Coming Clean about Hospital Decontamination

Presentation to: 8 Hour Operations Class

Presented by: DPH Trainer the Trainers

Date:

Question 1:

During decon, hospitals must

make an attempt to capture

and retain as much runoff from

victim and/or mass casualty

decontamination operations as

possible to comply with EPA

and other environmental laws.

Reality

Myth

The Facts

• Protecting the environment should NEVER be considered ahead

of protecting people.

• Contaminated people cannot have enough chemical on them to

seriously harm the environment.

• The perceived liability cause by potential environmental damage

is FICTION. Liability from delaying decon of victim is a FACT.

• The EPA agrees: The victims come first!

• “First Responders’ Environmental Liability Due to Mass

Casualty Decontamination Runoff” (Chemical Safety ALERT

July 2000)

Question 2:

• OSHA requires that hospital decon

teams learn and know how to use

the DOT ERG.

• This Guide will provide useful

information to help the decon

control officer in selecting proper

PPE and determining specific

hazards. Reality

Myth

• It provides absolutely no useful chemical information to

determine proper hospital MCI decon.

• It provides no accurate information to suggest the correct

PPE for hospital decon operations.

• It provides no specific chemical properties.

• It was developed only to aid 1st responders in quickly

identifying hazardous materials and protecting themselves

and the public during the INITIAL response phase of a

hazardous materials incident.

The Facts

• Water should not be used on people who

are contaminated with almost all of the

Class 4 water-reactive substances.

• Hospitals should have a plan for dry

victim decon or should use water

sparingly to avoid contact with the

substance on skin.

Question 3:

Reality

Myth

• Water should be used for water-reactive materials, but

only low pressure, high-volume.

• Garden hoses do not apply “copious” amounts of water

and can result in dangerous reactions.

• Dry decontamination of victims and responders increases

the dangers of the contamination.

• Every fire department in the USA has one or more “decon

units” (pumpers/engines).

The Facts

Oxidizers and Organic Peroxides

should be quickly washed from the

shoes and clothing of contaminated

victims because there is a chance

the victim’s clothing could

spontaneously ignite at any time.

Question 4:

Reality

Myth

• Organic Peroxides may have a Maximum Safe Storage

Temperature (MSST) or Self Accelerating

Decomposition Temperature (SADT), causing them to

react with heat.

• Many Oxidizers will self-ignite when they dry out on

clothing.

• Both classes like to decompose when contaminated

with organics, acids, etc.

• If you make contaminated victims wait for decon, you

may place them in great danger.

The Facts

• A MSDS provides accurate

information to hospitals for

decontamination, PPE, and

medical care to victims

contaminated with a known

substance.

• The MSDS also provides

specific information for

medical treatment.

Question 5:

Reality

Myth

• Material Safety Data Sheets rarely provide

accurate information about victim

decontamination or medical care beyond first

aid.

• The MSDS for the same chemical differ

between the manufacturers.

• MSDS’s mostly say use copious amounts of

water to wash product off the skin/eyes.

The Facts

• Victim decontamination should never be delayed while determining the proper soap or other additives.

Question 6:

Reality

Myth

• The rapid use of low pressure high volume water and quick disrobing are the best decon solutions.

• Initial decon operations don’t require soap or

additives to remove most chemicals.

• “Additives” or decon-solutions may cause

reactions if used without professional advice.

• Brushes of any kind are not recommended nor

required to decontaminate the skin.

• Soap dilutes quickly in decon buckets.

• After a few victims, the soap is gone and

effectiveness of brushing decreases.

The Facts

Cool or cold weather decontamination operations

should not be delayed to wait for the decon

shower water to be heated or “tepid.”

Question 7:

Reality

Myth

• Heating decon water is not very practical

because it delays decontamination and

heaters cannot heat large volumes quickly

enough.

• Great for secondary decon/personal

showers

• Cold water is uncomfortable but it does not

induce hypothermia when the people are

warmed quickly afterwards.

• U.S. Army Soldier and Biological Chemical

Command (SBCCOM) decon studies concur

The Facts

Over 1.6 million people

contaminated with a

nerve agent could be

decontaminated in an

Olympic-sized swimming

pool before the pool

became too

contaminated for further

decon.

Question 8:

Reality

Myth

• SBCCOM Cold Weather Decon Study

• Assumptions: 3,000,000L pool – Dose Brought

into pool by each person GB-100mg or VX-.1mg

• Calculation Results… 1,668,000 people for VX or

GB

• Comments: From the calculations above the

resultant number of people that could be put in a

pool without exceeding the no effects level has

been reduced by 50% to add an additional margin

of safety. In summary, for the agents above (GB

and VX) approximately 800,000 people could be

processed.

The Facts

The deluge system replaces the use of internal and

external showers during the

decontamination process.

Question 9:

Reality

Myth

• Removal of clothing and gross decontamination reduces the risk but does not eliminate the risk

• The triangle from armpits to groin is where the emphasis should be during secondary contamination

The Facts

OSHA requires that

hospitals establish 3

zones for their

decontamination

operation (Hot – Warm –

Cold) to control people

keeping them safer, and

avoiding secondary

contamination

Question 10:

Reality

Myth

• OSHA Best Practices for Hospital-Based 1st Receivers (January

2005) B.3.1 page 17 of 91

• “OSHA has found it appropriate to define two functional

zones during hospital-based decontamination activities.”

These zones, which guide the application of OSHA’s

recommendation are:

• Hospital Decon Zone: Includes any areas where the type and

quantity of hazardous substances is unknown and where

contaminated victims, equipment, or waste may be present.

This area typically ends at the ED Door

• Hospital Post-decontamination Zone: An area considered

uncontaminated. Equipment and personnel are not

expected to become contaminated in this area. (includes

the ED (unless contaminated)).

The Facts

Ammonia and Chlorine, two

very common industrial

chemicals, may cause severe

respiratory distress, skin burns,

and even death to victims, BUT

victim decon is simple because

there is very little chance of

adverse impacts on either the

decon workers or the

environment.

Question 11:

Reality

Myth

• Most gases do not create a hazard for decon workers,

even nerve agents.

• Chlorine and Ammonia are very corrosive but they off-

gas and dissolve in decon water.

• Concentrations may be IDLH when the victim is

contaminated, but below the Permissible Exposure

Limit/Time Weighted Allowance (PEL/TWA) by the time

they are in the warm zone at the incident site.• If the victim is still alive the danger to the protected

decon worker is usually minimal.

The Facts

• Pre-hospital

decontamination can

eliminate the risk of

secondary exposure.

• Removing contaminated

clothing can reduce the

quantity of the

contaminant by up to 25%

Question 12:

Reality

Myth

• Pre-hospital decontamination will limit the

risk of secondary exposure, not eliminate it.

• Removing clothing will reduce the quantity

of the contaminant by 75 % or more.

• SBCCOM Mass Casualty Decon Study.

The Facts

Clinicians, security officers,

triage teams and other

hospital staff members who

play a role in receiving and

treating contaminated

patients are considered by

OSHA to be 1st Receivers.

(same as the hospital’s

decon workers).

Question 13:

Reality

Myth

• OSHA Best Practices for Hospital-Based 1st Receivers

(January 2005) A.2 page 8 of 91

• “First Receivers typically include personnel in the

following roles: clinicians and other hospital staff who

have a role in receiving and treating contaminated

victims (e.g. triage, decontamination, medical

treatment, and security) and those whose roles

support these functions (e.g. set up and patient

tracking)”

• First Receivers are a subset of First Responders

The Facts

OSHA’s Best Practices for

Hospital-Based First

Receivers does not

include/cover infectious

outbreaks for which decon is

not needed.

Question 14:

Reality

Myth

• OSHA Best Practices for Hospital-Based 1st

Receivers (January 2005) A.2 page 8 of 91

• The scope of this best practices document does not

include situations where the hospital (or temporary

facility) is the site of the release. Nor does it

include infectious outbreaks for which

decontamination is not necessary.

The Facts

Hospital employees

assigned the task of

developing the

decontamination program,

procedures, and PPE

selection criteria require

additional training beyond

the 1st Receiver Operations

Level than the hospital

decon team members

require.

Question 15:

Reality

Myth

• OSHA Document 3152 (1997) “Hospitals and

Community Emergency Response What You Need to

Know” Training Employees - 7th page

• Individuals who develop the decontamination procedures

and select PPE for the workers who help decontaminate

patients, must be trained to the First Responder level

(changed to First Receiver in 2005) with additional training

in decontamination procedures, but such individuals would

not need the lengthy specialized training required for a

hazardous materials technician.

The Facts

When training hospital

decon teams, the

competencies identified

in the OSHA standard

for the Operations Level

can be deleted or

tailored to fit the

expected tasks.

Question 16:

Reality

Myth

• Interpretive Letter 12/2/02 to Capt. Kevin Hayden State of

N.M. E.M. Section (page 2)

• Generally, all competencies listed in 29 CFR 1910.120 (q) (6) (ii)

should be met for hospital employees trained to the First

Responder Operations Level designated to decontaminate victims.

• Competencies may be tailored to fit the tasks the employees are

expected to perform.

• For instance, placard recognition is not required as a basic hazard

and risk assessment technique. The ability to identify placards is

important for a Hazmat Team, but not for hospital personnel

designated to perform decontamination.

The Facts

OSHA requires

Awareness Level

training be completed

before Operations

Level Training begins

and Operations training

must be at least 8

hours in duration.

Question 17:

Reality

Myth

• Interpretive Letter 9/24/02 to Scott Cormier HCA

Richmond Market Hospitals (page 2)

• Question 4- Is a training course that combines the first responder

awareness level and first responder operations level competencies in

one 8 hour course acceptable?

• OSHA’s Reply: “Yes. The statement in the VA letter that a total of 16

hours of training is required for the first responder operations level

is not correct.”

• I.L. 4/22/03 to Mike Bolt Novant Health states, “If you spend two

hours training employees in the required competencies for the

Awareness Level, then you would need to spend at least six hours

training for the Operations level.”

The Facts

OSHA requires that

hospitals provide a

minimum of 8 hours of

annual refresher

training for staff

trained to the First

Receiver Operations

Level.

Question 18:

Reality

Myth

• Interpretive Letter 9/24/02 to Scott Cormier HCA

Richmond Market Hospitals (page 2)

• Question 5: Is there a minimum competency or hour

requirement for refresher training ?

• OSHA’s Reply: “No. There is no minimum time specified

for emergency response refresher training. The training

must be of sufficient content and duration to maintain the

competencies for the responder’s level. Alternately,

employees may demonstrate those competencies at least

annually.”

The Facts

• The employer (hospital)

is the only one who can

certify an employee to

any OSHA Hazwoper

Level.

• A public or private

training agency cannot

officially certify any

employee but their own.

Question 19:

Reality

Myth

• Interpretive Letter 12/2/91 to Richard Andree S&H Mgt.

Consultants Inc. (page 2)

• OSHA does not certify individuals, it is the employer who must show by

documentation or certification that an employee’s work experienced and/or

training meets the requirements of 1910.120.

• There must be a written document which clearly identifies the employee, the

person certifying the employee and the training and/or past experience which

meets the requirements.

• Interpretive Letter 3/10/99 to Daniel Burke St. John’s

Mercy MC. St. Louis (page 1)

• Hazwoper requires the employer to certify that the workers have the

training and competencies listed in (q) (6) (ii)

The Facts

Clinical hospital staff

without 1st Receiver

training may enter a

contaminated decon

zone without any prior

1st Receiver and/or PPE

training, if they are

deemed “skilled

support personnel.”

Question 20:

Reality

Myth

• OSHA Best Practices for Hospital-Based 1st Receivers (January 2005) C.3

page 22 of 91

• (A) A member of the staff who has not been designated, but is

unexpectedly called on to minister to a contaminated victim, or perform

other work in the hospital Decontamination Zone, is considered “skilled

support personnel.” Examples include a medical specialist or trade

person such as an electrician.

• These individuals must receive expedient orientation to site operations,

immediately prior to providing such services. The orientation must

include:• Nature of hazard (if known)• Expected duties• Appropriate use of PPE• Other appropriate safety and health precautions ( e.g.

decontamination procedures)

The Facts

Federal OSHA is

responsible for

enforcing 1910.120

“Hazwoper” in private

hospitals only, except

in OSHA States where

Federal OSHA does not

enforce OSHA

standards.

Question 21:

Reality

Myth

• Interpretive Letter 12/2/02 to Capt. Kevin Hayden State of N.M. E.M.

Section (page 3)

• State and municipal employees (e.g. EMS/Fire) are covered by the standard

in those states which operate their own Federally approved State OSHA

Program. In those states under Federal OSHA , the EPA regulates State and

Local employees including volunteers under 40 CFR 311.

• Interpretive Letter 12/2/02 to Capt. Kevin Hayden State of N.M. E.M.

Section (page 3)

• Federal OSHA has no jurisdiction over state and local government

employees such as the public employees of a state-owned hospital.

Twenty three states operate programs that cover both private and public

sector employees.

The Facts

While an environment

that is immediately

dangerous is possible,

it is extremely unlikely

that a living victim

could create an

Immediately Dangerous

to Life and Health

(IDLH) environment at a

receiving hospital.

Question 22:

Reality

Myth

• OSHA Best Practices for Hospital-Based 1st Receivers (January 2005)

B.2.1.1 page12 of 100

• The Georgopoulos Study of 2004 determined that 100 grams or 4 ounces of

the most moderately to highly volatile substances that might be sprayed on

a victim during a MCI would evaporate within 5 minutes from the time the

exposure occurred.

• Horton Study (2003) agreed stating that substances released as gases or

vapor are not likely to pose a secondary contamination risk to 1st Receivers.

Limited exposure may be possible.

• Quote: “It is extremely unlikely that a living victim could create and

Immediately Dangerous to Life (IDLH) environment at a receiving hospital,

particularly if contaminated clothing is quickly removed and isolated and the

victim is treated and decontaminated in an area with adequate ventilation.”

The Facts

OSHA Hazwoper

requires hospitals to

conduct basic pre-entry

medical surveillance for

decon workers and

those who use chemical

protective clothing and

respirators before they

begin work in their PPE.

Question 23:

Reality

Myth

NFPA 471 is only a standard and does not require

medical assessment before entry.

OSHA 1910.120 (f) Requires the following medical

surveillance for hazmat team members:

Prior to assignment and upon termination or reassignment

Once every 12 months or 2 years if physician deems

appropriate

If they exhibit signs or symptoms, injure, or exposed above

Permissible Exposure Limits (PEL)

Physician may require more frequent medical surveillance

The Facts

Because Hazwoper is a

“performance-based”

regulation hospitals are

allowed flexibility in

meeting the

requirements. They are

not required to follow

any specific procedures

or guidelines in OSHA

1910.120.

Question 24:

Reality

Myth

• OSHA Document 3152 (1997) “Hospitals and

Community Emergency Response What You

Need to Know” Training Employees 7th page:

• Hazwoper is a performance-based regulation allowing

individual employers flexibility in meeting the

requirements of the regulation in the most cost-

effective manner.

• There are numerous examples of this decision in

many Interpretive Letters.

The Facts

Question and Comments