Click on the following link to download the PDF Version of the COVID-19 Voluntary Guidelines: Medical-Hygiene Issues Related to COVID-19 - Frequently Asked Questions.

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1. Introduction
Updated: 21 April 2020

This document is for SAR organisations currently facing operating challenges as a result of COVID-19.

It is primarily based on guidelines issued by the World Health Organisation (WHO), existing national protocols provided by IMRF member organisations and consensus of an IMRF expert panel. Recommendations by ILCOR[1] and national resuscitation councils have also been included.

[1] ILCOR: International Liaison Committee on Resuscitation

Organisations should always adhere to national legislation/regulations or guidelines in cases where recommendations in this document contradict information given by local authorities. 

The understanding of the impact from the COVID-19 pandemic is constantly changing, and therefore guidelines and recommendations will also be constantly changing. Organisations should always seek the most updated information from reliable sources like WHO, Centres for Disease Control, National Health Authorities etc. 

In this document, the term “lifeboat crew” should be taken to include lifeguards, where they are part of a SAR organisation.

Any questions or suggestions can be sent to: [email protected], marked “COVID-19”.

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2. Background
Updated: 21 April 2020

Coronaviruses are a large family of viruses which may cause illness in animals or humans.  

In humans, several coronaviruses are known to cause respiratory infections ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS).

The most recently discovered coronavirus causes coronavirus disease COVID-19. This new virus and disease were unknown before the outbreak was identified in Wuhan, China, in December 2019.

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3. How Does COVID-19 Spread?
Updated: 21 April 2020

People catch COVID-19 from others who have the virus.

The disease can spread from person to person through small droplets from the nose or mouth, which are spread when a person with COVID-19 coughs or exhales.

These droplets land on objects and surfaces around the person. Other people then catch COVID-19 by touching these objects or surfaces, then touching their eyes, nose or mouth.

People can also catch COVID-19 if they breathe in droplets from a person with COVID-19 who coughs out or exhales droplets.

That is why it is important to stay more than 1,5 metres (5 feet) away from a person who may have COVID-19.

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4. How Can I Protect Myself and Prevent the Spread of Disease?
Updated: 21 April 2020

By following a few simple precautions, you can protect yourself from infection or from spreading the disease to others:

-	Regularly wash and thoroughly clean your hands with warm water and soap, or use an alcohol-based hand rub. Why? Washing your hands with soap and warm water, where possible, or using alcohol-based hand rub, kills viruses that may be on your hands.
-	Maintain at least 1,5 metres (5 feet) distance between yourself and anyone who is coughing or sneezing. Why? When someone coughs or sneezes they spray small liquid droplets from their nose or mouth which may contain the COVID-19 virus. If you are too close, you can breathe in these droplets.
-	Avoid touching eyes, nose and mouth. Why? Hands touch many surfaces and can pick up viruses. Once contaminated, hands can transfer the virus to your eyes, nose or mouth. From there, the virus can enter your body and can make you sick.
-	Make sure you, and the people around you, follow good respiratory hygiene. This means covering your mouth and nose with your bent elbow or tissue when you cough or sneeze. Then dispose of the used tissue immediately. Why? Droplets spread virus. By following good respiratory hygiene, you protect the people around you from viruses such as cold, flu and COVID-19.

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5. How Dangerous is the COVID-19 Virus?
Updated: 21 April 2020

Illness due to COVID-19 infection is generally mild, especially for children and young adults.

Hospitalisation rates are higher for those aged 60 years and above (national guidelines in some countries may set this age higher or lower, so follow local recommendations), and for those with other underlying health conditions (e.g. hypertension, diabetes, cardiovascular disease, asthma, or other chronic respiratory disease and cancer).

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6. When Should Lifeboat Crew Members NOT Report for Duty?
Updated: 21 April 2020

Lifeboat crew should not report for duty if:

-	they themselves are currently in quarantine or isolation;
-	they have a fever;
-	they are suffering from symptoms of airway infection;
-	someone in their household is quarantined/isolated or has symptoms of airway infection;
-	they have been without symptoms for fewer than 7 days after their infection has been confirmed/suspected.

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7. Should Crews Routinely Wear Face Masks?
Updated: 21 April 2020

There is no need for lifeboat crew members to wear face masks, as a routine, unless required by national guidelines.

The most effective ways to protect yourself and others against COVID-19 are to:

-	wash your hands frequently with warm water and soap, or an alcohol-based hand rub;
-	cover your mouth and nose with your bent elbow, or a tissue, when you cough or sneeze (the used tissue should then be disposed of immediately); and,
-	maintain a distance of at least 1,5 metres (5 feet) from people who are coughing or sneezing.

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8. Is It Safe for Our Organisation to Continue to Undertake Medical Calls?
Updated: 21 April 2020

Each organisation should familiarise itself with screening algorithms used by the requesting authorities (medical dispatch, coastguard, J/MRCC etc.) in its area. 

Screening will help determine the level of risk and the precautions that should be taken by responders.

The authority should also advise victims and bystanders on how to behave when responders arrive, including keeping distance, putting on surgical masks and following any other instructions given by the responders.

Ideally medical personnel should join the vessel on all medical calls, but in cases where this is not possible, such as due to lack of time, or where the rescue vessel operates without medical personnel onboard, the crew must undertake the necessary precautions themselves.

If the necessary protective equipment is not available, organisations should consider whether or not to accept the call. However, every alternative option for providing life-saving treatment and/or medevac should always be explored. The coxswain should, together with the requesting authority, and/or the organisations medical team, make the necessary assessments in advance of such missions.

With adequate screening, training of crew members and protective equipment in place, it should be safe for crews to continue to do medical calls.

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9. How Can Lifeboat Crew Members Carry Out Screening for COVID-19?
Updated: 21 April 2020

A quick way to screen patients or crew members on a casualty vessel is to ask these questions from a safe distance (also observe national guidelines):

1.	Do you have/have you had fever in the last few days?
2.	Are you coughing?
3.	Do you feel any pain or pressure to the chest?
4.	Do you have difficulty breathing or shortness of breath?
5.	Do you have/ have you had contact with anyone with proven COVID-19?

If the patient answers YES to one of these questions, the person should be treated as if there is a suspected/confirmed COVID-19 infection.

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10. When Should We Wear Personal Protective Equipment (PPE) and What Should We Wear?
Updated: 21 April 2020

As part of the standard of care, all providers must perform hand hygiene before and after all patient care activities, regardless of the etiology of the patient presentation.

Gloves are never a substitute for hand hygiene. All personnel should avoid touching their face while working and should be encouraged to remind other personnel, as people are often not conscious of touching their own face.

When handling and transporting patients with acute respiratory tract infection and/or symptoms such as fever, cough, shortness of breath or suspected/confirmed SARS-CoV-2 infection responders should wear surgical mask, eye protection, gown/coverall and gloves.

All other handling/transport of patients with uncertain infection status should be carried out with a surgical mask, gloves and goggles.

Measures that should be taken to limit exposure in the vessel:

-	Have clearly defined roles and responsibilities within the crew so that as few as possible of the crew members has to be in the "patient zone" within 1 metre distance of the patient;
-	Let patients wear surgical masks and gloves if possible (explain to the patient);
-	Wrap the patient/cover surfaces with infection control sheets;
-	Keep the patient (if feasible) isolated in a suitable location during transport;
-	Maintain ventilation at a high level of air exchange;
-	Next of kin can only accompany the patient if absolutely necessary (except young children);
-	Clarify all logistics in the evacuation chain as soon as possible.

Please see the table in Figure 1 (below) for further details of the appropriate items of PPE to be used for different levels of care.

* If the entire crew is involved in treatment of the patient, the bridge team should remove their PPE before entering the bridge (clean zone), but not the mask.

** Bag valve mask ventilation, airway suction, intubation, nebulizer, CPAP/biPAP, CPR.  Most of this would be performed when ambulance crew are on board, where ambulance crew are in attendance. Any ambulance crew in attendance would normally be expected to provide the N95/FFP2 masks to all lifeboat crew.

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11. How Can We Ensure Proper Use of Personal Protective Equipment (PPE) Among Crew Members?
Updated: 21 April 2020

Each organisation should establish its own procedures and training for the use of infection control PPE.

As a reference, the European Centre for Disease Prevention and Control has made a very good guideline with an online e-tutorial that can be useful: https://www.thinglink.com/scene/584726288351100929 

The US Centres for Disease Control also has a useful guideline: https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf

PPE should always be removed in an appropriate doffing area to prevent secondary contamination. Care should be taken to avoid self-contamination, for example by using a “buddy” system.

If members of the bridge team must be involved in direct patient care, after completing care and prior to entering an open bridge they should remove eye protection, gown and gloves and perform hand hygiene. The mask should remain in place during transport.

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12. How Do We Perform Patient Care During Transport?
Updated: 21 April 2020

Crew members should attempt to minimise patient contact during assessment. It may be permissible, for example, to defer obtaining vital signs if the patient appears stable, has no visual evidence of distress or shock, and transport time is not prolonged.

Individual isolation capsules are not needed to transport Covid-19 patients. Keeping a mask on the patient is enough for transport. 

After conducting an initial assessment focused on patient’s stability (respiratory distress, altered mental status, etc.), crew members should define appropriate interventions for patient deterioration before and/or during patient transport. 

Any patient belongings should be considered contaminated, placed in a biohazard bag, sealed, labelled and transported with the patient in the patient compartment.

Crew members should avoid opening compartments and cabinets unless essential to patient care. Equipment needs should be anticipated and the appropriate tools removed from cabinets prior to placing the patient in the vessel. 

After pre-arrival notification, the crew should continue to communicate with the medical dispatch or ambulance with updates on the patient’s condition and ETA to facilitate reception of the patient immediately upon arrival.

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13.  Is It Still Safe to Give Cardiopulmonary Resuscitation (CPR)?
Updated: 21 April 2020

Risk of Infection

The risk of infection varies over time and also between regions and countries, and it is recommended that each organisation keeps updated on the specific risk in their own area over time.

Most out-of-hospital cardiac arrest occur in private homes, where infection status most likely will be well known. It is also very unlikely that a person will suffer a sudden cardiac arrest at home as a result of Covid-19.  This is more likely to occur to patients who have already been admitted to a hospital.

Mitigate Age as Risk Factor

The health risk from Covid-19 increases with age, and according to the WHO the critical age for increased risk is at the moment 60 years. National guidelines in some countries may set this age higher or lower, follow local recommendations.

As a mean to mitigate the increased risk for elderly crew members, it is recommended that crew members above the age of 60 years, avoid performing CPR if possible.

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14. What Sort of Treatment is Appropriate for Casualties Suspected of Infection?
Updated: 21 April 2020

1)	Adults without clear or proven infection:
	-	Crew can deploy to incident;
	-	NO mouth-to-mouth ventilation;
	-	Chest compressions only (preferably with proper PPE* in place);
	-	Use of Automated External Defibrillator (AED).
2)	COVID-19 positive or strong suspicion:
	-	Crew can deploy to incident;
	-	NO mouth-to-mouth ventilation;
	-	Chest compressions only (only when proper PPE[2] is in place);
	-	AED only (when PPE is not available).
3)	Children, infants and newborns:
	-	Crew can deploy to incident;
	-	Give CPR (including mouth-to-mouth ventilation).

[2] Personal Protective Equipment for CPR: Goggles/face shield, N95/FFP2 respirator, gown/coverall, gloves.

It is rare for children to have cardiac arrest because of heart problems - these are more likely to be caused by primary oxygen deficiency / respiratory problems, which is why ventilation is of the utmost importance for the child's survival.

Although mouth-to-mouth breathing increases the risk of being infected with COVID-19, for children it is currently recommended that normal guidelines are followed, i.e. 5 rescue breathes followed by both chest compressions and mouth to mouth ventilation even in suspected / confirmed cases of COVID-19.

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15. Changes to the Basic Life Support (BLS) Protocol
Updated: 21 April 2020

Examples of adjustments to the normal BLS protocol. Each organisation should develop their own procedures/check card according to national guidelines. The example below is from RNLI.

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16. Drowning – Should We Perform Mouth-to-Mouth Resuscitation?
Updated: 21 April 2020

At the moment, there are no specific guidelines for drowning victims during the pandemic, but there are a lot of ongoing research efforts internationally to understand what measures can be taken.

Recommendations for drowning resuscitation are in development and will be available within a few weeks. The IMRF will continue to monitor the situation and will update our recommendations accordingly.

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17. How Can We Protect Crew Members Who Are Required to Board Other Vessels?
Updated: 21 April 2020

When boarding a casualty vessel, the lifeboat crew is at potential risk of getting exposed to someone infected with Covid-19. Due to this risk it is important to always consider the necessity of leaving your own vessel.

If it is absolutely required to board a casualty vessel crew should consider:

1.	Proper planning - allow as few lifeboat crew members as possible to board a casualty vessel;
2.	Perform proper hand hygiene;
3.	Wear disposable gloves;
4.	Consider wearing a survival suit or infection control coverall (if available);
5.	Put on safety goggles; If not available, you can close the face shield on your helmet;
6.	Instruct crew of casualty vessel to stay at least 2 metres away;
7.	If not possible to keep distance, consider wearing a surgical face mask;
8.	Avoid touching your face while working;
9.	Dispose of gloves and perform proper hand hygiene when returning to lifeboat.

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18. How Do We Decontaminate a Lifeboat After Transport of COVID-19 Patients?
Updated: 21 April 2020

Recent reports indicate that the virus can survive on certain surfaces for as long as 72 hours, and it is therefore important that no lifeboats are placed back on general service prior to decontamination. 

It is advisable to remove as much equipment from the lifeboat as possible before transporting a patient. This reduces the need for decontamination afterwards. Following patient transfer leave doors and windows open so that sufficient air exchange may occur.

Maintain proper precautions when decontaminating:

-	Wear gloves and surgical mask;
-	Avoid touching your face while cleaning;
-	Avoid exposing more people than necessary during cleaning;
-	Wash your hands and face or take a shower when you’re finished;

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19. What Supplies Are Needed for Decontamination?
Updated: 21 April 2020

-	PPE for personnel performing the decontamination;
-	Leak proof biohazard bags;
-	Garbage bags;
-	Spray bottles;
-	Disposable rags;
-	Alcohol based hand sanitizer;
-	Absorbent towels;
-	Bleach or alcohol-based cleaning solution or disinfection wipes.

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20. What Precautions Should Be Taken During Disinfection/Decontamination?

Updated: 21 April 2020

All visibly soiled surfaces should be cleaned and then decontaminated starting from the ceiling of the vessel and working down to the floor in a systematic process. 

All surfaces that may have had contact with the patient or materials that were contaminated during patient care (e.g. Control panels, floors, walls, work surfaces, stretcher, rails, etc) must be thoroughly cleaned including the underneath and base of the stretcher. 

To conduct cleaning, providers should follow routine cleaning and disinfection procedures for pre-cleaning. This can be done with water and soap. This pre-cleaning must be followed by the application of a high-grade disinfectant to any potentially contaminated surfaces or objects.

Corona viruses have a lipid envelope which makes a wide range of disinfectants effective.

Disinfectant solution options include:

•	An EPA-registered disinfected that is labelled for emerging viral pathogens. These may have descriptions such as “[product name] has demonstrated effectiveness against viruses similar to COVID-19 on hard, non-porous surfaces. Therefore, this product can be used against COVID-19 when used in accordance with the directions for use against [name of supporting virus] on hard, non-porous surfaces.”;
•	Chlorine-based compounds (bleach, calcium hypochlorite, NADCC tablets) must be at least 0.1% (1000 ppm) for 10 minutes on a clean surface;
•	Alcohol-based compounds (isopropyl alcohol, ethyl alcohol) must be at least 60-70% alcohol by weight or by volume;
•	Regular household disinfectant containing 0.5% sodium hypochlorite (that is, equivalent to 5000 ppm or 1 part bleach to 9 parts water).

Ensure adequate ventilation especially when using chemicals. Doors should remain open while cleaning the vehicle. 

Follow contact times on labels of the products used.

If patient care equipment is reusable, it must be cleaned and disinfected according to the manufacturer’s instructions.

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21. How Do We Decontaminate/Disinfect Equipment?

Updated: 21 April 2020

Disinfect the outside of any bags containing unused medical equipment as well as the stretcher.

PPE should be removed under supervision and placed into a final biohazard bag, which is then closed and disinfected.

Pre-Cleaning Technique

-	First clean with dry techniques;
-	Clean from clean area towards dirty and from "high" (e.g. on top of a cupboard) to "low" (e.g. a floor).
-	Dry cleaning of the floor and other surfaces is sufficient if there are no spills or visible contaminations;
-	Wet cleaning is necessary for adhering dirt and wet contamination, such as blood, urine and saliva.

Decontaminating the Survival Suit

While still wearing surgical mask and googles, clean the outside of the survival suit with soapy water, using a sponge. Pay special attention to neck cuffs that potentially have to be pulled over the wearers head. Rinse thoroughly with fresh water. 

Follow manufacturer’s instructions if further disinfection is required. 

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22. What Do We Do with Waste, Following Decontamination?
Updated: 21 April 2020

All waste, including PPE and wipes, should be considered Category A infectious substances, and should be packaged appropriately for disposal.

-	Linen should not be shaken. It should be contained and laundered according to standard operating procedures;
-	Wash and disinfect linen: washing by machine with hot water (60-90°C) and laundry detergent is recommended for cleaning and disinfection of linens. If machine washing is not possible, linen can be soaked in hot water and soap in a large drum, using a stick to stir, avoiding splashing. If hot water not available, soak linen in 0.05% chlorine for approximately 30 minutes. Finally, rinse with clean water and let linen dry fully in the sunlight.
-	All waste must be disposed of according to organisation protocols as well as local and national regulations for Category A infectious substances (best practice may be to transfer waste to the hospital for disposal).
-	Additional cleaning methods may also be used, though are not required (e.g. ultraviolet germicidal irradiation, chlorine dioxide gas, or hydrogen peroxide vapor). However, these should not replace the manual disinfection.

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