For Self-Presenting Patients HAZMAT/CBRN

Transcription

1 SH NCP 68 Standard Operating Procedure For Self-Presenting Patients HAZMAT/CBRN Summary: Keywords (minimum of 5): (To assist policy search engine) Target Audience: The Health and Safety team have developed (SOP) Standard Operating Procedure for Self presenting patients from a possible HAZMAT/CBRN Incident and identifies arrangements for managing the safety, health and welfare of SHFT staff, clients, patients, visitors and anyone else who can be affected. It outlines the organisational structure and arrangements to ensure the Trust fulfils its legal responsibilities from NHS England Core standards Emergency planning and duty of care to protect people from hazards associated with incidents. The HAZMAT/CBRN SOP is an integral component of SHFT safety management systems. This should also be aligned with the Trusts Lockdown, IRP (Incident Response Plan) policies. CBRN/HAZMAT, Chemicals All Trust Staff Next Review Date: December 2018 Approved & Ratified by: Health and Safety Forum Date of meeting: 27 April 2015 Date issued: Author: Sponsor: Darren Hedges AISFM, Tech IOSH, MCGI Health & Safety Advisor David White CMIOSH. FIFSM. MIIRSM. GIFireE Health and Safety/Fire Safety/ Security Manager Mark Brooks Chief Finance Officer 1

2 Version Control Change Record Date Author Version Page Reason for Change 9/5/16 Review date extended from May to July /6/16 Darren Hedges 1 all SOP reviewed no changes required, review date extended for 2 years 20/6/18 Review date extended from June to Dec 2018 Reviewers/contributors Name Position Version Reviewed & Date Dave White Health & Safety/Fire Safety/ Security Manager November 2014 Darren Hedges Health & Safety Advisor November 2014 Nigel Dowland Security Management Specialist November

3 CONTENTS Page 1. Introduction 5 2. Definitions 5 3. Legal Responsibilities 6 4. Decontamination Infrastructure 7 5. Incident Response Post Incident 17 Appendices A1 Preparation for Incidents involving Hazardous Materials and Guidance for Primary and Community Care Facilities 19 A2 Chemical Exposure Form 34 A3 Equality Impact Assessment / Equality Analysis Screening Tool 35 3

4 Forward This document provides Trust management and staff within Southern Health NHS Foundation Trust, with guidance in respect of their responsibilities for the decontamination and treatment of persons who may self- present or attend sites within SHFT following exposure to hazardous materials, or suspected exposure, to chemicals, biological agents, or radioactive material. This document also provides guidance on how SHFT staff should provide appropriate health care to such patients who may be so contaminated whilst protecting themselves, the site and other members of staff, other patients, and the public from exposure or cross-contamination from these substances. SHFT has a statutory duty to provide care for patients when and wherever required. SHFT also has a legal duty to protect staff from harm whilst carrying out their duties. Incidents involving chemicals, biological agents, and radiological materials by their nature can bring severe disruption to services and pose serious health risks to staff. In preparing this guidance clinical, nursing, and management, will be consulted to ensure that it is both appropriate and proportionate. The contents of the policy are intended to ensure that the effects of such an incident on normal SHFT services are minimised. It should be noted that this Policy is guidance only and it is for the board to determine how this should be implemented based on local risk assessment (contained within the Lockdown policy). 4

5 1. Introduction This practical guidance document is aimed at preparing primary and community-based health facilities to be able to manage the consequences of a hazardous incident occurring somewhere else (also referred to as a chemical, biological, radiological, nuclear or explosive incident CBRNE). In these incidents there is a need to care for people, but also to be aware of the safety risk to staff and patients from secondary contamination as a result of people self-presenting at their facility seeking assistance. Contamination can result from the accidental release of hazardous material (HAZMAT) from industrial and commercial premises, transport accidents, the illegal disposal of contaminated waste, or from the deliberate release of these hazardous materials e.g. by terrorist group or individual. A number of initiatives designed to improve the response to such incidents have been introduced. These include the provision of mass decontamination facilities to the Fire & Rescue Services, and clinical Decontamination Units to the NHS Ambulance Service (for use at the scene of incidents. These initiatives complement the decontamination equipment available. Any Hazmat or CBRN event should be appropriately risk assessed, planned for and managed as part of a multi-agency response. Decontamination is not an automatic or inevitable response to CBRN or Hazmat events. Whether or not to initiate decontamination procedures will depend on the initial assessment of the nature of the event by first responders and subsequently by Health Professionals. This SOP will also provide guidance on the roles and responsibilities of the emergency services in relation to the decontamination of casualties following a release of hazardous materials. 2. Definitions Definitions related to decontamination are provided below. 2.1 Decontamination Decontamination is defined as the removal or reduction of hazardous materials to lower the risk of further harm to casualties and/or cross contamination. Decontamination can range from self-help to full clinical decontamination by the Department. 2.2 HAZMAT A non-criminal accidental release of a substance, agent or material, which results in illness or injury to the public, the denial of access to an area or the interruption to the food chain. The commercial, industrial, medical, or military substances involved in a Hazmat incident could be from any of the CBRN categories outlined below. Strict guidelines exist for the storage, handling and transport of these materials and the number of incidents involving their accidental release or spillage is low, although likely to be the most common type of incident involving contamination. 2.3 Background on CBRN (Chemical, Biological, Radiological, Nuclear) A deliberate and malicious act, the intention of which is to cause harm or fear amongst a population by using or threatening to use CBRN materials. The incident is crime 5

6 focussed and may range from cases of relatively minor harassment and alarm through to terrorist acts of mass murder or genocide. CBRN is a term that covers a distinct range of hazards: i. Chemicals Poisoning or injury caused by chemical substances, including chemical warfare agents, or misuse of legitimate but harmful household or industrial chemicals ii. Biological Illnesses caused by the deliberate release of dangerous bacteria, viruses, fungi, or toxins (e.g. the plant toxin, ricin). iii. Radiological Illnesses caused by exposure to harmful, radioactive materials, possibly inhaled or ingested from food or drink. iv. Nuclear Where the explosion of a nuclear device causes widespread effects due to blast, heat, and large amounts of harmful radiation. All of the above categories also pose a threat of environmental contamination. (Although it is important that the terminology relating to Hazmat and CBRN is understood, the type of initial incident does not alter the role or procedures that should be adopted by a Hospital Decontamination Team as the effects of any release and the measures required to mitigate them, will be broadly the same.) 2.4 Contamination A person is contaminated when they have a hazardous substance in or on them. This document only refers to surface contamination. 2.4 Exposure A patient who has been exposed to a hazardous substance may be suffering from the effects of that exposure but only need to be decontaminated if they are contaminated, e.g. a patient exposed to radiation from a remote source, or to a gas such as carbon monoxide does not need to be decontaminated. 2.5 Infectious Disease/Exposure to a Biological Substance The dangers to others posed by a patient harbouring an infectious illness are not changed by decontamination. However, a patient contaminated with a biological material such as fungal spores does require decontamination. 3. Legal Responsibilities The Trust is identified as a category 1 responder and has a statutory duty to provide care for patients including those that may be contaminated with chemical, biological, radiological material (or where the explosion of a nuclear device causes widespread effects due to the blast, heat and large amounts of harmful radiation). An incident involving the presence of such contaminated patients could, however, result in the contamination of an area and the subsequent closure of a facility or an entire site, and 6

7 thus impair the trusts capability to fulfil its statutory duty to provide healthcare for the community. As an employer we have a statutory duty to protect our staff and members of the public who might be affected by their activities from risk to health [Health and Safety at Work Act (1974)]. This duty includes a requirement to ensure that: Appropriate Hazmat / Lockdown Risk Assessment has been carried out (within Lockdown policy) Staff are provided with suitable facilities and equipment to carry out their duties (including personal protective equipment PPE) Staff are adequately trained in their duties (including the use of any equipment) The Civil Contingency Act (2004) (CCA) established the legislative framework for civil protection within the UK. Deal with any emergency Deal with any threat to the provision of normal services during an emergency. Since the presence of self-presenting patients can be the result of an emergency that can pose a threat to the provision of normal service, The Trust should have plans in place to deal with such patients, and have such business contingency plans to deal with the consequential impact on normal service provision from such a scenario. 4. Decontamination Infrastructure 4.1 Board Responsibilities The Trust must have adequate measures in place to ensure that, as far as reasonably practical, they can continue to provide their critical services in the event that potentially contaminated patients self-present at receiving sites. We must ensure that: At strategic level there is a designated person (normally a Board Director, referred to here as the Decontamination Policy Lead Emergency Planning Director) responsible to the Board for ensuring that appropriate decontamination arrangements are in place and are properly maintained a documented Hazmat/ CBRN Incident Plan is in place that is proportionate, practical, and clinically effective The plan is subject to regular exercise (a minimum of at least once every 3 years) and review, and is maintained as a quality assured document appropriate equipment and facilities are provided suitable and sufficient quantities of Personal Protective Equipment (PPE) are provided Staffs have been identified to carry out the various operations required to safely decontaminate patients (including a Decontamination Lead Officer who will lead the decontamination response). Such staff must be suitably trained. This requirement includes the provision of regular refresher training. There is sufficient resource available to implement the plan whenever necessary in a timely manner Contingency Plans should account for self-presenters who arrive at SHFT facilities that do not have decontamination facilities. The Trust has no capability to deliver decontamination facilities. 7

8 4.2 Hazmat/CBRN Incident Plan and Risk Assessment The Boards Hazmat/ CBRN Incident Plans, including plans to deal with self-presenting casualties from a Hazmat or CBRN incident should be developed with the involvement of appropriate experts and local multi-agency partners contained within the (Incident Response Plan) IRP (e.g. Ambulance Service, local Fire and Rescue Service, local Police Force, Local Authority,) and based on robust local risk assessments. NHS England with NHS London has developed Guidance for Primary and Community Care Facilities in preparation for incidents involving hazardous materials, which is included within this SOP at Annex 1. Plans should be held as quality controlled documents authorized by the Decontamination Policy Lead, and be subject to regular exercise and review. It is recommended that such plans dovetail with the Trust s IRP which should include details of the appropriate communications arrangements. It is a requirement that the trust has a plan to lock down areas or an entire hospital to protect staff, patients, and facilities from possible cross contamination (see Trust Lockdown Policy). The procedures in the plan should accommodate a range of circumstances ranging from those where casualties are brought in by the Ambulance Service (usually, although not always, already decontaminated) from the site of a major incident to contaminated individuals arriving by personal transport. Local plans should also take account of circumstances where provisions for Clinical Decontamination may be overwhelmed and should therefore provide for Improvised or Interim Decontamination and the option of Mass Decontamination (see 4.4 for definitions). Where decontamination requirements exceed site capability there should be pre-agreed arrangements in place with local partner agencies on what support can be provided to the hospital. These agreements should be made locally; this is listed within the IRP. 4.3 Decontamination Option The majority of contaminated casualties will be decontaminated at the scene by the Fire and Rescue Services (this is also the case for Hazmat incidents). However causalities may present at SHFT sites with secondary contamination several hours after the incident. Our Community hospitals may be required by the FRS to help with decontamination of patients if a Major Incident has been issued by PHE (Public Health England). This will be directed by the on the on call director at suitable risk assed sites within the trust. (Lymington, Petersfield,GWMH). Decontamination can take several forms ranging from improvised decontamination by persons responding to an immediate and necessary need, through to full Clinical decontamination. Any decision to decontaminate should be taken after appropriate assessments. Plans should include the full range of decontamination options available to sites and any response should be proportionate and reasonable. In some cases removing outer garments might be sufficient to remove the majority of contaminant present. I. Improvised Decontamination: The use of an immediately available method of decontamination prior to the use of specialist resources. It may be appropriate to initiate improvised decontamination prior to establishment of full procedure at a Hospital. 8

9 Dry decontamination should be used for self - presenting patients. This is contained within the (Appendix 1). Contaminated clothing should be removed as soon as possible in accordance with the provisions in section the person and dressed in appropriate clothing rerobe packs should be available for this purpose. Following any improvised decontamination, the decontamination lead should decide on any further appropriate action. This might involve further, more rigorous decontamination, referral for medical care or discharge. II. Clinical Decontamination: The process where contaminated persons are treated individually by trained healthcare professionals using purpose designed decontamination equipment. This is full wet decontamination using Clinical Decontamination Units. SHFT sites who are trained in Infectious disease are Lymington, Petersfield MIU/MAU are not equipped or designed to carry-out Clinical decontamination. III. Mass Decontamination: The planned and structured procedure delivered by the Fire and Rescue Service using purpose designed decontamination equipment, where there are large numbers of casualties. 4.4 Decontamination Equipment a. First Strike Equipment (for improvised or Interim Decontamination) This equipment may include buckets (designated clear and dirty)/sponges (individual to each casualty)/ towels/blankets/contaminated clothing bags (clear)/labelled bags for personal effects/dignity packs/cordon tape to mark off dirty and clean areas and should be used in a designated area outside the building. The Trust should consider the provision of equipment that can be deployed as a First Strike response. This is held at Moorgreen Hospital by the Duty Estates Manager on in working hours. The duty engineer will be contacted and instructed to deliver the HAZMAT box where needed. The use of such equipment may be appropriate if it appears that there is a need for urgent decontamination and can be used alone or as an initial measure that is provided while other facilities are readied if required by PHE. 4.5 Decontamination Area SHFT should consider the following when deciding where to carry out dry decontamination operations. The area selected should: Allow for the creation of secure areas that allow proper flow of patients both pre and post decontamination Where practical, ensure that patients are treated with dignity and respect Ensure that access is maintained to the site for both the Ambulance Service and noncontaminated patients 9

10 Allow location of the dirty side such that it is both accessible for incoming contaminated patients and that it is away from entry and exit routes used for clean patients, other patients, and staff Allow location of the clean side such that clean patients can move into the hospital building through a designated access point Take cognisance of the direction of the prevailing wind and, where possible, the designated area should be down-wind of buildings. Similarly, with regard to the orientation of the decontamination unit/area, the clean-side should be up-wind of the dirty-side Access to water and power supply from the hospital where applicable Provide shelter and protection from the elements. 4.6 Personal Protective Equipment (PPE) SHFT have a statutory obligation to protect the health and safety of their staff. As such, Boards must provide suitable Personal Protective Equipment for use by staff who may become exposed during decontamination operations and provide appropriate training in its use (including refresher training). This is included within Appendix 1 The need for personal protective equipment, the type required (and the protection it offers) will be subject to local risk assessment and will depend on the contaminant involved. However the following provides a suitable baseline. Although the minimum requirements for PPE vary with the type of contamination present, it should be noted that, in the case of a terrorist incident, it may not be possible to tell if there is a single contaminant present or indeed what that contaminant is. A risk assessment may determine that the use of full PPE is most appropriate. If SHFT are in doubt then as a precaution full clinical decontamination (or in circumstances where numbers dictate, mass decontamination by FRS) using the appropriate PPE would be a reasonable course of action. For Airborne and VHF viruses (EBOLA) boxes are held at Lymington NFH MAU/MIU, Petersfield MIU, HAZMAT strike box Moorgreen Hospital. a. Patient Potentially Exposed to Chemical Contamination To protect staff from health risks arising from casualties who might have been exposed to chemical contamination the following PPE should be available: Chemical resistant overall with integral hood Chemical resistant gloves Chemical resistant boots Suitable respiratory protective equipment to protect against hazardous gasses, vapours, and airborne particles. b. Patient Potentially Exposed to a Biological Agent which may Present a Risk of Airborne Infection For casualties who might have been exposed to a biological agent that presents a risk of infection, the following PPE should be available: See SHFT EBOLA Policy. Full length fluid impermeable gown, apron, hair, and foot cover Suitable respiratory protective equipment to protect against hazardous airborne particles to FFP3 standard Face shield, visor, or goggles Latex/vinyl/nitrile single use disposable gloves 10

11 c. Patient Potentially Contaminated with Radioactive Material For casualties who might be contaminated by radioactive material, the following PPE should be available: Disposable plastic apron Full length fluid impermeable gown Suitable respiratory protective equipment to protect against hazardous airborne particles to FFP3 standard Latex/vinyl/nitrile double layer disposable gloves 4.7 Decontamination Team Roles There are a number of roles that will need to be filled during a response to an incident involving potentially contaminated self-presenting casualties and it will therefore be necessary to form a multi-disciplinary team. SHFT should consider carefully the makeup of their decontamination team. Decontamination team members must have an appropriate background where they have patient contact as part of their normal duties. Everyone with a role within the response should receive appropriate training which must reflect the possibility that patients may arrive unannounced at any time of the day. Some of the roles that should be considered are listed below (note, this list is not intended to be exhaustive). Where appropriate, some of these roles may be combined. a. Decontamination Lead Officer (Duty Nurse/Matron) The Decontamination Lead Officer should assume command of the management of the overall decontamination response and is responsible for the overall management and recovery of the incident. In anticipation of the incident occurring without warning at any time, this role should be allocated, at least in the initial period, to an on-duty member of staff such as the nurse in charge. He/she should follow the Primary or Community Care Lead Action Card 4 (Appendix 1) to determine whether there is a need to decontaminate self-presenters. If necessary expert advice should be sought to ensure that a suitable and sufficient risk assessment is carried out, based on the information available from self-presenting patients, the Ambulance Service, Medical Incident Officer (if deployed), Local Police, and other relevant professionals (i.e. on-call Public Health Professional, Radiation Protection Advisor etc.). The Decontamination Lead should take the lead role in determining the appropriate response with the support of relevant individuals. The factors that should be considered are the risk assessments, the number of casualties either present or expected, and the possible need to start decontamination urgently. This response could range from provision on buckets and sponges, the deployment of the decontamination facility, or the request for assistance from the Fire Rescue Service. b. Entry Control Officer The function of the Entry Control Officer is to log in and out staff undertaking decontamination of casualties and consider any safety requirements. SHFT should ensure that the staff that might be allocated this role are provided with specific training and equipment. c. Decontamination Team (as directed by management) SHFT should identify and train staff to carry out the decontamination of contaminated casualties. Consideration should be given to the make-up of this team. Decontamination 11

12 teams should include safety teams i.e. staff in PPE ready to assist should a member of the Decontamination team get into difficulty. All staff in the decontamination or safety team must be trained in the use of PPE and decontamination techniques d. Crowd Control/Security It may be necessary to control the movement of the public, patients, and staff, to ensure clean and dirty areas are clearly separated and, in particular, to prevent contaminated patients entering the hospital. It will be necessary to allocate staff duties associated with the creation of such zones (e.g. setting up barriers, directing traffic). Other roles that need to be considered include arrangements for staff call-out/incident alert, and arrangements to implement lockdown. Staff training should be augmented by the provision of Action Cards for each individual role, which provide users with clear, concise, and unambiguous instructions. These Action Cards must be easily accessible in the event of an incident (see Appendix 1 for suggested Action Card examples). 4.8 Other Healthcare Facilities It is likely that, following a Hazmat/CBRN incident, most self-presenting patients will attend an Emergency Department although some casualties may attend other health facilities, e.g. Health Clinics, GP Surgeries. In these circumstances it is not practical for such facilities to have formal arrangements in place to deal with these casualties. However, such facilities are recommended to have: The ability to lockdown should they receive a warning that self-presenting patients may arrive The ability to quarantine any self-presenting patient that may enter the facility to minimise the risk of cross contamination of staff and other patients Mechanisms in place to summon help from the emergency services Provide appropriate staff training The ability to undertake first strike if urgent decontamination required. 5. Incident Response 5.1 General Principles SHFT s incident response should reflect the following general principles: all persons who self-present from the scene of a Hazmat/CBRN incident should be considered contaminated until the UK CBRN and Hazmat Decontamination Algorithm/ decontamination triage has determined otherwise the need for critical medical care should take priority over decontamination provisions but should, to the maximum extent possible, be subject to risk assessment to determine the appropriate precautions notwithstanding the need for medical intervention, early decontamination remains a priority, and should be done before a casualty enters any part of a hospital building. 5.2 Incident Response Trigger An incident involving chemical, biological, or radiological contamination can be heralded by one or more of the following triggers: Receipt of a warning from the emergency services, an industrial site, the military, or other source The arrival of patients giving a history of exposure The unannounced presentation of a small or large number of casualties exhibiting collapse, skin blistering/burns, visual disturbance, sweating, breathing difficulties, 12

13 lachrymatory symptoms, salivation, convulsions, muscle tremors, hoarseness, or major gastro intestinal disturbance. (It is important to note that exposure to some dangerous substances may not result in symptoms in the initial period). In circumstances where the first notification of an event involving CBRN/ Hazmat materials is the unannounced presentation of casualties, SHFT have a requirement to notify other agencies. (ie PHE Wessex Health Protection Team / OoH ) 5.3 Incident Plan Activation Any of the triggers discussed in Sub-section 5.2 should activate the Business continuity plan and where appropriate the Trusts Hazmat/CBRN Incident Plan. The initial phase of such a plan should include a procedure which involves the notification of key departments/individuals. These include: Site responsible person On-call Duty Manager for service provided The Decontamination Lead Officer (on call director) The initial response might be to establish a Control and Management Team to make strategic decisions and communicate with other organisations. The team should be based at Tatchbury Mount Sterne 7. It might also be appropriate to initiate the Hospital Lockdown Plan as a temporary measure, pending receipt of further information relating to the extent of the incident. These arrangements can be revoked or extended as required. Plans should address what support will be available from the Police in locking down a hospital should it be required. 5.4 Casualty Reception Decontamination Plans should provide that, where there is adequate warning, of their impending arrival, contaminated casualties should be received out-with the hospital, in an area that prevents cross contamination of other patients, staff, and the public. Where there is no warning, it is possible that potentially contaminated self-presenting patients will gain access to the hospital building. Plans should include arrangements to remove such patients to an appropriate area, which might be outside the hospital, for triage and possible decontamination, and should also include arrangements to deal with any area of the hospital that might have become contaminated (see Sub-section for further details). Specific awareness training should be provided to those staff that may either receive the first notification of an incident or come into first contact with self-presenting patients (e.g. Receptionist, Porters). 5.5 Incident Intelligence Following activation of the Incident Plan, the Decontamination Lead Officer or appropriate on-call manager should seek the following information: The likely number of self-presenting casualties The type/identity of the contaminant symptoms Precautions necessary Preferred method for decontamination 13

14 The Decontamination Lead Officer/appropriate on-call manager might need to contact some or all of the organisations listed below, and up to date contact numbers should be readily available for: The local Emergency Services Ambulance Services/NHS Staff at scene of the incident (i.e. Medical Incident Officer) On-call Public Health Professional Radiation Protection Advisor National Poisons Information Service Police National CBRN Centre Centre for Radiation, Chemical and Environmental Hazards This information will assist the Decontamination Lead Officer/appropriate on-call manager to undertake a robust risk assessment, and to determine: The level of response that is required The decontamination equipment required The level of PPE required The nature and extent of any lockdown In cases where there is a lack of warning and a need for urgent action, prompt risk assessment and decision making based on limited information and advice from other organisations might be required. This may result in a decision for urgent decontamination of casualties whose contamination status is not clear. 5.6 SHFT Sites Preparation Plans to deal with the arrival of self-presenting contaminated or potentially contaminated casualties should include arrangements to segregate them from other patients. Decontamination should not be an automatic response to the arrival of potentially contaminated casualties. An initial assessment of self- presenting, potentially contaminated, casualties should be carried out by a suitably trained and suitably protected Decontamination Triage Officer. 5.7 Patient Care Prior to Decontamination Since the bulk of any contamination is likely to be present on casualties clothing, plan should include provision of the removal of clothing as soon as possible on arrival at hospital. Contaminated clothing should be placed in double (clear) plastic bags, sealed, and labelled. Personal belongings should also be placed in appropriately labelled bags. Plans must also consider the need to protect, as far as possible, patient dignity and be flexible enough to accommodate the needs of vulnerable persons (see section 5.7.4). In addition, plans should include arrangements to provide some protection from the elements. It should be noted that certain groups of patients may be unwilling to undress in public due to cultural and/or modesty issues and, where practical, alternate arrangements should be considered to accommodate such individuals. Only basic life support and first aid (simple airway opening manoeuvers, bag-valuemask ventilation, and pressure on wounds) might be possible prior to and during decontamination (notwithstanding the fact that clinical needs should determine the priority of life saving intervention if necessary). An emergency bag containing appropriate disposable equipment should therefore be available for this purpose. Staff conducting such interventions must be appropriately trained and wearing protective equipment where appropriate. 14

15 5.7.1 Decontamination Response The response to the arrival of self-presenting casualties requiring decontamination might range from the deployment of: a. First Strike Equipment The Decontamination Lead Officer might decide that the appropriate response to an incident may be the issue of first strike equipment. This response may be appropriate when: There is perceived need for urgent decontamination and /or treatment which cannot wait until a Decontamination Unit is deployed (further decontamination may then be undertaken within the Decontamination Unit depending on the risk assessment) a small number self-present at SHFT sites as a first response whilst awaiting deployment of the Decontamination Unit from local FRS (such decontamination may either be carried out by SHFT staff or by the patient). It will then be the subject of a local risk assessment as to whether an individual who has been through interim or improvised decontamination needs further decontamination. b. Assistance from Other Agencies If the numbers of self-presenting casualties is assessed as likely to exceed the capacity that the Decontamination Unit can cope with, it might be necessary to revert to First Strike provisions or to call for assistance from the Ambulance Service, the local Fire and Rescue Service and/or other Trusts. It should be noted that the resources of the Ambulance Service and the Fire and Rescue Service may already be deployed at the scene of the incident and their capability to respond to any call for assistance may be limited in the first instance. However, it is important that, in such circumstances, contact is made with the emergency services (including the Police) and any appropriate action can be determined by risk assessment of the overall situation. Prior multi-agency planning should consider what support will be made available to Hospitals. If the emergency services cannot provide the necessary support within a suitable time-frame, it is recommended that plans should include the ability to provide improvised decontamination (e.g. the provision of buckets and sponges, the facility to hose down patients etc.). c. Radiological Contamination Although the arrangements for dealing with persons contaminated with a radioactive substance will, in general, be the same as for those contaminated with a chemical or biological contaminant, the following should be noted: The radiation dose rate from contamination is usually small The risk to staff involved in decontamination of such patients is normally low The use of a radiation detection device by appropriately trained staff can determine initial levels of radiation and the efficiency of decontamination Patient s treatment can take priority over decontamination (however, in this cases where the need for treatment is not urgent, it may be prudent to decontaminate first to reduce the likelihood of cross contamination). It may be necessary to carry out secondary decontamination to remove residual contamination. Such decontamination is best carried out with the shower area and the use of a radiation detection device may assist in this progress. These instruments must only be used by appropriately trained staff. 15

16 Although the risk may be reduced, precautions should be in place to prevent/minimise potential cross contamination of persons/facilities. (Note: contamination with radiological material may be accompanied by chemical or biological contamination and appropriate precautions and decontamination procedures must be in place in such cases.) Vulnerable Persons The specific needs of vulnerable persons (as defined in the Protection of Vulnerable Groups (is recognised within the CCA (2004) and plans should include arrangements to deal with such groups. Vulnerable persons requiring consideration are: i. Children under the age of 16 may either attend the Emergency Department as a casualty or as a member of a family or group caught up in the event. Plans need to reflect procedures for dealing with children and young people that may arise directly or indirectly from an incident (including cohorting of family groups). ii. iii. iv. Persons inhibited in physical movement caused by age, illness (including mental illness), disability, pregnancy, or other reasons. Deaf, blind, and visually and hearing impaired persons. Those persons from non-english (or non-gaelic) speaking communities and faith groups. v. Persons with learning disabilities or mental illness Decontamination Methodology National Ambulance Resilience Unit (NARU) Initial Operating Response (IOR) for Community based services should be by the dry de-contamination method the link below explains the methodology behind this contained within Appendix 1. Initial Operational Response (IOR) for the wider NHS NARU Patient Care Post Plans should include provision for re-robing, and appropriate aftercare. This may involve admission to Hospital for treatment or observation, transfer to local Rest Centres or other place of safety (for continuing aftercare or observation) or discharge. Clothing and valuables will not be returned to individuals until appropriate scientific advice regarding decontamination has been received and plans should bear this in mind. Although externally decontaminated there may still be internal contamination. The Trust s Plan should provide provision for the isolation of such patients to avoid potential cross-contamination of staff and other patients. (Such a provision should also be in place for relevant patients transferred to hospital by the Ambulance Service). Staff should remain vigilant for ill effects in the decontaminated person and in potentially contaminated colleagues. Patients who self-present following a CBRN incident may have been witness to a criminal act. Although the need to preserve life remains the priority in such cases, plans should include arrangements to record contact details of those persons that do not require further treatment following decontamination prior to discharge. Plans should also consider aftercare requirements (i.e. follow up by Public Health). 16

17 5.7.5 Southern Health Staff Plans must address the need to consider those staff that may have come into first contact with self-presenting casualties (e.g. receptionists, porters, nurses) and who may have become contaminated. Arrangements should be in place to quarantine such staff, assess them for potential contamination, and if necessary decontaminate, and provide any medical treatment and counselling as necessary. 6. Post Incident 6.1 Staff Debrief A staff debrief should be held as soon as practical after the incident has been concluded and a report issued. This report should include lessons identified and any relevant actions. The trust Decontamination Plan should be amended as appropriate to reflect these lessons learnt. Where other agencies were involved a multi-agency debrief may be beneficial. 6.2 Management of Decontamination Equipment Equipment used during the decontamination process should be considered as potentially contaminated and should be quarantined until decontamination can be carried out. Advice on the appropriate method for equipment decontamination can be obtained from: the company responsible for the contamination (post a Hazmat incident at an industrial site/transport spillage etc.) other industry experts (i.e. the manufacturer) The Government Decontamination Service (GDS) Public Health Department 6.3 Building Decontamination When contaminated patients have gained entry to an SHFT site and/or other parts of the site, these areas should be considered as potentially contaminated and should be subject to quarantine/restricted access (see for measures) until the area can be decontaminated. Hospital Buildings should be treated in line with The Strategic National Guidance on the Decontamination of buildings, infrastructure and open environment exposed to chemical, biological, radiological or nuclear materials (Cabinet Office, 2011). 6.3 Contaminated Clothing and Personal effects Clothing, valuables and personal items removed from self-presenting casualties must be considered as contaminated and expert advice should be sought prior to their return to their owner (e.g. Public Health, HPS, GDS) or as to the appropriate means for disposal. It should be noted that, in those cases where there has been a CBRN incident, such items of clothing may be required by the Police as criminal evidence. Any equipment that cannot subsequently be decontaminated effectively and economically should be disposed of as contaminated waste. The final disposal of this waste should only be undertaken after the hazard has been identified and specialist advice taken on the safest disposal options to prevent further contamination or harm. 6.4 Transportation of Contaminated Waste Depending on the type of contaminated waste, advice must be sort from PHE guidance as mentioned b. A reputable and licenced waste contractor must undertake transport to the incinerator. Prior to collection by the contractor waste must be stored securely and access restricted to authorised and trained personal. To arrange waste collection please contact: 17

18 Veolia Helpdesk on or (working hours) Roger Scott or Andy Higgins (out of hours for Ebola waste only) 18

19 Appendix 1 Preparation for Incidents involving Hazardous Materials Guidance for Primary and Community Care Facilities This document has been adapted from the NHS London guidance for Southern Health NHS Foundation Trust. 19

20 Introduction 1 This practical guidance document is aimed at preparing primary and communitybased health facilities to be able to manage the consequences of a hazardous incident occurring somewhere else (also refer to as chemical, biological, radiological, nuclear or explosive incident CBRNE). In these incidents there is a need to care for people, but also to be aware of the safety risk to staff and patients from secondary contamination as a result of people self-presenting at their facility seeking assistance. Primary and community care facilities include GP practices, pharmacies, dentists, opticians, health clinics, walk-in-centres (WIC s), minor injury units (MIU s) and community hospitals without emergency departments. Aim of the guidance: To enable primary and community care practitioners to adopt simple planning and response principles that would enable care to be provided to people self-presenting as a consequence of a hazardous incident, at the same time as protecting staff, patients and property from secondary contamination. To support primary and community care practitioners in the planning for a hazardous incident by providing a resource pack, including: Action cards for front line responding staff Guidance for primary and community care leads to follow in the preparation and response to an incident. To promote an understanding of the implications of a hazardous incident on the business continuity of the primary or community care facility. Background: Experience from hazardous or potentially hazardous incidents such as the Tokyo sarin attacks of 1994 and 1995, and the London bombing of 2005, demonstrate that large numbers of people may self-evacuate, if they can, and leave the scene without first coming into contact with the responding emergency services. Later, once symptoms have developed, or as a result of widespread media coverage, they may self-present to primary or community care health facilities in search of treatment, advice and reassurance. A proportion of these people will be worried well who have not been contaminated, but still concerned about their possible exposure to toxic substances. However, some will have been exposed and may need treatment, and may retain a degree of contamination on their bodies or clothing, posing a risk to healthcare staff that they come in to contact with. It is likely that the resources of the emergency services would be fully committed at the scene of the incident. Primary and community care facilities should, therefore, plan for unsupported management of self-presenters in the initial stages, obtain specialist advice, provide information to keep people calm, and wait for the emergency services to release resources to provide assistance. 20

21 Findings from a number of exercises, studies and workshops carried out across the country and in London since 2005 that focused of primary care preparedness to hazardous incidents identified that the majority of staff felt unprepared; were concerned that their views (especially frontline staff most at risk) had not been considered; and had not received any training. For example interviews with frontline staff in South West London revealed that receptionists and nurses at GP practices were concerned that plans should include assurance that their families would not suffer from crosscontamination when staff members return home. If further assistance is required this can be supported by those responsible for NHS emergency preparedness; providing advice on localising the guidance and assistance with staff training where required. Although primary and community care practitioners have access to HPA guidance they have received little or no practical guidance on how to apply this locally, or support with staff training. This is supported by learning from exercises, which among other things has shown that there is a lack of specific guidance on the management of self-presenters, and not enough consideration given to primary or community care preparedness for each type of incidents. 21

22 Contents Ref No. Content 1 Contextual document outlining the purpose of the guidance 2 Receptionist Action Card 3 Preparation guidance and checklist for the primary or community care lead 4 Primary or community care lead Action Card 5 Actions to follow after an incident involving a hazardous material 6 Patient content template A1 A2 Additional information Signage Template Use and suggested storage For all staff contextualises the risk and explains the purpose of planning. Gives clear and direct actions for reception staff (or person in first contact) to follow when an incident occurs. To be kept accessible but out of public sight behind reception. An aide memoire for the primary or community care lead person giving information and guidance on local planning. Used in advance of an incident occurring for preparation of the staff and building. A flow diagram for the primary or community care lead to follow when suspected contaminated people begin to arrive. One copy to be kept easily accessible. Provides recovery considerations for your patients, staff and buildings after an incident has finished. For recording the details of people who are affected by the incident. Should be photocopied and copies kept in the Response box for ease of access. Providing further information on Lockdown, Personal Protective Equipment requirements and the Response Box (that is recommended you consider developing). Template to allow you to create specific local signage to direct people when an incident occurs. To be kept in your Response Box. 22

23 Receptionist Action Card Preparation for incidents involving Hazardous Materials 2 Something unusual has happened Which makes you suspicious Think through the following steps STEP 1 One casualty Manage us STEP 2 Two casualties with similar symptoms and no apparent cause Manage with caution and consider risk to staff and others STEP 3 Three or more casualties with similar symptoms and no apparent cause Manage as an incident involving hazardous materials risk assess before intervening Isolate and seel specialist help immediately FOLLOW YOUR ACTION CARDS Think of your own safety and that of your colleagues. Call for help. Isolate your area. Inform patients that help is on the way. IMMEDIATE CONTACT/LEAD PERSON INSERT NAME AND CONTACT DETAILS HERE Director on Call: Flextel: Public Health England HPU: Out of Hours:

24 Receptionist Action Card Preparation for incidents involving Hazardous Materials 2 Something unusual has happened Which makes you suspicious FOLLOW STEPS Alert primary/community cares leads using internal communication system and follows any advice provided Agree who calls 999 for the emergency services Consider yourself and others lose by as contaminated Lock down reception area see locally developed lockdown plan Prevent other staff from entering reception area Direct contaminated patients to isolation area Open response box Put on personal protective equipment (PPE) if available Put up pre-printed laminated signs Advise all patients that help is on the way Record patient details on the patient contact template Wait for assistance Keep patients informed Follow specialist advice provided by the emergency services or local health protection unit (PHE) 24

25 Aide Memoire Preparation for incidents involving Hazardous Materials 3 Preparation guidance and checklist 1 st PREPARE THE BUILDING TICK Identify an area where you can isolate people who self-present having been potentially exposed to a hazardous material or substance Identify how you would lock-down areas to protect staff and patients Produce signage for front of building, entrance area, reception area and isolation room to inform patients on actions they should take Place preparation and response cards in reception and back office 2 nd PREPARE MANAGEMENT AND LOGISTICS TICK Agree management arrangements with senior staff who will be in charge? Prepare a response box to be held near reception containing: A Map A drawing of the layout of the building showing isolation area marked, doors to be locked and where signage should be placed B Laminated signage Clearly identifying where they should be placed C Action Cards Identifying who will do what, where and when D Pre-printed forms List of effected people, patient contact template E Personal protection and cleaning equipment Gloves, aprons, masks, tissues Contact numbers Consider who you need to inform and who can provide advice and guidance: Insert contact details Director on call: Flextel Public Health England HPU: Prepare a management pack containing copies of this guidance, HPA CBRN guidance, contact numbers, map/layout drawing and pre-printed forms Consider staff welfare arrangements see recovery details (section 5) 3 rd PREPARE THE STAFF TICK Ensure all staff, in particular frontline staff, know how: to assess the risk, to lockdown the building, to obtain information and advice, to keep patients informed and who performs which role in the practice Ensure all staff know where the response box is held and what it contains Ensure all staff are aware of procedures and protocols for assessment and treatment of contaminated staff and patients Ensure all staff are familiar with (and can access) business continuity plans for the practice, know what they entail, and how and when to activate them Rehearse the plan with your staff regularly 25