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

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

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?

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

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

Tokyo Sarin Attack

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

Conyers, GA 2003

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???

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

Anthrax 2001-2002 Decon? Or Prophylaxis?

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

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

OSHA Draft Guidance www.osha.gov/dts/osta/bestpractices/firstreceivers_hospital.pdf In brief: Yes, you need to do it PAPR’s 8 hour staff training minimum

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

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

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

Decontamination Tent

“RAM Decon”

Hospital’s Trailer

Local FD Trailer

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

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

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

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?

Level B with supplied air

Level C with PAPR

C minus

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

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???

Case Review Sarin in Tokyo HSES data 1996-1998 No decon, no PPE 472 hospital workers surveyed Over 100 symptomatic 1 admitted HSES data 1996-1998 44,015 events 3,455 events produced 13,149 victims 5% were admitted Annals of Emergency Medicine 42:3, September 2003

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

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

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)

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

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

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

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?

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