Protecting hospital first receivers is critical in the age of terrorism
Protecting hospital first receivers is critical in the age of terrorism
OSHA provides guidance for hospitals
The Occupational Safety and Health Administration (OSHA) has released a guidance document that calls for using powered air purifying respirators (PAPRs) and other equipment to protect health care worker first receivers during a mass casualty incident such as a bioterrorism attack.
"[The document] is focused on the health care worker and skilled support personnel who would be involved in mass casualty incidents," says David Ippolito, director of science technology and assessment at OSHA in Washington, DC. "We feel the guidelines presented here will protect first receivers from all reasonably anticipated worst case scenarios including those created by a chemical weapon of mass destruction such as sarin or blister agents."
OSHA is getting more involved in the bioterrorism and mass casualty arena, including issuing new guidance for disaster response teams. That first receivers document is titled OSHA Best Practices for Hospital-based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances. (See editor’s note at the end of this article.) Bioterrorism Watch asked whether it was intended primarily as a guidance or compliance document.
"It really is a little bit of a combination of both," Ippolito explains. "It is best practices, and there are recommendations that are commingled with requirements — depending upon what the hospital already has in place. If you decide on any kind of respiratory protection, then the standards associated with that use of that respirator would have to be looked at and complied with."
For example, the document includes three tables designed to assist employers in selecting personal protective equipment (PPE) adequate to protect health care workers and to comply with relevant OSHA PPE standards. (See tables, below.) Tables 1 and 2 list the specific prerequisites that OSHA contends are necessary to adequately limit first receiver exposures and to assure the adequacy of the PPE presented in Table 3. Such conditions include a current hazard vulnerability analysis (HVA) and emergency management plan (EMP), as well as procedures to ensure that contaminated materials are removed from the area and contained so they do not present a continuing source of exposure.
Employers who meet the prerequisites in tables 1 and 2 may use the best practices document as the OSHA-required generalized hazard assessment.
Such employers may choose to rely on the PPE specified in Table 3 to comply with relevant OSHA standards and to provide effective protection for first receivers against a wide range of hazardous substances, the document states. However, such employers also must conduct a hazard assessment that considers hazards unique to the community in which they are located. In rare situations, these employers will need to augment or modify the PPE specified in Table 3 to provide adequate protection against unique hazards identified in the community-specific hazard analysis.
However, employers are not obligated to follow the guidance in Table 3, OSHA clarified, noting that an employer can choose instead to perform an independent hazard assessment that is sufficient to identify the hazards that its employees are reasonably anticipated to encounter, and then select PPE adequate to protect its employees against such hazards.
"With respect to the recommendations in Table 3, a hospital is free to walk away from those and not follow them," Ippolito says. "That’s fine. To the extent though that they need to use a respirator at all or do other things that would be necessary in most cases — not only for OSHA but for JCAHO requirements — you’re still going to have requirements associated with those things, such as respiratory protection training for employees."
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Table 1. Hospital Decontamination Zone
Conditions Necessary for Hospitals to Rely on the Personal Protective Equipment (PPE) Selection Presented in Table 3A,B
Source for all tables: Occupation Safety and Health Administration, Washington, DC. |
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Table 2. Hospital Post-Decontamination Zone
Conditions Necessary for Hospitals to Rely on the Personal Protective Equipment (PPE) Selection Presented in Table 3E,F
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TABLE 3. Minimum Personal Protective Equipment (PPE)
for Hospital-based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Unknown Hazardous Substances SCOPE AND LIMITATIONS This Table applies when: |
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| Note: This table is part of, and intended to be used with, the document titled OSHA Best Practices for Hospital-based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances. |
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ZONE |
MINIMUM PPE
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Hospital Decontamination ZoneI
(Includes, but not limited to, any of the following employees: decontamination team members, clinicians, set-up crew, cleanup crew, security staff, and patient tracking clerks.) |
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Hospital Post-Decontamination ZoneM
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Show good-faith effort
"In good faith, a hospital needs to have in place an emergency management plan at least internally if not externally," he continues.
"For formaldehyde spills, ethylene oxide emergencies, some kind of plan [is needed] even if you are just going to get out of the way and call in the HAZMAT team. [OSHA inspectors] will check to see how the hospital has done a hazard vulnerability analysis and followed through on that. Unless you are way off, they are probably going to say, OK that is your judgment and that may work.’ But if in fact a particular facility has an obvious sort of risk that was ignored during the analysis, they might question that," Ippolito adds.
So hospitals do not necessarily have to go out and buy PAPRs, but that is the equipment OSHA is recommending for first receivers as opposed to the self-contained breathing apparatus (SCBA) typically worn by firemen.
During mass casualty emergencies, hospitals can anticipate little or no warning before victims begin arriving, OSHA warns. Additionally, first receivers can anticipate that information regarding the hazardous agent will not be available immediately.
Hospitals also can anticipate a large number of self-referred victims and assume victims will not have been decontaminated prior to arriving at the hospital. In addition to a PAPR with an assigned protection factor of 1,000, OSHA recommends first receivers wear a chemical-resistant protective garment, head covering if it is not already included in the respirator, a double layer of protective gloves, and chemical-protective boots.
The OSHA document was created after requests by hospitals seeking guidance in protecting workers during mass casualty incidents.
"This document was created in response to a request, a very vociferous request, if I might add, from the health care community," Ippolito says. "The health care industry has said, We know what firemen and HAZMAT folks need to wear, but we have no idea what to do for hospital emergency departments first receivers.’"
The term first receivers — to describe health care workers treating incoming mass casualty patients — has caught on after being coined in the medical literature, he notes.
Health care workers risk occupational exposures to chemical, biological, or radiological materials when a hospital receives contaminated patients, particularly during mass casualty incidents. That means their exposures are limited to the substances transported to the hospital on victims’ skin, hair, clothing, or personal effects, OSHA states.
The location and limited source of contaminant distinguishes first receivers from other first responders (e.g., firefighters, law enforcement, and ambulance service personnel), who typically respond to the incident site (i.e., the release zone), the document indicates.
"We help define in this document what it means to be a first receiver as opposed to a first responder," Ippolito says. "The risk is different because the first responder typically goes to the site and could be exposed to ongoing emanation of materials. The first receiver is limited to secondary contamination associated with the victim."
OSHA already had decided the occupational risk was different but had not "quantified that difference in a meaningful way" until the creation of the document, he adds. The guidance should help standardize the broad array of approaches being used currently at hospitals.
"A lot of hospitals have either not done anything or purchased SCBAs — the kind firemen wear — only to find out they were just completely impractical for their personnel. That was really the impetus for doing this," Ippolito notes.
OSHA cites difficulties and hazards for health care workers who attempt to care for patients while wearing SCBAs, including trips, falls, and overexertion — particularly for infrequent users of the equipment. Instead, OSHA recommends that hospital-based first receivers use the less demanding PAPRs, which typically have a motor blower and a high-efficiency filter.
"That was a lot of the pushback as we developed the document," Ippolito says. "[Some hospitals argued] that patient protection can’t go forward with SCBAs. There was a huge fight [because] there were some very vocal hospitals out there — a few in New York, some in Chicago and most of the VA hospitals — who fought us on this. They said, No, we want SCBAs.’ Well, they can use SCBAs, but that is not what we are going to recommend because we don’t think for the vast majority of hospitals it is a practical solution. We came to the conclusion that we could, within the confines of our mission to protect the employees, recommend the PAPRs and feel comfortable with it."
(Editor’s note: The complete OSHA document is available on the web at: www.osha.gov/dts/osta/bestpractices/html/hospital_firstreceivers.html.)
The Occupational Safety and Health Administration (OSHA) has released a guidance document that calls for using powered air purifying respirators (PAPRs) and other equipment to protect health care worker first receivers during a mass casualty incident such as a bioterrorism attack.
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