CPSM Source Article | Author Matt Zavadsky

The COVID-19 pandemic has changed our world forever.  These are unprecedented times, and virtually every aspect of local governance and service delivery has been impacted.  Perhaps one of the service delivery models most impacted by the coronavirus is your local emergency medical services (EMS) system.

Whether your EMS service is provided by the fire department, a separate department of the city or county government, contracted to a private provider, a hospital-based agency, or a combination of these, the impact of COVID-19 on the workforce, operations, protocols, and even the role of your local EMS system is dramatically different than it was only a few months ago.

Workforce

Protecting the Front Line – EMS is healthcare, and healthcare workers are on the front line of this pandemic.  The highly contagious nature of the coronavirus places EMS workers, who often provide their services in dynamically diverse settings, at significant risk.  A tracking system implemented by the International Association of Fire Chiefs reports that since the COVID-19 outbreak, over 10,500 EMS and fire workers have been exposed to COVID-19, 4,800 have had to be quarantined, and 575 have been diagnosed with the disease.  Sadly, more than 20 of them have succumbed to the virus.

• Best Practice – Assure your EMS agency leadership is reporting personnel exposures, quarantines and COVID-19 diagnoses into this tracking system. It provides a basis for federal funding to help mitigate these impacts.

Mitigation of this risk requires EMS providers to take extreme measures to protect themselves, and the patients entrusted to their care, from airborne virus transmission.  The use of personal protective equipment (PPE) such as N95 masks, face shields and gowns has never been greater.  For example, at MedStar, the regional governmental EMS authority in Fort Worth, Texas, the daily ‘burn rate’ for N95 masks increased from an average of four per day in January 2020, to 160 per day in April.  The dramatic increase in use of PPE has strained supply chains, and although recently there has been some improvement, local governments will need to pay particular attention to the availability of PPE for their EMS agencies.

• Best Practice – Assure availability of PPE for your EMS workers.

Modification of Medical Protocols – There are medical procedures that place EMS workers at a higher risk for airborne viruses.  These include many advanced airway maneuvers and breathing treatments.  Agency medical directors should carefully review patient care protocols and modify protocols to minimize the use of these procedures, or at the very least, provide very specific guidance on how to safely administer these treatments when they are absolutely needed.  Similarly, the overall approach to resource dispatch and on-scene processes should be modified to minimize the number of personnel entering potentially infectious environments.

• Best Practice: EMS Medical Directors should modify medical protocols to minimize potential transmission of airborne pathogens.

Personnel Screening and Testing – The heightened risk of EMS workers contracting, and potentially spreading, COVID-19 requires the implementation of workplace controls.  At a minimum, EMS workers should undergo a health screening and temperature check at the start of every shift.  If their shifts are longer than twelve hours, the test should be administered every twelve hours.  Employees who are symptomatic for COVID-19 should not be allowed to work, or even enter EMS facilities.  Similarly, any EMS worker who has an exposure to a patient suspected of having COVID-19, should be placed on administrative leave and isolated while testing is completed.  To minimize the impact on staffing, priority testing should be provided to any EMS worker with a possible COVID-19 exposure.  You should also arrange for a safe and comfortable environment for them to be isolated such as a local hotel, or recreational vehicle.

• Best Practice – EMS workers should be health screened prior to on-duty shifts and given priority for testing after an exposure, or if they are symptomatic.

Information Exchange in the FOG of War – Dynamically changing information and guidance from sources like the CDC, NIH, federal administrative agencies and local health authorities, has created a FOG of War.  This adds to the concern of your local EMS providers.  Communication is key and you should assure that the lines of communication from your agency’s leaders to the field providers is timely, accurate and relevant to both the clinical impact of the virus and responsive to their fears and concerns.  This will not only help assure that clinical best practices are conveyed in a timely manner, but that you are continually aware of the ‘ground truth’ of what’s happening in the field and address any issues faced by your crucial field staff.

• Best Practice – EMS agency leadership should facilitate frequent information exchanges with EMS workers.

Operations

Response Procedures – Responses to potential COVID-19 patients should be modified to minimize the number of EMS personnel who enter potentially hazardous environments.  9-1-1 EMS calls should be screened for the presence of high-risk clinical presentations and any calls with a high index of suspicion should be handled differently.  For example, low-acuity calls (calls in which no significant life threat is present), may not require a response from first responders who may typically respond.  When multiple responders do arrive, the responders should meet on scene PRIOR to making patient contact and decide which essential personnel need to enter the scene.  This will reduce the number of EMS workers entering the potentially hazardous scene.  MedStar modified dispatch processes to screen 9-1-1 callers for the risk of potential of COVID-19 related illnesses and advise all responding personnel of calls with a high index of suspicion.  On-scene processes have been revised to limit the number of responders entering potentially hazardous environments.  Similarly, for CPR calls, whenever possible, mechanical CPR devices are used to minimize the need for EMS workers to actually provide external chest compressions.  Further, the local health authority should provide the EMS agency with a list of people under investigation (PUIs) in their response area.  These addresses can be ‘flagged’ so that calls to those addresses can be managed in the appropriate way.

• Best Practice – Dispatch, response and on-scene procedures should be revised to minimize the number of EMS responders in hazardous environments.

Inter-Agency Communications – When EMS does treat a potential COVID-19 patient, processes should be in place to rapidly test the patient for the presence of the coronavirus and report the test outcomes to the EMS agency(s) who were involved in patient care.  The federal government has loosened patient privacy requirements to facilitate this information exchange.

Ambulance Riders – During most transports to the hospital, it is standard practice for the EMS agency to allow a family member to ride in the ambulance with the patient.  Due to the close quarters in most ambulances, and the fact that many hospitals are restricting visitors, the practice of allowing family members to ride with the patient should be discouraged.  This may need to be allowed in rare cases such as a parent riding with a child, or if translation services are required.  The same restrictions should be applied to student observers or other third-party riders who may typically be allowed to ride on ambulances for clinical or educational purposes.

• Best Practice – Operational policies should be revised to allow the exchange of information for suspected COVID-19 patients between agencies and to limit riders on ambulances.

New Roles for EMS Agencies

Treat and Referral Protocols – To preserve healthcare system capacity, as well as minimize patient exposures, EMS systems should work with their medical control authority to implement protocols that facilitate EMS personnel referring low-acuity 9-1-1 patients to follow-up care other than transport to a hospital emergency department.  When implementing these protocols, instructions and leave-behind materials on how to access medical resources for follow-up should be provided to patients who are not transported.  These protocols and supplemental information can either be provided on-scene when EMS providers arrive, or over the telephone on 9-1-1 calls without EMS resources being sent to the scene.

COVID-19 Testing – One of the greatest needs in many communities is testing for coronavirus.  EMS agencies can be a valuable resource for this testing by staffing public access testing sites, or going to the homes of individuals who are quarantined to do specimen collection.  Skilled Nursing Facilities (SNFs) and jails often have unique environments that make residents of those facilities especially vulnerable to the spread of COVID-19.  In Texas, Emergency Medical Task Forces (EMTFs) comprised of EMS, public health and regulatory officials are deployed to SNFs identified by the state as “hot spots” for the coronavirus.  These EMTFs arrive at the facility to not only test all residents and staff, but provide education to the staff on PPE use and recommendation for isolating COVID positive residents.

• Best Practice – EMS agencies should partner with public health and the healthcare system to fill gaps created by the COVID-19 pandemic.

Economics

Financial Perfect Storm – Many cities and counties are experiencing significant financial impacts from the COVID-19 pandemic.  Stay in place orders reduce commerce in the jurisdiction, resulting in the loss of jobs and tax revenue.  Simultaneously, expenses for mitigating the impact of COVID-19 are skyrocketing.  EMS agencies are experiencing the same economic imbalance.  Backfill and other personnel expenses for quarantined personnel is dramatically increasing.  The use and price for PPE has exponentially increased.  In January, MedStar in Fort Worth paid $0.67 for an N95 mask; in April, that same mask was $3.65.  From a revenue perspective, due to stay in place orders, and orders to limit medical care to preserve hospital capacity, 9-1-1 response and transport volumes have dropped substantially in most communities.  EMS agencies are most often only reimbursed by 3rd party insurers when they transport patients to the hospital.  Decreases in both response and transport volume have dramatically reduced EMS revenue.  In a recent study conducted by the National Association of Emergency Medical Technicians, 69% of survey respondents indicated their response volumes have decreased since the declaration of the Public Health Emergency (PHE) and 35% of EMS agencies indicated they will only be able to sustain operations for 2 months without significant financial relief.

• Best Practice – Cities and counties should include EMS agencies in their plans for economic relief from sources such as CARES Act funding and FEMA grants.

Summary

Cities, counties and their respective departments have learned a lot from the COVID-19 pandemic, but the education is not over.  The full impact of the virus on local communities may not be known for months or years to come.

CPSM has numerous experts and resources available to assist governmental leaders navigate these uncharted waters.

References and Resources:

CDC EMS guidelines

NHTSA EMS Resources

MedStar EMS Protocols and Guidelines for COVID-19

National Association of Emergency Medical Technicians COVID Resources

International Association of Fire Chiefs COVID-19 Exposure Tracking

Global Medical Response Emerging Infectious Disease Resources