Senate Department for Health, the Environment and Consumer Protection H E A L T H NBC Preparedness in Hospitals Decontamination Plan As of: January 2010 0
If a nuclear, biological, or chemical (NBC) incident were to take place, hospital personnel could come into unexpected contact with patients who have been contaminated by NBC agents. A broad range of scenarios includes accidents involving hazardous chemical or biological substances or radioactivity, as well as criminal or terrorist attacks. In Tokyo, more than 70% of all patients arrived at hospitals as self-referrers. Consequently, 23% of the nursing staff and doctors were poisoned by contact with patients who had not been decontaminated because hospital personnel did not recognize the danger, for instance, and because proper protective equipment for hospital personnel was not available. Analysis of the Sarin attack in Tokyo in 1995 led to an important conclusion: until a decontamination site is established at the scene, victims will leave the scene unchecked and without being decontaminated to go to nearby hospitals on foot, by taxi, or by flagging down cars. They arrive at the hospital as self-referrers. Fig. 1: Decontamination exercise in Berlin Major Definitions NBC agents Nuclear, biological, or chemical substances and materials that are naturally occurring or artificially generated and are hazardous to life, health, the environment, and material assets. The term CBRN stands for chemical, biological, radiological, and nuclear. It can be used as an equivalent term to NBC. 1 Contamination Decontamination Contamination of skin, soil, liquids, or materials with NBC agents. Reduction or removal of NBC agents from surfaces, especially from clothes, skin, and equipment.
Goals of the plan Berlin s hospital decontamination plan is intended to protect all hospitals against secondary contamination, on the one hand (basic preparedness), and, on the other, to treat severely injured people (special preparedness). The plan has three main goals: 1. Occupational safety: Protection of on-duty personnel from hazardous substances As a result, all of the 38 Berlin hospitals providing emergency services practice basic preparedness on a permanent basis. The hospital decontamination plan was set up in preparation for the Football World Cup in 2006. Special preparedness will take place in selected hospitals, where seriously injured patients who could not be stabilized and decontaminated at the scene can be taken care of. 2. Individual treatment: Rapid and professional termination of the patient s exposure to hazardous substances to prevent further adverse effects on health 3. Protecting the health of the population: Protection of critical infrastructure hospitals in a disaster scenario and prevention of secondary damage to the health of patients who are not primarily involved Fig. 2: Emergency treatment team 2
Basic preparedness Basic preparedness is intended to get all hospitals ready to deal with self-referring, contaminated patients who have left the incident scene unchecked to go to the hospital. In particular, hospital personnel must have a heightened awareness of NBC hazards so they can recognize contaminated people quickly. In the early stages, when patients arrive unexpectedly at the emergency room, the situation calls for quick and simple protection measures ( speed before perfection ). One key measure that helps both patients and personnel is removing the clothing of affected patients. Because incidents involving chemicals are especially time-critical for contaminated patients and hospital personnel, it may also be necessary to shower affected body parts quickly. Berlin s hospitals have developed different solutions for these cases. Outdoor solutions, such as using emergency vehicle garages are preferred. However, showers in a plaster room near the emergency room can also be appropriate if walk-in patients have already contaminated the emergency room. The wastewater from decontamination is discharged into the public combined sewer system and, in an emergency, Berlin s water company is informed so that it can carry out its own protective measures. Fig. 3: Treatment of a self-referrer Personal protective equipment for personnel in the contaminated area consists of protective suits with powered air-purifying respirators. This protection enables personnel to carry out the most important emergency measures on patients. Because the suits do not cause breathing resistance, making them comfortable to wear, hospital personnel do not need a special occupational health exam and there are no limitations on how long the suits can be worn. Depending on the situation, powered air-purifying respirators can be used for more than seven hours. The suits also accommodate people who wear glasses or beards. 3
Special preparedness at selected hospitals The decontamination of severely injured patients (patients in the first triage group, who cannot be stabilized at the scene) is to take place at three specific hospitals offering full medical care. A three-part decontamination unit was developed for this purpose and is especially intended for the efficient decontamination of non-ambulant patients. These standardized units will be available at the selected locations and consist of three self-inflating tents connected by two sluices. Patients lying on spine boards are moved carefully through the tents using a rolling transport system. If necessary, ambulant patients can also use the tents to carry out their own decontamination (with assistance). All of the equipment is stored on dollies. Hookups and water and electricity lines have been pre-installed in the tents to ensure fast set-up times. Hand-held shower heads with spiral hoses are used to decontaminate patients. The aim is to be able to get these decontamination units up and running with hospital personnel on 30 minutes notice. Because complex threats require a greater number of trained personnel, staff from other relevant hospitals are to be sent to the hospital in question. The selected hospitals are the Charité (Campus Benjamin Franklin and Campus Virchow-Klinikum) and the Vivantes Klinikum im Friedrichshain. Emergency treatment Black zone Decontamination Black zone Non-ambulant Ambulant Further treatment White zone 4
Training The Senate Department for Health, the Environment and Consumer Protection started by giving theoretical and practical training to NBC representatives from all of the relevant Berlin hospitals, along with supervising emergency physicians, public health officers, and representatives from emergency services. As multipliers, they communicated what they had learned to their own hospitals and institutions and sought specific solutions for hospitals. The Senate Department is continuing to help the hospitals by organizing additional training seminars for their NBC representatives. Practical training for hospital personnel, such as how to put on protective equipment and decontamination training, is done by local NBC emergency services of the German Lifeguard Association (Deutsche Lebens-Rettungs- Gesellschaft DLRG) and the German Red Cross because of the specialized knowledge they already possess. Fig. 4: Group training in self-protection Research and cooperation Berlin s plan for NBC preparedness in hospitals is playing a pioneering role in Germany. The plan is based on international best practices, which were researched extensively by Berlin s Charité, Campus Virchow- Klinikum, under the direction of Dr. Frank Martens. The necessary training content was also outlined and program feasibility was assessed in hospitals. The plan that was 5 developed will be implemented in other German cities in the future. Transnational cooperation with Switzerland and Austria, for example, also proved to be a very useful exchange of experiences for all parties.
The plan in brief Basic preparedness Locations All 38 relevant hospitals Protection goals Status Limit further contamination Protect personnel with protective equipment Emergency treatment and decontamination, especially of self-referrers Secure the integrity of hospital processes, preserve vital processes Implementation completed in all hospitals Supervised training carried out in 17 of the 38 hospitals (45%) Special preparedness Locations 3 specific hospitals offering maximum medical care Extended protection goal Personnel requirements Time to set up one unit Capacity of one unit Status Personal protective equipment Type Period of wear per person Basic preparedness Special preparedness Decontamination of severely injured people who cannot be stabilized at the scene 8 14 people working in the black zone per unit/shift ca. 30 min (using 4 people for set-up) non-ambulant: ca. 12 patients/hour with 2 showers ambulant: ca. 60 patients/hour with 6 showers Currently being implemented Protective suit with powered air-purifying respirators (PAPR) Scheduled ca. 60-120 min., 7½ hrs. technically possible Each hospital: 6-8 suits and 4 training suits 28 protective suits with 14 PAPR (2 shifts) and 14 training suits per hospital 6
Publisher: Senate Department for Health, the Environment and Consumer Protection Medical Protection of the Population Oranienstrasse 106 10969 Berlin Germany http://www.notfallvorsorge-berlin.de 7