You’re at risk for contamination: Here’s how to protect yourself
Chemically contaminated patients pose risk
When a 40-year-old man swallowed insecticide in a suicide attempt, a friend rushed him to the nearest ED. Minutes later; the man was intubated for airway management and ventilation.
Within an hour of the patient’s arrival, the ED nurses who had cared for the patient began to feel sick. One nursing assistant had to be intubated after developing respiratory distress, profuse secretions, emesis, and diaphoresis, and was hospitalized for nine days. Other nurses who had shared the patient’s breathing space experienced diaphoresis, hypersalivation, nausea, and abdominal cramps.
As an ED nurse, you are at high risk for these injuries because you may care for patients contaminated with chemicals resulting from self-inflicted contamination, industrial incidents, and terrorist events. (See "CDC recommendations to avoid secondary contamination," in this issue.) There is no excuse for lack of preparation for these scenarios, argues Ann Stangby, RN, CEM, emergency response planner for San Francisco General Hospital. "You have a moral obligation to protect your staff," she says. "There is no choice in the matter."
If you don’t have the materials you need to protect yourself and your staff, you’ll have more victims when chemically contaminated patients come to the ED, warns Stangby. Here are ways to protect yourself when caring for contaminated patients:
• Recognize signs of contamination early.
You can minimize secondary contamination by recognizing it early, says Bettina Stopford, RN, chair of the national Weapons of Mass Destruction (WMD) work group for the Des Plaines, IL-based Emergency Nurses Association and chief nurse for the Denver-based U.S. Public Health Service’s Central U.S. National Medical Response Team for WMD. "If you know to immediately direct patients to an area that’s secured, you can minimize secondary contamination," says Stopford. Include decontamination as part of your annual competencies, including hands-on training with personal protective equipment, she recommends.
All nurses should be familiar with chemical contaminants and how to protect themselves, urges Stangby. There are excellent training courses available, she says. "Some of the people who received funding are now starting to share their expertise, which is a wonderful resource," she adds. (See "Resources," at the end of this article, for a list of training courses to take.)
• Don’t rely on pre-hospital providers to decontaminate patients.
No matter how much you prepare for a disaster, you’ll need to work with pre-hospital providers to ensure you’re ready to decontaminate large numbers of patients, says Stangby. "With staffing numbers and financial constraints, we cannot do it alone," she stresses. "We are the nontraditional first responders, and we need to think of ourselves that way."
Even if the fire department did some gross decontamination in the field, you should still consider the patients contaminated and conduct further decontamination, says Stopford. Stangby points to the 1995 saran attack in Tokyo, where 80% of the contaminated patients came to EDs using their own transportation. "People with milder symptoms were jumping in cabs and buses and going to the hospital on their own," she explains.
As a result, a significant number of ED staff were contaminated and had to be treated themselves, says Stangby. "If nurses are becoming patients because of exposure, there will be no one to take care of patients," she says. "That is frightening."
• Know what protective gear to use.
Aim for Level C protection, one of four levels of protection developed by the National Institute for Occupational Safety and Health, a division of the Atlanta-based Centers for Disease Control and Prevention, Stopford recommends. Level C protection consists of a chemical-resistant suit, powered air-purifying respirator, chemical protective gloves, and pull-on boots. "If you can exceed that level of protection by using a self-contained breathing apparatus, that’s great, but the cost and training for that is usually prohibitive," she adds.
Some traditional protective gear, such as high-filtration tuberculosis (TB) masks, doesn’t work for chemicals, notes Stangby. She recommends using powered air purifying respirators, which cost about $700 apiece. "They have battery packs with supplied air, so the air you breathe is filtered," she says. "They give you excellent peripheral vision and are very comfortable to wear." (See "Resources," at the end of this article, for list of manufacturers.)
New standards from the Washington, DC-based Occupational Safety and Health Administration (OSHA) require you to provide equipment to protect staff from TB exposure, she says. "If you don’t have high-filtration TB masks available, you must have something else," she says. "The powered air-purifying respirators are a good way to go." (See excerpt of OSHA guidelines, in this issue.)
• Have an identified area for decontamination.
The Tokyo incident occurred in cold weather, so patients had on heavy coats, notes Stangby. "It was airborne, and they were rebreathing the stuff. If they had simply taken off people’s clothing, that would have taken care of 90% of the decontamination," she says. "But because it was an unknown, no one knew what to do. Now we know better."
You need to consider how to increase the numbers of patients you can decontaminate, but you don’t have to build huge overhead showers to do this, says Stopford. "If you have a private area where patients can undress and shower so they won’t contaminate your facility, you will be in a lot better shape," she adds.
Stopford recommends starting small and working your way up. "You don’t have to prepare to decontaminate thousands of patients. Shoot for 100 patients to start with," she advises. She recommends using mass decontamination shelters for large groups of patients, which cost approximately $3,000 each. Inside, the tents have shower systems with separate areas for male and female patients. (See "Resources," at the end of this article, for more information.)
"The tent only takes two people to set up," she says. "It’s a good middle-of-the-road [product], when you don’t have thousands of patients, but you have more than a few."
• Determine the route of exposure.
The precautions you take will depend on how the patient was exposed, says Stangby. "For example, there is big difference if people were splashed with saran or chlorine, as opposed to inhalation or mild exposure on clothes," she says. If you hear there are chemical casualties, try to find out how the patients were exposed, she advises. "For example, if it’s only through inhalation, you don’t have to wear personal protective equipment," she notes.
She cautions that patients may "off gas" and contaminate you by releasing the agent through respiration or other body fluids. "They will not require external decontamination, but they will require internal decontamination," she says. "This may put you at risk if the correct personal protective equipment is not utilized."
• Have the fire department automatically respond.
At San Francisco General Hospital, the fire department automatically sends an engine, truck, and hose tender to the ED whenever the HazMat system is activated. "This is based on the threat assessment, including the level of decontamination that may be required, the number of potential victims, and the proximity to the hospital," says Stangby.
Recently, the ED asked the fire department to critique their decontamination system. "Sometimes you have to check your ego at the door to get things done," Stangby notes. "We told them, You are the experts, so tell us if we’re doing this right.’" As a result, several joint training exercises were held, which were videotaped and used to train staff.
"We’d now be able to decontaminate hundreds of patients because of the collegial relationship we forged with the fire department," she says. "That is probably going to save us if anything bad happens here."
Sources
For more information on secondary contamination, contact:
• Ann Stangby, RN, CEM, Emergency Response Planner, San Francisco General Hospital, 1001 Potrero Ave., San Francisco, CA 94110. Telephone: (415) 206-3397. Fax: (415) 206-4411. E-mail: [email protected].
• Bettina Stopford, RN, Denver Health Medical Center, 777 Bannock St., MC 8200, Denver, CO 80204. Telephone: (303) 436-3431. Fax: (303) 436-6828. E-mail: [email protected].
Resources
• TVI Corp. has a line of "quick-erect" mass decontamination shelters. For more information, contact: TVI, 7100 Holladay Tyler Road, Suite 300, Glenn Dale, MD 20769. Telephone: (301) 352-8800. Fax: (301) 352-8818. E-mail: [email protected]. Web: www.tvicorp.com.
• Louisiana State University offers training for health care providers in counterterrorism. Courses include Emergency Response to Domestic Biological Incidents and WMD Tactical Operations Course. For more information, contact: Louisiana State University, Academy of Counter-Terrorist Education, 334 Pleasant Hall, Baton Rouge, LA 70803. Telephone: (225) 578-1375. Fax: (225) 578-9117. E-mail: [email protected]. Web: www.doce.lsu.edu/ace.
• The U.S. Public Health Service offers instruction for health care personnel, including how to protect yourself against the effects of weapons of mass destruction, techniques and methods to protect the hospital physical plant, and current treatments for injuries/illnesses from nuclear, biological, or chemical incidents. For more information, contact: U.S. Public Health Service Noble Training Center, P.O. Box 5237, Fort McClellan, AL 36205. Telephone: (256) 820-9135. Fax: (256) 820-8694. Web: www.ndms.dhhs.gov. (Click on "Links," then "Federal Counterterrorism Sites," then "Noble Training Center.")
• The 2002 National Disaster Medical Service Conference will be held on April 13-17, 2002, in Atlanta. Courses will include public health, response teams, clinical medicine, health care facilities, and weapons of mass destruction. For more information, call (800) 872-6367 (press the "star" key), or e-mail [email protected].
• A complete copy of the Centers for Disease Control and Prevention (CDC) guidelines titled "Biological and Chemical Terrorism: Strategic Plan for Preparedness and Response," which were published in the April 21, 2000, issue of Morbidity and Mortality Weekly Report (MMWR), can be downloaded at the CDC web site: www.cdc.gov. (Click on "MMWR," then "Publications," then "MMWR Recommendations and Reports: Past Year Volumes," then "Volume 49 (2000)," then scroll down for the April 21, 2000, issue).
• 3M offers the Breathe Easy RRPAS (Rapid Response Powered Air System) and Butyl Rubber Hood (BE 10) PAPR for use when decontaminating patients. Cartridges are available for protection against many industrial chemicals and military agents. For more information, contact: 3M Occupational Health and Environmental Safety Division, 3M Center, Building 275-6W-01, P.O. Box 33275, St. Paul, MN 55133-3275. Telephone: (800) 896-4223 or (651) 737-0309. Fax: (800) 542-9373 or (651) 736-2555. E-mail: [email protected]. Web: www.3M.com/occsafety.
• Neoterik Health Technologies offers powered air-purifying respirators to protect first responders after accidents or terrorist events. The "First Responder" series includes the FR2 PAPR with full-face piece for $475, and the FR3 PAPR with full hood for $475. For more information, contact: Neoterik Health Technologies, 401 S. Main St., Woodsboro, MD 27198. Telephone: (301) 845-2777. Fax: (301) 845-2213. E-mail: [email protected].
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