Ambulance hygiene
Since the time of Hippocrates, the main purpose of medicine is to improve the health of individuals, at least not to harm it. However, mistakes and accidents are inevitable wherever there is a human and an application. In this context, medical errors are inevitable in the health industry, which is a sector where labor force use and technological applications are intense and which also includes dangerous elements. Ambulance is a vital tool used in patient transport, but sometimes it comes to the agenda as a source of accident, fall, drop, medical malpractice or infection, and in this sense, ambulance cleaning and hygiene gains importance.
Ambulance Hygiene for Patient Safety
The aim of patient safety, which is defined as önlen prevention of future harm to patients,, is to establish a system that will prevent errors during service delivery, protect the patient from possible damages due to errors and eliminate the possibility of errors. In this context, ensuring the safety of patients at every stage of health service delivery is the priority of the health system. Because, patient safety violations cause disability and complications and increase mortality and morbidity rates. In addition, these violations have extremely important consequences with economic and human characteristics such as unnecessary extra medication for patients, prolongation of treatment, increased health expenditures, loss of morale and motivation in health workers, and adversely affecting the trust of the patient / relatives and the society in the health system. In this sense, patient safety practices are an important requirement in the provision of all health services including ambulance services. Among these, infection control, including sterilization and disinfection, is of great importance. The importance of the subject will be better understood, especially considering that 5-15 percent of the infections in the world develop depending on the provision of health services and one third of these infections are preventable. In addition, the emergence of bacteria resistant to multiple antibiotics and their transport by patients necessitate infection control in ambulance services as in other health services.
Ambulance Hygiene Approaches
For the first emergency approaches and other reasons, the ambulance is infected during the use of the ambulance for the patient transplantation and the infection of the microorganism to the health worker or the next patient is very important for the safety of the patient and the employee. Ambulances can be the source of different pathogens because they are used during the transplant of many patients with various diseases or infections. Strict infection control protocols should be implemented and monitored to prevent the ambulance from becoming a source of infection to patients or employees. Current research on pre-hospital infection is mostly related to yaygın prevalence of pathogens in samples on the surface of ambulances or devices cihaz and “contamination rates of specific pathogens”. To prevent the ambulance from being a source of contamination, there should be an evidence-based and cost-effective infection control protocol for ambulances and their equipment. Medical devices and materials are generally classified into three categories (critical, semi-critical and non-critical) according to the possibility of being contaminated. Devices that are in direct contact with the airway mucous membranes of patients, such as, for example, a laryngoscope blade, are considered “critical.. Since the ambulance devices and materials are very large and varied, the schematic approach to contamination based on this risk grouping surveillance will be of great help in implementing infection control and quality assurance. During the ambulance services, it is very important that the health personnel are aware of both the ambulance hygiene and the preventive measures against infections, because both the patient and the health personnel share the indoor environment of the cabin, contact with the interventional devices and occasional penetrating injuries. For this reason, ambulance cleaning includes decontamination procedures inside and outside the vehicle, as well as decontamination or sterilization of medical devices used during patient interventions.
General Ambulance Cleaning
Routine cleaning of the ambulances should be done internally and externally once a week. It should be cleaned after every case and every morning. Cleaning is done by the health personnel on duty. All surfaces in contact with the patient / personnel in the ambulance should be cleaned. Cleaning must be complete and in accordance with hygiene rules, with gloves. The floor is swept, the cabinets and surfaces in the ambulance are wiped with 1/100 bleach. If patient secretions and blood contamination are present, 1/10 bleach is used for cleaning. Then dry with a soft cloth and ventilate the vehicle. In the exterior cleaning of the ambulance, starting from the top, wash the outer surface with warm or cold water using soap or vehicle shampoo, rinse with clean water and dry with a soft cloth.
Cleaning of Equipment Used in Ambulance
How and how often all equipment will be cleaned in the ambulance, and the cleaning materials to be used must be known to everyone at the station. Because unfortunately no other staff is assigned to do this job. In case of return, the ambulance equipment is cleaned by the duty team and the material is recorded in the cleaning checklist and signed. High or low level disinfectant is applied according to the pollution rate of the equipments used. High-level disinfection is applied for equipment contaminated with blood and body fluids, while low-level disinfection is applied in the absence of this transmission. Here, commonly; Bleach containing 5 percent chlorine is used for high level disinfection by diluting 1/10 ratio and used for low level disinfection by diluting 1/100 ratio. During decontamination, gloves, gowns, masks, if necessary, protective shoes or special shoes should be worn. Ideally, disposable garments should be used during the decontamination process and, after the process is finished, put in a biological waste bag and autoclaved or incinerated. In the absence of disposable garments, the garments worn during cleaning and disinfection should be transported to the laundromat by placing them in biological waste bags, where they should be washed at 71 ° C. Wetting the contaminated garments before they are sent to the laundry is useful to prevent possible aerosol scattering during the garment separation prior to washing. Personnel performing decontamination should take a shower with soap and water after the process is finished and after removing contaminated clothing. If a patient is diagnosed with an infectious disease or suspected of infection, the ambulance should be cleaned after transport, using a special method and special disinfectants, if notified.
Precautions During Ambulance Cleaning
The presence of infectious disease is very important for ambulance personnel. Carelessness and unexpected accidents may result in contamination of the injured skin or directly through a mucous membrane. In the presence of infectious diseases, it is important that staff protect both themselves and others from cross-infections. Therefore, it has to know some infectious diseases and ways of protection from them. The paramedical team should always wear gloves to protect itself, and wear a mask if there is a risk of respiratory infection. If an upper respiratory tract infection is present, it should not be reported and work in order to remove the risks posed by this close service during the disease. If the patient has a bleeding or severe vomiting, he should wear medical goggles. Needles, scalpels, disposable knives and similar instruments used in the ambulance should be disposed in special containers with “ biohazards zararlı emblem in order to prevent them from going out. Since such materials are medical waste, they should be treated separately from other wastes in the garbage. In cases where the ends of such materials and tools need to be closed, caution should not be caused and the accident should not be caused. Measures should also be taken to prevent people from collecting these wastes. It has been reported that many infectious diseases are transmitted as a result of carelessly disposing of incisive and incisive tools in random trash. Infectious diseases, in particular blood-borne microorganisms, are responsible for the development of serious illness on health personnel. Hepatitis B, Hepatitis C, other dangerous viral hepatitis, HIV / AIDS, Mycobacterium tuberculosis , and tetanus are among the leading ones. Regular, careful and calm work must be done to prevent these undesired accidents that may occur during work. Wear gloves is one of the most important protective measures (Figure 2). Spilled or spilled blood should be wiped with the aid of a disinfectant and the materials used should not be left in the middle, but should be placed in medical waste. Work areas should always be kept clean and spotless. As a result, ambulances are risk factors for spread of infection. All ambulance employees should be subjected to continuous in-service training. For this, the training subjects should be determined in detail and trainers from all levels should provide these trainings within a certain plan.
Infections Carried by Ambulance: Current Situation
Studies have reported that serious contamination may occur in ambulances before cleaning, and even after cleaning, pathogenic microorganisms may persist. However, contamination is usually reduced after vehicle cleaning. Many of the contaminated bacterial species shown in the various areas of the ambulance are harmless, non-pathogenic, skin flora and species found in nature. However, it is detected in S. aureus and other pathogen agents. In a Korean study, the presence of microorganisms in ambulance surveillance was 49 percent, some of which were identified as pathogens, many as environmental or normal flora members. In our study, 20 S. paucimobilis, 2 A. woffii, 2 S.aureus, 2 K.pneumoniae, 20 (CNS) were detected in the swab samples evaluated in 16.7 percent of the swab samples. In the US study, the rate of methicillin-resistant S.aureus (MRSA) was reported as 12.4 percent. In a study conducted in Korea, only one sample was found to be MRSA positive. Environmental microorganisms will cause problems for patients with weak immune systems. Noh et al. found environmental microorganisms such as Acinetobacter or Pseudomonas in ambulance workers. The presence of these microorganisms may mean that cleaning and washing are insufficient for the ambulance. Both the patient and the health care personnel come into contact with the instruments used during transportation and interventions, and stab wounds may occur. In order to protect against blood-borne infections, it is necessary to comply with universal precautions, to clean the barrier, used tools, gloves and other equipment and to eliminate waste, to take protective measures after immunization and exposure.
In our study, 82.5 percent of ambulance personnel were vaccinated against hepatitis B, 11.5 percent against influenza, 79.8 percent stated that they received medical waste training and 51.9 percent indicated that they paid attention to hand hygiene. 39.4 percent of the respondents reported that they experienced a case-to-case risk in the same ambulance cabin, and 15.4 percent reported case-personnel transmission. In our study, it was emphasized that the medical instruments used were cleaned after each application; 75% for instruments requiring high-level disinfection such as laryngoscope, and 28.8 percent for instruments requiring low-level disinfection, such as sphygmomanometer. Regular car cleaning is also very important. In our study, while 29.8 percent reported that the ambulance had done the patient cabin clean-up after each case, despite the fact that they were working at the same station, the rate of those who said that they could only be done once a day was 49 percent. In the results of working; It has emerged that ambulance employees need to raise awareness of both themselves and patients against infectious infectious diseases and ambulance hygiene. The fact that 36.5 percent of the ambulance personnel participating in the study stated that they needed additional training in ambulance hygiene shows a serious deficit in the field.
Ambulance Hygiene Recommendations
1. Areas and materials to be cleaned in the ambulance: Door handle, cabin wall and holding areas, patient carried canvas, sphygmomanometer sleeve, stethoscope head, monitor, jumping bag, patient safety belt, neck collar, ambu, aspirator connection part.
2. More susceptibility should be shown when transporting patients with an epidemic agent (bacteria resistant to multiple antibiotics-MRSA, VRE, CPE Kus - Avian influenza, swine flu, Crimean Congo Hemorrhagic Fever virus…).
3. Each new emergency case is a possible source of contamination and ambulance workers are in contact with possible bacteria. In case of spilled infected body fluid, disinfection of blood and body fluids should be done immediately with chlorinated disinfectant. Hepatitis B and HIV viruses can remain in dried blood for months. In addition, the time available to clean the vehicle prior to the next emergency call is a critical factor in taking due care.
4. Having an ambulance cleaning program with frequency and methods provides a systematic approach to cleaning and decontamination.
5. Studies show that the current levels of clearance are insufficient and may cause environmental contamination with potential pathogens. Therefore, vehicle cleaning procedures and regulations should be examined and applied as required to reduce the contamination of harmful bacteria and to prevent the ingress of bacteria from cleaning equipment.
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