St. John Northeast Community Hospital
Detroit

SUBJECT: HazMat (Hazardous Material) Patient Decontamination Response Plan
DEPARTMENT: Security/Emergency Departments
DATE: September 2000
DISTRIBUTION: All Departments


PURPOSE:

To establish guidelines to be followed regarding the decontamination of patients exposed to hazardous materials.


POLICY:

Notification of these personnel is required for any response when St. John NorthEast Community Hospital partakes in a Hazardous Materials or Weapons of Mass Destruction Incident. Go to policy on Disasters and Telecommunications phone list.

Notification of other support services and hospital interdepartmental services may be required based on the severity of an incident.

Other Optional Services:
Fire Department or Police Department 911
Universal Macomb Ambulance Service Decontamination Team (UMAS) (810) 274-2900
Agency for Toxic Substances & Disease Registry (ATSDR) (404) 639-0615
National Institute of Occupational Safety Health (NIOSH) (800) 356-4674
Pesticide Hotline (800) 858-7378
Poison Control (313) 745-4511
Wayne County Health Department (313) 224-0810
Young’s Environmental (Waste Management Contractor) (810) 789-7155

 

Emergency Department Preparation

1. Upon notification of a HazMat or Weapons of Mass Destruction (WMD) incident, all internal and external notification must be made per hospital disaster policy and procedure.

2. The ED attending physician will delegate assignments to the DRZ (Decontamination Reduction Zone) and Buffer Zone.

3. All personnel assigned to these positions will utilize PPE (Personal Protective Equipment) per procedure outlined in Attachment IV.

4. All personnel working in the DRZ will have medical surveillance performed prior to contact with potentially contaminated patient(s).

5. All personnel will be briefed by ED physician as to a variance (if needed) of specific decontamination procedures and other pertinent information.

6. Plant Operations and Security Services will be responsible for setting up the DRZ and equipment.

7. Plant Operations personnel will stand by for additional directions and assistance.

8. On weekends and holidays, Environmental Services will initiate setting up decontamination tent and assist Security Services in establishing DRZ.

9. Security Officers will assist in establishing influx points for contaminated patient(s) arriving via EMS or walk-ins and be responsible for traffic and crowd control based on hospital policy and procedure guidelines.

10. Attending physician will assist with contamination control and utilize resources to identify hazardous materials involved.


PROCEDURE:

Medical personnel must protect themselves and other patients from potential exposure to hazardous substances before providing initial care of contaminated patients.

A. The Administrative Director/PCC or designee directs the ED personnel involved in the 7 decontamination of the patient to:

1. Report to triage for baseline vitals. Obtain PPE supplies from the designated, locked storage area.

2. Check suit for leaks and zipper integrity.

3. Remove all jewelry, wallets, and valuables, prior to donning PPE and secure in personal locker.

4. Don chemical resistant suit over boots.

5. Place pant leg over top of boots. Depending on the type of equipment used, secure with chemical-resistant tape if necessary.

6. Don nonsterile latex or vinyl gloves (elastic of chemical suit is placed over the gloves).

7. Apply respiratory and face/eye protection.

8. Pull up hood of chemical-resistant suit and secure in place.

9. Seal hood and zipper of suit with chemical-resistant tape.

10. Apply nitrile rubber gloves over outside of suit and seal with chemical-resistant tape.

B. Plant Operations will:

1. Place plastic sheeting in area proximal to contamination area, and secure area with hazard tape as directed by ED physician to protect area from contamination, if necessary.

2. Secure additional HazMat supplies from DRZ such as salvage drums and linen cart.

C. Environmental Services will:

1. Bring an additional linen cart to the ER treatment area.

2. On the midnight shift, weekends, and holidays, initiate setting up decontamination tent.

D. Security Officers will:

1. Divert all traffic from the contaminated area.

2. Secure additional areas with hazard tape as necessary.

E. Patient:

1. The patient(s) will not enter the ED until they have been decontaminated.

2. If the patient(s) arrive to the ED unannounced, security will prevent the patients from entering the hospital until the DRZ is prepared for the patient.

3. If the patient(s) is still in a private vehicle and is known to be contaminated, the patient should be held in vehicle until the DRZ is prepared. Note: If the patient(s) is in a life-threatening situation and requires immediate attention, ED staff with proper PPE should begin treatment in the ambulance and an emergency decontamination should be performed.

4. Patient’s clothing should be removed in the ambulance (if not already removed at the scene). Note: The greatest portion of contamination is usually found on the patient’s shoes and clothing. Prompt removal of garments at the scene greatly reduced the amount of product the patient(s) and rescuers are exposed to.

5. Clothing should be placed in a clear plastic bag and labeled with the patient’s name and marked contaminated. Jewelry and other valuables should be placed in a zip-lock bag and labeled accordingly. Note: All items may be returned to the patient(s) if the product is determined to be nontoxic. If the substance is deemed toxic, all items will be disposed of with the exception of jewelry and other nonporous items such as credit cards.

6. Patient(s) should be covered with a disposable blanket and advanced to the DRZ.

7. Patient(s) should enter shower area.

F. Shower/Decontamination

Uncomplicated HazMat Exposure (without physical injury).

1. The patient(s) will be instructed to shower as long as necessary based on specific chemical product guidelines.

2. ED physician will determine decontamination solution based on available resources.

3. Eyes should be irrigated as directed by the ED physician.

4. Ears/Nose/Mouth: The ED personnel to decontaminate passages should use moist swabs.

5. Proceed with decontamination of body.

Complicated HazMat Exposure (with physical injury).

The patient(s) will be decontaminated using the above protocol. Use a gentle scrubbing technique with surgical sponge and soft brush to avoid irritation to skin. Remember, volume of water is more important than velocity.

G. Airway, Breathing, and Circulation (ABCs) should be maintained.

1. The patient(s) will be placed on a backboard.

2. ED staff will place the backboard on the sawhorses in the decontamination shower.

3. Wounds: After cleansing of the eyes, ears, nose, and mouth, irrigation of all wounds should be performed. When appropriate, use waterproof drapes to cover clean areas as to minimize cross-contamination.

4. Proceed to decontaminate patient’s body starting at the neck and working toward feet. Also include posterior portion of body, genitalia, and anus.

H. Decon Room Exit

1. The decontaminated patient(s) should exit the shower, and care should be transferred to the ED staff in the Buffer Zone. Note: Personnel in the Buffer Zone should not enter the DRZ because of potential increase of contamination. Nuclear Medicine Department (NMD) personnel will determine when the patient(s) and employees may be moved into the ED, if radioactive.

2. ED personnel will remove PPE according to protocol (see below). PPE will be placed in the salvage drum or hazardous waste bag and sealed. Personnel should remove inner clothing and shower. Substitute clothing should be made available.

Undressing sequence:

1. Stand in an open HazMat disposal bag.

2. Remove chemical boots.

3. Remove outer gloves.

4. Remove face/respiratory protection.

5. Remove chemical protective suit. Note: Suit should be rolled down, avoiding contact with outside of suit.

6. Step out of bag and secure bag.

7. Place HazMat disposal bag in designated barrels.

8. Proceed to shower, if necessary.

Pre-hospital providers should remove their clothing and shower following patient(s) decontamination. Clothing should be secured in a salvage drum or hazardous waste-disposal bag. Substitute clothing should be provided. Note: Determine if pre-hospital providers are using SCBA as they may require a rapid decon due to limited air supply.

I. Equipment removal:

All equipment used during the course of treatment such as cardiac monitors, BP cuff, etc. should be left in the DRZ. Disposition of the equipment will be determined by the Waste Management Team.

J. Waste Removal Contractor:

Young’s Environmental should be notified to determine disposal and clean-up procedure.

K. Environmental Services:

Environmental Services personnel will decontaminate shower and nondisposable medical equipment based on waste disposal contractor’s guidelines.

L. Nuclear Medicine Department (NMD):

Nuclear Medicine will decontaminate DRZ if radioactive materials are involved. Radioactive storage containers are available from the NMD if necessary.

M. Supply/Storage Replacement:

The PCC/ED Administrative Director or designee should inventory and order supplies as needed after an event and on a quarterly basis.

N. Documentation:

All documentation should be done on the patient(s) care record.


ROLES AND RESPONSIBILITIES

NOTE: THE SAFETY OF ED STAFF AND PATIENT(S) CURRENTLY IN THE ED ARE OF PRIMARY CONCERN. CONTAMINATED PATIENT(S) FROM A HAZMAT OR WMD INCIDENT SHOULD NOT POSE A RISK TO ED STAFF OR OTHER PATIENTS IN THE EMERGENCY DEPARTMENT.

The following section should be used as a quick reference based on duties performed during a HazMat or WMD incident based on job description. A thorough understanding of hospital policy and training are essential in an actual incident. This section should not be used as an alternative, but as an aid to assist personnel during a HazMat or WMD incident.

 

Emergency Department Physician Responsibilities

The ED Administrative Director/Medical Director/designee will make the determination to activate the HazMat/WMD Response Plan and coordinate all activities in regard to patient care. EMS will notify the ED via radio/cellular phone as to an incoming contaminated or potentially contaminated patient. Note: In the event of an unannounced walk-in patient(s), security personnel should be notified immediately to isolate patients and minimize cross-contamination. The physician should determine whether the patient should be diverted elsewhere, i.e., St. John Hospital (313) 343-4000 or Detroit Receiving Hospital (313) 745-3374. This determination should be based on the briefing from EMS (see No. 1 below). If the patient is rerouted, then the ED physician will notify the designated hospital.

The decision to activate the HazMat/WMD Response Plan will be made by the ED Administrative Director/Medical Director/Security Director/designee who will:

1. Obtain information from EDS or patient(s) regarding medical condition, level of contamination, and risk associated with the hazardous material involved.

2. Assign an individual to research chemical product utilizing available MSDS/Poison Control to assist in identification of product, choosing appropriate decontamination solution and antidote pharmacology that may be needed upon patient(s) arrival.

3. Based on primary medical assessment of the patient(s), hazardous material involved, and contamination levels:

  1. Provide medical treatment.
  2. Provide patient decontamination.

4. In the DRZ, direct all necessary medical procedures to accommodate patient(s) medical condition and maintain contamination control.

5. Direct all sample taking procedures and decontamination procedures as suggested per resource indications.

6. Direct and coordinate the debriefing of all personnel after the patient has been transferred from the DRZ.

 

PCC/Charge Nurse Responsibilities

The PCC/Charge nurse will obtain a briefing from the ED physician in regard to the patient(s).

Prior to Patient(s) Arrival:

The PCC/Charge nurse will:

  1. Obtain HazMat patient information.
  2. Ensure notification (see Disaster Policy Telecommunication List).
  3. Assign ED nurses to selected areas:

Complicated Exposure:

  • DRZ — Two nurses (or one nurse, one physician as available)
  • Buffer Zone — One nurse
  • Triage — One nurse

Uncomplicated Exposure:

  • DRZ — One nurse
  • Buffer Zone — One nurse
  • Triage — One nurse
  1. Ensure personnel are dressed in appropriate protective clothing.

Patient(s) Arrival:

The PCC/Charge nurse will:

  1. Provide guidance and direction to team members.
  2. Ensure Fire/EMS/HazMat personnel do not enter ED and are held for decontamination.
  3. Direct all media to Public Relations or designee.

 

DRZ and Hot Zone Staff Responsibilities

Note: Any nursing staff members who are pregnant should not be designated as support persons in the DRZ or Buffer Zone.

DRZ support staff that are located in the Ambulance area for emergency patient care or the DRZ (warm) zone must wear proper protective clothing.

The DRZ support staff will:

Prior to Patient(s) Arrival:

1. Obtain briefing from Charge Nurse.

2. Dress in required protective clothing and take appropriate preparations:

  1. Report to triage for baseline vitals.
  2. Check suit for leaks and zipper integrity.
  3. Remove all jewelry, wallets, and valuables prior to donning PPE and secure in personal locker.
  4. Don chemical-resistant suit over boots.
  5. Place pant leg over top of boots. Depending on the type of equipment used, secure with chemical-resistant tape, if necessary.
  6. Don non-sterile latex or vinyl gloves (elastic of chemical suit is placed over the gloves).
  7. Apply respiratory and face/eye protection.
  8. Pull up hood of chemical-resistant suit and secure in place.
  9. Seal hood and zipper of suit with chemical-resistant tape.
  10. Apply nitrile rubber gloves over outside of suit and seal with chemical-resistant tape.

Patient(s) Arrival:

1. Assist ED physician with medical treatment of patient.

2. Assist ED physician with obtaining samples, decontamination, and patient transfer.

3. Remove protective clothing and perform self-decon prior to departure of DRZ.

4. Following completion of the HazMat incident, the PCC/Charge Nurse will review supply cart and reorder as necessary.

 

Buffer Zone Staff Responsibilities

The Buffer Zone nurse is located in the Buffer Zone designated area (clean area).

Note: If the patient is contaminated with an unknown chemical product and you suspect the potential for secondary contamination, Buffer Zone nurse must don proper PPE.

Prior to Patient(s) Arrival:

1. Obtain a briefing from the Charge Nurse.

2. Initiate patient record.

3. Secure baseline vitals of DRZ staff.

Patient(s) Arrival:

1. Record the medical/hazard information provided by EMS.

2. Transfer medical equipment to DRZ staff as needed.

3. Control entrance and exit of personnel and equipment from DRZ.

4. Provide any additional information related to hazardous materials agent.

5. Document all medical information, sample-taking measures, and decontamination efforts as provided by DRZ staff.

6. Transfer the patient(s) to the appropriate area within the ED once the patient has been decontaminated.

Post Patient Exit:

Assist DRZ support personnel as they exit the DRZ, making sure the following procedures are performed:

1. All DRZ support personnel remove PPE in the DRZ and shower for decontamination prior to leaving the DRZ.

2. That exit vital signs are obtained from members of the DRZ and that personnel are properly hydrated.

3. That DRZ is isolated and secured by Security personnel.

4. Notify the waste management company per procedure for clean-up of DRZ.

 

Maintenance and/or Environmental Services Personnel Responsibilities

1. Will receive notification by the ED Physician/PCC/designee of classification (complicated vs. uncomplicated) of the HazMat Response Protocol.

2. Obtain the DRZ equipment immediately and set up tent.

3. Place two (2) 55-gallon waste drums with plastic liners in the DRZ.

4. Set up warning tape, signs, and stanchions as indicated.

5. Set up decontamination equipment in the DRZ.

6. Stand by for further direction from the ED PCC/Charge Nurse.

 

Security Personnel Responsibilities

Prior to Patient(s) Arrival:

1. Don proper PPE (if necessary).

2. Place warning tape, signs, and stanchions in the ambulance receiving area as per procedure.

3. Direct ambulance traffic to designated arrival area.

Patient(s) Arrival:

1. Secure ambulance with warning tape and stanchions.

2. Advise ambulance crew to stay in Hot Zone and anticipate decontamination. (Direct contact with EMS crew should be avoided due to possible cross-contamination.)

3. Limit access to the controlled area per procedure.

4. Maintain all control points until given the "all clear" notification by supervisory personnel.

 

Nuclear Medicine Personnel Responsibilities

Note: If incident is deemed a "Radioactive Emergency," all personnel must wear dosimeters.

1. The Nuclear Medicine Department (NMD) will assist the ED staff at checking patient(s), pre-hospital responders, and equipment for radioactive contamination.

2. If adequate personnel are available from the NMD, one individual should be assigned to assist the physician and nurse in the DRZ in regard to contamination control and assist in monitoring patients, staff, and equipment as needed.

3. A second individual from NMD should assist in the Buffer Zone in maintaining contamination control. This individual is responsible for monitoring all patient articles, patients, and staff who depart the DRZ for contamination.

 

Administration/Community Relations Responsibilities

1. Provide support, as needed, to medical staff and handle press/media inquiries.

2. Designate a spokesperson for the hospital and prepare an area in the hospital to address the media.

3. Maintain media control during the incident and post incident.

4. Appoint a liaison to coordinate efforts of ED staff and other agency resources.

 

Documentation: ED Patient Care Record
Compiled by: Disaster Committee Members
Written 11/99

References: U.S. Department of Health and Human Services, Public Health Service, Agency for Toxic Substances and Disease Registry. Managing Hazardous Materials Incidents, Hospital Emergency Departments. A Planning Guide for the Management of Contaminated Patients (Volume II).