As fire and EMS leaders learn more about the coronavirus epidemic and what it will mean for their agencies, one thing is clear: “We’re in this for the long haul.”
That’s how John Sinclair, Chair of the Coronavirus Task Force for the International Association of Fire Chiefs, opened the association’s second webinar on COVID-19 yesterday (read key takeaways from the first webinar here). “This is a long-term event, and we’re going to have to look at this from the perspective we would for any other long-term event—take a look at your ICS functions,” he says.
Other speakers on the event echoed this outlook, weighing in on PPE guidance, strain on the EMS system, concerns for fire/EMS personnel and more.
What’s to Come
Although much of what we hear about COVID-19 is how different it is and therefore how unprepared we are as a society to battle it, the IAFC leaders underscored it’s not that difficult to predict some of the near-term effects.
Dr. James Augustine, MD, FACEP, outlined several trends departments in the hardest-hit states have started to experience in the past week—which provide valuable clues for what other departments will face:
- COVID-19-positive patients needing care in their homes. “We are moving into a phase where the positive patients may be at home with known disease and if so, we are going to get calls that these patients have a fever, they’re in distress, they need an airway intervention, they need EMS and rapid transport, “ Augustine says. For this reason it’s critical 9-1-1 calltakers ask about the possibility of those in the house having tested positive and if so, advise responding crews “respiratory protection indicated.” As the number of these calls rise, so too will the pressure on EMS.
- Increase in lift-assist calls. The IAFC is reporting a rapid increase in the last week in lift-assist calls to EMS as home health agencies have difficulty fulfilling their responsibilities. As Augustine notes, this trend has been observed during other disasters.
- Nursing homes and assisted living facilities showing stress. Similar to home health, facilities caring for older and/or disabled adults are showing signs of strain, resulting in more demands for EMS. Augustine notes the importance of working with such facilities to designate a transition area, preferably outside, where personnel can assess the patient—this not only helps protect fire/EMS personnel from exposure, but reduces the chance of transmission into the facility.
- Modifications of airway intervention/CPR/termination protocols. Augustine notes a growing need to share information about modifying airway interventions, such as moving toward more use of supraglottic airway devices and away from doing endotracheal intubation, which is a much higher risk procedure. As EMS starts to see sicker and sicker patients, it may be necessary to modify protocols around CPR and termination of resuscitation efforts to reduce risk to providers. “An unfortunate statistic that we’ve known for many years is that patients who have a cardiac arrest as a result of an infectious disease have very, very poor outcomes,” he says.
- “Failure” patterns. It’s common for incident commanders to identify possible points of failure in operations. With COVID-19, Augustine believes the failure points are obvious: “The first failures are going to come in the ICUs. And then from the ICU the failures will move into the emergency departments and then out to the community. That’s what happened in Italy and in other places,” he says. “It’s very important for you as fire and EMS leaders to make sure you keep in touch with the hospitals and are listening as they begin to stretch their resources,” because that will be an important predictor of what your agency will be hit with soon after.
Managing PPE Shortages
Much has been made of nationwide PPE shortages and this remains a chief concern for fire/EMS agencies. “The strategy now in personal protective equipment is conservation and moving toward re-use of the equipment,” Augustine says.
It’s not enough to know six providers were on a call with a high-risk patient, but rather “which ones came within 6 feet of the patient and what PPE were they wearing?”
Conservation strategies include minimizing the number of personnel who come into contact—within a 6-foot radius—with the patient. “Typically we only need to put one person within that 6-foot radius to begin with,” Augustine says. That provider should wear an N95 mask or surgical mask, disposable gloves and goggles or a face shield, as well as a gown or coveralls if the patient is coughing or sneezing.
When treating a high-risk patient, the most important piece of PPE is a mask on the patient—but even then, providers can get creative to prolong PPE supplies. “Immediately provide a mask to the patient—that can be any form of mask, including a cloth mask,” Augustine says. The use of nebulizers, which has come under special scrutiny in the last week or so, should be considered a high-risk activity. Again, Augustine suggests improvising. “Cover the patient’s clothes with one of their own bedsheets” during the procedure, he advises—just remember to leave the sheet at the home after the treatment is over.
PPE shortages necessarily provoke discussion of reuse, and the media has seized on anecdotal reports of healthcare providers reusing masks, gowns and other PPE. Coronavirus Task Force Member and private sector representative Amit Kapoor notes guidance is expected soon on the reuse of PPE. “This is a very touchy subject,” he says. “For now, follow CDC guidance. There’s a lot of different methods of trying to disinfect N95 masks. We don’t know whether that’s going to work—there’s a test process that NIOSH needs to apply.” Guidance will also be issued soon on bunker gear decontamination.
Ideally, reuse will remain a worst-case scenario. The IAFC is working closely with government partners and the private sector to try to ease the equipment shortage. Two key points for fire chiefs here:
- Know your burn rate. “We’re seeing this as a major issue across states where there’s a high number of patients,” Kapoor says. “Look into what your burn rate is” for key PPE and then “try to control it.”
- Work with state officials to ensure fire/EMS gets first-priority classification for PPE. Sinclair says the IAFC has ensured that fire/EMS agencies are classified Priority 1 under the federal system, “but each state has its own classification. It’s vital that you have this discussion at the state level.”
As the number and severity of calls continues to increase, fire/EMS leaders must track key information that will be essential for continuing operations over the “long haul” Sinclair refers to.
First and foremost, all fire/EMS agencies should be using an incident tracking process “so you know who was exposed and when,” Augustine says. Detail here is important—for example, it’s not enough to know six providers were on a call with a high-risk patient, but rather “which ones came within 6 feet of the patient and what PPE were they wearing?” Such data will be essential to determining quarantine and isolation steps.
As EMS starts to see sicker and sicker patients, it may be necessary to modify protocols around CPR and termination of resuscitation efforts to reduce risk to providers.
Augustine also recommends departments develop a 14-day personal health form and ask personnel twice a day to use it to monitor their health, describe symptoms and record their temperature.
Another critical area of data is expenditure tracking. IAFC Director of Government Relations and Policy Ken LaSala notes FEMA is now the lead federal agency for COVID-19 response, working with Health and Human Services. That, he says, should hopefully make the process of getting help a little clearer.
“FEMA has been sending teams to regional offices, so I’d recommend touching base with your regional FEMA administrator,” he says. “COVID-19 expenses can be reimbursed through the public assistance program—FEMA has guidance for that. FEMA has said they can reimburse things like overtime and backfill as well as materials that have been used and even apparatus transport costs.”
The catch? You need to be accurately tracking and reporting your expenses to secure reimbursement. “One of the things I’d urge you to do immediately is to designate someone within your organization and start tracking the financial impact,” Sinclair notes. Reimbursement is available, but “you’re going to have to justify your expenses.”
The IAFC plans to hold weekly COVID-19 webinars on Monday afternoons. Check out their site for additional information.
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