Healthcare Workers, EMTs
Extend the Front Lines in the Battle Against Infection
By Kris Ellis
Emergency medicine personnel deal with a vast array
of demanding and complex situations on a daily basis. In a day and age in which
any number of infectious microorganisms and agents of bioterrorism could wind up
in any given community, emergency medical technicians (EMTs) and others on the
front lines must be prepared for the worst. A significant component of this
preparation involves infection control. Emergency medical services (EMS) can
play a vital role in containing the spread of infectious diseases both in terms
of protecting themselves and others from exposure. This is an area that
infection control practitioners (ICPs) are increasingly aware of.
Similarly, hospital and emergency department (ED) waiting
rooms warrant close attention as well. With the potentially large number of
patients waiting to be seen in relatively close proximity, mass exposure is a
possibility. Furthermore, patients often present similar symptoms, especially
during flu season, making initial differentiation between mild and dangerous
bugs dif. cult. ICPs must also be prepared to meet this challenge head-on.
At the EMS level, the effort to control infection is
indirectly built into the basic tenet of protecting oneself.
A lot of it is self-preservation to start with, says
William Coll, BA, M. Pub. Aff., LP, REHS, clinical commander and infection
control officer for the Austin-Travis County Emergency Medical Services
Department. The primary focus is on personal protection and making sure
we take appropriate precautions relative to each situation.
An EMT can utilize varying levels of personal protective
equipment (PPE) in order to maintain their own safety and prevent the
acquisition of infection from patients. A lot of our training is in early
recognition beginning to have your suspicions about a patient even as you
move in, says Coll.
Invariably, the basic level of protection is gloves. However,
Coll explains it is sometimes challenging for EMTs to hold off on donning their
gloves until it becomes absolutely necessary. If gloves are applied too early,
of course, they could become contaminated themselves. How many doorknobs have you handled, how many things could
have put a tear in the gloves? The possibilities are endless, he says. This
is a concept Coll tries to instill in his department.
If it becomes apparent that droplet or airborne exposure is a
concern due to coughing, more PPE is in order. We work in a six-foot zone
relative to droplet protection, where you start to move into that zone with an
eye toward whether or not it will be necessary to put on goggles and a mask,
because now Im getting into that place where the patient is coughing, Coll
If signs of respiratory or infectious disease are detected,
and after the proper precautions are taken, EMS personnel begin the process of
collecting information from the patient. The effort to get a history of the
patients problem and circumstances is vital in order to gain insight and
subsequently notify the hospital and health department if there is a potentially
EMTs are not responsible for the actual differentiation and
diagnosis of symptoms, however. It shouldnt be the role of EMS and . rst
responders, says Coll. But, one of the things weve tried to tie in
is attempting to understand who has communicable disease in the broadest sense.
Nonetheless, if EMS personnel suspect a patient is harboring
an infection that may pose a danger to the community, they must ensure that the
ED is noti. ed about the situation. Preparation on the ED side can eliminate
confusion and delays. then youre positioning the patient so that when
you deliver them to the ED theres a plan to insert the patient into the
appropriate place, whether it be a negative pressure room or whatever the
hospital is able to accommodate relative to the circumstance, says Coll.
The ED Waiting Room
The ED itself, and the waiting room in particular, have been
the subject of recent efforts to escalate infection control measures and
awareness. The Toronto SARS outbreak was a sobering wake-up call to many in
terms of the need for such a focus.
That really made us all stop and think about infection
transmission in the ERs and it probably, for the first time, really established
a series of algorithms as to how to handle patients, particularly with
respiratory disease who are coughing, sneezing, etc. during the influenza season
and with the possibility of SARS being out there somewhere, says Dr. Ted
Eickhoff, professor emeritus in the Division of Infectious Disease at the
University of Colorado Health Sciences Center. I think what we all recognize
now, more clearly than ever before, is that the ED waiting room is a place we
have to pay attention to.
To this end, many facilities are turning to
guidelines such as the CDCs Respiratory Hygiene/Cough Etiquette in
Healthcare Settings in order to institute precautionary measures. This
etiquette is intended to stem the spread of any and all respiratory infections
within the healthcare setting and is designed to be part of a facilitys
standard infection control practices.1 Components include:
Visual alertsalerts such as signs (in multiple
languages, if necessary) at facility entrances instructing all who enter to
notify healthcare personnel if they have symptoms of respiratory infection and
to practice the respiratory and cough etiquette.
Respiratory hygiene/cough etiquette: all individuals
with symptoms of respiratory infection are advised to cover the nose and mouth
when coughing or sneezing, use tissues to contain respiratory secretions and
then dispose of them, and perform hand hygiene. To facilitate compliance with
these measures, facilities are advised to provide the appropriate materials such
as tissues, no-touch waste receptacles and alcohol-based hand rub.
Masking and separation of those with respiratory
symptoms: facilities are advised to make masks available to persons with
symptoms during periods of high infection activity in the community. If space
allows, patients should be encouraged to sit at least three feet away from each
other in common waiting areas.
Droplet precautions: healthcare workers (HCWs) are
advised to use droplet precautions in addition to standard precautions when
examining patients with respiratory symptoms.
Instituting and enforcing this protocol in waiting rooms has
been an important accomplishment for many facilities and ICPs.
We had a subcommittee that we formed which started out as a
SARS group and then turned into a universal respiratory etiquette group, says
Bobbie Welch, MT, RN, CIC, an infection control specialist at Yale New Haven
Hospital. As far as the waiting room, thats been very successful, at least
We have developed signs which we have in English, Spanish
and Mandarin, she explains. Weve also built a Purell® standwhat we have is a
large post like youd put a light on, but instead we have Purell dispensers on
all four sides.
Welch points out that these components are most effective
when incoming patients confront them immediately. Thats right at the
entrance, she says. People coming in are directed to go and wash their hands
then if they have respiratory symptoms they would be directed to put on a mask.
We have a station with masks, tissues and a wastebasket. Thats worked really well.
The effort and investment certainly paid off at Welchs
facility during last years flu season. We had less people getting sick, and if they did get sick
it was less severe, she says. There was a very good response and I think
the community is actually looking for these types of things now.
The positive response generated by this system prompted other
departments to put it to use as well. We have it not only in our two EDs, but
we also have it in the primary care clinics here, and all the other clinics
adopted it this year, says Welch. We were trying to protect people from
the flu because it was a really bad flu season. We were also trying to protect people from the possibility of
SARS, which we didnt have a suspected case of this year, but we dont know
whats going to happen next year.
This sense of uncertainty underscores the importance of being
vigilant at all times, even during the off-season. Were preparing for the
worst and actually this is not just for the season were doing this
year-round because people come in with severe summer colds as well, says Welch.
Great strides have been made toward preventing
exposure in the waiting room at other facilities as well. I think some of our
success had to do with the fact that were fortunate enough, in our infection
control program, to have one of us who is dedicated to the ER, so it helps that
they have a central person, says Kathleen Schomer, RN, BSN, CIC at the
University of Colorado Hospital. Schomer monitors the hospitals outpatient
Prompted by a severe flu season, components of the respiratory
etiquette were also instituted in Schomers facility. We had a horrible flu
outbreak in Colorado last year and we put masks and hand gels in the waiting
room and asked patients who were coughing to utilize the masks and use the gel
to clean their hands, she says.
Aided by the media and a responsive state health department,
public reaction and compliance was positive. We had a good response because
there was such a media blitz here about the number of hospitals who, daily, had
hundreds of patients sitting in common waiting rooms coughing, says Schomer.
The entire citys message was the same; it wasnt just one hospital that
was showing leadership it was an entire community effort.
As far as our clinics and exposures having gone down in
those areas, Id like to think its because we do a lot of teaching and
updating with communicable disease exposure in those areas, Schomer
continues, again demonstrating the need for constant attention and commitment to
education and prevention efforts.
One such effort at Schomers hospital involved a drill set
up by the medical director and safety team which simulated circumstances that
led to suspicion of a SARS case. Everyone did really well as far as nursing and
physicians taking a history and having the red flag go off that this might
be a SARS case. Also getting the patient into proper isolation not letting
the patient go back into the common waiting area, she says.
The only thing we didnt do well was think about setting
up our command center, so the lesson learned was very valuable. The process of differentiating common flu from a potentially
more serious infection such as SARS begins almost immediately at most
facilities. It should start with the triage nurse, who is usually the first person someone who comes into the ER with symptoms would encounter, says
Eickhoff. Again, if there are respiratory disease symptoms, the person should
be masked. So the differentiating process starts right up front. Then, its
the ER doctors who go to the next level and try to sort through what this
Because of similar symptoms, it can be dif. cult to make a
definitive conclusion right away. In the case of SARS, epidemiologic evidence is the
most important factor most patients diagnosed with SARS have come in contact
with another SARS patient or have been in a geographic area where transmission
has been established.2 A number of factors may also be indicative of anthrax
infection as opposed to flu, such as a normal lymphocyte count, chest X-ray
abnormality and lack of runny nose.
It is, however, dif. cult to determine whether an infection
may or may not be particularly dangerous judging strictly by outward symptoms.
Its the whole assessment that gives doctors feelings about whether this is
just simple influenza or something more than that, says Eickhoff. There is
no single sign or symptom that would make it or break it for me.
Even before a diagnosis is made, EMTs, ICPs and patients
themselves can do their part to prevent the spread of infection. Working
together, these groups have the capacity to aid in protecting the health of the