Context

  • Maintaining access to high quality primary healthcare is critical including during the period of restrictions due to social distancing requirements
  • Many ACCHOs provide transport as an important part of primary healthcare to support patients to access healthcare services, including transport
    • from home to the primary healthcare centre
    • to regional centres for hospital outpatient appointments, treatments and investigations (which may be several hours of travel)
    • to dialysis services.
  • Several patients, sometimes with accompanying family members, may be transported in the same vehicle at the same time
  • SARS-CoV-2 (COVID-19) is known to be transmissible in the absence of symptoms (e.g. pre-symptomatic transmission)
    • Early studies show:
      • between 5-80% of people who test positive for SARS-CoV-2 may not show symptoms being either truly asymptomatic or pre-symptomatic (going on to develop symptoms in the week following) (1)
      • the duration of infectivity before onset of symptoms is uncertain (2)
      • children and young adults can be asymptomatic. (1)
  • There is a (potential) risk of transmission of SARS-CoV-2 (COVID-19) to or from any driver and passengers
  • SARS-CoV-2 (COVID-19) is transmissible predominantly by droplet infection and by contact with contaminated surfaces (immediate environment or objects that have been in contact with an infected person)
    • strong clinical and epidemiological evidence shows transmission of the virus is mainly through respiratory droplets via direct (direct close contact by exposure of mucosae) or indirect physical contact (touching surfaces or fomites contaminated by respiratory droplets and then touching face) (2, 3)
    • Reports of airborne transmission are rare. (2, 3)

Rationale

Recommendation Rationale
Make sure drivers who are at high risk of serious COVID-19 illness do not transport patients with
fever and/or respiratory symptoms and/or probable or confirmed COVID-19
Some chronic conditions have been identified as increasing the risk of serious illness from
COVID-19 infection (4).
Drivers identified as high risk need to be enabled to take precautions to protect their own health.
.

Make sure drivers are trained in the correct use of PPE including when and how to use PPE.

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All drivers could potentially come into contact with patients with SARS-CoV-2 (COVID-19) and need to be able to
use appropriate PPE for their own protection and to prevent the spread of infection to others (25).

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All passengers should be screened for fever, respiratory symptoms and/or exposure to a person known to have
COVID-19 prior to entering a transport vehicle, by asking the questions:

  • Have you any got or had recent fever, chills or night sweats?
  • Have you got a sore throat, cough or shortness of breath?
  • Have you had close contact in the last 14 days with anyone who has confirmed or probable COVID-19?
  • Have you travelled overseas in the past 14 days?
.

Questions from and federal and state government guidance (6).

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When passengers answer no to all questions:

  • they can be transported as usual
  • hand hygiene, using hand sanitiser of at least 70% alcohol, should be completed by all passengers prior to
    entering the vehicle
  • social distancing should be observed as far as possible
  • no PPE is required.
.

In patients who do not have confirmed or probable SARS CoV-2 (COVID-19) and answer no to all screening
questions, guidelines recommend: proper hand hygiene using hand sanitiser or soap and water, avoid touching
face, maintain 1.5 m distance as far as possible for those transporting clients (57)
and clean surfaces regularly (7).
Surgical masks are not required for drivers or passengers if healthy (<atitle=”Victoria State Government
Department of Health and Human Services. Coronavirus disease (COVID-19): Rational use of personal protective
equipment for coronavirus disease 2019 (COVID-19) for clinical transport services 2020 (updated 09/04/2020)
2020.” style=”color: #ff0000;”>5, 8),
however, health personnel must still take droplet and contact precautions if patients have fever and/or
respiratory symptoms and have a negative test for COVID-19 (9).

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When passengers answer yes to one or more of the screening questions:

  • do not transport until the need for transport for healthcare is confirmed with the local health service
    who should consider whether an alternative is available, such as telehealth, home delivery of medications,
    etc
  • arrange for an existing close contact (e.g. family/household member) who is not at high-risk of serious
    COVID-19 illness to transport the patient if possible
.

Derived from Institute for Urban Indigenous Health Network and National Aboriginal Community Controlled Health
Organisation recommendations (7).

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When passengers answer yes to one or more of the screening questions if transport for healthcare is
necessary

  • transport without other passengers in the vehicle if possible
  • transport in vehicle with driver compartment separated from passengers (e.g. Perspex shield between driver
    and passengers) when possible
  • hand hygiene, using hand sanitiser of at least 70% alcohol, should be completed by all passengers prior to
    entering the vehicle and on leaving the vehicle
  • social distancing should be observed as far as possible
  • patient and accompanying passengers (close household contacts) should wear masks
  • no specific PPE is recommended for drivers if patients are wearing masks, spatial distance is maintained
    and the driver compartment is separated from passengers
  • if the above requirements cannot be met, at a minimum, the driver should wear a mask. Consider greater
    precautions i.e. gloves, gown and goggles if higher risk of transmission of infection. A gown should be worn
    if close physical contact is needed e.g. assisting passengers in and out of the vehicle
  • transport with windows as open as is practical, at a minimum at least partially open on both sides of the
    vehicle and, if air conditioner is used, set to FRESH AIR rather than CIRCULATE.

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In patients who answer yes to any screening questions and still require transport, guidelines recommend:

  • as far as possible, patients should be transported as single passengers (1013)
  • as an alternative mode of transport, the patient may be transported via private vehicle by an existing
    close contact (1416)
  • transport in vehicle with driver compartment separated from passengers (e.g. Perspex shield between driver
    and passengers) when possible (17)
  • hand hygiene should be practiced for all people involved (passengers and health personnel) before and
    after transport (5)
    and patient and accompanying passengers must put a surgical mask on before entering the vehicle and
    throughout trip (10)
  • no PPE is needed for drivers if patients are using a mask throughout, spatial distance is maintained and
    the driver cab is separated from passengers (1017)
  • if this is not possible, the driver should wear a surgical mask at minimum (17)
    and consider greater precautions: i.e. gloves, gown and goggles if there is a higher risk of transmission of
    respiratory infection; a gown should be worn if close physical contact is needed e.g. assisting passengers
    in and out of the vehicle (71718)
  • ensure vehicles have proper ventilation and open windows. A/C should be set to fresh air to avoid
    re-circulation of air within the vehicle (51012)

No evidence has been found relating to use of equipment (such as seat covers) to prevent transmission of
COVID-19. Therefore, it is recommended that procedures are in place for cleaning of vehicles between patients,
and that vehicles and resources such as consumables and equipment are specifically allocated, where possible,
solely for transporting COVID-19 patients (1113).


Cleaning vehicles

Recommendation Rationale
When passengers answer no to all questions:

  • clean vehicles at the end of each transport shift/daily. This should include general cleaning and wiping
    down of all high touch surfaces (i.e. door handles, seat belts and seats) using detergent and disinfectant
    (at least 70% alcohol solution or bleach or TGA-approved hospital grade disinfectant). Detergent and
    disinfectant can be combined (2-in-1 product). Make sure there is adequate ventilation of the vehicle while
    using cleaning and disinfectant agents. After cleaning, allow at least 30 minutes before next use for
    surfaces to fully dry.

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Cleaning of vehicles for patients who do not have confirmed or probable SARS CoV-2 (COVID-19) and
answer no to all screening questions, recommendations include (1922):

  • routine cleaning of frequently touched hard surfaces with detergent AND disinfectant solution or wipe
  • 2-in-1 clean: a physical clean using combined detergent (soap and water) and disinfectant agent (1,000ppm
    chlorine solution or at least 70% alcohol solution or bleach or TGA-approved hospital grade disinfectant)
    solution made up daily from a concentrated solution, or
  • 2-step clean: a physical clean using detergent (soap and water) followed by a disinfectant agent (1,000ppm
    chlorine solution or at least 70% alcohol solution or bleach or TGA-approved hospital grade disinfectant)
  • combination disinfectant and detergent wipes can be used.

.

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When passengers answer yes to one or more of the screening questions if transport for healthcare is
necessary:

  • clean vehicles after each passenger journey. This should include general cleaning and wiping down of all
    high touch surfaces (i.e. door handles, seat belts and seats) using detergent and disinfectant (at least 70%
    alcohol solution or bleach or TGA-approved hospital grade disinfectant). Detergent and disinfectant can be
    combined (2-in-1 product). Make sure there is adequate ventilation of the vehicle while using cleaning and
    disinfectant agents. After cleaning, allow at least 30 minutes before next use for surfaces to fully dry.

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Cleaning of vehicles for patients who answer yes to any screening questions and still require transport,
guidelines recommend (192022):

  • during cleaning, ensure adequate ventilation when chemicals are in use, doors and windows should remain
    open when cleaning the vehicle. Personnel undertaking cleaning should wear appropriate PPE (gloves, gown,
    mask and goggles or face shield) (7)
    or disposable gloves compatible with the products, other manufacturer recommended PPE and a disposable gown
    (23)
  • targeted cleaning after each passenger journey using detergent AND disinfectant solution (or wipes)
  • 2-in-1 clean, a physical clean using combined detergent (soap and water)
    and disinfectant agent (1,000ppm chlorine solution [bleach] or at least 70% alcohol solution OR bleach OR
    TGA-approved hospital grade disinfectant solution made up daily from a concentrated solution, or
  • 2-step clean, a physical clean using detergent (soap and water) followed
    by
     a disinfectant agent (1,000ppm chlorine solution (bleach) or at least 70% alcohol
    solution OR TGA approved hospital grade disinfectant
    ). Combination disinfectant and detergent
    wipes also acceptable
  • concentrate on high touch hard surfaces that the patient and passengers have or likely to have touched (101223):
    • door handles, seat belts and seats
    • if patient didn’t use a mask, wipe the back of the seat in front
    • clothing, luggage, walking frames and other belongings are assumed to cause little contamination in a
      vehicle. Perform hand hygiene after handling items. (10)

There is no need to clean the entire car after transport of a person with suspected or confirmed COVID-19 (10)

All consumables that are unable to be cleaned should be discarded. To reduce the risk of transmission,
disposable or patient-dedicated equipment is preferred. Equipment that is unable to be dedicated should be
cleaned and disinfected after use, allowed to dry and stored clean (2022).

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Other considerations for patient transport:

  • Set-up patient transfer teams with equipment appropriate for COVID-19. This includes surgical masks, PPE,
    tissues, medical waste disposal, alcohol-based hand sanitiser, and cleaning supplies such as detergent (soap
    and water based), disinfectant (TGA-approved hospital grade disinfectant or 1,000ppm chlorine solution
    [bleach] or  at least 70% alcohol solution) and disposable wipes (101113).
  • Patients should be kept in the vehicle on arrival until prearranged movements are implemented (1113).
  • Where possible, do not use ordinary cars (e.g. 5-7 seats), but larger vehicles (e.g. bus, minibus) to
    allow for better physical distancing between the driver and passengers (710).

Other recommendations

Recommendation Rationale
All patients under quarantine must be transported as a single passenger and wear a surgical mask.
PPE for the driver and cleaning requirements should be determined as per responses to screening questions.

.

Transporting as a single passenger optimises social distancing recommendations. National
guidelines recommend quarantined patients wear a surgical mask when going outside and before presenting to any
healthcare setting for medical care (624).

 

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Make sure rubbish/tissue disposal is available and cleared from the vehicle after each transport.

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Good practice point.

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Consider displaying health protection messages in vehicles about coughing and sneezing hygiene, hand hygiene,
social distancing, avoiding touching the face and seasonal influenza immunisation.

 

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Good practice point.

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Check local travel restrictions and quarantine requirements for patients returning from regional centres to
community as these may impact on PPE requirements during transport.

 

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Transport of patients from regional centres back to community: Patients who are confirmed COVID-19, ready for
discharge and have not yet completed the clearance criteria, can be transported home by family/friend/support
person. Both the patient and driver should wear a surgical mask during transport. Health care facilities need to
supply the surgical mask and instructions on use of masks (putting on and taking off). On completion of journey
vehicles should be cleaned as described above (25).

.

Make sure drivers have received annual influenza immunisation and pneumococcal immunisation if eligible.

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Good practice point.

Rapid summary of evidence conducted by:  Deborah Wong, Andrea Timothy, Makayla-May Brinkley, Phyll
Dance, Karl Skewes

Australian National University –
ANU

References

  1. Heneghan C, Brassey J, Jefferson T. COVID-19: What proportion are asymptomatic? 6 April 2020 [Available HERE]
  2. Australian Government Department of Health. Guidance on the use of personal protective equipment (PPE) in hospitals during the COVID-19 outbreak 27/04/2020 [Available HERE]
  3. Brurberg K. SARS-CoV-2, MERS-CoV and SARS-CoV and risk of airborne transmission – a rapid review. Oslo: Norwegian Institute of Public Health.; 2020.
  4. Australian Health Protection Principal Committee (AHPCC). Australian Health Protection Principal Committee (AHPPC) Advice to National Cabinet on 30 March 2020 [Available HERE.]
  5. Victoria State Government Department of Health and Human Services. Coronavirus disease (COVID-19): Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19) for clinical transport services 2020 (updated 09/04/2020) 2020 [Available HERE]
  6. Communicable Diseases Network Australia. Coronavirus Disease 2019 (COVID-19): CDNA National Guidelines for Public Health Units v. 2.10: Communicable Diseases Network Australia; 2020 [updated 13 May 2020. Available HERE
  7. Institute for Urban Indigenous Health Network, National Aboriginal Community Controlled Health Organisation. IUIH Network Coronavirus/COVID-19 Toolkit 2020 (updated 23/04/2020. v 8.2) 2020 [Available HERE]
  8. Australian Government Department of Health. Information for Public Transport: Novel coronavirus (COVID-19) 2020 [Available HERE]
  9. Royal Australian College of General Practitioners. Face-to-face consultations for non-COVID-19 patients with respiratory symptoms 2020 [updated 30/03/2020. Available HERE
  10. Norwegian Institute of Public Health. Transport of people with confirmed or suspected COVID-19 by patient transport service/taxi 2020 (updated 03/04/2020) 2020 [Available HERE]
  11. Aboriginal Health & Medical Research Council (AH&MRC). Aboriginal Community Controlled Health Services Pandemic Response Toolkit Preparing a Comprehensive Plan and Response to Pandemics 2020 [Available HERE]
  12. Department of Health Western Australia. Information for public & private transport (cars, taxis, ride-hail services, trains, buses, community vans, trams) (updated 16/04/2020) 2020 [Available HERE]
  13. Government of South Australia. Patient Transport Provision SA Ambulance Service (SAAS) South Australia Pandemic Plan 2015 Pandemic Influenza sub plan 2015 [Available HERE]
  14. Department of Health and Social Care (DHSC), Public Health Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland (HPS), Public Health England. COVID-19 Guidance for infection prevention and control in healthcare settings. UK2020.
  15. Public Health England. COVID-19: interim guidance for primary care UK: Public Health England; 2020 [Available HERE]
  16. Victorian State Government Health and Human Services. Health services and general practice – coronavirus disease (COVID 19) 2020 [Available HERE]
  17. World Health Organization. Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19). 2020 27 February 2020.
  18. Royal Australian College of General Practitioners. Assessment and testing of patients with suspected mild COVID-19 May 1 2020 [updated 30/03/2020. Available HERE
  19. Australian Government Department of Health. Coronavirus disease (COVID-19) Environmental cleaning and disinfection principles for health and residential care facilities 2020 [Available HERE]
  20. Clinical Excellence Commission NSW Government. Infection Prevention and Control Novel Coronavirus 2019 (2019-nCoV) – Primary and Community Care. 2020.
  21. London Ambulance Service -NHS. Vehicle cleaning procedure 2018 [Available HERE]
  22. Queensland Health. Interim infection prevention and control guidelines for the management of COVID-19 in healthcare settings (Version 1.10: 27 March 2020). 2020.
  23. Centers for Disease Control and Prevention. Cleaning and Disinfection for Non-emergency Transport Vehicles : Interim Recommendations for U.S. Non-emergency Transport Vehicles that May Have Transported Passengers with Suspected/Confirmed Coronavirus Disease 2019 (COVID-19) 2020 [updated 14/04/2020. Available HERE.
  24. Australian Government Department of Health. Self-isolation (self-quarantine) for coronavirus (COVID-19): Department of Health; 2020 [Available HERE]
  25. Department of Health Western Australia. Coronavirus Disease-2019 (COVID-19) Infection Prevention and Control in the Hospital Setting. 2020.

Recommendations

  • Make sure drivers who are at high risk of serious COVID-19 illness do not transport patients with fever and/or respiratory symptoms and/or probable or confirmed COVID-19.
  • Make sure drivers are trained in the correct use of PPE including when and how to use PPE.
  • All passengers should be screened for fever, respiratory symptoms and/or exposure to a person known to have COVID-19 prior to entering a transport vehicle, by asking the questions:
    • Have you any got or had recent fever, chills or night sweats?
    • Have you got a sore throat, cough or shortness of breath?
    • Have you had close contact in the last 14 days with anyone who has confirmed or probable COVID-19?
    • Have you travelled overseas in the past 14 days?
  • When passengers answer no to all questions:
    • they can be transported as usual
    • hand hygiene, using hand sanitiser of at least 70% alcohol, should be completed by all passengers prior to entering the vehicle
    • social distancing should be observed as far as possible
    • no PPE is required
    • clean vehicles at the end of each transport shift/daily. This should include general cleaning and wiping down of all high touch surfaces (ie door handles, seat belts and seats) using detergent and disinfectant (at least 70% alcohol solution or bleach or TGA-approved hospital grade disinfectant). Detergent and disinfectant can be combined (2-in-1 product). Make sure there is adequate ventilation of the vehicle while using cleaning and disinfectant agents. After cleaning, allow at least 30 minutes before next use for surfaces to fully dry.
  • When passengers answer yes to one or more questions:
    • do not transport until the need for transport for healthcare is confirmed with the local health service who should consider whether an alternative is available, such as telehealth, home delivery of medications, etc
    • arrange for an existing close contact (e.g. family/household member) who is not at high risk of serious COVID-19 illness to transport the patient if possible
    • if transport for healthcare is necessary
      • transport without other passengers in the vehicle if possible
      • transport in vehicle fitted with driver compartment separated from passengers (e.g. Perspex shield between driver and passengers) when possible
      • hand hygiene, using hand sanitiser of at least 70% alcohol, should be completed by all passengers prior to entering the vehicle and on leaving the vehicle
      • social distancing should be observed as far as possible
      • patient and accompanying passengers (close household contacts) should wear surgical masks
      • no specific PPE is recommended for drivers if patients are wearing surgical masks, spatial distance is maintained and the driver compartment is separated from passengers
      • if the above requirements cannot be met, at a minimum, the driver should wear a surgical mask. Consider greater precautions i.e. gloves, gown and goggles if higher risk of transmission of infection. A gown should be worn if close physical contact is needed e.g. assisting passengers in and out of the vehicle
    • clean vehicles after each passenger journey. This should include general cleaning and wiping down of all high touch surfaces (i.e. door handles, seat belts and seats) using detergent and disinfectant (at least 70% alcohol solution or bleach or TGA-approved hospital grade disinfectant). Detergent and disinfectant can be combined (2-in-1 product). Make sure there is adequate ventilation of the vehicle while using cleaning and disinfectant agents. After cleaning, allow at least 30 minutes before next use for surfaces to fully dry.
  • All patients under quarantine must be transported as a single passenger and wear a surgical mask. PPE for the driver and cleaning requirements should be determined as per responses to screening questions.
  • Make sure rubbish/tissue disposal is available and cleared from the vehicle after each transport.
  • Consider displaying health protection messages in vehicles about coughing and sneezing hygiene, hand hygiene, social distancing, avoiding touching the face and seasonal influenza immunisation.
  • Check local travel restrictions and quarantine requirements for patients returning from regional centres to community as these may impact on PPE requirements during transport.
  • Make sure drivers have received annual influenza immunisation and pneumococcal immunisation if eligible.

Related topics

Assessing and managing HCWs at high risk of serious COVID-19 disease – recommendation under development.

Infection prevention and control RACGP Infection prevention and control standards

Use of PPE RACGP Infection prevention and control standards

Environmental cleaning RACGP Infection prevention and control standards