Full text of DOI:10.1080/10903120190940074

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EDUCATION AND PRACTICE
EMERGENCY MEDICAL SERVICES EQUIPMENT HYGIENE PRACTICES
Carl S. Goodman, DO, EMT-P, David C. Cone, MD
ABSTRACT
Infectious disease exposure is a known occupational
risk in health care personnel. In emergency medical
services (EMS) personnel, the average rate of preva-
lence for hepatitis B in a meta-analysis by Menegazzi
was 14.04%, compared with Centers for Disease
Control estimates that there is a 5% prevalence for the
general population.1,2 Patients are at risk for noscomi-
al disease transmission as well. A medical instrument
as common as the stethoscope has been shown to be a
vector for infection.3 Other fomites such as ambulance
cot rails, parts of the patient compartment and crew
cab, and patient care devices may also pose the risk of
transmitting a nosocomial infection in the prehospital
setting. Guidelines have been developed by the
Association for Professionals in Infection Control and
Epidemiology (APIC) to assist health care providers in
the judicious selection and use of disinfectants.4 The
Occupational Safety and Health Administration
(OSHA) has also established workplace practice regu-
lations to minimize the risk of infectious disease trans-
mission to health care providers.5 However, it is pos-
sible that many EMS systems are not compliant with
the guidelines or regulations. The literature contains
several papers discussing prehospital transmission of
infectious diseases in general,6–8 as well as transmis-
sion of specific diseases such as hepatitis,9 tuberculo-
sis,10,11 and HIV.12 Additionally, a growing body of lit-
erature is reviewing prehospital aspects of biological
terrorism, and the role of the prehospital care system
in the response to mass infectious disease inci-
dents.13–16 However, with the exception of one article
in a trade journal regarding proper cleaning of laryn-
goscope blades,17 we are aware of no EMS data
regarding compliance with infection control guide-
lines to prevent cross-infection of patients by contam-
inated surfaces or devices.
Objective. To determine whether emergency medical serv-
ices (EMS) systems adhere to accepted equipment hygiene
standards. Methods. Mail surveys were sent to the physi-
cian medical directors of the EMS systems of the 125 most
populous cities in the United States. Results. Eighty-five
surveys (68%) were returned. Seventy-three (86%) of the
responding services have a policy addressing equipment
decontamination, and 32 of these (44%) have an accompa-
nying quality assurance program. Seventy-nine (93%) utilize
either alcohol or a commercial disinfectant (A/CD) on non-
critical items when visibly contaminated with blood.
However, only 32 of those agencies (41%) use soap and
water in addition to A/CD. Another nine (11%) exchange
contaminated items at the hospital, one (1%) uses other
methods, and two (2%) respondents did not know. Seventy-
six (89%) of the responding agencies perform endotracheal
intubation. Of the 54 that decontaminate their own blades,
20 (37%) use soap and water in addition to A/CD, 32 (59%)
use A/CD alone, and two (4%) use soap and water alone.
Conclusion. Adherence to accepted hygiene standards
among EMS systems in our most populous cities is poor.
Many systems do not use soap and water prior to A/CD.
Failure to do so may minimize the effectiveness of disinfec-
tion. Several systems use A/CD or soap and water alone,
neither of which meets current standards for high-level dis-
infection recommended for items that will come in contact
with mucous membranes, such as laryngoscope blades. Key
words: emergency medical services; disinfection; equipment
and supplies; emergency medical technicians; hygiene.
PREHOSPITAL EMERGENCY CARE 2001;5:169–173
Received July 1, 2000, from Emergency Services, Brookhaven
Memorial Hospital Medical Center, Patchogue, New York (CSG);
and the Division of EMS, Section of Emergency Medicine, Yale
University School of Medicine, New Haven, Connecticut (DCC). At
the time of the study, both authors were at the Division of EMS,
Department of Emergency Medicine, MCP Hahnemann University,
Philadelphia Pennsylvania. Revision received November 29, 2000;
accepted for publication December 3, 2000.
One of the most important equipment decontamina-
tion practices outlined in the APIC guidelines is
cleansing with soap and water prior to disinfection
with alcohol or a commercial disinfectant (A/CD).
The objective of this investigation was to determine
whether good equipment disinfection practices in
Address correspondence and reprint requests to: Carl S. Goodman,
DO, EMT-P, Brookhaven Memorial Hospital Medical Center,
Emergency Services, 101 Hospital Road, Patchogue, NY 11772. e-
mail: <cgoodman@bmhmc.org>.
169

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170
PREHOSPITAL EMERGENCY CARE APRIL/JUNE 2001 VOLUME 5 / NUMBER 2
TABLE 1. Hygiene Methods
Hygiene Guidelines—
RESULTS
Device
Classification
Spaulding Process
Classification*
Eighty-five surveys (68%) were returned. Seventy-
three of the responding services (86%) have a policy
and procedure in place addressing equipment decon-
tamination, and 32 of these 73 (44%) have an accom-
panying quality assurance program.
Example
Critical
Semicritical
Noncritical
Intravenous catheter
Laryngoscope
Blood pressure cuff
Sterilization
High-level disinfection
Low-level disinfection
Seventy-nine of the responding agencies (93%) uti-
lize either alcohol or a commercial disinfectant
(A/CD) on noncritical items such as blood pressure
cuffs and stethoscopes when visibly contaminated
with blood. However, only 32 of those agencies (41%)
use soap and water in addition to A/CD. Another
nine agencies (11%) exchange contaminated items at
the hospital, one (1%) uses other methods not
described, and two (2%) respondents did not know
the method used by their agencies. Seventy-two (85%)
use A/CD on items such as backboards and cervical
collars, and 27 of these 72 (38%) use soap and water in
addition to A/CD. Six (7%) use soap and water only,
six (7%) use some other method, and one (1%) respon-
dent did not know.
Seventy-six of the responding agencies (89%) per-
form endotracheal intubation. Five (7%) autoclave
their laryngoscope blades, eight (11%) exchange the
blades at the hospital, 13 (17%) use disposable blades,
and seven (9%) use some other method. Of the 54
agencies that decontaminate their own blades, 20
(37%) use soap and water in addition to A/CD, 32
(59%) use A/CD alone, and two (4%) use soap and
water alone.
*Cleaning a device is essential prior to proceeding with sterilization or dis-
infection.
general, and this guideline in particular, are being
adhered to by large U.S. EMS services.
METHODS
A questionnaire (Fig. 1) was developed and sent to the
physician medical directors of the EMS agencies in the
125 largest U.S. cities using a previously compiled
database of agencies identified using the JEMS 1998
annual directory of the 200 most populous cities in the
United States.18 We chose to survey 125 cities in the
hopes of securing 100 responses. Nonresponders and
those sending unreadable fax replies were sent a sec-
ond mailing. The second mailing was 14 weeks after
the first and the only method of follow-up.
The survey queried the agency regarding the pres-
ence or absence of a written equipment hygiene pro-
tocol and an accompanying quality assurance plan.
The method of cleansing for certain common pieces of
equipment was also assessed. The APIC adheres to the
Spaulding classification of medical devices described
as critical, semicritical, and noncritical.19 Critical
devices enter sterilized tissue or the vascular system,
such as intravenous catheters. Semicritical devices are
those that contact mucous membranes. A laryngo-
scope blade would be considered a semicritical device.
Noncritical devices such as a sphygmomanometer
touch intact skin. Critical devices by definition are
sterile. Semicritical devices require high-level disinfec-
tion, and noncritical devices require low-level disin-
fection. Cleaning (the removal of all foreign material)
is essential, and is performed before proceeding with
sterilization or disinfection. Hence a laryngoscope
blade with dried blood would have to be “cleaned”
prior to high-level disinfection. Using these defini-
tions (summarized in Table 1), hygiene methods for
both nondisposable semicritical (laryngoscope blades)
and noncritical (blood pressure cuffs, stethoscopes,
backboards, and cervical collars) items were assessed.
Data were tabulated using Excel 97 SR-1 (Microsoft,
Redmond, WA), and simple descriptive statistics were
used to describe the infection control hygiene prac-
tices of the respondents. This protocol was deemed
exempt from institutional review board review in
accordance with policies and standards at the host
institution.
DISCUSSION
Emergency medical services personnel work in close
proximity to blood-borne pathogens and other bodily
fluids that pose an occupational hazard. Contam-
inated surfaces pose an infectious disease risk to the
crew, patients, and others in contact with them. The
federal OSHA standard, contained in 29 CFR
1910.1030, and the Ryan-White Comprehensive AIDS
Resources Act, Public Law 101-381, establish criteria
for an Infectious Disease Control Plan.5,20
The APIC defines several levels of medical equip-
ment hygiene and methods to achieve them.
“Cleaning” is the first line of defense in preventing
nosocomial transmission of pathogenic organisms.
Cleaning, the removal of all foreign material from
objects, is usually accomplished with soap and water.
Cleaning prior to disinfection is essential to remove
soil and other organic material. “Disinfection” elimi-
nates pathogenic microorganisms. “Sterilization” is
referred to as a form of disinfection; however, disin-
fection is further classified into high-level disinfection,
intermediate-level disinfection, and low-level disin-
fection. “High-level disinfection” achieves destruction
of all microbial life with the exception of bacterial

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Goodman and Cone EQUIPMENT HYGIENE PRACTICES
171
spores. “Intermediate-level disinfection” inactivates
Mycobaterium tuberculosis, vegetative bacteria, most
viruses, and most fungi, but does not eliminate bacte-
rial spores. “Low-level disinfection” cannot reliably
kill tubercle bacilli or bacterial spores. Most bacteria,
some viruses, and some fungi are eliminated by low-
level disinfection. Sterilization is the complete elimi-
nation of all microbial life. Liquid chemicals can be
FIGURE 1. Emergency medical services equipment decontamination survey.

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172
PREHOSPITAL EMERGENCY CARE APRIL/JUNE 2001 VOLUME 5 / NUMBER 2
utilized in addition to physical means such as steam,
dry heat, and gas chemicals to achieve sterilization.
Commercially available solutions such as glu-
taraldehyde are available to achieve chemical decon-
tamination of medical devices and equipment.
Disinfection can also be achieved by preparing a
dilute solution of sodium hypochlorite (household
bleach) ranging from 1:10 to 1:500 depending on the
desired chlorine concentration. Effectiveness of disin-
fection is dependent on contact time and chlorine con-
centration. Levels of decontamination are based on the
risk of secondary transmission of potentially infec-
tious pathogens. For example, an ambulance floor
does not require the same level of decontamination as
a laryngoscope blade.
Many agencies indicated that noncritical devices
were not cleaned prior to disinfection. This step is
essential in ensuring adequacy of disinfection by
removing gross contaminants. Some respondents
indicated that items were exchanged at the hospital,
but no attempt was made in this study to further iden-
tify hospital decontamination methods. Similar and
more alarming results were found regarding semicrit-
ical items, with many agencies indicating that clean-
ing was not performed prior to laryngscope blade dis-
infection. More concerning, two agencies responded
that they use soap and water alone on this semicritical
item.
CONCLUSIONS
It is alarming that many agencies report lack of com-
pliance with recommended infectious disease expo-
sure control procedures. Results from this survey
demonstrate that equipment hygiene practices are
variable. Many systems do not use soap and water
prior to A/CD use. Failure to do so may minimize the
effectiveness of disinfection and place the next patient
or patient care provider at risk of secondary disease
transmission. Several systems used A/CD or soap and
water alone, neither of which meet current standards
for high-level disinfection recommended for items
that will come in contact with mucous membranes,
such as laryngoscope blades. Appropriate infection
control measures are needed to prevent secondary
transmission of pathogens found on EMS medical
devices and equipment. Adherence to guidelines
established by APIC may reduce EMS vector sources
for infection disease transmission.
The authors thank Ernest Yeh, MD, for his assistance in preparing
the manuscript.
References
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It is apparent from these results that many agencies
are not familiar with or do not comply with estab-
lished guidelines for infection control practices. The
cost–effectiveness of decontamination versus utiliza-
tion of disposable items was not determined.
However, evaluating the costs of disinfection versus
replacement may be valuable in guiding future equip-
ment hygiene practice guidelines.
The usual limitations of survey methodology apply
to this study. The return rate was suboptimal, intro-
ducing the possibility of selection bias, particularly if
those who did not respond did so because they either
were not familiar with their systems’ practices, or
were aware that they do not meet established stan-
dards. Self reporting was relied upon and may not be
consistent with actual behavior. Although the survey
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of concern, patient care devices. Future studies of this
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decontamination.
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