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

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 (2, 5).

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 (5, 7)
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).

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 (10–13)
• as an alternative mode of transport, the patient may be transported via private vehicle by an existing
  close contact (14–16)
• 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 (10, 17)
• 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 (7, 17, 18)
• 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 (5, 10, 12)

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 (11, 13).

• 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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• 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 (19, 20, 22):

• 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 (10, 12, 23):
  • 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 (20, 22).

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 (10, 11, 13).
• Patients should be kept in the vehicle on arrival until prearranged movements are implemented (11, 13).
• 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 (7, 10).

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

Good practice point.

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

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.

Good practice point.