URGENT NEWS UPDATE

Administrative Strategies for EMS Agencies for H1N1 Influenza

October 5, 2009

This summer, the World Health Organization raised the pandemic level to Phase 6. The EMS Chiefs of Canada (EMSCC) and the National EMS Management Association are coordinating a process to identify and disseminate key strategies for EMS organizations to implement to protect their paramedics and to be public health partners in managing the care of the sick. EMSCC's Membership Services Committee is coordinating this third series of teleconferences to reveal the effectiveness of EMS service strategies in the management of the pandemic. The first series was conducted during the SARS outbreak in 2003 and the second following the spread of H1N1 influenza in Spring 2009. More information and documents can be found on www.emscc.ca and www.nemsma.org.

The following material has been developed as a result of information gathered from an international teleconference held October 1, 2009. Information from other specific and credible websites (such as the CDC) is also included. This information is provided to you as one resource. Local guidelines should always be established with local medical direction and local, regional or state/provincial public health agencies. Periodic updates of this information will be provided when new information is available as EMSCC and NEMSMA continue the teleconference series.

Intelligence: There has been no impact to the EMS systems in many areas yet. The dispatch centers of many agencies are no longer asking travel information or including them in triggers as H1N1 is now a global problem. Triggers are being linked to fever greater than 100°F (38°C) with persistent cough or sore throat, however, some areas are seeing up to 20% of patients with no fever. Paramedics (globally, paramedic is the word used to describe licensed EMS personnel regardless of varying skill levels) are acquiring the virus and are missing work. Some schools are seeing absentee rates exceeding 17% and have closed temporarily. Some hospitals have erected tents outside the emergency room specifically for treatment of flu cases and to be dispensing centers for vaccines. Otherwise healthy college students in some areas have become sick enough to require ventilator support and hospitalization.

Reference documents are being compiled by the EMS Chiefs of Canada. U.S. reference documents are available on the National EMS Association’s website on the Flu Resources tab.

Administrative Strategies Planned or in Place

·  Ambulance stations are being used as mass immunization clinics

·  EMS agencies are acquiring and outfitting "Flu Response Units" to respond to non-emergency calls for assistance for persons identified through dispatch interrogation as being likely flu cases. The units are small, agile and not capable of transport. They are staffed by paramedics trained to assess flu symptoms and to provide self help instructions while recommending "shelter in place".

·  Regional (multi-jurisdiction, state or provincial) EMS agencies are outfitting command posts designed for surveillance of dispatch records and of paramedics. These units are structured to be the “one stop shop” for EMS flu resources, including caches of flu-specific supplies

New Message for Responders from the USDOT's National EMS Advisory Council:
National EMS Advisory Council
Position Statement
Adopted September 30, 2009
(Not final pending final editing and formatting)

The National EMS Advisory Council (NEMSAC) asserts that the personal safety of the EMS responders in the United States is paramount in a pandemic flu outbreak. While guidelines have been developed and Federal funding established, there is widespread variation in EMS personnel awareness and compliance. There is concern that EMS personnel underestimate the severity and imminent impact on the EMS workforce. Social networking systems influence the EMS provider with information from unsubstantiated and often misleading sources. NEMSAC asserts the following key guiding principles promote the safety of EMS personnel in response to a pandemic flu outbreak:

• Promote proper hand washing as the fundamental practice of preventing the spread of disease.
• Promote vaccination of EMS providers for both seasonal and H1N1 influenza.
• Promote flu.gov as a credible source of current information regarding pandemic flu with emphasis on the following practices:
  • Encourage and promote the proper use of basic personal protective equipment.
  • Encourage the education of family members of EMS providers.
  • Encourage EMS providers to consult their local medical director in adopting the practice and procedures in patient care.

Ensure that dissemination of credible information to providers and the public through EMS agencies, organizations, associations, and EMS media is consistent with information from CDC, state and local public health.

CDC’s guidance is italics below.

By Administrators:

• Notification to staff of the emerging problem.
  • Fit test and issue N95 masks to paramedics and other responders, using non-operational personnel to perform fit tests
  • Issue hand sanitizer to paramedics and other responders
• Reviewing and updating local plans.
• Daily communication with hospitals and public health departments.
• Monitoring news reports and government resources, such as:
  • Public Health Agency of Canada
  • Centers for Disease Control EMS Guidance
  • www.pandemicflu.gov
  • CDC MMWR
  • CDC General Recommendations
• Identify a technical advisor to provide advice to paramedics and to track patients on a regional or state- or province-wide level
• Resolve issues of pay for paramedics who are quarantined.
• Establish procedures with local public health agencies to identify and pre-screen migrant workers entering the area
• Keep an accurate inventory of masks and other personal protective equipment, and an inventory of ventilators available in the service area.
• Develop a policy for limiting the dispatch of first responders to non-critical patients with flu symptoms, be ready to implement it when deemed necessary by medical directors
• In cooperation with medical direction, develop a treat and release protocol and patient information card for patients with minor flu symptoms. Implement the protocol and card when advised to in consultation with medical direction. Consider performing swabs in the home and deliver them to the identified local collection area (local public health, clinic or hospital) to be routed for testing. Consider the use of alternative care destinations like clinics or urgent care centers or identified receiving areas within the hospital away from the ED.
  • CDC Recommendations: Infectious Period
    • Persons with swine-origin influenza A (H1N1) virus infection should be considered potentially infectious from one day before to 7 days following illness onset. Persons who continue to be ill longer than 7 days after illness onset should be considered potentially contagious until symptoms have resolved. Children, especially younger children, might potentially be contagious for longer periods.
    • Non-hospitalized ill persons who are a confirmed or suspected case of swine-origin influenza A (H1N1) virus infection are recommended to stay at home (voluntary isolation) for at least the first 7 days after checking with their health care provider about any special care they might need if they are pregnant or have a health condition such as diabetes, heart disease, asthma, or emphysema. CDC guidance on care of patients at home.
• Work with local Health Districts to establish hotlines where the public can receive more information

By Paramedics:

CDC Recommendations:

If there HAS NOT been swine-origin influenza reported in the geographic area, EMS providers should assess all patients as follows:

• Step 1: EMS personnel should stay more than 6 feet away from patients and bystanders with symptoms and exercise appropriate routine respiratory droplet precautions while assessing all patients for suspected cases of swine-origin influenza.
• Step 2: Assess all patients for symptoms of acute febrile respiratory illness (fever plus one or more of the following: nasal congestion/rhinorrhea, sore throat, or cough).
  • If no acute febrile respiratory illness, proceed with normal EMS care.
  • If symptoms of acute febrile respiratory illness, then assess all patients for travel to a geographic area with confirmed cases of swine-origin influenza within the last 7 days or close contact with someone with travel to these areas.
    • If travel exposure, don appropriate PPE for suspected case of swine-origin influenza.
    • If no travel exposure, place a standard surgical mask on the patient (if tolerated) and use appropriate PPE for cases of acute febrile respiratory illness without suspicion of swine-origin influenza (as described in PPE section).

If the CDC confirmed swine-origin influenza in the geographic area (http://www.cdc.gov/h1n1flu/ )

• Step 1: Address scene safety:
  • If PSAP advises potential for acute febrile respiratory illness symptoms on scene, EMS personnel should don PPE for suspected cases of swine-origin influenza prior to entering scene.
  • If PSAP has not identified individuals with symptoms of acute febrile respiratory illness on scene, EMS personnel should stay more than 6 feet away from patient and bystanders with symptoms and exercise appropriate routine respiratory droplet precautions while assessing all patients for suspected cases of swine-origin influenza.
• Step 2: Assess all patients for symptoms of acute febrile respiratory illness (fever plus one or more of the following: nasal congestion/ rhinorrhea, sore throat, or cough).
  • If no symptoms of acute febrile respiratory illness, provide routine EMS care.
  • If symptoms of acute febrile respiratory illness, don appropriate PPE for suspected case of swine-origin influenza if not already on.

Personal protective equipment (PPE):

Interim recommendations:

• When treating a patient with a suspected case of swine-origin influenza as defined above, the following PPE should be worn:
  • Fit-tested disposable N95 respirator and eye protection (e.g., goggles; eye shield), disposable non-sterile gloves, and gown, when coming into close contact with the patient.
  • When treating a patient that is not a suspected case of swine-origin influenza but who has symptoms of acute febrile respiratory illness, the following precautions should be taken:
    • Place a standard surgical mask on the patient, if tolerated. If not tolerated, EMS personnel may wear a standard surgical mask.
    • Use good respiratory hygiene – use non-sterile gloves for contact with patient, patient secretions, or surfaces that may have been contaminated. Follow hand hygiene including hand washing or cleansing with alcohol based hand disinfectant after contact.
• Encourage good patient compartment vehicle airflow/ ventilation to reduce the concentration of aerosol accumulation when possible.

Infection Control:

EMS agencies should always practice basic infection control procedures including vehicle/equipment decontamination, hand hygiene, cough and respiratory hygiene, and proper use of FDA cleared or authorized medical personal protective equipment (PPE).

Interim recommendations:

• Pending clarification of transmission patterns for this virus, EMS personnel who are in close contact with patients with suspected or confirmed swine-origin influenza A (H1N1) cases should wear a fit-tested disposable N95 respirator, disposable non-sterile gloves, eye protection (e.g., goggles; eye shields), and gown, when coming into close contact with the patient.
• All EMS personnel engaged in aerosol generating activities (e.g. endotracheal intubation, nebulizer treatment, and resuscitation involving emergency intubation or cardiac pulmonary resuscitation) should wear a fit-tested disposable N95 respirator, disposable non-sterile gloves, eye protection (e.g., goggles; eye shields), and gown, unless EMS personnel are able to rule out acute febrile respiratory illness or travel to an endemic area in the patient being treated.
• All patients with acute febrile respiratory illness should wear a surgical mask, if tolerated by the patient.

Interfacility Transport

EMS personnel involved in the interfacility transfer of patients with suspected or confirmed swine-origin influenza should use standard, droplet and contact precautions for all patient care activities. This should include wearing a fit-tested disposable N95 respirator, wearing disposable non-sterile gloves, eye protection (e.g., goggles, eyeshield), and gown, to prevent conjunctival exposure. If the transported patient can tolerate a facemask (e.g., a surgical mask), its use can help to minimize the spread of infectious droplets in the patient care compartment. Encourage good patient compartment vehicle airflow/ ventilation to reduce the concentration of aerosol accumulation when possible.

Interim Guidance for Cleaning EMS Transport Vehicles After Transporting a Suspected or Confirmed Swine-origin Influenza Patient

The following are general guidelines for cleaning or maintaining EMS transport vehicles and equipment after transporting a suspected or confirmed swine-origin influenza patient. This guidance may be modified or additional procedures may be recommended by the Centers for Disease Control and Prevention (CDC) as new information becomes available.

Routine cleaning with soap or detergent and water to remove soil and organic matter, followed by the proper use of disinfectants, are the basic components of effective environmental management of influenza. Reducing the number of influenza virus particles on a surface through these steps can reduce the chances of hand transfer of virus. Influenza viruses are susceptible to inactivation by a number of chemical disinfectants readily available from consumer and commercial sources.

After the patient has been removed and prior to cleaning, the air within the vehicle may be exhausted by opening the doors and windows of the vehicle while the ventilation system is running. This should be done outdoors and away from pedestrian traffic. Routine cleaning methods should be employed throughout the vehicle and on non-disposable equipment.

For additional detailed guidance on ambulance decontamination EMS personnel may refer to "Interim Guidance for Cleaning Emergency Medical Service Transport Vehicles during an Influenza Pandemic".

EMS Transfer of Patient Care to a Healthcare Facility

When transporting a patient with symptoms of acute febrile respiratory illness, EMS personnel should notify the receiving healthcare facility so that appropriate infection control precautions may be taken prior to patient arrival. Patients with acute febrile respiratory illness should wear a surgical mask, if tolerated. Small facemasks are available that can be worn by children, but it may be problematic for children to wear them correctly and consistently. Moreover, no facemasks (or respirators) have been cleared by the FDA specifically for use by children.

By Dispatchers:

• When using ProQA software flagging MPDS protocols 6, 10, 18 and 26 for further interrogation, and using the drop down SRI (severe respiratory infection [flu-like] symptoms) screen to obtain, at a minimum, the following:
  • Are they febrile or have a fever, and if so, is it higher than 38° C (100°F)?
  • Do they have a cough or any other respiratory symptoms like difficulty breathing?
  • Use card 36 when your local EMS system experiences significant, sustained stress due to increased patient load or workforce reduction.
• For dispatch centers not using ProQA software (paper-based cards only), gathering the above information from all callers on protocol cards 6, 10, 18 and 26. Use card 36 when your local EMS system experiences significant, sustained stress due to increased patient load or workforce reduction.
• Dispatchers should report the responses to these questions to the paramedics before they arrive on the scene.

CDC Recommendations for 9-1-1 Public Safety Answering Points (PSAP):

It is important for the PSAPs to question callers to ascertain if there is anyone at the incident location who is possibly afflicted by the swine-origin influenza A (H1N1) virus, to communicate the possible risk to EMS personnel prior to arrival, and to assign the appropriate EMS resources. PSAPs should review existing medical dispatch procedures and coordinate any modifications with their EMS medical director and in coordination with their local department of public health.

Interim recommendations:

• PSAP call takers should screen all callers for any symptoms of acute febrile respiratory illness. Callers should be asked if they, or someone at the incident location, has had nasal congestion, cough, fever or other flu-like symptoms.
  • If the PSAP call taker suspects a caller is noting symptoms of acute febrile respiratory febrile illness, they should make sure any first responders and EMS personnel are aware of the potential for “acute febrile respiratory illness” before the responders arrive on scene.

The Emergency Medical Services Chiefs of Canada/Directeurs des services medicaux d’urgence du Canada (EMSCC/ DSMUC) is a National organization led by Chiefs and Directors of Canada’s EMS services across the country. The goal of the EMSCC is to advance and align emergency medical leadership across Canada. More information is available at www.emscc.ca.

The NAED is a national arm of the International Academy of Emergency Dispatch (IAED): a non-profit, standard-setting organization promoting safe and effective emergency dispatch services worldwide. Comprised of three allied Academies for medical, fire and police dispatching, the NAED supports first responder-related research, unified protocol application, legislation for emergency call center regulation, and strengthening the emergency dispatch community through education, certification and accreditation. Since 2003, the IAED has been working through its CBRN Committee to define and improve ways to capture information for calls related to chemical, biological, radiation, nuclear, and severe respiratory. More information is available at www.emergencydispatch.org

The National EMS Management Association represents 1,600 EMS management professionals and is dedicated to continually improving the care delivered to EMS patients by discovering, developing, and promoting the best EMS management practices. More information is available at www.nemsma.org. NEMSMA has offered to be the secretariat to the EMSCC National Outbreak Discussion Group. In return, meeting minutes and resource source lists will be distributed to our members.

FirstWatch is commercial-off-the-shelf (COTS) software that enables real-time Dashboard views and data analysis for statistically significant trends, patterns or geographic clusters of incidents, based on user-defined criteria – from a Situational Awareness, Public Health, Operational or Homeland Security standpoint. FirstWatch analyzes real-time data from 9-1-1 (EMS, Fire and Police) CAD systems, ProQA, Paramedic ePCR’s, Hospital Emergency Departments, Hospital Diversion systems, Poison Control Centers and more - in real time, automatically. Chosen by agencies in 90+ metro areas across the US and Canada, representing more than 68,000,000 citizens. Learn more online at: www.firstwatch.net.