infection control - EMS World

INFECTION CONTROL AND THE EMS PROVIDER

Hand protection is a key component of avoiding exposures for emergency medical services

L

ike a lot of longtime firefighters and

Americans and can lead to cancer, cirrhosis

infectious threats: protection for the hands,

paramedics, Elaine Brown doesn’t

and other damage to the liver.

mouth and eyes; effective cleaning solutions

know how she contracted hepatitis

Her story illustrates some hard truths

and tools; effective, ingrained and well-prac-

C. “I can recall two needlesticks, both

about life in the emergency services. One,

ticed procedures for avoiding exposure. We

before hepatitis C was ever tested for,” she

we do a lot of things that can injure us and

know the dangers, unlike decades past. But

told the International Association of Fire

leave us susceptible to infections that can

don’t be fooled into thinking the problem’s

Fighters for a short online profile as part of the group’s hep C support efforts.1 “It could have been on multiple vehicle accidents where we had to extricate patients and scraped our knuckles; it could have been while holding c-spine on people who had

The hands are unique in EMS in that they’re used on virtually every task every day. And in that they’re prone to getting some pretty nasty stuff on them.

blood running down their necks. I don’t know. I could’ve caught it a year ago, I could’ve caught it 15 years ago.”

harm and even kill us. Two, it’s often diffi-

solved: In 2015, according to the National

When she shared her account with the

cult, in the heat of an emergency, to protect

Fire Protection Association, there were,

IAFF, Brown was the infection-control nurse

against all potential threats and vectors of

among employees of fire departments,

for Florida’s Miami-Dade Fire Rescue, where

transmission. Three, the wrong infection can

more than 8,300 documented exposures

she oversaw the department’s policies on

have lifelong repercussions for providers and

to infectious diseases such as HIV, hepatitis,

exposures and their handling. She was also

everyone who loves them.

meningitis, etc.2 This amounts to an expo-

undergoing treatment for her hep C, a blood-

To be sure, today’s providers also have bet-

borne virus that infects around 3.5 million

ter safeguards to defend themselves from

sure every 2,500 EMS runs—a number that doesn’t include non-fire-based EMS.


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to damage. They can easily get abraded

Threats to the hands:

and pierced, compromising the effective barrier of intact skin. “With our job there’s always the issue of

Hand injuries account for more than a million ED visits by U.S. workers each year.

possible exposure to bloodborne pathogens,” says Scott Gilmore, MD, EMT-P, The remaining 30% wore gloves that were “inadequate, damaged or wrong for the type of hazard.”

70% of workers who experienced hand injuries were not wearing gloves.

FACEP, medical director for the St. Louis Fire Department. “That’s the nature of the work—there are always the cuts and scrapes and punctures, etc.” Such risks can be mitigated by dedicated use of appropriately sized and constructed hand protection as part of a comprehensive, multifaceted program of infection education and prevention. That’s a lesson EMS providers have largely learned; providers have routinely donned gloves as part of their universal precautions for

OSHA requires hand protection against:

years now, and body substance isolation is thoroughly taught and reinforced. Through such measures the risk of acquiring bloodborne diseases has been reduced.

Skin absorption of harmful substances

Severe cuts or lacerations

If the same isn’t true for airborne risks, it may be because we’ve emphasized them less in education, and they often lack an acute visual signal like blood to prompt

Chemical burns or thermal burns Severe abrasions or punctures

defensive measures. But the good news is that even if you’re slow in taking those added precautions, a practiced commitment to hand protection helps you here too.

Harmful temperature extremes

“Most people don’t think about it,” notes Gilmore, “but they’re touching their eyes constantly throughout the day. Whether it’s

—Source: www.nietc.org/safety-news-archive/121-safety-article-1.html

to brush something off, their eyes are itching, what have you, if they have the gloves

“You need to have a clearly defined policy on infection control and be consistent in applying it. We encourage our crews to use gloves any time they have patient contact and to change them often.”

—Jared Oscarson

on and then remove the gloves before touching their face, that affords some protection also from things like respiratory viruses, because those viruses can live on inanimate objects for a period of time. So even though you think of gloves as a contact precaution, they offer some protection against the airborne threats as well.”

The Infectious Threat to EMS

Ambulance. “Maybe you move a table that

The hands are unique in EMS in that

has something on it. You never know where

they’re used on virtually every task every

you’re going to put your hand or what it’s

day. And in that they’re prone to getting

going to go into.”

some pretty nasty stuff on them.

By hand isn’t the only way infections can

Risks and How to Reduce Them Surface threats in the EMS work environment aren’t difficult to quantify. Recent research suggests there are still many defi-

“You grab a door handle or pick something

endanger prehospital providers; airborne

up, and you can be exposed not just to bodily

threats ultimately may be an even larger

• Tests published in 2010 found emer-

fluids but other things—chemicals, house-

concern. But the hands are the key point

gency medical responders with a high

hold substances,” says Jared Oscarson,

of first contact and ongoing interface with

potential for exposure to methicil-

EMS director at Minnesota’s Dodge Center

patients, making them especially susceptible

lin-resistant Staphylococcus aureus

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ciencies in how we clean our workspaces:

“EMS services should work to improve hand-sanitization compliance.” [Minnesota, 2014]

“[Emergency medical responders] have a high potential for exposure to MRSA, not only through patient and hospital contacts but also in the fire station environment.” [Arizona, 2010]

“Staphylococcus aureus and Enterococcus were detectable on equipment thought to be clean.” [Denmark, 2016]

“The high prevalence of MRSA in Ohio EMS personnel is both an occupational hazard and patient safety concern.” [Ohio, 2016]

“Presence of clinically relevant bacterial contamination suggests that disinfection of the studied basic life support ambulances was not optimal and represents a potential risk of infection for the patients transferred in them.” [Spain, 2017]

“Potentially pathogenic bacteria are detectable on ambulance staff uniforms when a shift ends.” [Denmark, 2015]

“High microbial contamination (bacterial and fungal) in ambulance air during services and higher bacterial contamination on medical instrument surfaces and allocated areas after ambulance services.” [Thailand, 2015]

“Ambulance cars were contaminated with MRSA even at short transport times.” [Germany, 2011]

“Paramedic hand hygiene and gloving practices require substantial improvement to lower potential transmission of pathogens.” [Australia, 2017]

“Reported hand hygiene is poor amongst prehospital providers.” [USA, 2015]

(MRSA), not only through patient and hospital contacts but also in their station environments.3

“You grab a door handle or pick something up, and you can be exposed not just to bodily fluids but

• A 2011 study found ambulance compart-

other things—chemicals, household substances.

ments contaminated with MRSA even

Maybe you move a table that has something on it.

after short transports.4

• Thai investigators in 2015 found high

You never know where you’re going to put

levels of bacterial and fungal contami-

your hand or what it’s going to go into.”

nation in ambulance air during patient

—Jared Oscarson

care and increased contamination on medical instruments and surrounding areas afterward.5

• A 2017 study of surface bacterial con-

amounts of both Staphylococcus aure-

tamination in 10 Spanish ambulances

us and Enterococcus on blood pressure

found “disinfection…was not optimal

cuffs thought to be clean.7

and represents a potential risk of infection for the patients transferred.”6

• A 2016 Danish study found limited

shifts.8 Such findings comprise an eloquent argument for protecting your hands (not to

• A 2015 Danish study found potentially

mention doing a better job cleaning). But it

pathogenic bacteria could be detect-

turns out EMS providers aren’t as attentive

ed on ambulance staff uniforms after

to hand protection as you’d hope:


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How to Doff Dirty Gloves Safely

There’s more to wearing gloves than simply pulling them on and off. Donning and doffing may not get a lot of focus after initial education, but removing a glove properly is itself an infection-prevention technique. The CDC breaks it down in its PPE guidance:21 Assume the outside of the gloves is contaminated. Grasp the outside of one glove with the opposite gloved hand and peel it off. Holding the removed glove in the still-gloved hand, slide the fingers of the ungloved hand under the cuff of the remaining glove. Peel that glove off over the first one, encasing it; then discard both in an appropriate container. “The big thing is making sure you don’t take the dirty glove and touch underneath the cuff of the other glove to pull it off,” says Gilmore. “You actually want to grab the outside from the outside and pull it off so the outside turns inward as you’re pulling it off. That way any contaminant is encased within the inverted glove.” There are numerous other aspects to a good EMS infection-control program, including exposure reporting and follow-up, work-restriction guidelines and attention to provider vaccinations; check out the APIC publication for guidance. The biggest point is to teach, reinforce and, as an organization, clearly and consistently value doing the right thing. “You have to make it a culture of cleanliness,” says Oscarson. “Create peer pressure so that nobody wants to be the only guy standing by the side of the road with no gloves on.”

A Six-Step Process: 2.

1.

Assume outside of gloves is contaminated.

4.

5.

6.

Peel glove off over first glove, reversing it;

Discard gloves in waste container.

hygiene and gloving among para-

remains some amount of infection risk EMS

poor hand hygiene practices among

medics, concluding their practices

providers are assuming unnecessarily. How

U.S. prehospital providers “in all clini-

“require substantial improvement

can that be reduced?

cal situations.”9

to lower potential transmission of

• A 2014 study observed paramedics sanitizing their hands after fewer

4

Hold removed glove in gloved hand;

Grasp outside of glove with opposite gloved hand and peel off;

Slide fingers of ungloved hand under remaining glove at wrist;

• A survey published in 2015 found

3.

pathogens.”11

•A 2016 Ohio study found providers who

Elements of an IC Program Part of the answer is the dedicated use

than 63% of patient encounters. In

did not practice frequent hand hygiene

of hand protection. Per the CDC, gloves

12.4% of patient contacts, they didn’t

after glove use to be at increased risk

reduce hand contamination by 70%–80%,

wear gloves.10

for nasal MRSA carriage.12

prevent cross-contamination and protect

• A brand-new study from Australia

Between the suboptimal cleaning and

both patients and healthcare personnel

found poor compliance with hand

inconsistent hand practices, then, there

from infection.13 OSHA cites literature that


found 70% of workers who experienced hand injuries weren’t wearing gloves.14 In the words of one nursing text, gloves prevent contamination of the hands “when touching body fluids, reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to patients during invasive or other patient care procedures, and reduce the likelihood that hands of personnel contaminated with microorganisms from a patient or a fomite can transmit these microorganisms to another patient.”15 Wearing gloves and gowns for all patient contact correlated to fewer MRSA acquisitions among hospital workers,16 and glove use has been shown to reduce transmission of C. difficile and carriage of vancomycin-resistant Enterococcus on caregivers’ hands.17,18 An older study found that even with small leaks, gloves prevented hand contamination 77% of the time.19 Faithful glove use must be paired with strong hand hygiene practices and a comprehensive program of education about

Microflex's LifeStar EC examination gloves

infectious threats and how to mitigate them.

folks and volunteers may not do as much

In 2013 the Association for Professionals in

in the way of quality improvement. Every

Infection Control and Epidemiology (APIC)

now and then in my clinic we’ll send a nurse

published its Guide to Infection Prevention

undercover to monitor that all clinicians

in Emergency Medical Services.20 That docu-

wash their hands before patient encoun-

• Anthrax

ment looks at areas like the epidemiology

ters, and she’ll actually listen outside the

and pathogenesis of infectious diseases

door and then make a report to the quality

• Hepatitis B

in EMS; risk factors and assessment; engi-

improvement officer.”

Life-threatening infectious diseases transmitted by contact or bodily fluids to which emergency responders may be exposed:

• Hepatitis C • HIV

neering/work practice controls and personal

A pair of additional points from APIC:

protective equipment; health issues in occu-

Infection-prevention education should be

• Rabies

pational exposure; and education, training,

updated regularly and based on evidence-

compliance and monitoring.

based best practices and compliance; and

• Vaccinia

That last section emphasizes some key

because EMS providers constantly get new

points. It notes that training must come

information, infection prevention must be

from qualified instructors at levels students

presented often and reinforced.

• Viral hemorrhagic fevers thing like a door handle down and another

can understand and that responders are

“You need to have a clearly defined policy

doesn’t have it on their radar. That can be a

more likely to comply with infection-pre-

on infection control and be consistent in

huge exposure component after the call.”

vention strategies if they grasp the rationale

applying it,” says Oscarson. “We encour-

There’s generally clear guidance for such

behind them.

age our crews to use gloves any time they

cleaning, with empirical evidence to sup-

“I think in order to really appreciate the

have patient contact and to change them

port best practices. The same goes for what

risks, you have to understand the funda-

often. We do a PPE class and do our best to

protective garments to wear and when.

mentals of how these infections spread,

indoctrinate them: ‘This is where the gloves

Once personnel have a solid grounding in

how long they can live off the body on a

are, this is when and how you use them’—it’s

those issues, it becomes a matter of pro-

surface or in the air,” says Kevin O’Hara,

part of our training.

viding sufficient tools and gear for their use

MMSc, MS, PA-C, an assistant professor

“One weak spot is folks cleaning the rig

at the Yale School of Medicine and expert

after a call: People can have a tendency

and building a culture that encourages it. What’s essential for gloves, besides hav-

in infectious threats. “Education is impor-

to ditch the gloves and not wear them

ing enough on hand to carry providers safely

tant, and making sure people are doing the

while they’re cleaning up—they just don’t

through the bloodiest trauma calls, is that

right things. My guess is some of the smaller

think about it. Or one person wipes some-

they are sized appropriately.


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Cleanliness Challenges Familiar threats: In 2014 an epidemic of Ebola virus disease ravaging Western Africa spilled over into the United States when a Liberian victim visited Dallas. Two nurses who treated the man there contracted the disease, and EMS organizations across America scrambled to prepare for its spread to their areas. No one needs much prompting to prepare for an exotic disease that can make you bleed from the eyes. But with deadly threats that are less “sexy”—for instance, HIV or hepatitis B and C—familiarity and a sense of the protection provided by universal precautions may breed a bit of comfort. “I wouldn’t say people get complacent per se; HIV and viral hepatitis are bloodborne infections, and I’ve never seen an EMT not take blood seriously,” says O’Hara. “If there’s a drop of blood on the floor, maybe we can be complacent about not cleaning that up afterward. But that’s not so much a risk for HIV transmission—maybe something like hepatitis B, which can live outside the body for a period. But with MRSA, there’s absolutely complacency and not much of an understanding there. It wouldn’t surprise me to culture ambulances and find MRSA on surfaces. We need to make sure we use antibacterial wipedowns after a patient like that comes into our care.” Mass trauma/shootings: What’s a bit better understood is how to proceed safely when treating victims of mass trauma like shootings. Beyond issues of scene safety, hot/warm zones, triage and fast transport, these simply come back to dealing with lots of blood, for which our precautions are well suited. The challenge with big MCIs is having 1) enough PPE and 2) the opportunity to use it. “If you’re the first person in at a mass shooting, you’re not going to be the first person out,” notes Gilmore. “You’re going to be the last person out, because you’re the one who’s doing the first triage and starting to set up the whole incident command system. So you might have the same pair of gloves on for a while compared to someone just coming in to pick up a patient and take them to the hospital.” Make sure those gloves are comfortable, well constructed and fit appropriately. MIH-CP: Challenges of the fast-growing fields of community paramedicine and mobile integrated healthcare are a bit different. Standard precautions are generally sufficient in these patients’ homes, and providers often have the additional benefit of knowing the patient and their health profile in advance. That’s a big advantage over emergency/9-1-1 scenes. Homes are often more controlled environments as well, without complicators like traffic and other people. “The threats are often known, even if you’re doing something like changing out a urinary catheter,” says Gilmore. “You know what’s there. You generally know you’re not going to encounter a sharp object like if you’re outdoors at a rescue scene or motor vehicle accident or a scene where somebody might have a knife or other weapon.” Providers can also move more slowly and cautiously in MIH-CP environments, where there’s no impetus to rush and scene times can be longer. “That’s a 180-degree difference in the tempo and mind-set of the call,” notes Gilmore. These patients, however, may be weaker and more medically vulnerable than many patients, leaving them susceptible to threats caregivers carry in. And note that they may have medical waste that requires disposal or is disposed of differently than EMS is used to. “Many patients don’t dispose of their biohazards in a proper way,” warns O’Hara. “The person who has to give themselves a needle shot of testosterone or vitamin B12, or has a PICC line established and gets IV antibiotics once a day—are they disposing of those shot materials and blood-contaminated materials properly, or are they just throwing them in the regular garbage? If you’re going into people’s homes, you see a lot of that stuff.” Virginia-based Infection Control/Emerging Concepts, a longtime purveyor of IC guidance for EMS, is developing a guide for infection control/prevention in the MIH-CP environment.

“If a glove’s too big, it might be falling off,

doing an intravenous line, I think most

imprint includes a full range of disposable

or you might be at greater risk of ripping it

people can feel a blood vessel with a pret-

gloves for workers who contact blood and

because every time you grab something,

ty thick glove. Strength is good because

other potentially harmful fluids. Microflex

it crumples up and could get caught,” says

you’re rubbing against much more abrasive

brands are known for their strength against

O’Hara. “Same with it being too tight. So

surfaces than in the hospital setting.”

tears and snags despite being constructed

you want to make sure you pick the glove that’s the right size for you. “A thick glove is good; even if you’re

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Ansell has been a top provider of hand

from lighter-weight materials that enhance

protection for EMS and a number of other

grip and tactile sensitivity. Several Micro-

fields for more than a century. Its Microflex

flex models, such as the LifeStar EC, have


Recommended PPE for Common EMS Tasks Task

Gloves

Protective eyewear

Mask

Gown

Airway management/intubation/suction

Yes

Yes

Yes

No

Starting IVs/IOs

Yes

No

No

No

Trauma, dressing wounds

Yes

Yes

Yes

Yes

Obtaining blood samples

Yes

No

No

No

Public assist calls

Yes

No

No

No

Moving, evaluating or treating patients

Yes

No

No

No

Administering medications

No

No

No

No

Performing CPR/mouth-to-mouth resuscitation (if off-duty and no barrier device available)

Yes

No

No

No

Handling, cleaning, disposing of contaminated equipment/materials

Yes

Yes

No

Varies*

Extrication/trauma

Yes

Yes

Yes

Varies*

* Depending on volume of bodily fluids present —Source: Association for Professionals in Infection Control and Epidemiology, Guide to Infection Prevention in Emergency Medical Services, www.ems.gov/pdf/workforce/ Guide_Infection_Prevention_EMS.pdf.

extended cuffs that offer added protection for the wrist and forearm. That latter model has proven a big hit in St. Louis, where it was recently adopted by the fire department. Providers “really like the elasticity. When you reach into the box for them, you don’t have to worry about tearing,” Gilmore told EMS World (www.emsworld.com/12301553). “We’re not going to tear as many gloves, and you can’t really put a price on provider safety.”

Mitigating the Risk For responsible EMS leaders, safety is of paramount concern. We have a dangerous field. Back injuries and patient assaults can end careers. But the wrong infection can end a life. We have the measures, knowledge and opportunity to defend ourselves against most infectious threats. The ongoing responsibility for EMS providers is to keep themselves educated on those threats and rigorously employ the practices and techniques that mitigate them. “If I were talking about this to someone new, I’d emphasize that gloves are beyond blood and needlesticks,” says O’Hara. “Those are important, and you can get HIV

Microflex's Supreno EC examination gloves That’s the stuff to think about.”

detrimental to a provider from a social and

and viral hepatitis that way. But the stuff

“From an administrator’s standpoint,

mental standpoint. If you get exposed to

like the MRSA, the C. diff, the influenza—

exposures to infections and bloodborne

hepatitis, you now have 6–12 months to

every year there’s much more morbidity to

pathogens can be costly for an agency,”

wait to find out if you’ve contracted it. We

patients from those issues than the others.

adds Oscarson. “But they can be even more

don’t want that kind of long-term burden


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to the mental health of our providers. So by providing them with the knowledge and tools and culture of safety and infection control, hopefully we can mitigate some of that risk.”

REFERENCES 1. International Association of Fire Fighters. Hepatitis C: Resources, Real People—Elaine Brown, www.iaff.org/hs/Resi/ hepc/frames/HCV.html. 2. National Fire Protection Association. Firefighter injuries in the United States, www.nfpa.org/news-and-research/fire-statisticsand-reports/fire-statistics/the-fire-service/fatalities-and-injuries/ firefighter-injuries-in-the-united-states. 3. Sexton JD, Reynolds KA. Exposure of emergency medical responders to methicillin-resistant Staphylococcus aureus. Am J Infect Control, 2010 Jun; 38(5): 368–73. 4. Eibicht SJ, Vogel U. Meticillin-resistant Staphylococcus aureus (MRSA) contamination of ambulance cars after short term transport of MRSA-colonised patients is restricted to the stretcher. J Hosp Infect, 2011 Jul; 78(3): 221–5. 5. Luksamijarulkul P, Pipitsangjan S. Microbial air quality and bacterial surface contamination in ambulances during patient services. Oman Med J, 2015 Mar; 30(2): 104–10. 6. Varona-Barquin A, Ballesteros-Peña S, Lorrio-Palomino

S, Ezpeleta G, Zamanillo V, Eraso E, Quindós G. Detection and characterization of surface microbial contamination in emergency ambulances. Am J Infect Control, 2017 Jan 1; 45(1): 69–71.

14. Occupational Safety and Health Administration. Personal Protective Equipment for General Industry, Section 2–II. Workplace Hazards Involved, www.osha.gov/pls/oshaweb/ owadisp.show_document?p_table=PREAMBLES&p_id=1021.

7. Vikke HS, Giebner M. POSAiDA: presence of Staphylococcus aureus/MRSA and Enterococcus/VRE in Danish ambulances. A cross-sectional study. BMC Res Notes, 2016 Mar 30; 9: 194.

15. Hughes RG (ed.). Patient Safety and Quality: An EvidenceBased Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality, 2008.

8. Vikke HS, Giebner M. UniStatus—a cross-sectional study on the contamination of uniforms in the Danish ambulance service. BMC Research Notes, 2015; 8: 95.

16. Harris AD, Pineles L, Belton B, et al. Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial. JAMA, 2013 Oct 16; 310(15): 1,571–80.

9. Bucher J, Donovan C, Ohman-Strickland P, McCoy J. Hand washing practices among emergency medical services providers. West J Emerg Med, 2015 Sep; 16(5): 727–35.

17. Johnson S, Gerding DN, Olson MM, et al. Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission. Am J Med, 1990; 88: 137–40.

10. Ho JD, Ansari RK, Page D. Hand sanitization rates in an urban emergency medical services system. J Emerg Med, 2014 Aug; 47(2): 163–8.

18. Tenorio AR, Badri SM, Sahgal NB, et al. Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant Enterococcus species by health care workers after patient care. Clin Infect Dis, 2001; 32: 826–9.

11. Barr N, Holmes M, Roiko A, Dunn P, Lord B. Self-reported behaviors and perceptions of Australian paramedics in relation to hand hygiene and gloving practices in paramedic-led health care. Am J Infect Control, 2017 Apr 3 [e-pub ahead of print].

19. Olsen RJ, Lynch P, Coyle MB, Cummings J, Bokete T, Stamm WE. Examination gloves as barriers to hand contamination in clinical practice. JAMA, 1993 Jul 21; 270(3): 350–3.

12. Orellana RC, Hoet AE, Bell C, Kelley C, Lu B, Anderson SE, Stevenson KB. Methicillin-resistant Staphylococcus aureus in Ohio EMS providers: a statewide cross-sectional study. Prehosp Emerg Care, 2016; 20(2): 184–90.

20. Woodside J, Rebmann T, Williams C, Woodin J. Guide to Infection Prevention in Emergency Medical Services. Association for Professionals in Infection Control and Epidemiology, www. ems.gov/pdf/workforce/Guide_Infection_Prevention_EMS.pdf.

13. Centers for Disease Control and Prevention. Hand Hygiene Guidelines Fact Sheet, https://www.cdc.gov/media/pressrel/ fs021025.htm.

21. Centers for Disease Control and Prevention. Sequence for Removing Personal Protective Equipment (PPE), www.cdc.gov/ hai/pdfs/ppe/ppeposter148.pdf.

For more information on Ansell and its Microflex line of products for EMS, call 800-876-6866 or visit www.ansell.com/lifestarec.

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