Toxic Exposure Hazardous Materials

Issues of Concern

Epidemiology

In the United States, the National Toxic Substance Incidents Program (NTSIP) collects information about the hazardous material incidents that occur nationally. This is accomplished through state surveillance, the implementation of a national database, and incident investigations. In 2013, an estimated 14,175 incidents occurred across the country, with 65% occurring at industrial facilities and 35% during transportation. Of these incidents, 1527 people were injured, and 37 died. Substances causing the most injuries were carbon monoxide, methamphetamine chemicals, sulfuric acid, natural gas, ammonia, and sodium hydroxide. Around 35% of incidents needed multiple types of responders and 20% required evacuation. Hazmat incidents are not rare; therefore, emergency care providers in pre-hospital and hospital settings need to be prepared to deal with these scenarios and care for victims. Even though most victims are decontaminated in the field, some may come directly to the ED with no previous decontamination. Hospitals must have a plan to care for these patients in these cases.

Community and Hospital Planning

Hospitals that participate in planning for hazmat incidents must follow requirements established by different federal agencies and organizations such as the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) and the Occupational Safety and Health Administration (OSHA). The most important statute is the Superfund Amendments and Reauthorization Act (SARA) Title III, which is a part of the Emergency Planning and Community Right-to-Know Act of 1996. This statute mandates that every facility storing, using, and manufacturing hazardous materials reports its inventory and the release of hazardous substances to health personnel and public officials.[4] The SARA Title III also requires hospitals to establish state emergency response commissions (SERC) and local emergency planning committees (LEPCs).

LEPCs are formed by fire, police, public health authorities, hospitals, and media representatives. LEPCs are responsible for the development of emergency response plans (ERPs). The objectives of an ERP are to identify local facilities that use hazardous materials, designate coordinators in the community and industry, establish a mechanism to notify emergencies, establish procedures to determine the occurrence of an incident and the estimate of victims, create evacuation plans, and train emergency personnel.[5] ERPs vary for each community depending on the type of industries present, the hazardous substances produced, and the resources available. For instance, in metropolis areas, fire departments establish hazmat teams that are specifically trained to be first responders in HAZMAT incidents to contain spills and decontaminate victims in the field. After the HAZMAT team decontaminates, the patients are transported to the nearest hospital for medical care.

Communities lacking a hazmat team must develop an ERP that considers that victims will be transported to the hospital with no prior decontamination. In this case, measures must be taken to provide decontamination and medical care without exposing healthcare personnel to hazardous substances. The JCAHO requires that hospitals follow guidelines to be prepared to respond to incidents. The guidelines include planning activities to minimize risks by writing procedures that delineate the use of personal protective equipment (PPE), procedures to respond to hazardous chemical exposures or waste spills, and measuring gas and vapor levels to ensure safety in the hospital environment.

OSHA has established regulations to protect employees who may be exposed to hazardous materials. Respiratory protection and appropriate training for those in contact with chemical vapors are required, as well as the assurance of available PPE in the workplace.[6] OSHA also requires that all ED personnel are trained as first responders at the awareness level. This means recognizing a hazmat emergency, isolating the area, and calling for help. Additionally, any employee involved in decontamination must receive training to be a first responder at the operation level, which implies being responsible for the decontamination process and directly controlling the substance in question. Training requirements for hazmat and EMS workers are delineated by the Hazardous Waste Operations and Emergency Response (HAZWOPER) standards, which have been found to improve emergency preparedness and reduction in unsafe working conditions among different industries.[7]

Hospitals must be prepared to respond to hazmat incidents by establishing a plan that includes the following aspects of emergency care: triage, PPE, dealing with individuals that arrive at the hospital by private car, decontamination procedure, medical care after decontamination, and media relations. The implementation of guidelines varies depending on the location and availability of hazmat teams. Ideally, hazmat teams should perform decontaminating in the pre-hospital setting with subsequent usual hospital care. If several hospitals are located near the incident, only one facility should be chosen as the receiving hospital. This decision is made based on the availability of trained personnel, toxicology service, and decontamination facilities. Planning is critical in every hospital. Even though only one hospital is chosen as the receiving institution, situations occur where contaminated patients arrive by private vehicles at a hospital other than the established receiving facility. Failure to provide care and decontaminate the victim before transferring to the receiving facility is an Emergency Medical Treatment and Active Labor Act (EMTALA) violation.

Hazmat Management

An ERP delineates who is in charge of the situation. This person is known as the incident commander. The incident commander represents the LEPC or a hazmat team and is specially trained to command the incident, make decisions, and be responsible for protecting public health and the environment. An ERP addresses other aspects: the reasons for evacuation, the establishment of evacuation centers, and the degree of involvement of EMS personnel not trained in hazmat incidents. The community disaster response plan describes the chain of command, HAZMAT team, and EMS interaction. Ideally, the hazmat team decontaminates the victims before turning them over to EMS. However, there might be instances where the severity of the victims’ injuries overweight the training of the HAZMAT team, and EMS workers need to intervene before the decontamination is done. HAZMAT workers are usually fire department members, with some training as paramedics and emergency medical technicians.

The goals in the management of HAZMAT incidents are:

• Recognition and notification of the incident to emergency services
• Institution of a command center
• Safety of workers from further exposure to hazardous substances
• Recognition of the hazardous material
• Evaluating the risk and the degree of PPE required
• Rescuing victims on-site
• Management of the crowd and retaining exposed individuals until they are decontaminated
• Alerting healthcare facilities of the event and providing an estimate of the number of victims
• Decontamination of victims
• Containment of hazardous chemicals
• Assessment of public exposure and the need for evacuation

Site command center

The establishment of the command center is a priority in the emergency response. The command center should be located near the incident and ideally uphill and upwind to minimize contact and exposure to the hazardous chemical. A wind monitor with an alarm system should be used at the command center, as well as rapid communication systems. The site is divided into three zones: the hot zone, the intermediate zone, and the command center. The hot zone is where the hazardous substance and victims are located; only individuals with appropriate PPE can access the hot zone. The intermediate zone is where the decontamination occurs and where basic life support measures may be provided if needed. The command center is the zone where decontaminated victims who need medical care are turned over to EMS. Before entering the command center, all exposed workers and equipment must be decontaminated. Access to these zones must be rigorously controlled to avoid exposure and contain hazardous substances.

Transportation

Contaminated victims shall not be placed in an ambulance, as this introduces a high risk of exposure for those operating the ambulance. Additionally, this contaminates the ambulance, which can no longer be used until it is decontaminated. This leads to the loss of valuable resources during an emergency response. Patients can be transported in the back of open trucks when decontamination options in the field do not exist. However, in this scenario, victims would not be medically monitored, and the risk of medical complications increases.

Hazard identification

Identifying hazardous materials in a facility and the community is vital to applying control measures, reducing the occurrence of incidents, and implementing rescue operations.[8] The SARA legislation requires that industries report all the hazardous chemicals in their facilities and post them in external locations available to public authorities. Vehicles that transport hazardous substances must display placards that allow for identifying the class of substance being transported. These diamond-shaped placards have different colors and numbers that describe the different classes of substances, such as explosives, nonflammable gases, flammable liquids and solids, and corrosives, among others. Many placards contain the United Nations identification number, a 4-digit number that identifies individual chemicals or groups of similar chemicals. Identifying the hazardous materials present in facilities and those being transported throughout the country is critical to estimating the hazard of hazmat transport and guiding the emergency response.[9]

Personal Protective Equipment (PPE)

• OSHA defined four basic levels of PPE for hazmat incident response. As the grade of protection increases, so does the cost, weight, and physiological burden.
• Level A is the highest level of protection; this protects the user from both contact and vapor hazards and consists of a completely encapsulated suit, a self-contained breathing apparatus (SCBA), chemical-resistant boots, and double chemical-resistant gloves. A tight seal exists between the suit and the inner layer of the face, hands, and feet. Most hazmat teams use this level of protection to enter the hot zone.
• Level B provides high respiratory protection and is required for entry into unknown environments; this consists of an encapsulating suit or junctions and a supplied air respirator (SAR) or SCBA. No tight seals are required between the suit and the extremities or head.
• Level C is required when there is a lower risk of skin exposure and when the air concentration of the hazardous chemical is lower and consists of a splash suit with an air-purifying respirator. This type of suit is significantly better at mobility than Level A and B suits.
• Level D consists of usual work clothes and no respiratory protection, which is required when no risk of exposure to the hazardous chemical exists.
• A high level of protection also means decreased dexterity, mobility, and field of view. Risks of working in these conditions include slips, trips and falls, anxiety, heat stress, and seizures. The cardiovascular demand for users is higher. Therefore, the level of PPE should be determined on the basis that provides the protection necessary and does not inflict unnecessary risks on the user.[10]

Considering the material of the suits, gloves, and boots is important. Many hospitals have Tyvek suits available, which are inexpensive and widely used in laboratories. These suits provide poor protection, as most chemicals can penetrate easily. Therefore, Tyvek suits are not suitable for hazmat decontamination. Moreover, multiple layers of different materials of gloves are needed for hazmat response. This results in a bulky glove that limits hand dexterity.  Nitrile and Viton are ideal; however, substances like aldehydes, ketones, nitro-organic compounds, carbon disulfide, halogenated and aromatic hydrocarbons penetrate nitrile. In this case, Viton would be the ideal option until the patient is decontaminated. Two types of respiratory protection exist; cartridge respirators and supplied air respirators. Air-purifying cartridge respirators allow the individual to inhale air through a cylinder containing a special material that binds chemical vapors. Cartridge respirators are inexpensive and easy to use. The type of cartridge used is designed specifically for the substance in question. They must have a tight seal against the face, requiring a good fit, and cannot be used with facial hair. Adequate training is required to use this type of respirator. These are ideal for decontamination outside of the ED.

Battery-operated cartridge respirators were developed to improve upon the original cartridge respirators. These respirators use a pump that draws air across the cartridge and into the hood around the user’s head. These are easier to use, do not require a tight seal, can be used with facial hair, are cooler, and allow better visual contact with other individuals.  The supplied air respirators provide clean air through a hose and an external supply that can be compressed air or a pump. There are two types of supplied-air respirators: one that functions with a pressure-actuated valve and the other with a continuous flow of air. These respirators also require training, but a less strict fit is needed. Supplied air respirators are ideal for decontamination rooms inside the hospital.

Decontamination

Decontamination is the removal or neutralizing of the hazardous chemical from the victim. Decontamination goals are: 1) prevent further absorption of the chemical that could eventually result in toxicity, and 2) prevent the contamination and exposure of other individuals or equipment that come in contact with the patient. Different types of decontamination exist. However, dilution with high volumes of water is sufficient for most occasions. Removing all clothing is very important because most of the contaminants will be removed from it. Irrigation of the skin and mucous membranes with high volumes of water dilutes the hazardous chemicals and is the cornerstone of dilution management in most situations. Soap may be useful in the removal of oily substances.

Due to the water-chemical reaction, water should be avoided contaminated with certain chemicals: metallic sodium, potassium, cesium, lithium, and rubidium. When possible, these chemicals, along with any radioactive particles embedded in the skin, should be removed from the skin with forceps. Water runoff from the decontamination should be collected and contained until it can be properly disposed of. This is achieved by using collection pools or children's inflatable pools.

Hospital Protocols

Every hospital should create a hazmat response plan delineating the following:

Decontamination area: determining a decontamination place is the first step in creating a plan. This place can be located inside or outside the hospital. An inside decontamination area is ideal, given its proximity to the ED and its supplies. This area should be a room that is easily accessed without entering the hospital or ED. Everything inside this room must be removed so that decontamination and waste removal can be easily accomplished. The area should have a separate ventilation system and be under negative pressure. The collection of irrigated contaminated water should be done in a tank or an alternative system that prevents it from spilling into the hospital drain system.

In most scenarios, an inside decontamination area is not feasible. In this case, an outside area should be erected. An outside area is easier and less expensive than an inside area. Proper ventilation is more easily achieved outdoors than it is indoors. Waste and contaminated water should be collected in portable pools preventing them from entering sewer drains or over lawns.  The disadvantages of outside decontamination areas are weather conditions and less patient privacy. These can be minimized using heaters, controlling the temperature of the water, and building shelters for patient management.

Medical care: Being prepared to provide medical care in the decontamination area is important. Portable monitors and oxygen should be available and can be cleaned or discarded after use. Medical care should be limited to basic life support and life-saving measures. Decontamination should take 10 to 20 minutes, and the patient should be taken to the ED for further assessment and management as soon as possible.

Communication system: A special communication system is important for team performance when providers are required to use respiratory protection.

Runner: Additional hospital personnel are needed to obtain supplies and medications from inside the hospital.

Securing the area: The decontamination area should be enclosed by tape, limiting access to unauthorized individuals. The area must be properly secured until the waste is completely removed, which can take several days.

Observer: An observer from outside the decontamination area should monitor the team. Monitoring how long every team member is working in PPE is important to identify those needing to be removed from the field due to fatigue, stress, or risk of heat exhaustion.

Removal of PPE: Team members must be trained in the appropriate removal of personal protective equipment. PPE should be removed in the opposite order from which it was put on. The last item removed is an inner layer of disposable gloves. Chemical-resistant suits should be handled very carefully and must never have contact with bare skin.

Hospital protocol determines who performs decontamination and where it takes place. Although it may be easier to train only one hazmat team at the hospital, having 1 or 2 trained individuals per shift is more practical since hazmat events are unpredictable.

Clinical Significance

Incidents involving hazardous substances are not rare. Hospitals and EMS organizations must participate in community planning and develop ERP to handle such events. Preparing for these instances includes planning activities, writing protocols, training workers in proper PPE use, and decontamination processes. Appropriate PPE use is a priority in HAZMAT response since it protects workers from contamination in the field and the hospital. The decontamination process is usually performed in the field by specialized HAZMAT teams. However, individuals may be transported to the ED before decontamination. In these cases, the hospitals must be ready to care for victims promptly without contaminating the ED, which includes the staff and other patients at the hospital. Delays in the care for victims can increase medical complications and mortality. Furthermore, education and training in appropriate HAZMAT response leads to preparedness and better clinical outcomes for victims. Recent research has shown that educational intervention for ED staff can effectively improve knowledge, skills-based performance, and confidence in PPE and decontamination skills, which are all critical in HAZMAT events.[11]

Enhancing Healthcare Team Outcomes

Response to hazmat incidents requires an interdisciplinary team of professionals, including specialized hazmat teams, emergency medical service personnel, police departments, physicians, nurses, technicians, and specialists in toxicology. When a HAZMAT event is identified, every worker must know their role and responsibility. The HAZMAT team is responsible for approaching the area and decontaminating victims. EMS is important in providing life support and transporting decontaminated victims to the hospital. The police department is also vital in containing the crowd and performing pertinent investigations. Ultimately, physicians and nurses provide medical care to the victims and, along with toxicologists, determine the best medical management for the hazardous substance involved.

The outcomes of a hazmat event are not completely determined by the performance of the chain of responders, but public health preparedness for emergency response is critical. In 2008, the Institute of Medicine identified knowledge gaps in the U.S. public health system preparedness. In response to these knowledge and performance gaps, government agencies, including the Center for Disease Control (CDC), developed Preparedness and Emergency Response Centers (PERRCs) in schools of public health nationwide. The PERRCs conduct research in public health preparedness and response to all hazards, including training, communication, creation and maintenance of response systems, and identification of metrics to improve the system. Research by PERRCs has generated many publications, practice and policy tools, and recommendations to enhance the country’s health security.[12]