BWH Dermatology Ebola Essentials

1. BWH DermatologyEbola Essentials Adam Lipworth, MD 12/11/14

2. Goals • Review key Ebola Virus Disease features • Protocol for a potential EVD patient in clinic • Know when Personal Protective Equipment is needed • Demo donning/doffing of ambulatory PPE • Review of available resources

4. Ebola Transmission • Incubation: 2-21 days (usually 8-10d) • Not infectious while asymptomatic • Direct Contact with Infectious fluids • Includes extended time (20 min+) <3 feet away • Includes high volume fluid (eg puddles) outside of a body • Infection Risk • Increases with worse disease state: viremia, more fluids • Highest risk: family members, care providers, mortuary workers

5. Case Definition (CDC & MDPH guidance) SUSPECTED CASE MEETS BOTH OF THE FOLLOWING: • EITHER: • Fever > 38.0°C/100.4°F, or • One or more of: severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage AND • Potential exposure in 21 days prior to symptom onset.

6. POTENTIAL EXPOSURE (definitions) • High Risk: Direct contact with blood/bodily fluids/remains from a suspected or confirmed Ebola patient without the use of appropriate PPE. Includes lab personnel • Low Risk • Travel / residence to active Ebola area (Liberia, Sierra Leone, Guinea) AND • 1 of the following: • Residence in the same house as an Ebola patient, or • Provision of care to an Ebola patient (without known high risk exposure) or • Had other casual contact* with an Ebola patient. • Minimal or No Risk • Persons present in an Ebola-outbreak area without high- or low-risk exposures *Casual contact is defined as being in close proximity (e.g., within 3 feet) for a prolonged period of time while not wearing recommended personal protective equipment or having brief direct contact (e.g., shaking hands) with an Ebola case while not wearing personal protective equipment. Brief interactions, such as walking by a person or moving through a hospital, do not constitute casual contact.

7. “Point of Access” (CLINIC) Workflows • Minimize staff contact • ICE workflows • Identify • Contain and Consult • ED Transport

8. Protocol (from MD perspective) • All patients entering clinic screened at front desk

9. Attention Patients: Please be Ready to Provide Your Recent Travel History Please be aware that we are proactively asking all patients to provide us with their recent travel history prior to check-in. This measure is out of an abundance of caution to protect the health of our patients and staff. Thank you.

10. All Points of AccessInfection Risk Screening ToolAsk Patients the Following Questions • Upon arrival to any point of entry - Screen All Patients with the following questions: • 1. Have you traveled outside the United States during the past month? •  Yes  No (if no, continue with care) • 2. Have you been in Guinea, Liberia, or Sierra Leone? • Yes  No (if no, continue with care) • Have you had any of the following symptoms during the past 2 days: • Fever (subjective or ≥ 100.4°F / 38.0°C) ? Yes  No • Headache? Yes  No • Nausea or Vomiting? Yes  No • Diarrhea? Yes  No • Muscle Pain ? Yes  No • If patient answers yes to questions 2 and any of the symptoms listed in 3, this = Positive screen • Follow positive screen action steps and be sure to also screen those persons who accompanied • The patient to the visit.

11. Protocol (from MD perspective) • All patients entering clinic screened at front desk • MD notified of positive screen immediately

12. Screening & PPE Pathways

13. Screening & PPE Pathways

14. Protocol (from MD perspective) • All patients entering clinic screened at front desk • MD notified of positive screen immediately • Room patient: “No Touch” or with PPE • Gather basic info • Contact info • Symptoms: What and When (dates) • Travel info: Where, when (dates), purpose • Ensure Pt’s family/friends screened too • Page Infection Control: 11482 • Arrange Clean Up: Page 12007 (environmental svcs)

15. EVD Kits

16. What’s in the Kit? • Glove Nitrile EP Small • Glove Nitrile EP Medium • Glove Nitrile EP Large • Glove Nitrile EP XLarge • Gown Impervious • Mask Surgical Molded • Face Shield • Emesis Bag • Wipes Super Sani Cloths • Biohazard Bags • Signage and Screening Tools

17. PPE Technique *Be sure your hair is pulled back and secured.

18. Additional Resources Available

19. Managing Patients & Visitors LIP or RN: • Screen person/s accompanying the patient • Assess for symptoms or risk factors for Ebola Asymptomatic: • Gather the following information: • Name and MR if the individual is an existing BWH patient • Name of the BWH practice gathering and submitting the data • Name of Practice Manager with telephone contact • Date of incident • Fax this information to Infection Control at 617-975-0947 • Maintain a copy of all faxed information Positive Screen or Risk Factors • Follow steps for positive screen for patient. • All potentially infectious patients should be roomed separately

20. Telephone Triage Use screening tool provided. If screen is positive: • Gather patient’s contact information, telephone number and address. Inform them you will call them back and are seeking consultation. • Page Infection Control (IC) pager # 11482 (BWH) or # 66558 (FLK) and request EVD consult to review screening info • IF IC instructs that transport to an ED is necessary, follow these steps: • Instruct patient to go to the nearest ED and confirm pt has transportation • Call and notify ED to expect a patient with risk for Ebola • Patients with no ride, please arrange transport as follows: • Off-site Transport to: • BWH ED • Call EMS and inform them pt has a risk for Ebola. • Call Emergency Flow Manager at 617-525-6412, notify to expect pt • To Outside Hospital ED • Call the receiving hospital and notify them a patient with risk for Ebola is en route • As an FYI only, call the BWH Emergency Flow Manager at 617-525-6412 • Patients declining recommended treatment, call IC pager to discuss BPHC or MDPH referral • For Boston residents, call Boston Public Health Commission at 617-719-5415 • For patients living outside Boston, call MDPH 617-983-6800

21. Post Patient TransportRoom and Equipment Cleaning • Call Luis Soto from Environmental Services at pager 12007 • Perform Hand Hygiene. • Don PPE before entering room. • Place disposable supplies and linen in red Biohazard bag. • Disinfect exam table, counters, reusable equipment with Purple top Super Sani-Cloths • 2 minutes wet time • Employee cleaning room should remove PPE and put in red Biohazard bag. • Perform Hand Hygiene. • Page Infection Control at pager #11482 for further instruction.

22. Office Management of Staff who had contact with Positive Screens • Collect the following from all staff that had contact with patient: • Staff Name • Employee number • Indicate if employee had direct contact or indirect contact • Name of Source Patient & MRN • Name of Practice Manager and Contact information • Date of Contact • Fax list of names to Occupational Health - retain a copy • 617-713-3010 • Keep a list of all patients who may have been in the area

25. Resources Be sure to visit BWHPikenotes for up to date information on Ebola Virus Disease • Bi-weekly Ambulatory Webex • Email BWHAIM@partners.org to register • Employee Exposure: Contact Occupational Health at pager: 32845 (3 Stik) • Employee Assistance Program 617 732-6017 • Chaplaincy Services 617 732-7480 • Patient Family Relations 617 732-6636

26. Faulkner Resources Be sure to visit Faulkner 411for up to date information on Ebola Virus Disease • EAP: 617-983-4840 • Occupational Health: 617-983-4628 • Chaplaincy: 617-983-4856 • Patient Family Relations: 617-983-7425 • The pager for infection control is for Dr. Roger Clark, #66558

27. Attention Patients: S’il vous plait soyez prêts a procurer une histoire des voyages que vous aviez entrepris recemment et une liste des pays visités. S’il vous plait soyez avertis que nous demandons a l’avance à tous les patients de nous procurer une histoire des voyages qu’ils ont entrepris récemment avant leur enregistrement. Cette exigence est une des nombreuses mesures de précaution que nous prenons en vue de protéger la santé de nos patients et de notre personnel. Merci. FRENCH

28. Atenção Pacientes: Por Favor Esteja Preparado para Prover Informações Sobre Viagens Recentes: Queremos que saiba que estamos muito envolvidos em perguntar aos pacientes sobre viagems recentes antes de serem admitidos. Essas medidas, entre outras serve para proteger a saúde dos nossos pacientes e dos funcionários PORTUGUESE

29. Внимание, Пациентам! Просьба о Предоставлении Списка о Ваших Недавних Путешествиях Обращаем Ваше внимание на то, что мы предусмотрительно просим всех пациентов предоставить нам их список недавних путешествий перед регистрацией. Эта мера предпринята для обеспечения чрезмерной осторожности с тем, чтобы защитить здоровье наших пациентов и штата сотрудников. Спасибо. RUSSIAN

30. Atención Pacientes: Por favor provean la información de todos sus viajes más recientes Entiendan, por favor, que estamos pidiendo a todos los pacientes que nos den la información de todos los lugares que visitaron recientemente antes de registrarlos. Estamos tomando esta medida preventiva para proteger la salud de nuestros pacientes y nuestros empleados. ¡Gracias por su cooperación! SPANISH

31. PPE Technique *Be sure your hair is pulled back and secured.

32. BEFORE ENTERING Disinfect with alcohol hand gel Put on inner gloves Put on impervious gown Put on surgical mask Put on face shield Put on outer gloves PoA EVD ISOLATION PRECAUTIONS Staff and Visitors Must See Nurse Before Entering PLACE PT in Exam ROOM Keep all doors closed. BEFORE LEAVING Remove outer gloves Remove impervious gown Remove face shield Remove mask Remove inner gloves Disinfect hands with alcohol hand gel Dispose of PPE in red biohazard beg in room Do not remove sign until room terminally cleaned. 9/2014