How Evaluating Your Disinfection Procedures
Can Prevent Ambulance Acquired Infections
In 2016, leadership at Lethbridge Fire and Emergency Services (LFES) identified the need to evaluate their disinfection SOPs and sought expertise from scientific researchers. At the time, there were no dedicated researchers or companies who specialized in evaluating and improving disinfection SOPs for Emergency Services Providers. To fill this knowledge gap, LFES wrote a letter to the University of Lethbridge describing their needs with the hope that someone would help. This letter made its way to the lab of my Doctoral supervisor Dr. Hans-Joachim Wieden, a professor in the Department of Chemistry and Biochemistry at the University of Lethbridge. Upon learning of the needs of LFES, Dr. Wieden’s research group was eager to collaborate and performed a pilot study to examine disinfection procedures at LFES. This collaboration brought white-coat lab work to the Emergency Services environment, and enabled critical knowledge sharing between paramedics and researchers. The resulting work became the first peer-reviewed scientific research in Canada that detailed microbial communities present in an Emergency Services Department and how these threats can be addressed [9, 13]. Specifically, this study identified over sixty different organisms in the ambulances tested, including several bacterial genera connected with HAI such as Staphylococcus spp., Streptococcus spp., Listeria spp., and Clostridium spp. Bacterial distribution at various locations sampled within the LFES environment also allowed pinpointing of “hot spots” that warranted more frequent and enhanced disinfection procedures [13]. LFES was the first Emergency Services department to utilize this leading-edge approach, and it has paid dividends. As Dana Terry, who at the time was a Deputy Chief at LFES (currently a Deputy Chief at Strathcona County Emergency Services) described to me, “These evaluations identified pathogens that we suspected we had in our workplaces, but, before this, could not verify. With the information provided we implemented new disinfection protocols that better targeted the risks we identified, and we believe this has had a significant impact on the health of our patients and staff.”
Following the success of this initial pilot study, additional organizations in the Emergency Services Sector took notice including leaders at Maskwacis Ambulance Authority and Pincher Creek Emergency Services. To make these assessments assessible to a broader group of departments, companies such as dsBioscience Inc. have developed “Self-Sampling Kits” for use in the Emergency Services Sector. These kits allow departments to identify pathogens in any environment and navigate pathogen reduction through targeted improvements to disinfection SOPs. The process is straightforward for Emergency Services providers to adopt and involves sample collection before/after cleaning, followed by shipment to a laboratory for analysis. For a typical first evaluation, it is common to detect several bacteria associated with HAI including Staphylococcus aureus, Clostridium spp., Serratia spp., and Campylobacter spp. However, with intervention disinfection practices can be improved to better target the risks identified and drastically reduce pathogen quantity. Considering the financial burden of sick time, for many departments these evaluations pay for themselves after mitigating a single infection. Emergency Services leader Stew Schmidt (General Manager at Maskwacis Ambulance Authority & Maskwacis Mobile Mental Health, and Samson Cree Medical Services) explained to me that, “maintaining a clean and healthy workplace is essential for promoting the health and well-being of our team and the success of service. By understanding the microbial ecology of ambulances and our station, we were able to bolster our strategies to quantifiably create a safer and healthier environment. I would recommend this type of analysis to fellow Emergency Services Departments.”
Innovation is our way forward, and it’s critical to adopt additional measures to combat the spread of Ambulance Acquired Infections. There are over 220,000 HAI cases per year in Canada, with 8,000 of those cases resulting in death [9,14]. As antibiotic resistance continues to become more prevalent, so does the threat from these “superbugs” in our healthcare system. For example, there has been an alarming 1,000% increase in MRSA cases in Canadian hospitals in recent decades [15]. But with recent advances, we don’t need to accept these concerning trends as the norm. Why should an ambulance ride heighten HAI risk? Why should Emergency Services workers be subject to preventable exposures? Emergency Services leaders now possess tools proven to reduce these risks and create a safer environment for healthcare workers, their families, patients, and our community.
Don’t let shortcomings in your disinfection SOPs persist as vectors for pathogen transmission, or serve as a catalyst for a major outbreak. The time to act is now, and the wellness benefits of proactively improving your best practices are immense.
References:
[1]: Schaps, D., Godfrey, A. W., & Anderson, D. J. (2022). Risk of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) acquisition during ambulance transport: A retrospective propensity-score–matched cohort analysis. Infection Control & Hospital Epidemiology, 43(4), 442-447. DOI: 10.1017/ice.2021.272
[2]: Reichard, A. A., Marsh, S. M., Tonozzi, T. R., Konda, S., & Gormley, M. A. (2017). Occupational injuries and exposures among emergency medical services workers. Prehospital emergency care, 21(4), 420-431. DOI: 10.1080/10903127.2016.1274350
[3]: https://www.cdc.gov/niosh/topics/ems/data.html (2017 data)
[4]: Maguire, B. J., O'Meara, P. F., Brightwell, R. F., O'Neill, B. J., & Fitzgerald, G. J. (2014). Occupational injury risk among Australian paramedics: an analysis of national data. Medical journal of Australia, 200(8), 477-480. DOI: 10.5694/mja13.10941
[5]: Roberts, M. H., Sim, M. R., Black, O., & Smith, P. (2015). Occupational injury risk among ambulance officers and paramedics compared with other healthcare workers in Victoria, Australia: analysis of workers’ compensation claims from 2003 to 2012. Occupational and environmental medicine, 72(7), 489-495. DOI: 10.1136/oemed-2014-102574
[6]: Reichard, A. A., Marsh, S. M., Tonozzi, T. R., Konda, S., & Gormley, M. A. (2017). Occupational injuries and exposures among emergency medical services workers. Prehospital emergency care, 21(4), 420-431. DOI: 10.1080/10903127.2016.1274350
[7]: Maguire, B. J., & Smith, S. (2013). Injuries and fatalities among emergency medical technicians and paramedics in the United States. Prehospital and disaster medicine, 28(4), 376-382. DOI: 10.1017/S1049023X13003555
[8]: Nigam, Y., & Cutter, J. (2003). A preliminary investigation into bacterial contamination of Welsh emergency ambulances. Emergency Medicine Journal, 20(5), 479-482. DOI: 10.1136/emj.20.5.479
[9]: Hudson, A. J., Glaister, G. D., & Wieden, H. J. (2018). The emergency medical service microbiome. Applied and environmental microbiology, 84(5), e02098-17. DOI: 10.1128/AEM.02098-17
[10]: Orellana, R. C., Hoet, A. E., Bell, C., Kelley, C., Lu, B., Anderson, S. E., & Stevenson, K. B. (2016). Methicillin-resistant Staphylococcus aureus in Ohio EMS providers: a statewide cross-sectional study. Prehospital Emergency Care, 20(2), 184-190. DOI: 10.3109/10903127.2015.1076098
[11]: Mainous, A. G., Hueston, W. J., Everett, C. J., & Diaz, V. A. (2006). Nasal carriage of Staphylococcus aureus and methicillin-resistant S aureus in the United States, 2001–2002. The Annals of Family Medicine, 4(2), 132-137. DOI: 10.1370/afm.526
[12]: Roberts, M. C., Soge, O. O., No, D., Beck, N. K., & Meschke, J. S. (2011). Isolation and characterization of methicillin-resistant Staphylococcus aureus from fire stations in two northwest fire districts. American journal of infection control, 39(5), 382-389. DOI: 10.1016/j.ajic.2010.09.008
[13]: Sheahan, T., Hakstol, R., Kailasam, S., Glaister, G. D., Hudson, A. J., & Wieden, H. J. (2019). Rapid metagenomics analysis of EMS vehicles for monitoring pathogen load using nanopore DNA sequencing. PloS one, 14(7), e0219961. DOI: 10.1371/journal.pone.0219961
[14]: Zoutman, D. E., Ford, B. D., Bryce, E., Gourdeau, M., Hébert, G., Henderson, E., & Paton, S., Canadian Hospital Epidemiology Committee, Canadian Nosocomial Infection Surveillance Program, and Health Canada (2003). The state of infection surveillance and control in Canadian acute care hospitals. American journal of infection control, 31(5), 266-273. DOI: 10.1067/mic.2003.88
[15]: Public Health Agency of Canada. (2011) Results of the Surveillance of Methicillin Resistant Staphylococcus aureus From 1995 To 2009 A Project of the Canadian Nosocomial Infection Surveillance Program (CNISP).
Are cleaning practice deficiencies putting your staff and patients at risk? Surprising research has revealed that patients arriving at the hospital by ambulance are a staggering four times more likely get a Healthcare Acquired Infection (HAI) than those who arrive by private vehicle [1]. In addition to patient risk, Emergency Services workers are also at high risk of contracting and spreading Ambulance Acquired Infections. An estimated 27% of injuries in Emergency Services are due to exposures to harmful substances such as infectious materials [2,3]. Given that Emergency Services workers already have threefold higher rates of physical or mental injury than other healthcare professionals [4-7], it is clear that additional supports to combat these persistent risks to community health are required.
To address the challenge of Ambulance Acquired Infections, most departments would find it advantageous to assess their disinfection Standard Operating Procedures (SOPs). Failing to evaluate these SOPs often results in undetected contaminations, and it is noteworthy that the average Emergency Services Department only removes 8-45% of surface contaminants when cleaning [8,9]. Strikingly, some departments even increase the amount of contamination on a surface while cleaning - meaning their procedures are insufficient for disinfection and simply spread contamination to new sites [9]. These deficiencies in disinfection SOPs have direct linkages to the spread of Ambulance Acquired Infections. For example, Emergency Services workers have 3-20 times higher Methicillin-Resistant Staphylococcus aureus (MRSA) nasal colonization frequency than the general public, and the majority of spread can be traced back to contaminated surfaces in their workplace [10-12]. Unfortunately, for most departments identifying deficiencies in their disinfection SOPs is a challenging task. Is that new cleaning reagent working as advertised? Is the frequency of deep cleaning appropriate? Are there any problem areas? Has a dangerous pathogen become established in the workplace? Is human error preventing procedures from being effective? As Ward Eggli (Retired EMS Resource Officer, current Accreditation Canada Surveyor) explained to me, “as paramedics, it’s easy for us to know to clean an area heavily soiled with bodily fluids, but what about what we cannot see?” This concern of Eggli’s is clearly justified, as without evaluation of disinfection SOPs undetected deficiencies become a continued safety risk.
By: Dustin Smith, PhD
Published in Canadian Paramedicine, September 2023 Issue
