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Jenkins JL, Hsu EB, Russell A, et al. Infection Prevention and Control for the Emergency Medical Services and 911 Workforce [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2022 Nov. (Technical Brief, No. 42.)
Infection Prevention and Control for the Emergency Medical Services and 911 Workforce [Internet].
Show detailsWe first present the results from the Key Informant interviews. We then present the results of the published literature search, organized by Guiding Question (GQ). We then present the results from the Gray Literature search.
Results of the Key Informant Interviews
We organized and held a one-hour session on October 25, 2021, with eight Key Informants who were selected for their expertise on the topic, representing a broad range of national, state, and regional emergency medical services (EMS) and 911 agencies. Guided by a series of pre-determined questions, the purpose of the session was to obtain feedback and clarification regarding specific aspects of the protocol. Key Informants will be invited to review the draft report and will be acknowledged in the final report by name and affiliation with the disclaimer that all views expressed therein are strictly those of the report authors.
Modifications to the Analytic Framework
With respect to the analytic framework, several Key Informants indicated that “training” should be replaced by “training and education” to represent distinct concepts. Secondly, the Key Informants felt that protocols, guidelines, standard operating procedures, and procedures are needed to serve as the basis for the education and training. Furthermore, training and education should be competency-based with incorporation of requisite knowledge, skills, and attitudes, and methods for independent evaluation of competency. Regarding interventions of interest, the Key Informants perceived an overemphasis in infection control on personal protective equipment (PPE). They recommended an alternate approach for consideration - to look for evidence on diverse types of interventions across the hierarchy of controls: elimination, substitution, engineering, administration, and PPE, recognizing what has been learned with Ebola virus and Coronavirus disease 2019 (COVID-19). For example, the safety culture of an organization would represent an administrative control. The Key Informants also felt that the analytic framework should acknowledge that exposures may result from activities not involving direct contact with patients. Regarding workforce characteristics of interest, the Key Informants suggested examination of high-performing organizations. Funding levels could be used as a proxy measure, with the caveat that public and private providers may differ in their ability to receive governmental funds. The Key Informants also recommended consideration of organizational size, team response size, and vaccination status of the workforce. For outcomes of interest, the Key Informants advised considering “near misses” or “close calls.”
Scope
When the Evidence-based Practice Center (EPC) team proposed to define the scope of the Technical Brief as covering the EMS and 911 workforce primarily involved in medical care, including telecommunicators who support delivery of care, some Key Informants mentioned other groups. For example, while police or firefighters may interact with patients, their primary role does not directly involve provision of medical care. We decided to keep the brief focused on studies of EMS and 911 workers whose primary role is delivery or support of medical care. The Key Informants also noted the difficulties of parsing occupationally acquired exposures from off-duty exposures to infectious agents. Most Key Informants agreed that inclusion of studies assessing surface contamination would not be useful because contamination does not equate to infection. The presence of other important infectious particles might not be identified in such studies.
Criteria for Determining Effectiveness of Interventions
One of the Key Informants mentioned workforce mental health as a criterion for determining effectiveness of interventions, stressing the relationship between infection control and workforce mental health. To date, little is known about how PPE compliance in the EMS and 911 setting is impacted by stress or surge conditions. The EPC team explained that it was working on a separate topic development brief to address workforce mental health issues, though not specifically focusing on or examining linkages between workforce infection prevention and control (IPC) practices and mental health.
Relevant Contextual Factors
The Key Informants asked for clarification of whether the Technical Brief would include inter-facility transports and how to define such transports. Key Informants also wished to clarify if both ground and air transport would be considered. As indicated in Table 1, we only excluded evacuations from another country.
Quality of Studies
The Key Informants reported that studies on this topic used observational methods with serious limitations. Although they agreed with looking for studies of interventions using a comparison group, they noted that studies using the local community as a comparison group would require careful consideration of confounding factors.
Results of the Published Literature Search
We retrieved 8730 unique citations (Figure 2). After screening abstracts and full-text, we included 32 studies (N=88,658 participants).8, 11–41 The list of excluded articles is in Appendix B. Evidence tables are provided in Appendix C.
Figure 2
Results of literature search. * Articles could be excluded for more than one reason. † Four studies applied to both GQ 1 and GQ 2/3.
Twenty-one studies applied to GQ 1 only,11–17, 19, 20, 23, 25, 29, 30, 32–39 seven studies applied to GQ 2/3 only,18, 21, 22, 24, 27, 31, 40 and four studies applied to both GQ 1 and GQ 2/3.8, 26, 28, 41 Twenty-two studies were published in 2020 or later (Figure 3). Many of the studies published in 2020 or later assessed the prevalence of COVID-19.
Figure 3
Number of studies included for each Guiding Question by year of publication. GQ=Guiding Question
GQ 1. Characteristics, Incidence, Prevalence, and Severity of Occupationally Acquired Infectious Diseases and Related Exposures for the EMS and 911 Workforce
Characteristics of Studies
Of the 25 studies included for GQ 1, 16 were cross-sectional studies,8, 11, 13–16, 20, 23, 25, 26, 28, 30, 32, 33, 38, 41 four were retrospective cohort studies,12, 17, 19, 34 and five were a prospective cohort study.29, 35–37, 39 The majority, 14, were set in urban areas,13, 14, 17, 19, 20, 28–30, 32–34, 38, 41 with the remaining conducted in multiple settings (eight studies)8, 11, 12, 23, 25, 26, 35, 39 and unclear settings three studies).16, 36, 37 Studies were performed across the United States including six in the Northeast,17, 19, 20, 29, 32, 33 three in the South,8, 16, 25 four in the Midwest,13–15, 26 six in the West,12, 28, 30, 38, 39, 41 three in the Southwest,11, 34, 35 and one was nationwide.23 Studies were examined for any self-reported elements of high-performance systems, but very few systems were identified as such.
Study Quality
Most of the studies addressing GQ 1 used a cross-sectional design (16 of 25) and did not follow participants over time. As shown in Table 2, 76 percent of the studies on GQ 1 were somewhat or very likely to include individuals likely to be representative of the target population. However, only 36 percent of the studies reported that 80 percent or more of the targeted individuals agreed to participate. Most of the studies reported on the validity of the tests or measures of interest, but six did not, and four relied on self-reported data that was not validated.
Table 2
Quality of studies that reported on the characteristics, incidence, prevalence, or severity of occupationally acquired infectious diseases and related exposures to infectious diseases among the EMS and 911 workforce.
Findings on Incidence, Prevalence, and Severity of Infections
Table 3 displays the incidence, prevalence, and severity of occupationally acquired infectious diseases and related exposures in the EMS and 911 workforce reported in all studies that met our inclusion criteria. Most of the studies reported prevalence rates, most frequently focusing on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Few studies reported incidence rates, and no incidence rates were reported for infections other than SARS-CoV-2. Severity of disease was reported in a few studies in various terms such as death from infection, hospitalization, or separation from the workforce due to quarantine from exposure or symptoms. None of the studies reported on severity of infections other than SARS-CoV-2.
Table 3
Incidence, prevalence, and severity of occupationally acquired infectious diseases and related exposures among the EMS and 911 workforce.
GQ 1a. Differences by Demographic Characteristics
Figure 4 displays the number of studies that reported on the outcomes of pathogen incidence, prevalence, and hospitalization or death by age, race, or gender. Most of the studies focused on SARS-CoV-2 exposures or COVID-19 hospitalizations, as shown in red circles in the figure. Many of the studies were small, as depicted by the small shapes in the figure.
Figure 5 displays data on differences in incidence, prevalence, and healthcare utilization for occupationally acquired infectious diseases and related exposures in the EMS and 911 workforce based on age. Most studies reported on SARS-CoV-2 prevalence, incidence, and hospitalization. The highest odds ratio (OR) was reported in the Newberry 2021 study for immunoglobulin G seroprevalence in workers 50 or more years old.28
Figure 6 shows gender-based differences in incidence, prevalence, and healthcare utilization for occupationally acquired infectious diseases. All data reviewed was for SARS-CoV-2. Of the studies that included an OR, all confidence intervals (CI) crossed one.
Figure 7 highlights studies that reported on racial differences in incidence, prevalence, and healthcare utilization for occupationally acquired infectious diseases and related exposures. The majority of CIs cross one with the most prominent exceptions being for the Black non-Hispanic and other Hispanic groups in the Tarabichi study with ORs of 35.2 and 184 respectively.13 The Newberry study reported ORs of 5.72 and 4.84 for Black and Hispanic groups, respectively, compared to White non-Hispanics, with relatively wide CIs.28 One study, Webber 2018, examined differences based on race for hepatitis C and found an OR of 8.50 and 2.43 for Black and Hispanic groups when compared to their White co-workers.29
GQ 1b. Differences by Workforce Characteristics
Three studies (Tarabichi 2021, Weiden 2021, and Montague 2022) compared firefighters versus EMS workers on the prevalence and healthcare utilization for SARS-CoV-2 (Figure 8).13, 32, 39 The Weiden study reported a statistically significant 4.23 OR for EMS workers versus firefighters for hospitalization or death due to COVID-19.32
One study (Webber 2018) reported on hepatitis C prevalence for EMS workers versus firefighters and found an OR of 1.74 (Figure 9).29 Another study (Orellana 2016) examined methicillin-resistant Staphylococcus aureus (MRSA) differences in workforce characteristics and found that for years of experience, population density, and level of care, each outcome had an OR with a wide 95% CI that included 1.26
When examining studies that met our inclusion criteria for occupational fluid and sharps exposures, one study was included (Harris 2010).8 For blood and fluid exposure, the OR for workers with Advanced Life Support (ALS) certification versus Basic Life Support (BLS) certification was 3.10 and 5.80, respectively. For sharps exposures, needle sticks had a 10.8 OR for ALS versus BLS groups in comparison to lancet sticks, which had a 0.23 OR (with wide CI) for ALS versus BLS groups (Figure 10).
GQ 2/3. Characteristics and Reported Effectiveness of EMS and 911 Workforce Practices To Prevent, Recognize, and Control Infectious Diseases
Characteristics of Studies
Eleven studies were identified as being relevant to GQ 2/3.8, 18, 21, 22, 24, 26–28, 31, 40, 41 All studies were observational studies with a concurrent comparison group; nine studies were prospective cohorts8, 21, 22, 26–28, 31, 40, 41 and two were retrospective cohorts.18, 24 Six were in urban settings22, 24, 27, 28, 31, 41 and five were in multiple settings.8, 18, 21, 26, 40 The studies took place in eight different states. Although few listed a jurisdictional funding description, a post-publication analysis of the jurisdictions suggests that studies were funded by a mixture of fire and third services (i.e., stand-alone ambulance) departments. Seven studies included both EMS workers and firefighters involved in medical care8, 18, 22, 24, 28, 31, 41 and four studies only focused on EMS workers.21, 26, 27, 40 The total study sample size ranged from 186 to 10,612 EMS and 911 workers.
In the review of studies that address GQ 2 and 3, we have combined these questions for purposes of presentation and discussion because the workforce practices to prevent infectious disease (GQ 2) and workforce practices to recognize and control infectious disease (GQ 3) often overlap and therefore address both. For example, PPE and vaccines could be viewed as workforce practices which both prevent and control infectious diseases.
Study Quality
None of the studies on GQ 2/3 used an experimental study design. According to the inclusion criteria for this review, all 11 of the included studies had a concurrent comparison group. Although all studies were somewhat or very likely to include workers representative of the target population, only 27 percent of the studies reported that 80 percent or more of workers selected to participate ultimately agreed to participate (see Table 4). Regarding potential selection bias, only 3 studies presented data indicating no important differences between those who participated and those who did not, while 1 study reported important differences between groups (Table 4). The other 6 studies did not present enough information to assess selection bias.
Table 4
Quality of studies that reported on the characteristics and effectiveness of EMS and 911 workforce practices to prevent, recognize, and control infectious diseases.
Findings on Characteristics of IPC Practices
Figure 11 presents an evidence map of the main characteristics of the IPC practices that have been studied in the EMS and 911 worker population, and whether they reported on how practices vary by demographic, workforce, and practice characteristics. Each circle represents the number of studies, with vaccine uptake for influenza being the most frequently reported type of IPC practice. Only one study focused on prevention of needle stick injuries and only one study focused on standard precautions for IPC.
GQ 2/3a. Differences by Demographic Characteristics
Two studies reported on how an IPC practice varied by demographic characteristics.24, 40 Glaser, in 2011, focused on H1N1 influenza vaccine uptake among EMS workers through utilization of a vaccine clinic.24 The study found that vaccination was less likely in those younger than 30 years old (adjusted OR [aOR] 0.70; 95% CI 0.62 to 0.78), African Americans (aOR 0.46; 95% CI 0.40 to 0.50), and Hispanics (aOR 0.87; 95% CI 0.77 to 0.99) after adjusting for age, gender, race, class (EMS vs. firefighter), and smoking status. Gregory, in 2021, reported on odds of COVID vaccinations by associations with age (referent <28 years; 39 to 50 years: 1.56, 95% CI 1.17 to 2.08; >51 years: 2.22, 95% CI 1.64 to 3.01) and male sex (1.26, 95% CI 1.01 to 1.58).40
GQ 2/3b. Differences by Workforce Characteristics
Four studies addressed how IPC practices varied by workforce characteristics.8, 21, 31, 40 Three studies evaluated vaccine uptake.21, 31, 40 The third study evaluated needle stick exposures and standard precautions.8
Vaccine Uptake
Hubble, in 2011, found that EMS professionals in rural areas (35.5%) received the influenza vaccine at lower rates than urban (50.0%) or suburban (54.3%) EMS professionals (unadjusted p=0.01).21 In 2021, Halbrook found that COVID-19 vaccine uptake was higher among in-hospital healthcare workers (96.0%) compared to EMS workers (87.5%) and that EMS workers were significantly more likely to delay receiving a vaccine (aOR 2.94; 95% CI 1.71 to 5.04 after adjusting for age, sex, race, education, and patient contact).31 Gregory, in 2021, found that increased COVID-19 vaccination uptake was associated with residing in an urban/suburban area (referent rural; 1.36, 95% CI 1.08 to 1.70), advanced education (referent General Educational Development or high school and below; bachelor’s and above: 1.72, 95% CI 1.19 to 2.47).40 In addition, vaccination odds were significantly higher with greater perceived risk of COVID-19 (2.05, 95% CI 1.68 to 2.50), and higher vaccine confidence (2.84, 95% CI 2.40 to 3.36) while lower with higher medical mistrust (0.54, 95% CI 0.46 to 0.63). In this study, despite availability of vaccine, just 69.8 percent of EMS professionals reported having received a COVID-19 vaccine while 30.2 percent indicated that they had not.40
Needlesticks
Harris, in 2010, found that volunteer EMS workers were less likely to be exposed via needle stick than paid EMS workers (unadjusted OR 0.74; 95% CI 0.23 to 2.30).8 This mirrors Harris’ other finding that BLS-certified/licensed EMS workers, who are more likely to be volunteers, were also at lower risk for needle stick than ALS-certified/licensed workers. BLS-certified/licensed workers do not perform intravenous cannulation, likely accounting for the difference in volunteer and paid worker risk.
Standard Precautions
Harris also found significant differences in protective practices among ALS- and BLS-certified/licensed EMS workers.8 Specifically, ALS-certified/licensed EMS workers were more likely than BLS-certified/licensed EMS workers to wear gloves for all calls (unadjusted OR 1.75; 95% CI 0.81 to 3.79), use face masks (unadjusted OR 4.86; 95% CI 1.44 to 16.4), and use protective devices during resuscitation (unadjusted OR 17.3; 95% CI 1.04 to 28.8). Interestingly, ALS-certified/licensed EMS workers were also more likely to always recap needles (unadjusted OR 10.1; 95% CI 2.85 to 34.5), despite Centers for Disease Control and Prevention (CDC) and Occupational Health and Safety (OSHA) recommendations to not recap needles.
GQ 2/3c. Differences by Practice Characteristics
Four studies examined the association of vaccine uptake with practice characteristics, including the incorporation of training into practice, implementation of a vaccine clinic, presence of a mandatory vaccine policy, or a department of public health shelter-in-place order.21, 22, 24, 40 No studies directly examined how use of IPC practices varied by available budget to support the practice.
Vaccine Uptake
Hubble in 2011 found that influenza vaccine uptake was greater when the practice provided influenza vaccination education and training (unadjusted OR 1.5; 95% CI 1.1 to 2.1) or hosted a vaccine clinic (unadjusted OR 3.3; 95% CI 1.3 to 8.3) compared to when the practice does not.21 Glaser found that hosting a vaccine clinic in the workplace increased vaccine uptake (aOR 2.7; 95% CI 2.3 to 3.2) after adjusting for age, gender, race, class (EMS vs. firefighter), and smoking status.24 Rebmann in 2012 found that mandatory vaccine policies for H1N1 and other strains of influenza increased the vaccine uptake rates; 100 percent of participants reporting mandatory vaccine policies also reported being vaccinated while those who did not have a mandatory vaccine policy reported a 66.8 percent vaccination rate for H1N1 influenza (unadjusted p<0.01) and a 75.6 percent vaccination rate for seasonal influenza (unadjusted p<0.001).22 Gregory found increased odds of COVID-19 vaccination were associated with working at a hospital (referent fire-based agency; 1.53, 95% CI 1.04 to 2.24).40
Standard Practice
Grant descriptively reported higher selected self-reported PPE use among firefighters/paramedics, such as for gloves, N-95 respirators and eye protection, on medical versus non-medical runs.41 The study further detailed self-reported PPE use among firefighters/paramedics before versus after a Department of Public Health shelter-in-place order.41 On non-medical runs, use of individual PPE measures increased significantly after the shelter-in-place order (p<0.0001 for surgical masks, N-95 respirators, eye protection, and gowns; p<0.05 for gloves), while self-reported use of “no PPE” decreased significantly (p<0.0001). On medical runs, use of individual PPE increased significantly after the shelter-in-place order (p<0.0001) for surgical masks, N-95 respirators, eye protection, and gowns) while self-reported use of “no PPE” did not differ before versus after the shelter-in-place order.
GQ 2/3d. Reported Effectiveness of EMS and 911 Workforce Practices To Prevent, Recognize, and Control Infectious Diseases
Eight studies reported on the effectiveness of preventing infectious diseases among the EMS and 911 workforce.8, 18, 21, 22, 24, 26–28 The studies were very heterogeneous, involving five distinct types of IPC practices and focusing on four different infectious diseases. The studies were so different from each other that it would not be feasible to perform any meta-analysis. Figure 12 demonstrates our evidence map of studies reporting on the effectiveness of EMS and 911 workforce practices to prevent, recognize, and control infectious diseases. The most common infectious disease studied was influenza, and on-site vaccine clinics were the most commonly studied workforce practice.
Alternatives to Aerosol-Generating Procedures
Aerosol-generating procedures (AGPs) are procedures such as intubation or the use of positive airway pressure therapy that generate copious amounts of potentially infectious aerosolized particles. In 2021, Brown reported that AGP procedures, even with full PPE (defined as a mask, eye protection, gloves, and a gown), were positively correlated with SARS-CoV-2 diagnoses (unadjusted incidence rate ratio [IRR] 1.64; 95% CI 0.22 to 12.26).18 However, this data point is based on only one EMS clinicians developing COVID-19 infection in the cohort studied out of 182 total AGPs performed and 8,582 person-days at risk while in PPE and performing AGP. AGPs are included as a workforce practice due to the interest in decreasing aerosol particles through alternative treatment regimens such as metered-dose inhalers instead of nebulizer masks or the use of bag-valve mask ventilation prior to intubation.
Protective Equipment and Behaviors
Three studies reported on effectiveness of protective equipment and behaviors in preventing and controlling infectious disease.8, 26, 28 Newberry found that lack of PPE or PPE breach were correlated with higher SARS-CoV-2 seropositivity (unadjusted risk ratio [RR] 4.2; 95% CI 1.03 to 17.22).28 Orellana found that less frequent daily handwashing (survey-weight adjusted OR 4.20; 95% CI 1.02 to 17.27) and less frequent hand hygiene after glove use (survey-weight adjusted OR 10.51; 95% CI 2.54 to 43.45) were positively correlated with nasal colonization of MRSA.26 Harris found that needlestick injuries were associated with never recapping needles (unadjusted OR 1.49; 95% CI 0.44 to 5.04), always wearing a facemask (unadjusted OR 2.95; 95% CI 0.17 to 52.2), always disposing of needles in marked containers (unadjusted OR 1.8; 95% CI 0.22 to 14.6), and always using a protective device for resuscitation, such as a bag valve mask (unadjusted OR 1.72; 95% CI 0.09 to 31.0). Only disposing of other contaminated materials was negatively associated with needle stick injuries (unadjusted OR 0.2; 95% CI 0.06 to 0.64), perhaps indicating that improper disposal of contaminated materials is correlated with other poor safety practices.8
Level of Training
Miramonti found that practicing EMS workers (4.5%) and EMS students (5.3%) had similar levels of MRSA nasal colonization, suggesting that greater overall level of training and experience in EMS was not associated with a difference in this outcome measure.27 No other studies reported on how infectious disease outcomes of interventions varied by level of training.
On-Site Vaccine Clinics
Two studies reported on the effectiveness of vaccine clinics at the work site.21, 24 Hubble found that workers were more likely to be vaccinated against influenza if they recalled their employer offering the flu vaccine (unadjusted OR 3.3; 95% CI 1.3 to 8.3) and if they received training or education from their employer on the flu vaccine or influenza illness (unadjusted OR 1.5; 95% CI 1.2 to 2.1).21 In a study by Glaser, the acceptance rate of the H1N1 influenza vaccination was 57.2 percent (5,746 out of 9,559) during a targeted, active, and dedicated vaccine program in a bio-preparedness drill as compared to 34.4 percent (362 out of 1053) during medical visits.24 During the bio-preparedness drill, the EMS workers and firefighters also received targeted education.
Vaccine Policies
Rebmann found that emergency medical technicians whose employer had a mandatory vaccination policy were significantly more likely to receive the seasonal influenza vaccine (100% versus 75.6%) or the H1N1 influenza vaccine (100% versus 66.8%) compared with those without such a policy (unadjusted p<0.001 and p<0.01, respectively).22
GQ 4. Context and Implementation Factors of Studies With Effective EMS and 911 Workforce Practices
Studies relevant to GQ 4 included evaluation of a PPE protocol and examination of the context and implementation factors of previously mentioned studies on GQ 2/3d.
During the beginning of the COVID-19 pandemic, Brown et al. examined the risk for COVID-19 infection among EMS clinicians in King County, Washington. They deployed and studied a PPE protocol,18 which included appropriate masks, eye protection, gown, and gloves (MEGG). Surgical masks were deemed sufficient for routine patient encounters, but an N95 respirator was required PPE for AGPs. For any physical contact with the patient, a gown was required. EMS clinicians were advised to don full MEGG PPE if a patient had a febrile respiratory illness or had recently traveled from an endemic area. Later in the study period, as cases increased, EMS clinicians began to treat all congregate living facilities and dialysis centers as having elevated risk for exposure.
Using the MEGG PPE protocol model described above, the study group was able to identify one COVID-19 infection potentially occurring due to a patient encounter with an AGP. There were 1,592 EMS clinicians with one or more COVID-19 patient encounters and 520 (33%) with 3 or more COVID-19 patient encounters. During the study period, 30 EMS clinicians tested positive for COVID-19 by polymerase chain reaction (PCR), although 11 of these had never had a documented patient exposure. Of the remaining clinicians, 18 had a COVID-19 patient encounter but did not develop infection within the exposure window of 2-14 days, and only one clinician developed COVID-19 after an AGP within the exposure window.
The authors noted that these findings may be difficult to interpret because one third of their COVID-19 patients did not display any common symptoms, such as fever, cough, or shortness of breath. In addition, sources of infection risk for EMS personnel for SARS-CoV-2 are not confined to patients. They observed that most of the COVID-19 illness was potentially a consequence of encounters other than with patients.
Implementation factors from studies with effective EMS workforce practices included those associated with vaccine promotion and education. Glaser et al. demonstrated that active, targeted education modules, given on-site during a dedicated vaccine program for H1N1 influenza was effective at increasing vaccination rates.24 Workers were more likely to be accepting of a vaccine during an on-site vaccine clinic when surrounded by their peers who were also receiving the vaccine. In addition, the authors noted that supervisor and peer buy-in was a factor during the vaccine clinics. Another study by Hubble et al.21 emphasized the success of on-site vaccine clinics for seasonal influenza vaccine. Mandatory employee vaccination policies for both seasonal and H1N1 influenza vaccination were found to be effective at increasing vaccination uptake.22
Results From the Gray Literature
The EPC study team identified gray literature published by domestic organizations and agencies related to EMS and 911 workforce infection control practices. This included seven documents from the Department of Health and Human Services (HHS), the Assistant Secretary for Preparedness and Response (ASPR) along with its Technical Resources Assistance Center and Information Exchange (TRACIE), CDC, Society for Healthcare Epidemiology of America (SHEA), and the Association for Professionals in Infection Control and Epidemiology (APIC). The gray literature was characterized by a high degree of heterogeneity, ranging from description of training and educational sessions, and retrospective reports on public health emergency response, to IPC guidance aimed at prehospital care. Gray literature information most relevant to the GQs were derived from synthesis of official or best practice information reviewed by subject matter experts. Thus, by design, no comparators were provided. Furthermore, most of the gray literature on the topic of IPC included but did not pertain specifically or exclusively to the EMS and 911 workforce. Appendix D provides details of the results of the Gray Literature Searches.
GQ 1. Characteristics, Incidence, Prevalence, and Severity of Occupationally Acquired Infectious Diseases and Related Exposures for the EMS and 911 Workforce
Guide to Infection Prevention in EMS
An implementation guide from APIC for EMS released in 2013 provides a summary of potentially life-threatening infectious diseases and routes of transmission to which emergency response employees may be exposed.42 No other specific information on incidence, prevalence, and severity of occupationally acquired infectious disease and related exposures pertaining to this GQ was found in the gray literature.
GQ 2/3. Characteristics and Reported Effectiveness of EMS and 911 Workforce Practices To Prevent, Recognize, and Control Infectious Diseases
Best Practice Information
ASPR EMS Infectious Disease Playbook
This 86-page document was created using official or best practice information taken from multiple organizations. The playbook was vetted and assembled by subject matter experts working for TRACIE at the request of the ASPR.43 It was intended to unify multiple sources of information in a single planning document addressing the full spectrum of infectious agents and to create a concise reference resource for EMS agencies developing their service policies. Topics included: dispatch/ responder actions, standard precautions, contact precautions, droplet precautions, airborne precautions, special respiratory precautions, Ebola virus disease and viral hemorrhagic fever precautions, resources, and special considerations.
Guide to Infection Prevention in EMS
The APIC implementation guide noted above discusses work restrictions/duration following occupationally acquired infectious diseases and related exposures, immunization recommendations and immunization schedules, risk factors, and risk assessment of infectious hazards. The implementation guide further discusses engineering, work practice controls, and PPE.42
Knowledge Sharing
COVID-19 Clinical Rounds
As a mechanism to enable rapid sharing of promising practices for treatment and other response activities, the ASPR and Project ECHO (Extension for Community Health Outcomes) developed COVID-19 Clinical Rounds, a series of sessions designed to provide peer-to-peer, real-time knowledge-sharing regarding challenges and success in COVID-19 treatment for frontline, primarily pre-hospital and hospital-based clinicians.44 As of December 22, 2020, a total of 103 clinical rounds were held including presentations from expert clinicians complemented by question-and-answer time, with 10,866 session recording views and 40,826 participants.
Patient Management, Use of PPE, Non-Pharmaceutical Interventions
Two documents from the CDC offered guidance related to IPC patient management and PPE practices in the context of COVID-19 and Ebola virus disease.45 The third document from HHS highlights several considerations including use of respiratory protection and use of non-pharmaceutical interventions (NPIs).46
Interim Recommendations for EMS Systems and 911 Public Safety Answering Points in the US During the COVID-19 Pandemic
This document from the CDC offers guidance applicable to all U.S. settings where healthcare is delivered, without specifying the prehospital environment.45 Important topics relevant to the EMS and 911 workforce include: Establishing a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection, to include implementation of source control measures such as use of respirators or well-fitting facemasks, universal use of PPE for healthcare clinicians, physical distancing, SARS-CoV-2 testing, and a process to respond to SARS-CoV-2 exposures; Recommendation of IPC practices when caring for a patient with suspected or confirmed SARS CoV-2 infection, to include patient placement and PPE; and Duration of Transmission-Based Precautions, with setting-specific considerations and specific EMS considerations.
Interim Recommendations for EMS Systems and 911 Public Safety Answering Points for Management of Patients Under Investigation for Ebola Virus Disease in the US
The purpose of this CDC guidance is to assure EMS and first responders are safe and patients are appropriately managed while responding to persons under investigation (PUIs) for Ebola virus disease.46 It covers the topics of Patient Assessment, Safety and PPE, Patient Management and Infection Control, EMS Transport of Patient to a Healthcare Facility, Interfacility Transport, Documentation of Patient Care, Cleaning EMS Transport Vehicles, and Followup and Reporting by EMS Clinicians After Caring for a PUI. These recommendations apply to EMS clinicians (including emergency medical responders, emergency medical technicians, advanced emergency medical technicians, paramedics, and other first responders who could be providing patient care in the field, such as law enforcement and fire service personnel), managers of 911 Emergency Communications Centers/Public Safety Answering Points, EMS agencies, EMS systems, and agencies with medical first responders.
2009 H1N1 Improvement Plan
The HHS 2009 H1N1 Influenza Improvement Plan outlines priorities for those aspects of pandemic influenza preparedness that are influenza specific and describes the ways in which those next steps need to be accomplished, informed by the 2009 H1N1 influenza pandemic experience.47 Of direct relevance to the EMS and 911 workforce, the plan advocated for conducting research to better understand influenza transmission, effectiveness of respiratory protection devices, clarification of when surgical masks are sufficient, and when the use of N95 respirators or other devices may be more appropriate. The report further urged updated recommendations and guidance for the use of NPIs during a pandemic that incorporate the latest scientific findings, including transmissibility of the virus, availability of pharmaceutical interventions, and the practicality of implementation by states, locals, employers, and providers.
GQ 4. Context and Implementation Factors of Studies With Effective EMS and 911 Workforce Practices
Infrastructure
CDC Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services
This 70-page CDC document released in 2019 reflects updates to the Guideline for Infection Control in Health Care Personnel, 1998, and describes the infrastructure and routine practices for providing IPC services to healthcare personnel as well as special considerations associated with emergency response personnel.49
Retrospective Reporting
HHS Retrospective on 2009 H1N1 Influenza Pandemic to Advance All Hazards Preparedness
This 121-page HHS retrospective report on the 2009 H1N1 influenza pandemic concluded that the response was largely successful while noting that there were elements of preparedness that were not stressed in our response to the 2009 H1N1 pandemic, but could be in a very severe pandemic, as experienced in 1918.50 Of relevance to the EMS and 911 workforce, notable successes included the rapid identification and characterization of the 2009 H1N1 pandemic virus; the development and production of a 2009 H1N1 vaccine in record time; the efficient distribution of antiviral medications from the Strategic National Stockpile to the states; the use of Emergency Use Authorizations (EUAs) to increase the availability of antiviral medications and speed the availability of diagnostics; the development and rapid updating of clinical guidance on the treatment of 2009 H1N1; and the effective communication with the public regarding methods to prevent transmission of the influenza virus.
Information Needs
The HHS report recognized that while the CDC updated the clinical guidance as new data were received, keeping up with frequent changes may have been challenging for clinicians and by extension, EMS and 911 agencies. As an example, guidance for antiviral use was issued and updated throughout the pandemic 2009. Locating portions of the guidance that were clinically relevant to EMS and 911 needs was seen to be challenging. The Joint Information Center within the CDC also held more than 30 Clinician Outreach and Communication Activity calls for organizations representing physicians, nurses, emergency medical technicians, lab technicians, and veterinarians, which then delivered the information to their group members.
PPE/NPIs
The HHS report noted that priorities for PPE use may have been too narrowly focused on healthcare providers while overlooking other frontline workers also at risk for occupational exposure to the 2009 H1N1 virus. The report acknowledged the lack of scientific evidence on the effectiveness of respiratory PPE, which includes masks and respirators as a mitigation strategy. Other non-pharmaceutical methods to reduce disease transmission were critical to the 2009 H1N1 pandemic response with substantial effort invested by the United States government in developing and implementing risk communication messages about respiratory etiquette, hand hygiene, and staying home when sick.
Funding
On April 30, 2009, shortly after the HHS Secretary declared a public health emergency, a request was made to Congress for $1.5 billion to respond to the H1N1 pandemic. On June 24, 2009, a second request for an additional $2 billion was sent. On June 24, 2009, the supplemental appropriations for the 2009 H1N1 pandemic (P.L. 111-32) was signed into law, which included $7.65 billion to fund the pandemic response. HHS allocated the funding for a range of activities to prepare for and respond to the 2009 H1N1 pandemic, including: developing, purchasing, and distributing 2009 H1N1 vaccine; enhancing influenza surveillance; and assisting state and local health departments with mass vaccination plans and 2009 H1N1 response.
- Results - Infection Prevention and Control for the Emergency Medical Services an...Results - Infection Prevention and Control for the Emergency Medical Services and 911 Workforce
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