Assess pediatric considerations when performing decontamination, in general, and nerve agent care, specifically.

Decontamination principles /

With the reality of recent events, the possibility of a nuclear, biological, or chemical emergencies cannot be overlooked. Your health care organization needs to be prepared to quickly and effectively implement decontamination procedures to treat the contaminated individuals and protect other patients and staff by containing the causative agent.

Thoroughly prepared decontamination areas should have a location with strictly controlled access to decontaminate victims; an easy procedure for removing contaminants, regardless of the season; an appropriate means of handling the contaminated material and storing it as directed by proper authorities before removal by a certified hazmat (hazardous materials) removal contractor; disposable or cleanable medical equipment dedicated to treating victims’ injuries; and
appropriate personal protective equipment (PPE) for the decontamination team.

Location
The best place to set up a decontamination area is outside your main facility. If the weather is cold, prearrange for tents or other temporary structures. Outdoor decontamination is preferable to protect your facility’s staff, equipment, and other patients from becoming contaminated. If a large volume of victims flood into your facility, it can be very difficult to keep the contamination contained and away from other care settings. The possibility that the contamination may spread is real and must be considered. Your emergency management plan should address how your organization would respond to the functional loss of part of your facility due to contamination to ensure the continued quality and safety of patient care and protection of staff.

Some organizations have a dedicated decontamination room. This is fine, as long as you have only a few contaminated victims to treat and they do not have to be transported a long distance through the emergency department or other common areas. This room should have easy access; it should not be in close proximity to other care areas. It is important to coordinate decontamination efforts with your community’s local hazmat response team. This team may have portable decontamination units and prefer to go directly to the site of the contamination rather than risk spreading the contaminant to other sites, including your facility, by moving contaminated individuals. Realize, though, that in a large event, contaminated individuals will probably arrive at your facility before the hazmat team can access the situation, especially if individuals come via private car rather than through the local emergency medical service (EMS).

Also evaluate your facility’s air-handling systems. In a terrorist event, some victims may arrive at the health care facility before the details or implications of the event are clearly understood. Determine how you would isolate your HVAC systems to prevent spreading a contaminant throughout the building.

Training
An essential component of a successful decontamination program is training. OSHA mandates operations training requirements for those who will be involved in the actual decontamination. All employees in the emergency department should be trained at a minimum to the awareness level, with an understanding of patient decontamination issues.

Train staff to recognize possible hazardous situations and to respond properly and immediately. This includes your entire professional staff. “When I had a chance to look outside the command center I saw all the doctors and nurses watching and waiting,” said Mary Thompson, the incident commander (and COO) at Bellevue Hospital Center in Manhattan. “I realized if there was a biological component to this attack, they would all be contaminated. If that had been the case, I would have had to call all new surgeons.” Staff within Continuum Health Partners have developed and are working to gain consensus on clinical treatment algorithms to broaden clinical diagnosis to rule out biological and chemical contamination.

Focus the training on identifying patients who may have come in contact with biological agents or chemicals and on avoiding contamination of the facility and staff. If any part of the facility becomes contaminated, it may have to be shut down or the facility itself quarantined and victims diverted to another facility until the situation can be resolved.

Decontamination and treatment
Decontamination begins with clinical assessment and should proceed in an orderly manner from head to toe in keeping with the primary trauma assessment. The primary goal is to make the victim “as clean as possible” (ACAP) after life-threatening conditions have been addressed.

Whenever possible, have the victim remove his or her clothing, double-bag the items in plastic bags, and seal the bags. Staff can then label the bags clearly. With patients who cannot care for themselves, staff members must be prepared to conduct this procedure themselves while keeping protected from contamination. Clean any open wounds and cover them in waterproof dressing.

Gently wash the victim’s skin with soap and a sponge beneath a spray of water. Some organic materials require an emulsifier to aid in removal. It is important to explain to a victim what you are doing during the decontamination process to keep the individual as calm and compliant with these procedures as possible. If multiple victims arrive at your facility the principles of triage must apply. Medical treatment priorities will be to treat life-threatening conditions (with appropriately protected staff), perform a primary assessment together with contamination reduction, thoroughly decontaminate, and identify hazardous material. Remember that as soon as a victim is decontaminated, he or she can then be treated as a “normal” patient.

Maintaining future readiness
There’s no denying that purchasing decontamination chambers, facilities, and equipment, and stocking appropriate pharmaceuticals for possible emergencies will incur significant expenses. The nation as a whole must be prepared to support and fund these efforts. And planning must be accelerated. Assess your staffing in areas like security, infection control, pathology, medical records, and health education for the appropriate mix and number of trained personnel.

Educate security personnel as to what they are looking for in these situations. Security must look for suspicious packages or suitcases left in the facility, unusual powders and other substances, patients looking for drugs to treat themselves in a biological scare, reporters and other unauthorized individuals breeching security into unauthorized areas, and so forth. Controlling access is critical when locking down the facility in the event of a mass casualty or contamination event. The nature of health care security is changing.

As fears and threats of anthrax, smallpox, and other nuclear, biological, and chemical agents rise, you have to work with public health officials in defining who will be tested, when they will be tested, and how they will be treated. Your laboratory staff may need to rapidly expand to handle the testing capacity. Medical records or infectious disease staff must monitor medical records for evidence of disease related to these agents. “Surveillance is our greatest weapon in America’s new war,” says Steven Garner, MD, chief medical officer for Saint Vincent Catholic Medical Centers. “It’s not a chore. It’s a necessity.”

Decide whether personal protective equipment needs to be stored at all lobby entrances, not just the emergency department, in case staff need to suit up during a facility lockdown. Refer to guidelines from the Centers for Disease Control and Prevention (www.cdc.gov) to identify what type of PPE is appropriate for your facility. Plan for large-scale decontamination needs. Think of how you will ensure for privacy and modesty in such an event. Decide what part of your facility you are willing to convert to a decontamination site and how will you separate airflow.

If you don’t yet have the facilities, arrange with your local fire department to use an appropriate hose. Plan for how you will use it. It would be best to do a vertical spray, perhaps from the roof of your facility, so that a horizontal spray will not contaminate others in the vicinity.

There is a real risk to staff members’ health as they respond to contaminated victims. There are no easy answers for many of the tough questions that arise in response to current threats of terrorism. Dealing with infectious or off-gassed agents makes staff susceptible to injury and loss. Who will staff such events and how will they handle them? When do you provide treatment? How will you protect staff? What areas of your organization might you lose to contamination? Your staff needs direction in these areas.

As we adjust to the new “normal” of nuclear, biological, and chemical threats in America, health care organizations also must be prepared for increased need in the behavioral health arena. “The very nature of terrorism implies a major mental health function,” says Manuel Trujillo, MD, chair of the psychiatry department at Bellevue Hospital Center. He urges health care organizations to prepare for this aspect in far higher numbers and for the longer term. New York City, which may have the most mental health professionals per capita in the United States, mounted a major response to this need. Small communities across America will not be as effective without preplanning and building relationships with community and regional organizations.

Special Issue, Joint Commission Perspectives, December 2001, Volume 21, Number 12

some reading. the first 2 are important to have a look. and I will post the case study assignment, it is also related to this topic.

http://theconversation.com/novichok-the-deadly-story-behind-the-nerve-agent-93562

DHS_100-06ChemDetFinReport_3-20-07.pdf

Model Radioactive Material or Multiple Hazardous Materials Decontamination Procedure. Prepared For The Department of Energy Office of Transportation and Emergency Management. http://www.em.doe.gov/PDFs/transPDFs/Decon_Procedure.pdf

“Dirty Bomb” Attack: Assessing New York City’s Level of Preparedness from a First Responder’s Perspective. By John Sudnik, March 2006. http://www.fas.org/irp/threat/sudnik.pdf
?Taking an Early Bath?. Autumn 2010, CBRNE World Decon Taking a Bath.pdf

National Strike Teams: An Alternate Approach to Low Probability, High Consequence Events. Adam Crowe, HOMELAND SECURITY AFFAIRS, VOLUME IV, NO. 2 (JUNE 2008)
National Strike Teams – An Alternative Approach to Low Probability, High Consequence Events.pdf