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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 3 (continued)</span></p>
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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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<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 It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work.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>Decontamination Shelter</h3>
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<p>Health care facilities and emergency medical service agencies may choose to integrate resources with public safety organizations by making available specially designed trailers to decontaminate multiple patients simultaneously (e.g., New York City and Salt Lake City Metropolitan Medical Response Systems units). These units can provide protection from the environment, as well as privacy from onlookers, in addition to decontaminating multiple patients at a time. However, these trailers are expensive and cannot always be placed in desirable locations within the parameters of a health care facility's or a scene's needs.</p>
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<p>Easily erected tents are used as decontamination shelters. They provide some of the benefits of trailers and are less expensive, but generally take some time to assemble and require planning and coordination to handle large numbers of patients at a time. Inflatable shelters may be affected by environmental conditions such as snow, wind, and decreased temperatures, as well as come with a logistical burden of using powered air units or air tanks to inflate. Some facilities initially designed portable mass casualty decontamination capabilities with inflatable tents, only to switch to "exoskeleton" framed, lightweight pop-up tents when those became commercially available (58). The exoskeleton tents have their own trip hazards, but are generally lightweight and rapidly deployable. </p>
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<p>Tents come in a variety of sizes to accommodate different amounts of throughput. Some tents have different decontamination "tracks" or corridors to cover both ambulatory and non-ambulatory functions. Local communities will need a primary decontamination plan that the first personnel on the scene can rapidly implement, and a secondary plan to implement when additional personnel and equipment become available. The ultimate goal is rapid, definitive decontamination. </p>
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<p>While the portable units are often the cost effective answer to mass casualty decontamination, the ultimate best practice is an instantly operational, large capacity, fixed, warm water facility, such as that built at the Noble Training Center in Anniston, AL, and adapted at such facilities as George Washington University Medical Center in Washington DC, Vanderbilt University Medical Center in Nashville, TN, Good Samaritan Hospital in Islip, NY, Denver Health Medical Center in Denver, CO, and others, augmented by portable units for surge capacity and continuity of operations. </p>
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<p>While hospitals and other health care facilities are often viewed as private industry, a mass casualty WMD event is a community problem (personal communication with Zachary Goldfarb, BS, CEM, EMT-P, Deputy Chief, FDNY-EMS (Ret.), Consultant, Incident Management Solutions, Inc., December 2, 2003.) Protecting the critical medical services offered within a health care facility should be a primary goal within the community, region, and State. While some services can be relocated to secondary treatment facilities assembled in non-medical buildings such as gymnasiums, most medical equipment would be difficult to relocate, diminishing the level of care available. A primary goal of community emergency planning must be to minimize or eliminate the threat of contamination of health care facilities, thereby preserving the critical life-saving services.</p>
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<p>Critical to managing the decontamination of large numbers of patients is gaining control of the crowd. Repeatedly giving definitive instructions on what to do over loudspeakers in various languages and signage can be useful, along with having an adequate number of properly protected personnel directing the victims through the decontamination process. Providing verbal instructions may be all that is needed to care for the ambulatory populations, but non-ambulatory victims will require more assistance and equipment (e.g., back-boards). </p>
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<p>The military model of how to organize and manage such a decontamination effort primarily addresses how to handle young healthy soldiers already wearing protective clothing and respiratory protection. This model is not directly applicable to a heterogeneous, unprotected, and undisciplined population that has not had the benefit of a program to familiarize the public with their expected role in an event requiring decontamination. Ideally, what is needed is a program to educate the public about mass casualty decontamination before such an event occurs. </p>
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<p>The United States Public Health Service, now Department of Homeland Security (DHS) National Medical Response Teams: WMD (NMRT:WMD), has focused on building a methodology and capacity for civilian mass casualty decontamination and has achieved maximum, reported rates of ambulatory hourly decontamination of up to 1700 patients per hour. This capability is achieved with more personnel (36-50) and physical gear than any health care facility or agency is likely to have. Lessons learned from their response capabilities include frequent practice, immediate deployment of life-saving interventions pre-decontamination, not withholding life-saving medical stabilization during the decontamination process, and immediate access to WMD-specific antidotes.</p>
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<p> The United States Marine Corps (U.S.MC) Chemical Biological Incident Response Force (CBIRF) uses a similar rapid response methodology from which applicable lessons have been learned for the civilian community. In addition, CBIRF is exploring emerging technologies such as decontamination and protective solutions that will allow symptom mitigation and protection in the hot zone, geared toward eliminating the labor-intensive "roller system" (assembly line methodology using a track of rollers for smooth patient transfer and reduction of potential worker injuries) of victim decontamination.</p>
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<p>Health care organizational planning must also consider space limitations and geographic and demographic complications. Organizing a large decontamination corridor to handle inordinate numbers of patients is another vital concern. Research is needed to determine the optimal responder/patient ratio, how large an area is needed to decontaminate 50, 500, or 5,000 people, what level of medical training is required for the personnel performing decontamination, and how much medical care should be given in the warm zone as opposed to the cold zone or at the hospital. Delaying or improperly conducting decontamination increases the danger to the patient as well as the health care provider (personal communication with Steve Cantrill, MD, December 8, 2003). </p>
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<p>Estimating the number of potential casualties that must be decontaminated is a process that begins with an integrated hazards vulnerability analysis and assessment. The DHS Office of Domestic Preparedness State Homeland Security Assessment Strategy conducted by each U.S. State and territory in 2003 and early 2004 required local, regional, and State governments to identify credible threats along with their associated projections for mass casualties. Health care organizations and facilities should coordinate estimates for expected numbers of casualties with these data, in addition to reviewing baseline planning recommendations from such Federal funding sources as Health Resources and Services Administration, CDC, and Metropolitan Medical Response System contracts.</p>
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<p>In the absence of specific threat data, an initial planning effort of effectively decontaminating 100 patients is a reasonable default for the size of most communities (personal communication with John Sinclair, Deputy Chief (ret.) Chair, Emergency Medical Services Section, International Association of Fire Chiefs, February 20, 2004.). Often, if health care facilities that usually have the capability to decontaminate one or two patients are confronted with the need to prepare for staggering numbers such as 1,000 or 10,000, they feel overwhelmed, do not know where to start, and default to a plan of lock-down while waiting for the fire department. There are reasonable steps the health care facilities can take annually that comply with regulations, are fiscally responsible, and offer a spiral development of capabilities that are not overwhelming. </p>
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<p>Spiral development of mass casualty decontamination capabilities may start with sustained training of staff to recognize toxidromes that may require decontamination, and providing external, sheltered areas for patients to change clothing, thereby eliminating the greater percentage of contamination. Utilizing commercial, off the shelf products such as tarps, space heaters, curtains with tracks to provide rapidly deployable, environmentally protected, gender-segregated undress areas—with boxes of inexpensive Tyvek-style suits for redress and baggies to seal personal belongings—may increase crowd compliance. It may also reduce the immediate impact of contamination to the health care facility and provide an intermediary step to wet decontamination, with its inherent problems of potential hypothermia.</p>
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<p>Aside from the issues related to effective decontamination procedures, training of emergency department personnel must also be considered. There are few courses emergency department personnel may attend to improve their level of preparation for the decontamination of large numbers of people. Many rely on training with traditional fire department-based HAZMAT teams which, while an excellent resource, may not always address the differences in health care facility resources, regulations, or capabilities.</p>
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<h3>Disrobing</h3>
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<p>Decontamination by removing clothing and flushing or showering with water is the most effective method for definitive decontamination. Applying this to a rapidly evolving mass casualty event may be logistically difficult. Ideally, gender segregated, environmentally controlled disrobing areas would be rapidly provided while a warm water definitive decontamination capability is being deployed. A controversial school of thought persists that if people feel they are in danger due to potential contamination, they will willingly, publicly disrobe and submit to cold water "hasty" decontamination. Agencies subscribing to this theory are less likely to develop a definitive decontamination capability, since they believe that hasty, cold water decontamination is sufficient. </p>
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<p>In actual practice, there have been lawsuits resulting from forced public disrobing for hasty decontamination. Since cost effective methods exist to mitigate this, a best practice is to provide gender-segregated, sheltered, environmentally controlled areas to disrobe. This can be achieved in a rapidly deployable, inexpensive manner and serves the dual purpose of increasing crowd compliance and mitigating long-term psychological effects of loss of privacy. It is recommended that victims be encouraged to remove clothing at least down to their undergarments prior to showering. Issues of crowd control and compliance should be discussed with onsite security and local law enforcement personnel.</p>
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<p>Since onsite security forces are generally not available in large numbers and local law enforcement personnel are likely to be engaged at the incident scene at the time of an event requiring mass decontamination, the health care facility should promote crowd cooperation through an effective crisis communication plan. There should be a clear message that not participating in the decontamination process may impact a person's access to health care. Patients who are unwilling to disrobe or fully comply with the decontamination process should be separated from those who do comply to avoid causing a chokepoint in the decontamination process. </p>
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<p>In addition, the health care facility should promote directed patient self-decontamination. This will significantly decrease the required number of health care workers in the decontamination area with appropriate personal protective equipment. It is critical to have assigned health care staff monitoring the ambulatory decontamination area. If a patient's condition deteriorates, the progress of others may be impeded without health care provider intervention. </p>
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<h3>Belongings and Evidence Collection</h3>
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<p>Within the vicinity of the disrobing area, health care facilities need to ensure that a system is in place for the collection of personal belongings. For complete decontamination, personal items will need to be collected and either decontaminated or discarded. All items collected could be placed in a sealable bag and assigned a unique identifying number that corresponds with the triage tag or chosen patient tracking system. This system will ensure that the patient is either repatriated with the items relinquished, or notified that the item was discarded as a hazardous item or turned over to a law enforcement agency as evidence (<a href="devmodap3a.htm#english">English, 1999</a>). Belongings made with any type of animal hide, cotton, or other natural materials have a high potential for absorbing toxins and contaminants. These items may need to be identified as hazardous, discardable items and destroyed if they are unable to be decontaminated. Items collected as evidence will be processed by the law enforcement agency having jurisdiction. </p>
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<p>While health care facilities may insist on patients relinquishing their personal items, the reality is that victims may not be willing to part with sentimental or valuable items. A decision will need to be made addressing the level of force used to ensure compliance; however, there may be alternatives, such as allowing certain items, such as rings, through decontamination; allowing patients to bring a sealed bag of valuables through decontamination; or disallowing through decontamination those who are unwilling to part with belongings. Security officials will need to be on hand in appropriate personal protective equipment to assist in collecting items from patients unwilling to turn over those items to staff, or to facilitate crowd control and support the scripted procedures. </p>
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<p>Policies and procedures for the reimbursement or replacement of items discarded during decontamination should be included in a health care facility. For example, if a patient is unwilling to relinquish personal belongings, a health care facility might consider allowing the patient to self-decontaminate non-porous items during their shower and/or to double-bag the items and allow them to carry them through the decontamination process. The goal of separating the patient from their belongings is strictly medical: to remove contamination. Removing contaminated items can be accomplished by sealing them to avoid secondary contamination of the health care personnel or health care facility. Decisions about how to handle contaminated items can be made with law enforcement and HAZMAT agencies; for the detection of actual contamination, forensic evidence collection and remediation recommendations are needed.</p>
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<h3>Water Pressure/Temperature</h3>
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<p>It is recommended that high volume, low pressure water be delivered at a minimum of 60 pounds per square inch (psi) to ensure the showering process physically removes the agent. (A standard household shower pressure is typically between 60 and 90 psi.) Shower time will be incident-specific, based on the suspected amount of exposure and the number of patients requiring decontamination. OSHA standards for a chemical accident suggest a high volume-low pressure wash for contaminated patients. Incapacitated or non-ambulatory patients will require healthcare staff to assist with the decontamination procedures. To reduce the possibility of patients presenting with hypothermia, warm or temperate water should be used. Excessively hot water should be avoided, as this may promote peripheral vasodilatation and toxin absorption. Best practices would suggest using sponges and disposable towels in place of brushes to ensure that additional dermal damage does not occur.</p>
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<p>As a caveat, direct observation of fit, young, military personnel processing through rapid, sheltered decontamination with warm water while partially clothed in hot ambient temperatures (summer in the Nevada desert) still resulted in visible hypothermia secondary to convection (<a href="devmodap3a.htm#stopford">Stopford, Nov 2001</a>).</p>
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<h3>Decontamination Solutions</h3>
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<h4>Soap and Water</h4>
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<p>Limited data suggest that the most reliable solution for the rapid decontamination of mass casualty patients is soap and water. Soap will aid in emulsifying oily substances like vesicants/blister agents—e.g., mustard agents. Liquid soaps are quicker to use than solids and reduce the need for mechanical scrubbing. The biggest disadvantage of the use of soap is the large amount that will be necessary. The health care facility or responding agency will need to plan for the amount required in a mass casualty event. Ultimately, the damage to the patient will likely be done in the first few minutes of contamination. The goal of rapid, definitive decontamination of patients is to prevent secondary contamination to rescuers and receivers, in addition to potentially mitigating continued patient contamination. </p>
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<h4>Bleach and Water</h4>
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<p>Sodium hypochlorite (bleach) and water solutions remove hydrolyze and neutralize most chemical and biological agents. However, this approach is less favored in a mass casualty decontamination situation than soap and water, where speed is the paramount consideration, for the following reasons:</p>
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<ul><li>Commercial bleach must be diluted and applied with equipment that may not be readily available.</li>
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<li>Skin contact time is excessive. Laboratory studies indicate that that 15 to 20 minutes of contact time is necessary for hydrolysis or oxidation and, thus, for the inactivation of a chemical agent.</li>
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<li>Laboratory studies suggest that bleach solutions at the 0.5 percent level may not be better than flushing with water alone, although some of these data are limited in sample size.</li>
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<li>Bleach solutions are not recommended for use near eyes or mucous membranes, or for those with traumatic wounds.</li>
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<li>The lack of clear safety and efficacy data for bleach decontamination suggest that it should be avoided, especially if soap and water are available.</li>
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<li>Hypochlorite tends to exacerbate the effects of some riot control/irritant agents, causing vesiculation.</li>
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<li>Chemical neutralizers are exothermic reactors and may cause additional harm.</li> </ul>
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<p>A recent review of the literature suggests that under certain conditions bleach, even at the 0.5 percent level, may actually increase the toxicity of some nerve agents and abrade the skin, potentially causing additional damage in cases involving radiological contaminants (personal communication with Steve Cantrill, MD, December 8, 2003).</p>
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<h3>Non-Aqueous Methods</h3>
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<p>The use of dry, gelled, or powdered decontamination materials that absorb the chemical agent are appropriate if their use is expedient and no water is available. Commonly available absorbents include dirt, flour, Fuller's earth, baking powder, sawdust, and charcoal. The military M291 and M295 Skin Decontamination Kits employ a charcoal based resin as an absorbent, are used in the military, and may be purchased commercially. However, while these kits are effective in removing spots of liquid chemical agent contamination, they may not be suitable for treating mass casualties due to the potentially limited availability, relatively high labor requirements, and the need to use these kits quickly after the patient has been exposed. </p>
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<p>Additional mass casualty decontamination solutions that have been proposed include facilitating rapid clothing removal of potentially contaminated victims without exposing them to water, or a gross decontamination "drench drill." commercial off-the-shelf products (COTS) products have been developed that allow a patient to disrobe in public under bag-like overgarments for modesty and some environmental protection (<a href="devmodap3a.htm#marcus">Marcus, 2002</a>). A possible deficiency of this solution is the potential to transfer contamination located on the exterior clothing to the interior of the overgarment, thereby placing contamination against the skin. </p>
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<p>Continued evidence-based research is needed while these products are adapted from environmental site or equipment remediation to patient use, including the need for lengthy dwell times, potential absorption issues, and the logistics for managing the large quantities necessary. Other COTS products are emerging for decontamination purposes, such as decontamination foams and skin solutions as a barrier or a cleaner.</p>
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<p>Other models to consider for mass casualty decontamination include providing a basic large-scale sheltered area for victims to change clothing and the Israeli model of public fixed decontamination sites such as parking garages. Israel has successfully utilized public venues, such as parking garages, as mass casualty decontamination facilities and has educated the public to their use and location. Coupled with a sustained, effective public education program, the general public may report to local fixed mass casualty decontamination structures for self-treatment, similarly to the general public reporting to their closest tornado shelter. This may be an option to test in a recognized high threat location, such as the National Capital Region, or in high threat venues, such as large arenas or convention centers. A security concern with publicizing a decontamination facility is the risk of the facility itself becoming a primary or secondary target, which is ultimately no different from the current threat against hospitals and other icons of life-saving, such as ambulances or fire apparatus. </p>
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<h3>Summary of Solutions</h3>
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<p>The problems associated with the use of soap and bleach solutions include time delay, dilution and application, medical contraindications, and their efficacy compared with water alone. These limitations make the use of soap and bleach less desirable than using water alone for speed, but substances will often not rinse off with water alone, requiring a non-toxic solution to disrupt the surfactant layer allowing cleansing to occur. Limited studies exist of decontamination solution efficacies, particularly in a mass casualty situation with limited resources and dwell time.</p>
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<h4>Water Containment and Runoff</h4>
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<p>As health care facilities and providers begin to develop and evaluate mass decontamination systems, it is important to also consider the capabilities for managing the contaminated water run-off. Following a mass casualty event, environmental liability resulting from critical lifesaving actions may seem unlikely but could be a serious concern for many first responders and facilities. There currently is no legislation or regulatory mandate describing the details for the containment procedures and capacities of a decontamination system (<a href="devmodap3a.htm#berino">Berino</a>), although the Environmental Protection Agency (EPA) provides guidance for decontamination planning. An EPA letter is widely circulated limiting liability for agencies engaged in mass casualty emergency decontamination. However, since mass casualty decontamination should be a part of community's emergency planning, the appropriate containment of contaminated run-off should be addressed. Cost effective solutions exist to contain run off, including berms, pumps and containers. Each health care facility must establish water containment capacity based on the facility's hazards vulnerability analysis and assessment. </p>
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<p>In addition, health care facilities should consider the risks to the community of exposure to hazardous material exposure based on the potential number of victims that may present to the facility. Health care facilities should develop specific contaminated water containment plans in conjunction with the proper local regulatory authorities (Environmental Protection) and Municipal Separate Storm Sewer systems.</p>
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<p>Contaminated run-off should be avoided whenever possible but should not impede or interfere with necessary lifesaving actions. The key to managing the problem of water run-off is planning. Health care facilities need to coordinate with the local emergency planning committee to obtain community support and technical guidance and direction in minimizing the environmental impact of decontamination water run-off (personal communication with Kathy Dolan, Risk Manager, Safety and Disaster Coordinator, Mercy Medical Center, Nov 19 2003).</p>
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<p>While health care facilities with fixed or designated portable decontamination capabilities should address the issues of run-off to comply with EPA regulations, the EPA has also furnished a letter regarding run-off from a mass casualty event that suggests there will be leniency in dealing with a lack of proper containment. The health care facility or agency depending upon this in their decontamination plan should verify their risks with local government agencies, internal risk management, and legal counsel (personal communication with Kathy Dolan, Nov 19 2003).</p>
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<h4>Triage</h4>
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<p>The three primary objectives of a disaster response are: 1) to do the greatest good for the greatest number of victims; 2) to effectively use personnel, equipment, and health care facilities; and 3) to not relocate the disaster from one location to another by poor command, control, or communication practices. </p>
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<p>The triage process is the initial step taken to meet the primary objectives of a disaster response. The purpose of triage is to sort the injured by priority and determine the best use of available resources (e.g., personnel, equipment, medications, ambulances, and hospital beds). Many first responder agencies and health care facilities have a triage plan in place to implement in the event of an airplane crash, train derailment, or school bus accident. </p>
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<p>Traditional triage uses diagnosis-based criteria or involves the evaluation of each patient's respiration, perfusion, and mental status to determine whether they should be classified as immediate (urgent), delayed, low priority, or deceased. Both triage approaches require the examiner to see the patient and obtain certain clinical data by verbal communication and tactile examination. In a terrorist incident involving chemical or biological WMD, the victim(s) may suffer from the effects of toxins, trauma, or both. In a more conventional disaster, unless they are in danger, patients can usually remain in place until directed to relocate. Their evacuation and treatment priority is indicated on a triage tag or colored ribbon, with an emphasis on saving as many persons as possible (personal communication with Steve Cantrill, MD, December 8, 2003). </p>
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<p>There are several differences between the triage done for the traditional disaster scenario and that conducted for a HAZMAT incident or a chemical/biological terrorist event. Time demands, patient volume, and the personal protective equipment being worn by response personnel in the hot and warm zones may preclude normal life-saving measures from being rendered quickly, if at all. For example, verbal communication may not be possible because of the responder's personal protective equipment. A tactile examination may not be possible for the same reason. In a New York City model for mass casualty triage, responders in personal protective equipment may utilize a noxious stimulus, such as a forceful nudge, to elicit a victim response. The patients who react to the stimulus will become the highest priority for intervention, which includes scene extraction, antidote administration, and further medical care.</p>
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<p>In addition, the whole concept of traditional triage (treating the most seriously injured first) may not be applicable in a chemical or biological incident. Ambulatory victims may need to be among the first to be decontaminated and evacuated because they may have the best chance of survival. It is not desirable that victims remain in place in the hot zone until examined. Rather, immediate evacuation efforts should be undertaken and the victims directed toward the decontamination process established in the warm zone. Further theory propones initiating decontamination in the hot zone. For example, non-ambulatory patients who were victims of a non-persistent vapor causing life-threatening effects may be saved in the hot zone by immediate administration of antidote, neutralizing solution, and basic airway management. Also, there will be little if any time to indicate a patient's priority on a triage tag in the hot or warm zones. </p>
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<p> In addition, the patient data recorded on a triage tag is at risk of being defaced when the tag becomes wet during decontamination (17). The U.S. Marine Corps (U.S.MC) Chemical Biological Incident Response Force (CBIRF) has designed waterproof, mass casualty decontamination tags that other agencies have adapted to address this issue. Additional COTS products exist with a similar purpose. </p>
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<h4>Psychological Impact</h4>
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<p>The psychological impact of being exposed to a WMD is not well studied. Whether crowds will listen to instructions or panic, what they need to be told and how that message should be given, whether they will take off their clothes in the absence of an obvious immediate danger, whether they will shower with persons they have never met before, and how best to control or avoid hysteria are among the issues that need to be addressed.</p>
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<p>Actions that can be taken that may mitigate the long-term psychological consequences that will accompany a mass casualty WMD event include a robust crisis and risk communications plan, pre-prescribed actions that the public can take for self-protection, and providing sheltered, gender segregated undress, decontamination, and redress areas. One purpose of shelter is to protect against intrusion, such as by bystanders or the media. </p>
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<p>Ultimately, in a situation characterized by loss of control, allowing victims to retain or obtain as much control over their environment and themselves as possible is desirable. Methods for achieving this do not need to be complicated or expensive, but cannot be ignored in favor of "if they are really sick, they will just strip naked in the parking lot" mentality. Citizens of the United States are aware of both the credible terrorist threat and the concurrent funding and planning efforts occurring. They may not be so forgiving of a lack of planning that strips them of their usual civil rights (<a href="devmodap3a.htm#stopford">Stopford, 2001</a>).</p>
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<h4>Needs, Shortfalls, and Gaps</h4>
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<p>Research and development efforts in decontamination and mass triage must concentrate on operations research and research on procedures and techniques for the effective decontamination of large numbers of people. Such research should include: </p>
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<ul><li>Physical layout, equipment, and supply requirements for performing mass decontamination for ambulatory and non-ambulatory patients of all ages, in all kinds of health, in the field and at the hospital.</li>
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<li>Standardized patient assessment and triage process for evaluating contaminated patients of all ages, both in the hot zone and pre/post decontamination.</li>
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<li>Optimal solution(s) for performing patient decontamination, including decontamination of mucous membranes and open wounds.</li>
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<li>Benefit versus risk of removing patient clothing, including the need to remove undergarments.</li>
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<li>Effectiveness of removing agent from clothing by a showering process.</li>
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<li>How much contact time for showering is necessary to remove a chemical agent?</li>
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<li>Whether high pressure/low volume or low pressure/high volume spray is more effective for patient decontamination.</li>
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<li>Alternatives to the fire hose "drench drill" gross decontamination method.</li>
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<li>Best way to determine whether a patient is "clean."</li>
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<li>Psychological impact of undergoing decontamination on all age groups. </li>
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<li>The ideal avenues through which health care facilities can disseminate information during an event of this magnitude.</li>
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<li>Equipment and training requirements. How can health care facilities realistically provide support for mass casualty decontamination? And what is the funding source?</li>
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<li>Need for decontamination preparedness capabilities at all health care facilities. </li>
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<li>Cost-effective retrofitting for fixed decontamination at health care facilities and high-threat locations and venues.</li>
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<li>Educational and training materials specifically developed for the general public and mental health professionals.</li>
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<li>Enlist mental health professionals in mass casualty planning and emergency management to develop appropriate guides and standards.</li>
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<li>Psychological screening methods to differentiate the public reaction to terrorist attacks from other psychological illnesses.</li>
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<li>Evaluation of techniques for preventing or controlling adverse effects in health care and emergency workers, victims, and the "worried well."</li>
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<li>Debriefing methodologies on pediatric psychological issues following suspected or actual terrorist attacks (personal communication with Steve Cantrill, MD, December 8, 2003).</li></ul>
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<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 WMD 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>Decontamination capabilities are based on the hazards vulnerability analysis and assessment within the geographic boundaries of the health care facility and agency's service. In addition, the chosen decontamination system will be developed and prepared as the demographics of the community dictate.</p>
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<p>A baseline of standardized preparedness must occur throughout the United States and territories, to be augmented based on credible threats discovered during a systematic hazards vulnerability analysis and assessment (<a href="devmodap3a.htm#mann">Mann, 2003</a>).</p>
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<p>With the theory that a mass casualty decontamination event is a community problem, not just a health care facility or private industry problem, communities using a regional approach have provided mobile decontamination assets, such as those already in place in select Metropolitan Medical Response System cities (<a href="devmodap3a.htm#epa">United States Environmental Protection Agency, 2000</a>). Additional efforts should be made to ensure that all health care facilities have some expanded capacity to cope with contaminated casualties, even if they start with an undress area and small shower set up. A mobile regional approach alone will not be effective in the face of rapidly self-referring casualties to health care facilities if they have no containment or initial treatment capability while waiting for assets to arrive. </p>
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<h4>Progression through the Decontamination System—How many victims of a WMD attack will the best practice aid?</h4>
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<p>The best practices to maintain rapid progression through the decontamination system will require two systems (<a href="devmodap3a.htm#stopford">Stopford, 2001</a>). First, an ambulatory system; this system will allow for rapid progression of contaminated or suspected contaminated casualties experiencing minimal or no signs or symptoms of exposure. The ambulatory system will require self-decontamination by the individual, limiting the staffing requirements. Second, a non-ambulatory system; this system is specifically designed for contaminated casualties who are unable to walk or who are producing significant signs and symptoms of contamination, including unconsciousness and unresponsiveness. This system will require qualified and trained staff to actively assist and possibly provide life-saving care during patient decontamination.</p>
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<p>Depending upon the extent of the program adopted by particular regions—the cost for purchasing, maintaining, and storing decontamination equipment, in addition to the possible structural modifications to the facility—costs may be significant. Additional costs may be incurred for initial and in-service training. Although the costs may be considerable, failing to provide a system for decontamination may prove even more costly.</p>
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<p>One approach to progression through the decontamination system is that of spiral development. Based on a regional hazards vulnerability analysis and capabilities assessment, a plan can be developed with progressive capabilities. For example, first year funding can provide portable, regional mass casualty units such as tents or trailers to augment scene and facility needs, while initial augmentation of current health care facility capabilities ensues. A high end approach is ensuring each health care facility can accommodate an equal percentage of predicated casualty numbers, with both fixed and portable capabilities, in conjunction with a community public education plan and public and home-based decontamination options. </p>
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<h4>Operational Impact—What are the operational considerations of using the best practices?</h4>
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<p>The operational impact in decontamination system development may be significant. As with personal protective equipment, specialized training is required and regulated by OSHA. Competency-based, Operations level training will be required for all staff members responsible for ambulatory and non-ambulatory casualty decontamination. In addition, staff members assigned to non-ambulatory decontamination will need back-fill coverage to ensure their normally assigned duties are being completed. Thus, there will be a significant impact on manpower and staffing availabilities for other required duties. Health care facilities and agencies should address the rotational needs of maintaining staff at elevated levels of personal protective equipment as needed to conduct decontamination. </p>
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<p>In addition, an increase in the security of the facility must be managed. A large-scale incident involving mass casualties to a facility could maximize and surpass the capabilities of the institution. Health care facilities will need to mitigate this possibility by identifying surge capacity sites for patient overflow, as well as identifying or developing a hospital shared services call down. </p>
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<p>This call down system will provide contact information for agencies, organizations, and facilities able to provide medical staff as reserve or relief personnel in an emergency. A community planning consideration should be given to directing ambulatory, potentially contaminated but asymptomatic patients, to go home to shower during a mass casualty event, then to be able to report to a secondary treatment site for further screening. </p>
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<h4>Training—What level of training does this best practice require?</h4>
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<p>OSHA regulations affecting decontamination team training, including health care facility personnel providing decontamination services, require "operations" level training with an annual refresher or competency requirement. The Office for Domestic Preparedness describes this competency-based training as "performance offensive." Health care facilities will need to provide staff the appropriate level of training based on the responsibility involved in the assignment. (<a href="devmodap3a.htm#odp">Office for Domestic Preparedness, August 2001</a>).</p>
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<ul><li>Hazard Communications—all employees; orientation to HAZMAT in the workplace.</li>
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<li>First Responder/Receiver Awareness—employees likely to discover a HAZMAT situation or come in contact with a potentially contaminated casualty.</li>
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<li>First Responder/Receiver Operations—all members of a decontamination team.</li>
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<li>Skilled Support Personnel—personnel that are not part of the decontamination team or response team but have special skills that are immediately required in the contaminated area.</li>
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<li>On-Scene Incident Commander—oversight of the decontamination operation.</li></ul>
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<p>Once again, these OSHA-regulated levels of training require annual review and competency testing.</p>
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<h4>Resources—Does the practice build on existing practices/infrastructure? Are there available resources to implement the practices?</h4>
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<p>Very few health care facilities have decontamination capabilities able to handle a large number of contaminated casualties. In fact, those facilities that do have current decontamination systems are typically designed for the (individual) ambulatory patient. Failure to recognize the need and the potential for a mass casualty event may put the health care facility, its staff, and patients at great risk. While Federal funding supporting domestic preparedness is prevalent, the impact has not been greatly felt at the health care facility level. Decontamination is a medical procedure and must be supported as such by empowering health care professionals with training, equipment, and procedures to provide lifesaving care (<a href="devmodap3a.htm#mann">Mann, 2003</a>).</p>
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<h4>Morbidity and Mortality—What impact will this practice have on saving lives?</h4>
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<p>Health care facilities and health care agencies, including pre-hospital professionals with well-developed plans based on their hazards vulnerability analysis and assessment, will have a dramatically positive effect on saving lives. No one can prevent unannounced contaminated casualties from walking into a health care facility. But with staff vigilance and awareness of potential hazards and toxidromes, health care facilities can contain additional facility contamination and initiate decontamination policies and procedures. Pre-hospital medical personnel who can provide oversight, initiation, or conduct decontamination have the ability to save lives (<a href="devmodap3a.htm#mann">Mann, 2003</a>).</p>
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<h4>Evidence-Based Practice verses Theory—Is there a body of professional research supporting this practice or is it theoretical?</h4>
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<p>Research has been conducted in the area of decontamination specifically for on-scene response by emergency medical service, fire department, and law enforcement personnel. The need for standards for health care facilities is not a new concept. As mentioned earlier in this document, health care facilities are presented with patients possessing chemical exposures from industrial accidents and agricultural chemical exposure incidents. Only recently have government, military, academic, and public and private entities begun looking at mass casualties presenting to civilian health care facilities with chemical and/or biological contaminants. Logical hypotheses can be developed regarding the negative outcomes from failing to prepare appropriately, yet evidence-based scientific data are not available for the official support of a particular direction. The information is largely anecdotal and based on traditional HAZMAT response.</p>
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<h4>Regulatory Compliance—Does the practice comply with existing regulations or does it require a regulatory change?</h4>
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<p>JCAHO and OSHA provide the bulk of the regulations that impact health care facilities regarding decontamination. As the numbers of patients for which a facility must be prepared will vary by community, the focus has been on establishing an effective plan, to include role definition and training needs. Numerous periodicals and professional organizations offer suggestions, recommendations, and practices, yet there is no government authority regulating standards. It is important to note that with government regulation comes a price tag. To fully prepare a health care facility with decontamination design, facility modifications, equipment, training, and exercise, a significant cost will be incurred.</p>
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<p class="size2"><a href="devmodel1.htm#Contents">Return to Contents</a><br />
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<a href="devmodel4.htm">Proceed to Next Section</a></p>
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