Welcome to ZZ Chatham Hospital

Decontamination Tent - (Mass Casualty)

Click Here for Printabe .DOC Version

PURPOSE:
To establish procedures for activation of the decontamination tent and decontamination process.

POLICY:
This plan outlines the purpose and procedure for the decontamination of contaminated victims.  Decontamination of patients prior to entering the Hospital is essential to protect the facility, patients, and staff.  Unlike a typical mass casualty incident, as few as 5-10 patients needing decontamination can overwhelm normal resources in the Emergency Department (ED). Early communication and coordination are essential to the success of any decontamination response.

Notification and Activation:
Upon notification of incoming patients that have possibly been contaminated or if contaminated patients start arriving unannounced, and require set up of the decontamination tent, the ED charge nurse should page by dialing 30-00 and announcing overhead CODE D - Decon three times, which will activate the Decontamination Team.  The overhead announcement will be made to notify available team members that are in-house of the activation and to have them report outside the ED ambulance doors to set up the decontamination tent.

If patients will be arriving via EMS, it is important to ascertain whether gross decontamination has already been done.  This is generally done utilizing hoses and will dilute / decrease the contamination.  It does not replace decontamination measures at the hospital.

The Incident Commander in coordination with the ED physician will declare a disaster-external to help manage the patient surge.  If Emergency Management / EMS have not previously been involved; (i.e. multiple patients arriving via privately owned vehicles), notification of Emergency Management should be considered by the Incident Commander.  Emergency Management may be contacted to provide decon support at the hospital.

Concept of Operations:
The main priority of any decontamination operation is to protect the facility and staff.

Decontamination Trailer:
The decontamination trailer is located to the left of the ambulance bay as you exit the doors.  The key to unlock the trailer doors is located on the disaster/helipad key chain in the drawer to the right of the secretary area in the ED.  Unlock both locks and pull down the doors to form a ramp.  Inside the trailer is an organized stock of decontamination equipment and Personal Protective Equipment (PPE).  Depending on the offending agent, an explanation of what equipment to use when and by who is explained below.

The decon tent will be set up outside the ED ambulance doors at the edge of the parking area for the mobile Imaging vehicles.  Care must be taken to set up hot and cold zones to prevent contamination of staff and / or the facility.

Ambulatory Patients:
Patients will be instructed to disrobe inside the tent and proceed into the shower. All personal effects should be placed in the bags available in the tent or handed out by the attendant. Once inside the shower, patients should thoroughly wash themselves with soap and warm water. Special care should be given to the head and to all body crevices as these areas can easily retain contaminants easier than normal skin.

Once they have finished showering, the patients will be given clean gowns and directed to a holding and triage area. The location of this area will vary depending on the scale of the event. (In the event that numerous potentially contaminated victims start presenting for treatment without advance notice, the patients will be instructed to disrobe and staff will decontaminate them using hoses connected to the outside of the building or by utilizing the decon shower.  They will then be given hospital gowns and be brought into the ED waiting area and processed).  All personal effects will be bagged and secured until they can be checked for contamination.  Each patient will be given a bracelet with a number that corresponds to a bag that all personal belongings and clothing should be placed in. All belongings and clothes are considered to be contaminated and will be disposed of accordingly.  Only items that can be decontaminated onsite will be returned to patients (keys, coins, jewelry, etc.).

Non-ambulatory Patients:
Non-ambulatory decontamination will take place in the non-ambulatory tent which will be deployed along with its support equipment in the ambulance bay area.  Each non-ambulatory patient must be disrobed by cutting the clothing off. All clothing and personal effects should be placed in a numbered bag. Once clothing has been removed the patient will be washed with soap and warm water by the decontamination attendants. The attendants must blot and not rub the skin during the process as rubbing can cause injury and spread contamination on the body. Special care should be given to the head and to body crevices as these areas can retain contaminants easier than normal skin.  In the event that potentially contaminated victims start presenting for treatment without advance notice; staff will utilize the Decontamination Shower Room to process the patients.  Each patient will be given a bracelet with a number that corresponds to a bag that all personal belongings and clothing should be placed in. All belongings and clothes are considered to be contaminated and will be disposed of accordingly.  Only items that can be decontaminated onsite will be returned to patients (keys, coins, jewelry, etc.).

Security and Traffic Control:
During a mass casualty incident involving contaminated patients, the Hospital will be operating in a restricted access or lockdown mode. Hospital security or maintenance will ensure that all exterior entrances are secured.  (Follow External Disaster Plan)  Security or maintenance will also be responsible for traffic control.  All non-emergency traffic should be stopped from approaching the hospital by establishing traffic control points as determined by the security or maintenance staff.

Roles in Decontamination Response:
Incident Commander- the Incident Commander is responsible for the overall incident and should immediately appoint an Operations Section Chief, Decontamination Team Leader and Decontamination Site Safety Officer.

Decontamination Team Leader - the Decontamination Team Leader is responsible for all operational aspects of the decontamination response and will coordinate with the ED physician to designate staff for medical support teams. In large incidents it may be necessary to appoint subordinate positions to help coordinate planning, communication, administrative and logistical roles. This position also reports regularly to the Operations Section Chief.

Decon Site Safety Officer - The Safety Officer is responsible for ensuring that all applicable safety guidelines are being followed to include PPE usage and work/rest times.

Medical Officer - The medical officer is a member of the Decontamination Team responsible for ensuring all personnel donning PPE are medically fit to do so based on their pre and post PPE medical evaluations.

Technical Specialist - an Infection Control Professional, Radiation Safety Officer (RSO), Hazardous Material (HazMat) Specialist or other qualified professionals may serve as technical specialists for any contaminant related questions in the ED and in the Command Center. A HazMat specialist or RSO may also be tasked with periodic indoor air quality and surface area monitoring in the ED to ensure no cross contamination from chemicals or radiation has taken place.

Medical Support Personnel - Medical Support Personnel consist of ED staff tasked to provide medical support to patients during the decontamination process. Medical Support Personnel will also assist the Medical Officer with pre and post PPE vital signs.

Security Personnel - Security personnel are responsible for ensuring that the decontamination areas and Hospital remain secure and orderly.

Decontamination Attendants - Decontamination Attendants are members of the Decontamination Team responsible for the actual decontamination process.  Attendants will also assist ambulatory patients with removal and bagging of their clothing and the donning of hospital gowns.

Equipment Set-up and Support Personnel - The decontamination team is responsible for set-up and logistical support of the decontamination equipment.

Logistics and Administrative Support Personnel - Logistics and Administrative Support Personnel are individuals who are not required to dress out in full PPE and are responsible for recordkeeping, research, and the distribution and tracking of decontamination supplies (temporary dress kits, sponges, etc.)

PPE
PPE for use during a decontamination response is stored directly adjacent to the ED in the Disaster Trailers adjacent to the ED. Any person that could possibly be involved in the actual handling of or come in contact with contaminated patients or equipment must be equipped with and trained in the appropriate use of PPE. Appropriate PPE is defined based on the assigned job function and the source of the contamination.  All personnel must participate in a medical surveillance program in accordance with 29 CFR 1910.120 (f) prior to wearing any kind of respirator. Any personnel wearing an N-95 or Form Fitting Respirator must also be fit tested on the kind of respirator they will be wearing. Copies of these records must be on file.  In accordance with NFPA 471 Chapter 8, all personnel must be medically evaluated prior to donning PPE and immediately following doffing to check for signs of environmental stress.

Work and rest times must be strictly enforced. The chart below will serve as guidance for establishing work/rest times as well as fluid replacement. All work being performed by Medical Support Personnel and Decontamination Attendants is assumed to be in the Moderate to Hard category.

Following the incident, all non-disposable PPE items will be will be segregated until they can be properly decontaminated. All disposable PPE will be bagged in hazardous waste bags and stored until they can be removed by a disposal agency.

After personnel doff PPE, they will be directed to a rehab area to re-hydrate and have post PPE medical evaluations performed. This rehab area will be shielded from environmental extremes as much as possible. Regardless of the temperature, all personnel should consume 8-16 ounces of water or diluted energy drink prior to donning PPE and should immediately start re- hydrating as necessary after doffing PPE.

Environmental Considerations:
All run-off from decontamination operations should be contained to the greatest extent possible as required by EPA. In addition to the containment bladders assigned to the decontamination tents, a waste holding tank is located in the ambulance bay. Any run-off that escapes containment should immediately be reported to the Command Center.

If contaminated patients arrive prior to run-off containment being established, the patients must be decontaminated to protect life safety. An estimated amount of run-off should be reported to the Command Center as soon as possible.

Medical Evaluation:
During decontamination operations, in accordance with NFPA 471 Chapter 8, all personnel must be medically evaluated prior to donning PPE and immediately following doffing to check for signs of environmental stress. All vital signs and observations must be recorded on the appropriate forms for recordkeeping purposes.

Pre-entry:
The objective of pre-entry medical monitoring is to establish baseline vital signs and physical assessments for personnel. The monitoring also identifies and precludes participation of individuals at an increased risk of sustaining injuries and illness as a result of decontamination activities.

The following vital signs will be collected prior to donning PPE:

Blood Pressure

Pulse

Respiratory Rate

Temperature

In addition to the evaluation of vital signs, a skin evaluation, mental status, and recent medical history should be conducted.

The following exclusion criteria will be applied to medical monitoring to ensure only physically and medically fit personnel will don PPE for decon operations:

Blood pressure- diastolic greater than 105 mm Hg

Pulse- greater than 70% maximum heart rate (220-age)

Respiratory Rate- greater than 24 per minute

Temperature- greater than 99.5 F(oral) or greater than 100.5 F (core) or less than 97.0 F (oral) or less than 98.0 F (core)

Open sores, large areas of rash or significant sunburn

Altered mental status- Slurred speech, unusual clumsiness, weakness

ANY alcohol consumption in the past 6 hours

Pregnancy

The presence of vomiting, diarrhea, fever, upper respiratory infection, heat illness or heavy alcohol consumption in the past 72 hours could contribute to dehydration and should be considered prior to clearing personnel to don PPE. Any new prescription or over the counter medications started in the last 72 hours must be cleared by the medical officer prior to donning PPE.

Post-entry:
The objective of post entry medical monitoring is to evaluate personnel for immediate effects from exposure to hazardous materials or the environment. This monitoring also evaluates the health status of personnel for future entries. Upon exiting the work area and doffing PPE, evaluation for signs and symptoms for hazardous materials exposure should take place along with the evaluation of the following:

Blood pressure

Pulse

Respiratory rate

Temperature

Skin evaluation

Mental status

Monitoring should be repeated every 5-10 minutes until the pulse rate has returned to 85% of the maximum rate.
If after 10 minutes any of the following conditions exist, personnel should immediately seek medical attention:

Pulse increase of greater than 20 beats per minute or systolic blood pressure decrease by 20 mm Hg at two minutes standing

Greater than 85% maximum pulse at 10 minutes

Temperature greater than 101 F (oral) or 102 F (core)

Nausea, vomiting, diarrhea, altered mental status, or respiratory, cardiac, or dermatological complaints.

Appropriate PPE for Job Functions

Decontamination Attendants and Medical Support Personnel

Chemical or Unknown

PAPR or Full Face Respirator

1st layer of nitrile gloves

2nd layer of nitrile chemical gloves

TYCHEM Suit

PVC Rubber Boots

Pocket Dosimeter (if Unknown)

Biological

PAPR, N-95, or Full Face Respirator

1st layer nitrile gloves

2nd layer nitrile gloves

TYCHEM Suit or Surgical Scrubs

PVC Rubber Boots

Goggles or Face Shield (only if using an N-95)

Radiological

N-95 Mask

1st layer nitrile gloves

2nd layer nitrile chemical gloves

TYCHEM Suit or �Bunny Suit� ( at the discretion of RSO)

Goggles or Face Shield

Pocket Dosimeter

Hospital Security Personnel

N-95 or full face respirator

Single layer of latex or nitrile gloves

Equipment Support Personnel

N-95

Goggles

Nitrile gloves

US Patent Numbers 7,720,998 B2, 7,836,207