Patient arriving at facility in person Step 1: Travel Screen

1

Patient arrives at facility

Earliest point of contact administers travel questionnaire

Have you traveled to West Africa or the Middle East in the last 21 days? Have you been in contact with someone who has traveled to West

Africa in the past 21 days who is now ill? Determine whether it was one of the countries of concern.

Yes No

* Don’t know who this would be in your area? Ask your manager.

A script has been created to you with this step

If yes , travel screen is positive: Provide patient with mask Immediately contact clinical resource

designated for your area* to proceed with symptom screen and triage.

Caregivers implement Standard, Contact and Droplet precautions with eye protection.

Caregivers must use PPE.

If no, Proceed with registration, check-in, triage or care.

Hospital-Based Setting Clinic-Based Setting

If yes , travel screen is positive: Provide patient with mask and gloves. Escort patient to room designated at your

clinic for this purpose. Immediately contact clinical resource

designated for your area* to proceed with symptom screen and triage.

All Settings

* Don’t know who this would be in your area? Ask your manager.

Patient arriving at facility in person Step 2: Symptom Screen

2

Use contact and droplet in addition to standard precautions

If not there already, move the patient to a negative pressure isolation room. If none available, use private room. If no private restroom provide commode.

Notify Nursing Supervisor immediately and ask that they reach Infection Control personnel.

Notify local health authority.

If no, Proceed with registration, check-in, triage or care.

Yes No

If positive travel screen, Designated clinical resource dons PPE and escorts patient to isolation room to conduct symptom screen

fever above 100.4 F. (38 C) respiratory symptoms headache diarrhea joint and muscle pains vomiting, stomach pain or

lack of appetite

Does patient complain of or cite any of the following:

weakness or fatigue bleeding Exposure to ill individuals,

exposure to body fluids or needles, or exposure to animals such as bats or monkeys or bush meat?

Hospital-Based Setting Clinic-Based Setting

Use contact and droplet in addition to standard precautions.

Notify local health authority and regional lead.

All Settings

Ebola and MERS Screening/Triage Tool for Emergency Services and Urgent Care Settings

Version 1.1 Last updated 10/14/14

Registration/Front Desk Travel Screen:

1. Have you traveled to West Africa or the Middle East in the last 21 days?

2. Have you been in contact with someone who has traveled to West Africa in the past 21 days who is now ill?

3. Determine whether it was one of the countries of concern:

West Africa (Guinea, Liberia, Nigeria, Senegal, Sierra Leone)

Middle East (Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Yemen, United Arab Emirates)

If yes , immediately contact charge nurse (in ED) or other designated licensed provider to proceed with symptom screen and triage. Caregivers implement Standard, Contact and Droplet precautions with eye protection. Caregivers must use PPE.

RN/LIP Symptom Screen and Triage

Does the patient complain or cite any of the following :

fever above 100.4 F. (38 C)

respiratory symptoms

headache

diarrhea

joint and muscle pains

vomiting, stomach pain or lack of appetite

weakness or fatigue

bleeding

Exposure to ill individuals, exposure to body

fluids or needles, or exposure to animals

such as bats or monkeys or bush meat?

If yes:

Move the patient to a negative pressure isolation room. If none available, use private room. If no private restroom provide commode.

Notify Nursing Supervisor immediately and ask that they reach Infection Control personnel. [insert contact information for local infection control]

Place patient in private room per protocol, Contact and Droplet versus High Level Containment in negative pressure.

Notify local health authority at [insert contact information]

Further assessment tools and CDC guidelines are available online or at [insert intranet location] and cdc.gov.

Script for infectious disease screening: Registration and Check-In for all Hospital Services (including ED)

The following questions should be your first interaction with a patient, before taking insurance and ID cards, placing armbands or having any physical contact.

“The safety of our patients is our first priority. Before we get you checked in today, I need to ask you a few travel questions. Please understand that you may be asked these travel questions at a later date or if you are checking in at a different location. Thank you.”

1. “Have you traveled to West Africa or the Middle East in the last 21 days?

NO or YES

2. “Have you been in contact with someone who has traveled to West Africa in the past 21 days who is now ill?”

NO “Ok, thank you.” (Proceed with registration)

YES 3. “What country?” (Determine if it was a country of concern)

• West Africa - Ebola (Guinea, Liberia, Nigeria, Senegal, Sierra Leone)

• Middle East – MERS (Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Yemen, United Arab Emirates)

NO “Ok, thank you.” (Proceed with registration)

YES “Thank you. Based on your travel history, we want to ensure your safety and that you have not been exposed to an infectious disease. One of our care team members will be here shortly to complete a symptom screening. Please wait here.” (Notify clinical department manager or nursing supervisor)

Patient registration screening FAQs Patient confidentially and respect is paramount Our goal is to act in the best interests of our patients

While we know that an Ebola epidemic in the U.S. is not likely, the safety of our patients and caregivers is our first priority. Q: Why are you asking me about travel? A: Early recognition of any infectious disease is important for providing appropriate patient care and preventing the spread of

infection. Our goal is to act in the best interest of our patients, and to do this we are asking every patient about any recent

travel.

Q: I just want to get to my appointment. Is this really necessary? A: Out of an abundance of caution, we are increasing the use and practice of screening measures to identify potential cases of infectious disease. These include identifying every patient’s recent travel history. While this may result in a slight delay, we believe this is an appropriate measure to take as we follow protocols and is in the best interests of all our patients.

Q: Why do you need to know about travel from 3 weeks ago?

A: Signs and symptoms of several infectious diseases may appear anywhere from two to 21 days after exposure. We want to

make sure we are giving you the best, safest care possible. To do this, it’s important that we ask every patient about any travel

done in the past 21 days.

Patient Arriving at Ambulatory Clinic In-PersonStep 1: Travel Screen

Patient arrives at facility

Earliest point of contact administers

Travel Questionnaire

Have you traveled to West Africa or the Middle East in the last 21 days?Have you been in contact with someone who has traveled to West Africa in the past 21 days who is now ill?Determine whether is was one of the countries of concern.

If YES, travel screen is positive:Front desk person dons mask and gloves.Provide patient with mask and gloves.Escort patient to clinic designated room, closes door.Immediately contact designated licensed clinician (MD, DO, PA, ARNP, RN, LPN)* to proceed with symptom screen and triage.Symptom screening caregiver implements Standard Contact and Droplet precautions using appropriate PPE.Proceed to (Step 2).

YES

If NO:Proceed with registration, check-in, triage or care.

NO

* Don’t know who this would be in your area? Ask your manager.

Patient Arriving at Ambulatory Clinic In-PersonStep 2: Symptom Screen

If positive travel screen, Designated licensed clinician

dawns PPE and conducts symptom screen in clinic designated room

If YES, do the following:Use standard contact and droplet precautions.Contact your Clinic Manager.Notify local health authority and regional lead.Transport will be determined by local health authority

YES

If NO:Proceed with registration, check-in, triage or care.

NO

Does patient complain of or cite any of the following:

Fever above 100.4 F (38 C)Respiratory SymptomsHeadacheDiarrheaJoint and muscle painsVomiting, stomach pain or lack of appetiteWeakness or fatigueBleedingExposure to ill individuals, exposure to bodily fluid or needles, or exposure to animals such as bats or monkeys or bush meat?

Patient Scheduling Via PhoneTravel Screen

Patient scheduling via phone

Scheduler adminsters Travel Questionnaire

Have you traveled to West Africa or the Middle East in the last 21 days?Have you been in contact with someone who has traveled to West Africa in the past 21 days who is now ill?Determine whether is was one of the countries of concern.

If YES, travel screen is positive:Immediately contact designated licensed clinician (MD, DO, PA, ARNP, RN, LPN)* to proceed with symptom screen and triage.Clinic personal will triage patient and contact local health authority if needed.Local health authority will determine patient transport, if needed.

YES

If NO:Proceed with scheduling

NO

Ambulatory Clinic check-in script for infectious disease screening

The following questions should be your first interaction with a patient,

before taking insurance and ID cards or having any physical contact.

“The safety of our patients is our first priority. Before we get you checked in today, I need to

ask you a few travel questions. Please understand that out of an abundance of caution, you

may be asked these travel questions at a later date or if you are checking in at a different

location. Thank you.”

1. “Have you traveled to West Africa or the Middle East in the last 21 days?

NO or YES (Proceed to next question)

2. “Have you been in contact with someone who has traveled to West Africa in the past 21 days who is

now ill?”

NO

“Ok, thank you.” (Proceed with registration)

YES

3. “What country?” (Determine if it was a country of concern)

West Africa - Ebola (Guinea, Liberia, Nigeria, Senegal, Sierra Leone)

Middle East – MERS (Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Yemen, United Arab

Emirates)

NO

“Ok, thank you.” (Proceed with registration)

YES

“Thank you. Based on your travel history, we want to ensure your safety and that you have not

been exposed to an infectious disease. One of our care team members will be here shortly to

complete a symptom screening. For your safety and ours, please use these gloves and mask as

you wait here.”

(Notify your designated clinic team member. Front desk staff should put on gloves and mask as

well.)

Phone script for infectious disease screening

The following questions should be asked during a pre-registration or scheduling phone call.

“The safety of our patients is our first priority. I need to ask you a few travel questions. Please

understand that out of an abundance of caution, you may be asked these travel questions at a

later date and when you check in for your appointment. Thank you.”

1. “Have you traveled to West Africa or the Middle East in the last 21 days?

NO or YES (Proceed to next question)

2. “Have you been in contact with someone who has traveled to West Africa in the past 21 days who is

now ill?”

NO

“Ok, thank you.” (Proceed with registration or scheduling)

YES

3. “What country?” (Determine if it was a country of concern)

West Africa - Ebola (Guinea, Liberia, Nigeria, Senegal, Sierra Leone)

Middle East – MERS (Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Yemen, United Arab

Emirates)

NO

“Ok, thank you.” (Proceed with registration or scheduling)

YES

“OK, thank you. Your travel history should be evaluated by one of our clinicians. Please remain

at home until one of our clinicians can call you. A health care provider will be calling you back

within the hour. What is the best number to reach you?”

(Schedulers will be provided with appropriate contact on a regional basis. Target return call in

fifteen minutes and no longer than one hour.)

MyChart follow-up phone script for infectious disease screening

The following questions should be confirmed with any patient who scheduled an appointment

with MyChart and has not completed the travel questionnaire.

“Hello. Thank you for scheduling an appointment with MyChart. The safety of our patients is

our first priority and I need confirm with you some of the responses you made to the travel

questions. Please understand that out of an abundance of caution, you may be asked these

travel questions at a later date and when you check in for your appointment. Thank you.”

1. “Have you traveled to West Africa or the Middle East in the last 21 days?

NO or YES (Proceed to next question)

2. “Have you been in contact with someone who has traveled to West Africa in the past 21 days who is

now ill?”

NO

“Ok, thank you.” (Proceed with registration or scheduling)

YES

3. “What country?” (Determine if it was a country of concern)

West Africa - Ebola (Guinea, Liberia, Nigeria, Senegal, Sierra Leone)

Middle East – MERS (Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Yemen, United Arab

Emirates)

NO

“Ok, thank you.” (Proceed with registration or scheduling)

YES

“OK, thank you. Your travel history should be evaluated by one of our clinicians. Please remain

at home until one of our clinicians can call you. A health care provider will be calling you back

within the hour. What is the best number to reach you?”

(Schedulers will be provided with appropriate contact on a regional basis. Target return call in

fifteen minutes and no longer than one hour.)