Emergency Medicine Poses Challenges to Infection Control

September 1, 2002

Emergency Medicine Poses Challenges to Infection Control

By Kelly M. Pyrek

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."

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

"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

"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."