1. Core Lab Response to Ebola

2. Laboratory and JHH Response to Ebola is an Ever Evolving Process Please note changes are constantly taking place as discussions occur within the entire health care environment.

3. Communication Low Risk and High Risk Patient in the Hospital. Communications will come through Customer Service.

7. Obtaining a Sample for Laboratory Testing ER will contact HEIC before collecting samples. All testing must be approved by faculty and HEIC. Only essential approved tests will be performed. Specimens clearly labelled and sent to BSL-3 Lab Wipe samples down with 10% bleach, double bag,,wipe bags down with 10% bleach and place in special transport container. Specimens delivered directly to Micro BSL-3 Lab.

8. No Ebola Samples in Core Lab Do not accept Ebola samples at window. Phlebotomy will not collect samples Samples are never to be sent through the pneumatic tube system. Samples go to Micro BSL-3 Lab for testing. We will escort person carrying samples to the Micro BSL-3 lab.

9. Where do samples go? BSL-3 Biosafety Micro Lab-Meyer-B-171 Special Lab for dealing with dangerous pathogens. Special engineering and design requirements. Ducted exhaust air ventilation system draws air from clean to contaminated area. Air discharged outside after going through high efficiency air filter (99.97% of all 0.3 micron particles removed). All activities performed under hood and all personnel covered with PPE and air ventilation devices. Scientists work in teams to reduce chances of self contamination. Decontamination of PPE with 10% bleach, double red bag of waste materials and autoclave discarded materials.

10. Tests performed in BSL-3 lab. Test menu options based on recommendations by New York State, CDC, Emory University and JHH. Training of micro personnel by Core chemistry, hematology, coagulation and point of care staff and leadership. SOFT training and support by Jayesh All testing currently performed by micro personnel.

11. Test Menu Only tests on menu will be performed. Paper requisitions will be used for ordering tests.

12. Hematology- Sysmex XS-1000i and POUCHi CBC w/Electronic Diff Platelet estimate Slide for DIC

13. Chemistry GEM 4000 Blood gas (arterial and venous) Sodium Potassium Chloride Ionized calcium Glucose Bilirubin, Total Lactate Hemoglobin Oxyhemoglobin Carboxhemoglobin Methemoglobin Oxygen Saturation Base Excess of Blood

14. Coagulation Testing- Hemochron Signature Elite Protime Aptt Blood film screen for DIC

15. Urinalysis Urine Dip Stick Specific Gravity

16. Microbiology Malaria Thin Smear

17. Chemistry Analyzer for Liver Enzymes- Piccolo Alkaline Phosphatase Alanine Aminotransferase Aspartate Aminotransferase Creatinine Magnesium Phosphorus

18. Transfusion Medicine No pretransfusion testing Type O negative red cells Group AB plasma products

19. General Lab Comments Specimens should be labelled to indicate they came from Ebola patient. Lab testing should be limited to the lab menu. Log should be kept of lab personnel exposed to Ebola cases. Specimens transported within the hospital should be transported in a biohazard approved transportation container. Never send these samples through the pneumatic tubes Bacterial cultures should not be performed. If blood culture is needed use plastic bottles.

20. Ebola waste must be autoclaved Retention of specimens is discouraged. It is recommended that Ebola samples be isolated and disposed of as soon as possible. Any waste material that has come from an Ebola patient or come in contact with Ebola body fluids must be double red bagged, wiped with 10% bleach and autoclaved before disposal.

21. Core Lab Support through education * JHH updates and town meetings. Mandatory PPE lab in-services by HEIC Centralized Lab bulletin board. HEIC link on Core Lab website. HEIC assessment of lab safety Continuous updates and recommendations from established Ebola centers.

22. What is our big worry? “The elephant in the room” An Ebola sample comes to our lab. What if I didn't know it was an Ebola sample? What do I do?

23. Sample of low or high risk comes to lab without our knowledge. Samples run on TLA, Sysmex, BCS and Access. BMP, Heme-8 and diff, PT, APTT and troponin. HEIC has confirmed that your BSL2 safety lab coat, gloves and face shield worn properly at all times is sufficient. Note: The Dallas lab which had no infected lab scientists, ran the Ebola samples in their Core Lab using BSL-2 safety precautions.

24. Customer Service gets call from HEIC that a high/low risk patient sent to lab in error. What do we do: Customer service notifies CLS supervisor on sight. Supervisor talks with HEIC and contacts a Core Lab director. Customer Service activates phone tree and supervisor begins to collect the following information: sample received time, instrumentation utilized, personnel handling samples. In the event of an employee exposure, call 5-STIX and HEIC and report the route of exposure. Each area where sample was run is temporarily shut down until decontamination cleaning can take place.

25. What to do. Staff at affected analyzers and work areas take off current lab coats, gloves, face shields and place them in red bags. Wipe shoes with 10% bleach. Wipe outside of bags with 10% bleach and double bag in red bags. Wipe 2 nd red bag with 10% bleach. Place red bags in holding area. Wash hands. Put on disposable tear away fluid resistant yellow gowns, double glove (one under and one over coat cuff), clean face shields, face mask and disposable boots.

26. What to do. * Follow sample path by wiping all counters and instruments with 10% bleach or bleach dispatch wipes. Any heavily used or blood soiled areas soak with bleach wipes for 10 minutes. * Suspect patient samples and aliquots should be isolated into small red biohazard bag or small biohazard containers. Wipe each with 10% bleach. Set aside in holding area. Shut down or mask analyzers used by suspect samples, as time permits, take instrument through decontamination procedures after consulting with supervisor or director. Mop floors with 10% bleach. Rinse mop and let it soak for 10 minutes in new 10% bleach before rinsing it again and allowing it to dry.

27. What to do. Once cleaning is complete, discard yellow gown, gloves, face shields, face masks, boots and cleaning waste into red bag. Wipe shoes with 10% bleach. Wipe outside of red bag with 10% bleach wipes and place another red bag over this red bag. Again wipe with 10% bleach. Red bag will be isolated by setting aside. May or may not need to be autoclaved. Wait for supervisor to re-instate testing, on any analyzers requiring decontamination. Change into clean lab coat, gloves, face shield where applicable and return to work as usual. If highly suspect case, place clothes in double red bag, shower and wear disposable gowns.

28. Work in Progress HEIC PPE for all staff HEIC lab risk assessment Lab procedures Training of BSL-3 staff Development of Osler -8 Ebola unit