From left: Janet Woodside, RN, MSN, COHN-S; Lt. Aimee Rooney; Lt. Todd Eizenzimmer; Lt. Ryan Rossing; and Lt. Paul Komanecky.
By Kelly M. Pyrek
A new guide from the Association for Professionals in Infection Control and Epidemiology (APIC) serves as a reminder to hospital-based infection preventionists that even before emergency department (ED) personnel, there is another group of professionals which faces considerable risks from infectious exposures. Janet Woodside, RN, MSN, COHN-S, the EMS program manager for the Portland (Ore.) Fire and Rescue, is lead author of APIC's Guide to Infection Prevention in Emergency Medical Services (2013) and reminds us that "Emergency medical services (EMS) system responders deliver medical care in many unique and oftentimes dangerous environments. They render care to increasingly mobile populations who potentially have a higher likelihood of having an infectious or emerging disease. In addition to treating accident victims of every nature (vehicular, falls, cuts, burns, and more), they treat the homeless, nursing home patients, trauma victims, and the critically ill with multiple diseases and infections. They have unique concerns such as suspect searches, communal living arrangements, and the need to clean and disinfect their work equipment. Like many other healthcare professionals, they face ever-increasing exposures to infectious diseases."
According to Woodside, there is a tremendous need for greater awareness of infection prevention practices in EMS, which was a major impetus for the guide being developed by a team of collaborators and published by APIC. "EMS is behind where hospitals are at in terms of infection prevention and control, and it impacts the daily life of first responders," Woodside says.
Numerous challenges exist, Woodside says, and there is wide variability in the quality of infection prevention instruction offered to EMS personnel. "It runs the gamut," she says. "Some EMS agencies may have a nurse like myself, but some agencies don't have much guidance at all. In talking to people across the country I discovered that there are things we should be doing and some things that we should not, and that there was a great need for better guidance and risk assessment, since some cities are dialed in and others are not. This guide essentially grew out of talking to a lot of people and identifying common infection prevention and occupational health challenges to address."
As Woodside and colleagues describe in the guide, "Many of the agencies that employ EMS system responders are not hospital-based and therefore may not have the same knowledge of the importance of infection prevention as healthcare facilities. Many EMS agencies lack funding and have limited staffing. Infection prevention resources exist, but they are not easy to find."
That's why many EMS agencies depend on professionals known as designated infection control officers (DICOs) who have special training and serve as their agencies infection preventionists (IPs). Federal law requires that EMS agencies have a DICO who must be up to the challenging tasks of keeping current on infection prevention topics, conducting ongoing research, and updating procedures and policies as necessary. And as with their counterparts in hospitals, EMS leadership must support infection prevention staff and the development of infection prevention programs in compliance with laws and regulations, knowing that leadership support is critical to successful implementation of basic infection prevention strategies, according to the guide.
It cannot be emphasized enough that EMS personnel face intense challenges in the field, including being are exposed to all manners of infectious diseases and they must be trained to recognize them and prevent their spread. As Woodside and colleagues explain, "EMS agencies have known about bloodborne pathogens for years. However, it has only been in the last five to six years that articles describing methicillin-resistant Staphylococcus aureus (MRSA) in ambulances and fire stations have appeared in fire and EMS literature along with ways to prevent exposures. Two studies found in the American Journal of Infection Control address the transmission and carriage of MRSA within the fire department and ambulance environments. The University of Washington Department of Environmental and Occupational Health Services stated that fire and ambulance personnel have the unique opportunity to acquire and transfer infections from both hospital and community sources. (Roberts, et al., 2011) James V. Rago, PhD, and his team from Lewis University and Orland Fire Protection District, found that 70 percent of ambulances in the Chicago metropolitan area contained at least one strain of S. aureus bacteria. (Rago, et al., 2012) The National Institute for Occupational Safety and Health (NIOSH) completed national surveys that reveal a high incidence of exposures to bloodborne pathogens for paramedics. (CDC, 2010) Recent articles discuss the underreporting of exposures, the lack of safety equipment, the lack of PPE, and the lack of training in the use of PPE. (CDC, 2010) Although EMS system responders acknowledge the importance of protocols for cleaning and disinfecting equipment, several articles in EMS trade journals cite contamination of fire stations, ambulances, and equipment, such as with MRSA." (Merlin, et al. 2009 and Roline, et al. 2007)
Woodside says that MRSA has been on her first responders' radar for a number of years but that isn't always the case nationwide, thus underscoring the need for DICOS and EMS personnel to stay abreast of emerging infectious diseases and the pathogens that trigger them
"When we start seeing newly emerging infections of concern like MRSA, people started becoming more aware of a need to stay on top of these things," Woodside says. "Infections such as pertussis and norovirus are very real dangers to our EMS personnel because they answer calls to assist children and the elderly. Even though it's federal law to have a DICO, some EMS agencies don't have one or they or they contract with someone but all they get are bits and pieces of information on what to do if OSHA shows up, for example. We have to have an exposure plan, we have to show compliance with personal protective equipment (PPE), and we have to decontaminate our equipment. The guide is designed to take these basics a step further to make sure EMS agencies are doing compliance monitoring, risk assessments and epidemiology taking it to a more professional level. But it's also important to keep an eye on the basics such as handwashing."
"OSHA compliance is key," says Woodside, who describes an encounter with the federal agency last year. "OSHA is starting to look at more fire departments because of the high-risk nature of their jobs, and when they walked into our firehouse they were pleasantly surprised because our fire fighters were already well educated about things like MRSA. We had educated our fire fighters, making sure everyone went through training annually, checking all of their immunizations, things OSHA had asked for. We would have been written up and fined if we hadn't been prepared."
Woodside continues, "We have to be prepared because EMS personnel never know what they will be facing. Is it a simple case of someone not being able to breathe due to asthma, or is it also something you can't see, such as meningitis or TB? So they have to assume it's everything in order to protect themselves. A while back a crew of ours got called to a case and need prophylactic cipro treatment for bacterial meningitis. We see the whole spectrum of potential infections, so it's far less controlled than in the hospital environment. I think most EMS personnel are good at gloving and double-gloving and using their single-use N95 masks when needed. We try to focus on safety, reviewing our processes annually to see if there are safer devices and better PPE out there that we can use to keep personnel safe. They have handwashing facilities when they get back to the station, but we also have hand antiseptic gels on the rigs. We try to be as ready as we can for lots of unknowns and tough situations. We're not always working in the cleanest environments, whether it's starting an IV, or extricating someone out of a vehicle where there's lots of blood. We go on a lot off calls of a psychiatric nature, and EMS personnel may get bitten or scratched. If a patient has a cut, or if someone kneels down in a rainy pool that may also be bloody and then they get a cut and they are not sure whose blood it is -- the unknown is really tough for them, and they have to go home to their families and they worry, 'What did I get today?' One of the biggest challenges last year was the Occupy Portland event, which had hygiene issues such as needles, human waste, and we needed to make sure it wasn't a hazard. Even though we may eventually take people to the ED, the settings are so varied, EMS personnel never know if they are going to initially go to an opulent home and have to put covers on their boots, or go to a place that is squalor. A few weeks ago they responded to a home where the bed bugs were profuse. It's a complicated work setting, and because people haven't had exposure to epidemiology and microbiology, this guide is very important to keeping them safe."
APIC's Guide to Infection Prevention in Emergency Medical Services is available for download from: http://apic.org/Resource_/EliminationGuideForm/e1ac231d-9d35-4c42-9ca0-822c23437e18/File/EMS_Guide_web.pdf
Roberts MC, Soge OO, No D, Beck NK, Meschke JS. Isolation and characterizations of methicillinresistant Staphylococcus aureus (MRSA) from fire stations in two northwest fire districts. Am J Infect Control 2011 Jun;39(5):382-389.
Rago RV, Buhs K, Makarovaite V, Patel E, Pomeroy M, Yasmine C. Detection and analysis of Staphylococcus aureus isolates found in ambulances in the Chicago metropolitan area. Am J Infect Control 2012 Apr;40(3):201-205.
Centers for Disease Control and Prevention. Preventing exposures to bloodborne pathogens among paramedics. April 2010. Available at: http://www.cdc. gov/niosh/docs/wp-solutions/2010-139/.
Merlin AM, Wong ML, Pryor PW, Ryan K, Marques-Baptista A, Perritt R, et al. Presence of methicillinresistant Staphylococcus aureus on the stethoscopes of EMS providers. Prehosp Emerg Care 2009 Jan-Mar;13(1):71-74.
Roline CE, Rumpecker C, Dunn TM. Can methicillin resistant Staphylococcus aureus be found in an ambulance fleet? Prehosp Emerg Care 2007 Apr-June;11(2):241-243.