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August 31, 2014
How to prevent contamination and stay safe during large-scale incidents
Maintaining standard precautions during multi-patient incidents presents unique challenges
The use of personal protective equipment (PPE) during routine patient contact has been the standard of care for nearly two decades. With access to gloves, safety glasses, face shields, HEPA filter masks and gowns, EMS providers have many tools at their disposal to prevent cross infection, mainly of blood borne pathogens.
Yet, incidents that result in more than a couple of patients also create special challenges for maintaining infection control standard operating procedures (SOPs). Many agency protocols state the maintenance of standard precautions during mass casualty events, but do not provide specifics of how to do so.
Challenges to PPE use
Maintaining standard precautions during multi-patient incidents presents unique challenges. For example, at a multi-vehicle crash where there are several traumatized, bloody patients to be managed, it is not unusual for one EMS team to manage all of them for the first phase of the rescue. How does one prevent patients from being cross contaminated by the rescuers?
Motor vehicle crashes result in a wide variety of sharp hazards that can easily slice open patient care gloves. Meanwhile, heavy duty work gloves are bulky and nearly impossible to use when performing fine motor skills.
Incidents involving hazardous materials are even more challenging. Removing patients from the hot zone and decontaminating them requires specialized training and equipment, which is time-consuming and difficult to set up within a few minutes. EMS crews have to protect themselves from the same agent, and minimize the potential to carry the hazard off site and spread the contaminant to the emergency department.
The same issues go for biological events, which was highlighted by the recent transport of two Ebola patients into the U.S. EMS crews may not be trained or equipped to handle a large influx of patients infected with a serious disease.
Planning improves response
EMS providers use a series of approved, preplanned protocols when managing their patients in everyday situations. That mindset is applied to large scale events as well. Agencies should have plans in place that are evaluated on an ongoing basis. Table top exercises should be conducted at least annually. Agencies should also conduct full scale simulations on an ongoing basis; plans that look great on paper often fall apart under realistic situational and time constraints.
Use PPE that works
PPE must fit well in order to function effectively. Routine fit-testing of HEPA masks is essential. Wearing the right-sized glove will minimize the chance of tearing while optimizing tactile sensation. Gowns should be available in a variety of sizes to accommodate different body types.
It also helps to evaluate PPE fully by having a committee of field providers, supervisors and administrators weigh the pros and cons of each product and vendor before purchasing. Sometimes the most expensive version isn't the most effective; neither is the cheapest.
Maintain vaccinations and routine testing
EMS providers must maintain the full array of vaccinations and routine testing. Childhood diseases such as mumps, measles and rubella can be devastating to an adult. Maintaining immunity against serious illnesses such as hepatitis B and tetanus will greatly reduce the likelihood of contracting the disease. Establishing baseline knowledge about tuberculosis can reduce transmissibility of the disease with annual or biannual TB testing.
Sometimes the most common illnesses are the most harmful to prehospital operations. For example, during the height of flu season, a large number of EMS personnel may become ill and be unable to work, limiting operational readiness and stretching overtime budgets. Seasonal flu vaccinations are becoming increasingly mandatory for providers.
As a reminder, maintaining good health is critical. Immune systems that are compromised due to chronic illness or fatigue will allow opportunistic infections to take hold. Getting plenty of sleep, eating a balanced diet, staying hydrated and maintaining physical conditioning can go a long way in maintaining good health.
Prevent patient-to-patient contamination
Hand washing is the single most effective way to break disease transmission from one patient to another. Nearly all ambulances carry some form of waterless gel or foam that reduces infectious load on the hands; EMS providers should "goop in, goop out" each time they enter or leave the patient compartment. Follow this habit even after wearing gloves; don't forget to leave soiled PPE in the ambulance's waste disposal area, and not on the ground.
In events with a large number of patients, easy access to a large quantity of PPE is essential. Doff and don gloves each time you manage a new patient. If you are in the position of supervising an MCI, try to minimize your physical contact with patients overall.
Maximize provider safety during high-risk events
In the heat of the battle, it can be easy to forget or minimize the importance of using PPE effectively. The simple fact is, you can be affected by the illnesses of a patient by allowing an opening in the defensive systems designed to protect you.
Pay attention to the scene, and note structures and locations that can cause a glove to tear or be punctured. Some EMS providers prefer to "double glove" when taking care of patients after a motor vehicle crash; while there is little science to support the practice, it may be more ergonomic than heavy work gloves.
Be sure you have easy and rapid access to PPE. Having extra gloves in your pants pocket, and HEPA masks and gowns in your jump kit, makes it simple to retrieve basic equipment when you need it. Having a larger cache within the ambulance allows you to manage multiple patients. Safety glasses should be on your person at all times; some providers prefer to wear them the entire time while on duty, as a matter of routine.
Paying attention to the world's events can also help you prepare. During the SARS outbreak in 2002 – 2003, the Toronto, Canada EMS system struggled initially to manage the rapidly rising number of patients within the community. Many EMS providers became ill from the disease, or were exposed during routine patient care.
An earlier recognition of the illness pattern could have hastened a heightened awareness of the problem among EMS workers. As a front line defense against disease outbreak, EMS agencies must coordinate closely with public health officials to detect early signs of a possible epidemic.
Most importantly, be conscious and deliberate with standard precautions. By its very nature, a large scale incident may be a distraction to effective PPE use. By taking the time to make sure that a HEPA mask is properly fitted, or a glove is not torn, EMS providers can help keep themselves safe while helping others cope with their emergency.