COVID-19 Pandemic: The Role of EMS Physicians in a Community Response Effort

Abstract

The COVID-19 pandemic is a worldwide historical event that will continue to affect nearly every aspect of ordinary life, including affecting our economic, political, and healthcare eco-systems. An effective pandemic response demands a coordinated and integrated response across community healthcare stakeholders, including Public Health and Emergency Management Officials. EMS systems are in a unique position and perform an essential role on the frontlines of COVID-19, including facilitating coordination of response efforts to COVID-19 within their communities while supporting public health mitigation efforts to slow the spread of the SARS-CoV-2. EMS physicians serve their communities at a unique intersection as clinical leaders, population health experts, and advocates. This paper examines and recommends crucial roles for EMS physician leaders as communities work together in pandemic response.

Key words:

• emergency medical services
• pandemic
• public health
• COVID-19
• EMS medical director

Introduction

On Wednesday, March 11, 2020, the World Health Organization (WHO) declared the rapid-spreading SARS-CoV-2 virus, responsible for the COVID-19 outbreak, a pandemic (1). Since then, more than 37 million cases of COVID-19 have been reported in 200 countries and territories, resulting in more than 1 million deaths (2). A worldwide historical event, this pandemic has had, and will continue to have, a profound effect on our “normal.” Due to rapid community spread and poorly coordinated response, the United States has the world’s highest number of deaths from COVID-19. A severe disruption of local healthcare systems has been seen as overwhelming numbers of patients seek healthcare services beyond available system capacity.

EMS systems serve as part of a community’s medical safety-net, responding to 9-1-1 requests for service, triaging patients, and providing access to emergency medical care and transport for ill or injured persons. EMS systems are, therefore, in a unique position and perform an important role on the frontlines of COVID-19. Working together with public health and emergency management officials, EMS systems can ensure coordinated response efforts to COVID-19 within their communities while supporting public health mitigation efforts to slow the spread of the SARS-CoV-2. The breadth of EMS physician training and experience prepares the EMS physician to function effectively and integrate seamlessly into official incident management and command structures. These coordinated efforts are essential for preparedness while protecting vulnerable populations and the local healthcare system.

EMS physicians serve their communities at a distinctive intersection as clinical leaders, population health experts, and advocates for their communities. In addition to providing medical oversight to ensure EMS quality service delivery, as clinical leaders, EMS physicians offer a unique perspective of the healthcare needs of the most vulnerable persons within their communities during the COVID-19 pandemic. They serve as a resource for public officials, given their established relationships with community healthcare stakeholders, which are needed for a coordinated, community-wide response. The purpose of this paper is to examine and recommend crucial roles for EMS physician leaders as communities work together in pandemic response. Key roles include: (1) EMS system resource management, (2) clinical practice modifications, (3) public health response, (4) occupational health, and (5) advocacy.

EMS System Resource Management

EMS systems have limited resources, even in the best of times. Personnel, property, and infrastructure are, at any given point in time, fixed assets. While strategic planning efforts inform annual budgets to add staff, clinicians, and vehicles over time, EMS systems must confront the current pandemic with their current allocation of resources. Therefore, thoughtful deployment and conservation of these resources is of the utmost importance to sustain EMS system response.

The pandemic affects geographically separate EMS jurisdictions differently over time. New York has not had the same experience at the same time as North Carolina, Texas, or California, though lessons should certainly be learned and shared from one area to another as the pandemic spreads and new locales face challenges that others faced weeks ago. EMS system modifications designed to manage the pandemic must be considered in the context of point prevalence of disease in each community.

EMS system medical directors should acknowledge the dynamic nature of pandemic response with key community partners, and plan for nimble adjustments to response guidance and protocols. As disease prevalence changes within the geography of an EMS system response area, EMS physicians should consider key focus areas for EMS system resources including pandemic case identification, situational awareness for responding EMS personnel, and relationships with local health care institutions and hospital destinations in the community.

First, an EMS system must implement processes to identify responses in which COVID-19 exposure is likely or probable. Ideally, identification begins at the 9-1-1 center. Medical directors of 9-1-1 centers and Emergency Medical Dispatch (EMD) staff must work with public safety answering point (PSAP) leadership to enact early case identification. For example, 9-1-1 call takers should ask screening questions developed in coordination with medical direction to identify potential pandemic cases, as in the International Academies of Emergency Dispatch Emerging Infectious Disease Surveillance (EIDS) tool (3). Such tools can serve several purposes. Pre-alerting personnel responding to a person under investigation (PUI) allows EMS personnel to make informed decisions (ref: NCOEMS SC-2 protocol) regarding numbers of scene personnel and appropriate personal protective equipment (PPE). Screening tools also allow for retrospective tracking of possible cases in the community.

Similarly, the second key step in EMS resource management during COVID-19 is to ensure that responding EMS personnel are provided with situational awareness during a response. Depending on a community’s point prevalence, medical directors may enact “pandemic” dispatch protocols to ensure a consistent response to similar cases; these protocols allow a systematic change in standard of care for certain cases as warranted. For example, the Medical Priority Dispatch System “protocol 36” is a specific response protocol that may be implemented during an officially-declared disease outbreak (4). Use of the “36 card” or similar dispatch protocol can notify responding crews of a potential pandemic patient. Just as importantly, a pandemic dispatch protocol can change the typical non-pandemic response configuration (e.g., withhold first responders for minimal influenza-like-illness (ILI) patients), and can prioritize response only to critical patients when EMS system call volume overwhelms system resources during the height of a pandemic. Changing EMS system response standard of care in a community is not a decision that should be undertaken lightly or quickly. EMS system medical directors are encouraged to plan and network with colleagues in other areas of the country facing similar decisions. A scalable response protocol allows the system to make nimble modifications as point prevalence changes.

The third key element of EMS system resource management during the pandemic is coordination with local health care institutions and hospital destinations for EMS transports. Multiple pandemic-related responses to a health care facility (e.g., congregate living facilities, mental health institutions or specialty hospitals) should prompt further investigation and collaboration with public health colleagues. Once clusters in the community are identified, computer aided dispatch (CAD) systems may be able to “flag hotspots” or cluster facilities to ensure safe and appropriate public safety response. The Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services (HHS) has issued guidance on how covered entities may disclose protected health information (PHI) about an individual who has been infected with or exposed to COVID-19 to law enforcement, paramedics, other first responders, and public health authorities in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule (5). EMS Physician leaders should liaise with hospital physician leader counterparts to stay abreast of hospital capacities and any Emergency Department (ED) or inpatient resource strains across local health care systems. EMS medical directors should understand hospital triggers to modify hospital standards of care, and hospital medical directors should understand the same about EMS. Making coordinated decisions about community standards of care is in the best interest of patients, and these dialogues can identify needs for resource coordination or additional resources, such as mutual aid requests or construction of alternative care sites outside the walls of EDs or hospitals. EMS system resource management during the COVID-19 pandemic is about identifying cases to advise and protect personnel, surveilling prevalence trends to inform decisions about response, and coordinating with local healthcare entities to ensure awareness and shared decision making about standards of care to the extent possible. All EMS systems will not need to enact substantial changes in their management of resources all at once. Maintaining quality non-pandemic standards and practices is good for patients and clinicians alike. However, EMS system leaders should plan now for incremental step-wise changes to resource allocation, response protocols, and relationships with local health care institutions as necessary should the pandemic surge or resurge in the local community (Figure 1).

Figure 1. Example of EMS system modifications throughout the COVID-19 pandemic.

Clinical Practice Modifications

The Centers for Disease Control and Prevention (CDC) has published guidance for medical first responders, including fire services and emergency medical services, who will be caring for persons with suspected or confirmed COVID-19 infection. This guidance provides essential recommendations for infection prevention and control practices necessary to protect the workforce while caring for patients during the pandemic (6). The EMS system medical director provides clinical expertise in operationalizing these guidelines and recommendations, including the influence on clinical practice. Ensuring a coordinated donning and doffing protocol for PPE while caring for patients with suspected COVID-19, the EMS system medical director ensures the health and safety of EMS System personnel while balancing the need to promptly care for patients in need of time-critical interventions.

As COVID-19 continues to affect communities across the country, EMS system medical directors must consider the need for clinical practice changes which may range from minor modifications to ensure field clinicians can identify and safely care for patients with COVID-19 to significant departures from standard practices to limit exposures to field clinicians, future patients, and to protect the local healthcare system infrastructure. Because significant modifications to EMS evidenced-based practices due to the global pandemic can negatively affect clinical outcomes, clinical practice changes must be based on the best available evidence while considering real-time disease prevalence in the community. Clinical practice changes must be coordinated across the entire system of care, including hospital partners.

EMS system medical directors must understand the current community disease burden before making changes in clinical care for time and intervention-dependent conditions. Before making significant changes to cardiac arrest care, ensuring EMS clinicians utilize a coordinated approach that allows donning necessary PPE while providing early time-critical interventions is valuable. Although the exposure risk possibly generated from aerosols is unknown (7), EMS clinicians may be able to deliver timely initial defibrillation and early chest compressions wearing an appropriate mask and eye protection without the full PPE ensemble (i.e., including gown or coveralls) protective from aerosolized-generating procedures. Performing these vital initial interventions while the remainder of the resuscitation team dons appropriate PPE to provide invasive and ongoing airway management is critical for the patient’s chance of survival. For aerosol-generating airway procedures, EMS personnel must utilize an N95 or equivalent or higher-level respirator (8).

Adapting cardiac arrest care for the possibility of COVID-19 should be implemented with minimal disruption to evidence-based resuscitation interventions. New equipment or technology should only be implemented after sufficient time for training and implementation of new clinical procedures (i.e., Mechanical CPR).

COVID-19 response is dynamic with constantly changing conditions and discovery of new information. EMS system medical directors must enact a process for rapid communication flow and dynamic practice change. Most importantly, change must be coordinated with local clinical partners and provide a feedback mechanism from field clinicians. Rapid process change requires a team of leaders and field personnel to enact change, manage modifications, evaluate effectiveness, and implement further process change.

The COVID-19 pandemic provides a remarkable opportunity for change and will undoubtedly result in positive systems improvement worldwide. As the pandemic runs its course through the country, some jurisdictions may need to implement more drastic changes to protect the local healthcare system infrastructure. The Institute of Medicine (IOM) defines crisis standards of care as a substantial change in normal healthcare operations and level of care due to a pervasive or catastrophic disaster (9). As part of a well-coordinated community-wide plan leveraging the benefits of change while mitigating risk, alternative care pathways reserving available system capacity for those more critically ill should be considered. EMS Systems may consider treat and release protocols, transport to alternative care sites and nurse triage processes. The community’s needs will determine which are the best options for implementation.

The multivariate and dynamic nature of this pandemic requires EMS Systems to develop countermeasures while the situation evolves. A community experiencing rapid exponential viral spread may experience immense increase in call volume, potentially overwhelming the EMS System and local healthcare infrastructure. The National Association of EMS Physicians has published examples of alternative care pathways and protocols https://naemsp.org/resources/covid-19-resources/ that may be helpful during the pandemic. Figure 2 shows an example of a treat and release protocol.

Figure 2. Wake County EMS Treat and Release Protocol.

Telehealth also provides a mechanism for Public Health, physicians and other medical care providers to engage PUI’s for evaluation and treatment without accessing the EMS System. The Centers for Medicare and Medicaid Services (CMS) has issued temporary measures to allowing people enrolled in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) to receive medical care through telehealth services during the COVID-19 Public Health Emergency (10).

Public Health Response

EMS systems are force multipliers in public health. As safety-net clinicians caring for the most vulnerable persons in the community, EMS systems are firsthand witnesses to the effects of COVID-19. Engaging and collaboratively partnering with public health leaders and officials provide expanded opportunities to stem the transmission and flow of COVID-19 within communities. In addition, EMS physicians can serve as a liaison between public health and clinical providers, bridging any gaps in language and in understanding of the capabilities and job functions of each discipline. Mechanisms by which EMS system medical directors can participate in public health initiatives include monitoring and surveillance, case investigation and contact tracing, and community paramedicine.

EMS clinicians are often the first to detect an outbreak within a neighborhood or facility and serve as an early-warning system for public health. Monitoring and surveillance within the community are essential tasks for EMS systems. Critical to this role are alert informed clinicians, robust data systems, and near real-time quality assurance. Sharing outbreak concerns with public health is facilitated by established relationships and communication channels. Public health officials can then begin testing and tracing to limit spread of disease.

Case investigation and contact tracing are fundamental public health responsibilities. As a public health resource, EMS systems may aid in these efforts as a workforce multiplier. The burden of case investigation and contact tracing can strain public health departments beyond their capacity. Providing personnel to assist in these critical public health efforts can reduce the spread of disease and the ultimate burden of response placed on EMS.

The advent of community paramedicine provides further opportunities for public health partnerships through testing and vaccination programs. During the COVID-19 pandemic many EMS systems are working closely with public health departments to conduct facility-wide testing of congregate living facilities. EMS-public health partnerships expand the capacity of public health departments to manage their multiple competing duties during a pandemic. Similarly, once a vaccine for COVID-19 has been deployed, EMS systems may provide mass vaccination programs in the community.

Occupational Health

EMS physicians must play a role in the occupational health of their EMS systems during this pandemic. Even though the roles of “EMS Medical Director” and “Provider of Occupational Health Services to EMS personnel” are traditionally and appropriately separate, the EMS physician must use his or her knowledge and training to translate and apply the rapidly changing science around COVID-19 to ensure the health and safety of EMS system clinicians. EMS Physicians should lead occupational health efforts with both system policy guidance and education.

First, the EMS physician should lead the development of public safety occupational health guidelines and policies about COVID-19. While the traditional “blood borne pathogens” annual trainings and exposure follow-up pathways are often relegated to non-physician colleagues, EMS medical directors must confront the novelty of COVID-19 and develop “what to do if someone is exposed” protocols de novo. The CDC offers extensive and oft-changing guidelines that are of excellent help to these efforts (11). EMS physicians should read and understand these guidelines to apply them to preexisting department staff and infrastructure. For example, when an EMS clinician is exposed to COVID-19, what is the process for the EMS employer to investigate the exposure, contact-trace other possible work related exposures, and evaluate whether the exposed clinician should stay out of work and for how long? Given the novelty and rapid pace of the pandemic, the scientific understanding of virus characteristics such as contagiousness, exposure “risk,” and routes of spread are dynamic. EMS physician leaders should be prepared to advise public safety leadership regarding the science as it relates to preventing exposure, workforce protection, and return to work guidelines.

Perhaps an EMS physician’s greatest contribution is the education of EMTs and paramedics. EMS clinicians have a thirst for more knowledge and a desire to know “why” we do things a certain way, whether in policy or clinical care. In the case of occupational health and the COVID-19 pandemic, EMS physicians are in a unique position to work with compliance and occupational health experts to ensure guidelines are well understood by EMS personnel without any adverse impact on patient care. For example, common topics and questions may include a review of “precautions”—contact vs. droplet vs. airborne and why does that matter, or when and why is a respirator needed versus a standard surgical mask. Furthermore, EMS personnel will ask about the pandemic broadly, and how concepts apply to them or their job or their family—should I get a COVID test? What about an antibody test? How should I “decon” myself after a shift?

EMS physicians have always been an important education resource. In the case of the occupational health and safety of system clinicians during the COVID-19 pandemic, EMS physicians should be both policy-makers and educators. EMS physicians should be able to explain why certain PPE is indicated, and also explain why certain PPE policies may be necessary for conservation of supply chains during the pandemic. The EMS medical director should partner with other EMS system leadership to develop and maintain appropriate workforce protection and occupational health for the unknown duration of the pandemic.

Advocate

The effects of COVID-19 on the health of racial and ethnic minority groups are still emerging, with recent reports suggesting a disproportionate burden of illness and death among these groups (12, 13). Racial and ethnic minorities are at a higher risk for a more complicated course of disease given a higher prevalence of chronic medical conditions including diabetes, coronary artery disease, hypertension and obesity (14). This increased risk is further magnified by socioeconomic factors including housing, economic stability, working conditions and the disruption the pandemic has caused to healthcare safety-net systems (15). For instance, the Latinx community is three times more likely to be uninsured than white Americans (16). Inadequate access to healthcare services limits the ability to get tested for COVID-19 and is exacerbated by a long-standing distrust of the healthcare system, language barriers, and the financial implications of missing work to receive care.

EMS medical directors’ myriad leadership responsibilities include understanding the healthcare needs of their diverse communities and serving as a public health resource and advocate. One advocacy responsibility of the EMS medical director is to understand the resources available to their community and to bring those resources to bear for the benefit of the population. For example, many EMS physicians serve as medical advisors for federally supported regional healthcare preparedness coalitions. At minimum, local EMS medical directors should understand the supporting role that these coalitions play in preparedness and response, and the available resources that they can provide during a pandemic such as additional infrastructure, equipment and PPE.

Partnering daily with community stakeholders to improve the care and support of vulnerable patient populations, EMS clinicians evaluate many public health issues firsthand and from these evaluations provide valuable insight to agencies involved in the public health response. Their unique perspective on operationalizing policy initiatives tailored to the needs of vulnerable populations during the pandemic is invaluable. For instance, several communities have implemented innovative initiatives to protect people who are homeless or housing insecure including those who lack necessary resources to remain healthy. When an EMS physician serves as a clinical spokesperson, they can emphasize appropriate utilization of the EMS system while keeping the public informed on the integration of public health response efforts and the EMS system. Lastly, they provide a voice for patients that access healthcare through the EMS system and for those most impacted by this pandemic.

Conclusion

The COVID-19 pandemic provides an opportunity for change and will undoubtedly result in positive systems improvement worldwide. EMS system medical directors serve as clinical leaders for their communities. They provide valuable expertise in EMS system resource management, clinical practice modifications, public health response, occupational health and as advocate. To perform effectively, they must maintain vigilance with the latest science and clinical recommendations from appropriate public health authorities to ensure the EMS Systems are in a position to rapidly implement change based on the level of community transmission occurring in the community.