• Key Treatment Centers - Hospitals in large urban areas. (Hospitals A, B, C, and G)*
• Potential Risk Hospitals - Hospitals within 50 miles of a large urban area and high-visibility potential targets where a mass casualty incident could occur (e.g., major airport or sports stadium, large chemical manufacturing facility, nuclear power plant, major shopping mall, nationally recognized monument). (Hospitals D and E)*
• Minimum Risk Hospitals - Hospitals with populations less than 500,000 within a 50-mile radius and without a high-visibility potential target within that distance. (Hospital F)*

• Agency for Healthcare Research and Quality (AHRQ)
• Agency for Toxic Substances and Disease Registry (ATSDR)
• American College of Emergency Physicians (ACEP)
• American Hospital Association/American Society for Healthcare Engineering (ASHE)
• U.S. Navy Bureau of Medicine and Surgery (BUMED)
• California Emergency Medical Services Authority (CA-EMSA)
• Centers for Disease Control and Prevention (CDC)
• Emergency Nurses Association (ENA)
• EnMagine (hazmatforhealthcare.org)
• George Washington University - Institute for Crisis, Disaster and Risk Management
• Health Resources & Services Administration (HRSA), National Bioterrorism Hospital Preparedness Program
• Hennepin County (MN) Medical Center, Emergency Medicine
• Inova Health System, Emergency Management and Disaster Medicine; and Employee and Occupational Health Departments
• International Chemical Workers Union Council of the United Food and Commercial Workers Union (ICWUC)
• International Safety Equipment Association (ISEA)
• Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
• Kaiser Permanente
• National Incident Management System (NIMS) Integration Center
• National Organization for Victim Assistance (NOVA)
• Navy Environmental Health Center, Industrial Hygiene Directorate,
• Navy Medicine Office of Homeland Security, Bureau of Medicine and Surgery
• National Institute of Environmental Health Sciences (NIEHS), Worker Education and Training Program (WETP), National Clearinghouse for Worker Safety and Health Training
• National Institute for Occupational Safety and Health (NIOSH)
• NYU Medical Center, Environmental Services Department
• Rhode Island Department of Health
• Samaritan Regional Health System
• University of Maryland School of Medicine, National Study Center for Trauma & EMS
• U.S. Department of Veterans Affairs, Central Arkansas Veterans Healthcare System
• U.S. Department of Veterans Affairs, Office of Occupational Safety and Health
• U.S. Department of Veterans Affairs, Occupational Health Program
• U.S. Department of Veterans Affairs, Veterans Administration Medical Center (Washington, DC)
• U.S. Army Center for Health Promotion and Preventive Medicine (USACHPPM)

• Understanding the hospital emergency operations plan and their roles in the response.
• Site safety, including risks to receiving personnel.
• Appropriate selection and use of PPE.
• Decontamination procedures.

• When PPE is necessary.
• What PPE is necessary.
• How to properly put on, remove, adjust, and wear PPE.
• Limitations of PPE.
• Proper care, maintenance, useful life, and disposal of PPE.

• The nature of the respiratory hazard, and why a respirator is needed.
• Respirator capabilities, limitations, and consequences, if the respirator is not used correctly.
• How to handle respirator malfunctions and other emergencies.
• How to inspect, put on, remove, use, and check seals on the respirator.
• Maintenance and storage procedures.
• When to change cartridges on APRs.
• How to recognize medical signs and symptoms that may limit or prevent effective use of a respirator.
• General requirements of the respiratory protection program.

• Nature of the hazard (if known).
• Expected duties.
• Appropriate use of PPE.
• Other appropriate safety and health precautions (e.g., decontamination procedures).

APPENDICES

APPENDIX A
Background, Literature Review, and Site Visit Examples

• Examples of roles that hospitals fill in their communities and the benefits hospitals can derive from playing an active role in community emergency preparedness.
• Suggestions for coordinating Emergency Response Plans (EMPs) with other organizations.
• Tips for designating staff for decontamination teams.
• Discussion of the different levels of training for first receivers filling various roles, plus information on training requirements for the team members.
• Medical monitoring considerations for first receivers before, during, and after a response.

• Discussion of the benefits associated with different types of decontamination facilities and examples of factors hospitals consider when selecting a system.
• Outline of the basic steps typically involved in victim decontamination procedures.
• Examples of several organizations' shower flush times and practices used for victim decontamination.
• Review of OSHA requirements for employers whose employees wear respirators and other personal protective equipment (PPE).

• Discussion of management practices for contaminated solid waste.
• Examples of arrangements hospitals have made to manage wastewater during and after a response.
• Strategies for decontaminating surfaces and equipment.

• References to other appendices that offer emergency planners further examples and additional useful information.

• Victims will arrive with little or no warning to the hospital.
• Information regarding the hazardous agent(s) will not be available immediately.
• A large number of victims will be self-referred victims (as much as 80 percent of the total number of victims).
• Victims will not necessarily have been decontaminated prior to arriving at the hospital.
• A high percentage of people arriving at the hospital will have experienced little or no exposure and this eventuality should be considered in decontamination plans.
• Most victims will go to the hospital closest to the site where the emergency occurred.
• Victims will use other entrances in addition to the emergency department (ED).


Sources: Auf der Heide, 2002; Barbera and Macintyre, 2003; Vogt, 2002; Okumura et al., 1996.

• Providing decontamination and treatment for any and all victims.
• Promoting wider level of preparedness in the community by providing low-cost hazard communication or hazardous waste operations and emergency response (HAZWOPER) training for local government and business emergency response personnel.
• Providing information and services related to emergency preparedness (e.g., respirator medical clearance).
• Participating actively in multi-disciplined community-based planning and preparedness activities, such as LEPCs (e.g., Hospital D reports devoting a minimum of 12 man-hours per week to its active role in community preparedness. This time is in addition to the hours spent managing the hospital's internal preparations).

• Increased access to community records, which help managers improve the accuracy of the HVA and help the hospital customize its EMP.⁴⁵
• Increased access to grants and other financial resources.
• Group buying power that allows for volume discounts or government rates (including reduced sales tax) for equipment and supplies.
• More opportunities to contain costs by sharing or trading expertise, training resources, equipment, and services.
• Greater opportunity to tailor community drills so they test the hospital's emergency plans.
• Increased opportunities to network and develop useful alliances with emergency first responders and other emergency planners (particularly useful for resolving complex issues that emerge as groups coordinate their activities under difficult circumstances).
• Greater visibility in the community and increased respect as a valued resource and partner (including among business leaders).

• OSH Act – General Duty Clause (Section (5)(a)(1))
• HAZWOPER – 29 CFR 1910.120(q)
• Personal Protective Equipment – 29 CFR 1910.132
• Eye and Face Protection – 29 CFR 1910.133
• Respiratory Protection – 29 CFR 1910.134
• Hand Protection – 29 CFR 1910.138
• Hazard Communication – 29 CFR 1910.1200(h)
• Bloodborne Pathogens – 29 CFR 1910.1030
• Ethylene Oxide – 29 CFR 1910.1047
• Formaldehyde – 29 CFR 1910.1048

• Use an incident command system compatible with the National Incident Management System (NIMS) structure.^49,50
• Get to know members of the other organizations and the details of their plans. Seek opportunities to improve communication.
• Seek input from other organizations (such as local emergency planning groups) when developing or updating plans.
• Use compatible forms of communication, such as radios capable of operating on the same frequency. Keep compatibility in mind when purchasing equipment.
• Participate in multi-organizational drills. Execute multi-organizational drills that test the way organizations interact under adverse conditions.
• Analyze drills to identify areas that need improvement and meet directly with the other organizations to develop action plans that provide mutually agreeable, practical solutions to problems. Bear in mind that a solution suggested by one party might not be feasible for another organization to implement.
• Test inter-organizational communication systems at every opportunity (e.g., fire department, law enforcement, emergency medical services, environmental management, and other hospitals).⁵¹

• Public health groups (including special laboratories).
• Local emergency management organizations (e.g., LEPCs).
• Emergency medical services.
• Law enforcement, at all levels.

• *Decontamination team leader – responsible for management of the decontamination operation.⁵⁴
• *Decontamination safety officer – responsible for monitoring the decontamination area for developing hazards and for ensuring team safety.
• *Pre-decontamination triage – responsible for assessing medical status and prioritizing victims for decontamination.
• Decontamination system set-up.
• Security.
• Decontamination hospital attendants.
• Post-decontamination inspection.
• Cleanup and decontamination crew (surfaces, equipment, human and hazardous wastes).
• Other roles that might be performed in the Hospital Decontamination Zone under some circumstances (e.g., patient tracking, assistants helping team members with PPE).

• *An understanding of what hazardous substances are, and the risks associated with them in an incident.⁵⁶
• *An understanding of the potential outcomes associated with an emergency when hazardous substances are present.
• *The ability to recognize the presence of hazardous substances in an emergency through signs and symptoms of exposure.
• *The ability to identify the hazardous substances, if possible.
• *An understanding of their role in the hospital's emergency response plan, including site security and control, and decontamination procedures (OSHA, 1992c).
• *The ability to realize the need for additional resources and to make appropriate notifications to the communication center.
• Knowledge of the basic hazard and risk assessment techniques.
• Know how to select and use proper PPE.
• An understanding of basic hazardous materials terms.
• Know how to perform basic control, containment, and/or confinement operations within the capabilities of the resources and PPE available.
• Know how to implement basic decontamination procedures.
• An understanding of the relevant standard operating procedures and termination procedures.

• An understanding of what hazardous substances are, and the risks associated with them in an incident.
• An understanding of the potential outcomes associated with an emergency created when hazardous substances are present.
• The ability to recognize the presence of hazardous substances in an emergency.⁵⁸
• The ability to identify the hazardous substances, if possible.
• An understanding of their role in the hospital's emergency response plan, including site security and control, and decontamination procedures (OSHA, 1992c).
• The ability to realize the need for additional resources and to make appropriate notifications to the communication center.

1. Avoid physical contact with the patient.
2. Immediately notify supervisor and safety officer of possible hospital contamination.
3. Allow other properly trained and equipped staff to isolate and decontaminate the victim according to EMP.

• Methods and observations that may be used to detect the presence of a hazardous substance in the work area (e.g., an odor or announcement by staff trained to identify possible contamination).
• General information on victims as a possible source of hazardous substances.
• The measures employees can take to protect themselves during an incident, including specific procedures the hospital has implemented to protect employees from exposure to hazardous substances (e.g., emergency procedures for leaving the area).

• Overhead public broadcasting systems⁶⁰
• Telephones
• Cell phones
• Pagers
• Fax
• Runners with verbal or written messages
• Two-way radios
• E-mail and Intranet services

Overhead broadcasting systems, Intranet, and two-way radios are independent of external systems (such as telephone service) that might be impacted by a widespread emergency. A good EMP should consider the need for backup communications in the event of a power failure.
 

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

1.2.8.1

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.
 

1.2.8.2

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.
 

"Temple-transducer" style two-way radio headset stays in place under PAPR hoods.
Detail of "temple-transducer" style radio headset.

Thermal Stress

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.
 

1.2.8.3

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.
 

1.2.8.4

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.
 

2.0

RESPONSE

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:

• Hospital F has two existing physical characteristics that have proven advantageous: 1) in the event that one side of the ED became contaminated by an unannounced victim, doors between two sections of the ED can be closed and normal ED activities can continue on the uncontaminated side; and 2) a pair of unused, canopy-covered ramps leading to one entrance of the ER (left from a period of construction when the ER was used as the main entrance to the hospital) is being converted into a permanent decontamination shower for ambulatory patients. When considering use of divided spaces, hospitals should determine whether the ventilation systems are also separate and whether they recirculate air. If a space becomes contaminated, it might be necessary to shut down the area's ventilation system to prevent circulation of contaminated air to other spaces.

Visual aids help communicate to hospital managers the advantages and possible location of proposed permanent decontamination systems.

• While looking for an appropriate location for its large portable decontamination system, Hospital A (in a hot humid climate) considered the advantages of a particularly large shade tree for preventing heat stress. The tree shades the entire shower system and all support features (extensive mechanical systems, triage and victim inspection stations, and victim waiting areas).

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.
 

2.1.3

Decontamination

2.1.3.1

Equipment

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.

Although permanent decontamination systems have many advantages, portable facilities can be transported to other locations, if necessary.

Hospitals may select from an array of decontamination shower options. Portability is an advantage if the system might be required at different locations. A wide variety of portable, temporary decontamination systems are commercially available. Durable portable systems are designed to be cleaned and reused (if the type of contaminant is not highly toxic or persistent), while other systems are intended to be disposable and, thereby, simplify the post-incident recovery phase. The systems need to be stored in an easily accessible location. There is considerable variety in the sizes of portable decontamination systems available and the number of people required to set up the system. All require some set-up time.

A blower can increase fresh air circulation the decontamination system. In cold weather, the unit shown also heats air to a comfortable temperature.

Permanent decontamination facilities are generally recommended over temporary equipment because these facilities can be activated quickly (some permanent models may be activated by simply unlocking the doors and turning on the water) and offer reliable long-term service. They also function well in harsh climates. Although permanent facilities require a dedicated space and more maintenance than disposable systems, Hospital A finds that permanent decontamination showers can generally be installed for the same (or lower) cost than a portable system with comparable features.

Enclosed decontamination facilities should provide for fresh air circulation. When constructing a fully enclosed system, hospitals should consult a ventilation engineer or Certified Industrial Hygienist early in the system design phase.

Because of the time it takes first receivers to put on PPE and to set up decontamination facilities, hospitals may want to consider arranging for alternate rapid forms of decontamination until more sophisticated decontamination facilities are up and running. For example, some hospitals use high capacity, low-pressure hoses or showerheads, connected to high capacity, temperature-controlled water sources. These hoses and showers allow rapid preliminary drenching of multiple victims. Where multiple shower heads can be activated, ensure that the available water flow into, and through, the system is adequate to provide rapid decontamination at each shower head.⁶⁸
 

	A roller system platform helps move non-ambulatory victims on backboards through the decontamination facility.
	Hospitals can obtain military surplus equipment to supplement the decontamination facility supplies. (Shown here: a field stretcher for transferring non-ambulatory victims from arriving vehicles to the decontamination facility.)

Hospitals A through G report that they considered the following factors when evaluating their decontamination system options:

• Previous experience with a particular system during drills or demonstration events. Characteristics that first receivers prefer include systems that are easily and rapidly set up by a minimal number of personnel and require little storage space.
• Compatibility with other equipment in the community (e.g., already owned by the fire department or other local organization). This feature allows systems to be joined to create a larger shower area. Additionally, more individuals in the community will be familiar with the system setup.
• Cost.
• Requirements prescribed by funding sources.
• Availability of space for a permanent shower.
• Community needs (anticipated frequency of use and required capacity).
• Need to operate the system in harsh weather.

1. Activate the EMP.
2. Learn as much as possible (as soon as possible) about the number of victims, the contaminant, and associated symptoms. Previous arrangements with first responder organizations can improve the timeliness and quantity of information received.
3. Activate the decontamination system and assemble the decontamination team and site security staff.
4. Perform any medical monitoring (e.g., vital signs), if specified by the EMP.
5. Put on PPE.
6. Triage victims to determine which individuals require decontamination and provide critical medical treatment to stabilize them before decontamination (e.g., atropine).
7. Assist victims (ambulatory and non-ambulatory) in removing contaminated clothing and securing personal property as soon as possible (within minutes of arrival).
8. Place clothing and other contaminated items in an approved hazardous waste container that is isolated outdoors so the items are not a continuing source of exposure.
9. Wash victims using soap, with good surfactant properties, and water (preferably tepid water to improve victim compliance). This step should include copious rinsing. [See discussion below.]
10. Inspect victims to evaluate the effectiveness of decontamination and guide decontaminated victims to the medical treatment area (Hospital Post-decontamination Zone). Return inadequately decontaminated victims to the shower area and repeat cleansing.
11. Decontaminate equipment and the decontamination system (if not disposable).
12. Staff remove PPE and decontaminate themselves.

Put victim's personal items in a labeled plastic zip bag.	Use blunt scissors to cut away clothing. Avoid stretching or wringing cloth.

• The U.S. Army Center for Health Promotion and Preventive Medicine (USACHPPM) recommends one-minute rinsing from head to toe with tepid water (slightly warm, not hot) after removal of contaminated clothing, followed by a more thorough decontamination of washing with a soap with good surfactant properties (e.g., hand dishwashing detergent), tepid water, and soft sponges. Avoid stiff brushes and vigorous scrubbing, which can damage the skin and increase the chance the contaminant would be absorbed by the victim. USACHPPM recommends these procedures for most classes of contaminants, except certain reactive metal dusts (USACHPPM, 2003a).
• The U.S. Army Soldier and Biological Chemical Command's (SBCCOM) Mass Casualty Decontamination Research Team (MCDRT) states that actual showering time will be an incident-specific decision but might be as long as 2 to 3 minutes per individual under ideal circumstances (SBCCOM, 2000b).
• The Agency for Toxic Substances and Disease Registry (ATSDR) recommends that patients contaminated with an unidentified chemical should flush exposed or irritated skin and hair with plain water for 3 to 5 minutes. For oily or otherwise adherent chemicals, mild soap on the skin and hair followed by a thorough rinse with water is also recommended (ATSDR, 2003).
• A technical expert for Hospital A's Emergency Mass-Casualty Decontamination Program stated that research regarding how long it takes to decontaminate an individual is scarce. This organization recommends a 5-minute shower time, based on operational experience. However, in some cases the total decontamination period could last longer than five minutes, depending on the agent, its viscosity, the quantity on the victim, and the amount of clothing removed.

• SBCCOM's MCDRT recommends the rapid use of water, with or without soap, for decontamination. Using soap can marginally improve the results by ionic degradation of the chemical agent. Soap helps dissolve oily substances like mustard or blister agent. Liquid soaps are quicker to use than solids. However, the decontamination process should never be delayed to add soap (SBCCOM, 2000b).
• A multi-service effort of the U.S. Army, U.S. Marine Corps, U.S. Navy, and U.S. Air Force recommends that a contaminated individual use generous amounts of soap and water and scrub downward from head to toe. However, the decontamination process should not be delayed to due to a lack of soap (U.S. Army, 2001).
• A technical expert with Hospital A's Emergency Mass-Casualty Decontamination Program stated that this organization uses mild liquid (hand) dishwashing soap to avoid irritating the skin while still allowing, with enough water and friction, removal of the contaminant. He stated that the Department of Defense (DOD) has also suggested using mild soap for chemical warfare agents. USACHPPM suggests using mild (hand) dishwashing soap for removing a wide range of possible contaminants, including industrial chemicals, chemical warfare agents, biological agents, and radiological particles (USACHPPM, 2003a).

• Procedures for selecting respirators for use in the workplace.
• Medical evaluations of employees required to use respirators.
• Fit testing procedures for tight-fitting respirators.
• Procedures for proper use of respirators in routine and reasonably foreseeable emergency situations.
• Procedures and schedules for cleaning, disinfecting, storing, inspecting, repairing, discarding, and otherwise maintaining respirators.
• Procedures to ensure adequate air quality, quantity, and flow of breathing air for atmosphere-supplying respirators.
• Training of employees in the respiratory hazards to which they are potentially exposed during routine and emergency situations.
• Training of employees in the proper use of respirators, including putting on and removing them, any limitations on their use, and their maintenance.
• Establishing and implementing respirator chemical cartridge change schedules.
• Procedures for regularly evaluating the effectiveness of the program.

Most of the hospitals interviewed for this project had previously developed respiratory protection programs covering the use of respirators by other employees. The hospitals were able to expand the program to include the use, cleaning, storage, and maintenance of the PAPRs worn by first receivers.

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.|
 

NIOSH maintains a list of respirator makes and models certified for use against specific hazards or types of environments. Hospitals can search the list by contaminant type (e.g., organic vapors), facepiece style (e.g., hood) and other criteria. CBRN-approved respirators will appear on this list as they are certified. To access the list, see < www.cdc.gov/niosh/celintro.html >.

Staff can quickly move wheeled equipment carts from storage to the staging area.

A storage room near the ED door offers convenient access for first receivers' supplies.

Protective equipment deteriorates with use and time. To minimize the amount of costly equipment expended during frequent drills, the interviewed hospitals typically maintain sets of PPE that are designated for drills. These "reusable" items are marked accordingly and repackaged after each training session. In differently marked containers, the hospitals store identical PPE (still in the original or comparable packaging) that would be used during a real incident.

Protective equipment storage can present challenges. The hospitals that were interviewed typically use one of two methods: cabinets or plastic storage boxes on shelves. Hospital A uses large stainless steel rolling cabinets that can be pushed to the ED entrance for easy equipment access when the decontamination facility is activated. Other hospitals use clear (easy to see contents) or colored (for coding) plastic storage containers to hold PPE sets and other supplies. To ensure equipment is convenient during an emergency, the hospitals store equipment on shelves or cabinets near the ED door or in an adjacent room. One small hospital keeps equipment in locking cabinets along one wall of the small ED entry vestibule.

Long-term maintenance of battery-powered respirators, such as PAPRs, creates a special challenge. The batteries should be kept fully charged and should be maintained according to the manufacturer's directions. The respirator manufacturer's specific recommendations for charging, testing, and expected battery service life should be considered in any effort to maintain future readiness. Lithium-based batteries might offer more reliable long-term service. However, hospitals should discuss the relative merits and maintenance of the available batteries with the respirator manufacturer.
 

2.1.3.5

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 devices—about the size of an attaché case—will 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:

• Distinguish contaminated individuals from other patients arriving at the hospital (e.g., by identifying symptoms and victim's proximity to a known chemical release).
• Identify victims who require immediate stabilization before they enter the decontamination system (e.g., shock and respiratory arrest).
• Identify injuries or critical pre-hospital treatment materials that will require special handling inside the decontamination system (e.g., a tourniquet that must be replaced with an uncontaminated compression device).

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.)
 

Awareness Level:

See First Responder Awareness Level.
 

CBRN:

Chemical, biological, radiological, or nuclear [agent or substance].
 

Clinicians:

Physicians, nurses, nurse practitioners, physicians' assistants, and others.
 

Doff:

To take off or remove (e.g., PPE).
 

Don:

To put on, in order to wear (e.g., PPE).
 

ED:

Emergency Department.
 

EMP:

Emergency Management Plan.
 

First Receiver:

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.
 

First Responder:

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)].
 

HAZCOM:

OSHA's Hazard Communication Standard [29 CFR 1910.1200].
 

HAZMAT:

Hazardous Material.
 

HAZWOPER:

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.
 

Hazardous Substance:

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."
 

IDLH:

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.
 

JCAHO:

Joint Commission on Accreditation of Healthcare Organizations.
 

LEPC:

Local Emergency Planning Committee.
 

Mass Casualty:

"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).
 

NIMS:

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.
 

NFPA:

National Fire Protection Association.
 

Operations Level:

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.
 

Release Zone:

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.
 

Triage:

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.
 

WMD:

Weapon of Mass Destruction.

APPENDIX C
References
 

APPENDIX D
Additional Resources (Web Links)

 

APPENDIX E Advantages and Disadvantages of
Various Respirator Facepiece Styles

APPENDIX F
Hazard Vulnerability Analysis Examples

APPENDIX F
Example 1. Kaiser Permanente Hazard Vulnerability Analysis

1. Known risk
2. Historical data
3. Manufacturer/vendor statistics

1. Time to marshal an on-scene response
2. Scope of response capability
3. Historical evaluation of response success

1. Potential for staff death or injury
2. Potential for patient death or injury

1. Cost to replace
2. Cost to set up temporary replacement
3. Cost to repair
4. Time to recover

1. Business interruption
2. Employees unable to report to work
3. Customers unable to reach facility
4. Company in violation of contractual agreements
5. Imposition of fines and penalties or legal costs
6. Interruption of critical supplies
7. Interruption of product distribution
8. Reputation and public image
9. Financial impact/burden

1. Status of current plans
2. Frequency of drills
3. Training status
4. Insurance
5. Availability of alternate sources for critical supplies/services

1. Types of supplies on hand/will they meet need?
2. Volume of supplies on hand/will they meet need?
3. Staff availability
4. Coordination with any medical office buildings (e.g., doctors' offices and clinics) included in the EMP.
5. Availability of back-up systems
6. Internal resources ability to withstand disasters/survivability

1. Types of agreements with community agencies/drills?
2. Coordination with local and state agencies
3. Coordination with proximal health care facilities
4. Coordination with treatment specific facilities
5. Community resources

APPENDIX F - EXAMPLE 1.

APPENDIX F
Example 2. New York University Medical Center
Hazard Vulnerability Analysis
Version date: August 2003

1. Known Risk
2. Historical Data
3. Manufacturer/Vendor Statistics
4. Intelligence Information from Law Enforcement

1. Immediate Danger (Threat) to Life or Health (IDLH)
2. Disruption of Services
3. Damage/Failure Potential
4. Loss of Community Trust
5. Financial Impact
6. Legal Issues

1. Status of Current Plans
2. Training Status
3. Insurance
4. Availability of Back-up Systems
5. Community Resources

APPENDIX F - EXAMPLE 2.

APPENDIX G
Introduction to HEICS

ABOUT THE HEICS III PROJECT

• predictable chain of management
• flexible organizational chart allows flexible response to specific emergencies
• prioritized response checklists
• accountability of position function
• improved documentation for improved accountability and cost recovery
• common language to promote communication and facilitate outside assistance
• cost effective emergency planning within health care organizations

• Positions may or may not be activated.
  Each emergency must be evaluated as to the specific positions which will need activation in order to address challenges of the emergency. The disaster's nature, proximity, and other factors may mandate all or very few of the positions to be staffed.
• Positions may be filled immediately or later based upon needs and staffing.
  A particular disaster may require that a certain number of positions need to be filled. However, if there are only a few managers available for the next 12 hours, then each manager must take more than one position. If this is not acceptable, then the top priority positions must be identified and carried out in the best manner possible.
• More than one position may be assigned to an individual.
  Many managers are capable of carrying out more than one function at a time. Situations of a critical nature may require an individual to perform multiple tasks until additional support can be obtained. The use of checklists should facilitate the task of multiple position assignment.

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

Sources:
Northern Virginia Emergency Response Coalition. Available at:
http://www.hazmatforhealthcare.org/download/doc/misc/Patient_
Decontamination_Procedure-complete.doc
(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

• The medical monitoring equipment (blood pressure [BP] cuffs, stethoscopes, scales, thermometer, medical monitoring sheets) should be brought from the PPE storage area and placed in the PPE dress out area.
• 1–2 staff persons should be assigned responsibility to perform medical monitoring of all response personnel.
• Time permitting (ex. advance incident information and arrival notice has been given by emergency medical services[EMS]) each person intending to dress in PPE is to have the following pre-entry medical monitoring assessment completed and recorded on their Medical Monitoring Incident Response Record:
• BP
• Pulse
• Respirations
• Weight
• Temperature
• Listing of current medications
• Confirmation of no current, upper respiratory tract infection, chronic obstructive pulmonary disease, sinusitis, or gastrointestinal illness
• If there is inadequate time to perform pre-entry medical monitoring it will be important that each staff member exercises good judgment and dress out only if they know there is no preexisting condition that should preclude their use of PPE.
• The clinical data obtained from medical monitoring done on each person must fall within the participation criteria listed. Persons whose vital signs exceed the requirements should either be sent to rest for 15–30 minutes and then re-examined or given a responsibility not requiring the use of PPE. Staff are NOT to dress out until they meet the pre-requisite criteria.

• After the completion of each work rotation requiring PPE use, the staff member is to have post-entry medical monitoring done. The elements of this exam are the same as the pre-entry exam. They are to be recorded on the staff members Medical Monitoring Incident Response record. If significant changes in the clinical data are found or subjectively offered information indicate the need for more comprehensive evaluation or medical treatment the staff member is to be sent to the Emergency Department. The Emergency Department should be given a pre-alert ASAP about the staff members pending arrival.
• Staff dressing out in PPE for a second work rotation are to have another pre-entry medical monitoring evaluation before donning PPE if the last exam performed was a) abnormal or b) greater than 2 hours old.

• Once the incident is declared over the Medical Monitoring Incident Response Records for all staff are to be reviewed by the charge Emergency Department MD or Occupational Health MD to determine if any further short or long-term clinical evaluation is necessary. If the decision is made that additional evaluation is needed the staff member involved is to be immediately notified by the evaluating MD and arrangements made for the exam ASAP.
• The costs associated with any follow-up evaluation or treatment associated with the incident will be the responsibility of the hospital.
• Each staff member's Medical Monitoring Incident Response record is to be put into their personnel file and kept secure and retrievable for a period not less than 30 years following their retirement or resignation.

Appendix H
Example 2. U.S. Coast Guard National Strike Force

1. Medical Monitoring
1. Medical monitoring shall be conducted on all entry, backup, and decon personnel prior to Exclusion Zone entries. Follow-up medical monitoring shall also be conducted on all entry, backup, and decon personnel at the conclusion of each work shift. For workers wearing impermeable chemical protective clothing, workers shall also be monitored when the temperature in the work area exceeds 70ºF (21ºC). Medical monitoring shall be conducted during the rest period following each work cycle in accordance with chapter 8 of reference 1. If the work cycle specified in Table 8-10 of Reference 1 is less than 30 minutes, the supervisor may consult the Commanding Officer for authorization to extend the work cycle up to 30 minutes.
2. Recommended values from the American Heart Association are to be used as guidance for pre-entry medical monitoring:

Blood Pressure (Max): Pulse Rate (Max): Temperature:

140 bpm Systolic/100 Diastolic* 100 bpm 98.0ºF (Min), 99.2ºF (Max) (or +/- 0.6ºF from normal)

3. When a medical value is found to be outside the accepted guidance, the supervisor should be informed immediately. Anomalous readings require medical advice prior to continued entries by an individual.
4. Use appropriate forms to record field medical monitoring.
5. When questions regarding medical monitoring arise, the unit Safety and Occupational Health Coordinator (SOHC) shall be contacted.
* Note: At the onset of an incident, fear and anxiety may cause employees' blood pressure to be elevated.
 
2. Heat Stress (adapted from NIOSH Publication 86-112 "Working In Hot Environments")

Appendix H
Example 3. NIOSH Publication 86-112
Working In Hot Environments

1. HEAT STRESS CONSIDERATIONS. The Site Safety Officer or Site Safety Supervisor for the entire response should make heat stress determinations throughout the day. If it is determined that a heat stress hazard exists, an alert should be passed to all teams to implement mandatory rest periods. The Site Safety Officer/Supervisor should generally be guided by the American Conference of Governmental Industrial Hygienists (ACGIH) guidelines in determining work/rest periods. Fluids should be available at all times and encouraged during mandatory rest periods.
2. SAFETY CONCERNS. Certain safety problems are common to hot environments. The frequency of accidents, in general, appears to be higher in hot environments than in more moderate environmental conditions. One reason is that working in a hot environment lowers the mental alertness and physical performance of an individual. Increased body temperature and physical discomfort promote irritability, anger, and other emotional states which sometimes causes workers to overlook safety procedures or to divert attention from hazardous tasks.
3. HEALTH CONCERNS. Excessive exposure to a hot work environment can bring about a variety of heat-induced disorders.

C.1. HEAT STROKE

C.1.a. SIGNS AND SYMPTOMS. Heat stroke is the most serious of health problems associated with working in hot environments. It occurs when the body's temperature regulatory system fails and sweating becomes inadequate. The body's only effective means of removing excess heat is compromised with little warning to the victim that a crisis stage has been reached.

1. A heat stroke victim's skin is hot, usually dry, red or spotted.
2. Body temperature is usually 105º F or higher.
3. The victim is mentally confused, delirious, perhaps in convulsions, or unconscious.


C.1.b. MEDICAL ATTENTION. Unless the heat stroke victim receives quick and appropriate treatment, DEATH CAN OCCUR.

Any person with signs or symptoms of heat stroke requires immediate hospitalization.

SEND SOMEONE TO GET MEDICAL ASSISTANCE/EMT IMMEDIATELY!!!

While waiting for medical assistance first aid should be immediately administered.

This includes:
1. removing the victim to a cool area,
2. thoroughly soaking the clothing with water, and
3. vigorously fanning the body to increase cooling.


C.2. 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.

C.2.a. SIGNS AND SYMPTOMS. A worker suffering from heat exhaustion:

1. still sweats, but
2. experiences extreme weakness or fatigue, giddiness, nausea, or headache.

In more serious cases:

3. the victim may vomit or lose consciousness,
4. the skin is clammy and moist,
5. the complexion is pale or flushed, and
6. the body temperature is normal or only slightly elevated.

C.2.b. MEDICAL ATTENTION. General treatment:

1. notify the site EMT,
2. have the victim rest in a cool place, and
3. have the victim 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.

C.3. HEAT CRAMPS

C.3.a. SIGNS AND SYMPTOMS. 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.

C.3.b. MEDICAL ATTENTION. Cramps may occur during or after work hours and may be relieved by taking salted liquids by mouth.

C.4. FAINTING. A worker who is not accustomed to hot environments and who stands erect and immobile in the heat may faint.

C.4.a. SIGNS AND SYMPTOMS. 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.

C.4.b. MEDICAL ATTENTION. Upon lying down, the worker should soon recover. By moving around, and thereby preventing blood from pooling, the patient can prevent further fainting.

C.5. 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.

C.5.a. SIGNS AND SYMPTOMS. 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.

C.5.b. MEDICAL ATTENTION. Workers can prevent this by resting in a cool place part of each day and by regularly bathing and drying the skin.

C.6. 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.

4. PREPARING FOR WORK IN THE HEAT. One of the best ways to reduce the heat stress of workers is to minimize heat in the workplace. However, heat is difficult to control while working outdoors and exposed to various weather conditions.


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.
 
5. MECHANIZATION. 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 time. Mechanization of work procedures can often make it possible to isolate workers from the heat source and increase overall productivity by decreasing the time needed for rest.
    
6. WORK/REST PERIODS. 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 or regular (and enforced) breaks. 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.


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.
 

7. DRINKING FLUIDS. 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.

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.

CAUTION–PERSONS 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.
 
8. PROTECTIVE CLOTHING AND HEAT STRESS. 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 chemical protective clothes interfere with the evaporation of sweat.

APPENDIX I
Vital Signs & PPE Donning Checklists

APPENDIX I.

APPENDIX I.

APPENDIX J
Example of Patient Decontamination Procedure

Appendix J
Patient Decontamination Procedure
(Northern Virginia Emergency Response Coalition)

1. Direct patient to Decon Sector.
2. Children should be kept with their parents if at all possible; if no parent or older sibling is available then a Decon Team member should provide needed assistance to a child.
3. Patient should be given Personal Decon set as soon as it is available and be given rapid instructions on its use – PLAY THE TAPE recorded set of instructions, if available.
• The kit stays with you as you proceed through the process.
• Open up the bag – it has three parts.
• Take out the plastic bags now.
4. Patient should quickly remove all clothing, putting valuables into the clear plastic bag and clothing into the large bag, then put both bags into the 3^rd bag and cinch tight w/ tag number in pack. Patient should put numbered tag around their neck and wear it through decon and treatment.
5. The clothing bag should be set aside in a secure area.
6. If staff is available, patient's name and number should be recorded on the Patient Decon Record.
7. Patient should continue forward into the Decon Sector with remaining part of Personal Decon Kit.
8. Patient should quickly rinse themselves from head to toe with water using either the hand held sprayer, garden hose, or shower head.
9. Patient should next wash with soap and wash cloth or brush from the kit in a systematic fashion, cleaning open wounds first and then in a head-to-toe fashion for 5 minutes when the agent is non- persistent and 8 minutes when a persistent or unknown agent is involved. Discourage the patient from rubbing too vigorously while washing. Eye irritation may require the use of a topical anesthetic first before irrigating.
10. The Decon Team should closely observe each victim to ensure they are thorough in washing themselves. Particular attention should be made to ensure they wash the axilla, creases, folds, and hair. Help should be offered as necessary.
11. Once the washing is completed, each patient should thoroughly rinse themselves (this should require about a minute to complete).
12. Decon soap, wash cloths, brushes, and sponges should be put into a nearby trash can and NOT carried into the Cold Zone.
13. After the rinse/wash/rinse cycle is complete the patient should next proceed to the towel off area and complete drying off and leave the towel in the trash can.
14. Following drying off, the patient should put on the patient gown and proceed to the Triage Officer for rapid assessment and assignment to a Treatment Sector.
15. Additional treatment will be limited only to those interventions deemed life saving by the Decon Officer. Antidote administration should be done via the intramuscular (IM) route after cleaning the affected area first.
16. Decon Team members should be alert to the possibility that an ambulatory patient may clinically deteriorate and require immediate removal to the Non-Ambulatory Sector via backboard, stretcher, or wheelchair.

1. Patient should be brought to the Decon Sector and tended to by a minimum of 4 decon personnel.
2. Each patient should be put onto a backboard or EMS stretcher w/ the pad removed.
3. All patient clothing should be removed and valuables put into the clear plastic bag and clothing into the large bag, then put both bags into the 3^rd bag and cinch tight w/ tag number in pack. Clothing should be cut away where necessary.
4. Attention should be paid to minimizing the aerosolization spread of particulate matter by folding clothing inside out as removal is being done and dabbing the skin with sticky tape and or vacuuming.
5. Patient should have their clothing bag tag around their neck and wear it through decon and treatment.
6. The clothing bag should be set aside in a secure area. If staff is available, the patient's name and number should be recorded on the Patient Decon Record.
7. While resting the backboard on saw horses or other device or with the patient on an EMS stretcher, the patient should quickly be rinsed from head to toe with water using either the hand held sprayer, garden hose, or shower head; protection from aspiration of the rinse water should be ensured.
8. Next the patient should be washed with soap and either a brush or wash cloth in a systematic fashion, cleaning airway first followed by open wounds then in a head to toe fashion for 5 minutes when the agent is non persistent and 8 minutes when a persistent or unknown agent is involved. Avoid rubbing too vigorously.
9. The patient should be rolled on their side for washing of the posterior head, neck, back, buttocks and lower extremities by 2–4 personnel; attention to a possible neck injury should be given.
10. Careful attention should be given to washing the voids and creases such as the ears, eyes, axilla, and groin.
11. Topical eye anesthetic may be required for effective eye irrigation to be done.
12. The patient should then be rinsed in a head to toe fashion that minimizes contamination spread for about one minute. Overspray or holding the rinsing devise too close so as to irritate the skin should be avoided.
13. Decon Team members should be alert to the probability that the non-ambulatory patient may require ABC's support (airway positioning, suctioning, O₂ administration, spinal stabilization, etc.) and administration of life saving antidote administration by IM injection. If IV therapy is needed the extremity site for the IV should be deconned quickly before the IV is started. If IV therapy is needed the patient should be pulled out of line in the Decon Corridor but remain in the Decon Sector.
14. The patient should be dried off, put into a hospital gown, and transferred to a clean backboard (or clean off and dry the board they are on if additional boards are not available). Patients on an EMS stretcher should be transferred to a clean backboard.
15. Decon soap, brushes and sponges should be put into a trash can and not carried into the Cold Zone. O₂ material should remain in the Decon Sector.
16. The patient should be taken to the Triage Officer for rapid assessment and assignment to area in the Treatment Sector.

1. Patients with glasses should keep them if they cannot see without them. They must be washed and rinsed thoroughly during the decon process before being worn. Otherwise, the glasses should be placed in the valuables portion of the clothing bag.
2. Contact lenses should be removed and placed in the valuables portion of the clothing bag.

1. Patients who use walking assist devices may retain them, but the device must be washed with soap and water during the decon process before being allowed into the Treatment Sector.
2. Patients who are unsteady standing and/or walking should be given a walker upon entry into the Decon Corridor. The walker should be used to assist with ambulation until they get to the end of the line when it should be retrieved, deconned, and returned to the front of the Decon Corridor for the next patient who needs it.

1. Unless contaminated, percutaneous lines and saline locks should be covered with Tegoderm or Saran wrap before the area is decontaminated.
2. Contaminated percutaneous lines or saline locks should be removed before being decontaminated. After the area is cleaned, a dressing should be applied until in the Treatment Sector where antibiotic ointment and a new bandage should be applied.

1. Hearing aids CANNOT be immersed or otherwise be soaked with water. Thus, they should either be removed and placed in the valuables portion of the patient's clothing bag or if they must be used by the patient because there is no hearing without them, they should be carefully wiped off with a slightly saline moistened 4x4 gauze, dried off, put into a clear plastic bag, and handed to the patient. The cleaned hearing aid is NOT to be worn until the patient has completed the decon process (including washing the ears) and is in the Treatment Sector.

1. Unless the oral cavity is contaminated dentures should remain in place and no decontamination is necessary.
2. If the oral cavity is contaminated, then the dentures should be removed, placed in a clear plastic bag with the patient's name or clothing identification number placed on it. The dentures should later be decontaminated in accordance with instructions received from the Poison Center and/or a dentist. The patient's mouth should be decontaminated with mouthwash or saline that is gargled and safely spit out into a bio-hazard bag. Note that, depending on the contaminant, it may not be possible to decontaminate plastic items, such as dentures.

1. In most cases law enforcement personnel who have been injured on the scene will have had their gun(s) removed before arrival and given to a fellow officer. However, if that is not the case, the weapon should be left in the holster and the gun belt removed by a Decon Team member and placed in a clear plastic bag labeled with the patient's name and/or clothing number. The bag should then be passed to the Treatment Sector where it should be given to a fellow officer or hospital Security Officer for safe keeping until it can be given to a representative of the injured officers department. THE GUN SHOULD BE LEFT IN THE HOLSTER IF AT ALL POSSIBLE. If the gun must be removed, it should be handled by a Decon Team member familiar with firearms, rendered safe, placed in a clear plastic bag marked with the patient's name and/or clothing identification number, and given to a fellow officer or hospital Security Officer in the Treatment Sector.
2. Decon Team personnel should be aware that oftentimes an officer may have a backup weapon usually found in a holster near the ankle, in their pocket, in a ballistic vest, or near an armpit. The holster with the weapon in place should be removed and secured as described above.
3. An officer's gun belt may also contain items that could prove dangerous if allowed to get in the wrong hands. Thus, the belt should be collected and separately bagged ASAP and passed to a fellow officer or hospital Security Officer in the Treatment Sector. DECONNING OF AN OFFICER'S WEAPON AND/OR GUN BELT WILL BE THE RESPONSIBILITY OF THE POLICE DEPARTMENT.
4. If the officer is wearing a ballistic vest it must be removed prior to undergoing decon. The vest is usually easily removed by loosening the Velcro straps and then pulling the vest apart and off the patient. It should then be placed in a large plastic bag identified with the patient's name and/or clothing number on it and passed to a fellow officer or Hospital Security Officer in the Treatment Sector.

APPENDIX K
PPE Donning and Doffing Sequence

Appendix K
PPE Donning Sequence

1. Test PAPR flow rate to be sure it meets rate specified by the manufacturer.
2. Remove jewelry & clothing.
3. Put on inner nitrile gloves.
4. In COLD WEATHER: Put on inner suit. Tape gloves at wrist & zipper at neck.
5. In WARM WEATHER: Put on scrubs.
6. Put on outer chemical protective suit to waist. Put on boots & outer chemical protective gloves.
7. Connect PAPR to hood with hose; turn airflow on. Put on butyl hood (position the inside shroud between suits). Pull chemical protective suit up and on.
8. Ensure zipper is covered & secured, put tape on top.
9. Belt PAPR to waist.
10. Put outer butyl hood shroud over suit.
11. Stretch arms, pull suit sleeves OVER gloves, tape in place.
12. Pull suit cuff over boot top, tape in place.
13. Place a piece of tape on the hood exterior and label with the employee's name & time that employee is entering Hospital Decontamination Zone.

Appendix K
PPE Decontamination & Doffing Sequence

1. Wash hands thoroughly.
2. Still wearing PPE, wash self, starting at the top of the head and working down to the bottom of the boots. Have a partner wash your back.
3. Untape boots and gloves, but do not remove them.
4. Unlock PAPR and place it on chair/gurney/floor, etc.
5. Remove the outer suit—roll the suit away from you, inside out (with help from a partner). Remove outer gloves along with the outer suit.
6. Remove PAPR hood, place in waste.
7. Step out of boots and suit into final rinse area (keep inner gloves and clothing on). Wash and rinse thoroughly (with partner's help).
8. In COLD WEATHER: Remove (inner) suit, place in waste.
9. Remove nitrile gloves: first pinch one glove and roll it down partially, then place thumb in other glove & remove both gloves simultaneously.
10. Wash again, removing inner clothing, then step out of decontamination shower and into towels/blankets.

APPENDIX L
Example of Technical Decontamination Process for Hospital Personnel

Appendix L
Technical Decontamination Process for Hospital Personnel

1. Remove tape (if used), securing gloves and boots to suit.
2. Remove outer gloves, turning them inside out as they are removed.
3. Remove suit, turning it inside out and folding downward (first loosen and secure PAPR belt). Avoid shaking.
4. Remove boot/shoe cover from one foot and step over the clean line. Remove other boot/shoe cover and put that foot over the clean line.
5. Remove respirator. The last person removing his/her respirator may first wash all other respirator hoods or facepieces with soapy water and thoroughly wipe PAPR fan housing, then clean his/her own equipment before removing his/her suit and gloves. Place the masks in plastic bag and hand the bag over the clean line for placement in second bag held by another staff member. Send bag for decontamination. Discard items that cannot be effectively cleaned (e.g., it may not be possible to completely remove persistent contaminants from PAPR belts).
6. Remove inner gloves and discard them in a drum inside the dirty area.
7. Secure the dirty area until the level of contamination is established and the area is properly cleaned.
8. Personnel should then move to a shower area, remove undergarments and place them in a plastic bag. Double-bag all clothing and label bags appropriately.
9. Personnel should shower and redress in normal working attire and then report for medical surveillance.

APPENDIX M
Example of Integrated Procedures for First Receivers

	Policy #: Disaster Plan, 2002 Rev, Envir of Care Safety Manual
	Emergency Management Plan
INOVA HEALTH SYSTEM Emergency Management & Disaster Preparedness Plan
	Subject: ANNEX C- Chemically Contaminated Patient Care Protocol

1. Exposure to hazardous materials may produce a wide range of adverse health effects. The likelihood of an adverse health effect occurring, and the severity of the effects, are dependent upon:
1. The toxicity of the agent or pathogen
2. Route of exposure
3. The nature and extent of exposure to that substance
2. Toxic chemical effects may be localized at the site of exposure, or may result in systemic symptomatology after absorption into the blood stream.
3. The three main routes of exposure are:
1. Inhalation resulting in the introduction of toxic chemicals, radioisotopes, or pathogens via the respiratory tract. Most of the compounds that are inhaled are gases or vapors of volatile liquids. However, solids and liquids can be inhaled as dusts or aerosols. Inhalation of chemical agents generally result in a rapid absorption into the bloodstream because of the large surface and vascularity of the lungs. The signs and symptoms of pathologic exposure will usually occur 1–10 days after exposure.
2. Skin contact or absorption via mucous membranes is usually not as rapid as inhalation. Exposure can be through the mucus membranes (including conjunctiva) and open wounds.
3. Ingestion is a less common route of exposure. It can be the result of unintentional hand to mouth contamination or swallowing of saliva with trapped airborne particles. Or it may also be intentional, such as an oral ingestion for a suicide attempt.
4. In addition to the route of exposure, the amount of compound absorbed by the body depends upon the:
1. Duration of exposure
2. Concentration of contaminant
3. Time of exposure
4. Environmental factors
5. Response to toxic chemicals radiological agents and pathogens may differ among individuals because of the physiological variability present in the population.
1. Age
2. Preexisting medical conditions
3. Prior exposure
4. Medications
5. Concurrent injury
6. Pregnancy

1. Unannounced Arrival refers to a patient(s) that presents to the ED Triage Nurse or other healthcare provider. Once the healthcare provider determines a hazardous materials incident has occurred and contamination may be present he/she should:
1. Direct the patient outside the ED lobby entrance and proceed to the entryway of the decon room. Confine the patient in this location and remain with them.
2. Notify the charge nurse.
3. Notify security at Triage to secure the area.
4. Any persons the victim came in contact with, including the initial healthcare provider contact, should also be directed to the decon room until the extent of contact and the need for care can be determined.
5. If there are multiple patients affected, prepare to implement the mass decontamination procedure utilizing identified areas outside of the hospital facility but contiguous to the ED.
2. Announced Arrival is a patient already entered into the EMS system that arrives by ambulance. The major advantage created by pre-hospital notification is the provision of preparatory time and available clinical data and incident information from the field as well as initial intervention by EMS personnel. The arriving patient should be kept with the pre-hospital EMS personnel outside of the ED until the "decontamination team" is prepared to assume patient care.


Consultation with the referring agency as to the decontamination, if any, performed at the incident scene must occur prior to admitting these patients directly into the ED. This should depend upon the nature of the agent, degree of decontamination provided in the field, and suspicion of potential contamination upon visual inspection of the patient. If in doubt, have the patient go through decontamination at the hospital.
 

1. Communication Nurse
1. Determine caller's ID and telephone number.
• Type and nature of incident
• Number of victims
• Signs and symptoms being experienced by victim
• Nature of injuries
• Prior medical history of victim – meds and allergies
• Name of chemical involved and what information is readily available on product container if present
• Name of facility involved and/or type of contaminants found at facility
• Extent of victim decontamination in field
• Other medical interventions completed
• Estimated time of arrival (ETA)
2. Notify charge nurse.
3. Notify EMS Public Safety Communications Center (PSCC) of incident and request redirection of other ambulance traffic to ED lobby entrance.
4. If incident involves multiple patients, request that ED be placed on "reroute" status.
2. Charge Nurse
1. Consult with charge MD and assess the present patient capacity and acuity. If incident involves multiple patients, implement "Disaster Plan – Annex C."
2. Expedite movement of "admitted" patients to assigned beds.
3. Notify the ED Patient Care Director and Administrative Director as to the status of incoming contaminated patients. Consider the need for additional staff and resources and initiate response, if warranted.
4. Initially assign 2 nurses and 2 techs to the decontamination team.
5. Notify ED registration, triage nurse, and security.
6. Notify respiratory therapy and determine the number of adult/pediatric ventilators.
7. Determine number of available adult/pediatric beds.
3. Administrative Director
1. Notify security officers to redirect ED traffic and ambulances.
2. Notify physical plant staff.
3. Notify environmental services.
4. Notify Personal Health for follow up on staff involved.
5. Notify Media Relations to be available for purpose of public information if needed.
6. Notify Administrator-on-call that "Disaster Plan – Annex C" is being implemented.
4. Charge MD
1. Confer with ED Charge Nurse regarding the immediate need to implement the "Disaster Plan – Annex C" and assess the disposition status of existing patients in the ED.
2. Notify ED Chairman.
3. Notify Poison Control–obtaining available product info to decontaminate and care for patient(s), when available.
4. Notify critical care pharmacist with product info for anticipated antidote. Obtain inventory of available antidotes.
5. Determine appropriate level of Personal Protective Equipment (PPE) for Decon Team.
6. Assign MD and/or PA to Decon Team.
7. Direct 1–2 personnel to set up decon area and 1–2 persons to assist decon team with dress out procedures
5. Security
1. Secure entrances and exits to the ED.
2. Assist with traffic and crowd control around the ED
3. Will be responsible for maintaining "chain of custody" of personal belongings of patients undergoing decontamination. These items will NOT be individually catalogued, but rather placed in red biohazard plastic bags that will be tagged, numbered, and recorded.

1. Decon room preparation tech shall be assigned to:
1. Remove all non-essential and nondisposable equipment and items from established Hazmat/Decon wash room.
2. Activate drain switch to contain runoff, if available.
3. Obtain decon cart with necessary stocked items.
4. Obtain crash cart and place contiguous to Decon wash room.
5. Place D or E size O₂ tank with regulator.
6. Place clean stretcher in Hazmat/Decon wash room with additional O₂ tank, BVM, and non-rebreather mask.
7. Place stretcher outside of decon room on plastic ground cloth to receive non-ambulatory patient from ambulance.
8. Place bucket for soiled items used in wash room for technical decon.
9. Placed lined trash baskets in decon area for Biowaste.
10. Place Personal Decon Kits (PDK) in decon area.
2. Mass Decontamination Setup


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:
1. A hose bib splitter for each bib within 100 feet (within range) of the proposed decontamination area.
2. Two 100-foot hoses for each hose bib within range of the proposed decontamination area.
3. Four (2 sets) sawhorses to hold litter bound patients within the decontamination area and set of C-clamps.
4. Two backpack sprayers per facility.
5. Two baby pools per facility.
6. Four buckets for each hose bib within range of the proposed decontamination area.
7. Four scrub brushes for each hose bib within range of the decontamination area.
8. Duct tape, flashlights, permanent markers, soap, large trash cans, red biohazard bags, and towels.
9. One blood pressure cuff, stethoscope, and set of trauma scissors per litter decontamination station.
10. Towels and redress kits.
11. Two Geiger counters per facility (Reference "Disaster Plan – Annex R").
12. Two Bull horns per facility.
13. Polaroid camera with film or digital camera for later use in identification of moribund patients.
14. A locked, centrally located storage mechanism (cart, closet, etc.) for storage of the aforementioned items.
Included in this Annex is a schematic diagram for use in establishing a Mass Decontamination procedure that details the process flow of patients. This should be adapted to each individual healthcare facility.
 

1. Obtain appropriate personal protective equipment (PPE) as recommended by ED charge physician.
2. A minimum of 4 persons should don PPE.
3. Decon team personnel should undergo pre-entry medical monitoring as soon as possible. Only personnel meeting inclusion criteria, and having met the required training standards will be allowed to dress in PPE.
4. The Inova Health System has elected to use LEVEL C respiratory protection and chemical protective clothing as the highest level of protection available. LEVEL C respiratory protection is comprised of:


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:
• 2 layers of gloves
• chemical resistant suit (check for appropriate sizing)
• chemical resistant boots


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:
• Incident location (including area of significant downwind contamination) does not include your facility.
• Agent characteristics: Known or suspected agent doesn't require higher level of PPE (example: high-grade plutonium or other very rare agents).
• Event characteristics: Your facility is not being "overrun" by casualties.


Adjust the planned operations as indicated by the evolving circumstances. Possible adjustments include:
• Upgrading plan: more personnel protected, shorter rotation periods for PPE personnel, longer soap & wash cycles for victims, obtaining assistance from other hospitals or from emergency response resources.
• Evacuating or closing the facility to "shelter in place" if the hospital is in the zone of contamination.
• "Lock-down" of facility if agent, agent concentration, or the number of patients exceeds the safe operation of the plan or compromises the hospital integrity.
• Any need to isolate the decontamination wastewater (notify authorities to remove it per prior arrangement). Otherwise, notify "downstream" water authorities that decontamination wastewater is entering the sewer system.
• Downgrade the plan (lesser protective clothing and/or respiratory protection if agent is identified as non-threatening). This should be a high priority if possible, since safely downgrading the level of PPE will enhance the efficiency of the decontamination process.

1. Donning Procedures: Staff medical monitoring to be completed by assigned Registered Nurse (RN) or MD (use designated medical monitoring form included in this Annex). Use a room with privacy and plenty of sitting space to facilitate donning of PPE.
1. It is preferable that a scrub suit be worn in lieu of regular street clothes. Clothing should be suitable for preserving comfortable body temperature.
2. Remove all jewelry and leather material and place in plastic bag with your name on it—place in secure location for Security to maintain. Persons needing to wear glasses or with beards or mustaches are NOT to use a face mask device.
3. Persons with long hair should apply a hairnet or place up in a braid.
4. Hydrate with 8–16 ounces of fluid.
5. If time allows have blood pressure (BP), pulse, respiration rate, and temperature taken and recorded on Medical Surveillance form.
6. Obtain appropriate sized PPE ensemble pack or individual pieces, APR/ PAPR, battery, and appropriate cartridges (2–3 depending on APR/PAPR being used).
7. Layout PPE pieces and confirm they are right size and in working order.
8. Apply appropriate type of cartridges (most incidents will require HEPA/organic vapor cartridge set) and remove all pull-tabs. DO NOT OVERTIGHTEN the cartridges on the mask.
9. Put on latex or plastic inner glove—consider placing light circular band around top of glove to lessen chance of premature removal during doffing.
10. While sitting, remove shoes and place on foot covers (foot protection should not present tear risk to the suit nor be heelless).
11. Pull on chemical/biological protective suit to waist.
12. Place outer booties/boots on over the foot portion of the suit.
13. Using duct tape, seal top of booties to protective coverall (use a flap of tape at the end and place facing front to ease removal).
14. For chemical incident, place one set of nitrile gloves and one set of butyl rubber gloves on hands. For biological incident, use double plastic/latex gloves or plastic/latex and nitrile gloves.
15. Seal seam of protective suit and gloves with duct tape (use a flap of tape at the end and on the front of the wrist area to ease removal of tape).
16. Zip up protective suit to neck and close zipper securing and covering zipper seal.
17. If using PAPR, put on vest. Cinch up vest to snug fitting around with motor unit riding above the buttocks. Secure battery to the belt (side of the dominant hand is suggested) and plug in the PAPR. The air hose should come over the shoulder not under the arm.
18. Position APR/PAPR facepiece to ensure full visibility and comfortable fit. Tighten all bands in pairs by pulling them backwards and not up. Confirm tight seal by covering cartridge opening with hand and taking deep breaths—face shield should pull tight against face. If faulty seal is found, then retighten all bands and repeat seal test. If tight seal cannot be obtained, then seek second provider assistance or use hooded devise.
19. Pull suit hood up and over the head maximizing the coverage of the head, neck, and ears and covering the APR/PAPR seal edge around the face—ensure the suit is pulled up and fully under the chin and zipper is closed and covered. There should be NO EXPOSED SKIN.
20. Turn PAPR on, also making sure that all cartridge tabs are removed to allow airflow.
21. Have someone place a 3 in. piece of Velcro or tape across shoulders with staff member's last name and function (e.g., Jones RN) written with magic marker.
22. Have second person perform safety check before proceeding to assigned work area.
23. Note time personnel left the dress out area.
2. Ambulatory Patient Decontamination
• Children should be kept with their parents if at all possible; if no parent or older sibling is available then a Decon Team member should provide needed assistance to a child.
• Patient should be given Personal Decon kit as soon as it is available and be given rapid instructions on its use.


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.
1. If dry contaminant, remove first by using tape or dust off clothing or skin before wetting.
2. Have patient remove all valuables and place in the small plastic bag.
3. Clothing is removed and placed in the larger plastic bag. Place both bags into the red biohazard plastic bag. Place identifying tag with unique patient number on bag and seal off top. Place outside on ramp area for future disposition by Safety and Security.
4. Patient will do head-to-toe gross decontamination wash using mild soap and water. Have patient place ID band around wrist. This ID band will have the same identifying number that has been placed on the red biohazard plastic bag holding the patient's personal effects.
5. Special attention should be paid in the washing process to hair and all body crevices. Wash time cycle should be 5 (five) minutes per person under a single stream of water.
6. Water temperature should be tepid.
7. Washing should be gentle to avoid abrading skin.
8. Open wounds should be washed first with sterile water and covered with occlusive dressing prior to remainder of body decontamination.
9. Upon completion of wash cycle, patient should step away from the immediate wash area, towel dry, and put on a supplied Tyvek® gown from the Patient Redress Kit.
10. All ED towels and wash cloths used by patients in the showering process should be placed in a marked contaminated container for later clean up and decontamination.
11. Patient may then enter the ED, where the receiving RN can obtain vital signs, complete secondary triage, complete decon paperwork, and transport to an assigned bed in ED.
12. Decon team personnel should be decontaminated prior to entering the ED as described in Personnel (Technical) Decon section.
13. Soap should be changed out every five patients or whenever needed.
3. Non-Ambulatory Patients


In a mass exposure to chemical agents, non-ambulatory patients will most likely arrive after the initial arrival of ambulatory patients exposed in the same geographic location. Because of the trimodal distribution of injuries, non-ambulatory patients are likely to be more significantly exposed to the contaminating agent. Those who are most severely affected will be in the expectant category at the incident scene, and those who are least affected or only "potentially exposed" will arrive as ambulatory patients.

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.
1. Patient should be received on a backboard and stretcher by EMS staff. If incident involves a single non-ambulatory patient, utilization of the Emergency Department Decon Room may be considered. If multiple patients are expected, set up of the non-ambulatory mass decontamination corridor should commence.
1. Placement of saw horses with available C-clamps in order to secure backboards to the sawhorses.
2. Availability of water source for adequate decontamination, including use of backpack sprayers.
2. The Decon team for non-ambulatory patients must include a minimum of four (4) providers, two of whom will be responsible for turning the patient on the backboard and one who will be responsible for maintaining cervical spine precautions.
3. If the patient has not had a primary gross decon in the field (defined as the removal of clothing and first wash), visible particulate matter should be removed by gently brushing or dusting, and clothing should be cut and rolled away from the center of body, in order to contain the contaminants on the clothing.
4. Follow procedure for removal and bagging of personal valuables.
5. Follow procedure for head-to-toe decontamination wash cycle.
6. Irrigate open wounds with irrigation syringe and copious amounts of saline and cover with occlusive dressings. Any existing dressing must be removed and placed in bio-hazard trash container.
7. Eye irrigation may be done with Morgans lens and NS and/or IV tubing alone, if gross contaminants on the face are suspected. Otherwise, perform manual irrigation with copious fluids.
8. Gentle ear and nasal irrigation with frequent suctioning from portable suction may be done if such contamination is suspected.
9. C-collars as well as backboards must be washed or changed if they are still required for patient immobilization.
10. Patient should be transferred to a clean stretcher for entry into the ED.
4. Personnel (Technical) Decon


Prior to leaving the decon room the decontamination team must undergo decontamination.
1. All equipment used by the decon staff must be placed in appropriate receptacles or in bins designated for equipment which can be cleaned and reused. Refer to clean-up and recovery protocol for direction on rehabilitation of used equipment.
2. Decon staff will undergo a technical decontamination wash from head-to-toe involving the outer garments, gloves, and boots.
3. After the wash is complete, personnel should remove protective clothing in the following sequence:
1. Remove outer gloves, turning them inside out as they are removed and place in bio-hazard trash container.
2. Remove tape from wrist and boot tops.
3. Remove boots.
4. Remove suit, turning inside out and avoid shaking.
5. Remove APR mask or PAPR hood. The last member removing his/her respiratory protective equipment may take responsibility for washing all masks in soapy water. Refer to clean-up and recovery protocol.
6. Remove inner glove and discard into bio-hazard trash container.
7. Isolate all potentially contaminated materials until level of contamination is established and arrangements for cleaning and handling of trash and equipment can be determined.
8. Post-exposure medical monitoring should be initiated and new data recorded on the primary form.
9. Personnel should then remove scrub wear and shower and dress in replacement scrubs.
5. Emergency Decon

 
• Staff member distress is recognized.
• Staff member PPE immediately decontaminated with soap and water.
• PPE removed quickly in head to toe fashion in cold zone area. Medical care rendered as warranted.
   

1. Contain victims in area of incident until contamination is confirmed.
2. Administrative Director to be notified by area supervisor of incident site and specifics.
3. Hospital operator, notified by area supervisor, shall page ED charge nurse with HAZMAT location.
4. Hospital operator shall page Safety and Security to restrict access to the site.
5. ED charge nurse and ED charge physician assign HAZMAT team for response to site ONLY if patients are identified to be immediately in danger of exposure.
6. If Emergency Department HAZMAT team required to respond within facility have the communication nurse call PSCC to request ED "reroute" status and request Fire Department HAZMAT response per facility protocol.
7. The HAZMAT team should then dress in appropriate level of PPE for the given response. If unknown contaminant, dress in highest level of protection available.
8. The HAZMAT team responds to site bringing portable decontamination equipment for decontamination at a safe area closest to the site of incident.
1. Single patient – non-ambulatory bring 2 stretchers, one with containment cover and hose and container for runoff collection.
2. Ambulatory – bring kiddy pools (2) and backpack sprayers or large irrigation bottles for decon wash.
9. Decon shall be completed at site (as in previously described manner) until patient is clean enough for transport to ED for more definitive decon.
10. Transport to ED shall be on the clean stretcher with a clean transport team.
11. ED HAZMAT team to complete personal decon at the incident site prior to return to ED.

1. Medical monitoring is performed prior to donning PPE in order to:
1. Ascertain baseline vital signs.
2. Identify staff who will be disqualified from donning PPE and participating in the decontamination process due to pre-existing medical conditions.
3. Identify staff who may be at a higher risk for potential adverse effects while working in this environment.
2. Pre-entry physicals are required on all individuals in protective clothing and performing hazardous material operations. This is to be completed within one hour prior to entry, when possible.

1. Vital Signs
1. Blood pressure, pulse, respiration rate, temperature
2. Weight (estimated)
2. Skin evaluation for presence of:
1. Rashes
2. Lesions
3. Open wounds
3. Mental Status evaluation, including assessment of psychological stressors.
4. Medical History
1. Chronic illnesses
2. Recent illnesses
3. Medications, including OTC taken within past the 72 hours
4. Current symptoms of fever, nausea, diarrhea, vomiting, coughing, wheezing, or recent alcohol consumption.
5. Exclusion Criteria
1. Blood pressure: diastolic over 95
2. Pulse: greater that 70% maximum heart rate (220 - age) x 0.7 irregular rhythm not previously documented
3. Respiratory rate: greater than 24 per minute
4. Temperature: less than 97 or greater that 99.5
5. Weight or Size: inability to fit in available suit without causing undue strain on seams
6. Skin evaluation: open sores, large areas of rash, or significant sunburn
7. Mental status: any alteration
8. Recent medical history: nausea, vomiting, diarrhea within the past 72 hours, recent heat related injury, new prescriptions started within the past 72 hours.
9. Pregnancy

6. ENTRY Medical Monitoring
1. Performed before donning PPE.
2. Based on buddy evaluation by team member.
3. Observe for changes in gait, speech or behavior.
4. Any complaints of chest pain, dizziness, SOB, weakness, headache, nausea or vomiting should be reported.
5. Reporting of symptoms requires immediate personnel decon and removal from the decon site.
6. Personnel data should be recorded on HAZMAT Medical Monitor form (see attached).
7. POST-ENTRY Medical Monitoring
1. Vital signs repeated every 10 minutes until return to less that 85% of maximum pulse rate.
2. Oral rehydration started immediately upon completion of personal decon.
3. IV hydration and more aggressive medical evaluation shall be initiated for victims displaying medical illness and/or unstable vital signs.
8. The completed Hazmat Medical Monitoring form shall be forwarded to Employee Health for review and decision, if further evaluation is needed. The assessment form is to become part of the individual's occupational health file.
    

• Personal belongings and valuables of patients


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.
 
• Bio-hazard trash can contents


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.
 
• Towel discard bins


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.
 
• Wastewater effluent


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.

FOOTNOTES