Strip and shower:☆

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In this issue of Annals, Hick et al¹, ² publish 2 important articles that address personal protective equipment for health care facility–based personnel. The authors present their consensus opinion of recommendations for hospital worker personal protective equipment and the related training implications. Although these articles are extremely useful to open the personal protective equipment debate in the peer-reviewed literature, the authors' advice should not be taken as dogma.

Controversy rages in the United States regarding what level of personal protective equipment is appropriate for hospital personnel. The American Medical Association, American College of Emergency Physicians, and other organizations are vigorously addressing these issues. It is not uncommon to attend a national meeting and hear: “Are you a ‘Level B’ or ‘Level C’ person?” Yet, the answer cannot be reduced to a sound bite. The Department of Veterans Affairs, which is the largest integrated health care system in the country, with 162 hospitals and more than 800 clinics, explored this issue well before the terrorist attacks of September 11, 2001. An Emergency Management Strategic Healthcare Group Technical Advisory Committee with internal Department of Veterans Affairs and federal government–wide external experts met to assess the pros and cons of various approaches.³ The Emergency Management Strategic Healthcare Group Technical Advisory Committee recommended that each health care facility perform a hazards vulnerability analysis to address local threats and use a combination of Levels A through D on the basis of the results.

Although biologic and radiologic agent exposures are fairly straightforward, the most challenging scenario involves patients who self-present to emergency departments (EDs) after exposure to an unknown concentration of an unidentified chemical agent (eg, contamination level may not be below “immediately dangerous to life and health”). Some would argue that, if a patient presented to the ED alive, receiving personnel in Level C gear would be unlikely to be at significant risk. However, the science is unclear, and some toxic agents have delayed effects, so others would insist that Level B (or even Level A for chemicals with the potential to off-gas) is indicated. Although detection technology is rapidly improving, many devices cannot rapidly and accurately predict the presence and level of agent in real time and are subject to false positives and false negatives.

Much of the existing data come from the military experience. However, military and civilian populations differ, and civilian communities do not have an “acceptable degree of loss” concept; we cannot predetermine that a certain percentage of our emergency workers may die for the good of the overall mission. In addition to the relative lack of data, researchers have paid little attention to current scenarios, eventualities for which we must be prepared. Although it is true that an average hospital may receive 1 or 2 patients a year requiring decontamination (eg, insecticide exposure in a farm community, patients from an industrial accident), we, fortunately, have virtually no experience in this country with caring for patients after exposure to chemical terrorism agents. Just because it has not happened yet, does not mean that it will not happen. Furthermore, previous data show that it would be dangerous to assume that community emergency responders will provide out-of-hospital decontamination.⁴ In fact, as the authors point out, more than 80% of casualties from the scene of a release self-refer to the hospital.

Psychosocial and cultural issues must also be considered. For example, after the Tokyo sarin attack, it was unacceptable for Japanese citizens to remove their clothing to aid decontamination. Another country that has experience with chemical terrorism is Israel. A forward team on the hospital grounds dons the equivalent of US Level B, with the majority of persons at the entrance to the ED in Level C, after front-line patient receivers determine that this is safe (personal communication, Col. Boaz Tadmor, MD, April 29, 2003). It is useful to study the Israeli experience, but there are important cultural differences. For one, nearly all patients are brought to the hospital by emergency medical services providers. Additionally, public awareness, knowledge, and the availability of personal protective equipment for both the public and health care providers is much more prevalent.

Disasters are local and, particularly in the chemical terrorism event, the acute medical management portion of the incident will be over by the time state or federal assistance arrives. Resource-dependent solutions differ between urban and rural settings. A key principle is that hospital personal protective equipment must be a part of a community comprehensive emergency management program.⁵ Hospitals must not plan in a vacuum. A hospital incident management system must be in place to include such factors as patient triage, facility lock-down and security as indicated, and clear lines of authority. We need to de-emphasize the singular focus on “response” and focus on all 4 phases of comprehensive emergency management—mitigation, preparedness, response, and recovery. In fact, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) revised their emergency management standards in January 2001 to require hospitals to embrace the 4 phases of comprehensive emergency management and use an incident management system consistent with that of the local community.⁶

The fact that JCAHO is awaiting standards before requiring a specific level of personal protective equipment for hospitals illustrates that there is not yet a national consensus. This is not simply a matter of money. Even if the health care system had unlimited funds to purchase, train, and sustain Level A personal protective equipment, several other factors would come into play. It takes longer to don higher levels of gear. One cannot easily perform critical medical interventions, such as intubation, while wearing bulky gloves and with sight and hearing impaired. Providers must be physically fit and, even so, can only tolerate higher levels of personal protective equipment for a limited time. Beards, moustaches, and glasses may limit personal protective equipment choices. Medical screening and surveillance requirements can be labor intensive. In addition, regulations that may be cumbersome in mass casualty settings were developed without completely addressing current threat scenarios. These include the Emergency Medical Treatment and Active Labor Act, which requires a medical screening examination for all patients presenting to hospital grounds, and the Health Insurance Portability and Accountability Act privacy rules for patient record keeping.

A one-time decision and initial funding strategy for personal protective equipment is insufficient. Ongoing training, on all shifts, is a key issue. Will decontamination training be a “requirement” for the job? Is additional hazardous duty pay required? Are workers' compensation procedures in place? If the employee is unwilling or physically unfit, will job loss result? How will this complicate scheduling for an operation that runs 24 hours a day, 7 days a week? Sustainment of the training program is even more challenging. With nursing shortages, high staff turnover, increasing clinical demands that make it difficult to release staff for training, and various stakeholders including the unions and the new Department of Homeland Security, initiating a hospital personal protective equipment program can be an enormous undertaking. Yet, we must protect our health care providers and facilities and support a “continuity of business operations plan,” which allows continued patient care even in the face of an emergency.

In addition, technology is rapidly changing. There is currently confusion regarding what is meant by the various levels of personal protective equipment. Are we referring to the respiratory component, the suit, both, or some combination? Perhaps we will soon have personal protective equipment that provides adequate protection but is less cumbersome to don and wear. The current Occupational Safety and Health Administration regulations were likely developed to protect “first responders” going to the scene of a hazardous material incident and did not account for hospital workers receiving patients exposed elsewhere. Some have proposed that emergency physicians should be considered “first responders,” particularly for a biologic terrorism event. Funding is currently directed at the traditional “first responders,” yet the proportion of dollars earmarked for hospitals through programs like the Health Resources and Services Administration bioterrorism grants pales in comparison. Successfully redefining hospital personnel as first responders would no doubt direct more funding to health care facilities. However, perhaps it is more accurate to refer to the ED staff as “first receivers” and the forward hospital team as “first contact personnel.”

There are several systems to describe personal protective equipment. The A through D levels in common use in the United States are not well recognized in other countries. The National Fire Protection Administration and InterAgency Board have a system of Levels 1, 2, and 3. The military use 5 levels of Mission Oriented Protective Posture, or MOPP, gear. Reducing a recommendation to “Level C” is a dangerous oversimplification and does not take into account a full analysis. Maybe the way to skirt the emotive discussions of “Level B” and “Level C” people is to refocus the debate and develop “Level H” for “health care facility” or “hospital” gear.

Although training has been available for years,⁷ if history is our guide, it will unfortunately take another event to draw attention and focus real resources on this key issue. During the cold war, we told people to “duck and cover.” Although this would not protect people from a nuclear bomb, it gave them something to do and represented an important risk communications technique: it was something every American school child could remember. In the 21st century, with the threat of chemical, radiologic, and biologic terrorism, a new sound bite is needed—one that is scientifically based, effective, and easy to remember. Because more than 90% of contaminants will be removed by simply removing one's clothing and even more by washing with plain water, the answer is obvious. We need more science on which to base appropriate approaches to hospital worker personal protective equipment. The articles by Hick et al¹, ² will open the debate in the academic community where it belongs, but in the meantime, we should tell the public, “If you think you've been exposed to a terrorism agent, ‘strip and shower!’”

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References 

References
1. Hick JL, Hanfling D, Burstein JL, et al.  Protective equipment for health care facility decontamination personnel: regulations, risks, and recommendations. Ann Emerg Med. 2003;42:370–380
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2. Hick JL, Penn P, Hanfling D, et al.  Establishing and training health care facility decontamination teams. Ann Emerg Med. 2003;42:381–390
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3. Boatright CJ, Koenig KL. The Emergency Management Strategic Healthcare Group Technical Advisory Committee: expert guidance for complex issues. Veterans Health Syst J. 2001;6:27–32
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4. In:  Auf der Heide E editors. Disaster Response: Principles of Preparation and Coordination. StLouis, MO: Mosby; 1989;
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5. Veterans Health Administration, Emergency Management Program Guidebook, February 2002 [Department of Veterans Affairs Web site]Available at: http://www.va.gov/emshg/emp/emp.htm. Accessed July 10, 2003.
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6. Joint Commission on Accreditation of Healthcare Organizations Web siteFacts about the emergency management standardsAvailable at: http://www.jcaho.org/accredited+organizations/hospitals/standards/ems+facts.htm. Accessed July 10, 2003.
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7. Emergency Management Strategic Healthcare GroupVideo on hospital personal protective equipment and decontaminationAvailable at: http://www.va.gov/vasafety/page.cfm?pg=528. Accessed July 10, 2003.
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