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OSHA gives advice on planning for mass casualties

Materials Management in Health Care

Warning that this country is unprepared for a mass chemical, biological or radiological attack, authorities have been beefing up “first responders” to these attacks and are now focusing on “first receivers” -- caregivers treating victims back at the hospital emergency department.

The U.S. Occupational Safety and Health Administration offers advice on how to organize, train and suit up first receivers in a new a new 154-page booklet that can be downloaded for free on the OSHA Web site.

The booklet is based on best practices culled from two years of dialog with seven unnamed benchmark hospitals, the military and private organizations such as the Joint Commission and the American Hospital Association.

When the booklet was proposed in 2002, “everyone agreed that the federal government needed to give better direction to hospitals to fine-tune their first receivers programs,” says David Ippolito, director of OSHA's office of science and technology assessment, who worked on the report. For one thing, “hospitals needed better guidance on how to spend money on personal protective equipment.”

Admittedly, first receivers are in much less danger than first responders. OSHA cites a study of hazardous materials incidents, finding that hospital personnel were victims only 0.2 percent of the time. But the 1995 sarin attack on the Tokyo subway system shows they are still vulnerable.

One hundred healthcare providers experienced symptoms from treating victims in that attack. A study cited by OSHA shows they did not take simple precautions that could have protected them. They were not dressed in protective gear, patients were not decontaminated before care-giving and ventilation was poor in waiting areas.

Plan in advance

OSHA urges hospitals to plan carefully for a mass casualty because, according to studies of actual disasters, victims can arrive in large numbers, without warning, and the hazardous agent may not at first be known.

The Joint Commission requires each hospital to create and update a hazard vulnerability analysis, identifying the unique hazards it may face. OSHA also recommends creating an emergency management plan that outlines how the facility will respond to an emergency.

One key step is choosing employees to decontaminate victims. The decontamination team may be as large as 100 employees, to allow for shifts and a variety of duties, and include employees with relevant backgrounds, such as the military, firefighting or hazardous waste handling.

OSHA requires team members and direct caregivers to undergo eight hours of training a year, including drills where they suit up in protective gear. Less intensive training is also required for staff who would not be as involved with victims.

Suiting up your team

For the front-line receiver team, OSHA recommends a full set of “personal protective equipment” that covers the body from head to toe. The pieces are:

• A chemical-resistant suit, which restricts vapor flow and is flexible, durable and lightweight, with its openings sealed with tape. OSHA mentions suits of Tyvek, a plastic made by Wilmington, Del.-based Dupont. Tyvek suits have protection factors as high as 42, meaning that vapor levels outside the suit are 42 times higher than inside.
• Double-layer rubber gloves, made from nitrile, which offers resistance to the widest range of substances, and butyl, which protects best against chemical warfare agents and most toxic industrial chemicals. The double-layer gloves are three to four times thicker than normal exam gloves. Alternatively, foil-based gloves are also highly resistant to a wide variety of hazardous substances.
• Chemical-protective boots, which, because they are thicker, are more protective than gloves.
• A respirator with facepiece and hood that has a protection factor of 1,000. It should be fitted with high efficiency dust, organic vapor and acid gas cartridges.

The booklet reports that healthcare workers in this full set of protective equipment have been able to “effectively” perform endotracheal intubation, although it will take longer than normal.

OSHA says it requires hospitals to provide equipment that fits “appropriately.” One benchmark hospital provides sets of equipment based on boot size, including two sizes of gloves to ensure proper fit. Excess fabric on suits can be taped or rolled up to fit, the booklet says. It adds that while respirator hoods offer a universal fit, tight-fitting facepieces require fit testing.

OSHA says it is optimistic that hospitals will take the steps its new booklet recommends. “Recent incidents (including the World Trade Center and anthrax attacks) and current JCAHO requirements provide hospitals with strong incentive to take the necessary steps,” the booklet says.

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