Perspectives of Hospital Decontamination Preparedness
By Jerry Crow, RN, Disaster Program Manager Mobile Medical System, Pharmaceutical Cache and CHEMPACK, Los Angeles County Emergency Medical Services Agency
Most people know that in times of need their local hospital emergency room will be ready and available to handle their needs at any hour day or night. However, after a mass casualty terrorist attack, contaminated victims will quickly realize that the normal pathway of admission to the hospital has been altered. They may encounter a facility that has shut down and locked all the doors to prevent contaminated victims from endangering the unprotected workers inside. Medical care will be delayed due to a surge of victims. Confusion and panic may ensue, unaware that their hospital has activated a disaster plan and has trained for such an event. Prior to September 11, 2001, hospital decontamination capability was limited to one shower in preparation for a small industrial event. If a hospital was confronted with more than one victim, their plans may have called for the fire department to assist with washing victims. Now that terrorism is upon us, the realization is that fire department personnel and equipment may not be available since these resources may be on scene providing care to possibly hundreds of victims. In Los Angeles County, there are close to one hundred hospitals and most of them have a decontamination team and the appropriate personal protective equipment (PPE). Hospital Decontamination Team Training has been provided to these facilities by Emergency Medical Services (EMS) Agency personnel. Many hospitals have had multiple team trainings over the years due the need to refresh and due to staff moving on.
It can be a challenge to train people from various walks of life and education to do a job they know nothing about, they never thought of doing, and performing that job during a crisis in which no one has ever experienced
When the training was first initiated, it seemed that decon teams mostly consisted of emergency department personnel. Emergency staff are typically involved in disaster drills and emergency planning so it was thought that they should be trained to be decon team members. It didn’t take long to figure out that if all the emergency department (ED) nurses were in PPE, who would be taking care of the victims. The best approach now is to enlist volunteers from several different departments (e.g., environmental services, building services, safety/security, admissions, etc.) so that the hospital can continue to operate normally during a decon operation. The EMS Agency decontamination training is 8 hours long and conforms to California State and Federal laws. Many lessons have been learned providing this training over the last 20 years. Without getting too specific, and after completion of the training, team members certainly need to be familiar with their PPE, their hospital disaster/decontamination plan, and what their job entails. It can be a challenge to train people from various walks of life and education to do a job they know nothing about, they never thought of doing, and performing that job during a crisis in which no one has ever experienced. The key is keeping things simple, repetition of important concepts, explaining what the team member’s jobs are upfront and throughout the course of the training. Again, prospective team members show up for training knowing that they will be on a team and will be using some kind of specialized equipment, but what else? Of course, their training will include CBRN awareness, donning and doffing of PPE, hot/warm/cold zones, heat stress, etc., but knowing what their job entails and how they function within the hospital operation is of the utmost importance.
First of all, the hospital decon team member is not a first responder, but a first receiver of victims. A first receiver is functioning in a defensive manner protecting the hospital from secondary contamination and more importantly keeping their co-workers in the cold zone from coming in contact with contaminated victims. Once it has been determined that contaminated victims are present and seeking medical care, it’s time to start performing decon team member job duties. Keeping it simple there are “two G’s” and “three S’s”: 1- Setting up the warm zone:
- Establishing boundaries
- providing towels, blankets, soap, buckets, gowns, etc.
- Turning on showers
2- Gathering information from the victims:
- Name, How are you feeling (signs and symptoms)
- What happened (sights, sounds, smells, suspicious persons, etc.)
- Properties of contaminant (solid, liquid, powder, gas?).
- Dictates time in shower (gaseous substances shorter shower, viscous, non-water soluble substances longer shower.
3- Giving information to the victims:
- Provide reassurance to victims
- Instruct: take off clothes, place in bag, label bag with name
- Take soapy sponge, wash from head to toe
- discard dirty sponge
4-Supervision of victim self-decontamination:
- Watch victims perform self-decontamination (ambulatory victims can perform this themselves) This is not a car wash operation, less exertion of the team member reduces chance of heat stress
- Assist victim as needed
- First of all, safety of team members in suits
- Safety of co-workers in the hospital and cold zone Safety of victims in warm and cold zones
- Safety is in every operation
The hospital decon team member is not a first responder, but a first receiver of victims.
Team members on the front line of the operation must be empowered to make decisions such as: - Who requires decontamination and who does not - Have victims brought in by ambulance been decontaminated in the field and was it adequate, or is soap and water deconnecessary at the hospital site - Who is sick and who is not - Who goes first and who can wait Another thing to consider and remember that decontamination is handled differently for chemical, biological and radiological contaminated victims. Chemical: A victim who presents with chemical contamination and is sick or injured from that substance requires decontamination prior to treatment in the cold zone. First receivers must resist the urge to allow contaminated victims inside who are suffering. They must be clean to be treated safely. Just as first responders must resist the urge to rush into the scene without the proper PPE. Biological: Victims of a biological release probably have taken several showers and changed clothes many times before symptoms occur. This is due to the incubation period of the bacteria or virus. Therefore, no decontamination is required. A patient presenting with flu-like symptoms and a fever is treated as an everyday occurrence. Radiological: Radiation is dose related. The higher the dose of the substance, the farther away you need to be and be around it the least amount of time. Once a dirty bomb has detonated, that high dose chunk of radiological material has exploded into millions of low dose particles. Victims presenting with this dust on them require decontamination but certainly can wait in line to do so.
In terms of CBRN contamination, no one should enter the cold zone without first undergoing the decontamination process. However, there is an exception for radiological contaminated victims who have life threatening injuries. The experts say that these victims can be wrapped in a sheet, transported by ambulance and brought into the cold zone, bypassing decon in the warm zone. Life saving measures can be performed (using the Time, Distance, Shielding, Dose method of protection) and decon performed once the patient has been stabilized. The reason being that the amount or dose of particles on the patient is so small that life saving measures can be performed without significant risk to the caregiver. In conclusion, a successful and safe hospital decontamination team requires more than one training session. It requires a commitment from hospital administration, properly maintained equipment, and dedicated team leaders and members to carry out the mission according to existing plans. Team leaders must be proactive in learning all aspects of the training to ensure that members are provided ongoing refresher training. This article is certainly no substitute for training, but hopefully the reader can gain some insight in order to improve an existing hospital decontamination team.
Jerry Crow, RN, is a Disaster Program Manager Mobile Medical System, Pharmaceutical Cache and CHEMPACK at Los Angeles County Emergency Medical Services Agency. He has worked as a Hazardous Materials Technician and Reserve LA County Sheriff Deputy for 5 years. In addition to practicing as a Registered nurse for 40 years, of which he spent 18 years as an ER nurse/critical care transport nurse. The author also managed 18 caches of nerve agent antidote as part of the Federal Strategic National Stockpile (SNS), and two 32 ft. decontamination trailers which can be deployed to a hospital as an addition decon resource or to the field for fire department use.