DHQP/CDC Update as of 2/8/19
Initial Triage of Patients
Here are the steps that facilities should implement as a routine part of triage to quickly identify, isolate, and inform public health authorities about patients who may have communicable infections:
- Ask about and document international travel histories at initial triage. This information can alert healthcare personnel to the possibility of communicable infections, such as viral hemorrhagic fevers or emerging respiratory viruses, and other health conditions, such as malaria, that need specific treatment.
- Identify patients who have fever and other signs and symptoms of infection and might warrant isolation pending further evaluation.
- Post contact information in easily visible locations for infection control personnel and the local public health jurisdiction for reporting of communicable diseases.
Current Infection Prevention and Control Recommendations for Ebola Virus Disease in U.S. Healthcare Facilities
CDC recommendations for infection prevention and control for patients with confirmed EVD or persons under investigation (PUIs) for EVD in U.S. healthcare facilities have been recently reviewed and are considered up to date: https://www.cdc.gov/vhf/ebola/clinicians/index.html. To clarify,
- Separate personal protective equipment (PPE) guidance remains in place for the management of Clinically Stable PUIs and Confirmed Ebola Patients or Clinically Unstable PUIs.
- A PPE Calculator Tool is available to assist healthcare facilities in determining the appropriate supply of PPE to have on hand to manage a PUI or patient with confirmed EVD.
The Regional Treatment Network for Ebola and Other Special Pathogens
Healthcare facilities and public health officials should be familiar with the U.S. Regional Treatment Network for Ebola and other special pathogens. This includes facilities understanding their designated role as part of the network, continuing to be willing to serve in that capacity, and maintaining preparedness as a Frontline facility, State-designated Assessment Hospital, State-designated Treatment Center, or HHS Assistant Secretary for Preparedness and Response (ASPR)-designated Regional Treatment Center.
- Healthcare facilities and public health officials should have established plans for how PUIs or EVD patients are to be managed and referred.
- Officials with responsibility for infectious diseases epidemiology and healthcare infection control should be in communication with their preparedness counterparts to ensure mutual understanding of the designations and preparedness status of assessment and treatment centers in their jurisdictions.
- The National Ebola Training and Education Center (NETEC) is co-funded by ASPR and CDC. NETEC has additional online resources and a blog, and remains available to provide on-site readiness assessments to hospitals for Ebola and other special pathogens.
- Main CDC EVD portal: https://www.cdc.gov/vhf/ebola/index.html
- World Health Organization Ebola situation reports: Democratic Republic of the Congo
- CDC Travel Health Notice for the current outbreak in DRC, including special recommendations for healthcare personnel and organizations sponsoring healthcare personnel in the outbreak area.
- The National Institutes of Health (NIH) has an open-label clinical trial, entitled “Pre-Exposure Prophylaxis in Individuals at Potential Occupational Risk for Ebola Virus Exposure” or “PREPARE,” to vaccinate adult volunteers (including deploying healthcare personnel and other responders) against Ebola. Study sites are at NIH in Bethesda, MD, and Emory University in Atlanta, GA.
This information was disseminated 2/8/19 by the Division of Healthcare Quality Promotion (DHQP), Centers for Disease Control and Prevention (CDC).
Ebola: What Nurses Need to Know
Develop a preparedness plan that provides specific information on procedures and protocols to be used in your hospital or healthcare setting for identifying and caring for a patient with Ebola Virus Disease (EVD). A preparedness plan should include:
- Inpatient and ambulatory organizational policies and procedures that are in line with current CDC guidelines.
- Incorporation of appropriate screening criteria to be used during patient registration and triage.
- Rigorous training of all staff in screening procedures and what to do if a patient screens positive for suspected EVD.
- Isolation procedures to be used for patients in the ambulatory setting until transportation to an Emergency Department is facilitated, and isolation procedures to be used in the Emergency Department and inpatient setting if the patient is admitted to the hospital.
- Initial and ongoing face-to-face training plans for staff who may provide direct care to a patient with a confirmed diagnosis of EVD.
- Identification of appropriate isolation rooms and staffing plans to facilitate the care of a patient with EVD.
- Appropriate use of PPE in all health care settings when caring for a patient with a suspected or confirmed diagnosis of EVD emphasizing the importance of proper hand hygiene.
- Environmental cleaning procedures.
- Mechanism to ensure timely reporting to local and public health officials.
The following resources can be used to develop a preparedness plan at your facility:
When using the following resources, please be aware that the CDC issued new Ebola and PPE guidelines on October 20, 2014 and some resources may not yet have been updated with that information.
- CDC & ASPR’s Health Care Facility Preparedness Checklist for Ebola Virus Disease
- CDC & ASPR’s Detailed Emergency Medical Services (EMS) Checklist for Ebola Preparedness
- The Joint Commission: Preparing for Ebola response in U.S. health care facilities http://www.jointcommission.org/issues/article.aspx?Article=aQJBGQFS4EG9dUqpeUCr%2fm5YN5H%2fscKmK%2f6x6Ov0U2A%3d
- The Joint Commission’s Healthcare at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
- OSHA’s Hospital and Community Emergency Response: What You Need to Know
Early Identification of EVD and Transfer to a Higher Level of Care
Early identification of Ebola Virus Disease through effective triage is critical to preventing the spread of infection. Paramedics, RNs, physicians and other personnel employed at health clinics and medical offices may be the first health care professionals to come in contact with patients with suspected Ebola Virus Disease (EVD). The CDC provides the following guidance regarding identification and management of patients with suspected EVD:
- Signs and Symptoms of Ebola
- Ebola Algorithm for the Evaluation of the Returned Traveler
- 10.22.2014 Post-arrival Monitoring for Travelers from Impacted Countries
- Checklist for Patients Evaluated for Ebola in the US
- Case Definition for Ebola
- Caring for a Suspected Ebola Patient
Hospitals may encounter patients with suspected and/or confirmed Ebola Virus Disease (EVD) at any time. Updated CDC guidelines released on October 20th, 2014 remind all health care facilities that a preparedness plan that includes rigorous education, drilling and practice of any staff that directly interact with or care for patients is critical to ensure safe management of patients with EVD, particularly with PPE donning and doffing procedures. No skin, hair or other body parts should be exposed when caring for patient with a suspected or confirmed diagnosis of EVD. In addition, a trained monitor should oversee all PPE donning and doffing procedures. ANA encourages all nurses to use the highest level of PPE recommended by the CDC at all times when in contact with a suspected/confirmed Ebola patient.
- Updated CDC Guidelines (10.20.2014) for U.S. Healthcare Workers – Recommended Personal Protective Equipment for care of patients with suspected or confirmed EVD
- CDC Update on Ebola Response and PPE (10/20/14)
- CDC’s safe management practices of a patient with Ebola in the US, including FAQs
- CDC’s Website for Ebola- Healthcare Workers and Setting
- Video of Emory Hospital’s Ebola Isolation Unit with text story detailing ventilation and air filtering systems
- US Hospitals With Established Biocontainment Units
- Emory University Hospital, Atlanta, Georgia
- National Institutes of Health in Bethesda, Maryland
- Saint Patrick Hospital, Missoula, Montana
- University of Nebraska Medical Center, Omaha, Nebraska
As trusted members of the community, people look to nurses for information about Ebola. The six things nurses should communicate to family, friends and members of the community are:
- Ebola Virus Disease (EVD) is spread through direct contact with the blood and body fluids of someone who has EVD.
- EVD is not spread through casual contact, or through the air, food or water.
- A person infected with EVD can’t spread the disease until symptoms appear.
- Early symptoms of EVD include fever (usually higher than 101.5F), muscle pain, headache, sore throat and abdominal pain.
- If you or someone you know has been to an area known to have confirmed cases of EVD and develops symptoms within 21 days of travel, seek medical care immediately.
- There is no vaccine against Ebola, However, you can protect yourself by washing your hands frequently and avoiding contact with blood, urine and other body fluids of someone who is at risk for, or sick with Ebola.
Use these resources to educate, dispel myths, and address concerns:
- http://www.cdc.gov/vhf/ebola/resources/infographics.html (Resources available in multiple languages.)
- CDC-Information for West Africans Living in the US
Right to Refuse
ANA believes nurses are obligated to care for patients in a non-discriminatory manner, with respect for all individuals, yet ANA also recognizes there may be limits to the personal risk of harm nurses can be expected to accept as an ethical duty.
ANA strongly encourages nurses to speak up if they believe there is inadequate planning, education or treatment related to providing care to these or any patients, and seek to resolve any conflicts of risk and responsibility swiftly. Nurses should have the right to refuse an assignment if they do not feel adequately prepared or do not have the necessary equipment to care for Ebola patients. .
Isolation, Monitoring, and Quarantine
Isolation and Active Monitoring
The Centers for Disease Control and Prevention defines isolation as “the separation of an individual or group who is reasonable believe to be infected with a quarantinable communicable disease” from those who are not infected.
- CDC has released detailed guidance based on different levels of risk. See table.
- CDC recommends that people at risk for developing Ebola isolate themselves from others for 21 days. This includes restriction from traveling on airplanes and avoidance of public transportation and places where people congregate.
- CDC is also recommending a 21-day active monitoring period for all people with any level of potential exposure to Ebola. Through active monitoring, public health workers check-in with people at least once a day to monitor for fevers or other symptoms of Ebola. In addition, those being monitored must take their temperature two times each day and watch for symptoms.
- Direct active monitoring, which involves in-person observation, may be recommended for people with higher risks of exposure.
- Public health orders for mandatory direct active monitoring and restrictions on movement may be used to ensure compliance.
CDC defines quarantine as the “separation of an individual or group reasonably believed to have been exposed to a quarantinable communicable disease, but who is not yet ill, from others who have not been so exposed, to prevent the possible spread of the quarantinable communicable disease.”
Some states have issued mandatory quarantine of health care workers returning from West Africa. In these instances individuals are required, sometimes forcibly, to remain in their homes or a medical setting for 21 days. ANA asserts that the decision to restrict the movement of person potentially exposed to Ebola should be left to public health officials. Mandatory quarantine of all health care workers returning from Africa will only increase the level of fear and misinformation that currently exists.
Highlights from Partner Organizations
Best Practice Resources
CDC Ebola Key Messages (2.25.15)
Emergency Department Training Videos (2.17.15)
State Ebola Protocols (12.18.14)
CDC's Ebola Response Team (12.2.14)
CDC Video on Respiratory Protection (11.12.14)
Web-Based PPE Training (10.31.14)
NIOSH Training for Emergency Responders (12.8.14)
CDC Infographic – Is it Flu or Ebola? (10.29.14)
Decker, D., Sevransky, J., Barrett, K. Davey, R. & Chertow, D. (2014). Preparing for critical care services to patients with ebola. Retrieved from http://annals.org/article.aspx?articleid=1910124
Fishcer, W., Hynes, N. & Perl, T. (2014). Protecting health care workers form ebola: personal protective equipment is critical but is not enough. Retrieved from http://annals.org/article.aspx?articleid=1900481
Isakov, A., Jamison, A., Miles, W., Ribner, B. Safe management of patients with serious communicable diseases: Recent experience with ebola virus. Retrieved from http://annals.org/article.aspx?articleid=1906849
Preston, R. (2014, October 27th). The ebola wars. The New Yorker. Retrieved from
Wolz, A. (2014). Face-to-face with ebola—an emergency care center in Sierra Leone. Retrieved from https://www.nejm.org/doi/full/10.1056/nejmp1410179.
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