Katherine West, BSN, MSEd, CIC, infections control consultant for Infection Control/Emerging Concepts, Inc., says she’s often amazed at how many cleaning products most EMS agencies use. “You can consolidate and save money,” she says. “You don’t need the toxic products some departments use.”
According to West, the driving force behind selecting a chemical to clean an ambulance should be the type of organism the chemical is meant to eliminate. With the single exception of Clostridium difficile (commonly known as C diff), which requires a chlorine-based cleaning product, most ambulance providers need only low-level products.
For example, HIV doesn’t survive outside the body: It’s killed by light and air, so there’s no need to be concerned about it. There’s also no data to show that Hepatitis C survives outside the body. The real concern is Hepatitis B (HBV). “HBV has been shown in one study to survive up to seven days in the presence of dried blood on stainless steel in a hemodialysis center,” West says.
What’s Your Plan?
Every EMS provider must have an exposure control plan. This plan must clearly state how each piece of equipment and vehicle is to be cleaned, using the brand name of the cleaning products to be used. West recommends a simple, single sheet protocol that can be laminated and is easily available to employees. “This is a 3 a.m. reference,” she says. “It’s not that difficult to put together.” By Occupational Safety and Health Administration (OSHA) requirements, this document needs to be updated every year at a minimum, says West.
The plan should also include a cleaning schedule. Providers must wipe down equipment that was in contact with a patient before the next call, focusing on what was used for patient care or was in contact with the patient during patient care. “Always clean the entire ambulance at the end of the day,” West says. “You may want to completely empty the vehicle once a week.”
Levels of Disinfection
Decontaminating an ambulance is a process. The first step is cleaning to remove debris. Only after a surface has been cleaned can it be decontaminated using one of three types of disinfection. The first, or highest level, is sterilization. Sterilization completely eliminates all organisms and is used for equipment that will be reprocessesed (or reused) and comes into contact with mucus membranes, such as a laryngoscope blade. Chemical or steam-based sterilization can be used, but the correct procedure must be followed. Disposable items don’t need a high level of sterilization.
“This is the standard of care,” West says. Always follow the manufacturer’s guide to keep from voiding the product’s warranty, she says.
Non-critical items would include stethoscopes or blood-pressure cuffs. Cleaning of floors, stretchers and walls don’t require the same strict standards of the highest level of decontamination.
It’s important to read the label of all cleaning products, according to West. “You will find that many of them are quite toxic,” she says. Some require a gown, protective eyewear and special gloves when used. OSHA requires that providers wear dishwashing-type gloves, not disposable ones, when using any cleaning product, even disinfectant wipes.
For the most part, wipes and paper towels used in the cleaning process are not considered medical waste and can be disposed of in the regular trash, even if bodily fluids are present. Using the regular trash to dispose of this waste will significantly cut costs. However, West cautions that every state has different regulations, so she suggests reviewing state definitions regarding medical waste.
“The reality is that we have zero science to prove that medical waste is hazardous,” she says. “Most of the laws came about by emotion and are not supported by science.” Some states have strict regulations about what goes down the drain. West says to be aware of those laws as well.
According to West, one of the most effective disinfectants is a simple bleach and water solution, mixed at a ratio of 1:100 “It was never 1:10. That was for laboratories,” she says. The mixture works out to about a quarter cup of bleach for every gallon of water. It will be good for 24 hours, so it needs to be labeled. At that ratio, the mixture shouldn’t damage vehicles or equipment. Remember, more isn’t better in this case. “It’s not better; it becomes toxic,” West says.
Most products will say they’re good for so many days once they’re mixed, but how long is a day? For most solutions, it may be three immersions. Test strips are needed to ensure that a solution is still at the correct preparation.
Unless you live in Arizona, you do not need to purchase a name-brand bleach. Arizona laws are different because of evaporation rates typical in that state. Don’t store bleach and water in a glass container, especially in a hot vehicle. “It explodes,” West says.
Premixed wipes can be effective and efficient, says West. Studies by the Centers for Disease Control and Prevention (CDC) found that one minute of contact time is all that’s needed to decontaminate most surfaces. “You can clean en route between calls,” she says.
Just be sure that your wipes contain bleach. To make sure, read labels. For example, one might think that the Clorox wipes with the orange label contain bleach, but a careful examination of the label reveals that they don’t.
Soap & Water
Although alcohol-based foams and gels kill many germs, they won’t kill C diff. A chlorine-based product for cleaning surfaces works best. Bar soap and warm water removes the transient organism from hands. Remember, per OSHA requirements, all providers must wash with soap and water after every time they remove gloves.
West and the CDC strongly advocate against using anti-bacterial soap for hand washing, preferring anti-microbial instead. “Antibacterial soap kills the good germs. We can document that it sets you up for the bad, resistance-developing germs,” she says.
The Next Big Thing
What about fogging or ultraviolet (UV) lights or any of the myriad new products being introduced? West warns that everybody wants the quick fix. The reality is that we still need to clean first before using these products.
In fact, some of these new products are dangerous. A few of the fogging agents contain harmful pesticides. UV lights can cause eye damage. Several infectious disease groups have called on the environmental protection agency (EPA) to evaluate these products on the market.
Are they necessary or overkill? “There is no disease on the planet today that requires taking a vehicle out of service in order to clean it. We are truly in a wipe-and-go world,” West says.
Equipment Left at the Hospital
An ongoing controversy exists in some areas regarding who’s responsible for cleaning equipment left at the hospital. To get a clear ruling, West sent a formal letter to OSHA. OSHA’s answer, in writing, is considered its legal interpretation. The statement said that, because the hospital staff is removing the equipment from the patient, it must clean it or red bag it before returning it to the ambulance provider. “They cannot leave it outside, in a room or a hallway unclean. That’s an OSHA violation,” West says. Because the equipment isn’t medical waste, providers can transport a red bagged piece of equipment.
It’s a requirement of your exposure control plan that you monitor and keep records. If you find non-compliance with a cleaning protocol, it must go to the trainer, who will then provide reeducation. Further monitoring is needed to ensure that compliance has improved. If not, a progressive, disciplinary action policy must be followed, per OSHA. West recommends keeping monitor sheets on file in a three-ring binder so they are readily available.
Several recent studies have tested ambulances for organisms. The reality, West says, is that no cleaning product or process short of sterilization will eradicate everything. What isn’t addressed in the studies is how much of the organism is present and the exact type it is. “Is there enough to pose a risk to patients and caregivers?” she asks. “That has not been addressed.”
Aside from the OSHA requirements, there is an additional incentive for all providers to ensure they have a clean ambulance. As new regulations regarding Medicare and Medicaid reimbursement go into effect, the Center for Medicare and Medicaid Services is going to be monitoring readmission rates. Hospitals have a financial motive to start looking elsewhere for the culprit when a patient returns with an infection. “I suggest that you start doing compliance monitoring so you can support that the patient did not get an infection from you.” West says. “The same expectation for quality of care extends to EMS.”
Although quality is key, there’s nothing wrong with focusing on the bottom line, as long as procedures and products are CDC and OSHA-compliant. “Our goal is to protect patients and care providers from infection. Doing it in a cost-efficient manner is good,” West says. “We can keep things simple.”
All of the information about cleaning and decontaminating equipment and vehicles can be found in the OSHA Compliance Directive CPL2-2.69 and the CDC guidelines. “This is where you find the truth,” West says.
A copy of OSHA’s letter regarding who is responsible for cleaning equipment left at the hospital is available at the EMS Insider LinkedIn site.