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Emergency Medicine Poses Challenges to Infection Control
By Kelly M. Pyrek
Emergencymedicine is a study in contrasts and poses a significant challenge to infectioncontrol professionals caring for two distinct yet related populations ofcaregivers. Emergency department (ED) nurses work under blindingly bright lightsin the sanitary acute care hospital, while emergency medical technicians (EMTs),firefighters and paramedics often find themselves working in the dark of nightand oblivious to the body fluids they sometimes can't see.
Besides their dedication to caring for trauma victims, ED nurses andpre-hospital personnel share a significant exposure to bloodborne pathogens andother occupational risks. Taking care of these individuals is increasinglybecoming the territory of infection control practitioners (ICPs) andoccupational health nurses.
"It's not a controlled environment," says Mary J. Hegdal, RN, CEN,EMT-P, communicable disease coordinator in the Emergency Medical Technologydepartment at the University of Texas Health Science Center in San Antonio."ED nurses and pre-hospital folks don't always understand the risks ofexposure they face, so greater and more frequent education about thetransmission of infectious disease is necessary."
Sometimes no amount of preparation can prepare emergency workers for whatthey will encounter in the field. Speaking at a pre-hospital and infectioncontrol seminar hosted by APIC earlier this year, Hegdal related the bizarrehazards on the scene. "There was a strange case where a firefighter wasexposed to the blood of a car accident victim. He was cut by the guard rail thatactually went through the victim's body. So, pre-hospital personnel riskexposure while constantly pulling bloodied victims from vehicles in murkyweather or the dark of night. In this kind of environment, they face more riskof exposure that ED personnel."
Fosteringa good understanding of infectious agents and corresponding diseases betweenpre-hospital personnel, ICPs and ED workers is essential, especially when itcomes to debunking myths. David R. Wuertz, MS, EMT-P, RN, CIC, of the RoundrockMedical Center in Austin, Texas, reports that $12,000 worth of bunk beds wereremoved from a fire station because of a scare over methicillin-resistantStaphylococcus aureus (MRSA). Station personnel didn't understand the truenature of MRSA and its mode of transmission, and a rash decision was made as aresult, Wuertz says. "ICPs can help emergency personnel understand howmicrobes 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 FireDepartment has about 1,450 uniformed personnel. Of these, 275 to 300 of them areparamedics working on the EMS ambulances. Most of the fire fighters are EMTs whoconduct first-responder runs to assist EMS. EMTs are responsible for extricationand 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 DallasFire and Rescue Department. She reports working with about 1,700 uniformedpersonnel who average 140,000 to 150,000 medical runs each year. The crew hadapproximately 130 exposures and of which, 60 percent was from a source patientwho had a confirmed infectious condition.
"The key to managing pre-hospital personnel is providing ongoingeducation and making information about things like personal protective equipment(PPE) accessible to them. Assisted by EMS shift lieutenants, Lawrence sayswritten and verbal instruction about minimizing occupational exposures has beenextremely effective. "While we try to reach them before they have anexposure, once they do (have an exposure), they are more cognizant of potentialrisks. We do lots of education and I like to think I have the opportunity to doa lot of nurturing. I have been a nurse for 28 years and I've worked everywherein a hospital, serving in critical care, psychiatry, public health andepidemiology. Of all the roles, this is the most rewarding position I have heldbecause it feels family oriented."
Blood and body fluid contamination can facilitate transmission of disease, ascan sharps and other hazards encountered at the scene of trauma. It is essentialfor pre-hospital personnel to consider all patients' blood and body secretionsas infectious, to follow standard precautions, engage in vigilant hand hygieneand 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 fortheir health and safety.
"As their awareness increases they do take more precautions,"Lawrence observes. "They are there to take care of the patient and savelives and they take that very seriously. I want them to have an excellentunderstanding of how diseases are transmitted to decrease their fear. Theirbiggest concern is will they take something home? My role is to provideeducation and reassure them that as long as they follow our guidelines and weartheir PPE, they are not going to take something home to their families. That'stheir 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 inAmarillo, Texas. "There must be a continual emphasis on sharps safetyeducation," she says. "For EMTs in ambulances that are bouncing on theroad on the way to the hospital, sharps injuries are a reality. And can youimagine how difficult it must be to listen for that small click of a safetydevice when you are next to a loud engine and sirens? No concern of theirs istoo 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 amotor vehicle accident, frequently there is broken glass with the victim's bloodon it; occasionally a firefighter/EMT will get cut by this bloody glass. Ihaven't had anyone sero-convert after a blood exposure since I've been in thisjob. There are a couple of guys who are hepititis C positive who don't knowwhere or when they contracted it but they were in EMS back in the early tomid-1980s. Back in 'the old days,' before HIV, EMTs and paramedics would getbloody at a scene and wear the blood like a badge of honor. Now, they almostpanic when they get blood on them. It's taken a lot of education to teach themwhat exactly constitutes an exposure. I don't think they ever down-play thehazard of blood."
Hegdal says that the Occupational Health and Safety Administration (OSHA)'sstance on BBP exposures has improved to recognize the special hazardspre-hospital personnel face on the job. "OSHA recently included the factthat when we are on the scene and it's 2 a.m., you can't tell blood from otherbody fluids, so now everything is considered infectious until proven otherwise.I think the 'unknown' is their biggest risk. They walk into uncontrolledsituations, not knowing what is going to happen next, if someone is going toattack 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, trainingand experience," he says. "They need reassurance and they needinformation."
"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'swet and it's not yours. It's probably contagious. I tell them to be careful butexposures are inevitable. I have been successful in dealing with an agitatedupset employee, and I am able to reassure them and calm them down and be able todo their job," Lawrence concurs.
"Infection control nurses can take care of this population by answeringtheir questions honestly and to not make them feel dumb about the questions theyask," says Hegdal. "Give them the information they need to stay safe,such as how to protect themselves from needlestick injuries. Most paramedicshave only six months of education, which includes about two hours of infectioncontrol; 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 tounderstanding how some diseases are transmitted."
An infection control nurse's duties when working with pre-hospital personneloften 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 orless. I've been doing this for five years. Many fire departments across theUnited States are realizing what a bonus an infection control nurse can be forthem. We do more than just infection control; we also take care of theirimmunizations for hepatitis A and B, Td, MMRs, yearly TB skin testing, annualflu vaccine clinics and yearly classes about BBPs. We act as a liaison with thehospital ICPs to follow up on patients' status and we also act as a resourceperson for all kinds of questions about illnesses and disease. If they need toknow about something, they call their nurse. They know they can trust thatinformation. With the recent threat of bioterrorism, I'm educating them onsmallpox and anthrax, about how to recognize these threats and how to protectthemselves. All the time I hear how grateful they are that I am here; they nowhave someone who cares about them and their health. They are a great bunch ofguys 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 atie between PPE and handwashing. "For the most part, they are good aboutdonning gloves," Hegdal says. "Some are hesitant about wearing eyeprotection. They've gotten better about handwashing since I started beating itinto them. I've put up handwashing posters all over the fire stations, remindingthem to wash their hands."
In the PPE arena, the fire department making strides to protect its personnelis the Phoenix Fire Department. Several years ago the department created a fannypack that would allow the wearer to have fast access to PPE items such asgloves, N-95 masks, plastic eyewear, sanitary wipes and paper sleeves. The packremoves several bulky items from EMTs' medical boxes and vehicles, leaving themless cluttered and better organized. But more importantly, the fanny packs putessential PPE items within quick and easy reach of first responders so they canprotect themselves and patients from unnecessary exposure to infectious agents.
"If you have the PPE available on the scene, personnel are more apt touse it," says Capt. Doug Mummert, a public information officer for thePhoenix Fire Department. "Before the fanny packs, we had PPE in our medicalboxes with the other equipment and it wasn't as accessible. It is departmentpolicy to always use PPE, and the fanny packs make compliance much easier."
If there has been an occupational exposure, pre-hospital personnel are oftensent to healthcare professionals like Dr. James Fleming, OD, who works in aclinic that serves the Phoenix Fire Department and 13 other departments in theregion.
"BBP is the most common exposure we see, ranging from HIV and hepatitisA, B and C, as well as some of the airborne diseases like TB," Flemingsays. "On an annual basis we check folks for hepatitis C, and we evaluatethem to see if they have a conversion of their titers. Every once in a whilethere could be an exposure for meningitis. We have an infection control staffthat follows up so if they do have a positive result, appropriate treatment canbe recommended. Periodically there are a small number of firefighters whoconvert their TB skin tests. TB is endemic in the southwest. How much of that isactual workplace exposure vs. exposure from living in the area, who knows?However, we do treat those cases as if they are occupational exposures and getthem on a course of linage."
Fleming says he is impressed by the caution used by Phoenix pre-hospitalpersonnel to avoid unnecessary exposures. "When I first started here, I didride-alongs and saw the PPE they use. Before they start working on patients theydon gloves and most put on protective eyewear. Many wear masks to help preventairborne exposure. I've been in medicine for 25 years and it's my experiencethat some personnel can be pretty cavalier about all of this, although much lessnow than it was years ago."
Fleming continues, "The fire department is big on usingsafety-engineered sharps, with self-capping needles to cut down on needlestickand sharps injuries. I think the fanny packs, with the gloves, masks andhand-cleansing products is a timely idea and helps provide better care for thevictims and our personnel. If it is readily at hand there's a better chance theworker will use it."