COVID-19 after action report final with cover letter

Rochester Hills Professional Fire Fighters International Association of Fire Fighters Local 3472 Paul Wright – President Lee Mayes – Vice President Andrew Matz – Secretary Mike Reamer – Treasurer ________________________________________________________________________ Chief Canto, This after action report regarding the Rochester Hills Fire Department’s response to the COVID 19 pandemic has been prepared at your request. Members evaluated several aspects of the pandemic response including personnel, supplies, Chief’s Directives, and new or changed EMS protocols. Members reviewed the information and provided feedback and recommendations for future pandemic response. Please forward any questions to Secretary A. Matz. Respectfully, Ann Echols, Larry Gambotto, Andrew Matz, and Timothy Matz

COVID 19 AFTER ACTION REPORT Incident overview On December 31, 2019, a virus of unknown origin was found in Wuhan, China. This virus was later categorized as a novel virus in the coronavirus family and has come to be known as COVID 19. This virus quickly swept through Asia and Europe and gained the designation of a pandemic, which is a disease prevalent over a whole country or the world. Eventually the first U.S. case was found in Washington State on January 20, 2020. The virus then made its way throughout the U.S. with Michigan seeing its first case on March 1, 2020. The City of Detroit and the Counties of Wayne and Oakland were the first in the state to see rapidly increasing cases of COVID 19. The Oakland County Medical Control Authority (OCMCA) issued a safety bulletin and its first emergency protocol on March 10, 2020. At that time, N95 type respirators, in addition to gloves and glasses, were recommended on all patients with travel outside of the U.S., fever or respiratory symptoms. At the same time, senior facilities were beginning to restrict entry into the building. On March 16, 2020, Rochester Hills Mayor Bryan Barnett declared a local state of emergency and changed operations at City buildings. The same day the Rochester Hills Fire Department opened the Emergency Operations Center to assist with information and communications during the pandemic. 1

On March 23, 2020, the Governor of Michigan issued a “stay home, stay safe” order and closed all non- essential businesses to help curb the spread of the virus. Hospitals were being overwhelmed with patients and were at capacity in the ED’s and ICU’s. Hospitals cut all non-essential and outpatient procedures to cut down on hospital demand. The Rochester Hills Fire Department saw an increase of COVID 19 calls begin around March 20, 2020. RHFD responded 303 suspected COVID 19 cases between March 15 and June 10, 2020. RHFD also responded to a record number of cardiac arrests between March 1 and March 31, 2020. On average, RHFD sees 2-3 cardiac arrest calls per month but responded to 15 arrests in the last two weeks of March. Changes in PPE and disinfecting techniques were required for the stations and apparatus. EMS procedure changes were also put into place, including avoiding performing aerosolizing procedures (such as using a BVM for ventilation, nebulized breathing treatments, intubation) and wearing of gowns. As of June 11, 2020, four RHFD personnel have tested positive for COVID 19 and twenty eight others were tested due to possible exposure or not feeling well. Three of the four have returned to duty with one remaining off with persistent respiratory symptoms. What Was Observed EMS Response As noted above, Rochester Hills has responded to 303 possible COVID 19 cases since March 15. RHFD received 37 notifications from local hospitals regarding positive test results for transported patients. NFIRS began to track possible COVID 19 cases on March 15, 2020 with the code 321C. It was found that the Tyvek suits were not the best solution for protection due to the weather; the suits did not go on well in the rain and they became overbearing with increased outdoor temperatures. The gowns in the PPE kits that the department initially had were thin and difficult to put on. The ambulances were modified with visqueen to provide a separation between the patient compartment and the cab of the vehicle; High and continuous air circulation in 2

the patient compartment was recommended to reduce the chance of viral spread. The need for surgical masks increased due to the need for patients to wear face coverings. Number of Possible COVID 19 cases 200 150 100 50 0 March April May June (1-10) Supplies th A critical supply shortage within the Department was noted on March 19 and surgical masks, respirators and thermometers were immediate needs that were not available in stores or online. CRR members visited local businesses to ask for supply donations. RHFD had the following supplies in inventory on March 20, 2020: Temporal Thermometers: 2 Oral Thermometers: 0 Thermometer Covers: 50 boxes (25 ea) N95 (or similar respirators): 302 Procedure Masks: 2,000 PPE kits: 77 Safety Glasses: 76 Citrus II: 33 bottles Tyvek Suits: 150 3

There were several items that were in high demand that ended up being hard to obtain: PPE kits / gowns / Tyvek suits, disinfectant cleaner (spray and wipes), hand sanitizer, surgical masks, N95 (or similar type) respirators, nasal cannulas, non-rebreather masks, medical gloves, UV lights / replacement bulbs, and thermometers / thermometer covers. The ambulances also required a deep disinfecting between every patient. Since disinfectant spray was difficult to obtain, sprayers were purchased along with bromide tablets in order to make batches of disinfectant for daily use. Supplies were purchased in the event that temporary housing for infected employees was requested. Items such as air mattresses, sheets and bathing wipes were purchased for members that did not wish to be quarantined at their house. Several people were working on obtaining supplies for the Department. In addition to the regularly carried EMS supplies, other supplies were obtained through Purchasing or online. (See attachment for items purchased and pricing.) Supplies that were obtained for COVID 19 currently total $202,800.54. In the first few weeks of the pandemic, personnel were wearing full PPE on almost every call due to the unknown nature of the virus. Between March 15 and April 15 the Department responded to 610 calls. With a minimum of two personnel per call, they would have used 1220 masks and between 1220 and 1830 gowns, depending on whether both responders wore a gown during the initial call or only during ambulance disinfection. Facilities There was a need to arrange a facility to house sick employees if someone did not wish to quarantine at home. Arrangements were made with Rochester College and Oakland University. Some hotels were not taking COVID 19 positive people and it was difficult to make arrangements for a facility (like the schools) that had access to an area for sleeping along with separate men’s / women’s bathrooms. Arranging food for the temporary housing was also difficult. 4

City buildings were semi-closed to the public on March 16, 2020 and many City employees were sent to work at home. The fire stations remained staffed and members were advised to maintain social distancing, wear masks when in close contact with each other and to limit travel in the City and between fire stations. All public education programs were canceled and screening procedures were put in place for both employees and visitors to the stations. Access to DPS buildings was limited to only allow for DPS employees inside the facility. Fire Department personnel visiting the DPS facility unknowingly exposed a DPS employee to COVID 19 resulting in the DPS employee being quarantined for 14 days. Protocols The OCMCA released eleven new emergency system protocols (four of which are still in effect as of June 10, 2020) and began a bi-weekly podcast to discuss the COVID 19 situation in Oakland County and to keep people informed of the ever-changing recommendations on treating COVID 19 patients. The changes in protocol could be combined into two categories: Personnel and agency licensing protocols and treatment protocols. The changes in personnel and agency licensing protocols included temporary licensing for any EMS provider who had successfully passed a course but was unable to test, the ability to upgrade / downgrade medical units based on available staffing and call volume and suspension of in-person inspections for new vehicles. The changes in treatment protocol included recommendations for passive oxygenation and no intubation during CPR in suspected COVID 19 patients, refusing to transport suspected positive patients who were only mildly symptomatic, cleaning and decontamination of ambulances and equipment and exposure reduction practices when treating suspected COVID 19 patients. 5

Personnel Once the Governor issued the stay at home order, personnel were advised to stay in the station, limit grocery shopping to once per cycle and to limit travel to station 1. A Chief’s Directive was issued regarding the wearing of masks in the stations and keeping physical separation between personnel whenever possible. In person training was canceled and disinfecting of the stations and vehicles took priority. Contamination reduction procedures and equipment Several different means of decontamination and disinfection have been deployed since March 2020. Initially, Citrus II was used to disinfect ambulances and equipment, but the supply was quickly depleted and a replacement was found in TB Cide Quat cleaner from the City’s usual supply vendor. Another method of decontamination was utilized via electrostatic sprayers and a bromide solution, which was easily made at the stations and was more cost effective than bottles of spray cleaner. The bromide solution could also be left to evaporate on a surface making the overall process easier and the portability of the sprayers made turning over an ambulance between calls more efficient. Manual pump sprayers were also distributed to some stations as a way to spray down the ambulance interior between calls. Aeroclave decontamination units were ordered for the five main transport vehicles and will be delivered soon. These units will be installed and will ‘fog’ the ambulance with disinfectant while the crew is writing the 6

EMS report at the hospital and getting equipment back in service. This is a more permanent solution to ambulance decontamination. Departmental Communication Most departmental communication regarding COVID 19 procedures and Chief’s Directives was dispersed via email and the administrative Daily Briefing. Battalion Chiefs were responsible for disseminating information and ensuring compliance with new protocols and directives. Captain T. Matz and Lieutenant Echols held several virtual meetings with suppression personnel regarding the changing protocols, changing access to senior facilities, PPE, and to answer any questions about treatment, supplies or anything COVID 19 related. Improvement / Future Actions  Purchasing - Have one purchase person in the Department and be more familiar with emergency purchase guidelines in place prior to an emergency. Possibly have a member of Purchasing work out of the EOC initially.  Integrate more City Hall personnel into the EOC operations. Initially the COVID 19 crisis was about managing emergency medical calls but it was much greater than that.  Limit contact between personnel. We need to lock down on station travel and begin wearing masks and social distancing early and not become complacent. Also, consider separating administration from suppression personnel altogether and go with phone calls or virtual meetings from the beginning. Holding in-person meetings turned out to be potentially catastrophic.  There were several supply chain issues with cleaning supplies, EMS supplies, oxygen delivery supplies, and PPE. We should stock more PPE and other like materials on a regular basis and rotate stock. N95 masks will most likely be required on all calls in the future. Take inventory of current stock and overstock appropriately. 7

 There may be a need to social distance into the coming winter months. There was a concern from some about station 3 being able to spread out without wearing a mask in the station 24/7. We could look into patio heaters for the outdoor spaces and canopies for any station that does not currently have cover over the outdoor space to deter personnel from sitting in the bay where exhaust and gear can cause future health issues.  More clearly defined roles in the EOC at the City level. Personnel rotated between being in command for the division, but no one was assigned to specific tasks like logistics, operations, communications, etc. Some items were duplicated while others remained undone in the first weeks until people fell into a routine.  Storage of the PPE and excess stock will need to be placed somewhere other than Station 1. The loft areas of Station 3, 4 and 5 could keep a limited amount of stock on either shelves or locked in cabinets. The second floor of DPS could also be an option, as we do not want to keep 100% of the items extra in one location.  Create a google page or other type of dashboard for communications. There were so many changes and updates and between the protocols, chief’s directives and information about the disease, information was hard to manage. Having to go back through several days or weeks of daily briefings was not a reliable solution and things get lost in a 3-ring binder. Having one, central location online where you can click on ‘protocols’ or ‘chief’s directives’ and be provided with a list of active information would have helped in the first few weeks. Conclusion Having a stock of PPE kits and respirators is what saved our personnel from exposure in the first few days of the COVID crisis. A good working relationship with purchasing, City Council and the Mayor’s office enabled the Department to purchase PPE and supplies quickly from reputable sources. In order to prepare for 8

future pandemic emergencies, a large stock of PPE and disinfectant should be purchased and stored. In order to prepare for future COVID (or respiratory type virus) calls, a two month supply of EMS supplies and related equipment is recommended in addition to what is carried on a regular basis. That stock would include: 15 – no touch thermometers (with batteries), one per station, one per ambulance, administration, CRR, and two extra 7 case – Citrus II (or other disinfectant), one per ambulance 7 gallon disinfectant fluid – for aeroclave, one per station 7 case – medium gloves, one per ambulance 7 case – large gloves, one per ambulance 2,400 gowns – average 20 calls per day, 2 personnel per call, 60 days of calls 2,400 N95 type respirators – average 20 calls per day, 2 personnel per call, 60 days of calls 2,000 surgical masks - 1,200 for patients (average 20 calls per day, one patient per call, 60 days of calls) and 800 for suppression and administrative personnel 7 case – nasal cannulas, one per ambulance 126 small bottles hand sanitizer OR 63 large bottles hand sanitizer – one per person Gallon hand sanitizer refills with pumps (preferably gel) 60 containers bleach wipes – 10 per station and 10 for administration / CRR In addition to the recommendations listed in the previous section, new protocols should be created to assist with procedures for decontamination and pandemic type operations, along with an updated Emergency Operations Plan. 9