Question Is mobile integrated health care (MIH) delivered by emergency medical services more efficient than regular ambulance responses in addressing the needs of urgent care in the community?
Findings This economic evaluation compared 1740 calls serviced by MIH in 2018 to 2019 with propensity score–matched ambulance calls for the same period and 2 years prior and found that MIH was associated with a decrease in the proportion of patients transported to the emergency department and saved health care costs compared with regular ambulance responses.
Meaning These findings suggest that MIH is a promising and viable solution to meeting urgent health care needs while improving the efficiency in using emergency care resources.
Are you prepared for the 2020 hurricane season while the world is also responding to COVID-19? CDC’s National Center for Environmental Health is joining the CDC EPIC Team Wednesday, May 27, at 1 p.m. EST. CDC experts will discuss possible health risks that could come from hurricanes combined with COVID-19; planning for the 2020 hurricane season while adhering to guidance on social distancing; and how community leaders, nonprofit organizations, and public health professionals can effectively communicate messages. Closed captioning will be available. Click here to learn more about this webinar, including continuing education options.
More information on this webinar, previous EPIC webinars, and continuing education can be found on the EPIC Webinar website.
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This guidance is written to offer American Ambulance Association members the situational background and a list of resources and websites with which to draw guidance and further updates on the latest situation with COVID-19, colloquially referred to as “Coronavirus.” Key information for this update has been drawn from the NHTSA EMS Focus series webinar What EMS, 911 and Other Public Safety Personnel Need to Know About COVID-19, which took place on February 24, 2020. The on-demand recording is available below.
The COVID-19 Coronavirus Disease was first reported in Wuhan China in December 2019. CDC identifies that it was caused by the virus SARS – CoV-2. Early on, many patients were reported to have a link to a large seafood and live animal market. Later, patients did not have exposure to animal markets which indicates person-to-person transmission. Travel-related exportation of cases into the US was first reported January 21, 2020. For reference the first North American EMS experience of COVID-19 patient transport, including key lessons learned, can be found in the EMS 1 article Transporting Patient 1.
Spread and Identification
Global investigations are now ongoing to better understand the spread. Based on what is known about other coronaviruses, it is presumed to spread primarily through person-to-person contact and may occur when respiratory droplets are produced when an infected person costs or sneezes. Spread could also occur when touching a surface or object that has the virus on it and when touching the mouth, nose, or eyes. Again, research is still ongoing, and advice and guidance will inevitably follow.
For the cases that have been identified so far, those patients with COVID19 have reportedly had mild to severe respiratory illness with symptoms including fever and shortness of breath. Symptoms have typically appeared 2 to 14 days after exposure. Both the WHO and CDC advise that patients that have been to China and develop the symptoms should call their doctors.
COVID-19 Prevention and Treatment
To date, 30 international locations, in addition to the US, have reported confirmed cases of COVID-19 infection. Inside the US, two instances of person-to-person spread of the virus have been detected. In both cases, these occurred after close and prolonged contact with a traveler who had recently returned from Wuhan, China.
The CDC activated its Emergency Operations Center (EOC) on January 21 and is coordinating closely with state and local partners to assist with identifying cases early; conducting case investigations; and learning about the virology, transmission, and clinical spectrum for this disease. The CDC is continuing to develop and refine guidance for multiple audiences, including the first responder and public safety communities.
As at the date of publication there is still no specific antiviral treatment licensed for COVID-19, although the WHO and its affiliates are working to develop this.
The following are recommended preventative measures for COVID-19 and many other respiratory illnesses:
Wash your hands often with soap and water for at least 20 seconds.
Use an alcohol-based hand sanitizer with at least 60% if soap and water are not readily available.
Avoid touching your eyes, nose, and mouth with unwashed hands.
Avoid contact with people who are sick.
Stay home when you are sick.
Cover your cough or sneeze with a tissue, then throw it away.
Clean and disinfect frequently touched objects and surfaces.
The guidance identifies EMS as vital in responding to and providing emergency treatment for the ill. The nature of our mobile healthcare service delivery presents unique challenges in the working environment. It also identifies that coordination between PSAPs and EMS is critical.
Key points are summarized below:
Recommendations for 911 PSAP Locations
The link between PSAPs and EMS is essential. With the advent of COVID19 there is a need to modify caller queries to question callers and determine the possibility that the call concerns a person who may have signs or symptoms and risk factors for COVID19.
The International Academy of Emergency Dispatch (IAED) recommends that agencies using its Medical Priority Dispatch System (MPDS) should use its Emerging Infectious Disease Surveillance (EIDS) Tool within the Sick Person and Breathing Problem protocols. For those that are not MPDS users, IAED is offering its EIDS surveillance Tool for Coronavirus, SRI, MERS and Ebola-free of charge under a limited use agreement.
Recommended Personal Protective Equipment (PPE)
The CDC recommends that while involved in the direct care of patients the following PPE should be worn:
Single pair of disposable examination gloves
Disposable isolation gown
Respiratory protection (N95 or higher)
Eye Protection (goggles or disposable face shield)
EMS Transport of a Patient Under Investigation (PUI) or Patient with Confirmed COVID19
Notify receiving healthcare facility so appropriate precautions can be put in place
Discourage family and contacts from riding in transport vehicle
Isolate the vehicle driver from the patient compartment by closing the windows between compartments and ensuring that the vehicle ventilation system is set to the non-recirculated mode
Document patient care
Cleaning EMS Transport Vehicles After Transporting PUI or Patient
Don PPE for cleaning with disposable gown and gloves, facemask, and goggles or face shield if splashes are anticipated
Routine cleaning and infection procedures should follow organizational standard operating procedures
Use protect use products with EPA-approved emergent viral pathogens claims
Once transport is complete, organizations should notify state or local public health authorities for follow up. Additionally agencies should (if not done already) develop policies for assessing exposure risk and management of EMS personnel, report any potential exposure to the chain of command, and watch for fever or respiratory symptoms amongst staff.
While not specific to COVID-19, agencies should:
Assess current practices and policies for infection control
Job- or task-specific education and training
PPE training and supply
Decontamination processes and supplies
Local EMS Considerations
911 and EMD call taking activities
Appropriate approach to potential patients
Educational resources for EMS personnel
Interaction with local public health/healthcare systems/emergency management
Interaction with local fire and law enforcement
Considerations for local jails
World Health Organization (WHO)—For a wider perspective, the WHO provides both a daily live online briefing and written situation report.
The COVID19 situation constantly evolving. Agencies should defer to their local EMS authorities, Public Health departments, and the CDC for definitive guidance. Going forward, the AAA will continue to both monitor the disease and alert issues to the membership.
Ambulance services interact with people from all walks of life, and from all parts of the world. AAA checked in with expert Marcia Carteret, M.Ed., for some tips for communicating more effectively with people from other cultures. Marcia is an instructor of intercultural communications at University of Colorado School of Medicine in the Department of Pediatrics. She trains residents, faculty, and staff in healthcare communication with a focus on cross-cultural patient care and low health literacy. She has also trained in over 120 private pediatric and family practices across Colorado.
In all healthcare settings, successful communication with patients and families depends on awareness of three key barriers to their understanding and compliance:
Cultural Barriers: Understanding western medicine and the U.S. healthcare system is a challenge for many of us, but it is especially problematic for recent immigrants and refugees. 72% of U. S. population growth in the next 20 years will come from immigrants, or the children of immigrants.
Limited English Proficiency: The number of people who spoke a language other than English at home grew by 38 percent in the 1980s and by 47 percent in the 1990s. While the population aged 5 and over grew by one-fourth from 1980 to 2000, the number who spoke a language other than English at home more than doubled.
Low Health Literacy: While poor understanding of the health care system and difficulty understanding health care instructions may be associated with language and cultural barriers, low health literacy is also found in patients who are proficient in English and who share the common U.S. culture. This latter group may be especially at risk of having their low health literacy go unrecognized. 90 million “mainstream” Americans cannot understand basic health information.
Addressing These Barriers
How do people understand one another when they do not share a common cultural experience? Nowhere is this a more pressing question than in healthcare settings, especially in emergencies. There is no easy list of things “to do” or “not to do” that can be applied to each culture. What can be useful are communication guidelines that work for people from all cultures. These guidelines are also important for people with low health literacy.
[quote_left]“The essence of cross-cultural communication has more to do with releasing responses than sending messages. And it is most important to release the right responses.” — Edward T. Hall[/quote_left]
Perhaps the most important is framing questions to elicit appropriate answers. As Edward T. Hall, anthropologist and cross-cultural researcher wrote,“The essence of cross-cultural communication has more to do with releasing responses than sending messages. And it is most important to release the right responses.” What could be more crucial when, for example, an EMT or paramedic is attempting to establish level of consciousness by directly eliciting information from a patient? Being able to get quality responses from patients from any culture is a communication skill that comes with experience. Learning and practicing a set of strategically designed questions is key to building confidence in this important skill.
Key Communication Tips
Explain your professional role 911 is the number to dial in an emergency, but some people may not understand the roles of different emergency responders. You can’t expect people who are still learning to function in the U.S. mainstream society – recent immigrants or refugees especially – to understand the role of the EMT or paramedic.
Suggested explanation: “I am not a doctor. I am an emergency medical professional. I have come to help because someone called 911. I will take this person who is hurt/sick to the hospital safely.”
Use simple familiar words and short sentences “Stabilize” is a complex word, even though it might be the best word to describe what you do for a patient in an emergency. Help is a better word. With Limited English Proficiency (LEP) patients and families, the 5¢ word is always better than the 75¢ word. Basics such as give, take, more, less will be better choices than administer, increase, decrease.
Be clear when you are asking a question versus giving an instruction. Running questions and statements together is confusing for second language learners. Avoid sentences like this: “It looks like you are having a reaction (a statement of observation) so I need to know if you have taken any medication that made you feel sick.”Examples of concise phrasing:
“What medicine have you taken?
“Show me this medicine.”
“Show me where it hurts.”
Avoid close-ended questions These usually begin with do, did, does, is, are, will, or can. These can be answered with a simple yes or no – or a head nod. Avoid the use of close-ended questions with Limited English Proficiency (LEP) patients because in many cultures people will frequently simply say yes even if they don’t understand you.
Use open-ended questions These usually begin with the 5 Ws – who, what, when, where, why (and how or how many). It is awkward to answer these questions with a nod, shrug, or simple yes/no. For example, you might ask: “When did you take these pills?” instead of “Did you take these pills?”
Avoid starting sentences with negations such as isn’t and didn’t. Though this is a common speech pattern in English, it may be confusing for people who speak a different native tongue. For example: Didn’t you call 911? (Read more about this speech pattern.)
Clarify understanding – yours and theirs Even if you are using simpler words and shorter sentences, you can’t be certain there has been communication until the receiver acknowledges it with feedback. Remember, head nodding does not count as feedback with people from many different cultures. Even with Americans, and definitely with children, head nodding is often a sign of partial comprehension. So you must ask clarifying questions.
Repeat back what you have understood.
Examples: “Yes? – you took the medicine?”
“Yes? – you are his/her grandmother?”
Not understanding vs. misunderstanding When people do not understand what you say, there is more likely to be an indication of confusion than when they MISunderstand you. A person struggling with English, for example, may ask you to repeat what you have said. Their face may show confusion. But when people MISunderstand, it can be far less obvious. For example, the English words want and won’t sound very much alike to a non-native speaker. You may say to a person, “I want to help you,” but she may hear “I won’t help you.” She may be perplexed that this is your response, but she may be very inclined to accept the word of a healthcare professional. She may perceive you as being uncaring, but certainly won’t say so. Many MISunderstandings go unnoticed by both parties. Asking clarifying questions is crucial.
Speak slowly and clearly—NOT loudly Often when people don’t understand our language, we treat them as if they are hearing impaired or “slow” without realizing we are doing so. Articulate your words in shorter phrases rather than just speaking more loudly.
Cultural norms vary around the world. Here are some key norms to keep in mind when assisting patients and their families.
An EMT or Paramedic will often be perceived as an authority figure by the people from more traditional cultures. If a person is avoiding eye contact while listening to you or while answering questions, be aware that in some cultures direct eye contact with an authority figure is very rude. In trying to be respectful, people may appear to be avoiding looking you in the eye. This is not to be taken immediately as any indication of disrespect, dishonesty, or evasiveness
Silence Silence may be the only response a person can muster if he or she is frightened. Silence might also be a way of showing respect, similar to avoiding eye contact. Being thoughtful about answering a question shows humility and real effort in giving the best answer. Unfortunately, silence on the part of the non-English patient or family member is often interpreted as open hostility by Americans. It can be helpful to say: “I need your help. Please try to answer my questions. Your answers help me help you.” Also, try not to rush answers. Americans allow very little time between questions and responses. Impatient and in a hurry we tend to start talking before the other person is able to answer the question asked.
Reverting to Native Language Bilingual patients may revert to their language of origin in times of stress, and while this hinders communication with an EMT, it should not be seen as manipulative or uncooperative. Calmly ask the person, “Can you speak in English? Please try English.” If the person does not speak any English, this will at least help them realize you can’t understand.
As first-responders, EMS is often working in high stakes situations where communication is a challenge even without the added barriers associated with the “triple threat” to healthcare communication—language barriers, cultural understanding, and low health literacy. No matter which culture an EMT or Paramedic is interacting with, the key to good communication is asking good questions and phrasing all dialogue in simple short sentences. It should be clear that a question is being asked or a statement of information is being made by the EMS professional. Asking for clarification is essential. Head nods and affirmative answers should not be accepted immediately as evidence of sufficient understanding or agreement. EMTs will find that enhanced communication skills will not only improve cross-cultural interactions, these skills improve outcomes with all people – even “mainstream” Americans. Also, be aware that low health literacy is a problem for 90 million Americans. Never assume that same-culture communication in English requires less intentional speech on your part.