Questions and Answers Related to the Commissioner's Order on Ebola Virus Disease (EVD) Preparedness - Updated 10/20/14

Hospitals

1. If a hospital does not have the capability to provide ongoing care for a patient with EVD, what preparations are they required to complete based on the Commissioner's Order?

A. All hospitals must be prepared to identify, isolate, diagnose and provide initial care and stabilization for persons meeting the Centers for Disease Control and Prevention (CDC) definition of persons under investigation (PUI), i.e., persons with consistent symptoms and travel history to EVD affected countries within the last 21 days. The hospital must provide personnel who may come into contact with such individuals or their laboratory specimens, or who may be involved in cleaning or disinfection of equipment or their patient care areas, with personal protective equipment (PPE) and training. Isolated patients must receive appropriate clinical care. Under the Commissioner's Order, a hospital that does not have the capability to provide ongoing care must develop a written transport protocol for the safe transportation of a PUI or a patient with confirmed EVD. The transport protocol must identify an ambulance service as well as the receiving facility. The transport protocol must include provisions requiring prompt notification that the protocol has been initiated to the receiving facility, local health department (LHD), NYSDOH, and the ambulance service. The hospital should coordinate with the NYSDOH to determine if and when to carry out that plan. The Commissioner's Order should be reviewed for specifics regarding these items, as well as additional requirements.

2. Are hospitals required to designate an inpatient isolation room for a PUI or patient with confirmed EVD, or is the isolation room used for the initial evaluation of the patient in the ED or adjacent area sufficient?

A. Hospitals must designate an isolation room that meets the requirements of the Commissioner's Order and is most appropriate given the physical layout and other characteristics of the individual facility with the overall goal of minimizing any possible exposures to staff and other patients. If the hospital plans to provide ongoing care to a patient with EVD, it must designate a negative pressure room in the hospital, as outlined in the Commissioner's Order, to provide that care. It is not necessary for the isolation room to be an inpatient room unless the patient is being admitted to an inpatient unit.

3. Our hospital does not have negative pressure rooms in our operating or labor and delivery areas. How should we handle a patient with confirmed EVD who requires these services?

A. The Order requires facilities to designate a negative pressure room for the inpatient care of a PUI or a patient with confirmed EVD. Special circumstances such as patients with confirmed EVD that require an operating room or labor and delivery will be dealt with on a case by case basis with guidance from the NYSDOH and the CDC.

Hospitals Designated for the Care of EVD Patients

New 1. Will there be any additional hospitals designated for the care of EVD in other areas of the state?

A. The NYSDOH continues to work with all hospitals, including regional tertiary care centers, to prepare for a Person under Investigation (PUI) or patient with confirmed EVD. Additional hospitals may agree in the near future to be designated publicly for the care of patients with EVD. As stated in the Commissioner's Order, all hospitals must be prepared to rapidly identify, isolate, diagnose and provide initial care and stabilization for a PUI or patient with confirmed EVD.

New 2. How did the NYSDOH identify the eight hospitals as the centers for treating EVD? What requirements will the hospitals have to follow when treating a PUI or patient with confirmed EVD?

A. The eight hospitals are regional tertiary care centers that have agreed to be designated as centers for the care of PUIs or patients with confirmed EVD. These hospitals must comply with the requirements set forth in the Commissioner's Order, including but not limited to the requirement that the hospitals develop a written plan for the ongoing care of confirmed cases. The Commissioner's Order requires the plan to include specific items if ongoing care will be provided at the hospital. Hospitals agreeing to be designated to provide care to PUIs or patients with confirmed EVD may submit an initial plan to the NYSDOH for review. The NYSDOH is working closely with designated centers to ensure that New York is continuously prepared to safely treat anyone who is exposed to or contracts Ebola.

Other Settings

New 1. Guidance is needed for private physicians and drug stores. For the physicians' office staff, are there triage questions that should be asked in order to redirect a person to a more appropriate setting such as an emergency room?

A. The NYSDOH is developing additional education materials for pharmacies, primary care providers and community settings. In the interim, any setting with an area for patient reception should consider posting signage prominently at entrances and the reception area, asking patients presenting for care to provide their international travel history. Signage along with translations in English, French, Spanish, Chinese, Russian, Italian, Korean, and Haitian Creole is available on the NYSDOH website at: International Travelers Poster. In addition, it is recommended that these entities should consider establishing a process where staff inquires whether patients have traveled within the last 21 days to Liberia, Guinea, or Sierra Leone, and whether they are experiencing any symptoms of EVD including fever, headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage. Patients answering yes to both questions should be moved into a private room or area while arrangements are made to transfer the patient to a health care facility.

Personal Protective Equipment (PPE)

1. What are the current PPE recommendations for hospital employees?

A. The CDC website contains the most recent PPE recommendations. These recommendations are also included on the NYS DOH website, Specifications required under the Commissioner's Order at: Specifications Required Under Commissioner's Order.

2. Several types of PPE are on backorder. What should hospitals do to obtain these products? How should hospitals conduct PPE training and drills with staff when we are unable to obtain PPE supplies?

A. Covered Entities should continue to order the PPE needed to comply with the Commissioner's Order and document all efforts and communications with manufacturers and distributors. Covered Entities should explore whether other facilities within their healthcare system or geographic area have PPE that can be provided to them to help them comply with the Commissioner's Order. Entities with an inadequate supply of PPE should use the minimum amount of PPE needed to conduct training and drills for Covered Personnel who are most likely to come into contact with a PUI. When additional supplies become available, additional training should be conducted. The NYSDOH will monitor the availability of PPE through HERDS surveys and is maintaining a supply of PPE that can be deployed to any facility that is caring for a PUI or patient with confirmed EVD that has exhausted all local sources of PPE.

New 3. Will there be any training offered or easily accessible training materials?

A. Yes. On Tuesday, October 21, 2014, from 10 a.m. to 1:00 p.m. NYSDOH will join representatives from the CDC, the Greater New York Hospital Association, 1199 SEIU and the Partnership for Quality Care for an Ebola educational session for health care workers. The event will include national and New York City-area infection control experts, and a hands-on demonstration of wearing and removing equipment. The education session will take place at the Javits Convention Center in New York City. The session is available to live stream at http://gnyha.org/ebolatraining.

New 4. Guidance for Local Health Departments (LHD) on PPE for monitoring contacts is needed.

A. Contact monitoring guidance for LHDs is anticipated to be posted during the week of 10/20/14.

Transport Protocols

1. Should hospitals that have identified a PUI or patient with confirmed EVD coordinate with the LHD and NYSDOH to coordinate patient transport to an Ebola care center?

A. Yes.

2. How long do facilities need to keep a PUI or patient with confirmed Ebola prior to transport?

A: All Covered Entities must be prepared to identify, isolate, diagnose and provide initial care and stabilization for a PUI. Isolated patients must receive appropriate clinical care for as long as necessary to stabilize the patient and arrange transport. The hospital should coordinate with the NYSDOH to determine if and when to carry out their transport protocol.

3. Must hospitals have written agreements with ambulance service providers for the transport of persons with suspected or confirmed EVD?

A. The Commissioner's Order requires that a hospital's transport protocol identify an ambulance service that will be used to transport EVD patients. Verbal agreements with ambulance service providers are acceptable, but the details of the arrangement should be specified in the hospital's written protocol.

4. If a community-based clinic sees a patient with a fever and travel history to Sierra Leone, Guinea, or Liberia meeting the CDC definition of a PUI what should they do?

A: All Article 28 facilities should have a plan to isolate a PUI prior to transport and to provide PPE to staff. They should also have a transport protocol in place. The facility should notify their LHD of a suspected case. Facilities must develop a written transport protocol for the safe transportation of any patient to another facility. The transport protocol must identify an ambulance service as well as the receiving facility. The transport protocol must include prompt notification that the protocol has been initiated to the receiving facility, LHD, NYSDOH, and the ambulance service. The facility should coordinate with the NYSDOH to determine if and when to carry out that plan.

New 5. Must specific hospitals be named in the protocol to transfer patients with EVD for ongoing care if that is the hospital's plan?

A. Yes. The Commissioner's Order requires that written transport protocols developed by general hospitals that will not be providing ongoing care for patients with EVD must identify an ambulance service as well as the receiving facility. The transport protocol must also include provisions requiring prompt notification that the protocol has been initiated to the receiving facility, LHD, NYSDOH, and the ambulance service.The hospital should coordinate with the NYSDOH to determine if and when to carry out that plan. Notification to the receiving facility and the ambulance service will allow them to direct staff to use PPE and prepare vehicles and receiving areas.

Laboratory Testing

1. How should hospital laboratories arrange transport specimens to the NYSDOH Wadsworth Laboratory for EVD testing?

A. Hospitals must maintain a readily available inventory of biohazard containers for the safe transportation of specimens to the NYSDOH or the New York City Department of Health and Mental Hygiene laboratory for testing for EVD. Such containers must meet applicable specifications at: Specifications Required Under Commissioner's Order. Hospitals must ensure that staff are available on every shift, who are trained and certified in the packaging and shipping of infectious substances, for the purpose of submitting specimens for EVD testing. Training must cover classifying infectious substances, proper packaging of infectious substances, and labeling packages to meet regulatory requirements. Hospitals should coordinate with the LHD and NYSDOH to arrange transport.

2. Should hospitals collect blood specimens from patients with suspected EVDwhile awaiting transport to an Ebola care center?

A. Essential bloodwork should be obtained following the guidance on the CDC website and NYSDOH website.

Health Care Worker Exposures

1. What actions should hospitals take when they have identified an employee with a low or high-risk exposure? How will hospitals handle employees who provided care for a PUI or patient with confirmed EVD? Will they be allowed to continue working after providing care a PUI or patient with confirmed EVD?

A. All covered entities must maintain a log of all personnel who come into contact with either a PUI, or a patient with confirmed EVD, or a patient's area or equipment, regardless of the level of PPE worn at the time of contact. Covered Entities shall measure the temperature twice daily of all personnel who come in contact with a patient, a patient's area or equipment, or obtain the temperatures from off-duty personnel. The log must describe each person's measured temperatures and any symptoms. "Contact" for the purposes of this provision is defined as coming in physical contact, entering a patient room, coming within three feet of a Patient, or performing laboratory testing on a specimen from a Patient. Staff who come into contact with a person with confirmed EVD who were not wearing appropriate PPE must remain at home and self-monitor and report temperatures and symptoms for 21 days.

2. How should health care personnel who have travelled to Guinea, Sierra Leone or Liberia be managed? Is there any guidance or protocols for dealing with health care workers returning from trips to Africa?

A: All travelers returning from these three countries are screened at the airport when arriving in the U.S. The NYSDOH receives a list of individuals who have been screened. LHDs are provided with the names of the individuals arriving from these countries, and the LHDs will contact individuals to rescreen them and make a plan in the event they develop symptoms. Health care workers who have been exposed to patients with EVD, EVD patient body fluids or human remains from EVD patients without appropriate PPE must not return to work for 21 days after exposure and will be requested to voluntarily quarantine. Those who have not had any exposure may return to work but the employer/agency should measure the health care workers' temperature twice a day when on duty and obtain their temperature and any symptoms by telephone when off-duty.

Those entities subject to the Commissioner's Order (general hospitals; diagnostic and treatment centers and off-campus emergency departments; ambulance and advanced life support first response services; and funeral directors and funeral establishments) must follow the applicable specifications contained in the order for Covered Personnel who come in contact with a Patient.

Signage

1. Has the NYSDOH developed a document to share with hospitals which has the required signage with translations to keep them uniform across the state?

A: Yes, sample signage in the required languages can be found at the following location: International Travelers Poster.

New 2. Is the use of the NYSDOH signage requiredfor entrances to hospitals?

Yes. The Commissioner's Order states that all general hospitals, diagnostic and treatment centers and off campus emergency departments must post signs prominently at all entrances, at reception, and at triage locations in at least English, French, Spanish, Chinese, Russian, Italian, Korean, and Haitian Creole asking all persons presenting for care to provide their international travel history. For the convenience of facilities, signage with translations is available on the NYSDOH website at: http://www.health.ny.gov/diseases/communicable/ebola/docs/international_travel.pdf, but hospitals may use other signage that meets the requirements of the Commissioner's Order, if they wish.

New 3. Some of the signage translations are not downloading. Who can I call for help? An English version of the signage is needed and we cannot find it on your site. We also need a Polish version for the many Polish people in our community?

A. If you are unable to download the signage from the website, please submit an e-mail to Ebola.Preparedness@health.ny.gov and someone from the NYSDOH will contact you to provide technical assistance or find an alternate method of sending you the document files. The NYSDOH will order a Polish translation and post it when it becomes available. The English version of the signage is located on the website at: http://www.health.ny.gov/diseases/communicable/ebola/docs/international_travel.pdf .

Other

1. Does this notification pertain to Skilled Nursing Facilities/Long Term Care facilities?

A: No, this Commissioner's Order does not apply to nursing homes.

2. Are Nigeria and Senegal included in the countries considered as high risk for EVD?

A. No, not at this time. Check the CDC website for the current list of affected countries.

New 3. The Order, Attachment A pages 1-2 states that facilities have 10 days for compliance. Please confirm the deadline for compliance.

A. The Commissioner's Order requires all Covered Entities to immediately begin implementation and compliance with the requirements set forth in Attachment A to the Order. Full implementation and compliance must be achieved by no later than ­­­10 calendar days of the Covered Entity's receipt of the Order. The Attachment cites to specifications entities must meet that are available on the NYSDOH website at: Specifications Required Under Commissioner's Order. However, if there are changes to the information posted on the NYSDOH website, Covered Entities will be provided additional time per the web site update to achieve full implementation and compliance with such changes.