Last Update April 1, 2020 Owners: Deb Bowers, Carol Anne Doll, Gavin Greenfield

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STARS AMC Competency Skills CHECKLIST Infection Prevention and Control (COVID-19 edition)

AMC: _________________________________ Peer AMC: _________________________________ Date: _________________________

AMC DACUM Competencies • D15-D17 • E8

Note from Authors

• As the COVID-19 pandemic evolves we are continually reviewing the current best practices and guidelines of our provincial partners. This and all of our documents at stars.ca/covid19clinical will be updated accordingly

Learning Objectives AMC will

• Appreciate the importance of infection prevention and control • Recognize the need for Contact and Droplet Precautions for all patients • Recognize the need for Airborne Precautions when performing aerosol generating medical

procedures (AGMPs) • Don and doff personal protective equipment (PPE) correctly and appreciate that incorrect doffing

can be hazardous • Describe the two types of infection control precautions and when to implement them • Advise other team members to don appropriate PPE when necessary • List aerosol generating medical procedures (AGMPs) • Simulate safe oxygenation of patients considering the potential to aerosolize droplets • Describe how to adapt the work environment by minimizing equipment to avoid unnecessary

contamination of people and equipment • Describe the correct method to clean and decontaminate the work environment to include linens,

equipment and the helicopter Equipment

Flight suits, helmet, other equipment normally carried on a mission, BVM with AGMP circuit configuration, NRB, NP and airway head or mannequin in simulation room, PPE equipment** (gowns, masks, eye protection, gloves), Airway checklist (new version which includes COVID-19 information on the reverse) and COVID-19 Airway Management document. ** Please be mindful that many PPE items are in limited supply. If AMC are due for N95 mask fit testing, then please utilize this checklist as part of your fit testing so as not to waste the mask. If available, use surgical masks and washable isolation gowns for the checklist and practice. Instructions Working with an aeromedical crew (AMC) partner or your base educator in the simulation room, read the case, gather the equipment and work through the checklist. Numerous specific, important teaching points are available later in this document. Case You have been dispatched to transport a 62-year-old male with suspected COVID–19. His oxygen requirements have been increasing and he is now on 5L nasal prongs and a non-rebreather at 15L for an SpO2 of 81%. He indicates he is very short of breath and he has marked signs of increased work of breathing. The plan is to intubate the patient due to respiratory failure.

Last Update April 1, 2020 Owners: Deb Bowers, Carol Anne Doll, Gavin Greenfield

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Simulation Room Exercise (pilots included) COMPLETED 1. Utilizing the checklist, prepare the airway equipment, ventilator and circuit prior to

entering the patient’s room

2. Correctly don the appropriate PPE required for this patient using the buddy system of observation and feedback. Pilots to practice this under AMC observation as well

3. Explain who should be in room during intubation 4. List each of the options for pre-oxygenation and indicate if an AGMP or not 5. Perform preoxygenation with the mannequin in an upright position, using nasal prongs,

BVM with circuit and PEEP valve in place, good mask seal (refer to “Airway Management for the Critically Ill Patient with suspected COVID-19”)

6. Post-intubation correctly doff PPE using the buddy system of observation and feedback. Pilots to practice doffing at this point as well. Post proper doffing, practice the donning procedure including helmet as described below

7. List the procedures that require Airborne Precautions (AGMPs from page 7) that we may perform as AMC

8. Describe the difference in PPE between Contact and Droplet vs Airborne 9. Describe decontamination of all linens, equipment, helicopter & AMC post-mission

Peer Signature: _____________________________________ AMC Signature: _____________________________________ Important Teaching Points for Discussion Definitions

• Contact and Droplet Precautions: gown, simple (procedural or surgical) mask, eye protection, gloves

• Airborne/AGMP Precautions (During Transport or During AGMP): gown, N95 mask, eye protection, gloves

PPE below is the STARS Organizational Approach. Ensure these align with your Provincial Guidelines

• All patients will be presumed to screen positive for COVID-19 and thus at minimum AMC will wear Contact and Droplet Precautions for all patient encounters

• If possible, apply a simple mask to ALL patients that are not intubated • If an AGMP is performed the Precautions must be escalated to Airborne • During transport AMC must wear Airborne Precautions if:

o Patient is intubated (because of the potential for circuit disconnect) o If the patient has any respiratory, infectious or GI symptoms o If there is a reasonable chance an AGMP (see page 7) may be performed (regardless of

patient COVID-19 status) • During transport AMC may choose to wear Contact and Droplet Precautions (simple mask) if the

patient is GCS 15 and is clearly able to articulate they have had no respiratory, infectious or GI symptoms. As per above, the patient should wear a simple mask

• See “Putting on (Donning) Personal Protective Equipment (PPE)” (appendix below) for proper donning technique. Your AMC partner is your buddy and should observe and provide feedback. Donning should occur at the facility if an inter-facility transfer and at the Base if a Scene Call

• See “Taking off (Doffing) Personal Protective Equipment (PPE)” (appendix below) for proper doffing technique. Doffing should be deliberate and meticulous. Your AMC partner is your buddy and should observe and provide feedback. Not shown, but ideally, gloves and gown are doffed just inside patient room door and mask and goggles are doffed just outside patient room door. Reusable goggles are to be wiped down with an approved agent. Depending on weather and potentially other factors doffing post an AGMP during a scene call may not be practical

• See “PPE Checklist” below for a one-page checklist of donning and doffing • The helmet should be doffed when entering the sending facility

Last Update April 1, 2020 Owners: Deb Bowers, Carol Anne Doll, Gavin Greenfield

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• Appropriate (Contact and Droplet or Airborne) PPE should be donned prior to entering patient care area.

• All AMC in the room during an AGMP (i.e. intubation) should doff their PPE following patient care. AMC can do this one at a time (using the buddy system of observation and feedback) so as to leave a crew member with the patient. The time period between doffing and donning is a good time to use the bathroom and hydrate. Following this the AMC member needs to don the appropriate PPE for transport and their helmet and then return to the patient. At this point the second AMC member can repeat the procedure. Because of the risk of contamination with helmet donning (including chinstrap and microphone adjustment), the recommendation to doff and don post AGMP applies specifically to STARS AMC. This procedure for helmet donning would also apply to the situation where no AGMP was performed

• If no AGMP performed there is no need for a doff. • Ideally, avoid AGMPs during the actual transport in order to reduce viral exposure to “As Low as

Reasonably Achievable”. • Pilots should avoid contact (two metres) with patients. If contact is necessary during loading and

unloading, then the pilot is required to don the same PPE (Contact and Droplet or Airborne) as the AMC. Pilots should doff their PPE (see “Taking off (Doffing) Personal Protective Equipment (PPE)”) prior to entering the cockpit in order to avoid contaminating the cockpit. The pilots should then don the same type of mask (either simple or N95) as the AMC are wearing for transport. If pilots are wearing a simple mask and it requires adjustment for communications, safety, etc. the pilots are free to adjust their mask. The risk to pilots in scenarios where the AMC has chosen to wear a simple mask is extremely low. If the pilots are wearing N95 masks they should attempt to avoid adjusting inflight but adjustments for aviation safety are permitted and still relatively low risk given the barriers and distance between pilots and patient/AMC

• During the current pandemic, if at all possible, avoid hot loading/unloading. If the PPE required is Contact and Droplet (patient is GCS 15 and is clearly able to articulate they have had no respiratory, infectious or GI symptoms) hot loading/unloading is up to AMC discretion

• AMC should always operate with clear helmet shields down as an extra barrier • If mask or helmet adjustment is required, AMC should perform as follows: doff gloves, perform hand

hygiene, adjust mask/helmet, perform hand hygiene, don gloves • To avoid coughing and aerosol generation these patients should generally be heavily sedated and

paralyzed for the duration of the transport. Be especially aware toward the end of the expected duration of paralysis and sedate and re-paralyze at appropriate intervals to decrease risk

• If the circuit needs to be disrupted on the patient side of the HME/viral filter, ensure to clamp the ET tube with metal locking clamps and pause the ventilator. This will prevent crew exposure to aerosolized particles. Clamping of the tube is generally a good idea even if the disruption is on the ventilator side of the HME/viral filter as it will prevent de-recruitment.

Post Patient Care • To reduce contamination of the equipment, only bring in the necessary equipment to the patient

bedside. To do this, one AMC should enter the patient care area and assess the need while the second AMC selects and prepares the necessary equipment/checklist/medication outside the patient care area before he/she enters the patient care area

• Documentation of care should not be performed during transport in order to avoid contaminating the laptop. Consider leaving the laptop at the base for potential COVID-19 missions. Documentation should be deferred until after patient handover, doffing of PPE and all decontamination/showering complete

• At the receiving facility the following is suggested for helmet management o With one AMC staying with patient, the first AMC returns to the aircraft, doffs gloves,

performs hand hygiene and removes chin strap, reapplies gloves, removes helmet placing it top down on the floor of the helicopter; first AMC to return to patient and repeat process- keep the 2 m of distance between pilots and patient while doing this.

o proceed into hospital

Last Update April 1, 2020 Owners: Deb Bowers, Carol Anne Doll, Gavin Greenfield

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• Following handover at the receiving facility AMC should perform a complete doff as per “Taking off (Doffing) Personal Protective Equipment (PPE)” and then don as per Contact and Droplet precautions and proceed to hospital exit. Ensure to touch stretcher with hands only

o upon return to helicopter, doff gloves, perform hand hygiene, don gloves and then don helmet (including chin strap and microphone adjustment). Try not to touch any skin

o this is followed by doffing of gloves, hand hygiene and donning of new gloves • Once back at the base the interior of the helicopter, all equipment and helmets need to be thoroughly

cleaned with an approved agent. Follow aircraft decontamination procedures. Following helicopter, equipment and helmet decontamination all AMC need to doff PPE, gently place flight suit in washing machine and then shower. Following the shower, change into a new set of clothes. Avoid going anywhere else on base until shower completed. No further missions should be accepted or contemplated until this entire process is complete

• No entry is permitted into the aircraft (engineers, pilots) until full decontamination has taken place

APPENDIX 1 • Review this video for a demonstration of donning and doffing

https://ahamms01.https.internapcdn.net/ahamms01/Content/AHS_Website/Information_For/if-hp-ipc-donning-and-doffing.mp4

• Review this video for a demonstration of hand hygiene https://www.youtube.com/watch?v=eW-hmHFo4Oo&feature=youtu.be

• See page 7 for a comprehensive list of what is currently (April 1 2020) considered to be an AGMP (https://sharedhealthmb.ca/files/aerosol-generating-medical-procedures-AGMPs.pdf, https://www.ehealthsask.ca/services/resources/Resources/nrv-prevention-control%20(1).pdf, https://www.albertahealthservices.ca/assets/healthinfo/ipc/hi-ipc-respiratory-additional-precautions-assessment.pdf)

Last Update April 1, 2020 Owners: Deb Bowers, Carol Anne Doll, Gavin Greenfield

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Last Update April 1, 2020 Owners: Deb Bowers, Carol Anne Doll, Gavin Greenfield

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Last Update April 1, 2020 Owners: Deb Bowers, Carol Anne Doll, Gavin Greenfield

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PPE Checklist

Contact and Droplet Precautions

For more information contact infectionpreventioncontrol@ahs.ca

© Alberta Health Services

Original date: March 2019 Revised date: March 2020

Steps for putting on PPE Steps for taking off PPE

Clean hands

Gloves

Gown

Clean hands

Mask with visor or

mask and eye

protection

Gown

Gloves

Clean hands

Mask with visor or

mask and eye

protection

Hand sanitizer or soap and

water

Last Update April 1, 2020 Owners: Deb Bowers, Carol Anne Doll, Gavin Greenfield

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List of AGMPs endotracheal intubation manual ventilation with BVM (squeezing the bag) open endotracheal suctioning extubation humidified high flow oxygen systems (e.g. ARVO, Optiflow) non-invasive positive pressure ventilation (e.g. BiPAP, CPAP) nebulized therapy open respiratory/airway suctioning break in ventilatory circuit tracheostomy care bronchoscopy sputum induction cardiopulmonary resuscitation (chest compressions) high frequency oscillatory ventilation