COVID-19 Best Practices

The pandemic has challenged agencies around the world to implement new standards for operations and patient care. Fire and EMS departments struggle to keep personnel safe while employing cutting-edge medicine and still responding to “typical” emergencies each day.

The San Antonio Fire Department (SAFD) has taken important, notable measures to meet the demands of the pandemic while paying close attention to responder safety and patient treatment.

Transmission and symptoms

Understanding how COVID-19 is transmitted informs best practices that prevent infectious disease spread and keep patients and providers safe.

Contact, droplet and airborne transmission are the three ways that the SARS-CoV-2 virus can be spread. Per the Centers for Disease Control and Prevention (CDC), the principal mode by which people are infected with COVID is through respiratory droplets. Some authors and studies contradict this claim, but there is general agreement that airborne transmission of SARS-CoV-2 can occur under circumstances in which fire and EMS personnel often find themselves treating patients.

With such a large list of potential signs and symptoms (see “COVID Symptoms” sidebar), the differential illnesses can be large. Taking a good history will guide the provider’s diagnosis. Having chest pressure, with a fever, dry cough, fatigue and anosmia (loss of the sense of smell) would lean the diagnosis toward COVID. Determining that the patient has a sick family member, friend, co-worker, etc., increases the index of suspicion for COVID illness.

Since March, the UT Health San Antonio Emergency Health Sciences Office of the Medical Director (OMD) has discussed the signs and symptoms of COVID-19 in SAFD’s continuing education training.

On EMS calls, the SAFD sends what it calls a single scout to judge whether COVID-19 might be in play. This decreases the risk to providers and saves on PPE.

SAFD best practices

In March, the SAFD command staff and its EMS medical directors recognized the seriousness of the pandemic and adjusted operations. Many of these operations align with the CDC’s interim recommendations for EMS and public safety answering points (PSAPs) in the United States during the COVID pandemic. Recommendations for best practice include:

Using modified caller queries at the PSAP
Ensuring that providers are trained in donning and doffing PPE
Screening all providers at the start of a shift
Assessing all patients for SARS-CoV-2 infection
Implementing universal source control
Encouraging social distancing
Implementing universal use of PPE
Creating a process to address exposure

Operations

Prior to the pandemic, the SAFD became a member of the Texas Emergency Medical Task Force’s Infectious Disease Response Unit, which was implemented to respond to large-scale events. Membership in this team put the SAFD in a position to be prepared for the COVID pandemic.

Early in the pandemic, the SAFD ordered half-mask P-100 air-purifying respirators for all providers. This negated the need to compete for N-95 respirator allocation. The P-100 air-purifying respirator has proven useful in particular because it can be cleaned easily and used filters can be replaced readily. We believe that the seal is much more secure than an N-95 is when operating under austere prehospital conditions.

The SAFD opened a recently decommissioned firehouse to develop a dedicated decontamination location for EMS and fire after making a call that likely involved a COVID patient. This decontamination station has dedicated employees, which allows the responding crews time to shower and change as needed. The team utilizes electrostatic and ultraviolet decontamination to kill all SARS-CoV-2 virus.

The San Antonio healthcare system developed a regional crisis standards of care document that addresses how to provide care when the system is in crisis (https://tinyurl.com/SWTexasGuidelines). At higher crisis levels, patients may be able to be treated in place, or EMS can transport them to nontraditional settings rather than hospitals.

One of the ways that the SAFD planned to avoid an overwhelmed system is with telemedicine. The telemedicine program is performed by a clinical dispatcher via the GoodSAM app. The app allows the dispatcher to see the caller through the caller’s own phone.

Early in the crisis, the SAFD opted to obtain P-100 air-purifying respirators for providers rather than N-95 respirators. Cleaning and filter replacement of the former are easy to accomplish, and the department believes that their seal is much more secure than that of N-95 respirators. Another benefit: The department didn’t have to compete for a supply of the N-95s.

The clinical dispatcher immediately can assess whether the patient is ill and requires an ambulance. The call-taker can determine the respiratory rate, and the app takes the patient’s heart rate with an artificial-intelligence technology. This provides a level of patient safety that isn’t available with traditional phone dispatching.

This technology allows the SAFD to send patients who appear well to get a COVID test—or even allows the patient to stay home. The app also can provide follow-up surveys to callers to make sure that they still are doing well, thus providing advanced-level prehospital care. This is a very important asset, because fire and EMS resources can remain available for other emergency calls.

Provider health and wellness also is a priority. The SAFD has a dedicated clinical psychologist to help with pandemic fatigue. The SAFD employs an internal team that’s dedicated to testing, notifying, and monitoring providers and their families. A return-to-duty process ensures that the provider is able to perform the tasks that are required of firefighters and paramedics.

Clinical

On EMS calls, the SAFD sends a single provider into a residence or building to act as a scout to recognize any concern for the COVID-19 illness. If possible, providers will have patients walk to their front porch, given that COVID transmission is decreased when outdoors. Such simple practices decrease risk to providers and save on PPE, because only the scout must be suited in full PPE before there’s a determination as to whether the call involves a potential COVID patient. The remaining crew only will don full COVID PPE when needed.

For healthcare workers who perform aerosol-generating procedures on patients who have COVID-19, the CDC recommends the use of an N95 respirator or equivalent or higher-level respiratory protection. (Aerosol-generating procedures include endotracheal intubation, open suctioning of airways, manual ventilation, noninvasive positive pressure ventilation [NIPPV], cardiopulmonary resuscitation [CPR], and potentially nebulizer administration and high-flow oxygen delivery.)

There is a real concern for aerosolizing procedures in the prehospital environment. Very early in the pandemic, the OMD, which provides medical direction to the SAFD, determined that albuterol nebulizers had a theoretical risk of increasing aerosolized SARS-CoV-2 virus. The determination was made to use a metered dose inhaler (MDI) to decrease risk for aerosolization. The MDI would be given with a spacer adaptor for eight puffs, with repeat dosing in 10 minutes. The novel use of epinephrine, in a 1:1,000 concentration at 0.3 mg intramuscular, also was added to the difficulty breathing algorithm. Both changes were implemented to decrease risk of provider infection while providing an equivalent level of care for those who are having difficulty breathing.

At the SAFD, NIPPV (for example, continuous positive airway pressure) that’s deployed to treat a severely ill patient only is used when the provider is in full COVID-level (respiratory droplet) PPE. This includes gloves, gown, goggles and air-purifying respirator. The SAFD recently added an exhaust filter to decrease aerosolization. Again, the risk for aerosolization is weighed against the need to perform appropriate patient care.

The SAFD and the OMD elected to continue with intubations and CPR if providers were wearing full COVID-level PPE. The department purchased endotracheal tube expiratory filters that decrease levels of circulating SARS-CoV-2 aerosols. The potential to save a life and the safety precautions that are taken by SAFD personnel factored heavily into this decision.

Positioning patients who are hypoxic on their left or right side or in the prone position is on the horizon for SAFD COVID treatment. Prone-positioning treatments have proven very effective at improving oxygenation: The posterior part of the lungs is allowed to increase oxygen recruitment. This increases end expiratory lung volume and chest wall elastance, decreases alveolar shunt and improves tidal volume. Studies show that patients who had acute respiratory distress syndrome (ARDS) had decreased mortality. One limited study states that proning decreases mortality in patients who have ARDS because of COVID.

Prevention

The SAFD and the OMD recommend that all eligible providers get a vaccine. The majority of those who receive a vaccine will be spared from COVID illness. However, even after inoculation, infection control still is needed to prevent potential spread to others who haven’t had the vaccine.

The education continues

The SAFD has deployed a multitude of plans and process improvements to fight the COVID-19 pandemic. However, treating COVID patients will be a continual learning process. Information will change constantly, which will require agencies to remain updated with the latest resources to provide the most current evidence-based medicine for COVID-19 patients and providers.

This special coverage is sponsored by Zoll Medical.