CDC Issues Guidelines for Possible Ebola Cases in ED

October 31, 2014

When a patient possibly infected with the Ebola virus appears in a hospital emergency department (ED), clinicians need not necessarily cover themselves from head to toe with personal protective equipment (PPE), according to new guidelines from the Centers for Disease Control and Prevention (CDC).

That kind of discretion does not exist in CDC guidance for confirmed cases of Ebola in the hospital. In that situation, the agency recommends a full-blown PPE wardrobe that includes a full face shield, hood, and respirator, and leaves no patch of skin exposed. However, when a patient's travel history and symptoms suggest Ebola, but the laboratory results are not back yet, clinicians can choose PPE on the basis of the patient's clinical condition, state the new guidelines, which were issued on October 27.

If symptoms include obvious vomiting, bleeding, or copious diarrhea, or if the patient requires an invasive or aerosol-producing procedure such as intubation, then clinicians should don the PPE recommended for confirmed Ebola cases — no skin exposure should be allowed. But if the patient is clinically stable and the only symptoms are a mild fever or mild headache, clinicians may choose what the CDC considers minimum protection: a face shield and surgical mask, an impermeable gown, and two pairs of gloves.

"That level of PPE is adequate for patients at that stage in their disease," said Stephen Cantrill, MD, who chaired an expert panel of the American College of Emergency Physicians that advised the CDC about the ED guidelines. "Patients at that stage are not contagious."

ED clinicians still can choose full as opposed to partial coverage in these circumstances, "but they'll quickly run out of [full-coverage] PPE," Dr Cantrill told Medscape Medical News. "That's an issue. Many places are quite limited in what they have."

The CDC also emphasizes that ED patients with an unconfirmed Ebola infection are not contagious unless they are vomiting, bleeding, having diarrhea, or otherwise producing body fluids associated with an advanced stage of the disease and a healthcare worker comes in direct contact with them.

"If you're not at risk of being exposed to blood or body fluids, then you're not at risk of transmission," said Arjun Srinivasan, MD, associate director of the healthcare-associated infection prevention programs of the CDC's National Center for Emerging and Zoonotic Infectious Diseases. "When that risk exists — the patient is throwing up, for example — then you choose PPE that provides full-scale protection."

Goodbye Goggles

The new CDC guidelines for evaluating and managing patients who may have Ebola repeat much of what the agency has been promulgating over the past several months of America's Ebola scare.

The first step in the CDC's algorithm for ED clinicians is determining the patient's exposure history: Has she or she lived in or traveled to a country with widespread Ebola disease or had contact with an infected person in the previous 21 days? If so, then the identification of Ebola signs or symptoms comes next. One sign is fever, either subjective or 100.4°F and higher. Other signs include headache, weakness, and muscle pain, as well as the red-alert symptoms of vomiting, diarrhea, abdominal pain, and hemorrhage, as in bleeding gums or nose bleeds.

A patient with these signs and symptoms along with a definite exposure history should be isolated immediately, either in a private room or a separate enclosed area with a private bathroom or a covered bedside commode. The CDC guidance states that only essential healthcare workers with designated roles should care for the patient and should log in and out of the room.

At this point, clinicians choose an appropriate level of PPE. Whether they don the minimum or the maximum, they should wear a face shield instead of goggles. The reason? Goggles can fog up, tempting healthcare workers to either adjust them or take them off for cleaning, said Dr Srinivasan. In the process, they may touch their face with a contaminated glove.

If active resuscitation is required for a patient with a suspected Ebola infection, it should occur in a predesignated area with equipment dedicated to just that patient. Stethoscopes for routine evaluation also should be patient-specific, according to the CDC guidelines.

Finally, the ED should notify the hospital's infection control program and other pertinent hospital staff that it is caring for someone with Ebola virus exposure, regardless of his or her symptoms. In addition, the case should be reported to the local health department, which will consult with the hospital about testing the patient for the virus.

More information on the new Ebola guidance from the CDC is available on the agency's website.

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