Human Practices (Silver)
Introduction, Interviews, Literature Review
Our human practices story began when our local Fire and EMS Department contacted us about wanting to about the efficacy of their cleaning standards for their ambulances. In addition, they also wanted to find out about what microorganisms are found in the EMS vehicles and a way that they can detect any pathogens in a real time detection system.
To have more of an understanding of the issues the Fire and EMS Department were facing, we interviewed Ward Eggli, the Fire and EMS Resource Officer who initially contacted us, and four first responders.
In order to get opinions from a variety paramedics about their feelings on current cleaning standards, an unregulated survey was sent out to them. 32 first responders answered. Most responded with wanting to see a more standardized method of cleaning implemented. There was almost a 50/50 split in responses on whether or not the risk of infection would impact how the paramedic handled the call. The majority of respondents feel like risk of infection affects their family or social life because they are uncertain as to what exactly they are coming into contact with.
After being contacted by EMS, we conducted a literature search on previous practices in detecting pathogens in EMS vehicles. We discovered that no study has been conducted in Canada and sparsely in the United States and Europe. Below are tables summarizing what we found in the 8 papers we found.
Table 1. Overview of the sample sizes (where n= the number of ambulances), number of samples taken, and the sampling techniques used in each paper.
|First author, reference||Sample size (n=ambulances)||Number of samples taken||Sampling techniques|
|Alrazeeni, D. (2014)||10||60||Swabs followed by culturing|
|Alves, D.W. (2008)||4||20||cotton swabs with saline solution, agar plate cultures|
|Luksamijarulkul, P. (2015)||30||544||Air samples, surface swabs followed by culturing|
|Makiela, S. (2016)||2 helicopters||360||Swabs followed by culturing|
|Nigam, Y. (2003)||6||164||Swabs with saline solution, blood agar plate cultures|
|Roline, C.E. (2007)||21||105||Swabs followed by culturing|
|Vikke, H.S. (2016)||60||50||Swabs followed by culturing|
|Wepler, M. (2015)||150||2136||Swabs followed by culturing|
The number of ambulances and amount of samples taken varied greatly between the papers examined. The sampling techniques used were all based on cell culturing methods.
Table 2. Overview of sampling locations, study lengths, methods of disinfection, and pathogens found in the ambulances sampled in each paper.
|First author, reference||Target locations||Length of study||Disinfection techniques used||Pathogens found|
|Alrazeeni, D. (2014)||Stretcher handle, oxygen flowmeter knob, interior handle of the rear door||2 months||Fumigation with 6% hydrogen peroxide (H2O2) for 2 hours||Bacillus spp., Staphylococcus spp.|
|Alves, D.W. (2008)||Oxygen flow regulator knob, seat crack, radio, driver's side door handle, lower track of sliding door||N/A||Ethanol-based sanitizer, quaternary ammonium chloride||Bacillus spp., Staphylococcus spp. Pseudomonas fluorescens|
|Luksamijarulkul, P. (2015)||Stethoscopes, the adjustment knob of oxygen flows, long spinal boards, stretcher mattresses, and air flow adjustment fins||2 months||Gaseous chlorine dioxide (ClO2)||Staphylococcus spp., Gram negative bacilli, Gram positive bacilli, Fungi, Aspergillus spp., Penicillium spp., Fusarium spp., Septate hypha fungi, Rizopus and Mucor|
|Makiela, S. (2016)||Blood pressure cuffs, buttons on cardiac monitor, radio handpiece, floor between personnel seats and stretcher, seat-belt buckles of personnel seats||3 months||Helicopter ambulance cleaning protocols.||Methicillin Resistant Staphylococcus aureus (MRSA), Multi-resistant S.aureus (Multi-RSA)|
|Nigam, Y. (2003)||Stretcher mattress, inside cupboards, steering wheel, entonox mask, inside suction bottle, rails of grid/track or floor||12 months||Phenolic pine disinfectants, Tiket, 10% bleach solutions, Domestos, hypochlorite solutions, alcohol and chlorhexidine wipes||S. epidermidis, Bacillus spp., Coliforms, Corynebacterium, S. aureus, Pseudomonas spp.|
|Roline, C.E. (2007)||Steering wheel, left patient handrail, stretcher cushion, work area to the right of patient, yankauer suction tip||N/A||None given||MRSA|
|Vikke, H.S. (2016)||Blood pressure cuffs||2 months||80% ethanol rags, cuffs are made of anti-microbial protection fabric||S. aureus, Enterococcus|
|Wepler, M. (2015)||Carrying handles, oxygen saturation clip, carrying handle cardiovascular bag, tourniquet, ECG cable, BP cuff, headboard of patient stretcher, carrying handle pharmacists’ cabinet, ECG control panel, carrying chair||N/A||Regular ambulance disinfection protocols in Germany||Micrococci, Staphylococcus spp., Apergillus spp., environmental moulds, Methicillin Resistant Staphylococcus aureus (MRSA)|
Most of the studies sampled the oxygen flowmeter knob, a handle located in the ambulance, and a part of the stretcher. While the length of each study was not reported in each paper, most were two months. The most common methods of disinfection involved using alcohol-based wipes. The types of pathogens found varied between each study as some were looking at detecting specific pathogens while others were looking at the general microflora. Variations of Staphylococcus spp. were the most common microorganisms found.
Alrazeeni, D., & Al Sufi, M. S. (2014). Nosocomial infections in ambulances and effectiveness of ambulance fumigation techniques in Saudi Arabia: Phase I study. Saudi medical journal, 35(11), 1354.
Alves, D. W., & Bissell, R. A. (2008). Bacterial pathogens in ambulances: results of unannounced sample collection. Prehospital emergency care,12(2), 218-224.
Luksamijarulkul, P., & Pipitsangjan, S. (2015). Microbial air quality and bacterial surface contamination in ambulances during patient services.Oman medical journal, 30(2), 104.
Makiela, S., Taylor-Robinson, A. W., Weber, A., & Maguire, B. J. (2016). A Preliminary Assessment of Contamination of Emergency Service Helicopters with MRSA and Multi-Resistant Staphylococcus aureus. Emergency Medicine: Open Access, 2016.
Nigam, Y., & Cutter, J. (2003). A preliminary investigation into bacterial contamination of Welsh emergency ambulances. Emergency medicine journal, 20(5), 479-482.
Roline, C. E., Crumpecker, C., & Dunn, T. M. (2007). Can methicillin-resistant Staphylococcus aureus be found in an ambulance fleet?.Prehospital emergency care, 11(2), 241-244.
Vikke, H. S., & Giebner, M. (2016). POSAiDA: presence of Staphylococcus aureus/MRSA and Enterococcus/VRE in Danish ambulances. A cross-sectional study. BMC research notes, 9(1), 1.
Wepler, M., Stahl, W., von Baum, H., Wildermuth, S., Dirks, B., Georgieff, M., & Hafner, S. (2015). Prevalence of nosocomial pathogens in German ambulances: the SEKURE study. Emergency Medicine Journal, 32(5), 409-411.