Disclaimer

1. Disclaimer Specific products described or demonstrated during this session are provided as examples only and are not specifically endorsed by the presenters The views expressed in this session are not necessarily those of the U.S. Government, the National Disaster Medical System, nor the Chesapeake Health Education Program

2. Respiratory Protection: Decision Making for Health Care Providers April 21, 2004 NDMS Dallas, TX

3. Objectives • Review selected regulatory issues in respiratory protection • Review threats to responders and data on provider injuries • Discuss respiratory protection for: • Hospital ‘first receivers’ • Scene ‘first responders’ • Discussion and questions

4. Means of Hospital Arrival - Tokyo

5. Regulations • JCAHO EC 1.4 • Provide decontamination services • NFPA • SARA Title III • OSHA HAZWOPER 29 CFR 1910.120 • OSHA Respiratory Protection Standard 29CFR1910.134

6. HAZWOPER ‘emergency response or responding to emergencies means a response effort by employees from outside the immediate release area or by other designated responders (i.e. mutual-aid groups, local fire departments, etc.) to an occurrence which results, or is likely to result, in an uncontrolled release of a hazardous substance’

7. HAZWOPER - PPE ‘employees engaged in emergency response and exposed to hazardous substances presenting an inhalation hazard shall wear positive pressure self-contained breathing apparatus while engaged in emergency response until such time that the individual in charge of the ICS (incident command system) determines through the use of air monitoring that a decreased level of respiratory protection will not result in hazardous exposures to employees’

8. HAZWOPER - PPE ‘When hospital staff do not know the airborne concentration of a hazardous substance created by a chemically contaminated patient or do not know specifically what the contaminant is, would staff members decontaminating the patient be required to wear a positive pressure self-contained breathing apparatus?’ - September 5, 2002 from Richard E. Fairfax to Francis J. Roth.

9. HAZWOPER - PPE ‘the personal protective equipment they (hospital providers) need must be sufficient for the type and level of exposure the hospital anticipates under those conditions (eg: what airborne or absorption hazards can be anticipated from a patient whose skin or clothing is wetted with hazardous liquids or contaminated with hazardous particles?)’ - September 5, 2002 from Richard E. Fairfax to Francis J. Roth. (also see December 2, 2002 from Richard E. Fairfax to Kevin J. Hayden)

10. OSHA White Paper • HVA and EMP is critical and pre-requisite to decontamination and PPE planning • PAPR with protection factor of at least 1000 • HEPA/organic vapor/acid gas filtration is minimum • Rubber boots, double gloves (nitrile and butyl - USACHPPM), protective suit • Minimum conditions to enable use of these protections are present in the document

11. Hazard Vulnerability Analysis • Examines risk of community threats vs. impact and preparedness efforts • Natural disasters, technological, industrial, terrorist incidents, and relation to human injury • Required of communities and JCAHO accredited healthcare facilities • Guides training, equipment, mitigation projects • ASHE, JCAHO, others have good examples on web

12. Hazard Vulnerability Analysis

13. Acids 12.3% Ammonia 10.9% Bases 2.9% Chlorine 2.8% Inorganics NOS 16.1% Paint/dye 1.3% Pesticides 7.3% Mixtures 7.6% Volatile organic 19.3% Polychlorinated biphenyls 0.2% Other 19.3% Top 10 causes of chemical injuries

14. Historical Threats - Responders • ATSDR 1995-2001 • 44,015 HAZMAT events • 3455 with victims (13, 149) • 5% required hospital admission • 437 police officers (3.3%) • 272 professional firefighter (2.1%) • 176 volunteer firefighter (1.3%) • EMS personnel 72 (0.5%) • Horton, DK et.al.

15. 2001 ATSDR data • 8,978 events • 710 events caused injury to 2,168 victims • Respiratory irritation 1,145 injuries • 22 deaths overall • 274 responder injuries • 3 deaths – firefighters at hardware store fire • 1 death – police officer at meth lab • LE – 72% of injuries at transportation events, 42% at fixed facility events

16. Historical Threats - Responders • Responder injuries 1996-1998 • Respiratory irritation • Nausea • No deaths • Acids and ‘other substances’ involved • About 50% wore turnout gear, 1/3 had HAZMAT training

17. Historical Threats - Hospital • 1995-2001 • Six events injured 15 personnel • Meth labs (2), pepper spray, HF, Cl gas, malathion • 0.15% of all HAZMAT victims were ED personnel • Respiratory and eye irritation • No PPE used • Isolated case reports: • Ethyldichlorosilane • Aluminum phosphide • Petroleum products

18. Organophosphate experiences • Tokyo • 110 hospital and 135 EMS personnel reported sx • 6 MDs treated, none seriously affected • Suicidal ingestion exposures, US • At least one provider required intubation • At least two providers required hospital admission • At least two other cases have caused less severe respiratory symptoms

19. Threats to Providers • Biologic agents • HEPA filtration with appropriate respirator • Chemical terrorism agents • Particularly organic vapors and acid gases • Dusts and debris • Including radiologic contaminated • Industrial, criminal, household known and unknown agents • Oxygen deficient environment? • Applies to some providers

20. Roles and Responsibilities • LEPC, MMRS, Urban Security Initiative, other multi-agency stakeholder groups are good places to start • Define the expectations of your agency or facility in the community response • Help prioritize your needs for equipment and training relative to the community plan • Standardize regionally (training and equipment) • Plan, train, equip, exercise, rinse and repeat

21. Fire EMS Law Enforcement Healthcare Emergency Management Private Sector Infrastructure / Assets LEPC Community Resources

22. Particular Issues • What is the role of your personnel? • Clean patient care • Decontamination • Hazard recognition and initial defensive actions • Hazard containment actions (offensive) • What zone could you be operating in? • Could the warm zone come to you? • What is the environment that your personnel will be providing services in? (open air, closed room, court of law…)

23. Levels of PPE • Four levels of Chemical Protective Ensemble as specified by OSHA • Each has advantages and disadvantages • NONE of these is appropriate for all circumstances • These ensembles offer no protection against fire, explosion, gamma radiation, or telemarketers • These were not developed with healthcare facility use in mind

24. Level A – ‘A’ll wrapped up Total encapsulation Heavy, bulky suit Very expensive, cumbersome

25. Level B – ‘B’reathe air Note air supply is external to suit Minimum level of protection to enter release (hot) zone with agent unknown May be on air hose with escape bottle (SAR) SCBA limited to 20 min approx

26. Level C – ‘C’artridge filtered Filters air, does not supply air Powered models provide higher levels of protection vs. mask type NOT sufficient for ‘hot’ zone

27. Level D – ‘D’umbo

28. Type/Description Advantages Disadvantages Self Contained Breathing Apparatus A compressed air tank containing 30 or 60 minutes (usually effective for less than the rated time) of breathable air. It is mounted on a harness worn on the back with a tight fitting facepiece. 25-40 lbs Atmosphere-supplying respirator. Greater mobility. Can be used for unknowns, in oxygen deficient atmospheres, and atmospheres above IDLH levels Heavy and bulky (increased injury hazard). Limited air supply. Users must be fit tested. No facial hair allowed that interferes with mask. High level of training. High cost. SCBA

29. Type/Description Advantages Disadvantages Supplied Air Respirators A hose attaches the user to a regulator that is connected by another hose to either a compressed gas tank, compressor, or piped system. The mask can be either a tight fitting mask or loose fitting hood. Reduced potential of overexertion injuries. Can be configured for extended use. Loose fitting hoods do not require fit testing and allow beards. Limited to hose range. Greater slip, trip and fall hazard from hoses. Possible security risk. Most do not have escape air supply. SAR

30. Type/Description Advantages Disadvantages Air purifying respirators (APR) A specialized filter attached to either a facemask or hood. Can be of a demand valve or powered type (PAPR). A filtered air source. PAPRs are generally more comfortable than APR and less work of breathing. Often less expensive than atmosphere supplying respirators. Cannot be used for ‘hot zone’ without air monitoring, or atmospheres below 19.5% oxygen. Facepiece fitting issues as SCBA. Loose fitting hood can only be used with PAPR. Filters must be appropriate for contaminant present. APR/PAPR

31. Training and Medical Surveillance • 29CFR1910.134 • Medical surveillance and screening • Training requirements for respirators – initial and refresher • 29CFR1910.120 • Operations Curricula – 8h or to competance • Hospitals – 8h can include Awareness training, PPE training, other relevant training • (OSHA Bolt letter 2003)

32. Minneapolis / St. Paul Hospitals • MSP MMRS • Hospital equipment should be standardized • Hospitals should provide decontamination only, not response to site of release • Decontamination only in well-ventilated areas • Protect against: • Biologic agents (HEPA) • Organic vapors • Ammonia • Acid gases • Potential agents of terrorism

33. Protects against: HEPA filtered for biologics Filters radon daughters and beta particles Organic vapor – nerve agents, organophosphates, etc. Cyanide (CN) Ammonia Chlorine and other acid gases Phosgene Riot control agents Mustard Formaldehyde Methylamine Hydroflouric Acid BE 10 PAPR with FR57 filter

34. MMRS PPE • 3M BE PAPR with FR57 canisters • Tyvek SL / Tychem F • Nitrile undergloves, neoprene or butyl overglove • Butyl boots • Duct tape