1. Hospital Hazardous Materials Emergency Response: The Devil is in the Details Paul Penn Western Director/VP Environmental Hazards Management Institute ppenn@ehmi.org

2. Presented to The National Disaster Medical System Conference Atlanta, Georgia April, 14, 2002

3. “By the end of two hours what do we want to accomplish?” To remain awake (this is early Sunday morning) To have a better overall understanding of issues related to hazardous materials emergency response in a healthcare setting To recognize the challenges and opportunities presented To have a sense of the unanswered questions and some potential alternatives/solutions To segue into Ann and Loni’s Decontamination presentation

4. “Warning Will Robinson… Danger, Danger!” This is not rocket science. This will be a detailed oriented approach to the basics. You are expected to heckle when appropriate. Don’t take my word for anything.

5. Bottom Line, “What are the biggest challenges?” OK, you asked… –Respiratory Protection (Respiratory Protection Standard) –Time away from work for training (HAZWOPER) (All OSHA standards, when triggered, apply) These are institutional choices, not insurmountable barriers

6. “Before we get to those issues- Back to Basics” What do you want to do? 1.Nothing 2.Decon (no respiratory equipment) 3.Decon (w/respiratory equipment) 4.Incidental Spills (no respiratory equipment) 5.HazMat Spills (w/respiratory equipment) 6.Mix and match

7. “What do you base it on?” A Hazard and Vulnerability Assessment! –(Remember JCAHO EM 1.4) Organizational commitment –Materiel, –Personnel, –Funding

8. “Then, ask yourself…?” Which scope option will be implemented? What are the numbers of people who may be needed to carry out the identified functions? What is the staffing depth during all shifts? Are there special hazards (e.g., nuclear medicine, glutaraldehyde) that are department specific? Are there special skills (e.g., PharmD. with Poison Control Center experience, asbestos trained Engineers) available in the facility?

9. “Who needs to come to the table?” ( aka- “Who are the decision makers?”) CEO-Executive Team Nursing Leaders ED Impacted Department Heads Risk Management EH&S

10. “What Departments Need to Play?” ED * EH&S * Engineering/Plant Ops * EVS/Housekeeping * Lab Radiology Security * GI House Supervisor/Nursing * Materiel Management Oncology Couriers Volunteers Pharmacy And other departments that use chemicals; or, may encounter a hazardous materials event

11. “Who’s gonna do the work?” DepartmentTasksComments Engineering Decon, spill cleanup, setup, event termination Generally stable workforce, used to working in uncontrolled situations, good with tools and equipment, often on site 24/7 EVS/ Housekeeping Decon, spill cleanup, setup, event termination Often transient workforce, conducts non chemical cleanup as part of normal duties, often on site 24/7 Security Decon, site control, setup Often first on scene, will likely be used for site access control, on site 24/7

12. “Who’s gonna do the work?” DepartmentTasksComments Emergency Department Decon, triage, patient care Needed to determine effectiveness of decon, conducts triage of patients, provides ABCs prior to decon, provides patient care to patients after decon, on site 24/7 Laboratory, Pharmacy, Sterile Processing, Imaging Incidental spill response, technical reference Site of major chemical use, can be trained for quick response, often good source of knowledge regarding handling of chemicals Nuclear Medicine Radiological monitoring, technical reference Good source of knowledge regarding radiological materials

13. “Who’s gonna do the work?” DepartmentTasksComments RNs, Medical Assistants, etc. in departments that use chemicals Incidental spill response, decon Critical to preventing incidental spills from becoming emergencies, can be used for decon. Environmental Health and Safety Incident management, technical reference, liaison Often a good resource for managing hazardous material emergencies and coordinating with outside agencies

14. “Let’s talk PPE.” PPE is the last and least desirable Hazard Control option after: –Engineering Controls –Administrative Controls But, in “uncontrolled releases” or for managing contaminated patients it is often the only alternative.

15. “Let’s go through the litany” Four levels of Chemical Protective Ensemble Each has advantages and disadvantages NO ONE ENSEMBLE IS APPROPRIATE IN ALL CIRCUMSTANCES! THESE ENSEMBLES DO NOT PROTECT AGAINST FIRE OR EXPLOSION! These were not developed with healthcare in mind (more on that later).

16. Level A SkinRespiratoryComments Vapor Protective (also known as gas tight or fully encapsulating) Atmosphere Supplying Respirator (Self contained breathing apparatus [SCBA] or Supplied Air Respirator) Highest level of skin and respiratory protection. Bulky, heavy, and greater potential of heat stress and STF injuries.

17. Level B SkinRespiratoryComments Liquid Splash Protection Atmosphere Supplying Respirator (Self contained breathing apparatus [SCBA] or Supplied Air Respirator) Lower level of skin protection with highest level of respiratory protection.

18. Level C SkinRespiratoryComments Liquid Splash Protection Air Purifying Respirator Lower level of skin and respiratory protection

19. Level D SkinRespiratoryComments No chemical protection No respiratory protection Examples include: work uniforms, street clothes, scrubs, and Standard/Universal Precautions (provides minor chemical protection)

20. Other PPE items Head Shoulders Knees and Toes and Eyes and Ears and Mouth and Nose…. and Hands

21. “Let’s talk respiratory protection” (Two basic types) Atmosphere-supplying respirator means a respirator that supplies the respirator user with breathing air from a source independent of the ambient atmosphere, and includes supplied-air respirators (SAR) and self-contained breathing apparatus (SCBA) units. Air-purifying respirator means a respirator with an air-purifying filter, cartridge, or canister that removes specific air contaminants by passing ambient air through the air-purifying element.

22. SCBA Type/DescriptionAdvantagesDisadvantages Self Contained Breathing Apparatus A compressed air tank (less common is a rebreather system) containing 30 or 60 minutes (usually effective for less than the rated time) of breathable air. It is mounted on a harness worn on the back with a tight fitting facepiece. Weight ~ 25-40 lbs An Atmosphere- supplying respirator. Greater mobility. Can be used for unknowns, in oxygen deficient atmospheres, and atmospheres above the Immediately Dangerous to Life and Health level. Heavy and bulky (increased overexertion injury hazard). Limited air supply. Users must be fit tested. No facial hair allowed that interferes with mask. High level of training required. High cost.

23. SAR Type/DescriptionAdvantagesDisadvantages Supplied Air Respirators (In line system) A hose attaches the user to a hip mounted regulator that is connected by another hose to either a compressed gas tank, compressor, or piped system. The mask can be either a tight fitting mask or loose fitting hood. Reduced potential of overexertion injuries. Can be configured for extended use. Loose fitting hoods do not require fit testing and can be used by persons with beards. Can place multiple responders on one system through use of a manifold system with a variety of air sources. (Thanks Howard) Greater slip, trip and fall hazard from hoses. Limited range.

24. APR/PAPR Type/DescriptionAdvantagesDisadvantages Air purifying respirators (APR) A specialized filter attached to either a tight fitting or loose fitting facepeice. Can be of a demand valve or powered type (PAPR). A filtered air source. High mobility PAPRs are generally more comfortable than APR. Often less expensive than atmosphere supplying respirators. Cannot be used for unknown substances, atmospheres below 19.5% oxygen, materials with poor warning properties, or materials present above the Immediately Dangerous to Life and Health level. Same tight fitting facepiece issues as SCBA. Loose fitting hood can only be used with PAPR. Filters must be specific to type of contaminant present.

25. “So, what’s the hang up?” One extreme In HAZWOPER (q)(3)(D) “(D) Employees engaged in emergency response and exposed to hazardous substances presenting an inhalation hazard or potential inhalation hazard shall wear positive pressure self- contained breathing apparatus (SCBA) while engaged in emergency response, until such time that the individual in charge of the ICS determines through the use of air monitoring that a decreased level of respiratory protection will not result in hazardous exposures to employees.”

26. Another viewpoint “If the agent class for a sudden release cannot be identified, level C PPE with an organic vapor/HEPA filter cartridge mask is recommended.” JAMA / volume:283 (page: 242) Weapons of Mass Destruction Events With Contaminated Casualties: Effective Planning for Health Care Facilities, Anthony G. Macintyre, MD; et al, 2000

27. “What’s a mother to do?”

28. Moving on- Training The other “big” issue

29. “What is the intent of HAZMAT training in a healthcare setting?” To have staff protect themselves, victims, other patients & visitors, facility, and the community from the impact of hazardous materials To make the most efficient use of staff time by having the training appropriate to hospitals and be transferable To have the most applicability to the most likely scenarios To use response equipment and PPE safely and effectively

30. Hazard Communication 29CFR1910.1200 Employee Right-to-Know program –The building block of all hazardous materials training in hospitals –MSDS, etc. –Should be part of new employee orientation

31. First Responder- Awareness 29CFR1910.120 Hazardous Waste Operations and Emergency Response section (q) “…individuals who are likely to witness or discover a hazardous substance release and who have been trained to initiate an emergency response sequence by notifying the proper authorities of the release. They would take no further action beyond notifying the authorities of the release. “

32. First Responder- Operations “…individuals who respond to releases or potential releases of hazardous substances as part of the initial response to the site for the purpose of protecting nearby persons, property, or the environment from the effects of the release. They are trained to respond in a defensive fashion without actually trying to stop the release. Their function is to contain the release from a safe distance, keep it from spreading, and prevent exposures.”

33. Hazardous Materials Technician “…individuals who respond to releases or potential releases of hazardous substances for the purpose of stopping the release. They assume a more aggressive role than a first responder at the operations level in that they will approach the point of release in order to plug, patch, or otherwise stop the release of a hazardous substance.”

34. Hazardous Materials Incident Commander “…who will assume control of the incident scene beyond the first responder awareness level”

35. Specialist Employees (not to be confused with Hazardous Materials Specialist) “Employees who, in the course of their regular job duties, work with and are trained in the hazards of specific hazardous substances, and who will be called upon to provide technical advice or assistance at a hazardous substance release incident to the individual in charge” (e.g., Gatekeeper/ Intervener)

36. “OK, Whaddatheygonnado?” SINSIN CIACIA PCPPCP DDDDDD

37. FRA level Defensive Actions S afety I solate N otify SINSIN

38. “OK, Whaddatheygonnado?” CIACIA Command Identify Action Plans

39. “OK, Whaddatheygonnado?” PPE Control, Contain, Cleanup Protective Actions PCPPCP

40. “OK, Whaddatheygonnado?” Decon Dispose Document DDDDDD

41. Hospital Personnel Hazard Communication- all employees First Responder Awareness- those employees that may encounter a hazardous materials emergency and/or conduct “directed self-decon.” First Responder-Operations employees expected to take defensive actions and conduct decontamination Incident Commander /Safety/ Technical Reference Gatekeeper /Intervener 4 hours 12 hrs Total 16 hrs 8 hrs Total 24 hrs 16 hrs Total 40 hrs 16 hrs Total 40 hrs Technician A Tiered Approach to Training

42. Now, on to Monitoring Devices

43. Confined Space monitor Detects combustible gases, oxygen deficiency, carbon monoxide, and hydrogen sulfide Useful for in house spills. Has limitations inherent in direct reading instruments (e.g., other factors can cause interference, combustible gases are calibrated for one type of gas.)

44. Colorimetric tubes Chemical specific identification and general quantification Draws air through a glass tube that contains a medium that reacts with a specific chemical or class of chemicals. Not reliable to quantify level of contamination with great accuracy but useful for response purposes.

45. Chemical Identification Kits (e.g., HAZCAT) A kit “designed for on-site identification or categorization of… spilled or abandoned material. The system is based on a series of simple field tests arranged in an easy- to-follow flow chart format. A combination of test papers (e.g., pH paper, oxidizer test strips), reagents, glassware and other materials that allows the identification of a product or narrow it to a functional group through use of a flow chart/decision tree. Items such as the test strips can be used separately to test decon runoff water when appropriate.

46. Chemical Specific monitors Monitors designed to identify and quantify the presence of a particular chemical. Useful for in house spills (e.g., glutaraldemeter) and situations where a particular product is of concern and not easily detected or quantified.

47. Radiation monitors Monitors that can detect alpha, beta, or gamma radiation. Important due to lack of indicators or warning properties of radioactive materials. New radiation monitors are able to detect all three types easily. Allows responders to identify or rule out presence of radiological substances.

48. “Hey, what about Terrorism? Everyone is talking about terrorism.” Terrorism is a “menace,with malice.” –A chemical terrorism event (the “N&C” of B- NICE) is a “Hazardous Materials Incident” –A biological terrorism event (the “B” of B- NICE) is an “Infectious Disease Outbreak” –A fire or explosion terrorism event (the “I&E” of B-NICE) is a “Burn and/or Mass Casualty- Trauma Incident”

49. “But…” If you can’t do the small stuff, you can’t do the big stuff If you can do the small stuff, you still may not be able to do the big stuff If you can do the big stuff, you can probably to the small stuff

50. For more information, please contact: Paul Penn Western Director/Vice President Environmental Hazards Management Institute P.O. Box 280 Diamond Springs, California 95619 530-622-5964 (v) 530-622-5917 (fax) ppenn@ehmi.org http://www.ehmi.org http://hazmatforhealthcare.org