Disclaimer

1
Disclaimer

• Specific products described or demonstrated
  during this session are provided as examples only
  and are not specifically endorsed by the
  presenters
• The views expressed in this session are not
  necessarily those of the U.S. Government, the
  National Disaster Medical System, nor the
  Chesapeake Health Education Program

2
Respiratory Protection Decision Making for
Health Care Providers

• April 21, 2004
• NDMS
• Dallas, TX

3
Objectives

• Review selected regulatory issues in respiratory
  protection
• Review threats to responders and data on provider
  injuries
• Discuss respiratory protection for
• Hospital first receivers
• Scene first responders
• Discussion and questions

4
Means of Hospital Arrival - Tokyo
5
Regulations

• JCAHO EC 1.4
• Provide decontamination services
• NFPA
• SARA Title III
• OSHA HAZWOPER 29 CFR 1910.120
• OSHA Respiratory Protection Standard 29CFR1910.134

6
HAZWOPER

• emergency response or responding to emergencies
  means a response effort by employees from outside
  the immediate release area or by other designated
  responders (i.e. mutual-aid groups, local fire
  departments, etc.) to an occurrence which
  results, or is likely to result, in an
  uncontrolled release of a hazardous substance

7
HAZWOPER - PPE

• employees engaged in emergency response and
  exposed to hazardous substances presenting an
  inhalation hazard shall wear positive pressure
  self-contained breathing apparatus while engaged
  in emergency response until such time that the
  individual in charge of the ICS (incident command
  system) determines through the use of air
  monitoring that a decreased level of respiratory
  protection will not result in hazardous exposures
  to employees

8
HAZWOPER - PPE

• When hospital staff do not know the airborne
  concentration of a hazardous substance created by
  a chemically contaminated patient or do not know
  specifically what the contaminant is, would staff
  members decontaminating the patient be required
  to wear a positive pressure self-contained
  breathing apparatus?
• - September 5, 2002 from Richard E. Fairfax to
  Francis J. Roth.

9
HAZWOPER - PPE

• the personal protective equipment they
  (hospital providers) need must be sufficient for
  the type and level of exposure the hospital
  anticipates under those conditions (eg what
  airborne or absorption hazards can be anticipated
  from a patient whose skin or clothing is wetted
  with hazardous liquids or contaminated with
  hazardous particles?)
• - September 5, 2002 from Richard E. Fairfax to
  Francis J. Roth. (also see December 2, 2002 from
  Richard E. Fairfax to Kevin J. Hayden)

10
OSHA White Paper

• HVA and EMP is critical and pre-requisite to
  decontamination and PPE planning
• PAPR with protection factor of at least 1000
• HEPA/organic vapor/acid gas filtration is minimum
• Rubber boots, double gloves (nitrile and butyl -
  USACHPPM), protective suit
• Minimum conditions to enable use of these
  protections are present in the document

11
Hazard Vulnerability Analysis

• Examines risk of community threats vs. impact and
  preparedness efforts
• Natural disasters, technological, industrial,
  terrorist incidents, and relation to human injury
• Required of communities and JCAHO accredited
  healthcare facilities
• Guides training, equipment, mitigation projects
• ASHE, JCAHO, others have good examples on web

12
Hazard Vulnerability Analysis
13
Top 10 causes of chemical injuries

• Acids 12.3
• Ammonia 10.9
• Bases 2.9
• Chlorine 2.8
• Inorganics NOS 16.1
• Paint/dye 1.3

• Pesticides 7.3
• Mixtures 7.6
• Volatile organic 19.3
• Polychlorinated biphenyls 0.2
• Other 19.3

14
Historical Threats - Responders

• ATSDR 1995-2001
• 44,015 HAZMAT events
• 3455 with victims (13, 149)
• 5 required hospital admission
• 437 police officers (3.3)
• 272 professional firefighter (2.1)
• 176 volunteer firefighter (1.3)
• EMS personnel 72 (0.5)
• Horton, DK et.al.

15
2001 ATSDR data

• 8,978 events
• 710 events caused injury to 2,168 victims
• Respiratory irritation 1,145 injuries
• 22 deaths overall
• 274 responder injuries
• 3 deaths firefighters at hardware store fire
• 1 death police officer at meth lab
• LE 72 of injuries at transportation events,
  42 at fixed facility events

16
Historical Threats - Responders

• Responder injuries 1996-1998
• Respiratory irritation
• Nausea
• No deaths
• Acids and other substances involved
• About 50 wore turnout gear, 1/3 had HAZMAT
  training

17
Historical Threats - Hospital

• 1995-2001
• Six events injured 15 personnel
• Meth labs (2), pepper spray, HF, Cl gas,
  malathion
• 0.15 of all HAZMAT victims were ED personnel
• Respiratory and eye irritation
• No PPE used
• Isolated case reports
• Ethyldichlorosilane
• Aluminum phosphide
• Petroleum products

18
Organophosphate experiences

• Tokyo
• 110 hospital and 135 EMS personnel reported sx
• 6 MDs treated, none seriously affected
• Suicidal ingestion exposures, US
• At least one provider required intubation
• At least two providers required hospital
  admission
• At least two other cases have caused less severe
  respiratory symptoms

19
Threats to Providers

• Biologic agents
• HEPA filtration with appropriate respirator
• Chemical terrorism agents
• Particularly organic vapors and acid gases
• Dusts and debris
• Including radiologic contaminated
• Industrial, criminal, household known and unknown
  agents
• Oxygen deficient environment?
• Applies to some providers

20
Roles and Responsibilities

• LEPC, MMRS, Urban Security Initiative, other
  multi-agency stakeholder groups are good places
  to start
• Define the expectations of your agency or
  facility in the community response
• Help prioritize your needs for equipment and
  training relative to the community plan
• Standardize regionally (training and equipment)
• Plan, train, equip, exercise, rinse and repeat

21
Community Resources

• Fire
• EMS
• Law Enforcement
• Healthcare

• Emergency Management
• Private Sector Infrastructure / Assets
• LEPC

22
Particular Issues

• What is the role of your personnel?
• Clean patient care
• Decontamination
• Hazard recognition and initial defensive actions
• Hazard containment actions (offensive)
• What zone could you be operating in?
• Could the warm zone come to you?
• What is the environment that your personnel will
  be providing services in? (open air, closed room,
  court of law)

23
Levels of PPE

• Four levels of Chemical Protective Ensemble as
  specified by OSHA
• Each has advantages and disadvantages
• NONE of these is appropriate for all
  circumstances
• These ensembles offer no protection against fire,
  explosion, gamma radiation, or telemarketers
• These were not developed with healthcare facility
  use in mind

24
Level A All wrapped up
Total encapsulation Heavy, bulky suit Very
expensive, cumbersome
25
Level B Breathe air
Note air supply is external to suit Minimum level
of protection to enter release (hot) zone
with agent unknown May be on air hose with
escape bottle (SAR) SCBA limited to 20 min
approx
26
Level C Cartridge filtered
Filters air, does not supply air Powered models
provide higher levels of protection vs.
mask type NOT sufficient for hot zone
27
Level D Dumbo
28
SCBA
29
SAR
30
APR/PAPR
31
Training and Medical Surveillance

• 29CFR1910.134
• Medical surveillance and screening
• Training requirements for respirators initial
  and refresher
• 29CFR1910.120
• Operations Curricula 8h or to competance
• Hospitals 8h can include Awareness training,
  PPE training, other relevant training
• (OSHA Bolt letter 2003)

32
Minneapolis / St. Paul Hospitals

• MSP MMRS
• Hospital equipment should be standardized
• Hospitals should provide decontamination only,
  not response to site of release
• Decontamination only in well-ventilated areas
• Protect against
• Biologic agents (HEPA)
• Organic vapors
• Ammonia
• Acid gases
• Potential agents of terrorism

33
BE 10 PAPR with FR57 filter

• Protects against
• HEPA filtered for biologics
• Filters radon daughters and beta particles
• Organic vapor nerve agents, organophosphates,
  etc.
• Cyanide (CN)

• Ammonia
• Chlorine and other acid gases
• Phosgene
• Riot control agents
• Mustard
• Formaldehyde
• Methylamine
• Hydroflouric Acid

34
MMRS PPE

• 3M BE PAPR with FR57 canisters
• Tyvek SL / Tychem F
• Nitrile undergloves, neoprene or butyl overglove
• Butyl boots
• Duct tape