key: cord-0813159-wcd7ife9
authors: GULSEN, M. F.; KURT, M.; KALELI, I.; ULASTI, A.
title: PERSONAL PROTECTIVE EQUIPMENT (PPE) USING IN ANTALYA 112 EMERGENCY AMBULANCE SERVICES DURING OUTBREAK
date: 2020-06-19
journal: nan
DOI: 10.1101/2020.06.16.20129171
sha: 37e868bd5665ee09b7ef8d3a0727c0598cd6a965
doc_id: 813159
cord_uid: wcd7ife9

A new type of Coronavirus (SARS CoV2) which was identified on January 7th, 2020; which caused disease named COVID 19 caused by this virus. The first confirmed COVID 19 (+) case in Turkey was detected on March 11th, 2020. The first COVID-19 case in Antalya was detected on March 14th, 2020 and transferred by an Antalya 112 emergency ambulance to hospital. The aim of this descriptive, retrospective and cross-sectional study which is conducted between the dates of March 14th, 2020 and May 31st, 2020, is to evaluate the level of Personal Protective Equipment (PPE) usage, the risk analysis results and follow up measures of Antalya 112 ambulance teams during COVID-19 outbreak. There were 5344 possible and 787 confirmed COVID-19 (+) positive ambulance cases between the dates of study conducted. The majority of these cases were male (62%) and over the age of 65 (47%). The majority of cases were result in transferred to healthcare facilities (75.48%). The total 2361 ambulance team workers were taken to risk analysis measurements and then followed-up procedures. The majority of ambulance team members were assessed with no risk available. The Level 4 PPE (N95/FPP, Goggle/face protection, Gloves, Apron/coverall) were used most commonly (84.50%). The HCWs who use Level-4 PPE for confirmed COVID-19 (+) cases, were assessed no risk exposed. The using mask on patient and the level of PPE usage showed negative correlation with risk level of HCWs. There are only 2 HCWs diagnosed with COVID 19 by CT scan. The follow up procedures of two HCWs has been finalized, and both of them cured, follow ups ended. The studies about easy use, hightech PPE with maximum protection, are recommended for further investigations. Keywords: COVID 19, Ambulance Services, Personal Protective Equipment

The World has been witnessing of various pandemics in the last two thousand years. The plague of Justinianus (AD542-546), the Bubonic Plague (1347-1351), also known as Black Death, and Smallpox (1520) are among the most life-threatening outbreaks (1) . Influenza outbreaks (2) caused by Influenza A virus, have been occurred three times only in the 21st century. The most severe is "Spanish Flu" (type A H1N1), which was estimated to have as COVID-19 and the agent virus was named SARS-CoV-2 because of its similarity to previous SARS CoV (5) . The first imported case was a 61-year-old Chinese woman reported from Thailand on January 13 th , 2020. The first COVID-19 case was detected on . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The fight against pandemic outbreaks should be managed with international and intersectoral aspect. Ethical and legal issues are needed to be considered during preparing and managing of outbreaks. While adapting to national and international decisions, regional plans should be carried out by prioritizing access to healthcare resources during implementation of these plans. There are many ethical problems faced and difficult questions to answer should be taken account by authorities (7) . In order to stop the COVID-19 outbreak turning into a global health emergency situation, the governments have had to carry out their epidemic control activities with many uncertainties under the increased pressure (8) .

The Ambulance and ambulance staff insufficiency (9, 10) news appeared during the COVID-19 outbreak in press. Ambulance teams struggles to find health facilities that will accept patients in ambulance queues in front of the hospitals (11, 12) . It has been stated that the use of public transport or personal vehicles while going to the hospital, increases the transmission risk. Therefore, preliminary evaluation at home and avoiding hospital application without suspicious and severe symptoms have been recommended (13) . In order to prevent risks, reduce the unnecessary use of hospitals and ambulances, the home testing method have been applied in London, in cooperation of ambulance service providers (14) . The 90% percentage of test in the city was done in homes (15) . But effects . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted June 19, 2020. . https://doi.org/10.1101/2020.06.16.20129171 doi: medRxiv preprint of home testing method on human and material resources are unknown in long-term and "hospital transfer" is still needed for further examination and treatment.

Emergency call strategies during COVID-19 outbreak, vary from country to country according to allocation policies of healthcare workers (HCWs), ambulances, drugs, materials and equipment (16, 17, 18, 19) . Since the routine use of Personal Protective Equipment (PPE) in work standard requires extra time and effort, many difficulties occur in optimum and accurate use of PPE additional to material shortage.

Many country has realized prevention and control strategies to protect HCWs against COVID-19 exposure (20, 21) . WHO Pan American Health Organization and UK Public Health Authority gives important recommendations about prehospital emergency service process with administrative and operational approaches which start from call management till end of the patient transport included PPE use standards and ambulance decontamination during COVID-19 outbreak (22, 23).

Since demands of ambulance services extraordinarily increased while rising ambulance use hesitations due to high risk of transmission in the narrow area; the studies related rapid and safe ambulance disinfection and minimum PPE use (24, 25, 26) accelerated. The validity of the PPE standards in the transfer of aircraft cabin that is rather limited area, has been criticized (27) and become the subject of debate. How should be use of PPE in emergency ambulances with narrower area than aircraft cabin? What should be the minimum PPE to be used by the ambulance team who travel 20-30 minutes average with the patient in a narrow space during outbreaks?

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The copyright holder for this preprint this version posted June 19, 2020. In the interview dealt with three Canadian experts, they have been in consensus in priority allocation of PPE (especially N95 masks) to front-line healthcare professionals by eliminating access difficulty (32). Although there are several difficulties reported by HCWs regarding PPE use, they have the competence and willingness to comply with infection prevention and control guidelines. Participation of HCWs to preparation of guides by allowing the inclusion of their decisions, will facilitate to follow instructions well (33) .

According to the results of a study conducted in Singapore, well-organized staff protection system which is implemented in work routines is quite effective to protect frontline HCWs, if it is implemented in non-outbreak period (34).

Before the COVID-19 outbreak, required regulations and arrangements were already prepared for the execution of Turkish ambulance services in case of outbreaks. According . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted June 19, 2020. Preparedness for the outbreak had been already started before the first case was detected in Turkey. The scientific committee and 7/24 teams were formed; instructions, guides, algorithms, and documents were prepared and delivered to end users by electronically and physically through the communication network created according to National Pandemic Plan of Turkey (37) . Ministry of Health of Turkey, General Directorate of Public Health have prepared a website for infection control studies to manage COVID-19 outbreak (38) and conducted guidebook which is updated as needed (6) . These works have also guided the use of PPE, establishment of PPE standards that should be used in ambulances during outbreak.

These standards suggest different type of PPE using, depending on whether the patient is suspected, the job description of HCWs (paramedic, ambulance driver, or cleaning staff), exposure level to patient or which procedures operated in ambulance (39) . The visual guidance tools have been prepared by declaring the minimum PPE requirements, practical instructions of gloves, masks, eye and face protectors and aprons for healthcare professionals (40) .

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Antalya Ambulance Services Directorate is responsible authority for 61 Emergency Medical Services (EMS) Stations which give healthcare services with 101 ambulances (included one helicopter ambulance) and 972 HCWs. Every EMS station with 7/24 team is on duty consisted of at least 3 HCWs (driver, 2 paramedics and/or emergency medicine technician). Eight of the 61 EMS station give services with teams including medical doctor.

The EMS ambulance stations are directed to cases according to the calls received from 112 Call Centre; calls and operation procedures are managed according to the standard algorithms in routine.

Ambulance Services Directorate coordinated with Crisis Coordination Centre of Antalya Provincial Directorate of Health. All procedures during outbreak related with possible / confirmed cases in prehospital process, are managed by this team. This team has developed applications, algorithms, staff trainings for 112 call centre and ambulance stations during outbreak. The emergency call and case management strategies updated when necessary by this team. Some of the implementations during outbreak in Antalya EMS stations:

1. Work schedule planning team is formed, and problem-solving strategies and human resources with alternative scenarios created in case of over demand, 2. Ambulance equipment, device and material tracking planning team is formed, supply strategies and distribution chain with alternative scenarios created in case of over demand, . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 19, 2020. . https://doi.org/10.1101/2020.06.16.20129171 doi: medRxiv preprint 3. The ULV (ultra-low-dose) ambulance disinfection method is applied for 6 minutes by using hydrogen peroxide and colloidal silver. After each UVL procedure, the ambulance door closed for four minutes and then cabin is ventilated for 15 minutes. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 19, 2020. The ambulance staff are directed to the use of gloves, medical masks and goggles/face protection as minimum for ordinary cases. In possible cases, it is recommended that ambulance team has to use gloves, N95 / FFP2 mask, and goggles / face protection in minimum. In adult patients, no companion is accepted to ambulance in. In case of absolute necessity like parents of paediatric patients needed in cabin, they are accepted with a surgical mask (6).

When patient transfer is finalized, possible COVID-19 cases are confirmed in 24 hours by healthcare facilities by using not only PCR (polymerase chain reaction) but also CT (Computed Tomography) scan for more accurate results (41, 42, 43) . Even if the patient PCR (-) negative, CT scan results may show possible findings. The HCWs who exposed to patient, are assessed in terms of risks in case of possible COVID-19 infection.

An algorithm of "Risk Level Assessment of HCWs who exposed to COVID-19" (As shown Table 1 ) is used to determine risk level of exposure and level of PPE usage. And then "Laboratory Algorithm According to Risk Categories for HCWs who exposed to COVID-19" is applied as follow-up procedure (44) .

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The minimum PPE usage procedures are quite similar in Antalya ambulances compare the global applications. WHO (28) has recommended the use of gloves, masks and eye protection in minimum, and also emphasized to adequate PPE supply to meet minimum is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 19, 2020.  Hand disinfection recommended between wearing and removing pieces.

In the joint mission report of the WHO-China on COVID-19, it was recommended to the use of negative pressure ambulances and to study aims PPE for infection control and especially the most effective PPE use practices (47) . In this study we aimed to evaluate the use of PPE, by number of COVID-19 involved cases / infected HCWs.

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The copyright holder for this preprint this version posted June 19, 2020. This study is initial attempt to identify optimum PPE requirements to be used at emergency ambulance services in future outbreaks. In this study, it is aimed to evaluate the PPE use in Antalya 112 ambulance services by comparing risk level of HCWs. This descriptive, retrospective, cross-sectional study has been conducted between the dates of March 14th, 2020 -May 31st, 2020.

The results of the risk analysis (included the PPE use), the follow-up measures of HCWs and characteristic of confirmed COVID-19 (+) cases were analysed with frequency and percentage tests. The using medical mask on patient and the level of PPE used by HCWs were compared with the level of risk assessments with by using Pearson Chi-square test.

SPSS Statistics (Base v23) program was used to analyse to data.

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The copyright holder for this preprint this version posted June 19, 2020. Table 4 ).

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The copyright holder for this preprint this version posted June 19, 2020. . https://doi.org/10.1101/2020.06.16.20129171 doi: medRxiv preprint When team of ambulance departed for a case duty, the results of case may be differed according to general condition of patient and/or decision of teams. The COVID-19 (+) confirmed cases were resulted in "examination in place, transfer to healthcare facility, refusing transfer, and transport between facilities, transfer to home, exitus left in place" between the dates the study conducted. The highest percentage (75%) of confirmed COVID-19 cases, resulted in transferring to healthcare facilities (As shown Table 5 ). The rate of "transfers to healthcare facilities" is the most common result of ambulance cases at . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 19, 2020. . https://doi.org/10.1101/2020.06.16.20129171 doi: medRxiv preprint non-outbreak period as well. The "Transfer to Quarantine place" was emerged as a new type of result for ambulance cases which comes out during outbreak. The percentage of "transfer refuse" was 4,5% in confirmed cases. But in the whole cases (ordinary + possible cases: 115,777), "transfer refuse" was higher (March: 14%; April:

17%; May 14%) during outbreak than non-outbreak time which is 11 % average. This means that if patients are not suffering from COVID symptoms, they do not choose to use . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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an ambulance to access healthcare services. Fear of exposed to COVID-19 during transfer or in hospital, could be another reason for higher rate of ambulance transfer rejection.

According to the results of "Risk Level Assessment of HCWs who exposed to COVID-19" algorithm, the use of PPE is evaluated (As shown Table 6 ). For 787 case (patient), 2361

HCWs in total were on ambulance duty. According to profession, 73 of them are doctor, rest of them paramedic or emergency medicine technician. 

The indications which are needed to unmask patient, ambulance teams were tend to ready for . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 19, 2020. . https://doi.org/10.1101/2020.06. 16.20129171 doi: medRxiv preprint worst situation during transfers. That's why, ambulance team added extra gloves, coverall and sometimes aprons to routine PPE standard as a precaution. The total number of HCWs taken to risk analysis and then followed-up procedures were 2361; and 67 of them identified under the medium risk and 2081 of them under no risk assessment. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 19, 2020. . https://doi.org/10.1101/2020.06.16.20129171 doi: medRxiv preprint other staff has been found infected by COVID-19 from their shift. The follow-up procedures of infected HCWs have been finalized, both of them cured and follow-ups ended.

The level of PPE use, other measures against COVID-19 and awareness of HCWs are considered to be effective to achieve the results of this study. During the study conducted between March 14th, 2020 -May 31st, 2020; Antalya Ambulance teams intervened to 46% of whole COVID-19 confirmed cases in Antalya borderline. The rest of confirmed patients in Antalya, have directly applied to hospital, family physician, and other healthcare facilities or found by filiation (49) There were only 2 HCWs diagnosed with COVID-19: one of them from 112 call centre, and other one is from one of the ambulance station. Both of them were not exposed to . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted June 19, 2020. . https://doi.org/10.1101/2020.06.16.20129171 doi: medRxiv preprint COVID-19 (+) staff or patient during their shifts. COVID-19 exposure might had happened while they are off work. The procedures of HCWs' follow-ups has been finalized, and both of them cured, follow-ups ended.

Ongoing infection prevention and control studies in Antalya 112 Emergency Ambulance Services, have been effective in reducing the risk of HCWs exposure to COVID-19 and management of outbreak. Providing the supply of the PPE needed in time and without interruption, work planning, staff training program implementation, alternative scenarios planning for unexpected situations, staff participation in decision making process, were effective in managing the outbreak.

Furthermore, alternative plans and strategies specific to countries, regions and type of healthcare facilities; should be developed and implemented by following global practices and innovations. It is recommended that the studies to be conducted on easy-to-use, hightech PPE with maximum protection in future.

In addition to the standard PPE usage of the ambulance teams, the number of extra added PPE, could not be examined due time restriction and the lack of records and statistical data.

The additional strategies and decision making mechanisms which are used by HCWs during emergencies could not be searched and examined due to time restriction and over workload during outbreak.

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The copyright holder for this preprint this version posted June 19, 2020. . https://doi.org/10.1101/2020.06.16.20129171 doi: medRxiv preprint . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted June 19, 2020. . https://doi.org/10.1101/2020.06.16.20129171 doi: medRxiv preprint

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