Hospital DecontaminationHospital Decontamination

Jonathan L. Burstein, MD, FACEPJonathan L. Burstein, MD, FACEP

HSPH-CPHPHSPH-CPHP

The ProblemThe Problem

Hundreds of patients coming inHundreds of patients coming in

Do they need decon?Do they need decon?

Can I clean them?Can I clean them?

The RoadmapThe Roadmap

Do I really need to do this?Do I really need to do this?

How can I do it?How can I do it?

How can I protect my self and staff?How can I protect my self and staff?

How can I get it done?How can I get it done?

Do I Really Need to Do This?Do I Really Need to Do This?

The care imperativeThe care imperative– WMDWMD– Common events (industrial, lab)Common events (industrial, lab)

The regulatory imperativeThe regulatory imperative– JCAHO, OSHAJCAHO, OSHA

The financial imperativeThe financial imperative– To get state and Federal grantsTo get state and Federal grants

The publicity imperativeThe publicity imperative

ThreatsThreats

Weapons of mass destructionWeapons of mass destruction– Mainly, chemical or radioactiveMainly, chemical or radioactive

FiresFiresTransportation accidentsTransportation accidentsIndustrial accidentsIndustrial accidentsInternal spills (lab, chemo, radioactives)Internal spills (lab, chemo, radioactives)

Do a Hazard Vulnerability AnalysisDo a Hazard Vulnerability Analysis

Tokyo Sarin AttackTokyo Sarin Attack

Tokyo, March 20, 1995Tokyo, March 20, 1995

5 bags of sarin punctured in 5 5 bags of sarin punctured in 5 subway trainssubway trains

12 dead12 dead

5500 “sick” patients5500 “sick” patients

St. Luke’s Hospital (520 beds)St. Luke’s Hospital (520 beds)– Treated 500 patients in first hour; 640 Treated 500 patients in first hour; 640

on first dayon first day

Conyers, GA 2003

Explosives…

Decon???

Madrid, 11 March 2004

Radiation Is Easily DetectableRadiation Is Easily Detectable

ED door monitors?

Anthrax 2001-2002Anthrax 2001-2002

Decon? Or Prophylaxis? Decon? Or Prophylaxis?

JCAHOJCAHO

““Health Care at the Crossroads”, 2003Health Care at the Crossroads”, 2003– Emergency preparedness as key goalEmergency preparedness as key goal

Environment of Care StandardsEnvironment of Care Standards– Protect employeesProtect employees– Protect facilityProtect facility– Protect patientsProtect patients

OSHA and OthersOSHA and Others

OSHA regulates employee safetyOSHA regulates employee safety

NIOSH “certifies” equipmentNIOSH “certifies” equipment

CDC provides medical informationCDC provides medical information

EPA regulates pollutionEPA regulates pollution

Someone will fine you…Someone will fine you…– ……if you expose an employeeif you expose an employee– ……if you use the wrong gearif you use the wrong gear– ……if you contaminate the environmentif you contaminate the environment

OSHA Draft GuidanceOSHA Draft Guidance

www.osha.gov/dts/osta/bestpractices/firstrwww.osha.gov/dts/osta/bestpractices/firstreceivers_hospital.pdfeceivers_hospital.pdf

In brief:In brief:– Yes, you need to do itYes, you need to do it– PAPR’sPAPR’s– 8 hour staff training minimum8 hour staff training minimum

Finance and PublicityFinance and Publicity

Work with the governmentWork with the government– HRSA and CDC (Focus D) moneyHRSA and CDC (Focus D) money

Work with industryWork with industry– Financing from manufacturersFinancing from manufacturers

Public drills look goodPublic drills look good

Public evasion looks badPublic evasion looks bad

GoalsGoals

Need to do at least few-patient deconNeed to do at least few-patient decon– At any timeAt any time– With own resourcesWith own resources

May need to do or help with mass deconMay need to do or help with mass decon– Usually with help, e.g. FDUsually with help, e.g. FD– Need to practiceNeed to practice

Need to protect and train staffNeed to protect and train staff

Decon OptionsDecon Options

Outdoors (wading pools)Outdoors (wading pools)

TentsTents– OutsideOutside– InsideInside

RAM DeconRAM Decon

TrailersTrailers

IndoorsIndoors– Multipurpose roomMultipurpose room– Dedicated roomDedicated room

Slow, clumsy

Quick, easy

Cheap

Dear

Decontamination Tent

“RAM Decon”

Hospital’s Trailer

Local FD Trailer

““Mass” Decon UnitMass” Decon Unit

Undress Decon Dress

• 92 Mass Decontamination Units issued to Fire Departments in Massachusetts

• One Decon company in Each Fire District and One Decon Company protecting each hospital emergency department,

A permanent hospital decon room

Basic RequirementsBasic Requirements

Contain contaminationContain contamination

Control environmentControl environment

Protect staffProtect staff

Allow deconAllow decon

Contain runoffContain runoff

Allow cleanup or disposalAllow cleanup or disposal

Patient through-putPatient through-put

Standards?Standards?

American Institute of ArchitectsAmerican Institute of Architects– For roomsFor rooms

NFPA and ASTMNFPA and ASTM– For some field devicesFor some field devices

NIOSH eventuallyNIOSH eventually

Really, it’s still caveat emptorReally, it’s still caveat emptor

Try before you buyTry before you buy

Staff PPEStaff PPE

Levels of PPELevels of PPE– A: big suit, big tankA: big suit, big tank– B: little suit, big tankB: little suit, big tank– C: little suit, little maskC: little suit, little mask– D: no suit, no maskD: no suit, no mask

Level A for entryLevel A for entry

Level C for known hazardLevel C for known hazard

Level B or C for unknown?Level B or C for unknown?

Level B with supplied air

Level C with PAPRLevel C with PAPR

C minus

Standard (Universal) Standard (Universal) PrecautionsPrecautions

GownGown

GlovesGloves

MaskMask– N95 HEPA, to upgrade N95 HEPA, to upgrade

for plague or smallpoxfor plague or smallpoxRESPIRATORY RESPIRATORY PRECAUTIONSPRECAUTIONS

Shoe coversShoe covers

For RAD or BIO: level D plus

Level B vs. Level CLevel B vs. Level C

Training timeTraining time– 8 hours vs. 40 hours8 hours vs. 40 hours– B training requires escape bottles (OSHA)B training requires escape bottles (OSHA)

Equipment CostEquipment Cost– About $4000 per person for BAbout $4000 per person for B– About $1000 per person for CAbout $1000 per person for C

But is C safe???But is C safe???

Case ReviewCase Review

Sarin in TokyoSarin in Tokyo– No decon, no PPENo decon, no PPE– 472 hospital workers surveyed472 hospital workers surveyed– Over 100 symptomaticOver 100 symptomatic– 1 admitted1 admitted

HSES data 1996-1998HSES data 1996-1998– 44,015 events44,015 events– 3,455 events produced 13,149 victims3,455 events produced 13,149 victims– 5% were admitted5% were admitted

Annals of Emergency Medicine 42:3, September 2003Annals of Emergency Medicine 42:3, September 2003

Case Review Cont.Case Review Cont.

HSES 1996-1998HSES 1996-1998– 348 responder exposures348 responder exposures

Mostly PD and FDMostly PD and FD

– 6.6% admitted6.6% admitted– No deathsNo deaths

HSES Healthcare dataHSES Healthcare data– 11 events produced 15 HCW exposures11 events produced 15 HCW exposures

Mix of organo, pepper, HF, chlorine, solventsMix of organo, pepper, HF, chlorine, solvents

– 5 of these were INTERNAL to the facility5 of these were INTERNAL to the facility– No admissionsNo admissions

Case Review Cont.Case Review Cont.

OrganophosphatesOrganophosphates– GA case (suicide): one HCW intubated, one other GA case (suicide): one HCW intubated, one other

admitted, 2 more needed antidotesadmitted, 2 more needed antidotes– 4 anecdotal cases, no admissions4 anecdotal cases, no admissions

Outside USOutside US– Several cases reported, no PPE, but no admissionsSeveral cases reported, no PPE, but no admissions

ModelingModeling– C is enough for compounds more volatile than sarinC is enough for compounds more volatile than sarin

Case Review LessonsCase Review Lessons

Most HCW exposures are vaporMost HCW exposures are vaporOrganophosphates are the most Organophosphates are the most dangerous (judged by admit rate)dangerous (judged by admit rate)Level C would have been enough even in Level C would have been enough even in these settingsthese settings

Govt. agencies are considering similar Govt. agencies are considering similar data, may change recommendationsdata, may change recommendations– VA, NIOSH, HRSA (Hospital program)VA, NIOSH, HRSA (Hospital program)

How Do I Get It Done?How Do I Get It Done?

NeedsNeeds– MoneyMoney– Interested staffInterested staff– Competent trainersCompetent trainers– Institutional commitmentInstitutional commitment

MoneyMoney

FederalFederal– HRSA, CDCHRSA, CDC– DHS (work with public safety?)DHS (work with public safety?)

State or LocalState or Local

IndustryIndustry

Own facilityOwn facility

StaffStaff

CommittedCommitted

CompetentCompetent

TrainableTrainable

Low turnoverLow turnover

Present 24/7 in numbers (4 minimum)Present 24/7 in numbers (4 minimum)

Clinical? Maintenance? Custodial? Clinical? Maintenance? Custodial? Security? Safety? All?Security? Safety? All?

TrainingTraining

InternalInternal– Hospital basedHospital based

ExternalExternal– FD-basedFD-based– IndustrialIndustrial

Refresher training built into systemRefresher training built into system– Employee orienttation? Annual “special Employee orienttation? Annual “special

teams” training?teams” training?

Institutional CommitmentInstitutional Commitment

Doing the right thingDoing the right thing

Doing something to protect the institutionDoing something to protect the institution

Doing something for good publicityDoing something for good publicity

Doing something to avoid bad publicityDoing something to avoid bad publicity