Hospital Decontamination

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Hospital Decontamination

• Jonathan L. Burstein, MD, FACEP
• HSPH-CPHP

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The Problem

• Hundreds of patients coming in
• Do they need decon?
• Can I clean them?

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The Roadmap

• Do I really need to do this?
• How can I do it?
• How can I protect my self and staff?
• How can I get it done?

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Do I Really Need to Do This?

• The care imperative
• WMD
• Common events (industrial, lab)
• The regulatory imperative
• JCAHO, OSHA
• The financial imperative
• To get state and Federal grants
• The publicity imperative

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Threats

• Weapons of mass destruction
• Mainly, chemical or radioactive
• Fires
• Transportation accidents
• Industrial accidents
• Internal spills (lab, chemo, radioactives)
• Do a Hazard Vulnerability Analysis

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Tokyo Sarin Attack
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Tokyo, March 20, 1995

• 5 bags of sarin punctured in 5 subway trains
• 12 dead
• 5500 sick patients
• St. Lukes Hospital (520 beds)
• Treated 500 patients in first hour 640 on first
  day

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Conyers, GA 2003
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Madrid, 11 March 2004
Explosives Decon???
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Radiation Is Easily Detectable
ED door monitors?
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Anthrax 2001-2002

• Decon? Or Prophylaxis?

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JCAHO

• Health Care at the Crossroads, 2003
• Emergency preparedness as key goal
• Environment of Care Standards
• Protect employees
• Protect facility
• Protect patients

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OSHA and Others

• OSHA regulates employee safety
• NIOSH certifies equipment
• CDC provides medical information
• EPA regulates pollution
• Someone will fine you
• if you expose an employee
• if you use the wrong gear
• if you contaminate the environment

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OSHA Draft Guidance

• www.osha.gov/dts/osta/bestpractices/firstreceivers
  _hospital.pdf
• In brief
• Yes, you need to do it
• PAPRs
• 8 hour staff training minimum

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Finance and Publicity

• Work with the government
• HRSA and CDC (Focus D) money
• Work with industry
• Financing from manufacturers
• Public drills look good
• Public evasion looks bad

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Goals

• Need to do at least few-patient decon
• At any time
• With own resources
• May need to do or help with mass decon
• Usually with help, e.g. FD
• Need to practice
• Need to protect and train staff

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Decon Options
Cheap
Slow, clumsy

• Outdoors (wading pools)
• Tents
• Outside
• Inside
• RAM Decon
• Trailers
• Indoors
• Multipurpose room
• Dedicated room

Quick, easy
Dear
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Decontamination Tent
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RAM Decon
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Hospitals Trailer
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Local FD Trailer
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Mass Decon Unit
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• 92 Mass Decontamination Units issued to Fire
  Departments in Massachusetts
• One Decon company in Each Fire District and One
  Decon Company protecting each hospital emergency
  department,

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A permanent hospital decon room
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Basic Requirements

• Contain contamination
• Control environment
• Protect staff
• Allow decon
• Contain runoff
• Allow cleanup or disposal
• Patient through-put

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Standards?

• American Institute of Architects
• For rooms
• NFPA and ASTM
• For some field devices
• NIOSH eventually
• Really, its still caveat emptor
• Try before you buy

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Staff PPE

• Levels of PPE
• A big suit, big tank
• B little suit, big tank
• C little suit, little mask
• D no suit, no mask
• Level A for entry
• Level C for known hazard
• Level B or C for unknown?

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Level B with supplied air
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Level C with PAPR
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C minus
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Standard (Universal) Precautions

• Gown
• Gloves
• Mask
• N95 HEPA, to upgrade for plague or smallpox
• RESPIRATORY PRECAUTIONS
• Shoe covers

For RAD or BIO level D plus
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Level B vs. Level C

• Training time
• 8 hours vs. 40 hours
• B training requires escape bottles (OSHA)
• Equipment Cost
• About 4000 per person for B
• About 1000 per person for C
• But is C safe???

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Case Review

• Sarin in Tokyo
• No decon, no PPE
• 472 hospital workers surveyed
• Over 100 symptomatic
• 1 admitted
• HSES data 1996-1998
• 44,015 events
• 3,455 events produced 13,149 victims
• 5 were admitted
• Annals of Emergency Medicine 423, September 2003

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Case Review Cont.

• HSES 1996-1998
• 348 responder exposures
• Mostly PD and FD
• 6.6 admitted
• No deaths
• HSES Healthcare data
• 11 events produced 15 HCW exposures
• Mix of organo, pepper, HF, chlorine, solvents
• 5 of these were INTERNAL to the facility
• No admissions

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Case Review Cont.

• Organophosphates
• GA case (suicide) one HCW intubated, one other
  admitted, 2 more needed antidotes
• 4 anecdotal cases, no admissions
• Outside US
• Several cases reported, no PPE, but no admissions
• Modeling
• C is enough for compounds more volatile than sarin

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Case Review Lessons

• Most HCW exposures are vapor
• Organophosphates are the most dangerous (judged
  by admit rate)
• Level C would have been enough even in these
  settings
• Govt. agencies are considering similar data, may
  change recommendations
• VA, NIOSH, HRSA (Hospital program)

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How Do I Get It Done?

• Needs
• Money
• Interested staff
• Competent trainers
• Institutional commitment

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Money

• Federal
• HRSA, CDC
• DHS (work with public safety?)
• State or Local
• Industry
• Own facility

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Staff

• Committed
• Competent
• Trainable
• Low turnover
• Present 24/7 in numbers (4 minimum)
• Clinical? Maintenance? Custodial? Security?
  Safety? All?

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Training

• Internal
• Hospital based
• External
• FD-based
• Industrial
• Refresher training built into system
• Employee orienttation? Annual special teams
  training?

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Institutional Commitment

• Doing the right thing
• Doing something to protect the institution
• Doing something for good publicity
• Doing something to avoid bad publicity