ALLIANCE

1. OLD DOMINION ALLIANCE Regional Ebola Update & PPE Training October 2014 www.odemsa.vaems.org

2. Presented by: ODEMSA Staff: Adam Alford, ODEMSA Education Coordinator Holly Sturdevant, ODEMSA Special Project Coordinator Rachel Dillon, ODEMSA Program Coordinator Damien Coy, ODEMSA Field Coordinator Heidi Hooker, ODEMSA Executive Director

3. Purpose To provide: • Ebola facts • ODEMSA Ebola Virus Disease “EVD” Guidelines for EMS Providers • Donning/Doffing and disposal of Personal Protective Equipment (PPE) Oct 2014

4. Ebola Facts Oct 2014

5. Facts Regarding Ebola… • Commonly referred to as “EVD,” or Ebola Virus Disease • On August 6, 2014 members of the World Health Organization (WHO) officially declared Ebola a public health emergency of international concern. • Currently, the US has seen 4 cases with one death *This number may change daily*

6. Signs and Symptoms: • Fever • Severe Headache • Muscle Pain • Weakness • Diarrhea/Vomiting/Abdominal Pain • Unexplained Hemorrhage (Bleeding or Bruising) Symptoms may appear anywhere from 2-21 days after exposure to active EVD.

7. EVD Transmission • Animal-to-person • It is believed that the first case of human contracted EVD was transmitted from an infected animal to a susceptible host • Person-to-person • Once EVD is contracted in a human, the host can easily spread the virus through direct contact

8. The human body produces many body fluids, secretions and excretions that may contain pathogens - avoid direct contact with: • Blood or body fluids • Potentially infectious body fluids include: blood, vomit, feces, urine, sputum, saliva, and sweat, as well as amniotic, spinal, vaginal, pleural, pericardial, peritoneal, synovial fluids and semen ***To prevent exposure, ANY body fluid from any patient must be treated as potentially infectious!*** • Objects like needles & syringes that have been contaminated with EVD • Infected fruit bats or primates

9. During outbreaks of Ebola, the disease can spread quickly within healthcare settings. Healthcare workers should use the following precautions when treating EVD patients: • Standard Precautions (ALL patients) • Contact Precautions (“blood/body fluid”) • Droplet Precautions (think “flu”)

10. Standard Precautions • All patients, all the time, any setting • Minimum PPE required: • Disposable Gloves • Hand Hygiene • Additional PPE, as needed, to protect against blood, body fluids, secretions & excretions: • Eye protection (goggles or face shield) • Respiratory protection (surgical face mask) • Impermeable or fluid-resistant gown Oct 2014

11. Contact Precautions • Protection against viruses (such as Ebola), Influenza, HIV, Hepatitis; plague, MRSA, VRE, Strep; patients with diarrhea, vomiting, or generalized rash • Minimum PPE Required • Disposable Gloves (change if visibly soiled) • Gown • Hand Hygiene • Disinfection of all equipment/surfaces • Examples: monitor, glucometer, BP cuff, etc. Oct 2014

12. Droplet Precautions • Large particles created by coughing, sneezing, suctioning or intubation • Disease examples: Influenza, meningitis, pertussis, plague, Ebola, mumps, rubella, and most viruses (including Enterovirus D68) • Any patient with fever, respiratory symptoms, rash, and/or flu-like signs/symptoms, such as weakness, vomiting, diarrhea, severe headache, abdominal pain, or muscle and body aches Oct 2014

13. Droplet Precautions • Hand Hygiene • Minimum PPE required: • Gloves • Gown • Eye Protection • Bonnet • Leggings/Boot Covers (or Shoe Covers) • Respiratory Protection…. Oct 2014

14. Droplet Precautions • What level of respiratory protection? • Healthcare Providers (with eye protection): • At least standard surgical face mask • N95 mask for “Aerosol-Generating Procedures” or other high-risk procedures (e.g. CPR) • See UTSW/BioTel TB 14-007 PPE • Patient (especially if coughing or sneezing): • Standard surgical face mask or N95, if tolerated • Add Nasal Cannula O2, if supplemental oxygen needed Oct 2014

15. ODEMSA Ebola Virus Disease “EVD” Guidelines for EMS Providers Oct 2014

16. Compiled by a Regional Team of Experts: • EMS Professionals • Fire Service Professionals • Hospital Administrators • Epidemiologist • Hazardous Materials Specialists • Educators

17. Agencies MUST work with their local health department and Operational Medical Director to develop patient care plans. This is a fluid situation – be flexible as there may be frequent changes Changes made to this document will be posted to our website

18. Dispatch Centers – PSAP’s should screen calls for potential Ebola patients- PRIOR to YOUR Arrival “EVD ALERT” has been designated as the regional alert to be used by pre-hospital

19. Each agency should inventory available supplies and ensure an adequate supply ODEMSA is conducting a regional needs assessment. You WILL be contacted by ODEMSA staff

20. Ensure an adequate supply, for EMS personnel, of: • Fluid resistant or impermeable gowns Double layer of gloves • Shoe covers, boots, and booties • All of the following: • N95 respirators or greater (i.e. APR, PAPR, SCBA) • Eye protection • Fluid/splash shield (in addition to eye protection and N95 mask) • Other infection control supplies (e.g. hand hygiene supplies) • We will always use the current CDC recommendations

21. Don full PPE • Limit exposed personnel • Only allow the patient and protected providers in patient compartment • Cab of ambulance MUST remain clean • Seal cab compartment • Driver should not participate in patient care

22. Information to Convey to Hospital • Notify hospital as soon as you identify a potential case • Use “EVD ALERT” trigger • Describe Patient • Low Acuity – Delay transport • High Acuity – Transport • Hospital personnel may provide care until they are ready to receive the patient • EMS might be asked to assist hospital personnel

23. When arriving at the hospital: • You may be directed to park in an area away from other traffic • Remain in the ambulance and await direction from the hospital staff.

24. Patient Refusal or Pronouncement: • Report to your local Health Department by calling • 866-531-3068 • Ask for the Epidemiology Investigator on call • They will give instruction • Connect you with local team

25. If a Patient Reports to Your Facility: • Do NOT allow them inside • Resources should be dispatched like any other medical emergency • Wear appropriate PPE before patient contact

26. Doffing – PPE Removal: • MOST Exposures Occur during PPE Removal • Use a “Buddy System” • EMS Providers – Await Decontamination Assistance from Hospital Personnel. • Hospital Will Provide a Change of Clothing

27. Equipment/Ambulance Decontamination and Disinfection: • Plans should be made in advance • Suggest • Local HazMat response • 3rd Party Decontamination Company

28. Post-Exposure: • Follow Instructions from your OMD and VA Department of Health • Self-Monitor for Fever • If your patient is Ebola positive, monitor for EVD symptoms for 21 days in conjunction with VDH and CDC

29. Donning/Doffing PPE Oct 2014

31. PPE = Gloves and…. Oct 2014

32. PPE Components • Disposable Gloves • Disposable Gown (Impermeable or Fluid Resistant) • Eye Protection • Wraparound Goggles, Safety Glasses or Face Shield • Respiratory Protection (must be worn with eye protection) • Lowest: Standard surgical face mask • Higher: N95 filter mask (respirator) • Highest: Air-Purifying Respirator (“APR”) – powered or not; half-face, full-face or hood • Other components for high volume fluid environments: • Disposable Boot Covers (or Shoe Covers) • Disposable Bonnets Oct 2014

33. “Buddy System” • A trained observer shall monitor donning/doffing procedures • “Buddy” (in PPE) watches to prevent compromises or other procedural breaches • Any compromise/breach must be reported to your EMS Field Supervisor immediately Oct 2014

34. Donning

35. Donning Sequence Using Buddy System: • Remove all personal items (jewelry, watches, phones, pens, etc.) • Hand Hygiene, put on inner gloves • Inner Pair MUST be under cuff of the sleeve of gown/coverall • Leggings/Boot Covers (or Shoe Covers), if used • Gown or coverall suit (tie at waist and neck) • Eye Protection • Mask or Respirator (ensure proper fit) • Bonnet, if indicated. Must tape all visible gaps in suit • Outer Gloves • Outer pair must be over cuff of the sleeve of gown/coverall leaving NO SKIN exposed • Remember: Do NOT touch your eyes, nose or mouth Oct 2014

36. Decontamination

37. Doffing

38. Doffing (Removal) = Critical Process Most Provider exposures occur during PPE Removal (doffing)! Oct 2014

39. Doffing (Removal) = Critical Process • PPE must be removed in the proper sequence & with extreme care/caution, to prevent inadvertent exposure • Basic Principle: • Touch ONLY “clean to clean” and “dirty to dirty” • Perform hand hygiene & replace gloves if hands become contaminated during removal AND immediately after PPE removal • PPE must be removed immediately after patient care is transferred to hospital staff Oct 2014

40. Doffing Sequence • Needed BEFORE beginning: • Fresh disposable gloves • BioHazard bags/receptacles (“Triple bagged”) • Hand Hygiene supplies • Sequence - “Touch ONLY clean to clean AND dirty to dirty”: • Outer Gloves:Touching ONLY inside, remove  Biohazard disposal • Gown: Touching ONLY inside, Roll away from wearer, down to wrists, remove  Biohazard disposal • Leggings/Boot Covers (or Shoe Covers): Touching ONLY inside, roll down and away from wearer, remove  Biohazard disposal • Inner Gloves: Touching ONLY inside, remove  Biohazard disposal • Continued…. Oct 2014

41. Doffing Sequence • Hand Hygiene (dry hands as much as possible) • Don a fresh pair of gloves • Bonnet (grasp as far to the rear as possible)  Biohazard disposal • Goggles (grasp as far to the rear as possible)  Biohazard disposal • Respirator/Mask (grasp from as far to the rear as possible)  Biohazard disposal • Last Pair of Gloves: Touching ONLY inside, remove  Biohazard disposal • HAND HYGIENE, including wrists and fingernails Oct 2014

42. Disposal of Contaminated PPE • Once the contaminated PPE is placed in the Biohazard bag and bag is triple-sealed, follow directions of facility staff for proper disposal and decontamination. **Remember, the ODEMSA hospitals have committed to decontaminate EMS personnel (not vehicles) after contact with a potentially infectious EVD patient. Follow the direction of the hospital staff.** Oct 2014

43. Summary • Hand hygiene is the single most important way to prevent infection spread • Proper selection of appropriate PPE is vital • Standard: ALL Patients • Contact + Droplet: Sick Patients at risk for infectious diseases • Doffing (removal) = greatest risk to Providers • A “Buddy System” – especially during doffing – will reduce the risk of compromise/breach • PPE must be disposed of properly after removal Oct 2014

44. If you have questions… Virginia Department of Health – Ebola Hotline 1-877-ASK VDH3 (1-877-275-8343) ODEMSA Office Number: (804) 560-3300 Website: www.odemsa.vaems.org Oct 2014