The Centers for Disease Control and Prevention (CDC) recently published its third “Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola Virus Disease in the United States.” This third version is dated Oct. 24, 2014, and is the current version at press time.
The first Interim Guidance was published on Sept. 5 and was based on experience with Ebola Virus Disease (EVD) in Africa. At that time, there had been no experience with the disease in America. The latest guidance is based on the significant experience with Ebola since then.
It’s important to recognize that the guidance for this viral illness is going to be constructed based on a continual process of learning about the disease and its symptoms, methods of transmission, treatment, disinfection and means of control. EMS providers should expect continuous updates on the disease.
There are a number of important elements in the latest CDC update. In general, it’s written with elements that prioritize the safety of EMS workers and the patients for which they care.
The CDC has investigated the symptoms that American Ebola patients have presented with, and changed the guidance for the EMS system, for both the PSAP workers and the on-scene EMS personnel.
For the communicator in the PSAP, a few important symptoms that may indicate Ebola (fever, headache, vomiting, diarrhea, abdominal pain or unexplained bleeding) should lead to a screening for travel or exposure to Ebola patients.
EMS providers are asked to specifically ask for and report the symptoms of subjective fever or temperature of 100.4 degrees F (38 degrees C); as well as headache, weakness, muscle pain, vomiting, diarrhea, abdominal pain or bleeding.
What the CDC document provides is a description of late symptoms of EVD, and this is perhaps the greatest fear of EMS providers and leaders. It may be difficult to identify a patient who’s made it through the early stages of the disease and is only found after significant deterioration, when symptoms may represent other desperately ill patients, and the patient is at a much higher level of risk for transmission of infection to the EMS providers.
The communication of the risk of Ebola from the PSAP is extremely important because it allows EMS personnel to apply appropriate personnel protective equipment (PPE) before entering the scene. PSAPs are also asked to notify local public health officials earlier in the process.
PSAPs will want to use discretion in communicating information to the public safety responders, so that public listeners will not be unnecessarily alarmed before EMS providers have fully assessed the patient in person.
Develop Safe Practices On Scene
Once on scene with the patient, EMS providers are asked to prioritize the potential history of exposure, either by travel or by direct contact with a person who’s known to have—or
suspected to have—Ebola, because this is the factor that identifies the highest risk of the disease, as opposed to many other illnesses that present with symptoms at this time of the year.
EMS providers are encouraged to separate the patient from others immediately and limit the number of EMS providers close to the patient. The recommendation is for the initial “point” responder to perform the screening from at least three feet away.
There’s also a strong recommendation, consistent with other recent CDC guidelines, to don and doff PPE “under observation” to assure compliance with the safe methods to do those operations. Many operations in EMS take place with a “safety officer” in place, and the role of an observer specified in these guidelines may in fact be a safety officer in many EMS organizations.
The ambulance must have a separate patient compartment and is to be driven by an individual who isn’t potentially contaminated. Many systems interpret this recommendation to include a barrier that ensures protection of the driver from being in contact with any blood and body fluids, particularly if their ambulances don’t have a door and/or windows that can be closed to separate the driver from the patient compartment.
There’s no mention yet of transportation to dedicated EDs, but there are repeated recommendations to communicate early with the receiving ED to allow appropriate time to prepare for the patient’s arrival.
EMS providers are asked to limit activities that use sharps and create extra fluid wastes. If there are sharps used, they should be disposed of in dedicated sharps containers. Patient fluids (blood, urine, emesis and diarrhea) should also be contained using absorbents without aerosolizing them. A large bio-waste container (e.g., a red bag) will perform well if the patient vomits.
The document only recommends a single level of protection for EMS personnel. As referenced earlier, a key recommendation is that PPE must be placed on the provider, and removed, under observation.
The CDC recommends separation from the patient and donning of PPE if a relevant high-risk history is identified after an initial period of contact by EMS personnel. For unexpected exposures where patient fluids come into contact with the EMS provider, the guidelines recommend flushing, and immediate soap and water wash. Services need to develop a plan to ensure this happens rapidly.
Cleaning & Disinfection
Disinfection of the ambulance and patient equipment is specified. Cleaning should be done by personnel who are equally well protected using CDC guidelines, and begins with any large spills of body fluids. Disinfection should be done with EPA-registered disinfectants, to include surfaces, equipment and patient care materials. Any fluid permeable materials must be collected as waste. The CDC and Department of Transportation (DOT) have defined any materials used in or around the patient—and any waste—as “Category A,” which require special handling. That special handling is specified in DOT Hazardous Materials Regulations, which are beyond daily waste disposal practices and will require EMS organization leaders to investigate.
Reporting & Follow-Up
There’s a new section in the CDC guidelines on “follow-up and/or reporting measures by EMS personnel after caring for a suspected or confirmed Ebola patient,” which includes recommendations on the development of policies in concert with public health authorities. This very important section includes recommendations for 21-day monitoring of providers following exposure, and working with public health authorities.
The knowledge about this deadly disease and the way emergency responders should protect themselves, care for infected patients and decontaminate themselves, their equipment and their vehicles is evolving.
It’s important for EMS crews and managers to realize there will be a continuous process of updates based on the growing body of knowledge regarding Ebola.
Emergency providers in and out of the hospital, as well as public health authorities responsible for community safety, have the opportunity to share best practices to reduce risks and improve care to possible patients and caregivers. JEMS will continue to provide you with updates as they become available.