Study shows: Ambulances house MRSA
Methicilin-resistant Staphlococcus aureus (MRSA) is becoming bacterial public enemy #1 in emergency departments. But are patients contracting the superbug even before they come through the ambulance bay doors? In an eye-opening study, researchers swabbed 21 ambulances at two urban stations and discovered a veritable breeding ground for MRSA.
The study, published in the April–June 2007 issue of Prehospital Emergency Care, looked at swabs collected from five locations within each of the 21 ambulances. After 96 hours of plating, researchers found 10 out of the 21 ambulances tested positive for MRSA in at least one location.
We probably shouldn’t be surprised at these results. The Association for Professions in Infection Control and Epidemiology published their MRSA National Prevalence Study in June 2007. Looking at both community and hospital acquired MRSA, acute and long-term care facilities, they found prevalence rates 8 to 11 times higher than previously thought. This was the largest, most comprehensive study to date, and 46.3 of every 1000 patients were infected or colonized with MRSA.
Across the pond, the British have been studying and talking about MRSA contamination in ambulances at least since 2003, and have found similar results. How do we use this information? It’s tempting to write it off as just one more voice crying out about infection control in the wilderness of the overburdened American emergency medical system. For the sake of ourselves, our colleagues and our patients, we can’t.
To be fair, we ask paramedics to do a lot of work in a small space. We ask them to do it quickly, as call after call comes in. They wipe down the gurney with an antimicrobial and change linens after each patient. When they see body fluids, they follow OSHA guidelines. And they may be doing a good job for the “obviously contaminated” areas, but there’s more than meets the eye. In the Prehospital Emergency Care study, by far the largest single group of positive swabs (33.3%) was found not on equipment in contact with the patient, but on the work area to the right of the patient.
Existing guidelines aren’t as helpful as they could be—OSHA rules apply mainly to known body fluid contamination. CDC guidelines assume health care workers know in advance that the patient is MRSA positive; many will be difficult or impossible for ambulance personnel to follow. EMTs and paramedics rarely know they have a MRSA-infected patient, and they are unlikely to be wearing gowns over their uniforms, as the CDC suggests. For the same reason, ambulance personnel will not have dedicated equipment for each MRSA positive patient.
Most individual department standards are equally unhelpful, ranging from mandating thorough cleaning once a month to addressing only body fluid contamination. Some departments only specify the cleanser to be used.
An EP’s Role
There are many creative solutions being pioneered by other countries (see sidebar). However, we cannot force American ambulance companies and fire departments to adopt a particular solution.We can add our voice, though, and insist that a solution must be found and appropriately funded. Adding our voices might mean discussion between your ED director and the local EMS director. It might mean political support for additional funding so departments can find better solutions and monitor the effects of changed cleaning protocols.
We can also help with making sure paramedics and EMTs have the supplies and education they need. Just as importantly, remind paramedics to care for themselves as they care for patients; they should protect themselves by cleaning their work areas as they clean the patient contact areas.
One paramedic listed his department’s procedures, and then said, “We probably clean the outside of the ambulance more often.” It’s time to give paramedics the information and tools to reverse the ratio.
Perhaps we need to go beyond our existing rules. A 2005 Britain’s Ambulance Service Association study showed MRSA persisted in ambulances despite standard cleaning procedures. Their disinfection process was similar to that currently in the U.S., using similar microbicides. The British now take ambulances out of service to use a “deep cleaning” procedure with vaporized hydrogen peroxide; extra ambulances ensure service isn’t interrupted while the ambulances are cleaned by dedicated personnel. ~Ellen Lamel