Chem exposure tests hospital's readiness

Key concerns: Communication, access to PPE

At 3 o'clock on a Saturday afternoon in August, an SUV pulled up to the emergency department at SSM DePaul Health Center in St. Louis. A security officer peered in and saw three men covered in a yellowish powder. It looked like anthrax. Their skin was literally blue — they were cyanotic and near death.

A security officer, thinking of the patients more than his own safety, put on some synthetic gloves and pulled them out of the car. He immediately took them into the decontamination room, just inside the hospital, removed their clothes and showered them. Drifting in and out of consciousness, one man was able to reveal that the powder was the highly toxic industrial chemical nitroaniline, which can be absorbed through inhalation and skin contact. It can cause headache, dizziness, difficulty breathing, vomiting, increased heart rate, and eventually unconsciousness.

Elsewhere in St. Louis, five other men traveled on their own to three other hospitals. Officials later learned that they had all been exposed in an accident at Ro-Corp, a chemical packaging facility.

The sudden chemical exposure tested the hospitals' readiness for a disaster and provided an important reminder about preparedness. Lessons learned: Personal protective equipment needs to be readily available in the emergency department. Communication is the antidote to panic and fear. And employees need more training to be prepared.

The hospital successfully contained the contamination because of the swift actions of the security officer. Within minutes, the fire department arrived and set up an external command center, and the hospital was locked down. No one could come in or out.

But communications channels weren't as effective as they could have been. "It was a huge communications issue," recalls Joanie Riesmeyer, RN, infection control coordinator. The hospital didn't call a "Code D," which would have established an internal command center and created a system to inform supervisors and staff. "That was a huge mistake," she says. "That put our patients ill at ease because they didn't know what was happening."

Battling misinformation in media

While the men were being given an antidote to the chemical, the local news media was broadcasting that the powder was anthrax. Even when hospital officials told ED staff that it was a chemical exposure, employees were skeptical. "People were hearing about it from the media and not trusting us," says Riesmeyer.

"It became mass pandemonium. The families [of patients] were upset and they kept calling the media, also," she says. "They would leave the patients' room and go out and call the media."

News reports said that two people had died from the exposure — which was not true. All the exposed victims recovered within two days and only one remained in the hospital longer.

Riesmeyer worked with the hospital's public relations department to create an informational statement: "You are not at risk. [The contaminant] is not being recirculated in our air system. You have nothing to worry about. There are no reports of anyone who has died [at any hospital]."

It was easy for false information to spread. Even the assistant battalion chief of the fire department initially thought there were 50-75 people contaminated. In fact, three patients and 14 employees were considered exposed. They were decontaminated and given scrubs to wear; their clothes were destroyed.

They then waited on buses that served as a temporary detainment area until it was clear that they had no symptoms of poisoning. Two pregnant ED workers were kept in the hospital overnight to monitor them for symptoms. It's unlikely any of the employees except the initial security officer had actual exposure; air sampling and other tests in the ED failed to show even a trace of the contaminant.

Lessons lead to better preparedness

The hospital has already taken steps to improve training and preparedness, including fit-testing staff to use N95 respirators. Other personal protective equipment has been placed in the decontamination room, and staff are receiving training on donning and doffing PPE, says Elaine Allrich, MS, MT(ASCP), infection control specialist and co-chair of the hospital's Environment of Care Committee.

"We have a small decontamination team, but that's not to say they're going to be here when an incident occurs," she says.

In fact, in the recent chemical exposure, the appropriate PPE for chemical decontamination was stored in the basement. It has been moved to the Emergency Department. During the incident, employees wore N95 respirators with face shields, although the Material Safety Data Sheet (MSDS) for the chemical called for PAPRs, and they failed to wear foot coverings, Riesmeyer says.

The hospital also is creating a disaster-oriented Pyxis to store antidotes. Poisoning with nitroaniline can be treated with methylene blue, and ED physicians also wanted atropine, which is an antidote for organophosphate poisoning. With the existing system, "[employees] would have to come out of the pharmacy, which was clean, into what we determined was a hot zone, the ED," she says.

SSM DePaul has taken its lessons to heart. Everyone, from leadership to frontline employees, will receive additional training on emergency management, she says.