Hospital Decontamination Systems
Regardless of a hospital's current decontamination capabilities, a plan can be quickly developed to handle mass casualties from a chemical or biological incident. Fear and panic are perhaps the greatest concern following a chemical or biological attacks. Fortunately, with some straightforward precautions and procedures, basic safety equipment and supplies, hospitals can develop the self-confidence and competency to respond to the emergency health care needs of victims from a terrorist attack, even before longer-term solutions can be implemented.
A decontamination/triage facility is intended to protect hospital facilities and staff so that they can safely and securely carry out their health care responsibilities in a contamination-free environment. Ideally, a small number of suitably trained hospital staff with appropriate personal protection gear will meet victims at the entrance to the decontamination facility and assist them in completely disrobing, provide them a warm soapy shower, and temporary clothing. Simply removing a victim's clothing is probably the single most important decontamination measure. The decontamination facility is treated as the "Warm Zone," i.e. potentially contaminated through the presence of victims arriving from the scene of a terrorist attack.
Only after thorough decontamination will patients be transferred to the "Cold Zone," i.e., the main area of the hospital facility that will be free of contamination, where regular medical staff can provide appropriate care without being overly encumbered by the special equipment or unusual precautions required in the "Warm Zone."
Chemical warfare agents, both nerve and blister, are highly toxic materials that were intended to cause harm. Other agents that might be used in a terrorist attack such as industrial chlorine gas, are also very hazardous. Nevertheless, the individuals who are by far at the greatest risk are those at the site of the actual attack. Medical personnel who come into contact with these hazardous materials only through working with victims away from the attack site are at substantially less risk. Therefore, by taking simple precautions, medical personnel can readily provide care for victims with less risk to themselves. In fact, the basic elements of decontamination and triage for chemical weapon victims are the same as for hazardous materials victims - hospitals therefore should check if they have an on-site "Haz-Mat" team at their facility.
Scenario 1 - Following a terrorist attack, victims quickly arrive at local hospitals without any warning of the nature of the attack or indeed that an attack has occurred. Under these circumstances, responding hospital facilities and staff (particularly ER) can become contaminated before they realize the nature of the emergency (a backup ER might be required in this circumstance). Therefore, ER staff should be prepared to quickly:
- Activate the full decontamination plan as soon as a chemical attack is suspected. Even if an ER facility becomes a contaminated "Warm Zone," emergency decontamination of patients and ER equipment and patient flow control and security plans remain essential.
- Recognize the characteristic signs and symptoms of a chemical attack (pin-point pupils and excessive salivation for nerve agents; and skin reddening and eye irritation, and eventually skin blistering for blister agents).
- Be prepared to protect facility staff with at least a minimal face respirator and gloves (even simple face-masks designed to protect against pesticide spray and vapor exposure would provide some protection). Respirator protection is most critical, followed by skin protection with butyl rubber gloves, rubber boots, and non-porous protective outer garments such as Tyvek (see "Personnel Protective Equipment" below).
- Be prepared to quickly decontaminate victims by removing all clothing (plastic trash bags can be used for temporary disposal) and providing a warm shower with soap and shampoo. Lacking warm showers, a thorough sponge-bath with lots of warm soapy water will provide significant decontamination. Staff should be assured that decontamination itself is treatment.
- Have on-hand standard treatments for chemical agent poisoning, including atropine and 2- PAM to treat patients and hospital personnel, if required.
- Be prepared to replace or decontaminate potentially contaminated hospital equipment, including beds, gurneys, furniture, etc, with a warm soapy water wash-down.
Scenario 2 - At some point hospital staff will become aware that victims of a terrorist attack have arrived or will arrive at their facility. Simple decontamination procedures on victims prior to entrance to a hospital facility should be used to protect the facility and staff from contamination. Ideally, decontamination takes place outside the primary medical facility including the ER, to allow hospital staff to function without the need for special protective gear or procedures. Additionally, patient privacy and modesty is a major concern. Many hospitals will not have suitable dedicated resources, but adequate privacy can be provided with temporary measures such as tarps, plastic sheeting and similar materials hung from buildings or simple support poles, or tents. An adequate security plan (discussed below) will also be required after being alerted to a terrorist attack. Thus, in a recognized terrorist attack, a medical facility should be prepared to:
- Use all the recommendations on protective gear, recognize the characteristic signs and symptoms of poisoning, and have on hand the appropriate treatments described above under scenario 1.
- Provide basic decontamination with removal of all clothing followed by a 5-minute warm shower with soap and shampoo, and a warm rinse. Permanent shower facilities are best, but temporary "camping style" portable showers set up outside would work well too.
- Implement a patient-flow and security plan to direct patients after thorough decontamination to the "Cold Zone" portion of the hospital, provide temporary dress in paper scrub outfits or similar clothing, and provide medical examination and direction to the most appropriate treatment location within the hospital.
- Be on the alert for patients with immediate or delayed signs and symptoms of toxicity, who should be directed through the decontamination line ahead of patients estimated to be less likely to become ill (see triage definitions below). Moreover, staff should be prepared to administer antidotes, such as atropine or 2-PAM, in the event of patients who succumb before decontamination is completed.
- Be prepared for non-ambulatory patients who will require assistance from hospital personnel equipped with at least minimal protection (face respirator and gloves), and disposable or easily decontaminated stretchers such as fiberglass stretchers designed for ambulances.
- Have security in place to keep patients from unintentionally recontaminating themselves. Once patients leave the decontamination facility, they should not be allowed to re-enter.
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