Emergency Medicine Poses Challenges to Infection Control
By Kelly M. Pyrek
Emergency medicine is a study in contrasts and poses a significant challenge to infection control professionals caring for two distinct yet related populations of caregivers. Emergency department (ED) nurses work under blindingly bright lights in the sanitary acute care hospital, while emergency medical technicians (EMTs), firefighters and paramedics often find themselves working in the dark of night and oblivious to the body fluids they sometimes can't see.
Besides their dedication to caring for trauma victims, ED nurses and pre-hospital personnel share a significant exposure to bloodborne pathogens and other occupational risks. Taking care of these individuals is increasingly becoming the territory of infection control practitioners (ICPs) and occupational health nurses.
"It's not a controlled environment," says Mary J. Hegdal, RN, CEN, EMT-P, communicable disease coordinator in the Emergency Medical Technology department at the University of Texas Health Science Center in San Antonio. "ED nurses and pre-hospital folks don't always understand the risks of exposure they face, so greater and more frequent education about the transmission of infectious disease is necessary."
Sometimes no amount of preparation can prepare emergency workers for what they will encounter in the field. Speaking at a pre-hospital and infection control seminar hosted by APIC earlier this year, Hegdal related the bizarre hazards on the scene. "There was a strange case where a firefighter was exposed to the blood of a car accident victim. He was cut by the guard rail that actually went through the victim's body. So, pre-hospital personnel risk exposure while constantly pulling bloodied victims from vehicles in murky weather or the dark of night. In this kind of environment, they face more risk of exposure that ED personnel."
Fostering a good understanding of infectious agents and corresponding diseases between pre-hospital personnel, ICPs and ED workers is essential, especially when it comes to debunking myths. David R. Wuertz, MS, EMT-P, RN, CIC, of the Roundrock Medical Center in Austin, Texas, reports that $12,000 worth of bunk beds were removed from a fire station because of a scare over methicillin-resistant Staphylococcus aureus (MRSA). Station personnel didn't understand the true nature of MRSA and its mode of transmission, and a rash decision was made as a result, Wuertz says. "ICPs can help emergency personnel understand how microbes work and what they can do to stay safe."
ICPs can have a wide sphere of influence in the pre-hospital community. Hegdal works with local fire departments and reports the San Antonio Fire Department has about 1,450 uniformed personnel. Of these, 275 to 300 of them are paramedics working on the EMS ambulances. Most of the fire fighters are EMTs who conduct first-responder runs to assist EMS. EMTs are responsible for extrication and rescue while paramedics perform advanced medical care such as starting IVs, performing intubation and hooking up and monitoring EKGs.
Carol Lawrence, RN, BSN, is a communicable disease coordinator for the Dallas Fire and Rescue Department. She reports working with about 1,700 uniformed personnel who average 140,000 to 150,000 medical runs each year. The crew had approximately 130 exposures and of which, 60 percent was from a source patient who had a confirmed infectious condition.
"The key to managing pre-hospital personnel is providing ongoing education and making information about things like personal protective equipment (PPE) accessible to them. Assisted by EMS shift lieutenants, Lawrence says written and verbal instruction about minimizing occupational exposures has been extremely effective. "While we try to reach them before they have an exposure, once they do (have an exposure), they are more cognizant of potential risks. We do lots of education and I like to think I have the opportunity to do a lot of nurturing. I have been a nurse for 28 years and I've worked everywhere in a hospital, serving in critical care, psychiatry, public health and epidemiology. Of all the roles, this is the most rewarding position I have held because it feels family oriented."
Blood and body fluid contamination can facilitate transmission of disease, as can sharps and other hazards encountered at the scene of trauma. It is essential for pre-hospital personnel to consider all patients' blood and body secretions as infectious, to follow standard precautions, engage in vigilant hand hygiene and to use PPE and barrier techniques accordingly.
Hegdal and Lawrence say emergency personnel put their victims first, regardless of the exposure risk, but try not to act with reckless disregard for their health and safety.
"As their awareness increases they do take more precautions," Lawrence observes. "They are there to take care of the patient and save lives and they take that very seriously. I want them to have an excellent understanding of how diseases are transmitted to decrease their fear. Their biggest concern is will they take something home? My role is to provide education and reassure them that as long as they follow our guidelines and wear their PPE, they are not going to take something home to their families. That's their No. 1 concern-not for themselves, but for their families."
Needlesticks and sharps injuries are a concern for pre-hospital personnel, says Gwen Campbell, RNC, BSN, CIC, of Northwest Texas Healthcare Systems in Amarillo, Texas. "There must be a continual emphasis on sharps safety education," she says. "For EMTs in ambulances that are bouncing on the road on the way to the hospital, sharps injuries are a reality. And can you imagine how difficult it must be to listen for that small click of a safety device when you are next to a loud engine and sirens? No concern of theirs is too small to worry about."
"In this line of work, bloodborne pathogens are a real threat," Hegdal emphasizes. "When they are working to extricate a victim from a motor vehicle accident, frequently there is broken glass with the victim's blood on it; occasionally a firefighter/EMT will get cut by this bloody glass. I haven't had anyone sero-convert after a blood exposure since I've been in this job. There are a couple of guys who are hepititis C positive who don't know where or when they contracted it but they were in EMS back in the early to mid-1980s. Back in 'the old days,' before HIV, EMTs and paramedics would get bloody at a scene and wear the blood like a badge of honor. Now, they almost panic when they get blood on them. It's taken a lot of education to teach them what exactly constitutes an exposure. I don't think they ever down-play the hazard of blood."
Hegdal says that the Occupational Health and Safety Administration (OSHA)'s stance on BBP exposures has improved to recognize the special hazards pre-hospital personnel face on the job. "OSHA recently included the fact that when we are on the scene and it's 2 a.m., you can't tell blood from other body fluids, so now everything is considered infectious until proven otherwise. I think the 'unknown' is their biggest risk. They walk into uncontrolled situations, not knowing what is going to happen next, if someone is going to attack them or spit blood at them."
Wuertz characterizes it as the "I'm going to be dead by morning" syndrome. "First responders vary in levels of skill, education, training and experience," he says. "They need reassurance and they need information."
"You cannot tell if someone is contagious by looking at them," Lawrence tells her pre-hospital personnel. The best rule of thumb is, 'if it's wet and it's not yours. It's probably contagious. I tell them to be careful but exposures are inevitable. I have been successful in dealing with an agitated upset employee, and I am able to reassure them and calm them down and be able to do their job," Lawrence concurs.
"Infection control nurses can take care of this population by answering their questions honestly and to not make them feel dumb about the questions they ask," says Hegdal. "Give them the information they need to stay safe, such as how to protect themselves from needlestick injuries. Most paramedics have only six months of education, which includes about two hours of infection control; EMTs get six weeks of education with one hour of infection control. They don't have the background of knowledge that a nurse has when it comes to understanding how some diseases are transmitted."
An infection control nurse's duties when working with pre-hospital personnel often can be significant.
Hegdal says it's a role that continues to develop with time.
"(Our role) is pretty new, coming about in the last 7 to10 years or less. I've been doing this for five years. Many fire departments across the United States are realizing what a bonus an infection control nurse can be for them. We do more than just infection control; we also take care of their immunizations for hepatitis A and B, Td, MMRs, yearly TB skin testing, annual flu vaccine clinics and yearly classes about BBPs. We act as a liaison with the hospital ICPs to follow up on patients' status and we also act as a resource person for all kinds of questions about illnesses and disease. If they need to know about something, they call their nurse. They know they can trust that information. With the recent threat of bioterrorism, I'm educating them on smallpox and anthrax, about how to recognize these threats and how to protect themselves. All the time I hear how grateful they are that I am here; they now have someone who cares about them and their health. They are a great bunch of guys and gals and I can't think of ever doing any other job now."
If Hegdal finds herself lecturing about one issue more than any other, it's a tie between PPE and handwashing. "For the most part, they are good about donning gloves," Hegdal says. "Some are hesitant about wearing eye protection. They've gotten better about handwashing since I started beating it into them. I've put up handwashing posters all over the fire stations, reminding them to wash their hands."
In the PPE arena, the fire department making strides to protect its personnel is the Phoenix Fire Department. Several years ago the department created a fanny pack that would allow the wearer to have fast access to PPE items such as gloves, N-95 masks, plastic eyewear, sanitary wipes and paper sleeves. The pack removes several bulky items from EMTs' medical boxes and vehicles, leaving them less cluttered and better organized. But more importantly, the fanny packs put essential PPE items within quick and easy reach of first responders so they can protect themselves and patients from unnecessary exposure to infectious agents.
"If you have the PPE available on the scene, personnel are more apt to use it," says Capt. Doug Mummert, a public information officer for the Phoenix Fire Department. "Before the fanny packs, we had PPE in our medical boxes with the other equipment and it wasn't as accessible. It is department policy to always use PPE, and the fanny packs make compliance much easier."
If there has been an occupational exposure, pre-hospital personnel are often sent to healthcare professionals like Dr. James Fleming, OD, who works in a clinic that serves the Phoenix Fire Department and 13 other departments in the region.
"BBP is the most common exposure we see, ranging from HIV and hepatitis A, B and C, as well as some of the airborne diseases like TB," Fleming says. "On an annual basis we check folks for hepatitis C, and we evaluate them to see if they have a conversion of their titers. Every once in a while there could be an exposure for meningitis. We have an infection control staff that follows up so if they do have a positive result, appropriate treatment can be recommended. Periodically there are a small number of firefighters who convert their TB skin tests. TB is endemic in the southwest. How much of that is actual workplace exposure vs. exposure from living in the area, who knows? However, we do treat those cases as if they are occupational exposures and get them on a course of linage."
Fleming says he is impressed by the caution used by Phoenix pre-hospital personnel to avoid unnecessary exposures. "When I first started here, I did ride-alongs and saw the PPE they use. Before they start working on patients they don gloves and most put on protective eyewear. Many wear masks to help prevent airborne exposure. I've been in medicine for 25 years and it's my experience that some personnel can be pretty cavalier about all of this, although much less now than it was years ago."
Fleming continues, "The fire department is big on using safety-engineered sharps, with self-capping needles to cut down on needlestick and sharps injuries. I think the fanny packs, with the gloves, masks and hand-cleansing products is a timely idea and helps provide better care for the victims and our personnel. If it is readily at hand there's a better chance the worker will use it."