Detail basic management procedures, including decontamination of a chemical agent attack on a health care facility.
A chemical event, whether it happened outside the hospital or where the hospital was the primary target would essentially be handled the same except within the hospital itself; adjustments would have to be made, since part of the hospital would be contaminated along with the personnel in contact with the agent.
Decontamination would have to be done internally along with on-going treatment in another area of the hospital, or moved to other facilities. If the contamination was confined to a portion of the hospital, the A/C and vacuum system would have to be shut down and the area closed. If the entire facilities was affected, as with a gas attack, the entire facilities would have to be evacuated and patients moved to another facilities and decontamination set up as described in the following discussion.
If the event was within the confines of the hospital then this would also present a security issue, since the perpetrator (s) may still be in the immediate area and could cause more problems unless identifies and apprehended. They could be planning a secondary attack so it probably would be better to evacuate the facilities and set up in another area.
Decontamination is the removal or reduction of chemical agents on an object or person. This may be done by physical means, chemical neutralization or detoxification. In the civilian sector it most probably would be by physical means, i.e. clothing removal and washing with soap/water or flour followed by wet tissue wipes.
Decontamination basically accomplishes two purposes: 1.Removes the contaminant from the person to prevent further damage. 2. Prevents chemical contamination of the hospital, therefore keeping the hospital “clean “for patient care.
Decontamination of chemical casualties is an enormous task. The process requires dedication of both a large number of personnel and a large amount of time. Even with appropriate planning and training, decontamination demands a significant amount of resources. The critical resources are PPE equipment, linen, multitude of staff to relieve on the various positions on the decontamination line, and security to protect the hospital and control the perimeter.
The most important and effective decontamination of any chemical exposure occurs within the first minute or two post-exposure. This is self- decontamination (probably not possible in the civilian sector). The military are trained in this procedure and have specific kits (M291) to accomplish this. In the civilian sector decontamination would have to be handled in the field by first responders or in a designated, equipped decontamination area near the treatment facilities or hospital. Because of the time frame it is almost impossible to do decontamination at the site of the event. By the time the first responders arrive and setup, those patients that can walk will self refer to the hospital and only the severely injured will be on-site for the first responders to treat.
I will assume that the first responders and hospital personnel have been trained in decontamination (hospital having had the FEMA course HERT) and have available equipment to accomplish this task when the event occurs.
The chemical used in the event could be pulmonary, cyanide, vesicants, nerve agents or incapacitating agents. The basic decontamination method for any of the above is irrigation with water and removal of clothing (removing clothing will in itself remove about 90-95% of contaminant). If the first responders arrive early on, a decontamination area, using two fire pumper trucks, can be set up parallel with tarp over the top to create a passage way, where patients can be directed and sprayed with water. This is not as good as if they were disrobed (which is not going to happen in the field) but it is better than nothing and will remove some of the contaminant.
Hopefully, the EMS system had practiced this scenario and have called the hospital and alerted them to the event and type of chemical, if known. The hospital should immediately lock down the facility, notify the HERT team, set up the preplanned decontamination protocol, and activate the HICS team’s CP with the necessary equipment.
The primary purpose of the decontamination at the hospital is to remove the contaminant from the patient prior to the patient entering the emergency room for treatment, thus keeping the hospital free from contamination (chemical).
All casualties coming to the hospital after a chemical event are assumed to be contaminated, even if decontaminated in the field, until certified to be ‘clean’ after passing through the decontamination tent. They are then checked by CAM (chemical agent monitor) and only if “clean” are they allowed into the ER. If found to still be contaminated they will be sent back through the decontamination line or spot cleaned and rechecked.
Of the possible chemicals used in a terrorist event, only vesicants and nerve gas might present a hazard problem within any open wound present on the patient.
The ideal decontamination set up at the hospital is listed in bullet format.
1. First responders to scene, decontaminating the patients with water, if possible. Assess the scene as to what happened, number of casualties, type symptoms, describe the event (fire, explosives, gas release, etc., inform the hospital what type injuries to expect), number of survivors and deaths, agent used, if possible, severity of injuries, and start triage. I assume the first responders will be fire, police and EMS, so the appropriate authorities will be notified and disaster plan put into effect.
2. Notify the hospitals as to findings in #1. Notify the command center and declare a MCI alert
3. Hospital locks down with security at each entrance; one controlled entrance for patients and one entrance for call- in staff.
4. CP set up in hospital. HICS operational–operations, planning, logistics, and finance/records.
5. The Safety Officer, a part of the command staff and reports to the IC, is a key player in the decontamination process. He should monitor the entire process to insure safety for the hospital personnel as well as the patients. He has the authority to stop or change any unsafe operations.
6. Hospital Emergency Response Team (HERT) activated and begins setting up decontamination equipment in the ER area, about 30 meters from the entrance.
7. Check the weather and set up decontamination tent downwind from ER entrance if possible.
8. Maintenance sets up traffic barriers to have one way entrance to ER. Egress routes established-one way in and one way out. Routes are needed for both vehicles and foot traffic.
9. Notify wrecker service (previously arranged by mutual agreement) to stand by to move any vehicle that blocks the roadway.
10. Perimeter established around hospital to keep on-lookers and the “worried well” outside the area.
11. Security (armed with live ammunition) where ambulances and people enter to check for weapons or explosives. (Hospital is good secondary target.) At this point have barriers arranged in a manner that patients will be funneled into the registration area. Ideally, the entrance where security is checking the patients and ambulances should be at least 50 meters from decontamination area.
The patients will then be triages into immediate, delayed (walking wounding), non ambulatory, and green (no decontamination needed). From here they will proceed to the disrobing area and segreated by gender.
12. The decontamination tent is set up about 30 meters from ER entrance. There will be three separate lanes through the tent.
· Patients with ALS needs. They will be taken immediately to a special room in ER for ALS care and decontamination
· Patients that can walk through the decontamination line and soap and wash themselves
· Non ambulatory patients that requiring direct assistance for decontamination by hospital personnel.
13. All personnel on the decontamination line would have PPE level C, which consist of:
· PAPR with loose fitting hood and appropriate filter cartiage.
· Full face shield
· Chemical resistant suit
· Waterproof, chemical-resistant boots.
14. At the decontamination entrance point there would be personnel to:
· Register patients
· Take all personal items from patients and secure with I.D. tags.
· Geiger counter to check for radiation
· All clothing removed, bagged and labeled “contaminated”
· All children under 6 Y.A. stay with mother regardless of sex. All above 6 years old go through the appropriate line.
· Ambulatory patients can use soap and water in showers
to wash, under the direction of hospital personnel.
· All non- ambulatory patients will be disrobed and placed on a conveyer line that will have six personnel to scrub bodies with soap and water along with pressure showers with a rate of one person/ seven (7) minutes.
· At the end of the decontamination line personnel will check each patient to assure decontamination is complete. This will be done with M-8 paper, M-9 tape and CAM (Chemical Agent Monitor). Placed in hospital gowns and if certified “clean” moved into the ER for treatment, and if not, spot cleaned or returned to the decontamination tent for re- showering.
· Although OSHA will give some leeway on disposal of contaminated waste water during an emergency, it is critical that the hospital develop decontamination and waste water containment plans.
· All reasonable measures must be taken by the hospital to capture waste water runoff.
15. As any time in the above process there is an ALS problem with the patient, it is taken care of at that time. If necessary, to address life threatening problems, transfer to an isolation unit in the ER for treatment.
16. The personnel on the decontamination line cannot stay in the PPEs, depending on the temperature, over 30-45 min. The planning section in CP should be setting up a relief schedule with the personnel for rotation on the decontamination line.
17. Logistics should be inventorying linen and if they do not have enough for the event start calling supplies since this is a “choke” point in the process.
18. At the entrance point it is always prudent to have a psychologist and/or social worker to meet the patients, and if necessary, address emotional problems with disrobing. (It is said “why would anyone complain about disrobing if the decontamination will save their life”. This is a flash point, when you separate families and you ask a wife to disrobe with her husband there. Be prepared address the problem or the line will stop there.)
19. If the chemical event happened in the hospital the same procedure for decontamination would take place but the facilities would have to be rearranged. The areas that were contaminated would have to be closed off or cleaned. The contaminated personnel would have to go through the decontamination line set up at the ER entrance.
20. If a patient has an imbedded object or an open wound, the area should be irrigated and covered with a marking to indicate imbedded object. Only a doctor should remove the object, either in the decontamination line or in the hospital.
21. When the event is declared over, the decontamination equipment and the decontamination area must be decontaminated and this is usually done from the clean area to the dirty area.
22. The event is not closed until all personnel in the HICS CP concur.
23. An AAR should be held at some point after the event.
24. Algorithm for Chemical Decontamination In a Hospital Setting. This setting can be changed to fit the geography of the hospital.
25.A recommended list of equipment for patient decontamination is attached:
· Staff PPE
Full face shield
Hood or hair covering
Gloves
Water repelling gown
Rubber boots
· Equipment list
Waterproof triage tags
Sealable plastic bags, size small & large to accommodate belongings and clothing
Paper bags
Labels
Permanent marker
Mild soap
Sponges
Long handle brushes
Buckets
Hoses with gentle flow, controlled nozzles with hot and cold water
Showers—multiple heads
Plastic pallets to prevent slippage (minimum of three)
Water contamination/collection system
Gowns and /or suits for patients to don post decontamination
Towels and blankets
Self Decon “trash bag” kits
Tents or pre-fabricated decon tents
Modesty screens, portable screens
Rope and tarps, barrier tape
Duct tape, scissors, traffic cones, megaphones, plastic totes for hospital equipment
Laminated decon instructions in different languages ( community specific)
References:
1).Medical Management of Chemical Casualties Handbook U.S. Army Medical Research Institute of Chemical Defense (USAMRICD) Aberdeen Proving Ground, MD. 3rd ed. 2000
2.) Textbook of Military Medicine: Medical Aspects of Chemical and Biological Warfare Office of Surgeon General 2005
3.) Hospital Emergency Response Team (HERT) FEMA Ft. McClellan, Ala. 2006
4. ) Hospital and Healthcare Systems Disaster Interest Group. Califormia Emergency Medical Services Authority 9/2004
www.emsa.ca.gov/dms2/recommendations.doc
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