1. ALLIANCE Regional Ebola Update & PPE Training October 2014 www.odemsa.vaems.org OLD DOMINION

2. ODEMSA 2014 Regional Ebola Update & PPE Training Presented by: ODEMSA Staff: Adam Alford, ODEMSA Education Coordina tor Holly Sturdevant, ODEMSA Special Project Coordinator Rachel Dillon, ODEMSA Program Coordinator Damien Coy, ODEMSA Field Coordinator Heidi Hooker, ODEMSA Executive Director

3. ODEMSA 2014 Regional Ebola Update & PPE Training To provide: Ebola facts ODEMSA Ebola Virus Disease “EVD” Guidelines for EMS Providers Donning/Doffing and disposal of Personal Protective Equipment (PPE) Oct 2014 3 Purpose

4. ODEMSA 2014 Regional Ebola Update & PPE Training Oct 2014 4 Ebola Facts

5. ODEMSA 2014 Regional Ebola Update & PPE Training Facts Regarding Ebola… Commonly referred to as “EVD,” or Ebola Virus Disease On August 6, 2014 members of the World Health Organization (WHO) officially declared Ebola a public health emergency of international concern. Currently, the US has seen 4 cases with one death * This number may change daily*

6. ODEMSA 2014 Regional Ebola Update & PPE Training Signs and Symptoms: –Fever –Severe Headache –Muscle Pain –Weakness –Diarrhea/Vomiting/Abdominal Pain –Unexplained Hemorrhage (Bleeding or Bruising) Symptoms may appear anywhere from 2-21 days after exposure to active EVD.

7. ODEMSA 2014 Regional Ebola Update & PPE Training EVD Transmission –Animal-to-person It is believed that the first case of human contracted EVD was transmitted from an infected animal to a susceptible host –Person-to-person Once EVD is contracted in a human, the host can easily spread the virus through direct contact

8. ODEMSA 2014 Regional Ebola Update & PPE Training The human body produces many body fluids, secretions and excretions that may contain pathogens - avoid direct contact with: Blood or body fluids –Potentially infectious body fluids include: blood, vomit, feces, urine, sputum, saliva, and sweat, as well as amniotic, spinal, vaginal, pleural, pericardial, peritoneal, synovial fluids and semen ***To prevent exposure, ANY body fluid from any patient must be treated as potentially infectious!*** Objects like needles & syringes that have been contaminated with EVD Infected fruit bats or primates

9. ODEMSA 2014 Regional Ebola Update & PPE Training During outbreaks of Ebola, the disease can spread quickly within healthcare settings. Healthcare workers should use the following precautions when treating EVD patients: Standard Precautions (ALL patients) Contact Precautions (“blood/body fluid”) Droplet Precautions (think “flu”)

10. ODEMSA 2014 Regional Ebola Update & PPE Training All patients, all the time, any setting Minimum PPE required: –Disposable Gloves Hand Hygiene Additional PPE, as needed, to protect against blood, body fluids, secretions & excretions: –Eye protection (goggles or face shield) –Respiratory protection (surgical face mask) –Impermeable or fluid-resistant gown Oct 2014 10 Standard Precautions

11. ODEMSA 2014 Regional Ebola Update & PPE Training Protection against viruses (such as Ebola), Influenza, HIV, Hepatitis; plague, MRSA, VRE, Strep; patients with diarrhea, vomiting, or generalized rash Minimum PPE Required –Disposable Gloves (change if visibly soiled) –Gown Hand Hygiene Disinfection of all equipment/surfaces –Examples: monitor, glucometer, BP cuff, etc. Oct 2014 11 Contact Precautions

12. ODEMSA 2014 Regional Ebola Update & PPE Training Large particles created by coughing, sneezing, suctioning or intubation Disease examples: Influenza, meningitis, pertussis, plague, Ebola, mumps, rubella, and most viruses (including Enterovirus D68) Any patient with fever, respiratory symptoms, rash, and/or flu-like signs/symptoms, such as weakness, vomiting, diarrhea, severe headache, abdominal pain, or muscle and body aches Oct 2014 12 Droplet Precautions

13. ODEMSA 2014 Regional Ebola Update & PPE Training Hand Hygiene Minimum PPE required: –Gloves –Gown –Eye Protection –Bonnet –Leggings/Boot Covers (or Shoe Covers) –Respiratory Protection…. Oct 2014 13 Droplet Precautions

14. ODEMSA 2014 Regional Ebola Update & PPE Training What level of respiratory protection? Healthcare Providers (with eye protection): –At least standard surgical face mask –N95 mask for “Aerosol-Generating Procedures” or other high-risk procedures (e.g. CPR) See UTSW/BioTel TB 14-007 PPE Patient (especially if coughing or sneezing): –Standard surgical face mask or N95, if tolerated –Add Nasal Cannula O 2, if supplemental oxygen needed Oct 2014 14 Droplet Precautions

15. ODEMSA 2014 Regional Ebola Update & PPE Training Oct 2014 15 ODEMSA Ebola Virus Disease “EVD” Guidelines for EMS Providers

16. ODEMSA 2014 Regional Ebola Update & PPE Training Compiled by a Regional Team of Experts: EMS Professionals Fire Service Professionals Hospital Administrators Epidemiologist Hazardous Materials Specialists Educators

17. ODEMSA 2014 Regional Ebola Update & PPE Training Agencies MUST work with their local health department and Operational Medical Director to develop patient care plans. This is a fluid situation – be flexible as there may be frequent changes Changes made to this document will be posted to our website

18. ODEMSA 2014 Regional Ebola Update & PPE Training Dispatch Centers – PSAP’s should screen calls for potential Ebola patients- PRIOR to YOUR Arrival “EVD ALERT” has been designated as the regional alert to be used by pre- hospital

19. ODEMSA 2014 Regional Ebola Update & PPE Training Each agency should inventory available supplies and ensure an adequate supply ODEMSA is conducting a regional needs assessment. You WILL be contacted by ODEMSA staff

20. ODEMSA 2014 Regional Ebola Update & PPE Training Ensure an adequate supply, for EMS personnel, of: Fluid resistant or impermeable gowns Double layer of gloves Shoe covers, boots, and booties All of the following: N95 respirators or greater (i.e. APR, PAPR, SCBA) Eye protection Fluid/splash shield (in addition to eye protection and N95 mask) Other infection control supplies (e.g. hand hygiene supplies) We will always use the current CDC recommendations

21. ODEMSA 2014 Regional Ebola Update & PPE Training Don full PPE Limit exposed personnel Only allow the patient and protected providers in patient compartment Cab of ambulance MUST remain clean Seal cab compartment Driver should not participate in patient care

22. ODEMSA 2014 Regional Ebola Update & PPE Training Information to Convey to Hospital Notify hospital as soon as you identify a potential case Use “EVD ALERT” trigger Describe Patient Low Acuity – Delay transport High Acuity – Transport Hospital personnel may provide care until they are ready to receive the patient EMS might be asked to assist hospital personnel

23. ODEMSA 2014 Regional Ebola Update & PPE Training When arriving at the hospital: You may be directed to park in an area away from other traffic Remain in the ambulance and await direction from the hospital staff.

24. ODEMSA 2014 Regional Ebola Update & PPE Training Patient Refusal or Pronouncement: Report to your local Health Department by calling 866-531-3068 Ask for the Epidemiology Investigator on call They will give instruction Connect you with local team

25. ODEMSA 2014 Regional Ebola Update & PPE Training If a Patient Reports to Your Facility: Do NOT allow them inside Resources should be dispatched like any other medical emergency Wear appropriate PPE before patient contact

26. ODEMSA 2014 Regional Ebola Update & PPE Training Doffing – PPE Removal: MOST Exposures Occur during PPE Removal Use a “Buddy System” EMS Providers – Await Decontamination Assistance from Hospital Personnel. Hospital Will Provide a Change of Clothing

27. ODEMSA 2014 Regional Ebola Update & PPE Training Equipment/Ambulance Decontamination and Disinfection: Plans should be made in advance Suggest Local HazMat response 3rd Party Decontamination Company

28. ODEMSA 2014 Regional Ebola Update & PPE Training Post-Exposure: Follow Instructions from your OMD and VA Department of Health Self-Monitor for Fever If your patient is Ebola positive, monitor for EVD symptoms for 21 days in conjunction with VDH and CDC

29. ODEMSA 2014 Regional Ebola Update & PPE Training Oct 2014 29 Donning/Doffing PPE

30. ODEMSA 2014 Regional Ebola Update & PPE Training

31. ODEMSA 2014 Regional Ebola Update & PPE Training Oct 2014 31 PPE = Gloves and….

32. ODEMSA 2014 Regional Ebola Update & PPE Training Disposable Gloves Disposable Gown (Impermeable or Fluid Resistant) Eye Protection –Wraparound Goggles, Safety Glasses or Face Shield Respiratory Protection (must be worn with eye protection) –Lowest: Standard surgical face mask –Higher: N95 filter mask (respirator) –Highest: Air-Purifying Respirator (“APR”) – powered or not; half-face, full-face or hood Other components for high volume fluid environments: –Disposable Boot Covers (or Shoe Covers) –Disposable Bonnets Oct 2014 32 PPE Components

33. ODEMSA 2014 Regional Ebola Update & PPE Training A trained observer shall monitor donning/doffing procedures “Buddy” (in PPE) watches to prevent compromises or other procedural breaches Any compromise/breach must be reported to your EMS Field Supervisor immediately Oct 2014 33 “Buddy System”

34. ODEMSA 2014 Regional Ebola Update & PPE Training Donning

35. ODEMSA 2014 Regional Ebola Update & PPE Training Using Buddy System: 1.Remove all personal items (jewelry, watches, phones, pens, etc.) 2.Hand Hygiene, put on inner gloves Inner Pair MUST be under cuff of the sleeve of gown/coverall 3.Leggings/Boot Covers (or Shoe Covers), if used 4.Gown or coverall suit (tie at waist and neck) 5.Eye Protection 6.Mask or Respirator (ensure proper fit) 7.Bonnet, if indicated. Must tape all visible gaps in suit 8.Outer Gloves Outer pair must be over cuff of the sleeve of gown/coverall leaving NO SKIN exposed  Remember: Do NOT touch your eyes, nose or mouth Oct 2014 35 Donning Sequence

36. ODEMSA 2014 Regional Ebola Update & PPE Training Decontamination

37. ODEMSA 2014 Regional Ebola Update & PPE Training Doffing

38. ODEMSA 2014 Regional Ebola Update & PPE Training Most Provider exposures occur during PPE Removal (doffing)! Oct 2014 38 Doffing (Removal) = Critical Process

39. ODEMSA 2014 Regional Ebola Update & PPE Training PPE must be removed in the proper sequence & with extreme care/caution, to prevent inadvertent exposure Basic Principle: –Touch ONLY “clean to clean” and “dirty to dirty” Perform hand hygiene & replace gloves if hands become contaminated during removal AND immediately after PPE removal PPE must be removed immediately after patient care is transferred to hospital staff Oct 2014 39 Doffing (Removal) = Critical Process

40. ODEMSA 2014 Regional Ebola Update & PPE Training Needed BEFORE beginning: –Fresh disposable gloves –BioHazard bags/receptacles (“Triple bagged”) –Hand Hygiene supplies Sequence - “Touch ONLY clean to clean AND dirty to dirty”: 1.Outer Gloves: Touching ONLY inside, remove  Biohazard disposal 2.Gown: Touching ONLY inside, Roll away from wearer, down to wrists, remove  Biohazard disposal 3.Leggings/Boot Covers (or Shoe Covers): Touching ONLY inside, roll down and away from wearer, remove  Biohazard disposal 4.Inner Gloves: Touching ONLY inside, remove  Biohazard disposal –Continued…. Oct 2014 40 Doffing Sequence

41. ODEMSA 2014 Regional Ebola Update & PPE Training 5.Hand Hygiene (dry hands as much as possible) 6.Don a fresh pair of gloves 7.Bonnet (grasp as far to the rear as possible)  Biohazard disposal 8.Goggles (grasp as far to the rear as possible)  Biohazard disposal 9.Respirator/Mask (grasp from as far to the rear as possible)  Biohazard disposal 10.Last Pair of Gloves: Touching ONLY inside, remove  Biohazard disposal 11.HAND HYGIENE, including wrists and fingernails Oct 2014 41 Doffing Sequence

42. ODEMSA 2014 Regional Ebola Update & PPE Training Once the contaminated PPE is placed in the Biohazard bag and bag is triple-sealed, follow directions of facility staff for proper disposal and decontamination. **Remember, the ODEMSA hospitals have committed to decontaminate EMS personnel (not vehicles) after contact with a potentially infectious EVD patient. Follow the direction of the hospital staff.** Oct 2014 42 Disposal of Contaminated PPE

43. ODEMSA 2014 Regional Ebola Update & PPE Training Hand hygiene is the single most important way to prevent infection spread Proper selection of appropriate PPE is vital Standard: ALL Patients Contact + Droplet: Sick Patients at risk for infectious diseases Doffing (removal) = greatest risk to Providers A “Buddy System” – especially during doffing – will reduce the risk of compromise/breach PPE must be disposed of properly after removal Oct 2014 43 Summary

44. ODEMSA 2014 Regional Ebola Update & PPE Training Oct 2014 44 If you have questions… Virginia Department of Health – Ebola Hotline 1-877-ASK VDH3 (1-877-275-8343) ODEMSA Office Number: (804) 560-3300 Website: www.odemsa.vaems.org