Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
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Chapter 3. Decontamination
The presentation of contaminated patients seeking treatment at local health care facilities is not a new concept. Every day, health care facilities are presented with patients who are exposed to chemicals from industrial accidents and agricultural chemical incidents. Additionally, acute and chronically ill patients frequently present to health care facilities with possible contagious pathogens requiring that appropriate control procedures, such as personal protection and isolation by health care workers, be initiated. While a contaminated patient will likely require decontamination, an infectious patient will not. Care of the infectious patient should follow infection control standards, such as standard, droplet, or airborne precautions. While contaminated patient incidents can be relatively common in many health care facilities and communities, they frequently affect only a small number of patients and rarely pose a serious threat of toxic exposure to the health care staff, patients, bystanders, equipment, and infrastructure.
The attention and perceived threat of a terrorist incident directed against civilians involving chemical, radiological, or biological weapons of mass destruction (WMD) has reinforced the need for health care facilities to re-examine their level of preparedness in the management of contaminated casualties. This threat has forced health care facilities and first responders to scrutinize current methodologies and design rapid responses to the emerging threat of a WMD event resulting in mass contaminated casualties. Health care facilities and providers must implement a "best practice" approach in the management of contaminated casualties requiring decontamination specific to their facility policies, protocols, infrastructure, training and education, and situation.
The catastrophic nature of a terrorist attack involving WMD demands that the medical community be prepared. Unless such an attack is announced (overt), hospitals, clinics, and urgent care centers will become front line "emergency responders" or "first receivers" (personal communication with Dennis L. Jones, RN, BSN, State Hospital Community Preparedness Coordinator, Georgia Division of Public Health. November 19, 2003). The assumption can be made that many of the contaminated patients will present directly to the health care facility. Thus, health care facilities will need to activate a plan for initiating contaminated patient recognition, care, triage, and decontamination, and institute hospital emergency management decisions.
These decontamination best practices and guidelines will identify technical and operational submissions and recommendations for the health care provider and facility following a terrorist attack involving WMD. These best practices will identify the most efficient and effective techniques and procedures to best manage a large-scale mass casualty incident requiring decontamination.
This document offers evidence-based strategies and methodologies for giving health care providers and facilities options and direction for implementing a workable decontamination system. The information provided in this document is based on the collection and analysis of data from open source literature, government/industry regulations, public and private organizations and agencies, academic institutions, and subject matter experts.
To provide a "best practices" methodology, it is important for the health care facility and provider to understand the logic behind decontamination. The purpose of decontamination is to: 1) remove the agent from the victim's skin and clothing, thereby reducing further possible agent exposure and further effects among victims. This practice is the single most important action associated with an effective decontamination process; 2) protect emergency responders and medical personnel from secondary transfer exposures, which is the primary rationale for ensuring detailed decontamination at the health care facility, thereby preserving critical medical services and infrastructure; and 3) provide victims with psychological comfort at or near the incident site to mitigate negative long-term psychological impact (Tan, 2003).
The health care facility staff should conduct a hazard vulnerability analysis and review its operational capabilities and concept of operations in the framework of practice standards. This review should be community driven, based on perceived and substantiated data and intelligence, and the likely impact credible threats would have on the facility and community. The health care facility staff need to: 1) be conversant with the credible threat, presenting symptoms, available treatments and resources regarding potential chemical/biological/radiological/nuclear/explosive (CBRNE) agents; 2) possess a heightened index of suspicion; 3) have the ability to identify possible unusual disease patterns, toxidromes or clinical findings; 4) have a process for early notification of a potential threat or incident in the community; 5) possess established relationships with neighboring public health and healthcare organizations, pharmacies, labs, emergency responders and medical suppliers, usually via their local emergency management agency; 6) develop, train, and exercise decontamination procedures and facility treatment area re-organizations; and 7) be vigilant.
The regulatory authority for accredited health care facilities is the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). JCAHO has identified specific requirements under the emergency management standards EC 1.4 and 1.6.
This Federal government regulation requires the health care facility to be prepared to decontaminate patients and have regularly scheduled drills and exercises in order to test emergency preparedness (Hoover, 2001), although JCAHO does not specifically require the hospital to have its own onsite mass casualty decontamination capabilities.
In addition, JCAHO requires that:
- Health care facilities must implement and utilize an internal incident management system.
- Health care facilities must mitigate effects from possible contaminated patients presenting to facilities by conducting a hazard vulnerability analysis. This should identify potential credible hazards and threats to life, safety, property, and environment. (This analysis, when incorporated with the local and regional emergency management plans, offers the health care facility and providers estimated values of potential patient impact statistics following a CBRNE incident.)
- Health care facilities must be prepared to address contaminated casualty issues by developing decontamination plans. These plans must address the health care facility's normal approach to individual patient decontamination methods. In addition, these plans will require evaluation and validation by regular drills and exercises formatted to test the plans' efficiency and effectiveness.
In addition to JCAHO requirements, the following organizations have provided additional guidance:
- The Agency for Toxic Substances and Disease Registry (ATSDR) released a series of guidelines to help local emergency departments, communities, and other policymakers develop their own response plan for hazardous materials incidents (U.S. HHS, 1994a).
- The Centers for Disease Control and Prevention's (CDC's) Planning Guidance for the Chemical Stockpile Emergency Preparedness Program (CSEPP) provides recommendations for civilian communities near chemical weapons depots (U.S. HHS, 1995b). Although helpful, the outlines are generic, and do not address how to actually perform mass decontamination or contain information on many of the agents that are likely to be seen in a terrorist incident (Macintyre, 2000).
- The U.S. Army's Soldier and Biological Chemical Command (SBCCOM), now Research, Development, and Engineering Command (RDECOM), has published several documents addressing mass casualty decontamination.
- Regulations affecting decontamination team training are primarily those of Occupational Safety and Health Administration's (OSHA) Hazardous Waste Operations and Emergency Response regulations (29 CFR 1910.120). Though the emergency response provisions were written for operations at the scene of a release, OSHA requires health care facility personnel providing decontamination services to be trained to the "Operations" level. Annual refresher training or demonstration of competency is also required (O'Keefe, 2000).
To perform mass casualty patient decontamination safely and correctly requires a response plan, proper equipment, and trained personnel. Accepted military procedures and their adaptation for use in the civilian sector provide generic guidance for some highly specific situations, but to date there is no detailed national guideline on how to set up and conduct a mass casualty decontamination process in the civilian setting (personal communication with Steve Cantrill, MD, Associate Director of Emergency Medical Services, Denver Health Medical Center, December 8, 2003).
When developing a mass casualty plan, the three primary objectives of a disaster response are: 1) do the greatest good for the greatest number of victims; 2) effectively utilize personnel, equipment, and health facilities; and 3) do not relocate the disaster from one location to another by poor command, control, or communication practices.
Additionally, an assumption can be made that self-referred contaminated patients will not have been decontaminated in the field and that the hospital will be responsible for providing the detailed or technical decontamination that results from removing all clothing and washing the entire body. Gross field decontamination practices do not address this level of care. Gross or hasty decontamination practices designed to rapidly "put water" on potentially contaminated mass casualties may result in the inadequate washing of the contaminant from the victim, and may cause complications such as hypothermia, even in warm weather.
Practice and preparation will mitigate casualties to staff, patients, bystanders, and equipment. Without planning, education, supplies, equipment, and training, the casualty count may rapidly mount when the number of persons exposed escalates, particularly as the event is likely to be unprecedented in a community. Health care facilities have voiced concern with the development of decontamination systems. Limited funding, no direct regulatory authority, and the lack of approved/tested systems have created significant gaps in health care facility implementation. Local and State government agencies receiving Federal funding generally view hospitals as private industry and responsible for their own preparedness. In recent years, limited HRSA funding has been made available to hospitals, much of which has been spent on PPE and decontamination equipment, with little assurance of sustained funding or funding for training or backfill. Mass casualty decontamination is a community problem and should be addressed as such. Additionally, local governments and health care facility fiscal management are reluctant to spend large amounts of money and time preparing for what they judge to be low-probability events (Tan, 2003).
- Health care facilities and emergency management must coordinate an annual hazard vulnerability analysis and assessments to determine credible threats in conjunction with local, regional, and State assessments. Data collected can determine potential community risks and threats, such as neighboring industrial, transportation, chemical, biological, and nuclear hazards. Based on the hazards identified and the potential risk to the population, a health care facility can estimate a mass casualty patient flow factor. Health care facilities can expect at least a 20:1 ratio of unaffected to affected casualties (mentally impacted), although this ratio was well exceeded following the 1995 Tokyo subway Sarin release (Tan, 2003). Planning can be developed for appropriate decontamination needs, medications, antidotes, and equipment.
- Participation in community emergency planning, public health, local government, and inter-facility healthcare committees is critical in efforts to mitigate health and medical issues, as well as disseminate capabilities and limitations. Community involvement includes participation in the local emergency management planning committee (LEPC), local office of emergency management planning, and with public safety agencies and 911 dispatchers as applicable.
- Health care facilities need to have the ability to rapidly deploy a decontamination system (either internal-environmentally controlled yet not within the facility, or external) capable of capturing mass numbers of potentially contaminated, self-referred, ambulatory patients. In addition, the health care facility should develop decontamination system plans to accommodate non-ambulatory contaminated patients. The system of choice must provide the security, privacy, environmental control (heat and warm water), and size to allow for rapid progression through disrobing, decontamination, triage, gowning, and medical treatment. Some health care facilities are researching the possibility of sharing decontamination responsibilities based on the type of event. Some discussion has indicated a possible concentration of services with facilities designated as expert resources for certain event types. (Hospital A = Chemical Decontamination facility, Hospital B = Biological /Infectious Disease facility.). Designating hospitals in the same region with equivalent threat levels and different resources leaves the non-designated facilities at risk for the self-referred contaminated patients. Especially without an in-depth, ongoing public education program, victims will not know to go only to certain hospitals.
- A "best practice" system would have the decontamination infrastructure or system fixed to the external structure of the hospital. The idea behind this is to provide an area separate from the main health care facility, preventing facility contamination. The decontamination system would provide gender-segregated areas for undress, washing and redress, environmentally controlled conditions, warm water and soap for detailed decontamination, and all necessary supportive equipment. Ideally, the mass casualty decontamination capability would be immediately accessible and rapidly activated, such as by flipping a switch. When the detailed decontamination capability takes time to set up and deploy, the facility should be prepared with immediately accessible, gender-segregated, environmentally sheltered areas for undress. This would allow patients to remove gross contamination by removing clothing. Clothing and contaminated belongings should be secured, such as by sealing them in a vapor-resistant bag. This will assist healthcare facilities in limiting areas of contamination as victims self refer and give the victims treatment options while detailed decontamination capabilities are being deployed. Health care facilities should not wait for response assets to arrive to begin the contaminated patient treatment process, but develop a plan that can immediately protect the health care facility and health care professionals while providing appropriate lifesaving patient care. Health care facilities should not just rely on facility lock-down to keep potentially contaminated patients out while waiting for rescue. It is highly likely that the contaminated patients will already be within the health care facility at the time of discovery of contamination, rendering a complete lock-down as a barrier ineffective. Lock-down is a useful security measure that provides controlled ingress and egress, but not an absolute protection against secondary contamination. Rather, health care facilities should consider minimally providing an undress area as previously mentioned, compartmentalizing egress points for containment purposes, and strive to develop a "flip-switch" mass casualty definitive decontamination capability.
- While resource designations may assist with the fiscal constraints, it will not prevent self-referring contaminated patients from walking into a health care facility seeking treatment. Health care facilities must assume that their facility will receive mass numbers of contaminated casualties (walk-ins). A system must be in place to control this type of situation.
- As identified in the Personal Protective Equipment (PPE) Section, health care facilities providing decontamination services must fully and regularly provide the standard precautions for the highest, defensive impact against the contaminant. Personal protective equipment deficits for infectious pathogens currently exist with the number of on-hand supplies available for mass casualties. Newly published OSHA guidelines (2004) indicate that personal protective equipment should be based on a hazards vulnerability analysis and assessment, with a minimum of a National Institute for Occupational Safety and Health-approved, hooded, fit-tested, powered air purifying respirator with an assigned protection factor of 1000, in addition to Level C chemical resistant garments, gloves and boots.
- Health care facilities need to identify ancillary staff capable of assisting in the deployment and execution of the facilities' decontamination system. Non-patient care/ancillary personnel (i.e., housekeeping, maintenance, engineering, security) should ideally be trained to assist in the rapid execution of decontamination system set-up. In addition, HCFs must incorporate standardized all-hazards awareness training as part of the initial employee orientation education. Staff expected to participate in decontamination procedures or provide care to potentially contaminated patients should have an operations-level or performance offensive-level training that is competency based. (OSHA, JCAHO, Office for Domestic Preparedness [ODP, 2003]) Non-patient care providers need to understand and be trained in the threats, hazards, and facility response. The health care facility needs to assure annual training, education, and participation in community "live-water" full scale exercises. Additional education and training must be available for staff from all shifts to assure total facility preparedness 24 hours a day/7 days a week.
When identifying decontamination locations and the type of system that best suits the facility, keep in mind the body's response to ambient temperatures. The health care facility may need to establish multiple decontamination locations in the event that external temperatures prohibit a safe environment for decontamination.
Patient decontamination is to be performed when the contaminant poses a further risk to the patient or a secondary risk to response personnel. Fire and Emergency Medical Services (EMS) publications frequently describe how patient decontamination can be accomplished, but few of the recommendations are based on empirical research. Because little scientific documentation and regulation exist on patient decontamination, health care facilities and providers must make a "best guess," "most cost effective" approach until more conclusive research is reported.
Decontamination studies provided by the military are available, though there are numerous issues not addressed by these reports that are crucial in the development of a workable system in the civilian community. These issues fail to address key planning initiatives with regard to health care facilities and providers and the public, private, and local government sectors.
It can be expected that following a large scale mass casualty incident involving an agent of contamination, a large number of the patients seeking emergency medical care will self-refer to the nearest emergency health care facility. Facilities must have the capability to activate decontamination protocols, policies, and procedures while limiting further patient, bystander, staff, and equipment infrastructure exposure. The decontamination equipment or structure should be pre-constructed or capable of simple assembly and rapid utilization. Decontamination locations should be pre-established, offering environmental protection from the elements, privacy, security, and initial triage care.
Additionally, a critical gap in the healthcare system is the fact that the vast majority of health care facilities do not have onsite detection equipment or sensors to allow the rapid identification of a contaminated patient event. Health care facilities and EMS rely on presenting signs and symptoms alone.
Unless a health care facility has implemented structural modifications for a fixed decontamination facility, best practices would suggest the identification of an external location. The definition of an external location is an area within close proximity to the health care facility that will eliminate the risk of secondary contamination to health care facility patient treatment areas. This external location should incorporate a dedicated ventilation capability, the ability to keep runoff from entering the health care facility, and allow patients to access the location without entering the health care facility. The external location is typically more suitable for an influx of mass casualties. In addition, it lends itself to allowing the facility to lock down, preventing untrained or unprepared staff, bystanders, and equipment from becoming contaminated or exposed.
The external decontamination facility should provide environmental protection, lighting, and privacy, with the ability to become active at all hours. The health care facility should also provide a means of decontamination for non-ambulatory patients, in addition to those who are ambulatory. The decontamination facility should never allow contaminated patients to penetrate the patient care facility.
It can be assumed that due to the significant costs for developing a fixed decontamination facility, most health care facilities will be forced to create external or temporary locations and facilities. When a decontamination incident occurs, the health care facility needs to be aware of the environmental conditions to assure that additional harm or risk is not presented to those who have been contaminated. The health care facility needs to consider the four-method approach described below (United States Army Soldier and Biological Chemical Command, January 2000).
The first method is a general baseline external decontamination system. All decontamination tasks may be conducted externally. If decontamination is conducted outdoors, regardless of the temperature, hypothermia primarily due to convection will be a medical issue to be monitored. Accordingly, decontamination facilities should still be sheltered, offer environmental control, gender segregation to increase compliance, and the ability to funnel run-off away from the victims. This method provides the health care facility with the quickest way to execute and maximize throughput. Recommendations for Method I decontamination suggest environmental conditions and ambient temperatures of greater than 65 degrees Fahrenheit (Tan, 2003).
The baseline for Method II is identical to Method I. The primary difference is the evacuation of patients to a warm indoor facility for post-decontamination redress and medical screening. A pre-designated corridor or heated entranceway large enough to handle the number of casualties would be sufficient. Method II is recommended when the ambient temperature is colder than 35 and warmer than 65 degrees Fahrenheit (Tan, 2003).
Method III, disrobing/collection/assessment, can be conducted indoors or outdoors, yet the ambient temperatures may dictate indoor decontamination to avoid inducing additional cold weather related injuries to the patient. Method III challenges the facility as to the location of casualty collection and assessment. The actual decontamination will need to be accomplished indoors. Buildings that have indoor shower or pool facilities will best serve as mass decontamination locations. If the health care facility does not have access agreements with these types of locations, then a facility or building with indoor sprinkler-like capabilities may also provide an all-weather solution (Tan, 2003).
Method IV should be the method of choice when the environmental conditions prohibit the health care facility from activating an open-air, outdoor decontamination set-up; when ambient temperatures are generally less than 35 degrees Fahrenheit; or when conditions exist that prevent equipment deployment (73). Method IV incorporates dry decontamination options (use of blotting with absorbent materials) with indoor wet decontamination. These systems pose significant challenges to the health care facility. Method IV would require the movement of contaminated casualties to a location for complete indoor decontamination. The health care facility would need to assign a casualty collection point and decide on disrobing prior to transportation to the decontamination site. Failure to disrobe prior to transportation may lead to significant "off-gassing" in an enclosed vehicle, while disrobing may lead to cold-weather shock or hypothermia (Tan, 2003).
Generally, the decontamination process involves three stages: gross, secondary, and definitive (detailed or technical) decontamination.
- Evacuate the patient(s) from the high-risk area.
- Remove the patient's clothing.
- Perform a one-minute quick head-to-toe rinse with water.
- Field emergency decontamination often involves cold water from a fire hose, no clothing removal, and is targeted to ambulatory patients.
- Perform a quick full-body rinse with water.
- Wash rapidly with cleaning solution from head to toe.
- Rinse with water from head to toe.
Definitive (detailed or technical) Decontamination
- Perform thorough head-to-toe wash until "clean."
- Rinse with water thoroughly.
- Towel off and put on clean clothes.
It should be noted that in the absence of a rapidly accessible warm water decontamination capability, a best practice would be to provide a sheltered area for patients to undress and remove potentially contaminated clothing. This may also be a good solution to the initial timeframe when presenting victims are recognized to be potentially contaminated and the first contacted health care professionals are waiting for the decontamination capability to be deployed.
It is difficult to determine when a patient is "clean," especially when mass numbers require decontamination. Few chemical or biological agents can be readily seen on the skin or quickly assayed to determine whether any residual product remains after washing. The lack of detection equipment at health care facilities is a major gap in current capabilities. Existing technology does exist, though it is either too expensive or does not provide the needed reliability, ease, and versatility to be used in the civilian environment. In the absence of knowing "when clean is clean or safe enough," health care facilities and providers are left to use their best clinical judgment as to when the decontamination process is complete. This practice can be inefficient and potentially unsafe. Unfortunately, there are no approved standards that provide the health care facility with speed, reliability, and cost-benefit. Health care facilities must pre-designate large areas such as cafeterias or auditoriums for the observation of large numbers of patients with minor or no apparent injuries or illnesses following decontamination and an initial evaluation by the healthcare staff. This area must provide adequate ventilation in an effort to ensure that potential "off-gassing" consequences are minimized. Particularly in the case of potential radioactive contamination, the current standard of care is not to deny or withhold lifesaving treatment while waiting for or performing decontamination. Patient decontamination is a medical procedure, and maintaining lifesaving "ABC's" (airway, breathing, circulation) can be accomplished with proper personal protective equipment both before and during decontamination.
The ability to control and reduce anxiety, confusion, and panic among patients and staff will be key in managing this type of mass casualty incident. The health care facility must initiate a risk and crisis communication plan, providing up-to-date information on the exposure, potential short- and long- term effects, recommended treatments, and other relevant information. Ideally, local and State emergency management agencies recognize that a mass casualty decontamination event is a community problem, and work with health care professionals and health care facilities to provide ongoing, proactive public education before any mass casualty event to allow citizens to become part of their own care and response planning. An example of such public education is describing what citizens could do and expect to have happen during a mass casualty event that would require decontamination, including clothing removal and mass showering.
The most important aspect of decontamination is the timely and effective removal of the agent. The precise methods used to remove the agent are not nearly as important as the speed by which the agent is removed. The first steps in the decontamination process are the removal and disposal of clothing. Cox (1994) estimates that 70-80 percent of contaminants, and 90-100 percent of trapped vapors, will be removed with the patient's clothes. However, little scientific data exist to support this assertion. More scientific research is needed for the identification of an ideal skin decontaminant capable of removing and neutralizing a wide range of hazardous chemicals, that is inexpensive, readily available, quick-acting, and safe (personal communication with Steve Cantrill, MD, December 8, 2003). Although the FDA has just approved the use of a decontamination lotion (Reactive Skin Decontamination Lotion [RSDL]) for the U.S. military, it is not available for civilian use. Additionally, there are some systemic absorption issues to be addressed. Further research and more products are needed for the civilian health care setting. Although hospitals are required by JCAHO to be prepared to respond to disasters including hazardous material accidents, few have undertaken realistic planning and preparation. Many hospitals defer HAZMAT issues to the local fire department; however, in a mass casualty event, realistically the fire department assets may be otherwise engaged at the incident scene.
Some hospitals have decontamination facilities; however, very few have external facilities or an easy way of expanding their decontamination operations in a mass casualty event (Cox, 1994; Levitin and Siegelson, 1996). Often their initial response to an incident will be to contact the local fire department or HAZMAT team for assistance. This may not be a viable solution if the incident results in the rapid arrival of self-referred contaminated patients. The issue remains of what to do with a large number of contaminated patients who are actively seeking medical treatment, while waiting for external response to set up decontamination.
Ideally, the receiving facility can set up a capability that provides immediate containment of contaminated patients, climate controlled shelter, gender-segregated areas in which to remove contaminated clothing, the ability to secure belongings, and the ability to provide immediate medical screening and life-saving intervention. Unannounced, contaminated ambulatory patients or those brought in by ambulance may contaminate the facility before "outside" help arrives to address the situation and before internal resources can be organized to respond. If assistance from the local public safety agency is not available, the hospital is left to fend for itself and, if unprepared, the response is likely to place the patient, staff, and facility at great risk.
Recent reports on the Tokyo subway incident of 1995, which involved the non-persistent nerve agent Sarin, provide some support for this position (Okumura et al., 1998). No field decontamination was performed onsite, and emergency medical technicians (EMT) transported 688 victims to hospitals by ambulance. Ten percent of 1,364 EMTs showed symptoms and had to receive treatment at the hospital themselves. Once the hospitals learned that nerve agent was suspected, the most seriously ill patients were directed to a shower upon arrival. Their clothes were placed in plastic bags and sealed up. Despite these precautions and the use of surgical masks and gloves, 110 hospital staff (23 percent) complained of acute poisoning symptoms on a followup questionnaire.
There is little financial incentive for a hospital to be prepared for a "once in a lifetime" event, and proper equipment and training may be perceived as too expensive under the circumstances. Generally, hospitals that are prepared are usually capable of handling only a few patients an hour. What happens when a large number of patients begin to arrive? Currently, evidence-based, best practice research findings to assist hospitals with cost-effective HAZMAT or terrorist response planning are scarce.
Best practices should include addressing the needs of jurisdictional special populations; for example, translating directions and signage into languages other than English, providing accommodations for wheelchairs and seeing-eye dogs, being culturally sensitive, and providing guidance for the visually and hearing impaired.
ATSDR released a series of guidelines to help local emergency departments, communities, and other policymakers develop their own response plans or HAZMAT incidents (ATSDR, 1994a). The CDC's Planning Guidance for the Chemical Stockpile Emergency Preparedness Program provides recommendations for civilian communities near chemical weapons depots (CDC, 1995b). Since planning is left to the local jurisdictions, the success of any national initiative depends on cooperation at the local level.
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