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May 1, 2013

Infectious exposure in EMS: The dirty business of keeping clean

The most fundamental element of emergency medical services is the interaction between the EMS provider and the patient who is ill or injured. Simultaneously many of our patients present with a variety of infectious diseases or conditions that expose us to infection. The patient, your family, and your fellow employees are counting on you to not get them infected.

There are many potential areas of infectious exposure for the patient and the EMS provider. An important one, under the direct control of the EMS providers, is the patient compartment area of the ambulance. There are several important strategies to improve the cleanliness of that area, and reduce exposures to infectious agents. Broadly, they are broken down into the following areas:

  • Equipment maintenance and disinfection
  • Patient compartment maintenance and disinfection
  • Minimizing contamination during patient care activities
  • Personal hygiene habits

A variety of processes, methods, cleaners and disinfectants are available to accomplish the basic task of eliminating the spread of infectious agents. The most important of these are simple, reliable, inexpensive, and compliant with rules published by the federal agencies that oversee patient and employee safety1,2,3. Keeping the ambulance and patient equipment clean requires a few cleaning products, and good personal practices.

Clean equipment begins with good equipment.

EMS patient care should be provided with equipment designed for that purpose. It should be kept in good repair. This includes the stretchers, packaging equipment, and both durable and disposable patient care items. The surface of these items that are older or have been cleaned too many times will have their protective surfaces compromised, and may harbor all forms of infectious agents.

Consider all of the surfaces that you end up touching through the course of a call. Have you cleaned stethoscopes, BP cuffs, or handles of jump kits? What about grab rails of ambulance doors, or the steering wheel? You might want to wipe down these common areas of contact as part of your cleaning regiment.

Disposable equipment that is in packaging that has been torn or soaked in liquid may particularly be at risk of containing dangerous agents and should be discarded.

Protect equipment that is taken into the patient environment (street, home, business) by keeping it clean.

Keep the patient compartment tidy.

All of your mother's favorite rules about keeping your home clean also apply to the ambulance environment: "If stuff isn't laying on the floor or on the counters, it won't get dirty." Therefore, the best cleaning principles for the ambulance include the day to day responsibility of keeping the fewest amounts of material in the vehicle that are needed for the service (the rest of the inventory remaining in a clean storage area).

Keep vehicle compartments closed and the work surfaces clear, and only taking out what is immediately needed for patient care.

Reduce the load of dirt and infectious agents by keeping dirty equipment out of the vehicle. Promptly discard that is designed to be disposed after patient use, such as suction catheters, end-tidal carbon dioxide detectors, lancets, and emesis basins. Most contaminated equipment can be safely disposed of in regular trash bins found at the EMS service or at the emergency department. However, if the contaminated materials are clearly wet, i.e. fluids are draining from them, these should be safely disposed of in red biohazard bags and deposited in the designated biohazard waste bins.

Do not use seat cushions to "hold" needles. Sticking needles and sharps objects into the ambulance or stretcher cushion injects those materials with infectious agents. Under no conditions should you throw needles away in anything other than approved disposal containers, even if they are "safed" or capped appropriately.

Reduce the load of airborne agents in the ambulance. Patients with a known respiratory-spread infection, including tuberculosis, meningitis, and influenza should have a mask in place before they enter the vehicle. Take advantage of the compartment's ventilation system and circulate the air continuously.

The CDC recommends processes for "respiratory hygiene/cough etiquette." This includes providing tissue for the patient and a place to dispose of them, as well as masks for those who are coughing.

These basic steps keep the load of potential dirt and infectious agents out of the ambulance and away from patients and EMS personnel.

Minimize infection opportunities when providing patient care.

For patient encounters where dirt and infectious agents are likely, it is ideal if the patient can be cleaned before he/she is placed in the ambulance, or has protective equipment put in place before placement on the stretcher and in the vehicle.

Other examples include:

  • Masking patients who are febrile and have and a cough to reduce the spread of airborne agents
  • Covering wound infections with an absorbent pad (i.e. Chux) that will prevent an agent such as MRSA from contaminating the stretcher
  • Removing clothing that has been exposed to bodily fluids such as diarrhea, urine and emesis and leaving it at the home. Consider wiping the patient down before moving them to the stretcher. Place an absorbent pad under the patient's buttocks.
  • Providing a closable emesis container to the patient during transport. Open basins can spill their contents during transport.
  • Considering what type of PPE best suits your patient's presentation. We know that gloves and protective eyewear is essentially a minimum, but if the patient is presenting with signs of an infection, consider a HEPA mask (N95 or P100) if the patient is coughing, or a face shield and gown for a patient with a lot of bodily fluids present.

Listen to your mother: Personal hygiene matters

EMS personnel can reduce the load in the ambulance by using great personal hygiene. Use soap and water to clean hands when soiled with dirt or body fluids and after caring for patients. Soap and water and scrubbing are the best way to avoid obtaining or transmitting infections from Clostridium difficile (C.diff) or norovirus. Otherwise, the Center for Disease Control's recommended method for hand sanitation is alcohol-based hand rub.

General methods to clean and disinfect

Cleaning and disinfection of the ambulance and equipment, rely on surface disinfection with approved cleaners, especially bleach. Routine cleaning and disinfection of surfaces should focus on those surfaces in proximity to the patient and those most frequently touched. Use CDC-registered disinfectants or detergents/disinfectants that is labeled for use in healthcare. Closely follow label and manufacturer recommendations for use of those cleaners, including the amount, dilution, contact time, safe use, and disposal.

The CDC outlines disinfection protocols for dangerous agents like Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C.diff), tuberculosis, hepatitis, or norovirus to include the cleaning of surfaces with sodium hypochlorite (bleach) based product. The recommendation is for a bleach solution prepared fresh daily in a 1:10 dilution with water.

It is critical that certain patients be protected from infections that may be in the vehicle or carried by EMS personnel. In EMS we deal with all types of patients, including those who have reasons to be "afraid of you." Those are patients who have compromised immune systems, including little children, those with cancer, and those burned or badly injured. It is particularly important that those patients be cared for in a clean ambulance, with clean patient care equipment, and by EMS personnel who are using masks and gloves to protect the patient.

There is an excellent reference4 on EMS infection control that featured an interview of Katherine West, BSN, MSEd, CIC, who is an infection control consultant for Infection Control/Emerging Concepts, Inc. The article reviews a variety of cleaning materials and processes related to ambulance safety.

There are new techniques that are being introduced every year. Most are more expensive, and not yet proven for disinfection. As of 2013, the effectiveness and reliability of fogging, ultraviolet irradiation, and ozone are not proven to reduce infections in EMS providers or patients from the wide variety of agents that are present in the patient population, and will be present in the ambulance.

References

  1. OSHA Compliance Directive CPL2-2.69
  2. www.cdc.gov/hicpac/pdf/isolation/isolation2007.pdf
  3. www.cdc.gov/HAI/settings/outpatient/outpatient-care-guidelines.html
  4. "How Clean is Your Ambulance? The truth behind cleaning chemicals". McCallion, Teresa. EMS Insider May 10, 2012

About the Author

James J Augustine, M.D., is medical advisor for Washington Township Fire Department in the Dayton, Ohio, area. He is Director of Clinical Operations at EMP Management in Canton, Ohio, and a clinical associate professor in the Department of Emergency Medicine at Wright State University. He formerly served as Assistant Fire Chief and Medical Director for Washington, DC Fire EMS. He has served 29 years as a firefighter, and was the first Chair of the Ohio EMS Board.
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