ... Other close contact...

INFECTION PREVENTION POLICY AND

PROCEDURE MANUAL of 13

Title: Care of a Patient With Known or Suspect Ebola Virus Disease (EVD)

Policy No. IC.3.3.2

Joint Commission Chapter/Section: Infection Prevention

Effective Date: October 17, 2014

Source (e.g. document, award, or committee, etc.): Infection Prevention Committee

Publication Status: New Revised X Reviewed

Cross-Referenced Policy No: IC.3.11 Standard and Transmission Based Precautions IC.3.4 Hand Hygiene IC.3.1 Exposure to Blood and Body Fluids I. POLICY: 1. Early recognition of patients with Ebola Virus Disease (EVD) is critical for infection

prevention and control. Health care providers should be alert for and evaluate any patients suspected of having EVD.

2. Person Under Investigation (PUI): A person who has both consistent symptoms and risk factors as follows:

a. Clinical criteria, which includes fever of greater than 38.6 degrees Celsius or 100.4 degrees Fahrenheit, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage;

AND b. epidemiologic risk factors within the past 21 days before the onset of

symptoms, such as contact with blood or other body fluids or human remains of a patient known to have or suspected to have EVD; residence in—or travel to—an area where EVD transmission is active (including Guinea, Liberia, Sierra Leone, and the cities of Lagos and Port Harcourt, Nigeria, Dakar and Senegal) http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/distribution-map.html

or direct handling of bats or non-human primates from disease-endemic areas.

3. Probable Case a. A PUI whose epidemiologic risk factors include high or low risk exposure(s)

(see below)

4. Confirmed Case a. A case with laboratory-confirmed diagnostic evidence of Ebola virus infection

5. Exposure Risk Levels: Levels of exposure risk are defined as follows:

High risk exposures - A high risk exposure includes any of the following: a. Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or

body fluids of EVD patient. b. Direct skin contact with, or exposure to blood or body fluids of, an EVD

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patient without appropriate personal protective equipment (PPE). c. Processing blood or body fluids of a confirmed EVD patient without

appropriate PPE or standard biosafety precautions. d. Direct contact with a dead body without appropriate PPE in a country where

an EVD outbreak is occurring.

Low risk exposures - A low risk exposure includes any of the following a. Household contact with an EVD patient. b. Other close contact with EVD patients in health care facilities or community

settings. Close contact is defined as: i. being within approximately 3 feet (1 meter) of an EVD patient or

within the patient’s room or care area for a prolonged period of time (e.g., health care personnel, household members) while not wearing recommended personal protective equipment (i.e., standard, droplet, and contact precautions.

ii. having direct brief contact (e.g., shaking hands) with an EVD patient while not wearing recommended personal protective equipment.

iii. NOTE: Brief interactions, such as walking by a person or moving through a hospital, does not constitute close contact

No known exposure a. Having been in a country in which an EVD outbreak occurred within the past

21 days and having had no high or low risk exposures

II. PURPOSE: 1. To ensure the safety of health care providers, patients and visitors by:

a. Following evidenced based CDC guidelines and recommendations in caring for patients with suspected or confirmed EVD

b. Rapidly recognizing, isolating and appropriately managing a known or suspected EVD patient.

III PROCEDURE:

Screening:

1. All patients entering Saint Peter’s University Healthcare System for any in-patient or out-patient procedure will be screened for EVD using the Ebola Virus Disease Screening Tool. See Appendix 1.

2. Question #1 of the Ebola Virus Disease Screening is to be completed immediately upon arrival or check in by the staff person that has the initial contact with the patient. In most instances this will be the registrar.

3. If the answer to the question is “No”, the patient is not at risk for Ebola. Staff must sign, date and time the form and the process is complete.

4. If the answer to the question is “Yes”, an RN in the clinical area must be contacted to complete the Contact Risk Assessment portion of the form as instructed. All areas that don’t have nursing personnel must call the ED Charge RN at extension 7678 to complete Contact Risk Assessment. Place the patient in a private area for the clinical assessment.

5. If the subsequent screening is negative, Ebola is not a consideration at this time. Contact Infection Prevention, provide the DOH booklet “Ebola Information for

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Friends and Family Returning from NJ from West Africa: http://www.state.nj.us/health/cd/vhf/documents/West_Afr.pdf and review the temperature monitoring protocol with the patient. Instruct the patient to immediately call and report fever or other symptoms of Ebola to their doctor or care provider (ED/Clinic/Urgent Care) and include information that they have recently traveled to West Africa.

6. If the subsequent screening is positive, immediately isolate the patient on Contact and Droplet Precautions (Refer to IC.3.4 Standard and Transmission Based Precautions) and notify the on-site Supervisor and Infection Prevention. Call the ED Charge RN at ext. 7678 for coordination of transport to the Emergency Department.

7. Minimize staff contact with the patient while waiting for transport. Assemble and don PPE (personal protective equipment) (see page 5: Personal Protective Equipment (PPE)) for all patient contact.

8. Apply simple face mask on patient for transport and cover any open wounds or source of body fluids. Ensure transport team is aware of isolation status and wearing full PPE for the transport.

9. Contact Security to clear the hallways and secure elevators. 10. Notify the Manager of Environmental Services to coordinate terminal cleaning of

the area.

Emergency Department Procedures: 1. All patients are to be asked the following question upon arrival:

Have you traveled in West Africa (including Guinea, Liberia, Sierra Leone, and the cities of Lagos and Port Harcourt, Nigeria, Dakar and Senegal) or been with someone who recently traveled there in the past 3 weeks?

2. If No, document the answer in technician notes and free text: “Patient denies recent travel outside the country”

3. If yes, ask “Have you been in the area of West Africa (Guinea, Liberia, Sierra Leone, Lagos, Port Harcourt, Nigeria, Dakar or Senegal)”?

4. If YES: 5. Immediately move the patient (adult or pediatric) to triage room 1. 6. Notify Charge RN you have a patient with a positive Ebola Virus screen. 7. The treating RN will apply PPE and triage the patient in triage room 1 and complete

the Ebola Virus Screening assessment. 8. If positive, EDB9 is to be prepped for isolation (remove all unnecessary furniture or

equipment, place plastic bags on all reusable medical equipment, set-up zones and waste disposal system). EDB10 will be designated as the back-up isolation room.

9. Notify ED Provider, Nursing Supervisor and Infection Prevention. 10. No visitors will be allowed except for parents of a child. Utilize a log to record the

names of all persons entering the room. Ensure parent’s names are added to the log of those entering the room.

11. Facilities will erect a plastic barrier with a zipper to segregate the area of the ED with EDB9 and EDB10 from the rest of Pod B. A second plastic barrier will be erected in the patient care area, segregating the patient care area into a left side (patient area) and right side (entry / doffing of PPE area).

12. Patient is to be masked, placed in a wheelchair or stretcher, transported outside the ambulance bay doors and enter the ED via the outside decon door and brought to EDB9 and placed on Contact and Droplet Precautions.

13. Staff, using the buddy system and wearing hospital supplied scrubs, will don PPE (including double gloves, leg and shoe covers, impermeable gown, protective hood,

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surgical cap, N-95 and face shield), in the clean ante room. Staff will open the door and walk through the plastic barrier to enter the patient care area. When care is complete, staff must exit the plastic barrier to the other side of the room to remove PPE. PPE is to be removed in sequence from most to least contaminated, using the buddy system to monitor technique. From there staff will exit through the door to the sink area to perform thorough hand hygiene.

14. Always use a disposable thermometer, stethoscope and BP cuff. Leave a pen in the room.

15. Decon drum must be double red bagged and placed inside the room for all garbage and linen disposal and in the dirty ante room for PPE disposal.

16. Use disposable linen. If cloth linen is used, it must be discarded as regulated medical waste.

17. The isolation cart is to remain outside the primary treatment room. 18. Transport patient on a stretcher lined with impervious drapes and absorbent pads if

there are symptomatic with any vomiting, diarrhea or drainage of blood or body fluid. Prior to transport to 2B, apply simple face mask on patient for transport and cover any open wounds or source of body fluids. Ensure transport team is aware of isolation status and wearing full PPE for the transport.


the area. Labor and Delivery Patients:

1. All L&D patients entering Saint Peter’s University Healthcare System will be screened for EVD using the Ebola Virus Disease Screening Tool. See Appendix 1.

2. Question #1 of the Ebola Virus Disease Screening is to be completed immediately upon arrival or check in by the registrar that has the initial contact with the patient.

3. If the answer to the question is “No”, the patient is not at risk for Ebola. Staff must sign, date and time the form and the process is complete.

4. If the answer to the question is “Yes”, an RN in the clinical area must be contacted to complete the Contact Risk Assessment portion of the form as instructed.

5. If the subsequent screening is negative, Ebola is not a consideration at this time. 6. If the subsequent screening is positive, immediately isolate the patient on Contact

and Droplet Precautions (Refer to IC.3.4 Standard and Transmission Based Precautions) and notify the on-site Supervisor and Infection Prevention for coordination of transport to 2B.

7. Minimize staff contact with the patient while waiting for transport. Assemble and don PPE (see page 5: Personal Protective Equipment (PPE)) for all patient contact including transport.

8. Transport patient on a stretcher lined with impervious drapes and absorbent pads. Apply simple face mask on patient for transport and cover any open wounds or source of body fluids. Ensure transport team is aware of isolation status and wearing full PPE for the transport.


the area.

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Patient Placement: 1. Patients are to be placed on 2B in a single patient Airborne Infection Isolation (AII)

Room (containing a private bathroom) on Droplet and Contact Precautions, with the door closed.

2. AII Rooms 226 and 229 will be utilized for these purposes. 3. A log of all persons entering the patient's room must be maintained. See Appendix 2. 4. All porous items will be removed from the room and all equipment will be covered

with plastic (such as monitor, TV controls). 5. Use a disposable thermometer, pulse ox probe, stethoscope and BP cuffs.

Procedure for Flow / Movement in the Isolation Area:

1. Staff is limited to essential personnel (2 nurses and one Respiratory Therapist, if required, per patient).

2. Staff, wearing hospital supplied scrubs and using the buddy system, will don PPE (including double gloves, leg and shoe covers, impermeable gown, protective hood, surgical cap, N-95 and face shield), in the clean ante room. Staff will then enter the patient care area. When care is complete, staff must exit via the door into the dirty anteroom area. It is in this area that PPE will be removed, in sequence from most to least contaminated, using the buddy system to monitor technique. After thorough hand hygiene is performed, staff will exit through the outside door back onto the unit.

Personal Protective Equipment (PPE): 1. Prior to working with Ebola patients, all healthcare workers involved in their care

must have received repeated training and have demonstrated competency in performing all Ebola-related infection control practices and procedures, and specifically in donning/doffing proper PPE.

2. The overall safe care of Ebola patients in a facility must be overseen by an onsite manager at all times, and each step of every PPE donning/doffing procedure must be supervised by a trained observer to ensure proper completion of established PPE protocols.

3. Hospital laundered scrubs will be provided to all HCP’s entering the isolation area to care for a suspect or confirmed EVD patient.

4. Double gloving provides an extra layer of safety during direct patient care and during the PPE removal process. Beyond this, more layers of PPE may make it more difficult to perform patient care duties and put healthcare providers at greater risk for percutaneous injury (e.g., needlesticks), self-contamination during care or doffing, or other exposures to Ebola.

5. Perform hand hygiene prior to and after removal of PPE. Use soap and water if hands are visibly soiled. Otherwise alcohol based hand rub (ABHR) is acceptable.

6. It is imperative that proper donning and removal of PPE occurs for maximum protection and to avoid cross contamination. Refer to Appendix 3.

7. PPE must be donned correctly in proper order before entry into the patient care area and not be later modified while in the patient care area. The donning activities must be directly observed by a trained observer.

8. While working in PPE, healthcare workers caring for Ebola patients should have no skin exposed.

9. During Patient Care PPE must remain in place and be worn correctly for the duration of exposure to potentially contaminated areas. PPE should not be adjusted during patient care.

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10. Healthcare workers should perform frequent disinfection of gloved hands using an ABHR, particularly after handling body fluids.

11. If during patient care a partial or total breach in PPE (e.g., gloves separate from sleeves leaving exposed skin, a tear develops in an outer glove, a needlestick) occurs, the healthcare worker must move immediately to the doffing area to assess the exposure. The exposure plan must be implemented if indicated. (Refer to IC.3.1 Exposure to Blood and Body Fluids).

12. The removal of used PPE is a high-risk process that requires a structured procedure, a trained observer, and a designated area for removal to ensure protection

13. PPE must be removed slowly and deliberately in the correct sequence to reduce the possibility of self-contamination or other exposure to Ebola virus

14. PPE must be removed, in sequence from most to least contaminated. Refer to Appendix 3.

15. A buddy system for observing the donning and removal of PPE will be used at all times.

Donning PPE

1. Engage the trained observer to observe and confirm visually that all PPE is serviceable and has been donned successfully. The trained observer must use a written checklist to confirm each step in donning PPE and can assist with ensuring and verifying the integrity of the ensemble.

2. Remove Personal Clothing and Items: Change into hospital provided surgical scrubs (or disposable garments) and dedicated washable (plastic or rubber) footwear in the clean area. No personal items (e.g., jewelry, watches, cell phones, pagers, pens) should be brought into patient room.

3. Inspect PPE Prior to Donning: Visually inspect the PPE ensemble to be worn to ensure it is in serviceable condition, all required PPE and supplies are available, and that the sizes selected are correct.

4. The trained observer should review the donning sequence with the healthcare provider before they begin. It should be read it to the healthcare provider in a step-by-step fashion.

5. Perform Hand Hygiene: Perform hand hygiene with ABHR. When using ABHR, allow hands to dry before moving to next step.

6. Put on first pair of gloves (Inner Gloves) 7. Put on boot covers. 8. Put on impervious gown. Ensure gown is large enough to allow unrestricted freedom

of movement. Ensure cuffs of inner gloves are tucked under the sleeve of the gown. 9. Put on surgical cap that covers all of the hair and the ears. 10. Put on N95 respirator ensuring the correct size (Regular or Small) is selected.

Complete a user seal check. 11. Place a surgical hood that covers all of the hair and the ears, over the N-95. Ensure

that it extends past the neck to the shoulders. Be certain that hood completely covers the ears and neck.

12. Put on Outer Apron (if used): Put on full-body apron to provide additional protection to the front of the body against exposure to body fluids or excrement from the patient.

13. Put on second pair of gloves (with extended cuffs). Ensure the cuffs are pulled over the sleeves of the gown or coverall.

14. Put a full face shield on over the N95 respirator and surgical hood to provide

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additional protection to the front and sides of the face, including skin and eyes. 15. After completing the donning process, the integrity of the ensemble must be verified

by the trained observer. The healthcare worker should be comfortable and able to extend the arms, bend at the waist and go through a range of motions to ensure there is sufficient range of movement while all areas of the body remain covered. No exposed skin or hair of the healthcare worker should be visible at the conclusion of the donning process.

16. Place doffing pad at room exit prior to entering the patient room. 17. Disinfect outer-gloved hands with ABHR. Allow to dry prior to patient contact.

Removal of PPE

1. PPE doffing is performed in the designated PPE removal area on a doffing pad. Place all PPE waste in a leak-proof infectious waste container lined with two red plastic bags.

2. The process to remove PPE is conducted under the supervision of a trained observer, who reads aloud each step of the procedure and confirms visually that the PPE has been removed properly. Prior to removal of PPE, the trained observer must remind healthcare workers to avoid reflexive actions that may put them at risk, such as touching their face. Include this instruction in the checklist and repeat it verbally during removal. Although the trained observer should minimize touching healthcare workers or their PPE during the doffing process, the trained observer may assist with removal of specific components of PPE as outlined below. The trained observer disinfects the outer-gloved hands immediately after handling any healthcare worker PPE.

3. Step out of the room onto the doffing pad. Inspect the PPE to assess for visible contamination, cuts, or tears before starting to remove. If any PPE is visibly contaminated, disinfect using a Super Sani Cloth ® (an acceptable *EPA-registered disinfectant wipe).

4. Disinfect Outer Gloves: Disinfect outer-gloved hands with ABHR. 5. Remove Apron (if used): Remove and discard apron taking care to avoid

contaminating gloves by rolling the apron from inside to outside. 6. Following apron removal, inspect the PPE ensemble to assess for visible

contamination or cuts or tears. If visibly contaminated, then disinfect affected PPE using a Super Sani Cloth ®.

7. Disinfect outer-gloved hands with ABHR. 8. Remove Boot Covers: While sitting down, remove and discard boot covers. 9. Step onto clean area of the doffing pad and discard. Avoid returning to the

soiled area of the doffing pad from this point forward. 10. Disinfect and Remove Outer Gloves: Disinfect outer-gloved hands with either an

ABHR. Remove and discard outer gloves taking care not to contaminate inner gloves during removal process.

11. Inspect and Disinfect Inner Gloves: Inspect the inner gloves’ outer surfaces for visible contamination, cuts, or tears. If an inner glove is visibly soiled, cut, or torn, disinfect the glove with ABHR. Then remove the inner gloves and perform hand hygiene with ABHR on bare hands and don a clean pair of gloves. If there is no visible contamination, cuts, or tears are identified on the inner gloves, then disinfect the inner-gloved hands with ABHR and continue.

12. Remove Face Shield: Remove the full face shield by tilting the head slightly forward, grabbing the ear pieces and pulling away from the head. Allow the face

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shield to fall forward. Discard. Avoid touching the front surface of the face shield. 13. Disinfect inner gloves with ABHR. 14. Remove Surgical Hood: Unfasten (if applicable) surgical hood, gently remove, and

discard. The trained observer may assist with unfastening hood. 15. Disinfect Inner Gloves: Disinfect inner gloves with ABHR. 16. Remove Gown: Gently break fasteners. Avoid contact of scrubs or disposable

garments with outer surface of gown during removal. Pull gown away from body, rolling inside out and touching only the inside of the gown. Remove and discard.

17. Disinfect and Change Inner Gloves: Disinfect inner gloves with ABHR. Remove and discard gloves taking care not to contaminate bare hands during removal process. Perform hand hygiene with ABHR. Don a new pair of inner gloves.

18. Remove the N95 respirator by tilting the head slightly forward, grasping first the bottom tie or elastic strap, then the top tie or elastic strap, and remove without touching the front of the N95 respirator. Discard N95 respirator. Note: the surgical cap may move with the respirator straps as they are removed.

19. Remove the surgical cap and discard. 20. Step off doffing pad. Gather it up carefully by rolling the dirty surface inward.

Discard rolled up doffing pad. 21. Disinfect Inner Gloves: Disinfect inner gloves with ABHR. 22. Disinfect Washable Shoes: Sitting on a new clean surface (e.g., second clean chair,

clean side of a bench) use a Super Sani Cloth ® to wipe down every external surface of the washable shoes.

23. Disinfect and Remove Inner Gloves: Disinfect inner-gloved hands with either an ABHR. Remove and discard gloves taking care not to contaminate bare hands during removal process.

24. Perform hand hygiene with ABHR. 25. Have the trained observer perform a final inspection of the healthcare provider for

any indication of contamination of the surgical scrubs or disposable garments. If no breeches or contamination is identified the Healthcare provider can leave the PPE removal area wearing dedicated washable footwear and surgical scrubs or disposable garments.

26. If breeches or contamination are discovered do not leave PPE removal area. The observer is to cut off the scrubs, remove them by rolling them off away from the body and discard. The Healthcare provider must then exit PPE removal area and shower immediately. Notify Employee Health and Supervisor.

27. Showers are recommended at each shift’s end for healthcare providers performing high risk patient care (e.g., exposed to large quantities of blood, body fluids, or excreta). Showers are also suggested for healthcare providers spending extended periods of time in the Ebola patient room.

28. Protocol Evaluation/Medical Assessment: Either the Infection Prevention, EHS or designee on the unit at the time should meet with the healthcare worker to review the patient care activities performed to identify any concerns about care protocols and to record healthcare worker’s level of fatigue.

General Care of the Patient:

1. Dedicated medical equipment (preferably disposable, when possible) should be used for the provision of patient care

2. All non-dedicated, non-disposable medical equipment used for patient care must be cleaned and disinfected per manufacturer's instructions and hospital policies.

3. Meals are to be delivered on disposable tray and utensils.

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4. A WOW will be permanently assigned to the isolation area to facilitate documentation in the EMR.

Aerosol Generating Procedures (AGPs):

1. Avoid AGPs for patients with EVD. 2. If performing AGPs, use a combination of measures to reduce exposures from

aerosol-generating procedures when performed on patients with EVD. 3. Parents of children should not be present during aerosol-generating procedures. 4. Limiting the number of HCP present during the procedure to only those essential for

patient-care and support. 5. Conduct the procedures in a private AIIR 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.

6. HCP must wear double gloves, leg and shoe covers, impermeable gown, protective hood, surgical cap, face shield and a NIOSH certified, fit-tested N95 filtering face piece respirator.

7. Conduct environmental surface cleaning following procedures (see section below on environmental infection control).

8. If re-usable equipment is used, it must be thoroughly cleaned and disinfected according to manufacturer instructions and hospital policies.

Hand Hygiene: Refer to IC.3.4 Hand Hygiene

1. HCP should perform hand hygiene frequently, including before and after all patient contact, contact with potentially infectious material, and before putting on and upon removal of PPE, including gloves.

2. Supplies for performing hand hygiene must be readily available. 3. Hand hygiene can be performed by washing with soap and water or using alcohol-

based hand sanitizer, if not visibly soiled. 4. If hands are visibly soiled, use soap and water, not alcohol-based hand sanitizer.

Visitors:

1. No visitors will be allowed except for parents of a child. Ensure parent’s names are added to the log of those entering the room.

Linen: 1. To reduce exposure among staff, as a precautionary measure, all linens including

non-fluid impermeable pillows and mattresses, and textile privacy curtains must be discarded as regulated medical waste and ultimately destroyed, rather than laundered and reused.

2. This is limited only to patients who are known to have Ebola. 3. Testing for Ebola usually is completed within 1-3 days, so linens could be kept in

the room until the process is complete. If the tests are negative, all linens then can be laundered using normal procedures.

Regulated Medical Waste: 1. Medical waste generated in the care of patients with known or suspected EVD is

subject to procedures set forth by local, state and federal regulations. 2. Medical waste contaminated with Ebola virus is a Category A infectious substance

regulated as a hazardous material under the U.S. Department of Transportation’s (DOT’s) Hazardous Materials Regulations (HMR; 49 CFR, Parts 171-180).

3. Any item transported offsite for disposal that is contaminated or suspected of being

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contaminated with a Category A infectious substance must be packaged and transported in accordance with the HMR. This includes medical equipment, sharps, linens, and used health care products (such as soiled absorbent pads or dressings, kidney-shaped emesis pans, portable toilets, used Personal Protection Equipment (gowns, masks, gloves, goggles, face shields, respirators, booties, etc.) or byproducts of cleaning) contaminated or suspected of being contaminated with a Category A infectious substance.

4. Sanitary sewers may be used for the safe disposal of patient waste. Additionally, sewage handling processes (e.g., anaerobic digestion, composting, and disinfection) in the United States are designed to inactivate infectious agents.

Environmental Cleaning: 1. Environmental services staff must wear recommended personal protective

equipment (PPE) including, at a minimum, double gloves, gown (fluid resistant or impermeable), eye protection (goggles or face shield), face-mask, head cover / hood that covers the neck, leg covers and shoe covers to protect against direct skin and mucous membrane exposure of cleaning chemicals, contamination, and splashes or spatters during environmental cleaning and disinfection activities.

2. If reusable heavy-duty gloves are used for cleaning and disinfecting, they must be discarded.

3. Staff must be instructed in the proper use of personal protective equipment including safe removal to prevent contaminating themselves or others in the process, and that contaminated equipment is disposed of appropriately.

4. A buddy system for observing the donning and removal of PPE will be used at all times.

5. Use a U.S. Environmental Protection Agency (EPA)-registered hospital disinfectant with a label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus) to disinfect environmental surfaces in rooms of patients with suspected or confirmed Ebola virus infection.

6. TB Disinfectant /Virex® TB (quaternary germicide) and QF-Stat III TB/ Expose® (phenolic cleaner) are all (EPA)-registered hospital disinfectants effective in killing the Ebola virus.

7. Avoid contamination of reusable porous surfaces that cannot be made single use. Use only a mattress and pillow with plastic or other covering that fluids cannot get through.

8. Do not place patients with suspected or confirmed Ebola virus infection in carpeted rooms. Remove all upholstered furniture and decorative curtains from patient rooms before use.

9. Daily cleaning and disinfection of hard, non-porous surfaces (e.g., high-touch surfaces such as bed rails and over bed tables, housekeeping surfaces such as floors and counters) should be done.

10. Before disinfecting a surface, cleaning should be performed. Use disposable cleaning cloths, mop cloths, and wipes and dispose of these in leak-proof double, red RMW bags.

11. Use a rigid waste receptacle designed to support the bags to help minimize contamination of the bag's exterior.

Sharps Safety / Phlebotomy:

1. Limit the use of needles and other sharps as much as possible. 2. Bloods should be drawn off of a line when inserted.

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3. Nursing will draw all additional bloods. 4. Phlebotomy, procedures, and laboratory testing should be limited to the minimum

necessary for essential diagnostic evaluation and medical care. 5. Point of Care testing will be done whenever possible. 6. When blood is drawn to be sent to the Lab, the vacutainers must be placed in a

specific double cylinder obtained from Lab that is durable and leak proof. 7. If POC testing is not available, all specimens must be WALKED to the lab. NEVER

TUBE SPECIMENS from patients with suspected or confirmed EVD. 8. All needles and sharps should be handled with extreme care and disposed in

puncture-proof, sealed containers.

Ebola Virus Testing: 1. The Infection Prevention Department will coordinate all Ebola Virus Testing.

Contact Infection Prevention @ 908-202-8612 or Beeper 732-651-4299 (If unable to reach someone immediately ask the Hospital Operator to contact them).

2. Infection Prevention will contact the Local/State DOH for specific instructions. 3. The Infection Prevention Department will notify the lab with specific specimen

coordination, collection and shipping instructions. 4. Laboratory Send-Out Processing: Follow all routine lab procedures for safe of

handling specimens. 5. When sample is collected, assure that it is labeled with the patient’s identification.

i.e. Name, DOB, Medical Record , Date of collection and Ordering Physician 6. In Soft lab, order a MISC and in the comments enter where you were instructed to

send the sample. 7. Follow packaging instructions provided by Infection Prevention as per the

DOH/CDC 8. File in appropriate folder in Send-out area.

Post Mortem Care:

1. Prior to contact with body, postmortem care personnel must wear PPE consisting of: surgical scrubs, surgical cap, double gloves, gown (fluid resistant or impermeable), eye protection (goggles or face shield), face-mask, head cover / hood that covers the neck, leg covers and shoe covers.

2. Additional PPE might be required in certain situations (e.g., copious amounts of blood, vomit, feces, or other body fluids that can contaminate the environment).

3. PPE should be in place BEFORE contact with the body, worn during the process of collection and placement in body bags, and should be removed immediately after and discarded appropriately.

4. At the site of death, the body should be wrapped in a plastic shroud. Wrapping of the body should be done in a way that prevents contamination of the outside of the shroud. Change your gown and/ or gloves if they become heavily contaminated with blood or body fluids.

5. Leave any intravenous lines or endotracheal tubes that may be present in place. 6. Do not wash or clean the body. 7. After wrapping, the body should be immediately placed in a leak-proof plastic bag

not less than 150 µm thick and zippered closed. 8. The bagged body should then be placed in another leak-proof plastic bag not less

than 150 µm thick and zippered closed before being transported to the morgue. 9. Prior to transport to the morgue, perform surface decontamination of the corpse-

containing body bags by removing visible soil on outer bag surfaces with EPA-

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registered disinfectants i.e. TB Disinfectant /Virex® TB (quaternary germicide) or QF-Stat III TB/ Expose® (phenolic cleaner).

10. After any visible soil has been removed, reapply the disinfectant to the entire bag surface and allow to air dry.

11. Complete and affix a Communicable Disease Form to the body bag. 12. If possible, the body will be retrieved from 2B. If not, personnel transporting the

body to the morgue must wear a gown and gloves. 13. Use caution when removing PPE as to avoid contaminating the wearer. Hand

hygiene (washing your hands thoroughly with soap and water or an alcohol based hand rub) should be performed immediately following the removal of PPE. If hands are visibly soiled, use soap and water.

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

Employees Returning from West Africa: 1. All employees must immediately contact Employee Health Services, Ext. 8282, if

they have traveled or plan to travel to West Africa. 2. All employees who return from West Africa must take a 21-day furlough from their

job as a precaution upon their return to the United States. 3. These employees must undergo a 21-day self-monitoring program (described below)

for signs of the Ebola virus while they are on furlough from Saint Peter’s. 4. Employees may use vacation, holiday or sick time during their furlough. 5. Employees without benefit time will not be paid during their absence.

Health Guidance for Employees Returning from West African Countries: 1. Watch for symptoms of Ebola for 21 days after returning from West Africa. 2. Symptoms include: Fever, Diarrhea, Headache, Vomiting, Joint and Muscle Aches,

Stomach Pain, Lack of Appetite, Rash, Hiccups, Cough, Sore Throat, Chest Pain, Difficulty Breathing, Difficulty Swallowing or Unexplained Bleeding or Bruising.

3. Take your temperature twice a day – morning and evening. 4. IMMEDIATELY call your doctor and then EHS if you have a fever of 100.4

degrees or if you have any other symptoms. 5. When you call, tell your doctor, emergency medical service or emergency room that

you have traveled to West Africa in the last 21 days. Advance notice will help healthcare workers prepare to care for you.

Monitoring and Management of Potentially Exposed Personnel:

1. Persons with percutaneous or mucocutaneous exposures to blood, body fluids, secretions, or excretions from a patient with suspected EVD should: a. Stop working and immediately wash the affected skin surfaces with soap and

water. Mucous membranes (e.g., conjunctiva) should be irrigated with copious amounts of water or eyewash solution.

b. Immediately contact Employee Health Services (EHS)/supervisor for assessment and access to post-exposure management services for all appropriate pathogens (e.g., Human Immunodeficiency Virus, Hepatitis C, etc.)

2. HCP 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

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contact to blood or body fluids) to a patient with EVD should: a. Not report to work or should immediately stop working b. Notify their supervisor c. Seek prompt medical evaluation and testing d. Local and state health departments will be notified by Infection Prevention. e. Comply with work exclusion until they’re deemed no longer infectious to others.

3. For asymptomatic HCP who 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 Ebola should: a. Should receive medical evaluation and follow-up care including fever

monitoring twice daily for 21 days after the last known exposure. b. EHS must ensure twice daily phone contact with exposed personnel to discuss

potential symptoms and document fever checks. 4. Any HCP that has participated in the care of a patient with confirmed EVD should

self-monitor for symptoms and fever for 21 days even if there is no known unprotected exposure.

IV REFERENCES:

www.cdc.gov

Approved by:

Medical Chief Infectious Diseases

10/21/14

Signature Title Date Nursing Director

Infection Prevention and Respiratory Care

10/21/14

Signature Title Date Origination Date: 10/17/14 Supersedes Date(s): Reviewed Date: Revised Date:10/21/14

Appendix 2

Contact Information Log

Date Employee Name Employee ID # Time In

PPE Checked Prior to Entry Time Out

PPE Checked Removal Sequence Reason for Entry

Patient ID label here

Application of PPE (personal protective equipment) for known or suspect EBOLA patient

*Apply an outer apron after Step 7 to provide additional protection to the front of the body against exposure to body fluids or excrement

if appropriate for the clinical situation or procedure.

Prepare for application of PPE by removing all personal items. Change into hospital provided scrubs and washable footwear.

Step 1 Perform hand hygiene with ABHR (Alcohol based hand rub) and allow hands to dry.

Step 2 Apply first pair of gloves (inner gloves).

Step 3

Step 4

Step 5

Step 6

Step 7

*Step 8 Apply second pair of gloves and ensure cuffs are pulled over the cuff of the gown, fully extended.

Step 9

Step 10

Observer inspects the integrity of the PPE with no exposed skin or hair visible.

Apply Blue Standard Surgical Gown, secure Velcro at back of neck and side tie only.

Apply boot covers and fully extend.

Put on surgical cap and cover all hair and ears.

Apply N95 in the appropriate size per your fit test and ensure seal is tight.

Apply surgical hood, cover all hair and ears, over the N95 mask. It must extend past the neck to the shoulders. Hood should completely cover ears and neck.

Apply full face shield on over the N95 mask and surgical hood.

Removing PPE Step 1 Step out of room onto the doffing pad. Observer to inspect PPE for visible contamination, cuts

or tears prior to removal. Wipe any visibly contaminated areas with a Super Sani Cloth®. Step 2 Disinfect outer gloves with ABHR (alcohol based hand rub). Step 3 *If no apron go to step 5. Remove outer apron (if used) and discard in red bag medical waste,

check PPE for contamination and wipe with Super Sani Cloth® if visibly soiled. Step 4 Disinfect outer gloves with ABHR. Step 5 Remove boot covers. Grab front of leg cover and peel away and roll down over shoe and

discard. Step 6 Step onto clean area of doffing pad and remain in this pad moving forward. Step 7 Disinfect outer gloves with ABHR and remove outer gloves. Step 8 Inspect inner gloves. If contamination, cuts or tears disinfect inner gloves with ABHR. Remove

inner gloves, apply ABHR to bare hands and don a clear pair of blue nitrile gloves. Step 9 If inner gloves intact and not soiled, disinfect inner gloves with ABHR and continue. Step 10 Remove face shield and allow to fall forward pulling away from the head. Step 11 Disinfect gloves with ABHR. Step 12 Remove surgical hood, grab from back of head and pull off towards the front. Step 13 Disinfect gloves with ABHR. Step 14 Remove gown, untie side, grab it from the front by shoulders and gently release Velcro. Pull

gown away from body, rolling inside out and touching only the inside of the gown. Discard. Step 15 Disinfect gloves with ABHR then discard gloves, apply ABHR to bare hands, don new blue

nitrile gloves. *This is a glove change* Step 16 Remove N95 mask by grabbing straps from the back, DO NOT touch the front of the mask. Step 17 Remove surgical cap and discard. Step 18 Step off doffing pad. Gather it up carefully by rolling the dirty surface inward. Discard. Step 19 Disinfect gloves with ABHR. Step 20 Disinfect washable shoes: wipe all surfaces with Super Sani Cloth®. Step 21 Disinfect gloves with ABHR and then remove gloves and apply ABHR to bare hands. Step 22 Observer to inspect healthcare provider for contamination, tears or cuts of scrubs. If

discovered do not leave PPE removal area, observer to cut off scrubs and roll away from the body and discard. Provider to exit PPE removal area and shower immediately. Inform Employee Health and Supervisor.

All items must be disposed of in a red medical waste bag (double bagged) that is supported by a hard plastic container.

INFECTION PREVENTION POLICY AND … PREVENTION POLICY AND PROCEDURE MANUAL ... Other close contact...

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