COVID-19 EMS Patient Screening & Training Bureau of EMS & Trauma

30 Slides5.56 MB

COVID-19 EMS Patient Screening & Training Bureau of EMS & Trauma System July 6, 2020

Goal of Training This is an optional training to assist agencies in implementation of treat and keep home, treat and refer, and COVID-specific EMS guidelines The decision regarding if and when to implement these guidelines should be made in coordination with your agency’s Administrative Medical Director and/or Base Hospital It is critical to determine the incidence of COVID-19 in your community, the EMS call volumes, and hospital ED/inpatient bed availability/status when determining whether or not to implement these guidelines 2

COVID-19 Medical FAQs Incubation period: 2–14 days (median 4–5 days) Transmission: the virus is spread from person-to-person through close contact and respiratory droplets. Transmission can occur up to 48 hours before symptoms present. 3

COVID-19 Medical FAQs Risk factors for serious illness: Older age (age 65 yo) Cardiac disease Diabetes Immunocompromised (e.g., cancer treatment, smoking) Chronic lung disease or moderate to severe asthma Kidney disease Liver disease 4

COVID-19 Medical FAQs Symptoms: Fever ( 100.4 F or 38 C) and chills Cough Dyspnea Sore throat Congestion or runny nose GI symptoms: nausea, vomiting, diarrhea Headache, weakness, fatigue, myalgias (muscle pain) Loss of taste or smell 5

Overview of COVID-19 Medical Response Dispatch Screening EMS Guideline for Care of Patients with Suspected COVID-19 COVID-19 Respiratory Treatment Guideline COVID-19 Alternative Destination Guideline COVID-19 Patient Scripting COVID-19 Patient Education 6

Dispatch Screening - 2 Groups 1. Have you had fever or chills? 2. Have you had a cough or trouble breathing? Yes to 1 AND 2 Yes to 1 OR 2 COVID-19 Alert Infectious Disease Alert with Symptoms 7

COVID-19 PSAP Screening PSAP Screening for COVID-19 has been in place for several months This is the first step in screening a patient for possible COVID-19 Note: Due to COVID-19 being classified as “community spread,” travel history is not a part of PSAP patient screening 8

On-Scene Screening Questions It is critical to ask the screening questions a second time! Only essential EMS personnel should make patient contact Consider a “scout” paramedic to enter with ENHANCED PPE to perform these screening questions Ask these questions on every call to determine the type of PPE for all EMS personnel having patient contact All transported patients and patients with suspected COVID who are not transported should be given a surgical mask to wear upon initial patient contact 9

Other Patient Screening Questions Have you been exposed to anyone diagnosed with COVID-19? Has anyone in your [facility] been diagnosed with COVID-19? Do you work in a high-risk area? Healthcare (hospital, urgent care, doctor’s office, nursing home) Fire, EMS, or law enforcement Congregate setting (prison, residential facility for older adults, nursing home) Have you been tested for COVID-19? If so, do you have the result yet? 10

COVID-19 Guideline Significant change in clinical practice from conventional to contingency/crisis standard of care Approved by Arizona State Disaster Medical Advisory Committee (SDMAC) Goal is to protect EMS personnel who may lack sufficient PPE, maintain prehospital workforce, and allow safe transfer of care at the receiving facility Updated version approved by ADHS 7/7/2020 11

Why the change in patient management? Goal is to eliminate or reduce the risk of aerosolization of COVID-19 The following procedures are associated with aerosolization: SVN treatments (albuterol and atrovent) BVM Endotracheal intubation CPR High-flow oxygen via non-rebreather Supraglottic airway placement There are things you can do to limit your exposure risk! 12

Does this apply to all patients? If the patient resides in a congregate care setting, assume they have been exposed to COVID-19 Due to the widespread community spread of COVID-19 in many parts of Arizona, you should assume that most patients you encounter who are symptomatic have COVID-19 13

Stabilizing Measure 1. Perform all basic and advanced airway procedure in enhanced PPE ** Administer oxygen (NC preferred) and titrate to SaO 2 of 88%, using 6LPM O2. 2. 3. 4. 5. Avoid high flow oxygen. Place surgical mask over nasal cannula or oxygen mask. Obtain IV/IO access as indicated Administer IVF only to treat shock (SBP 90) Modify standard guidelines to minimize aerosolization of the virus.* When available, insert viral filter between BVM/SGA/ETT and bag/ventilator New language added includes emphasizing the use of viral filters when available 14

Transport Considerations 1. 2. Transport to the closest appropriate receiving facility Provide receiving facility notification: “Possible COVID-19” and Primary Symptoms If any aerosolizing measures (SVN, CPAP, BVM, CPR) are in use If a patient is not transported, provide strict follow-up or call back instructions Key addition is the emphasis on strict follow-up or call back instructions for any patient not transported. Some of these patients may worsen, and it is critical that they understand when to access 911 services again. 15

EMS COVID-19 Medication Changes No nebulizer use for patients with likely COVID-19, when nebulizer is absolutely necessary, administer in open air space and discontinue prior to entering any enclosed space, including hospital hallways. Consider using patient's own MDI, 1-2 puffs every 5 minutes. Administer 0.3 mg of IM epinephrine, 1mg/1mL, no more than once every 20 minutes, if needed for respiratory distress, use caution in patients over the age of 50 or with known cardiac disease. Nebulizers (SVNs) place all EMS personnel, bystanders, and hospital personnel at risk for exposure to aerosolized particles. 16

Noninvasive Positive Pressure Ventilation (NIPPV): CPAP and BiPAP Avoid CPAP/BIPAP unless absolutely necessary and discontinue prior to entry into a public space, including hospital hallways. If viral filter is available, place between the mask and oxygen delivery port. Viral Filter 17

Advanced Airway Management Early RSI is not recommended in the prehospital setting. Avoid endotracheal intubation and high flow O 2. Insertion of supraglottic airways (SGA) is preferred. Passive oxygenation during cardiac arrest may be achieved with a SGA device with viral filter if available. When ventilation is necessary, agencies should use available devices to limit exposure to aerosolized particles (examples: viral filters, etc.) 18

Why the recommendation for the Supraglottic Airways (SGA) Placement is rapid Much shorter time to adequate placement in comparison to ETT Limited time-frame for higher risk exposure Once in place, risk is decreased, unlike BVM which is ongoing For agencies preforming passive oxygenation as part of their out-ofhospital cardiac arrest protocol: The i-gel allows for passive oxygenation at 8 LPM through a separate passive O2 port. King airways do not have a separate port for passive oxygenation port and will need to be connected to self inflating bag connected to oxygen source. Both methods can be used with viral filter for passive oxygen insufflation. 19

Suspected COVID-19 & Oxygen Administration Summary Administer oxygen sparingly Nasal cannula at maximum 6 lpm Maintain SpO2 88% Place surgical mask over nasal cannula or oxygen mask Do not use non-rebreather mask at 15 lpm (risk of aerosolization) Avoid RSI and intubation 20

Suspected COVID-19 & Wheezing Treatment options: 1. Use patient’s own multi-dose albuterol inhaler: 1–2 puffs every 5 minutes 2. Epinephrine 0.3 mg 1:1,000 IM, once up to every 20 minutes Use with caution in patients 50 years old or with underlying cardiac disease 3. Oxygen via nasal cannula, at maximum 6 lpm, maintain SpO2 88% Remember: No nebulizer use for patients with likely COVID-19. When nebulizer is absolutely necessary, administer in open air space and discontinue prior to entering any enclosed space, including hospital hallways. 21

Suspected COVID-19 & Cardiac Arrest Enhanced PPE (N95, eye protection, face shield, gown) CCR – standard care Insert supraglottic airway, ie. King or i-gel If limited PPE, have EMS personnel with the most available PPE place airway Follow normal guideline: Return Of Spontaneous Circulation? Termination of Resuscitation? 22

Cardiac Arrest: COVID-19 not suspected CCR – treatment as usual Examples: Patient calls 911 with chest pain collapses on EMS arrival Patient with STEMI, has V-Fib arrest en-route to hospital CCR not indicated – treatment as usual, standard resuscitation Examples: Trauma code Drowning Overdose 23

Alternative Care Sites Alternate Care Sites need to be identified by your agency prior to referring a patient to them These may include: Urgent Care Tent in a hospital parking lot State or Military temporary hospital or medical site This will continue to evolve rapidly As the COVID-19 patient volume increases, we may transition to taking relatively ill patients to alternate care sites 24

Destination Determination - Alternate Care Sites Key deciding factors are: Oxygen saturation Work of breathing Risk factors (heart conditions, lung problems, diabetes, etc) If a patient meets ALS criteria for transport for other reasons (hypotension, arrhythmia, etc), they still need ALS transport to the hospital regardless of COVID severity If a patient has a positive response to an intervention, they still need transport based on their initial COVID severity Ex. Patient with initial room air oxygen saturation 68% meets severe category, even if oxygen saturation increases to 94% with supplemental oxygen 25

Scripting It is critical to explain to patients why they may not be transported to the hospital This is sample scripting language provided by ADHS 26

Patient Education If patients are advised to stay home, we must provide them with printed patient education materials regarding COVID-19 The next slide is a 2-page document patient education handout from the CDC Be sure to point out to the patient or their family the following: When to call 911 again, or go to the hospital To self-isolate 27


Notification to Receiving Facilities Notify any receiving facility using simple language: “This patient is high risk for COVID-19” Provide presenting symptoms: Fever and cough, hypoxemia, etc. Provide any additional information regarding interventions that might generate aerosols: Supraglottic airway, CPR, etc. 29

THANK YOU Gail Bradley, M.D. Bureau of EMS & Trauma [email protected] 602-364-3150 @azdhs 30

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