The current pandemic has resulted in an extraordinary amount of clinical practice changes for paramedics. The following is a list of all of the clinical and operational changes implemented during COVID-19 in chronological order. This list is current up to October 31, 2020 and includes all changes currently in effect. Original updates can be viewed in the BCEHS Handbook using the COVID-19 tab on the front page --> COVID-19 Clinical Practice Dashboard.

The most recent version of each change is listed. Previous versions of amended updates, and those discontinued, are not included in this list.

Please refer to the BCEHS Handbook for details on these clinical interventions and practice changes or email clinicalpractice@bcehs.ca for any questions.

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March 18, 2020

Discontinuation of Nebulized Medications
All nebulized medications are discontinued. Metered dose inhalers (MDIs) and spacers can be used in the place of nebulized salbutamol and ipratroprium bromide. See the BCEHS Handbook for dosing of these medications.

Use Extreme Caution During Tracheal Intubation by Critical Care Paramedics
CCPs are permitted to perform tracheal intubation using rapid sequence induction and the safest and best practices while wearing airborne PPE.

ILI/COVID Secondary Triage Pathway
An SOP was developed to allow assessment of patients over the phone who presented with ILI/COVID-19 symptoms using CDC information and Manchester Triage.

March 19, 2020

Extra Precautions Required for CPR (also updated March 22, 2020)
Paramedics are required to wear airborne PPE (N95/EHFR, face shield, gown, gloves) before initiating CPR and resuscitation. A surgical mask should be placed over the patient’s face before initiating CPR. Defibrillation, when indicated, should be administered as early as possible. If required, the airway should be managed using an iGel with a viral filter pre-connected before insertion or 2-person bag-valve-mask ventilation using a viral filter and a tight mask seal.

Discontinuation of Nebulized Epinephrine for Croup
Epinephrine should not be nebulized for croup. Clinical and Medical Programs and BC Children’s Hospital specialists are investigating alternatives for paramedic management of croup. Watch for a future practice update.

Avoid Use of Nitrous Oxide (Entonox)
Paramedics should avoid using Entonox where possible and consider the use of oral acetaminophen or ibuprofen in addition to other pain management interventions including the application of cold packs, splinting and elevating limbs, and transporting in the position of comfort. When using Entonox, paramedics should ensure an inline filter is used and the patient inhales and exhales through the mouthpiece to reduce AGMPs.

ACP Management of Foreign Body Airway Obstruction (FBAO)
Direct laryngoscopy should be avoided. When removing a FBAO, paramedics should use video laryngoscopy and wear airborne PPE.

March 20, 2020

Use of Ambulance Cab and Patient Care Area Divider
The slider window between the ambulance cab and patient care area should be closed during the transport of all patients. Fans and vents should be adjusted to create a positive pressure environment in the cab and a negative pressure environment in the patient care area. If transporting a suspected or confirmed COVID-19/ILI patient and an AGMP will be performed, the driver must (or continue to wear) wear a fit tested respirator.

Ibuprofen Not for Use in Patients with Suspected COVID-19 Including Fever
If required, acetaminophen should be used for patients with suspect COVID-19 and ibuprofen should not be used.

March 22, 2020

Airway Management Update – CPAP
CPAP should be used with extreme caution. Paramedics will wear airborne PPE when administering CPAP. If possible, CPAP should be discontinued prior to entering the emergency department and resumed when the patient is in an appropriate patient care area (i.e. negative pressure room).

Oxygen Administration Update – Oxygen Flow Rates (also updated March 31, 2020)
Paramedics should use the lowest oxygen flow rate possible to achieve an SpO2 of 90%. The maximum flow of a nasal cannula should be 5lpm. The maximum flow of a partial or non-rebreathing mask should be 15lpm. A nasal cannula may be placed under an NRB, CPAP or BVM when flow rates above 5lpm are required.

Oxygen Administration Update – Suction
Suction only when necessary. Exercise extreme caution when applying oral, nasal, orogastric, nasogastric, and endotracheal suction wearing airborne PPE.

N95 Safe Duration of Use and Face Shield Re-use
The elastomeric half-face respirator (EHFR) is the primary device to be used for respiratory protection during COVID-19. If an N95 is worn, it can be used for the full duration of a shift. The N95 mask and/or face shield should be replaced or discarded if it becomes grossly contaminated with blood, secretions, or body fluids. The N95 respirator and/or face shield must be discarded if it becomes obviously soiled or damaged (e.g., creased, torn, or saturated) or if visibility is impaired.
Reminder that paramedics should wear an N95 and not an EHFR when caring for vulnerable patients or when working in a sterile environment because the exhalation valve on the EHFR is not filtered.

March 23, 2020

Telephone CPR – Advice to Callers (also updated April 6, 2020)
Emergency call takers now advise the public to provide hands-only CPR for adults in cardiac arrest and to cover the patient’s mouth and face. Advice to the public when treating an infant or children in cardiac arrest recommends both chest compressions and mouth to mouth ventilation (if the bystander is willing and able), recognizing that arrests in this age group are often caused by hypoxia and the likelihood that the public responder will be a parent or family member of the patient.

CPR and BVM for EMR and FR Licensed Responders
Airway management by EMR and FR licensed responders who cannot insert an iGel should provide a tight seal with the BVM using a 2-person technique where possible. Chest compressions should pause for ventilation using a 30:2 ratio. An inline viral filter should be used between the mask and the bag-valve device.

March 25, 2020

Intramuscular Epinephrine for Adult and Pediatric Asthma
Epinephrine via intramuscular injection should be considered for a patient with SpO2 <90% and moderate to severe symptoms of asthma that are unresolved with the use of salbutamol administered by metered dose inhalers

March 26, 2020

Intranasal Medication Administration – Restriction and Caution
Use of IN medication administration in patients that are screened positive for COVID-19 is fully restricted. Patients without signs and symptoms of COVID-19 can receive IN medications and the paramedic requires airborne PPE. If IN medications are administered in an aircraft, ensure the pilots have donned PPE including an N95 mask and eye protection.

Use of Patient Salbutamol (Ventolin)
Due to world-wide shortages of some medications, paramedics are asked to use a patient’s own prescribed salbutamol MDI, providing it is in working order and in date. Bring the patient’s salbutamol MDI to the hospital for ongoing use.

CO detector location
While wearing PPE gowns paramedics should consider placing the detector in a location where the sensor is not blocked.

April 3, 2020

Discontinuation of Adult Resuscitation Attempts
Contact CliniCall at 15 minutes or earlier if ALL early discontinuation criteria are met: Unwitnessed cardiac arrest, and; No shocks delivered; and; No period of return of spontaneous circulation (ROSC). This includes traumatic causes of cardiac arrest, where early discontinuation is likely unless a penetrating injury in the cardiac window is present, or paramedics witness the loss of vital signs, and there is < 10 minutes to the nearest emergency department. See the full practice update for more details.

April 6, 2020

PPE Requirement in Postnatal Care
In order to minimize the chance of neonatal infection with COVID-19, where out-of-hospital birth has occurred: 1) The mother should be provided with a surgical mask and assisted to complete proper hand hygiene PRIOR to skin-to-skin contact or feeding, 2) If a birth partner is present, the same process should be applied. If the birth partner is displaying symptoms of COVID-19 they should not handle the child.

April 15, 2020

iGel Pharyngeal Suction
Primary Care Paramedics are now permitted to use a modified approach to the in-built suction port available on all iGel supraglottic devices to provide pharyngeal suction during cardiac arrest.

April 17, 020

Safe Care of Deceased Persons
Extra caution is required for ALL patients who undergo recognition of life extinct (ROLE) on scene. Any individual not wearing PPE, including mourners, should avoid contact with the deceased person. Paramedics should endeavor to explain the risks of close contact to mourners and support a physically distant grieving process, but with respect for cultural and religious practices.

In situations where mourners are in close contact with the body, the mourner should be encouraged to avoid touching the facial area or any area with potential bodily fluid exposure. Support mourners to perform hand hygiene following any contact. PPE should not routinely be provided. Paramedics should continue to wear airborne PPE when caring for a deceased person, including an N95, gloves, gown and face shield. If an inline filter has been attached to a supraglottic airway or tracheal tube, this should be left attached during handling.

In communities where paramedics are responsible for, or assist in, the transport of the deceased, the decedent should be placed in a body bag prior to leaving the scene and the exterior of the body bag wiped down on completion of transport and handling.

April 21, 2020

Influenza Like Illness Reporting for Community Paramedic Clients
An Influenza Like Illness (ILI) assessment is now available to support Community Paramedic patient’s screening for ILI symptoms and identify the risk of having been exposed to the coronavirus.

April 24, 2020

Approach to Pediatric Cardiac Arrest
Chest compressions and ventilations should be provided at a ratio of 15:2, with pauses to allow for ventilation. Where available, a pediatric iGel may be a preferable airway management strategy if sufficient face mask seal is difficult to obtain or maintain. Endotracheal intubation should not be performed in pediatric patients who do not show signs of puberty, generally those less than 12 years old. Direct laryngoscopy is permitted in pediatric patients ONLY for the removal of foreign body airway obstruction. Initiate appropriate resuscitation on scene (airway management/ventilations, chest compressions, and defibrillation as required) and then consider expedited transport to and appropriate hospital.

Advanced Airway Management by ACPs in Cardiac Arrest during COVID-19
In cases of cardiac arrest where effective ventilation and oxygenation cannot be achieved with an iGel, and where two-person bag-valve-mask technique may not be suitable, tracheal intubation can be considered using video laryngoscopy (VL), when it is safe to do so.

Restrictions remain on intubation of any patient not in cardiac arrest. Rare but life-threatening situations, including impending airway obstruction from upper airway burns or severe anaphylaxis should be discussed with CliniCall to make a risk versus benefit decision.

COVID-19 Cardiac Arrest Checklist
Communication, crew resource management and leadership during the management of a cardiac arrest is paramount, however, with the additional PPE requirements and stress of the situation it is acknowledged that communication can be difficult. To provide support to paramedics managing cardiac arrest an updated cardiac arrest checklist is now available in the BCEHS Handbook which will assist in improving team situational awareness, leadership, and communication during the resuscitation.

April 27, 2020

ILI/COVID-19 Assess/See/Treat/Refer (ASTAR) Clinical Pathway
This pathway allows paramedics to ensure a comprehensive assessment is completed and documented for patients who remain at home following clinician assessment, as well as ensuring these patients are subsequently reconnected with the healthcare system as required.

NEWS-2 Score
This has been added to the vital signs section to complement the ILI/COVID-19 ASTAR Clinical Pathway.

Paramedics to track use of Personal Protective Equipment in SIREN
Paramedics are required to complete a section called “Supplies Used/ PPE” in the SIREN ePCR to help BCEHS determine what PPE was used on any given event; as well as assist the ECC with determining inventory levels.

May 1, 2020

Cardiac Arrest-Transport of Patients without Return of Spontaneous Circulation
BCEHS and the Canadian Association of Emergency Physicians (CAEP) guidelines recommend that for patients transported to hospital, without return of pulses, that the patient should be assessed in the ambulance bay at the ED, by a physician wearing appropriate PPE, with consideration of pronouncement there, rather than bringing the patient into the emergency department.

Needle Thoracentesis Aerosol Generating Medical Procedure (AGMP)
Prehospital needle thoracentesis should be considered AGMP. Although this is a low occurrence procedure, it does potentially expose the practitioner to an increased risk of exposure. If this procedure is needed, crews are directed to proceed with airborne PPE including face-shield, EHFR/N95 mask, gown and gloves.

September 15, 2020

COVID-19 Personal Protective Equipment (PPE) Point of Care Risk Assessment and Guideline Change (also updated October 1, 2020)
A point of care risk assessment is used to determine the risk of COVID-19 and Influenza Like Illness (ILI). In situations where there is a negative screen, paramedics can revert to standard PPE as per the BCEHS Exposure Control Plan. Based on this risk assessment, paramedics will have the option of wearing a procedural mask and following routine practices and any additional precautions as per the Exposure Control Plan for non-COVID-19 specific reasons. A comprehensive frequently asked questions document was posted on October 1, 2020.

 

November 26, 2020

COVID-19 Personal Protective Equipment Update - Face Shields required for all patient contacts & procedure masks required over EHFR
To further protect paramedics and patients from potential asymptomatic carriers, effective immediately, BCEHS requires paramedics to wear a face shield in addition to a procedure mask and gloves for all patient contacts. In addition, because the exhalation valve on elastomeric half face respirators (EHFR) is not filtered, effective immediately, paramedics are required to wear a procedure mask over the exhalation port in order to protect patients, caregivers and our colleagues.

 

December 1, 2020

This update is intended to provide ACPs with information about the recent changes to advanced airway management during COVID-19.

For patients in cardiac arrest:

The iGel supraglottic airway with a viral filter remain the primary adjunct for airway management. Intubation should only be considered when paramedics are unable to obtain or maintain an effective seal with an SGA and when the patient cannot be effectively oxygenated by any other means, including a bag-valve-mask device. CliniCall consultation is not required.

• Video laryngoscopy remains the preferred approach for tracheal intubation for all patients. Direct laryngoscopy may be required in some cases of foreign body airway obstruction but should otherwise be avoided.
• Paramedics shall make no more than two attempts (per patient) at laryngoscopy following a systematic staged approach to optimize the probability of first-pass success.
• Reversion to bag-and-mask ventilation with a tight seal and viral filter should be used if tracheal intubation and SGA placement fail.

For patients with perfusing rhythms, or who are breathing spontaneously:

• SGAs are to be used as the principal advanced airway management device.
• Where SGAs and/or bag-valve mask ventilation fail to provide adequate oxygenation, tracheal intubation may be permissible in cases where paramedics are otherwise unable to obtain and maintain a patent airway. To be clear, this is for actual or immediately impending failure of airway patency unable to be managed by any other means other than intubation.
• CliniCall must be consulted prior to attempting intubation. The appropriateness of intubation will be predicated on:
  a. Whether all other airway intervention options have been exhausted.
  b. The predicted clinical course of the patient, including expected complications during transport.
  c. The logistical aspects of transport, including availability of trained and qualified personnel.
  d. The time required to reach definitive airway management (as distinct from the transport time to hospital).
  e. The known or predicted degree of COVID-19 risk presented by the patient and the environment and the ability for the paramedics on scene to mitigate the risk.