www.osha.gov Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances OSHA 3249-08N 2005 Employers are responsible for providing a safe and healthful workplace for their employees. OSHA’s role is to assure the safety and health of America’s work- ers by setting and enforcing standards; providing training, outreach and education; establishing part- nerships; and encouraging continual improvement in workplace safety and health. This handbook provides a general overview of a par- ticular topic related to OSHA standards. It does not alter or determine compliance responsibilities in OSHA standards or the Occupational Safety and Health Act of 1970. Because interpretations and en- forcement policy may change over time, you should consult current OSHA administrative interpretations and decisions by the Occupational Safety and Health Review Commission and the Courts for additional guidance on OSHA compliance requirements. This publication is in the public domain and may be reproduced, fully or partially, without permission. Source credit is requested but not required. This information is available to sensory impaired individuals upon request. Voice phone: (202) 693- 1999; teletypewriter (TTY) number: (877) 889-5627. Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances Occupational Safety and Health Administration U.S. Department of Labor OSHA 3249-08N 2005 ACKNOWLEDGMENTS 4 Appendix A: Background, Literature Review, and Site Visit Examples 29 EXECUTIVE SUMMARY 6 PREPAREDNESS 30 Introduction 9 CUSTOMIZING HOSPITAL EMERGENCY BACKGROUND 9 MANAGEMENT PLANS 30 DEFINING “FIRST RECEIVERS” 9 Using Information from a Hazard Vulnerability Analysis 30 SCOPE AND OBJECTIVES 9 Identifying the Hospital’s Role in the Community 31 DOCUMENT CONTENT AND ORGANIZATION 10 Updating Emergency Management Plans 32 Coordinating Emergency Plans with Personal Protective Equipment 11 Other Organizations 32 USING OSHA’S BEST PRACTICES 11 PREPARING STAFF AND MANAGEMENT 33 Using OSHA’s Rationale for PPE Selection Applicable Standards 33 and Hazard Assessment 11 Maintaining Decontamination Teams 34 Augmenting the PPE Selection to Address Specific Hazards Identified by the Hazard Orienting and Training Personnel 34 Vulnerability Analysis (HVA) and the Community 11 Competencies for First Responder Operations Level Training 35 RATIONALE FOR OSHA’S PERSONAL Competencies for First Responder PROTECTIVE EQUIPMENT BEST PRACTICES 12 Awareness Level Training 36 Respiratory Protection 12 Instruction for Employees Whose Limited Quantity of Contaminant on Victims 12 Participation in the Hospital Decontamination Hospital Experience with Contaminated Victims 13 Zone Was Not Previously Anticipated 36 Exposure Modeling 15 Training Similar to That Outlined in the Hazard Communication Standard 36 Gloves and Boots 16 Monitoring Performance During Drills 37 Protective Garments 17 Managing Internal Communications 37 CONCLUSIONS REGARDING PERSONAL Principles of Risk Communication 37 PROTECTIVE EQUIPMENT 18 Information Dissemination During an Incident 37 First Receiver Hospital Decontamination Zones 20 Monitoring Employee Health 38 PPE Table and Tables Listing Prerequisite Prior to an Incident 38 Conditions for Specified PPE 20 Medical Clearance for Respirator Use 38 During a Response 38 Training First Receivers 24 Thermal Stress 39 OPERATIONS LEVEL TRAINING 24 Following an Incident 39 Managing Employee Stress 40 AWARENESS LEVEL TRAINING 26 RESPONSE 40 BRIEFING FOR SKILLED SUPPORT PERSONNEL WHOSE PARTICIPATION WAS NOT PREVIOUSLY FACILITIES AND EQUIPMENT 40 ANTICIPATED 26 Evaluating Existing Resources 40 TRAINING SIMILAR TO THAT OUTLINED IN Isolation and Lockdown 40 THE HAZARD COMMUNICATION STANDARD 26 Decontamination 41 SUMMARY OF TRAINING FOR Equipment 41 FIRST RECEIVERS 27 Procedures 43 2 Occupational Safety and Health Administration Shower Flush Time and Practices 45 Appendix H: Soap 45 Examples of Medical Monitoring for First Receivers, Including Security 46 Information on Heat Stress 67 Personal Protective Equipment 46 Detection Equipment 47 Appendix I: Ionizing Radiation Meters 48 Vital Signs and PPE Donning Checklists 74 Chemical and Biological Agent Detection Equipment 48 Appendix J: TRIAGE CONSIDERATIONS 49 Example of Patient Decontamination Procedure 76 EXTERNAL COMMUNICATION 49 Obtaining Timely Information 49 Appendix K: Coordinating Activities 49 PPE Donning and Doffing Sequence 79 RECOVERY Appendix L: 50 Example of Technical Decontamination HOSPITAL DECONTAMINATION 50 Process for Hospital Personnel 80 Solid Waste Management 50 Wastewater Management 50 Appendix M: Decontaminating Surfaces and Equipment 51 Example of Integrated Procedures for First Receivers 81 MAINTAINING FUTURE READINESS 51 LIST OF FIGURES AND TABLES Appendix B: Figure 1. Acronyms and Definitions 53 Results of Simulation Tests on Several Chemical Suits 18 Appendix C: Table 1. Hospital Decontamination Zone 21 References 55 Table 2. Hospital Post-Decontamination Zone 22 Appendix D: Table 3. Additional Resources (Web Links) 59 Minimum Personal Protective Equipment (PPE) 23 Table 4. Appendix E: Training for First Receivers 28 Advantages and Disadvantages of Various Respirator Facepiece Styles 60 OSHA Assistance 95 Appendix F: OSHA Regional Offices 97 Hazard Vulnerability Analysis Examples 61 Appendix G: Introduction to HEICS 64 OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 3 ACKNOWLEDGMENTS These hospitals were identified by hospital organi- OSHA’s Directorate of Science, Technology and zations as having given notable consideration to the Medicine wishes to acknowledge the assistance provid- possibility of receiving contaminated victims from a ed by the following organizations: U.S. Department mass casualty incident involving hazardous substance of Veterans Affairs (VA), California Emergency Medical release. Hospitals interviewed were selected to repre- Services Authority (EMSA), Centers for Disease Control sent a range of circumstances, loosely based on loca- and Prevention/Agency for Toxic Substances and tion (U.S. region) and the hospital’s relative probability Disease Registry (CDC/ATSDR), National Institute for (risk) of receiving contaminated victims of a mass Occupational Safety and Health (NIOSH), INOVA casualty incident. This risk was estimated using a Health System, Northern Virginia Hospital Alliance, scale adapted from the Hospital Corporation of Kaiser Permanente, U.S. Coast Guard National Strike America (HCA, undated): Force, and the U.S. Army Center for Health Promotion • Key Treatment Centers – Hospitals in large urban and Preventive Medicine (USACHPPM). OSHA’s areas. (Hospitals A, B, C, and G.)* Directorate of Enforcement Programs (DEP), and the • Potential Risk Hospitals – Hospitals within 50 Directorate of Standards and Guidance (DSG), as well miles of a large urban area and high-visibility as the Office of the Solicitor, OSH Division (SOL) also potential targets where a mass casualty incident made notable contributions. could occur (e.g., major airport or sports stadi- um, large chemical manufacturing facility, Seven hospitals provided extensive information, nuclear power plant, major shopping mall, hospital tours, equipment demonstrations, interviews, nationally recognized monument). (Hospitals D photographs, and reference material for this project: and E.)* Central Arkansas Veterans Healthcare System, Little • Minimum Risk Hospitals – Hospitals with popula- Rock, Arkansas tions less than 500,000 within a 50-mile radius Enloe Medical Center, Chico, California and without a high-visibility potential target with- National Naval Medical Center, Bethesda, in that distance. (Hospital F.)* Maryland New York University Medical Center, New York Note: This risk scale was used only to help identify a City, New York diverse group of hospitals for interviews. Other scales Samaritan Regional Health System, Ashland, Ohio might have been used and OSHA does not promote this or any other scheme. Sutter Amador Hospital, Jackson, California Veterans Administration Medical Center, Washington, DC * To maintain a minimum level of confidentiality, hospi- tals were assigned letters according to risk category which do not reflect the alphabetical order in which they are listed above. 4 Occupational Safety and Health Administration The following agencies and organizations National Incident Management System (NIMS) reviewed and provided comments regarding Integration Center these OSHA Best Practices: National Organization for Victim Assistance (NOVA) Navy Environmental Health Center, Industrial Hygiene Agency for Healthcare Research and Quality (AHRQ) Directorate, Agency for Toxic Substances and Disease Registry Navy Medicine Office of Homeland Security, Bureau of (ATSDR) Medicine and Surgery American College of Emergency Physicians (ACEP) National Institute of Environmental Health Sciences American Hospital Association/American Society for (NIEHS), Worker Education and Training Program Healthcare Engineering (ASHE) (WETP), National Clearinghouse for Worker Safety U.S. Navy Bureau of Medicine and Surgery (BUMED) and Health Training California Emergency Medical Services Authority (CA- National Institute for Occupational Safety and Health EMSA) (NIOSH) Centers for Disease Control and Prevention (CDC) NYU Medical Center, Environmental Services Emergency Nurses Association (ENA) Department EnMagine (hazmatforhealthcare.org) Rhode Island Department of