Public Health Guidance for Community-Level Preparedness and Response to
Severe Acute Respiratory Syndrome (SARS) Version 2

Supplement I: Infection Control in Healthcare, Home, and Community
Settings

IV\. Infection Control for Prehospital Emergency Medical Services (EMS)

Effective communication among clinicians requesting emergency transport
of a patient with possible or known SARS-CoV disease, EMS personnel, and
receiving facilities is necessary to ensure the appropriate protection
of healthcare workers. Prehospital care personnel should follow the
updated Standard Precautions recommendations to prevent the spread of
respiratory infections described in III.B above. These include promoting
respiratory hygiene/cough etiquette
([www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm](http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm))
and using Droplet Precautions
([www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm](http://www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm)),
in addition to Standard Precautions, for all patients with symptoms of a
respiratory infection. When SARS is suspected in a patient needing
emergency transport, ***prehospital care providers and healthcare
facilities should be notified in advance that they may be transporting
or receiving a patient who may have SARS-CoV disease.***

## A. Patient Transport

> **Objective:** Safely transport patients with known or possible
> SARS-CoV disease.

**Activities**

> Patients who may have SARS-CoV disease may be safely transported in
> any emergency vehicle with the proper precautions.

-   Involve the fewest EMS personnel required to minimize possible
    exposures.

-   Family members and other contacts of SARS patients should not ride
    in the ambulance if possible. If necessary, they should be evaluated
    for fever and lower respiratory symptoms and, if either is present,
    asked to wear a surgical or procedure mask when riding in the
    vehicle.

-   When possible, use vehicles that have separate driver and patient
    compartments that can provide separate ventilation to each area.
    Close the door/window between these compartments before bringing the
    patient on board. Set the vehicle's ventilation system to the
    non-recirculating mode to maximize the volume of outside air brought
    into the vehicle. If the vehicle has a rear exhaust fan, use it to
    draw air away from the cab, toward the patient-care area, and out
    the back end of the vehicle. Some vehicles are equipped with a
    supplemental recirculating ventilation unit that passes air through
    HEPA filters before returning it to the vehicle. Such a unit can be
    used to increase the number of ACH (NIOSH HETA report 95-0031-2601
    \[[www.cdc.gov/niosh/hhe/reports/pdfs/1995-0031-2601.pdf](http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0031-2601.pdf)\]).

-   If a vehicle without separate compartments and ventilation must be
    used, open the outside air vents in the driver area and turn on the
    rear exhaust ventilation fans to the highest setting. This will
    create a negative pressure gradient in the patient area.

-   If possible, place a surgical mask on the patient to contain
    droplets expelled during coughing. If this is not possible (i.e.,
    would further compromise respiratory status, difficult for the
    patient to wear), have the patient cover the mouth/nose with tissue
    when coughing.

-   Oxygen delivery with a non-rebreather face mask may be used to
    provide oxygen support during transport. If needed,
    positive-pressure ventilation should be performed using a
    resuscitation bag-valve mask, preferably one equipped to provide
    HEPA or equivalent filtration of expired air.

-   If a patient has been mechanically ventilated before transport, HEPA
    or equivalent filtration of airflow exhaust should be available.
    (EMS organizations should consult their ventilator equipment
    manufacturer to confirm appropriate filtration capability and the
    effect of filtration on positive-pressure ventilation.)

-   Cough-generating procedures (e.g., mechanical ventilation, nebulizer
    treatment) should be avoided during prehospital care.

## B. Personal Protective Equipment

> **Objective:** Ensure the safety of prehospital care providers who
> transport patients with known or possible SARS-CoV disease.

**Activities**

-   Prehospital care providers who directly handle a patient with
    SARS-CoV disease or who are in the compartment with the patient
    should wear PPE as recommended for Standard, Contact, and AII
    Precautions. These include the following:

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-   Disposable isolation gown, pair of disposable patient examination
    gloves, eye protection (i.e., goggles or face shield).

-   Respiratory protection (i.e., N-95 or higher-level respirator)

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-   Personnel in the driver's compartment who will have no direct
    patient contact should wear an N-95 or higher-level respirator
    during transport. Drivers who also provide direct patient care
    (e.g., moving patients on stretchers) should wear the recommended
    PPE for patient contact. This PPE, with the exception of the
    respirator, should be removed and hand hygiene performed after
    completing patient care and before entering driver's compartment to
    avoid contaminating the compartment. Instructions on how to safely
    don, use, and remove PPE is being developed and will be provided
    when available on CDC's SARS website:
    [www.cdc.gov/ncidod/sars/](http://www.cdc.gov/ncidod/sars/).

## C. Safe Work Practices

> **Objective:** Ensure safe work practices among EMS personnel to
> prevent transmission of SARS-CoV.

**Activities**

-   Avoid touching one's face with contaminated gloves.

-   Avoid unnecessary touching of surfaces in the ambulance vehicle.

-   Arrange for the receiving facility staff to meet the patient at the
    ambulance door to limit the need for EMS personnel to enter the
    emergency department in contaminated PPE. (It may not be practical
    to change PPE before patient transfer into the facility.) Remove and
    discard PPE after transferring the patient at the receiving facility
    and perform hand hygiene. Treat used disposable PPE as medical
    waste.

## D. Clinical Specimens

> **Objective:** Safely collect clinical specimens from SARS patients
> during transport.

**Activities**

-   Handle clinical specimens that must be collected during transport
    (e.g., blood gas) in accordance with standard operating procedures.

## E. Post-Transport Management of the Contaminated Vehicle

> **Objective:** Safely clean vehicles used for transport of SARS
> patients to prevent SARS-CoV transmission.

**Activities**

-   Follow standard operating procedures for the containment and
    disposal of regulated medical waste.

-   Follow standard operating procedures for containing and reprocessing
    used linen. Wear appropriate PPE when removing soiled linen from the
    vehicle. Avoid shaking the linen.

-   Clean and disinfect the vehicle in accordance with standard
    operating procedures. Personnel performing the cleaning should wear
    a disposable gown and gloves (a respirator should not be needed)
    during the clean-up process; the PPE should be discarded after use.
    All surfaces that may have come in contact with the patient or
    materials contaminated during patient care (e.g., stretcher, rails,
    control panels, floors, walls, work surfaces) should be thoroughly
    cleaned and disinfected using an EPA-registered hospital
    disinfectant in accordance with manufacturer's recommendations.

-   Clean and disinfect reusable patient-care equipment according to
    manufacturer's instructions.

## F. Follow-up of EMS Personnel 

> **Objective:** Ensure appropriate follow-up and care of EMS personnel
> who transport SARS patients.
>
> **Activities**

-   Manage EMS personnel who transport SARS patients as recommended for
    hospital personnel (see Section IX).

For more information, visit
[www.cdc.gov/ncidod/sars](http://www.cdc.gov/ncidod/sars/) or call the
CDC public response hotline\
at (888) 246-2675 (English), (888) 246-2857 (Español), or (866) 874-2646
(TTY)