Interim Recommendations for Ambulance Service Providers in West African Areas with Ebola Outbreaks

Key Messages

• If possible, use dedicated ambulances for PUIs for EVD; try not to use vehicles that transport patients with other illnesses or injuries. Ebola call centers should screen callers for signs and symptoms of EVD and ensure the correct type of vehicle is dispatched.
• Ambulance team members should be trained in the proper use of personal protective equipment (PPE) and basic infection control.
• Vehicle cleaning and decontamination teams are an essential part of infection control and ambulance service during the Ebola outbreak. Teams should be stationed at Ebola care facilities and at the central ambulance maintenance depot.

Ambulance Team Members and Location

• Ambulance teams should consist of at least two people. There should be a driver plus at least one other person to help with patient transport.
• Vehicle cleaning and decontamination teams should be stationed at Ebola care facilities and the central ambulance maintenance depot.

Ambulance Setup

• Ambulances should be divided into two separate areas:
  • Front cab ("clean" zone)
  • Back cab ("contaminated" zone)
• Seats and surfaces of the vehicle should be covered with plastic or other easily cleanable materials.
• The following list of equipment should be in the ambulance. A supply checklist should be completed daily to make sure that enough supplies are in the vehicles.
  • Recommended supplies to be stored in the front cab:
    • Disposable (these should be thrown away after use)
      • Latex gloves
      • Gowns
      • Aprons
      • Face shields
      • Face masks
      • Shoe covers
      • Towels or absorbent pads
    • Reusable (these items should be appropriately disinfected after use)
      • Scissors
      • Heavy reusable outer utility gloves (for cleaning the vehicle)
      • Goggles
      • Rubber boots
      • Hand sprayers with mild (0.05%) chlorine solution (labelled and made new daily)
  • Recommended supplies stored in the back cab:
    • Basic stretcher covered with plastic or other material that does not allow fluid to pass through
    • Thin mattress pad covered with plastic or other material that does not allow fluid to pass through
    • Liquid waste bucket with a small amount of strong (0.5%) chlorine solution and tight-fitting lid
    • Biohazard waste bags or buckets with tight fitting lids, one each for disposable waste (for example, latex gloves) and reusable equipment (for example, googles)
    • Disposable towels or absorbent pads
    • Hand sprayers with mild (0.05%) and strong (0.5%) chlorine solution. These should be labeled and made fresh each day. Strong (0.5%) chlorine solution is a sufficient disinfectant for cleaning spills of body fluids¹.
    • Oral rehydration solution sachets and safe drinking water in bottles for passengers

PPE

• Appropriate PPE (gloves, gown, apron, goggles or face shield, face mask, rubber boots or shoe covers) should be worn any time a team member (including drivers) anticipates direct contact with PUIs or their body fluids, a caregiver, or their personal belongings.
• PPE should be counted and stocked at least daily, and stored in the front cab of the ambulance.
• All ambulance team members should receive training on putting on (donning) and removing (doffing) PPE before starting to work as an ambulance team member.
• PPE should be put on and removed under the supervision of a partner. Putting on and removing PPE should be performed per World Health Organization (WHO) Guidelines¹.
• All team members should wash their hands with soap and water or an alcohol-based hand rub containing at least 60% alcohol immediately after removing PPE. Use soap and water if hands appear dirty.
• Whenever possible, use disposable PPE and equipment. Reusable PPE requires cleaning and decontamination. Disposable PPE should be discarded after each use.

Infection Control Precautions

• Appropriate PPE should be worn any time a team member will have direct contact with PUIs or their body fluids, a caregiver, or their personal belongings.
• Ambulance personnel should touch PUIs (or their personal belongings) only as needed to help the patient into the ambulance.
• Patients, caregivers, and their personal belongings should not be allowed into the front cab of the ambulance; they should stay in the back cab.
• Used PPE should not enter the front cab of the ambulance; PPE should be removed and hands washed prior to getting into the front cab.  Used PPE should be discarded in tightly covered buckets or biohazard bags and these containers should be in the back cab of the ambulance. Separate containers should be used for reusable and disposable PPE.
• Avoid procedures that can splash infectious material (for example, moving liquid waste from one container to another).
• Cell phones and other personal items belonging to the ambulance team may be kept in the front cab of the ambulance, but should not come in contact with the patients, caregivers, contaminated surfaces on the outside or in the back cab of the ambulance, or used PPE (for example, gloved hands after contact with a patient).

Transport Procedures of PUIs

• Ambulance team members should not provide care in the home to PUIs.
• Patients and families should be told which Ebola care facility the patient will be taken to.
• Patients who can walk on their own should get in the back cab of the ambulance on their own without touching the outside of the vehicle.
• The ambulance team should help patients who cannot walk on their own. The ambulance team should wear appropriate PPE if they help the patient.
• Patients should be given a clean, disposable gown to wear in the ambulance, but they do not need to wear other types of PPE.
• Caregivers may come with sick children. Caregivers should be provided PPE (face mask, gown, single pair of gloves, shoe covers) and given help on how to put on and remove the PPE.
• Patients and caregivers should be transported only in the back cab of the ambulance.
• Personal items belonging to patients and caregivers should be kept to a minimum and placed only in the back cab of the ambulance.
• Patients should be provided a water bottle containing safe drinking water and oral rehydration solution (ORS).
• Provide a bucket with a tight-fitting lid and containing a small amount of strong (0.5%) chlorine solution to patients with vomiting and instruct them to vomit into the bucket.
• Do not use needles or other sharps when the ambulance is moving.
• Take only one patient at a time in the back cab of the ambulance (if possible).
• If it is necessary to take more than one patient in the ambulance (for example, several people from one household)
  • "Wet" cases, meaning those patients who are producing body fluids, such as vomiting or bleeding should not be transported with "dry" cases, meaning those people who are not vomiting or producing other body fluids.
  • Patients who are vomiting, bleeding, or producing other body fluids should be taken to the Ebola care facility first.  The ambulance should come back or another ambulance should be dispatched to transport the other patients.

Communicating with the Ebola Care Facility

• The ambulance team should notify the receiving Ebola care facility by phone or radio prior to arrival so that staff is ready to help the patient.
• Patients and caregivers should be helped from the ambulance as soon as possible by staff (wearing PPE) from the receiving Ebola care facility. The ambulance team should not be expected to put on PPE and help the patient upon arrival.

Vehicle Cleaning, Decontamination, and Maintenance

• Cleaning and decontamination of the back cab of the ambulance happens in two locations: the Ebola care facility and the centralized ambulance maintenance depot. Cleaning and decontamination of the front cab of the ambulance occurs only at the centralized depot (unless a breach in infection control procedures has occurred).
• The Ebola care facility should
  • Have a designated cleaning team that performs cleaning and decontamination of the outside surfaces and inside of the back cab (including stretchers, railings, any medical equipment control panels, floors, walls, and work surfaces) of the ambulance between patients. 
  • Check for needed equipment (including PPE) and restock supplies (including drinking water, ORS, and chlorine solutions) at least daily. A log book should be used to track equipment use.
• The centralized ambulance maintenance depot
  • Should be fenced off as an isolation zone so that water and waste are collected and disposed of appropriately².
  • Is responsible for cleaning and decontamination, maintenance, and inventory and restocking of supplies.  A log book should be used to track equipment use.
  • Perform maintenance on vehicles (for example, changing oil) only after they have been cleaned and decontaminated.
  • Park vehicles at the centralized vehicle maintenance depot in designated areas when not being used.
• Vehicle Cleaning and Decontamination Procedure
  • Cleaners should wear appropriate PPE (heavy utility gloves, gown, apron, goggles or face shield, face mask, rubber boots or shoe covers)¹. A partner or supervisor should ensure that PPE is put on and removed per WHO Guidelines¹.
  • Clean “clean” areas first (such as front cab if at maintenance depot) and then “dirty” areas (back cab) in order to avoid contaminating clean areas¹.
  • The front cab should be cleaned and decontaminated at least once daily at the centralized vehicle maintenance depot.  If the ambulance team determines that the front cab has become contaminated, cleaning and decontamination should be performed at the receiving Ebola care facility prior to returning to the depot.
  • Clean and disinfect surfaces or objects contaminated with blood or other body fluids as soon as possible.  Organic matter (blood, vomit diarrhea) on surfaces or objects should be cleaned with a disposable towel or pad before applying disinfectant. This will prevent inactivation of the disinfectant by the organic matter. Strong (0.5%) chlorine solution is a sufficient disinfectant¹.
  • High-pressure cleaning and decontamination of the ambulance is not recommended.

Management of Waste

• Waste includes medical equipment, sharps, linens, soiled towels or absorbent pads, used PPE, and cleaning materials. Waste should be handled or disposed of by the receiving Ebola care facility per facility protocol or WHO guideline.^1,3.
• The ambulance team should obtain appropriate waste containers:
  • Puncture-resistant sharps container.
  • Thick leak-proof biohazard waste bags (i.e., 75 microns) should line buckets with tight-fitting lids for disposable waste and reusable equipment. Teams should use two bags if thick bags are not available.
  • Liquid waste bucket with a small amount of strong (0.5%) chlorine solution and tight-fitting lid ("vomit bucket")
• Used reusable patient care equipment should be placed in biohazard bags and labeled for cleaning and decontamination by the receiving Ebola care facility.
• Keep sharps separate from other waste and place in puncture-resistant, biohazard labelled containers.
• Collect all solid, nonsharp waste in thick biohazard bags that line covered waste bins.
• Used disposable PPE (for example, gloves) or other used disposable equipment should be collected by the receiving Ebola care facility and disposed of in a medical waste container per facility protocol or WHO Guidelines.
• Used reusable PPE (for example, goggles) or other used reusable equipment (for example, mattresses) should be collected by the receiving Ebola care facility and cleaned and decontaminated per facility protocol or WHO guidelines. When collected, they should be clearly labelled and transported in leakproof material (bags, buckets) to avoid cross-contamination³.
• Soiled linen should be placed in clearly labelled, leakproof bags or buckets and set aside for laundry or disposal (for example, incineration)¹.
• Sharp containers and waste bags should be filled only 3/4 full. Containers and bags should be closed and transported to the receiving Ebola care facility before they are completely filled, so that they can be closed securely. Close bags using a swan neck technique (twist firmly, double over, and then seal with a plastic tie) to help prevent liquids from seeping out.
• Surfaces of containers should be disinfected (using strong [0.5%] chlorine) before removal from the ambulance and before replacing bags in waste containers.
• Waste, such as feces, urine, and vomit should be contained in a bucket with a tight-fitting lid and containing a small amount of strong (0.5%) chlorine solution. The receiving Ebola care facility should dispose of the waste according to facility protocol or WHO guidelines.

References

1. WHO Guidelines: Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola.
2. WHO Guidelines: Ebola virus disease (EVD) – Key questions and answers concerning water, sanitation and hygiene [PDF – 5 pages].
3. WHO Guidelines: Section 5 Disinfect Reusable Supplies and Equipment [PDF – 27 pages].