8.1 Infection Prevention and Control: Routine Practices, PPE & Sharps Safety

8.1 Infection Prevention and Control: Routine Practices, PPE & Sharps Safety

Chains and Routes of Disease Transmission

Prehospital clinicians operate in dynamic, uncontrolled environments where interrupting the chain of infection is foundational to patient and provider safety (CPCF Appendix A #8). Pathogen transmission requires six interdependent links: the infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and a susceptible host. Canadian paramedicine recognizes five primary transmission routes:

• Contact Transmission: Direct physical transfer (skin-to-skin contact during patient handling or wound care) or indirect transfer via contaminated fomites (stretchers, blood pressure cuffs, stethoscopes, monitor cables).
• Droplet Transmission: Expulsion of large respiratory droplets (>5 µm) during coughing, sneezing, or suctioning, traveling short distances (≤2 metres) before settling on conjunctival, nasal, or oral mucosa.
• Airborne Transmission: Dissemination of microscopic droplet nuclei (≤5 µm) that remain suspended in ambient air currents and disperse over long distances (e.g., Mycobacterium tuberculosis, measles, varicella-zoster).
• Common Vehicle Transmission: Multiple infections originating from a single contaminated source (e.g., multi-dose vials, intravenous solutions).
• Vector-Borne Transmission: Pathogen transmission via biological vectors (e.g., ticks transmitting Lyme disease, mosquitoes transmitting West Nile virus).

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Public Health Agency of Canada (PHAC) Framework: Routine Practices & PCRA

The Public Health Agency of Canada (PHAC) establishes a dual-tiered framework: universal Routine Practices and targeted Additional Precautions.

Point-of-Care Risk Assessment (PCRA)

The PCRA is a dynamic evaluation performed before every patient interaction. Paramedics evaluate:

1. Patient Presentation: Active cough, fever, vomiting, uncontained diarrhea, or draining lesions.
2. Task Parameters: Anticipated contact with blood, mucous membranes, or non-intact skin; generation of respiratory aerosols (Aerosol-Generating Medical Procedures [AGMPs]).
3. Environment: Confined ambulance patient compartment and ventilation capabilities.

Hand Hygiene: The Four Moments

Paramedics adhere to the Four Moments for Hand Hygiene:

1. Before initial patient or patient-environment contact.
2. Before clean or aseptic procedures (IV starts, glucometry, medication prep).
3. After body fluid exposure risk.
4. After patient or patient-environment contact.

• Alcohol-Based Hand Rub (ABHR): Formulations containing 60%–90% alcohol are preferred for non-soiled hands due to rapid, broad-spectrum microbial kill.
• Soap and Running Water: Mandatory when hands are visibly soiled or when caring for patients with spore-forming organisms, specifically Clostridioides difficile (C. diff), or non-enveloped enteroviruses (norovirus). ABHR cannot penetrate endospores; mechanical washing for ≥20 seconds physically rinses spores away.

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Transmission-Based Additional Precautions

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Personal Protective Equipment: Donning, Doffing & N95 Protection

Doffing carries the highest risk of provider self-contamination. Paramedics must follow standardized sequential protocols:

• Donning Sequence:

  1. Gown: Secure neck and waist ties, ensuring full torso coverage.
  2. Mask / N95 Respirator: Position elastic straps (crown and neck); mold metal nosepiece over nasal bridge.
  3. Eye Protection: Don CSA Z94.3-certified goggles or face shield. (Standard prescription glasses lack side/splash shields and are non-compliant.)
  4. Gloves: Pull cuffs up securely over the gown wrists.

• Doffing Sequence:

  1. Gloves: Remove using glove-to-glove and skin-to-skin technique; discard immediately into biohazard receptacle.
  2. Gown: Peel forward away from shoulders, rolling contaminated exterior inward into a bundle; discard.
  3. Perform Hand Hygiene: Cleanse hands with ABHR for 15–20 seconds.
  4. Eye Protection: Grasp rear strap without touching front lens; lift forward and discard or reprocess.
  5. Mask / N95 Respirator: Remove bottom strap over head, then top strap; pull away without touching front filter.
  6. Perform Final Hand Hygiene: Cleanse hands thoroughly with ABHR or soap and water.

N95 Fit Testing and Seal Checks

N95 respirators filter ≥95% of airborne particles down to 0.3 µm when an airtight facial seal is achieved. Fit testing (qualitative with Bitrex/saccharin or quantitative with particle counters) is mandatory every two years under CSA Z94.4. A User Seal Check is mandatory every time the respirator is donned:

• Positive Pressure: Exhale gently; the mask should bulge slightly with no air escaping perimeter edges.
• Negative Pressure: Inhale sharply; the facepiece should collapse slightly inward with no inward leaks.

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Biomedical Sharps Safety & Post-Exposure Protocols

Percutaneous injuries from hollow-bore needles carry transmission risks of approximately 30% for HBV (non-immune), 3% for HCV, and 0.3% for HIV.

• Sharps Handling: Never recap needles two-handed; use the one-handed scoop technique only when unavoidable. Activate integrated safety mechanisms immediately away from the body. Dispose at bedside in puncture-resistant biohazard containers filled to a maximum of 3/4 capacity.
• Stepwise Post-Exposure Protocol:
  1. Immediate First Aid: Wash puncture wounds immediately with soap and water. Do not aggressively squeeze or milk the site, which causes micro-trauma and increases viral absorption. Flush exposed eyes or mucous membranes with sterile saline or water for ≥15 minutes.
  2. Operational Reporting: Notify dispatch and supervisor immediately to initiate occupational injury reporting and transport relief.
  3. Source Evaluation: Request voluntary consent for source serology (HIV, HBsAg, HCV) or initiate provincial statutory testing processes.
  4. Medical Evaluation & PEP: Report immediately to an emergency department. For high-risk HIV exposures, Post-Exposure Prophylaxis (PEP) must be initiated as soon as possible, ideally within 2 hours (maximum 72 hours). Non-immune paramedics exposed to HBV require Hepatitis B Immune Globulin (HBIG) within 48 hours and a vaccine booster.

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Equipment Processing: Spaulding Classification & Dwell Times

[!IMPORTANT] Disinfectant Contact (Dwell) Time: Disinfectants do not neutralize pathogens instantly. Surfaces must remain visibly wet for the manufacturer-validated contact duration (1 to 5 minutes for hospital wipes, up to 10 minutes for bleach) to achieve certified microbial log reduction.

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Clinical Scenario: AGMP in Undifferentiated Respiratory Distress

Paramedics treat an 80-year-old resident with acute respiratory failure, fever (39.2°C), productive cough, and SpO2 80%. The patient requires bag-valve-mask (BVM) ventilatory support and supraglottic airway placement:

1. PCRA: Crew identifies acute respiratory infection with an Aerosol-Generating Medical Procedure (AGMP), requiring Airborne, Droplet, and Contact precautions.
2. PPE Configuration: Both paramedics don fluid-resistant gowns, fit-tested N95 respirators, full-face shields, and double gloves.
3. Engineering Controls: An in-line viral HEPA filter is connected between the airway and BVM. Ambulance ventilation is set to high exhaust non-recirculation, and the cab window is sealed.
4. Post-Call Reprocessing: Strict doffing sequence is executed with multiple hand hygiene cycles. Patient compartment surfaces are saturated with intermediate-level disinfectant for the full 5-minute dwell time.

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Exam Pitfalls & High-Yield Pearls

• Doffing Sequence: Never remove the mask/N95 before gloves; perform hand hygiene immediately following glove/gown removal.
• C. difficile Cleansing: ABHR is ineffective against bacterial spores; mechanical handwashing with soap and water is mandatory.
• Sharps Disposal Limits: Overfilling sharps containers past 3/4 capacity or forcing needles into full bins is a severe regulatory infraction.
• PEP Administration Window: Seeking medical evaluation at shift end compromises efficacy; the therapeutic window for optimal HIV PEP initiation is within 2 hours.