Learning from Mistakes: CDC Issues New ED-specific Ebola Triage Guidelines

October 9th, 2016

ATLANTA – With knowledge about Ebola virus disease and how to manage and treat it evolving by the minute, the CDC has released new guidelines for emergency departments based on recent experiences of U.S. hospitals caring for Ebola patients.

While the CDC provided some reassurance on the risk of exposure, it still urged a high level of vigilance by EDs.

“In general, the majority of febrile patients presenting to the ED do not have Ebola virus disease, and the risk posed by patients with early, limited symptoms is lower than that from a patient hospitalized with severe Ebola virus disease” public health officials noted. “Nevertheless, because early symptoms of Ebola virus disease are similar to other febrile illnesses, triage and evaluation processes in the ED should consider and systematically assess patients for the possibility of Ebola virus disease.”

That involves administrative and environmental controls, including a designated area for further evaluation of a patient with possible Ebola virus disease, as well as onsite management and oversight on the safe use of personal protective equipment (PPE), according to the CDC guidance, which added, “Best practice would include continuous safety checks through direct observation of healthcare workers during the process of putting on (donning) and taking off (doffing) PPE.”

The CDC has made available an algorithm to help ED personnel identify, isolate and inform appropriately when a patient with Ebola presents at a facility. The agency cautioned that even before any determination of illness is made, all patients should be routinely managed using precautions to prevent any contact with blood or body fluids

The triage recommendations include taking a relevant exposure history immediately upon entrance to determine whether the patient has resided in or traveled to a country with widespread Ebola transmission or had contact with an individual with confirmed Ebola virus disease within the previous 21 days.

“Because the signs and symptoms of Ebola virus disease may be nonspecific and are present in other infectious and noninfectious conditions that are more frequently encountered in the United States, relevant exposure history should be first elicited to determine whether Ebola virus disease should be considered further,” the CDC advises. “If the patient is unable to provide history due to clinical condition or other communication barrier, history should be elicited from the next most reliable source (e.g. family, friend or EMS provider).”

If patients meet the exposure criteria, they should be further questioned about the presence of signs or symptoms compatible with Ebola virus disease. These include:

• fever (subjective or ≥100.4°F or 38.0°C);
• symptoms such as headache, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or
• hemorrhage, including bleeding gums, blood in urine, nose bleeds, coffee ground emesis or melena.

“If a relevant exposure history is reported and signs or symptoms consistent with Ebola virus disease are present, the following measures should be implemented IMMEDIATELY,” according to the CDC guidelines.

A patient suspected of being infected with Ebola should be isolated in a private room or separate enclosed area with private bathroom or covered, bedside commode, and the ED should adhere to procedures and precautions designed to prevent transmission by direct or indirect contact, including dedicated equipment, hand hygiene, and restricted patient movement, the algorithm states. It adds that, if the patient is arriving by EMS transport, the ED should be prepared to receive the patient in a designated area away from other patients and have a process for safely transporting the patient on the stretcher to the isolation area with minimal contact with non-essential healthcare workers or the public.

“To minimize transmission risk, only essential healthcare workers with designated roles should provide patient care,” the CDC states. “A log should be maintained of all personnel who enter the patient’s room. All healthcare workers who have contact with the patient should put on appropriate PPE based on the patient’s clinical status.” Other guidelines offer details on exactly what equipment should be used in each circumstance.

“The risk of transmission of Ebola virus from a patient to a healthcare worker depends upon the likelihood that the patient will have confirmed Ebola virus disease combined with the likelihood and degree of exposure to infectious blood or body fluids,” the CDC explains. “That risk depends on the severity of disease; severe illness is strongly associated with high levels of virus production. In addition, close contact with the patient and invasive medical care can increase opportunities for transmission.”

The guidelines also state that EDs should notify their hospital infection control programs and report patients with Ebola virus exposure to the local health department, regardless of the presence of symptoms.

Whether patients should be tested for Ebola should be made in consultation with public health officials, according to the CDC.