Flu Outbreaks in Mexico Linked to Canada and the United States
Updated Best Practices for EMS Agencies Identified by EMS Chiefs of Canada

April 28, 2009

A recent outbreak of the flu in Mexico has been linked to cases of flu in Canada and the United States by the World Health Organization. The EMS Chiefs of Canada are leading a process to identify and disseminate key strategies for EMS organizations to implement to protect their paramedics and to be public health partners in managing the care of the sick.

Last week, the EMSCC's Membership Services Committee coordinated an international teleconference to reveal best practices. A follow up call was held today. The strategies identified last week have been updated by today's call and changes are reflected below. The National EMS Management Association, First Watch and the National Academies of Emergency Dispatch are participating in EMSCC's process.

Reference documents are being compiled by the EMS Chiefs of Canada. US reference documents are available on the National EMS Association's website (www.nemsma.org) on the Flu Resources tab.

Changes in the best practices from our April 25^th message are in red. New words are in red, deleted words are in red and in strikeout.

By Administrators:

• Notification to staff of the emerging problem.
  • Fit test and issue N95 masks to paramedics and other responders, using non-operational personnel to perform fit tests
  • Issue hand sanitizer to paramedics and other responders
  • the Public Health Agency of Canada (www.publichealth.gc.ca)
  • the Centers for Disease Control (www.cdc.gov)
  • www.pandemicflu.gov
  • www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0424a1.htm
  • www.cdc.gov/flu/swine/recommendations.htm
• Reviewing and updating local plans.
• Daily communication with hospitals and public health departments.
• Monitoring news reports and government resources, such as:
• Identify a technical advisor to provide advice to paramedics and to track patients on a regional or state- or province-wide level
• Resolve issues of pay for paramedics who are quarantined.
• Establish procedures with local public health agencies to identify and pre-screen migrant workers entering the area
• Keep an accurate inventory of masks and other personal protective equipment, and an inventory of ventilators available in the service area.
• Develop a policy for limiting the dispatch of first responders to non-critical patients with flu symptoms, be ready to implement it when deemed necessary by medical directors
• In cooperation with medical direction, develop a treat and release protocol and patient information card for patients with minor flu symptoms. Implement the protocol and card when advised to in consultation with medical direction. Consider performing swabs in the home and deliver them to the identified local collection area (local public health, clinic or hospital) to be routed for testing. Consider the use of alternative care destinations like clinics or urgent care centers or identified receiving areas within the hospital away from the ED.
• Work with local Health Districts to establish hotlines where the public can receive more information

By Paramedics:

• Requesting more information from dispatchers when sent to respiratory, sick person and fever related calls if limited initial information is provided upon dispatch.
• Initial interrogation of the patient from at least 2 meters (6.5 feet) away to determine if personal protective equipment precautions are necessary.
• Recommended PPE for taking care of ill/potentially infected patients includes: disposable gowns, gloves, goggles/face shields and N95 or better respirators. PPE should be donned and doffed according to published guidelines to prevent cross contamination, including eye and gown protection when splash or airborne contamination is possible.
• Wear goggles when intubating patients or providing nebulizer treatments.
• Placing a mask, and taking a temperature, on all patients with  respiratory symptoms, using filtered oxygen masks when available, or non-rebreather masks when oxygen is required. Place an N95 mask on patients with respiratory symptoms that do not require oxygen. Droplet producing procedures should be avoided whenever possible including nebulizers, bag-valve-mask, suctioning or intubation. If bag-valve-masks are needed, use those with HEPA filters whenever possible.
• Alert receiving hospital personnel of the possibility of an infectious patient as soon as possible and hold suspected infectious patients in the ambulance until their destination in the hospital is known, rather than immediately moving them into the emergency room.
• Perform a thorough cleaning of the stretcher and all equipment that has come in contact with or been within 2 meters (6.5 feet) with an approved disinfectant, upon completion of the call. Wash hands frequently.

By Dispatchers:

• When using ProQA software flagging MPDS protocols 6, 10, 18 and 26 for further interrogation, and using the drop down SRI (severe respiratory infection [flu-like] symptoms) screen to obtain, at a minimum, the following:
  • Are they febrile or have a fever, and if so, is it higher than 38° C (101°F)?
  • Do they have a cough or any other respiratory symptoms like difficulty breathing?
  • Use card 36 as soon as it is available
• For dispatch centers not using ProQA software (paper-based cards only), gathering the above information from all callers on protocol cards 6, 10, 18 and 26. Use card 36 as soon as it is available.
• For dispatch centers not using cards or software, include the questions above when the caller reports flu, breathing difficulty or fever.
• Dispatchers should report the responses to these questions to the paramedics before they arrive on the scene.

The worst cases of flu that have presented so far have been mostly adults from ages 25 to 45, but patients of all ages have been infected, so the same precautions should be used for all patients.

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