Infection Prevention and Control Measures for Pre-hospital Care and Ground Transport of Patients with Suspected or Confirmed Ebola Virus Disease

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This document provides infection prevention and control (IPC) guidance for safe prehospital^{Footnote *} care and ground transport of suspected persons under investigation (PUI) or confirmed Ebola virus disease (EVD) cases^{Footnote 1}. Its use is intended for prehospital personnel including, but not limited to, medical first responders, paramedics, emergency ground transport personnel, firefighters, enforcement officers, and personnel within prehospital organizations responsible for education and training for occupational health and safety (OHS) and IPC. The term prehospital personnel when used in this document refer to these personnel.

The guidance is based on currently available scientific evidence, standards and regulations, and adopts a precautionary approach where the evidence is lacking or inconclusive. It is subject to review and change as new information becomes available.

The IPC measures provided in this guidance are based on the Public Health Agency of Canada's Infection prevention and control measures for Ebola disease in acute care settings^{Footnote 2}, Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings^{Footnote 3}, and Hand Hygiene Practices in Healthcare Settings^{Footnote 4}.

The guidance should be read in conjunction with relevant local, provincial, territorial and federal legislation, regulations, and policies, and adapted to local requirements as necessary.

For information related to risk of transmission and public health (PH) management of cases and contacts of EVD refer to Public Health Management of Cases and Contacts of Ebola Virus Disease in the Community Setting in Canada ^{Footnote 5}.

Table of Contents

• Engineering Control Measures
• Administrative Control Measures
• Routine Practices
• Prehospital Call Assessment/Triage
• Point -of- Care Risk Assessment
• Personal Protective Equipment
• Notification/communication
• Source Control
• Prehospital and Transport Personnel Recommendations
• Hand Hygiene
• Moving Patient into and Out of Transport Vehicle
• Sharps Safety
• Dedicated Equipment
• Cleaning and Disinfection of Transport Vehicle
• Handling Waste and Linen
• References
• Appendix 1- Ebola Virus Disease: Management of Waste and Environmental Cleaning for Prehospital Care and Ground Transport

Engineering Control Measures

Engineering controls are those elements of the organization's infrastructure that function to prevent exposure to and/or transmission of the infectious agent, such as the Ebola virus, at the source, or along the path of the hazard.

Examples of engineering controls related to prehospital care and transporting suspected/confirmed EVD patients include the following:

• Use of designated emergency vehicles dedicated to a single patient; ensure thorough cleaning and disinfection following use. Refer to Cleaning and Disinfection of Transport Vehicle section.
• Removal of nonessential equipment from designated vehicle as part of vehicle preparation. Avoid contamination of reusable porous surfaces not designated for single use^{Footnote 6}.
• Cover the stretcher with an impermeable material. Use a stretcher mattress and pillow with plastic or other covering that fluids cannot penetrate^{Footnote 6}.
• Method of isolation measures to prevent blood and body fluid exposure for transport dependent upon point-of-care risk assessment and source control. Refer to Point-of-Care Risk Assessment and Source Control sections.
• Performing aerosol-generating medical procedures (AGMPs) only when absolutely necessary, controlling the situation as much as possible, i.e., performed prior to transport. Refer to Source Control section.
• Safety-engineered needles and needleless systems.
• Point-of-use sharps containers.
• Sufficient IPC supplies (e.g., personal protective equipment (PPE), disinfectant, hand hygiene products including point-of-care alcohol based hand rub, separate dedicated biohazard waste and linen receptacles, blood and body fluid containment products such as disposable absorbent pads, continence products) and other essential supplies and equipment for the duration of the transport.
• Provide ready-to-use (non-spray) or commercially prepared wipes to use for immediate cleaning and disinfecting of surfaces that become potentially contaminated during transport. Refer to Cleaning and Disinfection of Transport Vehicle section.

Administrative Control Measures

Administrative controls include policies, procedures, education, training and patient care practices intended to prevent exposure to and/or transmission of an infectious agent during the provision of care and transport. To be effective in preventing transmission of EVD and/or detecting cases of EVD, administrative controls must be implemented from the first encounter with a suspected case and continue until the patient is accepted into a receiving hospital. Ineffective or inconsistent application of administrative controls may lead to unnecessary exposure.

Examples of administrative controls for prehospital care and transport of a patient with suspected or confirmed EVD include the following:

• Screening protocols for EVD risk factors and EVD compatible symptoms during prehospital call assessment.
• Prehospital response (type and scope) based on call assessment/triage to identify suspected or confirmed patients.
• Ongoing education and training about routine practices and additional precautions including but not limited to prehospital call assessment/triage, point-of-care risk assessment, use of PPE including enhanced PPE, notification/communication, source control, personnel recommendations, hand hygiene, patient movement, sharps safety, patient equipment, cleaning and disinfection of equipment and transport vehicle, and handling waste and linen.
• Protocols for prehospital care and safe transport of suspected or confirmed EVD patients including prompt initiation of isolation measures and appropriate selection and use of PPE, including enhanced PPE based on a risk assessment, as outlined in the Agency's Infection prevention and control measures for Ebola disease in acute care settings^{Footnote 2} and organizational requirements.
• Assigning a trained monitor to coach and monitor proper use, putting on and removing PPE.
• Specialized training including drills in the selection, application, use, removal and disposal of PPE.
• Protocol for containing and disposing of body fluids, (e.g., urine, stool, emesis) including the use of disposable bedpan/urinal with the addition of a solidifier and disposed of as waste, during the transport of the patient. Refer to Appendix 1- Ebola Virus Disease: Management of Waste and Environmental Cleaning for Prehospital Care and Ground Transport.
• Respiratory Protection Program.
• Limiting the number of prehospital and transport personnel to the minimum required to safely provide care and transport.
• Monitoring and maintaining a log of all personnel involved in prehospital care and transport.
• Personnel recommendations, including protocols for determining personnel fitness to provide direct care to suspected or confirmed EVD patients and protocols for incident management (including breach in PPE, post exposure and first aid). Refer to Prehospital and Transport Personnel Recommendations section.
• A protocol to address vehicle breakdown during transport.
• A protocol to address critical interventions and/or issues such as need to stop the vehicle to manage breach of PPE, personnel exposure, or personnel requirements for bathroom breaks during extended transports.

Routine Practices

Routine practices are the IPC measures that should be applied in the routine care of all patients, at all times, in all healthcare settings, including prehospital care. Routine practices are determined by performing a risk assessment, taking into consideration the circumstances of the patient, the patient care environment and the task to be performed.

Routine practices outlined in this document include: call assessment/triage, point-of-care risk assessment, use of PPE including enhanced PPE, notification/communication, source control, personnel recommendations, hand hygiene, patient movement, sharps safety, patient equipment, cleaning and disinfection of transport vehicle, and handling waste and linen.

Prehospital Call Assessment/Triage

• When calls are assessed by a dispatcher from individuals concerned about Ebola, the following questions as per the Algorithm for screening and assessment for Ebola disease in persons presenting to healthcare settings^{Footnote 7} should be asked to identify a suspected EVD case:
  1. Within the previous 21 days, has the person lived in or travelled to a country with widespread Ebola transmission OR had contact with a person suspected or confirmed to have EVD:
     • If YES, enquire about EVD compatible symptoms:
       • Does the person have a fever: subjective or ≥38°C (if measured)
     • OR
       • Does the person have at least one of the other EVD compatible symptoms: malaise, myalgia, headache, arthralgia, fatigue, loss of appetite, conjunctival redness, sore throat, chest pain, abdominal pain, nausea, vomiting, diarrhea that can be bloody, hemorrhage, erythematous maculopapular rash on the trunk^{Footnote 1}

     If YES, to either enquiry about EVD compatible symptoms (i.e., person under investigation (PUI)/suspected patient) above, the dispatcher must inform prehospital personnel that an EVD response is required.

     • If NO to both symptom-based enquiries:
       • Usual prehospital service/care should be provided.

Point -of- Care Risk Assessment

• A point-of-care risk assessment (PCRA) should be performed prior to every interaction with a suspected or confirmed EVD patient (or contact with their care environment) to protect personnel from exposure to the Ebola virus (i.e., contact with or sprays of blood or other body fluids, respiratory tract or other secretions or excretions and used needles and other sharps). For details refer to the Agency's Infection prevention and control measures for Ebola disease in acute care settings^{Footnote 2}.
• A PCRA should also be performed to determine requirements for PPE and other IPC measures when responding to patients with EVD compatible symptoms (i.e., PUI/suspected EVD patient).
• Only one prehospital responder should approach the patient and perform the initial PCRA from at least one meter away from the patient. If EVD is suspected, PPE should be put on before entering the scene^{Footnote 6}.
• Prehospital response to a suspected or confirmed EVD patient where patient's body fluids are contained (i.e., personnel who have no direct contact with body fluids) will require the following PPE: gloves, fluid-resistant or impermeable gown, fluid-resistant mask with eye goggles or fluid-resistant mask with face shield. Head and neck coverings and foot and leg coverings are not required.
• The need for enhanced PPE is determined by assessing the increased risk of exposure to blood and other body fluids (e.g., patient is vomiting, has diarrhea, and/or is bleeding). Note: In late stages of EVD, copious secretions and excretions should be anticipated. In this situation, enhanced PPE that will cover all exposed skin should be worn.
• Enhanced PPE provides coverage to ALL exposed skin and includes the following: double gloves, fluid-resistant or impermeable body coverings(including foot and leg coverings), head and neck coverings (such as surgeon's head covering), gown or hazardous material suit, fluid impermeable apron, facial protection (fluid-resistant mask with eye goggles or fluid-resistant mask with facial shield), and a respirator for AGMP. Note: When enhanced PPE is required to care for a patient with EVD, the preferred eye protection would be a face shield long enough to prevent splashing underneath.

Personal Protective Equipment

• For details on selection and use of PPE refer to Infection prevention and control measures for Ebola disease in acute care settings^{Footnote 2}.
• The type of PPE and the sequence for putting on and removing PPE may vary slightly depending on organizational needs and preferences. Each organization must develop comprehensive policies and procedures for putting on and removing PPE with a clear goal of reducing the possibility of self-contamination.
• Personnel must be trained in the principles of safe and effective PPE use, including safely putting on and removing PPE.
• PPE must be put on correctly before entering the patient care/isolation area. Refer to Source Control section.
• PPE must remain on and be worn correctly for the duration of prehospital patient care, transport or when in contact with the patient's potentially contaminated care environment.
• PPE should not be adjusted during patient care.
• If a breach in PPE occurs, personnel should immediately stop patient care, initiate PPE removal process with the assistance of the monitor and remove themselves from the patient care/isolation area. Refer to Prehospital and Transport Personnel Recommendations.
• Personnel must have sufficient and undisturbed time to put on and remove PPE correctly, observed by a monitor.
• Removal of PPE requires a structured and monitored process and must be done slowly and carefully. Removal may present a high-risk for self-contamination if not done properly.
• PPE must be provided and put on outside the patient care/isolation area. PPE should be put on and removed in separate areas.
• A trained, tested and drilled monitor must be assigned to coach, observe and monitor appropriate selection, application, removal and disposal of PPE, to avoid potential contamination of personnel and the area outside of the patient care/isolation area.
• Those who do not wear PPE must not have contact with the patient or the patient care/isolation area.
• Those involved with moving the patient into and out of the transport vehicles must wear PPE.
• The driver of the transport vehicle should only wear PPE when in contact with the patient or their designated care/isolation area. If PPE is worn it should be removed (as outlined above) prior to operating the vehicle, in order to prevent contamination of the vehicle. The driver does not need to wear PPE to operate the vehicle.

Notification/communication

• The receiving hospital and PH should be notified as soon as a need for patient transport is determined.
  • Upon arrival to the receiving hospital, and prior to entry, transport personnel must ensure that the emergency department is ready for the patient.
  • The receiving hospital should notify PH of the arrival of a symptomatic person compatible with EVD or confirmed EVD case.
• Prehospital personnel should inform household members who shared the residence to not have further contact with items contaminated with blood or body fluids of the patient, and to not leave the residence until PH has contacted them with further information and instruction.
  • Household members who shared the residence should be advised to perform hand hygiene (HH) if they had contact with the patient's blood or body fluids.

Source Control

• The transport vehicle should be dedicated to a single patient. The stretcher should be covered with impervious material.
• The patient should wear a mask, if tolerated, to contain droplets. If a mask is not tolerated, advise the patient to use tissues to contain respiratory secretions and to cover nose and mouth during coughing or sneezing, with prompt disposal into a plastic-lined biohazard waste receptacle.
• Patients should be instructed and/or assisted with performing HH after contact with blood or body fluids (e.g., after use of toilet, using tissues for respiratory secretions, vomiting).
• If AGMP are absolutely necessary (e.g., endotracheal intubation), the following strategies to reduce aerosol generation are recommended:
  • AGMP should be anticipated and performed prior to transport whenever possible.
  • Appropriate patient sedation should be used.
  • The number of personnel in the patient care/isolation area should be limited to those required to perform the AGMP and to those highly skilled in performing the required task.
  • Household members should not be in the patient care/isolation area during an AGMP.
  • Fit-tested, seal-checked respirators (NIOSH) approved N95 at a minimum should be worn by all personnel in the patient care/isolation area during an AGMP.
  • Closed endotracheal suction systems should be used wherever possible.
• If point-of-care risk assessment indicates the potential for blood and body fluid exposure during transport (i.e., patient is vomiting, has diarrhea, and/or is bleeding) use methods to contain fluids (i.e., use continence products and place absorbent pads under the patient) to prevent exposure of personnel and contamination of emergency vehicle.
  • If patient is vomiting, assist them by providing a biohazard receptacle to contain the emesis.
• A designated patient care/isolation area should be established in the back of the transport vehicle and patient movement and patient care is to be restricted to this area.
  • Personnel wearing PPE should remain in this area.
• A risk assessment approach should be used to determine the type of PPE to use. Refer to Point-of-Care Risk Assessment section.
• Only essential personnel with appropriate PPE should enter the patient care/isolation area.
• A log should be maintained to monitor all persons entering and exiting the patient care/isolation area.
• Supplies should be stored outside the patient care/ isolation area. Plastic-lined biohazard waste receptacle should be placed inside the isolation area.
• Clean PPE and supplies should be stored in a designated area outside of the EVD patient care/isolation area.
• Space in the patient care/isolation area should be provided to allow monitoring of personnel by a trained monitor during personnel-patient interaction.
• If a portable, single Patient Isolation Unit (PIU) is considered for use to isolate the patient during transport, the following measures are recommended:
  • The patient should be assessed to determine their suitability for transport in a PIU (i.e., consider body morphology, potential for patient vomiting, having diarrhea, and/or bleeding, intubation/ventilation needs, and psychological safety and comfort).
  • Method for management of body fluids (e.g., emesis, feces, urine, blood) should be determined.
  • The PIU should be large enough for the patient to turn to the side to protect their airway if there is a possibility of the patient vomiting during transport. As PIUs may use safety belts to secure patients, assessment should include patient's ability to turn on own or with the safe assistance of personnel.
  • The PIU should provide re-sealable portals for allowing personnel to assist the patient as needed, including airway management (i.e., intubation/ventilation).
  • Personnel should have specific education and training in assessing the patient's suitability for transport in a PIU and the appropriate use of PIU's according to manufacturer's instructions including measures to reduce the risk of contaminating the unit, self and patient care area.
  • Used PIUs should be disposed of into EVD waste following use rather than cleaning and disinfection for reuse due to high risk of exposure to personnel and the ineffectiveness of complete cleaning and disinfection related to the PIUs construction.

Prehospital and Transport Personnel Recommendations

• Personnel should consult with OHS or delegate or primary physician if there are concerns related to fitness of personnel to provide direct care. For details/examples of such conditions, refer to the Agency's Infection prevention and control measures for Ebola disease in acute care settings^{Footnote 2}.
• Personnel should be aware of countries with travel advisories for EVD, signs and symptoms of EVD, appropriate control measures, and the need to self-monitor while caring for suspected/confirmed cases of EVD and for 21 days following last contact with an EVD patient (including being available to PH). Refer to WHO Global Alert and Response^{Footnote 8} webpage for frequent updates.
• Personnel must inform OHS or delegate and PH if symptoms arise.
• Eating or drinking should not occur in areas where direct patient care is provided.
• Personnel should avoid touching the mucous membranes of their eyes, nose and mouth to prevent self-contamination.
• Personnel should report potential occupational/community exposure to EVD (i.e., direct exposure without appropriate PPE, a breach in safely removing PPE, percutaneous injuries) to immediate supervisor, OHS or delegate and PH.
• First aid should be performed immediately if there has been exposure to blood or other body fluids.
  • The exposure should be reported immediately to the manager/supervisor and OHS or delegate and immediate medical attention should be obtained.
  • The site of a percutaneous injury should be thoroughly rinsed with running water (e.g., using a water bottle) and any wound should be gently cleansed with soap and water.
  • Exposed mucous membranes of the eyes, nose or mouth should be flushed with copious running water (e.g., using a water bottle) if contaminated with blood, body fluids, secretions or excretions.
  • Exposed non-intact skin should be rinsed thoroughly with running water (e.g., using a water bottle) and gently cleansed with soap and water.
  • All appropriate follow-up for blood-borne pathogens as per organizational policy should be initiated.

Hand Hygiene

• Frequent use of alcohol-based hand rub (60-90% alcohol concentration) (ABHR) or washing with soap and water (if hands are visibly soiled) including, but not limited to, the following recommended situations:
  • As outlined in the Infection prevention and control measures for Ebola disease in acute care settings^{Footnote 2} and the organization's policy.
  • Before putting on PPE.
  • During and after removing PPE (e.g., gloves, gown, mask, facial shield, eye goggles, head and neck coverings, etc.).
  • Before putting on a clean pair of gloves for the removal of soiled PPE.
  • After contact with blood/body fluids.
• The following measures are recommended for the use of hand wipes:
  • Hand wipes may be used as an alternative to soap and water when hands are visibly soiled and a designated handwashing sink/facility is not immediately available or when the handwashing sink/facility is unsuitable (e.g., contaminated sink, no running water, no soap). In this instance, ABHR should be used after the use of hand wipes and hands should be washed with soap and water once an acceptable sink/facility is available.
  • Hand wipes may be used as an alternative to soap and water when hands are not visibly soiled and a designated handwashing sink/facility is not immediately available or when the handwashing sink/facility is unsuitable (e.g., contaminated sink/facility, no running water, no soap). In this instance, ABHR should be used after the use of hand wipes.

Moving Patient into and Out of Transport Vehicle

• Personnel involved with moving the patient into and out of the transport vehicle should wear appropriate PPE.
• Appropriate care should be taken to avoid dislodging or tearing PPE and subsequent possible contamination during transfer of patient from stretcher to stretcher, as transfer requires close contact and physical manipulation of the patient.
• Emergency department personnel should meet the ambulance with a prepared stretcher to limit prehospital personnel movement within the facility.
• The patient must be taken directly to the receiving area in the hospital via the most direct route secured and monitored to avoid exposure of other individuals (e.g., patients, visitors) and HCWs who are not involved in the patient's care.

Sharps safety

• The following measures are recommended for the safe use of sharps:
  • The use of needles and other sharps should be limited as much as possible.
  • Needles should never be recapped.
  • Needles and other used single-use sharp items must be disposed of immediately into designated puncture-resistant containers that are easily accessible at the point-of-use.
  • Needles and other sharp instruments must be handled with care to avoid injuries during disposal.
  • Safety-engineered needles and needle-less systems should be made available and used.
• In the event of a percutaneous injury with an EVD-contaminated sharp, the following measures are recommended:
  • The worker or trained monitor should advise the immediate manager/supervisor, OHS or delegate and PH, as per usual organizational protocol. Refer to Prehospital and Transport Personnel Recommendations section.
  • The worker must immediately initiate and obtain first aid and notification as described in the Prehospital and Transport Personnel Recommendations section.

Dedicated Equipment

• Disposable equipment is preferred (i.e., bedpan, urinal, with the use of a solidifier) and should be discarded into a plastic-lined biohazard waste receptacle after use.
• Non-critical reusable patient-care equipment (e.g., blood pressure cuff) should be dedicated to the patient for single-patient use. Immediately after use, equipment should be placed into biohazard bags and labeled for cleaning and disinfection according to manufacturer's instructions and organization's policy by trained personnel wearing correct PPE before reuse with another patient.

Cleaning and Disinfection of Transport Vehicle

• Education, hands-on training, practice, and observation of ability to adhere to correct processes and procedures, and appropriate PPE should be provided to those responsible for environmental cleaning.
• Those responsible for cleaning and disinfection should wear the same level of protection as personnel providing care to the patient. Enhanced PPE should be determined by a risk assessment to exposure to blood and/or other body fluids.
• Responsibility and accountability for cleaning and disinfection of patient care/isolation area and vehicle should be assigned and monitored to ensure appropriate and consistent processes are followed.
• In selecting disinfectants that are expected to inactivate Ebola virus on non-critical hard surfaces and medical devices, Health Canada recommends products with the following approved criteria:
  • Registered in Canada with a Drug Identification Number (DIN);
  • The label should have a "broad spectrum virucide" claim and/or acknowledge effective testing against any of the following: Adenovirus type 5, Bovine Parvovirus, Canine Parvovirus or Poliovirus type 1^{Footnote 2}.
• Following completed transfer of the patient to the emergency department stretcher or inpatient bed, cleaning and disinfection measures should be taken.
• The following surfaces, equipment and other items used during transport should be cleaned and disinfected using a disinfectant with a broad spectrum virucide claim with a DIN and used according to the manufacturer's instructions:
  • All surfaces or equipment the patient or their blood and other body fluids have potentially contacted (e.g., transport stretcher surfaces).
  • All exposed surfaces in the transport vehicle.
  • All non-contaminated areas of the vehicle as per regular protocol (i.e., areas where there was no cross contamination from equipment/items, personnel with PPE etc.).
  • All equipment and reusable containers prior to their return to transport vehicle.
• Blood or other body fluid-contaminated seat cushions or webbed seats should be removed and disposed of into plastic-lined biohazard waste receptacle, as disinfection is not appropriate for these items.
• Compressed air or sprayers for vehicle cleaning should not be used.
• For additional information on environmental cleaning and blood and other body fluid spills, refer to Appendix I - Ebola Virus Disease: Management of Waste and Environmental Cleaning for Prehospital Care and Ground Transport.

Handling Waste and Linen

• Refer to Appendix I - Ebola Virus Disease: Management of Waste and Environmental Cleaning for Prehospital Care and Ground Transport.

References