Nov 14, 2014

Emergency Response Protocols for Suspected Ebola in Urgent Care and Primary Care Settings

 

By Brian B. Rogers1, DO, MPH; David M. Weitzman1,3, MD; Gregory S. Buzard2, PhD; Alexandra Boyd-Rogers

Publisher's Note: Dr. Rogers and his colleagues prepared these protocols to help physicians prepare to respond to suspected cases of Ebola virus. The contents have been edited for style and readability, but have not been reviewed by TMA for scientific accuracy.


I write to you from the "New Hot Zone," just a few miles from the newly famous Dallas Presbyterian Hospital. Like many of you in our field, I have been attempting to put together coherent protocols for addressing the potential Ebola cases that might arrive at our facilities from the often conflicting and scattered breadth of information available online. Making a synthesis of all suggestions by using the best information currently available on the CDC website, I have prepared an updated and comprehensive guide for Urgent and Primary Care Physicians. As a former Public Health Officer, I have chosen a conservative approach to these guidelines, preferring to err on the side of caution where Federal suggestions vary.

This article will cover:

  • How to determine if a patient is a potential Ebola case
  • What to do once you decide a patient might be an Ebola case
  • What to do if the patient requires life-saving procedures
  • What to do in the event of staff exposure
  • How to get the patient into the right hands for specialized and extended care

Determining if Your Patient is a Potential Ebola Threat

Symptoms of Ebola (if your patient has one or more of the following):

  • Fever (prolonged or spiking) greater than 38.0° C (100.4° F)1
  • Headache
  • Generalized Muscle Pain
  • Vomiting
  • Diarrhea
  • Generalized Abdominal Pain
  • Unexplained Bruising or Bleeding2

Risk Assessment:

High-Risk:

  • Patient has had percutaneous, mucosal, or direct skin contact with blood or body fluids (including sweat, saliva, semen, vomit, fecal material, etc.) of a confirmed Ebola victim
  • Patient has processed blood or body fluids of a confirmed Ebola victim
  • Patient has had direct contact with a dead body (as part of funeral rites, embalming, or body handling prior to cremation) of a suspected Ebola case in an outbreak-confirmed country or area

Some/Low-Risk:

  • Being within approximately 1 meter (3 feet) of an active-case Ebola patient
  • Being within an Ebola victim's room or care area for an extended period of time
  • Making direct or brief contact (shaking hands, physical exam) with an Ebola victim

No Known Exposure:

  • Having been in a country or facility with known Ebola patient(s) within 30 days BUT having had no high-risk or low-risk exposure2

If a patient is SYMPTOMATIC (fever OR other symptoms) AND fits into one of the above categories, IMMEDIATELY report the case to your local health department and infection control officer. Follow their directions regarding the immediate isolation and transportation of the patient OR the relay of conditional release/controlled movement* information to the patient.

If a high-risk or low-risk patient is ASYMPTOMATIC (low-grade or no fever AND lacks other symptoms) at presentation, STILL report the case to your local health department for directives regarding the relay of conditional release/controlled movement information to the patient.

If a patient is of the NO KNOWN EXPOSURE category and is ASYMPTOMATIC (NO fever AND lacks other symptoms), provide and discuss written self-monitoring instructions with the patient.

*Persons who are 'conditionally released' should self-monitor for fever and all other symptoms twice daily for a conservative minimum of 21 days beyond the last possible exposure date. They should report all potentially relevant temperature or symptom changes to a public health authority during the monitoring period. 'Controlled movement' involves reporting intended local, national, or international travel to the health authority to receive clearance for the intended travel (commercial travel is prohibited, although the use of local public transportation may be allowed).3

Initial Handling of an Ebola Suspect

Once you (and/or your local public health department) decide that a patient might constitute a potential Person Under Investigation (PUI), you must take immediate measures to protect your other patients, your staff, and yourself.

Isolate the Patient:

  1. IMMEDIATELY isolate the patient in a designated and predetermined room.
  2. Limit staff exposure (to the patient AND isolation room) to the fewest necessary, utilizing original Health Care Providers whenever possible to manage all aspects of patient care.
  3. Post infection-control trained personnel at patient's closed door, to ensure consistent and proper use of Personal Protective Equipment (PPE) by all persons entering the patient's isolation room.
  4. Maintain a log of all persons who enter and exit the patient's room, with evaluation of the proper PPE upon entry and a description of the condition of PPE upon exit4.Using a  coded picture chart of possible PPE will reduce PPE recording times.
  5. Prevent entry of visitors into the patient's room - essential staff ONLY.3
  6. Provide a means of communications if the patient is a care provider for young children (or special needs individuals), in order to prevent panic.
  7. Use caution when approaching a potential Ebola patient, as they may exhibit delirious, erratic, or violent behavior, which could put staff at risk (e.g., flailing, staggering)1.

Protect Yourself and Your Staff:

  1. Utilize a buddy system when donning and doffing Personal Protective Equipment (PPE).
  2. PPE should include SINGLE-USE, DISPOSABLE:
  3. waterproof boot covers (covering to mid-calf)
  4. N95 respirator
  5. full-face shield
  6. surgical hood
  7. waterproof apron (covering full torso to mid-calf)
  8. double gloves (long-cuff, nitrile)
  9. Remove PPE with the greatest of care (as this is the most frequent occasion for self-contamination), utilizing the buddy system to prevent inadvertent exposure, while a separate Containment Monitor observes and documents any potential exposures.
  10. Health Care Providers should perform hand hygiene with Alcohol-Based Hand Rub before and throughout the doffing of PPE.
  11. PPE should be worn during environmental cleaning (utilizing initial HEALTH CARE PROVIDER to limit exposure risk to additional staff), following all guidelines outlined above.4

Conduct a Thorough Interview of the Patient:

  1. Create a timeline for onset of symptoms
  2. Create a detailed and precise travel history (dates, times, places)
  3. Create a thorough and comprehensive 'patient contact list' since the most probable date of symptom onset (remember, a low-grade fever might not have been recognized by the patient for a few days)5

If Immediate Life-Sustaining Procedures MUST* be Performed

* To avoid inadvertent exposure to clinic staff, make an attempt to minimize ANY invasive procedures (including blood-draws) that are not IMMEDIATELY necessary to stabilize the patient 1

The timely transfer of a patient to a designated Ebola-care hospital is preferable to treatment in an Urgent Care or Primary Care setting, due to the superior resources and decontamination protocols in the hospital setting. The CDC indicates the necessity of treatment of other medical conditions (like hypertension and diabetes), as well as the assessment of potential comorbidities/alternate diagnoses; however, the risk of exposure to Urgent and Primary Care staff is greater than at the hospital level, due to the superior sterility of the isolation rooms and lab facilities in the hospital setting (it is unclear if the CDC directive as of October 20, 2014 is directed towards hospitals in particular or towards all potential healthcare points of contact).5

IF, however, medical-stabilizing procedures MUST be performed, the following guidelines should be followed:

  • Use infectious-disease-case-dedicated, preferably disposable, medical equipment
  • Limit the use of needles and other sharps as much as possible and dispose of them in puncture-proof, sealed containers
  • Laboratory testing should be limited to the bare minimum necessary6
  • Limit use of Aerosol-Generating Procedures (AGP) to life-saving functions ONLY* (i.e., open suctioning of airways, endotracheal intubation, cardiopulmonary resuscitation)1, and utilize an N95 respirator and covering head gear
  • Perform frequent gloved-hand disinfection utilizing an alcohol-based hand rub5

If a Health Care Provider (HCP) is Exposed

If PERCUTANEOUS or MUCOCUTANEOUS exposure to blood or body fluids occurs, HEALTH CARE PROVIDER should:

  • Immediately stop working
  • Immediately flush affected skin surfaces with soap and water and/or irrigate affected mucous membranes with copious amounts of water or eyewash solution6
  • Immediately contact the Containment/PPE Monitor for an assessment5
  • Report all exposures to local health department for post-exposure management

Post-Exposure Care:

  • Medical Evaluation
  • Medical Testing (potentially)
  • Fever & Symptom Monitoring/Reporting (2x daily)
  • Work Exclusion (minimum 21 days)6

Due to the exposure issues at Dallas Presbyterian Hospital in early October, it now seems prudent for all Health Care Providers who interact with patients or patient samples to self-monitor for fever and other symptoms for 21 days after the last contact, so that in the event of occult exposure, infected Health Care Providers can receive the earliest diagnosis and treatment (which has proven vital to survival). At the first sign of symptoms, the HEALTH CARE PROVIDER should immediately self-isolate and alert the local health department for monitoring, evaluation, and potential testing.

Responsible Transfer of Patient to Receiving Facility

  • Take transportation direction from the receiving hospital Emergency Department and/or your local or state health department
  • Notify the receiving healthcare facility, so that proper precautions may be prepared in advance of receiving the patient
  • Take note of logistical information from receiving facility, such as where to park (if patient is not to be transported by ambulance, also advise the patient not to mingle with other patients), which entrance to use, etc.1
  • Inform the US Centers for Disease Control and Prevention (CDC), via the 770-488-7100 hotline, or via eocreport@cdc.gov

Reporting Overview

As part of preparation for potential Ebola threats, a short-list of public health reporting contact information is invaluable. I suggest you take the time to find your local contact information, and confirm that it is still OPERATIVE (before you have to use it). Make the information available to all personnel and drill on its use.

Local Health Department:  _________________ 

State Health Department:  _________________ 

Preferred Receiving Facility:  _________________

CDC: eocreport@cdc.gov 770-488-7100

Note from TMA Here are some additional resources to keep handy:

Note:

It is my sincere hope that these plans may be of benefit to my fellow Urgent Care and Primary Care Physicians. I would like to emphasize that the information provided is up-to-date as of the writing of this article, but my expectations are that these suggestions will change often and quickly as the pandemic evolves. We should all strive to keep up with the newest protocol guidelines, as the CDC posts them.

I have chosen the side of caution in deciding which protocol suggestions to include (i.e., a lower fever temperature threshold, the 30-day exposure follow-up criteria over 21-days, the stringent end of exposure reporting), with the expectation that greater vigilance will save more lives.

Our Urgent and Primary Care facilities are in the unique position of being at the frontline to much of the infectious disease presentations in our local communities. Much of our time will necessarily be spent reassuring the "worried well." Let us stay well informed, highly prepared, and calmly vigilant, for the health of our patients and ourselves.

References

1. Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola Virus Disease in the United States. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html. Updated October 21, 2014. Accessed October 21, 2014.

2. Case Definition for Ebola Virus Disease (EVD). Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/case-definition.html. Updated September 5, 2014. Accessed October 21, 2014.

3. Interim Guidance for Monitoring and Movement of Persons with Ebola Virus Disease Exposure. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/monitoring-and-movement-of-persons-with-exposure.html. Updated August 29, 2014. Accessed October 21, 2014.

4. Guidance on Personal Protective Equipment to be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing). Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html. Updated October 21, 2014. Accessed October 21, 2014.

5. When Caring for Suspect or Confirmed Patients with Ebola. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/caring-for-ebola-suspects.html. Updated October 20, 2014. Accessed October 21, 2014.

6. Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Virus Disease in U.S. Hospitals. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html. Updated October 20, 2014. Accessed October 21, 2014.

Additional Resources:

Checklist for Patients Being Evaluated for Ebola Virus Disease (EVD) in the United States. Centers for Disease Control and Prevention Web site. www.cdc.gov/vhf/ebola/pdf/checklist-patients-evaluated-us-evd.pdf. Accessed October 21, 2014.

Tightened Guidance for U.S. Healthcare Workers on Personal Protective Equipment for Ebola. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/media/releases/2014/fs1020-ebola-personal-protective-equipment.html. Updated October 21, 2014. Accessed October 21, 2014.

What You Need to Know about Ebola. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/pdf/what-need-to-know-ebola.pdf. Updated October 16, 2014. Accessed October 22, 2014.

Health Care Workers: Could it be Ebola? Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/pdf/could-it-be-ebola.pdf. Accessed October 22, 2014.

Infographic: Facts about Ebola in the U.S. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/pdf/infographic.pdf. Accessed October 22, 2014.

Author Affiliations:

American Academy of Urgent Care Medicine (Rogers, Weitzman); Booz Allen Hamilton (Buzard); DDC Corp (Weitzman)

Corresponding Author:

Brian B. Rogers, DO, MPH, Board of Directors, American Academy of Urgent Care Medicine. (dr.brianrogers@gmail.com)

Author Contributions:

Drafting of the Manuscript: Rogers, Boyd-Rogers

Critical revision of the manuscript: Weitzman, Buzard

Affiliations:1American Academy of Urgent Care Medicine; 2Booz Allen Hamilton; 3DDC Corp.

Address correspondence to: Brian B. Rogers, DO, MPH, Board of Directors, American Academy of Urgent Care Medicine. [dr.brianrogers@gmail.com]

Short Title: Ebola Protocols in Urgent and Primary Care Settings

Abbreviations: CDC - U.S. Centers for Disease Control and Prevention; PPE - Personal Protective Equipment

Funding Source: No funding was secured for this study.

Financial Disclosure: The remaining authors have no financial relationships relevant to this article to disclose.

Conflict of Interest: The authors have no conflict of interest to disclose.

Contributor's Statement:

Brian B. Rogers and Alexandra Boyd-Rogers: Dr. Rogers and Ms. Boyd-Rogers drafted the initial manuscript and approved the final manuscript as submitted.

David M. Weitzman and Gregory S. Buzard: Drs. Weitzman and Buzard reviewed and revised the manuscript, and approved the final manuscript as submitted.

Nov 9, 2014

A "Bright New Day" for VA Health Care?

(DALLAS) - The issue of veterans’ access to timely health care returned to the American Medical Association House of Delegates this weekend in a far more positive light than it enjoyed five months ago.

In June, in the wake of scandals over excessive wait times in the Veterans Affairs Administration (VA) health care system, the AMA House pushed for President Barack Obama and Congress to make it easier for private practice physicians to care for VA patients. The Texas Medical Association was at the forefront of that fight, led by TMA Delegation Vice Chair Asa Lockhart, MD, of Tyler.

The president has replaced his VA secretary with former Procter & Gamble CEO Robert McDonald, and Congress passed the Veterans Access, Choice, and Accountability Act of 2014. That law will pay private health care providers $10 billion to treat veterans who cannot get VA appointments within 30 days or who live more than 40 miles from a VA health care facility. Another $5 billion will help the VA hire new doctors, nurses, and other medical staff.

The AMA House convened this weekend in Dallas for its first meeting since that debate. Secretary McDonald spent an hour telling delegates about changes in his agency and answering physicians’ questions. From May through September, he said. the agency saw a 46-percent increase in care provided by non-VA physicians; more than 1 million veterans saw doctors outside of the VA system.

The secretary also said the VA is working to reduce the hassles many community physicians have experienced in trying provide care to veterans covered by the VA.

“We need you to participate in the program,” he said. “We know you won’t if it’s too much trouble.”

We caught up with Dr. Lockhart after Secretary McDonald’s speech. He was favorably impressed. “I really see the promise of a bright new day for the veterans’ health system,” he said.