Abstract
Emergency medical service (EMS) providers have a higher potential exposure to infectious agents than the general public (Nguyen et al., 2020, “Risk of COVID-19 Among Frontline Healthcare Workers and the General Community: A Prospective Cohort Study,” Lancet Pub. Health, 5(9), pp. e475–e483; Brown et al., 2021, “Risk for Acquiring Coronavirus Disease Illness Among Emergency Medical Service Personnel Exposed to Aerosol-Generating Procedures,” Emer. Infect. Disease J., 27(9), p. 2340). The use of protective equipment may reduce, but does not eliminate their risk of becoming infected as a result of these exposures. Prehospital environments have a high risk of disease transmission exposing EMS providers to bioaerosols and droplets from infectious patients. Field intubation procedures may be performed causing the generation of bioaerosols, thereby increasing the exposure of EMS workers to pathogens. Additionally, ambulances have a reduced volume compared to a hospital treatment space, often without an air filtration system, and no control mechanism to reduce exposure. This study evaluated a containment plus filtration intervention for reducing aerosol concentrations in the patient module of an ambulance. Aerosol concentration measurements were taken in an unoccupied research ambulance at National Institute for Occupational Safety and Health (NIOSH) Cincinnati using a tracer aerosol and optical particle counters (OPCs). The evaluated filtration intervention was a containment pod with a high efficiency particulate air (HEPA)-filtered extraction system that was developed and tested based on its ability to contain, capture, and remove aerosols during the intubation procedure. Three conditions were tested (1) baseline (without intervention), (2) containment pod with HEPA-1, and (3) containment pod with HEPA-2. The containment pod with HEPA-filtered extraction intervention provided containment of 95% of the total generated particle concentration during aerosol generation relative to the baseline condition, followed by rapid air cleaning within the containment pod. This intervention can help reduce aerosol concentrations within ambulance patient modules while performing aerosol-generating procedures.
Issue Section:
Research Papers
References
1.
Nguyen
, L. H.
, Drew
, D. A.
, Graham
M.S.
, Joshi
, A. D.
, Guo
, C. G.
, Ma
, W.
, Mehta
, R. S.
et al., 2020
, “Risk of COVID-19 Among Front-line Health-care Workers and the General Community: A Prospective Cohort Study
,” Lancet Pub. Health
, 5(9
), pp. e475
–e483
.10.1016/S2468-2667(20)30164-X2.
Brown
,
A.
,
Schwarcz
,
L.
,
Counts
,
C.
,
Barnard
,
L.
,
Yang
,
B.
,
Emert
,
J.
,
Latimer
,
A.
, et al., 2021
, “
Risk for Acquiring Coronavirus Disease Illness Among Emergency Medical Service Personnel Exposed to Aerosol-Generating Procedures
,” Emer. Infect. Disease J.
,
27
(9
), p. 2340
.10.3201/eid2709.2103633.
Lindsley
,
W. G.
,
Blachere
,
F. M.
,
McClelland
,
T. L.
,
Neu
,
D. T.
,
Mnatsakanova
,
A.
,
Martin
,
S. B.
, Jr.
,
Mead
,
K. R.
, et al., 2019
, “
Efficacy of an Ambulance Ventilation System in Reducing EMS Worker Exposure to Airborne Particles From a Patient Cough Aerosol Simulator
,” J. Occup. Environ. Hyg.
,
16
(12
), pp. 804
–816
.10.1080/15459624.2019.16748584.
Sayed
,
M. E.
,
Kue
,
R.
,
McNeil
,
C.
, and
Dyer
,
K. S.
, 2011
, “
A Descriptive Analysis of Occupational Health Exposures in an Urban Emergency Medical Services System: 2007–2009
,” Prehospital Emerg. Care
,
15
(4
), pp. 506
–510
.10.3109/10903127.2011.5986085.
Gnugnoli
,
D. M.
,
S
,
A.
, and
Shafer
,
K.
, 2021
, “
StatPearls [Internet]
,” EMS Field Intubation
,
StatPearls Publishing
,
Treasure Island, FL
.6.
Meng
,
L.
,
Qiu
,
H.
,
Wan
,
L.
,
Ai
,
Y.
,
Xue
,
Z.
,
Guo
,
Q.
,
Deshpande
,
R.
,
Zhang
,
L.
,
Meng
,
J.
,
Tong
,
C.
,
Liu
,
H.
, and
Xiong
,
L.
, 2020
, “
Intubation and Ventilation Amid the COVID-19 Outbreak: Wuhan's Experience
,” Anesthesiology
,
132
(6
), pp. 1317
–1332
.10.1097/ALN.00000000000032967.
Simpson
,
J. P.
,
Wong
,
D. N.
,
Verco
,
L.
,
Carter
,
R.
,
Dzidowski
,
M.
, and
Chan
,
P. Y.
, 2020
, “
Measurement of Airborne Particle Exposure During Simulated Tracheal Intubation Using Various Proposed Aerosol Containment Devices During the COVID-19 Pandemic
,” Anaesthesia
,
75
(12
), pp. 1587
–1595
.10.1111/anae.151888.
El-Boghdadly
,
K.
,
Wong
,
D. J. N.
,
Owen
,
R.
,
Neuman
,
M. D.
,
Pocock
,
S.
,
Carlisle
,
J. B.
,
Johnstone
,
C.
, et al., 2020
, “
Risks to Healthcare Workers Following Tracheal Intubation of Patients With COVID-19: A Prospective International Multicentre Cohort Study
,” Anaesthesia
,
75
(11
), pp. 1437
–1447
.10.1111/anae.151709.
Ng
,
K.
,
Poon
,
B. H.
,
Kiat Puar
,
T. H.
,
Shan Quah
,
J. L.
,
Loh
,
W. J.
,
Wong
,
Y. J.
,
Tan
,
T. Y.
, et al., 2020
, “
COVID-19 and the Risk to Health Care Workers: A Case Report
,” Ann. Intern. Med.
,
172
(11
), pp. 766
–767
.10.7326/L20-017510.
Luo
,
M.
,
Cao
,
S.
,
Wei
,
L.
,
Tang
,
R.
,
Hong
,
S.
,
Liu
,
R.
, and
Wang
,
Y.
, 2020
, “
Precautions for Intubating Patients With COVID-19
,” Anesthesiology
,
132
(6
), pp. 1616
–1618
.10.1097/ALN.000000000000328811.
Weissman
,
D. N.
,
de Perio
,
M. A.
, and
Radonovich
,
L. J.
Jr.
, 2020
, “
COVID-19 and Risks Posed to Personnel During Endotracheal Intubation
,” JAMA
,
323
(20
), pp. 2027
–2028
.10.1001/jama.2020.662712.
U.S. Centers for Disease Control and Prevention
, 2020
, “
First Responders: Interim Recommendations for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points/Emergency Communication Centers (PSAP/ECCs) in the United States During the Coronavirus Disease (COVID-19) Pandemic,” U.S. Centers for Disease Control and Prevention, Atlanta, GA, accessed May 9, 2021
, https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-for-ems.html13.
Occupational Safety and Health Administration (OSHA),
2021, “
Healthcare Workers and Employers
,” OSHA, Washington, DC, accessed Aug. 3, 2021, https://www.osha.gov/coronavirus/control-prevention/healthcare-workers14.
Environmental Protection Agency (EPA),
2021
, “
About List N: Disinfectants for Coronavirus (COVID-19)
,” EPA, Washington, DC, accessed Nov. 9, 2021, https://www.epa.gov/coronavirus/about-list-n-disinfectants-coronavirus-covid-19-015.
U.S. Centers for Disease Control and Prevention
, 2022
, “
Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic
,” U.S. Centers for Disease Control and Prevention, Atlanta, GA, accessed Oct. 24, 2022, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#anchor_160436067915016.
Tsuda
,
A.
,
Henry
,
F. S.
, and
Butler
,
J. P.
, 2013
, “
Particle transport and Deposition: Basic Physics of Particle Kinetics
,” Compr. Physiol.
,
3
(4
), pp. 1437
–1471
.10.1002/cphy.c10008517.
Brown
,
J. S.
,
Gordon
,
T.
,
Price
,
O.
, and
Asgharian
,
B.
, 2013
, “
Thoracic and Respirable Particle Definitions for Human Health Risk Assessment
,” Part Fibre Toxicol.
,
10
, p. 12
.10.1186/1743-8977-10-1218.
Morawska
,
L.
, and
Buonanno
,
G.
, 2021
, “
The Physics of Particle Formation and Deposition During Breathing
,” Nat. Rev. Phys.
,
3
(5
), pp. 300
–301
.10.1038/s42254-021-00307-419.
Madas
,
B. G.
,
Füri
,
P.
,
Farkas
,
Á.
,
Nagy
,
A.
,
Czitrovszky
,
A.
,
Balásházy
,
I.
,
Schay
,
G. G.
, and
Horváth
,
A.
, 2020
, “
Deposition Distribution of the New Coronavirus (SARS-CoV-2) in the Human Airways Upon Exposure to Cough-Generated Droplets and Aerosol Particles
,” Sci. Rep.
,
10
(1
), p. 22430
.10.1038/s41598-020-79985-620.
Brant-Zawadzki
,
G. M.
,
Ockerse
,
P.
,
Brunson
,
J. R.
,
Smith
,
J. L.
,
McRae
,
B. R.
,
Fonnesbeck
,
A.
,
Ledyard
,
H.
,
Ruechel
,
A.
, and
Fassl
,
B. A.
, 2021
, “
An Aerosol Containment and Filtration Tent for Intubation During the COVID-19 Pandemic
,” Surg. Innov.
,
28
(2
), pp. 226
–230
.10.1177/155335062199997621.
Endersby
,
R. V. W.
,
Ho
,
E. C. Y.
,
Spencer
,
A. O.
,
Goldstein
,
D. H.
, and
Schubert
,
E.
, 2020
, “
Barrier Devices for Reducing Aerosol and Droplet Transmission in COVID-19 Patients: Advantages, Disadvantages, and Alternative Solutions
,” Anesth. Analg.
,
131
(2
), pp. e121
–e123
.10.1213/ANE.000000000000495322.
Fidler
,
R. L.
,
Niedek
,
C. R.
,
Teng
,
J. J.
,
Sturgeon
,
M. E.
,
Zhang
,
Q.
,
Robinowitz
,
D. L.
, and
Hirsch
,
J.
, 2021
, “
Aerosol Retention Characteristics of Barrier Devices
,” Anesthesiology
,
134
(1
), pp. 61
–71
.10.1097/ALN.000000000000359723.
Kumar
,
P.
,
Chaudhry
,
D.
,
Lalwani
,
L. K.
, and
Singh
,
P. K.
, 2020
, “
Modified Barrier Enclosure for Noninvasive Respiratory Support in COVID-19 Outbreak
,” Indian J. Crit. Care Med.
,
24
(9
), pp. 835
–837
.10.5005/jp-journals-10071-2359124.
Luk
,
H. N.
,
Yang
,
Y. L.
,
Huang
,
C. H.
,
Su
,
I. M.
, and
Tsai
,
P. B.
, 2021
, “
Application of Plastic Sheet Barrier and Video Intubating Stylet to Protect Tracheal Intubators During Coronavirus Disease 2019 Pandemic: A Taiwan Experience
,” Cell Transplant
,
30
, Article No. 963689720987527.10.1177/096368972098752725.
Gore
,
R. K.
,
Saldana
,
C.
,
Wright
,
D. W.
, and
Klein
,
A. M.
, 2020
, “
Intubation Containment System for Improved Protection From Aerosolized Particles During Airway Management
,” IEEE J. Transl. Eng. Health Med.
,
8
, p. 1600103
.10.1109/JTEHM.2020.299353126.
U.S. Food and Drug Admininstration (FDA),
2020
, “
Protective Barrier Enclosures Without Negative Pressure Used During the COVID-19 Pandemic May Increase Risk to Patients and Health Care Providers - Letter to Health Care Providers
,” FDA, Washington, DC, accessed Aug. 4, 2021, https://www.fda.gov/medical-devices/letters-health-care-providers/protective-barrier-enclosures-without-negative-pressure-used-during-covid-19-pandemic-may-increase27.
Vivek
,
C.
, 2021
, “
Creating and Validating a Negative Pressure Hepa Filtration Tent
,” American Society of Anesthesiologists, Schaumburg, IL.28.
Gupta
,
V.
,
Sahani
,
A.
,
Mohan
,
B.
, and
Wander
,
G. S.
, 2020
, “
Negative Pressure Aerosol Containment Box: An Innovation to Reduce COVID-19 Infection Risk in Healthcare Workers
,” J. Anaesthesiol. Clin. Pharmacol.
,
36
(Suppl 1
), p. S144
.10.4103/joacp.JOACP_217_2029.
Phu
,
H. T.
,
Park
,
Y.
,
Andrews
,
A. J.
,
Marabella
,
I.
,
Abraham
,
A.
,
Mimmack
,
R.
,
Olson
,
B.
,
A.
, Chaika
,
J.
, Floersch
,
E.
, Remskar
,
M.
, Hume
,
J. R.
, Fischer
,
G. A.
, Belani
,
K.
, and
Hogan
,
C. J.
, Jr.
, 2020
, “
Design and Evaluation of a Portable Negative Pressure Hood With HEPA Filtration to Protect Health Care Workers Treating Patients With Transmissible Respiratory Infections
,” Am. J. Infect. Control
,
48
(10
), pp. 1237
–1243
.10.1016/j.ajic.2020.06.20330.
Seger
,
C. D.
,
Wang
,
L.
,
Dong
,
X.
,
Tebon
,
P.
,
Kwon
,
S.
,
Liew
,
E. C.
,
Marijic
,
J.
,
Umar
,
S.
, and
Hoftman
,
N. N.
, 2020
, “
A Novel Negative Pressure Isolation Device for Aerosol Transmissible COVID-19
,” Anesth. Analg.
,
131
(3
), pp. 664
–668
.10.1213/ANE.000000000000505231.
Kim
,
S. C.
,
Kong
,
S. Y.
,
Park
,
G. J.
,
Lee
,
J. H.
,
Lee
,
J. K.
,
Lee
,
M. S.
, and
Han
,
H. S.
, 2021
, “
Effectiveness of Negative Pressure Isolation Stretcher and Rooms for SARS-CoV-2 Nosocomial Infection Control and Maintenance of South Korean Emergency Department Capacity
,” Am. J. Emerg. Med.
,
45
, pp. 483
–489
.10.1016/j.ajem.2020.09.08132.
Chen
,
Y.
,
Yang
,
Y.
,
Peng
,
W.
, and
Wang
,
H.
, 2021
, “
Influence and Analysis of Ambulance on the Containment of COVID-19 in China
,” Saf. Sci.
,
139
, pp. 105160
–105160
.10.1016/j.ssci.2021.10516033.
U.S. Centers for Disease Control and Prevention
, 2016
, “
Guidance for Developing a Plan for Interfacility Transport of Persons Under Investigation or Confirmed Patients With Ebola Virus Disease in the United States
,” U.S. Centers for Disease Control and Prevention, Washington, DC, accessed Oct. 19, 2021, https://www.cdc.gov/vhf/ebola/clinicians/emergency-services/interfacility-transport.html34.
Feldman
,
O.
,
Samuel
,
N.
,
Kvatinsky
,
N.
,
Idelman
,
R.
,
Diamand
,
R.
, and
Shavit
,
I.
, 2021
, “
Endotracheal Intubation of COVID-19 Patients by Paramedics Using a Box Barrier: A Randomized Crossover Manikin Study
,” PLoS One
,
16
(3
), p. e0248383
.10.1371/journal.pone.024838335.
Johnson
,
D. L.
,
Lynch
,
R. A.
, and
Mead
,
K. R.
, 2009
, “
Containment Effectiveness of Expedient Patient Isolation Units
,” Am. J. Infect. Control
,
37
(2
), pp. 94
–100
.10.1016/j.ajic.2008.05.01136.
Maloney
,
L. M.
,
Yang
,
A. H.
,
Princi
,
R. A.
,
Eichert
,
A. J.
,
Hébert
,
D. R.
,
Kupec
,
T. V.
,
Mertz
,
A. E.
,
Vasyltsiv
,
R.
,
Vijaya Kumar
,
T. M.
,
Walker
,
G. J.
,
Peralta
,
E. J.
,
Hoffman
,
J. L.
,
Yin
,
W.
, and
Page
,
C. R.
, 2020
, “
A COVID-19 Airway Management Innovation With Pragmatic Efficacy Evaluation: The Patient Particle Containment Chamber
,” Ann. Biomed. Eng.
,
48
(10
), pp. 2371
–2376
.10.1007/s10439-020-02599-637.
Mead
,
K.
, and
Johnson
,
D. L.
, 2004
, “
An Evaluation of Portable High-Efficiency Particulate Air Filtration for Expedient Patient Isolation in Epidemic and Emergency Response
,” Ann. Emerg. Med.
,
44
(6
), pp. 635
–645
.10.1016/j.annemergmed.2004.07.45138.
Mead
,
K. R.
,
Feng
,
A.
,
Hammond
,
D.
, and
Shulman
,
S.
, 2012
, “
Expedient Methods for Surge Airborne Isolation Within Healthcare Settings During Response to a Natural or Manmade Epidemic
,”
National Institute for Occupational Safety and Health (NIOSH)
, Atlanta, GA, Report No. 301-05f
.https://stacks.cdc.gov/view/cdc/3778139.
U.S. Centers for Disease Control and Prevention
, 2021
, “
SARS-CoV-2 Transmission
,” U.S. Centers for Disease Control and Prevention, Washington, DC, accessed Aug. 3, 2021, https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/sars-cov-2-transmission.html40.
Jayaweera
,
M.
,
Perera
,
H.
,
Gunawardana
,
B.
, and
Manatunge
,
J.
, 2020
, “
Transmission of COVID-19 Virus by Droplets and Aerosols: A Critical Review on the Unresolved Dichotomy
,” Environ. Res.
,
188
, p. 109819
.10.1016/j.envres.2020.10981941.
DURAG GROUP
, 2021
, “
Model 11-D the Dust Decoder
,” DURAG GROUP, Hamburg, Germany, accessed Dec. 1, 2022, https://www.grimm-aerosol.com/products-en/dust-monitors/the-dust-decoder/11-d/42.
Estill
,
C.
, 1999
, “
Chapter 9: Ergonomics
,” AIHA Engineering Reference Manual 2nd ed.
, American Industrial Hygiene Association Engineering Committee, Fairfax, VA.Copyright © 2023 by ASME
You do not currently have access to this content.
