EMS in a Post-COVID World

COVID-19 has tested EMS in ways we never imagined. It has the potential to infect up to 70% of the population. Critical infrastructure has been challenged, supply chains have been exhausted, and in some areas of the country EMS systems are dealing with significant portions of their workforce quarantined and over-worked. The availability of personal protective equipment (PPE) is measured in days, rather than years. 

Based on data available at the time of this writing, 81% of those infected are asymptomatic or have mild symptoms, 14% have severe symptoms requiring hospitalization, and 5% require ICU admission.^1,2 

Asymptomatic patients are our biggest problem. The insidious nature of this disease, combined with its devastating consequences for vulnerable populations, makes “normal” response assumptions moot. When we are on scene, is the patient asymptomatic? Is their spouse? The fire department? Your partner?

Industry experts speculate that the COVID-19 pandemic will prove a true game-changer, altering the long-term operations of emergency medical services even after the outbreak has subsided. 

Personal Protective Equipment 

During this pandemic crews should be wearing surgical N95s from the time we start until the time we go home. We should be placing a surgical mask on every patient, regardless of complaint. Unfortunately, this is impossible; however, one thing we can do is develop a plan for our PPE, both now and into the future. This plan should be clearly communicated to staff, since they are stressed and have serious concerns regarding their health as well as that of their families.

Regardless of where the COVID numbers are trending, there are always other patients we care for who require us to wear PPE—meningitis and tuberculosis patients, for example. Thus, the overall strategy for any organization should be to extend their existing stock of PPE until the supply chain has been restored. This can prove challenging to EMS organizations. The FDA, CDC, and National Institute for Occupational Safety and Health (NIOSH) have all recognized the seriousness of this pandemic and made significant changes in response.^3,4

First, examine your operations. While there is justifiable concern from responders, we may not need everyone to enter a home in full PPE. Are you screening calls at the time a 9-1-1 request is received? While screening isn’t perfect, having this information prior to arrival will allow crews to strategize on the best methods to approach the patient. Can the patient meet you outside?

When you arrive on scene, are you performing a triage for the need for PPE? Some organizations now have a crew member approach the patient from 6–10 feet away. If the patient is reporting signs of fever, cough, or sneezing, the crew member would don PPE, approach the patient, and apply a mask to them. Additional crew members would then don PPE, but only the number needed to complete the assignment. This is a sound strategy for agencies to adopt long-term, and many services are looking at the feasibility of these permanent changes to protocols.

The asymptomatic patient’s ability to pose a threat to responding units complicates this model. A better strategy would be to have a single crew member wearing PPE enter and make contact with the patient, placing a surgical mask on them to reduce the transfer of virus. 

Every organization should analyze its utilization of PPE, known as its burn rate, and have this information available for long-term planning, purchasing, and operations. The CDC has a burn rate calculator for PPE.⁵ What is your current stock on hand? How much are you using on every assignment? At current rates, how long will it last?  

Does your organization have access to a reusable powered air-purifying respirator (PAPR)? These may present a viable option to extend a limited supply of disposable masks. 

The CDC recently issued an emergency use authorization (EUA) to utilize expired masks, allowing you to transition from unexpired stock to expired stock.⁶ NIOSH, under CFR 42, has allowed the use of a greater variety of both medical and industrial respirators for EMS and healthcare providers. If these options present—old stock in a storeroom, public donations, or as supply chains improve—flex these into your inventory. 

Hygiene and Disinfection 

The key for any organization during an outbreak is having staff maintaining good hand hygiene and solid equipment-disinfection protocols. How many will stay with us after COVID? Regardless of whether we are facing a pandemic, standard hygiene practices should be the norm. Many of these will be familiar to anyone who has gone through basic EMT training.

Make sure you use clean gloves to don masks. Hand-washing for 20 seconds after removal and storage of a mask is key. Avoid touching the insides of masks before placing them on your face or after removal to avoid contamination. 

Along with enhanced PPE protection, many industry prognosticators are envisioning a “new normal” of distinct infection control and decontamination procedures in the future (see sidebar). What those look like will come into focus as more is learned about the virus, how it is transmitted, and the risks posed to providers and the community.

The back of any EMS unit is an enclosed space that allows concentrations of virus to build up rapidly. Use air conditioning, exhaust ventilation, and open windows to create a flow of air through the patient compartment away from you. Use good judgement that provides the safest solution to your crew.

Do you belong to a national leadership organization? What resources are available through it? Does it have an exchange for PPE, where people may have excess they would be able to share with you? You need to identify those resources and establish those relationships now, before the next crisis.

Do you save surgical masks for staff members who have never tested positive for COVID-19 and use cloth masks for staff members who have? If the only option you have is cloth masks, do you let high-risk employees opt out of responding? 

Community Paramedicine

Finally, even after the COVID outbreak eases, the lessons afforded by community paramedicine can and should remain. The public has seen that CPs can assist with screening, vaccination, treatment, and follow-up. Underserved, isolated, and medically fragile populations can benefit.

Your agency should work closely with community leaders and other healthcare partners to perform public health screenings, fever checks, patient education, and wellness services. These critical functions will be a part of EMS services moving forward, as they should be.

The moral and ethical challenges posed by this pandemic are tremendous. However, the resolve of EMS is never in doubt. Transparency and honest, clear communications will guide us forward. We are resolute in our service to community and resilient in the face of this enemy.  

Sidebar: Importance of Disinfection and PPE Reserves  

Second Alarmer’s Rescue Squad of Montgomery County, Pa., was in a better position than many EMS services when PPE usage skyrocketed in response to the COVID-19 outbreak. “We took advantage of some lessons learned from other areas and through a combination of good fortune and intentional planning, we started with a robust supply of N95s,” says SARS Assistant Chief Ken Davidson.” Relationships with vendors and some assistance from grant sources allowed the Philadelphia-area agency to not get caught in a scramble for equipment. For Second Alarmer’s, it’s a strategy that will continue even after the worst of the outbreak has subsided.

Second Alarmer’s crews are currently wearing normal PPE and at least a mask on every call. Every patient gets a mask (if feasible). If a patient is suspected COVID-positive, or when performing high-risk procedures, crews wear gown and gloves, N95s, or P100 half-mask respirators, and goggles go over the mask. 

Davidson offers advice for departments to implement even after the worst of the outbreak has subsided: Leverage relationships with multiple vendors so you’re not always relying on one supply chain. Davidson’s goal is to always have a 6–12-month supply of PPE on hand. Even if his squad eases some PPE restrictions in the future, Davidson predicts full PPE gear will continue to be carried on all company vehicles for use when needed.

Along with PPE stockpiles, a more thorough systematic cleaning and disinfection system, including a full “Level 1” clean-down after every call, will likely be made permanent. Working with neighboring agencies, a decontamination station was set up near an area hospital during the busiest days, where providers not assigned to the street that day helped decontaminate vehicles and equipment while crews decontaminated themselves and had a few minutes to decompress before the next call. 

Because of these strategies, the squad was able to maintain operations with full staff and minimal impact to its service, which will be long-term lessons learned.

“This is a marathon, not a sprint,” says Davidson.

—Jonathan Bassett

Sidebar: Seven Tips for Decontaminating Ambulances and Equipment  

An effective way to reduce the dangers of any communicable disease is by properly disinfecting the ambulances and equipment you work with. Here are seven tips.

Plan your disinfection routine—Effective and safe disinfection requires a methodical, consistent, and planned approach. “Plan for the correct PPE, cleaning, and disinfecting supplies ahead of time,” says Daren Whiteley, regional safety and risk director for GMR Northwest ground operations. “A little research will ensure you are using the right supplies the right way.”  

Cleaning and disinfection work together—“Cleaning always comes first,” says Scott Hartnett, chief medical officer of EcoloxTech. “Cleaning up the dirt and grime and organic matter with a soap is recommended before applying hypochlorous acid.” Once the visible dirt is gone, “Disinfecting works by using chemicals to kill germs on surfaces or objects,” according to the CDC. By “killing germs on a surface after cleaning, it can further lower the risk of spreading infection.” 

Clean all surfaces first to remove dirt that can harbor viruses and bacteria and get rid of the easiest-to-remove germs. Then disinfect the cleaned area to kill the germs that remain. Rinse these areas thoroughly before adding disinfectants to prevent toxic interactions.

Choose your disinfectant—There is a range of disinfection options, such as bleach-based products and liquid/wipes that use accelerated hydrogen peroxide. All of these must be handled with care. “There are several innovative products on the market for decontaminating ambulances, such as UV lights, ozone generators, and foggers,” says Whiteley. “Due to costs, logistics, and process time, these products can pose a challenge in busy systems. But they can help ensure effective decontamination of areas that are hard to reach or missed during standard decontamination procedures.”

Get product advice—Confused as to which disinfectant to use? Talk to your agency’s cleaning supplier for disinfectant options, plus other EMS agencies in your area for advice and contacts. “The EPA has established the EPA List N specifically for SARS-CoV-2,” says Whiteley. “The EPA continues to add to the list of approved disinfectants, so it’s prudent to check the updated list periodically, especially if you are having procurement challenges.”

Get away from work areas to disinfect—Once you are suited up in PPE and armed with the right chemicals, pull the ambulance away from the station to an open-air location—or to a covered area at a distance—and open up the doors. These should stay open during disinfection and for 10 minutes afterward to vent any germs that may have been aerosolized, plus the chemicals used during the cleaning/disinfection process. Wash the ambulance exterior first. Remove any equipment that needs to be disinfected. Review the manufacturers’ disinfection instructions to ensure that chemicals being used don’t damage the equipment. Have a trash bag ready to remove garbage, used cleaning wipes and supplies, and potential biological hazards. Keep other staff clear of the decontamination area. Traffic cones and signs are helpful reminders.

Allow enough time for disinfection—Many disinfectants must be left on treated surfaces for a matter of minutes before being rinsed away. For example, Clorox bleach products require five minutes on surfaces before being removed. Disinfectants have to be worked into surfaces using microfiber cloths or handheld mechanized surface scrubbers. “It’s not good enough to spray it on and wipe it off,” says Whiteley. “The product must remain visibly wet for the listed contact time to kill the virus. Start from the head of the patient compartment and work in stages toward the back doors, allowing disinfectant to work for the specified contact time before wiping it off. ”

Be thorough—When it comes to disinfecting an ambulance, basically everything needs to be washed and wiped down. “Ambulance areas vulnerable to contamination include cabinet faces near the patient, control panel action areas, seating, floors, doors, and handles,” says Whiteley. “Additionally, providers should be cognizant of touch areas when they need to move around to provide patient care or get supplies. There is a tendency to use bracing positions with contaminated gloves to prevent falls in a moving ambulance. This could be an overhead handrail, ceiling, wall, or cabinet, and these areas should receive special attention when decontaminating post-trip.” 

EMS equipment prone to contamination includes gurneys and mattresses, cardiac monitors, portable oxygen tanks, drug bags, blood pressure cuffs, radios and other in-car equipment, and stethoscopes. “Reusable equipment must be cleaned and decontaminated according to manufacturer instructions,” Whiteley notes. “Otherwise you risk damaging components and functionality.” 

—James Careless

References

1. World Health Organization. Coronavirus Disease (COVID-19) Pandemic, www.who.int/emergencies/diseases/novel-coronavirus-2019. 

2. Centers for Disease Control and Prevention. COVID-19 Update: Optimization Strategies for Healthcare Personal Protective Equipment (PPE). https://emergency.cdc.gov. 

3. Centers for Disease Control and Prevention. NIOSH-Approved Particulate Filtering Facepiece Respirators, www.cdc.gov/niosh/npptl/topics/respirators/disp_part/default.html. 

4. Centers for Disease Control and Prevention. Strategies for Optimizing the Supply of N95 Respirators, www.cdc.gov/coronavirus/2019-ncov/hcp.  

5. Centers for Disease Control and Prevention. Personal Protective Equipment (PPE) Burn Rate Calculator, www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/burn-calculator.html. 

6. U.S. Food & Drug Administration. Letter to Robert R. Redfield, MD, Director, Centers for Disease Control and Prevention, Mar 28, 2020; https://www.fda.gov/media/135763/download.  

Resources

Centers for Disease Control and Prevention. Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings, www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html. 

National Institute for Occupational Safety and Health. Influenza (Flu) in the Workplace, www.cdc.gov/niosh/topics/flu/respiratory.html. 

U.S. Food & Drug Administration. Establishment Registration and Device Listing, www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfRL/TextSearch.cfm. 

Daniel R. Gerard, MS, RN, NRP, is EMS coordinator for Alameda, Calif. He is a recognized expert in EMS system delivery and design, EMS/health-service integration, and service delivery models for out-of-hospital care.