Occupational Health Hazards of Commissioned Corps Officers in a ...

1. Occupational Health Hazards of Commissioned Corps Officers in a Field Medical Station CDR Nancy Sahakian MD, MPH (FOH) CDR Lisa Iwaszko (FDA)

2. Good morning. During this presentation I will describe the mission goals of RDF-2 during Hurricanes Gustav and Ike, the structure of the RDF-2 team, occupational health hazards that existed during our deployment, and finally provide our recommendations on how occupational health hazards can be mitigated during future deployments. Good morning. During this presentation I will describe the mission goals of RDF-2 during Hurricanes Gustav and Ike, the structure of the RDF-2 team, occupational health hazards that existed during our deployment, and finally provide our recommendations on how occupational health hazards can be mitigated during future deployments.

3. Mission Goals for RDF-2 Set up two Federal Medical Stations (FMS) � one for use by RDF-3 � one for use by RDF-2 Care for special needs persons evacuated prior to landfall of Hurricane Gustav Maintain state of readiness to receive special needs persons evacuated prior to landfall of Hurricane Ike There are five Rapid Deployment Force teams in the USPHS. RDF-1 and 2 are based in the DC area, RDF-3 is based in Atlanta, RDF-4 in Oklahoma City, and RDF-5 in the Phoenix-Santa Fe area. Prior to landfall of Hurricane Gustav, the mission goals for RDF-2 were to set up a Federal Medical Station in Baton Rouge that was to be staffed by RDF-3 and then to set up and run another Federal Medical Station in Alexandria Louisiana that was to be staffed by RDF-2. The Federal Medical Stations provide support to special needs persons as well as a close family member who were evacuated prior to landfall of Hurricane Gustav. The special needs people had medical needs such as the use of insulin or oxygen, had limited mobility requiring the use of a wheelchair, or were mentally disabled. After we had discharged our evacuees we remained in a state of readiness to potentially receive other evacuees prior to the landfall of Hurricane Ike. There are five Rapid Deployment Force teams in the USPHS. RDF-1 and 2 are based in the DC area, RDF-3 is based in Atlanta, RDF-4 in Oklahoma City, and RDF-5 in the Phoenix-Santa Fe area. Prior to landfall of Hurricane Gustav, the mission goals for RDF-2 were to set up a Federal Medical Station in Baton Rouge that was to be staffed by RDF-3 and then to set up and run another Federal Medical Station in Alexandria Louisiana that was to be staffed by RDF-2. The Federal Medical Stations provide support to special needs persons as well as a close family member who were evacuated prior to landfall of Hurricane Gustav. The special needs people had medical needs such as the use of insulin or oxygen, had limited mobility requiring the use of a wheelchair, or were mentally disabled. After we had discharged our evacuees we remained in a state of readiness to potentially receive other evacuees prior to the landfall of Hurricane Ike.

4. Chain of Command During our deployment, RDF-2 reported to the Incident Response Coordination Team who reported to the Governor of Louisiana. HHS had made a commitment to provide 600 beds in Federal Medical Stations until the governor indicated that this was no longer needed. Our FMS in Alexandria, Louisiana had a capacity of 250 beds.During our deployment, RDF-2 reported to the Incident Response Coordination Team who reported to the Governor of Louisiana. HHS had made a commitment to provide 600 beds in Federal Medical Stations until the governor indicated that this was no longer needed. Our FMS in Alexandria, Louisiana had a capacity of 250 beds.

5. RDF-2 Sections Command Staff: 8 Planning: 8 Administration/Finance: 11 Logistics: 14 Operations: 58 Safety/Preventive Medicine: 18 The RDF-2 team had 117 members and is comprised of the command staff and 5 sections. The RDF-2 team had 117 members and is comprised of the command staff and 5 sections.

6. Planning and Administration/Finance Sections The Planning and Administration/Finance Sections were responsible for travel arrangements and the planning of the day-to-day details of the mission.The Planning and Administration/Finance Sections were responsible for travel arrangements and the planning of the day-to-day details of the mission.

7. Logistics Section The logistics section was responsible for the delivery, security, distribution, ordering, and repackaging of supplies and equipment, contracts with the food vendor, and computer support.The logistics section was responsible for the delivery, security, distribution, ordering, and repackaging of supplies and equipment, contracts with the food vendor, and computer support.

8. Operations Section The Operations Section includes nurses, doctors, pharmacists, laboratory workers, and social workers. Pictured here is the pharmacy that was staffed 24/7 to provide services and maintain the security of pharmaceuticals.The Operations Section includes nurses, doctors, pharmacists, laboratory workers, and social workers. Pictured here is the pharmacy that was staffed 24/7 to provide services and maintain the security of pharmaceuticals.

9. Safety/Preventive Medicine Section The Safety/Preventive Medicine Section is composed of environmental health officers, industrial hygienists, cccupational health specialists, occupational medicine physicians, epidemiologists, engineers, and veterinarians. They are responsible for the a variety of safety and sanitation services to include oversight of the contractor service of the portajohns and portasinks serving the FMS, maintenance and safety of portasinks on the FMS floor, prevention of physical, chemical and biological hazards, prevention of occupational hazards, supporting food safety and security, and assisting on the FMS floor as needed. The Safety/Preventive Medicine Section is composed of environmental health officers, industrial hygienists, cccupational health specialists, occupational medicine physicians, epidemiologists, engineers, and veterinarians. They are responsible for the a variety of safety and sanitation services to include oversight of the contractor service of the portajohns and portasinks serving the FMS, maintenance and safety of portasinks on the FMS floor, prevention of physical, chemical and biological hazards, prevention of occupational hazards, supporting food safety and security, and assisting on the FMS floor as needed.

10. RDF-2 Deployment 8/29 � left DC 8/30 � set up 150 bed FMS in Baton Rouge LSU sports arena 8/31 � set up 200 bed FMS in Alexandria convention center and received 123 evacuees (99 special needs persons and 24 caregivers) 9/1 � Hurricane Gustav makes landfall in SE Louisiana 9/1 � 181 evacuees (135 special needs persons, 46 caregivers) Set up 100 extra cots for surge capacity 9/4 � began discharging patients 9/6 � 47 occupied beds 9/11 � all evacuees discharged. Waiting to be released as a LA asset (there was a possibility that the FMS was we utilized in response to a Hurricane Ike evacuation). 9/13 � Hurricane Ike makes landfall in Galveston, TX 9/14 � pack up durable equipment and unused supplies 9/15 � return home Our deployment lasted 17 days. The on-call month for RDF-2 was August and the on-call month for RDF-3 was September. RDF-2 left the DC area on a chartered jet on the evening of 8/29, and set up a 150-bed FMS in the Louisiana State University sports arena in Baton Rouge the following day. The next day we set up a 200 bed FMS in the Alexandria convention center and received 181 evacuees at the same time from buses that were already docked at the convention center. Hurricane Gustav made landfall the next day. By September 11 all the evacuees had been discharged via ambulance or other means of transport. We then waited to see whether we would be needed for Hurricane Ike. After Hurricane Ike made landfall on September 13, we started packing up our equipment and supplies and we returned home on September 15. Our deployment lasted 17 days. The on-call month for RDF-2 was August and the on-call month for RDF-3 was September. RDF-2 left the DC area on a chartered jet on the evening of 8/29, and set up a 150-bed FMS in the Louisiana State University sports arena in Baton Rouge the following day. The next day we set up a 200 bed FMS in the Alexandria convention center and received 181 evacuees at the same time from buses that were already docked at the convention center. Hurricane Gustav made landfall the next day. By September 11 all the evacuees had been discharged via ambulance or other means of transport. We then waited to see whether we would be needed for Hurricane Ike. After Hurricane Ike made landfall on September 13, we started packing up our equipment and supplies and we returned home on September 15.

11. Occupational Health Hazards Sleep deprivation Poor nutrition Biohazards Environmental conditions Musculoskeletal strain The occupational health hazards that were present during this deployment included sleep deprivation, poor nutrition, exposure to biohazards, cold environmental conditions, and conditions giving rise to musculoskeletal strain.The occupational health hazards that were present during this deployment included sleep deprivation, poor nutrition, exposure to biohazards, cold environmental conditions, and conditions giving rise to musculoskeletal strain.

12. Sleep Deprivation Sleep deprivation was a problem throughout the deployment. Sleep deprivation was a problem throughout the deployment.

13. Sleep deprivation Coffee was the only way that the night staff was able to keep awake throughout their shift. Luckily, during the last week of the deployment when the patient census was down, some night shift workers were able to be moved to day shift hours and some night shift workers were allowed to work 8-hour shifts. Coffee was the only way that the night staff was able to keep awake throughout their shift. Luckily, during the last week of the deployment when the patient census was down, some night shift workers were able to be moved to day shift hours and some night shift workers were allowed to work 8-hour shifts.

14. Causes of Sleep Deprivation Long travel schedule Long initial work hours 12-hour work schedule Shared sleeping area for day and night shift workers Uncomfortable cots The causes of sleep deprivation included a prolonged wait for our chartered flight on the way out and the intensive work schedule during the first 48 hours. We subsequently worked 12-hour shifts with the two shifts sharing the same sleeping area. To minimize patients from entering the area all entry ways except for one were barricaded. Despite this, officers of one shift were continually disturbing officers of the other shift when they needed to get to their cot to change clothes or pick up a belonging. In time, we all came to realize how uncomfortable the cots were with many electing to sleep on the floor. The causes of sleep deprivation included a prolonged wait for our chartered flight on the way out and the intensive work schedule during the first 48 hours. We subsequently worked 12-hour shifts with the two shifts sharing the same sleeping area. To minimize patients from entering the area all entry ways except for one were barricaded. Despite this, officers of one shift were continually disturbing officers of the other shift when they needed to get to their cot to change clothes or pick up a belonging. In time, we all came to realize how uncomfortable the cots were with many electing to sleep on the floor.

15. First 3 Days 8/28 1300 hours � Team officially activated 8/28 2200 hours � E-mail telling us o go to bed and not wait for travel orders 8/29 2300 hours � Depart from DC 8/30 0100 hours � Arrive in Baton Rouge 8/30 0300 hours � Billeted at FEMA Carville, LA facility 8/30 0730 hours � Blue team departs for Baton Rouge LSU sports arena to set up FMS 8/30 1800 hours � Blue and Gold Teams travel to Alexandria 8/30 2100 hours� Arrive at Alexandria Riverfront Convention Center and begin to set up FMS 8/31 0600 hours �Gold team begins day shift rotation and begins receiving evacuees. Blue team goes to bed. Blue Team: Work/travel 48 hours continuously (except for 3 hours sleep) then assigned to night-shift for deployment This slide should give you a feeling for what our deployment schedule was during the first few days. Obtaining seats on commercial flights for the whole team was difficult so a jet was chartered. After being on alert status for over 24 hours we left DC at 2300 hours on September 28. We arrived in the early morning hours in Baton Rouge and then travelled 2 hours on a bus to a FEMA facility. RDF-2 was then split into two teams. The Blue Team was designated as the first team to work, so officers on this team slept only three hours before they were bussed to Baton Rouge to set up an FMS over a 12 hour period. Then both Blue and Gold teams travelled for 3 hours to Alexandria to set up another FMS. Both teams worked initially, but the work was completed by the Gold Team. At this point officers on the Blue Team had been travelling or working 48 hours continuously except for three hours of sleep. The teams then continued to work 12-hour shifts for the remainder of the deployment with the Gold team working 7AM-7PM and the Blue team working 7PM-7AM. This slide should give you a feeling for what our deployment schedule was during the first few days. Obtaining seats on commercial flights for the whole team was difficult so a jet was chartered. After being on alert status for over 24 hours we left DC at 2300 hours on September 28. We arrived in the early morning hours in Baton Rouge and then travelled 2 hours on a bus to a FEMA facility. RDF-2 was then split into two teams. The Blue Team was designated as the first team to work, so officers on this team slept only three hours before they were bussed to Baton Rouge to set up an FMS over a 12 hour period. Then both Blue and Gold teams travelled for 3 hours to Alexandria to set up another FMS. Both teams worked initially, but the work was completed by the Gold Team. At this point officers on the Blue Team had been travelling or working 48 hours continuously except for three hours of sleep. The teams then continued to work 12-hour shifts for the remainder of the deployment with the Gold team working 7AM-7PM and the Blue team working 7PM-7AM.

16. Staff Sleeping Area Pictured here is our sleeping area. To minimize the spread of respiratory infectious diseases, cots should be spaced a minimum of 3 feet apart. As you see here due to space limitations, our cots were spaced much closer than this. The sleeping area did not have a separate room to allow separation of ill staff members. During this deployment two staff members who developed bronchitis were returned home early from the deployment. Bay windows allowed an excessive amount of sunlight to enter the billeting area. Within hours of establishing the area as our sleeping quarters, Safety and Logistics team members covered the windows with black boards which remained in place for the duration of the deployment. Pictured here is our sleeping area. To minimize the spread of respiratory infectious diseases, cots should be spaced a minimum of 3 feet apart. As you see here due to space limitations, our cots were spaced much closer than this. The sleeping area did not have a separate room to allow separation of ill staff members. During this deployment two staff members who developed bronchitis were returned home early from the deployment. Bay windows allowed an excessive amount of sunlight to enter the billeting area. Within hours of establishing the area as our sleeping quarters, Safety and Logistics team members covered the windows with black boards which remained in place for the duration of the deployment.

17. Poor Nutrition Non-nutritive Greasy Spoiled Monotonous Unpalatable Less available for PM shift Food was catered in by the only available vendor in the area. The food was non-nutritive, greasy, monotonous, unpalatable, and on several occasions spoiled. Because meals were served during daytime hours, night-shift were frequently in their rack when meals were served. Food was catered in by the only available vendor in the area. The food was non-nutritive, greasy, monotonous, unpalatable, and on several occasions spoiled. Because meals were served during daytime hours, night-shift were frequently in their rack when meals were served.

18. Over-cooked vegetables Vegetables were consistently over-cooked. Pictured here are green beans and broccoli.Vegetables were consistently over-cooked. Pictured here are green beans and broccoli.

19. Grease Food was also greasy. Pictured here are french toast that was saturated in grease and ham floating in grease.Food was also greasy. Pictured here are french toast that was saturated in grease and ham floating in grease.

20. Unpalatable food The food consisted of several varieties of hash served repeatedly which were unpalatable. Pictured here are a chicken gumbo and rice and beansThe food consisted of several varieties of hash served repeatedly which were unpalatable. Pictured here are a chicken gumbo and rice and beans

21. Spoiled produce On several occasions the lettuce in the salad was spoiled.On several occasions the lettuce in the salad was spoiled.

22. Biohazards Misuse of porta-sinks resulting in overflow Misuse of biohazard receptacles resulting in overflow and potential sharps injury Misuse of laundry bins Misuse of porta-sinks, biohazard trash receptacles, and laundry bins all resulted in potential contamination of FMS staff servicing those recepticals.Misuse of porta-sinks, biohazard trash receptacles, and laundry bins all resulted in potential contamination of FMS staff servicing those recepticals.

23. Protection against biohazards Personal protective equipment that was available included nitrile gloves, surgical masks, and face shields. Used needles were disposed of in sharps containers. Used iv bags, blood-soaked dressings, and soiled dressings were disposed of in biohazard trash receptacles on wheels. Due to misinformation of the appropriate use of and the availability of the biohazard trash receptacles many non-hazardous materials including lightly soiled chucks, food, and food containers were disposed of in biohazard trash containers resulting in them quickly overflowing. In addition, diabetic evacuees inappropriately disposed their used needles in the biohazard trash containers instead of the sharps containers. This is a concern because the person who removes the liner bag of the biohazard trash containers is then at risk of a needle stick injury. Personal protective equipment that was available included nitrile gloves, surgical masks, and face shields. Used needles were disposed of in sharps containers. Used iv bags, blood-soaked dressings, and soiled dressings were disposed of in biohazard trash receptacles on wheels. Due to misinformation of the appropriate use of and the availability of the biohazard trash receptacles many non-hazardous materials including lightly soiled chucks, food, and food containers were disposed of in biohazard trash containers resulting in them quickly overflowing. In addition, diabetic evacuees inappropriately disposed their used needles in the biohazard trash containers instead of the sharps containers. This is a concern because the person who removes the liner bag of the biohazard trash containers is then at risk of a needle stick injury.

24. Sharps Needle Survey Diabetic patients (N=20) Insulin-dependent patients (N=10) Self-administered insulin (N=6) - Spoke with 4 of 6 (67%) - All disposed of needles in general or biohazard trash ACTION: Patients educated on proper disposal Individual-sized sharps containers ordered When the Safety Team identified the problem of improper disposal of used needles by diabetic patients, we conducted a patient survey. Of 20 diabetic patients, half used insulin. Nurses administered insulin to 4 patients, and insulin was self-administered by 6 patients. Of the patients who self-administered their insulin, we were able to speak with 4. All four disposed of their needles in the general trash or in the biohazard trash and not in sharps containers. Patients were subsequently educated on how to properly dispose of their needles and individual-sized sharps containers were ordered.When the Safety Team identified the problem of improper disposal of used needles by diabetic patients, we conducted a patient survey. Of 20 diabetic patients, half used insulin. Nurses administered insulin to 4 patients, and insulin was self-administered by 6 patients. Of the patients who self-administered their insulin, we were able to speak with 4. All four disposed of their needles in the general trash or in the biohazard trash and not in sharps containers. Patients were subsequently educated on how to properly dispose of their needles and individual-sized sharps containers were ordered.

25. Porta-sinks The Portable sinks provided in the cache are not plumbed and have two sets of containers. One is for supply water and the other is for wastewater. The two sets of containers are volume matched so that when the supply water is depleted, the wastewater containers are nearly full. The water in the supply containers needs to obtained from a clean water source and the water in the wastewater containers needs to be discarded in an appropriate drain. Also the tubing within the unit needs to be secured. For these reasons, safety team members who are trained in the function of the porta-sinks should be the only ones who service these sink units. The porta-sinks can overflow for two reasons: the tubing is insecure or additional liquid is introduced into the system, such as the emptying of beverage containers or other personal liquid waste. The Safety team routinely sanitizes the surfaces of the porta-sinks. However, excessive contamination can occur if patients use the porta-sinks as a receptacle for their personal liquid wastes. The Portable sinks provided in the cache are not plumbed and have two sets of containers. One is for supply water and the other is for wastewater. The two sets of containers are volume matched so that when the supply water is depleted, the wastewater containers are nearly full. The water in the supply containers needs to obtained from a clean water source and the water in the wastewater containers needs to be discarded in an appropriate drain. Also the tubing within the unit needs to be secured. For these reasons, safety team members who are trained in the function of the porta-sinks should be the only ones who service these sink units. The porta-sinks can overflow for two reasons: the tubing is insecure or additional liquid is introduced into the system, such as the emptying of beverage containers or other personal liquid waste. The Safety team routinely sanitizes the surfaces of the porta-sinks. However, excessive contamination can occur if patients use the porta-sinks as a receptacle for their personal liquid wastes.

26. Laundry Bins Dirty or soiled linen, cotton blankets, and wool blankets were sent to a contract laundry service for cleaning. A system was established to segregate these items. Despite signage, patients disposed of items in any available bin, requiring the staff to sort through the soiled materials. This resulted in unnecessary exposure of staff to potentially infectious linen.Dirty or soiled linen, cotton blankets, and wool blankets were sent to a contract laundry service for cleaning. A system was established to segregate these items. Despite signage, patients disposed of items in any available bin, requiring the staff to sort through the soiled materials. This resulted in unnecessary exposure of staff to potentially infectious linen.

27. Cold ambient temperature During the deployment, one of our paraplegic patients was seen in a local Emergency department with a rectal temperature of 94�F. Many patients were sleeping with multiple wool blankets and night-shift workers were using thermal reflective sheets in order to stay warm. The HVAC system in the convention center was difficult to regulate for FMS purposes. During the deployment, one of our paraplegic patients was seen in a local Emergency department with a rectal temperature of 94�F. Many patients were sleeping with multiple wool blankets and night-shift workers were using thermal reflective sheets in order to stay warm. The HVAC system in the convention center was difficult to regulate for FMS purposes.

28. Hypothermia Patient Study Room temperature - as low as 66.0�F - as low as 68.9�F after additional heater turned on Patient study - 24 non-ambulatory persons from all sections of the room were selected for the study - 23 of 24 (95%) participated In response to this situation, we investigated the ventilation system along with building management and monitored the room temperature of the FMS. We found a set of pipes containing cold water circulated during daytime hours but not between midnight and 4am. Four boilers heated water which was circulated in another set of pipes, however, only one boiler system was functioning. The HVAC system introduced fresh outdoor air into the facility and blew air across the hot and cold water pipes to regulate the indoor air temperature. The room temperature was as low as 66.0 degrees Fahrenheit. This improved to 68.9 degrees when an additional boiler was turned on. We also conducted a patient study with a 95% participation rate. In response to this situation, we investigated the ventilation system along with building management and monitored the room temperature of the FMS. We found a set of pipes containing cold water circulated during daytime hours but not between midnight and 4am. Four boilers heated water which was circulated in another set of pipes, however, only one boiler system was functioning. The HVAC system introduced fresh outdoor air into the facility and blew air across the hot and cold water pipes to regulate the indoor air temperature. The room temperature was as low as 66.0 degrees Fahrenheit. This improved to 68.9 degrees when an additional boiler was turned on. We also conducted a patient study with a 95% participation rate.

29. Patient Hypothermia Study (N=23) The age of the patients ranged from 61 to 92 years of age. 43% indicated that they felt cold most of the time. Oral temperatures of participants ranged from 97.3 to 99.9 degrees Fahrenheit and ambient temperatures near their beds ranged from 70.5 to 73.0 degrees Fahrenheit. The results of the survey were reassuring in that all patients had normal body temperatures and the ambient room temperatures near their beds were within an acceptable range. The age of the patients ranged from 61 to 92 years of age. 43% indicated that they felt cold most of the time. Oral temperatures of participants ranged from 97.3 to 99.9 degrees Fahrenheit and ambient temperatures near their beds ranged from 70.5 to 73.0 degrees Fahrenheit. The results of the survey were reassuring in that all patients had normal body temperatures and the ambient room temperatures near their beds were within an acceptable range.

30. Musculoskeletal pain among staff Uncomfortable cots Unpacking/ repacking supplies and equipment Patient transfers Musculoskeletal pain among staff was due to multiple causes. These included uncomfortable cots, unpacking and repacking supplies and equipment, and patient transfers. All RDF staff helped with assembling and disassembling the FMS. Likewise all staff helped with patient transfers from bed to chair or wheelchair and wheelchair to toilet seat. Many of our special medical needs evacuees were amputees and non-ambulatory which limited their ability to assist during these transfers. Musculoskeletal pain among staff was due to multiple causes. These included uncomfortable cots, unpacking and repacking supplies and equipment, and patient transfers. All RDF staff helped with assembling and disassembling the FMS. Likewise all staff helped with patient transfers from bed to chair or wheelchair and wheelchair to toilet seat. Many of our special medical needs evacuees were amputees and non-ambulatory which limited their ability to assist during these transfers.

31. Patient Beds Approximately 20% of the patients were morbidly obese and many required the use of wheelchairs. The standard cots were low-lying which made patient transfers more difficult. Cots were lightweight and collapsed under the weight of morbidly obese patients. Staff improvised by using the plastic tops of the tri-fold cartons to make a wide secure platform for bedding for obese patients. However, these modified beds were even lower than the cots. Our cache contained 5 bariatric hospital beds which could support patients weighing up to 500 pounds and no standard hospital beds. Both bariatric and standard hospital beds are motorized and can be electrically elevated or lowered to assist in patient transfers. We were able to request and obtain several standard hospital beds while in the field. Approximately 20% of the patients were morbidly obese and many required the use of wheelchairs. The standard cots were low-lying which made patient transfers more difficult. Cots were lightweight and collapsed under the weight of morbidly obese patients. Staff improvised by using the plastic tops of the tri-fold cartons to make a wide secure platform for bedding for obese patients. However, these modified beds were even lower than the cots. Our cache contained 5 bariatric hospital beds which could support patients weighing up to 500 pounds and no standard hospital beds. Both bariatric and standard hospital beds are motorized and can be electrically elevated or lowered to assist in patient transfers. We were able to request and obtain several standard hospital beds while in the field.

32. Cot construction Lightweight aluminum construction - collapses if patient is obese - difficult to reposition patient without securing cot Cots were constructed of aluminum and as stated before easily collapse under the weight of obese patients. Also, repositioning a patient required another person to secure the cot so that it would not move. Cots were constructed of aluminum and as stated before easily collapse under the weight of obese patients. Also, repositioning a patient required another person to secure the cot so that it would not move.

33. Low cot height Poor body mechanics with patient transfers The cot height was 22 inches. For an average female the distance from heel to knee is 17 inches and from knee to hip is 18 inches. As diagramed here, in order to keep the waist near the level of the cot so as to keep the back straight, the knees need to be bent at an acute angle. This position is difficult to maintain when bearing weight. The cot height was 22 inches. For an average female the distance from heel to knee is 17 inches and from knee to hip is 18 inches. As diagramed here, in order to keep the waist near the level of the cot so as to keep the back straight, the knees need to be bent at an acute angle. This position is difficult to maintain when bearing weight.

34. Unused mechanical patient lift There was a mechanical patient lift that was part of our cache which was not used by nursing staff and others assisting in patient transfers. This was due to most staff being unaware it was present, lack knowledge of many staff on how to use it, and also its poor maneuverability.There was a mechanical patient lift that was part of our cache which was not used by nursing staff and others assisting in patient transfers. This was due to most staff being unaware it was present, lack knowledge of many staff on how to use it, and also its poor maneuverability.

35. Patient Lifting Study Nurses as well as support staff from the pharmacy, laboratory, logistics and safety/preventive medicine sections performed patient lifts and transfers. We conducted a patient lifting survey to compare the severity of musculoskeletal pain among staff who performed patient lifts or transfers. Controls were staff who never performed patient lifts or transfers. As expected, nurses performed more patient lifts or transfers per shift than support staff. On average nurses performed 23 transfers per shift and support staff 5. The greatest weight lifted by nurses and support staff was similar. Upper back pain was more prevalent among staff who performed patient transfers than among the controls. Lower back pain was present among all three groups and was more prevalent among controls; however some nurses and support staff lower back pain of grade 3 severity whereas the highest severity among controls was grade 1. Upper back and shoulder pain was reported by staff who performed patient transfers but not by controls. Shoulder pain was more prevalent among nurses who as a group performed more patient transfers compared to support staff who performed fewer patient transfers, suggesting that shoulder pain was due to this activity. The presence of lower back pain among controls suggests that cots that staff slept on as well as general demands of assembling the FMS were partially responsible for the reported lower back pain among nurses and support staff.Nurses as well as support staff from the pharmacy, laboratory, logistics and safety/preventive medicine sections performed patient lifts and transfers. We conducted a patient lifting survey to compare the severity of musculoskeletal pain among staff who performed patient lifts or transfers. Controls were staff who never performed patient lifts or transfers. As expected, nurses performed more patient lifts or transfers per shift than support staff. On average nurses performed 23 transfers per shift and support staff 5. The greatest weight lifted by nurses and support staff was similar. Upper back pain was more prevalent among staff who performed patient transfers than among the controls. Lower back pain was present among all three groups and was more prevalent among controls; however some nurses and support staff lower back pain of grade 3 severity whereas the highest severity among controls was grade 1. Upper back and shoulder pain was reported by staff who performed patient transfers but not by controls. Shoulder pain was more prevalent among nurses who as a group performed more patient transfers compared to support staff who performed fewer patient transfers, suggesting that shoulder pain was due to this activity. The presence of lower back pain among controls suggests that cots that staff slept on as well as general demands of assembling the FMS were partially responsible for the reported lower back pain among nurses and support staff.

36. Actions Ordered and received standard hospital beds Trained staff on how to use a mechanical patient lift and proper patient transfer techniques Interventions included ordering motorized hospital beds and a hands-on demonstration of how to use a mechanical patient lift and proper patient transfer techniques during the deployment. Interventions included ordering motorized hospital beds and a hands-on demonstration of how to use a mechanical patient lift and proper patient transfer techniques during the deployment.

37. Recommendations for staff billeting Provide all staff with air mattresses Provide a sleeping area for staff sufficient in size to allow a minimum of 3 feet between beds We recommend that staff be provided with air mattresses in lieu of cots and the provided sleeping area be sufficient in size to accommodate 3 feet of separation.We recommend that staff be provided with air mattresses in lieu of cots and the provided sleeping area be sufficient in size to accommodate 3 feet of separation.

38. Recommendations for nutrition of staff Allow staff to purchase food from local grocery stores Date and refrigerate nutritious food (e.g. canned or fresh fruit) provided by food vendors not consumed at one meal As we did during our deployment, we recommend that accommodations be provided so that staff can purchase food from local grocery stores to supplement catered food when food quality is poor. Additionally, nutritious food from one meal should be refrigerated for reuse during the following meal.As we did during our deployment, we recommend that accommodations be provided so that staff can purchase food from local grocery stores to supplement catered food when food quality is poor. Additionally, nutritious food from one meal should be refrigerated for reuse during the following meal.

39. Recommendations to minimize back injuries of staff Include in cache: sufficient number (15%) of hospital beds or bariatric beds mechanical patient lift with a smaller base (more maneuverable in bathroom) disposable patient belts for mechanical patient lift so that patients can be hoisted on to the toilet seat The cache should contain a sufficient number of beds. Given that 20% of our patients were obese and that many of the cots were used for people accompanying the special needs person, a minimum of 15% of the cots should be replaced by beds. A smaller more maneuverable patient lift device rather than the current model should be included and should be equipped with disposable or washable patient belts. The cache should contain a sufficient number of beds. Given that 20% of our patients were obese and that many of the cots were used for people accompanying the special needs person, a minimum of 15% of the cots should be replaced by beds. A smaller more maneuverable patient lift device rather than the current model should be included and should be equipped with disposable or washable patient belts.

40. Recommendations to minimize back injuries of staff Train staff prior to and during deployment on: proper use of the mechanical patient lift proper patient transfer techniques Staff should be trained prior to and during the deployment on the use of the mechanical patient lift device and patient transfer techniquesStaff should be trained prior to and during the deployment on the use of the mechanical patient lift device and patient transfer techniques

41. Log and track staff injuries and illness By logging and tracking staff injuries and illnesses a plan can be formulated to prevent similar injuries in others. For example, foot pain from wearing boots for 12 hours continuously led to a decision to allow staff to wear tennis shoes while working but not when leaving the FMS in uniform. By logging and tracking staff injuries and illnesses a plan can be formulated to prevent similar injuries in others. For example, foot pain from wearing boots for 12 hours continuously led to a decision to allow staff to wear tennis shoes while working but not when leaving the FMS in uniform.

42. Recommendations to minimize biohazard risks Include individualized size sharps containers in cache Instruct patients using insulin on the use of sharps containers upon admission Instruct staff on what is biohazardous trash prior to and early in deployment Individualized sharps containers should be included in the cache and patients using insulin should be instructed on proper disposal of their needles upon their admission to the FMS. Staff should be instructed on what constitutes biohazardous trash prior to and early in the deployment Individualized sharps containers should be included in the cache and patients using insulin should be instructed on proper disposal of their needles upon their admission to the FMS. Staff should be instructed on what constitutes biohazardous trash prior to and early in the deployment

43. Thank you for your attention. Thank you for your attention.