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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
slide13
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osha draft guidance
OSHA Draft Guidance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

slide29
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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