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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 Fires Transportation accidents
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. Luke’s Hospital (520 beds) Treated 500 patients in first hour; 640 on first day
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Conyers, GA 2003
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Explosives… Decon??? Madrid, 11 March 2004
Scenes from the 2004 Madrid train bombing. Bombings are actually a likely threat, as opposed to the NBC weapons. Explosives… Decon???
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Radiation Is Easily Detectable
Geiger counters and ionization detectors. These devices require training, but are not that hard to use. ED door monitors?
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Anthrax 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OSHA Draft Guidance In brief: Yes, you need to do it PAPR’s 8 hour staff training minimum
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Finance and Publicity Work with the government Work with industry
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 Outdoors (wading pools) Tents RAM Decon Trailers Indoors
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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Hospital’s Trailer
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Local FD Trailer
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“Mass” Decon Unit Transfer boards on center roller system
Show and explain graphic
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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,
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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 NFPA and ASTM
For rooms NFPA and ASTM For some field devices NIOSH eventually Really, it’s still caveat emptor Try before you buy
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Staff PPE Levels of PPE Level A for entry Level C for known hazard
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 As the example of what one needs to cope with a bio attack. Not “moonsuits”. For RAD or BIO: level D plus
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Level B vs. Level C Training time Equipment Cost But is C safe???
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 HSES data 1996-1998 No decon, no PPE
472 hospital workers surveyed Over 100 symptomatic 1 admitted HSES data 44,015 events 3,455 events produced 13,149 victims 5% were admitted Annals of Emergency Medicine 42:3, September 2003
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Case Review Cont. HSES 1996-1998 HSES Healthcare data
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 Outside US Modeling
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 State or Local Industry Own facility 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 External Refresher training built into system
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
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