Coronavirus, Exclusives, Operations

PPE in EMS Moving Forward: Lessons Learned from COVID-19

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In the last few months, COVID-19, a pandemic-level disease caused by the virus SARS-COV-2, has inflicted profound effects on virtually all facets of humanity. Global economies have lost significant momentum, and international trade has experienced stagnation. Many countries with active cases of the virus have instituted a variety of drastic safety and security measures – ranging from encouraging social distancing to full-scale lockdowns – in order to decrease potential person-to-person spread of the virus.

While all industries have felt the effects of the pandemic, it is likely that no industry has been hit as hard as the healthcare industry. Healthcare personnel of all levels are on the frontlines of fighting the disease, and tens of thousands of providers have been exposed to the disease. The entire healthcare system has been tested and pushed to its limit with the pandemic and the effects it has spawned.

Emergency Medical Services (EMS) play a crucial role in providing prehospital emergency care to millions per year and are currently on the front-lines of the COVID-19 outbreak.1 As they often respond to patients in uncontrolled environments, EMS providers face some of the highest risk of coming into contact with infectious diseases and bloodborne pathogens.2

Personal protective equipment (PPE) is commonly used by EMS personnel at all levels to mitigate the risk of contracting an unwanted pathogen. Examples of PPE used in the field range from gloves – used on almost every call – all the way to body isolation gowns used on the most high-risk patients. Adoption of PPE by EMS personnel has evolved over the years. Decades ago, the use of gloves was not widespread, whereas today, they are commonplace in almost every EMS call.

Specifically, the COVID-19 pandemic has put a lot of focus on using surgical and N-95 masks during patient contacts to decrease the likelihood of transmitting an infectious disease or respiratory illness.3 Many guidelines suggest both patients and providers should wear masks in suspected and confirmed COVID-19 cases.1

COVID-19 will almost certainly not be the last infectious disease dramatically affecting prehospital care. Even after the virus is eradicated, cured, or effectively managed, EMS providers will still likely be facing other infectious diseases or preparing for the next prospective pandemic. Many of the lessons learned during COVID-19 have the potential to institute broad-ranging changes to how EMS providers utilize personal protective equipment in the field moving forward.

Masks on Providers and Patients

It is likely that the use of masks, including surgical and N95-grade, will increase. Studies during this pandemic and experience from many prehospital providers suggests that providers wearing a mask and placing a mask on patients with suspected contagious infections reduces the risk of healthcare providers being exposed and subsequently contracting the disease.4 It is likely that, moving forward, masks will be utilized on a greater percentage of calls, if not on every call with a suspected contagious infection. There have been a number of studies looking at the possibility of safely decontaminating and reusing N95 masks.5,6,7

With reusable articles of PPE that are effective and likely to survive decontamination, there are four types of processes that have been validated as being effective: spraying articles with vaporized hydrogen peroxide, exposing them to 70-degree Celsius heat, basking them in ultraviolet light, or spraying them with 70% ethanol spray. When tested in a laboratory setting, each of these methods of treatment eliminated all traces of the SARS-COV-2.

However, when specifically applied to masks, the various methods inflicted varying levels of damage, and some compromised the mask’s ability to effectively form a tight seal. Ethanol spray could only be used once, UV and heat exposure could only be used three times, but vaporized hydrogen peroxide showed the most promise and could be used more than three times.6

Gowns on Every Patient Interaction

The virulence of the SARS-COV-2 virus has demonstrated that pathogens can survive on a multitude of surfaces and remain alive, without a host, for extended periods of time.8 Healthcare providers have learned the hard way that their uniforms could be carrying and transmitting these pathogens.9 Gowns have been one effective solution to prevent pathogens and harmful microorganisms from adhering to provider uniforms. However, using disposable gowns on every patient interaction is likely both cost-prohibitive and environmentally-deleterious.

For decades now, EMS providers have changed out linens and disinfected stretchers after every patient contact. It might be worthwhile for EMS agencies or the hospitals that they serve to invest in reusable gowns that can be worn by EMS providers during calls. Perhaps, like linens, these gowns could be dropped off and cleaned by receiving facilities, or they could be decontaminated by the EMS agency itself.

The advantages to reusable gowns in the prehospital setting make a lot of sense. Environments where patients are found in the prehospital setting are often less controlled and less sanitized than an in-hospital environment. Furthermore, uniforms visit multiple scenes during a single shift and can accumulate several strains of harmful microorganisms and pathogens – even personnel that did not respond to a call are at risk when a contaminated uniform enters a station’s common area.

EMS clinicians also potentially expose family members if they arrive home wearing a contaminated uniform. Wearing reusable gowns for the duration of a call rectifies these problems by creating a barrier between a provider’s uniform and any pathogens that are found on a call. Furthermore, changing to a different gown for each patient interaction prevents patients and other crews from being exposed to pathogens and microorganisms from a previous call.

In this situation, a provider could don a clean reusable gown immediately after being dispatched to a call or before entering the scene. During the call and while wearing the gown, they will be free to perform their assessments, carry out any needed interventions, and transport the patient to an appropriate facility – if needed – without fear of contaminating their actual uniform with patient matter or harmful microorganisms.

When decontaminating their ambulance and disposing of used linens, the providers could remove their gown and, if a partnership with the receiving facility has been established, deposit the gowns for cleaning and pick up new gowns. Alternatively, the EMS agency could be entirely responsible for the gowns and sanitize them inside the station, much like how turnout gear is cleaned after being used at the scene of a fire or hazardous materials incident.

Recommendations

  • Mask Placed on Patients with Suspected Contagious Infection and Worn by Crew Members During Patient Interactions
  • Lightweight Gowns Worn on All Patient Interactions and Changed Between Calls to Prevent the Spread of Pathogens (Gown Use Mimicking Glove Use in the Field)
  • EMS Agencies Becoming Capable of Decontaminating Reusable Gowns (Similar to Turnout Gear) or Partnering with Healthcare Centers to Provide and/or Decontaminate Reusable Gowns (Similar to Linens)
  • Improved Supply Chains for Personal Protective Equipment to Prevent Shortages, and Dramatically Increased Prices During a Pandemic-Level Event
  • Capability to Rapidly Manufacture New PPE During a Pandemic-Level Event and/or Deploy Stockpiles of Ready-to-Go PPE

Conclusion

Perhaps the largest wide-scale pandemic ever faced by modern-day EMS systems, this historic event has tested healthcare systems globally and will certainly change the culture surrounding personal protective equipment in the prehospital setting. Moving forward, masks will likely be used on a greater percentage of calls to prevent the spread of respiratory infections. Furthermore, the idea of wearing reusable gowns during a call and all patient interactions presents several unique advantages and could be a compelling prospect for EMS agencies if it can be successfully implemented.

References

  1. The Centers for Disease Control and Prevention. Summary of Key Changes for EMS Guidance. Interim Guidance for EMS. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-for-ems.html.
  2. Ratcliffe JM, Lyden JT, Sousa S, Orelien JG, Boal WL, Jagger J. Blood exposure among paramedics: incidence rates from the national study to prevent blood exposure in paramedics. Annals of epidemiology. 2006 Sep 1;16(9):720-5.
  3. The Centers for Disease Control and Prevention. Strategies for Optimizing the Supply of Facemasks. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html.
  4. Howard J, Huang A, Li Z, Tufekci Z, Zdimal V, van der Westhuizen HM, von Delft A, Price A, Fridman L, Tang LH, Tang V. Face masks against COVID-19: an evidence review.
  5. Avery S. Duke Starts Innovative Decontamination of N95 Masks to Help Relieve Shortages. Duke Health. March 26, 2020; updated March 31, 2020. https://corporate.dukehealth.org/news-listing/duke-starts-innovative-decontamination-n95-masks-help-relieve-shortages.
  6. Fischer R, Morris DH, van Doremalen N, Sarchette S, Matson J, Bushmaker T, Yinda CK, Seifert S, Gamble A, Williamson B, Judson S. Assessment of N95 respirator decontamination and re-use for SARS-CoV-2. medRxiv. 2020 Jan 1.
  7. Schwartz A, Stiegel M, Greeson N, Vogel A, Thomann W, Brown M, Sempowski GD, Alderman TS, Condreay JP, Burch J, Wolfe C. Decontamination and reuse of N95 respirators with hydrogen peroxide vapor to address worldwide personal protective equipment shortages during the SARS-CoV-2 (COVID-19) pandemic.
  8. van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, Tamin A, Harcourt JL, Thornburg NJ, Gerber SI, Lloyd-Smith JO. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. New England Journal of Medicine. 2020 Apr 16;382(16):1564-7.
  9. Akhter S. Your hospital shift is done. You ditch your contaminated scrubs on your porch. The Washington Post. March 31, 2020.