American Journal of Emergency Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Correspondence
Knowledge, attitudes, and practices regarding infection prevention among emergency medical services providers☆,☆☆,★ To the Editor, Infection prevention is a significant challenge in prehospital emergency care. Hand hygiene [1-3], adherence to standard and transmission-based precautions [4], and environmental disinfection [1] by emergency medical services (EMS) providers is variable and often suboptimal. Ambulances can become contaminated during patient care with multidrug-resistant organisms (MDRO) [5-7], increasing the potential for transmission. Little is known about the knowledge, attitudes, and practices of EMS providers in relation to infection prevention and MDRO transmission. We designed a questionnaire to assess EMS provider knowledge of and self-reported adherence to infection prevention practices. Familiarity with MDROs and how they are transmitted in health care settings was determined. The 22-item questionnaire was electronically distributed to a random sample of EMS providers certified through the National Registry of Emergency Medical Technicians between November 2013 and February 2014. Descriptive statistics were calculated using STATA/IC 12 (StataCorp LP, College Station, TX). Differences in MDRO knowledge based on level of training were examined using the χ2 test. Five hundred sixteen (9.7%) EMS providers completed the questionnaire. Mean age of respondents was 40 years. Thirty-five percent had less than 5 years of experience as an EMS provider, 22% had 5 to 10 years, and 43% reported 10 years or more. More than half (55%) were basic life support (BLS) providers, predominantly Emergency Medical Technician–Basics. Forty-five percent were advanced life support (ALS) providers, of which paramedics represented more than 75%. Eighty-five percent reported almost always wearing gloves during patient care. Although 95.3% felt that hand hygiene was necessary regardless of glove use, only 16.1% regularly disinfected their hands ☆ This article was presented as a poster abstract at 2014 IDweek, Philadelphia, PA (October 9, 2014). ☆☆ Conflicts of interest: J.M. has served as a consultant for Gilead Switzerland and was on an advisory board for Astellas Inc, Switzerland. None of the other authors have a conflict of interest to declare. ★ Funding and support: S.L. is the recipient of a KM1 Comparative Effectiveness Research Career Development Award (KM1CA156708-01) and received support through the Clinical and Translational Science Award (CTSA) program (UL1RR024992) of the National Center for Advancing Translational Sciences (NCATS) as well as the Barnes-Jewish Patient Safety and Quality Career Development Program, which is funded by the Foundation for BarnesJewish Hospital. J.M. was supported by the National Institutes of Health CTSA/NCATS (UL1RR024992) and was a recipient of a KL2 Career Development Grant (KL2RR024994). J.M. received support from the Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) Career Development Award through the NIH NCATS (5K12HD00145913). He is also the section leader for a subproject of the Centers for Disease Control and Prevention, Prevention Epicenters Program grant (U54 CK000162; PI Fraser). In addition, J.M. was funded by the Barnes-Jewish Hospital Patient Safety and Quality Career Development Program and by a research grant from the Foundation for Barnes-Jewish Hospital and Washington University’s Institute for Clinical and Translational Science.
before glove use (≥80% of the time); 68.9% did so afterwards (Table). Twenty-nine percent hardly ever disinfected their hands before glove use. Respondents cited lack of time (40.6%), interference with patient care (35.5%), and perceived low risk of exposure to blood or other body fluids (25.6%) as common reasons for hand hygiene nonadherence. Although 85.9% routinely disinfected their medical equipment and stretcher after each patient encounter, less than 60% disinfected the ambulance compartment during a shift, even after visible environmental contamination. Although 80.3% of respondents’ organizations had a written infection prevention policy, only 60.1% had a designated infection prevention officer. Most respondents reported receiving 1 to 5 hours of infection prevention training annually (62.0%). Although most BLS and ALS providers were familiar with methicillinresistant Staphylococcus aureus (93.2% vs 99.4%; P = .002), fewer BLS than ALS providers had heard of vancomycin-resistant Enterococcus (44.4% vs 80.8%; P b .001), Clostridium difficile (62.7% vs 87.8%; P b .001), or multidrug-resistant gram-negative bacteria (61.9% vs 78.5%; P = .001). Among EMS providers with knowledge of these organisms, more than two thirds correctly identified direct contact with an infected/colonized patient and their environment to be the route of transmission; there was no difference between provider levels. Sixty-three percent of respondents rated their level of knowledge of MDROs and C. difficile as either “fair” or “poor”. Providers also reported that they would more likely use gloves (94.6%), perform hand hygiene (91.2%), and disinfect their work environment (87.3%) if they knew that a patient was infected/colonized with an MDRO or C. difficile. Perceived barriers to such awareness included lack of communication among health care personnel (91.5%) and lack of clear documentation in the medical record (81.1%). Significant opportunities exist to improve awareness, knowledge, and infection prevention practices in prehospital emergency care. In an observational study of EMS providers arriving at a large urban US emergency department, hand hygiene was performed by only 27.8% of providers after patient contact [1]. In an urban US ambulance service, hand hygiene preceded merely 1.1% of paramedic-patient encounters and followed 62.8% of patient contacts [3], a trend that has been reported elsewhere [2]. Our findings align with these studies and demonstrate that EMS providers openly acknowledge a lack of adherence to appropriate hand hygiene. Lack of time and perceived interference with patient care are realistic concerns that should be addressed and overcome. Regarding MDROs and C. difficile, we identified a gap in awareness between BLS and ALS providers that could be narrowed through enhanced education. Interestingly, EMS providers reported they would more likely adhere to infection prevention practices, including hand hygiene and environmental disinfection, if they knew that a patient was infected/colonized with an MDRO. Improved communication between health care facilities requesting EMS response and EMS providers concerning a patient’s MDRO history, when known, is a
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Liang SY, et al, Knowledge, attitudes, and practices regarding infection prevention among emergency medical services providers, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.02.026
2
Correspondence / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Table Infection prevention practices and MDRO awareness of EMS providers Hand hygiene Wash/disinfect hands before glove use Almost always (≥80% of the time) Usually (60%-79% of the time) Sometimes (40%-59% of the time) Not very often (20%-39% of the time) Hardly ever (≤19% of the time) Wash/disinfect hands after glove use Almost always (≥80% of the time) Usually (60%-79% of the time) Sometimes (40%-59% of the time) Not very often (20%-39% of the time) Hardly ever (≤19% of the time) Wear gloves during patient care Almost always (≥80% of the time) Usually (60%-79% of the time) Sometimes (40%-59% of the time) Not very often (20%-39% of the time) Hardly ever (≤19% of the time) Reasons for not observing hand hygiene Lack of time Interference with patient care and/or procedures Exposure to blood or other body fluids is unlikely during a given patient interaction Lack of easy access to disposable gloves Does not prevent exposure to infectious organisms Ambulance disinfection At the beginning of each shift At some point during each shift After each patient encounter After patient encounters resulting in visible contamination of the environment Equipment/stretcher disinfection At the beginning of each shift At some point during each shift After each patient encounter After patient encounters resulting in visible contamination of the environment MDRO awareness MRSA VRE C. difficile Multidrug-resistant gram-negative bacteria
n (%) 62 (16.1) 63 (16.3) 77 (20.0) 72 (18.7) 112 (29.0) 263 (68.9) 79 (20.7) 31 (8.1) 7 (1.8) 2 (0.5)
Stephen Y. Liang MD Emergency Medicine Division Washington University School of Medicine St. Louis, MO, 63110-1093 Division of Infectious Diseases Washington University School of Medicine St. Louis, MO 63110-1093 Corresponding author. Divisions of Emergency Medicine and Infectious Diseases, Washington University School of Medicine 660 S. Euclid Avenue, Campus Box 8051, St. Louis, MO 63110-1093 Tel.: +1 314 747 0750; fax: +1 314 454 5392 E-mail address: [email protected] Paige Vantassell BS Emergency Medicine Division Washington University School of Medicine St. Louis, MO, 63110-1093
325 (84.9) 40 (10.4) 14 (3.7) 4 (1.0) 0 (0)
Remle P. Crowe BS National Registry of Emergency Medical Technicians Columbus, OH 43229
144 (40.6) 126 (35.5) 91 (25.6)
Brian R. Froelke MD Emergency Medicine Division Washington University School of Medicine St. Louis, MO, 63110-1093
47 (13.2) 15 (4.2) 135 (52.1) 143 (58.9) 48 (14.1) 172 (53.8)
Jonas Marschall MD Division of Infectious Diseases Washington University School of Medicine St. Louis, MO 63110-1093
124 (47.9) 100 (41.2) 292 (85.9) 148 (46.3)
373 (96.1) 231 (61.3) 283 (74.3) 267 (69.9)
Melissa A. Bentley MS National Registry of Emergency Medical Technicians Columbus, OH 43229
http://dx.doi.org/10.1016/j.ajem.2015.02.026
Abbreviations: MRSA, methicillin-resistant S. aureus; VRE, vancomycin-resistant Enterococcus.
reasonable step to optimize EMS infection prevention practices during high-risk situations. Given that our response rate was 9.7%, response bias could have influenced our findings. However, it is plausible that infection prevention knowledge and practices are even poorer among those who did not respond to our questionnaire. A higher response rate would likely have amplified the trends we observed. Our study highlights an urgent need to improve infection prevention awareness, education, and practices tailored to EMS providers. Further research is necessary to better understand the epidemiology of MDRO transmission in prehospital emergency care. Acknowledgments The authors thank Christian Hospital Emergency Medical Services, the National Registry of Emergency Medical Technicians, and the Health and Safety Committee of the National Association of Emergency Medical Technicians for their invaluable assistance in survey development.
References [1] Bledsoe BE, Sweeney RJ, Berkeley RP, Cole KT, Forred WJ, Johnson LD. EMS provider compliance with infection control recommendations is suboptimal. Prehosp Emerg Care 2014;18:290–4. [2] Emanuelsson L, Karlsson L, Castren M, Lindstrom V. Ambulance personnel adherence to hygiene routines: still protecting ourselves but not the patient. Eur J Emerg Med 2013;20:281–5. [3] Ho JD, Ansari RK, Page D. Hand sanitization rates in an urban emergency medical services system. J Emerg Med 2014;47:163–8. [4] Harris SA, Nicolai LA. Occupational exposures in emergency medical service providers and knowledge of and compliance with universal precautions. Am J Infect Control 2010;38:86–94. [5] Alves DW, Bissell RA. Bacterial pathogens in ambulances: results of unannounced sample collection. Prehosp Emerg Care 2008;12:218–24. [6] Eibicht SJ, Vogel U. Meticillin-resistant Staphylococcus aureus (MRSA) contamination of ambulance cars after short term transport of MRSA-colonised patients is restricted to the stretcher. J Hosp Infect 2011;78:221–5. [7] Rago JV, Buhs LK, Makarovaite V, Patel E, Pomeroy M, Yasmine C. Detection and analysis of Staphylococcus aureus isolates found in ambulances in the Chicago metropolitan area. Am J Infect Control 2012;40:201–5.
Please cite this article as: Liang SY, et al, Knowledge, attitudes, and practices regarding infection prevention among emergency medical services providers, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.02.026
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Correspondence
Knowledge, attitudes, and practices regarding infection prevention among emergency medical services providers☆,☆☆,★ To the Editor, Infection prevention is a significant challenge in prehospital emergency care. Hand hygiene [1-3], adherence to standard and transmission-based precautions [4], and environmental disinfection [1] by emergency medical services (EMS) providers is variable and often suboptimal. Ambulances can become contaminated during patient care with multidrug-resistant organisms (MDRO) [5-7], increasing the potential for transmission. Little is known about the knowledge, attitudes, and practices of EMS providers in relation to infection prevention and MDRO transmission. We designed a questionnaire to assess EMS provider knowledge of and self-reported adherence to infection prevention practices. Familiarity with MDROs and how they are transmitted in health care settings was determined. The 22-item questionnaire was electronically distributed to a random sample of EMS providers certified through the National Registry of Emergency Medical Technicians between November 2013 and February 2014. Descriptive statistics were calculated using STATA/IC 12 (StataCorp LP, College Station, TX). Differences in MDRO knowledge based on level of training were examined using the χ2 test. Five hundred sixteen (9.7%) EMS providers completed the questionnaire. Mean age of respondents was 40 years. Thirty-five percent had less than 5 years of experience as an EMS provider, 22% had 5 to 10 years, and 43% reported 10 years or more. More than half (55%) were basic life support (BLS) providers, predominantly Emergency Medical Technician–Basics. Forty-five percent were advanced life support (ALS) providers, of which paramedics represented more than 75%. Eighty-five percent reported almost always wearing gloves during patient care. Although 95.3% felt that hand hygiene was necessary regardless of glove use, only 16.1% regularly disinfected their hands ☆ This article was presented as a poster abstract at 2014 IDweek, Philadelphia, PA (October 9, 2014). ☆☆ Conflicts of interest: J.M. has served as a consultant for Gilead Switzerland and was on an advisory board for Astellas Inc, Switzerland. None of the other authors have a conflict of interest to declare. ★ Funding and support: S.L. is the recipient of a KM1 Comparative Effectiveness Research Career Development Award (KM1CA156708-01) and received support through the Clinical and Translational Science Award (CTSA) program (UL1RR024992) of the National Center for Advancing Translational Sciences (NCATS) as well as the Barnes-Jewish Patient Safety and Quality Career Development Program, which is funded by the Foundation for BarnesJewish Hospital. J.M. was supported by the National Institutes of Health CTSA/NCATS (UL1RR024992) and was a recipient of a KL2 Career Development Grant (KL2RR024994). J.M. received support from the Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) Career Development Award through the NIH NCATS (5K12HD00145913). He is also the section leader for a subproject of the Centers for Disease Control and Prevention, Prevention Epicenters Program grant (U54 CK000162; PI Fraser). In addition, J.M. was funded by the Barnes-Jewish Hospital Patient Safety and Quality Career Development Program and by a research grant from the Foundation for Barnes-Jewish Hospital and Washington University’s Institute for Clinical and Translational Science.
before glove use (≥80% of the time); 68.9% did so afterwards (Table). Twenty-nine percent hardly ever disinfected their hands before glove use. Respondents cited lack of time (40.6%), interference with patient care (35.5%), and perceived low risk of exposure to blood or other body fluids (25.6%) as common reasons for hand hygiene nonadherence. Although 85.9% routinely disinfected their medical equipment and stretcher after each patient encounter, less than 60% disinfected the ambulance compartment during a shift, even after visible environmental contamination. Although 80.3% of respondents’ organizations had a written infection prevention policy, only 60.1% had a designated infection prevention officer. Most respondents reported receiving 1 to 5 hours of infection prevention training annually (62.0%). Although most BLS and ALS providers were familiar with methicillinresistant Staphylococcus aureus (93.2% vs 99.4%; P = .002), fewer BLS than ALS providers had heard of vancomycin-resistant Enterococcus (44.4% vs 80.8%; P b .001), Clostridium difficile (62.7% vs 87.8%; P b .001), or multidrug-resistant gram-negative bacteria (61.9% vs 78.5%; P = .001). Among EMS providers with knowledge of these organisms, more than two thirds correctly identified direct contact with an infected/colonized patient and their environment to be the route of transmission; there was no difference between provider levels. Sixty-three percent of respondents rated their level of knowledge of MDROs and C. difficile as either “fair” or “poor”. Providers also reported that they would more likely use gloves (94.6%), perform hand hygiene (91.2%), and disinfect their work environment (87.3%) if they knew that a patient was infected/colonized with an MDRO or C. difficile. Perceived barriers to such awareness included lack of communication among health care personnel (91.5%) and lack of clear documentation in the medical record (81.1%). Significant opportunities exist to improve awareness, knowledge, and infection prevention practices in prehospital emergency care. In an observational study of EMS providers arriving at a large urban US emergency department, hand hygiene was performed by only 27.8% of providers after patient contact [1]. In an urban US ambulance service, hand hygiene preceded merely 1.1% of paramedic-patient encounters and followed 62.8% of patient contacts [3], a trend that has been reported elsewhere [2]. Our findings align with these studies and demonstrate that EMS providers openly acknowledge a lack of adherence to appropriate hand hygiene. Lack of time and perceived interference with patient care are realistic concerns that should be addressed and overcome. Regarding MDROs and C. difficile, we identified a gap in awareness between BLS and ALS providers that could be narrowed through enhanced education. Interestingly, EMS providers reported they would more likely adhere to infection prevention practices, including hand hygiene and environmental disinfection, if they knew that a patient was infected/colonized with an MDRO. Improved communication between health care facilities requesting EMS response and EMS providers concerning a patient’s MDRO history, when known, is a
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Liang SY, et al, Knowledge, attitudes, and practices regarding infection prevention among emergency medical services providers, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.02.026
2
Correspondence / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Table Infection prevention practices and MDRO awareness of EMS providers Hand hygiene Wash/disinfect hands before glove use Almost always (≥80% of the time) Usually (60%-79% of the time) Sometimes (40%-59% of the time) Not very often (20%-39% of the time) Hardly ever (≤19% of the time) Wash/disinfect hands after glove use Almost always (≥80% of the time) Usually (60%-79% of the time) Sometimes (40%-59% of the time) Not very often (20%-39% of the time) Hardly ever (≤19% of the time) Wear gloves during patient care Almost always (≥80% of the time) Usually (60%-79% of the time) Sometimes (40%-59% of the time) Not very often (20%-39% of the time) Hardly ever (≤19% of the time) Reasons for not observing hand hygiene Lack of time Interference with patient care and/or procedures Exposure to blood or other body fluids is unlikely during a given patient interaction Lack of easy access to disposable gloves Does not prevent exposure to infectious organisms Ambulance disinfection At the beginning of each shift At some point during each shift After each patient encounter After patient encounters resulting in visible contamination of the environment Equipment/stretcher disinfection At the beginning of each shift At some point during each shift After each patient encounter After patient encounters resulting in visible contamination of the environment MDRO awareness MRSA VRE C. difficile Multidrug-resistant gram-negative bacteria
n (%) 62 (16.1) 63 (16.3) 77 (20.0) 72 (18.7) 112 (29.0) 263 (68.9) 79 (20.7) 31 (8.1) 7 (1.8) 2 (0.5)
Stephen Y. Liang MD Emergency Medicine Division Washington University School of Medicine St. Louis, MO, 63110-1093 Division of Infectious Diseases Washington University School of Medicine St. Louis, MO 63110-1093 Corresponding author. Divisions of Emergency Medicine and Infectious Diseases, Washington University School of Medicine 660 S. Euclid Avenue, Campus Box 8051, St. Louis, MO 63110-1093 Tel.: +1 314 747 0750; fax: +1 314 454 5392 E-mail address: [email protected] Paige Vantassell BS Emergency Medicine Division Washington University School of Medicine St. Louis, MO, 63110-1093
325 (84.9) 40 (10.4) 14 (3.7) 4 (1.0) 0 (0)
Remle P. Crowe BS National Registry of Emergency Medical Technicians Columbus, OH 43229
144 (40.6) 126 (35.5) 91 (25.6)
Brian R. Froelke MD Emergency Medicine Division Washington University School of Medicine St. Louis, MO, 63110-1093
47 (13.2) 15 (4.2) 135 (52.1) 143 (58.9) 48 (14.1) 172 (53.8)
Jonas Marschall MD Division of Infectious Diseases Washington University School of Medicine St. Louis, MO 63110-1093
124 (47.9) 100 (41.2) 292 (85.9) 148 (46.3)
373 (96.1) 231 (61.3) 283 (74.3) 267 (69.9)
Melissa A. Bentley MS National Registry of Emergency Medical Technicians Columbus, OH 43229
http://dx.doi.org/10.1016/j.ajem.2015.02.026
Abbreviations: MRSA, methicillin-resistant S. aureus; VRE, vancomycin-resistant Enterococcus.
reasonable step to optimize EMS infection prevention practices during high-risk situations. Given that our response rate was 9.7%, response bias could have influenced our findings. However, it is plausible that infection prevention knowledge and practices are even poorer among those who did not respond to our questionnaire. A higher response rate would likely have amplified the trends we observed. Our study highlights an urgent need to improve infection prevention awareness, education, and practices tailored to EMS providers. Further research is necessary to better understand the epidemiology of MDRO transmission in prehospital emergency care. Acknowledgments The authors thank Christian Hospital Emergency Medical Services, the National Registry of Emergency Medical Technicians, and the Health and Safety Committee of the National Association of Emergency Medical Technicians for their invaluable assistance in survey development.
References [1] Bledsoe BE, Sweeney RJ, Berkeley RP, Cole KT, Forred WJ, Johnson LD. EMS provider compliance with infection control recommendations is suboptimal. Prehosp Emerg Care 2014;18:290–4. [2] Emanuelsson L, Karlsson L, Castren M, Lindstrom V. Ambulance personnel adherence to hygiene routines: still protecting ourselves but not the patient. Eur J Emerg Med 2013;20:281–5. [3] Ho JD, Ansari RK, Page D. Hand sanitization rates in an urban emergency medical services system. J Emerg Med 2014;47:163–8. [4] Harris SA, Nicolai LA. Occupational exposures in emergency medical service providers and knowledge of and compliance with universal precautions. Am J Infect Control 2010;38:86–94. [5] Alves DW, Bissell RA. Bacterial pathogens in ambulances: results of unannounced sample collection. Prehosp Emerg Care 2008;12:218–24. [6] Eibicht SJ, Vogel U. Meticillin-resistant Staphylococcus aureus (MRSA) contamination of ambulance cars after short term transport of MRSA-colonised patients is restricted to the stretcher. J Hosp Infect 2011;78:221–5. [7] Rago JV, Buhs LK, Makarovaite V, Patel E, Pomeroy M, Yasmine C. Detection and analysis of Staphylococcus aureus isolates found in ambulances in the Chicago metropolitan area. Am J Infect Control 2012;40:201–5.
Please cite this article as: Liang SY, et al, Knowledge, attitudes, and practices regarding infection prevention among emergency medical services providers, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.02.026
