In this module, we will cover the basic concepts for how to evaluate and briefly manage a patient under investigation for Ebola. While all US facilities need to provide screening and triage for Ebola virus disease, the tiered system encourages various capacities amongst different facilities. If your facility is a frontline facility, you will be working closely with public health authorities to arrange for prompt transport of patients to an Ebola Assessment Hospital for further testing and evaluation. The content of this module is primarily for Ebola Assessment Hospitals. If your facility is an Ebola Assessment Hospital, you will need to be capable of initial evaluation and care of the patient for up to 96 hours and the patient is transferred to an Ebola treatment facility. Ebola assessment hospitals must be prepared to identify, isolate, evaluate and briefly manage a patient under investigation for Ebola until the diagnosis can be confirmed or ruled out and until discharge or transfer of the patient is complete. Ebola Assessment Hospitals should be prepared to safely transfer patients with confirmed Ebola to an Ebola treatment center. The CDC provides guidance on the minimum capabilities that Ebola Assessment Hospitals should have in place before receiving any patients under investigation. This module summarizes the guidance, but it is not an exhaustive list. Refer to the CDC website for more detailed information on safely caring for, and managing patients under investigation for Ebola at Ebola Assessment Hospitals. Ebola Assessment Hospitals must be prepared to receive, isolate and care for a patient under investigation for Ebola up to 96 hours. To confirm or rule out an Ebola diagnosis in a patient under investigation may take up to 72 hours or longer and potentially require an additional 12 to 24 hours for specimen transport, testing and identification of another facility for transfer. Ebola Assessment Hospitals must have plans in place for transporting patients with possible or confirmed Ebola, both internally, within the facility, and externally, to an Ebola Treatment Hospital. Intrafacility plans should be in place for transporting a patient from the point of entry or from the ED to the designated treatment area and isolation room. Interfacility plans include plans to transfer a confirmed Ebola patient to a designated Ebola treatment center. Transport plans and procedures should be well developed and practiced in drills to ensure the transport mechanisms are understood by all staff who will be involved in the process. Proper staffing, training and worker safety plans should be in place at Ebola assessment hospitals. Staffing plans should be developed to support 96 consecutive hours of clinical care. At a minimum, staff should be trained and available to care for patients and a trained observer should be present at all times to supervise safe infection control practices, including donning and doffing of personal protective equipment. The facility should have a process to ensure availability of continuous staff input from a multidisciplinary group including those who may or may not be directly involved in Ebola patient care. Staff who are involved in or supporting patient care must be appropriately trained for their roles and should demonstrate proficiency in the activities in which they will be involved, including the donning and doffing of PPE, proper waste management, infection control practices, “Hello, infection prevention?” “We have a possible Ebola patient in the ED”, and specimen transport to the laboratory. “So good morning, thanks for “coming today. We’re going to learn about donning PPE.” Ongoing training should be provided, competency assessed and breaches should be addressed through retraining and practice sessions. Worker safety programs must also be in place. The hospital should be in compliance with all federal or state occupational safety and health regulations applicable to reducing employee exposure to the Ebola virus and direct active monitoring for all health care workers involved in direct patient care should occur for 21 days since the last known exposure. Because Ebola Assessment Hospitals must be prepared to care for patients under investigation for up to 96 hours, it is important that the facility have the proper infrastructure in place to care for these patients. The hospital must have a private room with an interim dedicated bathroom or covered bedside commode equipped with dedicated patient care equipment. There should be separate areas for donning and doffing of PPE that allow for the supervision of donning and doffing activities by a trained observer. After a patient under investigation for Ebola is safely isolated, several key actions should be taken to manage care. First, the detailed risk factor and symptom screening as described by the CDC should be performed by a clinician. Second, the institution’s Ebola preparedness plan should be activated and key staff, including the laboratory and public health authorities should be informed. All laboratory tests for Ebola should be done in consultation with the local public health authorities. They will provide guidance on what testing should be performed. It is important to consider other, more likely conditions including influenza and malaria. Plans for how to safely pursue other diagnostic considerations should be made with the laboratory team in order to minimize any risk of contamination in collecting, transporting and processing potentially infectious samples. Diagnostic laboratory procedures and protocols should be in place for specimen testing for Ebola by the nearest Laboratory Response Network capable of testing for Ebola, addressing dedicated space, possible point of care testing, equipment selection and disinfection, staffing, reagents, training and specimen transport for routine clinical diagnostic testing at the facility. Protocols for lab personnel PPE use and training should also be in place. Staff should notify the laboratory prior to sending any samples to the lab and all samples must be clearly labeled to identify that they are from a patient under investigation for Ebola. All specimens should be hand-carried to the lab. Do not transport specimens through a pneumatic tube system. Plan and distinguish which tests can be safely performed in your facility. Ebola testing itself is always performed in consultation with the public health authorities. All waste from patients with possible Ebola must be treated as highly infectious until Ebola is ruled out. Ebola is classified as a Category A Infectious substance according to the Department of Transportation Hazardous Material’s regulations. It is important that all waste from patients under investigation for Ebola is handled according to the CDC and local or state Department of Transportation guidelines. Ebola Assessment Hospitals should have in place the services of a waste management vendor, capable of managing and transporting Category A infectious substances, have appropriate containers and procedures for the safe temporary storage of Category A infectious waste, and ensure that staff are trained in the correct use of PPE, personal protective equipment and in the proper handling and storage of Category A waste. If a vendor capable of transporting Category A infectious substances has not been arranged, hospitals may consider sequestering medical waste until the patients Ebola test result becomes known. At that time, if a patient is confirmed to have Ebola, arrangements should be made to transport the waste by a vendor who services who have been procured for this purpose. If the patient is determined not to have Ebola, waste can be handled according to normal procedures in compliance with local waste management ordinances. Ebola Assessment Hospitals should have plans in place to clean and disinfect patient care areas and equipment, including the use of an EPA registered hospital disinfectant with a label claim at least equivalent to that for a non-enveloped virus and safe practices for use of the disinfectant in accordance with the manufacturer’s instructions for use. In managing the care of a patient under investigation for Ebola, it is important that to be deliberate and efficient with your interactions. One key strategy for minimizing risk to staff is to plan for clustering care, specifically you can use a log to help plan patient care activities so you can bundle tasks to minimize the number of trips into and out of room. Before entering the isolation room, plan the tasks that will be completed in the room and ensure all supplies needed to accomplish the planned tasks are available. If you happen to need additional medication or supplies while in the patient room, you may ask another staff member to supply these in a way that would prevent contamination, such as using a tray. Use a method of passing that would prevent you contaminating yourself. Consider using various communication devices to minimize the time in the room, such as an intercom or telephone. In addition, the communication devices can be used to allow the patient to communicate with their family and visitors. The proper use of personal protective equipment, or PPE, is critical in preventing transmission of Ebola virus disease. Ensure that PPE is readily available and the appropriate sizes are available for all health care workers who will enter the room. CDC guidance calls for two different types of PPE. The first type of PPE is recommended for care of patients under investigation for Ebola and who are clinically stable and not having bleeding, vomiting or diarrhea. There is a low risk of splashes and contamination in these situations. The first type of PPE consists of a fluid resistant gown, or coverall, surgical mask, full face shield and two pairs of gloves with extended cuffs. The second type of PPE is for health care workers caring for patients with confirmed Ebola, or to health care workers caring for patients with possible Ebola, who have obvious bleeding, vomiting, diarrhea or a clinical condition that warrants invasive or aerosol generating procedures. The PPE, personal protective equipment ensemble includes use of a PAPR or N95 respirator with boot covers, a fluid impermeable gown or coverall, two pairs of gloves with extended cuffs, and full head piece or N95 respirator plus a surgical hood, extending to the shoulders and a full face shield. Training on the use of PPE is critical. Ensure all health care workers who enter the room are trained on how to don and doff personal protective equipment safely. Practice is required to gain competence. Consider checking staff’s ability to demonstrate PPE donning and doffing to ensure they are competent in the process. Each step of every PPE donning and doffing event must be supervised by a trained observer to ensure proper completion of established PPE protocols. Any breaches should be identified immediately. Refer to the CDC website for PPE training videos for additional information on the donning and doffing of PPE. Ebola Assessment Hospitals should select appropriate Ebola PPE and have at least a 4 to 5 day supply of PPE in stock and should have identified a vendor capable of providing resupply. In the event that a facility does not have sufficient PPE, the facility should work with local health care coalitions, emergency management services, and local and state public health authorities to identify additional PPE resources. Refer to the CDC website for more information on PPE. In addition to clearly defined clinical protocols for Ebola, your facility should define expectations and protocols for internal and external communication. Make sure you are familiar with each protocol and have have the necessary contact information. The hospital should follow its emergency management structure for communication. It is critical to maintain open and efficient lines of communication between care providers and the patient using electronic communication when possible, care providers and patients families, keeping them updated. Care providers during handoffs, critical services of the hospital involved in safe Ebola patient management, such as lab and Environmental Services, the hospital and the Health Department and the patient and their family and visitors. Ebola is a serious disease and the emotional stress it produces can be damaging. The patient, family members and health care workers alike may be in need of counselors or peer support. Leaders at all levels should work to ensure that these resources are made available and accessible. We recommend having a process in place to connect patients, their families, and staff to support services, such as a list of contacts and appropriate educational materials. In this module, we have covered the basic considerations for how to evaluate and briefly manage a patient with suspected or confirmed Ebola at an Ebola assessment hospital. Additional information can be found on the CDC website. Your health department is available for assistance. The CDC is also available 24/7 for consultation by calling the CDC Emergency Operations Center.