Is anyone aware of any research on the use of BSI, specifically gloves, by BLS?  We're all taught "BSI, Scene Safety" the minute we start the class, but does anyone have statistical evidence that the way we were BSI works?  Having watched crew after crew come to the ED with the same gloves on that they started the call with, I have to assume that the instruction we receive actually PROMOTES infections by having potential bloodborne pathogens smeared over everything from the steering wheel of the rig to the pen used to sign in at the ED.  I'm looking for any hard research done on this subject.

Tags: BLS, BSI, Bloodborne, ambulance, body, gloves, infections, isolation, pathogens, substance

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Im all for bsi...i dont care if i have to change my gloves 5 times on the same call i do it...something as serious as not taking infection control caution (ex wearing the same gloves) their SOG or SOP should state something on that subject. Plus the crew should know better and practice better hygene.

I know this is an old topic, but here's a good resource that I recently came across during a gloves debate on a different forum:

http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf

Page 66 specifically covers what standard precautions are and page 79 covers when to use gloves. For EMS, I agree that gloves should be worn for the initial patient contact and assessment, but after the situation turns from unknown to known, BSI can be more appropriately titrated to the clinical situation.

Do we really need research to tell us not to touch clean stuff with dirty gloves? There are no randomized controlled trials of parachute use in gravitational challenge, but you wouldn't jump out of a plane without one....

While I agree, to a point, with the parachute analogy, how do we fight against the providers and schools who teach that every patient has every single communicable disease known and unknown, and touching the patient, even on dry intact and relatively clean skin will give you all of those diseases in three fold? The "gloves all time, every time, no exceptions" line of thought is up there with the insanity of 'every patient gets a NRB."

 

Identifying the infectious patients is not always as easy as taking an SpO2 or asking a patient if they are short of breath for the use of a NRB mask.

While gloves might not be required for every patient contact, they do serve as a reminder AND they must be used appropriately to stop the spread of infection.  For the healthy 25 y/o EMT, most of the bugs they come into contact with will not harm them. But, for the next patient they touch or surface they have touched and the patient comes into contact with might be deadly for that patient. 

 

Many believe the gloves are only there to protect themselves. They wear the gloves everywhere and touch everything along the way. They put extra gloves in their pocket which just had their unwashed hands in  or a gloved hand during the care of a patient.  These are the EMTs who will probably spread the most deadly bacteria to other patients.  

 BSI and Infection Control are multifactorial which is more than just protecting the provider.  When you get into the Infection Control aspect you are talking about a very broad topic which is a full time specialty and every health care agency must have ongoing education.

The topics in this journal are just some of the things those in health care must be aware of to keep the patient population from becoming sicker. I understand EMS is generally not concerned with this depth of Infection control but still, even the EMT should have access to some of the same information given to CNAs and transporters in the hospital every year and throughout the year.

http://www.ajicjournal.org/

By just looking at a patient you can not always tell if a patient has Acinetobacter or Clostridium difficile. In fact there are health care workers who are on medical leave after contracting a MRSA or MSSA infection by carelessness which then required treatment by Vancomyocin (antibiotic) which led to C. Difficile. They appear very normal but due to being still in a treatment stage they are not allowed to work in any health care environment. 

 

Patients can have the same appearance of not being infectious and not all of their infections will be listed in a chart since it may have been thinned many times. For this reason the hospital may run its own test IF IT IS PERTINENT TO THE CARE OR THE PATIENT IS ADMITTED with this policy in place. Often a patient is colonized and there is no treatment required nor is a full isolation protocol required. But, any contact with that patient will still require gloves. In the hospital we generally assume most of the patients, especially those with chonic illnesses,  are colonized and take precautions.  The general ritual is handwashing/sanitizer before gloves and patient contact then handwashing/sanitizer immediately after contact.  Stethoscopes should be cleaned after each patient and if there is an active confirmed infection, disposable steths are used.

 

The other issue is not understanding the disinfectants required to clean their equipment after patient contact. C. Diff is definitely one that requires special cleaning. Sometimes nursing homes and hospitals investigate to see why they have an outbreak of C. Diff or Acinetobacter when they have taken every precaution. Sometimes they notice the poor handwashing and cleaning of equipment by the EMTs who transport their patients and it starts to make sense. It could also be the equipment used by ALS or CCT which is not properly cleaned between patients such as IV Pumps and ventilators.  The proper disinfectant is usually by the patient doors and can be used in many facilities. There are places to wash hands before you chart at the desk or walk through the facility. Just wearing gloves does not make your hands clean.

 

The education and list of precautions we give patients who are immunosuppressed by diseases or medicatons are extensive. They must take steps the healthy EMT might never think of or take for granted just to prevent an infection and death. 

Also expect health care facilities to be more observant of you while you are transporting a patient.  CMS has taken a tough stand on facility acquired infections and anyone in the patient care area will be monitored.

If you're worried about cross contamination, then observing proper hand washing procedures is much more important than wearing gloves. Ideally, we should either be using soap and water or an alcohol based hand sanitizer BOTH before AND after treating a patient. However, instead of using appropriate infection control practices, we instead let ourselves be fooled that gloves make us clean.

Also, to highlight a very key phrase you used, "must be used appropriately...." Using gloves for every patient contact is not using gloves appropriately, and inappropriate over use of anything is always going to lead to complacency and even worse misuse.

Finally, I think infection control tests should include a required reading and testing on the manufacturer directions for one of the standard cleaning wipes ("Saniwipes" for example), and be tested on the length of time that the surface is required to be damp to be sanitized. If it's just wet for 10-15 seconds, it's not wet long enough to do much good.

Joe, I did state that gloves are not needed for every patient. But, check you company's policy and abide by the special precautions listed for the patient if you do transport between facilities.  I made a point about the use of hand washing/sanitizer before and after each contact. I also stated about wearing gloves everywhere.  I think you may have misunderstood as I did not at anytime imply gloves keep your hands clean.   You should also respect the policies of a hospital which advocate handwashing/sanitizer before and after.  

 

My point is that you can not always see the germs and you may still need to take precautions.  There are also patients who do not have an infectious disease and wish not to get one who will prefer you wear gloves to touch them since they do not know when you last washed your hands. We have in the hospital protection called Reverse Isolation.

 

It also does not mean you go to pieces and start screaming foul when you learn a patient has MRSA after a transport. I have seen that when EMTs threaten nurses for not being told of every bacteria the patient is colonized or infected with even if confirmation has yet to be made.  You can wash your hands and clean your equipment. If you chose not to follow recommendations because of something you read on a forum rather that your policy manual or the sign on the patient's door, then that is your problem although it could affect other patients if you fail in the follow through.

 

The manufacturers of the various Sani wipes and Sani cloths have recommendations and resources on their websites.

 

Allowing the wipe to dry is similar to allowing alcohol or some antiseptic prep to dry before puncturing the skin.  ED and EMS staff will often say they don't have 10 seconds.  At least in the hospital we do have some control to continue re-educating staff and reprimand when needed especially when infections are tracked.  It is more difficult to track in EMS which then may fall to the ED staff for responsibility.

Going back to your NRB mask example, I suppose you could take a company's stance on wearing gloves for every patient contact much like placing O2 on every patient. If you can not be sure of an assessment being done adequately each time, erring on the side of caution that a patient will not be hypoxic during transport might be best. If you can not be assured your employees will protect themselves by judgement, you make a policy that is a broad catch all.  Education should be the primary here but sometimes unless there is a mandatory influence such as accrediting organizations as an incentive, just a policy will have to suffice.

 

 

I thought the point of wearing gloves was to prevent provider contamination, not cross-contamination.   Cross-contamination can occur with or without gloves.

 



Joe Paczkowski said:

If you're worried about cross contamination, then observing proper hand washing procedures is much more important than wearing gloves. Ideally, we should either be using soap and water or an alcohol based hand sanitizer BOTH before AND after treating a patient. However, instead of using appropriate infection control practices, we instead let ourselves be fooled that gloves make us clean.

Also, to highlight a very key phrase you used, "must be used appropriately...." Using gloves for every patient contact is not using gloves appropriately, and inappropriate over use of anything is always going to lead to complacency and even worse misuse.

Finally, I think infection control tests should include a required reading and testing on the manufacturer directions for one of the standard cleaning wipes ("Saniwipes" for example), and be tested on the length of time that the surface is required to be damp to be sanitized. If it's just wet for 10-15 seconds, it's not wet long enough to do much good.



Ben Waller said:

I thought the point of wearing gloves was to prevent provider contamination, not cross-contamination.   Cross-contamination can occur with or without gloves.

 

Can it not be used for both preventing cross contamination AND provider protection?

If gloves are not indicated because there's no indication of infectious disease or bodily fluids other than sweat, how high of a risk for cross contamination to begin with? Something has to be contaminated before cross contamination can occur. If gloves are being worn, aren't they being worn because a provider is concerned about contamination? If so, what sense does it make then to take presumably contaminated gloves and interact with relatively clean areas of the ambulance?

Finally, how many ambulances now have alcohol based hand sanitizer mounted somewhere for use by the crew? Are they used appropriately?

Joe Paczkowski said:

The "gloves all time, every time, no exceptions" line of thought is up there with the insanity of 'every patient gets a NRB."


While I used think so too, our CCU has a "gloves-always" policy. They have been in the news (popular and trade) multiple times for having gone 18 months without a single central line infection, among other infection-control-related accolades, so it's tough to argue that it's a stupid policy. (Of course, that's a different patient population than the general ambulance-seeking population, but still....)

A few years ago most of the gloves had powder in them which told on the wearer, especially with dark trousers or scrubs,  as to where their hands had been on their own body before washing their hands. Some looked like they got an itch scratched real good right after removing their gloves.  That alone would be a reason to make a patient want their caregiver to wear gloves if they didn't see them wash their hands or if there was still powder on them. Pockets were always a powder zone. Even in some work areas today pockets on scrubs and lab coats are frowned upon.

 

I also have had co-workers who have kept their medical history well hidden until they came into the hospital as a patient. There was no way of telling what diseases they had until they told you to put on gloves for their protection and yours.  Prior to that you had decided not to wear gloves thinking you might offend them. But who knew if they don't wear their medical chart in the open for all to see.  The diseases  don't always have to be the usual headlining suspects either to warrant extra caution when providing care.

I have seen people touching patents with gloves then jump in the truck then drive with the gloves still on. I would be ok with natural selection taking these lazy bums out. 

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