Interim Guidance for Preparing Ebola Assessment Hospitals

Page Summary

Who this is for: State and local health departments and acute care hospitals that may serve as Ebola assessment hospitals

What this is for: Guidance to assist state and local health departments and acute care hospitals as they develop preparedness plans for patients under investigation (PUI) for Ebola Virus Disease (EVD).

How this relates to other guidance documents/purpose: This guidance is intended to inform efforts to prepare hospitals identified as Ebola assessment hospitals, and includes a summary of the capability elements needed for those hospitals. Context for this guidance document is provided in CDC’s Interim Guidance for U.S. Hospital Preparedness for Patients Under Investigation and with Confirmed Ebola Virus Disease: A Framework for a Tiered Approach. In addition, this guidance complements two other specific CDC guidance documents: Interim Guidance for Preparing Ebola Treatment Centers and Interim Guidance for Preparing Frontline Healthcare Facilities for Patients Under Investigation for Ebola Virus Disease.

Key points:

Ebola assessment hospitals are prepared to receive and isolate a PUI for EVD and care for the patient until an Ebola diagnosis can be confirmed or ruled out and until discharge or transfer is completed.
Functioning as an Ebola assessment hospital will be a decision made between state and local health authorities and the hospital administration.
Ebola assessment hospitals should be prepared to transport patients with confirmed EVD to an Ebola treatment center. Transfer decisions should be informed by discussions among public health authorities and referring and accepting physicians on a case-by-case basis, depending on the status of the patient and the capacity of the Ebola assessment hospital.
All states, particularly those that are not planning to designate in-state Ebola treatment centers, should consider identifying Ebola assessment hospitals to ensure that anyone, with symptoms and travel history consistent with EVD, can be cared for until an Ebola diagnosis is confirmed or ruled out.
Ebola assessment hospitals should be able to provide up to 96 hours of evaluation and care for PUIs until the diagnosis is either confirmed or ruled out and until discharge or transfer is completed.

Ebola assessment hospitals are prepared to receive and isolate a PUI for possible EVD and care for the patient until an Ebola diagnosis can be confirmed or ruled out. This guidance is intended to inform efforts to prepare hospitals identified as Ebola assessment hospitals, and includes a summary of the capability elements needed for those hospitals. It provides information for both state and local health departments as well as healthcare facilities serving in this role. Functioning as an Ebola assessment hospital will be a decision made between state and local health authorities and the hospital administration. All states, particularly those that are not planning to designate Ebola treatment centers, should consider identifying Ebola assessment hospitals to ensure that anyone, with relevant travel/exposure history and signs or symptoms consistent with EVD, can be appropriately cared for until an Ebola diagnosis is confirmed or ruled out. States should consider selecting enough Ebola assessment hospitals to provide adequate geographic coverage across the state and avoid extended transport times of more than 1–2 hours if possible, particularly from areas that have a large number of returning travelers.

Public health authorities may refer patients to Ebola assessment hospitals if they have traveled to an Ebola-affected area or had potential exposure to someone with EVD within the past 21 days and have developed signs and symptoms of EVD. Airport screening may have already identified these persons as at risk for EVD. If so, they will have been actively monitored on a daily basis by public health authorities during the 21 days following travel to a country with widespread Ebola transmission or other potential Ebola exposure (e.g., contact with a person with EVD). Travelers arriving from affected countries receive a CARE (Check and Report Ebola) kit that includes instructions to monitor their temperature and general health daily and immediately report any Ebola-symptoms to public health authorities. Ebola assessment hospitals may also receive patients transferred from frontline healthcare facilities that are not prepared to provide evaluation, arrange for testing, and care for PUIs. State and local public health authorities will coordinate closely with facilities when directing patients to an Ebola assessment hospital. Ebola assessment hospitals should ensure there is no delay in the care for these patients by being prepared to test, manage, and treat alternative etiologies of febrile illness (e.g., malaria, influenza) as clinically indicated.

Illness among persons who are under active monitoring because of potential exposure to Ebola is likely to be detected early in the clinical course. These patients are therefore likely to present for evaluation with mild symptoms such as isolated fever. Public health authorities will be promptly directing those persons to Ebola assessment hospitals for evaluation as soon as they report one or more symptoms. Initial isolation and evaluation of these clinically stable patients can be performed using personal protective equipment (PPE) and infection control practices according to the CDC’s guidance for Emergency Department Evaluation and Management for Patients Under Investigation for Ebola Virus Disease. Since these patients may also present with more severe symptoms or may exhibit vomiting, copious diarrhea, or obvious bleeding, Ebola assessment hospitals should be equipped and ready to implement use of PPE recommended for the care of hospitalized patients and ensure their staff is trained in its appropriate use.

Also, to confirm or rule out an EVD diagnosis in a PUI may take up to 72 hours or longer, and potentially require an additional 12-24 hours for specimen transport, testing, and identification of another facility for transfer (if needed). Ebola assessment hospitals should therefore be prepared to provide care for a PUI, including those with a high level of clinical suspicion for Ebola, for up to 96 hours. Ebola assessment hospitals complement state-designated Ebola treatment centers, which will care for and manage laboratory-confirmed Ebola patients through the full course of the illness. CDC has previously released Discharge Guidance for Persons Under Investigation for Ebola. Decisions regarding when to transport a PUI for possible EVD to an Ebola treatment center should be made on a case-by-case basis, informed by discussions among public health authorities and referring and accepting physicians, depending on the status of the patient and the capacity of the Ebola assessment hospital. Transport providers should be provided information about the patient’s status and have appropriate training and PPE to safely transport a patient to an Ebola treatment center. The state plan also may include plans to transfer the patient out of state based on the patient’s risk and severity of illness and the geographic location of Ebola treatment centers. CDC Ebola Response Teams (CERTs) may be deployed to the Ebola assessment hospital to provide technical assistance for infection control procedures, clinical care, and logistics of managing a patient with EVD.

Ebola assessment hospitals should be able to provide up to 96 hours of evaluation and care for PUIs until the diagnosis is either confirmed or ruled out and until discharge or transfer is completed. The following table summarizes guidance on minimum capabilities that Ebola assessment hospitals should have in place before receiving PUIs. State health officials are responsible for ensuring the readiness of Ebola assessment hospitals in their states. All Ebola assessment hospitals should conduct practice drills and correct any identified gaps.

Ebola Assessment Hospital Capability	Capability Description	Minimum Capability in Place? (Y/N)1
Facility Infrastructure: Patient room(s)	Hospital has a private room with in-room dedicated bathroom or covered bedside commode, equipped with dedicated patient-care equipment, including separate areas immediately adjacent to patient room: one for putting on (donning) of personal protective equipment (PPE) and one for taking off (doffing). These areas must be sufficient to allow a trained observer to safely and effectively supervise donning and doffing of PPE.
Patient Transportation	Joint determination by state and local public health agency, EMS, and hospital of interfacility transport plans (transfer of confirmed Ebola patients to the designated Ebola treatment hospital) including identification of transportation provider(s) (including ground and air transport) with appropriate training and PPE to safely transport a patient. Intrafacility plans for patient transport (e.g., from ambulance entrance to the designated ward or unit for patients under investigation) are developed and in place. Additional information on patient transport is available.
Laboratory	Diagnostic laboratory procedures and protocols are in place for specimen testing for Ebola by the nearest Laboratory Response Network (LRN) laboratory capable of testing for Ebola, addressing dedicated space (if possible), possible point-of-care testing, equipment selection and disinfection, staffing, reagents, training, and specimen transport for routine clinical diagnostic testing at the facility, as well as protocols for lab personnel PPE use and training. For more information, see CDC’s Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Persons Under Investigation.
Staffing	Readiness plans include input from a multidisciplinary team of all potentially affected hospital departments (including clinical and nonclinical staff). Staffing plans have been developed and scheduled to support 96 consecutive hours of clinical care. At a minimum, sufficient staff should be available such that two nursing staff are solely dedicated to each patient’s care each shift, and a trained observer is present at all times to supervise safe infection control practices including donning and doffing of PPE. The facility has a process for continuous staff input from those who may or may not be directly involved in Ebola patient care, including from employee unions, and has addressed employee safety questions and concerns.
Training	All staff involved in or supporting patient care are appropriately trained for their roles, and according to each role have demonstrated proficiency in donning and doffing of PPE, proper waste management, infection control practices, and specimen transport. Ongoing training is provided and breaches in infection control are addressed through retraining. Bearing in mind the need to limit the number of staff in direct contact with the patients, hospitals should consider comprehensive cross-training. For more information, see CDC’s Information for Healthcare Workers and Settings.
PPE	For patients who are clinically stable and without vomiting, copious diarrhea, or obvious bleeding, or a clinical condition that warrants invasive or aerosol-generating procedures (e.g., intubation, suctioning, active resuscitation), PPE recommended for Emergency Department assessment of minimally symptomatic patients may be used: i.e., face shield and surgical face mask, gown, and 2 pairs of gloves. For patients with vomiting, copious diarrhea, or obvious bleeding, or patients requiring invasive or aerosol-generating procedures, PPE designated for the care of hospitalized EVD patients should be used. Clinical staff has successfully drilled and demonstrated proficiency in donning/doffing PPE. The overall safe care of Ebola patients in a facility must be overseen by an onsite manager at all times, and each step of every PPE donning/doffing procedure must be supervised by a trained observer to ensure proper completion of established PPE protocols. Hospital has selected appropriate Ebola PPE and has at least a 4–5-day supply of PPE in stock and a vendor capable of providing re-supply. In the event that a facility does not have sufficient PPE, the facility should work with local healthcare coalitions, emergency management services, and local and state public health departments, in collaboration with CDC, to identify additional PPE resources Additional information regarding PPE supplies and how to increase access to PPE is available online.
Waste Management	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 staff are trained in the correct use of PPE and in the proper handling and storage of Category A infectious substances at the facility. If a vendor capable of transporting Category A infectious substances has not been arranged, hospitals may consider sequestering medical waste until the patient’s Ebola test result becomes known. At that time, if the patient is confirmed to have Ebola, arrangements should be made with a vendor capable of managing the waste as a Category A infectious substance; if the patient is ruled out for Ebola, waste can be handled according to procedures in compliance with local waste management ordinances. Additional information is available at Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus.
Worker safety	Worker safety programs and policies are in place. The hospital is in compliance with all federal or state occupational safety and health regulations applicable to reducing employee exposure to the Ebola virus. Hospital has a program for assuring direct active monitoring of all healthcare workers involved in direct patient care to assure monitoring for 21 days since the last known exposure. This monitoring should be done in coordination with local and state public health agencies.
Environmental Services	Hospital has a program in place to clean and disinfect patient care areas and equipment, including use of an Environmental Protection Agency-registered hospital disinfectant with a label claim of potency at least equivalent to that for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, and poliovirus), PPE, and safe practices. Designated staff are trained in correct cleaning and disinfection of the environment, safe practices, and correct use of PPE; and cleaning staff are directly supervised during all cleaning and disinfection. For more information, see Information for Healthcare Workers and Settings
Clinical Management	Staff who will be involved in managing the patient know the clinical protocols for management of PUIs for Ebola. For more information, see the evaluation and discharge of persons under investigation.
Operations Coordination	The hospital has an emergency management structure, plans and processes for routinely communicating with local and state public health agencies, emergency management authorities, its healthcare coalition (if appropriate), and hospital employees, patients, and community leadership, to ensure coordination of the response and communication regarding any PUIs for Ebola.