Recently, a young trauma patient on the East Coast became infected with a rare form of antibiotic-resistant Klebsiella pneumonia seen previously only in New York City, China and South America. Genetic fingerprinting helped trace its origin to an air medical helicopter and ground transport ambulance.
Are emergency medical providers routinely passing infections to patients, coworkers, friends and families? Maybe so, according to an ambulance study published in Prehospital Emergency Care (1).
The study published in April looked at 21 ambulances belonging to a fleet in western United States during June 2006. Five areas in each ambulance were cultured for Methicillin-resistant Staphylococcus aureus (MRSA), an increasingly common hospital and community-acquired infection.
A total of 47.6 percent of the ambulances tested positive for MRSA, more often in crew work areas than spaces contacted by patients. How MRSA got into the crew work areas is a matter of conjecture, but the percentage of contaminated ambulances would frighten any infectious disease specialist and most patients, and hopefully scares you, too.
MRSA is a resistant strain of Staphylococcus aureus or "staph," the most common skin infection seen in developed countries. Staph is so common that the CDC estimates up to 30 percent of the population is colonized with it (i.e. bacteria present but not causing infection).
Infections typically occur in people with open wounds and/or weakened immune systems, as are often found in nursing homes, hospitals, and — you got it — ambulances.
Misuse of antibiotics
MRSA is on the increase probably as a consequence of the overuse or misuse of antibiotics, which is thought to enhance development of antibiotic resistant organisms. While previously seen only in hospital settings, MRSA now has community-acquired strains, many of which appear more virulent and destructive than hospital-acquired MRSA. Up to 1 percent of the population may be colonized with MRSA.
Of growing concern is serious community-acquired MRSA skin infections among athletes, children, military troops, firefighters and others who share close living quarters, clothing, toys or equipment. Last month, it was reported that some union officials in Calif. want it classed as a work-related hazard.
While MRSA was the organism studied in ambulances, it is not the only infection you might pass on to your next patient or carry home to your family.
Clostridium difficile or "C. diff" is another bacteria often found in the intestinal tracts of children and, less commonly, in adults. C. diff also attacks when the immune system is weakened, which decreases normal intestinal flora, creating favorable conditions for the bacteria to thrive. Newer strains of C. diff are resistant to conventional antibiotics and have increased the incidence of infections.
Also contributing to the rise in cases is the robust nature of the C. diff bacteria itself, which can survive on surfaces for up to 70 days and is easily transferred on the hands of health care workers, sometimes even surviving hand cleaning with alcohol-based gels.
The list of common infectious agents regularly encountered in patients you treat and transport includes viruses such as influenza, Norwalk, HIV, hepatitis, herpes, mumps, measles, and HPV (Human Papilloma Virus, which causes warts). To MRSA and C. diff, add bacterial infections including E. coli, salmonella and tuberculosis. While nowhere near a complete list, perhaps you're now starting to get the idea that there is no picture: infectious agents are invisible.
19th century discovery
Hospitals awakened to this concept in the early 19th century when they discovered the connection between hand washing and deaths from infections. Physicians often delivered babies immediately after performing autopsies on women who had died from childbirth fever. Without washing their hands, they transmitted germs from the autopsy. Hand washing all but eliminated the infections.
The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal committee of 14 infection control experts that provide advice to the CDC and health care community on infection control practices. It meets several times each year and has produced numerous publications with evidence-based standards for preventing transmission of infection in health care settings like the back of your ambulance, squad or rescue.
First among the infection control practices is the same procedure that was shown to reduce deaths in hospitals during the 1800s: hand washing. Hand hygiene remains so important that the CDC has an entire Web page of education materials, slides and information encouraging health care workers to practice good hand hygiene.
The most recent Guideline for Hand Hygiene in Healthcare Settings (published in 2002) is available there, too. Of note, whenever hands are not visibly soiled, alcohol-based hand rubs are recommended for routine decontamination. There is little reason why this should not be consistently practiced in the prehospital environment; running water is not required.
With the surge of pandemic planning and preparedness, corporate America has gained an appreciation for infection control.
Many offices and factories have installed alcohol based hand gel dispensers throughout their buildings to encourage a culture of hygienic behavior. Should an outbreak or pandemic arrive, the likelihood of human-to-human transmission at these workplaces will be drastically less than employers without an indoctrinated culture of hygiene.
Multiple recommendations
Next to hand hygiene are multiple recommendations to reduce risks of transmitting an infection to your family members or the public, lower the risk of infecting yourself or a patient and protect health care facilities from outbreaks of communicable disease.
These include PPE, safe work practices and immunizations. Most Fire and EMS departments have already implemented programs, policies and procedures that address these practices with the exception of one significant recommendation: disinfection. In July, HICPAC issued a, "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007."
The title is slightly deceptive; the guideline is actually a comprehensive update and summary of the current best evidence for preventing spread of infections. If you have a question or concern, the answer is here.
In the 2007 guideline, cleaning and disinfecting surfaces and patient care equipment are part of standard precautions. All equipment must be cleaned and disinfected before use on another patient. In fact, disinfection may be the weakest link in the prehospital chain of infection control.
In the MRSA study, few patient contact areas tested positive — most of the contamination was in crew work areas. The stretchers and floors were probably wiped down thoroughly between patients. But what about the blood pressure cuffs, cardiac monitors, pulse oximeters and other equipment used on patients? Perhaps this equipment was simply placed back into the crew work area.
Culture shift
It may be time for a culture shift in order to assure that EMS doesn't become a modern day infectious agent on wheels. Behavioral change must begin in the classroom where career habits are formed. Alcohol-based hand cleansers should be available and accessible everywhere skills are practiced in the training center.
Blood pressure cuffs, splints and backboards should be disinfected in between each "patient." The mere fact that students practice skills on each other does not negate the need to clean and disinfect equipment. Students are people: they carry the same germs as patients found in an ambulance or hospital setting. The practice of "verbalizing use of PPE" in EMS training is exactly the same as if firefighters "verbalized" use of gloves and turnout gear when drilling at a live burn: someone is going to get hurt.
Every ambulance and EMS vehicle should have a plentiful and readily accessible supply of alcohol-based hand gel. Commercial wipes suitable for disinfecting equipment should also be available wherever patient care equipment is used so it can be immediately cleaned and disinfected before being placed in service for the next patient.
When the hand hygiene and equipment disinfection practices routinely used in hospitals and health care institutions become just as commonly used in EMS, researchers looking for germs such as MRSA in ambulances will come up empty handed. If EMS is unable or unwilling to at least match their health care counterparts in preventing transmission of infections, their role in passing germs will become increasingly common.
EMS providers and equipment will infect unknowing patients, transport resistant bacteria from hospital to hospital, cause infectious outbreaks in schools and community groups who tour our apparatus and stations, carry multiple germs home to family and loved ones, and see significant spikes in illness and infection amongst ourselves.
Germs are evolving and bacteria becoming more sophisticated. Efforts to combat infection and prevent transmission of disease must evolve as well.
References:
1. Roline, CE, Crumpecker, C, Dunn, TM. Can Methicillin-Resistant Staphylococcus Aureus Be Found In An Ambulance Fleet? Prehospital Emergency Care. 2007;11:241-244.
