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A recent case of chemical exposure and illness in health care workers treating a patient who had ingested pesticides reveals that health care emergency rooms (ERs) are unprepared to deal with such situations and may be placing their staff at risk.
Three health care workers - one who was subsequently hospitalized for nine days - fell ill after the patient came into an ER in a South Georgia hospital.1 (See related story on that case, p. 2.) As a result of the case, the Centers for Disease Control and Prevention recommended staff take personal protection measures beyond standard infection control precautions. (See recommendations, p. 3.)
For example, the CDC recommends, depending on the extent of the contamination, health care workers caring for chemically contaminated patients should use level C protection (i.e., full face mask and powered/nonpowered canister/ cartridge filtration respirator); or level B protection (i.e., supplied air respirator or self-contained breathing apparatus). If the chemical agent cannot be identified, an organic vapor/high efficiency particulate air (HEPA) filter is recommended.
But in the real world are ERs likely to have such equipment on hand? "Typically not," concedes Kevin Yeskey, MD, associate director for emergency public health and science at the CDC. "That’s a tough question to answer, whether
this equipment needs to be [stocked] in the [ER]. Certainly there is an expense associated with having the equipment and maintaining it and training personnel."
Add staff turnover and the prevalent expectation that few chemically contaminated patients are going to be seen, and you have a full gamut of disincentives for ERs to take action on the issue.
"It’s a difficult situation for hospitals that don’t see these kind of patients often, to maintain the level of preparedness," Yeskey says. "Our take-home message would be - with any contaminated patient - we need to be aware and vigilant of the possibility for secondary contamination."
For example, workers alerted to the chemical odor and condition of the patient could at a minimum isolate the person and minimize staff contact. "At a basic level, that is a good recommendation," he notes. "You have to be aware of contaminated patients when they come into the hospital, try to do as much decontamination as possible based on their condition and the contaminant, and then use basic protection of the hospital workers - including minimal contact with the patient."
A standard surgical mask will not be protective in such situations because it does not have adequate filtration to block inhalation of the chemicals. Likewise, latex gloves will not stand up to abrasive chemical substances, so the heavy rubber variety might be more effective at preventing skin exposures. The Georgia case was complicated by the equivalent of chemical spill in the ER, as the patient vomited and the chemicals began "off-gassing" from the residue.
The Joint Commission on Accreditation of Healthcare Organizations requires hospitals to have a plan to manage contaminated patients. However, those recommendations do not include a plan to protect health care workers caring for contaminated patients, the CDC reports.
During 1996-1998, surveys of hospitals in Georgia and at level 1 trauma centers nationally indicated that few acute care hospitals had trained staff, equipment, and procedures to safely care for contaminated patients.2-4
While the most recent case was the result of a suicide attempt, the threat of a bioterrorist releasing toxic chemicals has been discussed for several years. "With the number of industrial agents out there and the possibility of exposure to chemicals, case studies like this raises the awareness of secondary contamination," Yeskey says.
To address concerns, Anthony G. Macintyre, MD, and colleagues at George Washington Univer-sity in Washington, DC, published an overview article last year to heighten awareness of the threat of chemical exposures.5 "Clearly, across the board, hospitals are inadequately prepared for both chemical or biological [incidents]," says Macintyre, assistant professor of emergency medicine at George Washington.
"The original impetus behind writing this is that a lot of the initial defense preparedness programs were being targeted at the first responder and law enforcement communities. Nothing was being done for hospitals. We were hearing stories of one contaminated patient walking into a local ER and the entire emergency room being shut down. That quite simply shouldn’t happen," he adds.
As opposed to individual suicide attempts or accidental chemical exposures, a bioterrorism chemical incident would result in the "mass public showing up on the hospital doorstep," he says. "But clearly, the exposure risk at the hospital is much lower than at the site of release. In our opinion, there is no need to be walking around in space suits at the hospitals. I think level C - an air purifying respirator - would be adequate for the chemicals."
Due to the hospital’s location in the nation’s capital, Macintyre has stepped up ER preparedness with the addition of chemical decontamination showers. That allows an immediate attempt to decontaminate the incoming patient while providing a triage point away from staff and other patients. The ER staff at George Washington had a "this-is-not-a-drill" experience after a fire at the Department of Commerce in October 1999. It was feared that the firefighters and others may been exposed to chemically hazardous polychlorinated material in the basement fire, so the decontamination showers went into operation.
Staff wearing powered-air respirators ushered exposed people through the showers, which allow privacy, as each one is decontaminated in a matter of minutes. "We decontaminated 48 people," he says "That was probably our biggest real test, and we did that in a fairly short amount of time."
1. Centers for Disease Control and Prevention. Nosocomial poisoning associated with emergency department treatment of organophosphate toxicity -- Georgia, 2000. MMWR 2001; 49:1,156-1,158.
2. Sharp TW, Brennan RJ, Keim M, et al. Medical preparedness for a terrorist incident involving chemical or biological agents during the 1996 Atlanta Olympic games. Ann Emerg Med 1998; 32:214-223.
3. Meehan P, Toomey KE, Drinnon J, et al. Public health response for the 1996 Olympic games. JAMA 1998; 279:1,469-1,473.
4. Burgess JL. Hospital evacuations due to hazardous materials incidents. Am J Emerg Med 1999; 17:50-52.
5. Macintyre A, Christopher G, Eitzen E, et al. Weapons of mass destruction events with contaminated casualties. JAMA 2000; 283:242-249. n