“Train everybody to do decon [decontamination],” says Frank Califano, safety services specialist assigned to Network Emergency Management for the North Shore – LIJ Health System in Long Island, N.Y. “Everybody includes security guards, pharmacists, dieticians, and folks from the environmental services. It takes a lot of people to set up and staff a decon line, and ultimately you want the doctors and nurses in the emergency department [ED] treating patients.”
Califano’s comment underscores an issue hospitals across the country are wrestling with – the handling of contaminated patients in the emergency department. At first, it may seem like a simple task: identify the need for decontamination, set up an area in which to perform decon, determine the system to be used, and admit the patient(s) into the hospital for definitive care.
In actuality, the task is anything but simple, and there are many complex issues that influence the way decon is performed in the hospital setting. Those issues include, but are not limited to, internal politics, the types and levels of training appropriate for the facility, the chemical protective equipment that might be required, and the potential negative attitudes toward a hospital that might develop because of its decontamination work. “At the heart of it all, there must be a buy-in from upper management,” Califano says. “The decision makers must understand and support the entire operation, from training to buying the right equipment. If that [approval from decision makers] is not in place, everything else is an uphill battle. We are fortunate to have a CEO who has vision and supports us. But, amazing as it may seem, there are some hospitals that do not think there will ever be a major disaster in their area.”
Califano outlines the response program adopted by the North Shore-LIJ Health System – a system involved in the response to both of the attacks on the World Trade Center (the first on 26 February 1993; the second on 11 September 2001), the subsequent flood of anthrax hoaxes in New York City, and a constant stream of day-to-day incidents requiring a hospital-based decontamination plan: “We started looking at the problem well before 9/11, with a goal of developing a mechanism to handle contaminated patients arriving in the emergency departments of our hospitals. Our basic belief is that we need to be self-reliant in terms of patient decontamination – we don’t rely on the fire department or any other outside hazardous-materials response for our decon. Believe it or not, people will come to your facility without being decontaminated – and you better be ready for that.”
Self-Reliance and Federal Regulations
History bears out the wisdom of that philosophy. The Tokyo Subway attack of 21 March 1995, in which terrorists used the nerve agent Sarin, killed eight people and frightened thousands more. Most of these so-called “worried well” did not wait for ambulances, but went to local hospitals as fast as they could, either by private vehicle or by public transportation.
“Once we decided to be self-reliant in terms of patient decon,” Califano continued, “the next step was to decide how best to train our people. Unfortunately, the federal regulation governing hazardous materials response, Hazardous Waste Operations and Emergency Response (HAZWOPER), found in 29 Code of Federal Register (CFR) Part 1910.120, was not written with hospitals in mind. After some searching, we decided on a training program called Hazmat for Healthcare. It meets the intent of the federal regulations and is written with the hospital environment in mind.”
Hazmat for Healthcare offers a comprehensive list of downloads and other information, free of charge, geared at assisting hospitals with hazardous materials training, including patient decontamination.
“Over the last four years, we have trained thousands of people in our own hospital as well as other hospitals in the region,” Califano said, “using the Hazmat for Healthcare program. All hospital personnel trained to perform decon receive hazardous materials awareness and operations level training (see the HAZWOPER standards listed above for details). In addition, we have a group of emergency medical technicians, assigned to the EMS division, trained to the technician level; they are assigned to an incident to support hospital personnel and are part of the system’s Hazardous Materials/Special Operation Division response team. They also handle small chemical spills and other chemical situations inside the hospital. In the event of a mass casualty incident or other circumstances requiring patient decon, we activate our Special Operation Division.”
Califano sees several major benefits from having in place such a comprehensive training program and hazardous materials response plan, and is concerned about the complacency he sees in other hospitals “There are some hospitals … that, if they had to close their doors for 24 or 48 hours because of a contaminated ED, would not be able to recover from the financial hit – and might have to close their doors. There is also the stigma of having to close your ED because of contamination – that doesn’t make the rest of your patients feel very secure. In my opinion, you have to protect the hospital at all levels. Effectively dealing with contaminated patients is an important part of that.”
Hoods, Eyeglasses, and Rubber Gloves
Deciding on the type(s) and quantity of chemical protective equipment needed is often a controversial topic in the patient-decon field. Opinions vary from using level “A” chemical protective suits (seen in the photo below) to carry out the patient decon, to simply wearing surgical masks and latex rubber gloves. The best solution, according to Califano, is to keep it simple – and keep costs reasonable. “We originally looked at using self-contained breathing apparatus on our decon line, but decided against it because of the maintenance, training, and fit testing required, as well as the need to comply with medical requirements. We ended up going with a hooded, fan-powered, air-purifying respirator (PAPR) that uses an NBC [nuclear-biological-chemical] cartridge. The hooded respirator gives the people on the decon line better visibility. They also have less fatigue, and look less menacing – that reduces the patient’s stress level.
“It’s perfectly acceptable to wear eyeglasses under a hooded respirator, and facial hair is not an issue. That solves a lot of problems right there. We use nitrile rubber gloves under a heavier butyl rubber outer glove, and a durable but lightweight chemical suit. I would recommend trying several chemical suits before you decide – it’s important to choose a suit that will stand up to the wear and tear of your own decon process.”
When asked about possible “lessons learned” along the way, Califano offers a number of insights. “You know,” he commented, “I did not realize how many spills happen in a hospital until we went through this training. Also, throughout the process, we continued to refine our view of who meets the definition of ‘a contaminated patient.’ These days, for example, we think that most fire victims fit the definition of contamination just as much as the traditional patient who has been exposed to various types of chemicals. If you think about it, fire victims and their clothing may be contaminated by the off-products of combustion, and we don’t want our patients or staff exposed to that.
“I would summarize the whole process of hospital decon as follows,” Califano concluded: “Get approval from upper management early in the process, find a training program that fits what you do, decide on a reasonable chemical protective equipment ensemble–and actually wear it during training exercises—and, last but not least, practice, practice, practice. Doing it step by step like that might seem tedious, but it will pay off when it counts.”
Companion article on Decontamination submitted by our Emergency Medicine Channel Master, Joseph Cahill.
Rob Schnepp is division chief of special operations (ret.) for Alameda County (CA) Fire Department. His incident response career spans 30 years as a special operations fire chief, incident commander, consultant, and published author. He commanded numerous large-scale emergencies for the Alameda County (CA) Fire Department, protecting 500 square miles and two national laboratories in the East Bay of the San Francisco Bay Area. He twice planned and directed Red Command at Urban Shield, the largest Homeland Security exercise in the United States. He served on the curriculum development team and instructed Special Operations Program Management at the U.S. Fire Administration’s National Fire Academy. He is the author of “Hazardous Materials: Awareness and Operations.” He has developed risk assessment, incident management, and incident command training for Fortune 500 companies, foreign governments, and U.S. national laboratories.