Wicked Problems, Virtuous Solutions: How to Design a Risk-Based Medical Facility

The federal statute that governs personal protective equipment (PPE), training, and the standards established for responding to and dealing with hazardous materials (HAZMAT) events is known as the “Hazardous Waste and Emergency Operations Standard” or “HAZWOPER.”  That standard – developed for the benefit of employers and employees involved in the response to such events – is used to define the previously vague and varying levels of PPE gear, training, and operational standards that are both expected and required. In short, HAZWOPER was written to provide a uniform standard for training and equipment that can and should be adhered to by fire services, hazardous materials companies, and other agencies and personnel operationally involved in the responses to HAZMAT events.

The underlying concept permeating the HAZWOPER standard is that all responder personnel should be trained in such a way that they can carry out their assigned duties without creating new dangers to themselves or to others. In that context, a so-called “wicked problem” is defined as one in which the only solutions available would create new problems or further complicate the initial problem. The strict application of HAZWOPER standards to the design, building, and operation of medical facilities falls under the definition of a wicked problem because medical personnel often cannot function fully and properly while wearing standard PPE gear but, without PPE, would be endangering both themselves and others.  

Hospital personnel face a full set of such wicked problems, in fact. To begin with, their own frequently unique job skills do not always or readily adapt to a HAZMAT environment – and neither do the facilities within which they work. Prominent among the several wicked problems specific to medical facilities, and to medical staff, is one that has an obvious but perhaps costly solution – namely, the fact that HAZMAT suits are expensive and must be paid for from patient-care revenues. Because of continuing (and increasing) financial constraints, and without federal subsidies, most if not all of the nation’s hospitals can afford PPE suits for only a subset of their employees.  In addition:

  • HAZMAT suits are difficult to don and doff without mishap, and it is close to impossible to carry out certain medical procedures – e.g., starting an IV – while wearing one. 
  • Should a HAZMAT event occur, decontamination would almost always have to be carried out by personnel on duty at the time of the event, which means: (a) a probable degrading, of unknown degree, of the medical staff available for post-decontamination duties; and (b) a requirement that the remaining staff be that much more efficient – but its efficiency would be impaired by the requirement to wear HAZMAT suits. 
  • Within the hospital staff, there frequently are some individuals who may be well qualified professionally but are hampered by varying disabilities and/or physical handicaps that preclude the wearing of standard PPE gear.  Some of these personnel may be in leadership positions. 

A New Paradigm for Wicked Problems?

The wicked problems mentioned above are strong indicators that untrained personnel and under-equipped hospitals are likely to fail in varying degrees in their respective responses to a medium-sized or larger HAZMAT event. The inability to function without hazard would place medical personnel in a dangerous position when receiving contaminated casualties during the response to an event, if only because of the possibility of a cross-contamination affecting themselves, their facility, and the other patients at the facility.  To contaminate the hospital and sicken the medical staff means that they would have become secondary victims of the event.  

To solve this particular type of wicked problem requires, perhaps, an additional set of standards that can be used not only to guide medical-facility responses but also takes into account the needed skills and operations necessary to carry out certain medical procedures – the safe resuscitation of a contaminated victim, for example.  

The development of recommendations for hospital PPE devices and associated standards depends primarily upon four basic considerations. More specifically, the devices, training, and standards established must:    

(a) provide a clear safety benefit to the user;       

(b) be affordable and achievable for widespread hospital acquisition and use;       

(c) be user-friendly and not significantly degrade workplace performance; and,       

(d) Be capable of being implemented in ways that do not impose additional compliance-maintenance burdens on the hospital.

There are no devices, training, or standards that fit all of the requirements stated above. Moreover, the development of recommendations regarding how much personal protective gear and training are required, and what new or different standards are needed, will depend on a complete understanding of the various risks and benefits involved.  

Understanding Hospital Facility Risk Factors

As a first step in developing such recommendations, an overview of current hospital risk features and workplace “niches” must be developed.  To begin with, not all personnel working in the same facility face the same risks. Moreover, different hospital designs and/or modes of operation can and do alter the workplace-exposure risk. For example; a hospital can stop or greatly reduce interior contamination by closely controlling the facility’s heating and ventilation system and/or by altering the ventilation systems to the decontamination and treatment areas.

The net effect of stopping ventilation at the point of entry might be to increase contamination at that point, but decrease facility-wide contamination. An understanding of the airflow within a facility would be necessary in any case for the development of recommendations for the wearing of protective gear and the setting of various other standards.  

There is considerable evidence to suggest that, for various reasons, the full range of medical-facility features that contribute to the risk of cross contamination and/or the spread of infectious disease has not generally been included in disaster planning for hospitals and other medical facilities.  For example, multi-story facilities fully equipped with HVAC systems probably have different airflow characteristics than those typical of single-story facilities without HVAC systems.

How a facility’s features are used or configured also matters, for a number of reasons. Elevators that move columns of air within a structure can be stopped or slowed, for example. In addition, windows can be closed or opened, and the airflow within most HVAC systems can be stopped, reversed, or increased. Here, fixed hospital-risk features are defined as the basic structure and construction of the facility, which cannot be changed without reconstruction, and variable hospital-risk features are those features that move potentially contaminated air – but also can be modified in response to a threat.  

An understanding of the operational implications flowing from the fixed-risk rather than variable-risk characteristics of different facilities can be a significant factor in determining how to improve and upgrade hospital safety and to recommend training, equipment, and operating standards for the same facility.  

Risk Factors Related to Contaminated Victims

Although there are literally thousands of chemicals, radiological isotopes, and infectious hazards that must be (and are) dealt with every day, it can be safely assumed that, in most if not all situations, the risk of contaminating a specific healthcare facility and its staff would be less than the risk encountered by response personnel working at the primary HAZMAT site. Two additional “safe” assumptions are: (1) that if a victim is still alive, it is probable that the contamination encountered on that victim will be less toxic than it would be if he or she were not alive; and (2) that any decontamination of victims – either that occurs at the scene of the incident or in the medical facility – will further reduce the risk of cross-contamination.  

If these assumptions are correct, there is an obvious opportunity to establish new PPE gear standards that would be optimized more to carry out safe and efficient medical functions than to provide maximum protection for the wearer of the PPE gear (total protection still would be needed, though). For the personal protective gear now available to be made more useful would require the alteration or fine-tuning of a few design characteristics – to include a greater degree of fine motor activity, for example, improve both visual and auditory acuity, and accommodate the reality of multiple body types and physical conditions likely on most medical staffs.

Here, another safe assumption can be ventured: The design of affordable and medical-facility risk-based PPE will permit medical personnel to perform their jobs with greater efficiency and safety – and that would be a clear benefit not only to themselves but also to the victims of a HAZMAT event under their care.  Clearly, though, the design of these new devices and garments would have to take into consideration representative threat agents of known volatility and the penetration rates expected at lower concentrations.  

A Need to Focus on the Future

To summarize: By understanding the dangers posed by the fixed- and variable-risk features of a medical facility structure, the safest possible environment can be configured: (1) by clearly designating “contaminated” HVAC zones, hallways, and elevators; and (2) by preserving the “clean” areas in their present condition. The risk in contaminated areas can be estimated by using low levels of representative agents of known volatility and penetration rates, following which a viable PPE strategy can be devised.

Moreover, if new PPE devices and garments are designed in such a way that they may be worn in an intuitive manner, training costs can be significantly reduced and additional medical volunteers can be accommodated without the need for lengthy HAZWOPER training (or retraining).  

However, it is worth repeating that attempts to adapt existing HAZWOPER PPE devices, training, and standards to current medical facilities and personnel would in all likelihood fail, if only because of the transient nature of nursing and professional staff, the reduced ability to perform certain job functions, and – for most medical facilities – the lack of sufficient funds both to purchase the devices needed and to pay for the training that also would be required.

For a medical system to function without creating new hazards for its own personnel, and existing patients, the risks of contamination must be fully assessed and understood – and then balanced against the affordability and functionality of the various PPE devices and strategies available. To proceed on any other basis might well doom the entire medical system to failure at the time it is most needed. 

Michael Allswede

Dr. Allswede is the Director of the Strategic Medical Intelligence Project on forensic epidemiology. He is the creator of the RaPiD-T Program and of the Pittsburgh Matrix Program for hospital training and preparedness. He has served on a number of expert national and international groups on preparedness.



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