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UNITED STATES
DEPARTMENT OF LABOR

This section provides guidance for workers and employers involved in providing emergency services such as emergency medical services (EMS) and medical transport, fire and rescue, and law enforcement (other than border protection officers, who are specifically discussed below). This guidance supplements the general interim guidance for workers and employers of workers at increased risk of occupational exposure to SARS-CoV-2.

Employers should remain alert of changing outbreak conditions, including as they relate to community spread of the virus and testing availability, and implement infection prevention measures accordingly. As states or regions satisfy the gating criteria to progress through the phases of the guidelines for Opening up America Again, employers will likely be able to adapt this guidance to better suit evolving risk levels and necessary control measures in their workplaces.

EMS and medical transportation providers, firefighters, and law enforcement officers are on the front lines for dealing with individuals with suspected or confirmed COVID-19.

Employers should assess the hazards to which their workers may be exposed; evaluate the risk of exposure; and select, implement, and ensure workers use controls to prevent exposure. The table below provides examples of emergency response work tasks associated with the exposure risk levels in OSHA's occupational exposure risk pyramid, which may serve as a guide to employers in this sector.

Examples of emergency response tasks associated with exposure risk levels

Typically, emergency response workers are already familiar with safe work practices, the utilization of PPE, and standard precautions in preventing the transmission of infectious diseases, including for body substance isolation.

However, given the ongoing spread of COVID-19, employers and workers should take additional precautions by employing a combination of engineering and administrative controls, safe work practices, and PPE. Workers and employers involved in EMS or other medical transport operations will likely need to adapt guidelines from the guidance for healthcare workers and employees to the mobile work environment. That may mean relying on PPE (e.g., respirators, gloves, eye protection) to protect workers when the use of Airborne Infection Isolation Rooms (AIIRs) or other isolation mechanisms are not practical and when staff have close contact with suspected or confirmed COVID-19 patients in transit.

Engineering Controls

During the transport of potentially infectious individuals, use physical barriers and airflow controls to separate workers from individuals being transported.

• In ambulances:
  • Isolate the ambulance driver from the patient compartment and keep pass-through doors and windows tightly shut.
    • When possible, use vehicles that have isolated driver and patient compartments that can provide separate ventilation to each area.
      • Ensure the door/window between these compartments is closed before bringing the patient on board.
      • During transport, vehicle ventilation in both compartments should be on non-recirculated mode to maximize air changes that reduce potentially infectious particles in 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 air changes per hour (ACH).
    • If a vehicle without an isolated driver compartment and ventilation must be used, open the outside air vents in the driver area and turn on the rear exhaust ventilation, if equipped, fans to the highest setting. This will create a negative pressure gradient in the patient area.
• In law enforcement vehicles:
  • When possible, transport patients in vehicles equipped with plastic shields to isolate the driver (e.g., front seat) from the passenger compartment (e.g., back seat).

Administrative Controls

When preparing for and responding to patients with suspected or confirmed COVID-19, close coordination and effective communications are important among 911 Public Safety Answering Points (PSAPs). PSAPs or Emergency Medical Dispatch (EMD) centers (as appropriate) should question callers and determine the possibility that this call concerns a person who may have signs or symptoms and risk factors for COVID-19. If PSAP call takers/dispatchers are advised that the patient is suspected of having COVID-19, emergency responders should put on appropriate PPE, as discussed below, before entering the scene.

Emergency responders should consider the signs, symptoms, and risk factors of COVID-19 when interacting with potentially infectious members of the public.

During the transport of individuals in:

• Ambulances:
  • Limit the number of providers in the patient compartment to essential personnel to minimize possible worker exposures.
  • Family members and other contacts of patients with suspected COVID-19 should not ride in the transport vehicle, if possible. If riding in the transport vehicle, they should wear facemasks.
• Law enforcement vehicles:
  • Limit the number of officers in the vehicle to the minimum number required to safely manage individuals being transported and to minimize possible worker exposures.

Communicate with receiving facilities, including hospitals or jails, about potentially infectious individuals, including those experiencing signs and/or symptoms consistent with COVID-19 in advance of arrival so that receiving staff can take appropriate precautions.

Follow routine procedures for a transfer of transported individuals to the receiving facility (e.g., wheel the patient directly into an examination room). Follow protocols established by the jurisdiction's supervisory medical authority.

Employers should train and retrain workers on how to follow established protocols.

Safe Work Practices

Avoid unnecessary close (i.e., within 6 feet) or physical (i.e., touching) contact with members of the general public and especially those who are experiencing signs and/or symptoms consistent with COVID-19.

Perform as many tasks as possible in areas away from individuals with suspected or confirmed COVID-19 (e.g., do not remain in an ambulance, police car, or other vehicles with a potentially infectious person while performing administrative functions that could be done outside of the vehicle).

Use caution when handling needles or other sharps, and dispose of contaminated sharps in puncture-proof, labeled, closable sharps containers that comply with OSHA's Bloodborne Pathogens standard (29 CFR 1910.1030).

After transporting the patient, leave the rear doors of the transport vehicle open to allow for sufficient air changes to remove potentially infectious particles. The time to complete the transfer of the patient to the receiving facility and complete all documentation should provide sufficient air changes.

Follow safe work practices for cleaning and disinfection, including for vehicles, equipment, and other supplies:

• Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly, to include the provision of adequate ventilation when chemicals are in use. Doors should remain open when cleaning vehicles.
• Clean and disinfect the vehicle following standard operating procedures. 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-grade disinfectant in accordance with the product label.
• Clean and disinfect reusable patient-care equipment before use on another patient, according to the manufacturer's instructions. Medical equipment (e.g., stethoscopes, blood pressure cuffs) making patient contact should be disposable or cleaned and disinfected before use on another patient.
• Although disposable flexible restraints (such as zip-ties) are preferable, restraints such as handcuffs and shackles should be disinfected before being used on another person. Clean and disinfect duty belt and gear before reuse using a household cleaning spray or wipe, according to the product label.

Follow standard operating procedures for the containment and disposal of used PPE and regulated medical waste. See the Solid Waste and Wastewater Management Workers and Employers section, below, for additional information about the management of various waste streams that may be generated during the care and transport of potentially infectious individuals.

Follow standard operating procedures for containing and laundering used linen. Avoid shaking the linen.

Keep a complete change of clothes/uniform at the duty station, in case the clothes being worn become contaminated and need to be bagged for cleaning/disinfection. Avoid shaking the clothes. Follow standard operating procedures for laundering contaminated work clothing, including as described in the PPE Considerations section of the general guidance for workers and employers of workers at increased risk for occupational exposure.

Workers should avoid touching their faces, including their eyes, noses, and mouths, particularly until after they have thoroughly washed their hands upon completing work and/or removing PPE.

Personal Protective Equipment

Emergency responders must use proper PPE when exposed to a patient with suspected or confirmed COVID-19 or other sources of SARS-CoV-2 (See OSHA's PPE standards at 29 CFR 1910 Subpart I).

Personal protective equipment ensembles may vary depending on workers' job tasks, which may change frequently throughout the work shift. For many tasks, including those involving contact with the general public for whom there is no reason to suspect COVID-19, disposable gloves may be sufficient. When emergency responders have exposure to sick patients who are suspected of or known to have COVID-19, including individuals experiencing signs/symptoms consistent with COVID-19, they should wear, at a minimum:

• Gloves
• Gowns
• Eye/face protection (e.g., goggles, face shield)
• Face masks

A NIOSH-certified disposable N95 filtering facepiece respirator or better, instead of a facemask, should be worn in addition to the other PPE described above, for emergency responders present for or performing aerosol-generating procedures, including cardiopulmonary resuscitation (CPR).

Drivers, if providing direct patient care (e.g., moving suspected or confirmed COVID-19 patients onto stretchers), should wear all recommended PPE. After completing patient care and before entering an isolated driver's compartment, the driver should remove and dispose of PPE and perform hand hygiene to avoid soiling the compartment. If the transport vehicle does not have an isolated driver's compartment, the driver should remove the face shield or goggles, gown and gloves and perform hand hygiene (i.e., wash hands with soap and water for at least 20 seconds, if possible, or use an alcohol-based hand sanitizer with at least 60% alcohol). A respirator or facemask should continue to be used during transport.

On arrival, after releasing a transported person to the destination facility, emergency responders should remove and discard PPE and perform hand hygiene (i.e., wash hands with soap and water for at least 20 seconds, if possible, or use an alcohol-based hand sanitizer with at least 60% alcohol). Used PPE should be discarded in accordance with routine procedures.

Additional Considerations for Aerosol-Generating Procedures

• If possible, consult with medical control before performing aerosol-generating procedures for specific guidance.
• Emergency responders should exercise caution if an aerosol-generating procedure (e.g., bag valve mask (BVM) ventilation, oropharyngeal suctioning, endotracheal intubation, nebulizer treatment, continuous positive airway pressure (CPAP), biphasic positive airway pressure (BIPAP), or resuscitation involving emergency intubation or cardiopulmonary resuscitation (CPR)) is necessary.
  • BVMs, and other ventilatory equipment, should be equipped with HEPA filtration to filter expired air.
  • EMS organizations should consult their ventilator equipment manufacturer to confirm appropriate filtration capability and the effect of filtration on positive-pressure ventilation.
• If possible, the rear doors of the transport vehicle should be opened and the HVAC system should be activated during aerosol-generating procedures. This should be done away from pedestrian traffic.

Further information

When preparing for and responding to patients with confirmed or possible COVID-19, close coordination and effective communications are important among 911 PSAPs, commonly known as 911 call centers, the Emergency Medical Services (EMS) system, healthcare facilities, and the public health system. The CDC provides recommendations for PSAP coordination in its Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for 2019-nCoV in the United States.

The CDC also provides information for law enforcement personnel in its What Law Enforcement Personnel Need to Know about Coronavirus Disease 2019 guidance.