Proposed changes to the paramedic practice standards

Patient Care and Transportation Standards - Version 3.0

Section 1 – Patient Care

Definitions

For the purposes of this standard the following definitions apply:

General Requirements

Each ambulance service operator and each paramedic, emergency medical attendant (EMA) and regulated health professional employed, or engaged as a volunteer, by the ambulance service operator, shall ensure that:

1. Any emergency response vehicle (ERV) responder, or ambulance acting in the capacity of a first response unit, responding to a request for service is staffed with at least one person who is qualified as an EMA or paramedic under the regulations.
2. Each land ambulance responding to a request for service is staffed with at least one primary care paramedic and one EMA qualified under the regulations.
3. Each land ambulance that is designated by an ambulance service operator as an advanced care paramedic ambulance is staffed with at least one advanced care paramedic and one primary care paramedic when responding to a request for service or while transporting a patient.
4. Each land ambulance that is designated by an ambulance service operator as a critical care paramedic ambulance is staffed with at least one critical care paramedic and one advanced care paramedic when responding to a request for service or while transporting a patient.
5. Each air ambulance responding to a request for service is staffed with at least two primary care paramedics or one primary care paramedic and regulated health professional.
6. Each air ambulance that is designated by an ambulance service operator as an advanced care paramedic ambulance is staffed with at least one advanced care paramedic and one primary care paramedic or regulated health professional when responding to a request for service or while transporting a patient.
7. Each air ambulance that is designated by an ambulance service operator as a critical care paramedic ambulance is staffed with at least one critical care paramedic and one advanced care paramedic or regulated health professional when responding to a request for service or while transporting a patient.
8. Notwithstanding paragraph 5, an air ambulance may be staffed with only one primary care paramedic qualified under the regulations, if:
   1. the request is for an inter-facility transfer;
   2. there is no risk to patient safety by using a single paramedic crew configuration, as determined by the transport medicine physician (TMP);
   3. the patient requires a level of care that can be provided by a primary care paramedic, as determined by the TMP; and
   4. the paramedic is available exclusively for patient care throughout the transport; or
   5. patient care is being provided by a hospital-based transport team.
9. No person shall smoke any cannabis, tobacco products, or other substances or use a vapour product, as defined in the Smoke-Free Ontario Act, while in an ambulance or emergency response vehicle.
10. No EMA, paramedic, or regulated health professional shall:
    1. while on duty, take or consume any liquor within the meaning of the Liquor License and Control Act, or any drug which could impair their ability to function as an EMA or paramedic; or
    2. report for duty while under the influence of any liquor within the meaning of the Liquor License and Control Act, or any drug which impairs their ability to function as an EMA or paramedic; or
    3. respond to a request for ambulance service while apparently under the influence of liquor or drugs or is apparently suffering the effects of liquor or drugs.
11. Each person transported in an ambulance or ERV is properly restrained in the ambulance or ERV.
12. Each EMA, paramedic, and regulated health professional shall apply the Routine Practices and Additional Precautions outlined below, unless otherwise indicated by Ontario’s Chief Medical Officer of Health through a directive issued under the Health Protection and Promotion Act (HPPA), R.S.O. 1990, c. H.7.
13. Unless otherwise indicated by Ontario’s Chief Medical Officer of Health through a directive issued under the HPPA, R.S.O. 1990, c. H.7, the Provincial Equipment Standards for Ontario Ambulance Services (as may be amended from time to time) sets out the requirements for equipment described in this document.

Communicable Disease Management

Preamble

This Section shall apply in all cases of communicable disease outbreaks. Each ambulance service operator shall establish a communications linkage and consult with the local Medical Officer of Health when implementing these standards.

1. Each ambulance service operator shall designate one or more persons as a designated officer to implement and oversee the communicable disease management requirements for their service.
   1. The designated person will have received training that includes the following learning objectives:
      1. Applicable legislation and guidelines relating to the control of biological hazards and diseases.
      2. How to recognize, assess and control common infectious and communicable diseases.
      3. Procedures to follow when a Paramedic or Regulated Health Professional or student is exposed to an infectious disease.
2. Each ambulance service operator shall ensure that:
   1. A list of current communicable diseases of concern within their catchment area is maintained, in consultation with their local Public Health Unit (PHU).
   2. Paramedics, Regulated Health Professionals and students are aware of current communicable disease risks.
   3. Appropriate measure(s) are utilized by Paramedics, Regulated Health Professionals and students to protect themselves and patients from transmission of communicable disease between Paramedics, Regulated Health Professionals or students and patients.
   4. Each Paramedic, Regulated Health Professional and student takes appropriate infection control and occupational health and safety measures to prevent transmission of all infectious agents to and from themselves and does not knowingly expose themselves or their patients to any communicable disease in the course of work, without taking the precautions set out under this standard.
   5. Paramedics, Regulated Health Professionals, or students who are exhibiting an acute symptomatic illness that may be communicable shall not be involved in the assessment of or direct delivery of care to a patient.
3. Each ambulance service operator shall ensure that:
   1. A point-of-care risk assessment (PCRA) must be performed before every patient interaction.
   2. In keeping with the principles of good patient care, Paramedics, Regulated Health Professionals and students utilize “Routine Practices” for all patient care and initiates “Additional Precautions” (contact, droplet or airborne) based on the mode of transmission, to limit the potential for disease transmission .

   3. Paramedics, Regulated Health Professionals and students shall initiate droplet/contact precautions on any call when:

      1. patients have symptoms of respiratory infections
      2. performing any high-risk respiratory care or procedure on all patients (any procedure that has the potential to generate respiratory droplets)

      Droplet/contact precautions include:

      1. surgical mask
      2. eye protection

      For any patient where there is significant risk to the Paramedic, Regulated Health Professional or student of being splashed by body fluids (e.g., vomiting, uncontrolled hemorrhage, excessive coughing) add:

      1. long-sleeved gown/coveralls
      2. gloves

      The patient will wear:

      1. surgical mask, if tolerated. This may be used with or without nasal cannula oxygen, or
      2. low flow high concentration oxygen mask outfitted with a hydrophobic submicron filter if high concentration oxygen is required.
   4. For those patients requiring ventilatory assistance using a face mask or an endotracheal tube, a tube extender and a hydrophobic submicron filter shall be used. A tube extender is not necessary for pediatric patients and must not be used for any infants ( < 1 year old).
4. Where an unprotected Paramedic, Regulated Health Professional or student has reasonable cause to believe that they have been exposed to a communicable disease in the workplace, they shall:
   1. Report the suspected exposure to the designated person referred to in paragraph 1 immediately, and
   2. Follow the instruction of the designated person, and
   3. Complete an incident report relating to such exposure by the end of the shift in which the exposure occurred or at the earliest opportunity thereafter.
5. If a Paramedic, Regulated Health Professional, student or employee is instructed by a designated officer referred to in paragraph 1 to consult a physician, nurse practitioner or other heath care professional regarding a suspected and/or confirmed exposure to a communicable disease, the Paramedic, Regulated Health Professional or student shall:
   1. Follow direction from a physician or nurse practitioner respecting contact with patients, etc.
   2. Notify the ambulance service operator or their designated officer of the directions, and
   3. Return to work only when medically cleared by a physician, nurse practitioner or other healthcare professional authorized to provide the clearance.
6. The ambulance service operator shall develop, monitor, and enforce a local disinfection policy regarding vehicles and equipment to be used on a regular basis and to be used as appropriate when vehicles and equipment are exposed to a person with a suspected or confirmed communicable disease.
7. Paramedics, Regulated Health Professionals and students shall not eat or drink in the patient compartment of an ambulance or areas where patient care is being or is regularly provided. Food consumption shall be limited to designated areas.

Routine Practices

Routine Practices refer to infection prevention and control (IPAC) practices to be used with all patients during all care, to prevent and control transmission of microorganisms in all health care settings.

Hand Hygiene

Shall be performed:

1. before patient contact;
2. after patient contact;
3. after contact with blood, body fluids, secretions, excretions, items known or considered likely to be contaminated with secretions, etc.
4. before contact with the EMA’s or paramedic’s face;
5. before cleaning / decontamination of equipment and vehicles;
6. before putting on and after removing gloves and other protective equipment;
7. after personal body functions (e.g., blowing one’s nose) or;
8. whenever there is doubt about the necessity for doing so.

Guideline

When an EMA or paramedic is unable to wash their hands, they shall:

1. Use an alcohol-based hand sanitizer, following manufacturer’s instructions.
2. If there is visible soil or residue on hands and soap and water is not available, use moistened towelettes to remove visible soil, followed by an alcohol-based hand sanitizer containing between 70% and 90% alcohol.

Contact / Droplet Precautions

Contact Precautions are used in addition to Routine Practices for microorganisms where contamination of the environment or intact skin is a particular consideration. Droplet precautions are used in addition to Routine Practices for patients known or suspected of having an infection that can be transmitted by large respiratory droplets.

Gloves

1. A single pair of medical quality, non-latex, non-sterile gloves shall be worn when anticipating contact with blood, body fluids, secretions, excretions, mucous membranes or non-intact skin.
2. Gloves shall meet the specifications set out in the Provincial Equipment Standards for Ontario Ambulance Services.

Masks

1. A surgical/procedure mask shall be worn (in addition to eye protection) to protect the mucous membranes of the nose and mouth when it is anticipated that a procedure or care activity is likely to generate splashes or sprays of blood, body fluids, secretions or excretions, or within two metres of a coughing patient.
2. A surgical/procedure mask should be placed on a coughing patient, if tolerated, to limit dissemination of infectious respiratory secretions.

Protective Eyewear or Face Shield

1. Protective eyewear or face shields shall be worn to protect the mucous membranes of the eyes, nose and mouth during procedures and patient care activities likely to generate splashes or sprays of blood, body fluids, secretions or excretions, which include cough-producing and aerosol-generating procedures.

Gown / Coveralls

1. Long-sleeved gowns or coveralls shall be worn to protect uncovered skin and to prevent soiling of clothes during procedures and patient care activities likely to generate splashes or sprays of blood, body fluids or excretions.

Airborne Precautions

Airborne precautions are used in addition to Routine Practices for patients known or suspected of having an illness transmitted by the airborne route.

Air-Purifying Respirators

1. Shall be worn, in addition to droplet precautions (excluding surgical/procedure masks), when providing direct care to or interacting with a suspected, probable or confirmed airborne infectious disease to prevent the inhalation of particulates that may contain infectious agents.
   1. Cases are suspected or probable when the patient has been placed in precautions as high-risk contact, in an outbreak zone of the facility or recently transferred from a facility in outbreak.
2. Shall be worn for aerosol-generating medical procedures (AGMPs).
   1. A complete list of AGMPs where transmission has been documented can be found in the Provincial Infectious Diseases Advisory Committee (PIDAC): Routine Practices and Additional Precautions in All Health Care Settings.

Influenza Immunzation Education

Each ambulance service operator shall ensure that:

1. They develop, monitor and enforce a local education policy regarding influenza immunizations. The policy shall contain components on the personal, patient care, and public health benefits of receiving the immunizations.
2. Influenza immunization rates for paramedics, EMAs and regulated health professionals are reported by the individual and tracked by the service annually and available to the Ministry of Health (MOH) upon request.

Section 2 – Patient Transport

Each EMA, paramedic and regulated health professional shall:

1. Ensure that each individual follows every direction or instruction issued by a communications officer with respect to the assignment of calls to ambulances or emergency response vehicles.
2. Ensure that the operator of an ambulance, in which a patient is being transported, shall transport the patient to a receiving facility as directed by an ambulance communications officer (ACO) ordering the movements of the ambulance. In the absence of a direction from an ACO, the operator will transport the patient to the closest receiving facility or as per Patient Priority System (PPS) that can provide the care apparently required by the patient.
3. Ensure that each item of equipment transported in an ambulance or ERV is properly restrained in the ambulance or ERV.

Past proposed changes