Covid-19 Patient Transport: A Literature Review

The pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (COVID-19) is tremendously


INTRODUCTION
The COVID-19 pandemic is still ongoing.The Extraordinary Event (KLB) of viral pneumonia that began in early December 2019 occurred in Wuhan City, Hubei Siti Aisah / Covid-19 Patient Transport: A Literature Review Province, China and was caused by the new Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).On January 30, 2020, the World Health Organization (WHO) declared this outbreak a Public Health Emergency of International Concern (PHEIC) which is the highest warning issued by WHO. 1 In its press conference on 11 February 2020, WHO named this disease as Corona Virus Disease 2019 (COVID-19). 2 and a month later on March 11, 2020, WHO declared this COVID-19 outbreak a pandemic. 3e ease of transmission and the high death rate from COVID-19 has caused a worldwide health crisis.As of January 26, 2020, there were 2,794 confirmed cases of COVID-19 of which 80 died. 4Furthermore, as of April 13, 2020, more than 1,770,000 cases have been diagnosed in 213 countries, territories or territories. 5In a year later, the number of confirmed cases of COVID-19 globally has reached 130,422,190 people as of April 5, 2021. 6Meanwhile, new confirmed cases showed an upward trend again where at its peak on December 20, 2020 there were 851,249 new cases and then on February 16, 2021 it fell to 228,734 new cases, now there is an increase again because there are 685,576 new cases as of April 3, 2021. 7e of the complications of COVID-19 is pneumonia where the patient will feel short of breath and there is a drastic decrease in oxygen saturation in the blood.People who are hospitalized with Covid-19, 15-30% will experience COVID-19 associated acute respiratory distress syndrome (CARDS). 8here if it is not handled properly, the patient will require respiratory assistance with a ventilator later.This is a new problem because some small hospitals do not yet have ICU rooms, or the limited capacity of ICU rooms equipped with ventilators.For this reason, patients need to be referred to a larger hospital and/or a hospital that still has an ICU room with a ventilator available.COVID-19 patients who are self-isolating at home may also require transportation to the hospital in the event of a decline in health conditions.Referring to the events above, it is necessary to transport COVID-19 patients.Ambulance vehicles are a common means of transportation used for patients who are in critical condition such as the above incident.
Ambulance originated in France in the 15th century.There are two types of ambulance, namely 'the ward type' and 'the transfer type'.'The ward type' ambulance has resuscitation equipment and essential medicines.'The transfer type' is used to transfer patients whose condition is stable to the hospital.Various types of ambulances appear based on variations in the patient's condition 9 .Ambulances play an important role during a pandemic.COVID-19 patients who show an increase in symptoms such as shortness of breath will be transferred to a special COVID-19 health facility by ambulance so that their condition can be monitored closely.
WHO states that COVID-19 can be transmitted through close contact, droplet particles and small particles in the air (airborne).Methods of transmission through droplets and airborne mainly occur in close contact and in rooms with poor ventilation levels. 10The above conditions strongly describe the situation when transporting Covid-19 patients in the ambulance.This is a challenge for health workers who carry out patient transfers because it includes a high risk of infection in a limited space for several hours. 11sed on this, the authors are interested in raising the research topic "Literature Review: Transport of COVID-19 Patients".The general purpose of this study is to review the literature review on how to safely transport COVID-19 patients using ambulances.

METHODS
The method used to compile this literature review is done using an electronic database.Journal search method using ScienceDirect Siti Aisah / Covid-19 Patient Transport: A Literature Review and Pubmed.The keywords used are COVID-19 transportation and COVID-19 ambulance.The journal year is limited to 2020-2021.After the journals found were sorted according to the inclusion criteria, the authors obtained nine journals that would be used in this literature review.

RESULT
From the results of the sorting of journal articles using the PRISMA method, nine research articles related to the transportation of Covid-19 patients were obtained with the characteristics of the journal as presented in Table 1.

DISCUSSION
In connection with the high risk of transmission during the transportation of COVID-19 patients, there are steps that need to be taken to mitigate risk and prevent exposure.According to Koehler & Rule (2020), efforts to mitigate risk and prevent exposure to COVID-19 can be carried out through the hierarchical risk control framework approach created by NIOSH. 20Depicted in the inverted pyramid in Figure 1 below, the more effective controls are at the top of the pyramid, while the less effective controls are at the bottom.00 This risk control control hierarchy consists of five levels of control efforts, namely elimination, substitution, engineering control, administrative controls, and personal protective equipment (PPE). 20In the context of transporting COVID-19 patients by ambulance, exposure risk control can be structured based on the following framework: Elimination can be done by avoiding transportation of COVID-19 patients.Patients with COVID-19 with stable conditions and without complaints means it is possible to self-isolate at home 21,22 and there is no need to send the patient to a quarantine facility as was done by the Indonesian government at the beginning of the pandemic.
Substitution cannot be applied in the context of transporting COVID-19 patients.
Engineering controls aim to separate ambulance personnel from danger.One of the safest methods for transporting COVID-19 patients is the use of negative pressure isolation capsules as exemplified in the second research journal above using the Epishuttle PMIU. 12or by using Rega PIU. 11mbulances with a negative pressure system as mentioned in the first journal or the use of a hood on the patient's head with negative pressure as mentioned in the seventh journal are also highly recommended for use in the transportation of COVID-19 patients because they have been shown to reduce exposure by reducing the number of virus droplets or aerosols.COVID-19 in the air. 9,17 there is no separation wall between the front of the ambulance (where the driver and front passenger) and the rear compartment (where the patient is treated during the trip in the ambulance) then it is necessary to make a dividing wall to reduce exposure to the officers in front, as well as to the aircraft.the separator between the cockpit and the cabin. 23Air recirculation in the ambulance must also be avoided by turning off the recirculation button on the ambulance air conditioning system.Try to get fresh air into the ambulance. 24One literature recommends opening the ambulance windows in the driver's area whenever possible 25 and a guide issued by the Malaysian Ministry of Health (KKM) states that the windows in the driver's area should be lowered by 3 cm. 26iti Aisah / Covid-19 Patient Transport: A Literature Review Administrative control for infection risk control in the transportation of COVID-19 patients is carried out from before transportation, during transportation to after transportation by implementing certain protocols.Starting from the central operator who screens the level of risk of COVID-19 using a kind of scoring system, for people who need an ambulance to determine the criteria for suspects where the results are submitted to the ambulance staff as a suggestion for determining the proper use of PPE before the ambulance comes to the patient.[15] The central operator in collaboration with ambulance staff is also responsible for contacting the health facility or hospital where the patient will be taken to ensure the availability of beds in the ER or isolation room or ICU room according to the patient's needs before transportation is carried out, to avoid prolonged contact between the patient and the staff.health in the ambulance which increases the risk of exposure. 27Patients should also be advised to wear a surgical mask before contact with ambulance staff. 14Patients who need the help of an oxygen mask are still wearing a surgical mask over the oxygen mask. 24,25ring transportation, try as much as possible not to take medical actions that produce aerosols and if you do, high caution and strict mitigation are needed, for example by using a HEPA filter on an Ambu Bag or using a video intubation device to facilitate intubation or by using a Supraglottic Airway Device.such as Laryngeal Mask instead of Endo Tracheal Tube (ETT). 28Protocols for the use of PPE and routine hand washing before and after transportation also need to be regulated in administrative controls. 23 mentioned in the first and sixth journals above, after the COVID-19 patient has been transported and has been handed over to the designated health facility, disinfection and cleaning of the ambulance must be carried out.Disinfection of ambulances and medical equipment after transportation is important to prevent exposure to both health workers and patients who will use the ambulance afterwards. 9,16PPE and used medical materials must be disposed of in the medical waste bin to prevent exposure.
As discussed in the ninth journal above, routine PCR examinations for health workers working in high-risk areas such as ambulances and for staff with symptoms of illness must be carried out to prevent the spread of COVID-19 in the workplace. 19,29very ambulance officer needs to be vaccinated against COVID-19 if there are no contraindications because research shows that health workers who receive COVID-19 vaccination have a very low risk of contracting it. 30,31rsonal Protective Equipment (PPE).Although PPE is the lowest level in the risk control hierarchy, its presence is necessary and must be worn when health workers will carry out treatment or direct contact with COVID-19 patients as described in the fourth, fifth and sixth journals above.In general, the required PPE for ambulance staff in handling COVID-19 patients is at least level 2 PPE including surgical masks, non-sterile gloves, isolation gowns and eye protection (protective glasses or face shield).However, the use of level 2 PPE equipped with N95 masks is preferred.When health workers are about to take medical actions that have the potential to cause aerosols, surgical masks must be replaced with N95 masks. 32,33What is no less important is that training on the use of PPE and the removal of PPE must be given to health workers beforehand so that PPE can be used properly. 14,15The application of the Buddy Check System method where coworkers participate in ensuring that the PPE we wear is installed correctly and also ensuring that the sequence when removing PPE is followed correctly has proven to be very useful for preventing exposure. 16iti Aisah / Covid-19 Patient Transport: A Literature Review

CONCLUSION
The transfer of COVID-19 patients using land, water or air ambulances (heli or plane) can be carried out safely as long as it is carried out in accordance with strict procedures, namely the use of negative pressure ambulances, use of personal isolation capsules, use of negative pressure hoods, use of level 2 PPE with the use of N95 masks, disinfection of ambulances after use, screening of suspected COVID-19 patients by the central operator and ambulance officers, and routine COVID-19 checks on ambulance officers.Further studies are needed as a basis for making protocols for use in the transportation of COVID-19 patients.

ACKNOWLEDGMENTS
The author would like to thank all those who have helped and supported the research process and writing this research article.

CONFLICTS OF INTEREST
Ambulances play an important role during a pandemic.COVID-19 patients who show an increase in symptoms such as shortness of breath will be transferred to a special COVID-19 health facility by ambulance so that their condition can be monitored closely.