**5. Developing and implementing best practice guidelines for infection control**

In view of the collective body of research which highlights that bacterial contamination of ambulances of all types is a frequent occurrence [2–12], the universal implementation of standardized, optimized infection control protocols is a highpriority public health provision [1]. Emergency services crew, their patients and companions have an elevated risk of contracting infection without there being in place clear guidelines and an understanding of, and adherence to, these protocols by paramedics [1, 24]. Compliance with best practices for cleaning and disinfecting inside emergency medical vehicles, equipment and supplies is an important consideration in aiming to prevent the spread of antibiotic-resistant bacteria in pre-hospital care settings. This may also drive the more general development of new or improved policies and procedures the adherence to which could decrease the

**79**

*Contamination of Emergency Medical Vehicles and Risk of Infection to Paramedic First...*

day-to-day transmission of deadly pathogens and alleviate contagion by pandemic-

In an attempt to reduce infectious disease transmission, reputedly antimicrobial fabrics have been used to manufacture uniforms for emergency medical service crew. However, in one short-term trial a suit made of one such novel fabric that was designed specifically to reduce contamination risks showed no significant difference in microbial contamination compared to garments made of standard materials [29]. Future investigations should aim to examine microbiological swab samples from a range of emergency service vehicles across a breadth of locations in order to detail and quantify the associated infection threat to the paramedic profession and to those to which they attend. This will help to define more clearly what strategies are needed to safeguard the provision of best practice and in case of natural disasters, pandemic outbreaks or possible bioterrorism events [30]. Integral to any mitigation recommendation should be professional development tailored to paramedic first responders in air ambulance helicopters and other emergency medical vehicles that is conducive to raising levels of awareness of infectious diseases and best practice

Antibiotic-resistant bacteria are acknowledged to pose a profound and growing threat to human health, which, as recognized by the medical, nursing and paramedic professions, routinely cause a substantial proportion of healthcare-associated infections [31, 32]. Notwithstanding this realization, there is a knowledge gap in relation to the significance of antimicrobial resistance in pre-hospital emergency

While research from several countries has identified possible hazards [2–9], each of these preliminary studies focused on a single vehicle type. There is a shortfall in understanding of the relative contributions to potential infectious disease transmission of a wide spectrum of emergency service providers. The long-term objective should be to gauge the scale of contamination on or in emergency service vehicles, targeting police cars and fire trucks in addition to emergency medical vehicles. These include standard road-based ambulances, first response cars, motorcycle ambulances and helicopter air ambulances, as well as light aircraft used, for instance, by the Royal Flying Doctor Service in Australia to reach isolated patients in extremely remote locations. The data generated would be analyzed to assess the potential for uncontrolled disease spread, thereby facilitating the development of recommendations to minimize transmission risks for emergency response crews

Reflecting the bulk of findings to date, staphylococci form the focus of this chapter. However, the need to perform more research on Gram-negative coliforms as a source of potentially pathogenic bacterial contamination of emergency medical

The services of paramedics and other emergency medical professionals are a cornerstone of all civilized societies. Paradoxically, however, given the paramount importance of the role that this sector fulfills, there is a paucity of information on the risks of infectious disease transmission from contamination of vehicles, equipment or passengers by microbial pathogens. Assessment of potential threats to paramedics,

care [1], which is typically the primary point of patient contact.

and for the communities that they serve.

vehicles is highlighted.

**7. Conclusion**

*DOI: http://dx.doi.org/10.5772/intechopen.87219*

or bioterrorism-related microbes.

training in infection control.

**6. Discussion**

*Contamination of Emergency Medical Vehicles and Risk of Infection to Paramedic First... DOI: http://dx.doi.org/10.5772/intechopen.87219*

day-to-day transmission of deadly pathogens and alleviate contagion by pandemicor bioterrorism-related microbes.

In an attempt to reduce infectious disease transmission, reputedly antimicrobial fabrics have been used to manufacture uniforms for emergency medical service crew. However, in one short-term trial a suit made of one such novel fabric that was designed specifically to reduce contamination risks showed no significant difference in microbial contamination compared to garments made of standard materials [29].

Future investigations should aim to examine microbiological swab samples from a range of emergency service vehicles across a breadth of locations in order to detail and quantify the associated infection threat to the paramedic profession and to those to which they attend. This will help to define more clearly what strategies are needed to safeguard the provision of best practice and in case of natural disasters, pandemic outbreaks or possible bioterrorism events [30]. Integral to any mitigation recommendation should be professional development tailored to paramedic first responders in air ambulance helicopters and other emergency medical vehicles that is conducive to raising levels of awareness of infectious diseases and best practice training in infection control.

## **6. Discussion**

*Healthcare Access - Regional Overviews*

**4. Cleaning and disinfection protocols for emergency medical vehicles**

tion that is customarily fulfilled with regulated chemical products [25].

The notable findings of one study showed that the number of sites contaminated inside an ambulance increased from 57% before cleaning and disinfection to 86% afterwards [3]. Hence, not only were many areas till contaminated with bacteria others that were previously uncontaminated became freshly contaminated as a result of poor cleaning technique acting as an inadvertent means of spread. The deficiency in performance of regular manual infection control protocols has been associated with operator error, principally concerning selection, formulation, distribution and contact time of the disinfectant [22, 23, 25]. Perspectives on improving effectiveness include staff training programs, continuing education, real-time feedback on the thoroughness of cleaning and disinfection procedures, routine microbiological inspection of surface hygiene, and the use of fluorescent markers or assays to ascertain the robustness of the process [25]. Although these actions can, separately and collectively, improve the efficacy of standard measures to decontaminate in the shortterm, their sustainability is yet to be explored. The application of non-manual vehicle disinfection lowers the possibility of human errors linked to traditional cleaning methods and offers the prospect of more effective elimination of pathogens, thereby decreasing infection transmission [26]. However, at present definitive evidence is lacking to demonstrate the clinical effectiveness of non-touch or automated disinfection procedures, including those utilize steam cleaning, hydrogen peroxide or ultraviolet light irradiation, to eradicate or suppress infection rates in ambulances [27, 28].

**5. Developing and implementing best practice guidelines for infection** 

In view of the collective body of research which highlights that bacterial contamination of ambulances of all types is a frequent occurrence [2–12], the universal implementation of standardized, optimized infection control protocols is a highpriority public health provision [1]. Emergency services crew, their patients and companions have an elevated risk of contracting infection without there being in place clear guidelines and an understanding of, and adherence to, these protocols by paramedics [1, 24]. Compliance with best practices for cleaning and disinfecting inside emergency medical vehicles, equipment and supplies is an important consideration in aiming to prevent the spread of antibiotic-resistant bacteria in pre-hospital care settings. This may also drive the more general development of new or improved policies and procedures the adherence to which could decrease the

It is self-evident that surfaces or items that have come into contact with a patient's blood, body fluids, fecal matter or exposed skin should be considered as potentially contaminated. Since pathogenic microbes can survive outside the human body for extended periods the handling of contaminated objects is a means by which infection can spread [22]. A recurrent route of infection transmission is when a paramedic's gloved or ungloved hands touch a contaminated surface or medical equipment and/ or there is patient contact with contaminated surfaces or items [23]. For this reason, it is imperative that items of patient care equipment (such as blood pressure cuffs, monitors, stethoscopes and stretchers) that make routine contact with skin and/or mucous membranes undergo a two-step cleaning and disinfection process following every response [24]. Defined as the simple removal of foreign and organic materials from a surface or object, cleaning using water, detergents and a scrubbing action physically removes but does not kill or prevent the growth of microbes. Conversely, disinfection kills or disables microbes present on contaminated surfaces, an opera-

**78**

**control**

Antibiotic-resistant bacteria are acknowledged to pose a profound and growing threat to human health, which, as recognized by the medical, nursing and paramedic professions, routinely cause a substantial proportion of healthcare-associated infections [31, 32]. Notwithstanding this realization, there is a knowledge gap in relation to the significance of antimicrobial resistance in pre-hospital emergency care [1], which is typically the primary point of patient contact.

While research from several countries has identified possible hazards [2–9], each of these preliminary studies focused on a single vehicle type. There is a shortfall in understanding of the relative contributions to potential infectious disease transmission of a wide spectrum of emergency service providers. The long-term objective should be to gauge the scale of contamination on or in emergency service vehicles, targeting police cars and fire trucks in addition to emergency medical vehicles. These include standard road-based ambulances, first response cars, motorcycle ambulances and helicopter air ambulances, as well as light aircraft used, for instance, by the Royal Flying Doctor Service in Australia to reach isolated patients in extremely remote locations. The data generated would be analyzed to assess the potential for uncontrolled disease spread, thereby facilitating the development of recommendations to minimize transmission risks for emergency response crews and for the communities that they serve.

Reflecting the bulk of findings to date, staphylococci form the focus of this chapter. However, the need to perform more research on Gram-negative coliforms as a source of potentially pathogenic bacterial contamination of emergency medical vehicles is highlighted.

### **7. Conclusion**

The services of paramedics and other emergency medical professionals are a cornerstone of all civilized societies. Paradoxically, however, given the paramount importance of the role that this sector fulfills, there is a paucity of information on the risks of infectious disease transmission from contamination of vehicles, equipment or passengers by microbial pathogens. Assessment of potential threats to paramedics, patients and companions should be considered as an imperative in order to establish effective risk reduction interventions. Recent research has established that all types of emergency medical vehicle can act as vectors for infectious microbes. Items of equipment that are handled frequently by paramedics may be at heightened risk of contamination and should thus be prioritized for regular disinfection.

How to reduce the risk of antibiotic-resistant bacterial contamination of the interior of emergency medical vehicles is a pre-hospital care issue encountered on a daily basis but one which also has far-reaching implications in disaster management situations. Preventive measures intended to mitigate the threat of pathogenic bacterial transmission to ambulance staff, patients and their companions by ensuring a cleaner, safer medical environment exemplify paramedic industry best practice. Further detailed research is required to determine the potential risk of infection transmission among different vehicle fleets and under varied conditions of use. This may underpin the establishment and implementation of new or revised policies and protocols for cleaning and disinfection schedules. Committing to such action should fortify the paramedic sector's mission to save lives, speed recovery and serve the community through providing the highest standards of rapid response critical care.
