PERSONAL
PROTECTIVE EQUIPMENT GUIDELINES
FOR FIRST RESPONDERS. SWINE FLU
April
26, 2009
These
Guidelines will be continually updated as situation evolves.
Introduction
It is the intention of
this DSHS guidance to provide information and recommendations for
the transport of patients with potentially infectious respiratory
illnesses. This policy will also provide updated guidelines for
"respiratory etiquette" and the use of
Personal Protection Equipment (PPE) as well as recommendations for
preventive health care measures for EMS providers.
A novel Swine Flu virus
has been identified in persons with respiratory infections in Texas.
Since this is a novel virus most Texas residents will not have immunity
to this virus.
Human-to-human transmission
of swine flu can also occur. This is thought to occur in the same
way as seasonal flu occurs in people, which is mainly person-to-person
transmission through coughing or sneezing by people infected with
the influenza virus.
EMS providers should
be aware of the signs and symptoms of infectious respiratory diseases
and the procedures necessary for protecting themselves. Not all
respiratory infections are transmitted in the same way. Transmission
can occur from direct or indirect contact, large droplets, or small
droplet nuclei. The mode of transmission will depend on the etiological
agent. Certain procedures can also impact transmission of infectious
agents by producing aerosols. These are deemed "high risk respiratory
procedures" and include intubation, extubation, deep tracheal suctioning,
nebulized respiratory treatments and bronchoscopy. More often in
the field of emergency medicine, the etiologic agents of infections
are unknown. Given this, it is paramount that good infection control
practices be followed for contact with all patients.
Respiratory Etiquette
Strategy
- Implement the use
of surgical masks by healthcare personnel, during the evaluation
of patients with respiratory symptoms.
- Provide surgical masks
to all patients with symptoms of a respiratory illness. Provide
instructions on the proper use and disposal of masks.
- For patients who cannot
wear a surgical mask in addition to any medical treatment being
provided, provide tissues and instructions on when to use them
(i.e., when coughing, sneezing, or controlling nasal secretions),
how and where to dispose of them, and the importance of hand hygiene
after handling this material.
- Continue to use droplet
precautions to manage patients with respiratory symptoms until
it is determined that the cause of symptoms is not an infectious
agent that requires precautions beyond standard precautions.
Recommendations
1. Personal Protection
- When assessing a patient
with symptoms of a febrile respiratory illness, a surgical mask
is usually adequate protection. When directed by a medical advisor,
use the highest level of respiratory protection available. A fit-tested
N-95 respirator or higher is preferred.
- Adhere to Standard
Precautions - the use of gown, gloves and eye protection if contact
with bodily secretions or a contaminated environment is anticipated.
Additionally, EMS providers must be familiar with PPE application
(donning) and removal (doffing) procedures.
- Place a surgical mask
on the patient if not medically contraindicated.
- Prior to transporting
a patient with an infectious respiratory symptom, the door between
the driver and the patient compartment should be closed. If the
vehicle does not have a barrier between the cab and the patient
compartment, the driver and front seat passenger should, if so
directed, wear a surgical mask or higher.
- Practice good hand
hygiene. Hands must be properly washed before and after removal
of gloves with warm soapy water or disinfected with a waterless
hand sanitizer if a sink is not immediately available. Waterless
hand sanitizer should be available in the ambulance for use during
transport. Do not wait until you return to the ambulance
station to practice hand hygiene.
- Assure adequate cleaning
of the equipment and vehicles between transports. This cleaning
should minimally include:
- Use of Environmental
Protection Agency (EPA) approved disinfectant;
- Disinfecting any
reusable equipment used on the patient as per the manufacturer's
instructions;
- Frequently touched
surfaces of the vehicle;
- Visibly soiled
surfaces.
2. Medical
procedures, such as nebulized respiratory treatments, that
may re-aerosolize infectious material should only be done if medically
necessary. It is recommended that mechanical ventilators, including
BVM devices and suction equipment, should be fitted with a HEPA
filter, if available, to prevent re-aerosolization. EMS agencies
should contact equipment manufacturers for recommendations on a
HEPA filter. The highest level of respiratory protection should
be worn during these procedures.
EMS Provider Health
Precautions
- DSHS strongly recommends
the following to EMS agencies and providers:
- Fit testing for
an N-95 or higher respirator masks and insuring that each provider
knows the manufacturer and model of the N-95 mask for which
they were fit tested.
- Education on performing
a "fit check" (conforming the mask to the face and checking
for air leaks) after donning N95 respirators.
- Frequent and on-going
education including, but not limited to infection control measures,
PPE as well as proper personal/hand hygiene.
- Annual flu vaccinations
and other preventive health measures.
- EMS agencies should
monitor their crews for any type of infectious illness. EMS management
should monitor any provider that presents with signs and symptoms
of a febrile respiratory illness. Agencies should consider the
following (in order of preference):
- Release staff from
duty until they have sought medical attention and have sufficiently
recovered.
- Require EMS providers
to don surgical masks to protect their patients while providing
care.
- The EMS agency medical
director and the local health department should be advised of
any EMS healthcare provider who is hospitalized with pneumonia.
Chemoprophylaxis
Antiviral chemoprophylaxis
(pre-exposure or post-exposure) is recommended for close contacts
of a confirmed or highly suspected case of swine influenza virus
infection.
Chemoprophylaxis is recommended
for health care workers caring for patients ill with confirmed or
highly suspected swine influenza.
Conclusion
It is vitally important
that the EMS community get in the habit of using Standard Precautions,
such as donning Personal Protective Equipment and placing a surgical
mask on the patient when appropriate, while treating all patients
with a suspected infectious disease. Changing routine habits to
include these measures will allow EMS providers to protect themselves
and their patients against known infectious diseases as well as
SARS or other new emerging diseases.
In addition to changing
habits, providing initial and on going education on disease prevention,
proper donning and removing of PPE, hand hygiene and hand washing
techniques as well as equipment and vehicle cleaning will allow
the EMS community to protect patients and itself against all types
of infectious diseases.
For Additional
Resources:
More information is available at the following web sites;
References
- CDC Interim Guidance:
Ground Emergency Medical Transport for Severe Acute Respiratory
Syndrome Patients
- CDC Updated Interim
Guidance - Pre-Hospital Emergency Medical Care and Ground Transport
of suspected Severe Acute Respiratory Syndrome Patients.
Fuente
Texas, Department of Health Services
http://www.dshs.state.tx.us
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