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Table of Contents
List of Figures and Tables
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, ArkansasThese 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):
*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:
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.
Best Practices from OSHA
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 substancesfrom 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 Table 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 220.127.116.11 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 11th 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).
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:
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:
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.
C.0 TRAINING FIRST RECEIVERS
The training indicated for first receivers depends on the individuals' roles and functions, the zones in which they work, and the likelihood that they will encounter contaminated patients.41 OSHA recognizes that hospital staff who decontaminate victims at the hospital are removed from the site of the emergency (OSHA, 2002a, 2002b, 19992b). However, letters of interpretation provide that HAZWOPER First Responder Operations Level and First Responder Awareness Level training meet the requirements for first receivers in certain roles and positions. For other employees, a briefing at the time of the incident will be appropriate. In each case, the training must be effective, that is, be provided in a manner the employee is capable of understanding.42
The following sections discuss HAZWOPER training provisions and contemplate levels of training commensurate with the employees' designated role within the EMP.
C.1 OPERATIONS LEVEL TRAINING
OSHA letters of interpretation specify that hospitals must provide HAZWOPER First Responder Operations Level training to first receivers who are expected to decontaminate victims or handle victims before they are thoroughly decontaminated (OSHA, 2003, 2002b, 1999, 1992c, 1991a). This level of training is appropriate for anyone with a designated role in the Hospital Decontamination Zone.
Training requirements for First Responder Operations Level appear under 29 CFR 1910.120(q)(6)(ii), which indicates a minimum training duration of 8 hours and outlines topics to be covered (competencies the employee must acquire). Both the required competencies and training time were recently confirmed in an interpretive letter (OSHA, 2003). OSHA, however, allows these topics (but not the minimum training time) to be tailored to better meet the needs of first responders. For example, the training might omit topics that are not directly relevant to the employee's role (e.g., recognition of Department of Transportation placards), but instead should include alternative training on hazard recognition (e.g., signs and symptoms of contamination or exposure), on decontamination procedures provided by the hospital, and on the selection and use of PPE (OSHA, 1992c). Training that is relevant to the required competencies counts toward the 8-hour requirement, even if the training is provided as a separate course. For example, training on PPE that will be used during victim decontamination activities may be applied towards the 8-hour minimum Operations Level training requirement, regardless of whether the PPE training is conducted as part of a specific HAZWOPER training course or as part of another training program (OSHA, 1992c).
First Responder Awareness Level training also counts towards the 8-hour requirement for Operations Level training. This point is clarified in a recent letter of interpretation issued by OSHA: "...if you spend two hours training employees in the required competencies for First Responder Awareness Level as described in 29 CFR 1910.120(q)(6)(i)(A)-(F), then you would need to spend at least six additional hours training employees in the required competencies for First Responder Operations Level as described in 29 CFR 1910.120(q)(6)(ii)(A)-(F). Depending on the employees' job duties and prior education and experience, more than eight hours of training may be needed" (OSHA, 2003).
As an alternative to the 8-hour training requirement, the HAZWOPER Standard allows employees to demonstrate competence in specific areas, presented in 29 CFR 1910.120(q)(6)(ii) and reproduced in Section 18.104.22.168 of Appendix A. OSHA reaffirmed this point in a letter of interpretation, stating "...employees with sufficient experience may objectively demonstrate the required competencies instead of completing eight hours of training" (OSHA, 2003). However, it is important to note that in most hospital settings it might be difficult to ensure that employees have sufficient experience to waive the training requirement. Most hospital employees do not have extensive experience with hazardous materials or PAPRs, and decontamination activities are performed infrequently.
Hospitals must document how training requirements are met. This is particularly important whenever hospitals allow employees to satisfy any portion of the training requirement through other related training or through demonstration of competence. The HAZWOPER Standard requires and an OSHA letter of interpretation confirms that "the employer must certify in writing the comparable training or demonstrated competencies" (OSHA, 2003).
Annual refresher training is specified under 1910.120(q)(8)(i), or the parallel State Plan standards; however, the length of the refresher training is not specified. Instead, the standard requires that employees trained at the First Responder Operations Level "shall receive annual refresher training of sufficient content and duration to maintain their competencies, or shall demonstrate competency in those areas at least yearly." Additionally, the hospital must document that refresher training was performed, or alternatively, keep a record of how the employee demonstrated competency.
The initial and annual refresher training to the HAZWOPER First Responder Operations Level must be provided to all hospital personnel who have been designated to provide treatment, triage, decontamination, or other services to contaminated individuals or who may reasonably be expected to come in contact with those individuals arriving at the hospital. Training core elements must include:
Operations Level training also must include training required by OSHA's Respiratory Protection Standard (29 CFR 1910.134), or the parallel State Plan standards. Specifically, any employee who must wear a respirator must be trained in the proper use and limitations of that device prior to its use in the workplace. The training must be comprehensive enough that the employee is able to demonstrate knowledge of the seven training topics specified in the standard and outlined below. The employee also must be able to demonstrate competence in wearing the complete PPE ensemble, including respirator, protective garment, gloves, boots, and other safety equipment required for the employee's role. Refresher training is required at least annually, or sooner if changes in the workplace or type of respirator render previous training inadequate. Refresher training is also required if the employee does not demonstrate proficiency in the proper care and use of the respirator, or any other time when retraining appears necessary to ensure safe respirator use.
At a minimum, training under OSHA's Respiratory Protection Standard must cover the following topic areas:
C.2 AWARENESS LEVEL TRAINING
First Responder Awareness Level training is required for those employees who work in the contaminant-free Hospital Post-decontamination Zone, but might be in a position to identify a contaminated victim who arrived unannounced. This group includes ED clinicians, ED clerks, and ED triage staff who would be responsible for notifying hospital authorities of the arrival, but would not reasonably be anticipated to have contact with the contaminated victims, their belongings, equipment, or waste. The group also includes decontamination system set-up crew members and patient tracking clerks, if their roles do not put them in contact with contaminated victims, their belongings, equipment, or waste (e.g., setting up the decontamination system before victims arrive, or tracking patients from a location outside of the decontamination zone).
First Responder Awareness Level training also is required for hospital security guards who work away from the Hospital Decontamination Zone, but who may be involved tangentially in a mass casualty event (specifically, those security personnel who would not reasonably be anticipated to come in contact with contaminated victims, their belongings, equipment, or waste) (OSHA 1991b). Security staff assigned to roles in the Hospital Decontamination Zone would require a higher level of training (e.g., First Responder Operations Level).
Training requirements for First Responder Awareness Level appear under 29 CFR 1910.120(q)(6)(i), which does not require a specific minimum training duration, but outlines topics to be covered (competencies the employee must acquire). As with Operations Level training, the HAZWOPER Standard allows an alternative to the Awareness Level training requirement. Training can be waived if the employee has had sufficient experience to objectively demonstrate competency in specific areas. These areas are listed in 29 CFR 1910.120(q)(6)(i), or the parallel State Plan standards, and reproduced in Appendix A, Section 22.214.171.124.
Annual refresher training is required for employees trained at the Awareness Level. As with Operations Level refresher training, the class content must be adequate to maintain the employees' competence, and the hospital must document the training or the method used to demonstrate the employees' competence.
C.3 BRIEFING FOR SKILLED SUPPORT PERSONNEL WHOSE PARTICIPATION WAS NOT PREVIOUSLY ANTICIPATED
A member of the staff who has not been designated, but is unexpectedly called on to minister to a contaminated victim, or perform other work in the Hospital Decontamination Zone, is considered "skilled support personnel." Examples include a medical specialist or a trade person, such as an electrician. These individuals must receive expedient orientation to site operations, immediately prior to providing such services (OSHA, 1997). The orientation must include:
While a "just in time" briefing during the response is the only required training for these personnel, time and resource limitations inherent in a crisis likely will diminish the effectiveness of such training. Thus, hospitals should diligently consider the broad range of skills/capabilities that may be required within the Decontamination Zone during a mass casualty event and attempt to identify, and train, all persons who may be called to work in the Decontamination Zone prior to a mass casualty event.
C.4 TRAINING SIMILAR TO THAT OUTLINED IN THE HAZARD COMMUNICATION STANDARD
Hospitals should consider offering a basic level of training for other employees in the ED, such as housekeeping staff. This group could include those personnel who do not have a role in the decontamination process, reasonably would not be expected to encounter self-referred contaminated patients, and reasonably would not be expected to come in contact with contaminated victims, their belongings, equipment, or waste. OSHA's Hazard Communication Standard offers a useful model for appropriate training, which could include general information on the hospital's emergency procedures and plans for mass casualty incidents involving contaminated victims, steps the employees can take to protect themselves (usually by leaving the area), and the measures the hospital has implemented to protect employees in the ED. While not required under the OSH Act, such training could help to ensure that all staff in the ED understand what precautions and actions would (and would not) be expected of them if an incident occurred.
C.5 SUMMARY OF TRAINING FOR FIRST RECEIVERS
Table 4 summarizes OSHA's current guidance on training first receivers for mass casualty emergencies. References to related OSHA interpretation letters are included. Employees are categorized according to zone (namely, Hospital Decontamination Zone and Post-decontamination Zone); whether they have designated roles in the zone; and the likelihood of contact with contaminated victims, their belongings, equipment, or waste. Hospitals should note that the training levels presented are minimum training levels and can be increased or augmented, as appropriate, to better protect employees, other patients, and the facility in general.
The following appendices provide references and examples, which might be useful to hospitals developing or upgrading emergency management plans (EMPs). OSHA offers these examples for informational purposes only and does not recommend one option over the many effective alternatives that exist.
APPENDIX A: BACKGROUND, LITERATURE REVIEW, AND SITE VISIT EXAMPLES
This Appendix supplements the Best Practices from OSHA by providing useful background information on how various aspects of a hospital's preparation, response, and recovery impact employee protection during hazardous substance emergencies. Look in Appendix A for:
The following discussion provides examples of ways hospitals have attempted to enhance employee protection as part of general preparedness for mass casualty emergencies involving contaminated victims. This discussion is designed to further worker health and safety by referencing practices and procedures considered and/or adopted in the healthcare community. However, statements in this appendix cannot create nor diminish obligations under the occupational safety and health (OSH) Act.
In making preparations, hospitals must consider key assumptions regarding communication, resources, and victims. When developing plans, hospitals should anticipate:
Administrators making preparations for mass casualty incidents should note that hospitals are part of the community's critical infrastructure and continuity of operations must be maintained.
1.1 CUSTOMIZING HOSPITAL EMERGENCY MANAGEMENT PLANS
The hospital emergency management plan (EMP) outlines how the facility will respond to an emergency. The plan should address the hazards the hospital will encounter, identify the hospital's role in the response, and serve as a road map for incident preparation, response, and recovery.
No organization can prepare fully for every conceivable emergency. To use resources effectively, a hospital requires information that will help emergency planners make informed decisions about the type, probability, severity, and impact of specific hazards to which the hospital might be subject. A hazard vulnerability analysis (HVA) assists a hospital in organizing this information, which is used to customize the hazard assessment for personal protective equipment (PPE) selection (a critical aspect of the EMP). The Joint Committee for Accreditation of Healthcare Organizations (JCAHO) requires an HVA as the first step in emergency planning (JCAHO, 2004). Specific information on conducting HVAs may be obtained directly from JCAHO.
The HVA and resulting preparations are only as specific to the individual hospital as the information on which preparation decisions are based. Important modifying factors include the hospital's role in the community, how up-to-date the hospital EMP is, and formal planning agreements between the hospital and other organizations that have roles in emergency response activities. With knowledge of these details, hospitals can customize EMPs and effectively tailor preparedness (including employee protection) to address the circumstances relevant to that hospital.
1.1.1 Using Information from a Hazard Vulnerability Analysis
As noted previously, an HVA helps hospitals organize information and guide decision making. A thorough HVA can serve as the basis for informed decisions regarding the training and equipment employees will require to protect themselves under foreseeable emergency scenarios.
The hospitals interviewed use variations of a few publicly available HVA formats. See Appendix F for examples of two formats (additional examples are available from other sources). The tool is often slightly modified by the individual hospital to include additional information that the hospital finds helpful for making decisions or communicating with management.
A popular HVA, an electronic spreadsheet, prompts the user to enter a numerical rating (e.g., 1 to 3) for various factors associated with each of numerous listed threats (both from a standard list and additional hazards added by the user). JCAHO (2002) offers a matrix of threats that hospitals might consider. The user generates (or the spreadsheet calculates) a hazard vulnerability score based on the inputs. The inputs may be weighted to reflect the importance of certain information to the final score. Hospitals use both the final score and the individual numerical rating inputs to identify and rank priority areas that should receive administrative attention or resources.
Other hospitals use a tabular format HVA and more descriptive text input to guide the user through the analysis. The tables can provide more information, but are also more cumbersome for evaluating a large selection of threats. Because these formats are more likely to have been developed in-house, they tend to be more diverse.
None of the HVA formats have been validated to determine whether the inputs and final assessment accurately reflect hazard vulnerability. Nevertheless, an informal qualitative review conducted by the developer of one HVA spreadsheet tool suggested that independent users, when operating in similar hospital and community environments, do generally arrive at similar conclusions regarding vulnerability and priorities for improvement (Saruwatari, 2003).
The hospitals interviewed for this project agree that the HVA should be updated frequently and reviewed at least annually, as required by JCAHO (2004). By collaborating with Local Emergency Planning Committees (LEPCs), hospitals can keep current with information on changes in threats in their localities.43 Hospital D noted that, if appropriate, resources could be reallocated sooner if emergency managers are able to update the HVA as new information arrives (e.g., emerging threats), rather than waiting for an annual review cycle.44 These changes can also modify the local hospital's vulnerability to those hazards. As an example, Hospital D had rated "preparation for chlorine-related emergencies" as a top priority. When the local potable water facility changed processes, the threat of a large-scale chlorine emergency was eliminated from the community. Upon revising the HVA, Hospital D was able to redirect resources to address the next most urgent threat without waiting until the next annual review cycle.
Characteristics of the community (e.g., businesses, chemical inventory, population, transportation lines, clandestine drug labs, and possible targets of terrorism) influence the type of hazardous substance-related emergencies that a hospital might reasonably anticipate. This information should be considered in the HVA. These factors range from the number and condition of victims that the hospital might reasonably anticipate, to the rate at which hazard information could become available during an emergency.
1.1.2 Identifying the Hospital's Role in the Community
The community in which a hospital is located and the hospital's role in that community impact emergency preparations on several levels. Hospital D's emergency manager suggested that the real objective of emergency planning is "community preparedness, and a hospital's preparedness represents only one component." For the purposes of this discussion, "community" is defined as the local population center that the hospital serves on a day-to-day basis, as well as any additional population centers from which the hospital would reasonably expect to receive victims in the event of a mass casualty emergency involving hazardous substances.
Fully coordinated planning helps hospitals identify their roles in their communities. Roles vary considerably with individual circumstances, but ultimately have a strong impact on the conditions and hazards for which a hospital must plan employee protection. Examples of roles some hospitals fill (or expect to fill) in their communities include:
1.1.3 Updating Emergency Management Plans
EMPs should be reviewed periodically for the same reasons the HVA is updated situations change.46 Common changes that can impact employee protection include the types of foreseeable hazardous situations that might be encountered in an emergency, the anticipated needs of the community, the availability of other emergency response organizations to fill certain roles, the type of equipment available to protect employees, and personnel turnover.
Hospitals should already be in compliance with applicable OSHA health and safety standards, such as those listed below (or parallel OSHA-approved State Plan standards). Additionally, during the periodic EMP evaluation, hospitals should review the regulations to ensure the plan continues to be compliant.
Well-coordinated EMPs ensure that hospitals are aware of the capabilities of first responders and other hospitals, as well as what the local professional and response community expects from them.48 Coordinated plans encourage open lines of communication and improve the safety of both victims and healthcare workers. The following example demonstrates the value of coordinated EMPs. After problems were identified during a drill, Hospital D determined that healthcare workers needed faster access to information from hazardous materials incident sites. Initially, the fire department felt Hospital D's request for more timely information would be too burdensome during life-threatening emergencies. When the two organizations met, however, they each learned the reasons behind the other's needs. As a result, the first responders recognized that, by coordinating efforts, they could enhance the first receivers' ability to provide rapid and appropriate care to victims. The fire department was able to modify its own EMP to incorporate direct communication between the hospital and a representative of the incident commander at the scene.
The hospitals interviewed for this project mentioned several methods by which they improve EMP coordination and communication:
1.2.1 Applicable Standards
Organizations, such as OSHA, those states operating OSHA-approved State Plans, JCAHO, the National Fire Protection Association (NFPA), and other state or local government agencies, set standards that govern employee preparation, particularly regarding employee training and medical evaluations. OSHA standards, or the parallel State Plan standards, relevant to the training of first receivers include the HAZWOPER, Personal Protective Equipment, Respiratory Protection, and Hazard Communication Standards.52 Hospitals with decontamination facilities should also comply with the requirement for medical evaluations contained in the HAZWOPER and Respiratory Protection Standards.
JCAHO (2004) requires "an orientation and education program for all personnel, including licensed independent practitioners, who participate in implementing the emergency management plan." When plans involve management of chemical hazards, OSHA's HAZWOPER and hazard communication (HAZCOM) Standards complement the JCAHO requirements by providing specific topics that should be addressed during the training. Other requirements of these standards might also apply (e.g., training duration, demonstration of skills, and retraining), depending on whether the HAZWOPER (Hospital Decontamination Zone) or HAZCOM (Hospital Post-decontamination Zone) standard is in effect.53 NFPA (2002) suggests competencies for incident commanders and others responding to hazardous materials incidents.
1.2.2 Maintaining Decontamination Teams
A challenge for any hospital is the need to maintain a decontamination team, without compromising the ability of hospital departments to provide medical treatment for patients.
Hospitals interviewed for this project use employees from a range of specialties to maintain minimal staffing levels in patient care areas. In addition to drawing limited staff from the ED, Hospital A suggests including individuals from departments such as mental health, facilities and engineering, and security on decontamination teams.
The hospitals also indicate that it is often possible to identify individuals in unrelated departments who are uniquely qualified to serve on the team due to previous military experience, work history, or volunteer service. Hospital A staffs a particularly large decontamination team (over 100 members) by drawing from employees with relevant skills from past experience in fire departments, emergency medical services, rescue units, HAZMAT or hazardous waste handling, National Guard, and military reserve units. In these cases, the previous experience might be a more important selection criterion than the individual's day-to-day role in the hospital. Hospital A avoids assigning unwilling staff to their team, citing the advantages of volunteer team members' enthusiasm and willingness to participate in training and drills.
Decontamination teams might include individuals who perform the following functions:
Another hospital organization advocates a 12-member (minimum) decontamination team, all wearing PPE. Although it is recognized that smaller hospitals would not be able to staff such a robust team, the rationale may illustrate useful points. Under this model, the Northern Virginia Hospital Alliance calls for a single "team leader," three team members responsible for conducting ambulatory decontamination (one to assist in the undressing, one to supervise showering, and one to assist in the re-dressing), four team members to participate in the care of non-ambulatory patients, and four security personnel to preserve the perimeter of the Hospital Decontamination Zone.
1.2.3 Orienting and Training Personnel
First receiver training that was discussed previously in Section B is summarized here:
First Responder Operations Level training is required for employees (including security staff) who have a role in the Hospital Decontamination Zone, as well as the hospital's contamination cleanup crew.55
First Responder Awareness Level training is required for ED clerks and ED triage staff who might identify unannounced contaminated victims (then notify the proper authority) and security staff working outside the Hospital Decontamination Zone.
A briefing at the time of the incident is required for employees whose roles in the Hospital Decontamination Zone could not be anticipated before the incident ("skilled support personnel" – e.g., a medical specialist or a trade person, such as an electrician).
Information similar to hazard communication training is recommended for ED staff and other employees who work in the ED (Hospital Post-decontamination Zone), provided contaminated victims would not have access to them.
126.96.36.199 Competencies for First Responder Operations Level Training
The HAZWOPER Standard, paragraph 1910.120(q)(6)(ii) requires that employees trained at the First Responder Operations Level shall have received at least eight hours of training or have had sufficient experience to objectively demonstrate competency (e.g., in exercises and drills) in the following areas:
Hospital A and Hospital G opt to provide more than 8 hours of training to decontamination team employees. Hospital A requires staff who will have a direct role in decontamination activities to undergo 24 hours of initial training and an additional 16 hours of refresher training annually. Employees can satisfy some of the training requirement by attending monthly educational team meetings. Other training is provided using a standard course curriculum developed by the Department of Veterans Affairs.57
Hospital G is in the process of changing from a single yearly 8-hour course curriculum to a program that provides twelve 1-hour sessions. The emergency planner believes that an annual training day is not the best condition for learning and skills retention. Under the new system, Hospital G divides the required training topics into 12 modules, one for each month, including several opportunities to don PPE over the course of a year. The monthly module will be presented several times on each shift. Although the net hours of training per student will be greater annually, the departments might find it less burdensome to release students for the shorter classes. Thus, instructors will teach fewer classes, resulting in a net savings in man-hours.
As mentioned earlier, 8 hours of First Responder Operations Level training might not be necessary for employees who have sufficient experience. These employees are allowed to demonstrate competency as an alternative to 8 hours of training. In most hospital settings, however, it might be difficult to ensure that employees have sufficient experience to waive the training requirement. Most hospital employees do not have extensive experience with hazardous materials and decontamination activities are performed infrequently, thus more than 8 hours of training may be helpful to ensure competence. Employees particularly benefit from the practical experience they gain during training provided as part of exercises and drills. These events also offer employees an opportunity to demonstrate competence in critical areas.
188.8.131.52 Competencies for First Responder Awareness Level Training
First responders at the awareness level shall have sufficient training or have had sufficient experience to objectively demonstrate competency in the following areas, as required by the HAZWOPER Standard, paragraph 1910.120(q)(6)(i), (or the parallel State Plan standards):
184.108.40.206 Instruction for Employees Whose Participation in the Hospital Decontamination Zone Was Not Previously Anticipated
These personnel shall be given an initial briefing at the site prior to their participation in any emergency response. As specified in the HAZWOPER Standard, paragraph 1910.120(q)(4), the initial briefing shall include instruction in the wearing of appropriate PPE, what chemical hazards are involved, and what duties are to be performed. All other appropriate safety and health precautions (e.g., PPE) provided to personnel in the Hospital Decontamination Zone shall be used to assure the safety and health of these personnel.
220.127.116.11 Training Similar to That Outlined in the Hazard Communication Standard
OSHA recommends some form of basic training for employees who work in the Hospital Post-decontamination Zone and who would not be expected to come in contact with unannounced contaminated victims, their belongings, equipment, or waste. This training could take a format similar to hazard communication which might include at least the following:
1.2.4 Monitoring Performance During Drills
All hospitals interviewed for this project conduct several types of drills. The hospitals note that the greatest value occurs when their EMPs are tested rigorously as part of the drill, when realistic scenarios are involved (including interaction with outside organizations), and when the hospital follows the drill with a detailed evaluation and post-drill action plan for improvement.
It is essential to the success of the EMP that drills are conducted and that they reflect the actual conditions, resources, and personnel that would be available during a real incident.
In addition to self-assessments, some hospitals find it helpful to receive a performance evaluation from an outside organization. Hospital C participated in a community-wide drill that was observed by a contractor hired specifically for that purpose. The hospital used the contractor's observations and comments to help prioritize the emergency management team's activities. Alternatively, organizations that share post-drill analysis can critique each other.59 Any of these methods of assessment can lead to corrective actions and improved response, particularly if the process is formalized with hospital administrators.
1.2.5 Managing Internal Communications
The hospitals interviewed for this project report that they use a combination of methods for communicating with employees during an incident. As new information becomes available hospitals use any combination of the following methods to pass information to those who need it:
1.2.6 Principles of Risk Communication
Special care might be required in training healthcare workers regarding chemical, biological, or radiological hazards, particularly when the threat could be related to terrorism. Lundgren and McMakin (1998) recommend conducting an audience analysis to assess factors that will impact how information might best be presented. Non-clinical workers want basic information on the hazards, presented by a credible source with a clear message, and preferably in "detailed, role-specific training sessions that are ultimately tested by drills" (Thorne et al., 2003). To demonstrate training effectiveness, trainers should evaluate knowledge and skills by using objective measures such as pre- and post-training evaluations, as well as by observing performance.61
1.2.7 Information Dissemination During an Incident
Hospitals need to work with local emergency service organizations to provide clear, accurate information during large-scale emergencies. To avoid disseminating conflicting information, hospitals that use a National Incident Management System (NIMS)-compatible incident command system, such as HEICS, provide for an individual who will coordinate with other response groups and communicate with the media and other outside organizations.62 A representative of the public affairs department often assumes this role.
1.2.8 Monitoring Employee Health
18.104.22.168 Prior to an Incident
Hospitals A through G all indicate that they typically conduct a thorough baseline evaluation of an employee's health at the time the person is hired. Based on hospital policy, the employee's job category, or the hazards associated with tasks the employee performs, additional periodic health monitoring might also be provided.63 Most of the hospitals interviewed for this project indicate that they have no special additional requirements for members of the decontamination team, unless the individual might wear a respirator. In that case, the employee receives a baseline evaluation and any follow-up evaluations needed to obtain the necessary medical clearance, as discussed below.
One of the hospitals interviewed follows a somewhat more rigorous medical monitoring program. Under this program, each member assigned to the decontamination team receives a periodic physical exam (often every 1 or 2 years), which includes a basic health screening. Evaluations for medical clearance to wear a respirator are incorporated into these exams.
The HAZWOPER Standard requires that employees be provided periodic medical evaluations (annual or bi-annual) if they exhibit signs or symptoms of exposure, or if it is anticipated that the employee would be exposed to hazardous substances, in excess of the established permissible exposure limit (PEL), for 30 days per year or more.64 Drills and practice sessions that do not involve hazardous substances would not count toward the 30 days.
The hospitals interviewed for this project also mentioned that prophylactic vaccinations and antidotes should be stockpiled for employees in case the need arises.
Medical Clearance for Respirator Use
The OSHA Respiratory Protection Standard, in 29 CFR 1910.134(e), or the parallel State Plan standards, require employers to obtain, in writing, a medical opinion regarding an employee's ability to wear a respirator. The regulatory requirement applies regardless of whether other medical evaluations are needed under the HAZWOPER Standard. It also applies to all types of respirators (including hooded powered air-purifying respirators [PAPRs]), with the exception of filtering facepiece respirators ("dust masks") used by employees on a voluntary basis (i.e., when the employer has determined that a health risk does not exist, but the employee nevertheless wishes to wear a respirator). An additional medical evaluation is required by paragraph 1910.134(e)(7) under certain circumstances. For example, an employee's ability to safely wear a respirator must be reevaluated when an increase in the employee's physical activities or the weight of the protective clothing would place an added burden on the employee.
22.214.171.124 During a Response
The combination of first receivers' activities and PPE often create a greater physical workload for employees than they experience during their normal daily jobs. Thermal stress (heat and cold stress) also impacts the period for which first receivers can perform their duties. Some hospitals monitor employee vital signs as one method of tracking employee response to these stressors. For example, Hospital A evaluates each employee's vital signs before that individual dons PPE. Prior to a team member donning a protective suit and hooded PAPR respirator, a technician records the individual's weight, vital signs, and recent medical history. This information is obtained as other team members assist the individual into the protective gear. If vital signs exceed predetermined limits set by the hospital organization, the individual is prohibited from wearing PPE that day and the team member's activities are restricted accordingly. Decontamination safety officers at Hospital A report that during every drill conducted, they have rejected at least one participant (out of a dozen or more) due to elevated vital signs. When PPE is removed, vital signs and weight are recorded again. The employee's time in PPE is also recorded and tracked. Decontamination team members at Hospital A are generally permitted to wear a protective suit and hooded PAPR for 30 minutes at any one time, although this period can be adjusted up or down depending on workload, weather, and the condition of the first receiver. Appendices H and I provide examples of medical monitoring procedures and a separate vital signs checklist.
Hospital A uses two-way headset radios to communicate with and monitor the health status of individuals who are wearing hooded PAPRs and protective suits in hot weather. This hospital found that a behind-the-head "temple transducer" style headset is more practical under PAPR hoods than "over-the-head" models, which tend to dislodge and are difficult to reposition without removing the hood.
Both heat and cold stress can decrease first responders' ability to work safely for extended periods. Hospital A believes that in its hot, humid southern climate, heat stress presents the greatest threat to employee health. To combat this hazard, the hospital uses a combination of administrative controls and cooling devices. As noted above, team members whose vital signs are outside prescribed starting parameters are not allowed to don respiratory protection.65 To further reduce the risk of heat stress, the team makes extensive use of icepack vests.66 Freezers for icepacks are located in the Safety Office, fire department, and elsewhere for easy access. Although Hospital A recognizes that use of icepacks to combat heat stress is somewhat controversial, this hospital reports no problems among the many team members who have drilled over the years. Additionally, team members report that they find the icepack vests to be a comfortable asset in hot weather.
The American Conference of Governmental Industrial Hygienists (ACGIH) offers guidance for managing heat stress in employees wearing heavy protective clothing (ACGIH, 2001). This conservative approach uses a combination of common-sense administrative controls (e.g., good hydration) and physiological measures of heat strain (remove worker if body core temperature exceeds 100.4 degrees Fahrenheit or heart rate exceeds 180 beats per minute (bpm) minus the employee's age, or is greater than 110 bpm one minute after peak exertion). Appendix I provides examples of vital sign monitoring schemes used by other groups.
126.96.36.199 Following an Incident
Incidents involving hazardous substances are typically one-time incidents and medical monitoring is not required unless an employee develops signs or symptoms related to an exposure. Following such an occurrence, the hospital's occupational health provider should follow the hospital's regular policy regarding a chemically exposed worker. If an employee becomes ill or develops signs or symptoms specifically suggesting exposure to a particular contaminant, Hospital A would follow a policy designed for first responders that complies with the requirements outlined in OSHA's HAZWOPER Standard 29 CFR 1910.120(f).
Hospital D has direct experience with employees who developed symptoms while treating a contaminated patient. The victim drank a quantity of organophosphate pesticide. During subsequent episodes of vomiting, the victim contaminated clothing, an ambulance, and the ED. As a result, six symptomatic staff members required hospitalization after exposure to the concentrated pesticide and vapor. The hospital followed its usual procedures for managing an employee with an occupational injury, including entering the illnesses in the OSHA Log of Work-Related Injuries and Illnesses (OSHA 300 Form, previously OSHA 200 Form) and ensuring workers' compensation medical leave for one affected individual.
188.8.131.52 Managing Employee Stress
Understandably, disasters can be a notable source of stress for anyone involved (Young et al., 2002; Hodgson et al., 2004). Hospital A points out that employee stress is a concern for decontamination teams and the hospital includes a mental health provider on each team. While assisting with decontamination activities, this employee also observes team members for symptoms of excessive stress. Additionally, Hospital A ensures decontamination team members have ready access to post-event counseling if they request such services.
2.1 FACILITIES AND EQUIPMENT
2.1.1 Evaluating Existing Resources
Hospitals are challenged to identify spaces that will support decontamination activities (including equipment storage) and ensure operations can continue in the event one area of the hospital becomes contaminated. Hospitals planning additions or remodeling projects have a unique opportunity to design spaces appropriately. Other hospitals should use creative planning to identify existing architectural features that they can use to their advantage. Several examples follow:
The hospitals interviewed use a variety of methods to limit unauthorized access to the ED during emergencies until the victims have been decontaminated. The methods range from a guard with a key at the door to sophisticated keycard systems controlled at a central command center. The more complex systems tend to be associated with urban or recently modernized hospitals and are intended for use in any type of disturbance. Hospitals intend to use these methods if situations suggest that an unruly crowd will force its way into the hospital.
Hospital A, which trains other hospitals to offer decontamination services, notes that it is critical to match the decontamination equipment purchased to the needs of the hospital and the community it serves. Hospital advisors recommend that any hospital with an emergency room should be prepared to decontaminate victims. However, facilities such as long-term care facilities and specialty clinics do not necessarily need decontamination capability. A hospital with a minimal risk of receiving multiple contaminated victims should consider acquiring a small system that can be handled by a few employees.67 According to Hospital A, "every hospital should have a well-coordinated plan for arranging [timely] decontamination of any patients who may show up at the door, without putting staff at undue risk." The plan should include medical triage and treatment capability with proper precautions.
Hospitals A through G report that they considered the following factors when evaluating their decontamination system options:
Regardless of the type of decontamination system selected, hospitals should avoid locating the decontamination facility inside the ED.
Decontamination procedures can have a large impact on first receiver exposure to hazardous substances. All the hospitals interviewed agree that the basic steps include:
All of the steps above can influence the extent of healthcare workers' exposure to the contaminant. However, certain steps should be highlighted for their direct impact on the concentrations of contaminant first receivers will encounter. For example, disrobing might remove as much as 75 to 90 percent of the contaminant arriving on a victim (Macintyre et al., 2000; Vogt, 2002; USACHPPM, 2003a).69 By isolating (in an approved hazardous waste container) the contaminated clothing, staff prevent these materials from off-gassing into the work area. To minimize first receiver exposure levels, these steps should be implemented immediately as victims arrive.
Non-ambulatory victims can require a substantial proportion of first receivers time and efforts. First receivers are likely to experience the greatest exposures while assisting these victims. Staff should take steps to identify possible sources of contamination and limit their exposure to those sources. For example, Hospital A uses specific procedures for removing victims clothing to minimize first receiver and victim exposures. Assistants use blunt-nose scissors to cut away clothing, rather than pulling it off. Tugging on clothing can produce a wringing action that might distribute contaminant on the victim, healthcare workers, and the surrounding area. Once removed, the clothing is immediately placed into a sealed container.
Unless a hospital uses detection equipment with demonstrated accuracy and reliability, victim washing procedures and visual inspection offer the only practical way healthcare workers can conclude that victims are definitively decontaminated. Staff in the ED might become exposed if contaminated victims are permitted to enter the Hospital Post-decontamination Zone. All the hospitals interviewed for this project indicated that they currently require victims to soap and shampoo completely and spend 5 to 6 minutes under a flow of running water. Some hospitals time the individual victims' total wash periods, while others observe the victims to ensure they wash thoroughly. It may be advantageous to start the victim cleansing process with a full minute under a drenching shower to rinse away as much contaminant as possible, followed by subsequent soaping and rinsing steps, repeated as necessary (USACHPPM, 2003a). Hospital G has a progressive shower, in which each victim spends one minute at each of several wash stations.
Most of the hospitals interviewed also provide victims with written or pictorial instructions. In addition, tepid water, security of personal effects, single-gender facilities, shelter, and replacement clothing influence how quickly and completely victims comply with requirements to undress, shower appropriately, and wait for medical treatment until they are completely decontaminated. In cold climates, heated spaces and blankets might be necessary. Victim inspection provides a final check to ensure contaminant is not carried into the ED.
Victims from some incidents may arrive at the hospital after having been decontaminated at the incident site (Release Zone) or elsewhere. Before admitting a victim to the ED, first receivers should evaluate each individual to ensure the patient was adequately cleansed.
The methods staff use to decontaminate themselves and doff PPE also impact their own exposure. ATSDR (2000) and Appendices K and L offer examples of procedures used by some hospitals. While there is little definitive published information available regarding optimal shower procedures (for victims or staff), the following sections summarize information provided by organizations with some expertise in this area. These procedures apply to a wide variety of contaminants and are appropriate for unknown contaminants that could arise from a release of toxic chemicals, biological agents, or radiological particulates. Decontamination procedures, like PPE use, can be modified once the contaminant is identified; hospitals that are cleansing victims to remove known contaminants can tailor procedures as appropriate. For example, a longer rinse might be beneficial for corrosive substances or contamination in the eyes. Organizations such as the Center for Disease Control and Prevention (CDC) and the Department of Homeland Security offer specific recommendations for decontaminating victims exposed to individual hazards, such as ionizing radiation (CDC, 2003; Department of Homeland Security, 2003).70 After cleansing with soap and water, certain residual chemical warfare agents (sarin, mustard gas, and others) can be neutralized on the skin using a substance such as the reactive skin decontamination lotion (RSDL), used by the US Army and other military organizations.71
Shower Flush Time and Practices
Numerous agencies and organizations recommend a shower time of approximately five minutes for contaminated victims brought to a hospital. Despite the fact that there is no empirical data, operational procedures deem this time as adequate.
Numerous agencies and programs recommend the use of water and a liquid soap with good surfactant properties (such as hand dishwashing detergent) to decontaminate victims during emergencies and mass casualties involving hazardous substances. Their recommendations are summarized here.
Site security helps maintain order and control traffic around the decontamination facility and the hospital entrances. Security officers might need to control a contaminated individual to prevent other staff from becoming exposed and to protect equipment. Security officers also ensure contaminated victims do not bypass the decontamination hospital or enter the ED without passing inspection. In cases of civil disturbance, properly identified security officers protect the decontamination facility and staff so normal operations can continue.
184.108.40.206 Personal Protective Equipment
Hospitals should select PPE (e.g., respirators, suits, gloves, face and eye protection) based on a hazard assessment that identifies the hazards to which employees might be exposed. Under OSHA's Personal Protective Equipment Standard (29 CFR 1910.132) or the parallel State Plan standards, all employers, including hospitals, must certify in writing that the hazard assessment has been performed. For first receiver PPE, hospitals may base the hazard assessment on Section B of OSHA's best practices document, then use the PPE listed in Table 3. Hospitals likely to respond to incidents involving a specific hazard should adjust the PPE accordingly.
OSHA's Personal Protective Equipment Standard also requires that employees be provided with equipment that fits appropriately. Some hospitals assign a set of protective equipment (except the PAPR respirator) to a specific individual. The equipment is stored in a container marked with the individual's name. Other hospitals maintain general supplies of PPE, storing sets of equipment by size (one set includes a large suit, large gloves, and large boots). In this case, the packages are clearly marked only with the size. Each first receiver tries on equipment to determine what size group fits best, then, during an emergency, the employee can quickly locate an appropriate PPE set. One hospital reported that boot size serves as the basis for its PPE sets. It is sometimes necessary to include two sizes of each type of glove in the set to ensure proper fit for everyone who wears the PPE set. Suits do not need to fit as closely and excess fabric can be taped or rolled to fit. To prevent protective suits from tearing at the crotch, hospitals should order over-sized suits (larger than the individuals normal size) (SBCCOM, 2003). Loose-fitting PAPR respirator hoods offer a universal fit, thus are not included in individual or size-based PPE sets; however, tight fitting facepieces do require fit testing.
Hospitals must include first receivers' respirators in a respiratory protection program, as specified by OSHA's Respiratory Protection Standard (29 CFR 1910.134), or the parallel State Plan standards. These respirators can be integrated into the hospitals existing respiratory protection program, which should include the following elements (listed in 1910.134(c)(1)):
Certain materials absorb or are damaged by some chemical agents. As they become available, hospitals should select respirators that have been specifically tested for performance in the presence of chemical, biological, radiological, and nuclear hazards (CBRN). The National Institute for Occupational Safety and Health (NIOSH) is responsible for developing certification standards for approving various styles of CBRN respirators. When the HVA reveals a potential WMD threat and until NIOSH completes its CBRN certification process for PAPRs, use PAPRs that have been tested by the manufacturer for a CBRN environment.
220.127.116.11 Detection Equipment
Hospitals face a significant challenge in identifying contaminated individuals when they arrive unannounced, as well as after decontamination procedures. All the hospitals interviewed depend on triage personnel or clerical staff to identify self-referred patients who have been in contact with hazardous substances. The first indication for the need to activate the hospital's EMP and decontamination team might come from staff who identify these individuals through an initial interview, by visual observation, by the presence of indicative odors, and through signs that a substance appears to be affecting health. After a victim has been through the decontamination system, hospitals rely on visual inspection and the extent to which the victim followed prescribed showering procedures. A few hospitals have access to commercially available detection equipment that can help with the identification. Although published selection criteria are available (see NIJ, 2000), the interviewed hospitals agree that the available practical detection equipment only evaluates specific hazards (e.g., ionizing radiation and traditional chemical weapon nerve and blister agents).72
Ionizing Radiation Meters
Experts suggest that alpha or beta emitting particles may be the more likely contaminants in mass casualty events involving the release of radiological particles (CDC, 2003). Relatively reliable and easy to use instruments are available for measuring ionizing radiation. Hospitals that offer patients nuclear medicine services generally have access to specific types of radiation meters used in that department. For example, the Radiation Safety Office for Hospital F indicated that such meters would be available for post-decontamination evaluation of victims, staff, and hospitals, as deemed appropriate. It is important that meters used by first receivers be selected based on the types of radiological particles with which victims could be contaminated.73 To ensure more immediate access to appropriate equipment, Hospital B has obtained micro-roentgen per hour (µR/h) survey meters for the dedicated use of the decontamination team. In the event of a radiological emergency, the team will use the meters as they evaluate the effectiveness of victim decontamination.
To evaluate the effectiveness of decontamination procedures and also to help identify possible embedded fragments of radioactive materials, Hospital G obtained a pair of radiological monitoring devices (Ludlum Model 3 Survey Meters, with Model 44-7 End Window G-M Detectors and headphones). This choice was based on reports of good experiences with the instrument, price, and versatility (the equipment can be used for estimating exposure rate as well as detecting contamination). The hospital also acquired Radiagem-4 Personal Portable Radiometers, which are small hand-held gamma source meters that will potentially serve the dual purpose of screening victims for contamination and simultaneously recording the accumulated exposure of the employee using the equipment. These user-friendly detectors integrate the reading and will alarm after reaching a preset threshold.74
Ionizing radiation detection equipment could also be useful for identifying contaminated individuals that might enter the ED unannounced. Hospital G is in the process of obtaining and testing radiation detection meters (Syrena Gamma Source Finder) that will be located at patient entrances to the hospital. These portable devicesabout the size of an attaché casewill be tested at an entrance to determine whether they are useful for detecting radioactivity. The hospital hopes to use this type of equipment to avoid the spread of contamination by identifying contaminated individuals as they enter the hospital.75 The hospital also plans to evaluate equipment that could be used to screen victims by moving them past an instrument (e.g., at the entrance and exit of a shower system) eliminating the need for an employee in this position.
Chemical and Biological Agent Detection Equipment
User-friendly equipment of adequate sensitivity is also becoming available for specific agents typically used as chemical weapons (Environmental Technologies, undated). For example, two of the interviewed hospitals (Hospitals B and C) obtained the same make and model ("APD 2000" from Environmental Technologies) of hand-held detection meters designed to detect parts per billion levels of specific chemical "nerve and blister agents" used as chemical weapons (e.g., organophosphates, and mustard agent).76,77 However, a third hospital (Hospital A) felt that this type of equipment might be more useful for evaluating an incident site than for declaring victims to be thoroughly clean after decontamination efforts.
Equivalent equipment for detecting industrial chemicals and biological agents remains problematic. Although the interviewed hospitals indicated that they are interested in obtaining comparable detection equipment that would identify and measure low levels of industrial chemicals or biological agents, none of the hospitals feel the instruments currently available are practical for this purpose. Experts do agree, however, that some of the current broad-spectrum detection devices are capable of detecting classes of agents (although not the individual agent) with reasonable sensitivity and accuracy. Hospitals should determine the availability and utility of these instruments for the specific categories of substances identified in the hospital's HVA.
Hospital A indicated that optimal detection instruments would be 1) sensitive at low concentrations to a wide range of substances, 2) have a rapid response time (preferably a few seconds), 3) be easy to operate, 4) be rugged and portable enough to function outdoors under emergency conditions, 5) require only occasional routine maintenance, and 6) be reasonably priced. Macintyre et al. (2000) point out that the currently available detectors and monitors "would only complicate and lengthen the decontamination process," without providing substantial value.
2.2 TRIAGE CONSIDERATIONS
Hospital A notes that pre-decontamination triage serves three purposes:
Post-decontamination triage for medical treatment should occur in the Hospital Post-decontamination Zone, after victims are inspected and found to be free of contamination. Some hospitals combine decontamination and initial medical treatment (such as antidotes), which means either the healthcare worker attempts medical triage while wearing PPE (preferred) or the worker is at risk of exposure from victims that have not been adequately decontaminated.
2.3 EXTERNAL COMMUNICATION
2.3.1 Obtaining Timely Information
Experience has shown that hospitals cannot count on receiving immediate and complete information regarding an incident. However, hospitals can take steps to maximize their opportunities to receive useful and timely information. Hospitals D and F have found that the quality and timeliness of the received information improved as a result of strong working relationships with community organizations, coordinated EMPs, and drills conducted with other groups that respond to emergency situations.
2.3.2 Coordinating Activities
Coordinated response activities allow individual organizations to respond appropriately, when needed. Hospitals that work with the community to identify their roles can encourage coordinated responses. Hospital A (which maintains its own HAZMAT team in addition to a decontamination team) is located in a large urban area near other hospitals and fire departments, also with HAZMAT teams. As in many cities, the community's emergency management organization activates the appropriate HAZMAT team for each incident. This practice reduces the chance that response will be duplicated needlessly, thus protecting community resources that might otherwise be wasted. In the event that a large-scale emergency produced contaminated victims, Hospital A's two facilities (across a river from each other) would coordinate with the community to determine which one of its two decontamination locations to activate (based on number and location of victims)or whether both systems would be required.
Hospitals should also activate two-way communication with the incident site. The more information a hospital can obtain regarding the hazard, the better first receivers will be able to protect themselves and treat the victims. Additionally, while treating victims, hospital staff might obtain valuable information regarding the nature of the contaminant, the route of entry, and symptoms of exposure. By passing these details back to the Release Zone, hospitals provide first responders at the site with information that could help those workers recognize possible signs of exposure, initiate life-stabilizing medical treatment, or adjust their PPE to provide better protection.
3.1 HOSPITAL DECONTAMINATION
3.1.1 Solid Waste Management
All hospitals consulted indicate that solid waste generated during victim decontamination activities will be treated as hazardous waste following the hospitals' existing hazardous waste management procedures. These hospitals plan to work with contract hazardous waste management companies to test and dispose of waste that is considered hazardous (except for any items required by law enforcement as evidence). Anticipating that the need might arise, several of the hospitals have made advance arrangements with private companies that specialize in hazardous waste removal.
For emergencies involving only a few contaminated victims, hospitals typically plan to use plastic bags to collect individual's contaminated clothing for disposal. The bags will be sealed and double-bagged or put in hazardous waste containers, then stored in existing secure hazardous waste storage areas until disposal. Hospitals that anticipate that they might receive a large number of contaminated victims maintain a supply of hazardous waste barrels (with airtight lids) into which decontamination team members will place contaminated materials. Hospital representatives stress that sealing the bags or closing the containers is important to eliminate contaminated materials as possible continuing sources of victim or healthcare worker exposure.
In response to some incidents, federal authorities might request that certain types of waste be retained as evidence. In that case, the agency will provide instructions on handling the waste.
3.1.2 Wastewater Management
During an emergency, first receivers should take all necessary steps to save lives, protect the public, and protect themselves.78 Once imminent threats to human health and life are addressed, first receivers should make all reasonable efforts to contain contamination and avoid or mitigate environmental consequences (U.S. EPA, 2000).
Wastewater from decontamination showers can contain low-level concentrations of the substance(s) with which victims are contaminated. Given the opportunity to plan for decontamination activities (by designing and installing or purchasing decontamination facilities, developing procedures, and preparing staff), hospitals should consider the management of decontamination shower water as part of the plan. To determine appropriate wastewater management practices, hospitals should consult with LEPCs, whose members "can work together creatively using available resources to minimize the environmental impact of [hazardous materials] incidents" (U.S. EPA, 2000).
The hospitals interviewed follow several strategies for handling decontamination shower wastewater. Management methods range from complete water retention in a storage unit to uncontrolled release (e.g., into parking lot or storm drain). The choice is usually based on the circumstances under which the individual decontamination system will be used. For example, these hospitals have generally arranged for some level of treatment or containment of wastewater generated by their primary decontamination systems (i.e., the systems that would be used most frequently). However, the same hospitals do not typically apply specific controls to wastewater from additional, open-air showerheads intended for use only as backup shower capacity (in the event that an unexpectedly large number of victims overwhelms the hospital's primary decontamination system).
Hospital B has a memorandum of understanding with the municipal wastewater treatment facility, which allows the hospital to drain water from its large, permanent, indoor decontamination system to the sanitary sewer. The agreement specifies that the hospital notify the treatment facility immediately when the shower is used to treat contaminated victims. Hospital B includes this notification in the EMP protocol for activating the shower.
Hospital A and Hospital C incorporate large (1,000 or more gallons) underground storage tanks into the design of their permanent, enclosed decontamination systems. When necessary, the water can be held until tested. After consultation with local environmental authorities, the hospital can either treat the wastewater, pump it out, or drain the water to the sanitary sewer or storm drain.
Among the hospitals interviewed, those that have obtained portable decontamination systems typically use a wastewater-containment device built into the base of the system enclosure. These containment devices usually include a low supportive wall (a few inches high) around the perimeter of the shower and a plastic lining to catch and hold wastewater. The hospitals often pump water from the shower base containment into a separate bladder to limit the volume in the shower base and to increase water storage capacity.79 As with underground tanks, wastewater stored in bladders is held for subsequent testing and treatment or release, as deemed appropriate by authorities based on sample results.
An important consideration for positioning wastewater storage receptacles is the eventual need to drain or transport them (once filled, these containers are heavy and can only be shifted using special equipment). Hospital D noted that its hazardous waste management contractor provided useful advice about locating the wastewater receptacle where it could be easily accessed by the contractor's equipment, or could be drained with little assistance if water treatment was not required. This advice influenced the ultimate decontamination area design.
3.1.3 Decontaminating Surfaces and Equipment
The hospital EMP should include procedures for cleaning equipment and surfaces during and after an incident. Cleaning should be performed by properly protected and trained employees. Items that cannot be decontaminated safely should be processed for appropriate disposal. It is unlikely that portable gear could be adequately decontaminated after an incident involving a persistent or highly toxic agent.
The hospitals interviewed assign specifically trained individuals to be responsible for decontaminating and cleaning surfaces and equipment. These individuals are usually members of the decontamination team, but at least one of the hospitals uses specially trained housekeeping or facilities management staff (hospital employees) to fill this role. It is important to note, however, that hospitals are increasingly concerned about delegating this role to housekeeping staff. According to the hospitals interviewed, the current industry trend is toward using contract services rather than hospital employees for general housekeeping activities. Hospital E acknowledged that for contracted employees, protection and liability issues can be complicated when contractual arrangements do not specifically address these matters. Additionally, rapid personnel turnover among contract housekeepers often hinders the hospital's ability to ensure workers receive specialized training.
Hospital D is considering a different contractual option. The hospital anticipates that large, time-consuming decontamination and associated recovery-phase cleaning tasks will be performed under contract by the hospital's hazardous waste service provider. This arrangement will include cleaning and/or disposal of the portable decontamination facility and equipment, and any areas of the ED that might become contaminated.
Employees of the contract hazardous waste service provider should be trained as required under 29 CFR 1910.120(b) through (o). If hospital employees perform the cleaning, appropriate training would either be that specified under 29 CFR 1910.120(q)(11), or 120 (b) through (o), depending on the situation (this matter is currently under consideration by OSHA).
4.0 MAINTAINING FUTURE READINESS
To sustain a functional level of emergency preparedness, hospitals need to maintain equipment, supplies, and employee training. They should devote time and attention to evaluating and updating the HVA and EMP and coordinating these activities with the community. These efforts all require resources that will not be available without support at all levels of management. Hospitals D and F note that emergency planners can take active steps to help hospital management recognize the need for continuing effort. These steps might include providing management with after-action reports following drills and updated information regarding the community's expectations of the hospital.
Administrators need to be aware that all aspects of the EMP should be maintained equally. Continued employee training alone will not provide adequate protection if protective equipment (including respirator cartridges) is not replaced after use or when its shelf life expires. Some equipment, such as PAPR batteries, requires routine maintenance (e.g., charging and battery-life evaluation) for the life of the equipment. In addition, a well-maintained decontamination facility will not function well if employees do not have the experience of active, recent drills.
Hospitals in more mature stages of emergency management planning might require less concentrated efforts than during start-up, but continue to dedicate full- or part-time staff to ensure the hospital retains a full level of preparation. Emergency managers use creative methods to obtain additional help when needed. Hospital D uses an energetic emergency manager to direct the activities of employees from other departments who temporarily require light-duty work due to medical restrictions (after an illness or injury). These individuals provide some of the labor needed to update and improve the already-mature HVA and EMP.
APPENDIX B: ACRONYMS AND DEFINITIONS
Atmosphere supplying respirator (ASR):
A respirator that provides clean air from an uncontaminated source to the facepiece. Examples include supplied-air (airline) respirators, SCBA, and combination supplied-air/SCBA.
Assigned protection factor (APF):
a rating assigned to a respirator style by OSHA or NIOSH. This rating indicates the level of protection most workers can expect from the properly worn, maintained, and fitted respirator used under actual workplace conditions. An APF of 1,000 indicates that the concentration of contaminant inside the facepiece would be 1,000 times lower than concentration in the surrounding air. A respirator with an APF of 1,000 will provide greater protection than a respirator with an APF of 100. (Note: The APF should not be confused with a similar measure, the "fit factor," obtained during quantitative fit testing. Fit factors, which tend to be higher numbers, provide a relative indication of how well a respirator fits an individual, but do not represent the level of protection the respirator would provide in the workplace.)
See First Responder Awareness Level.
Chemical, biological, radiological, or nuclear [agent or substance].
Physicians, nurses, nurse practitioners, physicians' assistants, and others.
To take off or remove (e.g., PPE).
To put on, in order to wear (e.g., PPE).
Emergency Management Plan.
Employees at a hospital engaged in decontamination and treatment of victims who have been contaminated by a hazardous substance(s) during an emergency incident. The incident occurs at a site other than the hospital. These employees are a subset of first responders.
Personnel who have responsibility to initially respond to emergencies. Some examples are firefighters, HAZMAT team members, law enforcement officers, lifeguards, forestry personnel, ambulance attendants, and other public service personnel. In the case of hazardous materials incidents, these personnel typically respond at the site where the incident occurred.
First Responder Awareness Level:
Individuals who might reasonably be anticipated to witness or discover a hazardous substance release and who have been trained to initiate an emergency response sequence by notifying the proper authorities of the release. They would take no further action beyond notifying the authorities. [OSHA HAZWOPER Standard 29 CFR 1910.120(q)(6)(i)].
First Responder Operations Level:
Individuals who respond to releases or potential releases of hazardous substances as part of the initial response to the site for the purpose of protecting nearby persons, property, or the environment from the effects of the release. These individuals shall have received at least 8 hours of training or have sufficient experience to objectively demonstrate competency in specific critical areas. [OSHA HAZWOPER Standard 29 CFR 1910.120(q)(6)(ii)].
OSHA's Hazard Communication Standard [29 CFR 1910.1200].
OSHA's Standard on Hazardous Waste Operations and Emergency Response, 29 CFR 1910.120. In particular, paragraph (q) of this standard covers employers whose employees are engaged in emergency response to hazardous substance releases.
Hazard Vulnerability Analysis (HVA):
The identification of potential emergencies and direct and indirect effects these emergencies may have on the healthcare organization's operations and the demand for its services.
Any substance to which exposure may result in adverse effects on the health or safety of employees. This includes substances defined under Section 101(14) of CERCLA; biological or disease-causing agents that may reasonably be anticipated to cause death, disease, or other health problems; any substance listed by the U.S. Department of Transportation as hazardous material under 49 CFR 172.101 and appendices; and substances classified as hazardous waste.
Hospital Emergency Incident Command System (HEICS):
an example of an optional NIMS-based ICS tailored specifically for use by hospitals and designed to function in conjunction with other common ICSs used by emergency response organizations (e.g., Fire Service Incident Command System).
Hospital Decontamination Zone:
This 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 emergency department door. In other documents, this zone is sometimes called the "Warm Zone," "contamination reduction zone," "yellow zone," or "limited access zone."
Hospital Post-decontamination 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 emergency department (unless contaminated). This zone is sometimes called the "Cold Zone" or "Clean Area."
Or Immediately dangerous to life or health, means an atmospheric concentration of any toxic, corrosive or asphyxiant substance that poses an immediate threat to life or would interfere with an individual's ability to escape from a dangerous atmosphere.
Incident Command System (ICS):
A flexible organizational structure which provides a basic expandable system developed by Fire Services to mitigate an emergency situation of any size.
Incident Commander (IC):
The individual who holds overall responsibility for incident response and management.
Incident Command System (ICS):
A flexible organizational structure which provides a basic expandable system developed by Fire Services to mitigate an emergency situation of any size.
Incident Commander (IC):
The individual who holds overall responsibility for incident response and management.
Joint Commission on Accreditation of Healthcare Organizations.
Local Emergency Planning Committee.
"A combination of patient numbers and patient care requirements that challenge or exceed a community's ability to provide adequate patient care using day-to-day operations" (Barbera and MacIntyre, 2003).
The National Incident Management System, established by the US Department of Homeland Security as a standardized management approach to incident response that all responders will use to coordinate and conduct response actions.
National Fire Protection Association.
See First Responder Operations Level.
Personal Protective Equipment (PPE):
Examples include protective suits, gloves, foot covering, respiratory protection, hoods, safety glasses, goggles, and face shields.
Powered Air-Purifying Respirator (PAPR):
A respirator that uses a battery-powered blower to force air through a filter or purifying cartridge before blowing the cleaned air into the respirator facepiece.
An area in and immediately surrounding a hazardous substance release. It is assumed to pose an immediate health risk to all persons, including first responders. For the purposes of this document the Release Zone is always REMOTE from the hospital. This zone is also referred to as the "exclusion zone", the "red zone", and the "restricted zone" in other documents.
Self-contained Breathing Apparatus (SCBA):
A respirator that provides fresh air to the facepiece from a compressed air tank (usually worn on the worker's back).
Supplied-air Respirator (SAR):
A respirator that provides breathing air through an airline hose from an uncontaminated compressed air source to the facepiece. The facepiece can be a hood, helmet, or tight fitting facepiece.
The process of screening and classifying sick, wounded, or injured persons to determine priority needs in order to ensure the efficient use of medical personnel, equipment, and hospitals.
Weapon of Mass Destruction.
APPENDIX C: REFERENCES
ACGIH. 2001. Heat Stress and Strain. Documentation of Threshold Limit Values and Biological Exposure Indices. American Conference of Governmental Industrial Hygienists (ACGIH), Cincinnati, OH.
Managing Hazardous Materials Incidents: Hospital Emergency Departments – A planning guide for the management of contaminated patients. Volume II (revised). Agency for Toxic Substances and Disease Registry (ATSDR), U.S. Department of Health and Human Services. (Last accessed 2003, April 21)
Managing Hazardous Materials Incidents: Medical Management Guidelines (MMGs) for Unidentified Chemical. Volume III. Agency for Toxic Substances and Disease Registry (ATSDR), U.S. Department of Health and Human Services. (Last accessed 2003, April 21)
Auf der Heide, E. Disaster Medicine. (Part II (8) -Principles of hospital disaster planning). Hogan, D. and J.L. Burstein, editors. Lippincott Williams & Wilkins. Pp 57-89.
Barbera J.A., Anthony G. Macintyre. 2003. Mass Casualty Handbook: Hospital, Emergency Preparedness and Response. First ed: Jane's Information Group, Ltd.
Beatty J. 2003. Decontamination procedures (personal e-mail correspondence). Central Arkansas Veterans Healthcare System, Little Rock, AR. October 23.
BNA. 2003. Hospitals low on protective suits in event of bioterrorist attack, report says. Daily Labor Report Banner, Bureau of National Affairs. August 13.
Burgess J.L. 1999. Hospital Evacuations Due to Hazardous Materials Incidents. Am J Emerg Med 17:50-52. January.
CA EMSA. 2003a. Personal communication between Cheryl Starling of the California Emergency Medical Services Authority and Eastern Research Group, Inc. July 21.
CA EMSA. 2003b. Recommendations for Hospitals: Chemical Decontamination, Staff Protection, Chemical Decontamination Equipment and Medication List, Evidence Collection. Hospital and Healthcare System Disaster Interest Group (DIG). California Emergency Medical Services Authority. June.
CDC. 2003. Interim Guidelines for Hospital Response to Mass Casualties from a Radiological Incident. Center for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. December.
Department of Homeland Security. 2003. Working document from Department of Homeland Security Working Group on Radiological Dispersal Devices (RDD) Preparedness Response Subgroup. Version: May 1.
DuPont. 2002. Technical Data Sheet. DuPont Tychem F: Helps protect against chemical warfare agents. E.I. DuPont de Nemours and Company.
DuPont. 2003. Permeation Guide for DuPont Tychem Protective Fabrics. E.I. du Pont de Nemours and Company.
ECRI. 2002. ECRI Advisor Selecting personal protective equipment for chemical and bioterrorism preparedness: risks and costs. Center for Healthcare Environmental Management, Emergency Care Research Institute (ECRI), Plymouth Meeting, PA. March.
Environmental Technologies. (undated). Product literature for APD 2000. Environmental Technologies Group, Inc. Baltimore, MD.
Federal Register. 2003. Assigned Protection Factors; proposed rule. Occupational Safety and Health Administration (OSHA). 68 FR 34035. June 6.
Georgopoulos, P.G., P. Fedele, P. Shade, P.J. Lioy, M. Hodgson, A. Longmire, M. Sands, and M.A. Brown. 2004. Hospital response to chemical terrorism: personal protective equipment, training, and operations. American Journal of Industrial Medicine 46(5):432-445. November.
Goozner B., L. Lutwick, E. Bourke. 2002. Chemical Terrorism: a Primer for 2002. Journal of the Association for Academic Minority Physicians. 13(1):14-18. January.
HCA. (undated). Disaster Readiness: Guidelines for Emergency Management Planners. Hospital Corporation of America (HCA). Nashville, TN.
HAZMAT for Healthcare. 2003. Haz Mat for Healthcare – An Operations Course. EnMagine, Diamond Springs, CA. Last accessed September 16.
Hendler et al. 2000. The Effect of Full Protective Gear on Intubation Performance by Hospital Medical Personnel. Military Medicine, Volume 149. [As cited in USACHPPM 2003a]
Hick J. L., D. Hanfling, J.L. Burstein, J. Markham, A. G. Macintyre, J.A. Barbera. 2003a. Protective equipment for healthcare facility decontamination personnel: regulations, risks, and recommendations. Annals of Emergency Medicine 42(3):370-380. September.
Hick J. L., P. Penn, D. Hanfling, M.A. Lapp, D. O'Laughlin, J.L. Burstein. 2003b. Establishing and training health care facility decontamination teams. Annals of Emergency Medicine 42(3):381-390. September.
Hodgson, M.J., A. Bierenbaum, S. Mather, M.A. Brown, J. Beatty, M. Scott, and P. Brewster. 2004. Emergency management program operational responses to weapons of mass destruction: Veterans Health Administration, 2001-2003. American Journal of Industrial Medicine 46(5):446-452 (November).
Horton D. K., Z. Berkowitz, W.E. Kaye. 2003. Secondary contamination of ED personnel from hazardous materials events, 1995-2001. Am J Emerg Med 21:199-204. May.
JCAHO. 2002. Guide to Emergency Management Planning in Health Care. Joint Commission Resources, Joint Commission on Accreditation of Healthcare Organizations, Oakbrook, IL.
JCAHO. 2004. Revised environment of care standards for the comprehensive accreditation manual for hospitals (CAMH). Joint Commission on Accreditation of Healthcare Organizations, Oakbrook, IL. Accessed April 21.
Koenig K. 2003. Strip and shower: the duck and cover for the 21st Century. Annals of Emergency Medicine. 42(3): 391-394. September.
Lehmann J. 2002. Considerations for selecting personal protective equipment for hazardous materials decontamination. Disaster Manag Response: 21-25. September.
Lundgren R.E., A.H. McMakin. 1998. Risk Communications: A Handbook for Communicating Environmental, Safety, and Health Risks, Second ed. Columbus, OH: Battelle Press.
Macintyre A.G., G.W. Christopher, E. Eitzen et al. 2000. Weapons of Mass Destruction Events with Contaminated Casualties: Effective Planning for Health Care Facilities. JAMA 283(2):242-249. January 12.
MMWR. 2001. Nosocomial poisoning associated with emergency department treatment of organophosphate toxicity Georgia, 2000. Morbidity and Mortality Weekly, 49(51):1156-8. January 5.
NFPA. 2001. NFPA 1994 Standard on Protective Ensemble for Chemical/Biological Terrorism Incidents 2001 Edition. National Fire Protection Association (NFPA), NY.
NFPA. 2002. NFPA 472 Standard for Professional Competence of Responders to Hazardous Materials Incidents. National Fire Protection Association (NFPA), NY.
NIJ. 2000. Guide for the Selection of Chemical Agent and Toxic Industrial Material Detection Equipment for Emergency First Responders [2 MB PDF, 74 pages] Volumes I & II (NIJ Guide 100-00). National Institute of Justice, U.S. Department of Justice. June.
NIOSH. 2003. NIOSH Pocket Guide to Chemical Hazards and Other Databases (online edition). National Institute for Occupational Safety and Health (NIOSH), Department of Health and Human Services (DHHS), Cincinnati, OH. Last accessed April 20, 2004.
Nozaki H., S.O. Hori, Y. Shinozawa et al. 1995. Secondary exposure of medical staff to sarin vapor in the emergency room. Intensive Care Med 21:1032-1035.
Okumura, Takasu, Ishimatsu et al. 1996. Report on 640 victims of the Tokyo subway sarin attack. Annals of Emergency Medicine 28(2):129-135. August.
OSHA. 1991a. Letter of Interpretation. Addressed to Mr. Edward McNamara, Executive Director, Central Massachusetts Emergency Medical Systems Corporation, Re: Training Requirements for emergency medical service personnel. June 14. Accessed April 6, 2004
OSHA. 1991b. Letter of Interpretation. Addressed to Mr. Eugene D. McCoy, Police Department, City of Ft. Lauderdale, FL. Re: Minimum number of hours required for awareness level for police officers. June 17. Accessed April 6, 2004
OSHA. 1991c. Letter of Interpretation. Addressed to Mr. William Borwegen, Service Employees International Union, AFL-CIO, Re: HAZWOPER EPA and OSHA jurisdictional issues. December 18. Accessed April 6, 2004
OSHA. 1992a. Letter of Interpretation. Addressed to Randy Ross, Re: Medical personnel exposed to patients contaminated with hazardous waste. March 31. Accessed April 6, 2004
OSHA. 1992b. Letter of interpretation. From C.K. O'Toole to L. Bloomfield. Occupational Safety and Health Administration (OSHA), U.S. Department of Labor. Various questions on HAZWOPER. October 21. Accessed April 6, 2004
OSHA. 1992c. Letter of Interpretation. Addressed to Howard W. Levitin, Re: Training requirements for hospital personnel involved in an emergency response of a hazardous substance. October 27. Accessed April 6, 2004
OSHA. 1993. Letter of Interpretation. Addressed to Mr. Edward E. Hartin, Vice-President of Operations, HAZMAT Training Information Services, Inc., Re: Post-emergency response and medical surveillance requirements of HAZWOPER. August 5. Accessed April 6, 2004
OSHA. 1997. Letter of Interpretation. Addressed to Mr. Thomas Whittaker, New England Hospital Engineer's Society, Re: Emergency response training requirements for hospital staff. April 25. Accessed April 6, 2004
OSHA. 1999. Letter of Interpretation. Addressed to Daniel Burke, Safety Coordinator, St. John's Medical Center, Re: Emergency response training necessary for hospital physicians/nurses that may treat contaminated patients. March 10. Accessed April 6, 2004
OSHA. 2002a. Letter of Interpretation. Addressed to Mr. Francis J. Roth, Supervisor, Loss Protection, Princeton Insurance, Re: Level of respiratory protection required for hospital staff members. September 5. Accessed April 6, 2004
OSHA. 2002b. Letter of Interpretation. Addressed to Captain Kevin J. Hayden, Acting Commanding Officer, State of New Jersey Emergency Management Section, Re: Personal protective requirements for hospital employees. December 2. Accessed April 6, 2004
OSHA. 2002c. Memorandum for Regional Administrators (RAs) regarding enforcement policy change for respiratory protection for select respirators for use in the pharmaceutical industry. May 30. Accessed April 6, 2004
OSHA. 2003. Letter of Interpretation. Addressed to Mike Bolt, Re: HAZWOPER training requirements for hospital staff whole decontaminate chemically contaminated patients. April 22. Accessed April 6, 2004
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San Mateo County HAS. 1998. HEICS The hospital emergency incident command system. (Volumes I and II). San Mateo County Health Services Agency. June. Accessed August, 2003
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SBCCOM. 2001b. Swatch Test Results of Phase 2 Commercial Chemical Protective Gloves to Challenge by Chemical Warfare Agents: Executive Summary [2 MB PDF, 56 pages]. Domestic Preparedness Chemical Team, U.S. Army Soldier and Biological Chemical Command. June.
SBCCOM. 2003. Guidelines for Use of Personal Protective Equipment by Law Enforcement Personnel During a Terrorist Chemical Agent Incident [2 MB PDF, 101 pages]. U.S. Army Soldier and Biological Chemical Command. Original June 2001. Revised July 2003.
Schultz, M., J. Cisek, and R. Wabeke. 1995. Simulated exposure of hospital emergency personnel to solvent vapors and respirable dust during decontamination of chemically exposed patients. Annals of Emergency Medicine. 26(3):324-329. September.
Sutter Health. 2002. Training materials: First Responder Operations. Sutter Health, Sacramento, CA. October 1.
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U.S. EPA. 2000. First responders' environmental liability due to mass decontamination runoff [44 KB PDF, 3 pages]. (EPA 550-F-00.009) U.S. Environmental Protection Agency, Office of Solid Waste and Emergency Response. July.
USACHPPM. 2003a. Personal Protective Equipment Guide for Military Medical Treatment Facility Personnel Handling Casualties from Weapons of Mass Destruction and Terrorism Events (Technical Guide 275). U.S. Army Center for Health Promotion and Preventive Medicine. August.
USACHPPM. 2003b. Chemical Risk Assessment and Exposure Guidelines (and how AEGLs fit in) [3 MB PPT*, 35 slides]. U.S. Army Center for Health Promotion and Preventive Medicine, Directorate of Health Risk Management. March.
U.S. Army, U.S. Marine Corps, U.S. Navy, and U.S. Air Force. 2001. Multiservice Tactics, Techniques, and Procedures for Nuclear, Biological, and Chemical Aspects of Consequence Management. AFTTP (I) 3-2.37. December.
VA. 2003. VHA Decontamination Training Program – Train the Trainer Participant Manual. Little Rock Employee Education Resource Center, Employee Education System, Department of Veterans Affairs (VA), Little Rock, AR. April.
Vogt, B.M. and J.H. Sorrensen. 2002. How clean is safe? Improving the effectiveness of decontamination of structures and people following chemical and biological incidents [542 KB PDF, 115 pages]. Final Report (ORNL/TM-2002/178). Prepared by Oakridge National Laboratory for the U.S. Department of Energy. October. Accessed September 2004
Walter F. G., Bates G., Criss E. A. et al. 2003. Hazardous materials responses in a mid-sized metropolitan area. Prehosp Emerg Care 7:214-218. Apr-Jun.
Young Bruce H., Ford Julian D., Rusek Josef I. et al. Disaster Mental Health Services: A Guidebook for Clinicians and Administrators. National Center for PTSD. Last Accessed: 2002.
APPENDIX D: ADDITIONAL RESOURCES (WEB LINKS)
Agency for Toxic Substances and Disease Registry
Agency for Toxic Substances and Disease Registry, Division of Regional Operations
California Emergency Medical Services Authority
Centers for Disease Control and Prevention (CDC)
Department of Veterans Affairs
Healthcare Association of Hawaii
The InterAgency Board
Joint Commission on Accreditation of Healthcare Organizations
Local Emergency Planning Committee (LEPC) Locations
DisasterAssistance (U.S. Office of Management and Budget – Disaster Management Initiative)
National Institute of Justice
National Institute for Occupational Safety and Health (NIOSH)
Occupational Safety and Health Administration (OSHA) [includes contact information for OSHA-approved State Plans]
Office for Domestic Preparedness
U.S. Army Center for Health Promotion and Preventive Medicine (USACHPPM)
U.S. Army Medical Institute for Chemical Defense, Chemical Casualty Care Division
U.S. Army Soldier and Biological Chemical Command (Effective 9 October 2003, SBCCOM has been re-designated). *See sites below:
Research, Development and Engineering Command (RDECOM)
Chemical Materials Agency (CMA)
PM Nuclear, Biological and Chemical Defense (PM NBC)
Soldiers System Center (SSC)
APPENDIX E: ADVANTAGES AND DISATVANTAGES OF VARIOUS RESPIRATOR FACEPIECE STYLES
Adapted from: USACHPPM. 2003a. Personal Protective Equipment Guide for Military Medical Treatment Facility Personnel Handling Casualties from Weapons of Mass Destruction and Terrorism Events (Technical Guide 275). August 2003.
APPENDIX F: HAZARD VULNERABILITY ANALYSIS EXAMPLES
This appendix provides a brief look at the general format two healthcare organizations use as the basis for their HVAs. Contact the Joint Commissions on Accreditation of Healthcare Organizations (JCAHO) for more information, including additional format examples, instructions for completing HVAs, and lists of the types of events that might be included in an HVA.
American Society for Health Care Engineering (ASHE, 2000)
APPENDIX F - Example 1.
Kaiser Permanente Hazard Vulnerability Analysis
This document is a sample Hazard Vulnerability Analysis tool. It is not a substitute for a comprehensive emergency preparedness program. Individuals or organizations using this tool are solely responsible for any hazard assessment and compliance with applicable laws and regulations.
Evaluate potential for event and response among the following categories using the hazard specific scale. Assume each event incident occurs at the worst possible time (e.g. during peak patient loads). Please note specific score criteria on each work sheet to ensure accurate recording.
Issues to consider for probability include, but are not limited to:
APPENDIX F - Example 1.
Kaiser Permanente Hazard Vulnerability Analysis [234 KB PDF*, 1 page]. This table is an example of the format used with a complete threat list.
APPENDIX F - Example 2.
New York University Medical Center - Hazard Vulnerability Analysis -Version date: August 2003
Evaluate each potential event with respect to the probability, risk, and the perceived level of preparedness. Add additional events as needed.
Issues to consider for probability include, but are not limited to:
The event score is arrived at by multiplying each of the ratings (Probability * Risk * Preparedness). The total values in descending order represent the event in need of organization focus and resources for emergency planning. The organization needs to determine a value below which no action is required.
APPENDIX F - Example 2.
New York University Medical Center Hazard Vulnerability Analysis [87 KB PDF*, 1 page].
(Version date: 2003). This table is an example of the format used with a threat list.
APPENDIX G: INTRODUCTION TO HEICS
Source: California Emergency Medical Services Authority, Sacramento
In 1992, a generic disaster response plan was released to hospitals based upon the Incident Command System. The Hospital Emergency Incident Command System, modeled after the FIRESCOPE management system, was first tested by six hospitals in Orange County, California. A second edition was developed by a state-wide task force and tested again by Orange and Los Angeles County hospitals. In May 1992 the Second Edition of the Hospital Emergency Incident Command System (HEICS) was made available with copies having been sent throughout the United States, Canada, and across the globe.
HEICS features a flexible management (see attached) which allows for a customized hospital response to the crisis at hand. There is an organizational chart with forty-nine positions grouped into one of four sections. This all results in an organized division of tasks and a realistic span of control for each manager. This organizational structure provides a platform for common terminology to enhance communication and improve documentation.
Following the 1993 Northridge Earthquake, HEICS was used successfully by some hospitals damaged in the quake. The plan has also been used in single hospital emergencies and in many disaster exercises. From these repeated uses of the HEICS program, much insight has been gained. It is the goal of San Mateo County Emergency Medical Services that the Hospital Emergency Incident Command System Update Project recreate a HEICS plan which is more useful and relevant to the medical community. And, a plan which is more accessible, as is found in their website. You are invited to access and down load the Second Edition of the HEICS plan. You are encouraged to take a critical look at this document and return your comments to San Mateo County Emergency Medical Services team who are working on this exciting update.
For More Information...
about the Hospital Emergency Incident Command System contact the California Emergency Medical Services Authority. (916) 322-4336. Electronic copies of the materials contained in this appendix are available from the EMSA website.
HOSPITAL EMERGENCY INCIDENT COMMAND SYSTEM
Confusion and chaos are commonly experienced by the hospital at the onset of a medical disaster. However, these negative effects can be minimized if management responds quickly with structure and a focused direction of activities. The Hospital Emergency Incident Command System (HEICS) is an emergency management system which employs a logical management structure, defined responsibilities, clear reporting channels, and a common nomenclature to help unify hospitals with other emergency responders. There are clear advantages to all hospitals using this particular emergency management system.
Based upon public safety's Incident Command System, HEICS has already proved valuable in helping hospitals serve the community during a crisis and resume normal operations as soon as possible. A survey of California hospitals in the Spring of 1997, reveals a significant number of hospitals have, or will be incorporating HEICS within their emergency plans. HEICS is fast becoming the standard for healthcare disaster response and offers the following features:
HEICS and all of its support material is offered without charge. Implementation templates and instructional materials are free and make the cost of converting to the HEICS system minimal. HEICS is financially prudent as it assists the medical facility in staying open following a disaster and promotes the restoration of day-to-day hospital function. It is an efficient method for managing emergencies of disastrous proportions, as well as those of a lesser degree.
APPENDIX G - Hospital Emergency Incident Command System Organizational Chart [66 KB PDF*, 1 page].
APPENDIX H: EXAMPLES OF MEDICAL MONITORING FOR FIRST RECEIVERS, INCLUDING INFORMATION ON HEAT STRESS
Northern Virginia Emergency Response Coalition.
Decontamination Procedure-complete [39 KB DOC, 6 pages].
(Accessed September 2, 2003).
NIOSH Publication 86-112 "Working In Hot Environments."
APPENDIX H - Example 1.
NVERC Medical Monitoring of Response Staff
Northern Virginia Emergency Response Coalition
It is important to determine that personnel who are being asked to wear personal protective equipment (PPE) during a hazmat/weapon of mass destruction (WMD) incident have no preexisting medical conditions that might put them at increased risk for illness or injury. The following medical monitoring procedure is to be used from the outset of an incident to accomplish this objective.
I. At the Outset of the Incident
APPENDIX H - Example 2.
U.S. Coast Guard National Strike Force
A heat stroke victim's skin is hot, usually dry, red or spotted. Body temperature is usually 105º F or higher, and the victim is mentally confused, delirious, perhaps in convulsions, or unconscious. Unless the victim receives quick and appropriate treatment, death can occur.
Any person with signs of symptoms of heat stroke requires immediate hospitalization. However, first aid should be immediately administered. This includes removing the victim to a cool area, thoroughly soaking the clothing with water, and vigorously fanning the body to increase cooling. Further treatment, at a medical facility, should be directed to the continuation of the cooling process and the monitoring of complications which often accompany the heat stroke. Early recognition and treatment of heat stroke is the only means of preventing permanent brain damage or death.
HEAT EXHAUSTION. Heat exhaustion includes several clinical disorders having symptoms which may resemble the early symptoms of heat stroke. Heat exhaustion is caused by the loss of large amounts of fluid by sweating, sometimes with excessive loss of salt. A worker suffering from heat exhaustion still sweats but experiences extreme weakness or fatigue, giddiness, nausea, or headache. In more serious cases, the victim may vomit or lose consciousness. The skin is clammy and moist, the complexion is pale or flushed, and the body temperature is normal or only slightly elevated. In most cases, treatment involves having the victim rest in a cool place and drink plenty of liquids. Victims with mild cases of heat exhaustion usually recover spontaneously with this treatment. Those with severe cases may require extended care for several days. There are no known permanent effects.
HEAT CRAMPS. Heat cramps are painful spasms of the muscles that occur among those who sweat profusely in heat, drink large quantities of water, but do not adequately replace the body's salt loss. The drinking of large quantities of water tends to dilute the body's fluids, while the body continues to lose salt. Shortly thereafter, the low salt level in the muscles causes painful cramps. The affected muscles may be part of the arms, legs, or abdomen; but tired muscles (those used in performing the work) are usually the ones most susceptible to cramps. Cramps may occur during or after work hours and may be relieved by taking salted liquids by mouth.
FAINTING. A worker who is not accustomed to hot environments and who stands erect and immobile in the heat may faint. With enlarged blood vessels in the skin and in the lower part of the body due to the body's attempts to control internal temperature, blood may pool there rather than return to the heart to be pumped to the brain. Upon lying down, the worker should soon recover. By moving around, and thereby preventing blood from pooling, the patient can prevent further fainting.
HEAT RASH. Heat rash, also known as prickly heat, is likely to occur in hot, humid environments where heat is not easily removed from the surface of the skin by evaporation and the skin remains wet most of the time. The sweat ducts become plugged, and a skin rash soon appears. When the rash is extensive or when it is complicated by infection, prickly heat can be very uncomfortable and may reduce a worker's performance. The worker can prevent this condition by resting in a cool place part of each day and by regularly bathing and drying the skin.
TRANSIENT HEAT FATIGUE. Transient heat fatigue refers to the temporary state of discomfort and mental or psychological strain arising from prolonged heat exposure. Workers unaccustomed to the heat are particularly susceptible and can suffer, to varying degrees, a decline in task performance, coordination, alertness, and vigilance. The severity of transient heat fatigue will be lessened by a period of gradual adjustment to the hot environment (heat acclimatization).
PREPARING FOR WORK IN THE HEAT
Adjustment to heat, under normal circumstances, takes about a week, during which time the body will undergo a series of changes that will make continued exposure to heat more endurable. With each succeeding daily exposure, hazardous physiological responses will gradually decrease, while the sweat rate will increase. When the body becomes acclimated to the heat, the worker will find it possible to perform work with less strain and distress.
Gradual exposure to heat gives the body time to become accustomed to higher environmental temperatures. Heat disorders in general are more likely to occur among workers who have not been given time to adjust to working in the heat or among workers who have been away from hot environments and who have gotten accustomed to lower temperatures. Hot weather conditions of the summer are likely to affect the worker who is not acclimatized to heat. Likewise, workers who return to work after a leisurely vacation or extended illness may be affected by the heat in the work environment. Whenever such circumstances occur, the worker should be gradually reacclimatized to the hot environment.
Heat stress depends, in part, on the amount of heat the worker's body produces while a job is being performed. The amount of heat produced during hard, steady work is much higher than that produced during intermittent or light work. Therefore, one way of reducing the potential for heat stress is to make the job easier or lessen its duration by providing adequate rest. Rather than be exposed to heat for extended periods of time during the course of a job, workers should, wherever possible, be permitted to distribute the workload evenly over the day and incorporate work-rest cycles. Work-rest cycles give the body an opportunity to get rid of excess heat, slow down the production of internal body heat, and provide greater blood flow to the skin.
REST AREAS. Providing cool rest areas in hot work environments considerably reduces the stress of working in those environments. There is no conclusive information available on the ideal temperature for a rest area. Rest areas should be as close to the work area as possible, and provide shade. Individual work periods should not be lengthened in favor of prolonged rest periods. Shorter but frequent work-rest cycles are the greatest benefit to the worker.
DRINKING WATER. In the course of a day's work in the heat, a worker may produce as much as 2 to 3 gallons of sweat. Because so many heat disorders involve excessive dehydration of the body, it is essential that water intake during the workday be about equal to the amount of sweat produced. Most workers exposed to hot conditions drink less fluids than needed because of an insufficient thirst drive. A worker, therefore, should not depend on thirst to signal when and how much to drink. Instead, the worker should drink 5 to 7 ounces of fluids every 15 to 20 minutes to replenish the necessary fluids in the body. There is no optimum temperature of drinking water, but most people tend not to drink warm or very cold fluids as readily as they will cool ones. Whatever the temperature of the water, it must be palatable and readily available. Individual drinking cups should be providednever use a common drinking cup.
Heat acclimatized workers lose much less salt in their sweat than do workers who are not adjusted to the heat. The average American diet contains sufficient salt for acclimatized workers even when sweat production is high. If for some reason, salt replacement is required, the best way to compensate for the loss is to add a little extra salt to the food. Salt tablets SHOULD NOT be used.
CAUTIONPERSONS WITH HEART PROBLEMS OR THOSE ON A "LOW SODIUM" DIET WHO WORK IN HOT ENVIRONMENTS SHOULD CONSULT A PHYSICIAN ABOUT WHAT TO DO UNDER THESE CONDITIONS.
PROTECTIVE CLOTHING. Clothing inhibits the transfer of heat between the body and the surrounding environment. Therefore, in hot jobs where the air temperature is lower than skin temperature, wearing clothing reduces the body's ability to lose heat into the air. When air temperature is higher than skin temperature, clothing helps to prevent the transfer of heat from the air to the body. The advantage of wearing additional clothes, however, may be nullified if the clothes interfere with the evaporation of sweat (such as rain slickers or chemical protective clothing).
APPENDIX H - Example 3.
NIOSH Publication 86-112 Working In Hot Environments
C.1. HEAT STROKE
Humans are, to a large extent, capable of adjusting to the heat. This adjustment to heat, under normal circumstances, usually takes about 5 to 7 days, during which time the body will undergo a series of changes that will make continued exposure to heat more endurable.
Workers who return to work after vacation or extended illness may be affected by the heat in the work environment. Whenever such circumstances occur, the worker should be gradually reacclimatized to the hot environment.
Providing cool rest areas in hot work environments considerably reduces the stress of working in those environments. Rest areas should be as close to the work area as possible, and provide shade. Shorter but frequent work-rest cycles are the greatest benefit to the worker.
Most workers exposed to hot conditions drink less fluids than needed because of an insufficient thirst drive. A worker, therefore, should not depend on thirst to signal when and how much to drink.
5 to 7 ounces of fluids should be consumed every 15 to 20 minutes to replenish the necessary fluids in the body.
There is no optimum temperature of drinking water, but most people tend not to drink warm or very cold fluids as readily as they will cool ones.
Heat acclimatized workers lose much less salt in their sweat than do workers who are not adjusted to the heat. The average American diet contains sufficient salt for acclimatized workers even when sweat production is high. If for some reason, salt replacement is required, the best way to compensate for the loss is to add a little extra salt to the food.
Salt tablets SHOULD NOT be used.
CAUTIONPERSONS WITH HEART PROBLEMS OR THOSE ON A "LOW SODIUM" DIET WHO WORK IN HOT ENVIRONMENTS SHOULD CONSULT A PHYSICIAN ABOUT WHAT TO DO UNDER THESE CONDITIONS.
Central Arkansas Veterans Healthcare System.
U.S. Coast Guard National Strike Force.
APPENDIX I - Example 1.
Vital Signs & PPE Checklist [27 KB PDF*, 1 page].
(Central Arkansas Veterans Healthcare System).
APPENDIX I - Example 2.
Vital Signs Monitoring Checklist [25 KB PDF*, 1 page].
(U.S. Coast Guard National Strike Force).
APPENDIX J: EXAMPLE OF PATIENT DECONTAMINATION PROCEDURE
Northern Virginia Emergency Response Coalition.
Patient Decontamination Procedure-complete [39 KB DOC, 6 pages]. (Accessed September 2, 2003)
APPENDIX J - Example of Patient Decontamination Procedure
(Northern Virginia Emergency Response Coalition)
APPENDIX K: PPE DONNING AND DOFFING SEQUENCE
Adapted from Central Arkansas Veterans Healthcare System
APPENDIX K - PPE Donning Sequence
(NOTE: The following sequence outlines the order in which one hospital's employees find it efficient to put on their specific first receiver PPE. The list is not intended to provide detailed step-by-step instructions for putting on the PPE.)
APPENDIX K - PPE Decontamination & Doffing Sequence
(NOTE: The following sequence outlines the order in which one hospital's employees find it effective to decontaminate themselves and their PPE as one procedure, to minimize the chance of contaminating their skin while removing their first receiver PPE. The list is not intended to provide detailed step-by-step instructions.)
Adapted from Managing Hazardous Materials Incidents. Hospital Emergency Departments: A Planning Guide for the Management of Contaminated Patients. Volume II. U.S. Department of Health and Human Services. Public Health Service. Agency for Toxic Substances and Disease Registry (Revised 2000).
APPENDIX L - Technical Decontamination Process for Hospital Personnel
Personnel should remove protective clothing in the following sequence.
Note: The Emergency Management and Disaster Preparedness PlanChemically contaminated patient care protocol included in this appendix was developed by the INOVA Health System (Virginia) for use in INOVA facilities. The INOVA Health System uses powered air-purifying respirators (PAPRs). However, in cases where information is adequate to determine that an air-purifying respirator (APR) would provide adequate protection against the hazard, APRs might be used in place of PAPRs. At INOVA facilities, a specific, designated individual (the Charge MD) is responsible for determining the appropriate PPE for the decontamination team and for making appropriate adjustments as the situation evolves.
This example plan represents a portion of the emergency management plan used by one healthcare organization. Based on their individual circumstances, other organizations will have different procedures, terminology, and division of responsibilities.
To establish a policy for providing care to victims of hazardous materials and/or chemical terrorism incidents while ensuring the safety of the emergency department (ED) personnel and hospital environment.
The potential for hazardous materials exposure requires specific procedures for the protection of the patient, staff, and the environment. It differs from the other emergency situations because of that added risk of contamination to staff and facility. Worker safety and training are key factors in the management of these medical emergencies. Often these patients may arrive at the hospital unannounced. Patients being transported by EMS may not have been fully decontaminated prior to their arrival to the hospital.
To remove or neutralize harmful materials that have gathered on personnel and/or equipment and to prevent secondary contamination to healthcare workers and the facility. Decontamination is a systematic process that is determined by the nature and degree of contamination. Effective decontamination consists of making the patient as clean as possible, meaning that the contamination has been reduced to a level that is no longer a threat to the patient or healthcare provider.
In a "traditional" HAZMAT incident involving known exposure to chemical agents involving less than 3 patients simultaneously, consideration can be given to using the existing Emergency Department Decontamination Room, if available.
In the event that the chemical exposure incident involves more than 3 people requiring decontamination simultaneously, or incident information suggests the arrival of large numbers of patients requiring decontamination as a result of a mass exposure, preparation for mass decontamination should commence.
The following materials have been identified as basic prerequisites for Mass Decontamination set up and preparation:
Decon team preparation
Powered Air Purifying Respirator (PAPR): This provides air that is drawn through organic/HEPA filter cartridges affixed to a battery powered unit worn by the decon team personnel on a belt around their waist. It is worn as a hood placed over the head, with the inner sleeve tucked into the chemical protective clothing suit.
Air Purifying Respirator (APR): This provides air that is filtered through organic/HEPA filter cartridges dependent on the negative inspiration created by the work of breathing. This is worn as a full-face mask with the cartridges affixed to the mask.
Caution: These respiratory protective equipment contain LATEX products and are not to be worn by LATEX-allergic individuals.
LEVEL C chemical protective clothing is contained in the Tri-con PPE packs that include:
Note: Some Tri–Con PPE packs will also contain an APR mask. Consult with the ED physician in charge with regards to selection of APR or PAPR. Persons needing to use glasses, or those with beards or full moustaches, are NOT to use a face mask device.
A Decon team member should double check to assure all personnel have donned their PPE properly. Special attention should be paid to proper seal of mask/face and proper occlusion at wrists and ankles. Particular attention must be made to ensure all "pull tabs" are removed from respiratory cartridge filters prior to use.
Immediately evaluate the available information and confirm/re-confirm (as more information becomes available) that your key operational planning assumptions for Level C PPE are valid:
Adjust the planned operations as indicated by the evolving circumstances. Possible adjustments include:
The ambulatory patient may be directed by the decon nurse and tech to self-decon in the Emergency Department Decontamination Room thereby sparing additional staff from involvement (though the full decon team should remain dressed and ready in an adjacent room if intervention is needed). If the situation involves multiple patients requiring simultaneous decontamination, this process will occur using the Mass Decontamination set up.
The non-ambulatory patient decontamination should be performed simultaneously with patient stabilization. Basic life support (ABC's) will be maintained, but definitive intervention should be delayed until the patient is decontaminated, to a degree that ensures staff safety and that invasive procedures will not increase the patient's risk of systemic toxic absorption. If large numbers of non-ambulatory patients are delivered for decontamination and treatment simultaneously, the ED Charge Physician will be required to make urgent triage decisions.
Notifications of appropriate authorities:
Law Enforcement-IN-HOSPITAL HAZMAT INCIDENT
The need to perform ongoing medical monitoring of those healthcare personnel participating in the decontamination procedure is MANDATORY. This entails a systematic evaluation of all participants, focusing particular attention to the risk of suffering adverse reactions from heat, stress or hazardous materials exposure. This is performed for the purpose of prevention or early recognition of such symptoms, and in compliance with federal regulations.
If needed equipment and supplies are not available in the ED, the ED charge physician should be notified immediately. This information should then be immediately forwarded to the DISASTER SUPPORT CENTER, which can help procure needed materials. If all on-site resources have been exhausted, the Inova Health System DISASTER COMMAND CENTER will be contacted by the hospital Disaster Support Center in order to identify location of needed supplies and additional logistical support.
CLEAN-UP AND RECOVERY
Upon completion of the decontamination process, consideration must be given immediately to the following issues:
These items will be in tagged, sealed red biohazard bags kept outside of the healthcare facility under the direct supervision of the hospital Safety and Security staff, or local law enforcement personnel. These items may not be returned until they are deemed safe for handling and their evidentiary content has been evaluated.
These trash cans will contain soaps, sponges, scrub brushes, towels, and other items used by patients during the decontamination process. These bags must be sealed and segregated for later removal by contract waste haulers.
These bins will hold the towels discarded by patients who have completed the decontamination process just prior to their entry into the healthcare facility. These bags must be segregated for possible laundering or later removal by contract waste haulers.
In the event that mass decontamination efforts are required, the importance of life safety concerns supercedes the potential environmental impact of contaminated effluent. Every attempt should be made to direct this effluent into the sanitary sewer, with immediate notification of the proper municipal agencies. In those cases in which only limited numbers of patients are involved, every attempt should be made to contain this effluent using "baby pools" or similar methods. Such collected water must then be properly disposed of under the direction and supervision of the appropriate municipal agencies and contract waste haulers.
Any area outside of the healthcare facility that was used in the mass decontamination process and was inside of the WARM or HOT ZONES must be cordoned off until such time as it is verified by hazardous materials experts that no risk of contamination exists.
1. Hazardous substance is defined as any substance to which exposure may result in adverse effects on the health or safety of employees. This includes substances defined under Section 101(14) of CERCLA; biological or disease-causing agents that may reasonably be anticipated to cause death, disease, or other health problems; any substance listed by the U.S. Department of Transportation as hazardous material under 49 CFR 172.101 and appendices; and substances classified as hazardous waste.
2. 29 CFR 1910.120.
3. First responders, including firefighters, law enforcement, and emergency medical personnel, and many first receivers at public hospitals, are usually employees of local, municipal, or state governments. Although Federal OSHA's standards and enforcement authority do not extend to such state and local governments, these employers and employees are covered by the 26 states that operate OSHA-approved State Plans and, in states without State Plans, by the Environmental Protection Agency (EPA) with regard to HAZWOPER (29 CFR 1910.120). State Plan states set and enforce standards, such as the HAZWOPER and Respiratory Protection standards, which are identical to or “at least as effective as” Federal OSHA standards, and therefore may have more stringent or supplemental requirements. EPA's HAZWOPER parallel standard was adopted to cover emergency responders who would not be covered by the OSHA standard, including volunteers who work for a governmental agency engaged in emergency response, such as firefighters. For consistency, OSHA interprets the HAZWOPER Standard for the EPA. Federal OSHA administers the safety and health program for the private sector in the remaining states and territories, and also retains authority with regard to safety and health conditions for federal employees throughout the nation (OSHA, 1991c).
4. Note: Footnotes at relevant points in the text indicate current JCAHO Standards for Emergency Management, which are further described in Section EC 1.4 of JCAHO’s Comprehensive Accreditation Manual (JCAHO, 2004).
5. Mass casualty may be defined as “a combination of patient numbers and patient care requirements that challenges or exceeds a community’s ability to provide adequate patient care using day-to-day operations” (Barbera and Macintyre, 2003).
6. Applicable OSHA standards include: 29 CFR 1910.120 – HAZWOPER; 29 CFR 1910.132 – Personal Protective Equipment – General Requirements; 29 CFR 1910.133 – Eye and Face Protection; 29 CFR 1910.134 – Respiratory Protection.
7. These specific hazards will be identified in the hospital’s hazard vulnerability analysis (HVA). JCAHO Standards for Emergency Management require hospitals to: 1) develop a comprehensive emergency management plan (EMP) describing the hospital’s response to emergencies that would affect the need for the hospital’s services or the hospital’s ability to provide these services; 2) evaluate the EMP annually including the objectives, scope, functionality, and effectiveness; 3) conduct an HVA, to identify potential emergences that could affect the need for the hospital’s services, or its ability to provide these services; and 4) identify the hospital’s role in the community and coordinate plans.
8. For the purposes of this guidance, OSHA uses the definition of mass casualty provided by Barbera and Macintyre (2003): “A combination of patient numbers and patient care requirements that challenges or exceeds a community’s ability to provide adequate patient care using day-to-day operations.”
9. The term clinician refers to physicians, nurses, nurse practitioners, physicians’ assistants, and others.
10. HAZWOPER 29 CFR 1910.120.
11. First responders, including firefighters, law enforcement and emergency medical personnel, and many first receivers at public hospitals, are usually employees of local, municipal or state governments. Although Federal OSHA's standards and enforcement authority do not extend to such state and local governments, these employers and employees are covered by the 26 states that operate OSHA-approved State Plans and, in states without State Plans, by the Environmental Protection Agency (EPA) with regard to HAZWOPER (29 CFR 1910.120). State Plan states set and enforce standards, such as the HAZWOPER and Respiratory Protection standards, which are identical to or “at least as effective as” Federal OSHA standards, and therefore may have more stringent or supplemental requirements. EPA's parallel HAZWOPER Standard was adopted to cover emergency responders who would not be covered by the OSHA standard, including volunteers who work for a governmental agency engaged in emergency response, such as firefighters. For consistency, OSHA interprets the HAZWOPER Standard for the EPA. Federal OSHA administers the safety and health program for the private sector in the remaining states and territories, and also retains authority with regard to safety and health conditions for federal employees throughout the nation.
12. Hazard assessments for PPE are required under OSHA’s Personal Protective Equipment Standard – General Requirements, 29 CFR 1910.132(d), or the equivalent State Plan standards.
13. 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 emergency department (ED) door. In other documents this zone is sometimes called the “Warm Zone.”
14. Georgopoulos et al. (2004) suggest that "recognition of an event, identification of transportation means, and transportation to a healthcare facility are not expected to take less than 5 minutes even under ideal circumstances." The 10-minute (approximate) lag time can be reasonably assumed during a mass casualty event involving chemical release, except in cases where the release occurs immediately adjacent to the hospital (e.g., at a chemical plant next door to the hospital).
15. This incident is described in Horton et al. (2003) as part of an evaluation of hazardous materials incident data captured by the Agency for Toxic Substances and Disease Registry (ATSDR) Hazardous Substance Emergency Events Surveillance (HSEES) system.
16. The percentage of contaminant reduction depends on the type of clothing the victim was wearing when exposed. The estimates may be somewhat lower (down to 50 percent) for victims wearing short pants or skirts and higher (up to 94 percent) for victims exposed to biological warfare agents while wearing protective military uniforms (USACHPPM, 2003a).
17. Many liquid soaps have good surfactant properties (ability to cut grease) and are not excessively harsh on skin (e.g., major brands of hand dishwashing soap, such as Joy, Ivory, Dawn, and others, as well as shampoos). This is the method used by all seven hospitals interviewed for this project and is reportedly effective for all but the most tenacious substances. For example, the chemical weapon agent VX is difficult to wash from skin.
18. A related practice of spraying a 0.5 percent solution of hypochlorite (equivalent to a 10 percent solution of Chlorox® household bleach) may have value for deactivating biological agents, other than mycotoxins, and some chemical weapons agents (mustard gas, organophosphates) if left in contact for a period of time (15 to 20 minutes). The solution might be used to decontaminate facilities, but is no longer considered an optimal or necessary treatment for human skin (Macintyre et al., 2000). Sources agree that there is no substantive difference in decontamination methods for biological and chemical agents.
19. Using information from the 16 states that participated between 1995 and 2001, these authors determined that of the 44,045 hazardous materials events reported, 2,562 events (5.8 percent) involved victims who were transported to a hospital. Injuries to ED employees at the hospital were reported for six of these 2,562 events (0.2 percent).
20. ED personnel accounted for about half of all healthcare workers injured. Other healthcare workers in the group included medical examiners in an autopsy room, coroner’s assistants, a hospital worker at a highway rest area, and hospital employees injured when substances such as xylene and formalin were released in the hospital (“injuries were not the result of secondary contamination”).
21. This study only evaluated information on incidents that caused ED evacuation and did not consider other incidents that might have involved contaminated patients. The actual number of ED evacuation incidents may have been slightly higher due to under-reporting.
22. Hazardous substances in miscellaneous categories accounted for the remainder of the reported incidents.
23. Secondary exposures in the studies reviewed by Hick et al. (2003a) involved substances such as organophosphates (including sarin), hydrofluoric acid, pepper spray, chlorine gas, mixed solvents from methamphetamine laboratories, ethyldichlorosilane, and aluminum phosphide.
24. At a second Tokyo hospital, however, five of the most seriously exposed healthcare workers did require injection of antidote; although, they were able to continue to provide medical care (Nozaki et al., 1995).
25. Investigators used an adult size plastic mannequin dressed in lightweight cotton clothing and contaminated with either an industrial solvent (800 milliliters [ml] acetone or p-xylene in multiple tests) or respirable size metal oxide particulates. The 800 ml represented the greatest amount of solvent the victim could bring to the room—that was the amount that completely saturated the clothes when placed in a container.
26. The room measured 16 by 20 feet with a 10-foot ceiling and air temperature was reportedly 65º F.
27. Macintyre et al. (2000) suggest vacuuming as an alternative to dry brushing victims contaminated with water-reactive dust.
28. In this study, parameters for initial modeling of the maximum exposure that can reasonably be expected in a terrorist attack included a distribution of between 10 and 100 grams of chemical agent deposited over a mean of 1 square meter of surface area on 20 to 25 percent of the victims; lag time from initial dissemination of the agent to arrival of the victim at the hospitals represented with both truncated normal and an exponential distribution (mean value of 10 minutes); an air flow velocity distribution with a mean of 60 meters per minute across the victim, with chemical agent mixing occurring in an air column of 1 square meter cross-sectional area; and each first receiver directly participating constantly in a six-hour decontamination process. The healthcare worker was considered protected if the dose the worker would receive during 6 hours of continuous decontamination activity was less than the value of 2.1 mg-min/m3 for sarin. This concentration is the equivalent of the 60-minute National Research Council Acute Exposure Guideline Levels (AEGL-2) for sarin of 0.035 mg/m3 (multiplied by 60 minutes) (USACHPPM, 2003b). The Georgopoulos study shows that some transient effects and impairment might occur, but permanent health effects are highly unlikely.
29. Sarin was selected for this model because it has a moderate vapor pressure (similar to water) and thus would not necessarily evaporate before the victim could reach the hospital. Additionally, the substance does off-gas to an extent that can cause injury to healthcare workers. Finally, among chemical substances with vapor pressures in this range, sarin was selected as the most toxic. For purposes of comparison, NIOSH (2003) publishes vapor pressure levels for numerous industrial chemicals.
30. This provision is part of a proposed rule (68 FR 34035, June 6, 2003); the APF provisions that OSHA eventually develops may differ substantially from those in the proposed rule.
31. Respirator manufacturers must be able to show test results indicating the respirator meets specified criteria.
32. For comparison, a non-powered full facepiece air-purifying respirator has an APF of 50, while SCBA is assigned a protection factor of 10,000.
33. The contaminant might have been trapped in victims’ clothing (Horton et al., 2003). It is reasonable to anticipate that exposures would have been eliminated if the victim’s clothing had been removed in a well-ventilated space (or outdoors) immediately upon arrival at the hospital.
34. See the acknowledgments at the beginning of this document for a brief statement regarding the hospitals interviewed for this guidance.
35. SBCCOM tested several glove types. Results from two different studies are presented here as examples of the information available on breakthrough times. However, additional tests continue to be performed. Consult glove manufacturers for the most recent information. In their first study, SBCCOM tested eleven glove designs (including butyl, neoprene, and nitrile) for breakthrough times when exposed to concentrated Mustard (blister agent) or Sarin (nerve agent). Breakthrough times were dependent on material and thickness. A 30 mil Best Butyl glove had a breakthrough time of 810 minutes for Mustard and greater than 1440 minutes for Sarin. MAPA Neoprene gloves (mil not stated) had a breakthrough time of 298 minutes for Mustard and greater than 1440 minutes for Sarin. Ansell Edmont TNT Nitrile gloves [4 mil] had a breakthrough time of 20 minutes for Mustard and 106 minutes for Sarin. Ansell Edmont Sol-Vex (Nitrile) [15 mil] had a breakthrough time of 109 minutes for Mustard and greater than 1440 minutes for Sarin. Test data revealed that the chemical protective glove designs can protect wearers from liquid chemical warfare agents (SBCCOM, 2001a). In the second study, SBCCOM tested four glove designs (including butyl and nitrile) for breakthrough times when exposed to Mustard (blister agent) or Sarin (nerve agent). Breakthrough times were dependent on material and thickness. N-Dex Disposable Nitrile gloves (4 mil) had a breakthrough time of 53 minutes for Mustard and 51 minutes for Sarin. North Butyl gloves (20 mil) had a breakthrough time of greater than 1440 minutes for both Mustard and Sarin. Test data revealed that the chemical protective glove designs can protect wearers from liquid chemical warfare agents (SBCCOM, 2001b).
36. Independent accredited testing laboratories conducted permeation tests on Tyvek® F for Dupont. The breakthrough times for the chemical warfare agents, Mustard, Tabun, Sarin, Soman, and VX, exceeded 720 minutes. The breakthrough time for Lewisite was 360 minutes. The breakthrough times for industrial chemicals of special concern, Chlorine, Formaldehyde (Formalin solution), Hydrochloric Acid (37%), and Concentrated Sulfuric Acid was greater than 480 minutes. The breakthrough time for Ammonia was 79 minutes, for Ethylene Oxide 65 minutes, for Fuming Nitric Acid 14 minutes, for Sulfur Dioxide 38 minutes, and for Hydrogen Fluoride permeation was immediate (DuPont, 2003). Additionally, TNO Laboratories in the Netherlands tested and certified Tyvek® F, having passed all the standard North American Treaty Organization (NATO) tests for chemical warfare protection (DuPont, 2002).
37. In a 2003 Federal Register entry, OSHA proposed an APF of 1,000 for some models of PAPR (68 FR 34035, June 6, 2003).
38. 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.”
39. Tight-fitting respirators do require fit testing.
40. Hospitals should consider the HVA when specifying glove and boot materials, respirator cartridges and filters, and protective garment fabric.
41. State Plan States enforce standards, including the HAZWOPER Standard and its training requirements, which are “at least as effective as” Federal OSHA's standards, and therefore may have more stringent or supplemental requirements.
42. JCAHO standards require: 1) identification and assignment of personnel to cover all necessary staff positions under emergency conditions, 2) education as to their specific roles and responsibilities during emergencies, 3) information and skills required to perform assigned duties during emergencies, and 4) testing the response phase of EMPs twice a year, including a mandatory practice drill relevant to the priority emergencies in the organization’s HVA.
43. Listings for LEPCs by location.
44. See acknowledgments at the beginning of this document for a brief statement about hospitals interviewed for this guidance.
45. Hospitals report that some useful community records include statistics on local hazardous materials incidents, population census and demographic information, local probability rates for natural disasters, Chamber of Commerce data, and information on types and quantities of hazardous substances used by local industry (e.g., EPA Emergency Planning and Community Right-to-Know Act (EPCRA) Section 311/312. 40 CFR Part 370.
46. JCAHO (2004) requires that both the HVA and the EMP be evaluated annually, with particular attention to “its objectives, scope, functionality and effectiveness.”
47. OSHA Respiratory Protection Standard.
48. JCAHO (2004) requires, and OSHA (2001) recommends, that organizations coordinate emergency management planning efforts.
49. An example of a NIMS-compatible system, the publicly available Hospital Emergency Incident Command System (HEICS), uses the same structure and vocabulary as the widely used Fire Department Incident Command System. Emergency services leaders report that the respective command systems interface well, without loss of organizational identity (San Mateo County HSA, 1998). A brief introduction to HEICS appears in Appendix G.
50. For additional information on incident command systems see the OSHA eTool and Disaster Medical Services Division - Hospital Incident Command System (HICS)(also attached to this guidance document as Appendix G).
51. JCAHO standards require cooperative planning among healthcare organizations that together provide services to a contiguous geographic area (for example, among hospitals serving a town or borough). Such planning is intended to facilitate the timely sharing of information about: 1) essential elements of their command structures and control centers for emergency response; 2) names, roles, and telephone numbers of individuals in their commands structures; 3) resources and assets that could potentially be shared or pooled in an emergency response; and 4) names of patients and deceased individuals brought to their organizations to facilitate identification and location of victims of the emergency.
52. HAZWOPER – 29 CFR 1910.120(q); Personal protective Equipment – 29 CFR 1910.132; Respiratory Protection – 29 CFR 1910.134; Hazard Communication – 29 CFR 1910.1200(h).
53. Employer obligations pursuant to the HAZWOPER and HAZCOM standards are determined by the hazards to which it is reasonably possible for employees to be exposed, given the nature and locations of the employees’ work.
54. *Hick et al. (2003b) recommend job action sheets be developed for these positions and other decontamination team members who serve key roles. See sample job action sheets.
55. First Responder Operations Level and Awareness Level training requirements appear in OSHA’s HAZWOPER Standard, 29 CFR 1910.120(q), (or parallel State Plan standards).
56. * Indicates the item is also a competency for Awareness Level training.
57. Hospital A feels this level of training is the minimum required to maintain its world-class decontamination team, which drills with out-of-state military units and, due to location, would be called upon to decontaminate victims from a national chemical weapons arsenal, should an accident occur.
58. For first receivers, recognition of signs and symptoms would satisfy this training topic.
59. Other sources of critical observers might include peers from other hospitals, regulators, and members of fire department hazardous materials response teams.
60. Overhead public broadcasting systems are used to report information directly or announce codes. One code indicates that designated staff should report to a meeting point to obtain information.
61. JCAHO standards require an orientation and education program for all personnel who participate in implementing the EMP. This education addresses: 1) specific roles and responsibilities during emergencies, 2) methods used to recognize specific types of emergencies, and 3) information and skills required to perform assigned duties during emergencies.
62. The Hospital Emergency Incident Command
63. All health monitoring results should be provided to the employee in a timely manner and in accordance with 29 CFR 1910.1020 (OSHA’s Standard on Access to Employee Exposure and Medical Records).
64. Under most circumstances, first receivers would not be expected to perform decontamination duties in the presence of hazardous chemicals 30 days per year.
65. Vital signs may not exceed the following limits: diastolic blood pressure greater than 90 millimeters of mercury (mmHg), heart rate greater than 100 beats per minute, respiration greater than 24 breaths per minute, or oral temperature higher than 99.5 degrees Fahrenheit.
66. Although some employees note that they feel cooler wearing icepack vests, there is some controversy regarding whether this type of equipment offers much real benefit.
67. For example, a temporary shower facility with a wastewater collection device.
68. To transfer water out of the shower area, hospitals use a portable electric pump (approximately 2.5 gallons per minute, or a rate similar to the standard combined water flow rate of the most consistently used showerheads; approved for submersion and on a ground-fault interrupt circuit). The pump sits in the shower base containment and pumps the accumulating wastewater into a portable rubber bladder or barrel. Wastewater storage barrels and bladders used by these hospitals range in size from 50 to 2,500 gallons capacity, and are selected based on the size of the decontamination system, anticipated average total water flow rate, and the number of victims the hospital is prepared to treat. While larger portable decontamination systems with multiple showerheads can generate wastewater more quickly than smaller systems, the large systems also tend to have larger floor-level water-containment enclosures.
69. The percentage of contaminant reduction depends on the type of clothing the victim was wearing when exposed. The estimates may be somewhat lower (down to 50 percent) for victims wearing short pants or skirts and higher (up to 94 percent) for victims exposed to biological warfare agents while wearing protective military uniforms (USACHPPM, 2003a).
70. The International Commission on Radiological Protection (ICRP) and the National Council on Radiation Protection and Measurement (NCRP) also offer guidance for radiological incidents.
71. Neutralizing agents reduce toxic effects of agent already absorbed into the skin. RSDL won Food and Drug Administration (FDA) approval in 2003.
72. Traditional chemical weapon nerve agents are commonly in the organophosphate chemical class.
73. The US Department of Homeland Security has adopted several standards for the design and performance criteria of radiation and nuclear detection equipment.
74. Hospital G also obtained a more costly portable spectrum analyzer that can also be used to measure ionizing radiation exposure rates. This instrument, which requires a skilled operator, might also be used to identify radioactive isotopes.
75. In general, gamma source detectors are more useful for detecting a source of radiation, rather than for detecting contamination on an individual.
76. The meter detects some agents at lower levels than others.
77. The U.S. Armed Forces have also developed colorimetric contact paper to screen skin and equipment surfaces for these agents. However, the papers do not indicate potential for airborne exposures.
78. According to an EPA Alert [615 KB PDF, 276 pages]. (EPA, 2000), first responders’ liability under the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA) for environmental damages occurring during hazardous materials incidents is limited (when public health or welfare are in danger) by the “Good Samaritan” provision contained in Section 107(d)(1) of CERCLA. This provision applies to emergencies involving hazardous materials release, including acts of terrorism. However, first responders also may be subject to liability based on applicable state statutes and regulations. Thus, first responders may consider consulting with local legal counsel to ascertain the scope of their potential liability.
79. To transfer water, hospitals use a portable electric pump (approximately 2.5 gallons per minute, or a rate similar to the standard combined water flow rate of the most consistently used showerheads; approved for submersion and on a ground-fault interrupt circuit). The pump sits in the shower base containment and pumps the accumulating wastewater into a portable rubber bladder or barrel. Wastewater storage barrels and bladders used by these hospitals range in size from 50 to 2,500 gallons capacity, and are selected based on the size of the decontamination system, anticipated average total water flow rate, and the number of victims the hospital is prepared to treat. While larger portable decontamination systems with multiple showerheads can generate wastewater more quickly than smaller systems, the large systems also tend to have larger floor-level water-containment enclosures.
A. 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 emergency department (ED) door. In other documents this zone is sometimes called the “Warm Zone.”
B. Hospitals that do not meet these conditions must use more protective PPE or conduct a detailed hazard assessment to support a different selection.
C. Note: Georgopoulos et al. (2004) suggest that "recognition of an event, identification of transportation means, and transportation to a healthcare facility are not expected to take less than 5 minutes even under ideal circumstances." The 10-minute (approximate) lag time can be reasonably assumed during a mass casualty event involving chemical release, except in cases where the release occurs immediately adjacent to the hospital (e.g., at a chemical factory next door to the hospital). This number of minutes is approximate and intended to provide guidance regarding what might be considered "immediately adjacent."
D. Georgopoulos et al. (2004) recommend using fans to provide air movement.
E. 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.”
F. Hospitals that do not meet these conditions must use more protective PPE or conduct a detailed hazard assessment to support a different selection.
G. When the hospital is not the release site, the quantity of contaminant is limited to the amount associated with the victims.
H. If a hospital is specifically 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.
I. 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 emergency department (ED) door.
J. OSHA recently proposed an assigned protection factor (APF) of 1,000 for certain designs of hood/helmet-style PAPRs (Federal Register, 2003). An OSHA memorandum, which provides interim guidance pending the conclusion of the APF rulemaking, listed several PAPR hood/helmet respirators that are treated as having an APF of 1,000 for protection against particulates in the pharmaceutical industry (OSHA, 2002c (Memo for RAs)). The American National Standards Institute (ANSI), in Standard Z88.2 on Respiratory Protection, also indicates an APF of 1,000 for certain PAPRs. A hooded-style PAPR provides greater skin protection, has greater user acceptance, and does not require fit testing under 29 CFR 1910.134, thus might be preferred over a tight-fitting respirator. However, a tight-fitting full facepiece PAPR might offer more protection in the event of PAPR battery failure.
K. Hospitals must use NIOSH-approved CBRN (chemical, biological, radiological, and nuclear) respirators, as they become available, when the HVA reveals a potential WMD threat. Until NIOSH completes its CBRN certification process for PAPRs, use PAPRs that have been tested by the manufacturer for a CBRN environment.
L. Material for protective gloves, clothing, boots, and hoods must protect workers against the specific substances that they reasonably might be expected to encounter. However, given the broad range of potential contaminants, OSHA considers it vitally important that hospitals also select PPE that provides protection against a wide range of substances. No material will protect against all possible hazards.
M. 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).
N. The employer must certify that personnel trained at the “First Responder Operations Level” have received at least eight hours of specific training (which can include Awareness Level training, PPE training, and training exercise/drills), or have had sufficient experience to objectively demonstrate competency in specific key areas. Refresher training must be provided annually and must be of sufficient content and duration to maintain competencies. Alternatively, the employee may demonstrate competence (i.e., skills) (OSHA HAZWOPER 29 CFR 1910.120(q)(6)(ii)). Participation in training exercises/drills is recommended to ensure competency during initial and refresher training.
O. 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.
P. The term clinician includes physicians, nurses, nurse practitioners, physicians’ assistants, and others.
Q. The briefing must include (at a minimum) instruction on wearing the appropriate PPE, the nature of the hazard, expected duties, and the safety and health precautions the individual should take (OSHA, 1997 (Whittaker); 29 CFR 1910.120(q)(4)).
R. Note that the individual must be medically qualified (29 CFR 1910.134), fitted (1910.132 and .134), and trained (1910.132 and .134) to use the required PPE. These qualifications are difficult to achieve at the time of the incident and, whenever possible, should be accomplished prior to an incident.
S. While HAZCOM training is not required pursuant to the OSH Act for most of the scenarios contemplated in this document, a prudent employer may consider adopting and appropriately modifying the training provisions in the HAZCOM standard to provide information to personnel who would not be expected to come in contact with unannounced contaminated victims, their belongings, equipment, or waste.
T. 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).
U. If the ED becomes contaminated, the hospital’s decontamination procedures must be activated by the properly trained and equipped employees (refer to the Hospital Decontamination Zone in this table and Table 3).
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