Best Practices for the Protection of Hospital-Based First Receivers

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Occupational Safety & Health Administration
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Printing Instructions

OSHA BEST PRACTICES

for

HOSPITAL-BASED
FIRST RECEIVERS OF VICTIMS
from Mass Casualty Incidents
Involving the Release of Hazardous
Substances

photo of man helping patient

January 2005

Occupational Safety and Health Administration (OSHA)


Table of Contents
ACKNOWLEDGMENTS
EXECUTIVE SUMMARY
BEST PRACTICES FROM OSHA
	A.0	INTRODUCTION
	A.1	BACKGROUND
	A.2	DEFINING "FIRST RECEIVERS"
	A.3	SCOPE AND OBJECTIVES
	A.4	DOCUMENT CONTENT AND ORGANIZATION
	B.0	PERSONAL PROTECTIVE EQUIPMENT
	B.1	USING OSHA'S BEST PRACTICES
	B.1.1	Using OSHA's Rationale for PPE Selection and Hazard Assessment
	B.1.2	Augmenting the PPE Selection to Address Specific Hazards Identified by the Hazard Vulnerability Analysis (HVA) and Community
	B.2	RATIONALE FOR OSHA'S PERSONAL PROTECTIVE EQUIPMENT BEST PRACTICES
	B.2.1	Respiratory Protection
	B.2.1.1	Limited Quantity of Contaminant on Victims
	B.2.1.2	Hospital Experience with Contaminated Victims
	B.2.1.3	Exposure Modeling
	B.2.2	Gloves and Boots
	B.2.3	Protective Garments
	B.3	CONCLUSIONS REGARDING PERSONAL PROTECTIVE EQUIPMENT
	B.3.1	First Receiver Hospital Decontamination Zones
	B.3.2	PPE Table and Tables Listing Prerequisite Conditions for Specified PPE
	C.0	TRAINING FIRST RECEIVERS
	C.1	OPERATIONS LEVEL TRAINING
	C.2	AWARENESS LEVEL TRAINING
	C.3	BRIEFING FOR SKILLED SUPPORT PERSONNEL WHOSE PARTICIPATION WAS NOT PREVIOUSLY ANTICIPATED
	C.4	TRAINING SIMILAR TO THAT OUTLINED IN THE HAZARD COMMUNICATION STANDARD
	C.5	SUMMARY OF TRAINING FOR FIRST RECEIVERS
APPENDIX A:		BACKGROUND, LITERATURE REVIEW, AND SITE VISIT EXAMPLES
	1.0	PREPAREDNESS
	1.1	CUSTOMIZING HOSPITAL EMERGENCY MANAGEMENT PLANS
	1.1.1	Using Information from a Hazard Vulnerability Analysis
	1.1.2	Identifying the Hospital's Role in the Community
	1.1.3	Updating Emergency Management Plans
	1.1.4	Coordinating Emergency Plans with Other Organizations
	1.2	PREPARING STAFF AND MANAGEMENT
	1.2.1	Applicable Standards
	1.2.2	Maintaining Decontamination Teams
	1.2.3	Orienting and Training Personnel
	1.2.3.1	Competencies for First Responder Operations Level Training
	1.2.3.2	Competencies for First Responder Awareness Level Training
	1.2.3.3	Instruction for Employees Whose Participation in the Hospital Decontamination Zone Was Not Previously Anticipated
	1.2.3.4	Training Similar to That Outlined in the Hazard Communication Standard
	1.2.4	Monitoring Performance During Drills
	1.2.5	Managing Internal Communications
	1.2.6	Principles of Risk Communication
	1.2.7	Information Dissemination During an Incident
	1.2.8	Monitoring Employee Health
	1.2.8.1	Prior to an Incident
		Medical Clearance for Respirator Use
	1.2.8.2	During a Response
		Thermal Stress
	1.2.8.3	Following an Incident
	1.2.8.4	Managing Employee Stress
	2.0	RESPONSE
	2.1	FACILITIES AND EQUIPMENT
	2.1.1	Evaluating Existing Resources
	2.1.2	Isolation and Lockdown
	2.1.3	Decontamination
	2.1.3.1	Equipment
	2.1.3.2	Procedures
		Shower Flush Time and Practices
		Soap
	2.1.3.3	Security
	2.1.3.4	Personal Protective Equipment
	2.1.3.5	Detection Equipment
		Ionizing Radiation Meters
		Chemical and Biological Agent Detection Equipment
	2.2	TRIAGE CONSIDERATIONS
	2.3	EXTERNAL COMMUNICATION
	2.3.1	Obtaining Timely Information
	2.3.2	Coordinating Activities
	3.0	RECOVERY
	3.1	HOSPITAL DECONTAMINATION
	3.1.1	Solid Waste Management
	3.1.2	Wastewater Management
	3.1.3	Decontaminating Surfaces and Equipment
	4.0	MAINTAINING FUTURE READINESS
APPENDIX B:		ACRONYMS AND DEFINITIONS
APPENDIX C:		REFERENCES
APPENDIX D:		ADDITIONAL RESOURCES (WEB LINKS)
APPENDIX E:		ADVANTAGES AND DISADVANTAGES OF VARIOUS RESPIRATOR FACEPIECE STYLES
APPENDIX F:		HAZARD VULNERABILITY ANALYSIS EXAMPLES
APPENDIX G:		INTRODUCTION TO HEICS
APPENDIX H:		EXAMPLES OF MEDICAL MONITORING FOR FIRST RECEIVERS, INCLUDING INFORMATION ON HEAT STRESS
APPENDIX I:		VITAL SIGNS AND PPE DONNING CHECKLISTS
APPENDIX J:		EXAMPLE OF PATIENT DECONTAMINATION PROCEDURE
APPENDIX K:		PPE DONNING AND DOFFING SEQUENCE
APPENDIX L:		EXAMPLE OF TECHNICAL DECONTAMINATION PROCESS FOR HOSPITAL PERSONNEL
APPENDIX M:		EXAMPLE OF INTEGRATED PROCEDURES FOR FIRST RECEIVERS
List of Figures and Tables
FIGURE 1.		RESULTS OF SIMULATION TESTS ON SEVERAL CHEMICAL SUITS
TABLE 1.		HOSPITAL DECONTAMINATION ZONE
TABLE 2.		HOSPITAL POST-DECONTAMINATION ZONE
TABLE 3.		MINIMUM PERSONAL PROTECTIVE EQUIPMENT (PPE)
TABLE 4.		TRAINING FOR FIRST RECEIVERS

Acknowledgments

OSHA's Directorate of Science, Technology and Medicine wishes to acknowledge the assistance provided by the following organizations: Department of Veterans Administration (VA), California Emergency Medical Services Authority (EMSA), Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry (CDC/ATSDR), National Institute for Occupational Safety and Health (NIOSH), INOVA Health System, Northern Virginia Hospital Alliance, Kaiser Permanente, U.S. Coast Guard National Strike Force, and the U.S. Army Center for Health Promotion and Preventive Medicine (USACHPPM). OSHA's Directorate of Enforcement Programs (DEP), and the Directorate of Standards and Guidance (DSG), as well as the Office of the Solicitor, OSH Division (SOL) also made notable contributions.

Seven hospitals provided extensive information, hospital tours, equipment demonstrations, interviews, photographs, and reference material for this project:

Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
Enloe Medical Center, Chico, California
National Naval Medical Center, Bethesda, Maryland
New York University Medical Center, New York City, New York
Samaritan Regional Health System, Ashland, Ohio
Sutter Amador Hospital, Jackson, California
Veterans Administration Medical Center, Washington, DC

These hospitals were identified by hospital organizations as having given notable consideration to the possibility of receiving contaminated victims from a mass casualty incident involving hazardous substance release. Hospitals interviewed were selected to represent a range of circumstances, loosely based on location (U.S. region) and the hospital's relative probability (risk) of receiving contaminated victims of a mass casualty incident. This risk was estimated using a scale adapted from the Hospital Corporation of America (HCA, undated):

Key Treatment Centers - Hospitals in large urban areas. (Hospitals A, B, C, and G)*
Potential Risk Hospitals - Hospitals within 50 miles of a large urban area and high-visibility potential targets where a mass casualty incident could occur (e.g., major airport or sports stadium, large chemical manufacturing facility, nuclear power plant, major shopping mall, nationally recognized monument). (Hospitals D and E)*
Minimum Risk Hospitals - Hospitals with populations less than 500,000 within a 50-mile radius and without a high-visibility potential target within that distance. (Hospital F)*

Note: This risk scale was used only to help identify a diverse group of hospitals for interviews. Other scales might have been used and OSHA does not promote this or any other scheme.

*To maintain a minimum level of confidentiality, hospitals were assigned letters according to risk category, which do not reflect the alphabetical order in which they are listed above.

The following agencies and organizations reviewed and provided comments regarding OSHA's Best Practices:

Agency for Healthcare Research and Quality (AHRQ)
Agency for Toxic Substances and Disease Registry (ATSDR)
American College of Emergency Physicians (ACEP)
American Hospital Association/American Society for Healthcare Engineering (ASHE)
U.S. Navy Bureau of Medicine and Surgery (BUMED)
California Emergency Medical Services Authority (CA-EMSA)
Centers for Disease Control and Prevention (CDC)
Emergency Nurses Association (ENA)
EnMagine (hazmatforhealthcare.org)
George Washington University - Institute for Crisis, Disaster and Risk Management
Health Resources & Services Administration (HRSA), National Bioterrorism Hospital Preparedness Program
Hennepin County (MN) Medical Center, Emergency Medicine
Inova Health System, Emergency Management and Disaster Medicine; and Employee and Occupational Health Departments
International Chemical Workers Union Council of the United Food and Commercial Workers Union (ICWUC)
International Safety Equipment Association (ISEA)
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Kaiser Permanente
National Incident Management System (NIMS) Integration Center
National Organization for Victim Assistance (NOVA)
Navy Environmental Health Center, Industrial Hygiene Directorate,
Navy Medicine Office of Homeland Security, Bureau of Medicine and Surgery
National Institute of Environmental Health Sciences (NIEHS), Worker Education and Training Program (WETP), National Clearinghouse for Worker Safety and Health Training
National Institute for Occupational Safety and Health (NIOSH)
NYU Medical Center, Environmental Services Department
Rhode Island Department of Health
Samaritan Regional Health System
University of Maryland School of Medicine, National Study Center for Trauma & EMS
U.S. Department of Veterans Affairs, Central Arkansas Veterans Healthcare System
U.S. Department of Veterans Affairs, Office of Occupational Safety and Health
U.S. Department of Veterans Affairs, Occupational Health Program
U.S. Department of Veterans Affairs, Veterans Administration Medical Center (Washington, DC)
U.S. Army Center for Health Promotion and Preventive Medicine (USACHPPM)

The mention of any healthcare provider, product, or process in this publication does not constitute or imply endorsement by the Occupational Safety and Health Administration.

Executive Summary

Healthcare workers risk occupational exposures to chemical, biological, or radiological materials when a hospital receives contaminated patients, particularly during mass casualty incidents. These hospital employees, who may be termed first receivers, work at a site remote from the location where the hazardous substance release occurred.¹ This means that their exposures are limited to the substances transported to the hospital on victims' skin, hair, clothing, or personal effects (Horton et al., 2003). The location and limited source of contaminant distinguishes first receivers from other first responders (e.g., firefighters, law enforcement, and ambulance service personnel), who typically respond to the incident site (i.e., the Release Zone).

In order to protect their employees, hospitals benefit from information to assist them in emergency planning for incidents involving hazardous substances (BNA, 2003; Barbera and Macintyre, 2003). Emergency first responders, at the site of the release, are covered under OSHA's Standard on Hazardous Waste Operations and Emergency Response (HAZWOPER), or the parallel OSHA-approved State Plan standards, and depending on their roles, some hospital employees also are covered by the standard.^2,3 However, OSHA recognizes that first receivers have somewhat different training and personal protective equipment (PPE) needs than workers in the hazardous substance Release Zone, a point clarified through letters of interpretation (OSHA, 2002a).

In this best practices document, OSHA provides practical information to help hospitals address employee protection and training as part of emergency planning for mass casualty incidents involving hazardous substances. OSHA considers sound planning the first line of defense in all types of emergencies (including emergencies involving chemical, biological, or radiological substances). By tailoring emergency plans to reflect the reasonably predictable "worst-case" scenario under which first receivers might work, the hospital can rely on these plans to guide decisions regarding personnel training and PPE (OSHA, 2003, 2002b, 1999). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires an all-hazard approach to allow organizations to be flexible enough to respond to emergencies of all types, whether natural or manmade (unintentional or intentional).⁴

Worst-case scenarios take into account challenges associated with communication, resources, and victims. During mass casualty emergencies, hospitals can anticipate little or no warning before victims begin arriving.⁵ Additionally, first receivers can anticipate that information regarding the hazardous agent(s) would not be available immediately. Hospitals also can anticipate a large number of self-referred victims (as many as 80 percent of the total number of victims) and assume victims will not have been decontaminated prior to arriving at the hospital (Auf der Heide, 2002; Barbera and Macintyre, 2003; Vogt, 2002; Okumura et al., 1996).

The appropriate employee training and PPE selection processes are defined in applicable OSHA standards.⁶ An employee's role and the hazards that an employee might encounter dictate the level of training that must be provided to any individual first receiver. PPE selection must be based on a hazard assessment that carefully considers both of these factors, along with the steps taken to minimize the extent of the employee's contact with hazardous substances.

Despite many hospitals' strong interest in powered air-purifying respirators (PAPRs) as a practical form of respiratory protection for first receivers in the Hospital Decontamination Zone, many knowledgeable sources avoid making specific PPE recommendations, but rather point out the advantages and disadvantages of the various options, or recommend appropriate PPE (JCAHO, 2001; Lehmann, 2002; Penn, 2002). Others offer stronger opinions. CA EMSA (2003a) promotes the use of a multi-tiered approach to PPE. Burgess (1999) indicates, in an article published prior to more recent letters of interpretation specific to healthcare workers, that OSHA requires Level B protection or self-contained breathing apparatus (SCBA) for unknown hazards, but points out there are substantial difficulties for healthcare workers who attempt to care for patients while wearing this type of equipment and also addresses the hazards of wearing SCBAs (e.g., slips, trips, falls, and overexertion, particularly for infrequent users of this equipment). These sources demonstrate appropriate caution in the face of unknown contaminants of unknown concentration. However, OSHA believes that the substantial body of recent information on first receivers' actual experiences and probable exposure levels now allows more definitive guidance.

In this best practices document, OSHA specifies PPE that hospitals could use to effectively protect first receivers assisting victims contaminated with unknown substances, provided the hospital meets certain prerequisite conditions designed to minimize the quantity of substance to which first receivers might be exposed. This PPE for first receivers includes: a PAPR with an assigned protection factor of 1,000, a chemical-resistant protective garment, head covering if it is not already included in the respirator, a double layer of protective gloves, and chemical-protective boots (see Table 3, Section B.3). As part of OSHA's required hazard assessment process, each hospital also must consider the specific hazards first receivers might reasonably be expected to encounter.⁷ The hospital must then augment OSHA's PPE selection when necessary to provide adequate protection against those specific identified hazards.

The specified PPE is appropriate when the hazardous substance is unknown and the concentration is strictly limited by 1) the quantity of material associated with living victims and 2) the conditions, policies, equipment, and procedures that are in place and that will reduce employee exposure. Tables 1 and 2 of the best practices document list those specific prerequisites that OSHA believes are necessary to adequately limit first receiver exposures and to assure the adequacy of the PPE presented in Table 3. Such conditions include a current Hazard Vulnerability Analysis (HVA) and emergency management plan (EMP), as well as procedures to ensure that contaminated materials are removed from the area and contained so they do not present a continuing source of exposure.

The first receiver PPE listed in Table 3 is not the only option for first receivers. Employees at hospitals that do not meet the criteria shown in Tables 1 and 2 must determine whether more protective equipment is required (e.g., HAZWOPER Level B). A higher level of protection also may be necessary for any hospital that anticipates providing specialized services (such as Hazardous Materials Response Team at the incident site). Additionally, if a hospital is responding to a known hazard, the hospital must ensure that the selected PPE adequately protects the employees from the identified hazard. Thus, hospitals must augment or modify the PPE in Table 3 if the specified PPE is not sufficient to protect employees from the identified hazard. Alternatively, if a hazard assessment demonstrates that the specified PPE is not necessary to effectively protect workers from the identified hazard, a hospital would be justified in selecting less protective PPE, as long as the PPE actually selected by the hospital provides effective protection against the hazard.

This best practices document provides hospitals and other health care providers with information to assist in the provision of PPE and training for first receivers. Section A introduces the subject, while section B provides a detailed analysis of potential hazards, as well as a comprehensive discussion of the PPE currently available to protect workers from these hazards. In Section B.3, OSHA provides three tables designed to assist employers in selecting PPE adequate to protect healthcare workers and to comply with relevant OSHA PPE standards. Employers who meet the prerequisites in Table 1 and 2 may use this best practices document as the OSHA-required generalized hazard assessment. Such employers may choose to rely on the PPE specified in Table 3 to comply with relevant OSHA standards and to provide effective protection for first receivers against a wide range of hazardous substances. However, such employers also must conduct a hazard assessment that considers hazards unique to the community in which they are located. In rare situations, these employers will need to augment or modify the PPE specified in Table 3 to provide adequate protection against unique hazards identified in the community-specific hazard analysis. Of course, employers are not obligated to follow the guidance in Table 3; any employer can choose instead to perform an independent hazard assessment that is sufficient to identify the hazards that its employees are reasonably anticipated to encounter, and then select PPE adequate to protect its employees against such hazards. Section C of this best practices document contains a discussion of training required for first receivers and concludes with Table 4, which matches required training levels to employee roles and work areas.

Appendix A of this best practices document provides background information on how various aspects of a hospital's preparation, response, and recovery impact employee protection during hazardous substance emergencies. Appendices B, C, and D list additional information sources, while Appendices E through M offer examples of procedures and equipment used in some hospitals. OSHA offers these examples for informational purposes only and does not recommend one option over the many effective alternatives that exist. Emergency managers might find these resources helpful in developing or updating existing EMPs.

This document is based on presently available information, as well as current occupational safety and health provisions and standards. Employers should modify their procedures as appropriate, when additional, relevant information becomes available or when modifications to Occupational Safety and Health Act (OSH Act) or JCAHO standards necessitate revision. The OSH Act requires employers to comply with hazard-specific safety and health standards. In addition, pursuant to Section 5(a)(1), the General Duty Clause of the OSH Act, employers must provide their employees with a workplace free from recognized hazards, likely to cause death or serious physical harm. This document incorporates existing applicable regulatory provisions, as well as non-mandatory work practices and methods that may be implemented to further supplement employee protection against exposure to hazardous substances. OSHA has attempted to clearly distinguish between mandatory and recommended work practices/methods within this document. Where regulations establish performance criteria for compliance, this document attempts to provide specific guidance that employers may use to adequately protect employees and comply with these regulatory provisions. However, an alternative approach may be justified given specific workplace circumstances. This document does not enlarge or diminish an employer's obligation under the OSH Act.

Best Practices from OSHA

A.0	INTRODUCTION

A.1	BACKGROUND

Healthcare workers risk occupational exposure to chemical, biological, or radiological materials when hospitals receive patients contaminated with these substances during mass casualty incidents (Horton et al., 2003).⁸ Such incidents could be associated with manmade (intentional or unintentional) or natural disasters and can involve a wide range of hazardous substances—from chemical weapons agents to toxic industrial chemicals (Horton et al., 2003).

A.2	DEFINING "FIRST RESPONDERS"

Healthcare workers at a hospital receiving contaminated victims for treatment may be termed first receivers (Koenig, 2003). This group is a subset of first responders (e.g., firefighters, law enforcement, HAZMAT teams, and ambulance service personnel). However, most first responders typically act at the site of an incident (i.e., the location at which the primary release occurred). In contrast, inherent to the definition of first receivers, is an assumption that the hospital is not itself the primary incident site, but rather is remote from the location where the hazardous substance release occurred. Thus, the possible exposure of first receivers is limited to the quantity of substance arriving at the hospital as a contaminant on victims and their clothing or personal effects (Horton et al., 2003).

First receivers typically include personnel in the following roles: clinicians and other hospital staff who have a role in receiving and treating contaminated victims (e.g., triage, decontamination, medical treatment, and security) and those whose roles support these functions (e.g., set up and patient tracking).⁹

A.3	SCOPE AND OBJECTIVES

In order to protect their employees, hospitals benefit from information to assist them in emergency planning for incidents involving hazardous substances (BNA, 2003; Barbera and Macintyre, 2003). Emergency first responders at the scene of the incident, including fire, law enforcement, and emergency medical personnel, are covered by the requirements of OSHA's Standard on Hazardous Waste Operations and Emergency Response (HAZWOPER), or by parallel state standards in states with OSHA-approved State Plans.^10,11 However, the extent of the hazard to the hospital-based first receivers (a subgroup of first responders) can differ from that at the release site. A series of OSHA letters of interpretation clarifies when and how the HAZWOPER Standard applies to first receivers. This best practices document provides information useful to employers attempting to provide adequate protection for hospital-based first receivers during mass casualty incidents involving hazardous substances.

Specifically, this best practices document covers protection for first receivers during releases of chemicals, radiological particles, and biological agents (overt releases) that produce victims who may need decontamination prior to administration of medical care. Although intended for mass casualty incidents as they affect emergency department personnel at fixed hospitals, the basic principles and concepts of this guidance also apply to mobile casualty care facilities and temporary shelters, such as would be necessary in the event of a catastrophic incident involving tens or hundreds of thousands of victims.

The scope of this best practices document does not include situations where the hospital (or temporary facility) is the site of the release. Nor does it include infectious outbreaks for which victim decontamination is not necessary.

A.4	DOCUMENT CONTENT AND ORGANIZATION

This best practices document 1) provides information to assist hospitals in selecting personal protective equipment (PPE) based on current interpretations of OSHA standards, published literature, current hospital practices, stakeholder input, and the practical limitations of currently available respiratory protective devices and 2) consolidates OSHA standards and interpretations on training needs of first receivers. These best practices build on health and safety programs that hospitals already should have in place under existing OSHA regulations (such as those listed in Section 1.1.3 in Appendix A).

Section A introduces the document, while Section B addresses details concerning PPE selection. Specifically, Section B.1 describes how hospitals can use these best practices, and Section B.2 reviews the available information and indicates the rationale for OSHA's conclusions on first receiver respiratory protection, glove selection, and protective clothing. Section B.3 draws on information concerning hazards likely encountered by first receivers and specifies a minimum level of PPE for protecting first receivers against such hazards (Table 3). Unless a community-specific hazard analysis identifies unique hazards that first receivers are reasonably anticipated to encounter and that require greater (or varied) PPE, an employer who meets the prerequisites detailed in Tables 1 and 2 for limiting exposure can choose to rely on the PPE identified in Table 3 to comply with relevant OSHA PPE standards. Of course, employers are not obligated to follow the guidance in Table 3; any employer can choose instead to perform an independent hazard assessment that is sufficient to identify the hazards that its employees are reasonably anticipated to encounter, and then select PPE adequate to protect its employees against such hazards. Information on training first receivers appears in Section C, which concludes with a summary of first receiver training (Table 4).

The appendices provide examples, which might be useful to hospitals developing or upgrading emergency management plans (EMPs). Appendix A of this best practices document provides background information on how various aspects of a hospital's preparation, response, and recovery impact employee protection during hazardous substance emergencies. Appendices B, C, and D list additional information sources, while Appendices E through M offer examples of procedures and equipment used in some hospitals. OSHA offers these examples for informational purposes only and does not recommend one option over the many effective alternatives that exist.

OSHA recommends that this best practices document be used in conjunction with other available emergency preparedness information sources, such as those listed in Appendices C and D, and other references that may become available in the future. Footnotes indicating current Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Standards for Emergency Management (which are further described in Section EC 1.4 of JCAHO's Comprehensive Accreditation Manual for Hospitals) appear at key points in the document. In publishing this guideline, it is OSHA's intent to provide useful information that will assist hospitals and other healthcare providers in taking appropriate steps to protect first receivers and other affected workers from exposure to chemical, biological, and radiological substances.

B.O	PERSONAL PROTECTIVE EQUIPMENT

PPE selection for first receivers has been a topic of significant discussion (Hick et al., 2003a; Barbera and Macintyre, 2003; CA EMSA, 2003b; ECRI, 2002). At the root of this discussion is the need for hospitals to provide adequate protection for the reasonably anticipated worst-case employee exposure scenario, despite having limited information regarding the nature of the substance with which victims may be contaminated (OSHA, 2002b). This lack of information challenges hospitals' abilities to conduct the hazard assessments on which PPE selection must be based.¹²

Despite many hospitals' strong interest in powered air-purifying respirators (PAPR) as a practical form of respiratory protection for first receivers in the Hospital Decontamination Zone, many knowledgeable sources avoid making specific PPE recommendations, but rather point out the advantages and disadvantages of the various options, or recommend appropriate PPE (JCAHO, 2001; Lehmann, 2002; Penn, 2002).¹³ Others offer stronger opinions. CA EMSA (2003a) promotes the use of a multi-tiered approach to PPE. Burgess (1999), in an article published prior to more recent letters of interpretation specific to healthcare workers, indicates that OSHA requires Level B protection or self-contained breathing apparatus (SCBA) for unknown hazards, but points out there are substantial difficulties for healthcare workers who attempt to care for patients while wearing this type of equipment and also addresses the hazards of wearing SCBAs (e.g., slips, trips, falls, and overexertion, particularly for infrequent users). These sources demonstrate appropriate caution in the face of unknown contaminants of unknown concentration. However, OSHA believes that the substantial body of recent information on first receivers' actual experiences and probable exposure levels now allows more definitive guidance.

To assist hospitals, this section provides information that employers can use to provide a level of PPE that reasonably can be expected to protect first receivers from a wide range of hazards. OSHA's PPE selection guidance applies when the hazardous substance is unknown and the possible exposure is strictly limited by 1) the quantity of material associated with living victims and 2) other specific conditions, policies, equipment, and procedures in place that will reduce employee exposure. These best practices are preceded by instructions for using the document and by a discussion of the information considered in developing OSHA's PPE selection.

B.1	USING OSHA'S BEST PRACTICES

B.1.1

Using OSHA's Rationale for PPE Selection and Hazard Assessment

In Tables 1, 2, and 3 of this document, OSHA, outlines prerequisite conditions necessary to limit first receiver exposure to unknown hazardous substances and presents information that employers can use to provide adequate PPE for first receivers. The prerequisite conditions in the first two tables are designed to minimize the exposure of first receivers and form part of the basis for OSHA's rationale for the PPE selection listed in Table 3. By implementing those prerequisites, hospitals can reduce the exposures of their own first receivers. Hospitals may then use the discussion in Section B (Personal Protective Equipment) in conducting the required hazard assessment, which must consider hazards unique to the community in which they are located. In rare situations, these employers will need to augment or modify the PPE specified in Table 3 to provide adequate protection against unique hazards identified in the community-specific hazard analysis. Of course, employers are not obligated to follow the guidance in Table 3; any employer can choose instead to perform an independent hazard assessment that is sufficient to identify the hazards that its employees are reasonably anticipated to encounter, and then select PPE adequate to protect its employees against such hazards.

B.1.2

Augmenting the PPE Selection to Address Specific Hazards Identified by the Hazard Vulnerability Analysis (HVA) and the Community

The best practices presented in this document indicates the minimum PPE that OSHA anticipates generally will be needed to protect first receivers faced with a wide range of unknown hazards (providing the prerequisite conditions in Tables 1 and 2 are met). However, as with any generalized protection, OSHA's PPE for first receivers offers more protection against some hazards than others. When a hospital determines that first receivers could reasonably anticipate encountering a specific known hazard, the hospital also must determine whether this generalized protection must be supplemented to more fully address that specific hazard.

Specifically, to finish the hazard assessment and PPE selection process, each hospital must consult its own complete and updated HVA (required by JCAHO), as well as additional information available from the community (e.g., the Local Emergency Planning Committees (LEPC)). JCAHO requires that hospitals also consider their anticipated roles and coordinate activities with other emergency response agencies and hospitals within the community. When these sources point to a specific substance or situation from which the hospital should protect its first receivers, the hospital must confirm that PPE selection provides effective protection against that hazard. In rare situations, the process of considering the HVA and community-specific information will identify ways the hospital must augment the PPE specified in Table 3 for unknown hazards in order to help ensure protection against specific known hazards (e.g., by tailoring glove selection to address an identified, specific hazard, or by stocking additional supplies, such as a specific respirator cartridge known to protect the user from an identified, specific hazard).

Hospitals must adopt a more specialized level of protection (such as air-supplied respirators) if the hospital's role, position in the community, or HVA indicates a higher level of protection is necessary (e.g., if the hospital will field a HAZMAT team or provide other services at the release site, if the hospital is adjacent to a hazardous chemical storage facility that could subject first receivers to an environment immediately dangerous to life and health (IDLH), or if the hospital is the site of the incident).

B.2	RATIONALE FOR OSHA'S PERSONAL PROTECTIVE EQUIPMENT BEST PRACTICES

The following discussion reviews existing OSHA regulations, letters of interpretation, and published literature relevant to the selection of PPE for healthcare workers receiving contaminated victims. OSHA's best practices on first receiver PPE appear at the end of this section, in Tables 1, 2, and 3.

B.2.1

Respiratory Protection

B.2.1.1

Limited Quantity of Contaminant on Victims

A key factor supporting OSHA's PPE best practices is the limited amount of toxic substance to which first receivers might be exposed. Many recent sources note that the quantity of contaminant on victims is restricted. For example, OSHA has made a clear distinction between the site where a hazardous substance was released and hospital-based decontamination facilities (OSHA, 1992a, 2002a). This distinction is important because it helps define the maximum amount of contaminant to which healthcare workers might be exposed (i.e., the quantity of material on living victims and their possessions when they arrive at the hospital). Horton et al. (2003) stated that, during victim decontamination procedures, the hazard to healthcare workers is strictly from secondary exposure and "depends largely on the toxicity of the substance on the victims' hair, skin, and clothing; the concentration of the substance; and the duration of contact [first receivers have] with the victim."

The quantity of contaminant that healthcare workers might encounter can be dramatically less than the amount to which the victim was exposed or that was originally deposited on the victim. Gas or vapor releases can expose victims to toxic concentrations, but tend to evaporate and dissipate quickly. Georgopoulos et al. (2004) determined that 100 grams (approximately 4 ounces) of most moderately to highly volatile substances that might be sprayed on a victim during a mass casualty incident would evaporate within 5 minutes from the time the exposure occurred. Unless the substance release occurs immediately adjacent to a hospital, it is not anticipated that victims will be able to reach the hospital within that period of time, or the more realistic 10-minute period that Georgopoulos et al. (2004) used in the exposure model presented later in this section.¹⁴ Horton et al. (2003) agree, stating that substances released as gas or vapor "are not likely to pose a secondary contamination risk" to first receivers. It is important to note, however, that limited exposure might be possible. In an isolated incident reviewed by these authors, unprotected healthcare workers experienced skin and respiratory irritation from highly toxic volatile substances (chlorine gas) thought to have permeated victims' clothing.¹⁵ While an environment that is immediately dangerous is possible, it is extremely unlikely that a living victim could create an IDLH environment at a receiving hospital, particularly if contaminated clothing is quickly removed and isolated, and the victim is treated and decontaminated in an area with adequate ventilation.

Removal of victim's clothing, or, better yet, decontamination of victims before they arrive at the hospital have a marked effect on the quantity of contaminant that first receivers encounter. Pre-hospital decontamination can eliminate the risk of secondary contamination (Horton et al., 2003). Removing contaminated clothing can reduce the quantity of contaminant associated with victims by an estimated 75 to 90 percent (Macintyre et al., 2000; Vogt, 2002; USACHPPM, 2003a).¹⁶ To control unnecessary exposure, Hospital A promotes the use of prescribed procedures for first responders assisting victims to remove clothing. The clothing is cut away using blunt-nose shears to eliminate stretching, flapping, wringing, or excessive handling of fabric that might contribute to worker exposure (or additional victim exposure).

Showering with tepid water and a liquid soap with good surfactant properties is widely considered an effective (and preferred) method for removing the remaining hazardous substance from victims' skin and hair (Goozner et al, 2002; Macintyre et al., 2000).¹⁷ The U.S. Army promotes this method for chemicals (both chemical weapons and toxic industrial chemicals), radiological particles, and biological agents (USACHPPM, 2003a).¹⁸ In several cases involving secondary exposure incidents reviewed by Horton et al. (2003), contaminated victims who caused injury to healthcare workers were subsequently decontaminated. No further injury to healthcare workers was mentioned. See Appendix A, Section 2.1.3.2 for additional discussion of decontamination procedures for unknown contaminants. When the nature of the contaminant is known, the hospital can adjust the decontamination procedures to best remove the specific hazard.

As a final step in minimizing first receiver exposure to hazardous substances, the accepted industrial hygiene practice is for the healthcare workers also to shower following contact with contaminated victims and cleanse equipment as part of decontamination procedures. Hospital A uses a strict protocol for personnel to decontaminate themselves while removing gloves, protective suits, boots, and hooded powered air-purifying respirators (PAPRs). Hospital C includes decontamination of the shower system and associated equipment as part of those procedures.

B.2.1.2

Hospital Experience with Contaminated Victims

Several studies have reviewed public data and reports regarding victims of hazardous materials emergencies and associated secondary contamination of healthcare workers. First receivers rarely reported adverse health effects. Those workers who experienced symptoms were unprotected and tended to have close, extended contact with the contaminated victims. Horton et al. (2003) evaluated data from the Agency for Toxic Substances and Disease Registry (ATSDR) Hazardous Substance Emergency Events Surveillance (HSEES) system. Through 2001, the database had captured information on over 44,000 hazardous materials events involving substances other than petroleum products.¹⁹ Although overall, healthcare workers were the 11^th most common group injured in hazardous materials incidents, Horton determined that events affecting emergency department (ED) personnel appear to occur infrequently, representing only 0.2 percent of the 2,562 HSEES events in which victims were transported to a hospital.²⁰ Horton et al. (2003) also note that among the ED personnel injured, none wore any form of protection at the time of the injury. Respiratory tract and eye irritation were the primary symptoms and no employees required hospitalization.

A separate survey of ED evacuations at hospitals in the state of Washington also found a low incidence of secondary contamination of ED staff. Over a 5-year period, 101 hospitals reported only two evacuation incidents that also involved secondary contamination of staff, while ED evacuations due to hazardous substance incidents (usually caused by releases within the hospital) occurred 11 times.²¹ The victims were not decontaminated prior to arrival at the hospital in either of the cases involving secondary contamination to staff (Burgess, 1999).

Walter et al. (2003) also reviewed municipal records to characterize hazardous materials responses. These authors evaluated all fire department hazardous materials reports, along with the associated emergency medical services encounter forms and hospital records for a mid-size metropolitan area (population 400,000). More than 70 percent of the hazardous materials incidents involved flammable materials (e.g., methane gas, diesel fuel, gasoline, and hydraulic oils), all of relatively low toxicity. Approximately 7 percent of the incidents involved highly toxic materials, all of which fell into the categories of mercury, pesticides, and cyanides. An additional 5 percent of the events were associated with toxic gases (primarily carbon monoxide, with a few cases of anhydrous ammonia or chlorine exposure). Corrosive materials accounted for another 10 percent of the incidents and primarily involved mineral acids and basic materials such as lime and sodium hydroxide.²² Walter found that those patients transported to the hospital were usually treated for inhalation exposure to airborne toxicants, for which few required hospitalization. These findings may explain the results of Horton et al. (2003) and Burgess (1999) who, as previously noted, identified few injuries among healthcare workers who treated victims of hazardous materials incidents. Victims exposed to gases or vapors are not anticipated to be contaminated with substantial quantities of these materials upon arrival at the hospital.

Hick et al. (2003a) reviewed the published literature and some individual case reports to assess the risk of contaminated patients to healthcare workers in the U.S. and abroad. These cases included incidents in which healthcare workers were exposed to secondary contamination, generally for periods of less than one hour.²³ Hick et al. (2003a) concluded that "...a contaminated patient presenting at the ED poses a definite health risk to providers. However, even without personal protective equipment, the risks of significant injury appear to be low, as reflected in this review and analysis of published cases." These authors found that the more serious injuries to healthcare workers are frequently associated with organophosphate compounds (e.g., sarin and certain pesticides), which are "extremely toxic, prone to off-gassing, and might have prolonged clinical effects..." The affected healthcare workers identified by the authors rarely used PPE.

Okumura et al. (1996) reported on the 1995 Tokyo subway sarin attack, in which one hospital received 640 victims (80 percent self-referred), 107 of whom were moderately injured and five were considered severely injured. Hick et al. (2003a) also reviewed the literature describing this incident and noted that more than 100 healthcare providers in Tokyo experienced symptoms (e.g., blurred vision) while treating victims. Of these, the most affected were several physicians who spent up to 40 minutes attempting to resuscitate the initial victims of the incident. The victims had not been decontaminated. These and other worker exposures were attributed to the failure of healthcare providers to use PPE and the practice of placing still-clothed, contaminated victims in a poorly ventilated waiting area.

It is interesting to note that although sarin (a notorious chemical warfare agent) affected many of the healthcare providers, all exposed providers at one of the primary receiving hospitals were reportedly able to continue their duties (Okumura et al., 1996). In the Tokyo terrorism incident, although victims' clothing was not removed and continued to be a source of contamination, unprotected first receivers experienced only limited exposures.²⁴ It is reasonable to anticipate that healthcare worker exposures might have been dramatically reduced by a combination of removing victims contaminated clothing, improving ventilation in patient waiting areas, and using PPE.

B.2.1.3

Exposure Modeling

Two studies conducted modeling of various phases of the victim disrobing and decontamination process in order to characterize first receiver exposure levels and evaluate the need for respiratory protection. These studies point out the need for a carefully developed and implemented EMP that includes hazard-reducing work practices, appropriate respiratory protection, and full body protection. In the first study, Schultz et al. (1995) collected air samples in the breathing zone of two healthcare workers during decontamination activities.²⁵ The test took place in an unventilated room, where the workers removed the simulated non-ambulatory patients' clothing and cleaned the skin using dry brushing to remove particles.²⁶

The test periods included 5 minutes with the victim resting on a decontamination cart (to simulate a delay in clothing removal and decontamination), 2.5 minutes during which the healthcare workers cut away victims' clothing and placed it in a sealed container, and approximately 3 minutes of simulated skin cleaning. This latter activity generated visible dust during particulate trials.²⁷ The solvents evaporated completely during the 10-minute test periods and victim cleaning was not required for these agents. Healthcare worker exposure levels for dust ranged from 1.98 to 4.28 milligrams per cubic meter of air (mg/m³), while results for p-xylene ranged from 18 to 148 parts per million (ppm) and acetone concentrations were 185 to 459 ppm. The authors concluded that exposure levels were statistically lower than the applicable short-term exposure limits for these moderately toxic industrial chemicals; however, due to the uncertainties of hazardous materials management, "use of respiratory protective equipment should be continued."

In contrast to Schultz et al. (1995), which evaluated an industrial chemical of moderate toxicity, Georgopoulos et al. (2004) used a probability model to predict the level of respiratory protection that decontamination hospital staff would require to limit their exposure to several highly toxic industrial chemicals (chlorine, phosgene, and cyanide) and chemical weapons agents (nerve and blister agents). The model takes into account the substance's relative toxicity, vapor pressure, and dispersion characteristics, as well as the probable amount and distribution of contaminant on the victim, and the amount of time the substance would require to evaporate from the victim. The model also considered the number of victims, the length of time between the victims' exposure and arrival at the hospital, atmospheric conditions, and how soon after arrival the victims' contaminated clothing can be removed. Using Monte Carlo analysis and parameters set to consider extreme worst-case scenarios, the authors concluded that if contaminated clothing remains an ongoing source of contamination over a period of 6 hours of constant exposure, less than 2 percent of healthcare workers would be exposed to levels of sarin that would exceed the protection offered by a respirator providing at least 1,000-fold protection.²⁸ This percentage dropped when inputs associated with more likely scenarios were used (e.g., increased evaporation transfer rate or increased lag time before the victim reached the hospital). Furthermore, related analysis showed that if contaminated clothing is removed immediately when the victim arrives at the hospital, "the level of sarin exposure to a healthcare worker would be negligible" and adequate protection would be provided by air purifying respirators with an assigned protection factor (APF) of 1,000.²⁹

If correctly selected, fitted, used, and maintained, respiratory protective equipment reduces significantly the effective exposure level that an employee experiences. An employee wearing a respirator that offers a protection factor of 1,000 will breathe air that contains no more than 1/1,000 (or 0.1 percent) of the contaminant level outside the respirator. OSHA recently proposed an APF of 1,000 for certain designs of hood/helmet respirators.^30,31 Full facepiece and hood/helmet supplied air respirators (excluding loose-fitting facepieces) are also assigned an APF of 1,000 in the proposed rule (Federal Register, 2003 (68 FR 34035)).³²

The combination of high efficiency (HE) particulate filters plus organic vapor (OV) cartridges currently available for PAPRs will protect against many of the airborne hazards that first receivers might encounter (e.g., toxic dusts, biological agents, radioactive particulates, organophosphates and other pesticides, and solvents). Acid gas cartridges add an additional level of protection from gases such as chlorine, which generally will dissipate before victims arrive at the hospital, but which have been implicated in at least one case of healthcare worker injury.³³ It is not anticipated that first receivers would benefit from cartridges that remove carbon monoxide from air. Despite the number of carbon monoxide victims treated at hospitals, there are no reported cases of healthcare workers being injured through secondary contamination from victims of carbon monoxide poisoning (Horton et al., 2003; Hick et al, 2003a; Walter et al., 2003).

As an applied example, Hospital A used some of these modeling techniques to complement a detailed HVA, a comprehensive staff training program, and a detailed EMP that makes safety and exposure reduction strong priorities.³⁴ This modeling allowed Hospital A to determine that there was not a need for respiratory protection greater than a hooded powered air purifying respirator [PAPR], fitted with high efficiency dust, organic vapor, and acid gas cartridges." The hospital determined that employees need to be protected from skin contact with the contaminant. Thus, individuals involved in decontaminating victims at this hospital wear PAPRs, splash-resistant suits, a double layer of gloves, and chemical-protective boots. Openings to the suits are closed with tape to create a barrier.

B.2.2

Gloves and Boots

No single glove or boot material will protect against every substance. Most glove manufacturers offer detailed guides to glove materials and their chemical resistance. Butyl rubber gloves generally provide better protection than nitrile gloves for chemical warfare agents and most toxic industrial chemicals that are more likely to be involved in a terrorist incident, although the converse applies to some industrial chemicals. Foil-based gloves are highly resistant to a wide variety of hazardous substances and could also be considered when determining an appropriate protective ensemble. Hospitals must select materials that cover the specific substances that the hospital has determined first receivers reasonably might encounter. However, given the broad scope of potential contaminants, OSHA considers it of vital importance for hospitals also to select materials that protect against a wide range of substances. A double layer of gloves, made of two different materials, or foil-based gloves resist the broadest range of chemicals.

In general, the same material selected for gloves will also be appropriate for boots. Because boot walls tend to be thicker than gloves, boots of any material are likely to be more protective than gloves of the same material.

A combination of gloves, for example, butyl gloves worn over inner nitrile gloves, are often the best option for use by hospital workers during emergencies and mass casualties involving hazardous substances. However, hospitals are advised to select the combination that best meet their specific needs.

Glove thickness is measured in mils, with a higher number of mils indicating a thicker glove. Using common examples, exam gloves are often approximately 4 mil, while general-purpose household (kitchen) gloves are 12-16 mil, and heavy industrial gloves might be 20 to 30 mil.

Depending on the dexterity needed by the hospital worker, the glove selection can be modified to allow for the use of a glove combination that is thinner than that usually recommended for the best protection. As an example, the U.S. Army Center for Health Promotion and Preventive Medicine (USACHPPM) recommends that hospital personnel working with victims potentially contaminated with chemical warfare agents or toxic industrial chemicals wear a combination of chemical protective gloves, such as butyl rubber gloves over inner nitrile gloves (USACHPPM, 2003a).³⁵ Because thicker gloves offer greater protection, USACHPPM recommends a butyl glove with a minimum thickness of 14 mil (over a 4 or 5 mil nitrile glove). However, with increased thickness comes greater loss of manual dexterity. When advanced medical procedures must be performed before decontamination, thicker gloves might be too awkward, and, therefore, it might be necessary to use a butyl rubber glove of 7 mil over the nitrile glove, or a 14 mil butyl rubber glove alone (USACHPPM, 2003a). If sterility is required and decontamination is not possible before procedures, a double layer of disposable 4 to 5 mil nitrile gloves might be the best option (USACHPPM, 2003a). Not all sources recommend double gloves; for example, the U.S. Army Soldier and Biological Chemical Command's (SBCCOM) Domestic Preparedness Program (DPP) recommends butyl rubber gloves for personnel performing decontamination operations and casualty care (SBCCOM, 2000a). Among the sterile gloves readily available, those made of nitrile offer the best resistance to the widest range of substances (but not all). Note that thinner gloves deteriorate (tear and rip) more rapidly than thicker gloves. When thinner gloves must be used, they should be changed frequently.

Hendler et al. (2000), as cited in USACHPPM (2003a), conducted a study to determine the effect of full PPE (including 12-mil "tactile" gloves and a full facepiece mask) on intubation performance. Clinicians wearing this equipment could perform endotracheal intubation effectively (i.e., the tube was inserted in sufficient time), but the procedure did take longer than it would have without PPE. Intubation delays would cause subsequent decontamination procedures and medical treatment to be delayed by a corresponding amount of time.

B.2.3

Protective Garments

The optimal garment material for first receivers will protect against a wide range of chemicals in liquid, solid, or vapor form (phase). Because first receivers might become contaminated with liquid or solid (dust) contaminants through physical contact with a contaminated victim, the ideal fabric will repel chemicals during incidental contact (protection from gases is less important because, as shown earlier, gases generally will dissipate before a victim arrives at the hospital). Additionally, the optimal garment will restrict the passage of vapors, both through the suit fabric and through openings in the suit. Finally, optimal clothing is also sufficiently flexible, durable, and lightweight for long-term wear (up to several hours) during physically active work.

Manufacturers produce a variety of suit fabrics and designs, and several commercially available broad-spectrum protective fabrics might be appropriate, depending on the situations and hazards that the hospital anticipates first receivers reasonably might be expected to encounter. While OSHA does not test, endorse, or recommend specific products, examples of such products include: Tyvek® F, Tychem® CPF3, CPF4, Tychem® BR, Tychem® LV, Tychem® SL, Zytron® 100, Zytron® 200, Zytron® 300, Zytron® 400, Zytron® 500, and Zytron® 600, ProVent® 10,000, and DuraVent® 2.8. Before selecting materials, contact the manufacturer for specific application guidance.

Fabric and suit manufacturers can provide laboratory-testing information regarding specific materials. For example, Tyvek® F has been tested extensively by military organizations and accredited testing laboratories.³⁶ As another example, the SBCCOM DPP tested vapor-blocking properties of six different protective suits in a simulated, high-vapor environment. In the results tabulated below, the Tyvek® F suite (ProTech model) offered a protection factor of 42 (vapor levels outside the suit were 42 times higher than inside the suit), which was approximately twice the protection than was provided by the next best performing suits. Traditional Tyvek® (protection factor of 4) was twice as protective as a standard police uniform (protection factor of 2). These suits were tested by placing sensors for the test vapor under the suits at 17 specific body locations. Volunteers wore the protective gear while performing the activities normally associated with an actual first responder chemical response (but did not involve physical acts, such as patient handling, that would likely be required of first receivers) (SBCCOM, 2003).

Figure 1. Results of Simulation Tests on Several Chemical Suits
Suit Configuration	# Suits Tested	Protection Factor
Standard [Police] Uniform	2	2
Tyvek® Protective Wear Suit	4	4
Tychem® 9400 Protective Suit	4	17
Kappler® CPF4 Protective Suit	4	18
Tychem® SL Protective Suit	5	24
Tyvek® ProTech F Protective	5	42

(Source: SBCCOM, 2003)

The ability of protective garment fabric to withstand physical abrasion and tearing is also important. When assisting non-ambulatory victims, first receivers might subject the protective garments to physical stresses that should be considered in garment selection. The National Fire Protection Association (NFPA) in NFPA Standard No. 1994 on Protective Ensemble for Chemical/Biological Terrorism Incidents offers criteria for evaluating performance of protective garments, including detailed specifications for bursting, puncture, and tear resistance, as well as garment seam specifications (NFPA, 2001).

B.3	CONCLUSIONS REGARDING PERSONAL PROTECTIVE EQUIPMENT

Evidence in the U.S. and abroad show that unprotected healthcare workers can be injured by secondary exposure to hazardous substances when they treat contaminated patients. However, OSHA concludes that hospitals that make a conscientious effort can limit the secondary exposure of healthcare workers to a level at which chemical protective clothing (including gloves, boots, and garments with openings taped closed) and PAPRs will provide adequate protection from a wide range of hazardous substances to which first receivers most likely could be exposed. This conclusion is based on the infrequency with which healthcare workers have been affected (despite the numerous hazardous substance incidents), the experiences of hospitals treating contaminated victims, the nature of the injuries healthcare workers sustain when they are affected (during both acts of terrorism and accidental releases), and the exposure models described above. OSHA believes that the 1,000-fold protection factor that has been attained by certain PAPRs in simulated workplace conditions, in combination with protective gloves, boots, and garments with openings taped closed, will be adequate to protect first receivers who are decontaminating victims.³⁷ Government experts, researchers, and hospitals alike offer broad support for the use of PAPRs and chemical protective clothing (including gloves, boots, and suits with the openings taped closed) for first receivers performing decontamination activities (Hick et al., 2003a; Georgopoulos et al., 2004; Macintyre et al., 2000; MMWR, 2001). Furthermore, OSHA believes the decontamination process itself, along with adequate employee training, will prevent injury to ED staff working in the Hospital Post-decontamination Zone.³⁸

Based on information gathered from a wide variety of sources, OSHA has concluded that the PPE specified in Table 3 will provide adequate protection for first receivers exposed to unknown hazardous substances in most circumstances. Although applicable to a wide range of hospitals, the guidance in Table 3 for minimum first receiver PPE is conditional — to limit first receiver exposures to levels at which the PPE specified in Table 3 will provide effective protection, hospitals must meet the specified prerequisite conditions of eligibility set forth in Tables 1 and 2. Employers who meet the prerequisites in Tables 1 and 2 may use this best practices document as the OSHA-required generalized hazard assessment. Such employers may choose to rely on the PPE specified in Table 3 to comply with relevant OSHA standards and to provide effective protection for first receivers against a wide range of hazardous substances. However, such employers also must conduct a hazard assessment that considers hazards unique to the community in which they are located. In rare situations, these employers will need to augment or modify the PPE specified in Table 3 to provide adequate protection against unique hazards identified in the community-specific hazard analysis. Of course, employers are not obligated to follow the guidance in Table 3; any employer can choose instead to perform an independent hazard assessment that is sufficient to identify the hazards that its employees are reasonably anticipated to encounter, and then select PPE adequate to protect its employees against such hazards.

OSHA believes hospitals are becoming increasingly prepared for mass casualty incidents involving unidentified hazardous substances. As a result, OSHA anticipates that many (and eventually most) hospitals will meet the condition in Tables 1 and 2 that will help them manage secondary exposures such that employees can be effectively protected when using the first receiver PPE presented in Table 3. Recent incidents (including the World Trade Center and anthrax attacks) and current JCAHO requirements provide hospitals with strong incentive to take the necessary steps to prepare themselves and their staff to function safely during mass casualty incidents involving hazardous substance releases. Many of the JCAHO requirements help hospitals better identify the actual conditions that they might face in an emergency, which in turn allows the hospitals to make realistic plans for managing emergencies in a way that minimizes the risk to employees. The JCAHO requirements, along with the hospital's commitment to maintaining JCAHO accreditation and OSHA compliance, provide the basis for conducting detailed HVAs, identifying the hospital's role in the community, coordinating plans with other organizations, conducting drills to test all phases of preparedness, training personnel, and implementing PPE and respiratory protection programs. The additional exposure-limiting conditions, such as removing and safely containing contaminated clothing and other personal items as soon as victims arrive at the hospital, are primarily procedural and can be addressed through standard operating procedures and clear communication with victims and hospital staff.

OSHA concludes that PAPRs with helmet/hoods are a practical choice for first receivers. Helmet/hood PAPRs require no fit testing, can be worn by employees with facial hair and eye glasses, and are generally considered by most workers to be more comfortable than negative pressure APRs (see also Appendix E for a comparison of the relative advantages of various facepiece styles).³⁹ Hospitals that take the steps outlined in Tables 1 and 2 will limit the exposures of first receivers to a level against which PAPRs will normally offer suitable protection. Other respirators that provide an APF of 1,000 or higher are also alternatives.

OSHA recommends PAPRs to ensure the appropriate level of protection for situations when the hazardous substance is unknown and unquantified. Non-powered APRs have a role in protecting first receivers when the hazardous substance has been identified and quantified. First receivers may use such respirators after accurate information confirms that a negative pressure respirator will adequately protect the wearer from the identified inhalation hazard.

Any respiratory protection for first receivers must be included in a formal written respiratory protection program, as required by 29 CFR 1910.134 (Respiratory Protection), or the parallel State Plan standards. Hospitals can integrate the respirators into their existing respiratory protection program, which must include the following elements:

Procedures for selecting respirators for use in the workplace.
Medical evaluations of employees required to use respirators.
Fit testing procedures for tight-fitting respirators.
Procedures for proper use of respirators in routine and reasonably anticipated scenarios.
Procedures and schedules for cleaning, disinfecting, storing, inspecting, repairing, discarding, and otherwise maintaining respirators.
Procedures for establishing and implementing respirator chemical cartridge change schedules.
Procedures to ensure adequate air quality, quantity, and flow of breathing air for atmosphere-supplying respirators.
Training of employees in the respiratory hazards to which they are potentially exposed during routine and emergency situations.

B.3.1

First Receiver Hospital Decontamination Zones

OSHA has found it appropriate to define two functional zones during hospital-based decontamination activities. These zones, which guide the application of OSHA's recommendations, are:

Hospital Decontamination Zone
Hospital Post-decontamination Zone

The Hospital Decontamination Zone includes any areas where the type and quantity of hazardous substance is unknown and where contaminated victims, contaminated equipment, or contaminated waste may be present. It is reasonably anticipated that employees in this zone might have exposure to contaminated victims, their belongings, equipment, or waste. This zone includes, but is not limited to, places where initial triage and/or medical stabilization of possibly contaminated victims occur, pre-decontamination waiting (staging) areas for victims, the actual decontamination area, and the post-decontamination victim inspection area. This area will typically end at the ED door. In other documents this zone is sometimes called the "Warm Zone."

The Hospital Post-decontamination Zone is an area considered uncontaminated. Equipment and personnel are not expected to become contaminated in this area. At a hospital receiving contaminated victims, the Hospital Post-decontamination Zone includes the ED (unless contaminated). In other documents this zone is sometimes called the "Cold Zone."

B.3.2

PPE Table and Tables Listing Prerequisite Conditions for Specified PPE

The following pages contain three tables. The first two, Tables 1 and 2, list steps that hospitals must take or conditions that must exist before relying upon the PPE specified in Table 3. These steps and conditions help limit employee exposures and are necessary to ensure that the PPE for both zones listed in Table 3 will adequately protect employees. In other words, OSHA has determined that the minimum first receiver PPE outlined in Table 3 should protect healthcare workers as they care for contaminated victims of mass casualty incidents within the two zones; however, hospitals need to meet certain exposure-limiting conditions (outlined in Tables 1 and 2) to ensure that employees are adequately protected from all reasonably foreseeable hazards. Many hospitals can, or will soon be able to, meet these conditions, many of which parallel existing JCAHO and OSHA (OSHA-approved State Plan) requirements. These PPE best practices are applicable to all hospitals that might receive victims contaminated with unknown substances; however, hospitals must complete the hazard assessment process and tailor the PPE selection to also address specific hazards they might reasonably be anticipated to encounter.⁴⁰ Additionally, some hospitals may determine that an alternative mix of PPE is appropriate for their particular situations. These options include using more protective PPE (to perform specialized activities or when conditions in Tables 1 and 2 cannot be met), or conducting an independent hazard assessment to support an alternative PPE selection.

TABLE 1.
Hospital Decontamination Zone
Conditions Necessary for Hospitals to Rely on the
Personal Protective Equipment (PPE) Selection Presented in Table 3 ^A,B

Thorough and complete hazard vulnerability analysis (HVA) and emergency management plan (EMP), which consider community input, have been conducted/developed, and have been updated within the past year.
The EMP includes plans to assist the numbers of victims that the community anticipates might seek treatment at this hospital, keeping in mind that the vast majority of victims may self-refer to the nearest hospital.
Preparations specified in the EMP have been implemented (e.g., employee training, equipment selection, maintenance, and a respiratory protection program).
The EMP includes methods for handling the numbers of ambulatory and non-ambulatory victims anticipated by the community.
The hazardous substance was not released in close proximity to the hospital, and the lapse time between the victims' exposure and victims' arrival at the hospital exceeds approximately 10 minutes, thereby permitting substantial levels of gases and vapors from volatile substances time to dissipate.^C
Victims' contaminated clothing and possessions are promptly removed and contained (e.g., in an approved hazardous waste container that is isolated outdoors), and decontamination is initiated promptly upon arrival at the hospital. Hospital EMP includes shelter, tepid water, soap, privacy, and coverings to promote victim compliance with decontamination procedures.
EMP procedures are in place to ensure that contaminated medical waste and wastewater do not become a secondary source of employee exposure.

And

The decontamination system and pre-decontamination victim waiting areas are designed and used in a manner that promotes constant fresh air circulation through the system to limit hazardous substance accumulation.^D Air exchange from a clean source has been considered in the design of fully enclosed systems (i.e., through consultation with professional engineer or certified industrial hygienist) and air is not re-circulated.

TABLE 2.
Hospital Post-decontamination Zone
Conditions Necessary for Hospitals to Rely on the
Personal Protective Equipment (PPE) Selection Presented in Table 3 ^E,F

Emergency management plan (EMP) is developed and followed in a way that minimizes the emergency department (ED) personnel's reasonably anticipate