Distance Learning Working Group at HSPH John Spengler, ChairNancy Kane
Hospital Decontamination Jonathan L. Burstein, MD, FACEP HSPH-CPHP.
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Transcript of Hospital Decontamination Jonathan L. Burstein, MD, FACEP HSPH-CPHP.
Hospital DecontaminationHospital Decontamination
Jonathan L. Burstein, MD, FACEPJonathan L. Burstein, MD, FACEP
HSPH-CPHPHSPH-CPHP
The ProblemThe Problem
Hundreds of patients coming inHundreds of patients coming in
Do they need decon?Do they need decon?
Can I clean them?Can I clean them?
The RoadmapThe Roadmap
Do I really need to do this?Do I really need to do this?
How can I do it?How can I do it?
How can I protect my self and staff?How can I protect my self and staff?
How can I get it done?How can I get it done?
Do I Really Need to Do This?Do I Really Need to Do This?
The care imperativeThe care imperative– WMDWMD– Common events (industrial, lab)Common events (industrial, lab)
The regulatory imperativeThe regulatory imperative– JCAHO, OSHAJCAHO, OSHA
The financial imperativeThe financial imperative– To get state and Federal grantsTo get state and Federal grants
The publicity imperativeThe publicity imperative
ThreatsThreats
Weapons of mass destructionWeapons of mass destruction– Mainly, chemical or radioactiveMainly, chemical or radioactive
FiresFiresTransportation accidentsTransportation accidentsIndustrial accidentsIndustrial accidentsInternal spills (lab, chemo, radioactives)Internal spills (lab, chemo, radioactives)
Do a Hazard Vulnerability AnalysisDo a Hazard Vulnerability Analysis
Tokyo Sarin AttackTokyo Sarin Attack
Tokyo, March 20, 1995Tokyo, March 20, 1995
5 bags of sarin punctured in 5 5 bags of sarin punctured in 5 subway trainssubway trains
12 dead12 dead
5500 “sick” patients5500 “sick” patients
St. Luke’s Hospital (520 beds)St. Luke’s Hospital (520 beds)– Treated 500 patients in first hour; 640 Treated 500 patients in first hour; 640
on first dayon first day
Conyers, GA 2003
Explosives…
Decon???
Madrid, 11 March 2004
Radiation Is Easily DetectableRadiation Is Easily Detectable
ED door monitors?
Anthrax 2001-2002Anthrax 2001-2002
Decon? Or Prophylaxis? Decon? Or Prophylaxis?
JCAHOJCAHO
““Health Care at the Crossroads”, 2003Health Care at the Crossroads”, 2003– Emergency preparedness as key goalEmergency preparedness as key goal
Environment of Care StandardsEnvironment of Care Standards– Protect employeesProtect employees– Protect facilityProtect facility– Protect patientsProtect patients
OSHA and OthersOSHA and Others
OSHA regulates employee safetyOSHA regulates employee safety
NIOSH “certifies” equipmentNIOSH “certifies” equipment
CDC provides medical informationCDC provides medical information
EPA regulates pollutionEPA regulates pollution
Someone will fine you…Someone will fine you…– ……if you expose an employeeif you expose an employee– ……if you use the wrong gearif you use the wrong gear– ……if you contaminate the environmentif you contaminate the environment
OSHA Draft GuidanceOSHA Draft Guidance
www.osha.gov/dts/osta/bestpractices/firstrwww.osha.gov/dts/osta/bestpractices/firstreceivers_hospital.pdfeceivers_hospital.pdf
In brief:In brief:– Yes, you need to do itYes, you need to do it– PAPR’sPAPR’s– 8 hour staff training minimum8 hour staff training minimum
Finance and PublicityFinance and Publicity
Work with the governmentWork with the government– HRSA and CDC (Focus D) moneyHRSA and CDC (Focus D) money
Work with industryWork with industry– Financing from manufacturersFinancing from manufacturers
Public drills look goodPublic drills look good
Public evasion looks badPublic evasion looks bad
GoalsGoals
Need to do at least few-patient deconNeed to do at least few-patient decon– At any timeAt any time– With own resourcesWith own resources
May need to do or help with mass deconMay need to do or help with mass decon– Usually with help, e.g. FDUsually with help, e.g. FD– Need to practiceNeed to practice
Need to protect and train staffNeed to protect and train staff
Decon OptionsDecon Options
Outdoors (wading pools)Outdoors (wading pools)
TentsTents– OutsideOutside– InsideInside
RAM DeconRAM Decon
TrailersTrailers
IndoorsIndoors– Multipurpose roomMultipurpose room– Dedicated roomDedicated room
Slow, clumsy
Quick, easy
Cheap
Dear
Decontamination Tent
“RAM Decon”
Hospital’s Trailer
Local FD Trailer
““Mass” Decon UnitMass” Decon Unit
Undress Decon Dress
• 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,
A permanent hospital decon room
Basic RequirementsBasic Requirements
Contain contaminationContain contamination
Control environmentControl environment
Protect staffProtect staff
Allow deconAllow decon
Contain runoffContain runoff
Allow cleanup or disposalAllow cleanup or disposal
Patient through-putPatient through-put
Standards?Standards?
American Institute of ArchitectsAmerican Institute of Architects– For roomsFor rooms
NFPA and ASTMNFPA and ASTM– For some field devicesFor some field devices
NIOSH eventuallyNIOSH eventually
Really, it’s still caveat emptorReally, it’s still caveat emptor
Try before you buyTry before you buy
Staff PPEStaff PPE
Levels of PPELevels of PPE– A: big suit, big tankA: big suit, big tank– B: little suit, big tankB: little suit, big tank– C: little suit, little maskC: little suit, little mask– D: no suit, no maskD: no suit, no mask
Level A for entryLevel A for entry
Level C for known hazardLevel C for known hazard
Level B or C for unknown?Level B or C for unknown?
Level B with supplied air
Level C with PAPRLevel C with PAPR
C minus
Standard (Universal) Standard (Universal) PrecautionsPrecautions
GownGown
GlovesGloves
MaskMask– N95 HEPA, to upgrade N95 HEPA, to upgrade
for plague or smallpoxfor plague or smallpoxRESPIRATORY RESPIRATORY PRECAUTIONSPRECAUTIONS
Shoe coversShoe covers
For RAD or BIO: level D plus
Level B vs. Level CLevel B vs. Level C
Training timeTraining time– 8 hours vs. 40 hours8 hours vs. 40 hours– B training requires escape bottles (OSHA)B training requires escape bottles (OSHA)
Equipment CostEquipment Cost– About $4000 per person for BAbout $4000 per person for B– About $1000 per person for CAbout $1000 per person for C
But is C safe???But is C safe???
Case ReviewCase Review
Sarin in TokyoSarin in Tokyo– No decon, no PPENo decon, no PPE– 472 hospital workers surveyed472 hospital workers surveyed– Over 100 symptomaticOver 100 symptomatic– 1 admitted1 admitted
HSES data 1996-1998HSES data 1996-1998– 44,015 events44,015 events– 3,455 events produced 13,149 victims3,455 events produced 13,149 victims– 5% were admitted5% were admitted
Annals of Emergency Medicine 42:3, September 2003Annals of Emergency Medicine 42:3, September 2003
Case Review Cont.Case Review Cont.
HSES 1996-1998HSES 1996-1998– 348 responder exposures348 responder exposures
Mostly PD and FDMostly PD and FD
– 6.6% admitted6.6% admitted– No deathsNo deaths
HSES Healthcare dataHSES Healthcare data– 11 events produced 15 HCW exposures11 events produced 15 HCW exposures
Mix of organo, pepper, HF, chlorine, solventsMix of organo, pepper, HF, chlorine, solvents
– 5 of these were INTERNAL to the facility5 of these were INTERNAL to the facility– No admissionsNo admissions
Case Review Cont.Case Review Cont.
OrganophosphatesOrganophosphates– GA case (suicide): one HCW intubated, one other GA case (suicide): one HCW intubated, one other
admitted, 2 more needed antidotesadmitted, 2 more needed antidotes– 4 anecdotal cases, no admissions4 anecdotal cases, no admissions
Outside USOutside US– Several cases reported, no PPE, but no admissionsSeveral cases reported, no PPE, but no admissions
ModelingModeling– C is enough for compounds more volatile than sarinC is enough for compounds more volatile than sarin
Case Review LessonsCase Review Lessons
Most HCW exposures are vaporMost HCW exposures are vaporOrganophosphates are the most Organophosphates are the most dangerous (judged by admit rate)dangerous (judged by admit rate)Level C would have been enough even in Level C would have been enough even in these settingsthese settings
Govt. agencies are considering similar Govt. agencies are considering similar data, may change recommendationsdata, may change recommendations– VA, NIOSH, HRSA (Hospital program)VA, NIOSH, HRSA (Hospital program)
How Do I Get It Done?How Do I Get It Done?
NeedsNeeds– MoneyMoney– Interested staffInterested staff– Competent trainersCompetent trainers– Institutional commitmentInstitutional commitment
MoneyMoney
FederalFederal– HRSA, CDCHRSA, CDC– DHS (work with public safety?)DHS (work with public safety?)
State or LocalState or Local
IndustryIndustry
Own facilityOwn facility
StaffStaff
CommittedCommitted
CompetentCompetent
TrainableTrainable
Low turnoverLow turnover
Present 24/7 in numbers (4 minimum)Present 24/7 in numbers (4 minimum)
Clinical? Maintenance? Custodial? Clinical? Maintenance? Custodial? Security? Safety? All?Security? Safety? All?
TrainingTraining
InternalInternal– Hospital basedHospital based
ExternalExternal– FD-basedFD-based– IndustrialIndustrial
Refresher training built into systemRefresher training built into system– Employee orienttation? Annual “special Employee orienttation? Annual “special
teams” training?teams” training?
Institutional CommitmentInstitutional Commitment
Doing the right thingDoing the right thing
Doing something to protect the institutionDoing something to protect the institution
Doing something for good publicityDoing something for good publicity
Doing something to avoid bad publicityDoing something to avoid bad publicity