The primary reason why the Emergency Department of almost any U.S. hospital or other healthcare facility should be ready and able to respond to a hazardous material release is to protect patients, staff, and the hospitals’ own facilities from avoidable contamination. However, unlike many other patient-care procedures that are performed elsewhere in the hospital that – not incidentally – generate revenue, decontamination drills and exercises are rarely scheduled except for the training considered to be absolutely mandatory.
A recent healthcare system exercise was conducted on 19 April 2013 in Washington, D.C., where eight acute care hospitals responded to the notional release of an insecticide called malathion. That exercise was a reminder to local hospital and public health officials throughout the National Capitol Region about the high costs of patient decontamination training drills.
The “Wally’s Warehouse” Incident The two-day exercise centered on a scenario involving high winds and heavy rain, which culminated in a tornado striking a gas line that subsequently ruptured and ignited. The ensuing fire – at “Wally’s Pesticide Emporium,” a fictional warehouse containing the malathion – caused the pesticide to be released into the air as well as the ground areas adjacent to the warehouse. The fire itself caused more than 100 injuries – including many from pesticide poisoning – in the warehouse and surrounding neighborhood.
The local fire department provided preliminary care by performing a notional “gross decontamination” of many of the patients before transporting them to the hospital; some of the patients, though, were “rescued” and taken to the hospital in other vehicles. The eight hospital emergency departments participating in the exercise thus received patients who had been either partially or not at all decontaminated.
Some of the patients also had been administered initial doses of Duodote – an antidote for nerve agents – by the emergency medical systems units participating in the exercise. The MEDSTAR Washington Hospital Center (MWHC) was one of three hospitals that set up their own decontamination system and actually decontaminated 35 of the patients who had been transported to the Center.
Decontamination – Who Does What? Once it had been determined at the Center that decontamination of some type was needed, the hospital’s disaster and hazardous material response plans were quickly activated, and orders were issued that resulted in two types of staffing being mobilized to carry out the patient decontamination. The first group included three nurses and one technician from the emergency department who were given the assignment. Because they were already on duty, no additional costs were incurred. In some hospitals, other staff members within the same hospital who had completed the required site training would also have responded, with no additional costs incurred.
For the Wally’s exercise, the hospital also activated its “Team Decon,” a select group of 45 well-trained personnel – with varying skills and hospital assignments – who had agreed beforehand not only to assist but also to respond from home when off duty. These on-call personnel are compensated at a set rate of $30 per hour. For the exercise, 10 team members responded, as requested, and participated in the four-hour exercise – at a total initial cost of $1,200. In real-life situations, though, the cost undoubtedly would be much greater because more personnel probably would have been needed.
Pop-Up Tents & Other Decontamination Areas Most hospitals have at least one or more settings in which to conduct patient decontamination. Tents are a common setting used for this purpose and offer several operational advantages as well. They can quickly be set up in several locations, for example, and used in different but complementary ways. Each tent, though, usually requires the presence of at least two or more staff members – and the set-up time itself varies considerably, depending on the size and type of tent used. During the Wally’s exercise, the MWHC itself used three, each with two lanes, at a cost of $18,000 per tent (2009 prices). To add heated water as well as internal heating and/or air conditioning – and in some cases a conveyor system that could be used for non-ambulatory patients – all would incur relatively high additional costs.
Some facilities use trailers that are pre-plumbed and are equipped with two or more shower stations. The advantages provided by the use of trailers include not only their mobility but also the fact that they usually can be operational very quickly. Their disadvantages include the space required for set up, various equipment and other storage requirements, and routine as well as emergency maintenance costs. Most trailers range in price – depending on their size and operational capabilities – from a minimum of $65,000 to $200,000 or higher.
Many hospitals, of course, including the MWHC, already possess the indoor spaces, and associated capabilities, that also cost hundreds of thousands of dollars or more. Once again, the decontamination costs will vary considerably depending on the number of showerheads needed, the type of drainage system employed, and other design and/or operational considerations.
The principal advantage of using such facilities is that the room is always ready and very little, if any, additional preparation is needed to prepare them for the arrival of one or more patients. The MWHC’s current indoor shower area, for example, is part of a $2.5-million-dollar room designed as a multipurpose disaster response area. The Ready Room contains a decontamination shower area equipped with four fixed shower heads and a floor drain; however, there is no in-ground storage tank – probably because the cost of installing and maintaining one would be a large additional expense.
Equipment/Supplies & Other Costs To meet OSHA (the Labor Department’s Operational Safety & Health Administration) “First Receiver” personal protection requirements, hospitals must use Level C ensembles consisting of chemical-resistant boots ($75-$110 a pair), inner and outer gloves ($8), a protective suit ($75-$90 each), and a power air-purifying respirator (PAPR, which cost $1,100 each). Rather than buy all such items individually, some facilities purchase commercially prepared PPE (personal protective equipment) sets at a cost of about $125 each.
Depending on the operational situation involved, a personal radiation dosimeter also may be issued to each decontamination team member to wear, at an additional cost of several hundred dollars each. During the Wally’s exercise, MWHC used 14 of its 50 PAPRs and 14 Chem Pak Response kits ($1,750 each). The long-range plans of most U.S. hospitals project a future inventory that allows for multiple PPE change-outs during a response – resulting, therefore, in additional inventory expenses.
The most important variable cost involved in these same projections, obviously, involves the patients who are going through the decontamination process, who must: (a) first have their own clothing and valuables bagged and tagged; and (b) later, during the decontamination process itself, will be using a bar or bag of soap, followed by towels and a gown. The kits containing these items, plus flip-flops for foot protection, cost about $15 each; the MWHC used 35 during the Wally’s exercise, for a cost of $525.
The symptoms caused by malathion – and/or other nerve agents – can be treated with the antidotes atropine and 2Pam, which are packaged individually as a Mark I kit or mixed together as Duodote. For the Wally’s exercise, more than 100 notional doses of Duodote were administered at a cost of $50 each (more than $5,000).
Bullhorns & Brushes; Sump Pumps & Trash Cans The hospitals involved in the decontamination process also incur several other costs. One such cost, not easily calculated, is for the water used during the response. In many cases, the water runs continuously and the costs can add up very quickly depending on the number of shower positions being used. Portable basins collect the runoff (the cost varies by size, but can be several hundred dollars), which may be moved by a sump pump ($100) into a bladder (again, varies by size, but is usually several hundred dollars) and then sucked up by a hazardous waste hauler, at a significantly greater cost.
Nighttime operations require lighting – whether fixed on overhangs, erectable (halogen lights on stands cost $79 each), and/or headlamps ($20-$59 each) worn by members of the decontamination team. Among the many other medical/sanitation and/or operational items commonly needed are: radios equipped with throat or ear microphones ($300-$500 each); bullhorns ($100); white boards ($35); large trash cans ($75 each); liquid soap containers ($6 per bottle); buckets ($5); and brushes ($7-$15 each).
The costs associated with a hospital being fully prepared to deal with contaminated patients will vary, of course, depending on the response capability desired or needed. In an era where positive bottom lines are becoming harder to meet, justifying these important, unique, and usually nonrecoverable costs is becoming an increasingly greater challenge. But then again, it takes only one major warehouse fire to fully justify all of the costs involved.
________________________ 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, administrator for the District of Columbia Emergency Health Care Coalition, 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, and now also works as an emergency department physician assistant for Best Practices, a large physician group that staffs emergency departments in Northern Virginia. In addition, he has been both a volunteer paramedic with the Fairfax County (Va.) Fire and Rescue Department and a member of the department’s Urban Search and Rescue Team. He also has served, since 1991, as the assistant medical director for the Fairfax County Police Department.