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Interim Guidance for CWA Members: Emergency Medical Services (EMS) and First Responders on Covid-19

This guidance applies to all CWA members who work as first responders, including law enforcement, emergency medical services, and emergency management officials, who anticipate close contact with persons with confirmed or possible COVID-19 in the course of their work.

Updated March 10, 2020

Summary of Key Changes for the EMS Guidance:

Note: The following guidance is based on updated, interim guidance by the CDC, because of anticipated shortages in personal protective equipment (PPE). The CDC has downgraded their recommendations for PPE and other protocols. CWA is fighting to have the appropriate protocols restored, to increase the supply chain for respirators and other PPE, and to have all members protected. Facemasks (procedure masks) are not respirators and will increase the risk of transmission of COVID-19 from an infected patient to the member.

Updated CDC PPE recommendations for the care of patients with known or suspected COVID-19:

  • Face masks are an acceptable alternative until the supply chain is restored. Respirators should be prioritized for procedures that are likely to generate respiratory aerosols, which would pose the highest exposure risk.
  • Eye protection, gown, and gloves continue to be recommended.
    • If there are shortages of gowns, they should be prioritized for activities where splashes and sprays are anticipated and high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of HCP.
  • When the supply chain is restored, fit-tested EMS clinicians should return to use of respirators for patients with known or suspected COVID-19.

Background

Emergency medical services (EMS) play a vital role in responding to requests for assistance, triaging patients, and providing emergency medical treatment and transport for ill persons. However, unlike patient care in the controlled environment of a healthcare facility, care and transports by EMS present unique challenges because of the nature of the setting, enclosed space during transport, frequent need for rapid medical decision-making, interventions with limited information, and a varying range of patient acuity and jurisdictional healthcare resources.

When preparing for and responding to patients with confirmed or possible coronavirus disease 2019 (COVID-19), close coordination and effective communications are important among 911 Public Safety Answering Points (PSAPs)— commonly known as 911 call centers, the EMS system, healthcare facilities, and the public health system. When COVID-19 is suspected in a patient needing emergency transport, pre-hospital care providers and healthcare facilities should be notified in advance that they may be caring for, transporting, or receiving a patient who may have COVID-19 infection.

Updated information about COVID-19 may be accessed at https://www.cdc.gov/coronavirus/2019-ncov/index.html. Infection prevention and control recommendations can be found here: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control.html. Additional information for healthcare personnel can be found at https://www.cdc.gov/coronavirus/2019-nCoV/guidance-hcp.html.

State and local EMS authorities may direct EMS clinicians to modify their practices as described below:

Patient assessment

  • If information about potential for COVID-19 has not been provided by the PSAP, EMS clinicians should exercise appropriate precautions when responding to any patient with signs or symptoms of a respiratory infection. Initial assessment should begin from a distance of at least 6 feet from the patient, if possible. Patient contact should be minimized to the extent possible until a facemask is on the patient. If COVID-19 is suspected, all PPE as described below should be used. If COVID-19 is not suspected, EMS clinicians should follow standard procedures and use appropriate PPE for evaluating a patient with a potential respiratory infection.
  • A facemask should be worn by the patient for source control. If a nasal cannula, a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help, is in place, a facemask should be worn over the nasal cannula. Alternatively, an oxygen mask can be used if clinically indicated. If the patient requires intubation, see below for additional precautions for aerosol-generating procedures.
  • During transport, limit the number of providers in the patient compartment to essential personnel to minimize possible exposures.

Recommended Personal Protective Equipment (PPE)

  • EMS clinicians who will directly care for a patient with possible COVID-19 infection or who will be in the compartment with the patient should use the PPE as described below:
    • N-95 or higher-level respirator or facemask (if a respirator is not available),
      • N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol-generating procedure
    • Eye protection (i.e., goggles or disposable face shield that fully covers the front and sides of the face). Personal eyeglasses and contact lenses are NOT considered adequate eye protection.
    • A single pair of disposable patient examination gloves and an isolation gown. Change gloves if they become torn or heavily contaminated.
      • If there are shortages of gowns, they should be prioritized for aerosol-generating procedures, care activities where splashes and sprays are anticipated, and high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of EMS clinicians (e.g., moving patient onto a stretcher).
  • When the supply chain is restored, fit-tested EMS clinicians should return to use of respirators for patients with known or suspected COVID-19.
  • Drivers, if they provide direct patient care (e.g., moving patients onto stretchers), should wear all recommended PPE. After completing patient care and before entering an isolated driver’s compartment, the driver should remove and dispose of PPE and perform hand hygiene to avoid soiling the compartment.
    • If the transport vehicle does not have an isolated driver’s compartment, the driver should remove the face shield or goggles, gown and gloves and perform hand hygiene. A respirator or facemask should continue to be used during transport.
  • All personnel should avoid touching their face while working.
  • On arrival, after the patient is released to the facility, EMS clinicians should remove and discard PPE and perform hand hygiene. Used PPE should be discarded in accordance with routine procedures.
  • Other required aspects of Standard Precautions (e.g., injection safety, hand hygiene) are not emphasized in this document but can be found in the guideline titled Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.

Precautions for Aerosol-Generating Procedures

  • If possible, consult with medical control before performing aerosol-generating procedures for specific guidance.
  • An N-95 or higher-level respirator, instead of a facemask, should be worn in addition to the other PPE described above, for EMS clinicians present for or performing aerosol-generating procedures.,
  • EMS clinicians should exercise caution if an aerosol-generating procedure (e.g., bag valve mask (BVM) ventilation, oropharyngeal suctioning, endotracheal intubation, nebulizer treatment, continuous positive airway pressure (CPAP), bi-phasic positive airway pressure (biPAP), or resuscitation involving emergency intubation or cardiopulmonary resuscitation (CPR)) is necessary.
    • BVMs, and other ventilatory equipment, should be equipped with HEPA filtration to filter expired air.
    • EMS organizations should consult their ventilator equipment manufacturer to confirm appropriate filtration capability and the effect of filtration on positive-pressure ventilation.
  • If possible, the rear doors of the transport vehicle should be opened and the HVAC system should be activated during aerosol-generating procedures. This should be done away from pedestrian traffic.

EMS Transport of a Person Under Investigation (PUI) or Patient with Confirmed COVID-19 to a Healthcare Facility (including inter-facility transport)

If a patient with an exposure history and signs and symptoms suggestive of COVID-19 requires transport to a healthcare facility for further evaluation and management (subject to EMS medical direction), the following actions should occur during transport:

  • EMS clinicians should notify the receiving healthcare facility that the patient has an exposure history and signs and symptoms suggestive of COVID-19 so that appropriate infection control precautions may be taken prior to patient arrival.
  • Keep the patient separated from other people as much as possible.
  • Family members and other contacts of patients with possible COVID-19 should not ride in the transport vehicle, if possible. If riding in the transport vehicle, they should wear a facemask.
  • Isolate the ambulance driver from the patient compartment and keep pass-through doors and windows tightly shut.
  • When possible, use vehicles that have isolated driver and patient compartments that can provide separate ventilation to each area.
    • Close the door/window between these compartments before bringing the patient on board.
    • During transport, vehicle ventilation in both compartments should be in non-recirculated mode to maximize air changes that reduce potentially infectious particles in the vehicle.
    • If the vehicle has a rear exhaust fan, use it to draw air away from the cab, toward the patient-care area, and out the back end of the vehicle.
    • Some vehicles are equipped with a supplemental recirculating ventilation unit that passes air through HEPA filters before returning it to the vehicle. Such a unit can be used to increase the number of air changes per hour (ACH) (https://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0031-2601.pdf).
  • If a vehicle without an isolated driver compartment and ventilation must be used, open the outside air vents in the driver area and turn on the rear exhaust ventilation fans to the highest setting. This will create a negative pressure gradient in the patient area.
  • Follow routine procedures for a transfer of the patient to the receiving healthcare facility (e.g., wheel the patient directly into an examination room).

Cleaning EMS Transport Vehicles after Transporting a PUI or Patient with Confirmed COVID-19

The following are general guidelines for cleaning or maintaining EMS transport vehicles and equipment after transporting a PUI:

  • After transporting the patient, leave the rear doors of the transport vehicle open to allow for sufficient air changes to remove potentially infectious particles.
    • The time to complete transfer of the patient to the receiving facility and complete all documentation should provide sufficient air changes.
  • When cleaning the vehicle, EMS clinicians should wear a disposable gown and gloves. A face shield or facemask and goggles should also be worn if splashes or sprays during cleaning are anticipated.
  • Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly, to include the provision of adequate ventilation when chemicals are in use. Doors should remain open when cleaning the vehicle.
  • Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label) are appropriate for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in healthcare settings, including those patient-care areas in which aerosol-generating procedures are performed.
  • Products with EPA-approved emerging viral pathogens claims are recommended for use against SARS-CoV-2. Refer to the List N on the EPA website for EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program for use against SARS-CoV-2.
  • Clean and disinfect the vehicle in accordance with standard operating procedures. All surfaces that may have come in contact with the patient or materials contaminated during patient care (e.g., stretcher, rails, control panels, floors, walls, work surfaces) should be thoroughly cleaned and disinfected using an EPA-registered hospital grade disinfectant in accordance with the product label.
  • Clean and disinfect reusable patient-care equipment before use on another patient, according to manufacturer’s instructions.
  • Follow standard operating procedures for the containment and disposal of used PPE and regulated medical waste.
  • Follow standard operating procedures for containing and laundering used linen. Avoid shaking the linen.

Follow-up and/or Reporting Measures by EMS Clinicians After Caring for a PUI or Patient with Confirmed COVID-19

EMS clinicians should be aware of the follow-up and/or reporting measures they should take after caring for a PUI or patient with confirmed COVID-19:

  • State or local public health authorities should be notified about the patient so appropriate follow-up monitoring can occur.
  • EMS agencies should develop policies for assessing exposure risk and management of EMS personnel potentially exposed to SARS-CoV-2 in coordination with state or local public health authorities. Decisions for monitoring, excluding from work, or other public health actions for HCP with potential exposure to SARS-CoV-2 should be made in consultation with state or local public health authorities. 
  • EMS agencies should develop sick-leave policies for EMS personnel that are non-punitive, flexible, and consistent with public health guidance. Ensure all EMS personnel, including staff who are not directly employed by the healthcare facility but provide essential daily services, are aware of the sick-leave policies.
  • EMS personnel who have been exposed to a patient with suspected or confirmed COVID-19 should notify their chain of command to ensure appropriate follow-up.
    • Any unprotected exposure (e.g., not wearing recommended PPE) should be reported to occupational health services, a supervisor, or a designated infection control officer for evaluation.
    • EMS clinicians should be alert for fever or respiratory symptoms (e.g., cough, shortness of breath, sore throat). If symptoms develop, they should self-isolate and notify occupational health services and/or their public health authority to arrange for appropriate evaluation.

EMS Employer Responsibilities

The responsibilities described in this section are not specific for the care and transport of patients with confirmed COVID-19. However, this interim guidance presents an opportunity to assess current practices and verify that training and procedures are up-to-date.

  • EMS units should have infection control policies and procedures in place, including describing a recommended sequence for safely donning and doffing PPE.
  • Provide all EMS clinicians with job- or task-specific education and training on preventing transmission of infectious agents, including refresher training.
  • Ensure that EMS clinicians are educated, trained, and have practiced the appropriate use of PPE prior to caring for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin, and environment during the process of removing such equipment.
  • Ensure EMS clinicians are medically cleared, trained, and fit tested for respiratory protection device use (e.g., N95 filtering facepiece respirators), or medically cleared and trained in the use of an alternative respiratory protection device (e.g., Powered Air-Purifying Respirator, PAPR) whenever respirators are required. OSHA has a number of respiratory training videos.
  • EMS units should have an adequate supply of PPE.
  • Ensure an adequate supply of or access to EPA-registered hospital grade disinfectants (see above for more information) for adequate decontamination of EMS transport vehicles and their contents.
  • Ensure that EMS clinicians and biohazard cleaners contracted by the EMS employer tasked to the decontamination process are educated, trained, and have practiced the process according to the manufacturer’s recommendations or the EMS agency’s standard operating procedures.