Ebola Virus Frequently Asked Questions

Ebola Virus Frequently Asked Questions

In this document:

Hospital preparedness

EMS

Screening

Evaluation and diagnostic testing

Personal Protective Equipment (PPE)

Environmental cleaning/waste disposal

Regulations/standards applicable for Ebola

Miscellaneous

Hospital preparedness

When to contact MDH

If a patient has screened for Ebola, immediately contact the Minnesota Department of Health Epidemiology at 651-201-5414 or 877-676-5414.

Are there specific hospitals potential Ebola patients will be taken to?

Hospitals and health systems in Minnesota have developed a coordinated strategy to care for Ebola patients in Minnesota. Under the plan all hospitals will continue to detect, isolate and initially care for suspected Ebola patients. Should a case be identified, the patient will be assessed and treated at one of four designated hospitals:

University of Minnesota Medical Center, West Bank Campus, Minneapolis
Mayo Clinic Hospital – Rochester, Saint Marys Campus
Allina Health’s Unity Hospital in Fridley
Children’s Hospitals and Clinics of Minnesota – St. Paul campus

The four Minnesota hospitals are included on the CDC’s list of 35 U.S. hospitals designated as Ebola treatment centers. The CDC has put forth guidance for a tiered approach for identifying frontline healthcare facilities, Ebola assessment hospitals and Ebola treatment centers. In Minnesota, the four designated treatment hospitals serve as Ebola assessment and treatment centers. See CDC Interim Guidance for U.S. Hospital Preparedness for Patients Under Investigation or with Confirmed Ebola Virus Disease: A Framework for a Tiered Approach

What is the recommendation for critical access hospitals to identify the tertiary facility?

All hospitals in Minnesota are expected to be able to evaluate, isolate, and prepare an Ebola patient for transport. Hospitals are expected to provide initial care for a potential individual with Ebola and to discuss with MDH a transfer to one of the four designated Ebola assessment and treatment hospitals. At that time, standard procedure for patient transfers would be discussed.

EMS

Are there guidelines for transporting potential Ebola patients via ambulance or helicopter?

Refer to CDC Guidance on Air Medical Transport for Patients with EVD:

Are 911 dispatch employees asking Ebola screening questions?

Per CDC guidance for EMS, Public Safety Answering Points, such as 911 dispatch, should be screening for Ebola exposure risk factors. Refer to the CDC website for guidance on EMS Systems and 911 public safety answering points:

Screening

Refer to CDC Ebola Virus Disease Algorithm for Evaluation for the Returned Traveler

MDH Algorithm for Travelers Returning from Areas with Widespread Ebola Transmission:

Should facilities be inquiring about Ebola first when evaluating patients at intake, or assess travel history first?

Upon arrival to clinical setting/triage:

Assess the patient for a fever (subjective or ≥100.4°F / 38.0°C)
Determine if the patient has symptoms compatible with EVD such as headache, weakness, muscle pain, vomiting,diarrhea, abdominal pain or hemorrhage
Assess if the patient has a potential exposure from traveling to a country with widespread Ebola transmission or having contact with an Ebola patient in the 21 days before illness onset

Suspect Ebola if fever or compatible Ebola symptoms and an exposure are present.

Is there an EMTALA violation to have registration or front desk staff ask patient's travel history or symptoms at check in?

It is the position of MHA that EMTALA does not prohibit initial screening by front desk or registration staff that will help identify potentially infected or contagious patients. Hospitals are still prohibited from delaying a medical screening examination or the provision of necessary treatment of an emergency condition in order to ask about a patient’s financial information or insurance status.

Evaluation and diagnostic testing

Refer to MDH webpage Ebola Virus Disease Information for Health Professions

Personal Protective Equipment (PPE)

Will full Tyvek body suits be included as approved PPE used for Ebola patients?

Is there a recommendation for using duct tape with PPE?

See CDC Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing)

Will there be training materials, checklists available for PPE?

Are there donning and doffing training videos available?

Refer to the Greater New York Hospital Association PPE Training Demonstration:

See also the video developed by the Minnesota Department of Health demonstrating one sequence for donning and doffing PPE suitable for evaluating a patient with Ebola in an ambulatory setting.

Is there any extra PPE recommended in addition to standard precautions for frontline staff (registration staff) that are asking the screening questions, if they have a suspect patient?

Should PPE be worn when screening patients who have answered positively to travel and exposure questions?

PPE should be worn when having contact with a patient suspected of having Ebola.

Who will be considered a trained monitor for PPE?

As part of the hospital's Ebola preparedness plan, designate a trained observer for donning/doffing of PPE. Per CDC PPE Guidance, "The trained observer is a dedicated individual with the sole responsibility of ensuring adherence to the entire donning and doffing process. The trained observer will be knowledgeable about all PPE recommended in the facility’s protocol and the correct donning and doffing procedures, including disposal of used PPE, and will be qualified to provide guidance and technique recommendations to the healthcare worker. The trained observer will monitor and document successful donning and doffing procedures, providing immediate corrective instruction if the healthcare worker is not following the recommended steps. The trained observer should know the exposure management plan in the event of an unintentional break in procedure."

What should a hospital do if it does not have anterooms or designated isolation rooms?

All Minnesota hospitals are expected to be able to evaluate and isolate a patient for potential Ebola. Regarding ante rooms, per CDC guidance, "facilities should ensure that space and layout allow for clear separation between clean and potentially contaminated areas. It is critical that physical barriers (e.g., plastic enclosures) be used where necessary, along with visible signage, to separate distinct areas and ensure a one-way flow of care moving from clean areas (e.g., area where PPE is donned and unused equipment is stored) to the patient room and to the PPE removal area (area where PPE is removed and discarded)." - CDC Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing)

How much PPE equipment should each hospital have in stock?

The PPE inventory should be adequate to, at a minimum, protect healthcare workers to isolate, evaluate, and prepare an Ebola patient for transport. The CDC recommends amounts of PPE sufficient for the type of health care facility based on the three-tiered approach:

Frontline facilities – PPE sufficient for 12-24 hours of care
Ebola Assessment Hospitals – PPE for at least 4-5 days of patient care
Ebola Treatment Hospitals – PPE for at least 7 days of patient care

The four designated hospitals in Minnesota serve as both the Ebola assessment and treatment hospitals. All hospitals should assess current PPE inventory. If issues in PPE inventory are apparent, engage regional partners and/or healthcare system/coalition partners to develop a PPE inventory plan in the event of shortages or limited supplies. See CDC Considerations for U.S. Healthcare Facilities to Ensure Adequate Supplies of Personal Protective Equipment for Ebola Preparedness

Are there recommendations for PPE training when the necessary equipment isn't available?

If you have difficulty obtaining necessary PPE, contact MDH Healthcare Coalition Program and MHA (651-641-1121). Hospitals should develop an Ebola policy and procedure with highest level of PPE that is available at the health care facility. Train healthcare workers to use PPE as outlined in the facility’s protocols.

Can MDH or MHA assist with securing additional PPE? Are there plans for a state cache of materials?

The MDH Healthcare System Preparedness Program is assessing the need for a PPE cache and information is forthcoming

If Ebola is transmitted by contact, is the PAPR or N95 respirator required for all contact with an Ebola patient or contact of an Ebola patient with higher transmission (vomiting, performing procedures)?

The PAPR and N95 respirators are recommended for contact with an Ebola patient as part of the updated guidance on PPE from the CDC. Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing)

Can you explain why PAPR and N95 respirators are required but airborne isolation precautions aren’t?

CDC recommendations for Ebola patients were developed based on the science available and experience of those that have cared for Ebola patients (such as Doctors Without Borders, and Emory, Nebraska, and NIH biocontainment units). The tightened CDC guidelines recommend no skin exposure when PPE is worn and use of N95 respirator or PAPR help to facilitate this. Also, due to the complexity of Ebola patients and the rapid changes in status that may necessitate aerosol generating procedures, CDC has recommended the use of respiratory protection (PAPR or N95 respirator or higher).

Environmental cleaning/waste disposal

Is there guidance on environmental cleaning and waste disposal after caring for a patient with Ebola?

Ensure that environmental cleaning/disinfection procedures are included in Ebola policy development. Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus is posted at:

"Perform regular cleaning and disinfection of patient care area surfaces, even absent visible contamination. This should be performed only by nurses or physicians as part of patient care activities in order to limit the number of additional healthcare workers who enter the room" (CDC Ebola PPE Guidance to the CDC website for Ebola-Associated Waste Management:

Would it be helpful to have each hospital work out a waste management plan ahead of the first patient arriving?

Refer to the CDC website for Ebola-Associated Waste Management:

Are reusable linens processed differently?

Per CDC guidance: "To reduce exposure among staff to potentially contaminated textiles (cloth products) while laundering, discard all linens, non-fluid-impermeable pillows or mattresses, and textile privacy curtains into the waste stream and disposed of appropriately."

What about toileted waste? Are there guidelines about using bleach/quats before flushing toilets?

MDH is working with the MET Council, which coordinates toileted waste, to obtain approval for Ebola waste to enter the sewer system. CDC guidance states, "Sanitary sewers may be used for the safe disposal of patient waste. Additionally, sewage handling processes (e.g., anaerobic digestion, composting, and disinfection) in the United States are designed to inactivate infectious agents." In the experience of Ebola patients treated in the U.S., out of an abundance of caution one facility avoided the use of the sewer system by using solidifiers, while another facility poured bleach into toilets and waited ten minutes before flushing.

Will anyone be using UV sanitizing methods?

Meticulous cleaning must precede the disinfection method (such as UV light). Per CDC guidance: "Check the disinfectant's label for specific instructions for inactivation of any of the non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus) follow label instructions for use of the product that are specific for inactivation of that virus."

Are there plans or guidelines in place for funeral homes and the transportation of remains for an Ebola patient?

MDH has been coordinating with the University of Minnesota's mortuary science department. Letters were sent to all licensed funeral homes with weblinks for CDC guidelines. There are ongoing discussions with the Medical Examiner on the transportation of infected human remains. See also the CDC Guidance for Safe Handling of Human Remains of Ebola Patients in U.S. Hospitals and Mortuaries:

Regulations/standards applicable for Ebola

Is a receiving hospital allowed to follow up with a transferring hospital with patient specific information without violating HIPAA in the case of a Person Under Investigation (PUI) for Ebola?

The hospital should consider both the Minnesota Health Records Act and applicable The Joint Commission standards: two in Infection Control and one in Provision of Care, Treatment and Services Chapters. These Standards and EPs tie to a condition of participation as well.

I.According to The Joint Commission:

§482.43(d) The hospital must transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care.
IC 02.01.01 STANDARD
The hospital effectively communicates with patients when providing care, treatment, and services. We expect that organizations would procure consent forms signed by patients allowing hospitals to communicate such information to organizations where the patient is being transferred, or to organizations where the patient was previously treated, and that such exchange of patient information does not create a HIPAA problem under federal or state laws

IC.02.01.01 EP 10
When the hospital becomes aware that it transferred a patient who has an infection requiring monitoring, treatment, and/or isolation, it informs the receiving organization.
IC.02.01.10 EP 11
When the hospital becomes aware that it received a patient from another organization who has an infection requiring action, and the infection was not communicated by the referring organization, it informs the referring organization.
Note: Infections requiring action include those that require isolation and/or public health reporting or those that may aid in the referring organization's surveillance.
PC.04.02.01 STANDARD
When a patient is discharged or transferred, the hospital gives information about the care, treatment, and services provided to the patient to other service providers who will provide the patient with care, treatment, or services.
PC.04.02.01 EP 1
At the time of the patient's discharge or transfer, the hospital informs other service providers who will provide care, treatment, or services to the patient about the following:
- The reason for the patient's discharge or transfer
- The patient's physical and psychosocial status
- A summary of care, treatment, and services it provided to the patient
- The patient's progress toward goals
- A list of community resources or referrals made or provided to the patient (See also PC.02.02.01, EP 1)

II. The Minnesota Health Records Act requires one of three things to transfer the records from one provider to another:

patient consent
medical emergency where patient is unable to consent, or
transfer to another provider “within related health care entities” for purpose of continued treatment (a related entity is one “that controls, is controlled by, or is under common control with another entity”).

Below is the excerpt from the relevant portion of the statute: Minn Stat. Sect. 144.293 (emphasis added)

Subd. 3.Release from one provider to another.

A patient's health record, including, but not limited to, laboratory reports, x-rays, prescriptions, and other technical information used in assessing the patient's condition, or the pertinent portion of the record relating to a specific condition, or a summary of the record, shall promptly be furnished to another provider upon the written request of the patient. The written request shall specify the name of the provider to whom the health record is to be furnished. The provider who furnishes the health record or summary may retain a copy of the materials furnished. The patient shall be responsible for the reasonable costs of furnishing the information.

Subd. 4.Duration of consent.

Except as provided in this section, a consent is valid for one year or for a period specified in the consent or for a different period provided by law.

Subd. 5.Exceptions to consent requirement.

This section does not prohibit the release of health records:

(1) for a medical emergency when the provider is unable to obtain the patient's consent due to the patient's condition or the nature of the medical emergency;

(2) to other providers within related health care entities when necessary for the current treatment of the patient; or

(3) to a health care facility licensed by this chapter, chapter 144A, or to the same types of health care facilities licensed by this chapter and chapter 144A that are licensed in another state when a patient:

(i) is returning to the health care facility and unable to provide consent; or

(ii) who resides in the health care facility, has services provided by an outside resource under Code of Federal Regulations, title 42, section 483.75(h), and is unable to provide consent.

Miscellaneous

Is there guidance for facilities on employees that may have traveled to West Africa and want to return to work?

See MDH Algorithm for Assessing Travelers Returning to the Workplace from Areas Affected by Ebola

Where is there contact information for the healthcarecoalitions?

Updated 1/19/2015