Effective
communication among clinicians requesting emergency transport of a
patient with possible or known SARS-CoV disease, EMS personnel, and
receiving facilities is necessary to ensure the appropriate protection
of healthcare workers. Prehospital care personnel should follow the updated
Standard Precautions recommendations to prevent the spread of respiratory
infections described in III.B above. These include promoting respiratory hygiene/cough etiquette and using Droplet Precautions, in addition to
Standard Precautions, for all patients with symptoms of a respiratory
infection. When SARS is suspected in a patient needing emergency transport, prehospital
care providers and healthcare facilities should be notified in advance
that they may be transporting or receiving a patient who may have SARS-CoV
disease.
A. Patient Transport
Objective: Safely transport patients with known or
possible SARS-CoV disease.
Activities
Patients who may have SARS-CoV disease may be safely transported in
any emergency vehicle with the proper precautions.
- Involve
the fewest EMS personnel required to minimize possible exposures.
- Family
members and other contacts of SARS patients should not ride in the
ambulance if possible. If necessary, they should be evaluated for
fever and lower respiratory symptoms and, if either is present, asked
to wear a surgical or procedure mask when riding in the vehicle.
- When
possible, use vehicles that have separate driver and patient compartments
that can provide separate ventilation to each area. Close the door/window
between these compartments before bringing the patient on board.
Set the vehicle's ventilation system to the non-recirculating mode
to maximize the volume of outside air brought into the vehicle. If
the vehicle has a rear exhaust fan, use it to draw air away from
the cab, toward the patient-care area, and out the back end of the
vehicle. Some vehicles are equipped with a supplemental recirculating
ventilation unit that passes air through HEPA filters before returning
it to the vehicle. Such a unit can be used to increase the number
of ACH (NIOSH
HETA report 95-0031-2601 ).
- If
a vehicle without separate compartments and ventilation must be used,
open the outside air vents in the driver area and turn on the rear
exhaust ventilation fans to the highest setting. This will create
a negative pressure gradient in the patient area.
- If
possible, place a surgical mask on the patient to contain droplets
expelled during coughing. If this is not possible (i.e., would further
compromise respiratory status, difficult for the patient to wear),
have the patient cover the mouth/nose with tissue when coughing.
- Oxygen
delivery with a non-rebreather face mask may be used to provide oxygen
support during transport. If needed, positive-pressure ventilation
should be performed using a resuscitation bag-valve mask, preferably
one equipped to provide HEPA or equivalent filtration of expired air.
- If
a patient has been mechanically ventilated before transport, HEPA or
equivalent filtration of airflow exhaust should be available. (EMS
organizations should consult their ventilator equipment manufacturer
to confirm appropriate filtration capability and the effect of filtration
on positive-pressure ventilation.)
- Cough-generating
procedures (e.g., mechanical ventilation, nebulizer treatment) should
be avoided during prehospital care.
B. Personal
Protective Equipment
Objective: Ensure the safety of prehospital care providers
who transport patients with known or possible SARS-CoV disease.
Activities
- Prehospital
care providers who directly handle a patient with SARS-CoV disease
or who are in the compartment with the patient should wear PPE
as recommended for Standard, Contact, and AII Precautions. These
include the following:
- Disposable
isolation gown, pair of disposable patient examination gloves, eye
protection (i.e., goggles or face shield).
- Respiratory
protection (i.e., N-95 or higher-level respirator)
- Personnel
in the driver's compartment who will have no direct patient contact
should wear an N-95 or higher-level respirator during transport.
Drivers who also provide direct patient care (e.g., moving patients
on stretchers) should wear the recommended PPE for patient contact.
This PPE, with the exception of the respirator, should be removed
and hand hygiene performed after completing patient care and before
entering driver's compartment to avoid contaminating the compartment.
Instructions on how to safely don, use, and remove PPE is being developed
and will be provided when available on CDC's
SARS website.
C. Safe
Work Practices
Objective: Ensure
safe work practices among EMS personnel to prevent transmission of
SARS-CoV.
Activities
- Avoid
touching one's face with contaminated gloves.
- Avoid
unnecessary touching of surfaces in the ambulance vehicle.
- Arrange
for the receiving facility staff to meet the patient at the ambulance
door to limit the need for EMS personnel to enter the emergency department
in contaminated PPE. (It may not be practical to change PPE before
patient transfer into the facility.) Remove and discard PPE after transferring
the patient at the receiving facility and perform hand hygiene. Treat
used disposable PPE as medical waste.
D. Clinical
Specimens
Objective: Safely
collect clinical specimens from SARS patients during transport.
Activities
- Handle
clinical specimens that must be collected during transport (e.g.,
blood gas) in accordance with standard operating procedures.
E. Post-Transport Management of the Contaminated Vehicle
Objective: Safely
clean vehicles used for transport of SARS patients to prevent SARS-CoV
transmission.
Activities
- Follow
standard operating procedures for the containment and disposal
of regulated medical waste.
- Follow
standard operating procedures for containing and reprocessing used
linen. Wear appropriate PPE when removing soiled linen from the vehicle.
Avoid shaking the linen.
- Clean
and disinfect the vehicle in accordance with standard operating procedures.
Personnel performing the cleaning should wear a disposable gown and
gloves (a respirator should not be needed) during the clean-up process;
the PPE should be discarded after use. All surfaces that may have come
in contact with the patient or materials contaminated during patient
care (e.g., stretcher, rails, control panels, floors, walls, work surfaces)
should be thoroughly cleaned and disinfected using an EPA-registered
hospital disinfectant in accordance with manufacturer's recommendations.
- Clean
and disinfect reusable patient-care equipment according to manufacturer's
instructions.
F. Follow-up of EMS Personnel
Objective: Ensure appropriate follow-up and care of
EMS personnel who transport SARS patients.
Activities
- Manage
EMS personnel who transport SARS patients as recommended for hospital
personnel (see Section IX).
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