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October 7 Update

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10.07.2014

Scott Bourn, Dr. Ed Racht

Today marks the beginning of the second week since the identification of the first U.S. Ebola case in Dallas. At the present time, the CDC is monitoring 10 individuals who had definite exposure to the patient and 38 who had possible exposure; to date none of the monitored individuals have developed symptoms.

In the past seven days we’ve done a lot to protect our crews and the communities we serve:

  • Establishment of the amr.net/Ebola website. As of today that site has had more than 6,000 page views and 2,000 unique visitors.
  • Establishment of the 24- hour EVHC Clinician Hotline (855-448-1742) to provide information and referral for practices that are scheduling a transport, information requests from local regulators, and consultation to individuals providing direct care to patients. We’ve had four calls to the Hotline so far, most relating to accurate identification of patients at risk of Ebola.
  • Recommendation to all AMR and Evolution Health clinicians that they include the two CDC screening questions for any patient who exhibits any of the symptoms associated with Ebola.
  • Active communication with the International Academy of Emergency Medical Dispatch regarding modification of protocols to ask screening questions during call taking. We facilitated discussion in one EMS system about proposed changes in their Medical Dispatch protocols related to perceived community risk.

Clarification on the Two Screening Questions

In speaking with front line caregivers and leaders during the past week we’ve identified some uncertainty about how to use the screening questions. Here is a clarification:

  • The screening questions should be asked sequentially. Question number one determines whether the patient has the hallmark symptoms associated with Ebola: fever or chills; headache, joint, or muscle aches; weakness or fatigue; stomach pain, diarrhea, or vomiting; abnormal bleeding.
    • If the patient does not have any of these symptoms they do not present a risk for Ebola; there is no need to ask question number two.
    • For the patient who DOES have one or more of the hallmark symptoms, question number two determines whether these very non-specific symptoms are likely to be related to Ebola. This question determines whether the patient has traveled recently through a high-risk Ebola location (presently West Africa) or had contact with a known or suspected Ebola patient. If the patient has NOT travelled in a high risk region or been in contact with a known/suspected Ebola patient, their symptoms are NOT associated with Ebola.

Answers to these questions yield several alternatives:

  • If the patient has NO signs or symptoms of Ebola; they don’t have Ebola. Use PPE according to the patient’s presentation, and treat/transport/refer according to your usual protocols or treatment guidelines.
  • If the patient HAS signs or symptoms of Ebola but HAVE NOT recently traveled into a high risk area or had contact with an Ebola patient, they don’t have Ebola. Use PPE according to the patient’s presentation, and treat/transport/refer according to your usual protocols or treatment guidelines.
  • If the patient HAS signs or symptoms of Ebola and HAS recently traveled into a high risk area or had contact with an Ebola patient, the patient is AT RISK.
  • The CDC term for these individuals is Person Under Investigation (PUI). The caregiver should immediately don barrier protection (gloves, gown) and protect against splatter (goggles and mask). Minimize unnecessary caregiver exposure. If the patient is seen in the EMS setting, immediately notify the receiving facility to enable them to adequately prepare to isolate the patient. Notify any referring caregivers. Following patient care, get supervisors and others involved to assure safe and adequate decontamination of the ambulance, patient care equipment, and any disposables.

By the way, DON’T feel a need to be too rigid about EXACTLY 21 days; symptomatic patients with high risk contact (travel or individual) within the last three to four weeks should probably be isolated until Ebola is ruled out (thanks to Ventura County EMS Medical Director Angelo Salvucci for reminding us).

Be sure to document the screening questions and data collected in MEDS. If documentation is NOT in MEDS, consult with local clinical leadership to standardize where the information is recorded.

This week you will see several additional tools for our practices:

  • Inclusion of the screening questions on the Medical History screen of MEDS. This will facilitate transfer of the information to other healthcare providers, and enable our leaders to better monitor use of the screening questions for at risk patients
  • Release of guidance on the evaluation and monitoring of caregivers who have an Ebola exposure. Although this guidance has not been necessary to date, we’d prefer to have it in place prior to any significant increase in case counts
  • Release of an online training program for caregivers. Content will include an overview of Ebola, screening questions, and how to match PPE to meet patient needs and Ebola risk factors.

Thanks for your organizational vigilance. Keep the questions coming.

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