WebCast For Continuing Education

Transcription

1 WebCast For Continuing Education 2016 Northern California EMS, Inc. Engineer Bill Bogenreif. 1

2 Ebola Virus Disease Update 5/4/2016 Eric M. Rudnick, MD, FACEP,FAAEM Northern California EMS, Inc. Engineer Bill Bogenreif. 2

3 John Poland, SSV EMS Agency Kevin Perry, Regional Disaster Medical Health Specialist, SSV EMS Agency Engineer Bill Bogenreif. 3

4 In collaboration with SSV EMS Agency there are two Office of Emergency Services (OES) Mutual Aid Region III EMS transport agencies that have the required training, equipment, and vehicles to safely transport Ebola Persons Under Investigation (PUIs) and other individuals at high risk for Ebola Virus Disease (EVD) to regional healthcare facilities. At these regional healthcare facilities the determination will be made as to whether they have EVD. The EMS transport agencies involved are Mercy Medical Center Redding EMS and Butte EMS. Engineer Bill Bogenreif. 4

5 If it becomes necessary to transport a high risk patient, then notify the following agencies and/or persons to arrange for transport. First contact the Medical Health Operational Area Coordinator (MHOAC) in your County Public Health Department, Regional Disaster Medical Health Specialist (RDMHS) for OES Mutual Aid Region III, and Nor-Cal EMS Medical Director. Once notified it may take at least up to 1 hour for these EMS transport agencies to prepare to transport these patients. Then the required transit time to reach your area. Engineer Bill Bogenreif. 5

6 When these specified transport agencies are not available consultation with appropriate regional agencies is still required. Prior to attempting to have your local EMS agency transport these patients consult the MHOAC, RDMHS, and Nor-Cal EMS Medical Director. Engineer Bill Bogenreif. 6

7 Engineer Bill Bogenreif. 7

8 Ebola Virus disease (EVD), previously known as Ebola Hemorrhagic Fever, is a rare and deadly disease. Can cause disease in humans and primates (monkeys, gorillas, and chimpanzees). Ebola was first discovered in 1976 near the Ebola River in what is now the Democratic Republic of the Congo. Researchers believe that the virus is animal-borne and that bats are the most likely reservoir. Engineer Bill Bogenreif. 8

9 Reducing the risk of wildlife-to-human transmission from contact with infected fruit bats or monkeys/apes and the consumption of their raw meat. Animals should be handled with gloves and other appropriate protective clothing. Animal products (blood and meat) should be thoroughly cooked before consumption. Engineer Bill Bogenreif. 9

10 Ebola is a viral infection that causes severe illness with a percent mortality rate. Most of the outbreaks that have occurred are in Africa. The mortality rate in the United States is anticipated to be lower with earlier identification and greater medical resources. To date a viable vaccine against Ebola does not exist. Engineer Bill Bogenreif. 10

11 Ebola virus infection can cause severe illness and extra care is needed when coming into direct contact with a recent traveler who has signs and symptoms of Ebola and has travelled from a country with an Ebola outbreak. The initial signs and symptoms of Ebola are similar to many other more common diseases found in West Africa (such as malaria and typhoid). Ebola should be considered in anyone with a fever who has traveled to, or lived in, an area where Ebola is present. The potential risk posed to first responders and EMS in the U.S. by patients with early, limited symptoms are thought to be lower than that from a patient hospitalized with severe Ebola. Engineer Bill Bogenreif. 11

12 Ebola is classified as a viral hemorrhagic fever and had reached epidemic levels in West Africa in Contrary to some media reports, Ebola does not begin with flu-like symptoms, and is may be distinguished from the flu by the absence of upper respiratory symptoms (e.g. cough, sneezing, nasal congestion, runny nose). There are other serious infectious diseases that may present with flu-like symptoms. The EVD has a 2-21 day incubation period. The time interval from infection with the virus to onset of symptoms. Patients with Ebola are not considered contagious until symptoms are present. Engineer Bill Bogenreif. 12

13 People become infected with Ebola through direct contact through broken skin (cuts or abrasions) or mucous membranes (for example, the eyes, nose, or mouth) with blood or body fluids (including but not limited to urine, saliva, sweat, feces, vomit, breast milk, and semen) of a person who is sick with or has died from Ebola. Objects such as needles, syringes, fluid on surfaces (fomites) that have been contaminated with body fluids from a person who is sick with Ebola or the body of a person who has died from Ebola are infective. Infected fruit bats or primates (apes and monkeys) can expose humans to EVD. Contact with semen from a person who has recovered from Ebola (for example, by having oral, vaginal, or anal sex) can infect people. Engineer Bill Bogenreif. 13

14 Initial symptoms of the Ebola virus include fever (greater than Fahrenheit), body aches, headache, and nausea. Following the fever, the onset of chills, fatigue, weakness, and muscle aches occur. Followed approximately 4 6 days after illness onset by diarrhea, nausea, vomiting, and abdominal pain. The gastrointestinal symptoms can occur earlier. Other symptoms such as chest pain, shortness of breath, headache, or confusion, may also develop. As the disease progresses hemorrhaging internally and externally occur. Complications such as shock, and multi-organ system failure do occur. Engineer Bill Bogenreif. 14

15 The Ebola virus is not airborne, and it will not mutate to become airborne. Fluids from an infected person can become airborne (aerosolized). Ebola is transmitted through contact with infected bodily secretions, such as sweat, saliva, semen, blood, feces, urine, etc. It is important to note that the Ebola virus does not enter intact skin, as it has to touch a mucus membrane such as the eyes, nose, or mouth. EMS providers should be aware of any cuts or abrasions they might have in which Ebola can enter. Hand washing after every patient contact is the best way to prevent transmission. Engineer Bill Bogenreif. 15

16 Ebola can be aerosolized with procedures such as nebulizer treatments and M.A.D. medication delivery. CPAP may also produce forced expulsion of infected saliva. If the patients with suspected or confirmed Ebola require a nebulizer treatment, M.A.D. delivery, or CPAP, EMS providers shall wear eye protection (safety glasses or face shield) and a particle respirator (N95 or P100). Engineer Bill Bogenreif. 16

17 Person Under Investigation (PUI) A person who has both consistent signs or symptoms (of EVD) and risk factors as follows should be considered a PUI: 1.Elevated body temperature or subjective fever or symptoms, including severe headache, fatigue, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage; AND 2.An epidemiologic risk factor within the 21 days before the onset of symptoms Engineer Bill Bogenreif. 17

18 Ebola Risk Patient A patient who has Ebola risk factors but is not exhibiting any Ebola signs/symptoms. EMS Screened Possible Ebola Patient A patient presenting both Ebola risk factors and signs/symptoms. Confirmed Ebola Patient A patient with laboratory-confirmed diagnostic evidence of Ebola virus infection. Protected Exposure The use of appropriate PPE during direct patient care or decontamination activities involving bodily fluid contact. Engineer Bill Bogenreif. 18

19 If PSAP call takers advise that the patient is suspected of having Ebola, EMS personnel should don the PPE appropriate for suspected cases of Ebola before entering the scene. During patient assessment and management, EMS personnel should consider Ebola risk factors and signs/symptoms. A relevant exposure history (risk factors) should be taken including: Residence in or travel to a country with widespread Ebola transmission or uncertain control measures within 21 days (3 weeks) of symptom onset, and/or Contact with blood or body fluids of a patient known to have or suspected to have Ebola within 21 days (3 weeks) of symptom onset Engineer Bill Bogenreif. 19

20 Because the signs and symptoms of Ebola may be nonspecific and are present in other infectious and noninfectious conditions which are more frequently encountered in the United States. Relevant exposure history (risk factors) should be first elicited to determine whether Ebola should be considered further. Patients who meet the above criteria should be questioned further regarding the presence of signs/symptoms of Ebola, including: Fever (subjective or F), and Headache, fatigue, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage Engineer Bill Bogenreif. 20

21 To minimize potential exposure, only one (1) EMS provider should approach the patient and perform the initial screening from at least three (3) feet away from the patient. Any patient presenting with both Ebola risk factors and signs/symptoms shall be considered an EMS Screened Possible Ebola Patient. If, based on the initial screening, the EMS provider suspects the patient could have Ebola then PPE should be donned before coming into close contact with the patient. Keep the other emergency responders further away, while assuring they are still able to support the provider with primary assessment duties. No one should have direct contact with a patient who may have Ebola without wearing appropriate PPE. Engineer Bill Bogenreif. 21

22 Any confirmed or EMS Screened Possible Ebola Patient shall be presumed to be actively infectious with the Ebola virus and the appropriate level PPE shall be utilized. Based on the clinical presentation of the patient, there are two PPE options: 1) If the patient is not exhibiting obvious bleeding, vomiting, or diarrhea and there is no concern for bleeding, vomiting, or diarrhea, then EMS personnel should at a minimum wear the following PPE: Face shield and surgical face mask Impermeable gown Two pairs of gloves Engineer Bill Bogenreif. 22

23 If the patient is exhibiting obvious bleeding, vomiting, or diarrhea or there is concern for potential bleeding, vomiting, or diarrhea then EMS personnel should wear the highest level protection designed to eliminate any and all skin and mucous membrane exposure. No exposed skin or mucous membranes Level C splash protection Full body suit Two pairs of gloves Boots and boot covers (booties) Hooded Face shield or similar, covers front and sides of face N95 filtering face piece fluid resistant respirator (minimum requirement) or PAPR/SCBA respirator Engineer Bill Bogenreif. 23

24 All prehospital providers must don high risk PPE, including, but not limited to: Surgical hood, extending to the shoulders (exempt if coveralls or suit provides) Face shield Eye protection N-95 mask or P-100 particle respirator (mask) Impermeable coveralls or suit Impermeable gown Double glove with high cuff (high cuff second glove) Leg and shoe coverings (exempt if coveralls or suit provides) No skin shall be showing Engineer Bill Bogenreif. 24

25 Always exercise extreme caution when approaching a patient with suspected Ebola. Illness can cause delirium, with erratic behavior (e.g., flailing or staggering) that can place EMS providers at additional risk of exposure. Conduct appropriate patient assessment exercising caution to protect yourself. Engineer Bill Bogenreif. 25

26 Prehospital providers shall designate roles and responsibilities to each provider on scene: Safety Officer (Trained Observer): This Safety Officer is familiar with the use of high risk PPE and does not provide any direct patient care. They monitor the donning of PPE, ensure safety of responders while engaging in patient care on scene, and monitor the safe doffing of PPE. They are to remain separate from the patient by a minimum of three (3) feet. Engineer Bill Bogenreif. 26

27 Patient Care Leader: The Patient Care Leader is responsible for providing direct patient care while in full high risk PPE. Patient Care Support : The Patient Care Support position supports the patient care leader when a second care provider is needed. This person shall don full high risk PPE. Engineer Bill Bogenreif. 27

28 Ambulance Operator: The Ambulance Operator drives the ambulance to the receiving facility. This person shall not provide any direct care and shall only don standard precautions. The Ambulance Operator will remain with the ambulance while on scene of the event and prepare the ambulance prior to the patient being loaded (i.e. activating the exhaust vent, seal the operator s compartment, etc.). Engineer Bill Bogenreif. 28

29 Ambulance Operator The operator s compartment of the ambulance shall be separated from the patient care compartment by either closing all connections or separating with fluid impermeable shielding and activating the exhaust vent. The Ambulance Operator assumes the role of Safety Officer once the patient is secured in the ambulance at the scene until arriving at the hospital and being relieved by hospital staff. Engineer Bill Bogenreif. 29

30 Limit the number of providers who provide care for a patient with suspected Ebola. If patient is vomiting, give them a large red biohazard bag to contain any emesis. If patient has profuse diarrhea, consider wrapping the patient in an impermeable sheet to reduce contamination of other surfaces. Engineer Bill Bogenreif. 30

31 Prehospital providers shall immediately notify the MHOAC, if their patient s EVD (Ebola Viral Disease) Health Screening Questions are positive. Contact shall be made while on-scene over the phone. This information shall not be transmitted over any radio channel.. The first arriving prehospital providers who have made patient contact and donned the appropriate high risk PPE shall maintain patient care throughout the transport, to minimize potential provider exposure to the patient. Treat the patient according to the appropriate protocol. Use caution when performing invasive procedures (e.g. intubation, IV placement). Base hospital contact shall be made to clarify any clinical questions. Engineer Bill Bogenreif. 31

32 Monitored Patients are those patients that are under the supervision of the Public Health Officer but are not necessarily symptomatic for Ebola. In the event that the Public Health Officer orders transfer of a Monitored Patient to a designed hospital. The EMS Duty Chief shall initiate and support the transfer process. The monitored patient shall be transported to a destination that has been prescribed by the Public Health Officer if feasible. Engineer Bill Bogenreif. 32

33 Transfers to Designated Regional Ebola Hospitals In some instances, patients may be transferred to regional Ebola specialty centers from local Hospitals. Engineer Bill Bogenreif. 33

34 Prehospital treatment for Ebola is supportive. Only BLS procedures should be performed in the out-of-hospital setting for confirmed or EMS Screened Possible Ebola Patients unless ALS procedures are absolutely necessary based on the patient s condition. Contact base hospital physician for consult if there are any concerns. Engineer Bill Bogenreif. 34

35 Limit the use of needles and other sharps as much as possible. Any needles and sharps should be handled with extreme care and disposed in puncture-proof, sealed containers that are specific to the care of this patient. Follow OSHA s Blood borne Pathogens Standard, 29 CFR Do not dispose of used needles and sharps in containers that have sharps from other patients in them. Engineer Bill Bogenreif. 35

36 Due to the significant exposure concerns related to the treatment of a known or EMS Screened Possible Ebola Patient, prehospital personnel must weigh the risk/benefit of specific types of treatments. If a known or EMS Screened Possible Ebola Patient is determined to be in cardiac arrest and does not meet the termination requirements for determination of death, basic life support, including defibrillation, shall continue or begin immediately and EMS personnel shall contact the base/modified base hospital for further directions. Engineer Bill Bogenreif. 36

37 Invasive prehospital resuscitation procedures such as endotracheal intubation, open suctioning of airways, and cardiopulmonary resuscitation frequently result in a large amount of body fluids, such as saliva and vomit. Performing these procedures in a less controlled environment (e.g., moving vehicle) increases risk of exposure for EMS personnel. If conducted on a confirmed or EMS Screened Possible Ebola Patient, perform these procedures under safer circumstances (e.g., stopped vehicle, hospital destination). Engineer Bill Bogenreif. 37

38 Prehospital transport providers shall notify the receiving hospital via telephone as soon as practical after determining that patient s EVD (Ebola Viral Disease) Health Screening Questions are positive. Prehospital transport providers shall ask the hospital for any special arrival instructions, such as; parking location. In order to reduce the risk of potential exposure, family members or companions shall not be allowed to travel with the patient to the hospital in the ambulance. Engineer Bill Bogenreif. 38

39 Refer to Nor-Cal EMS Infectious Disease Module Protocol 102 Ebola Prevention Protocol Protocol 101 Infectious Disease Control Measures S-SV-EMS-Ebola-Guidelines Guidance for California EMS/Public Safety Personnel: Management of patients with potential Ebola infection (DRAFT Rev 8/28/2014) Engineer Bill Bogenreif. 39