This month’s winner is Dominick Walenczak. Dominick correctly identified the presence of classic signs of meningitis and the need for PPE. Additionally, Dominick would have alerted the hospital early and ensured proper decon of his vehicle and equipment following the call. Nicely done!
In patients where there is a suspicion of infectious disease, one of the first steps responders must take is to protect themselves. With the recent outbreak of Ebola virus disease there has been increased focus on levels of personal protective equipment (PPE). In order to determine what level of PPE is needed, the responders must understand how a particular disease is transmitted. Armed with that knowledge the correct decision can be made. It is important as well to understand what each level of PPE entails.
Standard precautions
The term “standard” or “universal” precautions refers to the PPE regularly worn by healthcare providers and is built on the assumption that all blood and body fluids are potentially infectious.1 Standard precautions generally include gloves, gown and faceshield or mask and goggles. The choice of particular elements of PPE is dependent on the presentation of the patient.
Use gloves in any instance where you will be touching blood or body fluids, any non-intact skin on the patient or when you have non-intact skin on your hands. A gown should be used when you anticipate that blood or body fluids may come in contact with your clothes or exposed skin. For example when assisting in childbirth or attending to a major trauma victim, a gown may be appropriate. The use of a faceshield or mask and googles should be considered whenever the potential exists for splashing or spraying of body fluids. Suctioning and intubating are examples of procedures which should be performed with a faceshield.
Expanded precautions
Since standard precautions are used on all patients based on the assumption that any body fluid may be infectious, what types of PPE should be used for patient known to be infectious? There are three categories of expanded PPE: contact, droplet and airborne[1].
Contact precautions include gloves and a gown when working with the patient. In the hospital, contact precautions generally apply whenever entering the patient’s room and in the prehospital environment should be used in the patient’s residence and in the back of the ambulance. Contact precautions protect you while touching the patient and when coming into contact with objects the patient has previously touched.
Droplet precautions include a surgical mask when you are within three feet of the patient. When a patient coughs or sneezes, droplets of saliva or mucus may travel through the air. If these droplets come into contact with your mucus membranes (eyes, nose, mouth, etc.) you may become infected.
Airborne precautions require the use of a respirator. Many agencies provide N95 or P100 masks to fulfill this requirement. It is important to note that you must be skilled in the use of the respirator and should be tested for a proper fit yearly. For patient contact requiring that you utilize airborne precautions for an extended period of time, a Powered Air Purifying Respirator (PAPR) may be a more comfortable choice.
Good hand hygiene
Remember, the single best method for reducing the spread of disease is good hand hygiene.2 This means washing hands with soap and warm water for 10-15 seconds. If soap and water are not available, the use of an alcohol-based hand sanitizer is sufficient until hands may be properly washed. Hand hygiene should be performed:
- Before and after each contact with a patient
- After removing PPE (including gloves)
- After handling or cleaning equipment
- After handling infectious materials
- After using the bathroom
- Before eating or preparing food
- After eating
PPE purposes
PPE serves two purposes in the healthcare environment. The first is to protect the caregiver from becoming infected and the second is to protect the patient. Patients with compromised immune systems, like those undergoing chemotherapy, are much more likely to become sick from pathogens which non-compromised individuals can overcome on a daily basis. When treating these patients, it is important to remember that your PPE is protecting them as well.
Putting on a single pair of gloves at the beginning of a call and not taking them off until the end can puts any patient at risk. Before you ever touch the patient, your gloves have touched the door handles in the ambulance, your equipment and bags, your gurney (how well did you clean it last time?) and multiple surfaces in the patient’s home. By wearing a single set of gloves you expose this patient to many different pathogens including some that may be deadly. Be sure to change gloves frequently putting on a new pair before touching the patient and throwing them away afterwards.
Treatment
Based on the patient’s symptoms you suspect that she may have meningitis. Before making patient contact, you don droplet precautions as well as an N95 mask. After confirming that the patient has a patent airway, you place a surgical mask on her. You obtain an initial set of vital signs and assess that the patient is relatively stable. After packaging her for transport, you call the receiving hospital early to advise them of your suspicion of meningitis.
Once the patient arrived at the ED, she is placed in a private room under droplet precautions. The physician assessment and a spinal tap confirm that she has bacterial meningitis. She is started on IV antibiotics and is expected to make a full recovery.
References
1. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions[P6] : Preventing Transmission of Infectious Agents in Healthcare Settings: http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
2. Boyce JM and Pittet D, Guideline for Hand Hygiene in Health-Care Settings: http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf
