1. Hospital Decontamination
Jonathan L. Burstein, MD, FACEP
HSPH-CPHP

2. The Problem Hundreds of patients coming in Do they need decon?
Can I clean them?

3. 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?

4. 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

5. 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

6. Tokyo Sarin Attack

7. 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

8. Conyers, GA 2003

13. 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???

14. Radiation Is Easily Detectable
Geiger counters and ionization detectors. These devices require training, but are not that hard to use.
ED door monitors?

15. Anthrax
Decon? Or Prophylaxis?

16. JCAHO “Health Care at the Crossroads”, 2003
Emergency preparedness as key goal
Environment of Care Standards
Protect employees
Protect facility
Protect patients

17. 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

18. OSHA Draft Guidance
In brief:
Yes, you need to do it
PAPR’s
8 hour staff training minimum

19. 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

20. 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

21. 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

24. Decontamination Tent

25. “RAM Decon”

26. Hospital’s Trailer

27. Local FD Trailer

28. “Mass” Decon Unit Transfer boards on center roller system
Show and explain graphic

29. 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,

30. A permanent hospital decon room

31. Basic Requirements Contain contamination Control environment
Protect staff
Allow decon
Contain runoff
Allow cleanup or disposal
Patient through-put

32. 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

33. 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?

34. Level B with supplied air

35. Level C with PAPR

36. C minus

37. 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

38. 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???

39. 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

40. 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

41. 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

42. 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)

43. How Do I Get It Done? Needs Money Interested staff Competent trainers
Institutional commitment

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

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

46. 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?

47. Institutional Commitment
Doing the right thing
Doing something to protect the institution
Doing something for good publicity
Doing something to avoid bad publicity