Bureau of EMS & Trauma System: EMS Guidance Update COVID-19 - April 2, 2020

April 2, 2020 - EMS Guidance Update COVID-19

 

State Disaster Medical Advisory Council

EMS System at Contingency Status and should expect to change to Crisis Status in the near future.

 

We are now a month into full preparation mode for COVID-19 here in Arizona, so we wanted to take this opportunity to review steps we have taken, are planning to take or are teed up in case they are needed.

 

First, we wanted to share information on a topic that is very important to all EMS Providers. Late last week we were happy to see a CDC Circular that added COVID-19 to the list of reportable exposures for first responders.  Each EMS agency’s Infection Control Officer can now work with local hospitals to obtain exposure information.  This information may not have reached all healthcare facilities, so you may need to provide a copy of the circular.

 

EFFORTS TO DATE

• State Disaster Medical Advisory Committee met yesterday and approved several EMS related actions, including:
  • Implement Treat and Refer Resources for COVID-19 surge, these include a specific EMS Guideline for Care of Patients with Suspected COVID-19. 
  • All EMS agencies should implement Treat and Refer.  For the duration of this event, an application is no longer required.  
  • EMS System is now at Contingency status, expect Crisis status in the near future related to COVID-19 surge.
  • All CON holders should implement Treat and Transport to alternate sites where appropriate to alleviate demand on emergency departments.
  • Fire service EMS agencies should consider deployment strategies to increase utilization of 2-person response units for the next 60 days.
• Personal Protective Equipment: In an effort to pump as much PPE into the healthcare system as possible, ADHS requested and distributed material from the Strategic National Stockpile to the 15 county health departments and then shared the instruction application that should be used to request supplies for your agency. Because the PPE shortage is a reality that will last for the next several weeks at least, we published guidance on appropriate PPE use for EMS personnel, guidance related to the waiver for annual fit-testing and guidance on how to reduce the burn rate.  Steps to reduce the burn rate include  limiting the number of providers involved in direct patient care to essential personnel only, extending the use of PPE, and minimizing exposures. Finally, Director Christ convened the State Disaster Medical Advisory Committee who recommended changes to the use of PPE and Testing for COVID-19.
• Reducing Exposure and Maintaining a Safe Workforce during Community Spread: You know better than anyone, EMS Providers operate at the frontline in the war against COVID-19. For this reason, all EMS providers must use appropriate PPE for EVERY CALL.  Because it is possible for individuals infected by COVID-19 to pass along the infection when no symptoms are present, EMS Providers must operate with the assumption that they have had an exposure. Every EMS Agency MUST implement a daily infection monitoring system for all staff that includes temperature screening and symptom evaluation.  An EMS Provider can safely continue to work as long as they do not have symptoms of COVID-19 infection.  An EMS Provider who has had a known exposure to COVID-19 but is asymptomatic, may continue to work and may elect to wear a surgical facemask if available.  
• Reducing Barriers: On Monday, March 16, stakeholders were invited to provide guidance on regulatory relaxation that will help agencies to provide the vital services to Arizona citizens. On March 24, Director Christ executed a broad waiver of regulations recommended by our stakeholders.  If you have questions about how this waiver affects your organization, please contact one of individuals identified below.
  • Trauma Centers: Please email Noreen Adlin at Noreen.Adlin@azdhs.gov
  • Base Hospitals: Please email Brian Beard at Brian.Beard@azdhs.gov
  • EMS Training Programs: Please email Doug Crunk at Douglas.Crunk@azdhs.gov
  • Certificate of Necessity Holders: Please email Ithan Yanofsky at Ithan.Yanofsky@azdhs.gov
  • Air Ambulance Providers: Please email Taylor Pike at Taylor.Pike@azdhs.gov
  • EMT Certification: Please email Maria Dominguez at Maria.Dominguez@azdhs.gov
  • Medical Control: Please email Dr. Gail Bradley at Gail.Bradley@azdhs.gov
  • All Other Topics: Please email Terry Mullins at Terry.Mullins@azdhs.gov

 

PLANNED EFFORTS

• Resource Maximization: Since the Governor issued the moratorium on elective surgery and a stay at home order, there has been a statewide, dramatic decrease in 9-1-1 call volume, inter-facility transportation and emergency department volumes that is likely to continue until we begin to see a surge related to COVID-19 cases. The Arizona Department of Health Services has submitted a recommendation that Arizona Fire Services consider deployment strategies to increase the utilization of 2-person response units for the next 60 days to the State Disaster Medical Advisory Committee.

 

ADDITIONAL STEPS UNDER CONSIDERATION

• Clinical Guidance: We are watching other states that have experienced significant EMS surge as a result of COVID-19 infections. At this point, the evidence does not suggest that a change to Crisis Standard of Care is necessary.  The Arizona Crisis Standards of Care Plan outlines how the State Disaster Medical Advisory Committee (SDMAC) makes that determination. The Department of Health Services is able to rapidly convene the State Disaster Medical Advisory Committee if necessary to address a change in the system
• Resource Maximization: Based upon the experience in other countries, New York, Washington State and California, the Arizona Department of Health Services could implement other initiatives designed to address a local, regional and statewide COVID-19 surge including:
  • Unified Interfacility Transportation Call Center: Two factors have led the Arizona Department of Health Services to consider standing up a centralized, one-call interfacility transport center. Because hospitals in the midst of a COVID-19 surge have few resources, locating a receiving facility can be a challenge.  Additionally, Director Christ signed an enhanced surveillance requirement for every hospital to update EMResource daily.  With this resource, we believe that we can ease the burden of hospitals needing to transfer patients to a higher level of care, and to also assist in transferring patients whose condition no longer requires traditional hospital services to an alternate care center.  This will free up more beds and staff to care for more seriously ill patients.
  • Transportation Service Augmentation: The rule waiver described above helps CON holders by allowing for the use of non-traditional staff to support operations, the ability to easily back-up neighboring providers and to easily transport patients to alternate care sites. 
  • However, during a COVID-19 surge, it may be important to add transportation resources into a system. One method already exists in R.S. 36-2208 B which states “….any individual, law enforcement officer, public agency or member of a city, town, fire district or volunteer fire department ……. in terms of the existing medical situation, it is deemed not advisable to await the arrival of an ambulance, from transporting emergency medical patients to a hospital or an emergency receiving facility….”.    

If needed, A.R.S.36-2242 says that, “If the director determines that there is an immediate and urgent need for service to one or more points or within an area lacking adequate ambulance service, the director may, at his discretion and without a hearing or other proceeding, grant an ambulance service temporary authority to provide the needed service.” At this point, The Arizona Department of Health Services does not believe that circumstances exist for the Director to issue a Temporary Authority certificate of necessity.  However, we are closely monitoring the situation around the state and are prepared to take rapid action if needed.

 

We would like to close by saying that we are appreciative of the work that you and your staff are doing on behalf of the citizens of Arizona.

 

                    Sincerely,

                    Terry Mullins                                                                   
                    Bureau Chief                                                          
                    Bureau of EMS and Trauma System                       

                    Gail Bradley, M.D.
                    Medical Director
                    Bureau of EMS and Trauma System

 

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