Compliance With Recommendations for Universal Precautions Among Prehospital Providers

EMS/ORIGINAL CONTRIBUTION

Compliance With Recommendations for Universal Precautions Among Prehospital Providers From the Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.

T Chadwick Eustis Seth W Wright, MD, FACEP Keith D Wrenn, MD, FACEP Elisabeth J Fowlie

Receivedfor publication May 27, i994. Revisionreceived October 1O, 1994. Acceptedfor publication October 17, 1994.

Corey M Slovis, MD, FACEP

Presented at the Societyfor Academic Emergency MedicineAnnual Meeting, Washington DC, May 1994. Copyright © by the American College of Emergency Physicians.

Study objective: To evaluate the compliance of emergency medical responders with local employer and Centers for Disease Control and Prevention recommendations for disposal of sharps and use of personal protective equipment in the prehospital environment. Design: Prospective, single-blinded observational study of 297 ambulance runs conducted for 3 months.

Setting: A metropolitan emergency medical service system. Participants: Sixty-nine emergency medical technicians and paramedics.

Interventions: None. Results: Observers recorded the handling of sharps and the use of personal protective equipment in four situations: IV line placement, endotracheal intubation, large-wound management, and body fluid hazard. Emergency medical workers properly handled sharps in 24 of 65 situations (37%). They were usually compliant with glove use during the observed procedures. However, compliance with the use of other personal protective equipment was poor. Conclusion: Sharps were often improperly handled. Most workers complied with recommendations for the use of gloves but often underused goggles, masks, and gowns. Although education and restructuring of the environment and equipment may improve compliance, strong consideration should be given to developing standardized and more practical recommendations for the prehospital environment. [Eustis TO, Wright SW, Wrenn KD, Fowlie EJ, SIovis CM: Compliance with recommendations for universal precautions among prehospital providers. Ann EmergMedApril 1995; 25:512-515.]

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INTRODUCTION

Compliance with universal precautions is recommended by the Centers for Disease Control and Prevention (CDC) for all health care workers to reduce the risk of exposure to bloodbome pathogens, s Although the risk of occupational exposure among health care providers in general is believed to be low 2, several studies have identified a high prevalence of HIV infection among emergency department patients. >4 Critically ill and traumatized patients in particular are most likely to be infected. 2,3 The nature of both traumatic injuries and of the urgent, invasive procedures that unstable patients often require may confer great risk on health care providers. Emergency medical responders (EMRs) may be at even higher risk because of the high proportion of critically ill and traumatized patients who are transported to the ED by ambulance. The considerably more chaotic and adverse situations encountered in the field compared with those in EDs may further increase the risk of exposure. Accordingly, EMRs believe that their chances of becoming infected with HIV are significantP Because of the threat of AIDS, glove use in the ED has become almost routine, with sporadic yet significant exceptions. However, several studies have shown that compliance with the use of other barrier precautions in the ED is frequently ignored. 6-9 There have been no prospective studies of the use of barrier precautions by EMRs in the typical prehospital setting. The purpose of this study was to examine the compliance with CDC and employer recommendations for universal precautions among emergency medical technicians and paramedics employed by the emergency medical services (EMS) system of Nashville, Tennessee.

fluid hazards. Sharps generally consisted of IV catheters and needles used for injections. Proper handling of sharps consisted of immediate disposal, or as soon as possible, into an approved container without recapping, bending or breaking by hand; or handing off to another person. If improper handling of sharps involved handing off, this was considered one event even though two people were involved. Available PPE included gloves, goggles, masks, and gowns. A large wound was defined as an open wound with active bleeding onto the ground, bleeding sufficient to soak through a dressing, or a wound believed in the judgment of the observer to warrant full barrier protection. A body fluid hazard was defined as the visible presence of emesis, urine, feces, or other nonblood body fluid on the patient or surrounding areas. The CDC publishes universal precautions guidelines for the procedures observed in this study. ~ However, the NFD-EMS has guidelines that are somewhat more restrictive for these same procedures (Table 1). This study evaluated compliance with the recommendations by both the CDC and the NFD-EMS. Training of paramedics by the NFD-EMS in the use of PPE consists of 4 hours during orientation on hiring and an annual 2-hour in-service review. Teaching is performed by two paramedics who specialize as infection control officers. An annual in-service review for all EMRs was held less than 1 month before the beginning of our stud> The EMRs were blinded to the existence of this study. However, they were aware that the observers were medical students collecting data for an unrelated research study involving violence in the prehospital setting. Statistical analysis is descriptive only.

MATERIALS AND METHODS

RESULTS

Two medical students prospectively observed EMRs from the Nashville Fire Department EMS (NFD-EMS) during the 3-month period of May through August 1993. ,Observations were made during 12-hour shift assignments of ambulances staffed with two EMRs, including at least one paramedic. Scheduling of the observers was on a convenience basis, but attempts were made to observe as many of the EMRs as possible, and observations were made during both day and night shifts, on all days of the week, and in all areas of the county served by NFD-EMS. The observers documented handling of sharps and the use of personal protective equipment (PPE) by the EMRs for all patients during IV line placement, endotracheal intubation, large-wound management, and other body

The observers were assigned to NFD-EMS ambulances for a total of 747 hours and observed 297 runs during the

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Table 1.

CDC and NFD guidelinesfor PPE. Guidelines Procedure

CDC

IV line placement Endotracheal intubation

Gloves Gloves

Large wound management

Gloves, goggles, mask, gown Gloves

Body fluid hazard

NFD Gloves, goggles Gloves, goggles, mask Gloves, goggles, mask, gown Gloves

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II

12-week study period. Sixty-nine different EMP,s were observed, representing approximately one half of the EMRs employed by NFD-EMS. The results of the study are displayed in Table 2. Prehospital providers were required to dispose of sharps 65 times. Proper handling of sharps was observed in only 24 (37%) of the cases. Usually, the improper disposal involved passing the sharp to another EMR. IV lines were placed in 51 patients. In 47 of the 51 IV line placement attempts (92%), the EMR wore gloves as recommended by both the CDC and the NFD-EMS. Glove use was also noted in a large majority of the other procedures surveyed but was not universal. The use of other suggested PPE, however, was uncommon. DISCUSSION

The results of this study suggest that EMRs in the Nashville metropolitan area rarely comply fully with the use of PPE as recommended by the CDC or the NFD-EMS. Most EMRs wore gloves during procedures such as IV line placement, but use was not universal. All recommended PPE is readily available on all ambulances, except surgical caps and shoe covers, which should be worn with gowns. However, only gloves are routinely carried in the cab of ambulances. Other recommended PPE was used much less often than gloves. For the situations studied, goggles were used only 6% of the time, and masks and gowns were never used when recommended. Universal precautions are recommended because bloodborne pathogen exposure includes the risk of acquiring HIV; the actual risk after an unintentional needlestick with HIV-positive blood is approximately Table 2.

Compliance with universal precautions by NFD EMTs and paramedics. Procedure

o

IV line 51 placement Endotracheal 7 intubatien Large wound 26 management Body fluid 58 hazard * Recommendedby CDC. t Requiredby employer.

514

Gloves{%)

Goggles(%)

Mask (%)

Gown(%)

47 (92)**

4 (8)*

NA

NA

7 (100)**

1 (14)*

0 (0)t

NA

25 (96)**

0 (O)**

0 (0}**

0 {0)**

50 (86)*~

NA

NA

NA

.5%. 1 The risk from nonparenteral exposure is much less, probably close to zero. Although diseases such as hepatitis B and C can cause considerable morbidity, they are not always fatal. The complications of AIDS, however, are believed to always be fatal. It is estimated that the US population infected with HIV is as high as 1.5 million ~°, and in some areas, the rate of HIV refection among ED patients is reported as 8% and increasing. ~~ The rate among urban trauma victims alone may be as high as 16%. ~2 There are several reasons why the compliance with universal precautions by EMRs may not be complete. Some providers may not have been trained properly, although this seems unlikely EMRs of the NFD-EMS receive at least 3 hours of universal precautions training before hiring, 4 hours as part of new employee orientation, and 4 hours as an annual update. However, the quality of this training is difficult to determine. Some EMRs may believe that they do not need to use PPE with patients they perceive as being at low risk of carrying HIV or hepatitis. In some ED studies, this was a reason often listed for noncompliance, s,9 Some providers may feel that certain types of PPE interfere with the ability to do procedures; others may just forget in the heat of the moment. Sometimes, the PPE may not be readily available once the EMRs leave the ambulance or may be perceived as slowing down the provision of emergency care. In three ED studies, these self-reported reasons accounted for most of the noncompliance.
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PRECAUTIONS

Eustis et al

workers without oLher risk factors are due to needlesticks. ~ Suboptimal training, attitudes, and practicality may also apply when sharp disposal regulations are n o t fulfilled. In particular, locating the disposal containers closer to where IV lines are placed would probably improve compliance. Recommendations for sharp disposal and PPE use may need some revision both at the local level and at the level of the CDC to meet the requirements of practicality yet maintain adequate protection for EMS personnel. Recommendations should be simplified such that they are straightforward and standardized. Because they are minimally disruptive, the commonplace use of goggles should be encouraged, along with gloves. Other PPE may need to be modified or efforts may need to be made to engineer the equipment so that its use is practical and comfortable. Ambulance design should take into account disposal of sharps and rapid access to PPE. Training in universal precautions may need more frequent updates and monitoring. Educational programs and policy development in the ED have been shown to improve compliance. ~3 There are at least four possible limitations to the results of this study. First, although the EMRs were blinded to the existence of this study, their behavior may have been influenced by the presence of the student observers. Students frequently ride on the ambulances in the NFD-EMS system, however, so maj or modifications of behavior were unlikely. Also, modifications in behavior would likely have been toward more compliance with regulations rather than less, which would only strengthen the results of this study. A second possible limitation is that we did not observe large numbers of procedures, particularly endotracheal intubations. The fact that compliance with certain types of PPE was extremely low makes it unlikely that observation of larger numbers would change the results in any meaningful way; compliance with universal precautions still would have not been universal. Furthermore, the results of our study are congruent with previous surveys and retrospective surveys. 6-9 Third, we do not have data on the reasons why regulations were ignored or on the attitudes of EMRs toward the requirements. Finally, because regulations may vary from place to place, the observed rates of compliance with NFD-EMS may not apply to other EMS systems. The data on compliance with CDC recommendations may be more generalizable.

sharps and PPE use in the prehospital setting. Compliance was not universal and varied depending on the situation, the procedure, and the recommended PPE. Recommendations for EMRs may need to be tailored to the unique aspects of the prehospital setting. Further study is necessary to determine whether specific risk factors predict noncompliance and whether specific interventions will make a difference in compliance and therefore in the risk of exposure to bloodborne pathogens by EMS personnel. REFERENCES 1. Centers for Disease Control and Prevention: Guidelines for prevention of human immunodeficiency virus and hepatitis B virus to health-care and public-safety workers. MMWR 1989;38(suppl S-6):111-155. 2. Marcus R, Culver DH, Bell DM, et ai: Risk of human immunodeficiency virus infection among emergency department workers. Am J Med 1993;94:363-370. 3. Kelen GD, Fritz S, Qaquish B, et el: Unrecognized human immunodeficiency virus infection in emergency department patients. N EnglJ Med 1988;318:1645-1650. 4. Lewandowski C, Ognjan A, Rivers E, et el: Health care worker exposure to H/V-1 and HTLV I-II in critically i[I, resuscitated emergency department patients. Ann EmergMed 1992;21 :t353-1359. 5. Smyser MS, Bryce J, Joseph JG: AiDS-related knowledge, attitudes, and precautionary behaviors among emergency medical professionals. PublicHealthRep 1990;105:496-504. 6. Kelen GD, DiGiovanna TA, Celentano DD, et ah Adherence to universal (barrier} precautions during interventions on critically ill and injured emergency department patients. JAcquirlmmum Doric Syndr1990;3:987-994. 7. Bereft LJ, Talan DA: Compliance with universal precautions in a university hospital emergency department. Ann EmergMed 1989;18:654-657. 8. Hammond JS, Eckes JM, Gomez GA, et ah HIV, trauma, and infection: Universal precautions are universally ignored. J Trauma1990;30:555-561. 9. Henry K, Campbell S, Maki M: A comparison of observed and self-reported compliance with universal precautions among emergency department personnel at a Minnesota public teaching hospital: Implications for assessing infection control programs. Ann EmergMed 1992;21:940946. 10. Centers for Disease Control: Estimates of HIV prevalence and projected AIDS cases: Summary of a workshop, October 31-November 1, 1989. MMWR 1890;39:110-119. 11. Kelen GD, Fritz S, Oaquish B, et ah Substantial increase in human immunodeficiency virus (HIV-1} infection in critically ill emergency patients: 1986 and 1987 compared. Ann EmergMeal 1989;18:378-382. 12. Baker JL, Kelen GD, Sivertson KT, et el: Unsuspected human immunodeficiency virus in critically ill emergency patients. JAMA 1987;257:2609-2611. 13. Kelen GD, Green GB, Hexter DA, et ah Substantial improvement in compliance with universal precautions in an emergency department following institution of policy. Arch InternMed 1991;151:2051-2056.

Reprint no. 47/1/63329 Address for reprints: Seth W Wright, MD, FACEP Departmentof EmergencyMedicine 703 OxfordHouse VanderbiltUniversityMedicalCenter

CONCLUSION

Nashville,Tennessee37212

This is the first prospective, blinded observational study of compliance with recommendations for disposal of

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