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Hospital Decontamination

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

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

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

  3. 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?

  4. 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

  5. Threats • Weapons of mass destruction • Mainly, chemical or radioactive • Fires • Transportation accidents • Industrial accidents • Internal spills (lab, chemo, radioactives) • Do a Hazard Vulnerability Analysis

  6. Tokyo Sarin Attack

  7. 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

  8. Conyers, GA 2003

  9. Madrid, 11 March 2004 Explosives… Decon???

  10. Radiation Is Easily Detectable ED door monitors?

  11. Anthrax 2001-2002 Decon? Or Prophylaxis?

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

  13. 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

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 OSHA Draft Guidance • www.osha.gov/dts/osta/bestpractices/firstreceivers_hospital.pdf • In brief: • Yes, you need to do it • PAPR’s • 8 hour staff training minimum

  15. 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

  16. 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

  17. Decon Options Cheap Slow, clumsy • Outdoors (wading pools) • Tents • Outside • Inside • RAM Decon • Trailers • Indoors • Multipurpose room • Dedicated room Quick, easy Dear

  18. Decontamination Tent

  19. “RAM Decon”

  20. Hospital’s Trailer

  21. Local FD Trailer

  22. “Mass” Decon Unit

  23. 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,

  24. A permanent hospital decon room

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

  26. 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

  27. 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?

  28. Level B with supplied air

  29. Level C with PAPR

  30. C minus

  31. 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

  32. 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???

  33. 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

  34. 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

  35. 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

  36. 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)

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

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

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

  40. Training • Internal • Hospital based • External • FD-based • Industrial • Refresher training built into system • Employee orienttation? Annual “special teams” training?

  41. 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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