IAFF Interim Guidance for Emergency Medical Services (EMS) Systems for COVID-19 in the United States
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.
This COVID-19 remains quite dynamic and information is updated often, it is important for you to refer to the IAFF website regularly to check for the most up-to-date information on signs, symptoms, and precautions. https://www.iaff.org/coronavirus/
The information below is the most current recommendations from the Centers for Disease Control and Prevention (CDC).
- If PSAP call takers advise that the patient is suspected of having COVID-19, EMS clinicians should put on appropriate PPE before entering the scene. EMS clinicians should consider the signs, symptoms, and risk factors of COVID-19
- 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 infection is suspected, all PPE as described below should be used. If COVID-19 infection 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 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 follow Standard, Contact, and Airborne Precautions, including the use of eye protection. Recommended PPE includes:
- A single pair of disposable patient examination gloves. Change gloves if they become torn or heavily contaminated,
- Disposable isolation gown,
- Respiratory protection (i.e., N-95 or higher-level respirator), and
- Eye protection (i.e., goggles).
- 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 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.
EMS Transport of a PUI or Patient with Confirmed COVID-19 to a Healthcare Facility (including interfacility transport)
If a patient with an exposure history and signs and symptoms suggestive of COVID-19 infection 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 infection 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 infection 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 on nonrecirculated 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)
- 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 Airborne Infection Isolation 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 COVID-19 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 COVID-19. These products can be identified by the following claim:
- “[Product name] has demonstrated effectiveness against viruses similar to COVID-19 on hard non-porous surfaces. Therefore, this product can be used against COVID-19 when used in accordance with the directions for use against [name of supporting virus] on hard, non-porous surfaces.”
- This claim or a similar claim, will be made only through the following communications outlets: technical literature distributed exclusively to health care facilities, physicians, nurses and public health officials, “1-800” consumer information services, social media sites and company websites (non-label related). Specific claims for COVID-19 will not appear on the product or master label.
- If there are no available EPA-registered products that have an approved emerging viral pathogen claim, products with label claims against human coronaviruses should be used according to label instructions.
- 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 COVID-19 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 COVID-19 should be made in consultation with state or local public health authorities.
- EMS agencies should develop sick-leave policies for EMS personnel that are nonpunitive, 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 PUIs or 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 AirPurifying Respirator, PAPR) whenever respirators are required.
- 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.
The International Association of Fire Fighters is the driving force behind nearly every advance in the fire and emergency services in the 21st century. With headquarters in Washington, DC, and Ottawa, Ontario, the IAFF represents more than 320,000 full-time professional fire fighters and paramedics in more than 3,500 affiliates. IAFF members protect more than 85 percent of the population in communities throughout the United States and Canada. The IAFF is also one of the most active lobbying organizations in Washington, DC. The IAFF Political Action Committee, FIREPAC, is among the top one-half of one percent of all federally registered PACs in the country. For more information, visit https://www.iaff.org/