October 3 Update

The steps below describe the process local practices should follow:

• During the prescreening and planning process place a call to the EVHC Clinician Hotline at 855-448-1742. The hotline is staffed 24/7 by Evolution Health Nurse Navigators in the Medical Command Center in Dallas who have access to Ebola-related information, protocols and resources. They will be valuable resources to assist you in completing planning for the transport.
• Ask for or coordinate a phone discussion between the treating physician and your Medical Director. The purpose of this call is to clarify the patient's diagnosis and discuss the patient's acuity and treatment plan. It will also be important to establish that the patient's condition is stable enough for transport.
• Identify hospital personnel who will be planning the transfer, accepting the patient, and coordinating disinfection and cleanup following the transfer. Have contact numbers on file for each.
• As with any inter-facility transport, confirm the treatment that the patient will need to receive during transit (medications, ventilator, etc.) and assure that it is within the scope of practice for your crew. If necessary request that the hospital provide an appropriately trained clinician to provide "out of scope" care during transport.
• Assure that the receiving facility is aware of the patient's status and has the appropriate team to receive the patient. Confirm the timing of the transport.
• Identify Safety & Risk and Clinical Leaders that will supervise vehicle preparation, monitor transfer and provide information and support to crews following the transport.
• Secure appropriate equipment and supplies for the transport, as listed below. This may take up to 24 hours. As you plan for the transport, consider disposables if needed and any airway or IV access equipment that could be necessary. An Ebola Caregiver PPE kit is available in Procureit. Gloves and respirators should be obtained from the ambulance. Duct tape and plastic sheeting can be obtained at most local hardware stores.
• EVD PPE Kits are available through ProcureIT with the following item numbers. Note these kits do not include the necessary N95 or P100 respirators.
  
  Item Number     Description
  934904        KIT, E-PPE MED (25/BX)
  934902        KIT, E-PPE LGE (25/BX)
  934903        KIT, E-PPE XLG (25/BX)
  

PERSONAL PROTECTION

Various means of protection will include protecting the Caregiver from all routes of entry through the use of PPE, barriers in the patient compartment of the ambulance, proper decontamination of the ambulance/equipment and proper disposal of the waste generated. The following guidelines will be observed during these processes.

• Isolation of the ambulance surfaces in the Patient Compartment while making available necessary patient care equipment.
• Wearing of appropriate PPE: Caregivers should wear: Tyvek suits (impermeable gown if Tyvek suit is not immediately available), eye protection (goggles which seal the orbital area with face shield), double glove and disposable shoe covers.
  • Available in EVD PPE kit that can be ordered on Procureit.
• N95 or P100 respirators will be worn from initial patient contact through completion of decontamination. N95 or P100 respirators are not included in the EVD PPE kit, because they are already stocked on the ambulance and routinely utilized by Caregivers.
• Prudent hand washing.
• Avoid aerosol-generating procedures, such as airway placement, administration of nebulized medications, tracheal suction, CPAP, etc. If it is necessary to perform these procedures, do so after the unit pulls to a safe location and stops and after donning the above PPE including the N95 or P100 respirator.
• If possible, avoid starting IV access during transport. If necessary, venous access should be obtained after the unit pulls to a safe location and stops. Careful attention should be taken with the disposal of all sharps in the sharps container.

AMBULANCE PATIENT COMPARTMENT PREPARATION

Ambulance preparation will be done with the purpose of segregating the cab from the patient compartment and covering the cabinetry/shelving, ceiling, seating and floor with an impermeable barrier.

• 6 mil clear plastic sheeting
• Duct Tape
• Scissors

1. Cover the ceiling of the patient compartment with plastic sheeting and affix with duct tape.
2. Place sheeting on the floor of the rig and affix to bench seat, jump seat and walls to create a bowl affect in an effort to channel any body fluids toward the center of the floor causing fluids to collect in one area.
3. Place plastic sheeting over the walls (sides and bulkhead) by affixing it to the edges of the sheeting for the ceiling and floor with duct tape to enable any flow of fluid to be captured on the sheet on the floor.
4. Wall sheeting should overlap with the upper portion over the lower portion to prevent any body fluid from leaking between sheets by gravity.
5. The gurney antlers and clamp will need to be accessible through the plastic sheeting for safe transport of the gurney and patient. Seal these openings generously with duct tape so that all fluids flow to the sheeting on the floor.
6. Leave openings around ventilation ports to allow proper airflow and exchange.
7. Continue to overlap sheeting down and over seating to the floor. Cover rear doors with plastic sheeting and duct tape.

GURNEY PREPARATION

• Impermeable mattress cover

Cover mattress pad with fitted impermeable mattress cover. If no impermeable mattress is available then use plastic sheeting and seal with duct tape.

AMBULANCE CAB

• Backup EVD PPE Kit or Equivalent
• N95 or P100 Respirator
• Impermeable Decontamination Disposal Sheet
• Multiple Red Biohazard Bags
• Extra Gloves and Shoe Covers
• MEDS Computer Etc.

CREW PREPARATION

EVD patient transports will be done by three person crews. The third crewmember, “Driver,” will assume no patient contact nor enter the patient compartment, to remain decontaminated during the transport and to avoid contamination of the cab area.

Prior to patient contact, each patient caregiver will don the PPE while the third crewmember assists by both checking for integrity issues or exposed body parts.

• EVD PPE Kit Available Through ProcureIT & N95/P100 Respirator

• Tyvek Suit
• Goggles
• N95 or P100 Respirator
• Face shield
• Gloves X2 (Double Glove)
• Additional Shoe Covers

FACILITY ARRIVAL

Driver will notify the receiving facility of arrival and don PPE.

Throughout movement of patient into facility, the patient care crew will take steps to prevent secondary contamination of any surfaces, such as avoiding the touching doors handles with contaminated gloves.

1. After notifying receiving facility staff of arrival, coordinate with Hospital staff for the transfer of the patient from the ambulance into the facility.
2. The following items may be considered with regard to the movement of the patient from the ambulance into the facility:
   • The Driver should take all precautions to remain a safe distance from the patient to avoid contamination. The Driver may assist by opening doors and clearing the path for patient movement.
   • The Driver will take decontamination and disposal sheet placing it on the ground at rear of unit with a change of shoe coverings and gloves available for the patient crew.
   • Any body fluid contamination on gurney wheels will be disinfected with a disinfectant that is proven to kill non-enveloped viruses.
     • Two disinfectant solutions proven to kill non-enveloped viruses include a 1:10 bleach to water solution allowed to dry for 10 minutes or McKesson's Pro-Tech RTU Disinfectant Cleaner available in ProcureIT through McKesson using these two item numbers:
       • Item #484484 CLEANER/DISINFECTANT, PRO-TECH RTU 32oz W/SPR (12/CS)
       • Item #484483 CLEANER/DISINFECTANT, PRO-TECH RTU 1GL LF (4/CS)
   • Patient crew will unload patient and then remove current shoe covering and outer gloves and put on clean ones so as not to track potential contamination into the receiving facility. Dispose of used PPE in Red Biohazard Bag.
   • Patient will be transferred into hospital by patient crew at the direction of hospital staff.
   • Patient crew will remove and dispose of PPE in the hospital isolation area at their direction following infection control procedures or on the decontamination sheet at the rear of the unit.
   • The gurney and all equipment will be considered infectious and handled with the appropriate PPE until properly decontaminated.
   • The decontamination sheet, PPE, materials and equipment will be collected and double bagged with Red Biohazard Bags at the ambulance observing body fluid precautions and then placed in the rear of the ambulance for proper decontamination and disposal later.

AMBULANCE DECONTAMINATION

If the facility requests, decontaminate the Ambulance onsite at their direction. Otherwise, the Ambulance will be driven to a designated AMR location for decontamination taking into consideration segregating it from nonessential personnel. Also, consider indoor facility to prevent contaminated materials from incidentally being blown away or protecting it from weather.

• Impermeable Decontamination Sheet
• Disinfectant proven to kill non-enveloped viruses, such as 1:10 bleach to water solution allowed to dry for 10 minutes (use bleach only in well-ventilated area with both rear and side doors open) or McKesson's Pro-Tech Disinfectant Cleaner available in ProcureIT through McKesson using these two item numbers:
  • Item #484484 CLEANER/DISINFECTANT, PRO-TECH RTU 32oz W/SPR (12/CS)
  • Item #484483 CLEANER DISINFECTANT, PRO-TECH RTU 1GL LF (4/CS)
• Disposable rags
• Red Biohazard Bags
• EVD Containers or Red Biohazard Containers labelled “Class A Infectious Waste”
• EVD PPE Kit or Equivalent

1. Don necessary EVD PPE.
2. Lay impermeable decontamination sheet on the ground at the back of the ambulance and side doors and have EVD containers available.
3. Clean up any body fluids and double bag (Red Biohazard Bags) cleaning materials placing those materials in EVD containers.
4. EVD containers should be red-biohazard containers labelled “Class A Infectious Waste” and maintained separate from all other red bag waste.
5. Double bag (Red Biohazard Bags) all disposable materials/equipment and place into EVD containers.
6. Place equipment including gurney antlers on decontamination sheet for proper disinfecting.
7. Remove any contaminated materials from equipment and disinfect equipment using recommended disinfectant and place on clean sheet for drying.
8. Double bag (Red Biohazard Bags) all contaminated rags/wipes into properly labeled Red Biohazard Bags.
9. Remove impermeable barriers from unit and double bag (Red Biohazard Bags) placing those properly labeled EVD containers.
10. Fold decontamination sheets and double bag (Red Biohazard Bags) placing those in proper EVD containers.
11. Place new contamination sheets out.
12. Wipe down all surfaces inside ambulance and outside door handles with recommended disinfectant and double bag (Red Biohazard Bags) materials placing them in properly labeled EVD containers.
13. Remove PPE and place PPE in double bag (Red Biohazard Bags) and place in EVD containers.
14. Using gloves, fold decontamination sheets, place in double bag (Red Biohazard Bags) with PPE and put into EVD containers.
15. Wash outside of ambulance in normal fashion and location using PPE.

Page Last Updated: October 13, 2014