Documentation & Patient Care Reporting, Operations, Patient Care, Training

Understand When to Remove Gloves and Other PPE

Issue 12 and Volume 39.

The call is over. The EMS crew is cleaning the ambulance, writing the patient care report and preparing for the next call. Their patient was a 44-year-old male who had a four-day history of nausea and vomiting. During their assessment, the EMTs identified the patient had postural hypotension and administered two IV fluid boluses during transport. The patient also received oxygen via nasal cannula and 2 mg ondansetron to help with the nausea.

The EMT writing the report asks her partner if he has the initial set of vital signs written down so she can add them to her report. Her partner answers to the affirmative and reaches into his pocket where he retrieves a glove he was wearing during the call, with the vital signs written on the back. Let’s take a closer look at what just occurred.

EMS Anthem
“BSI, the scene is safe” is the anthem sung by many (if not most) EMS providers during their initial training, commonly waiving their hands in the air with some form of “jazz hands.” If this ritual isn’t performed during many initial testing events, the candidate will fail the skill station.

EMS instructors have done a great job of teaching providers to glove up prior to coming in contact with patients. What’s missing in education, however, is information about when the gloves should come off.

Take a look at the call described above. Both EMTs donned gloves prior to entering the patient’s home. Their hands are protected. The patient was assessed: pulse, blood pressure, lung sounds and pulse oximetry. Both providers at different times during the call used their pens to take notes. One took notes on the back of his glove.

After being placed on the stretcher, the patient was wheeled into the ambulance. The driver shut the back doors, took off his gloves, placed them in his pocket and drove to the hospital. The provider caring for the patient kept her gloves on during the call. She placed the patient on a cardiac monitor, called the hospital and opened the iPad to begin typing her report. After the call, she removed her gloves, washed her hands, picked up her iPad and continued to write the report.

Discussion
In this instance the patient had dry skin, no open lesions and wasn’t actively vomiting. The risk of contamination through contact was most likely low, but the point to be made is that the only thing not exposed during this call was the EMS providers’ hands.

Once a provider comes in contact with an infectious pathogen, with or without a gloved hand, that pathogen can now be spread to everything else touched.

For example, an EMT touches a patient with a gloved hand to feel for a pulse. They then grab the blood pressure cuff and their stethoscope to obtain a blood pressure. After auscultating the blood pressure, the EMT grabs his pen to document his findings.

If there were a contagious pathogen on the patient, the EMT has now spread that pathogen to the blood pressure cuff, their stethoscope and their pen.

After the call, touching the contaminated equipment with bare hands could negate the entire body substance isolation process.

By not changing gloves during a call, EMS providers can spread an infectious pathogen throughout the ambulance, into the hospital and onto their personal items such as pens, notepads and clothing.

The Centers for Disease Control and Prevention’s (CDC) training document “Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings” describes what they refer to as “touch contamination.” The CDC states, “gloves can become a means for spreading infectious material to yourself, other patients or environmental surfaces.” It’s recommended that providers avoid contact with surfaces with contaminated gloves.

Best practice states healthcare workers should don gloves prior to coming in contact with a patient. After completing the assessment or other procedure, the healthcare worker should remove their gloves prior to touching non-contaminated surfaces. A new pair of gloves should be worn if the healthcare worker comes in contact with the patient again. This can be difficult in the prehospital setting. Sometimes, it may just not be possible to change gloves multiple times during a call. However, EMS can do a better job of protecting themselves.

When gloves are removed, they should be placed in the trashcan, not in pockets or on tables and benches. This means there are better places to take notes during patient care. It can be speculated that on the majority of calls, EMS workers have time to remove their gloves prior to using the radio or writing their reports. And, there’s really no reason to keep gloves on while driving the ambulance. If they’re required to recontact the patient, put on another pair of gloves.

On calls where surface and touch contamination can’t be avoided, EMS workers should work hard to clean and disinfect surfaces when the call is complete. Don’t let your “scene safe, BSI” procedures place you at risk.

Columns, Operations, Patient Care, Training

Understand When to Remove Gloves and Other PPE

Issue 12 and Volume 39.

The call is over. The EMS crew is cleaning the ambulance, writing the patient care report and preparing for the next call. Their patient was a 44-year-old male who had a four-day history of nausea and vomiting. During their assessment, the EMTs identified the patient had postural hypotension and administered two IV fluid boluses during transport. The patient also received oxygen via nasal cannula and 2 mg ondansetron to help with the nausea.

The EMT writing the report asks her partner if he has the initial set of vital signs written down so she can add them to her report. Her partner answers to the affirmative and reaches into his pocket where he retrieves a glove he was wearing during the call, with the vital signs written on the back. Let’s take a closer look at what just occurred.

EMS Anthem
“BSI, the scene is safe” is the anthem sung by many (if not most) EMS providers during their initial training, commonly waiving their hands in the air with some form of “jazz hands.” If this ritual isn’t performed during many initial testing events, the candidate will fail the skill station.

EMS instructors have done a great job of teaching providers to glove up prior to coming in contact with patients. What’s missing in education, however, is information about when the gloves should come off.

Take a look at the call described above. Both EMTs donned gloves prior to entering the patient’s home. Their hands are protected. The patient was assessed: pulse, blood pressure, lung sounds and pulse oximetry. Both providers at different times during the call used their pens to take notes. One took notes on the back of his glove.

After being placed on the stretcher, the patient was wheeled into the ambulance. The driver shut the back doors, took off his gloves, placed them in his pocket and drove to the hospital. The provider caring for the patient kept her gloves on during the call. She placed the patient on a cardiac monitor, called the hospital and opened the iPad to begin typing her report. After the call, she removed her gloves, washed her hands, picked up her iPad and continued to write the report.

Discussion
In this instance the patient had dry skin, no open lesions and wasn’t actively vomiting. The risk of contamination through contact was most likely low, but the point to be made is that the only thing not exposed during this call was the EMS providers’ hands.

Once a provider comes in contact with an infectious pathogen, with or without a gloved hand, that pathogen can now be spread to everything else touched.

For example, an EMT touches a patient with a gloved hand to feel for a pulse. They then grab the blood pressure cuff and their stethoscope to obtain a blood pressure. After auscultating the blood pressure, the EMT grabs his pen to document his findings.

If there were a contagious pathogen on the patient, the EMT has now spread that pathogen to the blood pressure cuff, their stethoscope and their pen.

After the call, touching the contaminated equipment with bare hands could negate the entire body substance isolation process.

By not changing gloves during a call, EMS providers can spread an infectious pathogen throughout the ambulance, into the hospital and onto their personal items such as pens, notepads and clothing.

The Centers for Disease Control and Prevention’s (CDC) training document “Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings” describes what they refer to as “touch contamination.” The CDC states, “gloves can become a means for spreading infectious material to yourself, other patients or environmental surfaces.” It’s recommended that providers avoid contact with surfaces with contaminated gloves.

Best practice states healthcare workers should don gloves prior to coming in contact with a patient. After completing the assessment or other procedure, the healthcare worker should remove their gloves prior to touching non-contaminated surfaces. A new pair of gloves should be worn if the healthcare worker comes in contact with the patient again. This can be difficult in the prehospital setting. Sometimes, it may just not be possible to change gloves multiple times during a call. However, EMS can do a better job of protecting themselves.

When gloves are removed, they should be placed in the trashcan, not in pockets or on tables and benches. This means there are better places to take notes during patient care. It can be speculated that on the majority of calls, EMS workers have time to remove their gloves prior to using the radio or writing their reports. And, there’s really no reason to keep gloves on while driving the ambulance. If they’re required to recontact the patient, put on another pair of gloves.

On calls where surface and touch contamination can’t be avoided, EMS workers should work hard to clean and disinfect surfaces when the call is complete. Don’t let your “scene safe, BSI” procedures place you at risk.