Updated NYS Advisory Documents
A few notifications from your new System Medical Director Dr. Jason Winslow. (This does not change any existing protocol.)
To All Suffolk County EMS Providers;
First, for clarification, any patient who has an influenza-like-illness including fever, cough, and respiratory difficulty should be considered as a potential COVID-19 exposure. This patient information may be obtained by the nature of the call dispatch or by the initial patient encounter by EMS. Some patients may have several complaints and the nature of illness may be difficult to obtain. For all patients who have an influenza-like-illness, the responding EMS providers should follow the recommended guidelines for proper PPE donning and doffing as previously outlined (N95 mask, gloves, gowns, goggles/face shields) to protect the provider from potential contact with a patient's respiratory secretions.
Second, responding EMS providers should minimize the number of EMS providers that make contact with, and transport, patients to the hospital to try to decrease the number of EMS providers potentially exposed on each call.
Third, please be advised that the following respiratory procedures may represent an increased infectious risk to the EMS providers by aerosolizing patient secretions: bag-valve-mask assisted ventilations; endotracheal intubation and King Airway/supraglottic airway; endotracheal suctioning; CPAP; non-rebreather face mask; and nebulization of medications. Patients who are in such respiratory distress that they require the above procedures, EMS responders should don proper PPE. Please be aware that a patient with respiratory difficulty/shortness of breath who is NOT in respiratory distress may have a nasal cannula placed on the patient for supplemental oxygen administration and a surgical mask (not N95 mask) to be placed over the patients mouth and nose in an effort to try to protect the EMS provider from exposure to the patient's respiratory secretions.
Fourth, all equipment (and that includes any intranasal medication administration such as naloxone) that has been contaminated by the patient's respiratory secretions should be considered a potential infectious source and handled with gloves and disposed of in a red bag for waste disposal at the receiving hospital.
Last, please notify the receiving hospital in advance if you are transporting a patient who is displaying fever, cough and influenza-like-illness symptoms so that they may be ready to accept your patient. This may decrease the time needed to get the responding EMS agency back in service and EMS may be directed to another entrance.
Thank you to all of our EMS providers in Suffolk County for working through this challenging event. The Suffolk REMSCO Website has up-to-date information from state and federal resources on this illness under the Infectious Diseases tab on the upper left side.
Please be assured we are working very diligently to ensure the safety of all EMS personnel in this pandemic.
Ebola Virus Disease Update - December 24, 2015
The purpose of this situational awareness bulletin is to keep you informed on the latest information regarding the ongoing Ebola Virus Disease (EVD) epidemic and the NY State Health Commissioner’s Order, issued October 16, 2014, as it affects ambulance services and others in health care. The size and scope of this epidemic, along with the prevalence of other emerging infectious diseases that have appeared in the United States through travel, illustrate the need for constant vigilance and adherence to worker safety standards for protection against bloodborne and airborne pathogens. Effective December 22, 2015 enhanced entry screening and ports of entry into the United States from the West African Coast have also been discontinued from all locations with an origination or pass through from Guinea, where travelers will still be admitted through either J.F. Kennedy Airport, Washington Dulles and Atlanta, and no longer through Chicago O’Hare or Newark NJ.
In recognition of the declining numbers of EVD cases in West Africa and concurrent decline in risk levels, NYSDOH now recommends that:
· ambulance services conduct PPE training in donning and doffing upon work assignment as an ambulance worker, and at least every twelve (12) months in a setting similar to where a patient would be treated;
· PPE training should consist of actual donning and doffing of PPE in the presence of a trained observer and should not be replaced by a video, lecture, or demonstration mechanism;
· ambulance services may limit the number of staff expected to have contact with a patient with confirmed EVD, or Person Under Investigation (PUI) for EVD, designated to receive this training at the discretion of the ambulance service; and
· the use of “regional ambulance response” limited to those services formally trained and designated as such, remains acceptable. In such cases, where a regional Ebola-ready ambulance service has a higher incidence of likelihood of contact with a patient with EVD or a PUI for EVD, the recommendation is PPE training in donning and doffing upon work assignment as an ambulance worker, and at least every six (6) months in a setting similar to where a patient would be treated.
· take advantage of a more robust supply chain and purchase PPE while it is available. PPE suitable for Ebola is also suitable for a variety of other bloodborne/airborne pathogens that an EMS provider may encounter;
· continue to apply due regard when selecting PPE for protection against blood or other potentially infectious materials on any patient;
· continue to maintain heightened awareness for clues in dispatch determinants and patient signs/symptoms;
· continue to include international travel history as part of the patient assessment; and
· continue to provide early pre-arrival notification to hospitals of any patient presenting with influenza-like illness, fever, cough, rash.
Influenza 2015 - 2016 - November 18, 2015 Update
Influenza – As we enter the 2015-2016 influenza season, local, state and federal health officials have begun monitoring the influenza progression, which at this time is sporadic. All EMS Providers are strongly encouraged to receive seasonal influenza vaccine. EMS providers should remain vigilant when approaching patients with influenza-like illness (ILI). EMS providers should take respiratory protection measures, universal precautions, and follow infection control and decontamination procedures to break the chain of infection. Dispatch centers have commenced using the suffix “FC” designation, indicating a call with the signs and/or symptoms of “fever/cough,” indicative of the potential for contact with a patient with flu. It is imperative that ambulance services communicate with FRES/MedCom on the assigned 800 MHz talk group to ensure exchange of information. Agencies not dispatched by FRES should consult with local PSAP to learn of local dispatch policy. It is recommended that routine cleaning of surface areas in the ambulance patient care compartment and driver’s compartment be regularly cleaned to avoid the spread of infection among providers. Please refer to the New York State EMS Policy Statement 13-05 Respiratory Disease Precautions.
Ebola Preparedness Update November 17, 2015
Since our last update, about a year ago, media coverage of Ebola Virus Disease (EVD) has significantly decreased. However, maintaining vigilance for patients with Ebola or any other infectious disease and maintaining competency with proper infection control procedure including the use of appropriate personal protective equipment is ongoing. Throughout the past year, Suffolk County has had a steady stream of Low Risk But Not Zero Risk travelers in the county, under 21 day health surveillance with indoctrination to the county’s 911 and emergency transport plan. In these cases, notification to the agencies in the area of residence has been made, with that policy continuing into the future. The suffix “ID” for Infectious Disease, added to six (6) specific determinant codes (1, 6, 10, 18, 21, 26) if the signs/symptoms/travel history indicate a suspect Ebola case, remains in effect.
This past week, CDC communicated changes to the status of Sierra Leone as an Ebola-affected country, much like they did with Mali and Liberia in the past. Travelers from Sierra Leone without enhanced risk factors will no longer require active 21-day monitoring. As a result of this change, travelers from Sierra Leone will no longer need to be actively monitored by or be in daily contact with the health department. Similar changes have occurred recently regarding Travelers from Sierra Leone will continue to be funneled through one of five enhanced-screening airports, encouraged to watch their health for 21 days, and contact their local health department if they develop symptoms consistent with Ebola.
We will now only be monitoring individuals with travel from Guinea from this point forward, with no change in entry or monitoring process. Per State DOH, the Commissioner’s Orders from last October are still in effect. Regional response with agencies that have declared themselves “Ebola-ready” through the EMS Division will continue as needed, in accordance with the still-active Interim Transportation Policy.
At the recommendation of the CDC and the NYSDOH, and in consultation with Health Commissioner Dr. Tomarken, we are adding the West African Country “Mali” to the list of hot zone countries (Sierra Leone, Liberia, Guinea) relative to travel history when evaluating Ebola risks. This is consistent with federally-performed travel screening enhancements at entry points here in the United States. As such, individuals arriving from Mali will be subject to 21-day monitoring and movement protocols, in coordination with state and local public health authorities.
Currently, Ebola Virus Disease is NOT widespread in Mali and we will be made aware of any travelers from the hot zone to Suffolk County, however, it is the prudent course of action to take to ensure we are consistent with state and federal agencies in addressing Ebola risks.
Reminder that all ambulance services are required to comply with the NYSDOH Health Commissioner’s Order for PPE donning/doffing competency, and to identify and register two (2) Points of Contact on the NYSDOH Health Commerce Site, under the general guidance previously posted.
Reminder to submit copies of your completed EMS Checklists documenting your agency’s compliance with meeting the requirements of the “Detection” and “Protection” phases of Ebola preparedness to the EMS Division Office, and ensure that you retain a copy of this checklist, along with your member-specific initial and on-going PPE competency checklists, at the agency level.
Ebola Preparedness Update November 13, 2014
We have been asked by the NYSDOH to reach out to all ambulance services in the region to advise that despite the lack of media attention to Ebola, and the recent recovery of all patients with Ebola in the United States, the DOH expectation is that the Commissioner’s Health order remains in effect. Ambulance and first response services are still required to identify two (2) 24/7 Points of Contact (POC) on the Health Commerce System (HCS) website. Please click here for the directions. For agencies that have already completed the registration process, please disregard.
Once registration is complete, the POC person will need to send an email to Tom Lateulere at firstname.lastname@example.org attaching a copy of their driver's license and their user ID from the registration site. The registration process is not complete until the EMS Division authorizes each POC to have access to the HCS website.
In addition, the DOH has re-transmitted the Health Order to all ambulance and first response services via U.S. Mail, with the expectation that EMS providers continue to demonstrate initial, and ongoing competency with the donning and doffing of Personal Protective Equipment (PPE), and that agencies document this competency as part of their training records. The EMS Division has training classes scheduled. Please go to CME Courses then Non Core for classes.
Finally, the EMS Checklist should be used by all agencies to document agency preparations for ensuring that providers are competent in the detection and protection phases of responding to an infectious disease call.
Suffolk County has developed an interim policy that governs the medical transportation of suspected patients infected with the Ebola Virus Disease ("EVD") to a medical facility for medical treatment. The purpose of this policy is to minimize the number of first responders, first response vehicles and medical facilities potentially exposed to EVD, and to develop a medical transportation policy that is harmonious with the New York State Department of Health’s designation that Stony Brook University Hospital ("SBUH") shall be the treatment hospital for suspected patients infected with EVD.
Current State and Federal policy requires that the Suffolk County Department of Health Services be notified when individuals with a travel history from West Africa return home to Suffolk County, where they will be monitored for the development of signs and symptoms indicative of Ebola. The onset of symptoms within 21 days of arrival, coupled with the confirmed travel history, places these individuals at high risk. We expect that at any given time, the 911 system could receive a call from someone not known to the system that displays signs / symptoms of EVD and the 911 system may in fact be activated and transport a suspect patient to the Emergency Department, so preparedness efforts must continue at the local level, and response should be undertaken in accordance with previous guidance document regarding EMS response to a suspected EVD patient.
Extensive regional planning continues in effort to ensure appropriate links between the public, the 911 system, ambulance services, hospitals, law enforcement agencies, the local health department, local emergency management, the state health department and the CDC. Effective 0900 hours Monday, October 27, 2014, the Suffolk County FRES Communications PSAP will institute the Emerging Infectious Disease Surveillance Tool, attached to the Computer Aided Dispatch System and the FirstWatch Biosurveillance Software. This tool facilitates specific questions to collect information about signs and symptoms, as well as travel history and close contact with traveler history in effort to rapidly identify suspect Ebola cases at time of 911 dispatch. The suffix “ID” for Infectious disease, will be added to six (6) specific determinant codes (1, 6, 10, 18, 21, 26) if the signs/symptoms/travel history indicate a suspect Ebola case. “ID” is specific to Ebola-like presentations. The suffix “FC” for fever and cough will still be used as we enter seasonal influenza season. It is imperative that ambulance services communicate with FRES/MedCom on the assigned 800 MHz talk group to ensure exchange of information. The other PSAPs in the county have indicated their desire to implement this procedure as well; agencies not dispatched by FRES should consult with your local PSAP for the implementation time frame.
We are aware of the shortage of PPE available to ambulance services. If your agency has been unsuccessful in obtaining PPE, please contact the EMS Division and we will work with you to secure PPE from FRES’ cache of equipment. Remember, the Tier I WMD kits issued to all ambulance services a number of years ago are still useful, provided they have been properly maintained. If you encounter an ID case and you do not have the appropriate PPE, contact FRES, or your local PSAP, to request activation of the closest “suit rescue” trailer.
Ambulance services are expected to follow response SOPs for response and decontamination of ambulances, click here, for the current response guidance document. While these calls are not classified as true “hazmat” calls, we are working with FRES to develop a Decon Task Force that can be mobilized to provide assistance. The Task Force can be activated by contacting FRES, or you’re local PSAP.
NEW INFORMATION - NY STATE COMMISSIONERS HEALTH ORDER OCTOBER 20, 2014
All EMS Providers and Agency Leaders;
The NY State DOH Acting Commissioner of Health has issued a Health Order that is applicable to all Ambulance and ALS First Response Services, hospitals, diagnostic treatment centers and other facilities regulated under the NY State Public Health Law. Please review this order by clicking here and take action immediately. The Division of EMS has posted a series of Leadership Awareness Classes for agency leadership and Donning/Doffing Personal Protective Equipment for EMS Providers Classes; these were scheduled before the Health Order was issued, so they will extend beyond the 10-day time frame referenced in the order. The intent of this is to recognize the very serious threat that Ebola puts on us, and to ensure that we protect our emergency medical response workforce. More classes will be scheduled. Click here for a listing of the Leadership Awareness Classes. Please go to CME Courses then Non Core for EMS Provider classes. In summary, the Health Order focuses on two (2) key areas. The first is ensuring that appropriate personal protective equipment is available and that EMS providers are competent in donning/doffing procedures. Two (2) cases of cross contamination occurred in the United States due to breaches in infection control protocol. This initial training is to be documented by the agency, with refreshers and repeat competency documentation performed monthly. The second is to provide contact information for two (2) key individuals in each agency that can be reached should the need arise, and to provide agency-level support for training, medical waste management and ensuring appropriate safety measures are in place at the agency level. At this time, we have learned that agencies cannot register directly with the Health Commerce System (HSC) as directed in the order. Please contact Bob Delagi, Tom Lateulere or Karl Klug via email so that we can work with you on registration. Click here for their emails.
The link below provides up-to-date information from the CDC on the tightened guidance for health care workers on PPE. Based on current OSHA recommendations in the Bloodborne Pathogen Standard, your agency should already have a training program in place; these guidelines are easily enhanced and applied. The EMS Division will make available a training program on the website shortly, stay tuned for updates. A sample checklist for documenting training can be found by clicking here. This may need to be revised based on the specific PPE available to you. Remember, the guidance is to ensure that no skin or mucous membranes are exposed.
Ebola - In follow-up to the August 11, 2014 Situational Awareness Bulletin Situational Awareness Bulletin - Ebola Outbreak, local, state and federal health officials continue to track this accelerating epidemic, which is expected to last at least the next 12-24 months. CDC has now identified the first case of Ebola in the United States, from a traveler who arrived from the affected area. This does indeed accelerate our risk in the United States. Current recommendations for identifying cases and protecting EMS providers and hospital personnel contained in the situational awareness bulletin above remain in effect. The New York State Department of Health, together with Federal Health Officials, has distributed additional guidance documents to the EMS community. EMS providers and ambulance service managers are strongly encouraged to review this documentation. The focus of this documentation is to remind us all of the need for universal precautions to protect us against exposure to blood and other potentially infectious body fluids, and to ensure respiratory protection by a fit-tested N95 face mask. EMS providers and ambulance services managers should take this opportunity to review, update and train on agency specific exposure control and respiratory protection plans. Please click on the links below to review New York State EMS Policy Statement 13-05 and the recommended EMS checklist.
Enterovirus D68 (EV-D68) – This virus, first identified in the United States in 1962, but one that has not been commonly reported, causes mild to severe respiratory symptoms, and may include fever, runny nose, sneezing, coughing, and muscle aches. As of September 20, 2014, 27 states, including New York are reporting confirmed cases. The virus is contained in an infected patient’s respiratory secretions, saliva, nasal mucus and sputum. Much like influenza, this virus is spread person-to-person when an infected person coughs, sneezes into an EMS providers unprotected breathing space or when the virus is shed to surface areas that are not regularly cleaned. In general, infants, children and teenagers are most at-risk for contracting EV-D68, with some states reporting an increased prevalence in children with asthma. There is no vaccine, anti-viral, or specific treatment for patients with respiratory illness caused by EV-D68. Remain vigilant when encountering any patient with respiratory symptoms, don fit-tested N95 mask, goggles and gloves when necessary, and decontaminate ambulance surfaces and durable medical equipment frequently. Remember to provide pre-arrival notification to receiving hospitals as soon as possible, and expect that your entry into the hospital may be altered.