Medical Center Wide - Policies & Procedures

Department: Old Policy Number: On-Line Policy #: Medical Center Wide - Environment of Care Section: Effective Date: Emergency Preparedness Page: 1of20 Title: Review / Revision Date Emergency Bio-Chemical Decontamination Accountable Department or Committee: Safety Department Med. Center-Wide Non-Clinical Approved by: Safety Committee / Department-specific Clinical

REFERENCE: JCAHO HAS EC 1.5, 1.6(l) 22 CCR 70413(e) 29 CFR 1910.120 Association for Professional in Infection Control (APIC) “Bioterrorism Readiness Plan” US Surgeon General - Medical Management of NBC Agents OSHA Standard Interpretation and Compliance Letter – Emergency Response Training Requirements for Hospital Staff (4-97) OSHA 3152 “Hospitals and Community Emergency Response -- What You Need to Know”

PURPOSE: To outline specialized aspects of the Emergency Management (preparedness) response designed to anticipate, assess and effectively manage emergency events involving exposure to harmful chemical, radiological or biological agents.

DEFINITIONS: Decontamination - The physical removal of harmful substances from victims (patients), equipment, surfaces and/or supplies. Decontamination should be performed where there is a risk of secondary exposure from a hazardous substance.

Methods of decontamination include mechanical removal, absorption, degradation, dilution and neutralization. For the purposes of this policy, decontamination refers to the dilution and removal of hazardous substances by means of cleansing with water, unless otherwise specified.

GENERAL INFORMATION: The basic management framework and operational principles of the Emergency Preparedness component are in alignment with the CDC's strategic plan for preparedness and response to emergency events involving biological and chemical agents. Ideally, decontamination will occur at the site of the bio-chemical incident. It is essential that those directing on-site treatment incorporate gross decontamination into their plan. Despite pre-planning, there will be occurrences when patients will be presented to the Emergency Department in need of decontamination.

POLICY: 1. As part of the overall emergency preparedness efforts and in keeping with our commitment to community service, Emergency Operations Center (EOC) staff, Emergency Department staff and others designated to assist in emergency response, (i.e. “skilled support personnel” to assist in decon activities without prior training) will institute principles of reasonable, practical Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 2 of 20 Wide/Emergency Prep

and safe management of the victims of nuclear, biological or chemical agents, should the need arise. 2. With respect to our internal emergency readiness and plans, the Emergency Operations Center will take the lead in organizing and directing hospital tactical response, as with any potential or realized disaster event.

Basic principles of emergency/crisis management such as those set forth in the Emergency Preparedness Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 3 of 20 Wide/Emergency Prep

Plans and Incident Command System protocols will be applied to the management of chemical, biological and radiological events including those originating and/or resulting from terrorist activities. Community, State and Federal authority may supercede these policies in the unlikely event the entire medical center or the community at large is threatened.

3. If confronted with possible terrorist activities involving a harmful agent, the EOC will take additional precaution and will involve the notification of and coordination with applicable governmental agencies, such as the FBI, local law enforcement and county health officials through Security and the Incident Commander. 4. Should an event involve possible biological agents, the local health and CDC will be consulted through the Incident Commander for guidance and technical assistance. If chemical exposures are involved, assistance and expert consultation may be sought from the local Fire Department HazMat Unit and other resources such as CHEMTREC. 5. Should an influx of casualties require decontamination, decision making processes must seriously and programmatically consider hospital abilities and limitations, based upon existing resources, requisite skills and relative risk, in order to ensure the optimal support and protection of the community, as well as the safety of our staff and building occupants. 6. Once notified that the ED may be receiving casualties of a harmful agent, the ED personnel will notify the Administrator On Call and Incident Commander.

Standard (external) Disaster procedures for an influx of casualties, relative to Triage, Stabilization and rapid Treatment, will be implemented, as outlined in the existing disaster plan(s). The Incident Commander will ensure Security is involved and, if terrorist activity is suspected, the Corporate Bio-Terrorism Notification Process will be followed (See Attached Flow Chart). The EOC will coordinate other required agency notifications through the Incident Commander.

General considerations for decontamination The emergency shower apparatus to be used for decontamination shall be readily available and located in proximity to the main ambulance entrance. Other necessary supplies and materials will be maintained within the ED (See Minimum Equipment List).

Security will be directed to control entrances and exits to the hospital, if practicable.

Security will demarcate the decontamination area using stanchions, cones and caution tape.

Security will establish two discernable areas on opposite sides of the decontamination shower facility; a "Soiled" side to route those awaiting decontamination and a "Clean" side to assemble and sort patients following decontamination.

Roll-away dividers can be used to provide visual privacy in addition to the materials in the Minimum Equipment List (MEL)

If patients are ambulatory and conscious or can be assisted by other exposed victims and are not in medical peril, encourage self-decontamination. Victims with only localized contamination can be decontaminated using disposable wash basins, soap, and towels. All water and disposables used in this process must be appropriately contained. Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 4 of 20 Wide/Emergency Prep

Reasonable efforts should be made to collect personal valuables in sealable plastic bags. If possible, separate individual billfolds and keys from all other personal items.

Have patients disrobe and have blankets, gowns, etc. readily available to keep warm and cover themselves until they use the shower area and are decontaminated.

As patients emerge from the shower area “hot zone”, have towels and dry blankets available on "clean" side.

ED staff should be waiting on the "clean" side to continue triage and begin to render medical treatment. Use proper PPE, including high efficiency respirators, if the contaminant is airborne (e.g., N-95 TB respirators) and other equipment, as indicated by existing standards for Universal Precautions and prevention of disease transmission (gloves, eye/face protection, impervious gowns, if splash is likely), - (See Table below).

The following table lists recommended general precautions, materials and equipment for decontamination: TABLE 1A Decon. Scenario Skin Protection Respiratory Equipment Protection Little to no physical Universal Precautions N95 (TB Mask) where  Seal-able plastic contact with the victim Eye Protection required for control of bags (to place prior to Latex or Nitrile Exam certain airborne clothes and other decontamination is Gloves biological exposures articles) anticipated. Impervious gown  Soap, sponges and long handles soft Initial medical triaging brushes is needed.  Permanent markers  Gowns, gloves and The specific agent and goggles approximate amount is  Blankets and known. towels  Decon hose with gentle flow controlled nozzle and flexible shower head  Modesty screens  Stanchions and barrier tape

There is potential for Universal/standard IC Air Purifying Respirator  Seal-able plastic staff contact with precautions with appropriate bags (to place contaminated patient Protective barriers filter/cartridge, as clothes and other against liquids, indicated articles) Agent type and including:  Soap, sponges and amount are likely to  Eye protection Note: long handles soft Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 5 of 20 Wide/Emergency Prep present known or low  Chemical resistant This level of response brushes risk contamination gloves (i.e. Silver and PPE requires  Permanent markers below the regulatory Shield) specialized  Gowns, gloves and permissible exposure  Chemical HAZWOPER training goggles limits protective Tyvek or commensurate with  Blankets and Saranex suit risk and towels  Boots responsibilities,  Decon hose with training on gentle flow decontamination controlled nozzle processes and and flexible shower respiratory protection head program.  Modesty screens (See “Staff Training”)  Stanchions and barrier tape  Plastic totes for equipment  Duct tape  Buckets, sponges  Traffic control cones  Transport devices

General Procedure for Patient Bio-Chemical Decontamination

Special Note: "Walk-In" Patients not brought by EMS

Walk-In patients who are victims of chemical decontamination may present to the triage desk, without notification, as a result of home, agricultural, industrial or transportation accidents. Upon recognition of the presence of a possible bio-chemical exposure, the triage nurse must take immediate steps to minimize the chance of secondary exposure. Immediately notify the Unit Coordinator of the situation (proceed with the internal notification procedure, as outlined in the hospital disaster plan). Direct all staff, visitors, and patients away from the contaminated person.

The staff should don protective gown and gloves. a. The patient should remain stationary, while a sheet is wrapped around them. A stretcher or wheelchair is obtained and an open sheet is draped over it. The patient lies on the stretcher or sits in the wheelchair with the least movement possible, and the sheet is wrapped around the patient. There should be as little creation of air currents as possible. Only the patient's face should remain uncovered. As soon as possible, move the patient to the decontamination stage area. Do not move the patient through the main Emergency Department corridors. c. Anyone who accompanied the contaminated individual to the facility should also be considered contaminated and treated accordingly. Security should be notified of the presence of a Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 6 of 20 Wide/Emergency Prep

contaminated vehicle. Security will cordon off the area around the vehicle to prevent the spread of contamination or additional exposures.

A. DECONTAMINATION TEAM DUTIES

1. Emergency Department Unit Coordinator -- Directs the E.D. Clerk to notify Administrative personnel, assigns E.D. staff members to the decontamination area and calls-in additional staff, as needed.

2. Emergency Department Nursing -- E.D. staff members will be assigned to the decontamination area. Team Member #1 must be a nurse trained in decontamination procedures and designated as qualified to staff the unit. This individual will usually be assigned to the HOT ZONE of the Decontamination Unit. Team Member #2 will be a nurse, technician or a clerk who has been trained to assist with decontamination procedures. Team Member #3 will be a nurse, EMT, or RT who has been trained to assist with decontamination procedures and can maintain victim airway if necessary. Team Member #4 will be either a nurse or a technician who has been trained in decontamination procedures and designated as qualified to staff the unit. This individual will be assigned to the WARM ZONE of the Decontamination Unit. The selection of a nurse or technician will depend upon the condition and number of victims involved. They will be responsible for providing the necessary supplies and documentation and will not be able to enter the HOT ZONE. Individuals who are or may be pregnant will not be assigned to the Decontamination Unit. This precaution is taken because of the possibility of receiving a patient contaminated with teratogenic or fetotoxic chemicals.

Ideally, two additional team members will don protective gear can standby to relieve the base team.

3. The patient's condition will determine if it is necessary for the physician to don personal protective equipment and enter the HOT ZONE. No other personnel, except those designated in this section will be allowed to enter the HOT ZONE without clearance by the physician. This includes the Trauma Team.

4. Safety Officer -- Selects appropriate PPE to be used. Determine need for air monitoring and interpret product hazard information.

5. Security -- Secure the exterior entrance to the E.D. and clear the ambulance unloading area.

6. Environmental Services -- Assist/prepare decontamination area.

7. Public Affairs – Contact Operations Communications. Designate and prepare an area to address the media, if necessary.

8. Infection Control – Assist in selection of PPE. Medical monitoring of personnel and decontamination team. Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 7 of 20 Wide/Emergency Prep

B. PERSONAL PROTECTIVE EQUIPMENT

1. In most decontamination situations, the PPE included in the Minimum Equipment List will afford adequate protection. If the situation warrants it, the decision to utilize other or additional PPE will be made by the Safety Officer, in consultation with Infection Control. These situations would include, but not limited to, incidents involving highly concentrated acids, bases or cyanide.

2. All personnel who will work in the HOT ZONE or handle contaminated patients or equipment will don appropriate PPE, prior to doing so. Vital signs will be recorded before PPE is put on.

3. The Protective Clothing Minimum Equipment includes the following items:

a. Tyvek/Saranex Suit b. Latex Gloves c. Nitrile Gloves d. Latex Boots e. Duct Tape f. Full Face PAR Respirator g. Chemical Gloves

1. Proper dressing sequence is as follows:

a. Remove and secure your jewelry. Put on scrubs. b. Vital signs shall be taken and recorded. c. Don disposable Tyvek/Saranex coveralls with hood and booty built in. If suit is too long, pull up any extra and duct tape at the ankle. d. Put on boots. Duct tape end of boot to the suit. e. Put on latex exam gloves. f. Put on nitrile gloves. Pull sleeves over the gloves and duct tape ends of the sleeves to the gloves. g. Put on the appropriate respiratory protection.

NOTE: These instructions are also included in each kit.

C. PRIOR TO PATIENT ARRIVAL

1. Security

a. Clear the ambulance unloading area of all unnecessary vehicles. b. Secure the area around the exterior entrance of the decontamination area using CAUTION tape. c. Direct the ambulance/vehicle transporting the contaminated patient(s) to unload as close as possible to the decontamination area entrance. d. Assist in setting up decontamination area, screens, pools, and decontamination equipment.

2. Safety Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 8 of 20 Wide/Emergency Prep

a. Prepare the decontamination area for the arrival of patients including water hoses and containment pools. b. Set up decontamination backboards in decontamination area based on anticipated arrival of any non-ambulatory patients. c. Assemble decontamination supplies that will be used. d. Assist staff with donning of PPE. e. Hazard Assessment

1) Obtain name of contaminant. 2) For chemicals, refer to MSDS if provided by emergency responders at the scene. 3) Begin to research available hazard information. 5) Identify any special hazards that may effect staff or patient. 6) Determine if additional PPE is needed with infection Control 7) Identify any specific decontamination procedures in the references. 8) Determine if any air sampling or monitoring is necessary. d. Assist in any efforts to identify an unknown contaminant.

NOTE: E.D staff may need to coordinate this process in the absence of the Safety Officer or until a representative to the department arrives.

3. Environmental Services

a. Assist Safety, Security and/or ED in preparing decontamination area.

D. PATIENT ARRIVAL AND EVALUATION

To insure the safety of the staff, other patients and the institution, strict protocol must be observed in the decontamination process. Critically ill or injured patients must undergo gross decontamination before definitive treatment can take place. Basic resuscitation measures, such as the following, may be safely carried out:

• Oxygen can be administered. • The airway can be maintained via suction or oral or nasal airways. • Respirations can be assisted with a bag/valve/mask . • Patient can be intubated. • An IV can be started and medications given, but the bag and tubing must be changed as the patient is transferred into the WARM ZONE. • A full CODE BLUE or TRAUMA CODE cannot be conducted in the HOT ZONE.

Any equipment that has been used on the patient during transport may be contaminated and should be brought into the HOT ZONE for continued use. This includes monitoring equipment. This equipment must remain in the HOT ZONE until it is decontaminated.

Because the first principle of the mitigation of a chemical incident is to prevent the creation of additional victims, there will be cases where decontamination will take precedence over definitive care.

E. DECONTAMINATION OF PATIENT Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 9 of 20 Wide/Emergency Prep

In most cases, soap and water will be sufficient to decontaminate the patient. You should be aware that chemicals do exist that may require other decontamination methods (i.e. hydrofluoric acid). The need for specialized decontamination procedures must be determined during the Hazard Assessment process at the start of the process.

Ambulatory Patient -- defined as those patients who are able to walk unaided and have minimal or no apparent trauma or symptomalology.

1. EMS assists the patient from the ambulance into the HOT ZONE. Staff should continue to monitor the patient for any signs and symptoms of trauma and/or reaction to the chemical contamination. If the patient's condition starts to decline, move patient to a backboard and treat as a non-ambulatory patient.

a. Have the patient remove all clothing and place in plastic bag. Remove jewelry, wallet, and other valuables. Place all valuables in separate plastic bag for later decontamination. Label bags with patient's name. If contamination occurred as a result of a potential terrorist act, clothing and valuables should be secured as possible evidence for the lead law enforcement agency.

b. Assist the patient into the first pool and have them stand on plastic pallet. Have the patient clean and rinse their entire body a minimum of (3) times, using liquid soap and shampoo. Repeat in second pool. Rinse in third pool.

c. Ensure that body creases orifices and under nails are cleaned. Wash cloths and swabs can be used for ears.

d. When done showering, the patient can be draped with a blanket and moved to the door to the WARM ZONE.

2. Patient Exit Procedures

a. Clean 6-mil plastic will be rolled in from the WARM ZONE door into the HOTZONE.

b. The patient may now walk into the WARM ZONE on the plastic. A wheel chair can be used in this area.

c. The patient can dress in hospital gown, scrubs or robe, and a Nursing Assessment can be carried out.

d. The patient can then be moved to a care area (Core or Fast Track), as appropriate.

NOTE: The Decontamination Team members should not walk on the clean floor covering. The person bringing the clean wheelchair into the Decontamination Room should not walk off the clean floor covering and assure that the wheelchair does not roll off the clean floor covering. Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 10 of 20 Wide/Emergency Prep

Non-Ambulatory Patient -- defined as a patient who exhibits significant trauma or symptomalogy to the point that they cannot walk unassisted. These patients will be placed on backboards. Wheelchairs will not be used in the HOT ZONE.

1. The ABC's and LOC of the patient will be initially assessed and monitored throughout the decontamination process. Intervention will be carried out within the confines of the above protocol.

2. Cut away the patients clothing, roll the clothing so that the inner surface is exposed. Log roll the patient and place the contaminated clothing into a plastic bag. Remove jewelry, wallet, and other valuables. Place all valuables into a separate plastic bag for later decontamination. Label bags with patient's name. If contamination occurred as a result of a potential terrorist act, clothing and valuables should be secured as possible evidence for the lead law enforcement agency.

3. Decontamination of wounds

a. Clean the wounds first, then the surrounding skin. b. Items that can be used in decontamination include: Saline, Betadine sponges (i.e., Cliniscrub), soft brushes (not bristle [i.e., E-Z Prep]), or gauze pads soaked in Betadine or Saline. c. Suggested sequence of decon solutions is saline, followed by Betadine, followed by saline. d. Following decontamination, dress wounds and cover with dressings and saran wrap. Secure with surgical tape. e. Discard used materials in lined waste container.

4. Decontamination of Body Orifices and Fingernails

a. Eyes -- rinse with a stream of water from nose to temple direction. b. Ear Canal -- Gently swab with cotton tip swab moistened with Saline. Rinse with Saline. NOTE: Suction may be required. c. Nostrils -- Turn head to side (if possible). Instruct patient not to swallow, if possible. Use cotton tip swab moistened with Saline. NOTE: Suction may be required. d. Nails -- Clean under nails with soft brushes, moist swabs and running water.

5. Decontamination of Intact Skin

a. Intact skin serves as the most effective barrier against absorption of contaminants. b. Abrading the skin with harsh brushes or other materials will only destroy the natural barrier. c. The following articles can be used to apply the various decontamination solutions. 1) Soft sponge brushes 2) trauma pads 3) Gauze Packs (4" x 4") 4) A 50/50 mix of granular soap and cornmeal for greasy residue. Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 11 of 20 Wide/Emergency Prep

d. Decontamination Method

1) Rinse area for approximately one minute, using lukewarm water or Saline. 2) Wash area with lukewarm water and a liquid soap, gently using scrubbing only as needed. 3) Rinse off with copious amounts of lukewarm water. 4) Proceed with two additional washings in second pool using the same method (i.e., soap and water). 5) Rinse off in third pool. 6) When done, cover with blanket to dry and prevent hypothermia.

CAUTION: Care should be taken not to abrade the skin excessively.

6. Decontamination of Hair

a. Shampoo hair and scalp using a mild shampoo and lukewarm water in second pool. b. Thoroughly rinse hair with lukewarm water. c. If necessary, repeat. d. If contamination persists, clip affected area. e. Localized hair contamination (i.e., legs) may require hair to be clipped or shaved.

7. Decontamination of Nail Bed

a. For contamination under nails, clip nails with nail clipper and/or wash area with soap and E-Z Scrub. Rinse with copious water.

8. Contamination Control Guidelines

a. Discard all potentially contaminated material in lined waste containers. b. Change gloves frequently and/or wash gloved hands. c. Rinse hands before handling/touching clean areas. d. Respect established traffic flow patterns and control points. e. Wear appropriate protective clothing. f. Contain contamination to HOT ZONE. g. Do not pass supplies out of HOT ZONE.

9. Patient Exit Procedure

a. Change gloves or rinse gloved hands. b. Clean 6-mil plastic will be rolled in from the WARM ZONE door into the HOT ZONE. c. A stretcher will be brought into the HOT ZONE. d. The patient will be transferred from the decontamination table to the clean stretcher. Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 12 of 20 Wide/Emergency Prep

e. The stretcher will be moved from the HOT ZONE to the WARM ZONE, as it is inspected for contamination. f. In the WARM ZONE, evaluation and definitive treatment can be carried out as necessary. If required, the patient can be moved directly to the appropriate Core Room. Although CODE BLUES and TRAUMA CODES could be carried out in the WARM ZONE, it would be preferable to move to an area where resuscitation equipment is readily available.

NOTE: The Decontamination Team members should not walk on the clean floor covering. The person bringing the clean stretcher into the HOT ZONE should not walk off the clean floor covering and assure that the stretcher does not roll off the clean floor covering.

F. EXIT OF DECONTAMINATION TEAM

1. Each member of the Decontamination Team will go to the clean line located between the HOT ZONE and the WARM ZONE. Here, the Decontamination Team will remove their PPE and place disposable items in a lined drum. Reusable items will be decontaminated, as directed by the Safety Department.

2. Removal of Personal Protective Clothing

a. Remove tape securing outer gloves to suit. b. Remove tape securing outer shoe cover to suit. c. Remove outer shoe cover turning them inside out, as they are removed. d. Remove outer gloves turning them inside out, as they are removed. e. Remove respiratory protection and place in plastic bag for cleaning. f. Remove the suit turning it inside out, as it is being removed. g. Remove one foot from the suit and step across the clean line, and remove the other foot and step across the clean line. h. Once across the clean line, remove inner gloves. i. Vital signs will be taken. j. Shower in the E.D. staff locker room.

G. EMPLOYEE HEALTH MAINTENANCE

Work in the decontamination area can be stressful, both physically and mentally. The use of PPE increases the physical stress on your body. It is important that certain procedures be followed to protect the health of all staff.

1. Pregnancy -- Due to the lack of comprehensive information on the effects of hazardous materials on the developing fetus, any individual who is pregnant or who suspects that they may be pregnant should not work in the Decontamination Unit. Actively nursing mothers are also excluded. 2. Staff Monitoring -- Before donning PPE, each staff member must have the following vital signs taken: • blood pressure • pulse • respirations Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 13 of 20 Wide/Emergency Prep

• temperature The same vitals will be taken when staff removes their PPE. If any individual becomes ill while in PPE, they should be evaluated for exposure and replaced as soon as possible.

3. Time Duration in PPE -- Due to the increased physical stress that is inherent with the use of PPE, no individual shall work for longer than one hour, while actively decontaminating patients. This time period may be extended for the decontamination of ambulatory patients, where little physical activity is required.

4. Breach of PPE -- In the event that a rip or tear occurs in the PPE, certain steps must be taken. Gloves with holes or tears must be replaced immediately. Small holes or tears in the suit can be sealed with duct tape. Large tears or faulty seams require that the suit be replaced immediately.

5. Post Unit Activities -- Individuals working in PPE may become dehydrated. Therefore, fluids should be taken after leaving the Decontamination Unit. A shower should also be taken in the locker room and clean clothes put on.

6. Recordkeeping -- The names of staff working in the Decontamination Unit should be recorded, as well as vital signs. The identity of the contaminant involved should also be recorded, along with a copy of the MSDS.

H. RETURN OF DECONTAMINATION AREA TO NORMAL USE

1. Unprotected personnel will not enter the decontamination area, until it has been cleared by the Safety Officer or Infection Control. Decontamination of the HOT and WARM ZONES will be at the discretion of the Safety Officer or Infection Control.

2. The Safety Department will handle hazardous waste generated by the decontamination incident.

3. Infectious waste will be handled according to established HUH Policy.

4. Personnel involved with clean-up activities should don appropriate protective clothing.

5. The hospital areas requiring clean-up will continue to be secured from unauthorized personnel, until clean-up operations are complete.

I DECONTAMINATION EQUIPMENT AND SUPPLIES

Decontamination equipment and supplies must be available to ensure effective and efficient service to the patient. The minimum equipment list (MEL) is the most basic items necessary to stock the decontamination area and the minimum quantities required. The E.D. is responsible for inventorying the supplies and replenishing depleted supplies.

Staff Training Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 14 of 20 Wide/Emergency Prep

Those individuals who will be responsible to assist in decontamination will receive appropriate training on management of chemical emergencies, pursuant to the OSHA HAZWOPER (29 CFR 1910.120(q)(6)) standard First Responder Operations Level. Such specialized training is coordinated through the facility safety office and infection control. Medical personnel who will decontaminate victims must be trained on the use of PPE and decontamination procedures.

All personnel who use respirators must receive training and evaluations in accordance with the OSHA Respiratory Protection Standard (29 CFR 1910.134) and the facility written respiratory protection plan as relates to selection, fit testing, inspection and maintenance of respirators.

“Support Personnel” such as physicians, nurses and clinical staff who are not expected to assist in decontamination, but are responsible to render care to patients needing immediate treatment should be trained in basic awareness of hazardous substances. Moreover, they must at a minimum be given a briefing at the time of the incident, to include Instruction on the nature of the hazardous agent involved,  The duties support personnel are expected to perform,  Appropriate personal protective equipment  Self decontamination, and  Other relevant health and safety precautions.

“Ancillary Staff” who will be expected to clean up the decontamination area must be trained in accordance with 29 CFR 1910.120(q)(11) and have access to Materiel Safety Data Sheets (MSDS) in accordance with 29 CFR 1910.1200.

Special Considerations for Biological Agent Decontamination

1. The Pathology department and clinical laboratory are to be apprised of a potentially infectious disease or biological exposures prior to submitting specimens for examination or disposition.

2. Clean, non-sterile gloves are to be worn when handling patients and potentially infectious materials, such as blood, body fluids, excretions and potentially contaminated surfaces.

3. Impervious gowns and face/eye protection are to be donned to prevent soiling of clothing and contamination of skin during procedures that are likely to involve splashing or spraying of liquids. Hands are to be washed routinely and after touching potentially infectious materials, regardless of whether or not gloves are worn. Hands are to be washed directly after gloves are removed and between patient contacts. (See Infection Control Manual)

The following table highlights considerations when assessing situations involving biological decontamination: TABLE 1B Description Clinical Transmission Decontaminatio IC - Isolation Features Modes n Anthrax Can occur in 3 Skin contact: The risk of re- Standard/Univers An acute forms: Inhalation of aerosolizing B. al Precautions Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 15 of 20 Wide/Emergency Prep infectious disease Pulmonary - Non spores (e.g., from anthracis is should be applied caused by specific flu-like contaminated extremely low. for care of Bacillus symptoms animals - "wool patients, anthracis. followed by a sorter's disease") In situations transport and brief period of Ingestion of where risk of management of Disease occurs improvement contaminated gross exposure to equipment. most frequently then an abrupt food. actual spores in sheep, goats onset of exists, consider Private room and cattle by respiratory failure Transmission of cleaning skin with placement is NOT eating after two to four Anthrax from soap & water to necessary. contaminated days. person to reduce risk of soil. person is cutaneous Cutaneous - Local unlikely. transmission. skin involvement Airborne following direct transmission does Instruct patients contact with not occur, but to remove spores (lesions transmission clothing and commonly seen could occur handle with on head, through direct minimal agitation. forearms and contact with skin hands). lesions. Decon surfaces using approved Gastro-intestinal - disinfectant. Abdominal pain, nausea, vomiting, bloody stool, typical following the ingestion of contaminated food.

Botulism Food borne Usually There is no risk of Standard/Univers Clostridium botulism is transmitted by dermal exposure al Precautions botulinum, an characterized by ingestion. or re- should be applied anaerobic gram- gastrointestinal aerosolization. for care of positive bacillus, symptoms. Aerosolization of Decontamination patients exposed produces a potent botulism may be is NOT required. to botulism and neurotoxin Inhalational and a mechanism for for the cleaning (botulinum toxin). food borne bioterrorism. and disinfection botulism share of surfaces and the following Botulism is NOT equipment. symptoms: transmitted  Blurred vision from person to Patient-to-patient  Symmetric person. transmission does descending not occur. weakness and paralysis  Drooping eyelids, Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 16 of 20 Wide/Emergency Prep

difficulty swallowing or speaking, weakened jaw clench, etc)  Respiratory dysfunction

Plague Fever, cough and Typically The risk of re- Aerosolized An acute bacterial chest pain. transmitted to aeorsolization of droplet disease caused man by an the bacteria is precautions (such by the gram- Muco-purulent or infected flea from low. as TB measures) negative bacillus watery sputum. an infected should be Yersinia pestis. rodent. Removal of employed in Evidence of clothing and addition to Bioterrorism bronchopneumoni Bioterrorism Decontamination Universal outbreak may be a in X-ray. related outbreaks with soap and Precautions. airborne causing could be caused water may be pneumonic by dispersion of considered in Infected patients plague. an aerosol. situations of should be placed gross exposures. in designated Person-to-person rooms with transmission atmospheric possible through isolation. large aerosol droplets.

Small Pox Latent onset of The disease is Removal of Patients must be Possible Viral flu-like highly contagious clothing and self- quarantined and biological symptoms. (contact with decontamination kept in isolation. exposure. vesicles and with water may Initial macules fluid). Effected be considered in The Variola virus progress to patients are situations of causes both pustular vesicles communicable gross exposures. major and minor that scab over until scabs are forms of the within 10 days. healed over. disease.

The virus could be relatively simple to disseminate as a biological agent.

While small pox was declared eradicated in the 1980s, concerns remain over Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 17 of 20 Wide/Emergency Prep possible stockpiling.

Tularemia The disease is Inhalation of The risk of re- Routine Universal The bacteria characterized by Tularemia is the aeorsolization of Precautions Fracisella inflammation and most deadly the bacteria is should be tularensis necrosis in the route of low. followed. typically causes lungs, throat, exposure. disease in eyes and skin Removal of animals. Humans (progressing 7 to Person-to- clothing and may be infected 14 days). person Decontamination by handling fluids transmission with soap and from diseased While initial does not occur. water may be animals or diagnosis is considered in through the bite generally difficult situations of of infected deer to confirm, gross exposures. flies or ticks. patients may present with fever, chills, headache, non- productive cough, muscle pain and pneumonia. Cutaneous ulcers can eventually progress to secondary pleuropulmonary infections.

Special Considerations for Chemical Agent Decontamination

1. The most common scenario involving a Chemical decontamination would be an individual or several individuals contaminated with a chemical, entering the facility (likely through the ED) for emergency medical care. (e.g. a worker covered with a solvent from an industrial accident, someone who ingests a toxic substance, over-spray of a pesticide, etc.) If an emergency event involves Chemical exposures, ED staff and the Safety Officer will quickly determine the exact chemical or at least what type of chemical agent, if possible (e.g., pulmonary irritant, nerve-toxin, vesicant, etc.). 2. If the patients can be handled without exposing staff, triage, decontaminate and treat using appropriate Personal Protective Equipment and the external decontamination shower facility:  Don appropriate gloves, face/eye protection and impervious gowns/covers, if splash is likely. Note: Do not continue contact with the victim if symptoms of chemical exposure are experienced, if the chemical is unknown, or if, per the information garnered through CHENTREC or the response agencies, the condition is considered IDLH (Immediately Dangerous to Health & Life).  Remove contaminated clothing (ensure privacy curtains/partitions are appropriately arranged), Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 18 of 20 Wide/Emergency Prep

 Flush and decontaminate skin,  If the victim is conscious and ambulatory or can be assisted by other exposed victims and are not in medical peril, allow him/her to use the external facilities to self-decontaminate,  Treat for chemical burns, skin and pulmonary irritation, etc. 3. If a potentially contaminated patient is taken inside the ED for treatment, use only rooms designed to contain contaminated air and exhaust it directly without re-circulating (e.g., negative pressure AFB room - 1510). If the chemical or quantity is unknown, it should be assumed that we cannot safely manage the patient without SCBA the appropriate level of PPE and specialized training. 4. If casualties are decontaminated (outside), make every reasonable effort to capture the effluent (using the floor drain specially designed for this purpose).

The following table highlights specific considerations when assessing situations involving chemical decontamination

TABLE 1C Type of Chemical Agent Symptoms of Exposure Decontamination Corrosive Chemical burns Remove clothing, if Acids Tissue damage contaminated. Alkaline (Caustic, Bases) Sloughing of skin Respiratory irritation Wash residual agent from skin Eye and mucous membrane with copious amounts of water. irritation/damage If patient is ambulatory and conscious, have patient self cleanse using decontamination shower facility.

Organic Solvents Possible chemical burns and Remove clothing, if Xylene skin damage contaminated. Toluene Eye and mucous membrane Alcohol irritation Wash residual agent from skin Phenol Pulmonary irritation with copious amounts of water. MEK Dizziness If patient is ambulatory and conscious, have patient self cleanse using decontamination shower facility.

Vesicants Vesicles and blisters Remove clothing, if Chemotherapy Drugs Sloughing of skin contaminated. Nitrogen Mustard Respiratory distress Sulfur Mustard Temporary blindness Wash residual agent from skin Nausea and vomiting with copious amounts of water.

If patient is ambulatory and conscious, have patient self cleanse using decontamination shower facility. Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 19 of 20 Wide/Emergency Prep

Toxic Substances Pulmonary irritation Fully decontaminate with Formaldehyde Eye irritation water. Glutaraldehyde Mucous membrane irritation Chemotherapy Drugs Shortness of breath Remove clothing and jewelry to Dizziness preclude secondary chemical Nausea exposure to healthcare workers, due to vapor off gassing. Lacrimators Severe eye and mucous Flush eyes with copious Tear producing chemicals, such membrane irritation amounts of sterile water or as pepper spray and tear gas saline solution.

Nerve Agents Nerve agent chemicals Fully decontaminate with soap Organophosphates and generally produce the and water. carbonates biological inhibition of enzyme Pesticides AChE and the accumulation of Remove clothing and jewelry to Tabun neurotransmitter ACh, causing preclude secondary chemical Sarin hyperactivity in organs. exposure to healthcare workers, due to vapor off Seizures gassing. Loss of consciousness Fatigue Memory loss Tacharrhythmias Muscle twitching, weakness Flaccid paralysis

Special Considerations for Radioactive Agent Decontamination

1. If the possible threat involves Radioactive material or radiation exposures, the Radiation Safety Officer (RSO) will be contacted immediately (by the EOC), to assist in determining the type of radiation, extent of dose and framing out our best, safest course of action and contingencies.

2. The RSO will determine the type and extent of injury/exposure (i.e., external irradiation, absorption through the skin, inhaled, introduced through wounds, etc.).

3. Conventional exposure prevention methods to protect staff and physicians  Time – Assessment, decontamination, treatment, etc. must be performed quickly and efficiently. The shorter the time in a radiation field, the less the radiation exposure.  Distance – The farther from the source of radiation the lower the dose. Establish “hot” and “cold” zones to allow for the clear discernment of the hazardous area, and promote strict isolation precautions and safe distances. Use brooms and implements with long handles to move contaminate materials to avoid physical contact. Medical Center Wide - Policies & Procedures Department: Med Ctr Policy #: NEW Revision Date: Page 20 of 20 Wide/Emergency Prep

 Shielding – Although not always practical in an emergency, barriers can reduce radiation exposure

Decontamination procedures will be incorporated as indicated, under the guidance of the RSO and response agencies. The RSO and Nuclear Medicine department will ensure the provision of appropriate monitoring instruments, including a Geiger-Mueller Survey Meter (GM) to detect low level gamma and most beta radiation, and personal dosimeters.

Patients known or suspected of being contaminated should be decontaminated with soap and water without delay. Open wounds should be irrigated first and covered with sterile dressing. Following decontamination, patients should be re-evaluated and, if negative, admitted to the hospital for assessment and treatment. Evidence of continued contamination will require addition washing.