One morning, a Joint Commission site surveyor was on a Med-Surg floor, when a BLS ambulance crew came in to transfer one of the patients to another hospital. The crew came out of the patient鈥檚 room with their gloves on and grabbed the hospital鈥檚 automatic blood pressure cuff, which was on a rolling cart in the hallway. They used it to take the patient鈥檚 blood pressure, and returned the cart to the hallway. The surveyor made a note that the cuff and cart handle were not cleaned before or after use and that the EMT had the same pair of gloves on the whole time.
Next, the EMT walked over to the counter at the nurse鈥檚 station, and entered the patient鈥檚 vital signs in her tablet computer with the same pair of gloves on her hands. A nurse came out of another patient鈥檚 room and asked if anyone could help him move his patient from a wheelchair back into bed. This same helpful EMT volunteered and went into the room, helped move the patient into bed. She then went back to transfer the original patient to the other hospital. The whole time she had the same pair of gloves on.
The surveyor reported her observations to the hospital administration with the admonition that the hospital would be penalized in the report for the unsafe actions of the EMT. She added that the hospital is responsible for the actions of EMS providers while they are in the facility.
This story was instantly shared with sister hospitals in the network.
That afternoon, a nurse educator working a shift in the ICU at one of these hospitals was at her desk. She observed an ALS ambulance crew doing an urgent transfer pushing their patient out of the hospital room with the same gloves on that they had used to move the patient onto their stretcher. One of the providers came over to the counter at the nurses鈥� station, wearing the same gloves, and picked up the patient鈥檚 transfer paperwork and touched the counter.
This nurse followed the crew to the ambulance and attempted to explain the risks of cross-contamination and why they needed to use better hand hygiene practices. Unfortunately, the crew was not receptive, stating, 鈥淵ea, that鈥檚 not going to happen,鈥� as they pushed the elevator button (with the same gloves on).
Immediate steps to improve hand hygiene
Most of us were taught that universal precautions and the use of gloves are to protect us from getting sick. That鈥檚 only part of the equation. It鈥檚 time for us to join the rest of the healthcare world and protect our patients as well as we protect ourselves.
Over the last few decades, I鈥檝e had the opportunity to ride with hundreds of fire, private ambulance, third service, air and hospital-based EMS crews throughout the U.S., Canada, Europe, Australia, Israel and Palestine. I鈥檝e yet to see one crew that practiced hand hygiene that would allow them to serve burgers and fries at an average fast food restaurant. Ninety percent of the time, the gloves go on before we arrive on the scene and only come off after the stretcher has been re-made at the hospital.
The problem is that viruses and bacteria that get picked up by touching one patient get transferred to med kits, blood pressure cuffs, EKG cables, pulse oximeter sensor, stethoscope diaphragms, heart monitors, ePCR tablets, steering wheels, and so on. Then, when those things are touched, the often-gloved hands pick up the bugs and can transfer them to the next patient. If that next patient has a compromised immune system from diabetes, chemotherapy, alcoholism, etc., the bacteria can multiply and cause a potentially or actually life-threatening infection.
You鈥檝e heard the term, 鈥渉ospital-acquired infection.鈥� Well, it鈥檚 likely that some of these are actually EMS-acquired, then hospital-grown infections. Yes, it鈥檚 difficult to know where a person who ends up with sepsis acquired their infection. It could have been in their gym locker room, at the homeless shelter, in the hospital or in their ambulance.
This Joint Commission surveyor and I share the belief that EMS providers and EMS systems should take reasonable action to decrease our contribution to cross-contamination. Here are some steps your crews can implement immediately:
- Improve hand hygiene. The goal is to stop spreading disease.
- Have alcohol-based sanitizer on your belt. If you鈥檙e a leader, make this part of the uniform requirement for your crews.
- When you are at the patient鈥檚 side, use the hand sanitizer while you鈥檙e introducing yourself to the patient, then place clean gloves on your clean hands and begin your assessment.
- If you鈥檙e going to start an IV, remove your gloves and put on a clean pair before starting the IV.
- If you鈥檙e the driver, remove gloves before driving to the hospital.
- If you鈥檙e the attendant, after loading the patient, remove the gloves you had on at the scene, use the hand sanitizer again, and put on a clean pair of gloves to provide care during transport.
- At the hospital, after transferring the patient to the hospital bed, if you鈥檙e going to help change IV bags, EKG electrodes, hook up O2, you should put on a clean pair of gloves before proceeding.
- You should remove gloves (NOT by launching them across the room like a rubber band which spreads all the germs off the gloves into the air), then scrub your hands with soap and water before leaving the patient鈥檚 room. This is the only way to get the clostridium difficile bacteria that the sanitizer won鈥檛 kill.
- You should never be outside the patient鈥檚 room with gloves still on after transferring patient care. You certainly should not be on the phone at the nurses鈥� station, on the hospital computer keyboard, or digging through the doughnut box 鈥� yes, I鈥檝e seen people do this 鈥� with gloves on.
Yes, this will increase the glove budget for most EMS organizations. It鈥檚 worth the investment to save lives. And improved hand hygiene practices might help decrease the sick time costs to offset the increased glove cost.
Additionally, it鈥檚 time to invest in the cleaning supplies and equipment to make it easy for crews to clean things that touch more than one patient. The supplies will need to include a cleaning solution delivered via spray or wipe. Make sure that you train your crews in the use of these products as it may seem counterintuitive to leave things wet with cleaning solution long enough for the cleaner to work. There are several cleaning products out there. One of the best ways to choose which to buy is to check with the infection control folks at your local hospital.
Additionally, there are several bug-killing innovations that are available to the EMS market: ozone generators, UV light systems, and materials that kill viruses and bacteria on contact. You鈥檒l have to evaluate your own system to see what bug killing tools are right for you.
I鈥檝e had up-close and personal experience with consequences of a healthcare-acquired infection. There鈥檚 nothing like seeing someone you love nudge against death鈥檚 door to inspire action. Well, that and a bad Joint Commission report. If you鈥檝e taken action to make improvements in this area, I鈥檇 love to hear what you鈥檝e done.
