The decontamination of the EMS environment and the personnel who work within it is a topic that is receiving increased attention lately. Decontamination encompasses myriad areas including the ambulance, patient-care equipment and, more recently, the station and work clothing. The increased interest is a result of two major pre-hospital-infection issues: methicillin-resistant staphylococcus aureus (MSRA) and H1N1, aka the swine flu.

In terms of personal and environmental decontamination, each category has two primary choices within the broad spectrum of available products. For personal use (hands) use either the alcohols or the benzalkonium chlorides. Each are effective, but you must be sure to use 70% alcohol products to get the full range of kill. You also must ensure that kill times are being followed as directed by the manufacturer.

For the environment, use sodium hypochlorite (bleach)-based products and quaternary ammoniums. Both are effective, but you must be aware of their limitations. Bleach, although a good disinfectant, has a short shelf life. You must re-mix to 10% solution daily. The quats usually are pre-mixed for spray or pump-mixed into solution. It is critical to mix them exactly as directed by the manufacturer. Failure to follow these precautions for any of the respective products can lead to a false sense of security. In the long run, it may be cheaper to go quat than bleach if you re-mix the bleach daily — as you should.

But whatever you use, make sure it is EPA-registered for the bugs that you want to ensure are killed.

The other critical piece is kill time. Most products will offer a kill time of 10 minutes. This means the area must be saturated with the product for that length of time, which is tough to do. There are products on the list for MRSA and tuberculosis — two infections that require the longest kill times — that are as low as three minutes. This makes more sense for the pre-hospital care-giver, as it usually is not easy to ensure that something stays wet for 10 full minutes.

Guidelines for avoiding contamination of EMS personnel and their working environments include:

Personal

• Don't bring it to begin with — in other words, don't come to work sick.
• Use basic personal-hygiene practices such as washing hands (warm water, for 20 seconds minimum); using hand sanitizers between patients where washing cannot take place; and, if soiled on one call, wear a gown when going to the next call if you're unable to change ahead of time. Finally, don't touch your face. The average adult touches his face approximately 150 times per day.

Prior to Arrival

• Have dispatch ask is the patient has a fever, cough or known communicable disease?
• If the answer to any of these is "yes," put on KDT/MDT to let crews know ahead of time.
• Company officers should ensure that their personnel are dressed appropriately. Gloves (double if needed), masks and goggles are a minimum. Gowns and sleeves are a good idea.

On-Scene

• If you're in the patient's face (3- to 6-foot range) — protect yours. Regarding masks and goggles: if you have 'em, wear 'em; if you don't have 'em, get 'em — pronto. Also, limit exposure by only having needed personnel within this range.
• Double glove, wear a gown and dispose of soiled gowns within the care facility prior to leaving. If not in a facility, put them into a bio-hazard bag. This can reduce significantly the spread of infection to the pre-hospital-provider environment. This does not mean to discontinue these levels of care, but to help ensure that cross-environmental contamination is decreased.
• Place barriers between the patient and your cot/equipment where feasible, without creating a direct detriment to patient care. Examples are extra sheets, disposable B/P cuffs and stethoscope covers.
• What about the driver? Make sure they remove gloves and throw them away (and it's best to put on a fresh pair) before they touch the steering wheel.

After the Save

• Air it out — open all ambulance doors and use ventilation.
• Clean equipment as the manufacturer prescribes.
• Remove the big stuff first. Clean the area before disinfecting. Otherwise the disinfectant cannot get to the area through the organic material.
• Use the products you have correctly. It may be a cliché, but what if your mother was to ride next?

Back at the Station

• Change your clothes if you even think you were contaminated. Don't plop down on the porous-material-covered couch and leave contaminants for others to take to their dorm rooms.
• It's all about the basics for uniforms. Good old soap and water is best, but it's the drying that really kills the bugs, so dry in a hot dryer whenever possible, or put uniforms out in the sun. Bugs don't like ultraviolet rays. Of course this does not apply to turnouts. And do not take uniforms home to wash.
• Within the station, designate clean and dirty areas. One easy way is a demarcation line at all entry points from the apparatus bay into the station. Put auto-dispensers of hand sanitizer at the entrances with the understanding that no PPE goes beyond that point.
• Change your upholstery when possible to a cleanable surface. Rave with PermaBlock3 is a good product that features an antibacterial liner and which can be cleaned with even the strongest products.
• Use metal wherever you can, e.g., tables and countertops. Metal is a natural barrier against bacterial and viral proliferation.
• Create a daily schedule for decontaminating the station — and follow it. Otherwise you're kidding yourself.
• Most of the quats should be rinsed with clean water afterwards. This will remove the film that sometimes is produced.

One final bit of advice: When you write the incident report, be sure to note that you took care of a patient with potential infectious disease. This will help should you need to seek medical treatment post-incident.

For More Info

Centers for Disease Control and Prevention
www.cdc.gov/ncidod/dhqp/gl_environinfection.html

Food and Drug Administration
www.fda.gov/cdrh/safety/103107-cleaners.html

Environmental Protection Agency
www.epa.gov/oppad001/chemregindex.htm

Ed Nied is the deputy chief of safety and health for the of Tucson (Ariz.) Fire Department. Nied has a master's degree in fire-service administration from Arizona State University and is currently enrolled in the Executive Fire Officer Program. At the local level, Nied serves as the chair of the Pima Fire Chiefs' safety section. Regionally, he is co-founder and chair of Southern Arizona Safety Officers. At the state level, Nied is a chair of the Arizona Fire Chiefs Safety and Health Section. Nationally, he was elected to the board of directors for the IAFC Safety, Health and Survival Section in 2007. Nied is a member of FDSOA and a ProBoard certified HSO/ISO.

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