All calls and requests for ambulance services should be screened for COVID-19. The current case definition includes:
➊ Acute respiratory symptoms and history of travel or local transmission
A patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath), AND a history of travel to or residence in a location reporting community transmission of COVID-19 disease during the 14 days prior to symptom onset.
➋ Acute respiratory symptoms and contact with confirmed cases
A patient with any acute respiratory illness AND having been in contact with a confirmed or probable COVID-19 patient in the last 14 days prior to symptom onset.
➌ Acute respiratory symptoms and no alternative diagnosis
A patient with severe acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath; AND requiring hospitalization) AND the absence of an alternative diagnosis that fully explains the clinical presentation.
When dispatch calls with a suspected (or confirmed) COVID-19 case, the EMT crew should take the following steps to prepare the ambulance for faster, easier, and more effective decontamination after transporting the patient:
➊ Protect the equipment from contamination
To reduce exposure and ease the decontamination process, store all supplies and equipment unlikely to be used in cabinets and secure. If cupboards do not close securely or have holes, they should be covered with plastic sheeting. Items likely to be used by EMT for a COVID patient include:
Pulse ox
BP machine
Oxygen tank
Nasal cannula/non-rebreather mask.
➋ Do not allow patients into the ambulance unless they need transport
Patients who screen positive for COVID-19 but do not need to be transferred to the hospital should not enter the ambulance.
On arrival to the patient, any equipment needed for assessment can be taken from the ambulance to the patient such as a pulse oximeter and BP machine.
This equipment should be immediately disinfected after use outside of the ambulance, along with doffing and bagging of PPE. This will ensure that you are not bringing any contaminants back into the ambulance after seeing the patient.
➌ Don (put on) PPE
Prior to patient assessment EMTs should don their PPE in the proper order starting with the gown:
1. Wash your hands
2. Gown
3. Mask
4. Goggles or face shield
5. Gloves
For complete information on donning and doffing PPEs in the correct order, reference the PPE procedures section.
Ventilation in the ambulance
Turn on the ventilation system to ensure as many air changes as possible. This includes turning on an extractor fan if available and/or turning on the ventilation system in the patient cabin to non-recirculated air and opening windows as much as possible. The barrier between the patient and driver should be sealed shut and ventilation in the driver’s cabin should be set to non-recirculated air, with windows open as possible.
When to mask the patient
If the patient is determined to require hospital admission or evaluation, place a surgical mask on the patient and keep it in place for the duration of transport unless O2 therapy is required. Note that a facemask can be safely placed over an O2 cannula, but not a non-rebreather mask.
Follow these steps after every COVID-19 case to protect yourself, your team members, and other patients. The order of the steps is intentional, so start at the top and work your way down.
Wear PPE – Don full PPE with eye protection if not already wearing.
Prepare disinfectant – Prepare .5% bleach (ie JIK) solution if not already prepared in the last 24 hours. Once diluted, bleach solutions lose their effectiveness after 24 hours.
For 3.5% liquid bleach, use a 1:6 ratio of liquid bleach to water. Do not exceed this ratio.
Other chlorine solutions may also be used and must be prepared to a concentration of .5%.
If chlorine tabs are in use on the ambulance, prepare according to manufacturer instructions for .5% or effective for cleaning blood and body fluids. Some, but not all, tabs require a waiting period of 30 minutes prior to their use to be fully effective.
Remove everything from the ambulance – Remove all items from the ambulance that are not fixed to the floor or wall or sealed behind cupboard doors.
Linens – Remove linens slowly from the stretcher, taking care not to shake them, and rolling them in on themselves. Put in the appropriate laundry bin at the hospital. If laundry is done at the ambulance HQ/base, place in a plastic bag and seal well.
Clean – Clean up any visible soiling within the vehicle and on any equipment.
Disinfect – Spray the entire patient cabin from top to bottom (ceiling to floor) from the front (closest to the driver) to the back (out the back door) with .5% bleach solution. This may vary depending on the design of the ambulance. The goal is to work in one direction towards the main door to the patient cabin. Allow the spray to dry for 10 minutes. If it dries earlier, reapply. Bleach requires a 10 minute drying time to be effective.
Driver cabin – Do the same for the driver cabin, working top to bottom.
Equipment – While the vehicle is drying, start spraying down all the equipment from the ambulance. ALL surfaces must be sprayed down, including the underneath of the stretcher and the flip-side of the mattress. This includes the outside of the plastic bag with linens if they will be transported.
Dry the cleaned surfaces – Return to the vehicle and spray and wipe all surfaces with a soft, absorbent cloth. Allow to air dry again.
Dry the equipment – Repeat with the equipment: wiping and air drying.
Remove PPE – Doff PPE and dispose in the proper waste bins at the hospital. Disinfect any reusable PPE such as face shields and goggles. Perform hand hygiene.
Reassemble the vehicle – Once all equipment has been wiped down and air-dried, the ambulance can be re-assembled and put back into use for the next patient.