By Scott A. Matin and Peter I. Dworsky
Like other healthcare professionals, emergency medical service (EMS) personnel face the growing number of multidrug-resistant organisms. In addition to protecting themselves from possible infection, EMS providers must ensure that their vehicles and equipment are adequately cleaned and disinfected so as not to expose future patients.
In a recent study published in the journal Prehospital Emergency Care, one department conducted environmental culturing of its ambulances; of 21 vehicles, 10 were colonized with methicillin-resistant Staphylococcus aureus (MRSA). In another study, the stethoscopes of 50 EMS personnel who visited a hospital emergency department (ED) during a 24-hour period were swabbed and 16 were growing MRSA. Yet another study tested equipment surfaces most likely to come in contact with patients’ skin and found that 57 percent of the equipment tested using the Kastle-Meyer technique was identified as still being contaminated with traces of blood despite being identified as ready for reuse. Because EMS providers are responsible for cleaning and disinfecting their own ambulance and equipment, an emphasis must be placed on strict policies and procedures in order to protect themselves and patients.
Despite there being a tremendous amount of literature available on infection control in the healthcare environment, the majority of it pertains to hospitals and fixed facilities. When focusing on the pre-hospital environment, there is not a substantial amount of guidance. In many cases, EMS attempts to adopt policies and procedures written for stable or controlled settings, but an ambulance is not the same as an ED or an operating room (OR). The majority of EMS systems have moved to disposable patient-care items where possible because typically those that are multi-use are too big or will melt when used in a standard hospital sterilization process.
Last year's brush with H1N1 influenza is a classic example of policies not being adaptable. Centers for Disease Control and Prevention (CDC) recommendations called for hospitals to have separate entrances or waiting areas for patients with suspected infections. The Joint Commission requires a separate air-handling system with negative-pressure rooms for patients with infectious airborne illnesses. This is clearly impossible in an ambulance. Although the CDC did release an interim guidance document for EMS, it related to 9-1-1 answering centers and the need for more detailed questioning regarding the patient's travel history. The recommendations included in that document also called for EMS to wear personal protective equipment (PPE). No mention was made as to the best practice on decontaminating the ambulance after transport.
The Occupational Safety and Health Administration (OSHA) estimates there are approximately 6 million workers in healthcare, of which 1.5 million are in EMS, who are at risk for being exposed to a bloodborne pathogen. In reality, every provider of EMS and first responder services are at risk and this risk is substantial based on the environment in which they work -- motor vehicle accidents and trauma, unlit areas, and unstable environments with limited manpower.
In many instances, hospitals own or operate the local EMS agency and it is incumbent upon the infection prevention and control department to ensure that the hospital exposure control plan covers the EMS department.
On paper it is quite simple to comply with the OSHA standards; in reality there are many barriers that an employer must overcome. The majority of them involve compliance on the part of the employee. It is not enough to supply PPE and training to staff; the employer must ensure that the staff is using it properly. However, this is not always practical given the environment in which EMS operates, so constant education and reminders are imperative.
The other often overlooked OSHA standard that applies to EMS is the respiratory protection standard 1910.134. This requires all responders to have an initial and annual fit test for the N-95 mask. Again, many EMS agencies are volunteer and are resistant to or have poor compliance with this requirement.
While some EMS agencies are part of a hospital, many are not. They may be volunteer or paid, part time or full time and in many cases do not have the expertise or manpower to ensure compliance with these standards. The Infection Control Departments should contact these local agencies and create a partnership to assist them with compliance, training and follow up information.
Because the majority of EMS agencies are not hospital-based, it is particularly important that procedures are in place that would allow for accurate and timely notification should pre-hospital personnel be exposed to a potentially infectious pathogen. A law that helps address this but not known by many in healthcare other than hospital infection control departments and EMS is the Ryan White Care Act. The law was named after a 13-year-old hemophiliac from Indiana who inadvertently became infected with HIV during a blood transfusion in the 1980s. Shortly after his death in 1990, Congress passed the Ryan White Care Act, intended to improve the quality and availability of care for low-income, uninsured, and underinsured individuals and families affected by HIV and AIDS. The Ryan White programs also fund and provide technical assistance to local and state primary medical care providers, support services, healthcare providers and training programs.
