VHA DECON TASK FORCE REPORT

**STEPS TO ESTABLISHING A PRACTICAL HOSPITAL EMERGENCY MASS CASUALTY
DECONTAMINATION CAPABILITY** [^1]

**March 27, 2002**

***Goal: Each VAMC will achieve a hospital mass casualty decontamination
capability that is appropriate to their needs and that meets basic
criteria for quality and cost-effectiveness.***

**Summary:** In the event of a terrorist attack with weapons of mass
destruction (WMD), nearby VA Medical Centers (VAMC) must be prepared to
protect hospital facilities, staff, patients and to provide care to mass
casualties in the event that local acute care facilities become
overwhelmed. This document provides a four-step approach to provide a
standardized hospital decontamination facility for approximately \$50K.
It involves a series of steps including:

1.  A site-specific needs assessment that addresses your VAMC and
    community needs and existing capabilities for WMD casualty
    decontamination,

2.  Development of a decontamination plan appropriate to the needs of
    your Medical Center and community,

3.  External review of that plan by VHA experts, and

4.  Implementation of the plan, with the assistance of VA large-scale
    purchases of standardized equipment.

Many VAMC may find that selection of a standardized, commercially
available temporary decon package will fill their needs -- to this end,
this document provides the minimal requirements of such a standard
package and an example drawn from a currently commercially available
package. In addition, documentation is provided for nine examples of
specific permanent or fixed hospital decon facilities, including
installations with small, medium and large patient capacity.

This document does not address the training requirements, personal
protective equipment (PPE), and maintenance and refresher training in
order to maintain readiness (these will be addressed in future
documents).

**Background:** All Americans are concerned about the potential threat
of a terrorist attack involving weapons of mass destruction (WMD). Such
an attack could produce an overwhelming number of casualties, and nearby
hospitals will be called upon to help manage both physical and
psychological victims in the first 24-hours following an incident.

All nearby hospitals may find both physical and psychological casualties
arriving at their facility. In the 1995 sarin (a potent nerve agent)
attack in the Tokyo subway system, contaminated casualties came to local
hospitals. Some health-care workers became ill from cross-contamination,
which also affect their capability to provide care. A simple
decontamination (decon) capability, involving the removal of clothing
and a show with soap, shampoo and water, would have prevented chemical
contamination from entering the medical facility and threatening health
care workers and the continued operation of the facility.

Regardless of a hospital's current decontamination capabilities, a plan
can be quickly developed to manage mass casualties from such an
incident. The resulting fear and panic are perhaps the greatest concern
following an attack. Nevertheless, with some straightforward precautions
and procedures, basic safety equipment and supplies, hospitals can
develop the self-confidence and competency to protect their hospital
facility, staff and patients, as well as providing needed care to
victims of such an attack who may present at their hospital. A
decontamination facility is designed to protect hospital facilities and
staff so that they can safely and securely carry out their health care
responsibilities in a contamination-free environment.

To be effective, any VA decon program must be inexpensive, appropriate
to a hospital's specific situation, simple in concept and practice, and
easy to implement. Moreover, every VAMC must develop procedures for
specific emergencies identified through a hazards vulnerability analysis
to be consistent with the new JCAHO guidelines. Fortunately, we have
available some specific cases of existing hospital decontamination
facilities that can be used as examples for developing new
decontamination plans that will meet these goals. The following provides
a step-wise approach to selecting and establishing an appropriate
hospital decontamination capacity, involving 1) a site-specific needs
assessment; 2) the development of an appropriate decontamination plan;
3) an external review of that plan; and 4) implementation, including
access to VA large-scale purchases of standardized equipment.

**STEP 1 --** **SITE-SPECIFIC NEEDS ASSESSMENT FOR YOUR HOSPITAL
DECONTAMINATION FACILITY**[^2].

***Expected Outcome:** Each VAMC will determine its specific decon needs
including mass casualty capacity, and requirements for a fixed versus
temporary facility.*

Every VAMC has unique features including 1) physical layout, 2) size of
the staff and facility that require protection, 3) available and
suitable space, 4) community and local emergency planners expectations
for an actual emergency, and 5) existing mass casualty decon
capabilities both at the VAMC and the community. These unique features
must be considered when developing an appropriate mass casualty
decontamination program.

The Needs Assessment exercise will determine the appropriate scope for a
mass casualty decon program, taking into account specific VAMC and
community needs in an actual WMD emergency, and existing resources.[^3]
The time period for responding to a mass casualty event in your
community is assumed to be a period of 24-hours following the incident.

The key criteria for appropriateness are ability to protect Medical
Center staff and facilities, and to provide appropriate health care to
mass casualties presenting at the hospital in an emergency. Therefore,
the first step of the program will require an initial simple
site-specific needs assessment self-survey.

Key site-specific needs assessment questions are 1) determining
community decon expectations, 2) evaluating existing decon capacities,
3) determining decon capacity needs, and 4) determining if your VAMC can
be best served by developing fixed or temporary decon facilities.
Answering most of these questions will require consultation with other
members of your community, including local emergency response planners,
other hospitals, and other facilities that may have existing decon
capabilities. Obviously, it is impossible to predict exactly how a
terrorist event could affect a given community, but educated projections
can be made based upon the size of the community and the number and
capacity of local hospitals.

1)  **Determine your own VAMC decon capacity needs:**[^4]

    a.  In a mass casualty event occurring near your Medical Center and
        in your community, how many of your Medical Center staff and
        patients could be affected and require decontamination in a
        24-hour period?

    b.  How many others in the immediate vicinity of your facility may
        present and require decontamination in a mass casualty
        emergency?

2)  **Determine your local community expectations for decon capabilities
    for both ambulatory and non-ambulatory casualties at your VAMC
    following an actual WMD mass-casualty event.**

    a.  What are the expectations of your local community emergency
        planners and others for decon capabilities at your VAMC in a
        24-hour period following an actual WMD mass casualty emergency
        in your area?

    b.  If a WMD mass casualty event took place in your community, how
        many local residents, including both veterans and non-veterans,
        ambulatory and non-ambulatory, do you estimate might present at
        your VAMC for decontamination and treatment in a 24-hour period
        (this may require consultation with other community members)?

    c.  Is your facility expected to be capable of decontaminating and
        treating both ambulatory and non-ambulatory patients? Or
        ambulatory patients only?

    d.  Are their other factors that could impact potential mass
        casualties numbers such as nearby storage of hazardous
        materials, or the presence of a military facility?

3)  **Evaluate your existing VAMC and local community decon resources,
    and how they complement your decon needs.**

    a.  What are the existing decon resources available to your
        community, including those at your VAMC, other hospitals in your
        community, and at other nearby non-VA facilities (this may
        require consultation with other community members)?

    b.  How many staff do you currently have or could have trained to
        meet OSHA 1910.120(q) 1^st^ Responder Operations Level, and
        relevant respiratory protection standard requirements found in
        1910.134, that could conduct necessary decon activities, during
        normal and after hours? And, are they available on-site or would
        a recall process be required?

    c.  What is the capacity of existing resources in terms of
        casualties that can be decontaminated in a 24-hour period,
        following a WMD emergency?

    d.  How effectively are these resources integrated into a community
        emergency response program that can effectively meet overall
        community mass casualty decon needs?

4)  **Given your answers above, calculate your VAMC decon capability
    requirements for ambulatory and non-ambulatory casualties, as:**

    a.  *Large capacity* (capable of handling more than 100 ambulatory
        casualties in 6-hours), e.g., for a hospital in a major
        metropolitan area or with few other decon resources, or near a
        hazardous materials storage site;

    b.  *Medium capacity* (capable of handling 20 to 100 ambulatory
        casualties in 6-hours), e.g., for a hospital in a medium-sized
        metropolitan area or with some existing community decon
        resources, or

    c.  *Small capacity* (capable of handling less than 10 ambulatory
        casualties in 6-hours), e.g., for a hospital in a low-population
        area or with significant community decon resources.

5)  **Determine if your calculated VAMC decon capacity requirements can
    be best served by developing fixed or temporary decon facilities.**

    a.  Given the specific physical layout of your Medical Center, is
        space available for installing a fixed, dedicated decon facility
        (such as a alley-way or outside external corridor), or is a
        temporary decon facility (such as an inflatable tent set up in a
        parking lot) more appropriate? (It is important to note that
        decontamination [must]{.underline} take place outside of the
        medical facility, and outside security will be required to
        ensure an effective and orderly process.)

    b.  If a temporary, portable decon facility is indicated, how many
        staff do you have available to set-up that facility during
        normal and after hours? And, are they available on-site or would
        a recall process be required?

Answering these questions will determine the capacity of the necessary
VAMC decontamination program. Those VAMC fortunate enough to be part of
a larger community with significant existing emergency decon
capabilities may need few or even no new capabilities to meet their
overall needs.[^5]

**STEP 2 -- DEVELOPMENT OF A DECONTAMINATION PLAN APPROPRIATE TO THE
NEEDS OF YOUR HOSPITAL AND COMMUNITY.**

***Expected Outcome:** Each VAMC will use their needs assessment results
to develop an appropriate decon plan for their facility, assisted by
existing examples of VAMC and private hospital decon facilities.*

After determining the appropriate decon capacity, each VAMC must develop
a decon program plan that fully meets those requirements. Each VAMC
should be able to use this information to develop a short narrative plan
for their own hospital, including the type of program selected, how it
meets hospital decon needs, and a simple "floor diagram" illustrating
the layout and location of the proposed decon facility.

Many Medical Centers can take advantage of standardized commercially
available decon packages designed to be rapidly set up in a parking lot
or other available space outside of the hospital. A standard,
commercially available rapidly deployable temporary decon package used
by the Brooklyn, NY, VA is one example of a system that could be
considered. These flexible packages supply the entire mass casualty
decon shower system, and are commercially available for about \$30K (VA
is currently evaluating such packages available from several vendors).
These have the advantages that they can be set up virtually anywhere,
such as a parking lot, require a minimum of maintenance when not in use,
and are relatively inexpensive.

A commercially available temporary tent-based decon showers system
offering at least medium decon capacity is based upon a rapidly
deployable ridged frame tent structure, equipped with a stand-alone hot
water generator, an air heater for operation in cold weather, along with
the materials required to assemble a complete decon system. A baseline
package will include: An outdoor Mass Casualty Decon System with an
approximately 16' X 16' rapidly deployable ridged framed tent (capable
of withstanding adverse weather conditions), equipped with a
self-contained powered water heater system capable of providing
warm-water showers appropriate to needed decon capacity under all
weather conditions, a self-contained fresh air heater to maintain
appropriate air temperatures for minimally clothed victims under all
weather conditions, all necessary water supply hoses, spray wands, decon
booms, decontamination litters for handling non-ambulatory victims,
modesty curtains for providing appropriate privacy, a full floor system
and temporary waste-water containment berm with the capacity of handling
waste-water from the decon shower system and corresponding wastewater
containment bladder, self-contained interior lights, and 4-hours
hands-on on-site training. The entire decon system should be deployable
within 30 minutes and should be placed in storage containers when not in
use.

Examples of large, medium and small hospital mass casualty decon
programs that have been successfully implemented at VAMC and other
hospitals, including the use of fixed facilities,[^6] are provided in
the attached document "Hospital Mass Casualty Decontamination Facility
Examples."[^7]). These examples provide sufficient detail (photographs,
numbers of showers, waste-water handling details, Personal Protective
Equipment, contact information, etc. to allow local hospital engineers
to plan for an appropriate facility at their VAMC.

The proposed VAMC decon plan should be submitted to Mr. John E. Kraemer,
room 864, VA Central Office, 810 Vermont Ave. NW, Washington, DC 20420
(email <john.e.kraemer@hq.med.va.gov>). Proposed plans should be no
longer than a few pages in length, and address the following issues:

-   Identification and rational for the calculated 24-hour decon
    capacity (as large, medium, or small).

-   Size of the staff and facility that will be protected.

-   Role the facility plays in support to the community for mass
    casualty care and mass casualty decontamination.

-   Existing on-site decon capabilities.

-   Existing decon capabilities within the community, and how those may
    complement on-site capabilities.

-   Patient flow diagram (should be part of the facility diagram but
    should be specified to ensure that all proper/required stations have
    been incorporated).

-   Estimated set-up requirements to include staff and time.

-   Selection and rational for a fixed versus temporary facility, and
    sources of water for decon showers.

-   Ambulatory and non-ambulatory patient capabilities.

-   Cold weather decontamination considerations

**STEP 3 -- EXTERNAL REVIEW OF THAT PLAN BY VHA EXPERTS.**

***Expected Outcome:** Specific decon facility plans developed by each
VAMC will be reviewed by a VHA expert group to ensure consistency, high
quality, and cost effectiveness.*

To ensure consistency, high quality and cost effectiveness of VAMC decon
facilities, each VAMC's proposed decon plan will be reviewed by a VHA
expert review group. The review is not a grading process; rather it will
help ensure that VAMC facilities can receive expert guidance in
decontamination, even if their staff has little experience in this area.
The review process will assure that the plan meets minimum quality, cost
and effectiveness standards for the required capacity needs as
determined from the Needs Assessment step. The proposed plan will
further be reviewed to ensure that it meets the two primary decon
program goals of protecting hospital and staff, and of providing care to
casualties. This review process will ensure a uniform level of
decontamination program across VHA, ensure consistent cost estimates,
and will support development of large-scale purchases of standardized
equipment and materials, when appropriate.

**STEP 4 -- IMPLEMENTATION OF THE PLAN, WITH THE ASSISTANCE OF VA
LARGE-SCALE COST-SAVING PURCHASES OF STANDARDIZED EQUIPMENT AND
MATERIALS.**

***Expected Outcome:** Following approval of each decon plan, each VAMC
will implement their plan at their facility, assisted by access to
large-scale cost-saving purchased materials.*

Following review and acceptance of a hospital decon facility plan by the
VHA expert review group, a hospital will be expected to implement that
plan at their facility. Most of the examples of functioning hospital
decon programs provided in the attachment were implemented using
hospital engineering staff and locally obtained materials. However, a
key advantage of the standardized large-scale contractual purchase
approach described above is that it will allow for potentially
significant cost savings from large-scale government purchases of
standard materials and equipment that can be used across all
installations. This will include standard inflatable or rapidly
deployable tent-based shower decon systems. These will be made available
to individual hospitals, as appropriate.

A VHA Executive Decision Memorandum "Accelerated Provision of Level C
Personal Protective Equipment (PPE) for Medical Center Employees
Involved in Emergency Decontamination of Victims Exposed to Nuclear,
Chemical, or Biological Contaminants as part of a more comprehensive PPE
program," was recently approved by the VA Policy Board. That memorandum
addressed the need for VHA to accelerate the acquisition of adequate
personal protective equipment (PPE) so that VHA personnel can begin to
train and use the equipment necessary to safely decontaminate incoming
patients in the event of a terrorism attack. It provided the basis for
funding decisions necessary to accelerate the acquisition of PPE needed
to carry out decontamination activities. For this purpose, a national
purchase of equipment was recommended to begin the implementation
process, utilizing a splash suit along with a full-faced or hooded air
purifying respirator or powered air purifying respirator (PAPR) with
cartridge equivalent to the 3M FR57 cartridge as defined by OSHA.

**VHA Decontamination Task Force Members**

1\. Tom Weaver, Director, Bay Pines VAMC

2\. John Beatty, Safety Officer, Little Rock VAMC

3\. Grace Stringfellow, M.D., Amarillo VAMC

4\. John Donnellan, CEO, New York Harbor HCS Brooklyn Campus

5\. Ed Thorsland, Director, Denver VAMC

6\. Arnie Bierenbaum, General Engineer, VACO (10NB)

7\. Cynthia Gavin, Project Manager, RPI/Titan Corporation

8\. John Siegmund, DoD US Army Soldier and Biological, Chemical Command

9\. Paul Fedele, DoD US Army Soldier and Biological, Chemical Command

10\. Anthony Macintyre, Emergency Medicine, George Washington University

11\. James Church , DoD US Army Soldier and Biological, Chemical Command

12\. Pete Farlow, DoD US Army Soldier and Biological, Chemical Command

13\. COL Craig Postlewaite (Staff Director/Director for Deployment
Health), Military and Veterans Health Coordinating Board

14\. Rosemary Sokas, NIOSH/CDC

15\. Mark Brown, Director Environmental Agents Services, VHA

16\. Craig Hyams, Chief Consultant Occupational and Environmental
Health, VHA

17\. Michael Hodgson, Director Occupational Health Program, VHA

[^1]: This document is based on a two-day meeting of the VHA
    Decontamination Task Force, held January 29-30, 2002 at VA Central
    Office, Washington DC (Task Force membership on page 8).

[^2]: The Emergency Management Program Guidebook
    ([http://vaww.ceosh.med.va.gov/DocsWeb/Guidebooks/data/EMP/emp.htm]{.underline})
    guides users through a process that leads to an enhanced capability
    to deal with all hazards. In the completion of the hazard
    vulnerability analysis and development of a Standard Operating
    Procedure, the VAMC should consider \[(Emergency Management Program
    Guidebook: Step 3.2 -- see also 3.10.3- Hazard Vulnerability
    Analysis (HVA) Instructions and Step 7: develop SOPS, see: 7.2.3:
    External Chemical Events\].

[^3]: Nevertheless, every hospital must consider a decon capability for
    an isolated incident involving one or two casualties.

[^4]: Any questions you may have about this needs-assessment exercise
    can be directed to Mr. John Kraemer, VACO, email
    john.e.kraemer@hq.med.va.gov.

[^5]: However, every VAMC should evaluate their current capability for
    both an isolated incident with one or two casualties, versus a
    general incident producing many casualties.

[^6]: Some experts believe that permanent or semi-permanent shower
    emergency decon facilities have several advantages over temporary
    tent type facilities. These include the speed of setting up the
    facility, lower manpower requirements for set-up, and lower training
    requirements for the fixed or semi-fixed facilities. Fixed and
    semi-fixed facilities can be implemented in a wide variety of
    situations such as outdoor corridors, alleys, along an external
    wall, or external smoking rooms. Such facilities may even be less
    expensive than temporary facilities.

[^7]: For an electronic copy of that document email your request to
    john.e.kraemer@hq.med.va.gov.