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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?.

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Hospital decontamination

Hospital Decontamination

Jonathan L. Burstein, MD, FACEP

HSPH-CPHP


The problem
The Problem

  • Hundreds of patients coming in

  • Do they need decon?

  • Can I clean them?


The roadmap
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
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
Threats

  • Weapons of mass destruction

    • Mainly, chemical or radioactive

  • Fires

  • Transportation accidents

  • Industrial accidents

  • Internal spills (lab, chemo, radioactives)

  • Do a Hazard Vulnerability Analysis



Tokyo march 20 1995
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



Madrid, 11 March 2004

Explosives…

Decon???



Anthrax 2001 2002
Anthrax 2001-2002

Decon? Or Prophylaxis?


Jcaho
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 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Osha draft guidance
OSHA Draft Guidance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
Finance and Publicity

  • Work with the government

    • HRSA and CDC (Focus D) money

  • Work with industry

    • Financing from manufacturers

  • Public drills look good

  • Public evasion looks bad


Goals
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
Decon Options

Cheap

Slow, clumsy

  • Outdoors (wading pools)

  • Tents

    • Outside

    • Inside

  • RAM Decon

  • Trailers

  • Indoors

    • Multipurpose room

    • Dedicated room

Quick, easy

Dear







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,



Basic requirements
Basic Requirements

  • Contain contamination

  • Control environment

  • Protect staff

  • Allow decon

  • Contain runoff

  • Allow cleanup or disposal

  • Patient through-put


Standards
Standards?

  • American Institute of Architects

    • For rooms

  • NFPA and ASTM

    • For some field devices

  • NIOSH eventually

  • Really, it’s still caveat emptor

  • Try before you buy


Staff ppe
Staff PPE

  • Levels of PPE

    • 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?





Standard universal precautions
Standard (Universal) Precautions

  • Gown

  • Gloves

  • Mask

    • N95 HEPA, to upgrade for plague or smallpox

      • RESPIRATORY PRECAUTIONS

  • Shoe covers

For RAD or BIO: level D plus


Level b vs level c
Level B vs. Level C

  • Training time

    • 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
Case Review

  • Sarin in Tokyo

    • 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
Case Review Cont.

  • HSES 1996-1998

    • 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 cont1
Case Review Cont.

  • Organophosphates

    • 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
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
How Do I Get It Done?

  • Needs

    • Money

    • Interested staff

    • Competent trainers

    • Institutional commitment


Money
Money

  • Federal

    • HRSA, CDC

    • DHS (work with public safety?)

  • State or Local

  • Industry

  • Own facility


Staff
Staff

  • Committed

  • Competent

  • Trainable

  • Low turnover

  • Present 24/7 in numbers (4 minimum)

  • Clinical? Maintenance? Custodial? Security? Safety? All?


Training
Training

  • Internal

    • Hospital based

  • External

    • FD-based

    • Industrial

  • Refresher training built into system

    • Employee orienttation? Annual “special teams” training?


Institutional commitment
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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