Public Health Emergency - Leading a Nation Prepared
During the 2014 Ebola epidemic in West Africa, several individuals were transferred from West Africa to the United States by air ambulance. In each case, these patients had to be transferred from the air asset to a ground ambulance for transport to a receiving health facility. Air transport of patients presented unique logistical issues. This guide is intended to help health facilities and transport providers become better prepared to manage patients who have Ebola or other highly infectious diseases and must be transported by air. This guide is based on the experiences of air and ground transport providers, receiving health facilities, and federal agencies including the HHS Office of the Assistant Secretary for Preparedness and Response (ASPR), the Centers for Disease Control and Prevention (CDC), and the Department of State (DOS) in Ebola patient air-to-ground ambulance transfer.
This document provides guidance to aid in developing standard operating procedures for air-to-ground transfers of patients with Ebola or other serious infectious diseases that present unique patient transport challenges. The 2014 Ebola epidemic led to the publication of articles describing how infected patients in the United States were transported by ambulance in a manner that protected the safety of the patient and the providers.1, 2 The common elements include provider education/training; vehicle preparation; patient preparation; personal protective equipment selection and use;3 work practices;4 decontamination of the vehicle; doffing of PPE; and waste management. While the U.S. health care system continues to strengthen preparedness and response capabilities for serious infectious diseases such as Ebola, patients may present at facilities that are neither capable of treating them for the course of their disease nor in close proximity to an appropriate facility, thus necessitating transport using a combination of air and ground ambulances.
This guide is intended for use by representatives of state and local health departments, emergency management agencies, Ebola treatment facilities, and the ground ambulance providers conducting the actual transfer. All communication flows should follow the appropriate chain of command.
There are six elements specific to the air-to-ground transfer to consider when developing a standard operating procedure (SOP):
Several of these elements have overlapping components – particularly with regard to security – and some may need to be addressed simultaneously.
These elements must be addressed in the SOP developed but are likely not the only elements of the SOP that will guide the care and transport of a patient. Once the SOP is created, the procedure should be tested regularly through exercises.
While not the specific focus of this guide, the ground transport of a patient with a confirmed case of Ebola or other severe, highly infectious disease is a significant undertaking requiring substantial preparation and attention. Ground transport providers supporting facilities that have agreed to accept Ebola (or other highly infectious disease) patients should review materials published by CDC5 , ASPR6 , and the private sector providers with experience in this area7 and incorporate that information in an SOP.
One of the keys to a successful patient transfer is early communication with the relevant state and local government officials. At a minimum, this outreach should include the governor and the head of the state health authority and should be expanded as is appropriate for the jurisdiction(s) and organization(s) involved in the transfer. Some additional examples include representatives from local public health and emergency management agencies/organizations.
Conversations with partners should define clear roles and responsibilities as well as the lines of authority. All potential issues should be resolved, to the extent possible, well in advance of the aircraft departing for its final destination.
Airfield issues are another potential stumbling block for a successful transfer. A number of items must be considered prior to selecting the primary landing site:
To date, air transports have been done using relatively small aircraft (Gulfstream, etc.) consistent with traditional air ambulance provider assets. It is critical that all parties involved have full knowledge of the aircraft type and its requirements (runway length, fuel, tarmac stress, etc.).
It is critical to secure approval from the appropriate party and in writing for the use of any airfield.
Throughout the process, it is vitally important to include the appropriate law enforcement and/or security forces. Safety of the patient, medical providers, and the public is paramount. These transports will be very high profile. Any interference risks danger to the patient and crew as well as exposure of unprotected persons to Ebola or another highly infectious disease. Similarly, patient privacy and confidentiality must be protected.
In addition to the security issues, it is important to have a primary and at least one alternate travel route identified along with contingency plans for any unusual events (protests, flat tire/vehicle breakdown, traffic, etc.) that might arise during the ground transport.
Finally, anticipating and preparing for public interest and media attention in the patient transport increases the agency’s ability to manage the public reaction, prevent unnecessary public concern, and educate the community on the infectious disease. Best practices in crisis and emergency risk communications should be incorporated into the SOP. CDC offers free crisis and emergency risk communications resources, including guides and training.8 Keep the plan simple and flexible. Use it as a reference tool, not a step-by-step guide. Information should come from sources of information that are credible and trustworthy from the public’s perspective. Messaging should be proactive and short, use plain language, and adhere to risk communication principles. Identify, in advance, media relations and/or communications officers with experience in emergency risk communication. These individuals will be critical in managing the media interest in the transport and can coordinate with counterparts among community organizations, local, state, tribal and other federal agencies. They can, when necessary, provide communications guidance or talking points to leaders involved in the transport.
1 Lowe et. al. Considerations For Safe Ems Transport of Patients Infected With Ebola Virus. Prehospital Emergency Care, 2014.
2 Isakov et. al. Safe Management of Patients With Serious Communicable Diseases: Recent Experience With Ebola Virus. Annals of Internal Medicine, 2014.
3 Recommendations on Selection and Use of Personal Protective Equipment for First Responders against Ebola Exposure Hazards. The Interagency Board, 2014.
4 Isakov et. al. Transport and Management of Patients With Confirmed or Suspected Ebola Virus Disease. Annals of Emergency Medicine, 2015.
7 See notes 1, 2, 3, and 4 above.
8 Available at emergency.cdc.gov/cerc
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