HazMat for Healthcare: An Awareness Level Course

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HazMat for HealthcareAn Awareness Level Course

• Module I

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Who needs to take the Awareness level course?

• EMS personnel who are likely 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.

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Who needs to take the Operations Level Course?

• EMS personnel who respond to a HazMat release as
  part of the initial response in a defensive
  action and contains the release from a safe
  distance.

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Regulations

• The Occupational Safety and Health
  Administration (or its state equivalent) has a
  mandate to ensure that employers provide a safe
  and healthful workplace.
• The primary standard applicable to this program
  is called Hazardous Waste Operations and
  Emergency Response (HAZWOPER).

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Regulations (cont.)

• Training categories in the Emergency Response
  section of the HAZWOPER Standard are
• First Responder-Awareness
• First Responder-Operations
• Hazardous Materials Technician/Specialist
• Hazardous Materials Incident Commander
• Hazardous Materials Skilled Support Personnel

Defensive
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Haz Mat for Healthcare at the Awareness Level

• Objectives
• What are
• Hazardous Material Incidents?
• The risks and problems that can occur?

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AwarenessObjectives, continued

• How can we
• Recognize an incident
• Identify characteristics of a chemical
• Respond safely and effectively
• Make proper notifications
• Isolate the scene and deny entry
• Conduct Directed Self-Decon

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CMT Policy and Procedure for Hazardous Materials
Incidents

• Policy
• 1. CMT will participate, when available, in local
  Hazardous Materials Incident Plans
• 2. AT NO TIME ARE FILED PERSONNEL AUTHORIZED OR
  EXPECTED TO PLACE THEMSELVES IN DANGER!

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Policy continued

• 3. If a potential hazardous material incident is
  identified prior to arriving on scene
• A. Advise CMTs dispatch center to contact the
  appropriate County Fire Control or 911 dispatch
  center for dispatch of the nearest Fire
  Department and the HAZMAT team.
• B. Post at a sufficient distance away from the
  scene,preferably upwind, as to avoid
  contamination.
• C. Follow the direction of the HAZMAT team or
  Fire Department upon their arrival.

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Policy continued

• 4. If a potentially hazardous material incident
  is not identified prior to entry of the scene
• A. DO NOT HANDLE OR DISTURB ANY SUBSTANCE OR
  MATERIAL!
• B. Exit from the scene
• C. If you have been contaminated, be aware not to
  cross contaminate any clean areas.
• D.Advise CMT dispatch to contact appropriate
  County Fire Control and dispatch nearest Fire
  Department and HAZMAT team.
• E. Follow the direction of the fire department
  and the HAZMAT team upon their arrival

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Awareness Objectives, continued

• Implementing the Hazmat Response Process
• -Awareness Level

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Definition of a Hazardous Material

• There is no one definition.
• OSHA definition Hazardous Chemical Any
  substance to which exposure results or may
  result in adverse affects on the health or safety
  of employees or any chemical which is a
  physical hazard or a health hazard. 29 CFR
  1910.1200 (c)

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What does the regulation state?

• "Hazardous substance" means any substance
  designated or listed under (A) through (D) of
  this definition, exposure to which results or may
  result in adverse effects on the health or safety
  of employees
• A Any substance defined under section 101(14)
  of CERCLA
• B Any biologic agent and other disease causing
  agent which after release into the environment
  and upon exposure, ingestion, inhalation, or
  assimilation into any person, either directly
  from the environment or indirectly by ingestion
  through food chains, will or may reasonably be
  anticipated to cause death, disease, behavioral
  abnormalities, cancer, genetic mutation,
  physiological malfunctions (including
  malfunctions in reproduction) or physical
  deformations in such persons or their offspring.
• C Any substance listed by the U.S. Department
  of Transportation as hazardous materials under 49
  CFR 172.101 and appendices and
• D Hazardous waste as herein defined.

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Examples of Hazardous Materials(OSHA Hazardous
Waste Operations and Emergency Response Standard
29 CFR 1910.120 Title 8 5192 CCR)

• Chemicals that cause cancer
• Biohazards or infectious materials
• Chemicals that can burn the skin or eyes on
  contact
• Radioactive materials

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Examples of Hazardous Materials(Continued)

• Chemicals that can catch fire or explode
• Chemicals that can cause violent chemical
  reactions
• Poisons
• Unknown chemicals

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Hazardous Materialsin Hospitals

• Internal incidents where the spill originates
  onsite and is limited to the facility and,
• External incidents that occur offsite and are
  brought to the hospital (either through a plume
  of hazardous material or by contaminated patients
  accessing the facility for treatment.)

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What are the impacts of Hazardous Materials
incidents on

• To YOU
• To YOUR COMMUNITY
• To the HOSPITAL
• To the EMERGENCY DEPARTMENT

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• Exercise

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Nomenclature and Accuracy
SIN

• TLAs - three letter acronyms
• Glossary

WMD
PPE
OSHA
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Hazard Classes and things that act like them
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Emergency Response Guidebook

• Identify potential hazards by using the emergency
  response guidebook from a safe distance away.

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Explosives (Class 1)

• External
• Commercial explosives
• Fireworks
• Ammunition
• Fertilizer bombs (Ammonium nitrate fuel oil)
• Hydrazine (A flammable liquid. Forms explosive
  mixtures hypergolic - a high energy rocket
  fuel, corrosive and poisonous)

• Internal
• Powder Actuated Cartridges

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Compressed Gases (Class 2)

• Internal
• Acetylene
• Propane
• Oxygen
• Nitrogen
• Nitrous Oxide
• Carbon Dioxide
• Anesthetic Gases
• Medical Air
• Argon

• External
• Hydrogen Sulfide
• Phosgene
• Methyl Bromide
• Ammonia

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Flammable/Combustible Liquids (Class 3)

• Internal
• Diesel
• Alcohols
• Xylene
• Methyl Methacrylate
• Methyl Ethyl Ketone

• External
• Gasoline
• Hydrazine
• Methanol
• Diesel
• Acetone

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Flammable Solids (Class 4)

• Internal
• Barium

• External
• Aluminum phosphide
• Naphthalene
• Sodium
• Carbon

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Oxidizers Organic Peroxides (Class 5)

• External
• Red Fuming Nitric Acid (a corrosive)
• Nitrogen Tetroxide
• Ammonium Nitrate
• Methyl Ethyl Ketone Peroxide
• Fluorine, Chlorine (also poison, compressed gas,
  corrosive)

• Internal
• Oxygen (actually a compressed gas or cryogenic
  liquid)
• Peroxyacetic Acid

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Poisonous Infectious Materials (Class 6)

• Internal
• Phenol (Carbolic Acid)
• Chemotherapy drugs
• Biohazardous Waste
• Blood Borne Pathogens
• Solvents
• Sewage
• Vesicants (blistering agent, Doxorubicine,
  Vincristine)
• Mercury
• ETO (ethylene oxide)
• Glutaraldehyde Formaldehyde

• External
• Pesticides
• WMD (Sarin, VX)
• Solvents
• Bioterrorism
• Tear Gas
• Vesicants (mustard gas, Lewisite)

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Radioactive Materials (Class 7)

• External
• Terrorist use
• Military Facilities
• Nuclear Reactors
• Commercial/Research facilities
• Industrial x-ray material

• Internal
• Nuclear Medicine

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Corrosive Materials (Class 8)

• External
• Pool chemicals
• Sulfuric acid
• Nitric acid
• Muriatic acid
• Sodium Hydroxide
• Chlorine, Fluorine

• Internal
• Lab acids (e.g., Hydrochloric Acid)
• Boiler treatment caustics

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Miscellaneous. Hazardous Materials (Class 9)

• Internal
• Hazardous waste
• Asbestos
• Anesthetics

• External
• Pepper spray/mace
• Molten Sulphur

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Unknown chemicals

• Internal
• Most of these are known

• External
• Limitless

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Internal Spills

• For example, lets look at a class of
  chemicals-the Aldehyde sisters-
• Form and
• Glut

Thanks to Kaiser Permanente Western Environmental
Health Safety Service Hub for permission to
modify their aldehyde presentation.
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Healthcare Uses of Formaldehyde

• Tissue Fixation and Preservation
• Dialysis equipment disinfection
• Stool specimen preservation
• Reticulum staining
• Biological Safety Cabinet decontamination
• Pharmacy compounding

• Pathology / Morgue
• Operating Room
• Labor and Delivery
• Hemodialysis
• Emergency Room
• Waste Storage
• Shipping Receiving

Formaldehyde Use Areas
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Formaldehyde Potential Adverse Health Effects

• Dermal Skin Irritant (dermatitis, cracking,
  scaling) Sensitizer.
• Inhalation Direct irritant at 1.0 ppm.
  Sneezing, coughing, sore throat. Chronic
  exposures may cause asthma and increase risk of
  pneumonia and bronchitis. Can cause olfactory
  fatigue.
• Eye Contact Transient discomfort to severe,
  corneal clouding/loss of vision.
• Ingestion Burning of mouth, pharynx, stomach.
  37 causes severe irritation, inflammation, and
  even death.

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Formaldehyde Health Effect Levels
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Healthcare Glutaraldehyde Uses

• Cold sterilizing and disinfecting solution
• As a component of X-ray film processing
  chemicals
• Histology Pathology Fixative ingredient

• Gastroenterology (GI)
• Operating Room or Ambulatory Surgery
• Respiratory Therapy
• Urology
• Sterile Processing
• Obstetrics/Gynecology
• Ultrasound/Radiology
• Histology/Pathology

Glutaraldehyde Use Areas
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Glutaraldehyde Health Effects -

• Eyes Clear dose-response relationship for
  conjuctival and corneal injury. Lowest
  concentration producing minor corneal injury is
  1 0.2 for conjunctival irritation.
• Skin Function of site on body, time of contact,
  concentration, and condition of skin. Threshold
  concentrations for primary dermal irritation
  under occlusive conditions on sensitive skin is
  about 0.4 solution. However, concentrations of
  up to 5 may not induce an irritant effect when
  applied briefly to bare skin.
• Respiratory The threshold for peripheral sensory
  irritation of the respiratory tract is 0.3 ppm.
  Short-term repeated exposure to Glutaraldehyde
  vapors in concentrations from 0.2 to 3.0 ppm
  shows a steep dose-response for toxicity and
  moderately severe irritation effects.

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Summary of Health Hazards

• In spill situations, both formaldehyde and
  glutaraldehyde have the potential to pose a
  significant threat to the respiratory system,
  skin or eyes.
• Proper selection of respiratory protection and
  protective clothing is key to mitigating risk to
  personnel during spill clean up. (Covered in FRO.)

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Definition of Spill Types

• Incidental Spill - Spill that can be cleaned up
  in first 10-15 minutes without risk of
  overexposure (above Cal/OSHA short-term or
  Ceiling Limits) to employees under normal
  conditions. (May be FRA.)
• Emergency Response Spill - Requires Haz Mat
  Response if risk of overexposure to employees.
  (Tech)

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Key Factors In Response

• Any one of these factors can affect the type of
  response
• Time - Vapor levels rise above regulatory levels
  before response occurs
• Volume of Spill - Surface area
• Concentration
• Ventilation - Type and location
• Spill Control Product - Some work better than
  others
• Personnel Location - closer worse

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Spill Response OptionsNeutralization/Absorption
Products

• Neutralizers react with the aldehyde and convert
  it to a non-hazardous product.
• Inert Absorbents capture the aldehyde but it
  still possesses its hazardous qualities.

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General Spill Clean-up Options

• Implement permanent engineering controls that
  will reduce exposure risk - could be floor
  exhaust, increased over-all exhaust, emergency
  exhaust fan.
• Departmental staff to apply spill control product
  (if available and trained) and work fast to
  minimize exposure. (FRA?)
• Clean up if an Incidental Spill and have been
  trained.
• Isolate and deny entry until qualified personnel
  arrive to evaluate/clean up. (FRA)
• Internal or external spill clean-up team (Tech)

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External Events

• We mentioned every day external events that can
  occur.
• So now,
• Lets talk about terrorism

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What is terrorism

• The unlawful use of force against persons or
  property to intimidate or coerce a government,
  the civilian population, or any segment there of,
  in the furtherance of political or social
  objectives.

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Types of Weapons of Mass Destruction (WMD)

• B - Biological
• N - Nuclear
• I - Incendiary
• C - Chemical
• E - Explosive

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Terrorism is a menace, with malice. A chemical
terrorism event (the NC of B-NICE) is a
Hazardous Materials Incident. A biological
terrorism event (the B of B-NICE) is an
Infectious Disease Outbreak. A fire or
explosion terrorism event (the IE of B-NICE)
is a Burn and/or Mass Casualty-Trauma Incident.
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Biologic Terrorism Is an Infectious Disease Event

• Types of Agents
• Bacteria
• Anthrax Plague Tularemia
• Viruses
• Smallpox Hemorrhagic Fevers (Ebola)
• Venezuelan equine encephalitis (VEE)
• Toxins
• Botulism Ricin

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Chemical Terrorism Is a Haz Mat Event

• Types of Agents
• Nerve - Sarin VX
• Blister (vesicants) - Mustard Lewisite
• Blood - Cyanide
• Choking - Chlorine Phosgene
• Irritating - Tear Gas Pepper Spray

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Potential Probability vs. Impact
NUCLEAR WEAPON
BIOLOGICAL AGENT
IMPROVISED NUCLEAR DEVICE
CHEMICAL AGENT OR TOXIC INDUSTRIAL CHEMICAL
POTENTIAL IMPACT
RADIOACTIVE MATERIAL
PROBABILITY/LIKELIHOOD
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Hazardous Materials Recognition Safety

• Recognition leads to safety
• Safety leads to lives preserved

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Not Always Reported as Hazmats

• Internal
• Spilled liquids

• External
• Traffic accident
• Medical aid
• Fire, person down, etc.

Initial report may not indicate presence of
hazardous materials!
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Haz Mat Recognition Clues
Markings and Colors
Placards and Labels
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Haz Mat Recognition Clues Material Safety Data
Sheets

• Should be available for each Haz Mat in the
  workplace
• Required by OSHA Hazard Communication regulations
• Provides valuable information

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Scene Clues

• People running from area
• People collapsed in the area
• Evidence of a leak
• Fire
• Vapors
• Unusual colors/ odors
• Loud roar or increased pitch of a valve

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Senses

• Last resort!
• Highest danger!

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Clues are Clues!

• They are a,
• Warning
• Note of caution
• Indication of things to come
• But not always all the answers!

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Watch Closely
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Triage CluesEMS

• Liquids or powders on the patient
• Odors
• What were they doing when this happened?
• Where were they?
• How long ago did the accident occur?

Need to recognize and act fast
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Information Resources

• Container Labels
• MSDSs
• Poison Control
• ERG
• ATSDR
• Computer programs
• People

Do not rely on only one source of information.
Be skeptical!!
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Definition - SIN

• S Safety
• I Isolation
• N Notifications
• Internal Spills
• and
• Contaminated
• Patients

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SAFETY (First, last, and always)

• Dont be a Dead Hero!
• Get the big picture.
• Can you handle it?
• What are the risks?
• What do you know?
• What dont you know?

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ISOLATE

• Isolate the scene and deny entry.
• (If someone has something on them dont let them
  go away. If others havent been exposed dont
  let them have contact with the chemicals.)
• Dont let yourself become contaminated!

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Perimeters Control Zones

• Purpose of Perimeters Control Zones
• Ensure safety and isolation
• Control the scene
• Limit spread of contamination
• Allow for safe working area

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Control Zones

• Exclusion / Hot / Red Zone
• Contamination Reduction / Warm / Yellow Zone
• Support / Cold / Green Zone . This is where CMT
  employees should be ONLY!

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Control Zones
Contamination Reduction Zone
Exclusion Zone
Support Zone
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NOTIFY

• Call Dispatch and notify them of a potential
  HAZMAT situation
• DISPATCH WILL THEN CALL
• Supervisor
• Haz Mat Coordinator
• Local Fire agency

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Directed Self Decontamination

• What are your first concerns?
• Is this patient contaminated with a hazardous
  material?
• How can contamination be minimized?
• How can the patient be managed so that he can
  receive medical care?

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Directed Self Decontamination (continued)

• What are your first actions?
• S
• Do not touch the patient or allow anyone else to
  have patient contact.
• I
• Get them out to a predesignated location!!!!
• N
• Activate your Companies protocol for a hazardous
  material incident.

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How soap (surfactants)works.

• Soap molecules are composed of a head (that likes
  water, hydrophilic) and a tail (that likes oils,
  hydrophobic/oleophilic)
• Soap
• breaks the surface tension of the water and make
  the water,wetter.
• also attracts the water soluble and oil soluble
  contaminants and sends them away.

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Trash Bag Decon

• intended to allow for
• placing potentially contaminated clothing in
  double clear plastic bags
• placing valuables in a separate sealable clear
  plastic bag
• tracking of patients
• clothing a decontaminated patient

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COMPLETION FORM

• Click here for second half