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Transcript of Coming Clean about Hospital Decontamination Presentation to: 8 Hour Operations Class Presented by:...
Coming Clean about Hospital Decontamination
Presentation to: 8 Hour Operations Class
Presented by: DPH Trainer the Trainers
Date:
Question 1:
During decon, hospitals must
make an attempt to capture
and retain as much runoff from
victim and/or mass casualty
decontamination operations as
possible to comply with EPA
and other environmental laws.
Reality
Myth
The Facts
• Protecting the environment should NEVER be considered ahead
of protecting people.
• Contaminated people cannot have enough chemical on them to
seriously harm the environment.
• The perceived liability cause by potential environmental damage
is FICTION. Liability from delaying decon of victim is a FACT.
• The EPA agrees: The victims come first!
• “First Responders’ Environmental Liability Due to Mass
Casualty Decontamination Runoff” (Chemical Safety ALERT
July 2000)
Question 2:
• OSHA requires that hospital decon
teams learn and know how to use
the DOT ERG.
• This Guide will provide useful
information to help the decon
control officer in selecting proper
PPE and determining specific
hazards. Reality
Myth
• It provides absolutely no useful chemical information to
determine proper hospital MCI decon.
• It provides no accurate information to suggest the correct
PPE for hospital decon operations.
• It provides no specific chemical properties.
• It was developed only to aid 1st responders in quickly
identifying hazardous materials and protecting themselves
and the public during the INITIAL response phase of a
hazardous materials incident.
The Facts
• Water should not be used on people who
are contaminated with almost all of the
Class 4 water-reactive substances.
• Hospitals should have a plan for dry
victim decon or should use water
sparingly to avoid contact with the
substance on skin.
Question 3:
Reality
Myth
• Water should be used for water-reactive materials, but
only low pressure, high-volume.
• Garden hoses do not apply “copious” amounts of water
and can result in dangerous reactions.
• Dry decontamination of victims and responders increases
the dangers of the contamination.
• Every fire department in the USA has one or more “decon
units” (pumpers/engines).
The Facts
Oxidizers and Organic Peroxides
should be quickly washed from the
shoes and clothing of contaminated
victims because there is a chance
the victim’s clothing could
spontaneously ignite at any time.
Question 4:
Reality
Myth
• Organic Peroxides may have a Maximum Safe Storage
Temperature (MSST) or Self Accelerating
Decomposition Temperature (SADT), causing them to
react with heat.
• Many Oxidizers will self-ignite when they dry out on
clothing.
• Both classes like to decompose when contaminated
with organics, acids, etc.
• If you make contaminated victims wait for decon, you
may place them in great danger.
The Facts
• A MSDS provides accurate
information to hospitals for
decontamination, PPE, and
medical care to victims
contaminated with a known
substance.
• The MSDS also provides
specific information for
medical treatment.
Question 5:
Reality
Myth
• Material Safety Data Sheets rarely provide
accurate information about victim
decontamination or medical care beyond first
aid.
• The MSDS for the same chemical differ
between the manufacturers.
• MSDS’s mostly say use copious amounts of
water to wash product off the skin/eyes.
The Facts
• Victim decontamination should never be delayed while determining the proper soap or other additives.
Question 6:
Reality
Myth
• The rapid use of low pressure high volume water and quick disrobing are the best decon solutions.
• Initial decon operations don’t require soap or
additives to remove most chemicals.
• “Additives” or decon-solutions may cause
reactions if used without professional advice.
• Brushes of any kind are not recommended nor
required to decontaminate the skin.
• Soap dilutes quickly in decon buckets.
• After a few victims, the soap is gone and
effectiveness of brushing decreases.
The Facts
Cool or cold weather decontamination operations
should not be delayed to wait for the decon
shower water to be heated or “tepid.”
Question 7:
Reality
Myth
• Heating decon water is not very practical
because it delays decontamination and
heaters cannot heat large volumes quickly
enough.
• Great for secondary decon/personal
showers
• Cold water is uncomfortable but it does not
induce hypothermia when the people are
warmed quickly afterwards.
• U.S. Army Soldier and Biological Chemical
Command (SBCCOM) decon studies concur
The Facts
Over 1.6 million people
contaminated with a
nerve agent could be
decontaminated in an
Olympic-sized swimming
pool before the pool
became too
contaminated for further
decon.
Question 8:
Reality
Myth
• SBCCOM Cold Weather Decon Study
• Assumptions: 3,000,000L pool – Dose Brought
into pool by each person GB-100mg or VX-.1mg
• Calculation Results… 1,668,000 people for VX or
GB
• Comments: From the calculations above the
resultant number of people that could be put in a
pool without exceeding the no effects level has
been reduced by 50% to add an additional margin
of safety. In summary, for the agents above (GB
and VX) approximately 800,000 people could be
processed.
The Facts
The deluge system replaces the use of internal and
external showers during the
decontamination process.
Question 9:
Reality
Myth
• Removal of clothing and gross decontamination reduces the risk but does not eliminate the risk
• The triangle from armpits to groin is where the emphasis should be during secondary contamination
The Facts
OSHA requires that
hospitals establish 3
zones for their
decontamination
operation (Hot – Warm –
Cold) to control people
keeping them safer, and
avoiding secondary
contamination
Question 10:
Reality
Myth
• OSHA Best Practices for Hospital-Based 1st Receivers (January
2005) B.3.1 page 17 of 91
• “OSHA has found it appropriate to define two functional
zones during hospital-based decontamination activities.”
These zones, which guide the application of OSHA’s
recommendation are:
• Hospital Decon Zone: Includes any areas where the type and
quantity of hazardous substances is unknown and where
contaminated victims, equipment, or waste may be present.
This area typically ends at the ED Door
• Hospital Post-decontamination Zone: An area considered
uncontaminated. Equipment and personnel are not
expected to become contaminated in this area. (includes
the ED (unless contaminated)).
The Facts
Ammonia and Chlorine, two
very common industrial
chemicals, may cause severe
respiratory distress, skin burns,
and even death to victims, BUT
victim decon is simple because
there is very little chance of
adverse impacts on either the
decon workers or the
environment.
Question 11:
Reality
Myth
• Most gases do not create a hazard for decon workers,
even nerve agents.
• Chlorine and Ammonia are very corrosive but they off-
gas and dissolve in decon water.
• Concentrations may be IDLH when the victim is
contaminated, but below the Permissible Exposure
Limit/Time Weighted Allowance (PEL/TWA) by the time
they are in the warm zone at the incident site.• If the victim is still alive the danger to the protected
decon worker is usually minimal.
The Facts
• Pre-hospital
decontamination can
eliminate the risk of
secondary exposure.
• Removing contaminated
clothing can reduce the
quantity of the
contaminant by up to 25%
Question 12:
Reality
Myth
• Pre-hospital decontamination will limit the
risk of secondary exposure, not eliminate it.
• Removing clothing will reduce the quantity
of the contaminant by 75 % or more.
• SBCCOM Mass Casualty Decon Study.
The Facts
Clinicians, security officers,
triage teams and other
hospital staff members who
play a role in receiving and
treating contaminated
patients are considered by
OSHA to be 1st Receivers.
(same as the hospital’s
decon workers).
Question 13:
Reality
Myth
• OSHA Best Practices for Hospital-Based 1st Receivers
(January 2005) A.2 page 8 of 91
• “First Receivers typically include personnel in the
following roles: clinicians and other hospital staff who
have a role in receiving and treating contaminated
victims (e.g. triage, decontamination, medical
treatment, and security) and those whose roles
support these functions (e.g. set up and patient
tracking)”
• First Receivers are a subset of First Responders
The Facts
OSHA’s Best Practices for
Hospital-Based First
Receivers does not
include/cover infectious
outbreaks for which decon is
not needed.
Question 14:
Reality
Myth
• OSHA Best Practices for Hospital-Based 1st
Receivers (January 2005) A.2 page 8 of 91
• The scope of this best practices document does not
include situations where the hospital (or temporary
facility) is the site of the release. Nor does it
include infectious outbreaks for which
decontamination is not necessary.
The Facts
Hospital employees
assigned the task of
developing the
decontamination program,
procedures, and PPE
selection criteria require
additional training beyond
the 1st Receiver Operations
Level than the hospital
decon team members
require.
Question 15:
Reality
Myth
• OSHA Document 3152 (1997) “Hospitals and
Community Emergency Response What You Need to
Know” Training Employees - 7th page
• Individuals who develop the decontamination procedures
and select PPE for the workers who help decontaminate
patients, must be trained to the First Responder level
(changed to First Receiver in 2005) with additional training
in decontamination procedures, but such individuals would
not need the lengthy specialized training required for a
hazardous materials technician.
The Facts
When training hospital
decon teams, the
competencies identified
in the OSHA standard
for the Operations Level
can be deleted or
tailored to fit the
expected tasks.
Question 16:
Reality
Myth
• Interpretive Letter 12/2/02 to Capt. Kevin Hayden State of
N.M. E.M. Section (page 2)
• Generally, all competencies listed in 29 CFR 1910.120 (q) (6) (ii)
should be met for hospital employees trained to the First
Responder Operations Level designated to decontaminate victims.
• Competencies may be tailored to fit the tasks the employees are
expected to perform.
• For instance, placard recognition is not required as a basic hazard
and risk assessment technique. The ability to identify placards is
important for a Hazmat Team, but not for hospital personnel
designated to perform decontamination.
The Facts
OSHA requires
Awareness Level
training be completed
before Operations
Level Training begins
and Operations training
must be at least 8
hours in duration.
Question 17:
Reality
Myth
• Interpretive Letter 9/24/02 to Scott Cormier HCA
Richmond Market Hospitals (page 2)
• Question 4- Is a training course that combines the first responder
awareness level and first responder operations level competencies in
one 8 hour course acceptable?
• OSHA’s Reply: “Yes. The statement in the VA letter that a total of 16
hours of training is required for the first responder operations level
is not correct.”
• I.L. 4/22/03 to Mike Bolt Novant Health states, “If you spend two
hours training employees in the required competencies for the
Awareness Level, then you would need to spend at least six hours
training for the Operations level.”
The Facts
OSHA requires that
hospitals provide a
minimum of 8 hours of
annual refresher
training for staff
trained to the First
Receiver Operations
Level.
Question 18:
Reality
Myth
• Interpretive Letter 9/24/02 to Scott Cormier HCA
Richmond Market Hospitals (page 2)
• Question 5: Is there a minimum competency or hour
requirement for refresher training ?
• OSHA’s Reply: “No. There is no minimum time specified
for emergency response refresher training. The training
must be of sufficient content and duration to maintain the
competencies for the responder’s level. Alternately,
employees may demonstrate those competencies at least
annually.”
The Facts
• The employer (hospital)
is the only one who can
certify an employee to
any OSHA Hazwoper
Level.
• A public or private
training agency cannot
officially certify any
employee but their own.
Question 19:
Reality
Myth
• Interpretive Letter 12/2/91 to Richard Andree S&H Mgt.
Consultants Inc. (page 2)
• OSHA does not certify individuals, it is the employer who must show by
documentation or certification that an employee’s work experienced and/or
training meets the requirements of 1910.120.
• There must be a written document which clearly identifies the employee, the
person certifying the employee and the training and/or past experience which
meets the requirements.
• Interpretive Letter 3/10/99 to Daniel Burke St. John’s
Mercy MC. St. Louis (page 1)
• Hazwoper requires the employer to certify that the workers have the
training and competencies listed in (q) (6) (ii)
The Facts
Clinical hospital staff
without 1st Receiver
training may enter a
contaminated decon
zone without any prior
1st Receiver and/or PPE
training, if they are
deemed “skilled
support personnel.”
Question 20:
Reality
Myth
• OSHA Best Practices for Hospital-Based 1st Receivers (January 2005) C.3
page 22 of 91
• (A) A member of the staff who has not been designated, but is
unexpectedly called on to minister to a contaminated victim, or perform
other work in the hospital Decontamination Zone, is considered “skilled
support personnel.” Examples include a medical specialist or trade
person such as an electrician.
• These individuals must receive expedient orientation to site operations,
immediately prior to providing such services. The orientation must
include:• Nature of hazard (if known)• Expected duties• Appropriate use of PPE• Other appropriate safety and health precautions ( e.g.
decontamination procedures)
The Facts
Federal OSHA is
responsible for
enforcing 1910.120
“Hazwoper” in private
hospitals only, except
in OSHA States where
Federal OSHA does not
enforce OSHA
standards.
Question 21:
Reality
Myth
• Interpretive Letter 12/2/02 to Capt. Kevin Hayden State of N.M. E.M.
Section (page 3)
• State and municipal employees (e.g. EMS/Fire) are covered by the standard
in those states which operate their own Federally approved State OSHA
Program. In those states under Federal OSHA , the EPA regulates State and
Local employees including volunteers under 40 CFR 311.
• Interpretive Letter 12/2/02 to Capt. Kevin Hayden State of N.M. E.M.
Section (page 3)
• Federal OSHA has no jurisdiction over state and local government
employees such as the public employees of a state-owned hospital.
Twenty three states operate programs that cover both private and public
sector employees.
The Facts
While an environment
that is immediately
dangerous is possible,
it is extremely unlikely
that a living victim
could create an
Immediately Dangerous
to Life and Health
(IDLH) environment at a
receiving hospital.
Question 22:
Reality
Myth
• OSHA Best Practices for Hospital-Based 1st Receivers (January 2005)
B.2.1.1 page12 of 100
• The Georgopoulos Study of 2004 determined that 100 grams or 4 ounces of
the most moderately to highly volatile substances that might be sprayed on
a victim during a MCI would evaporate within 5 minutes from the time the
exposure occurred.
• Horton Study (2003) agreed stating that substances released as gases or
vapor are not likely to pose a secondary contamination risk to 1st Receivers.
Limited exposure may be possible.
• Quote: “It is extremely unlikely that a living victim could create and
Immediately Dangerous to Life (IDLH) environment at a receiving hospital,
particularly if contaminated clothing is quickly removed and isolated and the
victim is treated and decontaminated in an area with adequate ventilation.”
The Facts
OSHA Hazwoper
requires hospitals to
conduct basic pre-entry
medical surveillance for
decon workers and
those who use chemical
protective clothing and
respirators before they
begin work in their PPE.
Question 23:
Reality
Myth
NFPA 471 is only a standard and does not require
medical assessment before entry.
OSHA 1910.120 (f) Requires the following medical
surveillance for hazmat team members:
Prior to assignment and upon termination or reassignment
Once every 12 months or 2 years if physician deems
appropriate
If they exhibit signs or symptoms, injure, or exposed above
Permissible Exposure Limits (PEL)
Physician may require more frequent medical surveillance
The Facts
Because Hazwoper is a
“performance-based”
regulation hospitals are
allowed flexibility in
meeting the
requirements. They are
not required to follow
any specific procedures
or guidelines in OSHA
1910.120.
Question 24:
Reality
Myth
• OSHA Document 3152 (1997) “Hospitals and
Community Emergency Response What You
Need to Know” Training Employees 7th page:
• Hazwoper is a performance-based regulation allowing
individual employers flexibility in meeting the
requirements of the regulation in the most cost-
effective manner.
• There are numerous examples of this decision in
many Interpretive Letters.
The Facts
Question and Comments