emergency medical service general order

Emergency Medical Service

General Order

Date of Issue:

October 15, 2014 Effective Date:

October 15, 2014 Number:

4.60 Subject:

Cleveland EMS Ebola Preparedness Plan No. Pages:

1 of 12 Classification:

Field Operations

Rescinds: All previous directives

Commissioner of Emergency Medical Service:

Purpose: The U.S. Department of Health and Human Services (DHHS) Centers for

Disease Control and Prevention (CDC) and Office of the Assistant Secretary for Preparedness and Response (ASPR), in addition to other federal, state,

and local partners, aim to increase the understanding of Ebola and encourage U.S. based EMS agencies and systems to prepare for managing

patients with Ebola and other infectious disease. This policy provides guidelines to ensure that employees can detect a person

under investigation (PUI) for Ebola, protect themselves so they can safely care for the patient, and respond in a coordinated fashion. Many of the sign

and symptoms of Ebola are non-specific and similar to those of other common infectious diseases such as malaria, which is commonly seen in

West Africa. Transmission of Ebola can be prevented by using appropriate infection control measures.

This policy in intended to enhance collective preparedness and response by highlighting key areas for EMS employees to review in preparation for

encountering and providing medical care to a person with Ebola. This policy is to help employees detect possible Ebola cases, protect employees and

ensure appropriate response.

Ebola

I. Ebola Overview

A. Ebola, previously known as Ebola hemorrhagic fever, is a severe, often fatal disease in humans and nonhuman primates. Ebola is caused by

infection with a virus in the family of Filoviridae, genus Ebolavirus. There are five identified Ebolavirus species, four of which have caused disease in humans. Ebola is found in several African countries; the

first Ebola species was discovered in 1976 near the Ebola River in what is now the Democratic Republic of the Congo. The natural reservoir

host of Ebola remains unknown; however, researchers believe that the virus is animal-borne with bats being the most likely reservoir.

Emergency Medical Service General Order

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Cleveland EMS Ebola Preparedness

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II. Ebola Transmission

A. Because the natural reservoir host of Ebola has not yet been identified,

the manner by which the virus first appears in a human at the start of an outbreak is unknown. Researchers believe that the first patient

becomes infected though contact with an infected animal. B. When an infection occurs in humans, there are several ways the virus

can be spread to others. These include: Direct contact with the blood or body fluids (including but not

limited to feces, saliva, urine, vomit and semen) of a person who is

sick with Ebola Contact with objects (like needles and syringes) that have been

contaminated with the blood or body fluids of an infected person or with infected animals.

C. The virus in the blood and body fluids can enter another person’s body

through broken skin or unprotected mucous membranes in, for example, the eyes, nose, or mouth. The viruses that cause Ebola are often spread among families and friends, because they come in close

contact with blood or body fluids when caring for ill persons.

D. During outbreaks of Ebola, the disease can spread quickly within healthcare settings, such as clinics or hospitals where hospital staff are

not wearing appropriate protective clothing including masks, gowns, gloves and eye protection.

III. Ebola Signs and Symptoms

A. A person infected with Ebola is not contagious until symptoms appear.

B. Signs and symptoms of Ebola typically include:

Fever (greater than 38.6*C or 101.5*F) Severe headache

Muscle pain Vomiting

Diarrhea Stomach pain

Unexplained bleeding or bruising

C. Symptoms may appear anywhere from 2 to 21 days after exposure to

Ebola but the average is 8 to 10 days.

IV. Ebola Risk of Exposure

A. Ebola is found in several African counties. The current outbreak is

centered in West Africa, primarily Liberia, Sierra Leone, and Guinea.


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B. During out of Ebola, those at highest risk include healthcare workers

and the family and friends of a person infected with Ebola.

V. Ebola Diagnosis

A. Diagnosing Ebola in a person who has been infected for only a few

days is difficult because the early symptoms, such as fever, are not specific to Ebola infection and are seen often in patients with more commonly occurring diseases.

B. However if a person has symptoms of Ebola and had contact with

blood or body fluids of a person sick with Ebola, contact with objects that have been contaminated with blood or body fluids of a person sick

with Ebola or contact with infected animals, the patient should be isolated and public health professionals notified.

VI. Ebola Treatment

A. Currently there are no specific vaccines or medicines (such as antiviral drug) that have been proven to be effective against Ebola.

B. Symptoms of Ebola are treated as they appear.

VII. Ebola Prevention

A. When cases of the disease do appear, there is increased risk of

transmission within healthcare settings. Therefore, healthcare workers must be able to recognize a care of Ebola and be ready to use

appropriate infection control measures. The aim of these techniques is to avoid contact with the blood and body fluids of an infected patient.

B. Appropriate procedures include:

Isolation of patients with Ebola and contact with unprotected

persons Wearing of protective clothing (including masks, gloves,

impermeable gowns, and goggles or face shields) by person caring for Ebola patients

The use of other infection-control measures (such as complete equipment sterilization and routine use of disinfectant)

Avoid touching the bodies of patients who have died from Ebola


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Communication’s Center Call-Taking Emerging Infectious Disease Surveillance Tool (SRI/MERS/Ebola) – EIDS

I. Procedures

A. The Emerging Infectious Disease Surveillance Tool EIDS is to be initiated after utilizing the following protocols

i. Protocol 6 – Breathing Problems ii. Protocol 10 – Chest Pain

iii. Protocol 18 – Headache iv. Protocol 21 – Hemorrhage (MEDICAL)

v. Protocol 26 – Sick Person (flu-like symptoms including alpha levels 2-12; 18, 21, 36 and 36)

B. Process for EMDs for receiving a call for a Chief Complaint covered on the above listed protocols:

i. Follow the standard call-taking procedures a. Case Entry, Key Questions, Final Code Determinant

ii. After the call has been entered into the pending queue for dispatch, the EIDS (Emerging Infectious Disease Surveillance) Tool

(SRI/MERS/Ebola) is to be activated by selecting the button along the top tool bar as shown below:

iii. This will launch a series of questions that must be asked to all

callers after completing Protocols 6, 10, 18, 21, and 26 (as above).


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C. After completing the EIDS Tool, the EMD shall do the following:

i. Determine if the patient has the symptoms listed on the EIDS Tool and has had recent travel (21 days or less) to areas known to have

active cases of the disease in question or ii. If the patient has the symptoms listed on the EIDS Tool and has

had recent contact with someone who has had recent travel (21

days or less) to areas known to have active cases of the disease in question or

iii. If the patient has the symptoms listed on the EIDS Tool and has been in close contact with someone with Ebola (or dead bodies or

exotic African animals likes bats or monkeys).

D. Documentation and Notification that shall be completed by the EMD i. Once signs and symptoms and confirmed travel

a. POSS SYMPTOMS & CONFIRMED TRAVEL; or ii. Signs and symptoms and confirmed contact exposure of travel;

a. POSS SYMPTOMS & CONFIRMED CONTACT TRAVEL; or iii. Signs and symptoms and confirmed contact disease exposure

a. POSS SYMPTOMS & CONFIRMED DISEASE EXPOSURE iv. After the verification has been made above, the EMD is to

immediately notify the RED Center Captain and Crew Chief. a. This information shall be immediately provided to all

responders (EMS, fire, police, etc.)

v. Since the information entered into the EIDS Tool do not carry over into CAD, the EMD shall document all symptom boxes that were

checked and any other documentation entered into the Tool.

E. Instructions that the EMD shall provide to the caller i. If the patient meets the criteria in C – i., ii., or iii.:

a. KEEP ISOLATED – from now on, don’t allow anyone to come in close contact with the patient.

ii. If the patient does not meet the criteria in C – i., ii., or iii.:

a. The EMD is to follow the Post-Dispatch and Pre-Arrival Instructions applicable to the patient’s chief complaint.


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Field Operations and On-Scene Guidelines

I. Personal Protective Equipment (PPE) recommendation guideline for suspected pre-hospital Ebola cases:

A. If field employees are advised by RED Center of a suspected pre-hospital Ebola case, EMS employees shall don the following PPE prior to entering the scene:

i. Ebola Level PPE consists of: a. Level B isolation suit

b. Goggles c. N-95

d. Surgical mask with visor (over the N-95 with goggles) e. Gloves (regular gloves plus additional glove in package worn

over the wrist of isolation suit (double gloving)) f. Rubber boots

ii. Employees are to follow the proper sequence for putting on

personal protective equipment (PPE); (see attached CDC guidelines)

B. If field employees are not advised of a suspected pre-hospital Ebola case and arrive on scene, identify suspected pre-hospital Ebola case:

i. EMS employees shall stay greater than six (6) feet of the patient for the initial screening.

ii. Ebola Screening (see attached CDC guidelines) a. Symptoms include but not limited to

1. Fever

2. Headache 3. Joint and muscle aches (pain)

4. Weakness and/or fatigue 5. Diarrhea and/or vomiting

6. Abdominal Pain and lack of appetite 7. Unexplained hemorrhage

b. AND 1. Has traveled within last 21 days to an affected area (West

Africa – Guinea, Liberia, Nigeria, Senegal, Sierra Leone); or

2. Has been in contact with someone who has traveled within 21 days to an affected area; or

3. Has been in direct contact with a someone with Ebola iii. If the patient has a positive Ebola screen, and the EMS employees

are not in Ebola Level PPE, back out of the scene, don the appropriate PPE and then re-enter.

a. Patient should be isolated and standard, contact, and droplet precautions followed during further assessment, treatment, and transport.


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II. Patient Care

A. When entering the residence of a suspected pre-hospital Ebola case, take the minimum amount of equipment based on the patient’s

condition provided in the dispatch information. B. Designate one Paramedic be the lead “contact” person for the patient,

the second Paramedic/EMT should avoid contacting the patient directly

unless necessary for carrying the patient or lifesaving interventions. C. Receiving hospitals shall be notified as soon as the patient is identified

for transport and the hospital destination determined. i. Hospitals will need time to prepare the isolation area for receiving

the patient(s). D. Airway procedures are considered high risk for exposure by the CDC,

this includes: i. Basic airway management ii. Placement of an airway adjunct

iii. Albuterol treatment administration a. Shall be

iv. CPAP administration v. Intubation or King Airway placement

vi. Suctioning E. Procedures

i. Absolutely no invasive procedures (airway or IV/IO) in a moving ambulance. a. If invasive procedures are urgently indicated, perform at the

scene prior to transport or stop the ambulance to perform. F. Body fluids

i. In the event there is spillage of body fluids onto patient compartment surfaces, linens shall be placed on top of the fluids to

stop the spread. ii. Pre-cleaning with following placing the linens in a red biohazard

bag.

III. Safe Transport of the Patient with a Positive Pre-Hospital Ebola Screen A. All employees should maintain Ebola Level PPE.

B. Hospital Destinations i. At this point, all approved hospitals have the capacity to handle an

Ebola patient. ii. Specific guidelines will be addressed in future directives.

C. Best practices i. Remove all loose items from the patient compartment of the

ambulance


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ii. Keep only absolutely essential equipment in the patient

compartment with you iii. Close the sliding door between the driver and patient compartment

iv. Close all equipment shelf doors / cabinets v. Avoid cross contamination of surfaces vi. Do not transport family members, high risk or low risk contacts, in

the ambulance. They should self-isolate at the residence. D. Arrival at the Emergency Department

i. Upon arrival at the emergency department, follow their instructions for the transfer of the patient.

IV. Employee, Equipment and Vehicle Decontamination

A. Employee i. Properly remove and dispose of PPE, linens and other disposable

equipment in a red biohazard bag.

ii. Employees are to utilize CDC recommended guidelines for safe removal of PPE and proper hand-washing and cleaning.

iii. Wash all exposed skin – shower as needed at the emergency department.

B. Equipment i. Disposable equipment shall be placed in a red biohazard bag.

ii. If the patient was placed on the cot, the cot mattress shall be placed in a red biohazard bag(s).

C. Vehicle and Non-Disposable Equipment

i. The vehicle shall be placed out of service for decontamination. ii. Steps for cleaning

a. The vehicle shall be pre-cleaned, all contaminated cleaning materials placed in a red biohazard bag.

b. On a cleaned surface, spray “Husky” brand cleaner on all exposed surfaces.

iii. Prior to being placed in-service, the ambulance and all non-disposable equipment will be cleaned and disinfected.

V. EMS Employee Ebola Exposure A. Not Exposed

i. No contact with a suspected Ebola patient; or ii. Maintained at least a six (6) foot distance from the patient and no

contact with any blood or body fluids. B. Low Risk Exposure

i. Contact with a suspected Ebola patient and not wearing complete Ebola PPE

ii. Having direct, brief contact with a suspected Ebola patient and not

wearing complete Ebola PPE


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C. High Risk Exposure

i. Percutaneous (needle stick) or mucous exposure to blood or body fluids of a suspected Ebola patient

ii. Direct skin contact or exposure to blood or body fluids of a suspected Ebola patient without appropriate Ebola PPE

iii. Direct contact with a DOA suspected Ebola patient

D. Exposure paperwork shall be completed as necessary.

VI. Notifications A. City of Cleveland Health Department Notification for Suspected Ebola

Patients i. Notification shall be immediately made to the City of Cleveland

Health Department for suspected Ebola patients. ii. It is the responsibility of the EMS crew and the on-duty Captain to

immediately notify the City of Cleveland Health Department.

iii. Notification shall be made if transported, refused, DOA, etc. including possible exposure to other persons in the home.

B. Immediate notification shall be made to the Commissioner and the Deputy Commissioner of EMS.


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Ebola Virus Disease Screening for EMS


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PPE Guidelines


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PPE Guidelines

emergency medical service general order

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