Contra Costa Emergency Medical Services

Infectious Disease Ambulance Response Team (IDART)

Conceptual Model

Background: Recent developments associated with emerging diseases have demonstrated the challenges and difficulties of assuring all health care providers are trained, equipped and competent in protocols that rarely needed but have the potential for tremendous harm if not managed effectively. Organizations1 expert in the management of emerging highly infectious disease understand that high risk, low frequency patient(s) require specialized, highly competent medical transportation teams to effectively protect patients, workforce and the community at large. The recent events associated with Ebola patients in the United States require the Contra Costa EMS System to respond by working with 9-1-1 emergency ambulance providers to create a new strategic asset. This new strategic asset will be called the Infectious Disease Ambulance Response Team (IDART) and will be capable of managing a potential or confirmed infectious scene much like a HazMat team would respond and manage the scene of toxic spill.

Goal: Provide a strategic ambulance asset supported by appropriate medical oversight to the medical health community facing the challenges of managing emerging infectious diseases.

Objectives:

1. To provide reliable specialized emergency medical transportation resource for patients with suspected and confirmed cases of known and emerging infectious diseases.

2. Assure the highest level of competency in EMS personnel responsible for the medical transportation of suspect or confirmed disease that warrants activation of IDART.

3. Reduce risk by reducing the number of first responders and non-IDART ambulance personnel needed to respond and manage a suspect or confirmed patient with infectious disease.

4. The IDART would be periodically evaluated and could be stood up or down during periods of high or low threat much as ambulance strike teams are used in the present system

1 Emory University Center, University of Nebraska Medical Center

10/16/2014 Pat Frost v1 5. IDART personnel would be recruited to serve on a dedicated elite team of prehospital professionals qualified to effectively manage high risk infectious disease medical transportation.

Concept of Operations: Efforts to support increase awareness and appropriate use of PPE as part of the normal EMS System workflow. However these measures may not be sufficient. Lessons learned from recent experience with Ebola have demonstrated that it is difficult to expect that expert PPE use among health care providers. The is especially true in the settings EMS personnel are force to work in which are unpredictable unlike the hospital setting that is more controlled.

The expectation that all providers in all medical settings can achieve a uniform level of technical expertise in the management of patients with a potentially highly infectious disease is unrealistic. Given that these diseases may have prolonged incubation periods complicate and confuse providers as to what level of PPE is really necessary during patient contact. In addition emerging disease are known to “evolve” and “change” and it is difficult to assure timely up to date education and training when there is minimal infrastructure in many EMS systems to support that function. The fact that EMS may come in contact patients at any point of the disease process requires a more strategic approach.

The ambulance strike team rapid response model provides an appropriate concept of operations. This approach would provide a small but highly trained team of EMS providers (paramedics and EMTs) skilled in PPE, isolation and safe medical transport of at risk patients creates an important and effective asset for the community while reducing risk within the emergency medical and med/health system. The asset would accessible 24/7 365 to respond to all settings for patients with suspect or confirmed conditions known to be highly infectious. An IDART unit could be activated in the following ways:

1. If during a 911 call the dispatcher learns of a possible suspect case e.g. caller reports risk factors of Ebola the unit would be deployed. Fire First responders would not be deployed to reduce potential for exposure and risk.

2. If during a 911 call the dispatcher learns from an ambulatory health care setting of a suspect case the unit will be deployed. Fire First responders would not be deployed to reduce potential for exposure and risk.

3. If on scene either first responders or first on scene emergency ambulance learn of a possible suspect case on initial screening the IDART unit will be deployed. Fire First responders would not be deployed to reduce potential for exposure and risk.

10/16/2014 Pat Frost v1 4. Response to landing zone for air to ground transfer of suspect patient to a receiving facility

5. Response to a hospital facility for planned or urgent intrafacility transfer of patients to receiving center.

6. IDART response times may be greater in some cases however control of the environment to reduce spread of the disease and protection of the workforce in are the highest priorities when responding to these events.

Participation: All 911 emergency ambulance providers in Contra Costa will be invited to participate in this voluntary program with an ideal minimum configuration of 3 AMR units (1 for East, West and Central County), 1 for Moraga Orinda Fire Protection District and 1 for San Ramon Fire Protection District

Plan: CCEMS in coordination with CCHS Public Health and the emergency ambulance providers will develop the program. The program oversight will be the responsibility of CCEMS Medical Director in close coordination with CCHS Public Health. Each ambulance provider will determine how best to integrate the units during down time into their normal 911 workflow.

Competency Based Training:

1. Overview of Emerging Infectious Disease, Mechanisms of transmission and principles for exposure risk.

2. Appropriate medical management of the patient during transport including mechanisms to limit patient contact to reduce exposure and potential for inoculation.

3. Instruction and competency testing in all levels of PPE both standard and extensive PPE including PAPR’s and respirators

4. Extensive competency in (donning and doffing with buddy) at all times

5. Isolation procedures including draping of the inside of the ambulance

6. Hospital early alert and notification procedures

7. Procedures for patient handoff for each receiving in county receiving facility

8. Procedures for decontamination of ambulance, equipment and personnel post transportation

9. Procedures for disposal, sterilization and cleaning of contaminated materials and provider clothing.

10/16/2014 Pat Frost v1 10. Protocols for reporting of accidental breach of PPE, exposure or inoculation

Next Steps:

1. Do not reinvent the wheel. Use lessons learned from experienced entities.

2. Develop timeline for implementation.

3. Task AMR for National Protocols and Technical Expertise (AMR is one of the ambulance providers in Texas dealing with these events and has transported these patients via IFT).

4. Contract Nebraska for their PPE transport protocols including equipment, draping of ambulances prior to patient transport and decontamination.

5. Establish competency based training curriculum with periodic refreshers (quarterly).

6. Establish activation protocols and educate EMS System to processes

7. Address and resolve any and all administrative issues to support the sustainability of the program.

8. Develop a plan for appropriate medical oversight with Public Health and participating ambulance providers.

9. Educate the first responders and non-IDART on the resource.

10. Identify equipment gaps and processes and effectively address in cooperation with Public Health and participating transport providers.

10/16/2014 Pat Frost v1