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TO: MVEMSA EMS Medical Dispatch Centers FROM: Greg Kann, Medical Director DATE: February 28, 2020 SUBJECT: UPDATE: Emerging Infectious Disease COVID-19 Guidance History: The Centers for Disease Control, California Department of Public Health, Mountain Valley EMS Agency and member county Health Departments are actively monitoring the outbreak of a 2019 novel coronavirus (COVID-19) which originated in Wuhan City, Hubei Province, China in December of 2019. There have been 2 cases reported in California, both located in Southern California. This situation is evolving; therefore, please visit: for the most up-to-date information regarding 2019-nCoV. Purpose: To provide guidance for the assessment, treatment and transport when COVID-19 is suspected during emergency call taking and response. This guidance is effective immediately and shall remain in effect until terminated by the Medical Director or Executive Director. Definitions: Person/Patient Under Investigation (PUI): Person who meets screening criteria for as well as risk factors for the emerging infectious disease (screening done by dispatch, or prehospital field staff). Suspect case: Patient who has signs and consistent with emerging infectious disease and has epidemiological link (usually determined by hospital upon clinical evaluation). Confirmed case: Patient with laboratory confirmation of emerging infectious disease. Emergency Medical Dispatch/Call Taking: A. Identification of which patients need special precautions when in contact with EMS personnel involves both the assessment of potential risk factors, and questioning of patients on the presence or absence of that meet criteria for a PUI. The most current CDC criteria for patients in the United States who meet PUI criteria in association with the outbreak of COVID-19 can be found at: nCoV/hcp/clinical-criteria.html ---PAGE BREAK--- Page 2 of 6 B. In general, if the call takers suspect a caller is reporting of an emerging infectious disease, they shall screen callers for risk factors. If there are AND risk factors present, immediately inform the responding EMS personnel that the patient meets criteria for a PUI using standard operating procedures for the individual responding agency. C. Dispatch center shall follow MPDS screening process as below. Centers not utilizing the current version of MPDS for caller interrogation/dispatch may use the attached caller screening algorithm. See attached for guidance from the IAED. D. If there are NO and NO risk factors present, proceed with normal call taking and dispatch duties. Medical Priority Dispatch Screening Questions: A. The following is required if your agency utilizes the International Academy of Emergency Dispatch (IAED) – Medical Priority Dispatch System (MPDS), Advanced Emergency Medical Dispatch (EMD) protocol in dispatch centers serving Stanislaus, Amador, Calaveras, Alpine or Mariposa Counties. 1. For MPDS-user agencies that implement medical dispatch enhanced screening procedures, the IAED recommends using the Emerging Infectious Disease Surveillance (EIDS) Tool for the following Chief Complaints: a. Sick Person (Protocol 26) b.Breathing Problems (Protocol 6) 2. Also, the EIDS Tool should be used for other Chief Complaints when the caller offers information that would lead the Emergency Medical Dispatcher (EMD) to suspect a respiratory-type illness. B. The EIDS Tool questions shall reflect current CDC COVID-19 screening criteria as follows: 1. Clinical Features: Fever -OR- of lower respiratory illness (cough, shortness of breath, difficulty breathing) AND 2. Epidemiologic Features: In the past 14 days before onset, a. A history of travel from China, Iran, Italy, Japan or South Korea b.Close contact with a person under investigation for COVID-19 while that person was ill -OR- c. Close contact with an ill laboratory confirmed COVID-19 patient C. For any call which screens “positive” to BOTH Clinical AND Epidemiologic features, immediately inform the responding EMS personnel that “EMS Screened Positive Patient” AND notification to the Primary PSAP. Field crews are responsible for early notification of the receiving hospital so that they can adequately prepare their staff for a patient with a possible contagious disease. D. If the call screens “negative” for the disease specific criteria, complete management of call as per existing protocol. First Responder Expanded Initial Assessment A. Routine contact and airborne exposure control precautions will offer protection to first responders for any COVID-19 PUI. B. Any patient identified by EMS Dispatch as meeting COVID-19 screening criteria shall be transported to an appropriate hospital per appropriate MVEMSA destination policy, using the PPE precautions as noted under Personal Protective Equipment (PPE). C. Patients not identified by EMS Dispatch as meeting COVID-19 PUI criteria, but who have fever AND respiratory (cough or difficulty breathing) shall undergo the following expanded assessment and management: 1. If the patient exhibits of an acute febrile* lower respiratory infection (fever, shortness of breath/difficulty breathing, cough): ---PAGE BREAK--- Page 3 of 6 a. Place a surgical mask on the patient AND b.Obtain a detailed travel history to China, Iran, Italy, Japan or South Korea within the past 14 days or close** contact with someone under investigation for COVID-19. 2. If there is a history consistent with concern for potential COVID-19, initiate standard contact and airborne precautions (gloves, gown, N95 respirator) and eye protection (goggles) for EMS clinicians. 3. High-risk, aerosol generating procedures require an N100 respirator. Use caution when performing these procedures. 4. Properly doff and dispose of PPE according to protocol. 5. Cleaning and disinfection using EPA registered disinfectants with known effectiveness against human coronaviruses. 6. Waste management per policy for medical waste (red bag). 7. Field crews are to contact their Supervisor on initial contact when a patient meets criteria for a PUI. 8. Field Supervisors shall confirm patient meets PUI criteria and immediately notify the MVEMSA Duty Officer ([PHONE REDACTED]) if PUI criteria is confirmed. The Duty Officer will notify the appropriate County Health Department. D. If the patient screens “negative” for the disease specific criteria, complete management of call as per existing procedure. Infection Control: A. First response and transport personnel can safely manage a patient with a PUI, suspected or confirmed emerging virus by following recommended isolation and infection control procedures, including standard, contact, and droplet precautions. Various means of protection will include protecting the Caregiver from all routes of entry through the use of PPE, barriers in the patient compartment of the ambulance, proper decontamination of the ambulance/equipment and proper disposal of the waste generated. Early recognition and identification of patients with a potentially infectious disease is critical. The following minimum standards will be observed during these processes: 1. Wearing of appropriate PPE for a PUI (surgical mask). 2. Limit activities, especially during transport that can increase the risk of exposure to infectious material airway management, cardiopulmonary resuscitation, use of needles). 3. Limit the use of needles and other sharps as much as possible. All needles and sharps shall be handled with extreme care and disposed in puncture-proof, sealed containers. 4. Prudent hand hygiene including hand washing and/or alcohol based hand rub. 5. If blood, body fluids, secretions, or excretions from a patient with a suspected emerging infectious disease come into direct contact with the provider’s skin or mucous membranes, then the provider shall immediately stop working. They shall wash the affected skin surfaces with soap and water and report exposure to a supervisor for follow-up. Personal Protective Equipment (PPE): A. Use of standard contact, and droplet precautions is sufficient for most situations when treating a PUI in the absence of a directive from the PHO, personnel shall wear: 1. Gown (fluid resistant or impermeable) 2. Eye protection (goggles or face shield that fully covers the front and sides of the face) 3. N95 Facemask (N100 for high-risk procedures) 4. Gloves ---PAGE BREAK--- Page 4 of 6 B. Additional PPE might be required in certain situations large amounts of blood and body fluids present in the environment), including but not limited to double gloving, disposable shoe covers, and leg coverings. C. Pre-hospital resuscitation procedures such as endotracheal intubation, open suctioning of airways, and cardiopulmonary resuscitation frequently result in a large amount of body fluids, such as saliva and vomit. Performing these procedures in a less controlled environment moving vehicle) increases risk of exposure. If possible, perform these procedures under safer circumstances stopped vehicle, hospital destination). Patient Transport/Receiving Facilities: A. Transport personnel shall provide early notification to the receiving hospital when transporting a PUI, Suspected or Confirmed patient with an infectious disease, so that appropriate infection control precautions may be prepared prior to patient arrival. All Amador, Calaveras, Mariposa and Stanislaus County hospitals are capable of safely managing a COVID-19 PUI and are capable of isolating the patient in a private room. Interfacility transfers or confirmed patients with COVID-19 require coordination with the appropriate Public Health Officer and EMS Administrator. B. Any bodily fluid or other contamination on gurney wheels will be disinfected with an EPA-registered hospital disinfectant with label claims against non-enveloped viruses (ie, norovirus, rotavirus, adenovirus, etc) or using a 1:10 bleach to water solution and allowed to dry for 10 minutes. C. Patient will be transferred into hospital by ambulance crew at the direction of hospital staff. Follow-up/Reporting: A. First response and transport personnel shall be aware of the follow-up and/or reporting measures they shall take after caring for a PUI, suspected or confirmed emerging infectious disease patient. B. First response agencies and transport services shall develop policies for monitoring and management of personnel potentially exposed to an emerging infectious disease. C. Personnel with exposure to blood, bodily fluids, secretions, or excretions from a patient with a suspected or confirmed emerging infectious disease shall immediately: 1. Stop working and wash the affected skin surfaces with soap and water. Mucous membranes conjunctiva) shall be irrigated with a large amount of water or eyewash solution; 2. Contact their supervisor and occupational health provider for assessment and access to post-exposure management services; and 3. Report potential exposures to their Supervisor/Designated Infection Control Officer (DICO) per company/agency policy. DICO shall then make appropriate notifications per County policy. D. Personnel who develop after an unprotected exposure not wearing recommended PPE) at the time of contact with a suspected or confirmed emerging infectious disease patient shall: 1. Not report to work or immediately stop working and isolate themselves; 2. Notify their Supervisor/DICO, who must make appropriate notifications per company/agency and County policy. 3. Contact occupational health/supervisor for assessment and access to post- exposure management services; and 4. Comply with work exclusions until they are deemed no longer infectious to others ---PAGE BREAK--- Page 5 of 6 Notes: *Fever may not be present in all patients; those who are immunocompromised, very young, elderly or taking fever-lowering medications. **Close contact is defined as being within about 6 feet, or within the same room or care area, or a patient with confirmed COVID-19 without wearing PPE for a prolonged period of time OR having direct contact with COVID-19 patient secretions. ---PAGE BREAK--- Page 6 of 6