Summary
The world has changed in just a few short weeks and we all want answers to the tough questions facing EMS. Coronavirus (COVID-19) is also redefining how we deal with many issues in the EMS workplace. Join us as the nation’s top EMS legal experts from the American Ambulance Association and Page, Wolfberg & Wirth address the hot topics such as patient privacy, workplace safety, staff shortages, pay practices, worker’s comp and leave, discipline practices, liability and more. The webinar will include a Q&A so that you can ask these experts about the issues that matter most to you.
Speakers Scott Moore, Esq.
Scott Moore is the owner of Moore EMS Consulting, LLC and an active EMT for nearly 30 years. Scott has held various executive positions, including Chief Executive Officer, Vice President, Director of Human Resources & Operations, at several ambulance services in Massachusetts. Scott is a licensed attorney, specializing in Human Resources, employment law, reimbursement, and compliance matters. Scott is the Human Resources & Operational Consultant to the American Ambulance Association (AAA) and frequently lectures at EMS conferences.
Ryan Stark, Esq.
Ryan Stark is a Managing Partner with Page, Wolfberg & Wirth, and is the firm’s resident “HIPAA guru.” Ryan is a featured speaker in PWW seminars and webinars, including the firm’s signature abc360 Conference, where he hosts the abc360 Game Show. Ryan developed, and is the primary instructor for the nation’s first and only HIPAA certification for the ambulance industry. He also co-authored PWW’s widely used Ambulance Service Guide to HIPAA Compliance.
Stephen Wirth, Esq., EMT-P
Attorney/Founding Partner, Page, Wolfberg & Wirth, LLC
Steve Wirth is a founding partner of the national EMS law firm Page, Wolfberg & Wirth, LLC. Steve has worked in virtually every facet of EMS in a four- decade career – as first responder, firefighter, EMT, paramedic, flight paramedic, EMS instructor, fire officer, and EMS executive. Steve brings a pragmatic, compassionate, and business‐oriented perspective to his diverse legal practice and served for nearly a decade as senior executive of a mid‐sized air and ground ambulance service.
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The AAA has sent a letter to CMS on how the agency can most help ground ambulance service providers and suppliers be better prepared to respond to potential cases of COVID-19. The AAA has requested priority access to personal protection equipment for EMS personnel and COVID-19 test kits and results, as well as easing Medicare and Medicaid policies on alternative destinations and treatment in place. The letter was also sent to the National Highway Traffic Safety Administration (NHTSA) and the Assistant Secretary for Preparedness and Response (ASPR). Read the letter HERE.
Updated PPE recommendations for the care of patients with known or suspected COVID-19:
Based on local and regional situational analysis of PPE supplies, facemasks are an acceptable alternative when the supply chain of respirators cannot meet the demand. During this time, available respirators should be prioritized for procedures that are likely to generate respiratory aerosols, which would pose the highest exposure risk to HCP.
Facemasks protect the wearer from splashes and sprays.
Respirators, which filter inspired air, offer respiratory protection.
When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19. Facilities that do not currently have a respiratory protection program, but care for patients infected with pathogens for which a respirator is recommended, should implement a respiratory protection program.
Eye protection, gown, and gloves continue to be recommended.
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 HCP.
Included are considerations for designating entire units within the facility, with dedicated HCP, to care for known or suspected COVID-19 patients and options for extended use of respirators, facemasks, and eye protection on such units. Updated recommendations regarding need for an airborne infection isolation room (AIIR).
Patients with known or suspected COVID-19 should be cared for in a single-person room with the door closed. Airborne Infection Isolation Rooms (AIIRs) (See definition of AIIR in appendix) should be reserved for patients undergoing aerosol-generating procedures (See Aerosol-Generating Procedures Section)
Updated information in the background is based on currently available information about COVID-19 and the current situation in the United States, which includes reports of cases of community transmission, infections identified in healthcare personnel (HCP), and shortages of facemasks, N95 filtering facepiece respirators (FFRs) (commonly known as N95 respirators), and gowns.
Increased emphasis on early identification and implementation of source control (i.e., putting a face mask on patients presenting with symptoms of respiratory infection).
The New England Journal of Medicine has rapidly published a peer-reviewed paper on the Snohomish County WA ‘Patient 1’. This was the first reported case of COVID 19 in the US. This seminal document, which given the magnitude of the case and its initial findings is released in full here
The work by Michelle L. Holshue, M.P.H., Chas DeBolt, M.P.H., Scott Lindquist, M.D., Kathy H. Lofy, et al for the Washington State 2019-nCoV Case Investigation Team was turned round in just over 5 weeks and below is an ‘Executive summary’ ( as extracted from the paper) but the full paper and range of results should be read in full.
Patient Presentation
On January 19, 2020, a 35-year-old man presented to an urgent care clinic in Snohomish County, Washington, with a 4-day history of cough and subjective fever. On checking into the clinic, the patient put on a mask in the waiting room. After waiting approximately 20 minutes, he was taken into an examination room and underwent evaluation by a provider. He disclosed that he had returned to Washington State on January 15 after traveling to visit family in Wuhan, China. The patient stated that he had seen a health alert from the U.S. Centers for Disease Control and Prevention (CDC) about the novel coronavirus outbreak in China and, because of his symptoms and recent travel, decided to see a health care provider.
On admission, the patient reported persistent dry cough and a 2-day history of nausea and vomiting; he reported that he had no shortness of breath or chest pain. Vital signs were within normal ranges. On physical examination, the patient was found to have dry mucous membranes. The remainder of the examination was generally unremarkable. After admission, the patient received supportive care, including 2 liters of normal saline and ondansetron for nausea.
Viral Presence
Both upper respiratory specimens obtained on illness day 7 remained positive for 2019-nCoV, including persistent high levels in a nasopharyngeal swab specimen (Ct values, 23 to 24).
Stool obtained on illness day 7 was also positive for 2019-nCoV (Ct values, 36 to 38).
Nasopharyngeal and oropharyngeal specimens obtained on illness days 11 and 12 showed a trend toward decreasing levels of virus
Day 8: Condition Improves
On hospital day 8 (illness day 12), the patient’s clinical condition improved. Supplemental oxygen was discontinued, and his oxygen saturation values improved to 94 to 96% while he was breathing ambient air. The previous bilateral lower-lobe rales were no longer present. His appetite improved, and he was asymptomatic aside from intermittent dry cough and rhinorrhea. As of January 30, 2020, the patient remains hospitalized. He is afebrile, and all symptoms have resolved with the exception of his cough, which is decreasing in severity.
History Taking
This case report highlights the importance of clinicians eliciting a recent history of travel or exposure to sick contacts in any patient presenting for medical care with acute illness symptoms, in order to ensure appropriate identification and prompt isolation of patients who may be at risk for 2019-nCoV infection and to help reduce further transmission. Finally, this report highlights the need to determine the full spectrum and natural history of clinical disease, pathogenesis, and duration of viral shedding associated with 2019-nCoV infection to inform clinical management and public health decision making.
Conclusion
There is little doubt that this paper is about to become a globally sited document as we continue to deal with COVID 19. As far as EMS and our first response to it goes, the paper reinforces the key actions currently being taken
Sample COVID-19 Policies for Mobile Healthcare Providers
Thank you to the following organizations for sharing their policies as examples.
Global Medical Response maintains a COVID-19 page to provide information to all members of the GMR community—clinicians and non-clinicians.
Updates from GMR Chief Medical Officer, Dr. Ed Racht
The intention of the COVID-19 Process/Policy Template is to provide agencies, medical directors, or others who want to utilize it, an outline/template on which to build an agency-specific policy/protocol to address COVID-19. This includes suggestions for development and/or oversight committees, outside partners and stakeholders, as well as preparation and process for EMS workers who provide best practice care for patients as well as providing for the protection of pre-hospital providers and medical director(s). Its application is totally up to the user.
This document is meant to be a living document that can be revised as circumstances or guidance changes. It can also be a discussion piece for those who choose to develop a different type of policy but may want to use some of the components of the document as a starting point.
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.
General Information
Background
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.
Employers Responsibilities
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
PPE supplies
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
Further Reading
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.
