Here is a shocking statistic: According to the United States Centers for Disease Control and Prevention (CDC) Nosocomial Infections (or Healthcare Associated Infections – “HAIs”) defined as “… infections which are a result of treatment in a hospital or a healthcare service unit, but secondary to the patient’s original condition” are the 4^th leading cause of death in the United States. The CDC estimates that nosocomial infections sicken 1.7million patients and are responsible for 99,000 associated deaths each year in US hospitals alone.

Let me repeat those above statements. HAIs KILL almost 100,000 people and make around 1.7 MILLION patients sick and/or sicker PER YEAR in the US. If you don’t believe me, here is the page from the CDC website where I got those facts. I’m inclined to believe the CDC, however I question how many people are weakened from their newly acquired HAI which allows their original condition to worsen and kill them? This means that in the United States of America, healthcare people kill all of those patients every year because we’re not doing things like washing our hands well enough?

My grandmother always told me that a hospital is no place for sick people, looks like she might be right.

Every person spews bacteria, viruses, fungi, and a host of other things everywhere they go. Our skin crawls with Staphylococcus Aureus, microscopic mites, cold and flu viruses, and hosts of other microbes that flake off with our skin and hair. Our fecal matter is full of E. Coli which gets on our hands when we *ahem* clean ourselves. Our coughs and sneezes spew droplets full of germs in a wide radius. Pretty much every time we touch anything our hands pick up thousands (if not millions) of germs that spread to everything else we touch. We are walking, talking Petri dishes being used by all kinds of nasty germs as unwitting patsies to help them breed, move, spread, and infect. Put a bunch of people together and you have an infection control problem. Put a bunch of sick people together and throw in people with all kinds of weakened immune systems and virulent infections and you have a healthcare organization.

Now imagine that every movement inside that organization collects, incubates, breeds, and spreads bacteria. You’re in the hospital and the dietary tray comes by? It left germs. The nurse comes in and holds your hand? She left germs. You take a pen from the registration person? You spread germs. You sneeze? You spread airborne germs. Hospitals are one of the most effective tools that germs have in their arsenal of spreading themselves and causing the diseases that they do and while no exact statistics exist that I’ve been able to find to back up my next statement, Ambulances are probably worse. It makes sense to me because we’re in a smallish enclosed environment that goes all around town to lots of private homes, nursing homes, hospitals, and who knows where collecting various bodily fluids and other types of DNA samples from every person we put in the back (and/or the front). Factor in high call volumes that leave little time for proper decontamination, EMS personnel that have little understanding of proper disinfection practices and that are already overworked, overtired, and under-motivated to properly clean and you have a Mobile Infection Causing Unit (MICU? Cute)

Bottom line: Hour for hour, time spent cleaning your ambulances and your equipment may ultimately save more lives than time spent training.

Before I launch myself into a full-fledged rant on my obsessive-compulsive ambulance cleaning techniques, I think that I should tell you the point of this article. I want to lay out a few simple steps that you can put in to place on your next shift that will keep you, your coworkers, and your patients much healthier and happier. With a little bit of information on proper cleaning practices, you have the potential to make a very large difference in the long-term outcomes of your patients.

Here are some terms you should know:

• Sterilization: (Also known as Terminal Sterilization): This is a term used to describe the total and complete removal of all forms of microbial life including bacteria, viruses, fungi, and other organisms in all phases of their lifecycle. Sterilization is accomplished by a few methods, two of the most popular being the heat and steam pressure used in an autoclave device and ethylene oxide gas however a long soak in a glutaraldehyde solution may be used. Sterilization is used for “Critical Devices” defined as tools or equipment that come into direct contact with the bloodstream or other normally sterile areas of the body such as IV needles, scalpels, and surgical tools.

• High-Level Disinfection: This is a term used to describe a very broad-spectrum disinfection process that destroys almost all microbial life but may not completely remove all possible bacteria, viruses, or spores. It is usually accomplished by a prolonged soak in a liquid chemical sterilant but not for the contact time needed for terminal sterilization. This process is used for “semi-critical devices” that come into contact with mucous membranes but for which sterilization is not completely attainable or would damage the equipment. Examples of semi-critical devices in the EMS field include laryngoscope blades, Magill Forceps, and oropharyngeal airways (that thank goodness are now almost always disposable!)

• Disinfection: This term is used to describe a process in which an environmental surface is first cleaned and then processed in a manner that kills a defined amount of known microbial organisms. There are two further loose classifications of disinfection practices below the above: “Intermediate” which is used for patient care equipment and surfaces such as EKG monitors, Ambulance cots, sphygmomanometers (OMG! I spelled that right the first time!! – It’s a bp cuff), stethoscopes, and other like equipment. “Low” level disinfection would be appropriate for environmental surfaces such as walls, floors, and countertops.

• Sanitization: This process is defined as a chemical substance or process that kills 99.999% of a specific bacterial sample within 30 seconds but when compared to a normal use concentration a disinfecting agent will kill a broader spectrum of microbial life.

• Antiseptic agent: This is a term used to describe a process that kills microbial life on living tissue, such as antiseptic soap or alcohol hand sanitizer.

• Cleaning (or Pre-Cleaning): This is a process used with a detergent and a cloth or other friction-causing device that removes dirt and other gross contaminants from a surface. By removing the gross contaminants, you remove the food that microbes eat, the dirt particles that they hide in, and the biofilms that they create and thrive in. Most disinfectants and sanitizers require a pre-cleaning process in order to be effective.

• Contact Time: The length of time that a surface must remain saturated with a sanitizer or disinfectant in order to kill the specified number and type of microbes desired.

Why did I go to the lengths that I just did to define such boring terms? Because it gives you an idea of how hard you should work to kill germs in the back of your ambulance. Bacteria and other like microbes grow, adapt, and change in response to various stimuli. There is scientific debate on the next statement but some of these changes may include developing resistance to the chemicals that we use to kill them. Remember, microbes are the ultimate adaptation machines capable of surviving almost anything anywhere. It takes a process to kill them all and to n
ot just kill the slower, weaker members of the microbial “herd”. Think about it, natural selection favors the strong organisms capable of resisting environmental change. Introduce a disinfectant improperly and all you’re really doing is killing the weak microbes and leaving the strong to survive and thrive on the added food source made of the microscopic corpses of their dead comrades.

Eww.

I may be nuts, but I clean hard. When I do my dishes at home by hand because on a medic’s pay I can’t afford a dishwasher (actually I’m just too lazy to install one) I thoroughly rinse my dish sponge, saturate it with water, and then microwave it for two minutes. I do this because a sponge is the perfect environment for bacteria to survive. It’s wet, dark, and warm. The heat and radiation generated by the microwave kill most of the bacteria that grow inside the sponge. Otherwise, all I’m doing is spreading new germs on my dishes. The same goes for cleaning my kitchen counters. Actual scientific studies (That I’ve learned about by reading this awesome column by Dave Barry) state that people who regularly clean their kitchens actually have more bacteria in them than people who don’t clean them much at all. It makes sense. With all of the wiping of surfaces and ineffective disinfection practices done in the home, microbes simply hitch a ride on the sponge or the cloth being used to “clean” and redeposit and breed on another surface. I’m sure they appreciate it.

Unfortunately, what happens in your kitchen also happens in your ambulance. Even more unfortunate for us and our patients, is that your kitchen usually isn’t exposed to MRSA, C. Diff, or Tuberculosis… or HIV, or Hepatitis B, or VRE… or hundreds more other microbes that I can’t spell properly. Start spreading those around and you’ve got yourself a rather deadly situation.

Needless to say, pretty much no matter how good you think you are cleaning your ambulance now you could be doing better. First of all, you should spend some time selecting the proper product for the job and pay attention to how it’s properly used. Fortunately, the good bureaucrats at the EPA, CDC, and a whole alphabet soup bowl of organizations have left you a trail. Always read the product label and instructions and look for the sentence that says “Using this product in a manner not consistent with its label instructions is a violation of federal law”. This is because it is the job of the Environmental Protection Agency (EPA) to regulate and test “Hospital-level Disinfectants” which are appropriate for use in EMS. The EPA tests these disinfectants which contain a wide variety of chemicals or combination of chemicals of varied efficacy against known bacterial cultures. It then measures the length of time that it takes the chemical(s) to kill specific organisms and the amount of the sample that is killed. It is important to remember that the disinfecting agent is only proven to be effective in specific concentrations in specific lengths of time. Any less than that and who knows what will or will not be killed. Also important to remember is that in the lab, they’re testing bacterial cultures without the presence of any dirt, proteins, or any other soil. Microbes hide in the pores of dirt particles, hide under proteins, and create “biofilms” that protect them against noxious stimuli. They’re the ultimate survivors, remember? Heck, even cockroaches get the sniffles.

So how do we translate this little bit of microbiology class into EMS? More importantly, how do we protect our patients’ and our own health by integrating proper cleaning and disinfection procedures into our shifts while still getting time for lunch? By arming yourself with a little more knowledge, and taking the steps that I’m putting forth below, that’s how. Proper ambulance disinfection doesn’t have to be a daunting task. It just has to be done properly. We also need to look over the volumes of cleaning and disinfecting products available as well and learn how to deploy them properly against our pathogenic enemies.

I can’t recommend any one cleaning product. (Although I would review them if they sent me a free case and paid me a lot of money to do so! Proems1@yahoo.com) However I have used a lot of them. My EMT textbook recommended bleach back when I went through my initial training. While common household bleach, which is a solution of the oxidizing agent sodium hypochlorite and some inert ingredients, is very effective in 1:10 bleach/water concentrations as a hospital disinfectant and in 1:30 concentrations as a sanitizer, it is fairly uncomfortable to use in the back of an ambulance. It can damage equipment and clothing and also can cause severe mucous membrane irritation and damage in humans. Bleach solutions are particularly affected by the presence of organic soil and require very thorough pre-cleaning for proper effect. I prefer to use commercially available hospital-level disinfectants that have a short-to-medium contact time against most pathogenic bacteria, viruses, pseudomonas, and fungi and also contain a detergent that can be used in the pre-cleaning steps. It is important to look at the contact time that it takes for the disinfecting agent to work against the microbes it is able to kill. Some products will advertise claims such as “Kills 99.999% of germs in 30seconds!” which is the definition of a sanitizer. However, if you look at the label directions, it kills 2 or 3 germs in 30 seconds but takes a full 10 minutes to be effective against HIV, Hep C, and pneumonia. Look for a chemical that is easy to apply, thoroughly wets the surfaces you’re disinfecting, and doesn’t dry too quickly in your environment. Lysol IC spray®, a popular commercial product, contains isopropyl alcohol and a benzyamoniumchloride compound. The isopropyl alcohol makes up the majority of the formulation and can sometimes dry too quickly to maintain effective saturation of the surface and therefore effective disinfection. If the disinfection product your agency uses dries too quickly, you should reapply it to keep up the proper contact time, or switch products.

My research in to the effectiveness of the popular pre-moistened disinfecting towelettes makes me cringe to think that they’re commonly used as the only cleaning and disinfecting procedure in a lot of places I’ve been to. I have yet to find one of these products that are soil tolerant enough to not require a pre-cleaning step prior to disinfection and I’ve never seen one that leaves behind enough moist product to maintain saturation to the contact time without drying too early. This may be an effective way to pre-clean and maybe sanitize, but I’ve not found one that can be an effective disinfectant with the ineffective contact time. They simply don’t do a good enough job as a disinfectant. However, their big advantage is that by using multiple towlettes on multiple surfaces you’re preventing cross contamination by simply throwing away a dry towlette and using a new wet one on the new surface. It’s the same principle as the people who don’t clean their kitchens often having less infected surfaces than those who continuously spread the germs around. Be careful though, how many times have you seen someone in the ER give the bed a quick wipe, not even wet 100% of the surface area, and then hastily throw on another sheet so they can get another body on the cart?

In the ambulance, I recommend bringing good cloth towels. Use at least 6 or 8 of them. You have to do a pre-cleaning step to remove gross contamination and eliminate the soils that will cause whatever disinfectant you use to lose effectiveness. If you use a combination cleaner/disinfectant you can use it for both a pre-cleaning and then a thorough wetting soak. However for the cost conscious I recommend using a good regular detergent for pre-cleaning because they tend to be cheaper and more effective at dissolving grease and removing soils. Be sure
to change towels often and use proper Body-Substance-Isolation (BSI) to protect yourself from the germs back there. After pre-cleaning, thoroughly saturate each surface in the ambulance with a proper hospital-level disinfectant and watch to make sure that each surface stays thoroughly saturated for the full contact time. Reapply it if necessary. Remember, if you’re not leaving the product on there to do its job, you’re not really doing anything but making the microbes angry. Pay special attention to commonly touched surfaces in the ambulance, such as door handles, radio microphones, the handles on the ceiling, o2 connections, drawer and cabinet handles, and the steering wheel. I even disinfect the handle that’s on our hand sanitizer dispenser. It gets touched a lot with filthy hands. My biggest tip? Take a vacuum into the back of the rig with you to suck the big garbage and dust out of the cracks and crevasses before you pre-clean. It works great and makes it simple to do a great job.

Patient care equipment should be disinfected after every use. Remember to clean and sanitize monitor cables, stethoscopes, BP cuffs, splints, backboards, head blocks, spider straps, cot straps, and anything and everything else we use. Your patients’ lives depend on it. So could yours.

Remember: Be sure to take the time to wait for the disinfectant to do its job. Pay attention to contact time. Always remember a pre-cleaning step. While some minimal soil can be ok, anything that is visibly dirty or that hasn’t been cleaned all shift should probably be pre-cleaned.

Whew! This was a long one. If you got this far, be proud. Remember. Plumbers have saved countless more lives than doctors. Doctors treat disease, plumbers carry it away to prevent it altogether. Next time you see an “Environmental Services” person in the hospital, thank them for being the life savers that they are. Every bit helps.

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Related Posts:

“The Shine Factor” – One of my first, and best, articles.

Reference Material:

http://en.wikipedia.org/wiki/Disinfection, http://www.wcponline.com/column.cfm?T=T&ID=1482&AT=T, http://firechief.com/ems/ambulance_transports_0301/, http://en.wikipedia.org/wiki/Nosocomial_infection, http://www.opticide.com/tb111503.htm, http://www.cdc.gov/ncidod/dhqp/hai.html, http://www.futurehealthcareus.com/?mc=appropriate-selection%20&page=ps-viewresearch, http://www.miamiherald.com/living/columnists/dave-barry/story/861087.html