EMS News in Focus
by Arthur Hsieh
09/30/2013

Infection control is your job


On a regular basis, EMS providers come in close contact with patients who are harboring some form of infectious process or communicable disease. Conditions range from the common cold to far more serious issues such as meningitis, tuberculosis, staph infections and hepatitis.

In 1998, the U.S. Centers for Disease Control and Prevention (CDC) identified EMS providers as being at risk for receiving or transmitting infections from patients, other healthcare professionals, and other community contacts.[i] In one national study of paramedics, 22 percent of respondents reported at least one blood exposure in the previous year.[ii] Even more ominously, only 72 percent of needlestick exposures, 29 percent of exposure to broken skin, and 49 percent of all exposures were reported by paramedics.[iii]

There are simple guidelines and work practices that can greatly reduce the chances of becoming infected by a patient encounter.

Be alert to potential exposures

Universal precautions mean exactly that. Since many diseases have a “prodromal” period where the carrier is contagious but doesn’t show significant outward signs of the disease, one has to assume that any patient has the potential to carry a communicable disease.

Additionally, there are several signs and symptoms that could signal a possible infectious process. EMS providers should pay attention to any of the general findings during the patient assessment:

  • Fever, chills, or general body aches and discomfort
  • Coughing or sneezing
  • Vomiting or diarrhea
  • Recent history of increasing weakness and general malaise
  • Open or weeping wounds
  • Recent trip overseas

Based on what you find, you might increase the level of personal protective equipment (PPE). For example, wearing a HEPA filtration mask while managing a patient with a severe cough or headache will reduce your chances of contracting airborne diseases such as tuberculosis or meningitis.

Maintain your immunizations

While there is ongoing public concern about childhood vaccinations, studies show that immunizations have reduced the frequency of diseases that used to kill people, such as rubella, diphtheria, polio, smallpox, measles, and Haemophilus influenzae type B (Hib).[iv], [v]

Make sure your immunizations are up to date. Most paramedic students (and an increasing number of EMT students) now have to show proof of immunizations against childhood diseases as a requirement to enter clinical arenas. Your employer likely requires you to have certain immunizations as an employment practice.

Wash your hands

No doubt, at some point as a child your parents admonished you to wash your hands before eating. Turns out they were right! Hand-washing has been recommended as one of the most important ways to break the transmission of communicable diseases. A review of available studies concluded that the rate of spread of an infection is reduced when there is an increase in the frequency of hand-washing, although other factors may also be involved.[vi]

Alcohol-based gels are highly effective, as is using soap and water. The goal is to wash continuously for 15 seconds or more, making sure you contact the surface of each finger, hand and wrist. If you are using soap and water, use the paper towel you just used to dry your hands to turn off the faucet.

Wash frequently, even if you used gloves during patient contact. Gloves can become contaminated, and may experience small tears during use or when removing them. Consider washing your hands after each patient contact, before any oral intake, and before going home at the end of the shift.

Cover up the cuts

Our skin does a marvelous job protecting us from a myriad of infectious contaminants such as bacteria, fungi and viruses. A break in the dermal layer provides an opportunity for such diseases to enter the body and begin an infection. Keep any open wound covered, if even with a simple bandage. Be especially aware if the cut is on your hands or arms. Wash the area with soap and water if you think it’s been exposed.

Eyewear is not just a fashion statement

Other parts of the body less resistant to infection include the surface of the eye and the mucous membranes of the nose and mouth. It’s prudent to wear eye protection when handling secretions that can suddenly become airborne, such as starting intravenous therapy or caring for a vomiting patient.

While standard eyeglasses provide some barrier, a better solution is eyewear that wraps around the sides of your face, in addition to the front. It’s  also common to get safety glasses with prescription lenses.

Masks and gowns

A simple cloth or paper mask on the patient may help trap large particulates when they cough or sneeze. However, they do not contain the microscopic droplets that contain diseases such as tuberculosis. You will need to wear a high-efficiency particulate air (HEPA) mask to reduce the chance of breathing in the disease.

The NiOSH-approved N95 respirator is the most common type of HEPA mask. It can filter 95 percent of all airborne particulates. You must be fitted with the appropriate size mask in order to achieve that level of protection.

More recently, EMS systems have begun adopting the P100 standard, which filters 99.97 percent of airborne particles. These too need to be carefully tested and fitted for each provider.

Other options include face shields, which cover the entire face. These can be helpful in close-quarter procedures such as advanced airway management and IV therapy.

Disposable paper gowns can help reduce being contaminated with emesis, blood and other secretions. They are absorbent on the external surface, but have a nonpermeable barrier on the inside.

Cleaning work surfaces

Use the appropriate disinfectant to clean the surfaces of commonly touched EMS items, such as:

  • gurney side rails, mattresses, and grab bars that operate the gurney
  • patient-carrying equipment
  • any reusable items, such as laryngoscope blades and handles
  • carry-in bags (both outside and inside surfaces)
  • stethoscope, blood pressure cuff, and other monitoring equipment
  • treatment equipment such as backboards and splints

The key is to clean regularly, not just when you see an exposure. Develop a routine that touches each surface on a schedule, whether daily or weekly.

The cleaning schedule includes the interior of the ambulance, including the cab. Floors and working surfaces are a given, but consider areas where your hands make contact regularly, such as the cabinet sliding doors, door handles, and overhead grab rails. In the front of the ambulance, wipe down the steering wheel, seat belts and seat surfaces. Door handles, the buttons that open and close windows, and any other control surfaces are more examples of places where contaminants can reside.

The importance of a plan

No EMS organization should be without an exposure control plan. Employers are responsible for providing the training and equipment necessary to minimize the chances of an exposure at the workplace. This includes supplying various levels of personal protective equipment, enough hand sanitizers to make hand-washing very accessible, and post-exposure protocol that directs the employee on what to do in case an exposure takes place. _

Training should include annual updates to the type and method of exposure, including airborne and blood-borne pathogens.

Summary

By the very nature of your work, you are exposed to potentially harmful illnesses regularly. Simple routines and practices can reduce the incidence of contracting an illness and spreading it your family and friends. At the very least, staying healthy is a positive goal in maintaining your career in EMS!

References

[i] Centers for Disease Control and Prevention. Guideline for infection control in health care personnel, 1998. http://www.cdc.gov/hicpac/pdf/infectcontrol98.pdf Retrieved 23 September 2013.

[ii] Leiss JK, Ratcliffe JM, Lyden JT, Sousa S, Orelien JG, Boal WL, Jagger J [2006]. Blood exposure among paramedics: incidence rates from the national study to prevent blood exposure in paramedics. Ann Epidemiol 16(9):720–725.

[iii] Boal WL, Leiss JK, Sousa S, Lyden JT, Li J, Jagger J [2008]. The national study to prevent blood exposure in paramedics: exposure reporting. Am J Ind Med 51(3):213–222.

[iv] Bisgard KM, Kao A, Leake J, et al. Haemophilus influenzae invasive disease in the United States, 1994-1995: Near disappearance of a vaccine-preventable childhood disease. Emerging Infectious Diseases 1998;4(2):229-237.

[v] Atkinson W, Wolfe C, Humiston S, Nelson R, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases. (The Pink Book) 6th ed. Atlanta: Centers for Disease Control and Prevention; 2000.

[vi] Allegranzi B, Pittet B. Role of hand hygiene in healthcare-associated infection prevention. Journal of Hospital Infection (2009) 73, 305e315. http://www.idpublications.com/journals/pdfs/jhi/jhi_mostdown_1.pdf retrieved 23 September 2013.

 

Art Hsieh, MA, NRP teaches in Northern California at the Public Safety Training Center, Santa Rosa Junior College in the Emergency Care Program. An EMS provider since 1982, Art has served as a line medic, supervisor and chief officer in the private, third service and fire-based EMS. He has directed both primary and EMS continuing education programs. Art is a textbook writer, author of "EMT Exam for Dummies," has presented at conferences nationwide and continues to provide direct patient care regularly. Art is a member of the EMS1 Editorial Advisory Board. Contact Art at Art.Hsieh@ems1.com and connect with him on Facebook or Twitter.

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