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Ten Steps to Bug Control
ALS providers, like all EMS providers, are susceptible to exposure to infectious organisms. However, ALS providers, through various invasive procedures, face increased possibilities of spreading infectious agents between themselves and their patients. With a simple series of 10 steps, ALS providers can significantly reduce these exposures. Although most EMS providers think of infection-control procedures as a way to protect themselves from patients' diseases, they also protect the patient from infectious agents that may be present on the EMS provider or in the EMS environment.
Know when to wear (and not wear) your gloves
A common mistake ALS providers make is when, not if, they wear their gloves. I have great respect for the provider who gets out of the ambulance with gloves on and ready to perform immediately. I also have great distaste for such providers. Why? Getting out of the ambulance and entering the scene involves steps like opening and closing the ambulance door, opening and closing the compartment with the jump kit, carrying the jump kit, oxygen and cardiac monitor, and finally opening and closing a door into the patient's home. If the provider has donned their gloves while responding to the call, the gloves have come into contact with microphones, multiple door handles, jump kits and the exterior of the ambulance. Here in the Northeast, using a gloved hand to close a compartment door in the winter results in a glove covered with dirt, ice and salt, none of which is helpful to your patient. What contaminants are present on the door handle, jump kit and household door? Wear your gloves during assessments, invasive procedures and treatments, but not so early that they are contaminated before you even reach the patient.
Wash when you're through
Though it's one of the easiest and most effective infection-control procedures, many providers still do not wash their hands. Hands should be washed as soon as possible after performing patient care, and also after cleaning and restocking the ambulance. Remember that infectious agents such as Clostridium difficile, vancomycin-resistant enterococci (VRE) and hepatitis B can live outside the body on surfaces or pieces of equipment (e.g., backboards, cots, laryngoscope handles) for as long as seven days. Hand-washing should last at least 30 seconds; pay particular attention to fingernails, under rings/watches, and the webs of your fingers.
Clean your ride
Sure, we all put in big efforts after the "big" calls, decontaminating and replacing equipment. But what about after routine calls? Think about how often you or another provider have put a bloody bandage down on the floor or a bench seat after starting an IV, then gave that seat or surface a cursory cleaning. Did you really get all of it cleaned? Has someone cleaned the radio microphone and controls in the patient compartment? How about the rail on the inside of the roof of the ambulance? What about the front of your ambulance—how often do you decontaminate the steering wheel, seat belts, door handles, gear shift and turn signal? These are touched on every shift, yet can be easily forgotten.
Air it out
With the possible exception of airborne transmissions, airing an ambulance out will not directly reduce your exposure to infectious agents. It will, however, let light and fresh air in. Opening the doors to ventilate the ambulance allows you to see what you may have missed while cleaning. It is also psychological—we are more likely to take extra time to properly clean if the ambulance doesn't smell like vomit or old socks.
Clean your tools
Contaminated equipment isn't just potentially infectious, it's just downright nasty. Every piece of equipment we use has the potential to transmit an infectious agent to patients, ourselves and other caregivers. Even though many pieces of EMS equipment have become disposable, many are not. When was the last time you disinfected all the blood pressure cuffs in your ambulance? Do you have a spare jump kit, so you can remove all the items and wash the kit itself? Hospital and EMS personnel have long been known as vectors of infectious diseases. Stethoscopes remain a prime source, with studies showing as many as 85% carrying Staphylococcus aureus, and even cases of MRSA. Further studies have shown only 48% of providers regularly disinfect their stethoscopes, and in some cases 14% of emergency care providers disinfect their stethoscopes no more than once a year.
Carry a spare
How often has someone on your EMS team had their clothing contaminated with blood, vomitus or other bodily fluids? This contamination may be a source of infection through an open wound or skin absorption, or may be inadvertently spread to your next patient. Although hospitals may loan you a pair of scrubs to wear until you can change your clothes, this can put your ambulance out of service for a long period and could significantly impact your system's ability to respond to calls in a timely manner. Carrying a spare uniform or jumpsuit does not take much space.
Do your laundry
EMS providers tend to lead very busy lifestyles, and hence may change directly from their EMS uniforms to go to other jobs. A dirty uniform may end up stuffed into a duffel bag or thrown on the back seat of a car. Potentially infectious organisms can be transferred this way. Providers who need to change uniforms should carry a specific bag for contaminated laundry and use laundry facilities at their place of employment—or, in the case of gross contamination, have their service professionally clean it.
Keep sterile sterile
ALS providers often perform invasive procedures, ranging from establishing IV lines to surgical cricothyrotomy. These procedures can represent a great source of patient infection. Ensure all devices are, and remain, sterile. For example, look at your airway kit and examine the endotracheal tubes. Do they have any tears or holes in the packaging? Is the package stained where it has gotten wet? Both of these circumstances indicate that a sterile device no longer is. Many manufacturers place expiration dates on sterile products, after which they can no longer guarantee the package is still sterile. Be cautious where you put equipment down. Wipe every IV port every time you use it. Attention to these details can help limit the spread of infections.
Use disposable equipment
One of the great advances in EMS is the availability and variety of disposable equipment. Gone are the days of rinsing and scrubbing suction canisters, defibrillator paddles covered with conductive gel, and reusable bag-valve masks. Sadly, some services still are reluctant to purchase disposable equipment, which puts providers and patients at risk. Disposable equipment choices may come with higher costs, but studies have shown that the costs of correct disinfection, maintenance and the time to clean equipment are generally much higher than the costs of using disposable equipment. Anyone who's ever tried to properly clean and disinfect a laryngoscope blade knows the advantage of "use and toss."
Stay informed
EMS services often have regular infection-control classes to remind and educate providers about proper cleaning and protection. In a recent episode of the Fox TV show House, the title physician remarks that, "I don't think the best time to tell the dog not to pee on the rug is semiannually." EMS services and providers have a shared responsibility to educate about infection control on every call. Seek out reliable sources such as the Centers for Disease Control and Prevention (www.cdc.gov) and World Health Organization (www.who.int), as well as your local hospitals' infectious-disease specialists, and trade publications and magazines.
In 1742, Thomas Gray wrote that "Ignorance is bliss," but nothing could be further from the truth in terms of infection control. ALS providers have a duty to understand how their actions, and even inactions, can lead to harm to themselves, their coworkers and especially their patients. Take the time to properly clean and maintain your ambulance, and always respond with the appropriate protection.
BibliographyYoungster I, Berkovitch M, Heyman E, Lazarovitch Z, Goldman M. The stethoscope as a vector of infectious diseases in the paediatric division. Acta Paediatr 97(9):1,253–5, Sept 2008.
Jones JS, Hoerle D, Riekse R. Stethosocopes: A potential vector of infection? Ann Emerg Med 26(3):296–9, Sept 1995.
Romig LA, Hudak D, Barnard J. Scrub or toss? Making the case for disposable laryngoscope blades. Emerg Med Serv 34(3):91–4, 120, Mar 2005.
Marc A. Minkler, NREMT-P, CCEMT-P, is a paramedic/firefighter with the Portland (ME) Fire Department and has been a student of EMS for over 19 years. He is the author of several internationally published EMS instructor programs. Reach him at pfd225@roadrunner.com.
