Standard Precautions Among Emergency Medical Services in Urban and Rural Areas

Abstract

Backround

Emergency medical services (EMS) workers are at risk of exposure to bloodborne pathogens and frequently exposed to blood and bodily fluids through percutaneous injuries. This study aimed to assess the consistency with which standard precautions (SPs) among rural and urban EMS providers were used.

Methods

This study consisted of a cross-sectional survey conducted with a sample of certified EMS providers in West Virginia in which we ascertained details about sociodemographic characteristics, and the frequency of consistent SP. An email invitation was sent to a comprehensive list of agencies obtained from the Office of West Virginia EMS.

Findings

A total of 248 out of 522 (47%) EMS providers completed the survey. The majority of the EMS providers (76%) consistently complied with SPs; however, more than one third (38%) of urban EMS providers indicated inconsistent use compared with 19% of rural EMS providers (p = .002). Most EMS providers reported low prevention practices to exposure of blood and body fluids in both areas.

Conclusion/Application to Practice

The results emphasize the need to enhanced safe work practices among EMS providers in both rural and urban areas through education and increasing self-awareness. Occupational health professional in municipalities that serve these workers are instrumental in ensuring these workers are trained and evaluated for their compliance with SPs while in the field.

Introduction

Blood and body fluids contain pathogens that cause harm to people through the transmission of infectious diseases. Risk of exposure to blood and other bodily fluids has been observed across numerous occupations, including emergency medical services (EMS) providers (Heick, Young, & Peek-Asa, 2009). EMS systems involve well-organized procedures and various actions for life support. EMS providers deliver prehospital care to patients and, therefore, have significant potential for pathogen transmission, especially in the case of severe injuries and illness (Mencl, Birkle, Blanda, & Gerson, 2000). EMS providers are often exposed to blood and body fluids, resulting in concerns regarding transmission of bloodborne and airborne pathogens (Heick et al., 2009; Sayed, Kue, McNeil, & Dyer, 2011).

EMS providers are frequently exposed to blood and body fluids through percutaneous injuries (Heick et al., 2009). In the United States, the rate of percutaneous injuries among EMS providers is higher than most hospital-based health care workers (HCWs; Boal et al., 2010; Chen & Jenkins, 2007). A previous study of EMS providers in Rhode Island from 1995 to 2001 estimated that 34% of the work-related injuries occurred due to percutaneous injuries (Merchant, Nettleton, Mayer, & Becker, 2009). Furthermore, a separate U.S. study reported that 15% of the work-related injuries among EMS workers occurred due to percutaneous injuries from 2003 to 2007 (Reichard, Marsh, & Moore, 2011). In contrast, a separate study found that exposure associated with nonintact skin such as the skin that was open due to cuts, abrasions, or being chapped, was higher than other routes of exposure such as percutaneous injuries among EMS providers (Boal et al., 2010).

Increased work shift duration including working eight, 12, 16, and 24 hours by EMS workers has been observed as a contributing risk to occupational injury (Weaver et al., 2015). An Australian report found that 92% of EMS providers reported being fatigued at work, and 88% expressed that fatigue affected their job performance (Sofianopoulos, Williams, Archer, & Thompson, 2011). In fact, a 2012 study found an association between sleep quality, fatigue, and safety outcomes such as self-reported injury and medical error among EMS providers (Patterson et al., 2012).

Despite continued exposure to blood and body fluids, EMS providers have been found to inconsistently use standard precautions (SPs) such as gloves and masks (Bledsoe et al., 2014; Harris & Nicolai, 2010). A study by Eliseo et al. (2011) observed that continued training is needed to decrease the occupational exposure among EMS providers. More specifically, EMS providers with frequent safety-related feedback/training had increased self-report of compliance with safe work practices by 50% (Eliseo et al., 2011). Studies have also found a greater provision of SPs would have contributed to a reduced occupational risk of bloodborne and airborne pathogens among EMS providers (Leiss, 2009, 2010; Mathews et al., 2008). EMS workers are at significant risk of percutaneous injuries and exposure to other pathogens, however, there is little to no research regarding EMS providers’ compliance and practice of SPs in rural areas. The primary objective of this study was to assess the consistent use of SP practice among rural and urban EMS providers. A secondary objective was to explore demographic and occupational characteristics of EMS providers and their association with SP compliance.

Method

Study Design and Population

This was a cross-sectional survey conducted among a sample of certified EMS providers in West Virginia. An invitation email was sent to a comprehensive list of 12 EMS agencies obtained from the Office of West Virginia Emergency Medical Services. Six out of 12 agencies replied via email and agreed to participate by distributing the survey link to their 522 EMS providers via email. These providers varied from critical care paramedics, paramedics, EMT-advanced, EMT-basic, and emergency medical responders. The West Virginia University Institutional Review Board approved this study.

Survey Instrument

An existing survey instrument was used, which was previously developed to examine knowledge, consistency, and attitude of SP practices in HCWs (Uchenna, Johnbull, Chinonye, Christopher, & Nonye, 2015). The survey was modified and reviewed for face validity by a paramedic (EMT-P) and an infectious disease officer who worked for a West Virginia Emergency Medical agency. Based on their feedback, the survey was revised and then pilot-tested among 10 EMS providers in multiple areas to assess readability, to simplify unclear questions, and to test the average time to completion.

The survey consisted of two sections including questions pertaining to sociodemographic characteristic and those pertaining to consistency of SP practice. The first section collected demographic details including age group (18–29, 30–39, 40–49, 50–59, and 60+ years), gender (male and female), and geographic area of practice (urban or rural) according to standards used by the U.S. Census Bureau (2017) as reported by the U.S. Office of Management and Budget (OMB). Urban areas were defined as having a population greater than 50,000, and rural areas were defined as having a population of less than 50,000. Additional demographics included level of professional certification (First Responders, EMT-Basic, EMT-Intermediate, paramedics, and critical care paramedics), employment status (full-time, part-time, and volunteer) and years of service category (<5, 6–10, 11–15, and >15).

The survey also asked about EMS providers’ consistency of SP use. Standard precautions was defined as hand hygiene, as well as the use of personal protective equipment (PPE) such as gloves, gowns, masks, eye protection, and face shields; and safety engineering practices such as disposing of sharps in appropriate containers, avoiding recapping needles, and covering open wounds with medical dressings (Siegel, Rhinehart, Jackson, & Chiarello, 2007). The use of gowns or the disinfection of ambulances were excluded as SPs in this study. EMS providers were asked how often they used SPs on patients with the options of always, sometimes, and never. Consistency of SPs was defined as SPs was “always” used. Participants who answered “sometimes” or “never” in response were directed to a follow-up question in which they were asked for an explanation as to why they did not always use SPs. Participants were then asked about the barriers that prevented them from complying with SPs in which they could choose the following options: inadequate supply of gloves, no hand sanitizer in the ambulance, inadequate supply of sharps containers, inadequate supply of mask and eyes protection, and difficulty with receiving restocking supplies.

The participants were also asked about what measures they had taken to avoid contact with blood and body fluids while in the field by providing them with images of best practices including wearing gloves, washing hands, avoiding recapping needles, disposing of sharps in appropriate sharps containers, and wearing mask/eye protection. Participants that chose any other option than these best practices were considered a lower level of prevention practice.

Data Collection

The anonymous web-based survey was administered using the secure, online software Qualtrics (2010). At the beginning of the survey, a general description of the study was provided. The link was sent to EMS workers via email from the EMS agency directors in West Virginia. Certified EMS providers who were currently working in West Virginia and above 18 years of age were invited to participate. The web link to the online survey was active for 30 days from the time the email was sent to EMS directors, and two reminder emails were sent during this time period.

Data Analysis

Data analysis was performed using Statistical Analysis System (SAS) software, Version 9.4. Descriptive statistics were performed first to summarize EMS providers’ demographic characteristics, including frequencies and proportions. We examined two outcomes in this study including inconsistent SP use and low exposure prevention behaviors. Inconsistent SP was defined as workers’ response that SPs that were not used on every patients, and low exposure prevention behaviors was defined as not selecting the complete components of SP practice. Chi-square tests were performed to test the relationship between inconsistent SP compliance and demographics of the EMS providers. In addition, it was used to test the relationship between low exposure prevention levels of SP practice and demographics of the EMS providers. An adjusted logistic regression model was used to examine the relationship of inconsistent SP use stratified by demographics of the EMS providers, including gender, age, years of experience, employment status and area of practice. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

Results

Demographic Characteristics

A total of 248 out of 522 (47%) EMS providers completed the survey (Table 1). More than half (67%) of the participants were male, and most (78%) reported serving in rural areas; whereas 21% served in urban areas. Most (89%) worked full-time, followed by part-time 24 (9.7%) and volunteer (0.8%). Most EMS providers were between the ages of 18 and 29 years (33%) and between 30 and 39 years (32.2%) years of age, followed by 40 and 49 years of age (20%). Almost half (43%) had certifications in EMT-Basic followed by paramedics (EMT-P; 32%), and first responders 3%. One third (35%) of participants reported having less than 5 years of experience in EMS, 23% reported between 6 and 10 years, 14% reported between 11 and 15 years, and 28% of reported more than 15 years.

Table 1.

Demographic Characteristics of Emergency Medical System Providers (n = 248)

Characteristics	n (%)
Gender
Male	167 (67.3)
Female	81 (32.7)
Area of practice
Urban area	54 (21.8)
Rural area	194 (78.2)
Age (years)
18–29	84 (33.9)
30–39	82 (33.1)
40–49	51 (20.6)
50–59	25 (10)
60+	6 (2.4)
Levels of certification
First responders	9 (3.6)
EMT-Basic	108 (43.5)
EMT-Intermediate	14 (5.7)
Paramedics	80 (32.2)
Critical care paramedics	37 (15)
Years of experience
<5	88 (35.5)
6–10	56 (22.6)
11–15	34 (13.7)
>15	70 (28.2)

Note. EMT = emergency medical technician.

Consistency With SPs

The majority of the EMS providers answered “always” (76%) in response to whether they used SPs when treating patients, followed by 23% that answered “sometimes,” and 0% answered “never.” When examining geographical region of practice and inconsistent use of SPs, we observed that those practicing in urban areas reported being more inconsistent than those practicing in rural with more than one third (38%) of urban EMS providers that indicated inconsistent use compared with 19% of rural EMS providers (p = .002; p = .01; Table 2). In addition, there was a statistically significant association between EMS provider’s age and inconsistent SP compliance (p = .03), and EMS providers aged 60 years and older had the greatest inconsistent SP compliance (66%), followed by those aged 40 to 49 years (29%), 50 to 59 years (28%), and 30 to 39 years (23%), respectively. In addition, years of experience was associated with inconsistent SP compliance (p = .01), with those having more than 15 years of experience having the greatest inconsistent SP compliance (43%) compared with those with 11–15 (2%) and 6–10 years (17%).

Table 2.

Relationship Between Inconsistency of SPs Use and Demographics of Emergency Medical Services Providers

Characteristics	Consistent SP	Inconsistent SPs	n	p
Gender
Male	123 (73.6)	44 (26.43)	167
Female	67 (82.72)	14 (17.23)	81	.11
Residence
Urban area	33 (61.11)	21 (38.89)	54
Rural area	157 (80.9)	37 (19.07)	19	.002
Age
18–29	71 (84.52)	13 (15.47)	84
30–39	63 (76.83)	19 (23.17)	82
40–49	36 (70.59)	15 (29.41)	51
50–59	18 (72.00)	7 (28.00)	25
60+	2 (33.33)	4 (66.66)	6	.03
Levels of certification
First responders	8 (88.89)	1 (11.11)	9
EMT-Basic	87 (80.56)	21 (19.44)	108
EMT-Intermediate	12 (85.71)	2 (14.28)	14
Paramedics	58(72.50)	22 (27.50)	80
Critical care paramedics	25 (67.75)	12 (23.43)	37	.31
Years of experience
< 5	75 (85.23)	13 (14.77)	88
6–10	46 (82.14)	10 (17.85)	56
11–15	23 (67.65)	11 (32.35)	34
>15	46 (65.71)	24 (43.29)	70	.01

Note. SPs = standard precautions; EMT = emergency medical technician.

In the geographical area of practice, the odds of having inconsistent SP compliance among EMS providers was 0.87 times less for those who worked in rural areas than those who worked in urban areas (OR = 0.87, CI = [0.42, 1.76]; Table 3). Gender, years of experience, years of age, employment status, and levels of professional certification were not associated with inconsistent SP compliance.

Table 3.

Adjusted Logistic Regression Modeling of Inconsistent Use of SPs

Characteristic (reference)	OR (95% CI)
Gender
Male (reference)	1.00
Female	0.74 [0.34, 1.53]
Area of practice
Urban area (reference)	1.00
Rural area	0.87 [0.42, 1.76]
Age
18–29 (reference)	1.00
30–39	0.59 [0.26, 1.33]
40–49	0.37 [0.14, 0.99]
50–59	0.58 [0.17, 2.16]
60+	0.29 [0.04, 2.62]
Levels of certification
EMT-Basic(reference)	1.00
First responder	0.34 [0.07, 1.53]
EMT-Intermediate	0.70 [0.21, 2.57]
Paramedics	0.68 [0.32, 1.46]
Critical care paramedics	0.54 [0.20, 1.46]
Years of experience
< 5 (reference)	1.00
6–10	1.48 [0.66, 3.41]
11–15	3.50 [1.13, 11.8]
>15	3.12 [1.04, 9.62]

Note. All variables were included in one model. OR = odds ratio; SPs = standard precautions; EMT = emergency medical technician.

Table 4 outlines responses to why inconsistently comply with SPs. The most selected response among all EMS providers was “I only use the SPs on very bad calls” with 59% in which is similarly selected response among rural EMS providers with 66%. However, the most selected response (52%) among urban EMS providers was “I don’t have time to use UPs on every patient.” With regard to barriers that prevented participants from the use of PPE, 33% of responders selected “inadequate supply of mask and eye protection,” in which 36% was of urban EMS providers and 32% was rural EMS providers. In addition, other 30% of total responders selected “Difficulty in receiving restocking supplies,” in which 33% was of urban EMS providers and 35% was rural EMS providers

Table 4.

Inconsistent Use of SPs Among EMS Providers by Geographical Regions

	Urban areas n(%)	Rural areas n(%)	Total n(%)
Reasons for inconsistent use of SPs
I don’t know what SPs are	0.0 (0.00)	1.0 (3.00)	1.0 (1.92)
I don’t have time to use SPs on every patient	10 (52.63)	10 (30.30)	20 (38.46)
I have immunity against infections	0.0 (0.00)	0.0 (0.00)	0.0 (0.00)
I only use SPs on really bad calls	9.0 (47.36)	22 (66.67)	31 (59.62)
Barriers
Inadequate supply of gloves	5.0 (20.00)	13 (14.13)	18 (15.38)
No hand sanitizer in the ambulance	4.0 (16.00)	8.0 (8.70)	12 (10.26)
Inadequate supply of sharps containers	4.0 (16.00)	8.0 (8.70)	12 (10.26)
Inadequate supply of mask and eyes protection	9.0 (36.00)	30 (32.61)	39 (33.33)
Difficulty in receiving restocking supplies	3.0 (12.00)	33 (35.86)	36 (30.77)

Note. SPs = standard precautions.

EMS providers were asked about the measures taken to avoid contact with blood and body fluids during the performance of duty. Thirty percent selected all correct components of recommended SPs practiced, which was categorized as optimal prevention practice. However, 70% of EMS providers did not select all the correct components of SPs, where one or more component of SP was omitted, and they were categorized as low prevention practices.

Table 5 shows the results of low prevention practices used to avoid contact with blood and body fluids among EMS providers. Within regard to years of experience, the odds of low prevention SP practice for those EMS providers with 11 to 15 years of experience was 2.44 times more than those who had = less than 5 years of experience (OR 2.44, CI [0.71, 8.56]). Moreover, the odds of having low prevention SP practice among the EMS providers who had 15 or more years of experience were 2.68 times more likely than those who had less than 5 years (OR 2.68, CI [0.77, 9.97]); however, neither estimate reached statistical significance.

Table 5.

Adjusted Logistic Regression Modeling of Low Prevention Practices of Standard Precautions Practice (n = 248)

Characteristic (Reference)	OR (95% CI)
Gender
Male (reference)	1.00
Female	0.76 [0.41, 1.44]
Area of practice
Urban area (reference)	1.00
Rural area	0.87 [0.42, 1.76]
Age
18–29 (reference)	1.00
30–39	0.87 [0.32, 2.34]
40–49	1.06 [0.31, 3.35]
50–59	0.92 [0.22, 3.54]
60+	3.64 [0.48, 34.4]
Levels of certification
EMT-Basic (reference)	1.00
First responder	0.64 [0.03, 4.05]
EMT-Intermediatea	0.85 [0.12, 3.76]
Paramedics	0.88 [0.38, 2.03]
Critical care paramedics	0.95 [0.32, 2.67]
Years of experience
< 5 (reference)	1.00
6–10	1.17 [0.42, 3.16]
11–15	2.44 [0.71,8.56]
>15	2.68 [0.77, 9.97]

Note. OR = odds ratio; EMT = emergency medical technician.

Discussion

EMS providers are at a high risk of occupational exposure to infectious diseases and are frequently exposed to blood and body fluids (Heick et al., 2009; Sayed et al., 2011). This study evaluated the consistent use of SP practice among rural and urban EMS providers. In this project, 248 of 522 (47.50%) targeted EMS providers completed a cross-sectional survey. The goal of this study was to identify possible areas for improvement in the area of occupational health and safety for both urban and rural EMS providers.

In our study, a large proportion of EMS providers reported that they always used SPs on every patient, and only one fourth indicated that they inconsistently used SPs, suggesting that most EMS providers comply with SP recommendations. Harris and Nicolai (2010) addressed different findings regarding the compliance of SPs. In their study, they found that a majority of EMS providers inconsistently used SPs. However, the study was conducted in Virginia, which included urban areas where EMS providers responded to many calls and may have been prone to larger numbers of patients and more subject to neglecting SP recommendations. Bledsoe et al. (2014) also demonstrated that most EMS providers inconsistently complied with SPs in which their study was based on observations where EMS providers were watched when they arrived at emergency departments. The higher demand for EMS providers and many requests for transfer would make the use of SPs among urban EMS providers difficult to consistently follow. EMS providers in urban areas might face insufficient supplies of SPs due to many requests for EMS providers. On the contrary, a lower demand for EMS providers and, therefore, an infrequent need for SPs could cause slightly inconsistent compliance among EMS providers in rural areas except for really bad cases as shown in our study.

EMS providers mainly transfer critically ill or injured patient expeditiously to emergency departments. Those EMS providers who inconsistently complied with SPs may choose only a portion of the appropriate PPE or practices recommended due to time constraints. Most EMS providers showed lower level of prevention by selecting an incomplete component of recommended SPs, and less than half selected the complete bundle SPs. In this study, we did not include every component of SPs due to EMS system environment. However, wearing gloves and washing hands were chosen and included in every choice. In contrast, Bledsoe et al. (2014) found that most EMS providers did not consistently use SPs, especially the use of gloves and hand washing practices; they found that only 56.9% of EMS providers arrived to the emergency department wearing gloves and only 27.80% washed their hands following patient contact. Consequently, there is a need for evaluating what components of SPs are used frequently.

Older and the more experienced EMS providers showed less SP compliance, which is in contrast to a previous study in which age and years of experience showed no association with these factors and exposure to blood exposure due to noncompliance (Boal et al., 2010). We found no association between gender and inconsistent compliance of SPs. However, Boal et al. found that there is a relationship between gender and nonintact skin exposure to blood due to noncompliance of SPs. More specifically, males were more often exposed to nonintact skin than females, with female EMS providers who showed better compliance (Boal et al., 2010).

Study findings suggest sufficient provision of SPs help in improving occupational health and safety of EMS providers (Leiss, 2009, 2010; Mathews et al., 2008). Mathews et al. (2008) found that some EMS providers ineffectively follow the complete practice of SPs because they are inadequately trained as well as the use of some components can limit their ability to care for their patients. Consequently, there is a need for encouraging increased use of all of SPs for every emergency response through proper training programs. Future research should evaluate the difference between urban and rural areas in terms of what types of SP supplies are needed as well as investigate how fast suppliers can provide insufficient items.

Limitations

This study has some potential limitations. First, the response rate of 47.50% created the potential for nonresponse bias, resulting in different findings. For example, EMS providers who are consistently compliant with, or optimally practice SPs tended to respond, and others who are less may have tended to be nonresponsive to the survey. Second, this study was limited only to one state (West Virginia), and the results may not be applicable to other states. Finally, it was impossible to categorize all EMS agencies as urban or rural because some agencies include stations and squads in different locations. Although the definition of area of practice was defined and explained to EMS providers as defined by OMB, some EMS providers may have specified the area of practice incorrectly, either because of the lack of knowledge concerning their work location or frequent transfer between EMS agencies.

Implications for Occupational Health Practice

Lack of SPs compliance among EMS providers means that they often encounter infectious agents in their ardent attempt to save lives. Best practices, an understanding of infectious diseases, are the best solutions for preventing such infections. This project focused on assessing the practice of EMS providers through various means of prevention specifically among urban and rural EMS providers. This study helps enhance the application to practice in terms the occupational health and safety in out of hospital in both urban and rural areas. This study provides evidence for continued need for educating these workers to prevent transmission of infectious diseases.

Applying Research to Practice.

We conducted a survey of consistent compliance and practice of standard precautions (SPs) among emergency medical services (EMS) providers indicates 76.61% of EMS providers always use SPs on every patient, and only 23.39% inconsistently use SPs, meaning most EMS providers comply with SP recommendations. EMS providers who work in rural areas showed extremely inconsistent use of SPs compared to EMS providers in urban areas. Most EMS providers show low prevention to exposure blood and body fluids in both areas. The results emphasize the need of enhanced safe work practices among EMS providers in both urban and rural areas by continued education and increased self-awareness. In addition, further research is needed to assess differences by EMS areas. Occupational health professional in municipalities that serve these workers are instrumental in ensuring these workers are trained and evaluated for their compliance with SPs while in the field.

Author Biographies

Riyadh A. Alhazmi, PhD, is an assistant professor in the Department of EMS in the Prince Sultan Bin Abdulaziz College for EMS, with a teaching focus on occupational health and EMS cores education. His research interests include workplace health and regulation, EMS practice, emergency disaster, and occupational epidemiology.

R. David Parker, PhD, is associate dean for Research & Professor in College of Nursing & Public Health. His research interests include global health, infectious diseases epidemiology, substance use disorders (injection drugs, overdose), sexual minority health, cyber security, and applied analytics.

Sijin Wen, PhD, is an associate professor in the Department of Biostatistics in the School of Public Health, with a joint appointment in the Mary Babb Randolph Cancer Center. His work includes the design and analysis of numerous clinical trials, laboratory experiments, and observational studies.