Hospital Threats - More to Address Than Just Donning & Doffing

An Ebola-infected American flown from Sierra Leone lies in critical condition at the National Institutes of Health. A nurse who contracted Ebola in 2014 when caring for a patient is suing Texas Health Resources for not properly training its employees. As these examples demonstrate, biological threats to hospital workers still exist, and the training must go beyond simply donning and doffing. 

The experiences over the past year with Ebola have once again highlighted the lengths to which healthcare facilities must go to protect their staff, including the use of personal protective equipment (PPE). However, Ebola is not the only clinical situation requiring PPE. Hospital personnel, otherwise designated as “first receivers” – by the Occupational Safety and Health Administration (OSHA) – who perform decontamination on patients affected by chemical or radiologic exposure also require protection. Regardless of the threat, each hospital is required to have a comprehensive program that addresses a variety of issues related to PPE. The OSHA Best Practices for Hospital Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances is a widely used document to help healthcare facilities, especially hospitals address a variety of response issues including donning (putting on) and doffing (removing) PPE.

Many Choices, but Availability May Be Limited Hospitals facing the threat of patients contaminated with biological or hazardous materials find themselves having to make a variety of decisions when it comes to staff protection. Although hazardous materials teams operated by fire departments and/or private sector companies may have four operating levels of PPE (Levels A, B, C, and D), hospitals generally maintain Level C as their highest level of protection, which is the minimum best practice recommendation set forth by OSHA. The ensemble composition and protective material used is based on what is required for the perceived threat.

PPE items typically include garb to protect the skin (impervious gown or suit/coverall), hands (gloves), and feet (boots/shoe covers) protection, along with respiratory protection (surgical mask, N95 respirator, or powered air purifying respirator – PAPR). Additional items such as portable radios, personal dosimeters, andentification vests also may be worn depending on a hospital’s operational procedures.

Outfitting a single responder in proper PPE can cost hundreds (or even thousands) of dollars, not including the PAPR, which depending on the brand and type purchased can run $600-$1,200. Increasingly, vendors are marketing PAPR systems that have disposable hoods that can be thrown away after use rather then put through a rigorous cleaning/reconditioning process that must be done in accordance with vendor instructions to ensure staff safety. Cartridge use and replacement also must be done in compliance with manufacturer recommendations. Depending on the type and duration of the incident, several change-outs per team member may be required. Some vendors now are selling battery packs that use D cell batteries for easier replacement, rather than continued reliance on rechargeable lithium or nickel cadmium batteries.

The amount of PPE to be kept on hand is another major decision and is determined by a variety of factors including but not limited to the amount of staff that will dress out, as well as available funding. Storage space must be found and may require considerable square footage depending on the amount of items purchased.eally, the space assigned is in proximity to where it will be used. OSHA and the vendors have outlined maintenance expectations for PAPRs and other items. These include documentation of regular equipment checks and replacing items before their expiration dates. The rechargeable battery packs for many of the PAPRs must be replaced every 3-5 years; users should consult with their vendors to ensure they are getting the optimum use of their systems. Even gloves, surgical masks, and N95 respirators have expiration dates, so sustainment funding is another commitment that must be made by the hospital.

Training Procedures to Perform & to Protect The OSHA First Receiver document also outlines the initial training that is to be provided to hospital personnel responsible for decontaminating patients exposed to hazardous materials. Subjects include response basics along with PPE and decontamination principles. The initial training may take eight hours to complete and includes actual practice of donning and doffing, as well as decontamination practice. Refresher training also should be presented annually with records kept of the training given to each team member.

Response guidance has been published and periodically updated by the Centers for Disease Control and Prevention and OSHA on PPE use when caring for a suspected or actual Ebola patient. Among the expectations is that everyone caring for these patients must be trained in proper donning and doffing techniques for the PPE they will be using (the PPE being worn varies somewhat between Ebola treatment centers, particularly in regards to the type of respiratory protection).

Also being stressed is the importance of a safety observer or “protector” always watching those working at the patient bedside for potential contamination contact and, if noted, then providing directions on personal decontamination. The doffing process is another phase where someone is observing and requires the PPE removal steps be done in a slow and deliberate manner to reduce the risk of contamination occurring since, unlike for chemical decontamination scenarios, the PPE for personnel caring for Ebola patients is not thoroughly decontaminated before removal.

The protection of hospital personnel working with patients contaminated with hazardous materials, or ill from a highly infectious disease, is of paramount importance. To meet that responsibility, the hospital must make administrative, logistical, and financial commitments that have short- and long-term implications to ensure that their staff has what is needed, and are properly trained to safely perform their tasks.

Craig DeAtley

Craig DeAtley, PA-C, is director of the Institute for Public Health Emergency Readiness at the Washington Hospital Center, the National Capital Region’s largest hospital. He also is the emergency manager for the National Rehabilitation Hospital, and co-executive director of the Center for HICS (Hospital Incident Command System) Education and Training. He previously served, for 28 years, as an associate professor of emergency medicine at The George Washington University. In addition, he has been both a volunteer paramedic with the Fairfax County (Virginia) Fire and Rescue Department and a member of the department’s Urban Search and Rescue Team. An Emergency Department PA at multiple facilities for over 40 years, he also has served, since 1991, as the assistant medical director for the Fairfax County Police Department.



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