California’s San Francisco Department of Public Health is staffed by over 8,000 employees serving 875,411 people who are approximately 50% White, 36% Asian, 15% Latino, and 6% Black (some reported > 1 race). Serving people who are most impacted by poverty and health inequities, the department delivers health promotion services and direct medical care, 

During the initial phases of San Francisco’s COVID-19 response, the city’s Emergency Medical Services Agency (SF EMSA) developed a pandemic response Transportation Hub to stage and dispatch medical transport resources independently from the 911 system. The Hub played a critical role in providing pandemic relief to vulnerable populations by facilitating the movement of people experiencing homelessness off the streets and into Shelter-In-Place (SIP) sites. It ensured testing and vaccination of people who bore the burden of COVID due to ethnicity, geography, language, age, profession, and/or incarceration. The Hub prevented delays to the 911 system that service these communities. 

The goal of the EMSA Transportation Hub was to provide non-emergent medical transport for Patients Under Investigation and COVID-19 positive patients between medical centers and field care clinics, assume routine patient transfers normally requested through the 911 system, transport mobile COVID-19 testing teams of nurses, and meet other Emergency Medical Technician (EMT) needs as identified by San Francisco’s COVID-19 Command Center (SF CCC).       

The EMSA Transportation Hub engaged the Department of Emergency Services (DES), Emergency Medical Dispatchers (EMD), Basic Life Support (BLS) ambulances and EMT crews, paramedic supervisors, mobility transit van operators, nurses, and certified industrial cleaning teams for decontamination. Daily operations were staged at a downtown concert halll because it offered centralized accessibility and provided a large, open space to organize the various roles and duties and provide safe social distancing.  A Hub control center streamlined communications with the 911 call center, SF CCC, operational branches, medical centers, clinics, and various entities functioning under COVID-19 response plans. The SF CCC procurement process activated the staffing, venue, ambulances, and equipment allowing for contracts and agreements between SF EMSA and its partners, e.g. ambulance service providers, Department of Emergency Services, and SF Municipal Transportation Agency.

Utilization was tracked and reported weekly to Hub partners and the SF CCC.  Within a month of launching, the Hub fulfilled more requests than the 911 system and operated 6 BLS ambulances, 15 mobility transit vans, 4 EMD, 1 EMSA specialist, 6 to 8 nurses staffing 3 mobile testing teams, and industrial cleaners. In the latter phases of the pandemic, EMT staffed  mass vaccination sites and mobile vaccination teams. These efforts are validated through a 16-month period in which the EMSA Transportation Hub logged 12,500 transports, 20,000 field tests, and 3,400 person hours at vaccination sites.    

The EMS Agency COVID-19 Transportation Hub took steps to ensure uninterrupted standard 911 services while launching testing, vaccination, and transportation services for people living in the most highly impacted communities. As seen by San Francisco’s record of low COVID case and hospitalization rates and high vaccination rate of BIPOC communities, the practice led to reduced health inequities.

With plans to erect Field Care Clinics, COVID-19 testing sites, establish mobile testing teams for homebound individuals, move vulnerable populations off the streets to SIP sites, and transfer non-symptomatic COVID-19 patients from hospitals to quarantine sites, EMSA recognized a significant increase in need for ambulances and other modes of patient transport. These services would normally be provided by private ambulance service providers; however, they were already designating their daily ambulance quotas to posture for EMSA COVID-19 surge plans. EMSA had to quickly adapt and thus secured a separate staffing pool of patient transport modes that would allow central management of several different transport service providers to meet the needs of populations most impacted by health inequities.

The EMSA Transport Hub was innovative as a center as it was not based on any specific disaster mitigation design, but rather formulated based on the specific needs of San Francico’s most vulnerable populations. For example, early in the pandemic the SF CCC recognized that testing was not adequately available in highly impacted communities and so mobile teams were launched. Another way the practice was innovative was that it centralized deployment of transport services, irrespective of the home company or agency. As the pandemic progressed, the roles of the hub also expanded as described below. 

The Hub had to adapt creatively to the changing needs and resources of the city’s COVID response. Demand for the mobile testing team increased; however, shortages of Public Health nurses made it difficult to fully staff teams and meet testing requests throughout the city. EMSA implemented an expanded local scope of practice that allowed EMT to perform COVID-19 tests after receiving the EMSA course for the swab test. EMT were dispatched to assisted living care facilities, private residences of mobility restricted patients as well as COVID testing tents in underprivileged neighborhoods. To ensure robust COVID prevalence data, EMT were also dispatched to funeral homes to conduct COVID testing on recently deceased members of the community.

The local context of COVID-19 in San Francisco builds on a history of health disparities experienced by low-income, Black, Latinx, Asian, and American Indian/Alaska Native (AI/AN) communities experiencing disproportionately higher rates of COVID-19 infections, hospitalizations, and deaths. The specific challenges related to COVID-19 that contributed the most to health inequities in these communities include lack of adequate public transportation to access services, language barriers, and historical distrust of health providers. The Hub responded to these challenges by providing the necessary transportation, employing staff with different language skills, distributing materials in Spanish, Mandarin, and other languages, and parterning with local community members and clinicians to provide health education and respond to people’s COVID-related concerns. 

When vaccines became available, the EMT staff at the hub played a significant role in the program. EMSA added Intra-Muscular (IM) injections to the local scope of practice and enrolled members into the EMSA Vaccine EMT course. EMT staffing accounted for 1,100 person-hours and over 60 outreach missions. They filled RN gaps at vaccine tents in targeted parts of the city and staffed mobile teams dispatched to assisted living care facilities.

This innovation increased the skillset of team members. Mobility-restricted transport van crews learned EMS radio communication and received PPE training. Drivers were also trained on how to recognize criteria that would warrant activation of Advance Life Support ambulances. The vans were re-configured for COVID-19 precautions and outfitted with plastic shielding that separated the driver’s compartment from the patient area.

EMS Agency COVID-19 Transportation Hub is a new, innovative practice developed to respond to the transportation needs of San Francisco’s most highly COVID impacted communities. By anticipating heightened demand on EMS services, the Transportation Hub ensured responsive and adaptive services in the face of several challenges including staffing shortages. The practice contributed to San Francisco’s notable record of vastly lower case and hospitalization rates as compared to other cities of its size.

EMSA’s existing and new partnerships developed during the Hub’s creation were instrumental to its operations. The partners were a part of the Hub’s planning and successful implementation. The objective of the EMSA Transportation Hub was initially to solely prevent interruptions to 911 system resources. However, as the pandemic progressed and the adaptive nature of EMS personnel and partners was found to be suitable in several key contributions, partnerships were forged with various departments in the city as well as within the private sector.

The pre-existing partners included the San Francisco Department of Homelessness and Supportive Housing (HSH) and the SF Homeless Outreach Team (HOT). They helped ensure that safe and efficient workflow was created to facilitate the movements of clients. Together, a request process, on-scene coordination of roles, and SIP-receiving process were defined to ensure safe and efficient movement of clientele. Other known partners included ambulance providers and DES.

The new partners included the SF Municipal Transportation Agency (MTA) and the city-contracted industrial decontamination cleaners. They benefitted the process by sharing new perspectives on transport procedures that alleviated early obstacles such as loading procedures in high traffic areas, designation of patient loading areas in mission-heavy areas, and cleaning workflow to efficiently stream vehicles through in-between transports. All Hub partners attended a weekly EMSA virtual huddle to remain updated on assignments, issues, and challenges posed within the operations and to collaboratively resolve such concerns. 

These partnerships were leveraged to incorporate health equity strategies into the Hub’s services by drawing on the diverse ethnic backgrounds and skill sets of the staff. For example, the SF Homeless Outreach Team were subject matter experts on the needs of people experiencing homelessness. Additionally, they were well networked with the homeless community. Their expertise and relationships ensured the Hub’s transport teams knew how to effectively and respectfully communicate with PEH and thus successfully transport them to SIP sites.

The strategic engagement of the SF HSH, the SF Homeless Outreach Team (HOT), ambulance providers, DES, SFMTA and the city-contracted industrial decontamination cleaners ensured a diverse work force that were subject matter experts and knowledgeable about San Franicsco’s different populations. These partnerships ensured effective transportation- and COVID-related services to communities experiencing health inequities.

The EMSA Transportation Hub continuously adapted to meet the needs of the community as COVID case and hospitalization rates fluctuated by adjusting its services to support testing and vaccine availability.  The Hub evolved from the initial concept of providing COVID-19 transportation into a complex operation that provided community testing, vaccination, and EMS training to the rest of the 911 system resources.

San Francisco’s response was always data-driven and evidence-based. The Hub established best practices and continued to refine these to meet the exigent circumstances. For example, as the demands on the Hub increased and decreased with the surge curves of the pandemic, a weekly utilization analysis process was established to monitor and anticipate staffing needs and maintain cost-effectiveness. Additionally, a weekly virtual huddle was attended by leadership of each of the partners to review utilization stats and operational findings and escalate issues and concerns.

These improvements helped to reduce inequitable health outcomes by ensuring that the appropriate amount of resources were provided to meet the needs of the communities and to avoid staffing and supply shortages.

EMSA, who provided the central management, attended the daily  SF CCC meetings to provide updates, anticipate next steps, and make strategic adjustments. This representation provided a critical link to SF CCC leadership and allowed for solutions that were beyond the Hub’s capacity and required input and support from other departments, agencies, and groups.

Early obstacles identified were gaps in communication and smooth fulfilling of service requests between the Hub and medical centers, SIP sites, shelters, etc.  However, with the support of the SF CCC, the challenges were identified, Hub leadership consulted, and resources identified to ultimately rectify these issues.

Lessons learned included establishing a strong organizational structure, communication chain, and clear workflow regardless of the size of the operation when involving multiple partners that come from different agencies. Additionally, it was key to ensure that the established structure, communications, and workflow was known in detail by all staff involved regardless of where they fit in the operational chain.  This resulted in rapid resolution of issues and prevented work stoppage regardless of the time of day.