Case Study

Florida ED revamps its decontamination plan

After 9/11, decontamination procedures became a top priority for ED managers nationwide. Although most EDs had included these in disaster plans, the focus was a small-scale event, according to Karen G. Ketchie, RN, EMT-P, disaster preparedness manager at Shands Jacksonville (FL) Medical Center. "We have to change our perception of treatment of the contaminated patient from a few to the hundreds, or even more," she says.

Here are several recent changes made to the facility’s decontamination procedures: 

1. Standby rescuers were added to assist team members. Ketchie says a signal was previously used for team members to convey distress. "However, we didn’t have a system to go get them if needed," she adds. Team members may become dizzy from the heat or chemicals and need help getting out of the mass decontamination unit (MDU), she explains. "The standby rescuer is already suited up to go get them, as opposed to a team member leaving a patient he is taking care of," Ketchie adds.

The idea is to be able to "rescue the rescuers," says David J. Vukich, MD, professor and chairman of the department of emergency medicine at the University of Florida in Jacksonville. "Should staff be overcome with heat exhaustion or the chemical or agent, we must be prepared to pull them out," he adds.

2. Team members are given "pre- and post-" medical screenings. The goal is to avoid exposing staff with borderline fitness or pre-existing diseases to heat stress or potential toxins, Vukich explains. Staff are screened before and after they enter the decontamination area, he says.

If pre-entry medical screenings reveal abnormal vital signs such as hypertension that could be exacerbated by the heat and stress, Ketchie says, those staff members will not enter the MDU. "Their knowledge will be utilized in a way without them having to suit up," she adds. The screening also includes a mental health assessment, she notes. "If they are near hyperventilating prior to entering due to stress, they do not go in," Ketchie says.

3. A staging area was selected for team members before entering the MDU. In this location, team members buddy up, are briefed, undergo suit inspection, and review distress and safety signals prior to entering the hot zone, Ketchie says.

4. The threat of contamination to the facility was addressed. Vukich advises that sites must be designed for a large number of casualties and to keep contamination away from the hospital itself. "Contaminating the facility and losing it as an asset is a very real threat," he underscores. To address this, Vukich says decontamination is done at a considerable distance from the building, to contain the runoff water and prevent patients or staff from wandering in.

5. The employee parking garage is utilized. Most hospitals have a covered walkway, overhang, or covered parking garage, Ketchie says. "Any of these areas can be quickly converted into chutes’ with the addition of tarps," she says. She explains that the ground floor of the employee parking garage serves as a mass decontamination area. Once dropped and anchored, tarps suspended from the ceiling create three chutes or corridors for males, females, and nonambulatory patients. "As I consult with other hospitals, I see items such as privacy screens and sheets being utilized for privacy," Ketchie says. "Although this is a start, a more clearly identified and permanent system is needed." Ketchie reports that one hospital fought the wind during a chemical incident drill, and their privacy screens kept falling over.

6. Staff are trained in decontamination. Ketchie teaches a quarterly class that follows the Department of Defense Domestic Preparedness Program. (See resources at the end of this article for more information on these courses.) "We have used this program here for four years, and it is excellent," she says. The class is mandatory for all ED staff, and consists of four hours of lecture and three hours in the MDU covering suit application, unit setup, and patient flow. 

In addition, ED staff attend inservices featuring presentations on decontamination procedures, developed by Ketchie. (These can be downloaded at no charge at the Northeast Florida Disaster Medical Assistance Team web site: www.dmatfl4.org. Click on "Mass Decontamination Unit," and "Personal Protective Equipment.)

7. Security concerns were addressed. Security is critical, because a real event could send hundreds, if not thousands, of potential patients storming your ED, Vukich says. "We have no real way to test this, and the thought is very daunting," he adds. Security is posted at the hospital entrances and outside the MDU to direct traffic, Vukich says. "Frankly, we do not have enough security. Our drills clearly show we would probably be overrun if more than 50 or 60 patients arrived in short order," he says. "I consider this to be the greatest problem for our system."

[Editor’s note: Do you have an innovative strategy to address security needs during a disaster? If you have a solution to share with other EDM readers, please contact Staci Kusterbeck, Editor, ED Management, 280 Nassau Road, Huntington, NY 11743. Telephone: (631) 425-9760. Fax: (631) 271-1603. E-mail: StaciKusterbeck@aol.com.] 

Resources

For more information on decontamination procedures, contact:

Karen G. Ketchie, RN, EMT-P, Disaster Prepared-ness Manager, Shands Jacksonville Medical Center, 655 W. Eighth St., Jacksonville, FL 32209. Telephone: (904) 244-2598. Fax: (904) 244-4285. E-mail: Karen. Ketchie@jax.ufl.edu.

• David J. Vukich, MD, Professor and Chairman, Department of Emergency Medicine, University of Florida, 655 W. Eighth St., Jacksonville, FL 32209. Telephone: (904) 244-4107. E-mail: vukich@ufl.edu.

The Office for Domestic Preparedness (ODP) offers training to state and local jurisdictions to prepare for and respond to events of terrorism involving weapons of mass destruction, including biological, nuclear/radiological, incendiary, chemical, and explosive devices. For more information regarding ODP training programs, or to obtain a copy of the Weapons of Mass Destruction Training Programs course catalog, call the State and Local Domestic Preparedness Support Helpline at (800) 368-6498. To download a copy of the Course Catalog, visit the web at www.ojp.usdoj.gov/odp/. For more information, contact:

Gabrielle Meszaros-Parada, Technical Assistance Coordinator. Telephone: (202) 307-6061. Fax: (202) 616-2922. E-mail: Meszaros@ojp.usdoj.gov.