NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
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 detailsSummary of Main Findings
Epidemiology of Occupationally Acquired Infections in the Emergency Medical Services and 911 Workforce
We found 25 observational studies on the characteristics, incidence, prevalence, and/or severity of occupationally acquired infectious diseases and related exposures in the emergency medical services (EMS) and 911 workforce (Guiding Question [GQ] 1). Twenty-two studies were published in the last 2 years (Figure 3), and most of them focused on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Thus, much of the evidence on occupationally acquired infections in the EMS and 911 workforce is limited to SARS-CoV-2. The incidence, prevalence, and severity of infections generally did not differ according to demographic differences in the EMS and 911 workforce, except for one study that reported an increased prevalence of hepatitis C in older versus younger EMS and 911 workers,29 and one study that reported a very large increased prevalence of SARS-CoV-2 in Black non-Hispanics and other Hispanics compared with White non-Hispanics.13 In the latter study, the associated 95% confidence intervals were very wide because of the low numbers of Black or Hispanic EMS and 911 workers in the study.
Only six studies reported on how occupationally acquired infectious diseases and related exposures differ by EMS and 911 workforce characteristics. The only significant differences were an increased prevalence and risk of hospitalization or death from SARS-CoV-2 in EMS workers versus firefighters,32 and a mildly increased prevalence of hepatitis C in EMS workers versus firefighters.29 One other study examined differences in risk exposures between advanced life support (ALS) versus basic life support (BLS) certified/licensed EMS workers, and the authors reported that ALS-certified/licensed EMS workers had an increased risk of blood exposure, fluids exposure, and needle sticks.8 Another study found no difference in methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization based on years of experience, density of patient population served, or level of care.26 No comparative studies were identified that reported on the epidemiology of occupationally acquired infections in dispatchers or telecommunicators.
Effectiveness of IPC Practices in the EMS and 911 Workforce
We found eleven observational studies on the characteristics and effectiveness of infection prevention and control (IPC) practices in the EMS and 911 workforce (GQ 2 and 3). Several workforce practices were examined, including hand hygiene, standard precautions, on-site vaccine clinics, and mandatory vaccination policies. The studies provided little information about contextual factors influencing the implementation and effectiveness of interventions, except as noted below.
Orellana found that both daily hand hygiene and hand hygiene following use of gloves were negatively correlated with nasal colonization of MRSA.26 While it is accepted that hand hygiene is effective, the real-world application of the practice is challenging and often disrupted by changing between multiple care sites and lack of access to water or hand sanitizer.
The increased use of standard precautions51 such as face masks, gloves, and protective devices for resuscitation was associated with a decreased likelihood of a needlestick.8 This study also reported that properly recapping needles and disposing of needles in marked containers were associated with fewer needlesticks. A study by Kinlin et al performed in healthcare workers (non-prehospital) has also shown that gloves decrease needlesticks.52
One study examined the real-world implementation and effectiveness of a masks, eye protection, gloves and gowns (MEGG) protocol which included appropriate masks, eye protection, gown, and gloves at the beginning of the Coronavirus disease 2019 (COVID-19) pandemic in Washington state.18 Brown reported that AGP procedures, even with full personal protective equipment (PPE), were associated with SARS-CoV-2 diagnosis. This finding was limited by having only one EMS clinician developing COVID-19 infection during 8,582 person-days at risk while in PPE and performing aerosol-generating procedures (AGP). No study that fit our inclusion criteria examined the protectiveness of N95 respirators or Powered Air-Purifying Respirators during AGPs in comparison to surgical masks alone or when paired with a face shield. However, Newberry found that lack of PPE or PPE breach were correlated with higher SARS-CoV-2 seropositivity.28
Other studies have examined workforce practices that prevent or control infectious diseases, but they were not included in our analysis because they did not focus on EMS and 911 workers. Bartoszko et al, reviewed four articles in a systematic review performed in Canada.53 The authors found no convincing evidence that surgical masks are inferior to N95 respirators for protecting healthcare workers against viral respiratory infections during routine care. However, this data does not extend to AGPs and does not address more recent evidence of the small particle size and airborne nature of the SARS-CoV-2 virus in small poorly ventilated spaces (such as the back of an ambulance).54 Another systematic review performed in Australia in 2021, conducted by Kunstler et al., found that the existing epidemiological evidence does not enable definitive assessment of the effectiveness of respirators compared to surgical masks in prevention of SARS-CoV-2 infection.55
The Hubble study on seasonal influenza21 and the Glaser study on H1N1 influenza24 highlighted the success of on-site vaccine clinics. They stressed the importance of the difference between mere availability of vaccines in a passive program and an active program with education, social influence, and advice from supervisors. Vaccine uptake and acceptance were enhanced not only by the presence of a vaccination program, but also by accompanying educational modules and buy-in from supervisors and trusted peers.
Mandatory vaccination policies for seasonal influenza and H1N1 influenza also were shown to be effective at increasing vaccine uptake amongst EMS and 911 workers.22 No studies on mandatory vaccination policies for SARS-CoV-2 fit within our inclusion criteria.
Challenges in Field EMS Research
We did not find any studies that used an experimental design to assess the effectiveness of IPC practices in the EMS and 911 workforce. Thus, health systems and policy makers must rely on observational studies to estimate the risk of occupationally acquired infections and the effectiveness of IPC practices in the EMS and 911 workforce. Another challenge in EMS research is the multiple different levels of providers in systems and heterogeneity of provider levels in different states across the US.
The lack of comparison groups and experimental designs undoubtedly stems from difficulties implementing such studies in a dynamic field environment. The field challenges to research create barriers to using an experimental design for testing workforce practices and make it difficult to obtain institutional review board approval for EMS research studies. A major concern arises in patient care situations requiring emergent intervention because of the inability to obtain informed consent from patients.
Other barriers to research in the prehospital field setting contribute to the limited nature of the science in EMS care today. Study recruitment and data collection are particularly challenging in the mobile work environment with multiple care sites such as homes, streets, outdoor venues, and the hospital. Previous research into IPC for EMS and 911 workers has been heterogeneous and qualitative in nature given these barriers to experimental design and quantitative data collection in the field environment.
Increase in Research Since Onset of the COVID-19 Pandemic
Since the onset of the COVID-19 pandemic, the examination of infectious diseases in EMS care has increased. Accordingly, most publications meeting our inclusion criteria have been published in the last two years, mostly focusing on the epidemiology of infections or exposures in the prehospital workforce. Several studies, however, examined workforce practices.
The effectiveness of PPE in AGPs was examined in one study which was limited by a small number of EMS clinicians infected with COVID-19.18 With evolution of SARS-CoV-2 to an endemic infection and with an overwhelmed public health contact tracing system, it was also challenging to determine whether COVID-19 infections in EMS clinicians were the result of occupational or non-occupational exposures. Prior to the COVID-19 pandemic, a small number of studies examined the epidemiology of exposure and effectiveness of workforce practices regarding influenza (including H1N1), MRSA, and hepatitis C.
No studies were identified that examined dispatchers or telecommunicators specifically.
Strengths and Limitations of the Evidence
This Technical Brief uses figures to provide a map of the evidence from studies of the epidemiology of occupationally acquired infections in the EMS and 911 workforce as well as studies of the effectiveness of IPC practices in the EMS and 911 workforce. The epidemiologic studies of incidence, prevalence, and severity of infections are representative of the target population of EMS and 911 workers in the United States, and most of those studies reported on the validity of the tests or measures of interest, and thus should provide appropriate estimates. The studies varied in reporting differences by age, gender, race, and other characteristics of the EMS and 911 workforce, partly because many of the studies were not large enough to support precise estimates of differences. Although we looked for studies that included 911 telecommunicators and emergency dispatchers, the studies in this review did not provide separate information about infections in that subset of the workforce.
While most of the studies were set in urban areas, most did not report whether their departments used salaried employees or were staffed by volunteers. In addition, although the name of the jurisdiction may have been listed, most studies did not explicitly state if they were a third service, fire-based, or hospital-based service. Studies were present from every region of the United States, and two were nationwide. No studies self-identified their jurisdiction as high-performance. Interventions reported in the studies include the workforce practices of hand-hygiene, standard precautions, educational sessions, on-site vaccine clinics, and vaccine mandates. One study reported on the effectiveness of PPE in preventing COVID-19, but this study was limited by sample size. These workforce practices appear to be similar to nationwide practices, however no published evidence was found to support this. Also, we found no study of on-site vaccine clinics or mandates focused on preventing COVID-19.
Studies of IPC practices included in this review are limited to those having a comparison group because effectiveness of a public health intervention cannot be reliably determined without a comparison group. Nevertheless, it is difficult to derive strong conclusions about the effectiveness of reported interventions when there have been no experimental study designs. Although the observational studies of IPC practices included EMS and 911 workers representative of the target population of interest, most of the studies did not provide enough information to assess potential selection bias and confounding factors. This limitation makes it even more difficult to draw firm conclusions about the effectiveness of the reported IPC practices in the EMS and 911 population. In addition, the studies of IPC practices provided sparse information about how practices differed by age, gender, race, and other characteristics of the EMS and 911 workforce. These studies also did not provide separate information about the effectiveness of IPC practices in 911 telecommunicators and emergency dispatchers.
Implications for Clinical Practice, Education, and Health Policy
The evidence in this Technical Brief demonstrates that EMS clinicians are at higher risk for exposure to infectious diseases than other first responders such as firefighters and the police. This evidence seems logical given the medical care and procedures provided and close patient contact. Policy makers recognizing this increased risk may allocate increased funds for protective measures, appropriate PPE, and educational programs for EMS clinicians. In addition, EMS clinicians could be prioritized to receive PPE when national stockpiles are activated or shortages occur. Organizations and departments may review their use of safety officers or their own culture of safety within their groups to determine if changes could be made in regard to educational programs and modeling behaviors of senior personnel for junior personnel.
The review also indicates that on-site vaccine clinics and educational programs have been effective at increasing vaccine uptake. In some jurisdictions, implementation of an on-site vaccine clinic may require a pivot in terms of how vaccines are offered and increased attention to logistical measures. In addition, some jurisdictions may not be able to afford the cost of some vaccines such as influenza or hepatitis C vaccines not covered by the government. Although vaccine mandates are controversial, evidence supports the effectiveness of vaccine mandates for prevention and control of influenza in the EMS and 911 workforce. While no studies were found on vaccine mandates for preventing SARS-CoV-2 infection, perceived risk, medical mistrust and vaccine confidence were strongly associated with COVID-19 vaccination, highlighting the challenges of promoting vaccination campaigns in the face of lower perceived risk, medical mistrust and issues surrounding vaccine confidence.
Future Research Needs
This Technical Brief has identified the current gaps in the evidence on the epidemiology of occupationally acquired infections and the effectiveness of IPC practices in the EMS and 911 workforce. Previous efforts and reports such as The National Occupational Research Agenda for Public Safety in 2019 called for additional research in EMS-related infectious disease risk.56 EMS Agenda 2050, also released in 2019, notes that EMS care needs to be evidenced-based and outcomes driven. Similar consensus based processes could be used to develop new research agendas. This evidence review has found that more research is needed on the effectiveness of diverse types of IPC interventions for the full range of occupationally acquired infections in the EMS and 911 workforce.57 Specific examples of future research needs include: (1) Studies on workforce practices or engineering methods to improve hand hygiene in the field; (2) Studies examining the effectiveness of various levels of PPE in the field; (3) Studies regarding the creation of a culture of safety in regard to infectious diseases; (4) Studies of multi-component strategies for improving vaccine uptake by targeting predisposing, enabling, and reinforcing factors; (5) Studies on the training and education of the workforce regarding infectious diseases; and (6) Studies on workforce retention of experienced clinicians. Research and policy teams proposing new agendas ideally would be interdisciplinary and include infectious disease experts, EMS clinicians, and administrators. Representation from national organizations such as the National Association of Emergency Medical Technicians (NAEMT), the National Association of EMS Physicians (NAEMSP), and the National Association of State EMS Officials (NASEMSO), is also important to engage stakeholders from across the country.
The studies in this review were very heterogeneous, making it challenging to determine the effectiveness of specific workforce practices. The usefulness of future research to policy makers will be enhanced by more uniform approaches to the assessment of outcomes, more consistent attention to selection bias and confounding factors in comparative studies, a more extensive analysis of how the effectiveness of interventions differs according to the characteristics of the targeted workforce and their practice setting, and more attention to the resources needed to implement IPC interventions in EMS settings. The field of EMS research could benefit from developing practical guidance on how to conduct such studies in the highly challenging mobile environments in which EMS personnel work, ideally taking advantage of opportunities for analysis of natural experiments in the implementation of IPC practices. Such studies could help to strengthen IPC standards such as those established by the National Fire Protection Association (NFPA) including the 1581 standard on fire department infection control and the 1582 standard on having a comprehensive occupational medical program for fire departments.58, 59
Conclusions
A moderate amount of evidence exists on the incidence, prevalence, and severity of occupationally acquired infections in the EMS and 911 workforce, but much of that evidence has been published in the last 2 years and mostly focuses on SARS-CoV-2. The incidence, prevalence, and severity of infections do not differ according to characteristics of the EMS and 911 workforce, with a few exceptions. A moderate amount of evidence exists on the characteristics and effectiveness of IPC practices in the EMS and 911 workforce, mostly focusing on the effectiveness of hand hygiene, standard precautions, on-site vaccine clinics, and mandatory vaccination policies. The evidence is limited by lack of experimental study designs in the EMS setting and insufficient attention to potential selection bias and confounding in observational studies. Studies provided little information about contextual factors influencing implementation and effectiveness of interventions.
- Discussion and Implications - Infection Prevention and Control for the Emergency...Discussion and Implications - Infection Prevention and Control for the Emergency Medical Services and 911 Workforce
Your browsing activity is empty.
Activity recording is turned off.
See more...