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Policies & Procedures Applicable to All Staff

During these emergency times, the policy/procedure and guideline documents will supersede any existing Aspirus or Business Unit Policy.

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Clinical Policies & Procedures

During these emergency times, the policy/procedure and guideline documents will supersede any existing Aspirus or Business Unit Policy.

Additional Guidelines For Clinical Departments


  • Perform hand hygiene alcohol-based hand rub or soap and water.
  • Do not enter room.

Handle the management of food service dishes and utensils using normal standard practices.

Respiratory Therapy

Additional steps to remember when caring for a Covid 19 patient:

  • Ensure an adequate hydrophobic/hepa filter is placed between the ETT and reservoir bag during transfers to avoid contaminating the atmosphere whenever manual bagging of patient is required.
  • Follow Guidelines for the set up and cleaning of Hamilton Vents.
  • Covid 19 Positive patients should use a V60 only with a bacterial filter at machine at the inspiratory port.

Use Caution When Performing Aerosol-Generating Procedures

Some procedures performed on COVID-19 patients could generate infectious aerosols. In particular, procedures that are likely to induce coughing (e.g., sputum induction, open suctioning of airways) should be performed cautiously and avoided if possible.

Much of what we do is considered a risk for Aerosol Generating Procedures.  Even nebs are listed as a possibility however unlikely.  Looking at current CDC guidelines, it is recommended that full Airborne (including face shield) precautions are observed for aerosol generating procedures for COVID19 positive patients.  At this time all Respiratory Therapists or other health care providers present in the room during respiratory therapy procedures on/with COVID 19 positive patients will continue to observe full Airborne Precautions.

If performed, these procedures should take place in an AIIR and personnel should use respiratory protection as described above. In addition:

  • Use in-line suction catheters whenever possible
  • Limit the number of HCP present during the procedure to only those essential for patient care and procedural support.

Current PPE Guidelines for Covid-19

  • Applies to COVID-19 patients receiving general patient care
    • Required PPE:
    • Gown,
    • Gloves
    • Surgical mask
    • Full Face shield over surgical mask
  • during aerosol generating procedures & 35 minutes post procedure.
  • Required PPE:
    • Gown
    • Gloves
    • N95 mask or PAPR
    • Full face shield over mask
  • Procedures considered Aerosol producing:
    • sputum induction
    • bronchoscopy
    • suctioning
    • Intubation or extubation
    • Pulmonary Hygiene Procedures
    • Mechanical ventilation-only if circuit must be broken
    • Manual ventilation
    • All Non-invasive ventilation
    • Open tracheostomy
    • nebulized medication administration


Basic EMS guidance for COVID 19

Refer to CDC for most current guidelines and recommendations

EMS Tracking Forms

Identifying potential or confirmed person of interest Screening for COVID-19

  • Fever and symptoms of lower respiratory illness (e.g. cough, difficulty breathing)
    • Onset of illness within 2 weeks of travel to any of the Geographic Areas with Sustained Transmission (Check CDC webpage as continues to evolve) or close contact with a person who is under investigation for COVID-19 while that person was ill
    • Any person (including healthcare worker) with close contact with an ill laboratory-confirmed COVID-19 patient
  • Any known person currently under investigation or quarantine by public health department

Recommended PPE for EMS providers

  • EMS clinicians who will directly care for a patient with possible COVID-19 infection or who will be in the compartment with the patient should follow Standard, Precautions and use the PPE as described below. Recommended PPE includes:
    • N-95 or higher-level respirator or facemask (if a respirator is not available),
      • N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol-generating procedure
    • Eye protection (i.e., goggles or disposable face shield that fully covers the front and sides of the face). Personal eyeglasses and contact lenses are NOT considered adequate eye protection.
    • A single pair of disposable patient examination gloves. Change gloves if they become torn or heavily contaminated, and isolation gown.,
      • If there are shortages of gowns, they should be prioritized for aerosol-generating procedures, care activities where splashes and sprays are anticipated, and high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of EMS clinicians (e.g., moving patient onto a stretcher).

Patient Assessment and Treatment

If COVID-19 is suspected:

  • Don appropriate PPE
  • Place (surgical type) Face Mask on patient if tolerated. 
  • The number of responders within six feet of the patient should be limited to the fewest number to provide essential patient care.
  • Follow local treatment protocols with emphasis on the following:
    • Oxygenation- Nasal Canula maybe worn under patient face mask
      • Treat per protocols
    • Minimize Aerosol Generating Procedures
    • Increase caution with BVM, suctioning, emergency airways, nebulizers)
    • Keep patient and aerosolization away from others without PPE
    • When in ambulance activate patient compartment exhaust fan to maximum level
    • When possible, consider HEPA filtration to expired air on ventilators, CPAP, BiPAP, BVM)
  • Contact Medical Control for specific guidance

EMS Transport to a Health Care Facility

If a patient with an exposure history and signs and symptoms suggestive of COVID-19 requires transport to a healthcare facility for further evaluation and management (subject to EMS medical direction), the following actions should occur during transport:

  • EMS clinicians NEED to notify the receiving healthcare facility that the patient has an exposure history and signs and symptoms suggestive of COVID-19 so that appropriate infection control precautions may be taken prior to patient arrival.
    • Notify Local Emergency Department/Medical Control for specific destination and/or treatment guidance.
  • Keep the patient separated from other people as much as possible.
  • Family members and other contacts of patients with possible COVID-19 should not ride in the transport vehicle, if possible. If riding in the transport vehicle, they should wear a facemask.
  • Isolate the ambulance driver from the patient compartment and keep pass-through doors and windows tightly shut.
  • When possible, use vehicles that have isolated driver and patient compartments that can provide separate ventilation to each area.

Patient Compartment

  • When practical, utilize a vehicle with an isolated driver and patient compartment.  Close window/door between compartments if able. 
  • Only necessary personnel should be in the patient compartment with the patient.
  • All compartments should have ventilation maintained, with outside air vents open and set to non-recirculated mode and rear exhaust fans should be used.
  • Patient could be placed in an ISOPOD for transport if available and if it wouldn’t impede patient care to further reduce risk.

Upon Arrival at a Health Care facility

  • The Health Care Facility may provide specific directions for arrival location and patient placement as it may differ from normal operating procedures with the triaging of COVID-19 Patients. 
    • Minimize exposures to others
    • Continue to provide appropriate medical care
    • Maintain PPE until transfer of care is complete
    • Provide detailed report to facility
    • Complete documentation only after all patient care is completed and appropriate employee decontamination is completed
    • Following guidelines for doffing PPE at patient drop off location

Cleaning of Transport Vehicle and Equipment

  • Leave patient compartment open for ventilation while patient is taken into receiving facility.
  • Personnel should wear disposable gown and gloves for decontamination of the vehicle. A face shield or facemask and goggles should be worn if there is a potential for splashing or sprays.
  • Maintain doors open during cleaning.
  • Disinfect and clean using EPA-registered, hospital-grade disinfectant to all surfaces that were touched, or all surfaces if aerosol-generating procedures were performed. Products with statements for emerging viral pathogens should be used that are approved on the EPA list.
  • Equipment should be cleaned with approved disinfectants
  • Refer to Aspirus Termination Cleaning checklist for additional details