Pan American Health Organization · Version 4.4, 2020
Operational guidance for emergency medical services and first responders managing suspected or confirmed COVID-19 patients in prehospital settings.
- Issuer
- Pan American Health Organization
- Edition
- Version 4.4, 2020
- Audience
- Emergency medical services personnel, dispatchers, first responders, EMS administrators, public health authorities
- Evidence
- Expert consensus based on WHO guidance and early pandemic evidence
- Reviewed
- 20 Oct 2026 · GMJ
What this guideline says
GMJ summary
This draft guideline provides comprehensive operational recommendations for prehospital emergency medical services responding to COVID-19. It addresses the unique challenges of uncontrolled prehospital environments, enclosed transport spaces, and resource variability that characterise EMS operations during the pandemic.
The document is structured around six functional areas: dispatch/call management, pre-transport scene assessment, transport procedures, post-transport decontamination, administration, and special considerations for paediatric and geriatric patients. Central to all recommendations is the principle of appropriate personal protective equipment (PPE) use based on risk stratification: standard + contact + droplet precautions for suspected COVID-19 patients, with escalation to airborne precautions when aerosol-generating procedures are performed.
Key operational principles include early identification of patients under investigation (PUI) through dispatcher screening, limiting direct patient contact to the minimum number of personnel, optimising ambulance ventilation, pre-notification of receiving facilities, and systematic decontamination protocols. The guideline emphasises that COVID-19 requires different precautions than Ebola virus disease and that excessive use of protective equipment wastes valuable resources.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Dispatchers must screen all callers reporting fever and/or lower respiratory symptoms (cough, shortness of breath) for travel/contact history to identify patients under investigation (PUI)
- For suspected COVID-19 without aerosol-generating procedures: standard + contact + droplet precautions (surgical mask, gown, gloves, eye protection)
- For suspected COVID-19 with aerosol-generating procedures (BVM ventilation, intubation, suctioning, nebulizers, CPAP/BiPAP, CPR): standard + contact + airborne precautions (N95/FFP2 respirator, gown, gloves, eye protection)
- All personnel must maintain at least 1 metre distance from patients before donning appropriate PPE; patients should wear surgical masks if tolerated
- Ambulance ventilation must be optimised: maximise air exchange by opening windows/vents, use fresh (not recirculated) air, set rear exhaust fans to highest setting
- Disinfection requires pre-cleaning with soap and water followed by either: EPA-registered disinfectant for emerging viral pathogens, 0.1% (1000 ppm) chlorine solution for 10 minutes, or 60-70% alcohol-based compounds
- Direct patient contact should be limited to the minimum number of personnel; reserve ALS ambulance activation for severe disease (chest pain, difficulty breathing, altered mental status)
- Air medical transport should be avoided for stable PUIs; if essential, all aerosol-generating procedures must be completed before loading, and HEPA filtration is required for recirculated air
Personal protective equipment (PPE) requirements by level of care
Table extracted from the guideline
| Level of care | Hand hygiene | Medical mask | Respirator (N95 or FFP2) | Gown | Goggle or face shield | Gloves |
|---|---|---|---|---|---|---|
| Suspected case assessment at 1 metre (ambulance crew) | X | X | ||||
| Driving WITH patient compartment isolated | X | X | ||||
| Driving WITHOUT patient compartment isolated | X | X | ||||
| Suspected/confirmed COVID-19 transport, NO aerosol-generating procedure | X | X | X | X | X | |
| Suspected/confirmed COVID-19 transport WITH aerosol-generating procedure | X | X | X | X | X | |
| Cleaning the ambulance | X | X | X | X | X |
Source: Pan American Health Organization, COVID-19 Recommendations: Prehospital Emergency Medical Services (EMS). Reproduced in summary form.
From the guideline
Verbatim
“Direct contact with a PUI should be limited to the least number of personnel possible. Personnel not in appropriate PPE should maintain a distance of at least 1 meter from the patient.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Chair of the Public Health Institute of Georgia and former WHO consultant, I recognize this PAHO guidance addresses critical gaps in Georgia's emergency response capacity that became evident during the COVID-19 pandemic. The tiered PPE approach—reserving N95 respirators specifically for aerosol-generating procedures—is particularly relevant for our resource-constrained settings across the South Caucasus, where indiscriminate use of high-grade PPE created shortages in 2020. I would emphasise to Georgian EMS providers the dispatcher screening protocol and the 1-metre assessment distance principle, which can be implemented immediately without additional resources. The realistic challenge for Georgia and neighbouring Armenia and Azerbaijan is establishing dedicated decontamination sites and maintaining supply chains for EPA-registered disinfectants in rural mountainous regions where many ambulance stations lack running hot water and dedicated cleaning areas, requiring adaptation of the 0.1% chlorine solution protocols to local infrastructure realities.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 20 Oct 2026
Applicability
Georgia and the South Caucasus
This guidance is directly applicable to Georgia’s emergency medical services, particularly the Emergency Medical Assistance Centre (113) system established nationwide. Georgian EMS systems would need to ensure dispatcher training on COVID-19 screening algorithms, adequate stocks of appropriately sized PPE (including N95/FFP2 respirators), and coordination protocols with receiving hospitals. The recommendation for integrated health services networks aligns with Georgia’s ongoing health system reforms. Implementation challenges may include ensuring adequate ventilation in older ambulance fleets, establishing designated decontamination sites in smaller municipalities, and maintaining supply chains for disinfectants and PPE in rural areas of the South Caucasus where resource availability is more limited than in Tbilisi or regional centres.
Questions this guideline answers
Quick answers
What PPE is required for transporting a suspected COVID-19 patient who is not receiving aerosol-generating procedures?
Standard + contact + droplet precautions: hand hygiene, surgical mask (not N95), gown, gloves, and eye protection (goggles or face shield). The patient should wear a surgical mask if able to tolerate it.
Which procedures are considered aerosol-generating and require N95 respirators?
Bag-valve-mask ventilation, oropharyngeal suctioning, endotracheal intubation, nebulizer treatment, CPAP, BiPAP, resuscitation involving emergency intubation, and cardiopulmonary resuscitation (CPR).
How should the ambulance be ventilated during COVID-19 patient transport?
Maximise air exchange by opening windows and vents, set all climate controls to fresh (not recirculating) air, and turn rear exhaust ventilation fans to the highest setting. If compartments cannot be isolated, create a negative pressure gradient in the patient area.
What disinfectant concentration is needed for ambulance decontamination after transporting a COVID-19 patient?
After pre-cleaning with soap and water, use either: an EPA-registered disinfectant for emerging viral pathogens, 0.1% (1000 ppm) chlorine-based solution for 10 minutes, 60-70% alcohol-based compounds, or 0.5% sodium hypochlorite (1 part bleach to 9 parts water).
Related on GMJ
Interconnected resources
Dictionary of Public Health
GMJ News coverage
- UK flu and COVID-19 surveillance data to May 2027 shows continued monitoring amid seasonal trendsOct 2026
- Community Health Workers Boost COVID-19 Testing Among Formerly Incarcerated PeopleAug 2026
- PEN-Plus Expands Severe Disease Care Across Africa: Third International Conference Charts ProgressOct 2026
Quality & accreditation
- ASF Hospital — Standard 5 — Safety & Emergency Preparedness
- ASF Hospital — Standard 11 — Critical Care
- ASF Medical Transport — Standard 6 — Emergency Response During Transport
- ASF Medical Transport — Standard 5 — Infection Prevention & Control
- ASF Laboratory — Standard 7 — Examination: Process & Safety
Other guidelines on this topic
- Ongoing Living Update of Potential COVID-19 Therapeutics: summary of rapid systematic reviews
- Recommendations on Public Environmental Health in Health Care Facilities
- A Checklist for COVID-19 Pandemic Risk and Impact Management
- Recommendations for the Preparation of Disinfectant Solutions
- Guidelines for Critical Care of Seriously Ill Adult Patients with Coronavirus (COVID-19) in the Americas (Short Version)
- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- Version 4.4, 2020
- Status
- Current
- Published
- 2020-01-01
- Languages
- English
- Scope
- Global, with focus on Pan American region
- Audience
- Emergency medical services personnel, dispatchers, first responders, EMS administrators, public health authorities
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- Expert consensus based on WHO guidance and early pandemic evidence
- Record history
- Created 20 Oct 2026 · updated 20 Oct 2026 · next check Apr 2027
Pan American Health Organization. COVID-19 Recommendations: Prehospital Emergency Medical Services (EMS). Draft document, Version 4.4. Washington, D.C.: PAHO; 2020 Mar 27. (PAHO/PHE/IHM/COVID-19-20-0014). Available from: https://iris.paho.org/handle/10665.2/52137GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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