Columns, Patient Care, Training

EMT Hand-Washing Habits Need Improvement

Issue 8 and Volume 39.

The Research
Ho JD, Ansari RK, Page D. Hand sanitization rates in an urban emergency medical services system. J Emerg Med. March 26, 2014. [Epub ahead of print.]

The EMS Science
To perform this study, paramedic students were asked to tabulate whether the paramedics they were observing performed hand sanitizing events (HSE) within five minutes before, during and after direct patient contact. They also counted HSE that occurred before and after eating. HSE included washing with soap and water or using an anti-germicidal gel, foam or wipe. The students didn’t record the length of time of each HSE or whether or not HSE occurred following toilet use—it was assumed all toilet use was followed by HSE.

The students observed 53 paramedics performing 258 patient contacts. Of those contacts, there were 165 HSE directly observed that immediately surrounded a patient contact for a compliance rate of 63.9%—162 (62.8%) of these occurred immediately after patient contact and three (1.1%) occurred just before. There were nine HSE that occurred during a patient contact (3.5%).

Sixteen bathroom visits were recorded immediately proximate to a patient contact (e.g., while awaiting a bed to open for the patient in the ED). HSE were assumed for each of these 16 visits, which increased the compliance rate to 68.9%. Glove use during patient contact was observed 226 times, for a compliance rate of 87.6%.

Forty-two meals were also observed during the study period. HSE took place 33(78.5%) times immediately proximate to this event, but only 8 (19%) times before the meal and 25 (59.5%) times after the meal.

The authors concluded that while HSE occurred in the majority of cases, there was room for improvement.

Doc Keith Wesley Comments
When I first read this paper I was appalled at the incredibly low rate of hand cleansing, particularly prior to patient contact and proximate to meals. I then reviewed dozens of hospital-based papers on the topic. What I found there truly sickened me—the paramedic HSE compliance rates are at the high end of rates seen in the hospital.

It still amazes me the words “BSI, scene safe” are the first out of an EMT’s mouth during every testing station, yet when they actually treat patients, body substance isolation (BSI) is given a low priority.

Healthcare professionals continue to believe glove use and hand washing are to protect them from infection, but it’s also about protecting the next immune-compromised patient you touch.

Although gloves were worn almost 90% of the time, I suspect they weren’t worn appropriately. I’ve witnessed medics don their gloves before they grab the first-in bag and still have on the same pair two hours later after dropping the patient off at the hospital. They’re often still on while completing the patient care report on the tablet. Proper glove use entails wearing them when you need to and taking them off immediately after contact ends. It also means performing HSE after discarding the gloves. Although this requires the use of several pairs of gloves during patient contact, it prevents the spread of germs throughout the ambulance and onto equipment.

Medic Karen Wesley Comments
I can sum up my comments to “eww.” When I began my career in EMS, we didn’t have gloves available to us. We didn’t even chant the mantra “is the scene safe?” And I lost my best friend to a significant exposure of Hepatitis B while working as a medic.

Now we have immunizations, gloves, gowns, masks and a greater knowledge of just how dangerous our jobs are because of medication-resistant bacteria. We have a reporting system that allows us to recognize exposure potential and report it. It doesn’t just allow the EMS provider to be examined and followed, it demands that employers have exposed individuals seen by a medical provider.

Doc is right about the glove issue and its disgusting reality. Many EMS providers put on one pair of gloves before entering the scene, and hang onto that same pair until the patient is transferred to the ED. To make matters worse, people are still using their gloves as notebooks for vital signs.

We need to unite to create better compliance to appropriate glove use and hand washing. Don’t let your partner walk into an unsafe scene or let them operate in an unsafe manner.

Stay in the game, use safe practices in caring for patients and don’t even get me started about what’s on the soles of your boots.

More Research from JEMS.com.