The Trip Report: Training and Education for Highly Infectious Disease

Reviewed This Month

Determining Training and Education Needs Pertaining to Highly Infectious Disease Preparedness and Response: A Gap Analysis Survey of U.S. Emergency Medical Services Practitioners.

Authors: Le AB, Buehler SA, Maniscalco PM, Lane P, et al. 

Published in: Am J Infect Control, 2018 Mar; 46(3): 246–52. 

I'm sure everyone remembers the Ebola outbreak in Dallas a few years ago. It was reported at the time that some healthcare workers may have been at risk of exposure to the virus.

The authors of the study we review this month wanted to better understand how prepared EMS providers are for patients and scenarios involving highly infectious disease (HID). Their objective was “to explore the depth of U.S. EMS practitioners’ HID training and education.”

They reviewed the EMS national standard curricula competencies and found only 1.3% address infectious diseases. Further, they noted that mandatory OSHA bloodborne pathogen training primarily focuses on protecting providers, rather than infection control and decontamination. 

To meet their study objective, the authors sent out a survey that asked EMS providers questions regarding their willingness to respond to HID events, current policies and procedures, their level of knowledge, and available resources to address HID patients. They sent the surveys to leaders such as directors, managers, and supervisors, as well as field providers.

The authors worked with the International Association of EMS Chiefs, National Association of EMTs, University of Nebraska Medical Center, and infection-control experts Infection Control/Emerging Concepts, Inc. In June 2016 these organizations sent e-mails to 108,800 EMS providers across the country with a link to the survey. Two follow-up e-mails were sent over three weeks, and the survey link was closed after 30 days. 

The survey defined an HID as “a disease transmissible from person to person that causes life-threatening illness and presents a serious hazard in healthcare settings and in the community, requiring specific control measures.” This definition was taken from the European Network of Infectious Diseases. They also gave some examples of HIDs. 

Results

A total of 2,165 EMS providers replied to the survey: 1,550 field providers and 615 in leadership roles. So the overall response rate was only 2%. That's low for any survey, but because so many people replied, the authors here still had a lot to work with. However, this low response rate can lead to some issues we will discuss later. 

The authors found some interesting differences when comparing responses from leadership to those from field providers. More in leadership roles indicated they’d received training on how to screen and provide care for patients who might have an HID (86% vs. 73%). Conversely, more field providers indicated they were very willing to encounter potential HID scenarios (40% vs. 21%). A higher percentage of field providers also indicated they were very comfortable encountering potential HID scenarios. 

This analysis was also stratified by certification level, and a higher percentage of paramedics indicated they were very willing and very comfortable (59%) with encountering potential HID scenarios. This rate was 8% for EMT-Intermediates and 31% for EMT-Bs. The authors indicated that many volunteers reported in open-ended questions that they did not feel confident enough to respond to an HID with the magnitude or severity of Ebola; however, exact percentages were not reported. 

The survey also asked whether the respondent’s agency maintained its own communicable disease emergency response plan. Only 51% of those in leadership indicated their agency did, while 11% said it was being developed and 11% did not know. For field providers, 32% said their agency did, 3% said in development, and 45% did not know.

Respondents were also asked whether their agency has standard operating guidelines or procedures for response to an HID. Most of those in leadership roles (71%) as well as field providers (57%) said they did, but 20% of field providers didn’t know.

The recent Ebola outbreak did appear to have an impact on these procedures/guidelines: Some 83% of leadership and 77% of field providers indicated their plans underwent revisions following the outbreak. 
There were 68% of leadership and 50% of field providers who indicated they received their up-to-date information about HIDs from official websites such as the CDC’s and WHO’s. This was followed by national organization websites such as the International Association of EMS Chiefs’ and NAEMT’s (51% of leadership and 42% of field providers).

A less-than-encouraging finding was that almost a quarter of leadership (23%) and more than a third of field providers (38%) indicated they received their updated information on HID from word of mouth or coworkers. The authors also indicated that updated information about HID was more commonly received through continuing education or agency training than from professional conferences or external organizations. The percentages for this result were not provided. 

When asked to select the routes of exposure for specific highly infectious diseases, 17% of leadership and 15% of field providers incorrectly believed that Ebola was airborne. The study authors indicated that similar percentages incorrectly believed viral hemorrhagic fevers such as Marburg virus and Lassa fever were airborne, but exact percentages were not provided.

There were also 16% of leadership and 15% of field providers who incorrectly indicated that anthrax is transmitted via human-to-human contact. Furthermore, 61% of leadership and 47% of field providers responding to the survey incorrectly responded that there are no maximum shift times in PPE without changing out PPE to prevent physiological stress. 

Some 97% of leadership and 86% of field providers indicated their agency provided training on infectious-disease patient and practitioner safety. Most agencies require new employees to successfully demonstrate competencies related to HID scenarios by a performing the skills rather than simply attending a CE course. There were 72% of those in leadership roles and 79% of field providers who indicated this was a requirement. Of these respondents, more than 80% of both groups indicated that actually wearing the appropriate PPE during the demonstration of skills was required.

A majority of respondents also reported that annual retraining or continuing education on HID scenarios was required (64% of leadership, 62% of field providers). The authors indicated that multiple respondents stated in open-ended questions that they wanted more quality training and/or more comprehensive low-cost HID training, and many (presumably those in leadership) reported they would like a greater budget to provide HID training and resources to their responders. 

Unfortunately, 55% of leadership reported they did not know if their agency had procedures in place to monitor an employee who was potentially exposed to a highly infectious disease. Over two-thirds of field providers did not know if their agency had these procedures in place.

However, the majority of both groups reported their agency had an employee assistance program (80% of leadership and 64% of field providers) as well as mechanisms, procedures, or protocols in place for quality improvement and safety (61% of leadership and 57% of field providers). 

Recommendations

The survey results led the authors to some interesting recommendations. The following were suggested to improve knowledge and training gaps: 

1. Changes to government and primary national organization websites that more effectively educate EMS practitioners on HID transmissibility and containment, as has been provided to other healthcare workers for years (e.g., by the CDC and World Health Organization websites).
2. Organizational changes that foster increased communication of HID training, knowledge, and available resources between administrators and leads with frontline responders, and between practitioners with differing certification levels. This model was utilized at the Omaha Fire Department and led to the safe and successful transport of three EVD patients.
3. Adhering to and expanding upon existing OSHA and CDC training guidelines and recommendations through an increased volume of HID-specific training, including proper PPE use and decon techniques.
4. Implementing and/or increasing the volume of regular HID trainings that focus on the epidemiology of emerging and re-emerging HIDs.
5. Utilizing existing national resources like training programs that specifically provide free HID training to specific worker populations.

The authors also recommended that a requirement for updated HID training and education be legislated and regulated, similar to other healthcare professions. They suggested NHTSA expand the scope of HIDs in national guidelines and that specific HID competencies be required for state licensure.

Limitations

As we discuss each month, all studies have limitations, and these authors did a good job of stating theirs. One of the most glaring is the very low response rate.

Now, it should be noted that the authors had no way to know whether the e-mail addresses to which they sent their survey link were still in use, and they did have a large study population.

However, with a response rate that low, it is quite possible that those who chose to respond may not accurately represent the entire EMS population. This is selection bias. A second limitation (a common issue with survey research) is that respondents self-assessed and -reported gaps and strengths within their respective systems. It should also be noted that the results likely don’t directly compare leadership to field providers in the same agency (there’s no way to know for sure because the survey was anonymous). 

There is one other thing I’d like you to recognize: Unlike most research we review, this study did not report any p-values—it simply reported percentages. Also, the analysis was conducted in Microsoft Excel. Research does not have to be intimidating. You don’t always need to have statistical expertise, and you don’t always have to have some fancy program to analyze data. All of you reading this can get involved in EMS research. I hope you do! 

Antonio R. Fernandez, PhD, NRP, FAHA, is research director at the EMS Performance Improvement Center and an assistant professor in the Department of Emergency Medicine at the University of North Carolina–Chapel Hill. He has been a nationally certified paramedic since 2005 and completed the EMS Research Fellowship at the National Registry of Emergency Medical Technicians.