Category Archives: Alerts

MERS Protocol

1.  Any patient with travel history (14 days) to the Arabian peninsula (Bahrain; Iraq; Iran; Israel, the West Bank, and Gaza; Jordan; Kuwait; Lebanon; Oman; Qatar; Saudi Arabia; Syria; the United Arab Emirates (UAE); and Yemen).presenting with fever (>=100.5 F) and respiratory symptoms (cough, shortness of breath) OR pneumonia (chest x-ray finding)

2.  Any patient with travel history (14 days) to South Korea with fever and contact with an ambulatory or inpatient medical facility.

3.  Any patient with fever and contact with a traveler to either the Arabian peninsula or South Korea that has met or potentially fulfills the above criteria

Patients should be placed on airborne, contact and faceshield precautions; the ED should contact IPaC or the NYC DoH and report as a possible MERS PUI (person under investigation).  If, the ED contacts the DoH directly, they should still contact IPaC for subsequent reporting to the DoH.

I’m available to the ED off hours and Saturday.  there is an IPaC nurse in the hospital on Sunday.

The DoH will “advise” as to whether the patient will be worked up as a MERS PUI.

As the DoH decision to test will likely span a day(s), the patient will likely leave the ED and go to either the floor or an ICU depending on the clinical judgment of the ED attending.  If, the patient proceeds to a non-icu area, the nursing supervisor should be contacted to provide faceshields to the target admission area.

Additionally,
a log should be kept of all staff and visitors entering the room(s) where the patient is kept.
Visitors should be limited to 2, until we’ve ruled out MERS or the PUI status has been lifted
Visitors should wear surgical masks with shields NOT N95 respirators
The DoH will likely want an induced sputum, a nasopharyngeal culture and a red top for PCR.  These should be kept in accessioning for DoH pick up

Nota bene: a traveler from an affected area falling within the target time span with bacterial bronchitis may have fever and a negative x-ray in the setting of respiratory symptoms.  This case would qualify for PUI.  For the DoH, the decision to perform or not perform a test can be leisurely discussed, but for hospital staff, there is no difference between a rule-out case and a true case.

thank you

George Alonso, M.D.
Director, Infection Prevention and Control (IPaC)
Elmhurst Hospital Center
718 334-3078
email alonsog@nychhc.org

Guideline for the Management of Persons Arriving at a New York City Airport Who Are Suspected to Have a Quarantinable Disease

Please refer to these documents:

Management of persons at airports with quarantinable disease

Ebola FAQ

EVD 

NYC DOHMH EVD Evaluation Algorithm (as of August 11, 2014) 

CDC.GOV Recommendations

KEY ACTIONS at Elmhurst Hospital Center:

Call DOH when you have the travel and exposure history of the patient
Call Infection Control early
DOH will arrange transfer to Bellevue for HIGH RISK patients.  Do not draw blood or collect other specimen
At this time DOH does not plan to transfer LOW RISK patients to Bellevue but DOH needs to tell us that specifically
No Risk exposure patients should still be isolated until a cause for their symptom is found
Admit to E7 isolation bed after consultation with Infection Control (tell bed-board that you need an E7 bed)

EBOLA SCREENING GUIDELINES

IF: Patient presents with fever of greater than 101.5 degrees Fahrenheit

AND

additional symptoms such as severe headache, myalgias, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage

AND

Meets epidemiologic risk factors within the past 3 weeks before the onset of symptoms, such as contact with blood or other body fluids of a patient known to have or suspected to have EVD; residence in—or travel to—an area where EVD transmission is active; or direct handling of bats, rodents, or primates from disease-endemic areas

THEN:

Patient will be placed in an isolation room, and you will need to call:

1-866-NYC-DOH1 (Bureau of Communicable Diseases Reportables) for additional guidance re: testing.

PPE Guidelines for providers evaluating patients with possible EVD

Hair 

Face shield with splash guard over N-95 respirator

 Blue impermeable gown

 Blue shoe covers

 Double sterile gloves

Ebola precautions

In the event that a suspected case of Ebola presents to the Emergency Department, I wanted to advise you as to the preliminary plan concerning use of personal protective equipment (PPE).

The ED will be stocked with face shields in addition to the routine stock of yellow (permeable) gowns, gloves and N95 respirators (Airborne, Contact and Face Shield precautions).

Blue (impermeable) gowns and booties will also be made available in the ED.

How to don and degown from your PPE


For patients that are not obviously hemorrhaging, e.g., presenting with fever and abdominal pain, the standard yellow gown is sufficient and the use of booties is unnecessary.

For patients actively bleeding or with uncontrolled diarrhea, the HCP can don the blue gown and booties.

As IPaC will become aware of suspect cases with a risk of a blood/body fluid exposure (excluding phlebotomy), we can ensure the availability of the (impermeable) blue gowns and booties to the destination area following admission and transfer to a medical unit.

The goal is to maintain our standardization of precautions and avoid storing all areas with blue gowns which will lead to staff confusion.  The blue gowns will accumulate heat and may be uncomfortable.  Thus, I prefer to use them when indicated.  Obviously, IPaC will need to educate staff when the blue gowns and booties are needed.

At this point, while it would appear that we are more likely to see a case of malaria or typhoid fever that is suspected to be Ebola, the psychological ramifications might be the same. 

Measles Update

April 1, 2014 ALERT # 8: Update on Measles in New York City

1) Twenty-five cases of measles have occurred in children and adults since February 5, 2014.

2) All unvaccinated children 12 months and older who live in zip codes listed below should be offered measles-mumps-rubella (MMR) vaccine.

3) Immediately institute airborne precautions for patients with fever and rash to prevent nosocomial exposures.

4) If you suspect measles, even if you do not have laboratory confirmation, obtain specimens and report the case immediately to the Health Department.

 

Transmission remains centered in Northern Manhattan but also includes a recent cluster of 3 cases who reside in the Lower East Side of Manhattan.

The median age of cases is 21 years (range 3 months to 63 years).

Cases include 12 children and 13 adults.

Among the children, 4 were aged 101°F, ill appearance, and a maculopapular rash that begins on the face then spreads to the rest of the body.

The rash generally lasts for 5–6 days. Exposures in health care facilities continue to occur. Clinics, emergency departments, and urgent care centers should ensure that all security, front office, registration, and triage staff ask every person entering the facility about generalized rash with fever and immediately place such patients into an airborne isolation (negative pressure) room.

If an airborne isolation room is not available, place the patient in a closed exam room with a mask, and do not use that room for 2 hours after the patient has left.

Place highly visible signs instructing patients with fever and rash to immediately notify facility staff.

You can download posters

To ensure rapid identification of cases, providers must report suspect cases to the health department immediately at the time of clinical suspicion. Serologic and PCR diagnostic testing is availability through the Public Health Laboratory.

Do not send measles specimens to commercial laboratories as this will cause delays in confirming the diagnosis.

Please refer to the February 24th alert for additional details on laboratory testing and post-exposure prophylaxis

High population-level immunity has helped to limit transmission of measles during this outbreak. During an outbreak, when population-level immunity is high, the relative proportion of cases who are previously vaccinated will increase. MMR vaccine is 90% to 95% effective in preventing measles. The best way to protect your patients from measles is to ensure that children receive their first dose of MMR routinely at age 12 months and their second dose at age 4 to 6 years. Adult patients without documentation of prior measles vaccination or immunity to measles, can have measles IgG titers drawn, or they can be vaccinated without obtaining serology.

There is no harm from administering additional doses of MMR vaccine.

Please call the Health Department at 866-692-3641 if you have questions or to request posters. To report a suspect measles case as part of this outbreak, call 347-396-2402 during regular business hours; after hours, call 866-692-3641.