NFPA 1999: SEVERAL PERSPECTIVES
NFPA 1999,Standard on Protective Clothing for Emergency Medical Operations (1991), has been met with mixed evaluations within the emergency medieal services community. Some of the points for discussion most commonly raised with regard to this standard are represented by the three questions addressed here by the following members of the emergency services, who represent varied perspectives.
■ DAVID J. BARILI.O, M.D., is clinical assistant professor of surgery at the University of Texas Health Science Center at San Antonio and a member of the adjunct faculty at the National Fire Academy. He is a consultant to the U.S. Fire Administration and was a member of the USFA core development teams on infection control. He has served in various fire departments as a firefighter/EMT, engineer, fire surgeon, deputy chief, and codirector of the fire death investigation team and has taught EMT courses at the University of Medicine & Dentistry of New Jersey and various police and fire academies and technical schools.
■ MARY LOU C. KELLER is owner of Keller Consulting in Newark, Delaware. Formerly she was affiliated with W.L. Gore & Associates, Inc., (1 1 years), where she ultimately became marketing specialist of EMS protective clothing. Previously, she had worked with police outerwear, firefighter turnout gear, and operating room gown teams. She was an integral component of the safety group that brought Gore into compliance with the OSHA Hazard Communication Standard in 1986. She was granted a patent for the GORE-TEX Cast Liner waterproof padding material she developed; the liner allows immobilized patients to bathe and even swim daily while wearing a cast. She is a member of the American Society of Law Enforcement Trainers and an American Red Cross-certified HIV instructor.
■ MURREY E. LOFLIN, a member of the Virginia Beach (VA) Fire Department since 1983, is a captain and has been its safety/infection control officer since 1986. He is a Virginia state-certified EMT/D and an adjunct faculty member and course developer for the National Fire Academy. He is a member and former president of the American Society of Safety Engineers, Greater Tidewater Chapter, and serves on the NFPA Member Advisory Council, Fire Service Section Executive Board, and Technical Committee for Fire Service Occupational Safety and Health.
■ PAUL M. MANISCALCO has 17 years of experience in EMS. He is deputy chief of NYC*EMS and commanding officer of the Special Operations Division. He is a member of the adjunct faculty of the National Fire Academy and one of the developers of the Infection Control for Emergency Responder Personnel program. He is an advisor to the U.S. Public Health Service, NIOSH, and the CDC.
■ DECKER WILLIAMS, a fire captain of the City of Phoenix (AZ) Fire Department’s Emergency Services Institute/Special Operations, has been a firefighter for 24 years and a paramedic since 1974, when Arizona passed its paramedic law. He spent 18 years as a medical corpsman in the Air Force Reserves.
Are the NEPA 1999 requirements too restrictive, appropriate, or not restrictive enough?
Barillo: In my opinion, the requirements are too restrictive. Portions of garments intended as a barrier to liquid bloodborne pathogens must pass a bacteriophage penetration resistance test. Since all of the garment is subject to splashes of blood, the entire garment must thus be “virusproof.” This assumes that (1) the specified test accurately predicts protection against HIV and hepatitis virus and (2) that EMS responders wearing these garments spend all of their time in direct patient contact (which obviously isn’t true).
While the described bacteriophage pcnelralion lest is ingenious, in my opinion, this method should first be published in a peerreviewed medical journal, allowing independent duplication of the results by other investigators, before being accepted as gospel truth.
Keller: In my previous work with a manufacturer of protective clothing for many years, I had significant exposure to this document. Since I have started my own business, I have become more familiar with the user side of the market, and my sentiments have been tempered by this experience.
The NFPA 1999 requirements are too restrictive because they are unrealistic. There currently are only a few products that can meet the testing requirements and even fewer garments that can be worn by emergency response personnel without their succumbing to heat fatigue. To expect a worker to wear an impermeable garment throughout a work shift is untenable, especially in hot weather.
In addition, the few garments that pass the tests and are water-vapor permeable (which can lessen the danger of heat fatigue) are probably too expensive for common consideration. The design requirements make the garments expensive to put together, and the certification adds to the expense. Few manufacturers are likely to be willing to invest in this process, and it will be years before suitable products are commonly available.
Loflin: I feel the requirements specified in NFPA 1999 are appropriate. With the mandated requirements specified in 29 CFR 1910.1030, Occupational Exposure to Bloodborne Pathogens, this standard addresses personal protective equipment that would be used for fire and EMS personnel. Specifically, the three items addressed by the standard are medical gloves, medical garments, and medical face protection to be used during the delivery of emergency patient care.
From the standpoint of a user or consumer, how does this standard affect me? Currently, I have not specified that any of the personal protective equipment be NFPA 1999-eompliant because few manufacturers market personal protective equipment compliant with NFPA 1993. The compliant products available are too expensive or too inadequate to meet performance requirements for fire and EMS personnel. I am more concerned that I meet the requirements of 29 CFR 1910.1030 than I am with those of NFPA 1999 at this time. This does not mean I will not change to NFPA 1999-compliant products once they are readily available, are cost-effective, and meet the needs of the department and our personnel.
One of my primary functions is to ensure personnel wear the infection-control personal protective equipment currently provided them. This includes medical gloves, eye protection, face protection, and gown. The wearing of medical gloves is not a real problem, but eye and face protection and gown/body protection are not always worn when they should be. This personal protective equipment is not NFPA 1999-compliant, but it provides the protection needed against liquidbome pathogens. Also, personnel have structural turnout gear to wear as personal protective equipment, though it is expensive to replace if it cannot be cleaned and properly decontaminated. The bottom line is the safety, health, and welfare of personnel.
NFPA 1999 will have an impact on the quality of personal protective equipment to be used for emergency medical care. The standard will force manufacturers to develop new cost-effective and practical products that meet the requirements of the standard.
Maniscalco: The NFPA 1999 standard is in fact a misnomer. This standard could have and should have been entitled “Protective Clothing for Blood Borne Infectious Disease Exposure”—the limited area it addresses. The current title of this standard implies that the particulars contained within are the only areas of concern EMS providers need to observe for effective and safe EMS operations. I am fully cognizant that this is a very simplistic view of the standard, but one needs to remember that in some cases irresponsible or unscrupulous persons could interpret this as such, which already has happened in some communities.
In a number of cases, nonfire service EMS providers lobbied their organizations for protective articles, such as turnout coats, Nomex® hoods, SCBAs, etc. and were denied even the consideration of such issuance with the citing of NFPA 1999 as (he professional standard of protection required for “EMS operations.” The role of EMS providers varies from community to community and should be addressed accordingly. This means EMS members should be issued protective garments appropriate for Ihe risks to which they are exposed. How many times have we seen pictures of fire suppression personnel in full protective ensembles engaged in auto-disentanglement operations with hydraulic tools and other equipment surrounding EMS providers conducting patient care without protective apparel? Probably too many times.
The need for NFPA to convene an EMS Operations/Management Technical Committee cannot be overemphasized. A realistic fundamental review of operations and management that will enable EMS to commence its own standardization process applicable and acceptable to all users is long overdue. Through such a forum, the emergency service community at large can fully address and resolve issues such as these.
The standard does exceed the existing OSHA requirement, but the dynamics in the prehospital setting are cause for concern, and in this case, more could be better. But, how much more? Who should decide how much more? This decision must be reached through a forum of inclusion, not exclusion. The committee should be well-rounded and should include all fields of expertise pertinent to the final product and its end users. I admire the committee’s initiative in developing the standard, but medical experts who specialize in the field of infectious diseases must be included. Excluding these individuals is equivalent to developing electrical standards without consulting an electrical engineer. Irrespective of the final outcome, a review of the present NFPA 1999 needs to be convened with the appropriate disciplines represented to fully ensure the best results.
Williams: In the 18 years I served as a medical corpsman in the Air Force Reserves, I dumped more filthy bedpans than I care to remember. I understand enough about hospital infection control to know the fire service is different and must have its own tailor-made standards on infection control. NFPA 1581, Fire Department Infection Control Program, 1991, is that standard. NFPA 1999 helps ensure that protective clothing called for in NFPA 1581 actually does protect the firefighter. 1 am biased toward requiring the best available protective clothing for emergency medical operations.
NFPA 1999 is too restrictive for protective clothing manufacturers/vendors who like selling the fire service clothing that is protective in name only. NFPA 1999 is a standard to assist the manufacturers/vendors who understand the nature of the fire service and its needs in furnishing the fire service with the product it needs to protect our health.
Manufacturers/vendors who may argue that it’s too hard to comply with the standard should sell their inferior product to some less demanding occupation. 1 must remind those in our profession who say the standard will make clothing too costly that car manufacturers originally had complained that air bags were “too expensive.” I remember wearing a canister mask when I was a recruit firefighter and being told that if SCBA were ever required in the fire service, many fire departments would have to get out of the business because the “worthless contraptions” were too expensive. NFPA 1999 is an appropriate, nonrestrictive standard to protect the rescuer’s health.
Note: The City of Phoenix (AZ) Fire Department operates 45 engine companies, of which 24 are advanced life support EiMTP and 21 are basic life support EMT-B. It has 12 full-time and eight part-time ambulances. Like many fire departments, it does more EMS work (75,(XX)-plus calls a year) than firefighting work (13,000-plus calls/year).
Do you feel NFPA 1999 is a user’s standard or a performance standard for manufacturers?
Barillo: In my opinion, this is a manufacturer’s standard. I am concerned that this standard does not require a product flammable performance test. Many departments provide both fire and EMS services; even “third-service” EMS response involves substantial proximity to flame, spilled gasoline at extrication sites, and the occasional hazardous material.
I am also concerned about the cost of such garments to the end user. These days, no fire department has an excess of funding, and chief officers are deluged with a plethora of federal regulations and national standards regarding infection control. I can envision a situation in which a department may be forced to purchase expensive new EMS garments (which may not be necessary) and then will not be able to afford the hepatitis B vaccination (which has substantial scientific evidence to support its use).
Keller: NFPA 1999 appears to be a minimum performance standard for manufacturers. Very few (if any) users have the resources or the desire to examine a protective garment in the detailed manner set out in NFPA 1999. The intent of making users aware of the high quality fabrics and designs used in an NFPA 1999-certilied garment is admirable, but to require a user to wear such a garment regardless of weather conditions is irrational. Heat fatigue is a more serious safety issue than possible intact skin expo sure to btxly fluids.
I.oflin: NFPA 1999 was developed by the NFPA’s Technical Committee on Fire Service Protective Clothing and Equipment as a performance standard for protective clothing used during emergency medical operations. As with any standard, the requirements specified in this standard are the minimum performance criteria. Nothing prohibits a manufacturer from meeting or exceeding these requirements or the user from specifying requirements in its specifications that will exceed those of this or any standard.
Paragraph 1-1.4 of NFPA 1999 states, “This standard is not intended to be utilized as a detailed manufacturing or purchase specification, but can be referenced in purchase specifications as minimum requirements.” This means as a user, I cannot order medical garments simply by attaching a copy of NFPA 1999 to the specification sheet. I will have to provide written specifications stating exactly which type of garment 1 want. I must consider sizes, type of material, reinforcement of excessive-wear or load-bearing areas, disposable vs. reusable, interface with other personal protective equipment, and other factors.
The standard provides the user with the avenue for specifying appropriate equipment to be used as protection against communicable diseases, especially liquidborne pathogens. The standard requires manufacturers to develop and produce personal protective equipment that meets the criteria of NFPA 1999. NFPA 1999-compliant garments and equipment are required to meet tests for abrasion resistance, bacteriophage penetration resistance, tear resistance, isopropanol degradation, dexterity, and several other performance abilities. Also, products must meet third-party certification to be NFPA 1999-compliant.
Maniscalco: A review of NFPA 1999 clearly indicates it is a manufacturer’s standard. Unlike NFPA 1581, which dictates operational performance, this standard guides the manufacturer with regard to what is expected of its garment if it is to receive compliance rating. 1 once again must point out that the lack of technical expert involvement from the targeted discipline in the development process of any standard is dangerous and can result in a standard that is bombastic or woefully inadequate. To finally resolve the controversy that surrounds this standard, it is imperative that it be revisited with all of the players around the table. Then and only then—when everyone’s “fingerprints are on the knife”—will final concurrence take place.
Williams: NFPA 1999 is an absolute performance standard for manufacturers. There certainly is very little room for interpretation of the criteria the protective clothing must meet. If the product is manufactured to the NFPA 1999 standard and we (the users) buy it, then it certainly becomes a user’s standard for protective clothing for emergency medical operations. To not purchase an NFPA 1999-compliant product would be gambling on buying less than the best to protect firefighters’ health.
Do you think that intact skin is a sufficient barrier against bloodborne pathogens? Do you consider small pinholes in protective garments a concern in everyday emergency medical responses?
Barillo: I know of no study suggesting that intact skin is not a barrier to bloodborne pathogens. I hedge this with the thought that there is no good reason to allow the blood or other bodily fluids of a victim access to the skin of a responder. Proper selection of personal protective equipment in accordance with OSHA regulations (29 CFR 1910.1030), NFPA 1581, and U.S. Fire Administration guidelines will prevent this from happening. 1 am not concerned about pinhole leaks in regular protective garments . (for example. Nomex® jumpsuits or bunker gear) when covered by proper barrier protecf tion.
Keep in mind that every day researchers work with concentrated HIV and hepatitis viruses’, surgeons operate on patients with HIV, HBV. or HCV infection: and nurses work in some intensive care units where most, if not all, patients are seropositive. We all rely on the OSHA bloodborne pathogen standard for protection; so far, this has worked well.
Keller: Intact skin exposure to bloodborne pathogens is not considered a significant exposure according to the OSHA regulation pertaining to occupational exposure to bloodborne pathogens. However, it is my experience that people often are not aware of having nonintact skin. In my training programs, I sometimes pass around a bottle of alcohol so that class members can rub some on their hands. Nonintact skin will sting when alcohol contacts it. The areas under the nails and the cuticles frequently are not intact, and the person often is not aware of such cuts. This finding highlights the need for wearing protective gloves whenever body fluid contact is anticipated. The alcohol test, however, has shown that most of the skin on the rest of the body— with the exception of areas that recently had been shaved or had scratches or bug bites— was intact. Personnel should do a quick assessment of their hands and arms before work so that nonintact skin can be covered with a bandage; they also should cover any known cuts on the rest of the body before work begins.
The key to infection control is common sense—washing hands after exposures, covering areas known to be at high risk for cuts with gloves or bandages, avoiding needle sticks, obtaining appropriate vaccinations, and staying healthy so the body can overcome minimal exposures. Minimizing the risk is the goal, and absolutes are rarely attainable. In any department, resources are few and serious safety needs are many.
Users arc capable of deciding whether a garment offers adequate protection. If they frequently have blood on their skin, the protective garment is not adequate. If a garment has small pinholes in the seams or closure but no body fluids are found to penetrate under in the vast majority of cases, then the product is likely to be perceived as adequate by users and government regulators. OSHA has stated that it is not its intent that workers wear “moonsuits” for every call. Perhaps in the future there will be pinhole-free. comfortable, and affordable protective garments for emergency responders. Perhaps NFPA 1999 is a worthy goal ahead of its time.
Loflin: In our infection-control training, personnel are taught that intact skin serves as an effective barrier against blood and other body fluids. This does not mean that they are not to wear personal protective equipment. Personnel should be wearing appropriate personal protective equipment so they do not get blood on intact skin. This does not mean it is not going to happen, especially if a firefighter is wearing only medical gloves and gets blood or body fluids on his/her anti for whatever reason. Our personnel wear short-sleeve t-shirts the majority of the year, so an exposure could occur. If they have a cut, rash, or other skin problems, then they must cover the exposed areas by wearing a gown or other protection.
Small pinholes in personal protective equipment are a very real concern. We try to reduce the possibilities of causing defects in personal protective equipment the best we can. We provide personnel with glove pouches within which to carry one or two pairs of medical gloves rather than carrying gloves in pant or turnout coat pockets. In multiple-patient or trauma situations, personnel double-glove for added protection. Eye and face protection and gowns are carried with EMS equipment so they can be donned quickly.
Based on feedback from personnel and through testing and evaluation of personal protective equipment, we try to provide the best protective equipment and clothing for infection control.
Maniscalco: The issue of intact skin is one of great emotion. Although no scientific data exist to support transmission through intact skin, the emotions that accompany a perceived or actual exposure are very real. These emotions can greatly influence the present or future performance of rescuers who may let fear override their sense of reason. The rapidly changing technology that surrounds infectious disease has provided the emergency response community with new insight into the scary and often confusing world of infectious diseases. Presently, scientific data support that blood is not absorbed through intact skin as chemical agents are; but with the rapidly changing world of pathogens, what is next? Asbestos was safe once, too. Unfortunately, when a structured approach to EMS was developed many years ago, infectious disease protection was not a priority for training program content; only recently has it started to receive the attention it deserves, leaving us in the catch-up mode.
Williams: For years 1 emptied bedpans (without gloves) in hospitals and gave patients baths with my bare hands. It was stupkl behavior on my part, but I believe my employer shared some of the blame for ignorance in infection control. However, I washed my hands frequently and always after patient contact. If I had cuts on my hands. I kept them out of the “grungies.” I apparently did not catch anything from intact skin contact with infectious material, so I believe that skin is an excellent barrier to infectious material.
But, now I wear protective clothing and wash even more because I don’t care to take any unnecessary chances where infectious disease is concerned. I also don’t consider small pinholes in protective garments a problem if they happen by chance and infrequently while doing emergency medical operations. If they are allowed as part of the manufacturing process. I won’t buy those products because, in my opinion, they are inferior.
Additional comments
Loflin: The passage of 29 CFR 1910.1030 has required fire and EMS organizations as well as other agencies involved in emergency medical care to develop a new philosophy associated with patient care. We will continue to deliver quality patient care, yet we w ill protect our personnel and ensure that they protect themselves against bloodborne pathogens. NFPA 1999-compliant equipment will serve as a resource for this process.
Maniscalco: Within the past six months, three emergency service members in different states approached me at lectures and confided that they had tested positive for HIV and had not engaged in high-risk behavior. In each case, the individual could only speculate about the point of transmission: an unreported needle stick; failure to wear gloves during contact with a bloody patient despite having small cuts on his hands; and exposure to a patient’s blood as a result of a glove failure caused by a hand cut from jagged metal while working on the patient at a motor vehicle accident. I share this information with you because it is disturbing and people need to be aware of this looming disaster. How many of our peers will be in similar situations?
I advised these members to seek independent assessment and treatment (these individuals discovered their status through anonymous testing) and to enroll in the Centers for Disease Control’s Exposure Study for tracking purposes. The eventual outcome of each of these situations probably will be known only to the individuals and their families. How many more of us have occupationally acquired diseases we do not know about?
In any event, the level of protection for bloodborne pathogens needs to be determined via scientific data and must be commensurate with the prevailing level of risk. The cost factor of these items should not be the driving force behind whether we choose or do not choose to use an item for protection. Conversely, we as a community should expect a protective garment that is lightweight, nonstressing, and easy to maneuver around in so we can be effective in the discharge of our duties. Placing all emergency responders in moonsuits to render treatment to a patient is not necessary and certainly will be costly. Prudence, scientific data, and patient condition should be the driving forces behind selecting protective equipment for bloodborne pathogens.
Williams: I could put out most fires without SCBA or high-dollar turnouts, but I don’t! I could take vital signs, start IVs, and intubate patients without NFPA 1999and NFPA 1581-compliant procedures and protective equipment, but I don’t!
If you have a comment or observation relative to NFPA 1999 you would like to share, please send it to Fire Engineering, NFPA 1999, Park 80 West, Plaza Two, 7th Floor, Saddle Brook, NJ 07663 (please note our new zip code).
