Interim Guidance for Preparing Frontline Healthcare Facilities for Patients Under Investigation (PUIs) for Ebola Virus Disease (EVD)

Key Points

Frontline healthcare facilities should, in coordination with local and state health authorities, be able to

• Rapidly identify and triage patients with relevant exposure history AND signs or symptoms compatible with EVD as outlined in CDC’s guidance for Emergency Department Evaluation and Management for Patients Under Investigation (PUIs) for Ebola Virus Disease (EVD).
• Immediately isolate any patient with relevant exposure history and signs or symptoms compatible with EVD and take appropriate steps to adequately protect staff caring for the patient, including appropriate use of personal protective equipment (PPE). If the patient has vomiting or bleeding follow the PPE guidance for confirmed Ebola patients or PUIs. If the patient is clinically stable, and is not vomiting or bleeding, follow the PPE guidance for clinically stable persons under investigation for Ebola.
• Immediately notify the hospital/facility infection control program, other appropriate facility staff, and the state and local public health agencies that a patient has been identified who has relevant exposure AND signs or symptoms compatible with EVD; discuss level of risk, clinical and epidemiologic factors, alternative diagnoses, plan for EVD testing, and plan for possible patient transfer to another facility and further care.
• Frontline healthcare facilities should consider, in coordination with state and local health authorities and according to the state’s plan, transferring the patient to an Ebola assessment hospital that can provide Ebola testing and care until an Ebola diagnosis is either confirmed or ruled out. Patients who are deemed to have low likelihood of EVD on the basis of clinical and epidemiologic factors and who have mild illness, but who nonetheless require Ebola virus testing, may, in some circumstances, remain at the frontline healthcare facility while testing is conducted.
• Patients with confirmed EVD should be transferred to an Ebola treatment center.

This document is intended to guide Ebola preparedness efforts by frontline healthcare facilities and state and local health departments. This tier includes most U.S. acute care facilities (acute care hospitals, other emergency care settings including urgent care clinics, critical access hospitals). Frontline healthcare facilities should be prepared for the low likelihood that they might need to evaluate a person arriving with EVD-like symptoms who has a recognized potential exposure to Ebola. Frontline healthcare facilities should make sure they are prepared to identify and isolate PUIs immediately and promptly inform state and local public health authorities so care is not delayed for these patients. This guidance includes a summary of the necessary EVD training and resources needed for those facilities.

Identify

All frontline healthcare facilities should ensure that facility-specific protocols and procedures are in place to rapidly identify and isolate persons with a travel or exposure history and signs and symptoms of Ebola. They should follow recommendations in CDC’s guidance for Emergency Department Evaluation and Management of Patients Under Investigation (PUIs) for Ebola Virus Disease (EVD). State and local public health departments are actively monitoring people with a recognized EVD exposure risk within the last 21 days (CDC’s Interim U.S. Guidance for Monitoring and Movement of People with Potential Ebola Virus Exposure). Therefore, these people will be directed to designated facilities for evaluation if they become ill, making it unlikely that patients with unrecognized EVD disease will present to a frontline healthcare facility without warning. However, it is also possible that people with unrecognized EVD will present to a frontline healthcare facility unannounced, or rarely, patients may be temporarily referred to frontline healthcare facilities when it is not feasible to refer to an Ebola assessment hospital or treatment center (for example, based on distance, bed availability, or other considerations).

Isolate

A PUI should immediately be placed in a private room with an in-room bathroom or covered bedside commode. For clinically stable patients without vomiting, copious diarrhea, or obvious bleeding, healthcare workers should, at a minimum, use PPE in accordance with CDC’s guidance for clinically stable PUIs. If the patient is exhibiting obvious vomiting, copious diarrhea, or obvious bleeding, or presents with a clinical condition that warrants invasive or aerosol-generating procedures, hospitals should use PPE recommended for care of hospitalized patients with EVD. Frontline healthcare facilities should discuss with public health authorities the possibility of immediate transfer of these patients to an Ebola assessment hospital or to an Ebola treatment center, considering the patient’s condition, facility’s capacity, and risks to the health of the patient and staff (for example, if untrained in proper PPE use and infection control procedures) to manage the patient on site.

Inform

After isolating the patient, the hospital/facility infection control staff and state/local health department should be notified immediately according to state protocols. Frontline healthcare facilities should consult with the state/local health department to determine the need for EVD testing, and, if testing is indicated, determine where the patient should be cared for while EVD testing is being performed. Frontline healthcare facilities should consider, in coordination with state and local health authorities and according to the state’s plan, transferring the patient to an Ebola assessment hospital that can provide Ebola testing and care until an Ebola diagnosis is either confirmed or ruled out. In some circumstances, patients who have a low likelihood of EVD based on clinical and epidemiologic factors and who present with mild symptoms but who nonetheless require EVD testing, may remain at the frontline healthcare facility while initial testing is being performed, according to the state’s plan. For patients who have a high probability of EVD or who are more severely ill, direct referral to an Ebola treatment center could be considered, based on the state’s plan. All frontline healthcare facilities should be aware of the closest Ebola assessment hospitals and Ebola treatment centers and have an established plan for patient transport in the unlikely event that this becomes necessary. When the decision has been made to transport a patient, preparations should ensure that transport providers are aware of the patient’s status and have appropriate training and PPE to safely transport the patient. See CDC’s additional guidance on patient transport.

All states are strongly encouraged to consider identifying Ebola assessment hospitals; however, in geographic areas where state and local public health authorities have elected not to identify or designate Ebola assessment hospitals, all hospitals should plan, in coordination with state and local authorities, for adequate staff training and PPE supplies if a PUI has to be managed. In this instance, frontline healthcare facilities should have plans in place to safely collect, package, and transport laboratory specimens for PUIs, if needed. If frontline healthcare facilities cannot immediately transfer the patient to another facility, they should also have plans in place to ensure that routine laboratory tests needed to determine alternative diagnoses are performed while the patient is evaluated for EVD.

Resources Needed

The number of staff with direct patient contact should be minimized, and cross-training should be considered where appropriate. Staff members involved in or supporting patient care should be trained for their roles and demonstrate proficiency in putting on (donning) and taking off (doffing) of PPE, infection control practices, and proper waste management. Hospitals should provide ongoing training and address breaches in infection control through retraining. All hospitals should conduct a PUI practice drill and correct any identified gaps. Plans should be in place for safe, temporary storage of Category A infectious waste until Ebola testing is completed. The facility has a process for continuous staff input from those who may or may not be directly involved in the care of PUIs, including from employee unions, and has addressed employee safety questions and concerns.

It is unlikely that frontline healthcare facilities will be required to provide prolonged care (>12–24 hours) for a severely ill patient at high risk for EVD. Accordingly, most patients can be cared for in these hospitals using PPE in CDC’s guidance for clinically stable PUIs. Plans for PPE supplies in frontline facilities should focus on ensuring adequate stock of gloves, gowns, surgical facemasks, and face shields, and ensuring that all staff are regularly trained on its use. In the unlikely event that PPE recommended for care of hospitalized patients with EVD is needed, frontline healthcare facilities may want to have access to PPE sufficient for 12 to 24 hours of care and ensure that all healthcare workers who may be required to use PPE for EVD should be trained for their roles in the care of patients with EVD and have demonstrated proficiency in use of PPE, including donning and doffing.

Frontline healthcare facilities should work with their state and local public health departments, emergency medical services providers, and other relevant partners to develop plans for interfacility transport to a state-designated Ebola assessment hospital or an Ebola treatment hospital. The state plan may also include plans to transfer the patient out of state based on the patient’s risk and severity of illness and the geographic location of Ebola assessment hospitals and Ebola treatment centers. These plans should include identifying transport provider(s) with appropriate training and PPE to safely transport a patient. Finally, all frontline healthcare facilities should conduct a first-patient drill or exercise to review and practice procedures and identify potential gaps in readiness.