Importance of Hand Hygiene Compliance in Reducing Occupationally Acquired Infections for Emergency Departments and Emergency Medical Services

Abstract 

In the realm of frontline healthcare, where the well-being of both patients and healthcare  workers hangs in the balance, there is a heightened vulnerability of healthcare workers  (HCWs) to occupationally acquired infectious diseases (OAI), particularly evident during recent  infectious disease outbreaks. Ethical principles in healthcare mandate that HCWs provide care  regardless of the associated risks, leading them to be in close proximity to infected patients  during triage and care provision. The unavoidable risk of OAI is exacerbated by insufficient  protection, resources, training, and compliance, making HCWs, especially Emergency  Department (ED) clinicians and Emergency Medical Service (EMS) providers, disproportionately  affected during outbreaks. This paper emphasizes the crucial role of handwashing and hygiene  in an infection control model for ED and EMS workers. We recommend the implementation of a  range of strategies to enhance hand hygiene compliance. This proactive approach is essential to  mitigate the daily risks HCWs face with OAIs. By investing in multimodal strategies, healthcare  facilities aim to fortify the resilience of the healthcare system while providing enhanced  protection for frontline workers. These individuals willingly risk their lives to ensure the well being of others. Therefore, prioritizing improvements in hand hygiene compliance becomes a  crucial step in safeguarding HCWs and reinforcing the overall effectiveness and robustness of  the healthcare system.

Introduction 

Recent infectious disease outbreaks have highlighted the vulnerabilities of healthcare  workers (HCWs) to occupationally acquired infectious diseases (OAI). As the ethical principles  of healthcare dictate, patients must receive care no matter the risks presented by their  illness or injury. This necessitates that HCWs be in close proximity to infected patients while  triaging and providing care, thus placing them at a greater risk for a variety of infections.  The risk for OAI is an unavoidable part of daily patient care, and HCWs often become the  most affected populations during infectious disease outbreaks due to a lack of proper  protection, resources, training, and compliance.¹ Both emergency department (ED) clinicians  and Emergency Medical Service (EMS) providers are at an increased risk of exposure by  being on the frontlines, often as the first contacts patients have with the medical system.  HCWs are often the first to confront a new or emerging outbreak or even seasonal spikes in  epidemics as patients who possess symptoms seek care for their illnesses. Particularly in the  case of emerging or new outbreaks, HCWs, especially EMS providers and ED staff, may have  interactions with index cases before baseline epidemiological data is known and before the outbreak risk can be reported and communicated to the healthcare community as well as  the general public, putting them at an increased risk for OAI. This paper will demonstrate the  importance of handwashing and hand hygiene as part of an infection control model for ED  and EMS workers and will provide recommendations to improve hand hygiene compliance to  protect these HCWs from OAIs. 

Background 

Healthcare workers, including ED and EMS personnel, are frequently exposed to a variety of  infectious diseases that have their own complicating transmission factors that require various  levels of precaution. This paper explores risks, vulnerabilities, and compliance with infection  prevention measures in light of novel emerging diseases like COVID-19. A study from the first  four months of the COVID-19 pandemic in Wuhan (November 2019–February 2020) suggested  that of 25,961 PCR-confirmed² COVID-19 diagnoses, 5.1 percent were HCWs.³ The estimated  COVID-19 incidence using epidemiological data for denominators was higher in HCWs than in  the general population.⁴ HCWs are particularly vulnerable to COVID-19 infections and other  emerging infectious diseases due to close contact with infected patients and contaminated  materials.⁵ SARS-CoV-2 was not the first coronavirus to spill over to humans and lead to  global case counts. Previous coronavirus outbreaks have demonstrated extensive nosocomial  transmission risks, including Severe Acute Respiratory Syndrome coronavirus (SARS) and Middle  East Respiratory Syndrome coronavirus (MERS).⁶ The high incidence of nosocomial infections  during these outbreaks is believed to be related to suboptimal infection control practices and  the performance of aerosol-generating medical procedures.⁷ During the SARS epidemic in  2003, the World Health Organization (WHO) reported that, of the 8,098 total cases, 1,707 or  21 percent of the cases were HCWs.⁸ Similarly, 18 percent of all laboratory-confirmed cases  of MERS-CoV from 2012 to June 2, 2018, were HCWs.⁹ WHO regularly reports on new cases  of MERS, which have continued to lead to HCW and patient illnesses.¹⁰ According to official  data analyzed in a 2021 study from several other published studies, there was a rate of 12–15  percent of nosocomial COVID-19 in patients reported around the world until May of 2020.¹¹ COVID-19 and other airborne respiratory illnesses are only some of the occupational hazards  that healthcare workers face daily. In the later phases of the pandemic, rates around the globe  were slightly reduced. For example, hospital-acquired infections (HAI) were reported in 7.4  percent of cases in Switzerland and 8.6 percent in Brazil.¹² 

The probability of nosocomial transmission to healthcare workers depends on several factors  including the availability of personal protective equipment (PPE), transmissibility and virulence  of the pathogen, operating environment, and behavioral interventions, like hand hygiene. Each  of these factors should be considered in infection prevention control (IPC) measures to best  protect healthcare workers from infection while treating the most vulnerable in the community.  When determining IPC measures, it is important to evaluate what is available to HCWs during  an outbreak. Initial studies during the COVID-19 pandemic revealed low amounts of available  supplies of PPE, hand hygiene products, and disinfection supplies for equipment and hospitals,  all of which increased the risk of OAI.¹³

The safety of HCWs is crucial for healthcare systems to remain resilient in the emergence of  an infectious disease, a seasonal epidemic, or in the event of a major global pandemic. OAIs  in these workers threaten to disrupt the entire healthcare system and its ability to treat the  sick within our communities due to the loss of able-bodied HCWs, especially in the specialized  climates of EMS and EDs. In 2020, more than 2,900 HCWs in the United States died as a result  of the pandemic.¹⁴ WHO estimated that between 80,000 and 180,000 HCWs could have  died from COVID-19 in the period between January 2020 to May 2021.¹⁵ COVID-19 deaths  decreased significantly in the third year of the pandemic compared to the first two years, largely  because most deaths in the first year occurred before the availability of vaccines, medical  countermeasures, and renewed access to PPE.¹⁶ 

Personal Protective Equipment (PPE) 

The emergence of SARS-CoV-2 has highlighted existing vulnerabilities within supply chains that  put HCWs at risk and the need for correct application of appropriate measures and compliance  for IPC. Viruses that transmit person-to-person through respiratory droplets and close contact  

require HCWs to evaluate aerosolization and exposure risks for patient treatment that may  require close-contact care and procedures.¹⁷ In the event of severe respiratory infections,  care such as intubation and nebulizer treatments necessitate contact with the healthcare  system through EMS and EDs.¹⁸ An estimated 20–30 percent of SARS patients, pre-vaccine,  required mechanical ventilation, and 10 percent of SARS patients died, with those deadly  cases potentially having EMS or ED intervention before resuscitation efforts terminated.¹⁹ Aerosolization risk exposure assessments require stringent precautions in order to protect  HCWs, including adhering to strict and proper PPE utilization. The U.S. Occupational Safety and  Health Administration (OSHA) mandates that PPE be selected based on the specific hazards  that are likely to be encountered during work. The selection of appropriate PPE must consider  key factors including the type of hazard and the prospective routes of infection (inhalation, skin  absorption, blood, ingestion, and eye or skin contact).²⁰ 

Access to and use of PPE, however, is not sufficient for protection from various pathogens,  as proper donning and doffing is necessary for adequate protection and prevents potential  contamination to the user. In addition, specific equipment such as respirators require fit testing for individual use. ED clinicians and EMS providers often do not have the luxury of pre patient diagnostic contact testing which places the decision on the providers to assess clinical  symptoms to determine the level of PPE to wear. Typical ED and EMS precautions for general  non-respiratory illnesses, such as car accidents or chest pain, will likely only result in the use  of gloves.²¹ In contrast, more high-risk patients, such as those with respiratory complaints or  infectious disease diagnoses, will necessitate respirators such as N95s and/or isolation gowns.  The adoption of PPE in EMS has shifted towards more protection over the years, as the gloves  that are commonplace on almost every EMS call now were not widely used throughout the  system decades ago.²² The U.S. Centers for Disease Control and Prevention (CDC) recommends  minimum precautions that apply to all patients, regardless of their suspected or confirmed  infectious status, in all healthcare settings.²³ The suggested PPE protection is recommended for  HCWs treating various types of patients. The appropriate use of PPE for adherence to standard precautions includes the “use of gloves in situations involving possible contact with blood or  body fluids, mucous membranes, non-intact skin, the use of protective clothing to protect  skin and clothing during procedures or activities where contact with blood or body fluids is  anticipated, and the use of mouth, nose, and eye protection during procedures that are likely to  generate splashes or sprays of blood or other body fluids.”²⁴ 

Various methods, including standard operating procedures (SOPs) and standardized trainings,  are meant to assist HCWs in assessing risk and selecting the appropriate PPE.²⁵ Early suggestions  for PPE during the SARS-CoV-2 outbreak included all forms of precautions;²⁶ however, gloves,  face shields, and respirators were the most important PPE to prevent OAI due to aerosolization  and close-contact transmission routes. A national study by the Association for Professionals  in Infection Control and Epidemiology (APIC) COVID-19 task force found in March 2020, soon  after the emergence of SARS-CoV-2 in the United States, that face shields and respirators were  the least available supplies, with only 13.6 percent and 18.2 percent of infection preventionists  reporting sufficient supplies of face shields and respirators respectively.²⁷ Many infection  preventionists (66.9 percent) reported sufficient hand soap, but far fewer had sufficient hand  sanitizer (29.5 percent, P < .001), and only 45.4 percent had sufficient disinfection supplies.²⁸ The scarcity of PPE made HCWs more vulnerable to OAIs since they had to either forgo wearing  PPE, reuse PPE, or make their own PPE.²⁹ 

Pathogen Transmission and Virulence 

HCWs can potentially be exposed to various pathogens during their daily operations in patient  care. They must consider various routes of transmission and potential exposure in their  IPC practices. Transmission of infectious diseases within a healthcare setting requires the  combination of three elements: source, host, and mode.³⁰ The source, known as a reservoir,  must be present of an infectious agent(s), a susceptible host with a portal of entry receptive to  the agent, and a mode of transmission for the agent to enter the host. Transmission routes will  vary depending on the pathogen, and some routes may have more than one to consider. Some  pathogens are transmitted “primarily by direct or indirect contact with an infected individual,  (e.g., Herpes simplex virus [HSV], respiratory syncytial virus, Staphylococcus aureus), others by  aerosol droplet, (e.g., influenza virus, B. pertussis) or airborne routes (e.g., M. tuberculosis).”³¹ There are also bloodborne virus pathogens that are transmitted via percutaneous or mucous  membrane exposure. Contact transmission is the most common mode of transmission.³² 

HCWs are taught that all body fluids, secretions and excretions, should be considered potential  routes of exposure, and activities that create aerosols or put the HCW into close contact with  a patient should be done with caution, considering the risk of nosocomial infection.³³ Universal  precautions were developed to address the risk of bloodborne pathogens by treating all blood  and bloody body fluids as infectious. Standard precautions, later developed by the CDC to  leverage the major features of universal precautions and Body Substance Isolation (BSI), are  a tenet of healthcare to help reduce the risk of the transmission of pathogens through body  substances.³⁴ Standard transmission-based precautions can be applied to protect healthcare  workers from known or unknown sources within hospitals or ambulances.

Hand Hygiene 

The final tenet of OAI prevention is a common global health promotion process. This method of  infection prevention serves as an important connection between PPE and the pathogen itself,  bridging the protection gap that may be present in the utilization of PPE. Hand hygiene is a crucial  precaution element to break the infection chain, reducing the risk of OAI (Table 1). The CDC lists  hand hygiene as the most important measure to prevent the spread of infections and has it listed  as the first standard precaution.³⁵ Hand hygiene with an alcohol-based solution is widely used  throughout the world as the most simple, low-cost, and effective OAI prevention measure in lieu  of soap.³⁶ The alcohol-based hand rubs denature certain surface proteins of enveloped viruses,  inactivating them and preventing survival and spread, improving the antimicrobial efficacy and  rate of compliance with hand hygiene.³⁷ A systematic review of alcohol-based hand rubs found that  they removed microorganisms effectively, requiring less time, and thus less hand irritation than  handwashing with soap or other antiseptics and water. The authors found that the availability of  these alcohol-based solutions in HCWs’ work environments with easily accessible supplies helped  to increase compliance with hand hygiene among HCWs.³⁸ Various agents have been suggested as  effective for hand hygiene in lieu of alcohol when handwashing stations are not available; this is  especially important for EMS professionals who do not have access to stations in the field. These  agents should be made available based on the potential exposure as seen in Table 1.

Table 1. Various Hand Hygiene Agents³⁹

While all components of infection control are important to decrease the risk of transmission, hand  hygiene has been demonstrated to be a leading factor in preventing transmission in healthcare  environments.⁴⁰ Relying heavily on PPE alone can become a risky solution, particularly when  supplies and availability of PPE may be limited. Hand hygiene can be completed in as little as 20  seconds and is an inexpensive measure that can be addressed by an individual to reduce their  exposure risk to OAIs. The ease of implementing regular hand hygiene and the ability to regulate  compliance provides an easy and effective solution to OAI prevention failures.  

The lack and variability of hand hygiene access and compliance in healthcare environments  poses an elevated risk of OAI. The restrictive nature of emergency medical healthcare  environments, including access to handwashing stations, is unlikely to change. However,  through informed policy recommendations and uniform hand hygiene guidelines, necessary  procedures can be enacted to reduce the risk of OAIs to frontline workers.  

ED and EMS Factors that Reduce Compliance 

The factors discussed above provide an important context for the vulnerabilities that exist;  however, in order to decrease the risk of OAIs, there must be compliance across the healthcare  system, particularly in EDs and EMS. Of particular importance is the role of hand hygiene  compliance. Numerous environmental, institutional, behavioral, and clinical factors have been  suggested as reasons for lower hand hygiene compliance in healthcare settings (Table 2). While  the rates are low across the healthcare industry, both EDs and EMS are distinct sectors that  complicate the ability to remain compliant.⁴¹ Previous hand hygiene studies have often focused  on inpatient locations such as intensive care units with failure rates around 60 percent.⁴² Still, few  have investigated the rates of failure in the less structured and more chaotic environments that  can be present in the ED or EMS. ED and EMS HCWs are subject to a unique set of institutional  and human-behavior based factors that can limit hand hygiene compliance. The urgent nature  of the work, as well as the potential limited availability of handwashing measures in the field,  complicate the ability of HCWs in the emergency sector to remain fully compliant with hand  hygiene precautions. Relatively few studies have investigated hand hygiene compliance in these  environments. However, limited studies have shown hygiene compliance in the ED to be as low as  29 percent internationally⁴³ and 38 percent in United States’ EMS systems.⁴⁴

One approach may be to apply data from patient-centered studies to key HCW populations. A  New Jersey hospital system enacted an electronic hand hygiene compliance monitoring system  to track compliance based on the WHO’s “5-Moments for Hand Hygiene,”⁴⁶ which promotes  hand hygiene at five distinct times during healthcare delivery, and the CDC hygiene standards  in an effort to reduce HAIs.⁴⁷ The system uses monitors on point-of-care hand sanitizer and  soap dispensers to monitor compliance.⁴⁸ The DebMed System software assesses real hand  hygiene event data (actuation events recorded by monitored dispensers) by juxtaposing it with  an evidence-based estimate of overall hand hygiene opportunities, relying on the WHO’s 5  Moments.⁴⁹ These computations serve as the reference point for establishing a Hand Hygiene  Compliance Index (HHCI) for the 5 Moments.⁵⁰ Since 2015, participating units across the entire  healthcare system have had increases of nearly 70 percent in overall hand hygiene compliance,  with the system sustaining a 57 percent improvement overall. Currently, the entire system,  composed of seven hospitals, is nearing 90 percent compliance, while the main hospital,  Morristown Medical Center, is nearly at 100 percent compliance. The increased compliance  has yielded a 47 percent decrease in catheter-associated urinary tract infections, a decrease of  58 percent in surgical site infections, a decrease in C-difficile of 64 percent, and an 82 percent  decrease in Methicillin Resistance Staph Aureus blood infections.⁵¹ This decrease in the infection  rate of HAIs from an increase in hand hygiene compliance in a healthcare system suggests the  importance of hand hygiene in preventing OAIs.  

The constant flow of patients in and out of the ED with various acuity levels causes frequent  distractions and interruptions that may be barriers to infection control activities.⁵² A study  conducted in an urban, academic ED in Massachusetts with more than 57,000 annual visits  found numerous complications for hand hygiene compliance within its EDs.⁵³ The ED hand  hygiene compliance differed from non-ED hand hygiene compliance studies throughout  healthcare institutions.⁵⁴ The ED had 45 private treatment spaces and 17 hallway treatment  spaces, of which 25 private and 11 hallway spaces were being prescribed as high visibility on the basis of proximity to a nursing station. The ED had 146 alcohol-based hand hygiene  dispensers and 45 sinks. Within the study, the same traditional indicators for poor hand hygiene  compliance among HCWs, including glove use and the HCW role, were found in addition to ED specific predictors based on layout characteristics, including hallway bed location and patient  location in an observational unit.⁵⁵ Unlike inpatient units, the variable volume and emergent  needs of patients often mandate that additional bed space be made available in an ED. Hallway  patient location was found to be the strongest predictor of poor hand hygiene compliance in  the study.⁵⁶ The lower hand hygiene compliance for patients in hallway locations indicates that  environmental factors such as the location of hand hygiene supplies and work-related factors  such as crowding have major impacts on hand hygiene compliance in EDs. 

A study of a 1,100-bed ED at Methodist Hospital of Indiana in Indianapolis, a facility that conducts  tertiary care and is part of a teaching hospital, found that handwashing occurred at an overall  frequency of only 32.3 percent.⁵⁷ The study suggested the “large number of patient contacts,  simultaneous management of multiple patients, high illness acuity, and severe time constraints”  to be potential factors for poor compliance with hand hygiene in the ED, even though there  were accessible handwashing stations. The study found that handwashing after clean activities  averaged only 18.4 percent but was 59.8 percent for dirty and gloved contacts.⁵⁸ The study defined  clean contact as activities in which patient contact occurred, and in which there was contact with  materials that were associated with patients but were not known to be contaminated with patient  secretions. The presence of viruses on surfaces can be an exposure risk if there is unprotected  contact without hand hygiene following the contact. Glove use was also shown to diminish  compliance with handwashing by as much as 25 percent in another study, which is further  discussed in this section.⁵⁹ This behavioral factor may be based on HCW’s perception that gloves  are an alternative option to handwashing, based on a belief that the alternative would save time  in an ED setting where the number of distinct contacts with each patient is high.⁶⁰ 

A rebuild of an 800-bed referral hospital in the United Kingdom included a decrease in the  distance from clinical activity to sinks from 30 meters to no more than 5 meters and often much  less.⁶¹ This improved accessibility to sinks did not lead to an improvement in handwashing  compliance, suggesting there are other critical factors that must be addressed in hand hygiene  models to ensure a reduction in OAI.⁶² Low hand hygiene compliance has been shown to be  attributed to workloads within EDs.⁶³ Contributing factors from a study of low hand hygiene  compliance in a 40‐bed ED of a 475‐bed academic hospital in Toronto, Canada, were high and  unpredictable patient volumes, increasing acuity in the presenting patients, overcrowding of  the ED, insufficient staffing, and an associated lack of time.⁶⁴ With a variable volume consistent  within the United States and variable nurse-to-patient ratios throughout the shift, these  factors can be generalizable to the United States, serving as a platform from which to make  improvements.⁶⁵ EDs additionally face challenges in which presenting patients may not have  had any laboratory-confirmed results to identify positive presentation of infectious diseases to  dictate the need for various types of PPE.  

Similar to EDs, hygienic behavior has infrequently been studied in pre-hospital emergency care  settings. There are no sinks in the back of ambulances within the United States, or generally  around the globe, complicating hand hygiene compliance in an EMS environment.⁶⁶ A study of  1,494 EMS providers across the United States found that only 33 percent of providers reported cleaning their hands following invasive procedures, and 16 percent reported they never  cleaned their hands following invasive procedures. This was accompanied by only 52 percent  of respondents reporting wearing gloves with every patient contact.⁶⁷ Studies have found that  after patient care, a significant number of EMS providers have a heavy bacterial load on their  hands (77 percent) and only 24 percent of providers perform hand hygiene in between patients,  increasing the potential for exposure.⁶⁸ EMS providers frequently have contact with multiple  patients per day with varying health conditions and medical needs at the time of patient  contact. Unlike the cleaner environments of a hospital setting, EMS providers often contact  patients in their homes or other social environments such as restaurants or parks.  

There remains a gap in the expansive studies of the OAI risk factors within these pre hospital environments in the United States. A German study, however, which hygienically  and microbiologically examined the “handwashing area, equipment for artificial respiration,  insufflation, intubation, aspiration, intravasal catheterization, blood-pressure measurement, and  sterile materials storage” in 44 ambulances, found that blood pressure cuffs and stethoscopes  had the highest areas of contamination.⁶⁹ In high-volume areas, it is unlikely that multi-use  items will be disposed of due to the cost inhibition.⁷⁰ This can pose an additional source of  continued contamination outside of immediate patient contact should decontamination not be  done adequately—a concern in the fast-paced environments of EMS.⁷¹ 

While EMS providers in the United States receive mandatory annual OSHA training on  bloodborne pathogens, there remains a gap in training on the logistics and importance of  protocols for IPC and decontamination, which is necessary for infectious disease containment.⁷² EMS training focuses on swift and effective patient care, but lacks the comprehensive training  needed to conduct an extensive patient history assessment, which “could result in an inaccurate  diagnosis where early symptoms of an emerging or re-emerging [infectious disease] could be  mistaken for a routine influenza-like illness.”⁷³ Only 1.3 percent of the national EMS education  standards and curricula competencies are allocated to address the complex nature of infectious  diseases, placing EMS providers at risk. EMS practitioners are often the first HCWs to evaluate  patients and are frequently required to assess and treat patients without advanced notice  of diagnosis. Ebola Virus Disease was incorrectly marked as airborne by “17.3% of Frontline level respondents [with] similar percentages found in the airborne category for other viral  hemorrhagic fevers,” and 14.6 percent of frontline-level respondents incorrectly marked anthrax  as transmitted via human-to-human contact.⁷⁴ These gaps in infection control training can lead  to increased unease within EMS providers when responding to patients who are potentially  infected with transmissible diseases, reducing the response framework’s ability to respond to  and control an infectious disease outbreak.⁷⁵ 

Traditional hospital-based hand hygiene methods are complicated, and there is no easy method  that is directly applicable to an EMS setting. EMS providers often work in non-sterile environments  where invasive procedures may occur in the pre-hospital setting, which further increases the  potential for exposure and OAI. Ambulances may contain hand hygiene supplies such as hand  sanitizers, but there is an overall access issue during patient triage.⁷⁶ While hand hygiene solutions  can be available in the cabinets, the foaming solutions or liquid hand sanitizers are often not wall mounted at access points, leading to a further decrease in compliance. These EMS and ED-specific  factors increase the vulnerabilities and risks of OAI from the already elevated general risk of HCWs,  suggesting a need for a comprehensive approach to hand hygiene improvement strategies.

Available Approaches for Hand Hygiene Compliance 

Hand hygiene practices reflect attitudes, behaviors, and beliefs, which must all be addressed  to increase HCWs’ hand hygiene compliance. A multimodal strategy is necessary to increase  handwashing compliance and reduce OAIs in the complex environment of healthcare.  Multimodal strategies for hand hygiene have consistently been shown to be more successful in  improving rates of adherence than single interventions.⁷⁷ 

The WHO’s multimodal hand hygiene improvement strategy includes five key components  necessary for sustained and significant improvement in compliance.⁷⁸ The five components are  system change, training and education, evaluation and feedback, reminders in the workplace,  and institutional safety climate. The system change component ensures that the necessary  infrastructure is in place to allow HCWs to practice hand hygiene. The two major requirements  of system change are access to continuous water supply, soap, and towels as well as readily  accessible alcohol-based hand hygiene supplies at the point of care. The improvement strategy  must also include regular training on the importance of hand hygiene, leveraging the “5 Moments  for Hand Hygiene.”⁷⁹ The training should include discussing and displaying correct procedures for  hand rubbing and washing for all HCWs. Following the first two components, it is important to  have monitoring of hand hygiene practices and infrastructure. This evaluation and feedback will  include an inquiry into the perceptions and knowledge of HCWs and feedback on compliance and  correct practices for staff so they can make changes if needed. The improvement strategy also  calls for reminders in the workplace to prompt HCWs about the importance of hand hygiene and  to remind HCWs of the indications and procedures for the performance of hand hygiene. The final  component requires that institutions create a safety climate in which the environment for HCWs  precipitates awareness about safety issues while guaranteeing compliance with and consideration  of hand hygiene improvement at all levels within the institution. This includes active participation  at the individual and institutional levels, self-efficacy to make the improvements, and partnerships  with various outside organizations to promote improved compliance.⁸⁰ 

Multimodal approaches have been shown to be successful in the context of EDs.⁸¹ One specific  study was conducted from May–September 2013 in an ED in the Netherlands with an average  of 21,000 annual visits. The ED had 23 beds: three resuscitation rooms, 19 beds, and one triage  room. Approximately 1,000 opportunities for hand hygiene were evaluated among 57 ED nurses  and physicians. Compliance with hand hygiene increased significantly from baseline from 18  percent to 41 percent after the first week of education, reminders, and regular feedback and  stabilized to 50 percent and 46 percent after the second and third weeks, respectively.⁸² This  study found success with an intervention strategy that addressed knowledge (education),  awareness (performance feedback), action control (reminders), and social influences (role  models) in a team-directed strategy that included both individual providers and the institution  itself.⁸³ Although there are no identical studies in the EMS space, the lessons learned from the  ED can be applied to the EMS environment, which contains many of the same vulnerabilities  for OAI. While WHO recommendations are critical to a successful infection prevention system,  some gaps can be addressed through focused interventions within EDs and EMS.

Discussion and Recommendations 

EDs and EMS should leverage the WHO’s multimodal strategy to increase hand hygiene  improvement to reduce the vulnerabilities that place HCWs at an increased risk for OAI.  Actions that consider all five focus areas would be needed to address the complex human,  environmental, and institutional factors within these specialties that place them at an increased  risk for OAI compared to other HCWs. Integrated within the multimodal strategy, the 5  Moments for Hand Hygiene can be a valuable tool to help influence system change through  easy-to-remember reminders for HCWs. 

Integrated Infection Control Teams 

Hospitals frequently have infection control teams, but greater focus should be placed on OAI  prevention, and the infection control team model should be expanded to EMS, which typically  do not have dedicated infection control teams. These infection control teams should be  responsible for providing evaluation and feedback to ensure that there is compliance with hand  hygiene measures. Developing tools for compliance analysis, assessment of HCW knowledge,  and self-efficacy can further refine the focus of these teams for their respective providers. This  is especially critical for EMS workers who “have limited time in their national curricula devoted  to highly infectious disease identification and containment.”⁸⁴ The infection control teams  should also be responsible for installing visible and accessible workplace reminders, including  WHO’s “5 Moments for Hand Hygiene” posters, posters on handwashing, and hand hygiene  reminders on screensavers. This would be especially important for EMS, which has less space  to place reminders in the back of the ambulance but still requires some prompting to engage in  hand hygiene when in the field. 

EDs and EMS must also work collaboratively to share patient information and alert staff to any  precautions that must be taken at patient transfer if they are available. This collaboration also  requires a reporting and communication structure. By increasing collaboration and education,  EMS can specifically increase their ability to quickly and accurately recognize the presenting symptoms of an infectious disease, which can assist downstream resources in preparing for an  appropriate response.⁸⁵ Improved collaboration between the two services can also promote  the dissemination of evidence-based knowledge about handwashing and infection prevention.  Through this collaboration, there should also be hand hygiene compliance tracking, education,  and training, as well as increased access to hand hygiene supplies. Promoting a safety climate  where each service holds the other accountable by providing feedback and reminders can  promote systemic changes, which are essential. The operational separation between EMS and  EDs in many locations throughout the United States prevents EMS providers from accessing the  comprehensive training resources available to hospital providers.

Accessible and Easy-to-Use Hand Hygiene Supplies 

In the chaotic environments of EDs or in the field where EMS providers work, handwashing  stations or available hand hygiene supplies need to be placed in a way that providers can easily  use them. While it is not possible to immediately provide handwashing stations in ambulances,  there still exists a need for hand hygiene supplies such as hand sanitizer or other antiseptic hand  rubs to be available and easily accessible at ambulance entry doors. Handwashing stations should  also be available to EMS providers within the hospital to allow them to be compliant with full hand  hygiene following the transfer of a patient or decontamination of their equipment.  

EDs have been shown to have unique institutional features that limit the compliance of hand  hygiene. While crowding and understaffing within departments continue to be issues, providing  staff to support the influx and acuity of patients would allow more time to complete hand hygiene.⁸⁶ 

Training Programs 

Access to hand hygiene materials alone does not increase compliance.⁸⁷ Due to the variations  among state licensures, a cohesive and comprehensive model must be adopted through the  national curricula to promote mandatory infectious disease standards and training, increasing EMS  provider knowledge and readiness for infectious disease response.⁸⁸ The national EMS curricula  should collaborate with infection control professionals to develop training modules about infectious  disease and OAI prevention, increasing the allotment for this critical training from the minimal  1.3 percent currently in the curricula. The training should be completed in collaboration with the  CDC and WHO to ensure an alignment of recommendations for EMS personnel.⁸⁹ It is necessary to  include the other measures of the multimodal strategy. Training for EMS and EDs is necessary to  advise providers that there is no one-size-fits-all approach to hand hygiene or decontamination.  There must be annual training to ensure providers are reminded of the importance of hand  hygiene and best practices. This must include a demonstration of understanding the indicators  for hand hygiene and a demonstration of proper practices. There have been studies suggesting  that interactive education programs combined with the availability of hand hygiene products  increase compliance with hand hygiene. Additional programs that included positive role modeling  of proper hygiene behaviors and utilization of performance indicators also remarkedly improved  compliance.⁹⁰ A study in the United States suggested that embedding hand hygiene within a  stronger institutional safety climate while optimizing staffing levels dedicated to OAI prevention  would improve compliance and safety.⁹¹ A coordinated campaign to improve awareness of the risks  of non-compliance with hand hygiene in association with the WHO’s global campaign can begin  to change the safety culture within EDs and EMS. Without a culture change that promotes and  mandates hand hygiene compliance, the availability of hand hygiene products and handwashing  stations alone will be insufficient, leaving our frontline HCWs at risk for OAI. 

Additionally, in various fields, including the emergency response space, it is common for  services to regularly exchange data and insights regarding injuries, illnesses, and fatalities  stemming from the duties of responders.⁹² The firefighting sector, in particular, actively  disseminates information on near-misses to extract valuable lessons. This practice allows  departments worldwide to glean insights from these incidents, facilitating the implementation of necessary adjustments to prevent similar situations in the future.⁹³ The National Fire Fighter  Near-Miss Reporting System is a voluntary reporting system where firefighters can document  hazards, near-misses, injuries, and deaths.⁹⁴ A similar reporting system could be implemented  in the healthcare sector, particularly for EMS and EDs. By recording and sharing occupational  adverse incidents, healthcare professionals can learn from each other’s experiences, implement  preventive measures, and reduce the risks associated with OAIs to protect healthcare workers. 

Conclusion 

ED providers, EMS professionals, and all healthcare workers often face numerous diseases during  their lifesaving work.⁹⁵ One of the major constraints in the understanding of OAIs, especially in  EMS and EDs, is the limited number of studies and available data that can be leveraged to address  the vulnerabilities. For example, the largest nosocomial outbreak of SARS occurred in Hong Kong,  with an attack rate of 41 percent of hospital inpatients.⁹⁶ There is no detailed description of the  response, which hinders the ability for corrective action in Hong Kong and the infection control  community at large to collaborate on best practices.⁹⁷ Even less research and data are available  regarding EMS-based OAIs and the infection control procedures implemented, proving a major  gap in the protection of some of the most vulnerable and critical HCWs. An additional, unexplored  potential contributing factor in EMS may be the differences in training and education among  full-time, part-time, and volunteer staff. Research must include comprehensive evaluations of  the impacts of low hand hygiene compliance as an explicit factor in OAI while also investigating  the challenges of EMS and ED providers. This data can then be applied to address systematic  changes to improve compliance and prevent exposures. In addition, there is a large gap in  legislative protections for HCWs that could mandate data collection and analysis to find gaps and  vulnerabilities. For instance, only after legislation was passed by the New Jersey State Senate and  Assembly in December of 2020 were hospitals, surgery centers, long-term care facilities, hospice  centers, and home healthcare agencies required to report the incidence of COVID-19 cases and  fatalities among their employees to the Department of Health.⁹⁸ This should be expanded across  the country and include other pathogens to better protect our HCWs from OAI. 

The infection prevention infrastructure within the United States is necessary to protect frontline  workers. By applying the recommendations at the state level, public health departments can  leverage their traditional funding to help establish healthcare IPC approaches in the United States  as a model that can be adopted worldwide to promote greater protection of our healthcare  workers from OAI. EMS and ED staff are crucial parts of a critical infrastructure who are constantly  strained in steady-state conditions and even more so during epidemics and pandemics. The  COVID-19 pandemic has highlighted vulnerabilities within our IPC systems, particularly across EMS  and EDs. These systems and their personnel are in a constant cycle of exposure risk for OAIs until  we address the known IPC and training/awareness gaps. While protection will require the proper  use of PPE in the context of the pathogen, limitations in the availability of PPE, as seen during  the COVID-19 pandemic, mandate that hand hygiene is the most important but most underused  precaution measure. An investment in multimodal strategies for hand hygiene compliance can  have a three-fold impact on IPC compliance, decreases in nosocomial transmission risk, and  reducing OAIs to improve the resilience of our healthcare system and protection of our frontline  workers who put their lives on the line so that others may live.

Notes 

1. Chenchen Tian et al., “Risk Factors and Protective Measures for Healthcare Worker Infection during Highly  Infectious Viral Respiratory Epidemics,” Infection Control & Hospital Epidemiology, January, 639. https://doi. org/10.1017/ice.2021.18. 
2. Roger Chou et al., “Epidemiology of and Risk Factor for Coronavirus Infection in Health Care  Workers,” Annals of Internal Medicine 173, no. 2 (2020): 123, https://doi.org/10.7326/M20-1632;  Tian et al., “Risk Factors and Protective Measures for Healthcare Worker Infection during Highly  Infectious Viral Respiratory Epidemics,” 639.  
3. Roger Chou et al., “Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers,” 123. 
4. Tian et al., “Risk Factors and Protective Measures for Healthcare Worker Infection during Highly Infectious  Viral Respiratory Epidemics,” 639. 
5. Tian et al., 639. 
6. Tian et al., 639. 
7. Tian et al., 639. 
8. “World Health Organization Summary of Probable SARS Cases with Onset of Illness from 1 November 2002 to  31 July 2003,” World Health Organization, 2003, http://www.who.int/csr/sars/country/table2003_09_23/en/. 
9. Amgad A. Elkholy et al., “MERS-CoV Infection among Healthcare Workers and Risk Factors for Death:  Retrospective Analysis of All Laboratory-Confirmed Cases Reported to WHO from 2012 to 2 June 2018,”  Journal of Infection and Public Health 13, no. 3 (2020): 420, https://doi.org/10.1016/j.jiph.2019.04.011. 
10. Jian Xiao, Min Fang, Qiong Chen, and Bixiu He, “SARS, MERS and COVID-19 among Healthcare Workers:  A Narrative Review,” Journal of Infection and Public Health 13, no. 6 (2020): 844, https://doi.org/10.1016/j. jiph.2020.05.019. 
11. Rosario Barranco, Luca Vallega Bernucci Du Tremoul, and Francesco Ventura, “Hospital-Acquired SARS Cov-2 Infections in Patients: Inevitable Conditions or Medical Malpractice?” International Journal of  Environmental Research and Public Health 18, no. 2 (2021): 489, https://doi.org/10.3390/ijerph18020489. 
12. Aline Wolfensberger et al., “Nosocomial COVID-19 Incidence and Secondary Attack Rates among Patients  of Tertiary Care Center, Zurich, Switzerland,” Emerging Infectious Diseases 28, no. 10 (2022): 2088, https:// doi.org/10.3201/eid2810.220321. 
13. Jeffrey Cohen et al. Fields’ Virology, 6th ed. (Philadelphia: Wolters Kluwer Health/Lippincott Williams &  Wilkins), 17. 
14. Christina Jewett, Robert Lewis, and Melissa Bailey, “More than 2,900 Health Care Workers Died This Year— and the Government Barely Kept Track.” KFF Health News, December 23, 2020, https://kffhealthnews.org/ news/article/more-than-2900-health-care-workers-died-this-year-and-the-government-barely-kept-track/. 
15. “Health and Care Worker Deaths during COVID-19,” World Health Organization, 2021, https://www.who. int/news/item/20-10-2021-health-and-care-worker-deaths-during-covid-19. 
16. Deidre McPhillips, “Covid-19 Killed Fewer People in the US in 2022, but Early Data Suggests It Was Still a  Leading Cause of Death,” CNN, January 17, 2023, https://www.cnn.com/2023/01/17/health/covid-death reporting-2022/index.html.
17. Catharine I. Paules, Hilary D. Marston, and Anthony S. Fauci, “Coronavirus Infections—More Than Just the  Common Cold,” JAMA 323, no. 8 (2021): 707, https://doi.org/10.1001/jama.2020.0757. 
18. Terri Rebmann, Angela Vassallo, and Jill E. Holdsworth, “Availability of Personal Protective Equipment  and Infection Prevention Supplies during the First Month of the COVID-19 Pandemic: A National Study  by the APIC COVID-19 Task Force,” American Journal of Infection Control 49, no. 4 (2021): 436, https://doi. org/10.1016/j.ajic.2020.08.029. 
19. Paules, Marston, and Fauci, “Coronavirus Infections—More Than Just the Common Cold,” 707. 
20. “1910.120 App B – General Description and Discussion of the Levels of Protection and Protective  Gear,” United States Department of Labor, 1994, https://www.osha.gov/laws-regs/regulations/ standardnumber/1910/1910.120AppB. 
21. Aditya Shekhar, “PPE in EMS Moving Forward: Lessons Learned FROM COVID-19,” Journal of Emergency  Medical Services, June 2, 2020, https://www.jems.com/major-incidents/ppe-in-ems-moving-forward/. 
22. Shekhar, “PPE in EMS Moving Forward: Lessons Learned FROM COVID-19.” 
23. “Standard Precautions,” Centers for Disease Control, 2018, https://www.cdc.gov/infection-control/hcp/ basics/standard-precautions.html. 
24. Centers for Disease Control, “Standard Precautions.”  
25. Jos H. Verbeek et al. “Personal Protective Equipment for Preventing Highly Infectious Diseases Due to  Exposure to Contaminated Body Fluids in Healthcare Staff,” Cochrane Database of Systematic Reviews 2020,  no. 5 (2020), https://doi.org/10.1002/14651858.CD011621.pub5. 
26. Shekhar, “PPE in EMS Moving Forward: Lessons Learned FROM COVID-19.” 
27. Rebmann, Vassallo, and Holdsworth, “Availability of Personal Protective Equipment and Infection  Prevention Supplies during the First Month of the COVID-19 Pandemic,” 436. 
28. Rebmann, Vassallo, and Holdsworth, 436. 
29. Sherry L. Burrer et al., “Characteristics of Health Care Personnel with COVID-19—United States, February  12–April 9, 2020,” Morbidity and Mortality Weekly Report 69, no 15 (2020): 480, https://doi.org/10.15585/ mmwr.mm6915e6. 
30. “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings,”  Centers for Disease Control, 2019, https://www.cdc.gov/infectioncontrol/guidelines/isolation/scientific review.html. 
31. Centers for Disease Control, “Guideline for Isolation Precautions: Preventing Transmission of Infectious  Agents in Healthcare Settings.” 
32. Centers for Disease Control. 
33. Yatin Mehta et al., “Guidelines for Prevention of Hospital Acquired Infections,” Indian Journal of Critical Care  Medicine 18, no. 3 (2014): 150–51, https://doi.org/10.4103/0972-5229.128705. 
34. J. S. Garner et al., “Guideline for Isolation Precautions in Hospitals. Part I. Evolution of Isolation Practices,”  University of Texas Medical Branch, 1996, https://researchexperts.utmb.edu/en/publications/guideline for-isolation-precautions-in-hospitals-part-i-evolution. 
35. Centers for Disease Control, “Guideline for Isolation Precautions: Preventing Transmission of Infectious  Agents in Healthcare Settings.”
36. Emmanuelle Girou, “Efficacy of Handrubbing with Alcohol Based Solution versus Standard Handwashing  with Antiseptic Soap: Randomised Clinical Trial,” BMJ 325 (2002), https://doi.org/10.1136/bmj.325.7360.362. 
37. N. Lotfinejad, A. Peters, and D. Pittet, “Hand Hygiene and the Novel Coronavirus Pandemic: The Role  of Healthcare Workers,” Journal of Hospital Infection 105, no. 4 (2020): 776, https://doi.org/10.1016/j. jhin.2020.03.017; Andreas F. Widmer et al., “Introducing Alcohol-Based Hand Rub for Hand Hygiene  the Critical Need for Training.” Infection Control & Hospital Epidemiology 28, no. 1 (2007), https://doi. org/10.1086/510788. 
38. Wilawan Picheansathian, “A Systematic Review on the Effectiveness of Alcohol-Based Solutions for  Hand Hygiene,” International Journal of Nursing Practice 10, no. 1 (2004), https://doi.org/10.1111/j.1440- 172X.2003.00457.x. 
39. Purva Mathur, “Hand Hygiene: Back to the Basics of Infection Control,” The Indian Journal of Medical  Research 134, no. 5 (2011): 611, https://doi.org/10.4103/0971-5916.90985. 
40. A.S. Collins, “Preventing Health Care–Associated Infections,” in Patient Safety and Quality: An Evidence Based Handbook for Nurses, ed. RG Hughes (Agency for Healthcare Research and Quality, 2008), 553. 
41. Jeffrey D. Ho, Rebecca K. Ansari, and David Page, “Hand Sanitization Rates in an Urban  Emergency Medical Services System,” The Journal of Emergency Medicine 47, no. 2 (2014): 165,  https://doi.org/10.1016/j.jemermed.2013.08.070.; Jonathan Teter, Michael G. Millin, and Rick  Bissell, “Hand Hygiene in Emergency Medical Services,” Prehospital Emergency Care 19, no.  2 (2015): 316, https://doi.org/10.3109/10903127.2014.967427; Ryan S. Houser, “NJ EMS Line of  Duty Deaths,” Journal of Occupational & Environmental Medicine 64, no. 7 (2022): 576, https://doi. org/10.1097/JOM.0000000000002524. 
42. Michelle R. Meengs et al., “Hand Washing Frequency in an Emergency Department,” Annals of Emergency  Medicine 23, no. 6 (1994): 1308, https://doi.org/10.1016/S0196-0644(94)70357-4. 
43. Matthew P. Muller et al., “Hand Hygiene Compliance in an Emergency Department: The Effect of  Crowding,” Academic Emergency Medicine 22, no. 10 (2015): 1218–21, https://doi.org/10.1111/acem.12754. 
44. Ho, Ansari, and Page, “Hand Sanitization Rates in an Urban Emergency Medical Services System,” 165. 
45. Arjun K. Venkatesh, et al., “Predictors of Hand Hygiene in the Emergency Department,” Infection Control &  Hospital Epidemiology 32, no. 11 (2011): 1122, https://doi.org/10.1086/662374. 
46. The World Health Organization’s “5 Moments for Hand Hygiene” is a set of guidelines that helps HCWs  identify when to wash their hands to reduce the risk of spreading microorganisms: Moment 1: Before  touching a patient, Moment 2: Before a clean or aseptic procedure, Moment 3: After exposure to body  fluids or a risk of exposure, Moment 4: After touching a patient, Moment 5: After touching a patient’s  surroundings. 
47. “Save Lives – Clean Your Hands Campaign,” World Health Organization, 2021, https://www.who.int/ campaigns/world-hand-hygiene-day. 
48. “Morristown Medical Center Lauded Nationally for Nearly Perfect Clinical Hand Hygiene,” Atlantic Health  System, 2019, https://www.atlantichealth.org/about-us/stay-connected/news/press-releases/2019/hand hygiene-compliance-award.html. 
49. “Electronic Monitoring of Hand Hygiene Compliance,” Industry Innovations 1, no. 1 (2019).
50. “Electronic Monitoring of Hand Hygiene Compliance.” 
51. Atlantic Health System, “Morristown Medical Center Lauded Nationally for Nearly Perfect Clinical Hand  Hygiene.”
52.  Venkatesh, et al., “Predictors of Hand Hygiene in the Emergency Department,” 1122. 53. Venkatesh, et al., 1122. 
    54. Venkatesh, et al., 1122. 
    55. Venkatesh, et al., 1122. 
    56. Venkatesh, et al., 1122. 
    57. Meengs et al., “Hand Washing Frequency in an Emergency Department,” 1308. 
    58. Meengs et al., 1308. 
    59. M. Whitby and M.-L. McLaws, “Handwashing in Healthcare Workers: Accessibility of Sink Location Does  Not Improve Compliance,” Journal of Hospital Infection 58, no. 4 (2004): 249, https://doi.org/10.1016/j. jhin.2004.07.024. 
    60. Muller et al., “Hand Hygiene Compliance in an Emergency Department: The Effect of Crowding,” 1219. 
    61. Whitby and McLaws, “Handwashing in Healthcare Workers: Accessibility of Sink Location Does Not  Improve Compliance,” 249. 
    62. Whitby and McLaws, 249. 
    63. Muller et al., “Hand Hygiene Compliance in an Emergency Department: The Effect of Crowding,” 1219.
    64. Muller et al., 1219. 
    65. Alp Arkun et al., “Emergency Department Crowding: Factors Influencing Flow,” The Western Journal of  Emergency Medicine 11, no. 1 (2010): 14. 
    66. Amanda Ferreira Araujo et al., “Pre-Hospital Assistance by Ambulance in the Context of Coronavirus  Infections,” Revista Brasileira de Enfermagem 74, suppl 1 (2021), https://doi.org/10.1590/0034-7167-2020- 0657. 
    67. Joshua Bucher et al., “Hand Washing Practices Among Emergency Medical Services Providers,” Western  Journal of Emergency Medicine 16, no. 5 (2015): 734, https://doi.org/10.5811/westjem.2015.7.25917. 
    68. Teter, Millin, and Bissell, “Hand Hygiene in Emergency Medical Services,” 316. 
    69. P. Kober, “Hygienestatus von Fahrzeugen Und Ausrüstung Im Rettungsdienst,” AINS – Anästhesiologie ·  Intensivmedizin · Notfallmedizin · Schmerztherapie 36, no. 1 (2001): 28, https://doi.org/10.1055/s-2001-10237. 
    70. Bucher et al., “Hand Washing Practices Among Emergency Medical Services Providers,” 734. 
    71. Bucher et al., 734. 
    72. Aurora B. Le et al., “Determining Training and Education Needs Pertaining to Highly Infectious Disease  Preparedness and Response: A Gap Analysis Survey of US Emergency Medical Services Practitioners,”  American Journal of Infection Control 46, no. 3 (2018): 249, https://doi.org/10.1016/j.ajic.2017.09.024. 
    73. Le et al., “Determining Training and Education Needs Pertaining to Highly Infectious Disease Preparedness  and Response,” 249. 
    74. Le et al., 249.
    75. Le et al., 249. 
    76. Bucher et al., “Hand Washing Practices Among Emergency Medical Services Providers,” 734.
    77. Mathur, “Hand Hygiene: Back to the Basics of Infection Control,” 611. 
    78. “Guide to Implementation: A Guide to the Implementation of the WHO Multimodal Hand Hygiene  Improvement Strategy,” World Health Organization, 2009. https://qualityhealthservices.who.int/ quality-toolkit/qt-catalog-item/a-guide-to-the-implementation-of-the-who-multimodal-hand-hygiene improvement-strategy. 
    79. World Health Organization, “Guide to Implementation: A Guide to the Implementation of the WHO  Multimodal Hand Hygiene Improvement Strategy.”  
    80. World Health Organization. 
    81. 81. P.R.H. Arntz et al., “Effectiveness of a Multimodal Hand Hygiene Improvement Strategy in the  Emergency Department,” American Journal of Infection Control 44, no. 11 (2016): 1205, https:// doi.org/10.1016/j.ajic.2016.03.017; Qiu Du et al., “Nosocomial Infection of COVID-19: A New  Challenge for Healthcare Professionals (Review).” International Journal of Molecular Medicine 47,  no. 4 (2021): 31. https://doi.org/10.3892/ijmm.2021.4864; Manasij Mitra et al., “Prevention of  Hospital-Acquired Infections: A Construct during Covid-19 Pandemic,” Journal of Family Medicine  and Primary Care 10, no. 9 (2021): 3350, https://doi.org/10.4103/jfmpc.jfmpc_742_21; Mamdooh  Alzyood et al., “COVID-19 Reinforces the Importance of Handwashing.” Journal of Clinical Nursing 29, no. 15–16 (2020): 2760, https://doi.org/10.1111/jocn.15313; Bryan C. Knepper, Amber M. Miller,  and Heather L. Young, “Impact of an Automated Hand Hygiene Monitoring System Combined  with a Performance Improvement Intervention on Hospital-Acquired Infections,” Infection  Control & Hospital Epidemiology 41, no. 8 (2020): 934, https://doi.org/10.1017/ice.2020.182; Dinah  J. Gould et al., “Interventions to Improve Hand Hygiene Compliance in Patient Care,” Cochrane  Database of Systematic Reviews 2017, no. 9 (2017), https://doi.org/10.1002/14651858.CD005186. pub4; Nadia Masroor et al., “Approaches to Hand Hygiene Monitoring: From Low to High Technology  Approaches,” International Journal of Infectious Diseases 65, December (2017): 103, https://doi.org/10.1016/j. ijid.2017.09.031. 
    82. Arntz et al., “Effectiveness of a Multimodal Hand Hygiene Improvement Strategy in the Emergency  Department,” 1205. 
    83. Arntz et al., 1205. 
    84. Le et al., “Determining Training and Education Needs Pertaining to Highly Infectious Disease Preparedness  and Response,” 249. 
    85. Le et al., 249. 
    86. Eileen J. Carter et al., “Environmental Factors and Their Association with Emergency Department Hand  Hygiene Compliance: An Observational Study,” BMJ Quality & Safety 25, no. 5 (2016): 376, https://doi. org/10.1136/bmjqs-2015-004081. 
    87. Janet P. Haas and Elaine L. Larson, “Impact of Wearable Alcohol Gel Dispensers on Hand Hygiene in an  Emergency Department,” Academic Emergency Medicine 15, no. 4 (2008): 395, https://doi.org/10.1111/j.1553- 2712.2008.00045.x. 
    88. Le et al., “Determining Training and Education Needs Pertaining to Highly Infectious Disease Preparedness  and Response,” 249. 

Le et al., 249.

90. Mathur, “Hand Hygiene: Back to the Basics of Infection Control,” 611. 
91. Benedetta Allegranzi et al., “Status of the Implementation of the World Health Organization Multimodal  Hand Hygiene Strategy in United States of America Health Care Facilities,” American Journal of Infection  Control 42, no. 3 (2014): 228, https://doi.org/10.1016/j.ajic.2013.11.015. 
92. Houser, “NJ EMS Line of Duty Deaths,” 576. 
93. Houser, 576. 
94. Houser, 576. 
95. Kent A. Sepkowitz and Leon Eisenberg, “Occupational Deaths among Healthcare Workers,” Emerging  Infectious Diseases 11, no. 7 (2005): 1006, https://doi.org/10.3201/eid1107.041038. 
96. I. T. S. Yu et al., “Temporal-Spatial Analysis of Severe Acute Respiratory Syndrome among Hospital  Inpatients,” Clinical Infectious Diseases 40, no. 9 (2005): 1240, https://doi.org/10.1086/428735. 
97. Vincent C.C. Cheng et al., “Clinical Management and Infection Control of SARS: Lessons Learned,” Antiviral  Research 100, no. 2 (2013): 415, https://doi.org/10.1016/j.antiviral.2013.08.016. 

98. Susan Livio, “N.J. Hospitals, Nursing Homes Could Soon Be Required to Report COVID-19 Cases, Fatalities  among Workers,” NJ.Com, December 19, 2020, https://www.nj.com/politics/2020/12/nj-hospitals-nursing homes-could-soon-be-required-to-report-covid-19-cases-fatalities-among-workers.html.

Bibliography 

Allegranzi, Benedetta, Laurie Conway, Elaine Larson, and Didier Pittet. “Status of the Implementation of the  World Health Organization Multimodal Hand Hygiene Strategy in United States of America Health Care Facilities.”  American Journal of Infection Control 42, no. 3 (2014): 224–30. https://doi.org/10.1016/j.ajic.2013.11.015. 

Alzyood, Mamdooh, Debra Jackson, Helen Aveyard, and Joanne Brooke. “COVID-19 Reinforces the Importance of  Handwashing.” Journal of Clinical Nursing 29, no. 15–16 (2020): 2760–61. https://doi.org/10.1111/jocn.15313. 

Araujo, Amanda Ferreira, Eric Rosa Pereira, Sabrina da Costa Machado Duarte, and Priscilla Valladares Broca. “Pre Hospital Assistance by Ambulance in the Context of Coronavirus Infections.” Revista Brasileira de Enfermagem 74,  suppl 1 (2021). https://doi.org/10.1590/0034-7167-2020-0657. 

Arkun, Alp, William M. Briggs, Sweha Patel, Paris A. Datillo, Joseph Bove, and Robert H. Birkhahn. “Emergency  Department Crowding: Factors Influencing Flow.” The Western Journal of Emergency Medicine 11, no. 1 (2010):  10–15. 

Arntz, P.R.H., J. Hopman, M. Nillesen, E. Yalcin, C.P. Bleeker-Rovers, A. Voss, M. Edwards, and A. Wei. “Effectiveness  of a Multimodal Hand Hygiene Improvement Strategy in the Emergency Department.” American Journal of Infection  Control 44, no. 11 (2016): 1203–7. https://doi.org/10.1016/j.ajic.2016.03.017. 

Atlantic Health System. “Morristown Medical Center Lauded Nationally for Nearly Perfect Clinical Hand Hygiene.”  2019. https://www.atlantichealth.org/about-us/stay-connected/news/press-releases/2019/hand-hygiene compliance-award.html. 

Barranco, Rosario, Luca Vallega Bernucci Du Tremoul, and Francesco Ventura. “Hospital-Acquired SARS-Cov-2  Infections in Patients: Inevitable Conditions or Medical Malpractice?” International Journal of Environmental  Research and Public Health 18, no. 2 (2015): 489. https://doi.org/10.3390/ijerph18020489. 

Bucher, Joshua, Colleen Donovan, Pamela Ohman-Strickland, and Jonathan McCoy. “Hand Washing Practices  Among Emergency Medical Services Providers.” Western Journal of Emergency Medicine 16, no. 5 (2015): 727–35.  https://doi.org/10.5811/westjem.2015.7.25917. 

Burrer, Sherry L., Marie A. de Perio, Michelle M. Hughes, David T. Kuhar, Sara E. Luckhaupt, Clinton J. McDaniel,  Rachael M. Porter et al. “Characteristics of Health Care Personnel with COVID-19—United States, February 12–April  9, 2020.” Morbidity and Mortality Weekly Report 69, no. 15 (2020): 477–81. https://doi.org/10.15585/mmwr. mm6915e6. 

Carter, Eileen J., Peter Wyer, James Giglio, Haomiao Jia, Germaine Nelson, Vepuka E. Kauari, and Elaine L. Larson.  “Environmental Factors and Their Association with Emergency Department Hand Hygiene Compliance: An  Observational Study.” BMJ Quality & Safety 25, no. 5 (2016): 372–78. https://doi.org/10.1136/bmjqs-2015-004081. 

Centers for Disease Control. “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in  Healthcare Settings.” 2019. https://www.cdc.gov/infectioncontrol/guidelines/isolation/scientific-review.html. 

———. “Standard Precautions.” 2018. https://www.cdc.gov/infection-control/hcp/basics/standard-precautions.html. 

Cheng, Vincent C.C., Jasper F.W. Chan, Kelvin K.W. To, and K.Y. Yuen. “Clinical Management and Infection  Control of SARS: Lessons Learned.” Antiviral Research 100, no. 2 (2013): 407–19. https://doi.org/10.1016/j. antiviral.2013.08.016. 

Chou, Roger, Tracy Dana, David I. Buckley, Shelley Selph, Rongwei Fu, and Annette M. Totten. “Epidemiology of  and Risk Factors for Coronavirus Infection in Health Care Workers.” Annals of Internal Medicine 173, no. 2 (2020):  120–36. https://doi.org/10.7326/M20-1632.

Cohen, Jeffrey, Diane Griffin, Robert Lamb, Malcolm Martin, Vincent Racaniello, and Bernard Roizman. Fields’  Virology. 6th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2013.  

Collins, A.S. “Preventing Health Care–Associated Infections.” In Patient Safety and Quality: An Evidence-Based  Handbook for Nurses, edited by RG Hughes, chapter 41. Agency for Healthcare Research and Quality, 2008. 

Du, Qiu, Dingding Zhang, Weimin Hu, Xuefei Li, Qiongrong Xia, Taishen Wen, and Haiping Jia. “Nosocomial Infection  of COVID-19: A New Challenge for Healthcare Professionals (Review).” International Journal of Molecular Medicine 47, no. 4 (2021): 31. https://doi.org/10.3892/ijmm.2021.4864. 

Elkholy, Amgad A., Rebecca Grant, Abdullah Assiri, Mohamed Elhakim, Mamunur R. Malik, and Maria D. Van  Kerkhove. “MERS-CoV Infection among Healthcare Workers and Risk Factors for Death: Retrospective Analysis of All  Laboratory-Confirmed Cases Reported to WHO from 2012 to 2 June 2018.” Journal of Infection and Public Health 13, no. 3 (2020): 418–22. https://doi.org/10.1016/j.jiph.2019.04.011. 

Garner, J. S., W. J. Hierholzer, R. D. McCormick, A. B. Adams, D. E. Craven, D. W. Fleming, M. J. Gilchrist et al.  “Guideline for Isolation Precautions in Hospitals. Part I. Evolution of Isolation Practices.” University of Texas Medical  Branch. 1996. https://researchexperts.utmb.edu/en/publications/guideline-for-isolation-precautions-in-hospitals part-i-evolution. 

Girou, Emmanuelle. “Efficacy of Handrubbing with Alcohol Based Solution versus Standard Handwashing with  Antiseptic Soap: Randomised Clinical Trial.” BMJ 325, (2002). https://doi.org/10.1136/bmj.325.7360.362. 

Gould, Dinah J, Donna Moralejo, Nicholas Drey, Jane H Chudleigh, and Monica Taljaard. “Interventions to Improve  Hand Hygiene Compliance in Patient Care.” Cochrane Database of Systematic Reviews 2017, no. 9 (2017). https:// doi.org/10.1002/14651858.CD005186.pub4. 

Haas, Janet P., and Elaine L. Larson. “Impact of Wearable Alcohol Gel Dispensers on Hand Hygiene in an Emergency  Department.” Academic Emergency Medicine 15, no. 4 (2008): 393–96. https://doi.org/10.1111/j.1553- 2712.2008.00045.x. 

Ho, Jeffrey D., Rebecca K. Ansari, and David Page. “Hand Sanitization Rates in an Urban Emergency Medical  Services System.” The Journal of Emergency Medicine 47, no. 2 (2014): 163–68. https://doi.org/10.1016/j. jemermed.2013.08.070. 

Houser, Ryan S. “NJ EMS Line of Duty Deaths.” Journal of Occupational & Environmental Medicine 64, no. 7 (2022):  573–77. https://doi.org/10.1097/JOM.0000000000002524. 

Infection Prevention and Control Canada. “Electronic Monitoring of Hand Hygiene Compliance.” Industry  Innovations 1, no. 1 (2019). 

Jewett, Christina, Robert Lewis, and Melissa Bailey. “More than 2,900 Health Care Workers Died This Year—and the  Government Barely Kept Track.” KFF Health News. December 23, 2020. https://kffhealthnews.org/news/article/ more-than-2900-health-care-workers-died-this-year-and-the-government-barely-kept-track/. 

Knepper, Bryan C., Amber M. Miller, and Heather L. Young. “Impact of an Automated Hand Hygiene Monitoring  System Combined with a Performance Improvement Intervention on Hospital-Acquired Infections.” Infection  Control & Hospital Epidemiology 41, no. 8 (2020): 931–37. https://doi.org/10.1017/ice.2020.182. 

Kober, P. “Hygienestatus von Fahrzeugen Und Ausrüstung Im Rettungsdienst.” AINS – Anästhesiologie ·  Intensivmedizin · Notfallmedizin · Schmerztherapie 36, no. 1 (2001): 25–30. https://doi.org/10.1055/s-2001-10237. 

Le, Aurora B., Sean A. Buehler, Paul M. Maniscalco, Pamela Lane, Lloyd E. Rupp, Eric Ernest, Debra Von Seggern, et  al. “Determining Training and Education Needs Pertaining to Highly Infectious Disease Preparedness and Response:  A Gap Analysis Survey of US Emergency Medical Services Practitioners.” American Journal of Infection Control 46,  no. 3 (2018): 246–52. https://doi.org/10.1016/j.ajic.2017.09.024. 

Livio, Susan. “N.J. Hospitals, Nursing Homes Could Soon Be Required to Report COVID-19 Cases, Fatalities among  Workers.” NJ.Com, December 19, 2020.

Lotfinejad, N., A. Peters, and D. Pittet. “Hand Hygiene and the Novel Coronavirus Pandemic: The Role of Healthcare  Workers.” Journal of Hospital Infection 105, no. 4 (2020): 776–77. https://doi.org/10.1016/j.jhin.2020.03.017. 

Masroor, Nadia, Michelle Doll, Michael Stevens, and Gonzalo Bearman. “Approaches to Hand Hygiene Monitoring:  From Low to High Technology Approaches.” International Journal of Infectious Diseases 65, December (2017): 101– 4. https://doi.org/10.1016/j.ijid.2017.09.031. 

Mathur, Purva. “Hand Hygiene: Back to the Basics of Infection Control.” The Indian Journal of Medical Research 134,  no. 5 (2011): 611. https://doi.org/10.4103/0971-5916.90985. 

McPhillips, Deidre. “Covid-19 Killed Fewer People in the US in 2022, but Early Data Suggests It Was Still a Leading  Cause of Death.” CNN, January 17, 2023. 

Meengs, Michelle R., Beverly K. Giles, Carey D. Chisholm, William H. Cordell, and David R. Nelson. “Hand Washing  Frequency in an Emergency Department.” Annals of Emergency Medicine 23, no. 6 (1994): 1307–12. https://doi. org/10.1016/S0196-0644(94)70357-4. 

Mehta, Yatin, Abhinav Gupta, Subhash Todi, Sn Myatra, D P Samaddar, Vijaya Patil, Pradip Kumar Bhattacharya et  al. “Guidelines for Prevention of Hospital Acquired Infections.” Indian Journal of Critical Care Medicine 18, no. 3  (2014): 149–63. https://doi.org/10.4103/0972-5229.128705. 

Mitra, Manasij, Amrita Ghosh, Ranabir Pal, and Maitraye Basu. “Prevention of Hospital-Acquired Infections: A  Construct during Covid-19 Pandemic.” Journal of Family Medicine and Primary Care 10, no. 9 (2021): 3348–54.  https://doi.org/10.4103/jfmpc.jfmpc_742_21. 

Muller, Matthew P., Eileen Carter, Naureen Siddiqui, and Elaine Larson. “Hand Hygiene Compliance in an Emergency  Department: The Effect of Crowding.” Academic Emergency Medicine 22, no. 10 (2015): 1218–21. https://doi. org/10.1111/acem.12754. 

Paules, Catharine I., Hilary D. Marston, and Anthony S. Fauci. “Coronavirus Infections—More Than Just the  Common Cold.” JAMA 323, no. 8 (2020): 707. https://doi.org/10.1001/jama.2020.0757. 

Picheansathian, Wilawan. “A Systematic Review on the Effectiveness of Alcohol-Based Solutions for Hand Hygiene.”  International Journal of Nursing Practice 10, no. 1 (2004): 3–9. https://doi.org/10.1111/j.1440-172X.2003.00457.x. 

Rebmann, Terri, Angela Vassallo, and Jill E. Holdsworth. “Availability of Personal Protective Equipment and Infection  Prevention Supplies during the First Month of the COVID-19 Pandemic: A National Study by the APIC COVID-19 Task  Force.” American Journal of Infection Control 49, no. 4 (2021): 434–37. https://doi.org/10.1016/j.ajic.2020.08.029. 

Sepkowitz, Kent A., and Leon Eisenberg. “Occupational Deaths among Healthcare Workers.” Emerging Infectious  Diseases 11, no. 7 (2005): 1003–8. https://doi.org/10.3201/eid1107.041038. 

Shekhar, Aditya. “PPE in EMS Moving Forward: Lessons Learned FROM COVID-19.” Journal of Emergency Medical  Services. June 2, 2020. https://www.jems.com/major-incidents/ppe-in-ems-moving-forward/. 

Teter, Jonathan, Michael G. Millin, and Rick Bissell. “Hand Hygiene in Emergency Medical Services.” Prehospital  Emergency Care 19, no. 2 (2015): 313–19. https://doi.org/10.3109/10903127.2014.967427. 

Tian, Chenchen, Olivia Lovrics, Alon Vaisman, Ki Jinn Chin, George Tomlinson, Yung Lee, Marina Englesakis et al.  “Risk Factors and Protective Measures for Healthcare Worker Infection during Highly Infectious Viral Respiratory  Epidemics: A Systematic Review and Meta-Analysis.” Infection Control & Hospital Epidemiology 43 (2022): 639–50.  https://doi.org/10.1017/ice.2021.18. 

United States Department of Labor. “1910.120 App B – General Description and Discussion of the  Levels of Protection and Protective Gear.” 1994. https://www.osha.gov/laws-regs/regulations/ standardnumber/1910/1910.120AppB.

Venkatesh, Arjun K., Daniel J. Pallin, Stephanie Kayden, and Jeremiah D. Schuur. “Predictors of Hand Hygiene in  the Emergency Department.” Infection Control & Hospital Epidemiology 32, no. 11 (2011): 1120–23. https://doi. org/10.1086/662374. 

Verbeek, Jos H., Blair Rajamaki, Sharea Ijaz, Riitta Sauni, Elaine Toomey, Bronagh Blackwood, Christina Tikka et  al. “Personal Protective Equipment for Preventing Highly Infectious Diseases Due to Exposure to Contaminated  Body Fluids in Healthcare Staff.” Cochrane Database of Systematic Reviews 2020, no. 5 (2020). https://doi. org/10.1002/14651858.CD011621.pub5. 

Whitby, M., and M.-L. McLaws. “Handwashing in Healthcare Workers: Accessibility of Sink Location Does  Not Improve Compliance.” Journal of Hospital Infection 58, no. 4 (2004): 247–53. https://doi.org/10.1016/j. jhin.2004.07.024. 

Widmer, Andreas F., Martin Conzelmann, Milanka Tomic, Reno Frei, and Anne M. Stranden. “Introducing Alcohol Based Hand Rub for Hand Hygiene The Critical Need for Training.” Infection Control & Hospital Epidemiology 28, no.  1 (2007): 50–54. https://doi.org/10.1086/510788. 

Wolfensberger, Aline, Verena Kufner, Maryam Zaheri, Marius Zeeb, Isabelle Nortes, Peter W. Schreiber, Miriam  Vazquez, et al. “Nosocomial COVID-19 Incidence and Secondary Attack Rates among Patients of Tertiary Care  Center, Zurich, Switzerland.” Emerging Infectious Diseases 28, no. 10 (2022): 2087–90. https://doi.org/10.3201/ eid2810.220321. 

World Health Organization. “Guide to Implementation: A Guide to the Implementation of the WHO Multimodal  Hand Hygiene Improvement Strategy.” 2009. https://qualityhealthservices.who.int/quality-toolkit/qt-catalog-item/ a-guide-to-the-implementation-of-the-who-multimodal-hand-hygiene-improvement-strategy. 

———. “Health and Care Worker Deaths during COVID-19.” 2021. https://www.who.int/news/item/20-10-2021- health-and-care-worker-deaths-during-covid-19. 

———. “Save Lives – Clean Your Hands Campaign.” 2021. https://www.who.int/campaigns/world-hand-hygiene-day. 

———. “World Health Organization Summary of Probable SARS Cases with Onset of Illness from 1 November 2002  to 31 July 2003.” 2003. http://www.who.int/csr/sars/country/table2003_09_23/en/. 

Xiao, Jian, Min Fang, Qiong Chen, and Bixiu He. “SARS, MERS and COVID-19 among Healthcare Workers: A  Narrative Review.” Journal of Infection and Public Health 13, no. 6 (2020): 843–48. https://doi.org/10.1016/j. jiph.2020.05.019. 

Yu, I. T. S., T. W. Wong, Y. L. Chiu, N. Lee, and Y. Li. “Temporal-Spatial Analysis of Severe Acute Respiratory Syndrome  among Hospital Inpatients.” Clinical Infectious Diseases 40, no. 9 (2005): 1237–43. https://doi.org/10.1086/428735.