Revised February 1991 by the California EMS Authority

Every effort should be made to obtain accurate information about the health hazards of the toxic materials involved in the incident, the potential for secondary contamination, and the level of decontamination required, if any. Information may be obtained from the Incident Command Safety Officer, the base hospital or the Regional Poison Control Center.

1925 Wilshire Boulevard

Los Angeles, CA 90057

Physicians / Hospitals Only: (213) 664-2121 or (800) 825-2722

Fax: (213) 413-5255

Counties Served: Los Angeles, Ventura and Santa Barbara

Pre-hospital health care providers who are not members of the hazardous materials team and properly outfitted with protective gear should not enter the contaminated area (hot zone and decontamination corridor, but must wait at the perimeter for decontaminated victims to brought to them. It is assumed that members of the hazardous materials team working in the hot zone and decontamination area are trained and capable of providing initial airway and spine stabilization and basic decontamination. Rescuers wearing level (fully encapsulated suit with self-contained breathing apparatus) equipment will probably experience several factors that will limit their ability to provide emergency care in the hot zone such as:

• Vision Impairment
• Reduction in Dexterity (Lifting, Disentangling, etc.)
• Limited Air Support
• Heat Stress

Other factors such as the number of rescuers allowed in the hot zone would also limit what care can be given.

The table below "Emergency Medical Services Vehicle Equipment for Hazardous Materials Incidents" identifies how an ambulance should be outfitted to respond to a hazmat incident.

Unprotected EMS responders must advise on and observe the decontamination procedures from a distance to ensure that they are properly carried out. They should practice with the local hazmat team to become familiar with the steps involved. If there is any doubt about the potential for secondary contamination, decontaminate the victim. A contaminate appendage can be washed without wetting the whole body if that is the only part contaminated. Clothing covering the rest of the body and exposed skin should be carefully checked for contamination.

If victims are already properly decontaminated before they are brought to the health care providers at the perimeter of the hot zone / decon area, they will pose very little, if any, risk to pre-hospital care health providers or their vehicle. Health care providers will not generally need to use any specialized protective gear, even for substances considered as potential secondary contaminants.

In many cases, (e.g., corrosive materials in the eye, oily pesticide skin exposure), pre-hospital health care personnel may need to repeat or continue decontamination procedures (e.g., eye irrigation; soap/water skin wash) after receiving the victim at the perimeter. Although specialized protective gear should not be necessary, it is prudent for providers to don the protective gear listed in Table 5. Some of these items are often carried as a "communicable disease" kit. All leather items, wool or other highly absorbent materials that cannot be decontaminated should be removed prior to providing care.

If the transport vehicle is inadvertently contaminated, advise from the local environmental health department, hazardous materials team, or local hazardous materials spill clean-up companies should be sought on how to determine the level and location of the contamination and on how to clean it up. Advice should also be sought on how to preserve evidence for law enforcement, and dispose of or clean contaminated clothing and personal items.

Victims with obvious significant illness or injury will need rapid transport and treatment after initial stabilization and basic decontamination is carried out. In virtually all cases, patients with serious trauma or medical illness can be quickly stripped and flushed with water prior to delivery to pre-hospital care providers outside the cold zone. This is true even in cold or inclement weather. If this cannot be performed because of life-threatening conditions or other circumstances, then the vehicle must be protected and those providing care during transport and driving the vehicle must be properly fitted and trained with the appropriate level of specialized protective gear. However, every effort should be made to decontaminate the victim at the scene if the means to do so are available. In those jurisdictions where a pre-hospital care provider might be placed in such a situation without assistance from a properly trained hazmat specialist, advance arrangements for additional training and protective equipment should be made.

Victims with few or minimal symptoms are not necessarily safe from progression of illness. Many toxic substances have delayed onset effects, which may appear several hours later, after the victim has returned home. If the toxic substance is known, obtain consultation from the Regional Poison Control Center to determine if delayed effects might be seen and for guidance on triage of asymptomatic or mildly symptomatic exposure victims. Any persons suspected of being exposed should be seen and evaluated by emergency department staff.

Pre-hospital workers will not normally need personal decontamination. In those rare circumstances where they have been in the hot zone or have attended to a victim who was not properly decontaminated, they should consider themselves to be potentially contaminated. Consult Tables 1 and 2 or knowledgeable sources to determine the risk of secondary contamination, since in many, if not most cases, no personal decontamination will be necessary. Information can be obtained from the Incident Command Safety Officer at the scene, the base station hospital, or the Regional Poison Control Center. If in doubt, decontaminate.

The names, addresses, telephone numbers and email addresses of all personnel and victims who have been or may have been exposed at a hazmat scene should be recorded for future notification if it is subsequently determined that medical evaluation or treatment is required.

If a patient / victim arrives at an emergency medical care facility and there is suspicion of contamination, those patients should be stopped immediately, and directed to the facilities established decontamination area (if such an area exists). The decontamination area should consist of an area (inside/outside) that minimizes further exposure due to airborne contaminants, gases / fumes, or any other emission that could potentially expose staff and / or patients. The area surrounding the exposed patient’s and all passages should be immediately cleared and secured until the area can be assessed for exposure.

If no such area exists, the patient(s) must be directed outside the facility in an area that is open and does not pose further risk to the facility or its staff. The patient(s) must be isolated and monitored until the fire department or qualified personnel arrive on scene. Monitoring does not include contact with an exposed victim, it means to observe in a safe manner. It is extremely important that no further contamination to staff, patients, and visitors, occur. Therefore, no person shall approach a person who has known or unknown chemical contaminant, unless proper (level "B" minimum) is worn by staff trained in the management and recognition of hazardous materials exposure.

The Fire Department should be immediately notified by 9-1-1 and advised of the hazardous materials incident occuring at the facility, regardless of manageability. Coordination of the incident can then be jointly coordinated with the facilities emergency response team and the fire department.

A clinical facilities ability to manage a hazardous materials incident must be developed in a manner that meets Federal, State and local statute. It should also be developed in a manner that allow for maximum coordination with the local jurisdictional agency(s) managing an emergency hazmat response. A unified approach to management will reduce the potential for injury, minimize risks to staff and patients, and improve overall coordination and communication during an emergency.

No person shall manage a hazardous materials incident unless they have received the appropriate level of training consistent with Federal, State and Local laws. If a facility plans to manage a hazmat situation, the staff must be trained to the response level in accordance with Federal Law.

The individual responsible for supervision (or hazardous materials response staff) shall immediately establish the three following zones:

• "Hot Zone" (Red-Exclusion Zone) – the area immediately exposed by the patient or contaminant.
• "Contamination Reduction Zone" (Yellow Zone) – the area surrounding the exposure and limited to entry only by authorized staff.
• "Support Zone" (Green – Cool Zone) – recovery area.

The contaminated area "Hot Zone" would include all areas the patient / victim has traversed prior to the determination of their contamination status. Once this area(s) is determined, all personnel, patients, and visitors should be evacuated, and the immediate area cordoned off and security posted to keep people out of the area.

If the victim has not yet entered the facility, he/she should be isolated where they are (automobile, standing, etc.) and the above mention zones identified.

IF, staff is immediately available and able to begin decontamination procedures, then decontamination procedures should be established as soon as possible. ONLY those staff who have been trained to manage such situations should attempt to initiate decontamination procedures. If there is any doubt about the situation, IMMEDIATELY notify the Fire Department via 9-1-1. The scene will be managed as a pre-hospital hazardous materials incident upon the fire departments arrival.

1. Barrier Precautions: To prevent mucous membrane, blood, and exposure to other fluids; masks (HEPA filtered), gloves, protective eyewear, face shields, gowns.
2. Washing Hands: To remove contaminated blood or other bodily fluids; hands and other skin surfaces washed thoroughly after gloves removed.
3. Sharps Precautions: To prevent injuries caused by needles, scalpels, other sharp instruments; disposable instruments put in puncture resistant disposal containers.
4. Saliva Precautions: To prevent contact with patient saliva; minimize mouth-to-mouth contact using mouth pieces, resuscitation bags, other ventilation devices.
5. Worker Skin Lesions: To prevent transfer of infection from patient; workers with exudative lesions or weeping dermititis refrain from all direct patient care.
6. Clean Up of Spills of Blood or Other Body Fluids: to decontaminate and dispose of spilled materials; use of gloves, disposable towels, sterilization container; use germicide or hypochlorite solution.

1. Centers for Disease Control and Prevention. "Recommendations for Prevention of HIV Transmission in Health Care Facilities," in Morbidity and Mortality Weekly Reports. August 21, 1987, 36 (SU02).

 

 

Field Decontamination and Disposal ^2,3,4

 

Dermal Exposure: Immediately and thoroughly scrub skin with brush using soap and water; wash with 1/10^th concentration of sodium hypochlorite (reduce commercial hypochlorite from 5.25% to 0.5% by mixing one part sodium hypochlorite to 9 cups of water); minimum surface contact time to 10 to 15 minutes.

 

Non-Cavity Injury Exposures: 1/10^th concentration of hypochlorite may be instilled in non-cavity injury exposures and then removed by suction to an appropriate disposal container; sodium hypochlorite not recommended for open abdominal exposures (may form lesions) or brain and spinal cord injuries.

Other Decontamination: Apply 1/10^th concentration of hypochlorite to cadavers, extreta, spills of body fluids; apply 1/100^th concentration (1/4 cup hypochlorite to 1 gallon of water) to floors, clothing, equipment and other surfaces.

 

2. United States Army Medical Research Institute of Infectious Diseases and Centers for Disease Control and Prevention. Biological Warfare and Terrorism; The Military and Public Health Response." Student Manual. Satellite Broadcast September 21 to 23, 1999.

Disposal: Autoclave (steam sterilization) at 121 degrees centigrade and 1 atmosphere overpressure (15 pounds per square inch) for 20 minutes and / or incinerate using an accelerant (flammable liquid) for maximum heat.

• Gluteraladehyde
• Paraformaldehyde
• Hydrogen Peroxide (technical grade)
• Lysol Disinfectant (phenolics)
• Sodium Hydroxide
• Chemical Toilets (all are toxic, corrosive or highly irritating)

1. Centers for Disease Control and Prevention (Special Pathogens Branch) and World Health Organization. Infection Control for Viral Haemorrhagic Fevers in the African Health Care Setting. Atlanta, Georgia, 1998. http://www.cdc.gov/ncidod/dvrd/spb/mnpages,vhfmanual.htm

 

2. Prescott, Lansing M., et al. "Chapter 7: Control of Microorganisms by Physical and Chemical Agents," in Microbiology. 3^rd Edition. William C. Brown Publishers, Chicago, Illinois, 1996.

"… to best protect the public, the prepardness efforts must be focused on agents that might have the greatest impact on U.S. Health and Security, especially agents that are highly contagious or that can be engineered for widespread dissemination via small-particle aerosols."

• Enhance epidemiologic capacity to detect and respond to biological attacks.
• Integrate public health agencies and hospitals into emergency response planning.
• Support the development of local and state diagnostic tests.
• Establish communication programs to ensure delivery of accurate information.
• Enhance bio-terrorism related education and training for health care professionals.
• Prepare educational materials to inform and reassure the public after bio-attack.
• Prepare, distribute and stockpile appropriate vaccines and drugs.
• Establish molecular surveillance for unusual or drug resistant microbial strains.
• Obtain appropriate PPE (personnel protective equipment) for first response personnel, paramedic teams and hospital emergency room staffs; practice decontamination and disposal.

1. Centers for Disease Control and Prevention. "Biological and Chemical Terrorism; Strategic Plan for Preparedness," in Morbidity and Mortality Weekly Reports. Atlanta, Georgia, April 2 , 2000.

Typically, hospitals rely on local fire department hazmat teams to provide the necessary expertise and guidance in the event of an incident involving hazardous materials and patient care. In the past, this has been an acceptable approach to dealing with these incidents. However, in the event that the fire department is involved with an incident where field decontamination is being set up for victims, this expertise may not be immediately available for hospitals.

Protecting health care workers who may be faced with dealing with emergencies involving hazardous materials must be addressed before an incident occurs. Health care workers may find themselves dealing with emergencies where victims / patients may not have used the EMS system for transportation to the hospital, but instead, arrived by walking or private vehicle. Hospitals must be prepared to carry out their missions without jeopardizing the safety and health of their own personnel. Of special concern are the situations where contaminated patients arrive at the hospital for triage or definitive care following a major incident.

OSHA published the Hazardous Waste Operations and Emergency Response Standard, Title 29, Code of Federal Regulations (CFR) 1910.120, which became effective in 1990. Hazwopper requires employers, including hospitals, to plan for emergencies if they expect to use their employees to handle hazardous substances. A hospital designated by the Local Emergency Planning Committee (LEPC) to handle hazardous substances emergency victims must have an Emergency Response Plan (ERP), decontamination equipment, personnel protective equipment (PPE) and trained personnel.

Ideally, fire departments within the community will have coordinated emergency response planning with the hospital prior to any emergency event. However, the hospital may need to treat contaminated victims of emergency incidents without the benefit of pre-emergency planning. Both scenarios need to be addressed in the hospital’s Emergency Response Plan, along with plans for responding to a hazardous substance incident that occurs in the hospital itself.

The hospital should prepare an Emergency Response Plan even if community coordination has not been initiated or completed. The hospital’s Emergency Response Plan must be prepared in writing and established prior to an actual emergency. All employees and affiliated personnel expected to be involved in an emergency response including physicians and nurses, as well as maintenance workers and other ancillary staff should be familiar with the details of the plan.

The Emergency Response Plan is intended for hospitals involved in a community response to a hazardous substance incident. The plan should address the following elements:

• Pre-emergency drills implementing the hospitals emergency response plan.
• Practice sessions using the Incident Command System (ICS) with othe local emergency response organizations.
• Lines of authority and communication between the incident site and hospital personnel regarding hazards and potential contamination.
• Designation of a decontamination team, including emergency department physicians, nurses, aides and support personnel.
• Description of the hospitals system for immediately accessing information on toxic materials.
• Designation of alternative facilities that could provide treatment in case of contamination of the hospital’s Emergency Department.
• Plan for managing emergency treatment of non-contaminated patients.
• Decontamination procedures and designation of decontamination areas (either indoors or outdoors but if indoors, ensure adequate ventilation (H-7 Health Hazard Fixed Facility / Uniform Building Code Ventilation Requirements ie. 1 cubic foot of air flowing for every square foot of floor area serviced, spill control, etc.).
• Hospital staff use of PPE based on routes of exposure, degree of contact, and each individuals specific tasks.
• Prevention of cross-contamination of airborne substances via the hospital’s ventilation system (ie. Ability when necessary to shut down the "HVAC:" heating, ventilation and air conditioning sytem.)
• Air monitoring to ensure that the facility is safe for occupancy following treatment of contaminated patients.
• Post emergency critique of the hospitals emergency response.

When a hospital has been designated by the LEPC, it must prepare to fulfill its role in community emergency response. This is accomplished by engaging in emergency response planning activities that involve all segments of the community. With this in mind, hospitals should consider the following:

• The hospital must define ints role in community emergency response by pre-planning and coordinating with the fire department. In particular, the hospital must be familiar with the ICS system used by fire departments during emergencies and should participate in training and practice session using the ICS system.
• All hospital personnel who are expected to respond in emergencies where hazardous substances are released must be trained in handling contaminated patients and objects including body fluids.
• Training must be based on the duties and responsibilities of each employee.
• Hospitals should have a contingence plan for managing other patients in the emergency response system when a contaminated patient is being treated.
• There should be communication between other members of the ICS, the incident site, and the hospital personnel regarding the hazards associated with potential contaminants.
• Hospitals should have access to a database that is compiled by the local LEPC to provide immediate information to hospital staff on the hazards associated with exposure to toxic materials that may be used in the community.

Ideally, when medically appropriate, patients should be decontaminated before reaching the hospital, preferably at the incident site. However, complete on-site decontamination of victims may not be possible due to the medical conditions of the employees, training and skills of emergency responders, weather conditions and equipment availability. Therefore, hospitals should have designated decontamination areas.

Although areas dedicated solely to decontamination need not be set aside, hospitals need to take appropriate precautions to prevent the spread of contamination to other areas within the hospital. Decontamination should be performed in areas of the facility that will minimize any exposures to uncontaminated employees, other patients, or equipment. Morgues are often used as decontamination rooms because of the pre-existing drainage and ventilation systems. Morgues often have ventilation isolation to prevent mixing of airflow with other area systems.

An alternative to an indoor decontamination area would be setting up an area outside of the hospitals emergency room. Equipment used would include provisions for both ambulatory and non-ambulatory patient / victims. Once word reaches the hospital of a hazardous substance incident, all hospital personnel engaged in the response should be notified of the nature of the emergency and the type of chemical contamination expected. Then the hospital should outfit all necessary personnel with appropriate PPE.

All persons along the route from the emergency entrance to the decontamination area need to be relocated. This area may need to be protected by plastic or paper sheeting, and the area outside the emergency department entrance set up to direct the flow of contaminated patients to the decontamination area.

Airborne contaminants may be transported via the hospital’s ventilation system. Therefore, ventilation in the decontamination area should be separate from the rest of the hospital. Morgues, with an isolated ventilation system, are often used as decontamination rooms. If a contaminated victim is emitting airborne contaminants, the ventilation system in the decontamination area should be turned off. However, not all chemicals will be volatile enough to cause off-gassing.

Because emergency department personnel could be at risk if the ventilation system is shut off during decontamination in an enclosed area (ie. Santa Barbara Cottage Hospital’s Decontamination Room), ambient air should be monitored using direct read instrument, and the plan should provide means of supplementary or auxiliary ventilation. Prior to restarting the ventilation system, air monitoring with appropriate direct reading instruments is advised to assure the atmosphere is safe for circulation. The use of direct reading instruments to evaluate air quality must be made by an individual who has been properly trained in the use of instruments.

Failure to prepare is preparing for failure… Be prepared!