One of the most difficult and costly requirements for the nation’s hospitals to comply with in the field of emergency preparedness involves the planning for mass-decontamination situations. The Joint Commission recommendations and most state departments of health require that U.S. hospitals be prepared not only for incidents requiring decontamination but also for the protection of patients and staff before, during, and after the decontamination process. These requirements have been widely interpreted as requiring hospitals to be prepared to decontaminate large numbers of patients (mass decontamination) as opposed to the small number of patients that might realistically be expected in most situations.
All hospitals should understand, of course, that some level of decontamination preparedness is needed. An event as simple as a traffic accident could contaminate patients exposed to gasoline fumes and/or diesel fuel. The subsequent “off-gassing” of such chemicals from a patient’s clothes, in a confined trauma room or elsewhere in a hospital’s emergency department, could have dangerous consequences for patients and staff alike. If patients “self-refer” themselves to a hospital – as happened in the aftermath of the 1995 Sarin gas attack on the Tokyo subway system – prior to decontamination of the scene by healthcare or fire services personnel, the hospital itself is given additional responsibility it did not ask for and may not be prepared for.
National surveys show that U.S. hospitals run the spectrum from “reasonably prepared” to almost totally unprepared when it comes to the level of decontamination they are supposed to be prepared for. Some are trained and equipped to carry out what are called “level B” decontamination procedures, but others are capable only of level-C decontamination – or something less. The principal factors determining what level of decontamination is or should be provided would be the air system and personal protective equipment (PPE) used during decontamination. Level B calls for use of a Self-Contained Breathing Apparatus (SCBA) unit capable of supplying air in a fully encapsulated suit similar to that worn by a municipal hazmat technician. Level C or below would designate a lower level of preparedness – e.g., the use of Positive Air Purification Respirators (PAPRs) and fully hooded suits with no exposed body parts.
The High Cost of Basic Capabilities
To provide even modified Level C decontamination, however, requires equipment, a water source, a remote location, and appropriately trained staff (quickly available 24 hours a day, however, seven days a week). The proper equipment can range in cost (depending on the number of showers available) from $25,000 for a basic system to a cost in excess of $250,000 for more elaborate systems. The training for staff probably is the most costly budget line, though, and creates a problematic issue for many hospitals – most of which are seeking answers to two important and interrelated questions: (1) How many staff members must be retained/trained to carry out decontamination operations? (2) What is the best way to ensure that those staff members retain their decon skills?
If hospitals want to be able to provide a decontamination team on a 24/7 basis, they may have no choice but to rely on clinical staff at least part of the time. If they do so, however, it will decrease the hospital’s ability to use those same staff members to provide medical care for patients. Moreover, if staff members themselves are victims of an incident requiring decontamination it not only would eliminate them as decon staff but also increase the number of patients in need of medical care. If hospitals choose to train non-clinical staff the principal question is whether those staff members will be able to recognize the signs and symptoms of health problems so that treatment can be initiated quickly. The obvious approach, therefore, might well be to have a blend of both clinical and non-clinical staff.
Hospitals must for that reason not only organize training to the level of decontamination they want and need, but also realize that skill and refresher training needs should be scheduled and practiced on a regular basis. The PPE gear available must be relied on by staff and they will have to train while wearing that gear, in all types of climates. Not until then can questions about the number of staff in need of training be answered with any reasonable degree of accuracy.
Six People, Ninety Minutes, in the Middle of the Night
Most small “two-lane” decontamination systems usually need a minimum of six staff members to operate: Two on the “hot” or entrance side, two on the “cold” or exit side, and two available to be suited up if a problem develops or a need for a rescue develops. These six can possibly operate (depending on the environment) from 30 to 60 minutes in PPE gear before they have to be replaced. The arithmetic is simple: Three six-member teams will provide only 90 to 180 minutes of staff time to decontaminate patients. The upper total just barely reaches the 180 minutes usually targeted for a mass-decontamination operation. From a management point of view, this means that – at 2:00 a.m., perhaps – a relatively small community hospital needs to have a system in which 18 knowledgeable and well trained staff members will be consistently available to effectively and safely respond to a decontamination incident.
Another important question facing decision making officials: What should a hospital do to prepare for mass-decontamination events? Here it should be noted that most of the nation’s hospitals usually are involved only a few times a year in relatively small decontamination events – i.e., events in which one, two, or a handful of patients need decontamination. In that context, mass decontamination for a hospital can be conservatively put in the same hazard as the proverbial “50-year storm” – and, depending on the hospital’s location, even that rare situation might be a worst-case scenario.
Such events can and do happen, though. And when one does happen, it almost always will take help to deal with it, and patients may die in even a best-case situation. The question that the nation’s hospitals need to ask themselves, therefore, is whether they are any better prepared to deal with these events than they were prior to 9/11, given the equipment and training they have purchased – or do they simply accept the fact that they are doing “something” to prepare for this type of event, and that something is better than nothing?
Greater Awareness But Lower Funding Levels
There is an increasing awareness at all levels of government that most U.S. hospitals are still not fully prepared to deal with a mass-decontamination situation. Decreases in funding are putting decontamination requirements under scrutiny by hospital emergency planners as well. Answers are hard to come by, but there seems to be general agreement that, if nothing else, all U.S. hospitals should at least have the ability to safely decontaminate a small number of victims, if only to ensure that those victims do not contaminate the hospital itself and/or the hospital staff.
Most disaster victims can be decontaminated simply by disrobing them and requiring them to go through a thorough washdown process. Local fire departments can be relied on in most scenarios if the number of victims is too large for a hospital to manage on its own. The biggest concern here, probably, is that the fire departments are likely to be otherwise occupied at the incident scene. The end result could be that dozens of contaminated patients might arrive at a hospital within a very short time frame, and there might not be enough responders available to handle them both safely and effectively.
The training issue alone is so daunting a challenge for hospitals that few can do it safely, and even fewer do it well. Requiring medical staff to wear PAPRs or SCBAs can injure staff if it is done wrong and probably would eliminate those staff members from being able to adequately evaluate and/or care for patients. Another important question for hospitals to consider is this: If patients are so contaminated that they are not able to decontaminate themselves, will those patients even survive? Fortunately, patients who self-refer to a hospital are probably not the ones in the greatest need of high-level decontamination – and for that reason probably could decontaminate themselves. Hospitals must ask themselves, therefore, if they are better served: (a) by training with fire-service or hazmat teams to assist them in decontamination; (b) by setting up systems that permit self-presenting patients to decontaminate themselves; and/or (c) by spending time to train staff on awareness – and, perhaps, by counting on the effective decontamination of perhaps only one to five patients (a much higher probability than a mass-decontamination event).
Because of the reduced funding now available to hospitals and the increasing demands of emergency preparedness, hospitals have to make smart choices on what they can afford to do. Which leads to a final question: If it is virtually impossible for most hospitals to prepare for a mass-casualty event, involving dozens of contaminated victims, that may never happen in 50 years – and, when it does occur, find that not enough staff is adequately trained or equipped to handle it – then why do hospitals still insist on spending money and allocating valuable staff time on such unlikely possibilities?
Theodore (Ted) Tully, AEMT-P, is President of STAT Healthcare, an Emergency Management consulting group. He previously served as Administrative Director for Emergency Preparedness at the Mount Sinai Medical Center in New York City, as Vice President for Emergency Services at the Westchester Medical Center (WMC), as Westchester County EMS (emergency medical services) Coordinator, and as a police paramedic/detective in Greenburgh, N.Y. He also helped create the WMC Center for Emergency Services, which is responsible for coordinating the emergency plans of 32 hospitals in the lower part of New York State.