Infection prevention and control recommendations for medical evacuation by aircraft of patients with suspected or confirmed COVID-19 from remote and isolated communities in Canada’s North

October 2, 2020

On this page

• Introduction
• Assumptions for development of recommendations
• Patient (suspected or confirmed COVID-19)
• Escort
• Flight crew
• Medical evacuation personnel (personnel)
• Patient care equipment and environment
• Strategies to reduce production of aerosols during aerosol-generating medical procedures
• Bibliography
• Acknowledgements

Introduction

The Public Health Agency of Canada (PHAC) develops evidence-informed infection prevention and control (IPC) guidance to complement provincial and territorial public health efforts in monitoring, preventing, and controlling healthcare-associated infections. The purpose of this document is to provide IPC guidance for the medical evacuation of patients with suspected or confirmed COVID-19 by air, based on current PHAC COVID-19 guidance and the PHAC Routine Practices and Additional Precautions guidance. This document should be read in conjunction with relevant provincial, territorial and local legislation, regulations, and policies.  

Recommendations in this document refer to the minimum IPC measures needed for the medical evacuation of patients with suspected or confirmed COVID-19. Existing local public health and airline industry directives (e.g., symptom screening and temperature checks) as well as organizational standard operation procedures (that consider engineering controls such air flow, etc.) may have additional recommendations and requirements.

Assumptions for development of recommendations

1. The medevac is a non-commercial, medical evacuation flight dedicated for the transport of a patient.
2. There are pre-existing organizational infection prevention and control (IPC) policies and procedures that align with routine practices and additional precautions, including cleaning and disinfection and waste management.
3. Medical evacuation personnel are healthcare workers (HCWs) arriving by the air transport and who will have direct contact with the patient.
4. Medical evacuation personnel follow appropriate precautions based on local public health advice or directives if required to go into the community (rather than the local staff transporting the patient to the aircraft).
5. All personnel on the aircraft have been trained in putting on and removing personal protective equipment (PPE), and basic IPC principles.
6. Appropriate personnel on the aircraft (e.g., medical evacuation personnel or flight crew) will be pre-identified to provide instructions on relevant COVID-19 public health measures and PPE to the patient, escort and any ground personnel that may board the aircraft.
7. The escort may be infected with COVID-19.

Patient (suspected or confirmed COVID-19)

Appropriate flight personnel (e.g., medical evacuation personnel or flight crew) should ensure that the patient:

• Receives instruction on in-flight IPC and public health measures (e.g., why, how and when to perform hand hygiene and put on a medical mask, respiratory etiquette). If patient is unable to perform independently, flight personnel should facilitate these measures.
• Wears a medical mask if medically tolerated for duration of flight and afterwards until admitted to room in healthcare facility under appropriate additional precautions (i.e., single room, droplet and contact precautions).
  • If the mask is not tolerated, the patient should be instructed on respiratory hygiene/cough etiquette and provided with tissues, alcohol-based hand rub and a waste receptacle/bag.
  • While there is no available evidence to support the use of a face shield as a sole means of source control for COVID-19, it may be reasonable to consider the use of a face shield if a patient cannot tolerate a mask.
• Changes the medical mask when visibly soiled or wet—does not reach into clean supplies of PPE (e.g., box of masks or gloves) unless the box is provided for their sole use.
• Performs hand hygiene prior to entering the aircraft and as per usual hand hygiene recommendations for public health measures or under direction of in-flight personnel.
• Performs hand hygiene after using the toilet facilities, coughing or sneezing.
• Has access to toilet facilities nearby (if feasible).
• Is positioned as far downwind as possible, with regards to cabin air flow; where feasible, the airflow of the aircraft should form the basis of seat assignments.

Escort

• Appropriate flight personnel (e.g., medical evacuation personnel or flight crew) should ensure the escort is not symptomatic (e.g., new or worsening respiratory symptoms, fever, shortness of breath, etc.) prior to boarding the aircraft and follows existing local public health and airline industry directives on symptom screening. Refer to the full list of COVID-19 symptoms.
• If the escort is symptomatic, COVID-19 positive within the last two weeks, or has been in contact with someone who tested positive for COVID-19 within the last two weeks, they should not board the aircraft, as their clinical situation will need to be evaluated and managed accordingly. If there is no other option and the escort must accompany the patient, follow the same IPC measures as for the patient.
• If the escort is asymptomatic, they should perform hand hygiene as per usual hand hygiene recommendations for public health measures and should be provided with a medical mask to wear and instructions on its use, when boarding the aircraft.
• The escort should wear a medical mask and maintain a 2-metre distance from the patient for the duration of the flight, if feasible.
• If it is not feasible for the escort to maintain a 2-metre distance from the patient during the flight appropriate flight personnel (e.g., medical evacuation personnel or flight crew) should:
  • Instruct the escort on when and how to perform hand hygiene.
  • Provide the escort with a gown, medical mask, gloves, and face or eye protection (e.g., face shield or goggles).
  • Instruct the escort on how to put on and remove PPE.
• In the situation where aerosol generating medical procedures (AGMP) must be performed:
  • Medical evacuation personnel should instruct the escort to distance themselves as much as possible from the location of the AGMP.
  • If the escort has been fit-tested for an N95 respirator (e.g., the escort is a healthcare professional), appropriate flight personnel should provide them with the respirator in addition to a gown, gloves and face or eye protection (e.g., face shield or goggles). 
  • If the escort has not been fit-tested, the medical evaluation personnel should brief the escort on application of available respirators (e.g., Universal size) to be worn in addition to the other identified PPE, if feasible and medically tolerated. The escort should be made aware that in the absence of fit-testing, there is a risk of being exposed to aerosols and that they will be managed as per local public health directives.

Flight crew

• If feasible, they should have no direct contact with the patient, maintain a 2-metre distance from the patient at all times, wear a medical mask and follow the same guidance as for escort.
• If a 2-metre distance is not feasible, flight crew should follow the same guidance as for medical evacuation personnel.

Medical evacuation personnel (personnel)

• Routine practices are in place for all patients, at all times, in all healthcare settings.
• Perform hand hygiene as per best practices.
• In addition to following routine practices, implement contact and droplet precautions which includes:
  • Wearing a long sleeved cuffed gown, gloves, medical mask and face or eye protection (e.g., face shield, mask with visor or goggles).
• If standard operating procedures for the medical evacuation company includes the use of a respirator:
  • The respirator (fit-tested N95 or higher level of protection) replaces the mask, but face or eye protection is still required, such as a face shield or goggles.
• In the situation where an AGMP (e.g., intubation) must be performed during the flight):
  • All personnel should replace the mask with a respirator that they have been fit tested for.
  • Face or eye protection is required, if not already worn.
  • Refer to strategies (see below) that should be applied to reduce level of aerosol generation.
  • If feasible, the personnel should instruct all individuals to move as far away as possible from the area where the AGMP is being performed.
  • If feasible, a physical barrier (e.g., drape) should be used to separate those who are not essential to performing the AGMP from those that are.
  • In the exceptional situation that not all individuals are appropriately protected (e.g., escort present during AGMP), those individuals should be considered as potentially exposed and managed as per local public health directives.

Patient care equipment and environment

• After the patient and escort have disembarked, terminal cleaning and disinfection should be completed to prevent transmission to other individuals via fomites. Environmental cleaning products registered in Canada with a Drug Identification Number (DIN) and labelled as a broad-spectrum virucidal agent are sufficient for SARS-CoV-2.
• Disinfection should include:
  • Reusable patient care equipment (e.g., stethoscope).
  • The patient compartment and care environment.
  • All high-touch surfaces in the aircraft, including in the cockpit.
• PPE should remain on until cleaning and disinfection is completed in the aircraft.
• No special precautions are recommended for waste management; routine practices should be used.

Strategies to reduce production of aerosols during aerosol-generating medical procedures

This section was extracted from the PHAC Routine Practices and Additional Precautions guidance.

Strategies should be applied to reduce the level of aerosol generation with suspect or confirmed COVID-19 cases during a Medevac flight. AGMPs should be limited to those that are medically necessary; examples include intubation and related procedures, bronchoscopy, sputum induction, and non-invasive positive pressure ventilation such as continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP).

Follow provincial or territorial guidance for procedures that require the use of an N95 respirator. This guidance may vary among provinces and territories.

Strategies to reduce production of aerosols during AGMPs include:

• AGMPs should be anticipated and planned for.
• Fit-tested respirators should be worn by all personnel in the compartment during the procedure.
• Appropriate patient sedation should be used.
• If feasible (e.g., AGMP performed before takeoff), the number of personnel in the space or room should be limited to those required to perform the AGMP.
• The most experienced person available should perform the procedure.
• If feasible, AGMPs should be performed in a private compartment/space of the aircraft or a barrier be placed between the compartment or a closed door between the pilots/other occupants and the space.
• Appropriate ventilation (e.g., level of air filtration and direction of air flow) should always be maintained.
• Closed endotracheal suction systems should be used wherever possible.

Always follow the medevac standard operating procedures for AGMP, as well as federal/provincial/territorial infection prevention and control directives.

Bibliography

• PHAC: Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings
• PHAC: Hand Hygiene Best Practices in Healthcare Settings
• PHAC: Interim IPC guidance for COVID-19 in acute care settings
• Government of Canada: Coronavirus disease (COVID-19): For health professionals
• Transport Canada: Aviation measures in response to COVID-19

Acknowledgements

The National Advisory Committee on Infection Prevention and Control (NAC-IPC) is an external advisory body that provides subject matter expertise and advice to the Public Health Agency of Canada on the prevention and control of infectious diseases in Canadian health care settings.

This guideline was prepared by: Ms. Katherine Defalco, Ms. Adina Popalyar, Ms. Sabrina Chung, Ms. Toju Ogunremi, Dr. Kahina Abdesselam.

NAC-IPC members: Dr. Joanne Embree, (Chair), Dr. Jennie Johnstone (Vice-Chair), Ms. Molly Blake, Ms. Josiane Charest, Dr. Maureen Cividino, Ms. Nan Cleator, Ms. Jennifer Happe, Dr. Susy Hota, Ms. Anne Masters-Boyne, Dr. Matthew Muller, Ms. Patsy Rawding, Ms. Suzanne Rhodenizer Rose, Dr. Patrice Savard, Dr. Stephanie Smith, Dr. Nisha Thampi.

PHAC Healthcare-Associated Infections Prevention and Control Section: Dr. James Brooks (Director), Ms. Kathy Dunn (Manager), Dr. Kahina Abdesselam, Ms. Anna Bottiglia, Ms. Sabrina Chung, Mr. Steven Ettles, Mr. John McMeekin, Ms. Toju Ogunremi, Ms. Adina Popalyar.

The authors gratefully acknowledge the contributions of Dr. Marianna Ofner, the COVID-19 Public Health Working Group on Remote and Isolated Communities, Indigenous Services Canada, and the Northwest Territories Health Authority.