In early 2020, with the novel coronavirus (COVID-19) looming, Boston Emergency Medical Services eyed the unfolding outbreaks with a growing sense of unease. As healthcare systems struggled with onslaughts of cases and hospitalizations, the department wanted to be proactive. Leaders quickly began extensive planning for a patient surge and enhancement of infection-control processes to support their personnel. At the same time we bolstered dispatch protocols, intensified ambulance-disinfection protocols, and modified patient care as part of a comprehensive approach to address anticipated needs and threats to the EMS system.
As of early August 2020, Boston EMS had encountered more than 2,300 confirmed COVID-19-positive patients. During the height of Boston’s surge, the department encountered 44 confirmed cases a day.
Boston EMS, a bureau of the Boston Public Health Commission, is the primary 9-1-1 emergency medical services provider for the city of Boston. Responding to a residential service population of approximately 700,000 that traditionally increases to 1.2 million during the daytime, the department is organized as a two-tiered system offering both ALS and BLS skills. In 2019 its 399 EMTs and paramedics responded to more than 127,000 clinical incidents. In providing primary EMS coverage across the city, Boston EMS has no jurisdictional boundaries and responds to both federal and state properties, including Logan International Airport, the Port of Boston, and Boston Harbor.
Building a Team
There was no question for Chief Jim Hooley that the No. 1 COVID-19 priority was the health and wellness of the department’s personnel, followed closely by patient care and medical surge. With a concentration on enhanced personal protective equipment (PPE) and source control, along with the institution of barrier protection, measures focused on minimizing the risk of exposure for patients, providers, and bystanders.
This included screening all 9-1-1 calls for COVID-19 symptoms at the point of call-taking. Early in the pandemic, screening was more focused on travel. That quickly progressed to assuming all callers could be at risk. Of Boston EMS’s more than 2,300 COVID-19 encounters, 84% were identified by the department’s EMT telecommunicators during the call-screening process.
While Boston EMS’s infection-control protocols were adequate for routine operations, the COVID-19 pandemic called for additional support. An infection-control physician and three nurses were added to the existing Designated Infection Control Officer (DICO) team.
“Things ramped up really fast,” says the team’s Liz Blair, APRN-BC. “Nursing was helpful in support of the physicians, having the clinical background to be able to risk-assess EMT calls and patient presentations. When EMTs started getting sick, we were able to clinically follow them and guide them with medical advice. Nursing provided classic support of the whole picture.”
Retooling the DICO team reflected the department’s priorities, recognizing the ability to effectively care for patients is contingent upon a healthy workforce. This foundation was key in the team-building process and development of actionable goals. These included:
Encouraging self-reporting of symptoms by employees;
Remaining up to date and informed on COVID-19 research;
Ensuring adequate testing of employees;
Recommending proper use of PPE; and
Providing case management and adapting to workforce-specific needs.
The entire Boston EMS team collaborated to ensure the DICO team could reach and maintain these goals. For example, we developed chatbot technology and integrated it into daily personnel operations. With this system all department members received automated text messages once a day, to which they responded with a Y if they were experiencing COVID-like illness or an N if not. This system was also utilized for personnel quarantined out of work for potential exposures, with the aim of catching any early symptoms. This allowed the DICO team to remain proactive and ensure appropriate responses and services for department members.
Adapting Internal Processes
A timely response became necessary as COVID-19 reached Boston in late January. As personnel started to contact victims and even occasionally fall sick with COVID-19, the DICO team was committed to providing accessible medical and psychosocial support. All ill members had direct access to nursing and medical staff. Regular check-ins with ill personnel, whether COVID-19 or something else, became a stalwart feature of daily activities. The DICO team created an intake protocol for any new illnesses to ensure consistency and informed care.
We instituted a holistic model to ensure care encompassed all affected areas of life for the workforce. The Boston EMS peer support team was vital in this process. Traditionally, “peer support is a wrap-around service,” says Lt. Pat Calter, the team lead. “In the beginning [of the pandemic], it was a lot of putting out small fires. There was a high stress level with a lot of unknowns and hearing of other members of public safety dying.” Peer support, which typically offers support for the social and mental well-being of members, had to adjust its entire platform to provide these still-vital services virtually during stay-at-home orders. Utilization of these services increased during COVID-19.
The peer support team has been an important partner to the DICO team during the pandemic. Calter describes peer support as the “confidential conduit” to deliver supplies, services, and general support. The team assembled and delivered care packages to sick and quarantined members, bringing necessary items such as disinfectant wipes, thermometers, tissues, and other supplies.
“It was the perfect offering to open up a conversation to reach out to DICO—so simple, but very impactful,” says Calter. “I can tell you, it meant a ton to all of them [Boston EMS members]. It’s the simple gesture of ‘You matter—we didn’t forget you,’ because it was very difficult for our members to be sidelined. These folks don’t want to stay home. It’s stressful to say ‘You can’t.’ That’s a tough pill to swallow, because they feel fine and want to be at work but could be infectious.”
Due to these concerns, housing facilities for first responders was recognized as a need early on. The city coordinated with local universities and hotels to provide free housing for first responders in need of a place to quarantine or isolate. Deputy Superintendent Lee Alexander coordinated these offerings and facilitated quick access for personnel in need. This service was utilized by members who became ill with COVID-19 and by healthy members who had household members with high-risk conditions.
Alexander also provided moral support. “People were missing their families—I was able to just talk to them to hear their struggle,” she says. “Dropping off meals opened up conversations, and people were really appreciative. I would check in on members on a regular basis. For many it was a big sigh of relief—they were so thankful they didn’t have to bring this home to their families.”
New Infection-Control Processes
An addition to the DICO processes, COVID-19 involved risk assessment of patient encounters. The DICO team continuously monitored patient incidents, paying close attention to PPE use and high-risk procedures, to determine potential exposures. The team collaborated closely with healthcare partners to follow up on any positive patients the workforce contacted. This information was shared with the infection-control teams of other public safety partners who responded to the same incident.
The process is constantly evolving. As the situation changed in Boston and the United States, the team adapted and remained flexible, altering protocols to match evolving reality. At one point the Boston Public Health Commission conducted a large-scale first responder testing event; this was incorporated into the monitoring strategy. Like the pandemic, processes evolved to become more efficient and data-driven. In collaboration with a vendor, we developed an electronic database to support our infection-control system.
As the world progresses through the pandemic, we continue to learn and adapt to its risks and impacts. On the individual level, some COVID-19 patients have ongoing health effects that linger for months. The EMS profession is a hands-on and physically taxing job; Boston EMS wanted to ensure every member felt ready and able to perform their duties as they returned to work.
Following personnel throughout their entire illness, even after recovery, established a holistic care model and safely assisted members in resuming their lives. The model put employee wellness first.
“At the beginning of the pandemic, when little was known about COVID-19, particularly about how it is transmitted, our EMTs and paramedics faced daily uncertainty and fear regarding whether they could contract the disease and bring it home to their families,” says Mike MacNeil, EMT-P, president of the Boston Police Patrolmen’s Association EMS Division. “Due to the outstanding work of the DICO, employees had faith in the office and were able to focus on providing lifesaving medical services to the people of Boston. The success of the DICO in responding to COVID-19 is directly attributable to the city’s commitment to funding the office and the proactive approach of ramping up the DICO before the pandemic took hold.”
While this feature highlights the efforts of the Boston EMS DICO team, we owe the utmost honor and recognition to the men and women of Boston EMS, who are courageously serving the residents and visitors of the city during this unprecedented time.
Katie Klatt is a COVID-19 infection-control nurse at Boston EMS. She is currently a Master of Public Health in Health Management student at the Harvard T.H. Chan School of Public Health. Katie received her bachelor’s degree in nursing from the University of Virginia. She worked as a pediatric intensive care unit nurse in California and Australia before beginning her MPH studies.
Erin Serino is currently serving as the deputy chief of staff at Boston EMS. In this role she is primarily responsible for policy and planning and special project initiatives, as well as serving as a lead for the department’s media relations. With a background in government, Erin began her career in public service in 2009. She is an active member of the Massachusetts bar, obtaining a Juris Doctorate from the Massachusetts School of Law in 2014.