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Nigam and Cutter totally fail to present evidence to justify the claim that “Welsh emergency vehicles examined exhibited an unacceptable level of bacterial contamination”.1 What is more, a press release from the editorial team to local newspapers led Madeline Brindley of the Western Mail to write, “Dirty ambulances infested with huge amounts of harmful bacteria are carrying seriously ill patients to hospital in Wales, according to a report published today. The new research discovered that even after they have been cleaned, ambulances are still home to “unacceptable” levels of bacteria.”2
The authors make no attempt to quantify levels of bacteria for organisms that are expected to be present in an environment occupied by people. Inevitably, steering wheels will be home to Staphylococcus epidermidis and viridans group streptococci, as they represent normal skin commensals. Bacillus sp are ubiquitous environmental organisms. Similar comments can be levied for all areas sampled throughout the ambulances.
The method used by Nigam and Cutter is suitable for a qualitative assessment and is normally used to identify specific pathogens. The only potential pathogen identified by the study is Staphylococcus aureus. A quantitative method should have been used for this type of study, if the conclusions were to be supported. Quantitative methods, such as those discussed by Roberts et al,3 take a measured area of a given surface and allow the number of bacteria to be counted and expressed per square centimetre. Such a technique allows for the assessment of reduction of bacterial load after a cleaning process.
Quite reasonably, the press will pick up on stories such as these when prompted by the editorial team. However, there is a responsibility on the editorial board of journals, their reviewers, and the researchers to ensure that study methods and the review process are rigorous. Only then can proper conclusions be drawn. Without that, fear can be instilled in the patient population and the NHS challenged inappropriately.
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Authors’ reply
We fully accept that the methods used were not rigorous enough to accurately quantify numbers of bacteria for any given measured area. However, our work was simply described as a preliminary investigation and this pilot study did identify shortfalls in cleaning practices in use at the time of the study. These included a lack of designated cleaning equipment for ambulances, insufficient time for thorough cleaning, and lack of suitable decontamination processes for medical equipment.
Most organisms identified in the study were unlikely to pose any threat of infection to patients or ambulance personnel. This was clearly stated in our article, but sadly was often ignored in the subsequent press reports, resulting in public concern.
Having identified that there were shortfalls in cleaning practices, action was required. The Welsh Ambulance Trust responded immediately to the results of the study and, supported by one of the authors (JC), took action to improve standards of cleanliness. This included the following:
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The Infection Control Committee and Regional Infection Control Teams continue to monitor cleanliness through regular environmental audits;
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Colour coded cleaning equipment has been introduced to prevent cross contamination during cleaning and standardisation of detergents and disinfectants has been completed;
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All vehicles have now been provided with “spillage kits” to absorb fluid spills;
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A chlorine releasing disinfectant is provided for each vehicle for prompt decontamination of blood and body fluids;
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Significant investment has been made to replace re-usable medical equipment, for example, Entonox masks and suction canisters with disposable alternatives. Disposable covers are provided for laryngoscope blades and single use bougies for intubation have been supplied;
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Infection control training is provided during all patient transport services and emergency technician training courses in which the importance of cleaning is included.