Mike Yarnell Compliance Assistance Specialist HCFMSNJ – Union, NJ

2. Role of the Health Care Facility in Emergencies Mike Yarnell Compliance Assistance Specialist HCFMSNJ – Union, NJ

3. What is an Emergency? • Unplanned event – accidental, natural or deliberate • Can cause death or significant injury • Can also cause physical or environmental damage • Can affect anyone • Can disrupt, shut down or destroy the normal way of life

4. Power outage Communication failure Winter storm Flood Hurricane / tornado Mud slide HAZMAT incident Fire or explosion Earthquake Civil disturbance Pandemic flu Bombing Terrorist attack Radiological incident Typical and Atypical Emergencies

5. Terrorist Act • Targets • Economic assets, symbolic structures, high density population / occupancies, critical infrastructure, historic / cultural sites, transportation services, emergency services, other high visibility targets • Select certain dates, special events, shock value • Goals • Casualties / fatalities, destruction of critical infrastructure, economic disruption

6. Terrorist Act • Types • Bombing, WMD attack, assassination, cyber • WMD agents - BNICE • Biological (bacteria, virus, toxin), nuclear (weapon, suitcase, dirty bomb), incendiary, chemical (lung, nerve, blister, blood, choking, incapacitation, riot agents), explosive

7. The National Response Framework • National Contingency Plan requires communities to prepare local emergency response plans • NRF uses NIMS as a template • Focuses on response and short-term recovery • Uses the “All Hazards” approach

8. The National Response Framework • Incorporates government, community, non-government and private sector assistance • Integrates these resources for an incident requiring a “Coordinated Federal Response” • Outlines special circumstances in catastrophic incidents where significant support is needed • Requires compliance with the Incident Command System

9. The Incident Command System

10. Emergency Response Plans • A health care facility may be designated by the LEPC to serve as an active partner in preparedness and response organizations • Considered to be part of the infrastructure, as a response resource to conduct decontamination and treatment of affected individuals • Must develop an ERP that addresses roles of personnel, decontamination, PPE and training • Facilities that have not been designated may still have a role in response

11. What is Incident Management? • Operational risk management which considers • Preparing for • Responding to • Mitigating and • Recovering from AN EMERGENCY to minimize the loss!

12. Overview • Basic Concepts • Work with the LEPC / OEM • Develop a plan • Role of health care personnel • Assumptions to anticipate exposures • Personal protective equipment • Training • Putting it all together

13. Basic Concepts • Never accept an unnecessary risk • Risk a lot to save a lot • Risk little to save little • Risk nothing to save that which is already lost

14. Work With the LEPC / OEM • The health care facility should establish contact with the local emergency planning committee / office of emergency management • Describe facility capabilities and limitations • Learn what assistance may be expected • Meet and know the players • Ensure transported victims are decontaminated (if possible) prior to arrival

15. Work With the LEPC / OEM • Key treatment center – within a large urban area • Potential risk center - <50 miles from a large urban area or situated near a potential target • Primarily mass casualty incidents • Inventory of all toxic chemicals within the community • “All Hazards” approach makes decision logic more flexible

16. Why Develop a Plan? • Fulfills responsibility to protect employees, the community and the environment • Decision making tool, puts the response mechanism in place • Enhances the ability to recover • Reduces liability, risk, injury and illness

17. Develop a Plan • Complete a hazard vulnerability analysis • Assign roles for communication, directing the response and training • Designate teams to address decontamination, treatment and support • Implement preparations – training, equipment selection and maintenance, respirator program • Determine methods of communication with response organizations

18. Develop a Plan • Determine routes of exposure, degree of contact and specific tasks for each team member • Consider how to obtain information on toxic materials • Manage supply of PPE • Prevent cross-contamination through ventilation systems and handling contaminated materials • Develop an emergency evacuation plan • Returning to normal following the emergency • Pre-emergency drills and practice sessions with LEPC using the ICS

19. Develop a Plan • Anticipate number of victims • Methods of handling ambulatory and non-ambulatory victims • Victim decontamination equipment, procedures and designated areas • Managing treatment of non-contaminated patient • Joint Commission requirements

20. Decontamination Considerations • Precautions to prevent spread of contamination • Minimize exposure to unprotected staff, patients, visitors or equipment • Outdoors preferable with easily decontaminated or disposable equipment • Indoors with ventilation isolation

21. Role of Health Care Personnel • Viewed as “First Receivers”, not HAZMAT “First Responders” • Nearly always remote from the site of the emergency or point of release • Primary exposure is from victim’s skin, hair and personal effects • In rare instances, personnel may be called to respond at the scene (must be capable)

22. Roles of First Receivers • Decontamination staff • Clinicians who may triage and / or stabilize victims prior to decontamination • Security staff that will control entry • Setup crew • Victim tracking clerks • Other support personnel

23. Assumptions / Exposures • Little or no warning, contaminant unknown • Up to 80% self-referred, not decontaminated • Some stretcher-bound (symptomatic) • Clinical issues may include triage, CPR, IV insertion or life support • PPE depends on decontamination prior to entry and duty of personnel

24. Assumptions / Exposures • Security or sign on entrance to prevent facility entry prior to decontamination • Risk is low, even without PPE • Primary determinants • Clothing removal, field decontamination, time lapse since exposure, extent of exposure, type of agent, evaporation / dissipation of agent • Secondary determinants • Clothing handling and disposal, wash water disposal

25. Personal Protective Equipment • Sufficient for the type and level of exposure anticipated; goal is to prevent inhalation and contact with the skin an mucous membranes • Must consider splashes or patient contact • There are no clear or absolute answers • Latitude in judgment • Independent decision-making • Decontamination zone vs. treatment zone

26. PPE at the Site • Level B protection • Supplied air respirator including face protection • Full coverage chemical-resistant suit • Chemical resistant gloves • Chemical resistant boots • Taped at seams

27. Training at the Site • First responder operations level – 29 CFR 1910.120 (q)(6)(ii) (8 hours) • Selection and use of PPE, decontamination procedures, hazard recognition, controlling spread of contamination, adequacy of equipment • Respirator training which includes fitting and medical evaluation • ICS level 200 as a minimum

28. PPE for First Receivers • Level C protection for chemicals • Respirator of choice is a PAPR - helmet and hood with an APF of 1,000 • Filter includes HEPA and AG/OV cartridge • Chemical-resistant coveralls (Tychem F, Kappler 9400), head cover (if not part of the suit), boots and double layer of gloves (openings taped) • Outer glove should be chemical-resistant e.g. butyl over nitrile, or two layers of nitrile for dexterity

29. PPE for First Receivers • Level C protection for biological agents • N-95 or equivalent respirator – NOTE: a surgical mask is not a respirator • Tyvek or other coveralls, surgical gloves, shoe covers

30. Training for First Receivers • First responder operations level – 29 CFR 1910.120 (q)(6)(ii) (8 hours) • Selection and use of PPE, decontamination procedures, hazard recognition, controlling spread of contamination, adequacy of equipment • Respirator training which includes fitting and medical evaluation • ICS level 100 as a minimum

31. PPE for Triage / Treatment • Personnel not expected to have contact with a contaminated victim or their personal effects and those who may encounter self-referred victims without prior notification • Standard healthcare gear including a lab coat and surgical gloves (infection control) • May need a respirator for a patient in respiratory distress or for high hazard procedures

32. Training for Triage / Treatment • First responder awareness level suggested • Risks of hazardous materials, recognition of presence (hazard communication), knowledge of roles, notification to others, knowledge of the response plan • Important that these personnel avoid physical contact with a contaminated victim, are aware of notification procedures and that properly-equipped personnel decontaminate the victim before proceeding

33. Putting it All Together • Learn number of victims, type or nature of contaminant, associated symptoms • Activate decontamination system • Initial medical monitoring of staff • Staff dresses out with PPE • Triage and stabilize victims • Disrobe victim and remove personal effects

34. Putting it All Together • Place clothing and effects in isolated area • Wash victims with mild liquid soap and tepid water – step must include copious rinsing • Dry and gown victim – treatment follows • Decontaminate equipment • Staff decontaminates themselves (showering) • Post response medical monitoring of staff

35. Important Considerations • Always consider periodic vital sign monitoring during extended events • Limit response time and provide rest breaks • Consider post response traumatic stress

36. Disclaimer • This information has been developed by an OSHA Compliance Assistance Specialist and is intended to assist employers, workers, and others as they strive to improve workplace health and safety. While we attempt to thoroughly address specific topics, it is not possible to include discussion of everything necessary to ensure a healthy and safe working environment in a presentation of this nature. Thus, this information must be understood as a tool for addressing workplace hazards, rather than an exhaustive statement of an employer’s legal obligations, which are defined by statute, regulations, and standards. Likewise, to the extent that this information references practices or procedures that may enhance health or safety, but which are not required by a statute, regulation, or standard, it cannot, and does not, create additional legal obligations. Finally, over time, OSHA may modify rules and interpretations in light of new technology, information, or circumstances; to keep apprised of such developments, or to review information on a wide range of occupational safety and health topics, you can visit OSHA’s website at www.osha.gov.