NOTE: CREMSC · 2020-03-21 · Thoroughly after transferring patient care &/or cleaning equipment / ambulance. Maintain Records: All pre-hospital providers exposed to patient at scene

MODEL

(field) Policies, Procedures, & Protocol Guidelines (P3G) for Toxin / Environmental (TE) as

approved by the CREMSC Medical Director & your Agency Medical Director

(AMD).

NOTE: These are to be utilized as a resource & must be reviewed, adapted (as

needed), & approved by your AMD for your agencies

utilization.

High-Consequence Pathogens

(Respiratory Diseases, SARS, MERS-Co-V, Coronavirus) T

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P3GTE15 (A) 00This policy has been approved by the Office of the Medical Director Central Region EMS Committee &Office of the Medical Director - ___________________________________________ Ambulance Distr ict 2020v. 03172020

High Consequence Pathogen Algorithm P3GTE01 High Consequence Pathogen Notes / “Pearls” P3GTE02 Notes (Continued) P3GTE03 Outbreak Screening P3GTE03 Influenza Screening P3GTE03 Patient Travel Screening P3GTE03 Treat & Release P3GTE04 EMD Considerations P3GTE05 Donning & Doffing PPE P3GTE05 EMS Well-Being P3GTE06 MAA COVID-19 Employee Screen Form P3GTE07 MAA COVID-19 Employee Exposure Log P3GTE08

CREMSC

CREMSC Medical Director approved by:

Dr. J. Coughenour 03.20.2020Agency Medical Director _______________________________

CREMSCGuidelines

Evolving Guideline(s):

Guideline subject to change at any time dependent on changing outbreak locations & national Tx guidelines

Monitor for Guideline updates

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History

Exposure to infected persons

Recent travel to an endemic area

Signs and Symptoms

Fever / Headache

Cough / Sore Throat

Malaise / Weakness / Fatigue

Myalgia / Muscle Aches

Respiratory Symptoms

Vomiting / Diarrhea

Differential

Influenza

Other common viral infections

Sepsis

Tick-borne illness

Biological warfare agent exposure

Non-infectious metabolic crisis


(Respiratory Diseases, SARS, MERS-Co-V, Coronavirus)

P3GTE15(A)1This policy has been approved by the Office of the Medical Director Central Region EMS Committee &Office of the Medical Director - ___________________________________________ Ambulance Distr ict

2020v. 03172020

EMS Personnel must screen all potential patients for exposures, risk factors, travel history, and symptoms

Local PSAP / EMD

Suspected Infectious Disease

-and/or-

Risk Factor Screening Guidelines

Exit to appropriate

Treatment Guideline(s)

NOYES

Do not rely solely on EMD personnel to identify a potential exposure patient:

EMD may be constrained by time & caller information

Obtain a travel & exposure history & assess for clinical signs & symptoms

(utilize provided screening tools)

Limit numbers of providers necessary for care & to limit potential exposures

EMS Immediate Concern

Fever &/or signs of a respiratory illness with either:

Contact with someone or personal travel to affected geographical regions

within the past 14 days;

Contact with someone with diagnostically confirmed illness of interest?

Recent hospitalization with respiratory illness & no clear diagnosis

May also consider fever >/ = 100.4°F without travel as well

DO NOT DISPATCH

FIRST RESPONDERS

Dispatch EMS Unit

(& notify EMS Field

Supervisor [if applicable])

On-Scene EMS Field

Supervisor can request

first responders as needed

If available ask caller to

place a mask on patient

Positive EMS Screening

CREMSC

Evolving Guideline:



(If available): Notify the Designated Infection Control Officer, or designee, for any potential patient with a

high consequence pathogen exposure

Negative EMS screeningNO

YES

Place simple mask/

surgical mask on source

patient

Negative EMD/PSAP screening

YES

Positive EMD/PSAP

screening

Exit to appropriate

Treatment Guideline(s)

Patient:

Nasal Cannula: place under surgical mask ensuring seal at nose/under chin

Non-Rebreather Mask if Oxygen needed (adequate flush rate may increase

exposure )

If unable to tolerate mask, have patient cover mouth & nose when coughing

Providers utilize:

Standard contact/airborne precautions

Eye protection (e.g. goggles/ face shields)

N95 mask (or higher) or PAPR

Exam Gloves

Disposable Gown

Negative pressure in patient compartment (see Pearls)

Personnel in cab utilize:

Standard contact/airborne precautions

N95 mask (or higher) or PAPR

Aerosol generating procedures:

(NIPPV / Nebulizer therapy / Intubation / BIAD / Suctioning) / CPR/CCR

Use ALL PPE devices & strategies listed herein

Notify receiving facility of possible infectious patient & be prepared for

additional triage questions

EMS

General Treatment

Considerations

EMS

Personal Protective

Equipment

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2020v. 03172020

Pearls

Dispatch Screening:

If caller interrogation results in a positive screen this only means first responders should not be sent. Remember this screening process will result

in many false positive screens in order to be very sensitive.

EMS Screening:

Limit distance initially to > six (6) feet & conduct a secondary screening using the EMS specific questions. If this results in a positive screen,

immediately place a simple/surgical mask on the source patient & all providers don appropriate PPE.

Close Contact Definition:

Healthcare provider exposure is defined as being within six (6) feet for > ten (10) minutes in a patient with suspected illness.

Unprotected (no or incorrect PPE) direct contact with body fluids, including respiratory generated body fluids.

Place a simple/surgical mask on any patient complaining of respiratory problems with or without fever .

Transport: (NOTE: Limit transport to patient ONLY[No family or others unless absolutely necessary]. Have family apply PPE.)

Occupants in cab of transport vehicle all should wear a simple/surgical (or higher as deemed available) mask, N-95 mask or PAPR.

Limit number of providers in vehicle required to provide patient care in order to limit exposures

Ensure use of all PPE for crew and passengers when aerosol-producing procedures utilized.

Negative Pressure in patient care compartment:

Door or window available to separate driver’s and care compartment space:

Close door/window between driver’s and care compartment and operate rear exhaust fan on full.

No door or window available to separate driver’s and care compartment space:

Open outside air vent in driver’s compartment and set rear exhaust fan to full.

Set vehicle ventilation system to non-recirculating to bring in maximum outside air.

Use recirculating HEPA ventilation system if equipped.

Airborne Precautions:

Standard PPE with fit-tested N95 mask (or PAPR respirator) and utilization of a gown, change of gloves after every patient contact, and strict

hand washing precautions.

This level is utilized with Aspergillus, SARS/MERS/COVID-19, Tuberculosis, Measles (rubeola) Chickenpox (varicella-zoster), Smallpox,

Influenza, disseminated herpes zoster, or Adenovirus/Rhinovirus.

Contact Precautions:

Standard PPE with utilization of a gown, change of gloves after every patient contact, and strict hand washing precautions.

This level is utilized with GI complaints, blood or body fluids, C diff, scabies, wound and skin infections, MRSA. Clostridium difficile (C diff) is not

inactivated by alcohol-based cleaners and washing with soap and water is indicated.

Droplet Precautions:

Standard PPE plus a standard surgical mask for providers who accompany patients in the treatment compartment and a surgical mask or NRB

O2 mask for the patient.

This level is utilized when Influenza, Meningitis, Mumps, Streptococcal pharyngitis, Pertussis, Adenovirus, Rhinovirus, and undiagnosed rashes.

All-Hazards Precautions:

Standard PPE plus airborne precautions plus contact precautions.

This level is utilized during the initial phases of an outbreak when the etiology of the infection is unknown or when the causative agent is found to

be highly contagious (e.g. SARS, MERS-CoV, COVID-19).

COVID-19 (Novel Coronavirus):

For most current criteria to guide evaluations of patients under investigation: http://www.cdc.gov/coronavirus/2019-nCoV/clinical-criteria.html

CREMSC

Disposition:

EMS Transport: ALS: All Patients

EMS Personnel Requiring Decontamination

Driver:

Should wear full PPE as described when caring for patient.

Remove all PPE, except N95 mask (or higher) or PAPR

Perform hand hygiene prior to entering cab of vehicle to prevent contamination of driver ’s compartment

Wash Hands:

Thoroughly after transferring patient care &/or cleaning equipment / ambulance.

Maintain Records:

All pre-hospital providers exposed to patient at scene & during ambulance transport (self-monitoring for symptoms for 14 days is recommended, even

if wearing appropriate PPE).

This does not mean the providers can no longer work.

List all pre-hospital providers names (including, but not l imited to: students, observers, supervisors, other emergency responders, etc.)

EMS Equipment / Transport Unit Requiring Decontamination

Safely clean vehicles used for transport:

Follow standard operating procedures for the containment & disposal of regulated medical waste.

Follow standard operating procedures for containing & reprocessing used linens.

Wear appropriate PPE when:

Removing soiled linen from the vehicle. Avoid shaking the linen.

Clean & disinfect the vehicle in accordance with agency standard operating procedures.

Personnel performing the cleaning should wear a disposable gown & gloves (a respirator should not be needed) during the clean-up process; the PPE

should be discarded after use.

Any & 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, etc.) should be thoroughly cleaned & disinfected using an EPA-registered disinfectant appropriate for SARS, MERS-CoV,

or coronavirus in healthcare settings in accordance with manufacturer’s recommendations.

Decontamination Recommendations

PPE Supply Chain Disruption / Shortage:

If Respirators/N95 masks are in short supply it is acceptable to use surgical masks.

Prioritize Respirators/N95 masks / Gowns to aerosol generating procedures.

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P3GTE15(A)3This policy has been approved by the Office of the Medical Director Central Region EMS Committee &Office of the Medical Director - ____________________________________________ Ambulance Distr ict

2020v. 03172020

Documentation should include the following:

Risk factors and suspicions for infection with specific disease

Specific precautions taken to prevent transmission

Names of all personnel who had contact with patient

Steps taken to decontaminate equipment and ambulance

Department of Health notification if appropriate

Cardiac Arrests or Obvious Deaths

Many infections are still transmissible after death of the host

patient. Consider that either the screening questions may

not have been asked, or travel history and recent symptoms

are unknown.

CREMSC

Influenza Patient Screening

Signs & Symptoms:

Y / N – Flu Suspected?

Onset time ____:____ Onset Date ____/____/______

Symptoms:

⃣ Myalgia/ Muscle Ache

⃣ Fever >100.4°F

⃣ Cough

⃣ Sore Throat

⃣ Runny Nose

⃣ Nasal Congestion

History:

Y / N - Has the patient had an influenza vaccination this year?

Y / N - Has the patient traveled outside the United States in the last two (2) weeks?

Y / N - Has the patient had household or other close contact with someone with the above travel history & symptoms?

Y / N - Has the patient had household or other close contact with someone with a confirmed diagnosis of influenza?

Y / N – Are you taking any anti-viral medication?

Patient Travel

Y / N - Has the patient traveled outside the community in the last 30 days?

Y / N - Has the patient traveled outside the United States in the last 30 days?

Outbreak Patient Screening

Signs & Symptoms:

Onset time ____:____ Onset Date ____/____/______

Symptoms:

⃣ None

⃣ Fever

⃣ Cough

⃣ Sore Throat

⃣ Shortness of Breath

⃣ Myalgia/Muscle Ache

History:

Y / N - Has the patient traveled outside the community?

Y / N - Has the patient traveled outside the United States in the last 30 days?

Y / N - Has the patient had household or other close contact with someone with the above travel history & symptoms?

Y / N - Has the patient had household or other close contact with someone with a confirmed diagnosis of the illness for which

we are screening?

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History

Exposure to infected persons

Recent travel to an endemic area

Signs and Symptoms

Fever / Headache

Cough / Sore Throat

Malaise / Weakness / Fatigue

Myalgia / Muscle Aches

Respiratory Symptoms

Nausea / Vomiting / Diarrhea

Differential

Influenza

Other common viral infections

Sepsis

Tick-borne illness

Biological warfare agent exposure

Non-infectious metabolic crisis


(Treat-&-Release; Shelter in Place)

(Respiratory Diseases, SARS, MERS Co-V, Coronavirus)


2020v. 03172020

CREMSC

Evolving Guideline:



General Comment:

In the event that there is a public health or safety emergency in which health care resources are overwhelmed by demand , the EMS

response will have to adapt to the severity of the situation and the available resources. This Influenza Pandemic Guideline is to be

used as a guide in the development of a local plan (based on the severity of the situation and the available resources) remembering

that the local situation will change frequently, perhaps daily or hourly. This Guideline is assuming that an Influenza Pandemic has

overwhelmed the medical community and normal EMS operating procedures are not feasible or practical. The Central Region EMS

Committee recognizes that an organized “treat and release Guideline” would not only be advantageous but necessary to

maintain control and order to providing medical assistance in the community.

ALL RESPONDERS: Physical Assessment:

When conducting your initial assessment, a patient, maintain a safe distance (6 feet) and utilize personal protection until you

determine if influenza-like symptoms exist. If no symptoms exist, then proceed with your patient assessment as normal. If influenza-

like symptoms are present; utilize the triage tool identified below to assess and determine the severity of the illness and assist in

transport decisions. The local medical director must determine, in consultation with the local public health department and

health care facilities, what scores would facilitate transport or treat and release, & at what point online medical control

should become involved; this could change depending on the evolving characteristics of the viral infection and may

change daily or even hourly depending on available medical resources. Consider tele-video with On-Line Medical Control.

Patients who score: >14 Immediate contact with local On-Line Medical control for transport decision / determination8 - 14 Should be transported to the emergency department for treatment 4 - 8 Should be directed for additional screening/assessment but does not require ambulance transport < 4 Should not be transported and should remain home with provided instructions

Demographics: ____y/o Score_______

Age <6 months: 2

6 mo – 5 yrs 1

5 yrs- 65 yrs 0

65 yrs- 75 yrs 1

>75 yrs 5

Caregiver at home -1

Respiratory rate:____RR Score_______

8 - 24 resp / min 0

24 – 60 2

< 8 or > 60 3

Blood pressure: ___/___ Score_______

<6 mo & cap refill > 2 seconds 2

90 - 100mmHg 2

< 90mmHg 4

Mental Status: ______ Score_______

Alert / Verbal 0

Confused 2

Unresponsive/ Obtunded 3

Co morbidities: ________Score_____

DM, asthma/COPD, CHF 1 each

Obesity 1

Pregnancy 2

Sub-Total Score (1) = _______

O2 saturation: ____ % Score_______

> or = to 90% 0

86% - 89% 3

76% - 85% 4

= to or < 75% 5

Heart rate: ______bpm Score_______

< 6 mo & > 150 HR 2

Children > 6 mo & > 120 HR 2

Adults: > 110 HR 2

Temperature: ______ Score_______

>103°F (39.4 C) 1

Able to tolerate PO? Score_______

Yes -1

No 1

Evaluator discretion: _ _Score_

Evaluator may assign subjective -1, 0, or +1

Sub-Total Score (2) = _______

Sub-Total Score (1) ____ + (2) ____=_____

TOTAL:

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2020v. 03172020

CREMSC

Dispatch Center Screening Tool

Donning PPE

Remove all jewelry, valuables, and tie hair back. If time permits,

change into scrubs prior to donning PPE.

Gloves (double gloves, extra long cuffs)

Fluid resistant or impermeable Tyvek-like suit

Tyvek-like hood with apron

Full-face splash shield

N-95 face mask or APR/PAPR

Shoe covers up to mid-calf or knees

Utilize the buddy system to check your PPE. PPE must be in

place BEFORE approaching the patient. It should not be doffed

until personnel are no longer in contact with the patient, ideally

at the receiving hospital.

Doffing PPE

PPE must be carefully removed without contaminating

one’s eyes, mucous membranes, or clothing with

potentially infectious materials. Utilize the buddy system

to ensure no cross contamination occurs.

PPE must be double bagged and placed into a regulated

medical waste container and disposed of in an appropriate

location.

Appropriate PPE must be worn while decontaminating /

disinfecting EMS equipment or unit.

Re-useable PPE should be cleaned and disinfected

according to the manufacturer’s reprocessing instructions

Enter ScreeningTool perPSAP

Guideline

Are you suffering from any of the following symptoms?:

Fever (hot-to-touch &/Or >100°F);

Cough;

Shortness-of-breath;

Body aches;

Chills;

Headaches;

Sore Throat

Have you been in direct contact with a known positive case of

coronavirus (COVID-19) or are you under mandatory or voluntary

quarantine?

Provide referral information for County Health Department for

further Screening *

Have you are someone that you have had close personal contact with

traveled outside; of your community?;

of the region?;

of the state of Missouri?;

of the United States?:

If Yes, Where?(Consult List of Affected Areas)

Screening Negative;

EXIT Protocol

ModerateRisk:Notify

Provider(s)

HighRisk:Notify

Provider(s)

NO YES

YES

NO

NO

YES

EXIT to Appropriateprotocol

DISPATCH ONLY EMS TRANSPORT UNITS

ALERT any EMS providers of a

potential exposure patient before they arrive on-scene

* Dispatch EMS per local guidelines

&/or as resources are available

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2020v. 03172020

COVID – 19 Employee Screening:

Information:Date of Screening: ____/____/________ Time of Screening: ________:________

Employee Name: _____________________________________ Agency Name: __________________________________

Signs & Symptoms:

Onset time ____:____Onset Date ____/____/______

Symptoms:

⃣ None

⃣ Fever (temperature: ________ F / C )

⃣ Cough (of unknown origin)

⃣ Sore Throat (of unknown origin)

⃣ Shortness of Breath

⃣ Chills/Myalgia/Muscle Ache (of unknown origin)

⃣ Runny/Stuffy Nose (of unknown origin)

⃣ Recent Pneumonia/Flu

History:

Y / N - Has the employee traveled outside the community?

Y / N - Has the employee traveled outside the United States in the last 14 days to a Level 2 or 3 as determined by the CDC?

Y / N - Has the employee been to or traveled through an area within the U.S. that has communicable spread of the disease in the last 14 days?

Y / N - Has the employee had household or other close contact with someone with a confirmed diagnosis of the illness / under investigation for which we are screening?

Employee Signature: _____________________________________________ Supervisor Signature: _______________________________________________

Y / N - Employee cleared to provide patient care / enter facilities

CREMSC

EMS Provider Exposure Risk & Monitoring Recommendations:

Close Contact:

Less than six (6) feet for > 10 minutes

Source patient NOT wearing a mask or applied within 10 minutes

Increase Exposure Risk Level by 1 Higher if any of the following

Extensive body contact such as log-rolling patient

Presence during aerosol-producing procedures like intubation, NIPPV, or

nebulizer.

Self-Monitoring with Delegated Supervision:

Self-monitoring with oversight by agency s infection control officer, occupation or public health department per agency policy.

Prior to duty shift measure temperature and assess for illness symptoms either by provider, infection control officer, occupational or public

health.

Refer to CDC website for additional information at regarding provider exposure risk assessment and monitoring recommendations:https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html

Close Contact:

Less than six (6) feet for > 10 minutes

Source patient WEARING a mask or applied within 10 minutes

PPE Utilized Exposure Risk Monitoring Work Restrictions

Exclude from work for 14 days

ACTIVEHIGHNONE


ACTIVEHIGHNo Mask N95 or

PAPR


ACTIVEMEDIUMNo Eye

Protection

NONESelf-monitor Supervision

LOWNo gown/gloves

NONESelf-Monitor Suprevision

LOW

All recommended PPE except mask instead of N95 or

PAPR

PPE Utilized Exposure Risk Monitoring Work Restrictions


ACTIVEMEDIUMNONE


ACTIVEMEDIUMNo Mask N95 or

PAPR

NONEACTIVELOWNo Eye

Protection

NONESelf-monitor Supervision

LOWNo gown/gloves

NONESelf-Monitor Suprevision

LOW

All recommended PPE except mask instead of N95 or

PAPR

Self-monitor Supervision

Employee sent home to contact Primary Care Physician & self-quarantine if positive for Three (3) items &/or fever greater than 100.4°F. Not eligible to return to work until symptom free for 24 hours.

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P3GTE15(A)7This policy has been approved by the Office of the Medical Director Central Region EMS Committee &Office of the Medical Director -___________________________________________ Ambulance Distr ict

2020v. 03172020

CREMSC

Evolving Guideline:



Form provided by MissouriAmbulanceAssociation

COVID-19 Employee Screening Tool

Employee Name

Date:

Time:

Symptoms: YES No

Cough/Shortness of Breath

Fever of 100.4F or higher

Chills

Runny/Stuffy Nose

Shortness of Breath

Sore Throat

Recent Pneumonia/flu

Have you traveled out of the country in the last 14 days to a level 2 or 3 country as determined by the Centers for Disease Control and Prevention?

Have you been to or traveled through an area within the US that has communicable spread of the disease in the last 14 days?

Have you had exposure to someone with, or under investigation for COVID-19?

Employee Temperature

Cleared to provide patient care/ enter facilities (Circle One):

YES NO

Employee Signature

Supervisor Signature:

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2020v. 03172020

CREMSC

Evolving Guideline:



Form provided by Missouri Ambulance Association

Documents

NOTE: CREMSC · 2020-03-21 · Thoroughly after transferring patient care &/or cleaning equipment / ambulance. Maintain Records: All pre-hospital providers exposed to patient at scene