Chemical and Radiological Agent Response Plan.pdf

Emergency Management Plan Orlando VA Medical Center

Orlando VA Medical Center

Emergency Management Program

Standard Operating Procedure No. (EP-02-04)

Subject: Chemical and Radiological Incident Procedures

1. Description of the Threat/Event.

A. Chemical Agents. An event involving the unintentional or deliberate release of a hazardous chemical material presenting exposure to the public, or a large targeted group of people. The substance is considered to be acutely toxic or hazardous to human life.

This includes, but is not limited to the following agents that are used for deliberate exposure:

• Military Agents and Organophosphates (V agents, G agents, Vescants,)

• Cyanide

• Chlorine, Phosgene, Ammonia gases

• Industrial Organophosphates (Pesticides: Malathion, Diazinon, Parithion)

• Riot Control Agents (CS-Chlorobenzalmalononitrile, CN-Chloroacetophenone, and

OC/Pepper Spray-Oleoresin Capsicum)

• Incapacitating agents (Agent 15- phenylbenzeneacetate, Kolokol-1)

It can also include other chemicals that may not be agents of deliberate exposure, but if released in a large enough quantity, may create broad health effects on exposed persons, including but not limited to:

• Ammonia, Anhydrous

• Bromine Trifluoride

• Butyl Perbenzoate

• Dibenzoyl Peroxide

• Diethylzinc

• Diisopropyl Peroxydicarbonate

• Dilauroyl Peroxide

• Ethylamine

• Methyl Chloride

Emergency Management Plan Orlando VA Healthcare Center

• Methyl Iodide

• Trifluorochloroethylene

Although many of these chemicals are not available in the organization, commerce in and around the facility can expose the environment to these hazards. Individuals may also present to the covered facilities with acute exposure to these agents, seeking care and assistance.

B. Radioacive Agents. Radiological material is used in Nuclear Medicine and cardiological care service for the purposes of conducting diagnostic tests and treatment. The exposure of these materials to intended patients, in a controlled environment, presents little to no harm to the person or the general public. However, deliberate or unintended and uncontrolled releases of the material used in these services may present a danger to the occupants of the facility that houses these radioactive isotopes, including Acute Radiation

Syndrome.

Radiation sickness, known as acute radiation syndrome (ARS), is a serious illness that occurs when the entire body (or most of it) receives a high dose of radiation, usually over a short period of time. Many survivors of the Hiroshima and Nagasaki atomic bombs in the 1940s and many of the firefighters who first responded after the Chernobyl Nuclear

Power Plant accident in 1986 became ill with ARS.

People exposed to radiation will get ARS only if:

• The radiation dose was high (doses from medical procedures such as chest X-rays are too low to cause ARS; however, doses from radiation therapy to treat cancer may be high enough to cause some ARS symptoms),

• The radiation was penetrating (that is, able to reach internal organs),

• The person’s entire body, or most of it, received the dose, and

• The radiation was received in a short time, usually within minutes.

The first symptoms of ARS typically are nausea, vomiting, and diarrhea. These symptoms will start within minutes to days after the exposure, will last for minutes up to several days, and may come and go. Then the person usually looks and feels healthy for a short time, after which he or she will become sick again with loss of appetite, fatigue, fever, nausea, vomiting, diarrhea, and possibly even seizures and coma. This seriously ill stage may last from a few hours up to several months.

People with ARS typically also have some skin damage. This damage can start to show within a few hours after exposure and can include swelling, itching, and redness of the skin (like a bad sunburn). There also can be hair loss. As with the other symptoms, the skin may heal for a short time, followed by the return of swelling, itching, and redness days or weeks later. Complete healing of the skin may take from several weeks up to a few years depending on the radiation dose the person’s skin received.

The chance of survival for people with ARS decreases with increasing radiation dose.

Most people who do not recover from ARS will die within several months of exposure.

The cause of death in most cases is the destruction of the person’s bone marrow, which results in infections and internal bleeding. For the survivors, the recovery process may last from several weeks up to 2 years.

The following isotopes are present in the organization:

• Technetium-(99mTc) - a silvery-grey radioactive metal with an appearance similar to platinum. However, it is commonly obtained as a grey powder. the radiation from this isotope is a gamma ray with the same wavelength as X-rays used for common medical diagnostic X-ray applications, giving it adequate penetration while causing minimal damage for a gamma photon. It has a half life of 6.01 hours.

• Thallium 201- used for diagnostic purposes in nuclear medicine, particularly in stress tests used for risk stratification in patients with coronary artery disease A(CAD).

This metal is very soft and malleable and can be cut with a knife. When it is first exposed to air, thallium has a metallic luster but quickly tarnishes with a bluish-gray tinge that resembles lead (it is preserved by keeping it under oil). It has a half life of

73 hours.

• Iodine 123 - a radioactive isotope of iodine often used in whole-body nuclear scanning. Typically iodine-123 is prescribed by pill; the patient is later imaged by a nuclear camera. Areas where the radioactive iodine concentrates will show up on the nuclear camera. Iodine-123 is most commonly used to detect cancers of the thyroid, as this is the organ most receptive to forms of iodine. Its half-life is 13.13 hours; the decay emits gamma radiation.

2. Impact on Mission Critical Systems. Significant impact will be experienced, with exposure depending on a number of factors, including:

• The type of isotope or material

• Amount of material

• Method of release or exposure

• Wind direction and speed

• Population of the exposure area

• Location of consumable resources ( water, food, medication, etc.)

http://en.wikipedia.org/wiki/Metal http://en.wikipedia.org/wiki/Platinum http://en.wikipedia.org/wiki/Nuclear_medicine http://en.wikipedia.org/wiki/Coronary_artery_disease http://en.wikipedia.org/wiki/Luster http://en.wikipedia.org/wiki/Lead http://en.wikipedia.org/wiki/Radioactive_decay http://en.wikipedia.org/wiki/Isotope http://en.wikipedia.org/wiki/Iodine http://en.wikipedia.org/wiki/Whole-body_nuclear_scanning http://en.wikipedia.org/wiki/Whole-body_nuclear_scanning http://en.wikipedia.org/wiki/Thyroid http://en.wikipedia.org/wiki/Organ_%28anatomy%29 http://en.wikipedia.org/wiki/Half-life http://en.wikipedia.org/wiki/Gamma_radiation

• Distance from point of release

The medical center or its covered facilities may be too close to the exposure or release area to render assistance to any victims and would require immediate evacuation of the facility to the closest receiving facility deemed to be of safe distance from the point of release. If so, an emergency evacuation must be ordered (EP-05-01 Organizational Evacaution Plan). Services within the organization would have to be cancelled to prevent inadvertent exposure to non-contaminated personnel in the environment.

The agents may enter the human body through inhalation, skin contact absorbtion, ingestion, or the external access mucosa (nose, eyes, mouth, etc). Each chemical or radiological agent may have specific effects or non-effects on the human body depending on these points of exposure.

The mass release of any agent may cause the substance to gain access to facilities through utility systems (water, HVAC, etc) or through the off-gassing or contact exposure of the agent from contaminated personnel or equipment.

If a facility receives a primary or significant secondary contamination from any of these materials, the need to isolate those contaminated areas and conduct decontamination activities will prevent the use of these facilities or systems for an extended period of time. HVAC systems, in particular, may cause the distribution of contaminates throughout the facility as most large, multi-level structures utilize recirculative air handling systems that take air from one area, through a filter, and redistributes it to another area. The HVAC filters normally fitted in these systems may be HEPA rated filters, but may not be effective with organic vaporized agents.

Consequences could include the closure of operatories, acute care units, sterile processing areas, isolation rooms and the contamination of storage areas.

3. Operating Units and Key Personnel with Responsibility to Manage this Threat/Event.

• Radiology Service

• Pharmacy Service: All-Hazards Emergency Cache

• Pathology and Laboratory Medicine Service

• Cardiology

• Logistics Service

• Facilities Management Service

• Safety Office

• Occupational Health

• Medical Service

• Nursing Service

4. Mitigation/Preparedness Activities for the Threat/Event. The use of chemicals and radioactive material for the healthcare services will continue in the organization and its covered facilities. All steps must be taken to safe-guard these materials to ensure there is little risk of accidental or uncontrolled release into the environment.

A. Hazard Reduction Strategies and Resource Issues.

1) Resource Minimization. The Nuclear Medicine Service, Pathology, Radiology, and all other services that use these hazardous materials will maintain the minimal quanitities on hand in order to continue continuity of services and care for all process involving these items.

2) Security Protocols. All hazardous materials of this class will be secured in a locked storage container or an otherwised restricted area, granting access only to those staff members who are authorized and trained to use the materials in the performance of their official duties.

Delivery of significant quanities of any high-risk chemical or radioactive agents will be limited to licensed tranporters and handlers and will be coordinated with the

Logistics Service and/or the receiving service, prior to arrival, to ensure proper control and management of the material.

The Courier of isotopes will give notice to the Nuclear Medicine Supervisor and VA

Police when the shipment of isotopes will arrive. The courier is escorted to the nuclear medicine hot laboratory, where the material is secured under double-locked containment.

3) Isolation of Usage Locations. The hazardous chemical or radioactive material is stored and used in the same locations, preventing movement through common areas and the possibility of spillage, due to operational transit from storage area to application area.

4) Inspections. The Safety Office and Radiation Safety Officer will conduct weekly inspections of all areas maintaining or storing hazardous chemicals and radioactive material to ensure proper storage and use.

B. Preparedness Strategies and Resource Issues.

1) Monitoring. The Emergency Mamagement Office will monitor all information sources to track, predict, and alert the facility of any possible sources of chemical or radiological releases and exposures. The EM will report all issues or events that can produce a risk for the organization and its persons served to the Director or his designee, to determine whether an activation of the ICS is warranted of if an informative brief should be completed, upon any changes in threat conditions.

Information will be published out of the Emergency Management Office through e-mail and briefings to supervisors informing of the nature of the threat and the characteristics/symptoms of exposure for the agent involved.

Heightened levels of monitoring will be initiated through all service areas for the symptoms described in the alert. Administrative and clinical staff will review their service level policies and procedures for chemical exposures and actively monitor the patients presenting to the clinical areas. Staff will observe the patients in and around the campus, looking for parculiar behavior or characteristics. Once a person exhibits characteristics of the categorized monitoring, staff will intervene and follow the response procedures in this document.

2) Nuclear Medicine Technologists. Nulcear Med Techs are trained in the personnel decontamination process for radiological exposures and isolation techniques for the environmental exposures. They will conduct refresher training to staff, if a significant threat is received for the area.

3) Air Handler Shut Off Drills. Facilities Management Service staff in the Central

Energy Plants at all covered facilities familiarize themselves periodically with the process for shutting down air handlers within the structure.

4) Drills or Exercises. The facility holds emergency preparedness drills and exercises a minimum of twice per year, involving different aspects of emergency response and planning, including for responses to chemical or radiological exposure events. The events are critiqued and corrections to policies are implemented, based on those reviews.

5) Response Staff Training. The organization’s Emergency Response Team (The

Director’s 50) conducts training and exercising no less than 3 times each year to refresh skills and update procedures for responding to all types of emergencies, including decontamination of personnel and equipment from chemical or radiological exposure.

6) Decontamination Equipment. Equipment utilized to decontaminate large numbers of exposed people are located and maintained at the Lake Nona main campus. There are also mobile decontamination assets that can travel to the other covered facilties or to remote community locations to assist in a local emergency related to chemical or radiological material exposures.

7) Radiactive Isotope Spill Kits (RISK). RISK Kits are placed in the rooms where the isotopes are stored or used, in case there is a spill of radioactive material. This allows for minimal transporting of potentially radioactive personnel around non-contaminated areas. RISK Kits include the following:

• Surgical Foot Booties (4 Pair)

• Disposable Gloves

• Cellulose Sorbents or Chucks

• 3 Sets of Disposable Scrubs

• Thick Gauge Trash Bags (5 bags min.)

• 2” Packing Tape (2 Rolls)

• Foaming Bathroom Cleaner (1 can)

• Liquid Bath Soap (1 Bottle)

• Scrubs for staff to change garments (may want to include shoes and undergarments)

5. Response/Recovery from the Threat/Event.

A. Hazard Control Strategies. Whether through an accidental small-scale release or an intentional mass exposure event, nearly 85% of the casualties will self-refer to the nearest medical facilties for treatment. All staff must be vigilant in their surveillance of patient who may present to a clinic or reception area with acute and unique symptoms. The symptoms will be mild to moderate if the casualty is conscious or who have self-transported to the facility and will most likely exhibit symptoms in the cardio-pulmonary, dermatological, and muscular systems. The casualties of a mass exposure in the community will be expected to arrive before information can be provided on the nature of the exposure or identification of the involved hazardous material. It is important that all employees be familiar with the symptoms and characteristics of a chemical exposure.

It is important for staff at all levels to recognize the symptoms and characteristics of a chemical exposure quickly to allow the isolation of the patient from the rest of the occupants at the facility. The following are the characteristics or symptoms for specific chemical agent exposure:

• Military Agents and Organophosphates (V agents, G agents, Vesicants, Pesticides:

Malathion, Diazinon, Parithion)

• Pupil constriction – pin point size (vapor exposure)

• Rhinorrhea

• Dyspnea

• Diarrhea

• Vomiting

• Convulsions

• Hypersalivation

• Drowsiness

• Coma and unconsciousness.

• Cyanide

(Low Doses)

• Weakness

• Giddiness

• Headaches

• Vertigo

• Confusion

• Perceived difficulty in breathing

(High Doses)

• Coma with seizures

• Apnea and cardiac arrest, with death following in a matter of minutes

• Chlorine

• Airway irritation

• Wheezing

• Difficulty breathing

• Sore throat

• Cough

• Chest tightness

• Eye irritation

• Skin irritation http://en.wikipedia.org/wiki/Seizures http://en.wikipedia.org/wiki/Cardiac_arrest

• Phosgene

• Coughing

• Burning sensation in the throat and eyes

• Watery eyes

• Blurred vision

• Difficulty breathing or shortness of breath

• Nausea and vomiting

• Skin contact can result in lesions similar to those from frostbite or burns

• Following exposure to high concentrations of phosgene, a person may develop fluid in the lungs (pulmonary edema) within 2 to 6 hours.

• Ammonia

• Rapid onset of eye, nose, and throat irritation

• Coughing and bronchospasm

• Laryngospasm and laryngeal edema resulting in upper airway obstruction

• Stinging pain (Skin Contact)

• Erythema and vesiculation, especially on moist skin areas

• Skin contact with compressed, liquid ammonia causes frostbite injury; severe burns with deep ulcerations

• Eye irritation; conjunctival edema and corneal erosion

• Burning in the mouth and throat with swallowing difficulty, drooling, and vomiting

• Riot Control Agents (CS, CN, OC Spray)

• Excessive eye tearing, burning, blurred vision, and redness

• Runny, burning, and swelling nose

• Burning, irritation in the throat, difficulty swallowing or drooling

• Chest tightness

• Coughing and choking sensation noisy breathing (wheezing), shortness of breath

• Skin burns or rash

• Nausea and vomiting

• Incapacitating Agents (BZ, Agent 15, Fentanyl, Kolokol-1)

• Decreased or altered mental status

• Miosis

• Respiratory depression

• Non-reactive mydriasis

• Dry axillae and mucous membranes

• Decreased bowel sounds

• Flushed skin

• Urinary retention

• Hyperthermia (decreased evaporative heat loss

• Delirium

The First Receivers Decontamination Program (FRDP) prepares the medical center to respond to incidents involving contaminated patients seeking care. FRDP is specifically designed to decontaminate patients arriving at the facility from off-site locations where a potential or actual release of hazardous materials, including chemical, biological, radiological, and/or nuclear (CBRN) agents has occurred.

The Occupational Safety and Health Administration(OSHA) guidance specifically states that Personal Protective Equipment (PPE) worn by First Receivers provides sufficient protection when the hazardous substance was not released in close proximity to the facility and the lapse time between vicim exposure and arrival for care exceeds approximately 10 minutes, thereby permitting substantial levels of gases and vapors to dissipate.

If the VA facility is the site of the release or exposure, or when the FRDP capability is non-operational, obtaining fire department response through the 911 system is the most appropriate response.

When an individual presents with potential exposure to a chemical or radioactive substance and the VA facility is not the site of release or exposure, staff will immediately don the appropriate PPE and take steps to remove any contaminated garments off of the exposed person.

If feasible and practical, initiate formal decontamination procedures with organization decontamination equipment. If that equipment is not available, use a water hose, shower, or any other means of flushing the persons skin and body with copious amounts of water. The Lake Nona Emergency Department breezeway has a drainage system that isolates decontamination water runoff in a 2,500 gallon tank located at the base of the helipad. The drains in the two shower rooms located in the

Emergency Department are connected to the regular sanitary system and not to the breezeway decontamination drainage system. Facility Management Service conducts quarterly preventative maintenance on the breezeway drainage system. The tank at the base of the helipad also has a high level alarm that alerts staff that a vendor needs to service the tank. In the case of hazmat drainage, a authorized contractor must be used to service the tank.

All contaminated garments/items will be double-bagged and placed in an isolated area for pick up by an authorized contractor by the Safety Office or the Radiation

Safety Officer, as appropriate. The cleaning up of the exposed/contaminated area will be coordinated by the Safety Office. Notify Occupational Health when staff perform decontamination operations.

If the event is an expanding incident, the Medical Center Director may activate the

Hospital Command Center (HCC). When the HCC is operational, the following are the section priorities:

1) Incident Commander and Command Section:

• Provide organizational guidance on the management of incoming and impacted victims of the exposure

• Establish restricted areas for staff and patients/visitors

• Establish the reporting and briefing frequency

• Provide communication guidance to staff and patients on risks areas and exposure hazards

• Develop a press release and other media public communication statements to address the event

• Provide guidance and direction on locking down the facility to limit access to non-contaminated areas

• Activate the organization’s Emergency Response Team to provide immediate response to the facilities and victims involved in the event

• Determine support to the community for decontamination and treatment, as appropriate

• Develop a Radiological monitoring protocol with the Radiation Safety Officer, to determine levels and rates of exposure to the environment and staff

• Monitor radiation levels from baseline through periodic testing throughout the response

• Prepare and publish news releases from the organization to inform the public and the patient population of any adjustment to services

2) Planning Section:

• Provide information on the characteristics and specific risks of the hazardous release and how it may impact the organization and community

• Provide information requirements for reporting to VISN/VACO

• Coordinate and prepare the written initial Incident Action Plan (IAP) and establish the schedule for publishing follow-on IAPs

• Provide advice and guidance on the impacts to services and evaluate the need for any systematic closures of facilities and the reduction of services during the event

• Establish protocol for rescheduling patients for outpatient, services, and surgery appointments in the affected facilities

• Receive information from FEMA, the local Emergency Management Offices, or from media sources to determine the location and exposure area of the chemical or radioactive material. Determine whether the location or direction of wind currents prevents the continual operation of service at the affected facility(ies)

3) Operations Section:

• Conduct decontamination operations for all exposed personnel and equipment

• Conduct triage and treatment activities in conjunction with the Mass Casualty

Plan, with specific guidance from the Safety Officers and Occ. Health

• Tranport or conduct coordination for transfer of all exposed personnel to the nearest emergency treatment facility (Emergency Room)

• Determine which staff are essential (by category) and who may be released from work

• Determine trigger points where an evacuation would be recommended or required

• Communicate report requirements for treatment and support activities

• Develop and implement an employee protection plan, including PPE requirements and maximum exposure times to potential radioactive material or personnel

• Close air handlers to areas not utilized or involved in the response (Facilities may determine to close the AHUs to the treatment areas as needed)

• Support infection control protocols with periodic and ad hoc cleaning of treatment areas or any area utilized by responding staff. Determine needs for final cleaning post-event

• Report known exposures to the Incident Commander during periodic situational brief

4) Logistics Section:

• Coordinate with the Operations Section to develop a key supply list for the triage and treatment being performed and develop a schedule for replenishing the supplies throughout the event.

• Determine supply route to the triage, treatment, and support areas that will avoid passing through any unsecure or possibly contaminated areas

• Determine the supply list replenishing plan, if critical supplies may be depleted significantly as a result of the event or may exhaust during the response.

Coordinate with contractors/vendors to organize a resupply plan.

5) Finance Section:

• Provide status of budgeted funds and contingency funds for the organization

• Establish protocols for expenditures of funds for the emergency response and recovery

• Establish reimbursement and claims process, as appropriate

• Request additional funding from VISN or VACO as appropriate

6) General Instructions:

• Emergency Department staff, HAS staff, and police/security personnel are the staff members who will most likely be the first persons to make contact with a patient presenting themselves to the facility suffering from a hazardous chemical exposure. Once staff identify symptoms or characteristics of a possible chemical exposure, they are to avoid excessive inhalation around the patient and isolate them from the rest of the people in that particular area

• Staff will immediately contact the Safety Office and/or a Radiology technologist to further evaluate the symptoms

• Staff who first came in contact with the victim will immediately wash their hands with soap and water and remove a minimum of one layer of their upper garment

(replace with a scrub top). Place the removed garments in a plastic bag and store in an area away from occupants

• The Safety office or Radiation staff will evaluate the exposed symptoms against the Chemical Exposure Symptoms Tool (CHEST) and the patient history for possible exposure to a hazardous chemical.

• Once the nurse determines that the patient has been exposed to a hazardous material, they will immediately inform the Emergency Manager/Safety Office and the Primary Care Provider on the team

• The Emergency Management and Safety Staff will receive the circumstances from the staff and the clinical team to evaluate the possible source of the exposure

(through media bulletins or alerts)

• Service or Area Supervisors may conduct an evacuation of a work site, if the presence or the exposure to the contaminant in the environment poses a reasonable risk to the occupants. The Safety Office may also direct the evacuation, under these circumstances.

B. Recovery Strategies and Resource Issues. These are activities to initiate after the event has been rendered safe or the response efforts completed:

1) Incident Commander and Command Section:

• Incident Command declares the transition of the response to recovery operations

• Provide organizational guidance on the management of exposured areas

• Update restricted areas for staff and patients/visitors

• Provide final reporting to the VISN/VACO

• Update communication guidance to staff and patients on risks areas and exposure hazards

• Develop an updated press release and other public communication statements to inform patients on the status of services at the affected facility and any additional instructions for receiving care

• Provide update on facility access until the impacted areas are ready to assume normal operations

2) Planning Section:

• Provide information on the long-term impacts to exposure to the identified contaminant

• Provide information requirements for reporting to VISN/VACO

• Coordinate and prepare the final summary report

• Ensure all patient rescheduling appointments are completed for outpatient, services, and surgery appointments

• Track all transferred patients’ care until complete

3) Operations Section:

• Conduct decontamination operations for response personnel and all organizational equipment involved in the exposed areas

• Coordinate for the repatriating of all patients transferred to other care facilities for treatment

• Refine staffing needs and close the labor pool as appriopriate

• Initiate employee medical surveillance protocols for staff exposed to the contaminant or directly involved in the response

• Clean and inspect all affected air handlers to ensure they will not re-contaminate cleaned areas

• Coordinate with the Safety Office to properly identify and collect the known or suspected hazardous material and contaminated waste for disposal.

4) Logistics Section:

• Replenish all medical and general supplies used to support the response

• Provide support to the removal of contaminated material and waste, as needed.

5) Finance Section:

• Provide update of budgeted funds and contingency funds for the organization

• Submit reimbursement requests through the VISN for emergency response expenditures

• Process reimbursement of claims, as appropriate

6) Nuclear Medicine Staff. Survey the area of exposure to determine the coverage of the release. Coordinate with the Emergency Response Team to conduct decontamination of equipment, surfaces, and floors utilizing the appropriate neutralizing cleaner.

Enlist the assistance of the Enviornment Management Service (EMS) as needed.

7) Safety Office Staff. Ensure the proper PPE is available for all employees assisting in the recovery activities in the exposed area. Indentify all personnel who need to enter the contaminated site and restrict access to non-essential personnel. The Safety

Office will take all hazardous waste from the contamination and store it in approved containers in the hazardous waste storage building and secure the building until it can be removed by a licensed contractor for hazardous waste removal.

8) Environment Management Service. Support the cleaning of the contaminated area by conducting terminal cleaning of the location of the spill and securing all used cleaning utensil/equipment in a segregated location, until the RSO can deem the items safe for use.

a) Coordinate with the Safety Officer and the Infection Control staff to ensure the proper method of cleaning the specific or any possible contaminated areas.

9) Radiation Safety Officer (RSO). Conduct final inspection and survey of the area to determine that the radiation levels are at a safe level. Recommend the commencement of normal services to the Incident Commander/Director.

6. External Notification Procedures.

A. Within VA. VISN 8 Network Director will be notified if the spill involves contamination of two or more personnel or if it requires a discontinuance of services.

B. Other Federal Agencies.

1) OSHA – Notify within eight (8) hours of one (1) employee fatality, or three (3) employee hospitalizations resulting from a single incident.

C. Community Entities.

1) City of Orlando, Office of Emergency Management

2) Orange County Emergency Operations Center (as needed)

3) Orlando Fire Department/HAZMAT Unit – Via 911

7. Specialized Staff Training.

A. Nuclear Medicine Staff amd Emeregncy Response Team: Decontamination training of radioactive exposures on personnel and material

8. References and Further Assistance.

A. VHA Emergency Management Guidebook.

9. Review December 2024.

Appendix A – DECON Team Organization

1. DECON Team Leader. Direct oversight of the DECON Operations and team personnel directly engaging in decontamination activities and support. Directly reports to the HAZMAT

Branch Chief and the Director’s 50 Team Leader. Coordinate with the Decon Safety Officer and supervise the Decon Triage Leader, Decon Entry Team Leader, Decon Site Access

Control Unit Leader, and Decon Logistics Officer.

2. Ambulatory DECON Personnel. Instruct ambulatory patients how to conduct Directed Self

Decontamination. Instruct patient(s) how to remove contaminated clothing and cleanse, while maintaining patient privacy. Instruct patients where to place contaminated clothing and personal items for return, disposal or evidence.

3. Non-Ambulatory DECON Coordinator. Organize and direct aspects relating to the Decon

Non-Ambulatory or Ambulatory Team. Carry out directives of the Incident Commander and/or Director’s 50 Team Leader. Coordinate with the Decon Safety Officer, the Decon

Triage Coordinator, and Decon Security Officer as may be necessary.

4. Non-Ambulatory DECON Personnel. Conduct decontamination of non-ambulatory patients.

Actions will require proper removal of contaminated clothing, use proper decontamination techniques to remove contaminants, monitor health status, and initiate life-saving appropriate procedures, such as using Mark I auto injectors for moderate or severe nerve agent exposure.

5. DECON Logistics Leader. Set up and provide supplies to the Contamination Reduction

Corridor, for patient(s) or for the Decon Response Team. Supervise the cleanup of the contaminants and equipment. Arrange for disposition of contaminated items.

6. DECON Safety Officer. Monitor and have the authority over the safety of decontamination operations and hazardous conditions. Organize and enforce employee protection and traffic security. The Safety Officer has the authority to modify, alter or stop the decontamination process and order personnel to leave the dangerous area.

7. DECON Triage Nurse. Sort contaminated patients according to appropriate triage priorities.

Oversee the health of victims going through decontamination process.

8. DECON Security Officer. Establish Safe Refuge Area. Prevent access and egress from contaminated patients or substance into the facility.

9. DECON Perimeter Control Officer. Establish perimeter control for triage and routing of contaminated patients to protect hospital patients, staff, and facilities from becoming contaminated.

Appendix B - Mission Critical Systems Considerations for DECON Operations

Mission Critical

Engineering System

Decontamination Subcategorized by Precaution Level

(Natural occurring events and terrorism) Impact categories:

0 = N/A, 1= Low, 2 = Variable, 3 = High

Operational Considerations

(Includes utilization; communication and patient care factors)

Contacts for Assistance in

Preparing for Potential

Problems

Personnel Decon

Equipment

PPE

Average

Score

1. Lighting

2 1 1 1.3

Emergency back-up in all critical care, ER, critical function areas, Decon area.

Facilities Management

Service; Chief of Staff;

Clinical Service Chiefs.

2. Electrical Power

3 3 2 2.6

Power Failure Setting: Failure of alarms; ventilation fans and portable negative-air units may cause contamination of surrounding areas post triage and Decon.

Facilities Management

Service; Infection Control;

Safety Officer; Laboratory

Service; Director; Chief of

Staff, Associate Director of

Patient Care Service.

3. Steam Distribution

1 1 1 1

Autoclave operations; Nutrition and

Food Service; Operating room sterilizers; Environmental

Management Services (cleaning).

Facilities Management

Service; Infection Control;

Safety Officer; Director; Chief of Staff; Surgery; Nursing;

Nutrition/Food Service; and

Environmental Management

Services.

4. Heating, Ventilation

& Air Conditioning

(HVAC)

3 3 3 3

Extent of breach; shut-down (partial or full); clinical notification; patient evacuation needs; system clearance mechanism; external notifications, Must be aware of the HVAC intake and any potential off-gassing at the

Decon/triage area.

Facilities Management

Service; Infection Control;

Safety Office; Director; Chief of Staff; Associate Director of

Patient Care Service.

5. Room or Hood

Exhaust

1 1 1 1

Extent of facility breach or contamination; options for continued use; shut-down; potential staff and/or patient relocation.

Facilities Management

Service; Infection Control;

Safety Office; Director; Chief of Staff.

Mission Critical Facilities

Management Service

System

Decontamination Subcategorized by Precaution Level

(Natural occurring events and terrorism) Impact categories:

0 = N/A, 1= Low, 2 = Variable, 3 = High

Operational Considerations

(Includes utilization; communication and patient care factors)

Contacts for Assistance in

Preparing for Potential

Problems

Personnel Decon

Equipment

PPE

Average

Score

6. Water Delivery

1 1 1 1 Intentional or naturally occurring contamination is High Risk; well-water sources at risk for both biologic and chemical contamination; partial or total evacuation; external resources;

notification; clearance mechanism.

Facilities Management

Service; Safety Office;

Infection Control; ICS

Manager; Director; Chief of

Staff.

7. Waste Stream

(Sanitary, Solid, Liquid, & Biohazard)

3 3 1 2.3

Compliance with Hazardous waste regulations; EMS handling guidelines; transportation hazard;

employee awareness; EPA; OSHA

1910.120 regulations.

Facilities Management

Service; Safety Officer;

Radiation Safety Officer;

EMS.

8. Critical Supplies

2 2 2 2

Initial inventories and ongoing needs assessments; external resource contacts; situation reporting; internal communication needs.

Facilities Management

Service; Fiscal; PADS;

Pharmacy; Laboratory;

Respiratory Therapy;

Radiology; Nuclear Medicine;

Chief of Staff; Associate

Director of Patient Care

Service.

9. Communications

(Telephone, Radio, etc.)

3 1 2 2

High Utilization Needs;

communication scripts;

communication among team members, VISN and community notification; situation status; resource status; action plan reporting.

Facilities Management

Service; ICS Manager; Office of Director; COS; Associate

Director of Patient Care

Service; DECON Team

Leader; Public Affairs Officer.

10. VISTA & Other

Computer

Applications

2 0 0 0.6

DECON/HAS Tracking Team and

CBO Fiscal tracking mechanism for

VA and Non-VA patients; ongoing

CPRS impact; contingency plans;

human resource needs to meet entry surge.

Facilities Management

Service; Office of Information

Management; Director;

Information O&IT Service;

Public Affairs.

11. Elevators & Other

Vertical Transport

3 0 0 1 In-house movement and patient transport; limited transport of patients and/or contaminated materials.

Facilities Management Service;

Safety Officer; Infection control;

Chief of Staff; Associate Director of Patient Care Service, (transportation staff).

Mission Critical Facilities

Management Service

System

Decontamination Subcategorized by Precaution Level

(Natural occurring events and terrorism) Impact categories:

0 = N/A, 1= Low, 2 = Variable, 3 = High

Operational Considerations

(Includes utilization; communication and patient care factors)

Contacts for Assistance in

Preparing for Potential

Problems

Personnel Decon

Equipment

PPE

Average

Score

12. Central Medical

Gases (Oxygen, Medical

Air, Vacuum) 0 0 0 0

Ongoing resource assessments;

external resource options.

Facilities Management Service;

Fiscal; Logistics Service; Chief of Staff; Associate Director of

Patient Care Service.

Appendix C – Medical Monitoring for PPE

Name______________________________________________________________________________

Date_______________________________________________________________________________

>> INSPECT the condition of ALL PPE prior to use <<

*Medical Exclusion

PRE POST

Blood Pressure:

* > 160/110

Pulse:

* > 90

Respiration, at rest:

* > 24 / min

Temperature:

* > 99.0ºF oral

Weight:

Skin:

*Open sore, large rash or sunburn

Hydration:

Mental Status:

Alert; oriented to time and place; clear speech;

normal gait

Medical History:

*Any meds last 72 hours _________________

*Alcohol past 24 hours___________________

*New meds Rx/diagnosis last 2 weeks

*Symptoms fever, NV, diarrhea, cough in past

72 hours ______________________

*Pregnant_______________________

*Prior heat stress or exhaustion________________

Notes:

Checked By:_______________________

Hydrated

Minimum 8 oz. water

PAPR–CBRNE Cartridges

PAPR Flow Checked

Removed Shoes, Jewelry, etc.

Suit to Waist

Outer Boots

Cool Vest

Suit to Shoulders

Hand Radio

PAPR Back Pack

Butyl Hood (hose connected)

Inner Shroud Tucked Inside

Suit Front Seal Secured

Name & Time Taped on Back.

Notes:

Safety Checked By:

Time in Suit:

Time Out: ___________________________

Appendix D – PPE Donning and Doffing Sequence

PPE Donning and Doffing Sequence

PPE Donning Sequence PPE Decon and Doffing Sequence

1. Test PAPR flow rate (min. 6 CFM).

2. Remove jewelry and clothing.

3. Inner nitrile gloves.

4. Cold Weather: Inner suit. Tape gloves at wrist and zipper at neck.

Warm Weather: Scrubs.

5. Outer chem protective suit to waist.

Don boots and outer chem protective gloves.

6. PAPR to hood with hose; air flow on.

Don butyl hood (inside shroud between suits). Chem protective suit up and on.

7. Zipper covered and secured; tape top.

2 pieces of tape for cartridges (drills only).

8. Belt PAPR to waist.

9. Outer Butyl shroud over suit.

10. Stretch arms, suit sleeves over gloves;

tape.

11. Cuff suit over boot top; tape.

12. Place tape on hood w/name and time in.

1. Wash hands thoroughly. Partner tape 2 side PAPR filters (drills only).

2. Wash self, top to bottom. Partner wash your back.

3. Untape boots, gloves; but don’t remove.

4. Unlock PAPR; place on chair/ gurney/floor, etc.

5. Remove outer suit. Roll suit away from you, inside out (partner help). Remove outer gloves with outer suit.

6. Remove PAPR hood; place in waste.

7. Step out of boots/suit into final rinse room; wash, rinse thoroughly (with partners help).

8. Cold Weather: Remove (inner) suit;

place in waste.

9. Remove nitrile gloves: Pinch a glove, roll down partially, then place thumb in other glove and remove both.

10. Wash again; remove inner clothing;

step out of decon into towels, blankets.

Approved EMPC 1/19/2024

X SJL

Steve J. Leve

Emergency Manager

Signed by: STEVE LEVE