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<p><strong>You Are Here:</strong> <span class="crumb_link"><a href="/" class="crumb_link">AHRQ Archive Home</a> > <a href="/prep/" class="crumb_link">Public Health Preparedness Archive</a> > <a href="." class="crumb_link">Development of Models for Emergency Preparedness</a> > Chapter 2 (continued)</span></p>
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<tr>
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<td height="30px"><span class="title"><a name="h1" id="h1"></a>Development of Models for Emergency Preparedness </span></td>
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<tr>
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<td><div id="centerContent"><p><strong>Public Health Emergency Preparedness</strong></p> <div class="headnote">
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<p>This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.</p>
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<!-- <p>Now this resource is supported by the <a href="http://emergency.cdc.gov/">Centers for Disease Control and Prevention</a> (CDC).</p> -->
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<p>This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: <a href="https://info.ahrq.gov/">https://info.ahrq.gov</a>. Let us know the nature of the problem, the Web address of what you want, and your contact information. </p>
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<p>Please go to <a href="https://www.ahrq.gov/">www.ahrq.gov</a> for current information.</p></div>
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<h3>PPE Classifications</h3>
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<p>PPE for hazardous materials response are traditionally classified as Level A (highest), B, C, and D (lowest).<2E> While <strong>Level A</strong> precautions provide the maximum protection available, the incorporation of Level A use in incident response by hospital and EMS staff is not conducive to sustained medical operations; requires the highest level of ongoing training, suit acclimation, and medical monitoring; and provides the shortest length of time in a protective garment.<2E>Additionally, Level A protection for health-care workers may exceed the protection level necessary to accomplish the health-care facility mission. The complete encapsulation condition of Level A diminishes the health care
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worker's movement, ability to access patients, and ability to render care.</p>
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<p><strong>Level B</strong> protections offer less vapor protection than Level A, but still have similar training, medical monitoring, and sustainability issues. Some facilities have opted to provide Level B protection to their decontamination staff, usually on a supplied air line to extend the length of time possible in the suit.<2E>Level B ensembles generally restrict motor skills less than Level A, yet the addition of an air line hose may limit the health care professional's range of motion and create a potential trip hazard.</p>
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<p><strong>Level C</strong> PPE is defined as a liquid splash-resistant suit with the same level of skin protection as Level B, along with a full-faced positive or negative pressure respirator (a filter-type mask) rather than an SCBA or air line, used when the concentration(s) and type(s) of airborne substances(s) are known and the criteria for using air-purifying respirators are met (National Fire Protection Agency 2001b). Level C is increasingly supported as the ensemble of choice for health-care professionals
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engaged in warm zone care of potentially contaminated patients.<2E></p>
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<p><strong>Level D</strong> is equivalent to everyday uniforms worn by health-care professionals and provides no additional protection against an infectious pathogen or a contaminant.<2E>Level D PPE consists of a work uniform affording minimal protection used for nuisance contamination only (<a href="devmodap2a.htm#osha91a">U.S. Department of Labor, OSHA, 1991a</a>). Level D PPE is, by definition, acceptable in a cold zone environment.</p>
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<p>Military-specific PPE levels, such as mission-oriented protective postures (MOPP) gear, are not generally discussed in this document, as battlefield conditions should rate different standards and guidelines than those applicable in a civilian setting.</p>
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<p>Elements for consideration include:</p>
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<ul>
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<li>The contaminant or infectious agent personnel may be exposed to during patient care and scene operations.</li>
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<li>The level or amount of contamination or method of transmission.</li>
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<li>The minimal ensemble of PPE that will protect personnel against the agent.</li>
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<li>The training necessary to allow personnel to safely choose, don, doff, and operate in that level of PPE.</li>
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<li>The requirements of safe operation in that PPE, including medical screening programs, fit testing, the ability to have facial hair, glasses, or changes in size or shape of personnel between fit testing; safety monitoring and rehabilitation during operation in the PPE; availability of enough PPE to sustain safe operations, the ability to maintain enough personnel competent and eligible to operate in that PPE, and the ability to maintain enough PPE in safe working order for a mass casualty situation.</li>
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</ul>
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<p>The OSHA 29 CFR standards of required PPE in effect at the time of this writing refer to donning the highest level of PPE if workers are entering a contaminated zone with an unknown level of contamination or an unknown agent.<2E>This is a sound principle meant for protection of workers primarily in an industrial setting. Field or hospital based health-care professionals would find maintaining the training, medical screening program, equipment, and operational skills set for Level A prohibitive. Much discussion and some research has taken place, including by OSHA, to determine the safest, most reasonable, and most achievable level of PPE guideline specifically for health-care professionals or first responders. In 2005, OSHA published first receiver standards, with first responder standards for hot zone entry remaining
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aligned with 29 CFR industrial standards.</p>
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<table border="1" cellspacing="0" cellpadding="8" width="90%">
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<tr valign="top">
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<td><p><strong>OSHA 29 CFR 1910.120 excerpt:</strong> </p>
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<p>Based on the results of the preliminary site evaluation, an ensemble of PPE shall be selected and used during initial site entry, which will provide protection to a level of exposure below permissible exposure limits and published exposure levels for known or suspected hazardous substances and health hazards and which will provide protection against other known and suspected hazards identified during the preliminary
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site evaluation.<2E>If there is no permissible exposure limit or published exposure level, the employer
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may use other published studies and information as a guide to appropriate PPE (<a href="devmodap2a.htm#osha91b">U.S. Department of Labor, OSHA, 1991b</a>).</p>
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</td></tr></table>
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<p>According to the OSHA HAZ-WOPER standard (specified by 1910.120(a)(1)(i-v), these standards apply to employees who are exposed or potentially exposed to hazardous substances, including "emergency response operation for releases of, or substantial threats of release of, hazardous substances, regardless
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of the location of the hazard."</p>
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<p>HAZ-WOPER requires that hospital workers be trained to perform their anticipated job duties without endangering themselves or others. To determine the level and type of training that workers need, the community's hazards must be considered, as well as the capabilities personnel need to respond to those hazards. A determination should be made based on worst-case scenarios.<2E> </p>
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<p>If personnel are expected to provide limited decon services in order to attend to medical problems, they must be trained to the first responder operations level, with emphasis on the use of PPE and decon procedures.<2E>This level of emergency response training is described in 29 CFR 1910.120(q)(6)(ii), OSHA First Responder Guidelines. Hospitals may develop in-house training or they may send personnel to a standard first responder operations level course, and then provide additional training in decon and PPE, as needed. HAZWOPER requires the employer to certify that workers have the training and competencies listed in (q)(6)(ii).<2E> The standard also requires annual refresher training or demonstration of competency, as described in (q)(8).</p>
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<p>"The approach in selecting PPE must encompass an "ensemble" of clothing and equipment items which are easily integrated to provide both an appropriate level of protection and still allow one to carry out activities involving chemicals.<2E> In many cases, simple protective clothing by itself may be sufficient to prevent chemical exposure, such as wearing gloves in combination with a splash apron and face shield or safety goggles.<2E> The following is a list of components that may form the chemical protective ensemble:</p>
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<ul>
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<li>Protective clothing (suit, coveralls, hoods, gloves, boots).</li>
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<li>Respiratory equipment (SCBA, combination SCBA/SAR, Powered Air Purifying Respirator (PAPR) Air Purifying Respirator (APR).</li>
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<li>Cooling system (ice vest, air circulation, water circulation).</li>
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<li>Communications device.</li>
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<li>Head protection.</li>
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<li>Eye protection.</li>
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<li>Ear protection.</li>
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<li>Inner garment.</li>
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<li>Out protection (overgloves, overboots, flashcover).</li>
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</ul>
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<p>Factors that affect the selection of ensemble components include:</p>
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<ul>
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<li>How each item accommodates the integration of other ensemble components. Some ensemble components may be incompatible because of how they are worn (e.g., some SCBAs may not fit within a particular suit).</li>
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<li>The ease of interfacing ensemble components without sacrificing required performance (e.g., a poorly fitting overglove that reduces wearer dexterity).</li>
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<li>Limiting the number of equipment items to reduce donning time (e.g., some communications devices are built into SCBAs, which as a unit are NIOSH certified).</li>
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</ul>
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<a id="Tab3" name="Tab3"></a><a id="Fig1" name="Fig1"></a>
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<p>Select <a href="devmodtab3.htm">Table 3</a> for a comparison of PPE levels by OSHA, NFPA, ODP, and NIOSH. Select <a href="devmod2fig1.htm">Figure 2.1</a> (113 KB) for DoD Personal Protective Equipment Levels.</p>
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<p>Since health care professionals in their traditional settings of either a health care facility or EMS in the field, generally lack detection and testing equipment to rapidly screen and confirm the presence of specific agents, health care professionals would likely determine the presence of contaminant or infectious
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agents by the presenting symptomatology of their patients or by physiologic sensory indicators.<2E> </p>
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<p>While suggestions and policies exist to protect health care professionals and health care facilities by separating potentially contaminated or infected patients, either on the scene away from the health care professionals or outside the health care facilities in a lock down setting, the reality of daily scene operations limits the effectiveness of these strategies. Contamination may not be readily apparent by symptomatology; health care professionals can not easily apply force or erect barriers to separate themselves from potentially contaminated patients; and self-referred patients can be within the health care facility before health care professionals realize the potential for contamination.<2E>To effectively reduce the risk of contamination and to insure that a system can accommodate such an event, a procedure for early recognition of potential contamination requires:</p>
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<ul>
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<li>Relevant sustained training for health care professionals.</li>
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<li>Early access to appropriate PPE.</li>
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<li>Early access to effective detection equipment.</li>
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<li>The ability to isolate areas of contamination.</li>
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<li>The ability to provide swift decontamination of patients, personnel, equipment and facilities.</li>
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<li>Access to and the ability to rapidly administer pertinent antidotes.</li>
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<li>Realistic answers to a force continuum with law enforcement professionals, involvement for patient containment.</li>
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<li>A public education and crisis communications program empowering the public to take appropriate action to avoid and reduce contamination.</li>
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</ul>
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<p>Many gaps currently are being addressed by Federal, State, and local agencies to help the Nation effectively respond to a mass casualty event involving patient contamination or infection. Health care facilities and health care<72> professionals do not have the luxury of waiting for a final, overarching consensus of best practices, and have had to make choices as to how best to prepare for such an event despite the many unanswered planning and preparedness questions.<2E> </p>
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<p>The lack of overarching, clear, evidence-based guidelines has resulted in a wide spectrum of planning and preparedness choices by health care professionals who do not have the option of not responding to an event.<2E>As further evidence-based guidelines and regulations emerge, there should be a period for health
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care professionals and health care facilities to conform to the newest standards, as the time and financial impact of additional safety programs and supplies will be onerous.</p>
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<p>A pattern of PPE ensemble choices is emerging as health care professionals and health care facilities examine the research and regulations related to contamination and infectious event response.<2E>The ability to diminish the in-depth HAZMAT physical and fit testing programs traditionally required with higher levels of PPE (level A or B) is a trend based on practicality and resources.<2E> </p>
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<p>Theory and some tentative research (<a href="devmodap2a.htm#sbccom">SBCCOM, etc.</a>) have suggested that most victims of a chemical or radiological event will rapidly self refer to health care facilities, vastly reducing the ability of public safety professionals to mobilize a rapid, effective, mass casualty decontamination and detection effort to treat patients and protect health care facilities from contamination.<2E>Theory also supposes that self-referred patients will generally be healthier than patients at the scene unable to self evacuate.<2E> Self-referred patients will, therefore, have less contamination, reducing the risk of secondary contamination in health care facilities and to health care professionals. This theory would suggest the ability to use lower levels of PPE for health care professional protection, such as level C, in providing care to these patients.<2E></p>
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<p> Traditional level C protection consists of:</p>
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<ul>
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<li>Full-face or half-mask air purifying respirators (NIOSH approved).</li>
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<li>Hooded chemical-resistant clothing (overalls, two-piece chemical-splash suit, disposable chemical-resistant overalls).</li>
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<li>Coveralls (as needed).</li>
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<li>Gloves, outer, chemical-resistant.</li>
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<li>Gloves, inner, chemical-resistant.</li>
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<li>Boots, outer, chemical-resistant, steel toe and shank (as needed).</li>
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<li>Boot-covers,
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outer, chemical-resistant (disposable) (as needed).</li>
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<li>Hardhat (as needed).</li>
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<li>Escape mask (as needed).</li>
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<li>Face shield (as needed); (U.S. Department of Labor, OSHA, 1991b).</li>
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</ul>
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<p>Level C PPE ensembles provide protection from liquids and are designed to protect personnel at chemical/biological terrorism incidents in which a risk analysis indicates victims are ambulatory and symptomatic and/or there is a potential for direct liquid droplet or aerosol contact (<a href="devmodap2a.htm#nfpa01a">National Fire Protection Agency, 2001a</a>).</p>
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<p>A current best practice to address the issues of sustained operations and fit testing is use of hooded powered air purifying respirators, a chemical resistant laminate suit such as Tyvek F or CPF 3 fabric, chemical resistant boots, and a set of surgical gloves under a set of chemical resistant gloves.<2E>The hooded Powered Air-Purifying Respirator (PAPR) eliminates the fit testing required of a fitted face mask used in the APR and affords a higher level of protection than the APR. A PAPR is more comfortable and easier to use for a sustained operation.</p>
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<p>In the absence of detection equipment to determine the exact contaminant present, In the absence of detection equipment to determine the exact contaminant present, a combination filter may serve as the best initial choice, such as a combined organic vapor (OV), acid gas (AG), and HEPA filter, or one that is
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designed as a "WMD" cartridge. Health care facilities and health care professionals must be aware that this cartridge, while multi-purpose, does not protect against all industrial hazards that may be present in the community.<2E> </p>
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<p>Regulatory agencies, including JCAHO, require a regular hazards vulnerability analysis by health care facilities that integrate with the community required hazards vulnerability assessment, to determine if additional or alternative levels of PPE and/or different ensemble versions, such as additional filter cartridges, are necessary.<2E>Health care facilities must be able to demonstrate an integrated community hazards vulnerability assessment that results in pertinent plans and procedures, training, and equipment and supplies to include PPE.</p>
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<p>What is appropriate PPE for EMS professionals is not clear, as EMS professionals straddle the line between facility-based health care professionals and HAZMAT teams. Many think EMS personnel should not be executing hot zone entry, extraction, or decontamination, and as such should require a lower level of PPE, such as Level C, since they would remain in the warm or cold zone of a contaminated scene. Newer response standards advocate EMS hot zone entry in appropriate PPE for rapid victim triage, time sensitive antidote administration and decontamination triage and decision with ALS intervention, this would likely require SCBA and on scene time dependent, minimally bunker gear for the first hour of rescue or the OSHA industrial standard of Level B or A. With on scene agent detection confirmation, EMS hot zone PPE can be ppropriately adjusted. </p>
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<p>NFPA 1994 standard (<a href="devmodap2a.htm#nfpa01b">National Fire Protection Agency, 2001b</a>) provides the following requirement for the following environments:</p>
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<p><strong>Level A</strong></p>
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<ul><li>Identity or concentration of the vapor or liquid is unknown.</li>
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<li>If liquid contact is expected and no direct skin contact can be permitted, as exposure of personnel at these levels will result in the substantial possibility of immediate death or immediate serious injury
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or illness, or the ability to escape with be severely impaired.</li></ul>
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<p><strong>Level B</strong></p>
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<ul><li>Victims are not ambulatory and are symptomatic.</li>
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<li>Potential for direct liquid droplet or aerosol contact is probable.</li></ul>
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<p><strong>Level C</strong></p>
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<ul><li>Victims are ambulatory and symptomatic.</li>
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<li>Potential for direct liquid droplet or aerosol is possible.</li></ul>
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<p>Current EMT curriculum supports the process of scene safety as a paramount consideration and initial assessment by EMS professionals.<2E>The possibility of contamination should result in EMS professionals maintaining distance from the scene, while appropriate HAZMAT personnel are deployed to identify the agent and level.<2E>The reality is that it may not be readily apparent to first responders that contamination
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or infection is present, and they will likely be engaged in patient care before such a determination is made.<2E> </p>
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<p>A gap exists in the readily available, lightweight detection equipment that EMS professionals can wear or attach to a response vehicle that will warn them of contamination, other than newer efforts in radiological detection. Likewise, limited small, lightweight, field applicable PPE, such as wearable filters or barrier cream, is available or approved for civilian use to decrease or eliminate the risk of secondary contamination and infection.<2E>It is widely recognized and accepted that initially responding units to an event where contamination or infection risks have not been identified may become casualties themselves.</p>
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<a id="Tab4" name="Tab4"></a>
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<p>Select <a href="devmodtab4.htm">Table 4</a> for a list of Best Practices at time of publication.</p> <a id="Guidelines" name="Guidelines"></a>
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<h3>Guidelines for Building the Model</h3>
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<p>The following areas specify items that should be explored when developing a best practices methodology for dealing with biological terrorism preparedness planning:</p>
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<h4>Adaptability—Is the best practice suitable for use in any region?</h4>
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<p>PPE choices should be guided by the results of a facility-specific hazards vulnerability assessment that is integrated with a regional threat analysis. If one health care facility is deemed at risk from casualties contaminated from a local industrial site accident, other local facilities may also be at risk and, as such, should consider similar levels of protection.<2E>Regional models have been proposed in which certain facilities become the designated "contaminated" or "infectious" receiving facility, and greater funding and preparedness efforts are concentrated there.<2E> </p>
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<p>The danger is that this does not address the highly likely circumstance where patients self-refer to
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the closest or known facility. It would be difficult to ensure that all patients self-refer to the designated receiving facility.<2E>Even with a robust public education plan that is designed to inform the public about where to report for appropriate treatment, other health care facilities will most likely be receiving self-referred contaminated or infectious patients.<2E> </p>
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<p>While health care facilities are viewed as private industry, whether they are for-profit or non-profit, a mass casualty event or a WMD event is a community problem (personal communication with Zachary Goldfarb, BS, CHSP, CEM, EMT-P, Consultant, Incident Management Solutions, Inc., December 2003).<2E> As such, best practices should be reflected on a community and regional planning level. </p>
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<p>Additional regional environmental concerns, such as heat or cold stressors, will affect length of time and type of appropriate PPE.<2E>In hot environments, rotations of health care providers must be provided so that all have appropriate rehabilitation time to avoid heat related injuries. In cold environments, health care providers need appropriate layers of clothing to protect against cold related injuries without compromising their protection levels.</p>
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<h4>Throughput—How many victims of a WMD attack will the best practice aid?</h4>
|
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|
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<p>The ability to sustain the par levels of available PPE to care for infectious or contaminated patients will affect the number of victims who can be safely treated. Standard on-hand numbers would not be enough for the ensemble changes necessary to care for a large number of infectious patients requiring quarantine or isolation. For a chemical event, having enough trained staff to rotate in and out of higher PPE levels, such as Levels B and C, would be key in providing sustained medical services for contaminated patients prior to definitive decontamination. The number of health care providers and the amount and availability of protective equipment at their disposal would determine how many victims could be treated quickly and efficiently.</p>
|
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<h4>Cost—How much will it cost regions to implement the best practice?</h4>
|
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|
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<p>Depending upon the extent of the program adopted by particular regions, the cost for purchasing, maintaining, and storing PPE can be significant. Costs also will be incurred for initial and ongoing training for health care providers designated to use higher levels of PPE. Also, cost consideration must be given to how many staff members a health care facility will need to be suited for what function at what level. Will standards allow the suit to be re-used after decontamination, or will the facility need to have additional stock? Some Federal funding exists to support the initial purchase of PPE. While current funding levels from such sources as ODP, CDC and Health Resources and Services Administration (HRSA), are not enough to cover all purchasing costs to achieve necessary par levels, accessing these sources through
|
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State and regional planning committees can help mitigate the initial cost for some organizations. Funding has not fully addressed equipment maintenance and replacement, sustained training, staffing and backfill
|
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(personal communication with Fran Santagata, MS, Domestic Preparedness Officer, ODP, DHS, February 26, 2004).</p>
|
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<p>An additional item for cost and planning consideration is the provision of PPE for the general public, especially during times of elevated threat, or at high threat locations or events.<2E> As with the Israeli model (<a href="devmodap2a.htm#marcus">Marcus 2002</a>), the general public becomes an active participant in mitigating the negative health effects of a WMD event. Public education addresses such public health strategies as sheltering in place, public facility decontamination and appropriate use of PPE for all ages.<2E><> </p>
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<a id="Tab5" name="Tab5"></a>
|
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<p>Select <a href="devmodtab5.htm">Table 5</a> for a sample cost chart for PPE equipment purchase.</p>
|
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<h4>Operational Impact—What are the operational considerations of implementing best practice?</h4>
|
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|
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<p>The operational impact for using Level B or C PPE may be significant.<2E>Since specialized training is needed to participate and function properly in a WMD incident, the initial and sustained training burden is significant.<2E>Performing medical care and screening in elevated levels of PPE is difficult, and prolonged activity in these PPE ensembles is not sustainable.<2E>During an incident, providers selected to operate in elevated PPE levels will be excused from their regular functions to mitigate the incident, which will impact the personnel requirements for other standard operations. Using Level C or B protective ensembles will restrict the health care provider's movement, range, and function in the decontamination and patient treatment areas. </p>
|
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|
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<p>PPE must be used in the framework of an effective all-hazards emergency response plan, with logistics, maintenance, re-supply, training, fit testing, medical monitoring, safety, and exercise components. An effective all-hazards emergency response plan would best be developed with a dedicated, experienced emergency planner with the ability to provide dedicated expertise to all the planning and maintenance components that will allow a sustained, safe, effective PPE choice and capability.</p>
|
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|
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<h4>Training—What level of training does this best practice require?</h4>
|
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|
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<p>OSHA has current guidelines for health care professionals related to PPE and expected function.<2E><> Awareness level is recommended for all employees, and a competency based Operations level of 8-16 hours is recommended for all employees engaged in decontamination processes or patient care utilizing PPE. ODP SHSAS recommends several levels of training, such as performance defensive and performance offensive, for health care personnel engaged in the treatment of WMD casualties.<2E> </p>
|
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|
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<p>Training should be ongoing and competency based to be compliant with JCAHO standards. The training provided to health care providers needs to be comprehensive in addressing the indicators, application, limitations, and proper use of the protective equipment.<2E>Training should incorporate both didactic and
|
||
functional components, which are compliant with regulatory, equipment manufacturer and current safety recommendations.<2E>Additionally, repetitive and ongoing training is crucial to maximizing the health care provider's safety and proficiency in Level B and C protection.</p>
|
||
|
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<h4>Resources—Does the practice build on existing practices/infrastructure? Are there available resources to implement the practices?</h4>
|
||
|
||
<p>In a radiological, biological or infectious agent incident, current infection control standards provide the appropriate response framework. Gaps in this model may exist in addressing the number of patients that can be expected in a large scale incident, with concurrent staffing and supply deficits, and the potential emergency of infectious diseases that can defeat commonly available standard precaution PPE, such as a fitted, N-95 respirator. </p>
|
||
|
||
<p>Current health care practices are already in place reflecting daily use of standard precautions; the deficits are slowly being addressed by various Federal funding sources and plans, such as CDC, HRSA, ODP and the National Disaster Medical System (NDMS). Health care facilities and communities should plan to be self sufficient for up to 72 hours before significant Federal supplies and personnel are efficiently functioning (personal communication with Fran Santagata MS, February 26, 2004).</p>
|
||
|
||
<p>In a chemical event, the fire-based hazardous material response standard is the most applicable.<2E>The gap exists in number of personnel trained and equipped, and the lack of definition in the medical role, both EMS and health care facility based.<2E> </p>
|
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|
||
<p>The fact is that contaminated casualties will need care, both at health care facilities and at the scene, and health care professionals are best qualified to render that care.<2E>Accordingly, health care professionals must be able to access the contaminated patients as soon as safely possible to institute life saving measures.<2E>Resources for expanding the health care professional's capacity to function in PPE are becoming slowly available via Federal funding sources, such as those mentioned previously. However, the main fiscal burden of health care preparedness has fallen on the already beleaguered medical system. As such, preparedness efforts have been slow, incomplete and inconsistent.</p>
|
||
|
||
<p>Training sources include ODP funded courses found in their training catalog. The courses are subsidized, and can be accessed through each State's training officer. Metropolitan Medical Response System (MMRS) cities have received some training, and are targeted for additional support, primarily in the exercise arena. The ODP Homeland Security Exercise and Evaluation Program (HSEEP) is also providing exercise support to States and encourages a medical component. The Federal Emergency Management Agency (FEMA) Emergency Management Institute (EMI) is embarking on health care leadership courses at the Noble Training Center in Anniston, Alabama; the Radiation Emergency Assistance Center/Training Site (REAC/TS), out of Oak Ridge Institute for Science and Education has radiological training opportunities, and a plethora of other courses exist in the United States. <20></p>
|
||
|
||
<p>Generally, a person interested in this training and education must be aggressive about pursuing available time and traveling to the out-of-State course location.<2E>Continuing education units are often provided, and funding subsidies may be available. Overall, there is no centralized, large-scale, funded effort to provide up-to-date clinical and planning information to health care professionals, on a larger
|
||
scale than the past domestic preparedness series. Currently, health care professionals must seek resources, such as local infection control and HAZMAT experts, university-based classes, out-of-State courses, Web-based training classes from a variety of sources, or consultants/contractors.<2E> </p>
|
||
|
||
<p>There is a continued need to embed appropriate all-hazards education in health care professional education and training programs, and the provision of an accredited, expert endorsed, cadre of clinical and didactic education in a variety of formats (<a href="devmodap2a.htm#acep">American College of Emergency Physicians, Terrorism Response Task Force 2002</a>).</p>
|
||
|
||
<h4>Morbidity and Mortality—What impact will this practice have on saving lives?</h4>
|
||
|
||
<p>Providing victims of a WMD event rapid access to appropriately protected health care professionals who can institute early life saving measures will positively impact morbidity and mortality.<2E>Health care professionals in appropriate PPE, in conjunction with proactive public education, can facilitate access to antidotes, educated triage personnel, and basic and advanced life support capabilities.<2E>PPE will reduce the danger of infection or contamination to critical health care services and infrastructure, providing the sustained capability to impact morbidity and mortality.<2E>This can only occur with an effective all-hazards response plan that is integrated on a facility, local community and regional level, with State and Federal support.<2E>PPE is one component of an effective plan, albeit a critical piece. PPE will prevent transmission of infection and eliminate secondary contamination.</p>
|
||
|
||
<p>Following the National Medical Response Team (NMRT) model (<a href="devmodap2a.htm#staiti">Staiti, Katz, and Hoadley 2003</a>; personal communication with Robert Knouss, April 2002), if health care professionals can function effectively in PPE with appropriate supplies and can have rapid access to WMD victims, lives can be saved. PPE must work in conjunction with emerging detection and decontamination technologies, such as hand held devices on site sensors and on-the-spot decontamination solutions (personal communication with Duane Caneva, CDR, MC, U.S. Naval Reserve, Medical Corps, December 8, 2003).</p>
|
||
|
||
<h4>Evidence-based Practice versus Theory—Is there a body of professional research supporting this practice or is it theoretical?</h4>
|
||
|
||
<p>While unclassified research addresses various WMD agents and effective PPE, there is a lack of definitive scientific research specific to choosing PPE for health care professionals engaged in scene or health care facility triage, care and decontamination of WMD victims.<2E>Anecdotal evidence is derived from the mélange of available studies, in combination with available regulations and guidelines. Best demonstrated practice favors the stringent adherence to standard precautions in the face of an infectious agent, and a minimum of Level C components, defined as a hooded, powered air purifying respirator with appropriate filters, laminate chemical resistant gloves, boots and suits, all deployed within the parameters of an effective, regionally integrated, all-hazards emergency response plan.</p>
|
||
|
||
<h4>Regulatory Compliance—Does the practice comply with existing regulations or does it require a regulatory change?</h4>
|
||
|
||
<p>While current OSHA industrial-based hazardous materials response guidelines indicate Level A PPE for response to an unknown agent of unknown concentration, the newly developed OSHA guidelines for health care professional<61>PPE are pending, as such, there is no current regulation specifically mandating health care professional PPE in a WMD event.<2E>OSHA guidelines suggest Level C, as a minimum, with the possibility of higher levels based on an accurate hazards vulnerability assessment, while JCAHO necessitates OSHA compliance, and compliance with infection control standards of care (<a href="devmodap2a.htm#osha96">U.S. Department of Labor, OSHA, 1996</a>).</p>
|
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|
||
<p>Federal, State, local, and agencies have regulations that mandate the use of specific protection levels for certain health care facilities such as laboratories with virulent agents, but these depend on the nature and work of the facility, exposure probability, and other factors related to the risk of infection. Essentially, health care facilities may implement a system that mandates the use of a certain PPE level after conducting a hazards vulnerability analysis to justify that decision and when firmer guidelines and standards of care exist for PPE selection regarding infection control. </p>
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<a id="Bottom" name="Bottom"></a>
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<h3>The Bottom Line—Guidelines for Selecting PPE<50> </h3>
|
||
<p>Facilities and agencies must:</p>
|
||
|
||
<ul>
|
||
<li>Conduct a hazards vulnerability analysis, integrated with the community, that details relative threats, including industrial and terrorist, pertinent credible threat scenarios with a casualty impact..</li>
|
||
<li>Based on the hazards vulnerability analysis, decide which contaminants and infectious pathogens for which they are most credibly at risk.</li>
|
||
<li>Based on the credible threat data, evaluate their resources and existing plans.</li>
|
||
<li>Based on their resources and plans evaluation, identify the areas with opportunities for improvement.</li>
|
||
<li>Based on contaminant and pathogen credible threats, such as nearest industrial facilities, proximity to areas with documented infectious disease outbreaks, borders, ports, rail or highway shipping routes, etc, choose the best practice PPE.</li>
|
||
<li>Choose a baseline level of PPE for an unknown contaminant that is operationally feasible to obtain and sustain, such as hooded, powered, air purifying respirators with chemical resistant laminate suits such as Tyvek F or CPF 3 fabric, chemical resistant gloves and boots and combination organic vapor/acid gas/HEPA filters, with access to additional filters that are appropriate for other identified industrial hazards.</li>
|
||
<li>Understand that the baseline level of PPE for an infectious pathogen are standard and transmission based precautions, such as barrier gown, gloves, mask, eye protection and respirator are appropriate for infection control standards.</li>
|
||
<li>Be aware that higher levels of PPE may be necessary if the community hazards vulnerability analysis reveals a greater threat to that agency's or facility's response.</li>
|
||
<li>Provide awareness level training to <em>all</em> staff, with the required competencies in recognizing a Hazardous Materials situation, initiating immediate safety, isolation, and notification activities, and being aware of their role in an emergency.</li>
|
||
<li>Provide operations level/ functional training to staff engaged in care of contaminated or infectious patients, decontamination or triage procedures, and/or mass casualty response, including staffing secondary treatment facilities.</li>
|
||
<li>Use competency based training with a focus on staff safety. Staff should be able to demonstrate safe operations in all PPE, and perform expected tasks, such as mass casualty triage and decontamination.</li>
|
||
<li>Conduct regular and sustained training that allows for staff turnover and includes regularly scheduled hands-on exercises to promote skill competencies.</li>
|
||
<li>Involve staff expected to function in PPE, such as a PAPR, in a medical screening and monitoring program, and monitor staff safety during incidents where PPE is utilized, with plans for rehabilitation and rotation of personnel that is activity and weather dependent.</li>
|
||
</ul>
|
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|
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<p class="size2"><a href="devmodel1.htm#Contents">Return to Contents</a><br />
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<a href="devmodel3.htm">Proceed to Next Section</a></p>
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