Coming Clean about Hospital
Decontamination
Presentation to: 8 Hour Operations Class
Presented by: DPH Trainer the Trainers
Date:
Question 1:
During decon, hospitals must make an
attempt to capture and retain as much
runoff from victim and/or mass
casualty decontamination operations
as possible to comply with EPA and
other environmental laws.
 Reality
 Myth
The Facts
•
Protecting the environment should NEVER be considered ahead of
protecting people.
•
Contaminated people cannot have enough chemical on them to seriously
harm the environment.
•
The perceived liability cause by potential environmental damage is
FICTION. Liability from delaying decon of victim is a FACT.
•
The EPA agrees: The victims come first!
•
“First Responders’ Environmental Liability Due to Mass Casualty
Decontamination Runoff” (Chemical Safety ALERT July 2000)
Question 2:
•
OSHA requires that hospital decon teams
learn and know how to use the DOT ERG.
•
This Guide will provide useful information
to help the decon control officer in
selecting proper PPE and determining
specific hazards.
 Reality
 Myth
The Facts
•
It provides absolutely no useful chemical information to determine proper
hospital MCI decon.
•
It provides no accurate information to suggest the correct PPE for hospital
decon operations.
•
It provides no specific chemical properties.
•
It was developed only to aid 1st responders in quickly identifying
hazardous materials and protecting themselves and the public during the
INITIAL response phase of a hazardous materials incident.
Question 3:
•
Water should not be used on people who
are contaminated with almost all of the
Class 4 water-reactive substances.
•
Hospitals should have a plan for dry victim
decon or should use water sparingly to
avoid contact with the substance on skin.
 Reality
 Myth
The Facts
•
Water should be used for water-reactive materials, but only low
pressure, high-volume.
•
Garden hoses do not apply “copious” amounts of water and can result
in dangerous reactions.
•
Dry decontamination of victims and responders increases the dangers
of the contamination.
•
Every fire department in the USA has one or more “decon units”
(pumpers/engines).
Question 4:
Oxidizers and Organic Peroxides
should be quickly washed from the
shoes and clothing of contaminated
victims because there is a chance the
victim’s clothing could
spontaneously ignite at any time.
 Reality
 Myth
The Facts
• Organic Peroxides may have a Maximum Safe Storage
Temperature (MSST) or Self Accelerating Decomposition
Temperature (SADT), causing them to react with heat.
• Many Oxidizers will self-ignite when they dry out on clothing.
• Both classes like to decompose when contaminated with
organics, acids, etc.
• If you make contaminated victims wait for decon, you may
place them in great danger.
Question 5:
•
A MSDS provides accurate
information to hospitals for
decontamination, PPE, and
medical care to victims
contaminated with a known
substance.
•
The MSDS also provides specific
information for medical treatment.
 Reality
 Myth
The Facts
• Material Safety Data Sheets rarely provide
accurate information about victim
decontamination or medical care beyond first aid.
• The MSDS for the same chemical differ between
the manufacturers.
• MSDS’s mostly say use copious amounts of water
to wash product off the skin/eyes.
Question 6:
•
Victim decontamination
should never be delayed
while determining the
proper soap or other
additives.
•
The rapid use of low
pressure high volume
water and quick
disrobing are the best
decon solutions.
 Reality
 Myth
The Facts
• Initial decon operations don’t require soap or additives
to remove most chemicals.
• “Additives” or decon-solutions may cause reactions if
used without professional advice.
• Brushes of any kind are not recommended nor required
to decontaminate the skin.
• Soap dilutes quickly in decon buckets.
• After a few victims, the soap is gone and effectiveness
of brushing decreases.
Question 7:
Cool or cold weather decontamination operations should
not be delayed to wait for the decon shower water to be
heated or “tepid.”
 Reality
 Myth
The Facts
• Heating decon water is not very practical because it
delays decontamination and heaters cannot heat large
volumes quickly enough.
• Great for secondary decon/personal showers
• Cold water is uncomfortable but it does not induce
hypothermia when the people are warmed quickly
afterwards.
• U.S. Army Soldier and Biological Chemical Command
(SBCCOM) decon studies concur
Question 8:
Over 1.6 million people
contaminated with a nerve
agent could be
decontaminated in an
Olympic-sized swimming
 Reality
 Myth
pool before the pool
became too contaminated
for further decon.
The Facts
•
SBCCOM Cold Weather Decon Study
• Assumptions: 3,000,000L pool – Dose Brought into pool by
each person GB-100mg or VX-.1mg
• Calculation Results… 1,668,000 people for VX or GB
• Comments: From the calculations above the resultant
number of people that could be put in a pool without
exceeding the no effects level has been reduced by 50% to
add an additional margin of safety. In summary, for the
agents above (GB and VX) approximately 800,000 people
could be processed.
Question 9:
The deluge system
replaces the use of
internal and external
showers during the
decontamination
process.
 Reality
 Myth
The Facts
• Removal of clothing and gross
decontamination reduces the risk but does
not eliminate the risk
• The triangle from armpits to groin is where
the emphasis should be during secondary
contamination
Question 10:
OSHA requires that
hospitals establish 3 zones
for their decontamination
operation (Hot – Warm –
Cold) to control people
 Reality
 Myth
keeping them safer, and
avoiding secondary
contamination
The Facts
•
OSHA Best Practices for Hospital-Based 1st Receivers (January 2005) B.3.1
page 17 of 91
“OSHA has found it appropriate to define two functional zones during
•
hospital-based decontamination activities.” These zones, which guide the
application of OSHA’s recommendation are:
•
Hospital Decon Zone: Includes any areas where the type and quantity of
hazardous substances is unknown and where contaminated victims,
equipment, or waste may be present. This area typically ends at the ED
Door
•
Hospital Post-decontamination Zone: An area considered
uncontaminated. Equipment and personnel are not expected to become
contaminated in this area. (includes the ED (unless contaminated)).
Question 11:
Ammonia and Chlorine, two very
common industrial chemicals,
may cause severe respiratory
distress, skin burns, and even
death to victims, BUT victim
decon is simple because there is
 Reality
very little chance of adverse
impacts on either the decon
workers or the environment.
 Myth
The Facts
• Most gases do not create a hazard for decon workers, even nerve
agents.
• Chlorine and Ammonia are very corrosive but they off-gas and
dissolve in decon water.
• Concentrations may be IDLH when the victim is contaminated, but
below the Permissible Exposure Limit/Time Weighted Allowance
(PEL/TWA) by the time they are in the warm zone at the incident
site.
• If the victim is still alive the danger to the protected decon worker
is usually minimal.
Question 12:
 Reality
 Myth
•
Pre-hospital
•
Removing contaminated
decontamination can
clothing can reduce the
eliminate the risk of
quantity of the
secondary exposure.
contaminant by up to 25%
The Facts
• Pre-hospital decontamination will limit the risk of
secondary exposure, not eliminate it.
• Removing clothing will reduce the quantity of the
contaminant by 75 % or more.
• SBCCOM Mass Casualty Decon Study.
Question 13:
Clinicians, security officers,
triage teams and other hospital
staff members who play a role
in receiving and treating
contaminated patients are
considered by OSHA to be 1st
Receivers. (same as the
hospital’s decon workers).
 Reality
 Myth
The Facts
•
OSHA Best Practices for Hospital-Based 1st Receivers (January 2005)
A.2 page 8 of 91
• “First Receivers typically include personnel in the following roles:
clinicians and other hospital staff who have a role in receiving
and treating contaminated victims (e.g. triage, decontamination,
medical treatment, and security) and those whose roles support
these functions (e.g. set up and patient tracking)”
• First Receivers are a subset of First Responders
Question 14:
OSHA’s Best Practices for
Hospital-Based First Receivers
does not include/cover
infectious outbreaks for which
decon is not needed.
 Reality
 Myth
The Facts
• OSHA Best Practices for Hospital-Based 1st Receivers
(January 2005) A.2 page 8 of 91
• The scope of this best practices document does not include
situations where the hospital (or temporary facility) is the site
of the release. Nor does it include infectious outbreaks for
which decontamination is not necessary.
Question 15:
Hospital employees assigned the
task of developing the
decontamination program,
procedures, and PPE selection
criteria require additional
training beyond the 1st Receiver
Operations Level than the
hospital decon team members
require.
 Reality
 Myth
The Facts
•
OSHA Document 3152 (1997) “Hospitals and Community
Emergency Response What You Need to Know” Training
Employees - 7th page
•
Individuals who develop the decontamination procedures and select
PPE for the workers who help decontaminate patients, must be trained
to the First Responder level (changed to First Receiver in 2005) with
additional training in decontamination procedures, but such individuals
would not need the lengthy specialized training required for a
hazardous materials technician.
Question 16:
When training hospital
decon teams, the
competencies identified in
the OSHA standard for the
 Reality
 Myth
Operations Level can be
deleted or tailored to fit
the expected tasks.
The Facts
•
Interpretive Letter 12/2/02 to Capt. Kevin Hayden State of N.M. E.M.
Section (page 2)
•
Generally, all competencies listed in 29 CFR 1910.120 (q) (6) (ii) should be
met for hospital employees trained to the First Responder Operations
Level designated to decontaminate victims.
•
Competencies may be tailored to fit the tasks the employees are expected
to perform.
•
For instance, placard recognition is not required as a basic hazard and risk
assessment technique. The ability to identify placards is important for a
Hazmat Team, but not for hospital personnel designated to perform
decontamination.
Question 17:
OSHA requires Awareness
Level training be
completed before
Operations Level Training
begins and Operations
training must be at least 8
hours in duration.
 Reality
 Myth
The Facts
• Interpretive Letter 9/24/02 to Scott Cormier HCA Richmond
Market Hospitals (page 2)
•
Question 4- Is a training course that combines the first responder awareness
level and first responder operations level competencies in one 8 hour course
acceptable?
•
OSHA’s Reply: “Yes. The statement in the VA letter that a total of 16 hours of
training is required for the first responder operations level is not correct.”
•
I.L. 4/22/03 to Mike Bolt Novant Health states, “If you spend two hours
training employees in the required competencies for the Awareness Level,
then you would need to spend at least six hours training for the Operations
level.”
Question 18:
OSHA requires that
hospitals provide a
minimum of 8 hours of
annual refresher
 Reality
 Myth
training for staff trained
to the First Receiver
Operations Level.
The Facts
• Interpretive Letter 9/24/02 to Scott Cormier HCA Richmond
Market Hospitals (page 2)
• Question 5: Is there a minimum competency or hour requirement for
refresher training ?
• OSHA’s Reply: “No. There is no minimum time specified for emergency
response refresher training. The training must be of sufficient content
and duration to maintain the competencies for the responder’s level.
Alternately, employees may demonstrate those competencies at least
annually.”
Question 19:
• The employer (hospital) is
the only one who can
certify an employee to any
OSHA Hazwoper Level.
• A public or private training
 Reality
agency cannot officially
certify any employee but
 Myth
their own.
The Facts
Interpretive Letter 12/2/91 to Richard Andree S&H Mgt.
•
Consultants Inc. (page 2)
•
OSHA does not certify individuals, it is the employer who must show by documentation or
certification that an employee’s work experienced and/or training meets the requirements
of 1910.120.
•
There must be a written document which clearly identifies the employee, the person
certifying the employee and the training and/or past experience which meets the
requirements.
Interpretive Letter 3/10/99 to Daniel Burke St. John’s Mercy MC.
•
St. Louis (page 1)
•
Hazwoper requires the employer to certify that the workers have the training
and competencies listed in (q) (6) (ii)
Question 20:
Clinical hospital staff
without 1st Receiver
training may enter a
contaminated decon
zone without any prior 1st
Receiver and/or PPE
 Reality
 Myth
training, if they are
deemed “skilled support
personnel.”
The Facts
OSHA Best Practices for Hospital-Based 1st Receivers (January 2005) C.3 page 22 of 91
•
•
(A) A member of the staff who has not been designated, but is unexpectedly called on
to minister to a contaminated victim, or perform other work in the hospital
Decontamination Zone, is considered “skilled support personnel.” Examples include a
medical specialist or trade person such as an electrician.
•
These individuals must receive expedient orientation to site operations, immediately
prior to providing such services. The orientation must include:
•
•
•
•
Nature of hazard (if known)
Expected duties
Appropriate use of PPE
Other appropriate safety and health precautions ( e.g. decontamination
procedures)
Question 21:
Federal OSHA is
responsible for enforcing
1910.120 “Hazwoper” in
private hospitals only,
except in OSHA States
 Reality
 Myth
where Federal OSHA
does not enforce OSHA
standards.
The Facts
•
Interpretive Letter 12/2/02 to Capt. Kevin Hayden State of N.M. E.M. Section
(page 3)
•
State and municipal employees (e.g. EMS/Fire) are covered by the standard in those
states which operate their own Federally approved State OSHA Program. In those
states under Federal OSHA , the EPA regulates State and Local employees including
volunteers under 40 CFR 311.
•
Interpretive Letter 12/2/02 to Capt. Kevin Hayden State of N.M. E.M. Section
(page 3)
• Federal OSHA has no jurisdiction over state and local government employees
such as the public employees of a state-owned hospital. Twenty three states
operate programs that cover both private and public sector employees.
Question 22:
While an environment that
is immediately dangerous is
 Reality
possible, it is extremely
unlikely that a living victim
could create an Immediately
Dangerous to Life and
Health (IDLH) environment
at a receiving hospital.
 Myth
The Facts
•
OSHA Best Practices for Hospital-Based 1st Receivers (January 2005) B.2.1.1
page12 of 100
•
The Georgopoulos Study of 2004 determined that 100 grams or 4 ounces of the
most moderately to highly volatile substances that might be sprayed on a victim
during a MCI would evaporate within 5 minutes from the time the exposure
occurred.
•
Horton Study (2003) agreed stating that substances released as gases or vapor are
not likely to pose a secondary contamination risk to 1st Receivers. Limited exposure
may be possible.
•
Quote: “It is extremely unlikely that a living victim could create and Immediately
Dangerous to Life (IDLH) environment at a receiving hospital, particularly if
contaminated clothing is quickly removed and isolated and the victim is treated and
decontaminated in an area with adequate ventilation.”
Question 23:
OSHA Hazwoper requires
hospitals to conduct
basic pre-entry medical
surveillance for decon
workers and those who
use chemical protective
clothing and respirators
 Reality
before they begin work
in their PPE.
 Myth
The Facts

NFPA 471 is only a standard and does not require medical
assessment before entry.

OSHA 1910.120 (f) Requires the following medical surveillance
for hazmat team members:

Prior to assignment and upon termination or reassignment

Once every 12 months or 2 years if physician deems appropriate

If they exhibit signs or symptoms, injure, or exposed above Permissible
Exposure Limits (PEL)

Physician may require more frequent medical surveillance
Question 24:
Because Hazwoper is a
“performance-based”
regulation hospitals are
allowed flexibility in
meeting the
requirements. They are
 Reality
 Myth
not required to follow
any specific procedures
or guidelines in OSHA
1910.120.
The Facts
• OSHA Document 3152 (1997) “Hospitals and Community
Emergency Response What You Need to Know” Training
Employees 7th page:
• Hazwoper is a performance-based regulation allowing individual
employers flexibility in meeting the requirements of the
regulation in the most cost-effective manner.
• There are numerous examples of this decision in many
Interpretive Letters.
Question and Comments