Nosocomial infections in ambulances and effectiveness of ambulance fumigation techniques in Saudi Arabia

تاببسم ثودح لدعمو ىودعلا ةحفاكم مييقت :فادهلأا ةئراطلا ةيبطلا تامدلخا فاعسإ تارايس يف ةيريتكبلا ضارملأا كلذ ىلإ ةفاضلإابو .ةيدوعسلا ةيبرعلا ةكلملما ,ضايرلا ةنيدم يف يتلا )Fumigation( ريخبتلاب ميقعتلا تاينقت ةيلاعف ىدم يف ينلوقنلما ىضرلما ىلإ ىودعلا راشتنا نم دحلل اهمادختسا تم . ةئراطلا ةيبطلا تامدلخا يمدقمو فاعسلإا تارايس ثودح ةيناكمإ ىلإ تراشأ ةقباس تاسارد ىلع ءانب :ةقيرطلا عقاوم 3 رايتخا تم ,فاعسلإا تارايس يف ةيلاع ةبسنب تابوركيم ,ىضرلما ةلاقن كسمم يهو تانيعلا عملج فاعسلإا ةرايس لخاد ,فاعسلإا ةرايسل يفللخا بابلاو ينجسكلأا قفدت سايقم كسمم ةيلمع دعبو لبقو راهنلاو ليللا يف تاحسلما تانيع عمج تمو مادختساب ةقيقد تانئاك ىلع فرعتلا تمو .ميقعتلاو ريهطتلا رايتخا تم ثيح ىلولأا ةلحرلما جئاتن انه مدقنو .ةيرايعم سيياقم ةئيه تارايس نم راهنلاو ليللا يف ةلماع فاعسإ تارايس 10 .ضايرلا ةقطنم يف يدوعسلا رمحلاا للاهلا فاعسلإا تارايس نم ةذوخألما تانيعلا عيمج ترهظأ :جئاتنلا دعب تاحسلما تانيع ضعب ترهظأو .ةهباشتم جئاتن ةرشعلا ةيلاع ىلإ ةطسوتم تايمك ونم ىلإ ريخبتلاب ميقعتلا لبقو ريهطتلا ناف لاح لك ىلعو .ريهطتلا دعب ىتح ةيدللجاو ةيئيبلا ارولفلا نم .ميقعتلا ةينقتل ةضرع تناك ةقيقدلا تانئاكلا عيمج ميقعتلا تاينقت ةءافكو ةريتو مييقت ادج مهلما نم :ةتمالخا لقنل لمتحم ردصم فاعسلاا تارايس نوكل ةفلتخلما .ينلماعلاو ىضرلما ىلإ تابوركيلما Objectives: To evaluate infection control and the incidence of bacterial pathogens in Emergency Medical Service (EMS) ambulances in Riyadh, Saudi Arabia. The effectiveness of fumigation techniques used for these ambulances to minimize the spread of infection to transported patients and pre-hospital care providers was also assessed. Methods: Based on previous literature review indicating a higher propensity of microbial load, 3 areas within the ambulance, such as, stretcher handle, oxygen flow meter knob, and interior handle of the rear door were selected for specimen collection. Swab samples were collected both in the day and night shift, after the intended disinfection and cleaning (before and after fumigation). Micro-organisms were identified using standard procedures. This phase-I study was conducted at the Emergency Medical Services Department, Prince Sultan Bin Abdulaziz College of Emergency Medical Services, Al Malaz, King Saud University, Riyadh, Saudi Arabia between October and November 2013, wherein a total of 10 ambulances from the Saudi Red Crescent Authority in Riyadh were selected for inclusion in the study. Results: The specimens from all 10 ambulances showed similar results. In post disinfection and before fumigation, swab samples showed positive cultures that grew moderate to large quantities of environmental and skin flora. However, almost all organisms were susceptible to the fumigation technique. Conclusion: This study confirms the importance of evaluating the frequency and efficiency of various fumigation techniques as an ambulance is a potential reservoir for microbial transmission to patients and staff. Saudi Med J 2014; Vol. 35 (11): 1354-1360 From the Emergency Medical Services Department, Prince Sultan Bin Abdulaziz College of Emergency Medical Services, King Saud University, Al-Malaz, Riyadh, Kingdom of Saudi Arabia. Received 30th April 2014. Accepted 26th August 2014. Address correspondence and reprint request to: Asst. Professor Daifallah Alrazeeni, Vice Dean of Academic Affairs, Prince Sultan Bin Abdulaziz College of Emergency Medical Services, Al-Malaz, King Saud University, PO Box 25063, Riyadh 11466, Kingdom of Saudi Arabia. Tel. +966 (11) 2097928. E-mail: [email protected]/ [email protected] 1354 Saudi Med J 2014; Vol. 35 (11) www.smj.org.sa OPEN ACCESS 1355 www.smj.org.sa Saudi Med J 2014; Vol. 35 (11) Evaluation of ambulance fumigation ... Alrazeeni & Al Sufi H care associated infections are acquired in a health care setting, and despite the presence of many disinfection methods, microbial contamination remains a significant health concern throughout the world.1,2 Ambulances can conceivably be a potential source of different pathogenic microbes by virtue of their role in transporting patients from a scene to a healthcare facility, or during an inter-facility transfer. This creates a scenario wherein not only the patients but also the paramedical staff and relatives of the patients may be exposed to various pathogens, some of which may cause infections and diseases. Although some universal precautions and disposable equipment reduces risk to patients and providers, the ambulance remains vulnerable to bacterial contamination from blood, secretions, and other potential infectious material. Therefore, many different infection control procedures are being employed to prevent ambulances from potentially transmitting, either to medical personnel or patients, or relatives of patients. Studies indicated that infections acquired from ambulances cause a significant financial burden, which is most likely due to the presence of contaminated devices within the ambulances. Infections could thus arise from the home, ambulances, or hospitals.3,4 Although many hospitalbased infection control programs are being used at present,5-7 ambulance disinfection has not been widely stressed upon as an important part of public health administration. The Ambulance Service (Emergency Medical Service [EMS]) in Saudi Arabia is managed by the Saudi Red Crescent Society Authority (SRCSA). By 2009, there were approximately 1,300 ambulances in the SRCSA, and 447 EMS centers run by 5,507 staff in the country. Research conducted regarding prehospital infection should not only include assessments of prevalence of microbes from various locations in an ambulance, but also the effect of sterilization, or disinfection techniques in causing a decrease, or removal of various pathogens.8-10 In this scenario, it is important to have an evidence-based and cost-effective approach. Such a holistic approach will enable the best control of probable nosocomial infections that may arise from pre-hospital infection due to exposure in ambulances. A regional study8 examined the levels of bacterial contamination in Welsh ambulances over a 12-month period on a monthly schedule. The results showed a variety of microbes were present in the samples before cleaning of emergency vehicles most important though is the observation of fresh contamination in ambulances of previously uncontaminated zones in the vehicle due to cleaning methods. Unacceptable levels of microbes have been found re-emphasizing the need for more stringent infection control programs. The current study is based on a hypothesis that the EMS ambulances of the Kingdom of Saudi Arabia (KSA) can carry pathogenic bacteria hazardous both to the paramedical personnel, as well as, patients that are transported within these ambulances to the hospitals. The relation between disinfection and cleaning procedures along with the use, and effect of fumigation of ambulances in order to minimize further spread of infections to patients and paramedical personnel needs to be closely investigated. Therefore, the purpose of the current study is to understand, identify pathogens, and recommend appropriate solutions for a pathogen-free environment in the pre-hospital setting in KSA. Methods. This was a surveillance-based prospective experimental study conducted in an EMS setting. The current study (Phase 1) is part of a project, which comprised 3 phases in total (1 identification of microorganisms and efficacy of fumigation technique in ambulances; 2 identification of effective disinfectant techniques in pre-hospital setting; and 3 identification of any incidents of nosocomial infections transported through ambulances). In Phase 1, conducted between October to November 2013, 10 busy ambulances operating both in day and night shifts with SRCA in Riyadh region were included. Selection of sampling sites. A total of 3 areas within the ambulances were selected for specimen collection, that is; stretcher handle, oxygen flowmeter knob, and door handle of the ambulance (Figure 1). These locations were selected based on confirmed previous literature review and experience for their increased propensity to microbial contamination. A sample of an ambulance operating under the SRCA, and model fumigator equipment currently used is presented in Figure 2. The ambulances were swabbed both in the day and night upon readiness to return to service, after all the intended cleaning and decontamination with multi-organism surface disinfectant spray (AZO, Synergy Health plc, Chorley, UK) had been completed. Disclosure. Authors have no conflict of interests, and the work was not supported or funded by any drug company. All tests were performed by Al Borg Laboratories, Riyadh, KSA. This study has been supported by funding from the Scientific Research Grant (Research Project No: NFG224-33) from King Saud University, Riyadh, Kingdom of