Ebola emergency department evaluation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: : Yazan Daaboul, M.D.

Overview

Triage and evaluation processes in the ED should consider and systematically assess patients for the possibility of Ebola virus disease. Healthcare facilities should be able to rapidly identify and triage patients with relevant exposure history and signs or symptoms compatible with Ebola virus disease, immediately isolate any suspected patient, and immediately notify the hospital/facility infection control program, other appropriate facility staff, and the state and local public health agencies. Healthcare facilities must implement administrative and environmental controls and provide onsite management and oversight on the safe use of personal protective equipment (PPE).

Triage Recommendations

1. Immediately upon entrance to the ED, or in advance of entry if possible, a relevant exposure history should be taken including exposure criteria of 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. 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).
2. Patients who meet the exposure criteria should be further questioned regarding the presence of signs or symptoms compatible with Ebola Virus Disease. These include: fever (subjective or ≥100.4°F or 38.0°C) or headache, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or hemorrhage (e.g., bleeding gums, blood in urine, nose bleeds, coffee ground emesis or melena). All patients should be routinely managed using precautions to prevent any contact with blood or body fluids. If an exposure history is unavailable, clinical judgment should be used to determine whether to empirically implement the following protocol. 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:
3. Isolate the patient in a private room or separate enclosed area with private bathroom or covered, bedside commode and adhere to procedures and precautions designed to prevent transmission by direct or indirect contact (e.g. dedicated equipment, hand hygiene, and restricted patient movement). 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 in place 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. 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. If the patient is exhibiting obvious bleeding, vomiting, copious diarrhea or a clinical condition that warrants invasive or aerosol-generating procedures (e.g., intubation, suctioning, active resuscitation), PPE designated for the care of hospitalized patients as outlined in CDC guidance should be used. If the patient requires active resuscitation, this should be done in a pre-designated area using equipment dedicated to the patient. If these signs and symptoms are not present and the patient is clinically stable, healthcare workers should at a minimum wear: 1) face shield, 2) surgical face mask, 3) impermeable gown and 4) two pairs of gloves. All equipment used in the care of these patients should not be used for the care of other patients until appropriate evaluation and decontamination.
4. Notify the Hospital Infection Control Program and other appropriate staff and report to the relevant local health department immediately of patients with Ebola Virus Disease exposure history regardless of symptoms.
5. Once appropriate PPE has been put on, continue obtaining additional history and performing physical examination and routine diagnostics and interventions which may include placement of peripheral IV and phlebotomy. The decision to test patient for Ebola Virus Disease should be made in consultation with the relevant local health department. Patient evaluation should be conducted with dedicated equipment as required for patients on transmission-based precautions.
   

Algorithm for the Emergency Department Evaluation and Management of Patients with Possible Ebola Virus Disease

Shown below is the Centers for Disease Control and Prevention (CDC) algorithm for the emergency department evaluation and management for patients who present with possible Ebola virus disease. Click here to access the PDF version of the CDC algorithm and print it.

Patient encounter in emergency department (ED)

Has the patient lived 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?

Yes

No

Does the patient have FEVER (subjective or ≥ 100.4 °F or 38.0 °C) OR Ebola-compatible symptoms (listed below)? Headache Weakness Muscle pain Vomiting Diarrhea Abdominal pain Hemorrhage

Continue with usual triage and assessment

Yes

No

Continue with usual triage and assessment Notify relevant health department Monitor for fever and symptoms for 21 days after last exposure in consultation with the relevant health department

Isolate and determine personal protective equipment (PPE) needed Place patient in private room or separate enclosed area with private bathroom or covered, bedside commode. Only essential personnel with designated roles should evaluate patient and provide care to minimize transmission risk.

Inform: IMMEDIATELY notify the hospital infection control program and other appropriate staff IMMEDIATELY report to the health department

The use of PPE should be determined based on the patient's clinical status Is the patient exhibiting obvious bleeding, vomiting, copious diarrhea, or a clinical condition that warrants invasive or aerosol-generating procedures (e.g. intubation, suctioning, active resuscitation)?

Yes

No

Use PPE designated for the care of hospitalized patients If the patient requires active resuscitation, this should be done in a pre-designated area using pre-designated equipment

For clinically stable patients, healthcare worker should have a minimum wear: Face shield and surgical face mask Impermeable gown Two pairs of gloves If patient's condition changes, re-evaluate PPE

Further evaluation and management Complete history and physical examination; decision to test for Ebola should be made in consultation with relevant health department Perform routine interventions (e.g. placement of peripheral intravenous phlebotomy for diagnosis) as indicated by clinical status Evaluate patient with dedicated equipment (e.g. stethoscope)

^{Algorithm adapted from the Centers for Disease Control and Prevention - Identify, Isolate, Inform: Emergency Department Evaluation and Management for Patients Who Present with Possible Ebola Virus Disease.}