Infection Control Today - 06/2004: Are You Prepared

Are You Prepared for a Mass-Contamination Event at YourFacility?

By Lori Hagen, CPHQ

All over the United States, healthcarefacilities are focusing their attention on how to prepare for incidents in whichmass decontamination would be necessary. In these times, a healthcareorganization must be prepared to respond to a terrorist attack involving weaponsof mass destruction that could occur in their community. When facilities arereviewing their preparedness, they must work with the resources within theircommunity and surrounding area. Preparation for how to handle a massdecontamination event requires planning, training, and organization. There is noway to predict the contaminant, whether it be nuclear, biological, or chemical.

The Joint Commission on Accreditation of HealthcareOrganizations (JCAHO) has standards requiring that emergency management plansspecifically identify procedures which address preparation, response, andrecovery from emergencies in hospitals and other medical facilities. Thehealthcare organization must develop these plans through the completion of ahazards-vulnerability analysis. JCAHO standard EC.4.10 states that the hospitaladdresses emergency management. The following are some of the elements of performance:

• The plan provides for processes for notifying externalauthorities of emergencies, including possible community emergencies identifiedby the hospital (for example, evidence of a possible bioterrorist attack).

• The plan identifies means for radioactive, biological, and chemical contamination and isolation.

• The plan identifies specific procedures that describe mitigation. Mitigation activities are those activities a hospital undertakes in attempting to lessen the severity and impact of a potential emergency.

As you can see, it is important for medical centers to reviewcurrent JCAHO standards. The plan on handling decontamination of individuals if thereis a mass casualty event with contaminants is just one part of preparedness.

Decontamination is the process of removing biological,nuclear, and/or chemical residue from victims, staff, first-responders, andpossibly even the physical plant of your facility. It is very important toprovide education on how to handle suspected contaminated patients toprotect the facility. If the emergency room gets contaminated, then it will beof no further use in treating patients.

Therefore, the first line of defense is to protect thefacility and its staff. If an area of the hospital becomes contaminated, boththe area and the air-handling systems must be isolated; it is critical for staffto understand this.

Our medical center has four core members of the DECON team whohave identified functions. The team consists of an industrial hygienist (leaderand detection), a registered nurse with infection control and militaryexperience (administrative), a plant-operations specialist with a militarybackground (operations), and an emergency room nurse practitioner (medical).

They have all completed the HAZMAT/Weapons of Mass Destruction(WMD) Awareness/Operations-Level Hospital Decontamination Train-the- Trainercourse. This core team is responsible for such key elements as equipment andsupply issues, education and training, and controlling the disasterflow/treatment.

This core team is providing a four-hour awareness- leveltraining to the staff in our facility who have been identified as staff memberswho might be seeing patients who are potentially contaminated first. Thesefront-line individuals include, but are not limited to, staff in the emergencyroom, at information desks, in urgent care, and members of the facility police.This training is designed to educate the first contact personnel aboutrecognizing possible contamination threats and being able to take theappropriate steps to protect themselves, staff, patients, and the medicalcenter.

Most medical staff members have the natural response toprovide an immediate and emergent response. But in the case of possible contaminated victims, staff mustbe educated to stop and take two steps back. Staff must protect themselves andthe medical center. This point is stressed to medical center employees, as thefacility must be protected from contamination. If a patient is suspected of being contaminated, he or sheshould be taken out the same way they came into the medical center or out theclosest exit. The staff must be educated about the importance of activating theemergency response plan in this situation.

Outdoor decontamination protects staff, equipment, and otherpatients from being contaminated. If victims are kept outside, there must be anorganized plan on how the facility will decontaminate and treat them. Of course,in an emergency situation, many victims may inundate a facility, which will makecontamination difficult to contain. Some medical centers may utilize a small,quickly deployable shower unit to decontaminate one or a few victims; however,for mass decontamination, the larger inflatable shelters with DECON capabilitiesmust be set up rapidly.

The operations-level training is provided to the group ofapproximately 30 volunteers who will serve as the facility DECON team. Thesepersonnel are trained to set up the decontamination system, wear thedecontamination suits with respirators, and properly decontaminate victims.These volunteer staff members will respond to the medical center in the case ofa possible mass-decontamination event.

When possible, the best place for a decontamination area isoutside the main facility. This team has strategically decided the placement ofa rapidly deployable tent structure equipped with a decontamination system. Anoutdoor mass-casualty decontamination system capable of decontaminatingambulatory and non-ambulatory casualties is utilized. The facility shouldconsider such issues as wind direction, placement near the emergency room,traffic control, and entry points. The source of water-supply hook-up must beidentified. Depending on the number of victims, there could be a lot of waterused which must be contained and isolated.

The DECON team members in the hot zone and warm zonewill wear the appropriate protective equipment. The DECON team members providingdecontamination will wear hoods, gloves, and chemical protective suits toprotect themselves from contact with the hazardous material. They also will use air-purifying cartridges for respiratoryprotection. The appropriate level of protection should be reviewed related tothe task. Patients should perform as much of the decontamination aspossible to decrease cross-contamination. After they are decontaminated in thehot zone, they are moved to the warm zone for further decontamination; they arethen moved to the clean treatment area.

Depending on the number of individuals that are possiblycontaminated, there will be some degree of confusion and hysteria. It will beimportant for healthcare facility staff to identify a plan to control the sceneas much as possible. It is key to control the contamination.

The facility will continue to learn and make changes to itsdecontamination plan, and the requirement for drills will promote continuousimprovement in this process. It is impossible to predict what will happen ifthis type of event happens in your facility. The more training and educationthat is provided will only prove to be beneficial. Another key element is thecoordinating and communication of medical centers with their local, county, andstate emergency preparedness officials.

Lori Hagen, CPHQ, is a member of the DECON team at the JamesH. Quillen VAMC in Mountain Home, Tenn. along with Doug Dulaney,Dale Shoop, and Dan Knell.