decon: tag, you’re it! deborah j persell, phd, rn, cnp
TRANSCRIPT
Decon: Tag, You’re It!
Deborah J Persell, PhD, RN, CNP
St. Louis -- 2008– Industrial Accident– Three self-report to St. Anthony’s– Three self-report to DePaul Health Center– Two report to St. Louis University & Barnes Jewish– Two die
– Nitroaniline
Risk• Probability of occurrence– One or more causes– One or more impacts• Schedule• Scope• Cost• Quality• Priority
PHE Toolkit, 2011
Risk Management Definition• The identification, assessment, and
prioritization of risks followed by a coordinated application of resources to minimize, monitor, and control the probability and/or impact of unfortunate events.
Parsons, 2013
Risk Management Objective• Decrease the probability and impact of
adverse events– Mitigation– Contingency plans
PHE Toolkit, 2011
Corporate ComplianceThe ability of an organization to be able to adjust and adhere to industry-specific government regulations that standardize organizational processes or implement specific requirements.
Parsons, 2013
Risk Management PerspectiveCategories of Risk– Patient care – Medical staff – Employee – Property – Financial
Parsons, 2013
Costs• GAO in 1999 -- estimated costs for 10 years
sustainability for a city of 500,000 – basic capabilities to be $4.6 million – $43 million for higher capability
GAO, 1999
Costs• Incident 1:– 3 chemically contaminated patients– 2 ED nurses contaminated– Decontamination– ED closure for 4 hours– $6,000 ($1000 each for police & traffic control,
$4000 for fire; no hospital expense reported)
Horton, Burgess, Rossiter & Kay, 2005
• Total incidents: 163,231• Total deaths: 127• Total major injuries: 2,761 • Total cost: $737,024,028
Pipeline Occurrences
Internet Search• Key words:– “to hospital after hazmat incident”– 1,510,000 results in 0.59 seconds
• Chemical leak at Scarborough factory sends one to hospital
• Peterborough ball bearing plant explosion injures at least 15
• Officials: Man injured with sulfuric acid at Samsung• Faulty AC spurs lockdown at West Forsyth High
School• Chlorine Dioxide Fumes send 19 to Hospital in
Blytheville Hospital Sunday morning
, • 180 to hospitals after leak Springdale Tyson Foods • 12 people taken to hospital after hazmat incident
at Myrtle Beach hotel pool• 2 taken to hospital after President’s Island
hazmat incident• 3 hospitalized after hazmat incident in Bucks
County• Orlando International Airport workers (3) taken
to hospital after formaldehyde exposure
• Chemical blaze in Orrtanna sends 11 to hospitals
• Lakewood: Hazmat incident sends dozens to hospital
• One man with organophosphate ingestion sickened 25 hospital workers (UK, 2004) – no decontamination on scene
• Villanova PA – university 10 students in a chem lab – three chemicals, 230 firefighters responded. One injured student to hospital contaminated; others on scene – everyone fled the building ???decon all
• Rhode Island Feb 2013 – 2 firefighters hospitalized – toluene – docs and nurses brought in to decontaminate
• 10 hospitalized, 50 evacuated in temple square, salt lake city – janitor mixed chemicals – no reports of decontamination
• Carlsbad – evacuations after gas cloud, mixing of chemicals
• Hospital ER closes for an hour after hazmat incident – a man walked in and told the receptionist he had been exposed to a hazardous incident Snellville, GA
• Emergency room reopens after hazmat incidence – pt brought chemical into hospital (St. Mary’s, Amsterdam)
• Villanova officials: 29 sent to hospital after chemical incident
Myths of Decontamination• All exposed persons will be decontaminated at
the scene• Contaminated patients will not be transported
by ground or air ambulances• Hospitals will always receive notice when
contaminated patients are being transported• Medical decontamination does not require
special training
Assumptions• Self-referred contaminated patients will not have
been decontaminated in the field • The hospital will be responsible for providing the
detailed or technical decontamination• Gross field decontamination does not address this
level of care• Gross or hasty decontamination may cause
inadequate removal of contaminant, hypothermia• Hospitals reluctant to spend money on low
probability eventsStopford, 2005
Common Responses• “We don’t provide that capability”• “We lock the door and call the fire
department” • “To a variety of Level A, B, or C
Stopford, 2005
Hospital Preparedness Capabilities• Capability #10 – Medical Surge
• Function 3 – Assist healthcare organizations with surge capacity and capability– P9 – Decontamination assistance to healthcare organizations– E3 – Decontamination assets– S2 – Decontamination training
ASPR, 2012
• Capability #14 – Responder Safety & Health• Function 2 – Provide assistance to healthcare
organizations with additional access to PPE for healthcare workers in the response– P1 – PPE needs assessment– P2 – PPE caches– P3 – PPE supply and dispensing– E1 – PPE for healthcare workers– S1 – PPE training
ASPR, 2012
Gap Analysis • Decon a universal gap across the state– Size/scope of hospital– Staff Turnover– Maintenance of equipment & supplies– Storage of equipment & supplies– Training– Belief that decon occurs at scene and not a
hospital function– EOP to call someone else
Case Law r/t hospital decontamination
• Medical Malpractice, Sept 30, 2013
• 18 patients Lack of decontamination Cruzfeld Jacob
• Decontamination decreases MSRA by 40%
• Tanner, L. (2013). Decontaminating Patients Limits MRSA Infections. Yakima Herald, June 9, 2013
Consequences of Intentional Misconduct
• Civil Court = Malpractice
• Criminal Court = Felonious misconduct
• Administrative hearing = Adverse licensure or certification action
Shipman, 2014
Types of Contamination
ChemicalBiologicalRadiologicalNuclearExplosive
Contributing Factors to Contamination Levels• Fire, spill or leak• Terrain• Risk to people, property or environment• Need for immediate rescue• Resources required for rescue and containment• Additional personnel requirements• PPE requirements• Population evacuation
Types of Contamination• Primary – direct transfer from source to
person or object
• Secondary – transfer from person or object to another person or object
Blackwell, Brennan & DeAtly,
Decontamination
“Process of removing or deactivating harmful contaminates from surfaces of persons or objects by dilution or physical measures.”
Blackwell, Brennan & DeAtly, p 197
Types of Decontamination• Wet• Dry• Gross• Medical• Technical• Emergency
Evidence-Based Decontamination• GAO – lack of definitive evidence• HPP – anecdotal; based on traditional HAZMAT
response• Estimates, not evidence• Models exist but are not consistent, reproducible nor
measureable• Challenging to know when to rotate staff – Temperature– Rigor– Humidity
Best Practices• HVA• LEPC Involvement• Capability of rapid decontamination system• Fixed external decontamination system• System for walk-ins• PPE based on HVA• Ancillary staff for decon team
Stopford, 2005
There’s an App for That
• Paper resources• Computer Databases• Internet Resources• Poison Control Center• Apps
Index of Suspicion(Detection)• History– Medical– Occupational– Alarms– EMS
• Presentation including toxidromes• Situational Awareness – News– Reports from other hospitals/within hospital
• Sutter et al (2010) found that 87% of hazmat incidents involving patient transport were not reported to poison control centers– 9.7% within 360 minutes (6 hours)– 2.6% within 360- 1440 minutes (6-24hours)– 0.7% after 4320 minutes (72 hours)