Tracking, reporting EMS exposures takes team approach

Emergency medical service (EMS) workers face volatile situations daily that may result in high-risk exposures, but critical follow-up may fall by the wayside if a network of communication does not exist among key infection control professionals.

In that regard, public health, hospital, and EMS infection control professionals in Dallas are working together to ensure reporting and follow-up of exposures to EMS workers. The system relies on open and frequent communication between the principals, as well as a paper trail to document exposure data at each stage of the program. (See form on p. 8.) The form developed by the Dallas County Health Department is filled out by the EMS worker reporting the exposure, turned in at the hospital where the source patient is delivered, and then reported back to the EMS station and the health department for follow-up as needed.

"The emergency personnel fill out the form and leave it with a charge nurse in the hospital ER," explains Kate Lujan, RN, BSN, communicable disease nurse at the health department. "The ER charge nurse forwards it to the infection control nurse, and the infection control nurse then forwards it to me."

Meanwhile, the exposure is reported by the EMS employee to Carol Lawrence, RN, BSN, communicable disease coordinator for the EMS service at the Dallas Fire Department. Working with the EMS shift commanders, follow-up is then initiated based on standing protocols for bloodborne pathogens, tuberculosis, and other infectious diseases -- with the employee receiving initial information and direction for follow-up before that work shift is completed, she says.

"I contact employees within 24 hours -- 48 hours max -- and talk to each one of them individually to make sure they understand what the protocols are, all of the disease information, any precautions they have to take," Lawrence says. "We don't wait until we try to get source patient's [test] results back."

For example, a serious blood exposure to a patient with suspected or confirmed HIV infection could result in testing of the EMS worker at baseline, then at six weeks, three months, six months, and one year, Lawrence explains. Fortunately, the EMS workers are all immunized for hepatitis B virus before they make their first run, but exposures possibly involving hepatitis C virus are understandably more difficult. Realizing the current tests may not be completely accurate, HCV testing is done at baseline following exposure, she says.

"We go back and test again at six months, and then follow them for any signs of illness," Lawrence says. "If that occurs, then we would refer them out to a specialist for appropriate follow-up on that."

Needlesticks, TB exposures top reports

In general, the two largest categories of reported exposures are related to TB (i.e., throat examination, intubation) and those to bloodborne pathogens via needlesticks or splashes to the mucous membranes or nonintact skin. While the EMS workers have the standard regalia of barrier protective gear -- including gloves, impervious gowns, and the new N95 class TB respirators -- they work in unpredictable, fluid situations that may not lend themselves to compliance with infection control precautions.

"There are times that it is very difficult to control the situation, particularly in major car wrecks," Lawrence says. "Sometimes they are not able to wear those gowns, for example, because they would be shredded to pieces."

Covering an area of nearly 400 square miles, the department includes 54 stations operating three shifts, making over 122,000 runs last year. The approximately 2,000 employees include 425 paramedics, 1,200 uniformed personnel, and several hundred civilian support staff, she says.

Though the number of exposure reports averages from eight to 20 reported exposures monthly, the emergency service has not had any workers seroconvert for a bloodborne pathogen since the program began after the passage of a state EMS law 1989. However, three EMS workers converted TB skin tests following occupational exposures last year, Lawrence says.

"That is overall out of 2,000 people, out of the all the exposures last year -- a very low rate," Lawrence says.

Regardless, all reported exposures are taken seriously in the network of information that includes key players Lucy DeTamble, RN, manager of the medical communications dispatch center, and Patti Grant, RN, BSN, CIC, infection control coordinator at Parkland Memorial Hospital. A level one trauma center, Parkland is the starting point for many of the reported exposures from incoming EMS workers.

"We receive the patients and have access to the [patient] information that the EMS workers need via the health department," Grant says. "I receive those exposure forms and process them -- hopefully within 48 hours. Of course, that is difficult because sometimes you are waiting for confirmation of HIV testing."

Indeed, throughout the process, clinicians must strike a delicate balance between protecting patient confidentiality and ensuring follow-up for the exposed EMS worker.

"First and foremost, we respect the confidentiality of the patient that was transported," Lawrence says. "Whenever we are able to obtain patient information, it does not go out of my office with the patient's name on it. All of us work very hard together to protect the patients' confidentiality, but at the same time to provide care to our [EMS] people and make sure that they get everything they need to prevent illness."

Under Texas law, an exposed EMS worker may seek court action to have patients tested, but that is viewed as a worst-case scenario by the infection surveillance team.

"Usually everybody wants to do the right thing, including [source] patients," Grant says, though adding that EMS workers cannot expect carte blanche access to patient medical information.

Likewise, Lawrence adds, the EMS department sets up protocols to move ahead regardless of patient information and has not sought a court intervention. "There is a mechanism to mandate it, but it is by court order and is an expensive, drawn-out procedure," Lawrence says. "We do not feel that is beneficial because, in most cases, the patient results are not going to change what we do for our employee. We have a very aggressive follow-up procedure."

EMS workers who want to know if the source patient was HIV-positive, for example, must understand that a negative initial test in the source patient does not rule out the potentially infectious "window phase" prior to seroconversion, Grant notes. By the same token, a baseline negative test for the EMS worker still awaits the confirmation of a second negative test at six months before they can breathe easier.

"They are still going to have to live for the next six months as if they are going to seroconvert if they had a true occupational exposure incident," Grant says.

Tracking and reporting of occupational exposures to EMS workers was recommended in 1994 by the Centers for Disease Control and Prevention in Atlanta as a provision of the Ryan White Act.1 Though preceding that action, and drawn along slightly different lines than the federal system of "designated officers," the Dallas system anchored by the local health department can serve as a model for those considering establishing similar networks.

"The intent of both is the same -- get information to the emergency responder," Grant says. "They should not live in fear just because they have a dangerous job. Anything an infection control professional can do to make their lives less stressful, then we have an obligation to do that."

Reference

1. Centers for Disease Control and Prevention. Ryan White comprehensive AIDS resources emergency act; emergency response employees; notice. Fed Reg 1994; 59[54]:13,417-13,428. *