ReIGNITE Quick Take: COVID-19 response – where to next?

Global Medical Response, the parent company of ambulance service American Medical Response (AMR), first began preparing for COVID-19 in January – the same month the Centers for Disease Control and Prevention confirmed the first case of the novel coronavirus in the United States. In hindsight, fire and EMS departments across the country should have been preparing for such a pandemic long before then, explained GMR Chief of Fire & Federal Services Mike Ragone.

COVID-19 became a wake-up call for public safety departments across the country that responded rapidly and dutifully to the national health threat but did so despite PPE stockpiles or outbreak protocols that could address the unprecedented impact this disease has had on every aspect of emergency response.

Ragone presented “COVID Response and Where to Next?” at the IAFC ReIGNITE Virtual Conference, reviewing the timeline of GMR’s response to the outbreak, lessons learned, and guidance for evolving public safety to always be prepared for another infectious disease emergency. After all, preparedness shouldn’t have only started with, and shouldn’t end with, COVID-19.

Notable quotes about COVID-19 response and preparing for future outbreaks

• “Many tools were developed out of these responses that we’re still using today that are pretty amazing. Many of our folks likened it to ‘repairing the motor as we’re flying the aircraft.’”

• “The end of March, beginning of April, [we] instituted 100% masked — you’re not allowed to be around the premises without a mask on, and that was to protect and reduce communication [of the virus]. We ended up with a less communicable rate downrange than we actually saw throughout the country, in most first response organizations. Way overboard in terms of watching people ... but quite frankly, well worth it in my opinion.”

• “We have got to start looking at infectious control standard training, crisis [standards] of care. We struggled the beginning of these responses with should we do CPR, should we not do CPR? Should we use ventilators, should we not use ventilators? What does the aerosolizing of COVID look like? We need to know that before, not in the heat of the battle.”

• "[Since 1970] there have been 40 emerging infectious diseases ... the rate of those has increased. We’re getting them more often. Currently, as we sit right here today, there’s 27 of them out there, 13 of which do require quarantine. So it’s not like COVID-19 is it once we get done, we’re golden, we can move on. There are many more of these.”

• “EMS has got to get a voice and the voice has got to be as good as the healthcare system’s, cause they had a voice. Nursing homes had a voice here, hospitals had a voice here, EMS tended to lack a voice ... We’re still hearing about systems that cannot get PPE, they cannot get the equipment and stuff to protect themselves. So I task everybody on this call with – you’ve got to get that voice, we’ve got to get it in front of the folks that make the decisions.”

Key takeaways about COVID-19 response

Over the last nine months, GMR crews have been deployed throughout the country, not only responding directly to the COVID-19 threat but also to other disasters that have occurred in tandem, namely hurricanes that struck the Gulf Coast this summer. Ragone detailed the experiences and lessons from each deployment and the innovations made along the way.

‘Not in Kansas anymore': Early efforts by GMR included assisting with airport screenings by Jan. 23, implementing a “nurse navigation” assessment tool for employees by Jan. 24, and activating a national command center by Jan. 28.

The first major deployment was to New York in March where, over a total of 61 days, GMR activated 350 ambulances and 1,318 personnel, and conducted more than 34,000 missions and 17,000 transports. By then, everything providers knew about disaster response had changed, and people realized they “weren’t in Kansas anymore.” Everything transformed – where personnel were sheltered, how they ate, what they needed to wear and disinfect on every call, and how daily briefings were conducted. Providers dealt with “information overload,” and the service’s nurse navigation phone line was overrun with questions and concerns.

Despite the immense challenges and uncertainty, many lessons and positive experiences also came out of New York – GMR quickly added specialized infection control nurses to its nurse navigation resource and implemented mental health programs to assist members while they were deployed. Ragone characterized New York’s public safety community as very welcoming and not “territorial,” which led to successful cooperation in tackling their shared mission. Additionally, overwhelming community support from locals and on social media boosted morale and helped keep people going throughout the response.

GMR continued to take these lessons and improve its system through further deployments to New Jersey and Texas. In Texas, crews with met with a duel threat when a Category 1 hurricane passed over, delaying some response efforts. This would not be the last natural disaster to coincide with COVID-19 response this year.

Disasters don’t stop during a pandemic: In August, GMR sent more than 300 ALS ambulances, 25 aircraft and paratransit vehicles with 3,500 seats to Texas and Louisiana for Hurricane Laura response. One lesson learned from this mission was that the need to social distance patients and evacuees created the need for twice as many paratransit resources, as an ambulance bus that could normally carry 10 people would have seats spaced apart, reducing its capacity to five.

Hurricane Laura made landfall on Aug. 27, and the last crews were demobilized just last week, making it a longer deployment than usual. GMR staff stayed on site running 911 responses at shelters in New Orleans, which in this case were hotels rather than the large shelters typically seen during disasters.

GMR also assisted with Hurricane Delta response, which struck in early October around the same area as Laura. The biggest concern at this point was power supply, and crews stood by for dozens of nursing homes running on generators in case residents needed to be evacuated.

Ragone emphasized that not only should public safety departments be training and drilling for infectious disease response in the same way they train for hurricane and earthquake response, but they should be preparing for crisis standards of care when an outbreak and a natural disaster strike together, limiting resources and compounding threats to life and safety. Agencies should proactively create protocols to sufficiently prepare for a variety of these situations, rather than reactively developing procedures while the disaster is unfolding, especially in a dynamic situation where a protocol developed one day could become obsolete the next day as new information comes in.

Short-term impacts

Ragone outlined the short-term impacts of the pandemic that agencies will continue to see in the coming weeks and months, issues that are directly impacting their providers and organizations and need to be addressed immediately to mitigate devastating consequences down the line.

Recruitment and retention: The biggest impact is the human impact, the most obvious form being illness and the loss of life. It goes without saying that the safety and health of caregivers should always be top priority. But another human impact coming to the forefront is the loss of the “pipeline” of students and “a whole pool of people that are going, ‘I’m not even going to choose that path because I’m not going to play with invisible bugs.” Ragone said.

Ragone estimated that the closing of schools and limitations of virtual education will stem the flow of new employees, setting back recruitment by six months to a year.

Retention is also suffering, with some providers “literally turning in their certifications, turning in their paramedic licensure, turning in their EMT certifications and choosing not to renew their certificates.”

“In an industry that was already struggling with staffing and enough people, providers, things like that, I think this is truly going to be something that we here are going to have to collaborate ... we’re going to have to work together on this because this is really going to be a challenge for us,” Ragone said.

Economic impact: Many local governments are estimating revenue losses of 25-30% due to the pandemic, leading to furloughs, layoffs and other cuts to fire and EMS budgets. Many EMS transport agencies saw decreases in transports from 20-50% at the height of the pandemic, and widespread unemployment has led many patients to lose higher-paying commercial health insurance, further compounding the financial losses. Ragone said transport systems need to identify and adapt to their “new normal” as the pandemic continues and going forward.

Mental health: A third short-term concern is the impact on the psychological well-being of providers dealing with “stress on top of stress,” fear, burnout and the lack of an “escape” through usual outlets like going to the gym or to social events. Ragone said agencies need to take a closer look at their mental wellness programs, and take the time to search for programs that truly work — it’s not enough to say you have something in place if that something isn’t meeting your members’ needs or isn’t easily accessible. GMR has its own caregiver well-being program in place that includes resources for stress and grief management, resources for parents and children, specific resources for deployed members and a crisis text line.

Long-term impacts and what’s next?

PPE paradigm change: Ragone said that a major long-term effect of the pandemic will be a paradigm change in terms of PPE, both in ensuring an adequate supply of PPE at all times and in encouraging caregivers to wear their PPE regularly. Ragone compared N95 respirators to SCBAs, bringing up the “old days” of firefighters thinking they didn’t need them, and said all providers should be fit-tested for their respirators and ready to wear them, not only for an outbreak on the scale of COVID-19 but for any situation in which they might need one.

A seat at the table: Another focus that will remain important long after the pandemic is the need for EMS to have a voice and a seat at the table to be recognized by those charged with their safety, funding and resources. Ragone noted that early on, some governments were not providing priority testing for EMS providers, even if they were exposed or symptomatic, leading to many to end up out sick or quarantined for long periods of time when they were needed the most.

There have been some improvements, with many vaccine distribution plans including EMS providers in the top priority group to receive immunization. But Ragone stressed that EMS providers, leaders and organizations need to continue to make their voices heard in order to improve the outlook for the industry going forward.

Not the last pandemic: Ragone repeatedly emphasized the need for public safety to recognize that the end of COVID-19 will not be the end of infectious disease preparation and response. With 27 emerging infectious diseases currently out there, including 13 that require quarantining of exposed and infected individuals, Ragone said it is not realistic to think that a COVID-19 vaccine or herd immunity will solve everyone’s problems. Agencies need to take the lessons learned from this pandemic to develop and implement the tools, strategies, procedures and training that could have prepared them for COVID-19, and will prepare them for any other invisible enemy that comes their way.