Harbor:Infectious Disease Threats
The County Department of Public Health has declared a Hepatitis A Outbreak in Los Angeles County and we are being asked in the emergency department to do our part to stem this outbreak. In order to help we need to do the following things for all ADULTS (>18 years):
- Suspect: Consider acute viral hepatitis, especially in homeless patients or patients using illicit drugs.
- Test: If you suspect the patient may have acute viral hepatitis, order appropriate serologic studies (Hep A IgM, Hep B Core IgM, Hep B Surface Ag, Hep C Antibody Ab.) These are all available in the "AMB Hepatitis Workup" order set. STAT 45 minute turnarounds for the Hep A IgM is available, must be ordered as a standalone STAT test from the ED Quick Orders Page. If it is bundled with other Hepatitis tests, the machine runs all of them, delaying the turnaround time.
- Report: All suspected and confirmed cases of Hepatits A should be immediately reported to both the Dept of Health at (888) 397-3993 or after hours (213) 974-1234 AND Harbor Infection Control at x3838 While Patient Is Still in the Emergency Department
- Vaccinate: Anyone (regardless of why they are here) who is or has been homeless in the last two months, or uses illicit drugs (NOT JUST IV; except marijuana) should be offered the initial dose of Hep A vaccine while in the ED (the Cerner order is "Hepatitis A adult vaccine" on ED Quick Orders Page). They can be referred to the Department of Health for their second injection in six months. Check the "immunizations" area in Cerner to make sure they are not already immunized.
- Protect Yourself: If you haven't gotten the hepatitis A vaccine, it is recommended that you go to employee health to get vaccinated.
- Influenza-like-illness (ILI) is defined as fever >100.0 F / 37.8 C AND cough or sore throat.
- Per our DHS policy, please consider treatment for high-risk populations.
- Antivirals for influenza are most effective when administered when symptoms have been present for <48 hours.
- May benefit for severely ill patients who have had >48 hours of symptoms.
- High risk patients for complications include:
- Age < 2 years or > 65 years
- Chronic disease. Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes)
- Immune suppression, including that caused by medications or HIV
- Persons younger than 19 years of age who are receiving long term aspirin therpay
- Don't send POC influenza test, due to low sensitivity (50-70%).
- Please send the Biofire / Respiratory Panel PCR for admitted ILI patients.
- Don't send POC RSV unless it will change your management.
Harbor Ebola Precautions
- Never enter a room with an Ebola PUI (Person Under Investigation) without full Ebola level PPE.
- The definition of a PUI is simple - possible exposure to Ebola and subjective complaints consistent with Ebola infection (basically viral syndrome symptoms or abdominal pain or bleeding). No fever or other visible findings are required to classify the patient as a PUI patient.
- Currently countries identified as travel locations we should be concerned about are coded into the "ID Risk Screen" the routers perform and you can find on Cerner under "Provider Notes"
- There are other ways to be exposed to Ebola virus: including sexual intercourse with a patient who has recovered from an Ebola infection.
- As soon as the patient is identified as a PUI - they should go straight into isolation (in AAED or PED, not RME); all further evaluation is done there.
- Residents should not be in a room with a PUI patient - only attendings and fellows acting as attendings should be involved in wearing PPE and entering a PUI room
- Notify the infectious disease service that you have a PUI patient in the emergency department - they will guide further screening to determine if the patient can be cleared or not.
- PUI patients are not allowed to use the sink or toilet. Mechanical should bring a porta-potty for patient use.
- The policy of the County of Los Angeles is that any provider may decline to care for a PUI patient. Nursing has a list of nurses who have volunteered to care for PUI patients.
- Extreme care should be taken in any situation where a PUI patient may undergo a procedure that aerosolizes body fluids - the best PPE in this case is a PAPR unit - which is a helmet with a positive pressure fan. We will receive additional training on these in the future.
- There is a cart in the AAED that contains all of the PPE equipment to care for a PUI patient. It is currently across from the B side desk in the AAED, and looks like all the other yellow PPE carts. We are in the process of having it marked with a large "E" to distinguish it from the other PPE carts.
- In the top drawer of the Ebola PPE cart is a binder that has step by step instructions for getting into and out of PPE for both the treating provider and that provider's "buddy". We will plan more training to refresh everyone on this.
- The instruction book also contains a log to record who goes in and out of a PUI room.
- UCLA Medical Center in Westwood will be our referral center for patients who cannot be cleared in a reasonable timeframe' or become confirmed Ebola patients. The decision for the timing of transfer will be made in conjunction with the infectious disease consultant.
- EMS has a special unit to transport such patients - make sure they're aware that you have a PUI or confirmed case of Ebola.
M. Peterson 5/8/15