Best Practices for

Hospital-Based First Receivers

of Victims from Mass Casualty Incidents 

Involving the Release of Hazardous Substances

www.osha.gov

OSHA 3249-08N 2005
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training, outreach and education; establishing partnerships; and encouraging continual improvement

in workplace safety and health. 

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consult current OSHA administrative interpretations

and decisions by the Occupational Safety and Health

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guidance on OSHA compliance requirements.

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Best Practices for

Hospital-Based First Receivers

of Victims from Mass Casualty Incidents

Involving the Release of Hazardous Substances

Occupational Safety and Health Administration

U.S. Department of Labor

OSHA 3249-08N 

2005
ACKNOWLEDGMENTS 4

EXECUTIVE SUMMARY 6

Introduction 9

BACKGROUND 9

DEFINING “FIRST RECEIVERS” 9

SCOPE AND OBJECTIVES 9

DOCUMENT CONTENT AND ORGANIZATION 10

Personal Protective Equipment 11

USING OSHA’S BEST PRACTICES 11

Using OSHA’s Rationale for PPE Selection 

and Hazard Assessment 11

Augmenting the PPE Selection to Address 

Specific Hazards Identified by the Hazard 

Vulnerability Analysis (HVA) and the Community 11

RATIONALE FOR OSHA’S PERSONAL 

PROTECTIVE EQUIPMENT BEST PRACTICES 12

Respiratory Protection 12

Limited Quantity of Contaminant on Victims 12

Hospital Experience with Contaminated Victims 13

Exposure Modeling 15

Gloves and Boots 16

Protective Garments 17

CONCLUSIONS REGARDING PERSONAL 

PROTECTIVE EQUIPMENT 18

First Receiver Hospital Decontamination Zones 20

PPE Table and Tables Listing Prerequisite 

Conditions for Specified PPE 20

Training First Receivers 24

OPERATIONS LEVEL TRAINING 24

AWARENESS LEVEL TRAINING 26

BRIEFING FOR SKILLED SUPPORT PERSONNEL 

WHOSE PARTICIPATION WAS NOT PREVIOUSLY 

ANTICIPATED 26

TRAINING SIMILAR TO THAT OUTLINED IN 

THE HAZARD COMMUNICATION STANDARD 26

SUMMARY OF TRAINING FOR 

FIRST RECEIVERS 27

Appendix A: 

Background, Literature Review, 

and Site Visit Examples 29

PREPAREDNESS 30

CUSTOMIZING HOSPITAL EMERGENCY 

MANAGEMENT PLANS 30

Using Information from a Hazard 

Vulnerability Analysis 30

Identifying the Hospital’s Role in the Community 31

Updating Emergency Management Plans 32

Coordinating Emergency Plans with 

Other Organizations 32

PREPARING STAFF AND MANAGEMENT 33

Applicable Standards 33

Maintaining Decontamination Teams 34

Orienting and Training Personnel 34

Competencies for First Responder 

Operations Level Training 35

Competencies for First Responder 

Awareness Level Training 36

Instruction for Employees Whose 

Participation in the Hospital Decontamination 

Zone Was Not Previously Anticipated 36

Training Similar to That Outlined in 

the Hazard Communication Standard 36

Monitoring Performance During Drills 37

Managing Internal Communications 37

Principles of Risk Communication 37

Information Dissemination During an Incident 37

Monitoring Employee Health 38

Prior to an Incident 38

Medical Clearance for Respirator Use 38

During a Response 38

Thermal Stress 39

Following an Incident 39

Managing Employee Stress 40

RESPONSE 40

FACILITIES AND EQUIPMENT 40

Evaluating Existing Resources 40

Isolation and Lockdown 40

Decontamination 41

Equipment 41

Procedures 43

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Occupational Safety and 

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Shower Flush Time and Practices 45

Soap 45

Security 46

Personal Protective Equipment 46

Detection Equipment 47

Ionizing Radiation Meters 48

Chemical and Biological Agent 

Detection Equipment 48

TRIAGE CONSIDERATIONS 49

EXTERNAL COMMUNICATION 49

Obtaining Timely Information 49

Coordinating Activities 49

RECOVERY

50

HOSPITAL DECONTAMINATION 50

Solid Waste Management 50

Wastewater Management 50

Decontaminating Surfaces and Equipment 51

MAINTAINING FUTURE READINESS 51

Appendix B: 

Acronyms and Definitions 53

Appendix C: 

References 55

Appendix D: 

Additional Resources (Web Links) 59

Appendix E: 

Advantages and Disadvantages of 

Various Respirator Facepiece Styles 60

Appendix F: 

Hazard Vulnerability Analysis Examples 61

Appendix G: 

Introduction to HEICS 64

Appendix H: 

Examples of Medical Monitoring 

for First Receivers, Including 

Information on Heat Stress 67

Appendix I: 

Vital Signs and PPE Donning Checklists 74

Appendix J: 

Example of Patient Decontamination 

Procedure 76

Appendix K: 

PPE Donning and Doffing Sequence 79

Appendix L: 

Example of Technical Decontamination

Process for Hospital Personnel 80

Appendix M: 

Example of Integrated Procedures 

for First Receivers 81

LIST OF FIGURES AND TABLES

Figure 1.

Results of Simulation Tests on 

Several Chemical Suits 18

Table 1.

Hospital Decontamination Zone 21

Table 2.

Hospital Post-Decontamination Zone 22

Table 3.

Minimum Personal Protective Equipment (PPE) 23

Table 4.

Training for First Receivers 28

OSHA Assistance 95

OSHA Regional Offices 97

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 3
ACKNOWLEDGMENTS

OSHA’s Directorate of Science, Technology and

Medicine wishes to acknowledge the assistance provided by the following organizations: U.S. Department

of Veterans Affairs (VA), California Emergency Medical

Services Authority (EMSA), Centers for Disease Control

and Prevention/Agency for Toxic Substances and

Disease Registry (CDC/ATSDR), National Institute for

Occupational Safety and Health (NIOSH), INOVA

Health System, Northern Virginia Hospital Alliance,

Kaiser Permanente, U.S. Coast Guard National Strike

Force, and the U.S. Army Center for Health Promotion

and Preventive Medicine (USACHPPM). OSHA’s

Directorate of Enforcement Programs (DEP), and the

Directorate of Standards and Guidance (DSG), as well

as the Office of the Solicitor, OSH Division (SOL) also

made notable contributions.

Seven hospitals provided extensive information,

hospital tours, equipment demonstrations, interviews,

photographs, and reference material for this project:

Central Arkansas Veterans Healthcare System, Little

Rock, Arkansas 

Enloe Medical Center, Chico, California 

National Naval Medical Center, Bethesda,

Maryland

New York University Medical Center, New York

City, New York

Samaritan Regional Health System, Ashland, Ohio 

Sutter Amador Hospital, Jackson, California 

Veterans Administration Medical Center,

Washington, DC 

These hospitals were identified by hospital organizations as having given notable consideration to the

possibility of receiving contaminated victims from a

mass casualty incident involving hazardous substance

release. Hospitals interviewed were selected to represent a range of circumstances, loosely based on location (U.S. region) and the hospital’s relative probability

(risk) of receiving contaminated victims of a mass

casualty incident. This risk was estimated using a

scale adapted from the Hospital Corporation of

America (HCA, undated):

• Key Treatment Centers – Hospitals in large urban

areas. (Hospitals A, B, C, and G.)*

• Potential Risk Hospitals – Hospitals within 50

miles of a large urban area and high-visibility

potential targets where a mass casualty incident

could occur (e.g., major airport or sports stadium, large chemical manufacturing facility,

nuclear power plant, major shopping mall,

nationally recognized monument). (Hospitals D

and E.)*

• Minimum Risk Hospitals – Hospitals with populations less than 500,000 within a 50-mile radius

and without a high-visibility potential target within that distance. (Hospital F.)*

Note: This risk scale was used only to help identify a

diverse group of hospitals for interviews. Other scales

might have been used and OSHA does not promote this

or any other scheme.

* To maintain a minimum level of confidentiality, hospitals were assigned letters according to risk category

which do not reflect the alphabetical order in which they

are listed above.

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Occupational Safety and 

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The following agencies and organizations

reviewed and provided comments regarding

these OSHA Best Practices:

Agency for Healthcare Research and Quality (AHRQ)

Agency for Toxic Substances and Disease Registry

(ATSDR) 

American College of Emergency Physicians (ACEP)

American Hospital Association/American Society for

Healthcare Engineering (ASHE)

U.S. Navy Bureau of Medicine and Surgery (BUMED)

California Emergency Medical Services Authority (CAEMSA)

Centers for Disease Control and Prevention (CDC)

Emergency Nurses Association (ENA)

EnMagine (hazmatforhealthcare.org)

George Washington University - Institute for Crisis,

Disaster and Risk Management

Health Resources & Services Administration (HRSA),

National Bioterrorism Hospital Preparedness

Program

Hennepin County (MN) Medical Center, Emergency

Medicine

Inova Health System, Emergency Management and

Disaster Medicine; and Employee and

Occupational Health Departments

International Chemical Workers Union Council of the

United Food and Commercial Workers Union

(ICWUC)

International Safety Equipment Association (ISEA)

Joint Commission on Accreditation of Healthcare

Organizations (JCAHO)

Kaiser Permanente

National Incident Management System (NIMS)

Integration Center

National Organization for Victim Assistance (NOVA)

Navy Environmental Health Center, Industrial Hygiene

Directorate, 

Navy Medicine Office of Homeland Security, Bureau of

Medicine and Surgery

National Institute of Environmental Health Sciences

(NIEHS), Worker Education and Training Program

(WETP), National Clearinghouse for Worker Safety

and Health Training

National Institute for Occupational Safety and Health

(NIOSH) 

NYU Medical Center, Environmental Services

Department

Rhode Island Department of Health

Samaritan Regional Health System

University of Maryland School of Medicine, National

Study Center for Trauma & EMS

U.S. Department of Veterans Affairs, Central Arkansas

Veterans Healthcare System

U.S. Department of Veterans Affairs, Office of

Occupational Safety and Health

U.S. Department of Veterans Affairs, Occupational

Health Program

U.S. Department of Veterans Affairs, Veterans

Administration Medical Center (Washington, DC)

U.S. Army Center for Health Promotion and Preventive

Medicine (USACHPPM)

The mention of any healthcare provider, product, or

process in this publication does not constitute or

imply endorsement by the Occupational Safety and

Health Administration.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 5
EXECUTIVE SUMMARY

Healthcare workers risk occupational exposures to

chemical, biological, or radiological materials when a

hospital receives contaminated patients, particularly

during mass casualty incidents. These hospital

employees, who may be termed first receivers, work

at a site remote from the location where the hazardous substance release occurred.1 This means that

their exposures are limited to the substances transported to the hospital on victims’ skin, hair, clothing,

or personal effects (Horton et al., 2003). The location

and limited source of the contaminant distinguishes

first receivers from other first responders (e.g., firefighters, law enforcement, and ambulance service personnel), who typically respond to the incident site (i.e.,

the Release Zone).

In order to protect their employees, hospitals benefit from information to assist them in emergency planning for incidents involving hazardous substances

(BNA, 2003; Barbera and Macintyre, 2003). Emergency

first responders, at the site of the release, are covered

under OSHA’s standard on Hazardous Waste Operations

and Emergency Response (HAZWOPER), or the parallel OSHA-approved State Plan standards, and depending on their roles, some hospital employees also are

covered by the standard.2,3 However, OSHA recognizes that first receivers have somewhat different

training and personal protective equipment (PPE)

needs than workers in the hazardous substance

Release Zone, a point clarified through letters of interpretation (OSHA, 2002a). 

In this best practices document, OSHA provides

practical information to help hospitals address

employee protection and training as part of emergency planning for mass casualty incidents involving

hazardous substances. OSHA considers sound planning the first line of defense in all types of emergencies (including emergencies involving chemical, biological, or radiological substances). By tailoring emergency plans to reflect the reasonably predictable

“worst-case” scenario under which first receivers

might work, the hospital can rely on these plans to

guide decisions regarding personnel training and PPE

(OSHA, 2003, 2002b, 1999). The Joint Commission on

Accreditation of Healthcare Organizations (JCAHO)

requires an all-hazard approach to allow organizations

to be flexible enough to respond to emergencies of all

types, whether natural or manmade (unintentional or

intentional).4

Worst-case scenarios take into account challenges

associated with communication, resources, and victims. During mass casualty emergencies, hospitals

can anticipate little or no warning before victims begin

arriving.5 Additionally, first receivers can anticipate

that information regarding the hazardous agent(s)

would not be available immediately. Hospitals also

can anticipate a large number of self-referred victims

(as many as 80 percent of the total number of victims)

and assume victims will not have been decontaminated prior to arriving at the hospital (Auf der Heide,

2002; Barbera and Macintyre, 2003; Vogt, 2002;

Okumura et al., 1996). 

The appropriate employee training and PPE selection processes are defined in applicable OSHA standards.6 An employee’s role and the hazards that an

employee might encounter dictate the level of training

that must be provided to any individual first receiver.

1 Hazardous substance is defined as any substance to which

exposure may result in adverse effects on the health or safety

of employees. This includes substances defined under Section

101(14) of CERCLA; biological or disease-causing agents that

may reasonably be anticipated to cause death, disease, or

other health problems; any substance listed by the U.S.

Department of Transportation as hazardous material under 49

CFR 172.101 and appendices; and substances classified as hazardous waste.

2 29 CFR 1910.120.

3 First responders, including firefighters, law enforcement, and

emergency medical personnel, and many first receivers at public hospitals, are usually employees of local, municipal, or state

governments. Although Federal OSHA's standards and

enforcement authority do not extend to such state and local

governments, these employers and employees are covered by

the 26 states that operate OSHA-approved State Plans and, in

states without State Plans, by the Environmental Protection

Agency (EPA) with regard to HAZWOPER (29 CFR 1910.120).

State Plan states set and enforce standards, such as the HAZWOPER and Respiratory Protection standards, which are identical to or “at least as effective as” Federal OSHA standards, and

therefore may have more stringent or supplemental requirements. EPA's HAZWOPER parallel standard was adopted to

cover emergency responders who would not be covered by

the OSHA standard, including volunteers who work for a governmental agency engaged in emergency response, such as

firefighters. For consistency, OSHA interprets the HAZWOPER

Standard for the EPA. Federal OSHA administers the safety and

health program for the private sector in the remaining states

and territories, and also retains authority with regard to safety

and health conditions for Federal employees throughout the

nation (OSHA, 1991c).

4 Note: Footnotes at relevant points in the text indicate current

JCAHO Standards for Emergency Management, which are further described in Section EC 1.4 of JCAHO’s Comprehensive

Accreditation Manual (JCAHO, 2004). 

5 Mass casualty may be defined as “a combination of patient

numbers and patient care requirements that challenges or

exceeds a community’s ability to provide adequate patient care

using day-to-day operations” (Barbera and Macintyre, 2003).

6 Applicable OSHA standards include: 29 CFR 1910.120 – HAZWOPER; 29 CFR 1910.132 – Personal Protective Equipment –

General Requirements; 29 CFR 1910.133 – Eye and Face

Protection; 29 CFR 1910.134 – Respiratory Protection.

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Occupational Safety and 

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PPE selection must be based on a hazard assessment

that carefully considers both of these factors, along

with the steps taken to minimize the extent of the

employee’s contact with hazardous substances. 

Despite many hospitals’ strong interest in powered

air-purifying respirators (PAPRs) as a practical form of

respiratory protection for first receivers in the Hospital

Decontamination Zone, many knowledgeable sources

avoid making specific PPE recommendations, but

rather point out the advantages and disadvantages of

the various options, or recommend appropriate PPE

(JCAHO, 2001; Lehmann, 2002; Penn, 2002). Others

offer stronger opinions. CA EMSA (2003a) promotes

the use of a multi-tiered approach to PPE. Burgess

(1999) indicates, in an article published prior to more

recent letters of interpretation specific to healthcare

workers, that OSHA requires Level B protection or

self-contained breathing apparatus (SCBA) for

unknown hazards, but points out that there are substantial difficulties for healthcare workers who attempt

to care for patients while wearing this type of equipment and also addresses the hazards of wearing

SCBAs (e.g., slips, trips, falls, and overexertion, particularly for infrequent users of this equipment). These

sources demonstrate appropriate caution in the face

of unknown contaminants of unknown concentration.

However, OSHA believes that the substantial body of

recent information on first receivers’ actual experiences and probable exposure levels now allows more

definitive guidance.

In this best practices document, OSHA specifies

PPE that hospitals could use to effectively protect first

receivers assisting victims contaminated with unknown

substances, provided the hospital meets certain prerequisite conditions designed to minimize the quantity

of substance to which first receivers might be exposed.

This PPE for first receivers includes: a PAPR with an

assigned protection factor of 1,000, a chemical-resistant protective garment, head covering if it is not

already included in the respirator, a double layer of

protective gloves, and chemical-protective boots (see

Table 3 at page 23). As part of OSHA’s required hazard

assessment process, each hospital also must consider

the specific hazards first receivers might reasonably

be expected to encounter.7 The hospital must then

augment OSHA’s PPE selection when necessary to

provide adequate protection against those specific

identified hazards. 

The specified PPE is appropriate when the hazardous substance is unknown and the concentration is

strictly limited by (1) the quantity of material associated with living victims and (2) the conditions, policies,

equipment, and procedures that are in place and that

will reduce employee exposure. Tables 1 and 2 of the

best practices document list those specific prerequisites that OSHA believes are necessary to adequately

limit first receiver exposures and to assure the adequacy of the PPE presented in Table 3. Such conditions include a current Hazard Vulnerability Analysis

(HVA) and emergency management plan (EMP), as

well as procedures to ensure that contaminated materials are removed from the area and contained so they

do not present a continuing source of exposure.

The first receiver PPE listed in Table 3 is not the

only option for first receivers. Employees at hospitals

that do not meet the criteria shown in Tables 1 and 2

must determine whether more protective equipment

is required (e.g., HAZWOPER Level B). A higher level

of protection also may be necessary for any hospital

that anticipates providing specialized services (such as

a Hazardous Materials Response Team at the incident

site). Additionally, if a hospital is responding to a

known hazard, the hospital must ensure that the

selected PPE adequately protects the employees from

the identified hazard. Thus, hospitals must augment

or modify the PPE in Table 3 if the specified PPE is not

sufficient to protect employees from the identified

hazard. Alternatively, if a hazard assessment demonstrates that the specified PPE is not necessary to effectively protect workers from the identified hazard, a

hospital would be justified in selecting less protective

PPE, as long as the PPE actually selected by the hospital provides effective protection against the hazard.

This best practices document provides hospitals

and other health care providers with information to

assist in the provision of PPE and training for first

receivers. The first section introduces the subject,

while the second section provides a detailed analysis

of potential hazards, as well as a comprehensive discussion of the PPE currently available to protect work7 These specific hazards will be identified in the hospital’s hazard vulnerability analysis (HVA). JCAHO Standards for

Emergency Management require hospitals to: (1) develop a

comprehensive emergency management plan (EMP) describing the hospital’s response to emergencies that would affect

the need for the hospital’s services or the hospital’s ability to

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 7

provide these services; (2) evaluate the EMP annually including

the objectives, scope, functionality, and effectiveness; (3) conduct an HVA, to identify potential emergences that could affect

the need for the hospital’s services, or its ability to provide

these services; and (4) identify the hospital’s role in the community and coordinate plans.
ers from these hazards. In the Personal Protective

Equipment section OSHA provides three tables

designed to assist employers in selecting PPE adequate to protect healthcare workers and to comply

with relevant OSHA PPE standards. Employers who

meet the prerequisites in Tables 1 and 2 may use this

best practices document as the OSHA-required generalized hazard assessment. Such employers may

choose to rely on the PPE specified in Table 3 to

comply with relevant OSHA standards and to provide effective protection for first receivers against a

wide range of hazardous substances. However, such

employers also must conduct a hazard assessment

that considers hazards unique to the community in

which they are located. In rare situations, these

employers will need to augment or modify the PPE

specified in Table 3 to provide adequate protection

against unique hazards identified in the communityspecific hazard analysis. Of course, employers are not

obligated to follow the guidance in Table 3; any

employer can choose instead to perform an independThis document is based on presently available information as well as current occupational safety and health provisions and standards. Employers should modify their procedures as appropriate when additional, relevant

information becomes available or when modifications to Occupational Safety and Health Act (OSH Act) or

JCAHO standards necessitate revision. The OSH Act requires employers to comply with hazard-specific safety

and health standards. In addition, pursuant to Section 5(a)(1), the General Duty Clause of the OSH Act, employers must provide their employees with a workplace free from recognized hazards likely to cause death or serious

physical harm. This document incorporates existing applicable regulatory provisions as well as non-mandatory

work practices and methods that may be implemented to further supplement employee protection against exposure to hazardous substances. OSHA has attempted to clearly distinguish between mandatory and recommended work practices/methods within this document. Where regulations establish performance criteria for compliance, this document attempts to provide specific guidance that employers may use to adequately protect

employees and comply with these regulatory provisions. However, an alternative approach may be justified

given specific workplace circumstances. This document does not enlarge or diminish an employer’s obligations

under the OSH Act.

ent hazard assessment that is sufficient to identify the

hazards that its employees are reasonably anticipated

to encounter, and then select PPE adequate to protect

its employees against such hazards. The Training First

Receivers section of this best practices document contains a discussion of training required for first receivers

and concludes with Table 4, which matches required

training levels to employee roles and work areas.

Appendix A of this best practices document provides background information on how various aspects

of a hospital’s preparation, response, and recovery

impact employee protection during hazardous substance emergencies. Appendices B, C, and D list additional information sources, while Appendices E

through M offer examples of procedures and equipment used in some hospitals. OSHA offers these

examples for informational purposes only and does

not recommend one option over the many effective

alternatives that exist. Emergency managers might

find these resources helpful in developing or updating

existing EMPs. 

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Occupational Safety and 

Health Administration
BACKGROUND

Healthcare workers risk occupational exposure to

chemical, biological, or radiological materials when

hospitals receive patients contaminated with these

substances during mass casualty incidents (Horton et

al., 2003).8 Such incidents could be associated with

man-made (intentional or unintentional) or natural

disasters and can involve a wide range of hazardous

substances—from chemical weapons agents to toxic

industrial chemicals (Horton et al., 2003).

DEFINING “FIRST RECEIVERS”

Healthcare workers at a hospital receiving contaminated victims for treatment may be termed first receivers

(Koenig, 2003). This group is a subset of first responders (e.g., firefighters, law enforcement, HAZMAT

teams, and ambulance service personnel). However,

most first responders typically act at the site of an

incident (i.e., the location at which the primary release

occurred). In contrast, inherent to the definition of first

receivers is an assumption that the hospital is not

itself the primary incident site, but rather is remote

from the location where the hazardous substance

release occurred. Thus, the possible exposure of first

receivers is limited to the quantity of substance arriving at the hospital as a contaminant on victims and

their clothing or personal effects (Horton et al., 2003).

First receivers typically include personnel in the

following roles: clinicians and other hospital staff who

have a role in receiving and treating contaminated victims (e.g., triage, decontamination, medical treatment,

and security) and those whose roles support these

functions (e.g., set up and patient tracking).9

SCOPE AND OBJECTIVES

In order to protect their employees, hospitals benefit

from information to assist them in emergency planning for incidents involving hazardous substances

(BNA, 2003; Barbera and Macintyre, 2003). Emergency

first responders at the scene of the incident, including

fire, law enforcement, and emergency medical personnel, are covered by the requirements of OSHA’s

standard on Hazardous Waste Operations and

Emergency Response (HAZWOPER), or by parallel

state standards in states with OSHA-approved State

Plans.10, 11 However, the extent of the hazard to the

hospital-based first receivers (a subgroup of first

responders) can differ from that at the release site. A

series of OSHA letters of interpretation clarifies when

and how the HAZWOPER standard applies to first

receivers. This best practices document provides

information useful to employers attempting to provide

adequate protection for hospital-based first receivers

during mass casualty incidents involving hazardous

substances. 

Specifically, this best practices document covers

protection for first receivers during releases of chemicals, radiological particles, and biological agents

(overt releases) that produce victims who may need

decontamination prior to administration of medical

care. Although intended for mass casualty incidents

as they affect emergency department personnel at

fixed hospitals, the basic principles and concepts of

this guidance also apply to mobile casualty care facilities and temporary shelters, such as would be necessary in the event of a catastrophic incident involving

tens or hundreds of thousands of victims. 

The scope of this best practices document does

not include situations where the hospital (or temporary facility) is the site of the release. Nor does it

include infectious outbreaks for which victim decontamination is not necessary. 

8 For the purposes of this guidance, OSHA uses the definition

of mass casualty provided by Barbera and Macintyre (2003): “A

combination of patient numbers and patient care requirements

that challenges or exceeds a community’s ability to provide

adequate patient care using day-to-day operations.”

9 The term clinician refers to physicians, nurses, nurse practitioners, physicians’ assistants, and others.

10 HAZWOPER 29 CFR 1910.120. 

11 First responders, including firefighters, law enforcement and

emergency medical personnel, and many first receivers at public hospitals, are usually employees of local, municipal or state

governments. Although Federal OSHA's standards and

enforcement authority do not extend to such state and local

governments, these employers and employees are covered by

the 26 states that operate OSHA-approved State Plans and, in

states without State Plans, by the Environmental Protection

Agency (EPA) with regard to HAZWOPER (29 CFR 1910.120).

State Plan states set and enforce standards, such as the HAZWOPER and Respiratory Protection standards, which are identical to or “at least as effective as” Federal OSHA standards, and

therefore may have more stringent or supplemental requirements. EPA's parallel HAZWOPER Standard was adopted to

cover emergency responders who would not be covered by

the OSHA standard, including volunteers who work for a governmental agency engaged in emergency response, such as

firefighters. For consistency, OSHA interprets the HAZWOPER

Standard for the EPA. Federal OSHA administers the safety and

health program for the private sector in the remaining states

and territories, and also retains authority with regard to safety

and health conditions for Federal employees throughout the

nation.

Introduction

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 9
DOCUMENT CONTENT 

AND ORGANIZATION

This best practices document (1) provides information

to assist hospitals in selecting personal protective

equipment (PPE) based on current interpretations of

OSHA standards, published literature, current hospital

practices, stakeholder input, and the practical limitations of currently available respiratory protective

devices and (2) consolidates OSHA standards and

interpretations on training needs of first receivers.

These best practices build on health and safety programs that hospitals already should have in place

under existing OSHA regulations (such as those listed

in Updating Emergency Management Plans at page

32).

The section immediately following the introduction

addresses details concerning PPE selection. The way

in which hospitals can use best practices and the

rationale for OSHA’s conclusion on first receiver respiratory protection, glove selection, and protective

clothing are all covered under the section “Personal

Protective Equipment.” Conclusions regarding personal protective equipment draws on information

concerning hazards likely encountered by first

receivers and specifies a minimum level of PPE for

protecting first receivers against such hazards (Table

3). Unless a community-specific hazard analysis identifies unique hazards that first receivers are reasonably anticipated to encounter and that require greater

(or varied) PPE, an employer who meets the prerequisites detailed in Tables 1 and 2 for limiting exposure

can choose to rely on the PPE identified in Table 3 to

comply with relevant OSHA PPE standards. Of course,

employers are not obligated to follow the guidance in

Table 3; any employer can choose instead to perform

an independent hazard assessment that is sufficient to

identify the hazards that its employees are reasonably

anticipated to encounter, and then select PPE adequate to protect its employees against such hazards.

Information on training first receivers appears in the

final section. It also contains a summary of first

receiver training (Table 4).

The appendices provide examples, which might be

useful to hospitals developing or upgrading emergency management plans (EMPs). Appendix A of this

best practices document provides background information on how various aspects of a hospital’s preparation, response, and recovery impact employee protection during hazardous substance emergencies.

Appendices B, C, and D list additional information

sources, while Appendices E through M offer examples of procedures and equipment used in some hospitals. OSHA offers these examples for informational

purposes only and does not recommend one option

over the many effective alternatives that exist.

OSHA recommends that this best practices document be used in conjunction with other available

emergency preparedness information sources, such

as those listed in Appendices C and D, and other references that may become available in the future.

Footnotes indicating current Joint Commission on

Accreditation of Healthcare Organizations (JCAHO)

Standards for Emergency Management (which are 

further described in Section EC 1.4 of JCAHO’s

Comprehensive Accreditation Manual for Hospitals)

appear at key points in the document. In publishing

this document, it is OSHA’s intent to provide useful

information that will assist hospitals and other healthcare providers in taking appropriate steps to protect

first receivers and other affected workers from exposure

to chemical, biological, and radiological substances.

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Occupational Safety and 

Health Administration

This document is based on presently available information as well as current occupational safety and health provisions and standards. Employers should modify their procedures as appropriate when additional, relevant

information becomes available or when modifications to Occupational Safety and Health Act (OSH Act) or

JCAHO standards necessitate revision. The OSH Act requires employers to comply with hazard-specific safety

and health standards. In addition, pursuant to Section 5(a)(1), the General Duty Clause of the OSH Act, employers must provide their employees with a workplace free from recognized hazards likely to cause death or serious

physical harm. This document incorporates existing applicable regulatory provisions as well as non-mandatory

work practices and methods that may be implemented to further supplement employee protection against exposure to hazardous substances. OSHA has attempted to clearly distinguish between mandatory and recommended work practices/methods within this document. Where regulations establish performance criteria for compliance, this document attempts to provide specific guidance that employers may use to adequately protect

employees and comply with these regulatory provisions. However, an alternative approach may be justified

given specific workplace circumstances. This document does not enlarge or diminish an employer’s obligations

under the OSH Act.
PPE selection for first receivers has been a topic of

significant discussion (Hick et al., 2003a; Barbera and

Macintyre, 2003; CA EMSA, 2003b; ECRI, 2002). At the

root of this discussion is the need for hospitals to provide adequate protection for the reasonably anticipated worst-case employee exposure scenario, despite

having limited information regarding the nature of the

substance with which victims may be contaminated

(OSHA, 2002b). This lack of information challenges

hospitals’ abilities to conduct the hazard assessments

on which PPE selection must be based.12

Despite many hospitals’ strong interest in powered

air-purifying respirators (PAPR) as a practical form of

respiratory protection for first receivers in the Hospital

Decontamination Zone, many knowledgeable sources

avoid making specific PPE recommendations, but

rather point out the advantages and disadvantages of

the various options, or recommend appropriate PPE

(JCAHO, 2001; Lehmann, 2002; Penn, 2002).13 Others

offer stronger opinions. CA EMSA (2003a) promotes

the use of a multi-tiered approach to PPE. Burgess

(1999), in an article published prior to more recent letters of interpretation specific to healthcare workers,

indicates that OSHA requires Level B protection or selfcontained breathing apparatus (SCBA) for unknown

hazards, but points out there are substantial difficulties

for healthcare workers who attempt to care for patients

while wearing this type of equipment and also addresses the hazards of wearing SCBAs (e.g., slips, trips, falls,

and overexertion, particularly for infrequent users).

These sources demonstrate appropriate caution in the

face of unknown contaminants of unknown concentration. However, OSHA believes that the substantial body

of recent information on first receivers’ actual experiences and probable exposure levels now allows more

definitive guidance.

To assist hospitals, this section provides information that employers can use to provide a level of PPE

that reasonably can be expected to protect first

receivers from a wide range of hazards. OSHA’s PPE

selection guidance applies when the hazardous substance is unknown and the possible exposure is strictly limited by: (1) the quantity of material associated

with living victims; and (2) other specific conditions,

policies, equipment, and procedures in place that will

reduce employee exposure. These best practices are

preceded by instructions for using the document and

by a discussion of the information considered in

developing OSHA’s PPE selection.

USING OSHA’S BEST PRACTICES

Using OSHA’s Rationale for PPE Selection 

and Hazard Assessment

In Tables 1, 2, and 3 of this document, OSHA outlines

prerequisite conditions necessary to limit first receiver

exposure to unknown hazardous substances and presents information that employers can use to provide

adequate PPE for first receivers. The prerequisite conditions in the first two tables are designed to minimize

the exposure of first receivers and form part of the

basis for OSHA’s rationale for the PPE selection listed

in Table 3. By implementing those prerequisites, hospitals can reduce the exposures of their own first

receivers. Hospitals may then use the discussion in

this section in conducting the required hazard assessment, which must consider hazards unique to the

community in which they are located. In rare situations, these employers will need to augment or modify the PPE specified in Table 3 to provide adequate

protection against unique hazards identified in the

community-specific hazard analysis. Of course,

employers are not obligated to follow the guidance in

Table 3; any employer can choose instead to perform

an independent hazard assessment that is sufficient to

identify the hazards that its employees are reasonably

anticipated to encounter, and then select PPE adequate to protect its employees against such hazards.

Augmenting the PPE Selection to Address Specific

Hazards Identified by the Hazard Vulnerability

Analysis (HVA) and the Community

The best practices presented in this document indicate

the minimum PPE that OSHA anticipates generally

will be needed to protect first receivers faced with a

wide range of unknown hazards (providing the pre12 Hazard assessments for PPE are required under OSHA’s

Personal Protective Equipment standard – General

Requirements, 29 CFR 1910.132(d), or the equivalent State Plan

standards.

13 The Hospital Decontamination Zone includes any areas

where the type and quantity of hazardous substance is

unknown and where contaminated victims, contaminated

equipment, or contaminated waste may be present. It is reasonably anticipated that employees in this zone might have

exposure to contaminated victims, their belongings, equipment, or waste. This zone includes, but is not limited to, places

where initial triage and/or medical stabilization of possibly contaminated victims occur, pre-decontamination waiting (staging)

areas for victims, the actual decontamination area, and the

post-decontamination victim inspection area. This area will

typically end at the emergency department (ED) door. In other

documents this zone is sometimes called the “Warm Zone.”

Personal Protective Equipment

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 11
requisite conditions in Tables 1 and 2 are met). However, as with any generalized protection, OSHA’s PPE

for first receivers offers more protection against some

hazards than others. When a hospital determines that

first receivers could reasonably anticipate encountering a specific known hazard, the hospital also must

determine whether this generalized protection must

be supplemented to more fully address that specific

hazard. 

Specifically, to finish the hazard assessment and

PPE selection process, each hospital must consult its

own complete and updated HVA (required by JCAHO),

as well as additional information available from the

community (e.g., the Local Emergency Planning

Committees (LEPC)). JCAHO requires that hospitals

also consider their anticipated roles and coordinate

activities with other emergency response agencies

and hospitals within the community. When these

sources point to a specific substance or situation from

which the hospital should protect its first receivers,

the hospital must confirm that PPE selection provides

effective protection against that hazard. In rare situations, the process of considering the HVA and community-specific information will identify ways the hospital must augment the PPE specified in Table 3 for

unknown hazards in order to help ensure protection

against specific known hazards (e.g., by tailoring

glove selection to address an identified, specific hazard, or by stocking additional supplies, such as a specific respirator cartridge known to protect the user

from an identified, specific hazard). 

Hospitals must adopt a more specialized level of

protection (such as air-supplied respirators) if the hospital’s role, position in the community, or HVA indicates a higher level of protection is necessary (e.g.,

if the hospital will field a HAZMAT team or provide

other services at the release site, if the hospital is

adjacent to a hazardous chemical storage facility that

could subject first receivers to an environment immediately dangerous to life and health (IDLH), or if the

hospital is the site of the incident).

RATIONALE FOR OSHA’S PERSONAL 

PROTECTIVE EQUIPMENT BEST PRACTICES

The following discussion reviews existing OSHA regulations, letters of interpretation, and published literature relevant to the selection of PPE for healthcare

workers receiving contaminated victims. OSHA’s best

practices on first receiver PPE appear at the end of

this section in Tables 1, 2, and 3.

Respiratory Protection

Limited Quantity of Contaminant on Victims

A key factor supporting OSHA’s PPE best practices is

the limited amount of toxic substance to which first

receivers might be exposed. Many recent sources

note that the quantity of contaminant on victims is

restricted. For example, OSHA has made a clear distinction between the site where a hazardous substance was released and hospital-based decontamination facilities (OSHA, 1992a, 2002a). This distinction is

important because it helps define the maximum

amount of contaminant to which healthcare workers

might be exposed (i.e., the quantity of material on living victims and their possessions when they arrive at

the hospital). Horton et al. (2003) stated that during

victim decontamination procedures the hazard to

healthcare workers is strictly from secondary exposure and “depends largely on the toxicity of the substance on the victims’ hair, skin, and clothing; the concentration of the substance; and the duration of contact [first receivers have] with the victim.”

The quantity of contaminant that healthcare 

workers might encounter can be dramatically less

than the amount to which the victim was exposed or

that was originally deposited on the victim. Gas or

vapor releases can expose victims to toxic concentrations, but tend to evaporate and dissipate quickly.

Georgopoulos et al. (2004) determined that 100 grams

(approximately 4 ounces) of most moderately to

highly volatile substances that might be sprayed on

a victim during a mass casualty incident would evaporate within 5 minutes from the time the exposure

occurred. Unless the substance release occurs immediately adjacent to a hospital, it is not anticipated that

victims will be able to reach the hospital within that

period of time, or the more realistic 10-minute period

that Georgopoulos et al. (2004) used in the exposure

model presented later in this section.14 Horton et al.

(2003) agree, stating that substances released as gas

or vapor “are not likely to pose a secondary contamination risk” to first receivers. It is important to note,

however, that limited exposure might be possible. In

an isolated incident reviewed by these authors, unprotected healthcare workers experienced skin and respi14 Georgopoulos et al. (2004) suggest that “recognition of an

event, identification of transportation means, and transportation to a healthcare facility are not expected to take less than 5

minutes even under ideal circumstances.” The 10-minute

(approximate) lag time can be reasonably assumed during a

mass casualty event involving chemical release, except in

cases where the release occurs immediately adjacent to the

hospital (e.g., at a chemical plant next door to the hospital). 

12

Occupational Safety and 

Health Administration
ratory irritation from highly toxic volatile substances

(chlorine gas) thought to have permeated victims’

clothing.15 While an environment that is immediately

dangerous is possible, it is extremely unlikely that a

living victim could create an IDLH environment at a

receiving hospital, particularly if contaminated clothing is quickly removed and isolated, and the victim is

treated and decontaminated in an area with adequate

ventilation.

Removal of victim’s clothing, or, better yet, decontamination of victims before they arrive at the hospital

have a marked effect on the quantity of contaminant

that first receivers encounter. Pre-hospital decontamination can eliminate the risk of secondary contamination (Horton et al., 2003). Removing contaminated

clothing can reduce the quantity of contaminant associated with victims by an estimated 75 to 90 percent

(Macintyre et al., 2000; Vogt, 2002; USACHPPM,

2003a).16 To control unnecessary exposure, Hospital A

promotes the use of prescribed procedures for first

responders assisting victims to remove clothing. The

clothing is cut away using blunt-nose shears to eliminate stretching, flapping, wringing, or excessive handling of fabric that might contribute to worker exposure (or additional victim exposure). 

Showering with tepid water and a liquid soap with

good surfactant properties is widely considered an

effective (and preferred) method for removing the

remaining hazardous substance from victims’ skin

and hair (Goozner et al, 2002; Macintyre et al., 2000).17

The U.S. Army promotes this method for chemicals

(both chemical weapons and toxic industrial chemicals), radiological particles, and biological agents

(USACHPPM, 2003a).18 In several cases involving secondary exposure incidents reviewed by Horton et al.

(2003), contaminated victims who caused injury to

healthcare workers were subsequently decontaminated. No further injury to healthcare workers was mentioned. See Procedures at page 43 for additional discussion of decontamination procedures for unknown

contaminants. When the nature of the contaminant is

known, the hospital can adjust the decontamination

procedures to best remove the specific hazard. 

As a final step in minimizing first receiver exposure to hazardous substances, the accepted industrial

hygiene practice is for the healthcare workers also to

shower following contact with contaminated victims

and cleanse equipment as part of decontamination

procedures. Hospital A uses a strict protocol for personnel to decontaminate themselves while removing

gloves, protective suits, boots, and hooded powered

air-purifying respirators (PAPRs). Hospital C includes

decontamination of the shower system and associated equipment as part of those procedures.

Hospital Experience with Contaminated Victims

Several studies have reviewed public data and reports

regarding victims of hazardous materials emergencies

and associated secondary contamination of healthcare

workers. First receivers rarely reported adverse health

effects. Those workers who experienced symptoms

were unprotected and tended to have close, extended

contact with the contaminated victims. Horton et al.

(2003) evaluated data from the Agency for Toxic

Substances and Disease Registry (ATSDR) Hazardous

Substance Emergency Events Surveillance (HSEES)

system. Through 2001, the database had captured

information on over 44,000 hazardous materials

events involving substances other than petroleum

products.19 Although overall, healthcare workers were

the 11th most common group injured in hazardous

materials incidents, Horton determined that events

affecting emergency department (ED) personnel

15 This incident is described in Horton et al. (2003) as part of an appear to occur infrequently, representing only 0.2

evaluation of hazardous materials incident data captured by

the Agency for Toxic Substances and Disease Registry (ATSDR)

Hazardous Substance Emergency Events Surveillance (HSEES)

system.

16 The percentage of contaminant reduction depends on the

type of clothing the victim was wearing when exposed. The

estimates may be somewhat lower (down to 50 percent) for

victims wearing short pants or skirts and higher (up to 94 percent) for victims exposed to biological warfare agents while

wearing protective military uniforms (USACHPPM, 2003a).

17 Many liquid soaps have good surfactant properties (ability

to cut grease) and are not excessively harsh on skin (e.g.,

major brands of hand dishwashing soap, such as Joy, Ivory,

Dawn, and others, as well as shampoos). This is the method

used by all seven hospitals interviewed for this project and is

reportedly effective for all but the most tenacious substances.

For example, the chemical weapon agent VX is difficult to wash

from skin. 

18 A related practice of spraying a 0.5 percent solution of

hypochlorite (equivalent to a 10 percent solution of Chlorox®

household bleach) may have value for deactivating biological

agents, other than mycotoxins, and some chemical weapons

agents (mustard gas, organophosphates) if left in contact for a

period of time (15 to 20 minutes). The solution might be used

to decontaminate facilities, but is no longer considered an optimal or necessary treatment for human skin (Macintyre et al.,

2000). Sources agree that there is no substantive difference in

decontamination methods for biological and chemical agents.

19 Using information from the 16 states that participated

between 1995 and 2001, these authors determined that of the

44,045 hazardous materials events reported, 2,562 events (5.8

percent) involved victims who were transported to a hospital.

Injuries to ED employees at the hospital were reported for six

of these 2,562 events (0.2 percent). 

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 13
percent of the 2,562 HSEES events in which victims

were transported to a hospital.20 Horton et al. (2003)

also note that among the ED personnel injured, none

wore any form of protection at the time of the injury.

Respiratory tract and eye irritation were the primary

symptoms and no employees required hospitalization.

A separate survey of ED evacuations at hospitals in

the state of Washington also found a low incidence of

secondary contamination of ED staff. Over a 5-year

period, 101 hospitals reported only two evacuation

incidents that also involved secondary contamination

of staff, while ED evacuations due to hazardous substance incidents (usually caused by releases within

the hospital) occurred 11 times.21 The victims were

not decontaminated prior to arrival at the hospital in

either of the cases involving secondary contamination

to staff (Burgess, 1999). 

Walter et al. (2003) also reviewed municipal records

to characterize hazardous materials responses. These

authors evaluated all fire department hazardous materials reports, along with the associated emergency

medical services encounter forms and hospital records

for a mid-size metropolitan area (population 400,000).

More than 70 percent of the hazardous materials incidents involved flammable materials (e.g., methane

gas, diesel fuel, gasoline, and hydraulic oils), all of relatively low toxicity. Approximately 7 percent of the incidents involved highly toxic materials, all of which fell

into the categories of mercury, pesticides, and

cyanides. An additional 5 percent of the events were

associated with toxic gases (primarily carbon monoxide, with a few cases of anhydrous ammonia or chlorine exposure). Corrosive materials accounted for

another 10 percent of the incidents and primarily

involved mineral acids and basic materials such as

lime and sodium hydroxide.22 Walter found that those

patients transported to the hospital were usually treated for inhalation exposure to airborne toxicants, for

which few required hospitalization. These findings

may explain the results of Horton et al. (2003) and

Burgess (1999) who, as previously noted, identified

few injuries among healthcare workers who treated

victims of hazardous materials incidents. Victims

exposed to gases or vapors are not anticipated to be

contaminated with substantial quantities of these

materials upon arrival at the hospital. 

Hick et al. (2003a) reviewed the published literature

and some individual case reports to assess the risk of

contaminated patients to healthcare workers in the

U.S. and abroad. These cases included incidents in

which healthcare workers were exposed to secondary

contamination, generally for periods of less than one

hour.23 Hick et al. (2003a) concluded that “...a contaminated patient presenting at the ED poses a definite

health risk to providers. However, even without personal protective equipment, the risks of significant

injury appear to be low, as reflected in this review and

analysis of published cases.” These authors found

that the more serious injuries to healthcare workers

are frequently associated with organophosphate compounds (e.g., sarin and certain pesticides), which are

“extremely toxic, prone to off-gassing, and might have

prolonged clinical effects....” The affected healthcare

workers identified by the authors rarely used PPE.

Okumura et al. (1996) reported on the 1995 Tokyo

subway sarin attack, in which one hospital received

640 victims (80 percent self-referred), 107 of whom

were moderately injured and five were considered

severely injured. Hick et al. (2003a) also reviewed the

literature describing this incident and noted that more

than 100 healthcare providers in Tokyo experienced

symptoms (e.g., blurred vision) while treating victims.

Of these, the most affected were several physicians

who spent up to 40 minutes attempting to resuscitate

the initial victims of the incident. The victims had not

been decontaminated. These and other worker exposures were attributed to the failure of healthcare

providers to use PPE and the practice of placing stillclothed, contaminated victims in a poorly ventilated

waiting area. 

It is interesting to note that although sarin (a notorious chemical warfare agent) affected many of the

healthcare providers, all exposed providers at one of

the primary receiving hospitals were reportedly able

to continue their duties (Okumura et al., 1996). In the

20 ED personnel accounted for about half of all healthcare

workers injured. Other healthcare workers in the group included medical examiners in an autopsy room, coroner’s assistants, a hospital worker at a highway rest area, and hospital

employees injured when substances such as xylene and formalin were released in the hospital (“injuries were not the result

of secondary contamination”).

21 This study only evaluated information on incidents that

caused ED evacuation and did not consider other incidents that

might have involved contaminated patients. The actual number of ED evacuation incidents may have been slightly higher

due to under-reporting. 

22 Hazardous substances in miscellaneous categories accounted for the remainder of the reported incidents.

23 Secondary exposures in the studies reviewed by Hick et al.

(2003a) involved substances such as organophosphates

(including sarin), hydrofluoric acid, pepper spray, chlorine gas,

mixed solvents from methamphetamine laboratories, ethyldichlorosilane, and aluminum phosphide.

14

Occupational Safety and 

Health Administration
Tokyo terrorism incident, although victims’ clothing

was not removed and continued to be a source of

contamination, unprotected first receivers experienced only limited exposures.24 It is reasonable to

anticipate that healthcare worker exposures might

have been dramatically reduced by a combination of

removing victims contaminated clothing, improving

ventilation in patient waiting areas, and using PPE.

Exposure Modeling

Two studies conducted modeling of various phases of

the victim disrobing and decontamination process in

order to characterize first receiver exposure levels and

evaluate the need for respiratory protection. These

studies point out the need for a carefully developed

and implemented EMP that includes hazard-reducing

work practices, appropriate respiratory protection, and

full body protection. In the first study, Schultz et al.

(1995) collected air samples in the breathing zone of

two healthcare workers during decontamination activities.25 The test took place in an unventilated room,

where the workers removed the simulated non-ambulatory patients’ clothing and cleaned the skin using

dry brushing to remove particles.26 

The test periods included 5 minutes with the victim

resting on a decontamination cart (to simulate a delay

in clothing removal and decontamination), 2.5 minutes during which the healthcare workers cut away

victims’ clothing and placed it in a sealed container,

and approximately 3 minutes of simulated skin cleaning. This latter activity generated visible dust during

particulate trials.27 The solvents evaporated completely during the 10-minute test periods and victim cleaning was not required for these agents. Healthcare

worker exposure levels for dust ranged from 1.98 to

4.28 milligrams per cubic meter of air (mg/m3), while

results for p-xylene ranged from 18 to 148 parts per

million (ppm) and acetone concentrations were 185 to

459 ppm. The authors concluded that exposure levels

were statistically lower than the applicable short-term

exposure limits for these moderately toxic industrial

chemicals; however, due to the uncertainties of hazardous materials management, “use of respiratory

protective equipment should be continued.” 

In contrast to Schultz et al. (1995), which evaluated

an industrial chemical of moderate toxicity,

Georgopoulos et al. (2004) used a probability model

to predict the level of respiratory protection that

decontamination hospital staff would require to limit

their exposure to several highly toxic industrial chemicals (chlorine, phosgene, and cyanide) and chemical

weapons agents (nerve and blister agents). The

model takes into account the substance’s relative toxicity, vapor pressure, and dispersion characteristics, as

well as the probable amount and distribution of contaminant on the victim, and the amount of time the

substance would require to evaporate from the victim.

The model also considered the number of victims, the

length of time between the victims’ exposure and

arrival at the hospital, atmospheric conditions, and

how soon after arrival the victims’ contaminated

clothing can be removed. Using Monte Carlo analysis

and parameters set to consider extreme worst-case

scenarios, the authors concluded that if contaminated

clothing remains an ongoing source of contamination

over a period of 6 hours of constant exposure, less

than 2 percent of healthcare workers would be

exposed to levels of sarin that would exceed the protection offered by a respirator providing at least 1,000-

fold protection.28 This percentage dropped when

inputs associated with more likely scenarios were

24 At a second Tokyo hospital, however, five of the most seriously exposed healthcare workers did require injection of antidote; although, they were able to continue to provide medical

care (Nozaki et al., 1995).

25 Investigators used an adult size plastic mannequin dressed

in lightweight cotton clothing and contaminated with either an

industrial solvent (800 milliliters [ml] acetone or p-xylene in

multiple tests) or respirable size metal oxide particulates. The

800 ml represented the greatest amount of solvent the victim

could bring to the room—that was the amount that completely

saturated the clothes when placed in a container.

26 The room measured 16 by 20 feet with a 10-foot ceiling and

air temperature was reportedly 65o F.

27 Macintyre et al. (2000) suggest vacuuming as an alternative

to dry brushing victims contaminated with water-reactive dust.

28 In this study, parameters for initial modeling of the maximum exposure that can reasonably be expected in a terrorist

attack included a distribution of between 10 and 100 grams of

chemical agent deposited over a mean of 1 square meter of surface area on 20 to 25 percent of the victims; lag time from initial

dissemination of the agent to arrival of the victim at the hospitals represented with both truncated normal and an exponential

distribution (mean value of 10 minutes); an air flow velocity distribution with a mean of 60 meters per minute across the victim,

with chemical agent mixing occurring in an air column of 1

square meter cross-sectional area; and each first receiver directly participating constantly in a six-hour decontamination

process. The healthcare worker was considered protected if the

dose the worker would receive during 6 hours of continuous

decontamination activity was less than the value of 2.1 mgmin/m3 for sarin. This concentration is the equivalent of the 60-

minute National Research Council Acute Exposure Guideline

Levels (AEGL-2) for sarin of 0.035 mg/m3 (multiplied by 60 minutes) (USACHPPM, 2003b). The Georgopoulos study shows that

some transient effects and impairment might occur, but permanent health effects are highly unlikely.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 15
used (e.g., increased evaporation transfer rate or

increased lag time before the victim reached the hospital). Furthermore, related analysis showed that if

contaminated clothing is removed immediately when

the victim arrives at the hospital, “the level of sarin

exposure to a healthcare worker would be negligible”

and adequate protection would be provided by air

purifying respirators with an assigned protection factor (APF) of 1,000.29

If correctly selected, fitted, used, and maintained,

respiratory protective equipment reduces significantly

the effective exposure level that an employee experiences. An employee wearing a respirator that offers a

protection factor of 1,000 will breathe air that contains

no more than 1/1,000 (or 0.1 percent) of the contaminant level outside the respirator. OSHA recently proposed an APF of 1,000 for certain designs of hood/helmet respirators.30, 31 Full facepiece and hood/helmet

supplied air respirators (excluding loose-fitting facepieces) are also assigned an APF of 1,000 in the proposed rule (Federal Register, 2003 (68 FR 34035)).32

The combination of high efficiency (HE) particulate

filters plus organic vapor (OV) cartridges currently

available for PAPRs will protect against many of the

airborne hazards that first receivers might encounter

(e.g., toxic dusts, biological agents, radioactive particulates, organophosphates and other pesticides, and

solvents). Acid gas cartridges add an additional level

of protection from gases such as chlorine, which generally will dissipate before victims arrive at the hospital, but which have been implicated in at least one

case of healthcare worker injury.33 It is not anticipated

that first receivers would benefit from cartridges that

remove carbon monoxide from air. Despite the number of carbon monoxide victims treated at hospitals,

there are no reported cases of healthcare workers

being injured through secondary contamination from

victims of carbon monoxide poisoning (Horton et al.,

2003; Hick et al, 2003a; Walter et al., 2003).

As an applied example, Hospital A used some of

these modeling techniques to complement a detailed

HVA, a comprehensive staff training program, and a

detailed EMP that makes safety and exposure reduction strong priorities.34 This modeling allowed

Hospital A to determine that there was not a need for

respiratory protection greater than a hooded powered

air purifying respirator [PAPR], fitted with high efficiency dust, organic vapor, and acid gas cartridges.

The hospital determined that employees need to be

protected from skin contact with the contaminant.

Thus, individuals involved in decontaminating victims

at this hospital wear PAPRs, splash-resistant suits, a

double layer of gloves, and chemical-protective boots.

Openings to the suits are closed with tape to create a

barrier.

Gloves and Boots 

No single glove or boot material will protect against

every substance. Most glove manufacturers offer

detailed guides to glove materials and their chemical

resistance. Butyl rubber gloves generally provide better protection than nitrile gloves for chemical warfare

agents and most toxic industrial chemicals that are

more likely to be involved in a terrorist incident,

although the converse applies to some industrial

chemicals. Foil-based gloves are highly resistant to a

wide variety of hazardous substances and could also

be considered when determining an appropriate protective ensemble. Hospitals must select materials that

cover the specific substances that the hospital has

determined first receivers reasonably might encounter.

However, given the broad scope of potential contaminants, OSHA considers it of vital importance for hospitals also to select materials that protect against a wide

range of substances. A double layer of gloves, made of

two different materials, or foil-based gloves resist the

broadest range of chemicals. 

In general, the same material selected for gloves

will also be appropriate for boots. Because boot walls

tend to be thicker than gloves, boots of any material

29 Sarin was selected for this model because it has a moderate

vapor pressure (similar to water) and thus would not necessarily evaporate before the victim could reach the hospital.

Additionally, the substance does off-gas to an extent that can

cause injury to healthcare workers. Finally, among chemical

substances with vapor pressures in this range, sarin was

selected as the most toxic. For purposes of comparison, NIOSH

(2003) publishes vapor pressure levels for numerous industrial

chemicals.

30 This provision is part of a proposed rule (68 FR 34035, June

6, 2003); the APF provisions that OSHA eventually develops

may differ substantially from those in the proposed rule.

31 Respirator manufacturers must be able to show test results

indicating the respirator meets specified criteria.

32 For comparison, a non-powered full facepiece air-purifying

respirator has an APF of 50, while SCBA is assigned a protection factor of 10,000. 

33 The contaminant might have been trapped in victims’ clothing (Horton et al., 2003). It is reasonable to anticipate that

exposures would have been eliminated if the victim’s clothing

had been removed in a well-ventilated space (or outdoors)

immediately upon arrival at the hospital. 

34 See the acknowledgments at the beginning of this document for a brief statement regarding the hospitals interviewed

for this guidance.

16

Occupational Safety and 

Health Administration
are likely to be more protective than gloves of the

same material. 

A combination of gloves, for example, butyl gloves

worn over inner nitrile gloves, are often the best

option for use by hospital workers during emergencies and mass casualties involving hazardous substances. However, hospitals are advised to select the

combination that best meet their specific needs. 

Glove thickness is measured in mils, with a higher

number of mils indicating a thicker glove. Using common examples, exam gloves are often approximately

4 mil, while general-purpose household (kitchen)

gloves are 12–16 mil, and heavy industrial gloves

might be 20 to 30 mil. 

Depending on the dexterity needed by the hospital

worker, the glove selection can be modified to allow

for the use of a glove combination that is thinner than

that usually recommended for the best protection. As

an example, the U.S. Army Center for Health

Promotion and Preventive Medicine (USACHPPM) recommends that hospital personnel working with victims potentially contaminated with chemical warfare

agents or toxic industrial chemicals wear a combination of chemical protective gloves, such as butyl rubber gloves over inner nitrile gloves (USACHPPM,

2003a).35 Because thicker gloves offer greater protection, USACHPPM recommends a butyl glove with a

minimum thickness of 14 mil (over a 4 or 5 mil nitrile

glove). However, with increased thickness comes

greater loss of manual dexterity. When advanced

medical procedures must be performed before decontamination, thicker gloves might be too awkward, and,

therefore, it might be necessary to use a butyl rubber

glove of 7 mil over the nitrile glove, or a 14 mil butyl

rubber glove alone (USACHPPM, 2003a). If sterility is

required and decontamination is not possible before

procedures, a double layer of disposable 4 to 5 mil

nitrile gloves might be the best option (USACHPPM,

2003a). Not all sources recommend double gloves;

for example, the U.S. Army Soldier and Biological

Chemical Command’s (SBCCOM) Domestic Preparedness Program (DPP) recommends butyl rubber gloves

for personnel performing decontamination operations

and casualty care (SBCCOM, 2000a). Among the sterile gloves readily available, those made of nitrile offer

the best resistance to the widest range of substances

(but not all). Note that thinner gloves deteriorate (tear

and rip) more rapidly than thicker gloves. When thinner gloves must be used, they should be changed frequently.

Hendler et al. (2000), as cited in USACHPPM

(2003a), conducted a study to determine the effect of

full PPE (including 12-mil “tactile” gloves and a full

facepiece mask) on intubation performance. Clinicians

wearing this equipment could perform endotracheal

intubation effectively (i.e., the tube was inserted in

sufficient time), but the procedure did take longer

than it would have without PPE. Intubation delays

would cause subsequent decontamination procedures

and medical treatment to be delayed by a corresponding amount of time.

Protective Garments

The optimal garment material for first receivers will

protect against a wide range of chemicals in liquid,

solid, or vapor form (phase). Because first receivers

might become contaminated with liquid or solid (dust)

contaminants through physical contact with a contaminated victim, the ideal fabric will repel chemicals during incidental contact (protection from gases is less

important because, as shown earlier, gases generally

will dissipate before a victim arrives at the hospital).

Additionally, the optimal garment will restrict the passage of vapors, both through the suit fabric and

through openings in the suit. Finally, optimal clothing

is also sufficiently flexible, durable, and lightweight

for long-term wear (up to several hours) during physically active work.

35 SBCCOM tested several glove types. Results from two different studies are presented here as examples of the information available on breakthrough times. However, additional tests

continue to be performed. Consult glove manufacturers for the

most recent information. In their first study, SBCCOM tested

eleven glove designs (including butyl, neoprene, and nitrile)

for breakthrough times when exposed to concentrated

Mustard (blister agent) or Sarin (nerve agent). Breakthrough

times were dependent on material and thickness. A 30 mil Best

Butyl glove had a breakthrough time of 810 minutes for

Mustard and greater than 1440 minutes for Sarin. MAPA

Neoprene gloves (mil not stated) had a breakthrough time of

298 minutes for Mustard and greater than 1440 minutes for

Sarin. Ansell Edmont TNT Nitrile gloves [4 mil] had a breakthrough time of 20 minutes for Mustard and 106 minutes for

Sarin. Ansell Edmont Sol-Vex (Nitrile) [15 mil] had a breakthrough time of 109 minutes for Mustard and greater than 1440

minutes for Sarin. Test data revealed that the chemical protective glove designs can protect wearers from liquid chemical

warfare agents (SBCCOM, 2001a). In the second study, SBCCOM tested four glove designs (including butyl and nitrile) for

breakthrough times when exposed to Mustard (blister agent)

or Sarin (nerve agent). Breakthrough times were dependent on

material and thickness. N-Dex Disposable Nitrile gloves (4 mil)

had a breakthrough time of 53 minutes for Mustard and 51

minutes for Sarin. North Butyl gloves (20 mil) had a breakthrough time of greater than 1440 minutes for both Mustard

and Sarin. Test data revealed that the chemical protective

glove designs can protect wearers from liquid chemical warfare agents (SBCCOM, 2001b).

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 17
Manufacturers produce a variety of suit fabrics and

designs, and several commercially available broadspectrum protective fabrics might be appropriate,

depending on the situations and hazards that the hospital anticipates first receivers reasonably might be

expected to encounter. While OSHA does not test,

endorse, or recommend specific products, examples

of such products include: Tyvek® F, Tychem® CPF3,

CPF4, Tychem® BR, Tychem® LV, Tychem® SL, Zytron®

100, Zytron® 200, Zytron® 300, Zytron® 400, Zytron®

500, and Zytron® 600, ProVent ® 10,000, and DuraVent ®

2.8. Before selecting materials, contact the manufacturer for specific application guidance.

Fabric and suit manufacturers can provide laboratory-testing information regarding specific materials.

For example, Tyvek® F has been tested extensively

by military organizations and accredited testing laboratories.36 As another example, the SBCCOM DPP tested vapor-blocking properties of six different protective

suits in a simulated, high-vapor environment. In the

results tabulated below, the Tyvek® F suite (ProTech

model) offered a protection factor of 42 (vapor levels

outside the suit were 42 times higher than inside the

suit), which was approximately twice the protection

than was provided by the next best performing suits.

Traditional Tyvek ® (protection factor of 4) was twice as

protective as a standard police uniform (protection

factor of 2). These suits were tested by placing sensors for the test vapor under the suits at 17 specific

body locations. Volunteers wore the protective gear

while performing the activities normally associated

with an actual first responder chemical response (but

did not involve physical acts, such as patient handling,

that would likely be required of first receivers) (SBCCOM, 2003).

Figure 1. Results of Simulation Tests on 

Several Chemical Suits

Suit Configuration # Suits Tested Protection Factor

Standard [Police] Uniform 2 2

Tyvek® Protective Wear Suit 4 4

Tychem® 9400 Protective Suit 4 17

Kappler® CPF4 Protective Suit 4 18

Tychem® SL Protective Suit 5 24

Tyvek® ProTech F Protective Suit 5 42

(Source: SBCCOM, 2003)

The ability of protective garment fabric to withstand physical abrasion and tearing is also important.

When assisting non-ambulatory victims, first receivers

might subject the protective garments to physical

stresses that should be considered in garment selection. The National Fire Protection Association (NFPA)

in NFPA Standard No. 1994 on Protective Ensemble

for Chemical/Biological Terrorism Incidents offers criteria for evaluating performance of protective garments,

including detailed specifications for bursting, puncture, and tear resistance, as well as garment seam

specifications (NFPA, 2001). [Editorial note: Previous

versions of this Best Practices document made specific reference to NFPA 1994 Classes 2 and 3. This reference has been removed.] 

CONCLUSIONS REGARDING PERSONAL 

PROTECTIVE EQUIPMENT

Evidence in the U.S. and abroad shows that unprotected healthcare workers can be injured by secondary exposure to hazardous substances when they

treat contaminated patients. However, OSHA concludes that hospitals that make a conscientious effort

can limit the secondary exposure of healthcare workers to a level at which chemical protective clothing

(including gloves, boots, and garments with openings

taped closed) and PAPRs will provide adequate protection from a wide range of hazardous substances to

which first receivers most likely could be exposed.

This conclusion is based on the infrequency with

which healthcare workers have been affected (despite

the numerous hazardous substance incidents), the

experiences of hospitals treating contaminated victims, the nature of the injuries healthcare workers

sustain when they are affected (during both acts of

terrorism and accidental releases), and the exposure

models described above. OSHA believes that the

1,000-fold protection factor that has been attained by

36 Independent accredited testing laboratories conducted 

permeation tests on Tyvek® F for Dupont. The breakthrough

times for the chemical warfare agents, Mustard, Tabun, Sarin,

Soman, and VX, exceeded 720 minutes. The breakthrough 

time for Lewisite was 360 minutes. The breakthrough times 

for industrial chemicals of special concern, Chlorine,

Formaldehyde (Formalin solution), Hydrochloric Acid (37%),

and Concentrated Sulfuric Acid was greater than 480 minutes.

The breakthrough time for Ammonia was 79 minutes, for

Ethylene Oxide 65 minutes, for Fuming Nitric Acid 14 minutes,

for Sulfur Dioxide 38 minutes, and for Hydrogen Fluoride permeation was immediate (DuPont, 2003). Additionally, TNO

Laboratories in the Netherlands tested and certified Tyvek® F,

having passed all the standard North American Treaty

Organization (NATO) tests for chemical warfare protection

(DuPont, 2002). 

18

Occupational Safety and 

Health Administration
certain PAPRs in simulated workplace conditions, in

combination with protective gloves, boots, and garments with openings taped closed, will be adequate

to protect first receivers who are decontaminating victims.37 Government experts, researchers, and hospitals

alike offer broad support for the use of PAPRs and

chemical protective clothing (including gloves, boots,

and suits with the openings taped closed) for first

receivers performing decontamination activities (Hick

et al., 2003a; Georgopoulos et al., 2004; Macintyre et

al., 2000; MMWR, 2001). Furthermore, OSHA believes

the decontamination process itself, along with adequate employee training, will prevent injury to ED

staff working in the Hospital Post-decontamination

Zone.38

Based on information gathered from a wide variety of sources, OSHA has concluded that the PPE

specified in Table 3 will provide adequate protection

for first receivers exposed to unknown hazardous substances in most circumstances. Although applicable to

a wide range of hospitals, the guidance in Table 3 for

minimum first receiver PPE is conditional – to limit

first receiver exposures to levels at which the PPE

specified in Table 3 will provide effective protection,

hospitals must meet the specified prerequisite conditions of eligibility set forth in Tables 1 and 2.

Employers who meet the prerequisites in Tables 1 and

2 may use this best practices document as the OSHArequired generalized hazard assessment. Such

employers may choose to rely on the PPE specified in

Table 3 to comply with relevant OSHA standards and

to provide effective protection for first receivers

against a wide range of hazardous substances.

However, such employers also must conduct a hazard

assessment that considers hazards unique to the community in which they are located. In rare situations,

these employers will need to augment or modify the

PPE specified in Table 3 to provide adequate protection against unique hazards identified in the community-specific hazard analysis. Of course, employers are

not obligated to follow the guidance in Table 3; any

employer can choose instead to perform an independent hazard assessment that is sufficient to identify the

hazards that its employees are reasonably anticipated

to encounter, and then select PPE adequate to protect

its employees against such hazards. 

OSHA believes that hospitals are becoming increasingly prepared for mass casualty incidents

involving unidentified hazardous substances. As a

result, OSHA anticipates that many (and eventually

most) hospitals will meet the conditions in Tables 1

and 2 that will help them manage secondary exposures such that employees can be effectively protected when using the first receiver PPE presented in

Table 3. Recent incidents (including the World Trade

Center and anthrax attacks) and current JCAHO

requirements provide hospitals with strong incentive

to take the necessary steps to prepare themselves and

their staff to function safely during mass casualty incidents involving hazardous substance releases. Many

of the JCAHO requirements help hospitals better identify the actual conditions that they might face in an

emergency, which in turn allows the hospitals to make

realistic plans for managing emergencies in a way

that minimizes the risk to employees. The JCAHO

requirements, along with the hospital’s commitment

to maintaining JCAHO accreditation and OSHA compliance, provide the basis for conducting detailed

HVAs, identifying the hospital’s role in the community,

coordinating plans with other organizations, conducting drills to test all phases of preparedness, training

personnel, and implementing PPE and respiratory

protection programs. The additional exposure-limiting

conditions, such as removing and safely containing

contaminated clothing and other personal items as

soon as victims arrive at the hospital, are primarily

procedural and can be addressed through standard

operating procedures and clear communication with

victims and hospital staff. 

OSHA concludes that PAPRs with helmet/hoods

are a practical choice for first receivers. Helmet/hood

PAPRs require no fit testing, can be worn by employees with facial hair and eyeglasses, and are generally

considered by most workers to be more comfortable

than negative pressure APRs (see also Appendix E for

a comparison of the relative advantages of various

facepiece styles).39 Hospitals that take the steps outlined in Tables 1 and 2 will limit the exposures of first

receivers to a level against which PAPRs will normally

offer suitable protection. Other respirators that provide an APF of 1,000 or higher are also alternatives. 

OSHA recommends PAPRs to ensure the appropriate level of protection for situations when the haz37 In a 2003 Federal Register entry, OSHA proposed an APF of

1,000 for some models of PAPR (68 FR 34035, June 6, 2003).

38 The Hospital Post-decontamination Zone is an area considered uncontaminated. Equipment and personnel are not

expected to become contaminated in this area. At a hospital

receiving contaminated victims, the Hospital Post-decontamination Zone includes the ED (unless contaminated). In other

documents this zone is sometimes called the “Cold Zone.” 39 Tight-fitting respirators do require fit testing.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 19
ardous substance is unknown and unquantified. Nonpowered APRs have a role in protecting first receivers

when the hazardous substance has been identified

and quantified. First receivers may use such respirators after accurate information confirms that a negative pressure respirator will adequately protect the

wearer from the identified inhalation hazard.

Any respiratory protection for first receivers must

be included in a formal written respiratory protection

program, as required by 29 CFR 1910.134 (Respiratory

Protection), or the parallel State Plan standards.

Hospitals can integrate the respirators into their existing respiratory protection program, which must

include the following elements:

• Procedures for selecting respirators for use in the

workplace.

• Medical evaluations of employees required to

use respirators.

• Fit testing procedures for tight-fitting respirators.

• Procedures for proper use of respirators in routine and reasonably anticipated scenarios. 

• Procedures and schedules for cleaning, disinfecting, storing, inspecting, repairing, discarding,

and otherwise maintaining respirators.

• Procedures for establishing and implementing

respirator chemical cartridge change schedules.

• Procedures to ensure adequate air quality, quantity, and flow of breathing air for atmospheresupplying respirators.

• Training of employees in the respiratory hazards

to which they are potentially exposed during routine and emergency situations.

First Receiver Hospital Decontamination Zones

OSHA has found it appropriate to define two functional zones during hospital-based decontamination activities. These zones, which guide the application of

OSHA’s recommendations, are:

• Hospital Decontamination Zone

• Hospital Post-decontamination Zone

The Hospital Decontamination Zone includes any

areas where the type and quantity of hazardous substance is unknown and where contaminated victims,

contaminated equipment, or contaminated waste may

be present. It is reasonably anticipated that employees in this zone might have exposure to contaminated

victims, their belongings, equipment, or waste. This

zone includes, but is not limited to, places where initial triage and/or medical stabilization of possibly contaminated victims occur, pre-decontamination waiting

(staging) areas for victims, the actual decontamination

area, and the post-decontamination victim inspection

area. This area will typically end at the ED door. In

other documents this zone is sometimes called the

“Warm Zone.”

The Hospital Post-decontamination Zone is an area

considered uncontaminated. Equipment and personnel are not expected to become contaminated in this

area. At a hospital receiving contaminated victims, the

Hospital Post-decontamination Zone includes the ED

(unless contaminated). In other documents this zone

is sometimes called the “Cold Zone.”

PPE Table and Tables Listing Prerequisite Conditions

for Specified PPE

The following pages contain three tables. The first

two, Tables 1 and 2, list steps that hospitals must take

or conditions that must exist before relying upon the

PPE specified in Table 3. These steps and conditions

help limit employee exposures and are necessary to

ensure that the PPE for both zones listed in Table 3

will adequately protect employees. In other words,

OSHA has determined that the minimum first receiver

PPE outlined in Table 3 should protect healthcare

workers as they care for contaminated victims of

mass casualty incidents within the two zones; however, hospitals need to meet certain exposure-limiting

conditions (outlined in Tables 1 and 2) to ensure that

employees are adequately protected from all reasonably foreseeable hazards. Many hospitals can, or will

soon be able to, meet these conditions, many of

which parallel existing JCAHO and OSHA (OSHAapproved State Plan) requirements. These PPE best

practices are applicable to all hospitals that might

receive victims contaminated with unknown substances; however, hospitals must complete the hazard

assessment process and tailor the PPE selection to

also address specific hazards they might reasonably

be anticipated to encounter. Additionally, some hospitals may determine that an alternative mix of PPE is

appropriate for their particular situations. These

options include using more protective PPE (to perform

specialized activities or when conditions in Tables 1

and 2 cannot be met), or conducting an independent

hazard assessment to support an alternative PPE

selection.

20

Occupational Safety and 

Health Administration
Table 1. Hospital Decontamination Zone

Conditions Necessary for Hospitals to Rely on the

Personal Protective Equipment (PPE) Selection Presented in Table 3 A,B

1. Thorough and complete hazard vulnerability analysis (HVA) and emergency management plan 

(EMP), which consider community input, have been conducted/developed, and have been updated

within the past year.

2. The EMP includes plans to assist the numbers of victims that the community anticipates might 

seek treatment at this hospital, keeping in mind that the vast majority of victims may self-refer to 

the nearest hospital.

3. Preparations specified in the EMP have been implemented (e.g., employee training, equipment 

selection, maintenance, and a respiratory protection program).

4. The EMP includes methods for handling the numbers of ambulatory and non-ambulatory victims 

anticipated by the community.

5. The hazardous substance was not released in close proximity to the hospital, and the lapse time 

between the victims’ exposure and victims’ arrival at the hospital exceeds approximately 10 minutes, thereby permitting substantial levels of gases and vapors from volatile substances time to 

dissipate.C

6. Victims’ contaminated clothing and possessions are promptly removed and contained (e.g., in an 

approved hazardous waste container that is isolated outdoors), and decontamination is initiated 

promptly upon arrival at the hospital. Hospital EMP includes shelter, tepid water, soap, privacy, 

and coverings to promote victim compliance with decontamination procedures.

7. EMP procedures are in place to ensure that contaminated medical waste and waste water do not 

become a secondary source of employee exposure.

And

8. The decontamination system and pre-decontamination victim waiting areas are designed and 

used in a manner that promotes constant fresh air circulation through the system to limit hazardous substance accumulation.D Air exchange from a clean source has been considered in the 

design of fully enclosed systems (i.e., through consultation with a professional engineer or certified industrial hygienist) and air is not re-circulated.

A The Hospital Decontamination Zone includes any areas

where the type and quantity of hazardous substance is

unknown and where contaminated victims, contaminated

equipment, or contaminated waste may be present. It is reasonably anticipated that employees in this zone might have

exposure to contaminated victims, their belongings, equipment, or waste. This zone includes, but is not limited to, places

where initial triage and/or medical stabilization of possibly

contaminated victims occur, pre-decontamination waiting

(staging) areas for victims, the actual decontamination area,

and the post-decontamination victim inspection area. This

area will typically end at the emergency department (ED) door.

In other documents this zone is sometimes called the “Warm

Zone.”

B Hospitals that do not meet these conditions must use more

protective PPE or conduct a detailed hazard assessment to

support a different selection.

C Note: Georgopoulos et al. (2004) suggest that “recognition

of an event, identification of transportation means, and transportation to a healthcare facility are not expected to take less

than 5 minutes even under ideal circumstances.” The 10-

minute (approximate) lag time can be reasonably assumed

during a mass casualty event involving chemical release,

except in cases where the release occurs immediately adjacent

to the hospital (e.g., at a chemical factory next door to the hospital). This number of minutes is approximate and intended to

provide guidance regarding what might be considered “immediately adjacent.”

D Georgopoulos et al. (2004) recommend using fans to provide

air movement.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 21
Table 2. Hospital Post-decontamination Zone

Conditions Necessary for Hospitals to Rely on the 

Personal Protective Equipment (PPE) Selection Presented in Table 3 E,F

1. Emergency management plan (EMP) is developed and followed in a way that minimizes the 

emergency department (ED) personnel’s reasonably anticipated contact with contaminated victims 

(e.g., with drills that test communication between the hospital and emergency responders at the 

incident site to reduce the likelihood of unanticipated victims).

2. Decontamination system (in the Hospital Decontamination Zone) and hospital security can be 

activated promptly to minimize the chance that victims will enter the ED and contact unprotected 

staff prior to decontamination.

3. EMP procedures specify that unannounced victims (once identified as possibly contaminated) 

disrobe in the appropriate decontamination area (not the ED) and follow hospital decontamination 

procedures before admission (or re-admission) to the ED.

4. Victims in this area were previously decontaminated by a shower with soap and water, including a 

minimum of 5 minutes under running water. Shower instructions are clearly presented and 

enforced. Shower facility encourages victim compliance (e.g., shelter, tepid water, reasonable degree 

of privacy). 

5. EMP procedures clearly specify actions ED clerks or staff will take if they suspect a patient is 

contaminated. For example: (1) do not physically contact the patient, (2) immediately notify 

supervisor and safety officer of possible hospital contamination, and (3) allow qualified personnel 

to isolate and decontaminate the victim.

And

6. The EMP requires that if the ED becomes contaminated, that space is no longer eligible to be 

considered a Hospital Post-decontamination Zone. Instead, it should be considered contaminated 

and all employees working in this area should use PPE as described for the Hospital Decontamination Zone (see Table 3).

E The Hospital Post-decontamination Zone is an area considered uncontaminated. Equipment and personnel are not

expected to become contaminated in this area. At a hospital

receiving contaminated victims, the Hospital Post-decontamination Zone includes the ED (unless contaminated). In other

documents this zone is sometimes called the “Cold Zone.”

F Hospitals that do not meet these conditions must use more

protective PPE or conduct a detailed hazard assessment to

support a different selection.

22

Occupational Safety and 

Health Administration
Table 3. Minimum Personal Protective Equipment (PPE)

for Hospital-based First Receivers of Victims from Mass Casualty Incidents

Involving the Release of Unknown Hazardous Substances

SCOPE AND LIMITATIONS

This Table applies when:

• The hospital is not the release site.G • The identity of the hazardous substance is unknown.H

• Prerequisite conditions of hospital eligibility are already met (Tables 1 and 2).

Note: This table is part of, and intended to be used with, the document entitled OSHA Best Practices for Hospitalbased First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances.

ZONE MINIMUM PPE

Hospital Decontamination Zone I

• All employees in this zone

(Includes, but not limited to, any of the 

following employees: decontamination 

team members, clinicians, set-up crew, 

cleanup crew, security staff, and patient 

tracking clerks.)

Hospital Post-decontamination Zone M

• All employees in this zone • Normal work clothes and PPE, as necessary, for infection 

control purposes (e.g., gloves, gown, appropriate respirator).

• Powered air-purifying respirator (PAPR) that provides a protection factor of 1,000.J The respirator must be NIOSH-approved.K

• Combination 99.97% high-efficiency particulate air 

(HEPA)/organic vapor/acid gas respirator cartridges 

(also NIOSH-approved).

• Double layer protective gloves.L

• Chemical resistant suit.

• Head covering and eye/face protection 

(if not part of the respirator).

• Chemical-protective boots.

• Suit openings sealed with tape.

G When the hospital is not the release site, the quantity of contaminant is limited to the amount associated with the victims.

H If a hospital is specifically responding to a known hazard,

the hospital must ensure that the selected PPE adequately protects the employees from the identified hazard. Thus, hospitals

must augment or modify the PPE in Table 3 if the specified PPE

is not sufficient to protect employees from the identified hazard. Alternatively, if a hazard assessment demonstrates that

the specified PPE is not necessary to effectively protect workers from the identified hazard, a hospital would be justified in

selecting less protective PPE, as long as the PPE actually

selected by the hospital provides effective protection against

the hazard.

I The Hospital Decontamination Zone includes any areas

where the type and quantity of hazardous substance is

unknown and where contaminated victims, contaminated

equipment, or contaminated waste may be present. It is reasonably anticipated that employees in this zone might have

exposure to contaminated victims, their belongings, equipment, or waste. This zone includes, but is not limited to, places

where initial triage and/or medical stabilization of possibly

contaminated victims occur, pre-decontamination waiting

(staging) areas for victims, the actual decontamination area,

and the post-decontamination victim inspection area. This

area will typically end at the emergency department (ED) door.

J OSHA recently proposed an assigned protection factor (APF)

of 1,000 for certain designs of hood/helmet-style PAPRs

(Federal Register, 2003). An OSHA memorandum, which provides interim guidance pending the conclusion of the APF rulemaking, listed several PAPR hood/helmet respirators that are

treated as having an APF of 1,000 for protection against particulates in the pharmaceutical industry (OSHA, 2002c (Memo for

RAs)). The American National Standards Institute (ANSI), in

Standard Z88.2 on Respiratory Protection, also indicates an

APF of 1,000 for certain PAPRs. A hooded-style PAPR provides

greater skin protection, has greater user acceptance, and does

not require fit testing under 29 CFR 1910.134, thus might be

preferred over a tight-fitting respirator. However, a tight-fitting

full facepiece PAPR might offer more protection in the event of

PAPR battery failure.

K Hospitals must use NIOSH-approved CBRN (chemical, biological, radiological, and nuclear) respirators, as they become

available, when the HVA reveals a potential WMD threat. Until

NIOSH completes its CBRN certification process for PAPRs, use

PAPRs that have been tested by the manufacturer for a CBRN

environment.

L Material for protective gloves, clothing, boots, and hoods

must protect workers against the specific substances that they

reasonably might be expected to encounter. However, given

the broad range of potential contaminants, OSHA considers it

vitally important that hospitals also select PPE that provides

protection against a wide range of substances. No material will

protect against all possible hazards.

M The Hospital Post-decontamination Zone is an area considered uncontaminated. Equipment and personnel are not

expected to become contaminated in this area. At a hospital

receiving contaminated victims, the Hospital Post-decontamination Zone includes the ED (unless contaminated).

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 23
The training indicated for first receivers depends on

the individuals’ roles and functions, the zones in

which they work, and the likelihood that they will

encounter contaminated patients.41 OSHA recognizes

that hospital staff who decontaminate victims at the

hospital are removed from the site of the emergency

(OSHA, 2002a, 2002b, 19992b). However, letters of

interpretation provide that HAZWOPER First Responder

Operations Level and First Responder Awareness Level

training meet the requirements for first receivers in certain roles and positions. For other employees, a briefing at the time of the incident will be appropriate. In

each case, the training must be effective, that is, be

provided in a manner that the employee is capable of

understanding.42

The following sections discuss HAZWOPER training provisions and contemplate levels of training commensurate with the employees’ designated role within

the EMP. 

OPERATIONS LEVEL TRAINING

OSHA letters of interpretation specify that hospitals

must provide HAZWOPER First Responder Operations

Level training to first receivers who are expected to

decontaminate victims or handle victims before they

are thoroughly decontaminated (OSHA, 2003, 2002b,

1999, 1992c, 1991a). This level of training is appropriate for anyone with a designated role in the Hospital

Decontamination Zone. 

Training requirements for First Responder

Operations Level appear under 29 CFR 1910.120

(q)(6)(ii), which indicates a minimum training duration

of 8 hours and outlines topics to be covered (competencies the employee must acquire). Both the required

competencies and training time were recently confirmed in an interpretive letter (OSHA, 2003). OSHA,

however, allows these topics (but not the minimum

training time) to be tailored to better meet the needs

of first responders. For example, the training might

omit topics that are not directly relevant to the

employee’s role (e.g., recognition of Department of

Transportation placards), but instead should include

alternative training on hazard recognition (e.g., signs

and symptoms of contamination or exposure), on

decontamination procedures provided by the hospital,

and on the selection and use of PPE (OSHA, 1992c).

Training that is relevant to the required competencies

counts toward the 8-hour requirement, even if the

training is provided as a separate course. For example, training on PPE that will be used during victim

decontamination activities may be applied towards

the 8-hour minimum Operations Level training

requirement, regardless of whether the PPE training is

conducted as part of a specific HAZWOPER training

course or as part of another training program (OSHA,

1992c). 

First Responder Awareness Level training also

counts towards the 8-hour requirement for Operations

Level training. This point is clarified in a recent letter

of interpretation issued by OSHA: “...if you spend two

hours training employees in the required competencies for First Responder Awareness Level as described

in 29 CFR 1910.120(q)(6)(i)(A)-(F), then you would need

to spend at least six additional hours training employees in the required competencies for First Responder

Operations Level as described in 29 CFR 1910.120(q)

(6)(ii)(A)-(F). Depending on the employees’ job duties

and prior education and experience, more than eight

hours of training may be needed” (OSHA, 2003). 

As an alternative to the 8-hour training requirement, the HAZWOPER standard allows employees to

demonstrate competence in specific areas, presented

in 29 CFR 1910.120(q)(6)(ii) and reproduced in the section, Competencies for First Responder Operations

Level Training at page 35. OSHA reaffirmed this point

in a letter of interpretation, stating “...employees with

sufficient experience may objectively demonstrate the

required competencies instead of completing eight

hours of training” (OSHA, 2003). However, it is important to note that in most hospital settings it might be

difficult to ensure that employees have sufficient

experience to waive the training requirement. Most

hospital employees do not have extensive experience

with hazardous materials or PAPRs, and decontamination activities are performed infrequently.

Hospitals must document how training requirements are met. This is particularly important whenev41 State Plan States enforce standards, including the HAZWOPER standard and its training requirements, which are “at

least as effective as” Federal OSHA's standards, and therefore

may have more stringent or supplemental requirements. 

42 JCAHO standards require: (1) identification and assignment

of personnel to cover all necessary staff positions under emergency conditions, (2) education as to their specific roles and

responsibilities during emergencies, (3) information and skills

required to perform assigned duties during emergencies, and

(4) testing the response phase of EMPs twice a year, including

a mandatory practice drill relevant to the priority emergencies

in the organization’s HVA.

Training First Receivers

24

Occupational Safety and 

Health Administration
er hospitals allow employees to satisfy any portion of

the training requirement through other related training or through demonstration of competence. The

HAZWOPER standard requires and an OSHA letter of

interpretation confirms that “the employer must certify in writing the comparable training or demonstrated

competencies” (OSHA, 2003). 

Annual refresher training is specified under

1910.120(q)(8)(i), or the parallel State Plan standards;

however, the length of the refresher training is not

specified. Instead, the standard requires that employees trained at the First Responder Operations Level

“shall receive annual refresher training of sufficient

content and duration to maintain their competencies,

or shall demonstrate competency in those areas at

least yearly.” Additionally, the hospital must document that refresher training was performed, or alternatively, keep a record of how the employee demonstrated competency.

The initial and annual refresher training to the

HAZWOPER First Responder Operations Level must

be provided to all hospital personnel who have been

designated to provide treatment, triage, decontamination, or other services to contaminated individuals or

who may reasonably be expected to come in contact

with those individuals arriving at the hospital. Training

core elements must include:

• Understanding the hospital emergency operations plan and their roles in the response.

• Site safety, including risks to receiving personnel.

• Appropriate selection and use of PPE.

• Decontamination procedures. 

The Operations Level training related to the use of

PPE must include topics such as those specified by

OSHA’s Personal Protective Equipment standard (29

CFR 1910.132). Under that standard, training must be

provided to each employee who is required to use

PPE. At a minimum, that training must cover the following:

• When PPE is necessary.

• What PPE is necessary.

• How to properly put on, remove, adjust, and

wear PPE.

• Limitations of PPE.

• Proper care, maintenance, useful life, and disposal of PPE.

Employees must demonstrate their understanding

of the training by showing they can use the PPE properly, prior to using the protective equipment in the

workplace. Refresher training is warranted when the

employee cannot demonstrate proficiency in the proper care and use of the PPE, when changes in the workplace render the previous training obsolete, or when

changes in the type of PPE to be used render the previous training obsolete. OSHA specifies that the hospital must maintain a written record of employee PPE

training.

Operations Level training also must include training required by OSHA’s Respiratory Protection standard (29 CFR 1910.134), or the parallel State Plan standards. Specifically, any employee who must wear a

respirator must be trained in the proper use and limitations of that device prior to its use in the workplace.

The training must be comprehensive enough that the

employee is able to demonstrate knowledge of the

seven training topics specified in the standard and

outlined below. The employee also must be able to

demonstrate competence in wearing the complete

PPE ensemble, including respirator, protective garment, gloves, boots, and other safety equipment

required for the employee’s role. Refresher training is

required at least annually, or sooner if changes in the

workplace or type of respirator render previous training inadequate. Refresher training is also required if

the employee does not demonstrate proficiency in the

proper care and use of the respirator, or any other

time when retraining appears necessary to ensure

safe respirator use.

At a minimum, training under OSHA’s Respiratory

Protection standard must cover the following topic

areas:

• The nature of the respiratory hazard, and why a

respirator is needed.

• Respirator capabilities, limitations, and consequences, if the respirator is not used correctly.

• How to handle respirator malfunctions and other

emergencies.

• How to inspect, put on, remove, use, and check

seals on the respirator.

• Maintenance and storage procedures.

• When to change cartridges on APRs.

• How to recognize medical signs and symptoms

that may limit or prevent effective use of a respirator.

• General requirements of the respiratory protection program.

Note that first receivers who wear respiratory protection must be deemed medically qualified to do so,

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 25
following the process required by 29 CFR 1910.

134(e)(1) through (e)(6) of OSHA’s Respiratory Protection standard. Employees who wear tight-fitting respirators also must be properly fit tested as required in

29 CFR 1910.134(f) (Respiratory Protection), or the parallel State Plan standards.

AWARENESS LEVEL TRAINING

First Responder Awareness Level training is required

for those employees who work in the contaminantfree Hospital Post-decontamination Zone, but might

be in a position to identify a contaminated victim who

arrived unannounced. This group includes ED clinicians, ED clerks, and ED triage staff who would be

responsible for notifying hospital authorities of the

arrival, but would not reasonably be anticipated to

have contact with the contaminated victims, their

belongings, equipment, or waste. The group also

includes decontamination system set-up crew members and patient tracking clerks, if their roles do not

put them in contact with contaminated victims, their

belongings, equipment, or waste (e.g., setting up the

decontamination system before victims arrive, or

tracking patients from a location outside of the decontamination zone).

First Responder Awareness Level training also is

required for hospital security guards who work away

from the Hospital Decontamination Zone, but who

may be involved tangentially in a mass casualty event

(specifically, those security personnel who would not

reasonably be anticipated to come in contact with

contaminated victims, their belongings, equipment, or

waste) (OSHA 1991b). Security staff assigned to roles

in the Hospital Decontamination Zone would require a

higher level of training (e.g., First Responder

Operations Level). 

Training requirements for First Responder

Awareness Level appear under 29 CFR 1910.120

(q)(6)(i), which does not require a specific minimum

training duration, but outlines topics to be covered

(competencies the employee must acquire). As with

Operations Level training, the HAZWOPER standard

allows an alternative to the Awareness Level training

requirement. Training can be waived if the employee

has had sufficient experience to objectively demonstrate competency in specific areas. These areas are

listed in 29 CFR 1910.120(q)(6)(i), or the parallel State

Plan standards, and reproduced in the section First

Responder Awareness Level Training at page 36. 

Annual refresher training is required for employees

trained at the Awareness Level. As with Operations

Level refresher training, the class content must be

adequate to maintain the employees’ competence,

and the hospital must document the training or the

method used to demonstrate the employees’ competence.

BRIEFING FOR SKILLED SUPPORT PERSONNEL

WHOSE PARTICIPATION WAS NOT PREVIOUSLY

ANTICIPATED

A member of the staff who has not been designated,

but is unexpectedly called on to minister to a contaminated victim, or perform other work in the

Hospital Decontamination Zone, is considered skilled

support personnel. Examples include a medical specialist or a trade person, such as an electrician. These

individuals must receive expedient orientation to site

operations immediately prior to providing such services (OSHA, 1997). The orientation must include:

• Nature of the hazard (if known).

• Expected duties.

• Appropriate use of PPE.

• Other appropriate safety and health precautions

(e.g., decontamination procedures).

As part of the briefing, these personnel also must

be medically cleared for respirator use and properly fit

tested (if wearing a tight-fitting respirator), as required

by 29 CFR 1910.134 (Respiratory Protection), or the

parallel State Plan standards. See the section

Instruction for Employees Whose Participation in the

Hospital Decontamination Zone Was Not Previously

Anticipated at page 36 for additional information on

briefing content. 

While a just in time briefing during the response

is the only required training for these personnel, time

and resource limitations inherent in a crisis likely will

diminish the effectiveness of such training. Thus, hospitals should diligently consider the broad range of

skills/capabilities that may be required within the

Decontamination Zone during a mass casualty event

and attempt to identify and train all persons who may

be called to work in the Decontamination Zone prior

to a mass casualty event.

TRAINING SIMILAR TO THAT OUTLINED IN THE

HAZARD COMMUNICATION STANDARD

Hospitals should consider offering a basic level of

training for other employees in the ED, such as housekeeping staff. This group could include those personnel who do not have a role in the decontamination

process, reasonably would not be expected to

26

Occupational Safety and 

Health Administration
encounter self-referred contaminated patients, and

reasonably would not be expected to come in contact

with contaminated victims, their belongings, equipment, or waste. OSHA’s Hazard Communication standard offers a useful model for appropriate training,

which could include general information on the hospital’s emergency procedures and plans for mass casualty incidents involving contaminated victims, steps

the employees can take to protect themselves (usually

by leaving the area), and the measures the hospital

has implemented to protect employees in the ED.

While not required under the OSH Act, such training

could help to ensure that all staff in the ED understand what precautions and actions would (and would

not) be expected of them if an incident occurred.

SUMMARY OF TRAINING FOR FIRST RECEIVERS

Table 4 summarizes OSHA’s current guidance on training first receivers for mass casualty emergencies.

References to related OSHA interpretation letters are

included. Employees are categorized according to

zone (namely, Hospital Decontamination Zone and

Post-decontamination Zone); whether they have designated roles in the zone; and the likelihood of contact

with contaminated victims, their belongings, equipment, or waste. Hospitals should note that the training

levels presented are minimum training levels and can

be increased or augmented, as appropriate, to better

protect employees, other patients, and the facility in

general.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 27
N The employer must certify that personnel trained at the

“First Responder Operations Level” have received at least

eight hours of specific training (which can include Awareness

Level training, PPE training, and training exercise/drills), or

have had sufficient experience to objectively demonstrate

competency in specific key areas. Refresher training must be

provided annually and must be of sufficient content and duration to maintain competencies. Alternatively, the employee

may demonstrate competence (i.e., skills) (OSHA HAZWOPER

29 CFR 1910.120(q)(6)(ii)). Participation in training

exercises/drills is recommended to ensure competency during

initial and refresher training. 

O The Hospital Decontamination Zone includes any areas

where the type and quantity of hazardous substance is

unknown and where contaminated victims, contaminated

equipment, or contaminated waste may be present. It is reasonably anticipated that employees in this zone might have

exposure to contaminated victims, their belongings, equipment, or waste. This zone includes, but is not limited to: places

where initial triage and/or medical stabilization of possibly contaminated victims occur, pre-decontamination waiting (staging)

areas for victims, the actual decontamination area, and the

post-decontamination victim inspection area. This area will

typically end at the ED door.

P The term clinician includes physicians, nurses, nurse practitioners, physicians’ assistants, and others.

MANDATORY TRAINING

First Responder 

OPERATIONS LEVELN

Initial training

Annual refresher 

Both initial and refresher 

training may be satisfied by

demonstration of competence.

Briefing at the time of the

incidentQ,R

First Responder 

AWARENESS LEVEL

Initial training

Annual refresher

Both initial and refresher 

training may be satisfied by

demonstration of competence.

RECOMMENDED TRAINING

Training similar to that 

outlined in the Hazard

Communication standardS

Table 4. Training for First Receivers

FIRST RECEIVERS COVERED

All employees with designated roles in the Hospital

Decontamination Zone.O This group includes, but is not limited to: 

• Decontamination staff, including decontamination victim 

inspectors; clinicians who will triage and/or stabilize victims 

prior to decontamination; P security staff [e.g., crowd control 

and controlling access to the emergency department (ED)]; 

set-up crew; and patient tracking clerks.

Other employees whose role in the Hospital Decontamination Zone

was not previously anticipated (i.e., who are called in incidentally).

(e.g., a medical specialist or trade person, such as an electrician.)

a) Security personnel, set-up crew, and patient tracking clerks 

assigned only to patient receiving areas proximate to the 

Decontamination Zone where they might encounter, but are 

not expected to have contact with, contaminated victims,

their belongings, equipment, or waste.

b) ED clinicians, clerks, triage staff, and other employees associated with emergency departments, who might encounter 

self-referred contaminated victims (and their belongings,

equipment, or waste) without receiving prior notification that

such victims have been contaminated.

PERSONNEL COVERED

Other personnel in the Hospital Post-decontamination Zone who

reasonably would not be expected to encounter or come in contact with unannounced contaminated victims, their belongings,

equipment, or waste.T,U

(e.g., other ED staff, such as housekeepers.)

REFERENCE

OSHA, 2003,

1992c, 1999

OSHA, 1997

OSHA, 1991a,

1991b

REFERENCE

29 CFR

1910.1200(h)

Q The briefing must include (at a minimum) instruction on

wearing the appropriate PPE, the nature of the hazard, expected duties, and the safety and health precautions the individual

should take (OSHA, 1997 (Whittaker); 29 CFR 1910.120(q)(4)). 

R Note that the individual must be medically qualified (29 CFR

1910.134), fitted (1910.132 and .134), and trained (1910.132 and

.134) to use the required PPE. These qualifications are difficult

to achieve at the time of the incident and, whenever possible,

should be accomplished prior to an incident.

S While HAZCOM training is not required pursuant to the OSH

Act for most of the scenarios contemplated in this document, a

prudent employer may consider adopting and appropriately

modifying the training provisions in the HAZCOM standard to

provide information to personnel who would not be expected

to come in contact with unannounced contaminated victims,

their belongings, equipment, or waste.

T The Hospital Post-decontamination Zone is an area considered uncontaminated. Equipment and personnel are not

expected to become contaminated in this area. At a hospital

receiving contaminated victims, the Hospital Post-decontamination Zone includes the ED (unless contaminated).

U If the ED becomes contaminated, the hospital’s decontamination procedures must be activated by the properly trained

and equipped employees (refer to the Hospital Decontamination Zone in this table and Table 3).

28

Occupational Safety and 

Health Administration
The following appendices provide references and examples which might be useful to hospitals developing or

upgrading emergency management plans (EMPs). OSHA offers these examples for informational purposes only

and does not recommend one option over the many effective alternatives that exist.

This Appendix supplements the Best Practices from

OSHA by providing useful background information on

how various aspects of a hospital’s preparation,

response, and recovery impact employee protection

during hazardous substance emergencies. Look in

Appendix A for:

PREPAREDNESS page 30

• Examples of roles that hospitals fill in their communities and the benefits hospitals can derive

from playing an active role in community emergency preparedness.

• Suggestions for coordinating Emergency

Response Plans (EMPs) with other organizations.

• Tips for designating staff for decontamination

teams.

• Discussion of the different levels of training for

first receivers filling various roles, plus information on training requirements for the team members.

• Medical monitoring considerations for first

receivers before, during, and after a response.

RESPONSE page 40

• Discussion of the benefits associated with different types of decontamination facilities and examples of factors hospitals consider when selecting

a system.

• Outline of the basic steps typically involved in

victim decontamination procedures.

• Examples of several organizations’ shower flush

times and practices used for victim decontamination.

• Review of OSHA requirements for employers

whose employees wear respirators and other

personal protective equipment (PPE).

RECOVERY page 50

• Discussion of management practices for contaminated solid waste.

• Examples of arrangements hospitals have made

to manage wastewater during and after a

response.

• Strategies for decontaminating surfaces and

equipment.

MAINTAINING FUTURE READINESS page 51

• Discussion of critical steps for sustaining a functional level of emergency preparedness.

Appendix A: 

Background, Literature Review, and Site Visit Examples

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 29
PREPAREDNESS

The following discussion provides examples of ways

hospitals have attempted to enhance employee protection as part of general preparedness for mass casualty emergencies involving contaminated victims. This

discussion is designed to further worker health and

safety by referencing practices and procedures considered and/or adopted in the healthcare community.

However, statements in this appendix cannot create

nor diminish obligations under the Occupational

Safety and Health (OSH) Act. 

In making preparations, hospitals must consider key

assumptions regarding communication, resources, and

victims. When developing plans, hospitals should

anticipate:

• Victims will arrive with little or no warning to the

hospital. 

• Information regarding the hazardous agent(s) will

not be available immediately. 

• A large number of victims will be self-referred

victims (as much as 80 percent of the total number of victims).

• Victims will not necessarily have been decontaminated prior to arriving at the hospital. 

• A high percentage of people arriving at the hospital will have experienced little or no exposure

and this eventuality should be considered in

decontamination plans.

• Most victims will go to the hospital closest to the

site where the emergency occurred.

• Victims will use other entrances in addition to the

emergency department (ED).

Sources: Auf der Heide, 2002; Barbera and

Macintyre, 2003; Vogt, 2002; Okumura et al., 1996.

Administrators making preparations for mass

casualty incidents should note that hospitals are part

of the community’s critical infrastructure and continuity of operations must be maintained.

CUSTOMIZING HOSPITAL EMERGENCY 

MANAGEMENT PLANS

The hospital emergency management plan (EMP) outlines how the facility will respond to an emergency.

The plan should address the hazards the hospital will

encounter, identify the hospital’s role in the response,

and serve as a road map for incident preparation,

response, and recovery.

No organization can prepare fully for every conceivable emergency. To use resources effectively, a

hospital requires information that will help emergency

planners make informed decisions about the type,

probability, severity, and impact of specific hazards to

which the hospital might be subject. A hazard vulnerability analysis (HVA) assists a hospital in organizing

this information, which is used to customize the hazard assessment for personal protective equipment

(PPE) selection (a critical aspect of the EMP). The

Joint Committee for Accreditation of Healthcare

Organizations (JCAHO) requires an HVA as the first

step in emergency planning (JCAHO, 2004). Specific

information on conducting HVAs may be obtained

directly from JCAHO.

The HVA and resulting preparations are only as

specific to the individual hospital as the information

on which preparation decisions are based. Important

modifying factors include the hospital’s role in the

community, how up-to-date the hospital’s EMP is, and

formal planning agreements between the hospital and

other organizations that have roles in emergency

response activities. With knowledge of these details,

hospitals can customize EMPs and effectively tailor

preparedness (including employee protection) to

address the circumstances relevant to that hospital.

Using Information from a Hazard Vulnerability

Analysis

As noted previously, an HVA helps hospitals organize

information and guide decision-making. A thorough

HVA can serve as the basis for informed decisions

regarding the training and equipment employees will

require to protect themselves under foreseeable emergency scenarios.

The hospitals interviewed use variations of a few

publicly available HVA formats. See Appendix F for

examples of two formats (additional examples are

available from other sources). The tool is often slightly modified by the individual hospital to include additional information that the hospital finds helpful for

making decisions or communicating with management. 

A popular HVA, an electronic spreadsheet, prompts

the user to enter a numerical rating (e.g., 1 to 3) for

various factors associated with each of numerous listed threats (both from a standard list and additional

hazards added by the user). JCAHO (2002) offers a

Appendix A: 

Background, Literature Review, and Site Visit Examples

30

Occupational Safety and 

Health Administration
matrix of threats that hospitals might consider. The

user generates (or the spreadsheet calculates) a hazard vulnerability score based on the inputs. The

inputs may be weighted to reflect the importance of

certain information to the final score. Hospitals use

both the final score and the individual numerical rating inputs to identify and rank priority areas that

should receive administrative attention or resources. 

Other hospitals use a tabular format HVA and

more descriptive text input to guide the user through

the analysis. The tables can provide more information, but are also more cumbersome for evaluating a

large selection of threats. Because these formats are

more likely to have been developed in-house, they

tend to be more diverse.

None of the HVA formats have been validated to

determine whether the inputs and final assessment

accurately reflect hazard vulnerability. Nevertheless,

an informal qualitative review conducted by the developer of one HVA spreadsheet tool suggested that

independent users, when operating in similar hospital

and community environments, do generally arrive at

similar conclusions regarding vulnerability and priorities for improvement (Saruwatari, 2003).

The hospitals interviewed for this project agree

that the HVA should be updated frequently and

reviewed at least annually, as required by JCAHO

(2004). By collaborating with Local Emergency

Planning Committees (LEPCs), hospitals can keep current with information on changes in threats in their

localities.43 Hospital D noted that, if appropriate,

resources could be reallocated sooner if emergency

managers are able to update the HVA as new information arrives (e.g., emerging threats), rather than waiting for an annual review cycle.44 These changes can

also modify the local hospital’s vulnerability to those

hazards. As an example, Hospital D had rated “preparation for chlorine-related emergencies” as a top priority. When the local potable water facility changed

processes, the threat of a large-scale chlorine emergency was eliminated from the community. Upon

revising the HVA, Hospital D was able to redirect

resources to address the next most urgent threat without waiting until the next annual review cycle.

Characteristics of the community (e.g., businesses,

chemical inventory, population, transportation lines,

clandestine drug labs, and possible targets of terrorism) influence the type of hazardous substance-related emergencies that a hospital might reasonably

anticipate. This information should be considered in

the HVA. These factors range from the number and

condition of victims that the hospital might rreasonably anticipate, to the rate at which hazard information could become available during an emergency. 

Identifying the Hospital’s Role in the Community

The community in which a hospital is located and the

hospital’s role in that community impact emergency

preparations on several levels. Hospital D’s emergency manager suggested that the real objective of

emergency planning is “community preparedness,

and a hospital’s preparedness represents only one

component.” For the purposes of this discussion,

“community” is defined as the local population center

that the hospital serves on a day-to-day basis, as well

as any additional population centers from which the

hospital would reasonably expect to receive victims in

the event of a mass casualty emergency involving

hazardous substances.

Fully coordinated planning helps hospitals identify

their roles in their communities. Roles vary considerably with individual circumstances, but ultimately

have a strong impact on the conditions and hazards

for which a hospital must plan employee protection.

Examples of roles some hospitals fill (or expect to fill)

in their communities include:

• Providing decontamination and treatment for any

and all victims.

• Promoting a wider level of preparedness in the

community by providing low-cost hazard communication or hazardous waste operations and

emergency response (HAZWOPER) training for

local government and business emergency

response personnel.

• Providing information and services related to

emergency preparedness (e.g., respirator medical clearance).

• Participating actively in multi-disciplined community-based planning and preparedness activities,

such as LEPCs (e.g., Hospital D reports devoting

a minimum of 12 man-hours per week to its

active role in community preparedness. This

time is in addition to the hours spent managing

the hospital’s internal preparations).

The hospitals interviewed for this project also note

that, in addition to a better coordinated community

43 Visit www.epa.gov/swercepp/lepclist.htm to see listings for

LEPCs by location.

44 See acknowledgments at the beginning of this document

for a brief statement about the hospitals interviewed for this

guidance. 

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 31
emergency response plan, they receive additional

financial, informational, and business benefits from

active participation in community-focused emergency

preparedness and planning. The following list indicates benefits that hospitals can derive from an active

role in community emergency preparedness:

• Increased access to community records, which

help managers improve the accuracy of the HVA

and help the hospital customize its EMP. 45 

• Increased access to grants and other financial

resources.

• Group buying power that allows for volume discounts or government rates (including reduced

sales tax) for equipment and supplies. 

• More opportunities to contain costs by sharing or

trading expertise, training resources, equipment,

and services.

• Greater opportunity to tailor community drills so

they test the hospital’s emergency plans.

• Increased opportunities to network and develop

useful alliances with emergency first responders

and other emergency planners (particularly useful for resolving complex issues that emerge as

groups coordinate their activities under difficult

circumstances).

• Greater visibility in the community and increased

respect as a valued resource and partner (including among business leaders).

Updating Emergency Management Plans

EMPs should be reviewed periodically for the same

reasons the HVA is updated — situations change.46

Common changes that can impact employee protection include the types of foreseeable hazardous situations that might be encountered in an emergency, the

anticipated needs of the community, the availability of

other emergency response organizations to fill certain

roles, the type of equipment available to protect

employees, and personnel turnover.

Hospitals should already be in compliance with

applicable OSHA health and safety standards, such as

those listed below (or parallel OSHA-approved State

Plan standards). Additionally, during the periodic

EMP evaluation, hospitals should review the regulations to ensure the plan continues to be compliant. 

• OSH Act – General Duty Clause (Section (5)(a)(1))

• HAZWOPER – 29 CFR 1910.120(q).

• Personal Protective Equipment – 29 CFR 1910.132.

• Eye and Face Protection – 29 CFR 1910.133.

• Respiratory Protection – 29 CFR 1910.134.47 

• Hand Protection – 29 CFR 1910.138.

• Hazard Communication – 29 CFR 1910.1200(h). 

• Bloodborne Pathogens – 29 CFR 1910.1030.

• Ethylene Oxide – 29 CFR 1910.1047. 

• Formaldehyde – 29 CFR 1910.1048. 

Coordinating Emergency Plans with Other

Organizations

Well-coordinated EMPs ensure that hospitals are

aware of the capabilities of first responders and other

hospitals, as well as what the local professional and

response community expects from them.48 Coordinated plans encourage open lines of communication

and improve the safety of both victims and healthcare

workers. The following example demonstrates the

value of coordinated EMPs. After problems were identified during a drill, Hospital D determined that healthcare workers needed faster access to information

from hazardous materials incident sites. Initially, the

fire department felt that Hospital D’s request for more

timely information would be too burdensome during

life-threatening emergencies. When the two organizations met, however, they each learned the reasons

behind the other’s needs. As a result, the first responders recognized that, by coordinating efforts, they

could enhance the first receivers’ ability to provide

rapid and appropriate care to victims. The fire department was able to modify its own EMP to incorporate

direct communication between the hospital and a representative of the incident commander at the scene. 

45 Hospitals report that some useful community records

include statistics on local hazardous materials incidents, population census and demographic information, local probability

rates for natural disasters, Chamber of Commerce data, and

information on types and quantities of hazardous substances

used by local industry (e.g., EPA Emergency Planning and

Community Right-to-Know Act (EPCRA) Section 311/312, 40

CFR Part 370, Hazardous chemical storage reporting requirements, described in further detail at: http://yosemite.epa.gov/

oswer/ceppoweb.nsf/vwResourcesByFilename/epcra.pdf/$File/

epcra.pdf.)

46 JCAHO (2004) requires that both the HVA and the EMP be

evaluated annually, with particular attention to “its objectives,

scope, functionality and effectiveness.”

47 For additional information on the OSHA Respiratory

Protection standard, see http://www.osha.gov/SLTC/etools/ 

respiratory/index.html.

48 JCAHO (2004) requires, and OSHA (2001) recommends, that

organizations coordinate emergency management planning

efforts.

32

Occupational Safety and 

Health Administration
The hospitals interviewed for this project mentioned several methods by which they improve EMP

coordination and communication:

• Use an incident command system compatible

with the National Incident Management System

(NIMS) structure.49,50

• Get to know members of the other organizations

and the details of their plans. Seek opportunities

to improve communication.

• Seek input from other organizations (such as

local emergency planning groups) when developing or updating plans.

• Use compatible forms of communication, such as

radios capable of operating on the same frequency. Keep compatibility in mind when purchasing

equipment.

• Participate in multi-organizational drills. Execute

multi-organizational drills that test the way

organizations interact under adverse conditions.

• Analyze drills to identify areas that need improvement and meet directly with the other organizations to develop action plans that provide mutually agreeable, practical solutions to problems.

Bear in mind that a solution suggested by one

party might not be feasible for another organization to implement.

• Test inter-organizational communication systems

at every opportunity (e.g., fire department, law

enforcement, emergency medical services, environmental management, and other hospitals).51

Barbera and Macintyre (2003) suggest the following organizations with which hospitals should coordinate:

• Public health groups (including special laboratories).

• Local emergency management organizations

(e.g., LEPCs).

• Emergency medical services.

• Law enforcement, at all levels.

PREPARING STAFF AND MANAGEMENT

Applicable Standards

Organizations, such as OSHA, those states operating

OSHA-approved State Plans, JCAHO, the National Fire

Protection Association (NFPA), and other state or local

government agencies, set standards that govern

employee preparation, particularly regarding employee training and medical evaluations. OSHA standards,

or the parallel State Plan standards, relevant to the

training of first receivers include the HAZWOPER,

Personal Protective Equipment, Respiratory Protection, and Hazard Communication standards.52

Hospitals with decontamination facilities should also

comply with the requirement for medical evaluations

contained in the HAZWOPER and Respiratory

Protection standards.

JCAHO (2004) requires “an orientation and education program for all personnel, including licensed

independent practitioners, who participate in implementing the emergency management plan.” When

plans involve management of chemical hazards,

OSHA’s HAZWOPER and hazard communication (HAZCOM) standards complement the JCAHO requirements by providing specific topics that should be

addressed during the training. Other requirements of

these standards might also apply (e.g., training duration, demonstration of skills, and retraining), depending on whether the HAZWOPER (Hospital Decontamination Zone) or the HAZCOM (Hospital Post-decontamination Zone) standard is in effect. NFPA (2002)

suggests competencies for incident commanders and

others responding to hazardous materials incidents.

49 An example of a NIMS-compatible system, the publicly

available Hospital Emergency Incident Command System

(HEICS), uses the same structure and vocabulary as the widely

used Fire Department Incident Command System. Emergency

services leaders report that the respective command systems

interface well, without loss of organizational identity (San

Mateo County HSA, 1998). A brief introduction to HEICS

appears in Appendix G.

50 For additional information on incident command systems

see http://www.osha.gov/SLTC/etools/ics/index.html and

http://www.emsa.ca.gov/Dms2/HISTORY.HTM (also attached to

this guidance document as Appendix G).

51 JCAHO standards require cooperative planning among

healthcare organizations that together provide services to a

contiguous geographic area (for example, among hospitals

serving a town or borough). Such planning is intended to facilitate the timely sharing of information about: (1) essential elements of their command structures and control centers for

emergency response; (2) names, roles, and telephone numbers

of individuals in their commands structures; (3) resources and

assets that could potentially be shared or pooled in an emergency response; and (4) names of patients and deceased individuals brought to their organizations to facilitate identification

and location of victims of the emergency.

52 HAZWOPER – 29 CFR 1910.120(q); Personal Protective

Equipment – 29 CFR 1910.132; Respiratory Protection – 29 CFR

1910.134; Hazard Communication – 29 CFR 1910.1200(h).

53 Employer obligations pursuant to the HAZWOPER and HAZCOM standards are determined by the hazards to which it is

reasonably possible for employees to be exposed, given the

nature and locations of the employees’ work.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 33
Maintaining Decontamination Teams

A challenge for any hospital is the need to maintain a

decontamination team, without compromising the

ability of hospital departments to provide medical

treatment for patients. 

Hospitals interviewed for this project use employees from a range of specialties to maintain minimal

staffing levels in patient care areas. In addition to

drawing limited staff from the ED, Hospital A suggests

including individuals from departments such as mental health, facilities and engineering, and security on

decontamination teams. 

The hospitals also indicate that it is often possible

to identify individuals in unrelated departments who

are uniquely qualified to serve on the team due to

previous military experience, work history, or volunteer service. Hospital A staffs a particularly large

decontamination team (over 100 members) by drawing from employees with relevant skills from past

experience in fire departments, emergency medical

services, rescue units, HAZMAT or hazardous waste

handling, National Guard, and military reserve units.

In these cases, the previous experience might be a

more important selection criterion than the individual’s day-to-day role in the hospital. Hospital A avoids

assigning unwilling staff to their team, citing the

advantages of volunteer team members’ enthusiasm

and willingness to participate in training and drills.

Decontamination teams might include individuals

who perform the following functions:

• *Decontamination team leader – responsible for

management of the decontamination operation.54

• *Decontamination safety officer – responsible for

monitoring the decontamination area for developing hazards and for ensuring team safety.

• *Pre-decontamination triage – responsible for

assessing medical status and prioritizing victims

for decontamination.

• Decontamination system set-up.

• Security.

• Decontamination hospital attendants.

• Post-decontamination inspection.

• Cleanup and decontamination crew (surfaces,

equipment, human and hazardous wastes).

• Other roles that might be performed in the

Hospital Decontamination Zone under some circumstances (e.g., patient tracking, assistants

helping team members with PPE).

The size of the decontamination team depends on

the minimum number of people required to operate

the decontamination system and implement the hospital’s decontamination procedures. Activities involving a few victims and small decontamination systems

usually require only a few staff members, each of

whom might fill several functional roles. Hick et al.

(2003b) suggest that a small hospital might have a 2-

person team available at all times, while a metropolitan hospital might need a 5-person team available to

work in the Hospital Decontamination Zone, with

additional personnel on-call to allow for staff rotation.

According to Hick, the 5-person team would include

one person handling triage and coordinating predecontamination treatment, two people working with

non-ambulatory victims, and two team members

working with ambulatory victims. During a major

emergency in a metropolitan area, hospitals might be

required to continue operations “at maximum capacity for at least 2 to 4 hours, with appropriate staff rotations” (Hick et al., 2003b).

Another hospital organization advocates a 12-

member (minimum) decontamination team, all wearing PPE. Although it is recognized that smaller hospitals would not be able to staff such a robust team, the

rationale may illustrate useful points. Under this

model, the Northern Virginia Hospital Alliance calls for

a single “team leader,” three team members responsible for conducting ambulatory decontamination (one

to assist in the undressing, one to supervise showering, and one to assist in the re-dressing), four team

members to participate in the care of non-ambulatory

patients, and four security personnel to preserve the

perimeter of the Hospital Decontamination Zone.

Orienting and Training Personnel

First receiver training that was discussed previously in

the Personal Protective Equipment section is summarized here:

First Responder Operations Level training is

required for employees (including security staff) who

have a role in the Hospital Decontamination Zone, as

well as the hospital’s contamination cleanup crew.55

54 Hick et al. (2003b) recommend job action sheets be developed for these positions and other decontamination team

members who serve key roles. Sample job action sheets are

available at www.hazmatforhealthcare.org.

55 First Responder Operations Level and Awareness Level

training requirements appear in OSHA’s HAZWOPER standard,

29 CFR 1910.120(q), (or parallel State Plan standards).

34

Occupational Safety and 

Health Administration
First Responder Awareness Level training is required for ED clerks and ED triage staff who might

identify unannounced contaminated victims (then

notify the proper authority) and security staff working

outside the Hospital Decontamination Zone.

A briefing at the time of the incident is required for

employees whose roles in the Hospital Decontamination Zone could not be anticipated before the incident

(“skilled support personnel” – e.g., a medical specialist or a trade person, such as an electrician).

Information similar to hazard communication training is recommended for ED staff and other employees

who work in the ED (Hospital Post-decontamination

Zone), provided contaminated victims would not have

access to them.

Competencies for First Responder Operations 

Level Training

The HAZWOPER standard, paragraph 1910.120(q)(6)(ii)

requires that employees trained at the First Responder

Operations Level shall have received at least eight

hours of training or have had sufficient experience to

objectively demonstrate competency (e.g., in exercises and drills) in the following areas:

• *An understanding of what hazardous substances are, and the risks associated with them

in an incident.56 

• *An understanding of the potential outcomes

associated with an emergency when hazardous

substances are present.

• *The ability to recognize the presence of hazardous substances in an emergency through

signs and symptoms of exposure.

• *The ability to identify the hazardous substances,

if possible.

• *An understanding of their role in the hospital’s

emergency response plan, including site security

and control, and decontamination procedures

(OSHA, 1992c).

• *The ability to realize the need for additional

resources and to make appropriate notifications

to the communication center.

• Knowledge of the basic hazard and risk assessment techniques.

• Know how to select and use proper PPE.

• An understanding of basic hazardous materials

terms.

• Know how to perform basic control, containment, and/or confinement operations within the

capabilities of the resources and PPE available.

• Know how to implement basic decontamination

procedures.

• An understanding of the relevant standard operating procedures and termination procedures.

Several examples of HAZWOPER First Responder

Operations Level training curricula are available for

hospitals preparing employees to conduct decontamination activities (HAZMAT for Healthcare, 2003; CA

EMSA, 2003a; VA, 2003; Sutter Health, 2002). However, these curricula are not necessarily designed as 8-

hour presentations (some are longer, others are shorter and intended for use when employees are able to

demonstrate specific areas of competency).

Hospital A and Hospital G opt to provide more

than 8 hours of training to decontamination team

employees. Hospital A requires staff who will have a

direct role in decontamination activities to undergo 24

hours of initial training and an additional 16 hours of

refresher training annually. Employees can satisfy

some of the training requirement by attending monthly educational team meetings. Other training is provided using a standard course curriculum developed

by the Department of Veterans Affairs.57

Hospital G is in the process of changing from a single yearly 8-hour course curriculum to a program that

provides twelve 1-hour sessions. The emergency

planner believes that an annual training day is not the

best condition for learning and skills retention. Under

the new system, Hospital G divides the required training topics into 12 modules, one for each month,

including several opportunities to don PPE over the

course of a year. The monthly module will be presented several times on each shift. Although the net hours

of training per student will be greater annually, the

departments might find it less burdensome to release

students for the shorter classes. Thus, instructors will

teach fewer classes, resulting in a net savings in manhours. 

56 * Indicates the item is also a competency for Awareness

Level training.

57 Hospital A feels this level of training is the minimum

required to maintain its world-class decontamination team,

which drills with out-of-state military units and, due to location, would be called upon to decontaminate victims from a

national chemical weapons arsenal, should an accident occur.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 35
As mentioned earlier, 8 hours of First Responder

Operations Level training might not be necessary for

employees who have sufficient experience. These

employees are allowed to demonstrate competency

as an alternative to 8 hours of training. In most hospital settings, however, it might be difficult to ensure

that employees have sufficient experience to waive

the training requirement. Most hospital employees do

not have extensive experience with hazardous materials and decontamination activities are performed

infrequently, thus more than 8 hours of training may

be helpful to ensure competence. Employees particularly benefit from the practical experience they gain

during training provided as part of exercises and

drills. These events also offer employees an opportunity to demonstrate competence in critical areas.

Competencies for First Responder Awareness 

Level Training

First responders at the awareness level shall have sufficient training or have had sufficient experience to

objectively demonstrate competency in the following

areas, as required by the HAZWOPER standard, paragraph 1910.120(q)(6)(i), (or the parallel State Plan standards):

• An understanding of what hazardous substances

are, and the risks associated with them in an incident.

• An understanding of the potential outcomes

associated with an emergency created when hazardous substances are present.

• The ability to recognize the presence of hazardous substances in an emergency.58 

• The ability to identify the hazardous substances,

if possible.

• An understanding of their role in the hospital’s

emergency response plan, including site security

and control, and decontamination procedures

(OSHA, 1992c).

• The ability to realize the need for additional

resources and to make appropriate notifications

to the communication center.

In addition to the HAZWOPER training topics, staff

who might identify contaminated victims that arrive

unannounced require specific instructions for handling the situation. Once ED clerks or staff suspect a

patient is contaminated, they should be well trained in

the following procedure: 

1) Avoid physical contact with the patient.

2) Immediately notify supervisor and safety officer

of possible hospital contamination.

3) Allow other properly trained and equipped staff

to isolate and decontaminate the victim according to

EMP.

All the hospitals interviewed for this project provide Awareness Level training for staff who have a

role during decontamination activities, but are not

directly involved in patient decontamination. As with

First Responder Operations Level training, there is

considerable variability in the extent of training provided at the Awareness Level. The hospitals use curricula that range from 2 to 4 hours and most require

an annual refresher course of 1 to 4 hours. 

Instruction for Employees Whose Participation 

in the Hospital Decontamination Zone Was Not

Previously Anticipated

These personnel shall be given an initial briefing at

the site prior to their participation in any emergency

response. As specified in the HAZWOPER standard,

paragraph 1910.120(q)(4), the initial briefing shall

include instruction in the wearing of appropriate PPE,

what chemical hazards are involved, and what duties

are to be performed. All other appropriate safety and

health precautions (e.g., PPE) provided to personnel in

the Hospital Decontamination Zone shall be used to

assure the safety and health of these personnel.

Training Similar to That Outlined in the Hazard

Communication Standard

OSHA recommends some form of basic training for

employees who work in the Hospital Post-decontamination Zone and who would not be expected to come

in contact with unannounced contaminated victims,

their belongings, equipment, or waste. This training

could take a format similar to hazard communication

which might include at least the following:

• Methods and observations that may be used to

detect the presence of a hazardous substance in

the work area (e.g., an odor or announcement by

staff trained to identify possible contamination).

• General information on victims as a possible

source of hazardous substances.

• The measures employees can take to protect

themselves during an incident, including specific

procedures the hospital has implemented to protect employees from exposure to hazardous sub58 For first receivers, recognition of signs and symptoms

would satisfy this training topic.

36

Occupational Safety and 

Health Administration
stances (e.g., emergency procedures for leaving

the area). In developing a training program of

this type, hospitals should consider which specific topics would best help this group of employees respond appropriately during an incident.

Monitoring Performance During Drills

All hospitals interviewed for this project conduct several types of drills. The hospitals note that the greatest value occurs when their EMPs are tested rigorously as part of the drill, when realistic scenarios are

involved (including interaction with outside organizations), and when the hospital follows the drill with a

detailed evaluation and post-drill action plan for

improvement.

It is essential to the success of the EMP that drills

are conducted and that they reflect the actual conditions, resources, and personnel that would be available during a real incident.

In addition to self-assessments, some hospitals

find it helpful to receive a performance evaluation

from an outside organization. Hospital C participated

in a community-wide drill that was observed by a contractor hired specifically for that purpose. The hospital

used the contractor’s observations and comments to

help prioritize the emergency management team’s

activities. Alternatively, organizations that share postdrill analysis can critique each other.59 Any of these

methods of assessment can lead to corrective actions

and improved response, particularly if the process is

formalized with hospital administrators. 

Managing Internal Communications

The hospitals interviewed for this project report that

they use a combination of methods for communicating with employees during an incident. As new information becomes available hospitals use any combination of the following methods to pass information to

those who need it:

• Overhead public broadcasting systems 60

• Telephones

• Cell phones

• Pagers

• Fax 

• Runners with verbal or written messages

• Two-way radios

• E-mail and Intranet services

Overhead broadcasting systems, Intranet, and twoway radios are independent of external systems (such

as telephone service) that might be impacted by a

widespread emergency. A good EMP should consider

the need for backup communications in the event of a

power failure.

Principles of Risk Communication

Special care might be required in training healthcare

workers regarding chemical, biological, or radiological

hazards, particularly when the threat could be related

to terrorism. Lundgren and McMakin (1998) recommend conducting an audience analysis to assess factors that will impact how information might best be

presented. Non-clinical workers want basic information on the hazards, presented by a credible source

with a clear message, and preferably in “detailed,

role-specific training sessions that are ultimately tested by drills” (Thorne et al., 2003). To demonstrate

training effectiveness, trainers should evaluate knowledge and skills by using objective measures such as

pre- and post-training evaluations, as well as by

observing performance. 61

Information Dissemination During an Incident

Hospitals need to work with local emergency service

organizations to provide clear, accurate information

during large-scale emergencies. To avoid disseminating conflicting information, hospitals that use a

National Incident Management System (NIMS)-compatible incident command system, such as HEICS,

provide for an individual who will coordinate with

other response groups and communicate with the

media and other outside organizations. 62 A representative of the public affairs department often assumes

this role.

59 Other sources of critical observers might include peers

from other hospitals, regulators, and members of fire department hazardous materials response teams.

60 Overhead public broadcasting systems are used to report

information directly or announce codes. One code indicates

that designated staff should report to a meeting point to obtain

information.

61 JCAHO standards require an orientation and education program for all personnel who participate in implementing the

EMP. This education addresses: (1) specific roles and responsibilities during emergencies, (2) methods used to recognize

specific types of emergencies, and (3) information and skills

required to perform assigned duties during emergencies.

62 The Hospital Emergency Incident Command.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 37
Monitoring Employee Health

Prior to an Incident

Hospitals A through G all indicate that they typically

conduct a thorough baseline evaluation of an employee’s health at the time the person is hired. Based on

hospital policy, the employee’s job category, or the

hazards associated with tasks the employee performs,

additional periodic health monitoring might also be

provided.63 Most of the hospitals interviewed for this

project indicate that they have no special additional

requirements for members of the decontamination

team, unless the individual might wear a respirator. In

that case, the employee receives a baseline evaluation

and any follow-up evaluations needed to obtain the

necessary medical clearance, as discussed below.

One of the hospitals interviewed follows a somewhat more rigorous medical monitoring program.

Under this program, each member assigned to the

decontamination team receives a periodic physical

exam (often every 1 or 2 years), which includes a

basic health screening. Evaluations for medical clearance to wear a respirator are incorporated into these

exams.

The HAZWOPER standard requires that employees

be provided periodic medical evaluations (annual or

bi-annual) if they exhibit signs or symptoms of exposure, or if it is anticipated that the employee would be

exposed to hazardous substances, in excess of the

established permissible exposure limit (PEL), for 30

days per year or more. 64 Drills and practice sessions

that do not involve hazardous substances would not

count toward the 30 days.

The hospitals interviewed for this project also

mentioned that prophylactic vaccinations and antidotes should be stockpiled for employees in case the

need arises.

Medical Clearance for Respirator Use

The OSHA Respiratory Protection standard, in 29 CFR

1910.134(e), or the parallel State Plan standards,

require employers to obtain, in writing, a medical

opinion regarding an employee’s ability to wear a respirator. The regulatory requirement applies regardless

of whether other medical evaluations are needed

under the HAZWOPER standard. It also applies to all

types of respirators (including hooded powered airpurifying respirators [PAPRs]), with the exception of

filtering facepiece respirators (“dust masks”) used

by employees on a voluntary basis (i.e., when the

employer has determined that a health risk does not

exist, but the employee nevertheless wishes to wear

a respirator). An additional medical evaluation is

required by paragraph 1910.134(e)(7) under certain

circumstances. For example, an employee’s ability to

safely wear a respirator must be reevaluated when an

increase in the employee’s physical activities or the

weight of the protective clothing would place an

added burden on the employee. 

During a Response

The combination of first receivers’ activities and PPE

often create a greater physical workload for employees than they experience during their normal daily

jobs. Thermal stress (heat and cold stress) also

impacts the period for which first receivers can perform their duties. Some hospitals monitor employee

vital signs as one method of tracking employee

response to these stressors. For example, Hospital A

evaluates each employee’s vital signs before that individual dons PPE. Prior to a team member donning a

protective suit and hooded PAPR respirator, a technician records the individual’s weight, vital signs, and

recent medical history. This information is obtained

as other team members assist the individual into the

protective gear. If vital signs exceed predetermined

limits set by the hospital organization, the individual is

prohibited from wearing PPE that day and the team

member’s activities are restricted accordingly.

Decontamination safety officers at Hospital A

report that during every drill conducted, they have

rejected at least one participant (out of a dozen or

more) due to elevated vital signs. When PPE is

removed, vital signs and weight are recorded again.

The employee’s time in PPE is also recorded and

tracked. Decontamination team members at Hospital

A are generally permitted to wear a protective suit

and hooded PAPR for 30 minutes at any one time,

although this period can be adjusted up or down

depending on workload, weather, and the condition of

the first receiver. Appendices H and I provide examples of medical monitoring procedures and a separate

vital signs checklist. 

63 All health monitoring results should be provided to the

employee in a timely manner and in accordance with 29 CFR

1910.1020 (OSHA’s standard on Access to Employee Exposure

and Medical Records).

64 Under most circumstances, first receivers would not be

expected to perform decontamination duties in the presence of

hazardous chemicals 30 days per year.

38

Occupational Safety and 

Health Administration
Hospital A uses two-way headset radios to communicate with and monitor the health status of individuals who are wearing hooded PAPRs and protective suits in hot weather. This hospital found that a

behind-the-head “temple transducer” style headset

is more practical under PAPR hoods than “over-thehead” models, which tend to dislodge and are difficult

to reposition without removing the hood.

Thermal Stress

Both heat and cold stress can decrease first responders’ ability to work safely for extended periods.

Hospital A believes that in its hot, humid southern climate, heat stress presents the greatest threat to

employee health. To combat this hazard, the hospital

uses a combination of administrative controls and

cooling devices. As noted above, team members

whose vital signs are outside prescribed starting

parameters are not allowed to don respiratory protection.65 To further reduce the risk of heat stress, the

team makes extensive use of icepack vests. 66 Freezers

for icepacks are located in the Safety Office, fire

department, and elsewhere for easy access. Although

Hospital A recognizes that use of icepacks to combat

heat stress is somewhat controversial, this hospital

reports no problems among the many team members

who have drilled over the years. Additionally, team

members report that they find the icepack vests to be

a comfortable asset in hot weather.

The American Conference of Governmental

Industrial Hygienists (ACGIH) offers guidance for managing heat stress in employees wearing heavy protective clothing (ACGIH, 2001). This conservative

approach uses a combination of common sense

administrative controls (e.g., good hydration) and

physiological measures of heat strain (remove worker

if body core temperature exceeds 100.4 degrees

Fahrenheit or heart rate exceeds 180 beats per minute

(bpm) minus the employee’s age, or is greater than

110 bpm one minute after peak exertion). Appendix I

provides examples of vital sign monitoring schemes

used by other groups.

Following an Incident 

Incidents involving hazardous substances are typically

one-time incidents and medical monitoring is not

required unless an employee develops signs or symptoms related to an exposure. Following such an occurrence, the hospital’s occupational health provider

should follow the hospital’s regular policy regarding a

chemically exposed worker. If an employee becomes

ill or develops signs or symptoms specifically suggesting exposure to a particular contaminant, Hospital

A would follow a policy designed for first responders

65 Vital signs may not exceed the following limits: diastolic

blood pressure greater than 90 millimeters of mercury

(mmHg), heart rate greater than 100 beats per minute, respiration greater than 24 breaths per minute, or oral temperature

higher than 99.5 degrees Fahrenheit.

66 Although some employees note that they feel cooler wearing icepack vests, there is some controversy regarding whether

this type of equipment offers much real benefit.

“Temple-transducer” style two-way

radio headset stays in place under

PAPR hoods.

Detail of “templetransducer” style

radio headset.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 39
that complies with the requirements outlined in

OSHA’s HAZWOPER standard 29 CFR 1910.120(f).

Hospital D has direct experience with employees

who developed symptoms while treating a contaminated patient. The victim drank a quantity of

organophosphate pesticide. During subsequent

episodes of vomiting, the victim contaminated clothing, an ambulance, and the ED. As a result, six symptomatic staff members required hospitalization after

exposure to the concentrated pesticide and vapor.

The hospital followed its usual procedures for managing an employee with an occupational injury, including entering the illnesses in the OSHA Log of WorkRelated Injuries and Illnesses (OSHA 300 Form, previously OSHA 200 Form) and ensuring workers’ compensation medical leave for one affected individual. 

Managing Employee Stress

Understandably, disasters can be a notable source of

stress for anyone involved (Young et al., 2002;

Hodgson et al., 2004). Hospital A points out that

employee stress is a concern for decontamination

teams and the hospital includes a mental health

provider on each team. While assisting with decontamination activities, this employee also observes

team members for symptoms of excessive stress.

Additionally, Hospital A ensures decontamination

team members have ready access to post-event counseling if they request such services.

RESPONSE

FACILITIES AND EQUIPMENT

Evaluating Existing Resources

Hospitals are challenged to identify spaces that will

support decontamination activities (including equipment storage) and ensure operations can continue in

the event one area of the hospital becomes contaminated. Hospitals planning additions or remodeling

projects have a unique opportunity to design spaces

appropriately. Other hospitals should use creative

planning to identify existing architectural features that

they can use to their advantage. Several examples follow:

• Hospital F has two existing physical characteristics that have proven advantageous: (1) in the

event that one side of the ED became contaminated by an unannounced victim, doors between

two sections of the ED can be closed and normal

ED activities can continue on the uncontaminated side; and (2) a pair of unused, canopy-covered

ramps leading to one entrance of the ER (left

from a period of construction when the ER was

used as the main entrance to the hospital) is

being converted into a permanent decontamination shower for ambulatory patients. When considering use of divided spaces, hospitals should

determine whether the ventilation systems are

also separate and whether they recirculate air. If

a space becomes contaminated, it might be necessary to shut down the area’s ventilation system

to prevent circulation of contaminated air to

other spaces.

• While looking for an appropriate location for its

large portable decontamination system, Hospital

A (in a hot, humid climate) considered the advantages of a particularly large shade tree for preventing heat stress. The tree shades the entire

shower system and all support features (extensive mechanical systems, triage and victim

inspection stations, and victim waiting areas).

Isolation and Lockdown

The hospitals interviewed use a variety of methods to

limit unauthorized access to the ED during emergencies until the victims have been decontaminated. The

methods range from a guard with a key at the door to

sophisticated keycard systems controlled at a central

command center. The more complex systems tend to

be associated with urban or recently modernized hospitals and are intended for use in any type of disturbance. Hospitals intend to use these methods if situations suggest that an unruly crowd will force its way

into the hospital. 

Visual aids help communicate to hospital managers

the advatages and possible location of proposed

permanent decontamination systems.

40

Occupational Safety and 

Health Administration
Decontamination

Equipment

Hospital A, which trains other hospitals to offer decontamination services, notes that it is critical to match

the decontamination equipment purchased to the

needs of the hospital and the community it serves.

Hospital advisors recommend that any hospital with

an emergency room should be prepared to decontaminate victims. However, facilities such as long-term

care facilities and specialty clinics do not necessarily

need decontamination capability. A hospital with a

minimal risk of receiving multiple contaminated victims should consider acquiring a small system that

can be handled by a few employees. 67 According to

Hospital A, “every hospital should have a well-coordinated plan for arranging [timely] decontamination of

any patients who may show up at the door, without

putting staff at undue risk.” The plan should include

medical triage and treatment capability with proper

precautions.

Hospitals may select from an array of decontamination shower options. Portability is an advantage if

the system might be required at different locations. A

wide variety of portable, temporary decontamination

systems are commercially available. Durable portable

systems are designed to be cleaned and reused (if the

type of contaminant is not highly toxic or persistent),

while other systems are intended to be disposable

and, thereby, simplify the post-incident recovery

phase. The systems need to be stored in an easily

accessible location. There is considerable variety in

the sizes of portable decontamination systems available and the number of people required to set up the

system. All require some set-up time.

Permanent decontamination facilities are generally

recommended over temporary equipment because

these facilities can be activated quickly (some permanent models may be activated by simply unlocking

the doors and turning on the water) and offer reliable

long-term service. They also function well in harsh climates. Although permanent facilities require a dedicated space and more maintenance than disposable

systems, Hospital A finds that permanent decontamination showers can generally be installed for the

same (or lower) cost than a portable system with

comparable features. 

Enclosed decontamination facilities should provide

for fresh air circulation. When constructing a fully

enclosed system, hospitals should consult a ventilation engineer or Certified Industrial Hygienist early in

the system design phase. 

Because of the time it takes first receivers to put

on PPE and to set up decontamination facilities, hospitals may want to consider arranging for alternate

rapid forms of decontamination until more sophisticated decontamination facilities are up and running.

For example, some hospitals use high capacity, lowpressure hoses or showerheads, connected to high

capacity, temperature-controlled water sources. These

hoses and showers allow rapid preliminary drenching

of multiple victims. Where multiple showerheads can

be activated, ensure that the available water flow into,

67 For example, a temporary shower facility with a wastewater

collection device.

Although permanent decontamination systems

have many advantages, portable facilities can be

transported to other locations, if necessary.

A blower can increase fresh air circulation through 

the decontamination system. In cold weather, the unit

shown also heats air to a comfortable temperature.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 41
and through, the system is adequate to provide rapid

decontamination at each showerhead. 68

Hospitals A through G report that they considered

the following factors when evaluating their decontamination system options:

• Previous experience with a particular system during drills or demonstration events. Characteristics that first receivers prefer include systems

that are easily and rapidly set up by a minimal

number of personnel and require little storage

space. 

• Compatibility with other equipment in the community (e.g., already owned by the fire department or other local organization). This feature

allows systems to be joined to create a larger

shower area. Additionally, more individuals in

the community will be familiar with the system

setup.

• Cost.

• Requirements prescribed by funding sources.

• Availability of space for a permanent shower.

• Community needs (anticipated frequency of use

and required capacity).

• Need to operate the system in harsh weather.

Macintyre et al. (2000) suggest that the decontamination system should be operational within 2 to 3

minutes of notification of an incident. While this periHospitals can obtain military surplus equipment to supplement the

decontamination facility supplies.

(Shown here: a field stretcher for

tranferring non-ambulatory victims

from arriving vehicles to the decontamination facility.)

A roller system platform helps move

non-ambulatory victims on backboards through the decontamination facility.

68 To transfer water out of the shower area, hospitals use a

portable electric pump (approximately 2.5 gallons per minute,

or a rate similar to the standard combined water flow rate of

the most consistently used showerheads; approved for submersion and on a ground-fault interrupt circuit). The pump sits

in the shower base containment and pumps the accumulating

wastewater into a portable rubber bladder or barrel. Wastewater storage barrels and bladders used by these hospitals

range in size from 50 to 2,500 gallons capacity, and are selected based on the size of the decontamination system, anticipated average total water flow rate, and the number of victims the

hospital is prepared to treat. While larger portable decontamination systems with multiple showerheads can generate

wastewater more quickly than smaller systems, the large systems also tend to have larger floor-level water-containment

enclosures.

42

Occupational Safety and 

Health Administration
od can be reasonable for some permanent decontamination facilities, realistically few temporary/portable

systems can be activated that quickly. According to

Hospital A, activation periods of 10 to 15 minutes are

more typical for temporary decontamination facilities,

even with highly trained and experienced staff. The

hospitals interviewed for this site visit indicated that

an inexperienced staff might require two to four times

longer for set-up activities. Regular practice sessions

and drills improve set-up teams’ efficiency.

Regardless of the type of decontamination system

selected, hospitals should avoid locating the decontamination facility inside the ED.

Additional information on evaluating and

selecting decontamination equipment may be

found at the Department of Veterans Affairs website http://www1.va.gov/vasafety/page.cfm?pg=291

and the National Institute of Justice website

http://www.ojp.usdoj.gov/nij/pubs-sum/189724.htm.

Procedures

Decontamination procedures can have a large impact

on first receiver exposure to hazardous substances.

All the hospitals interviewed agree that the basic

steps include:

1) Activate the EMP.

2) Learn as much as possible (as soon as possible)

about the number of victims, the contaminant,

and associated symptoms. Previous arrangements with first responder organizations can

improve the timeliness and quantity of information received.

3) Activate the decontamination system and

assemble the decontamination team and site

security staff.

4) Perform any medical monitoring (e.g., vital

signs), if specified by the EMP.

5) Put on PPE.

6) Triage victims to determine which individuals

require decontamination and provide critical

medical treatment to stabilize them before

decontamination (e.g., atropine). 

7) Assist victims (ambulatory and non-ambulatory)

in removing contaminated clothing and securing

personal property as soon as possible (within

minutes of arrival).

8) Place clothing and other contaminated items in

an approved hazardous waste container that is

isolated outdoors so the items are not a continuing source of exposure.

9) Wash victims using soap, with good surfactant

properties, and water (preferably tepid water to

improve victim compliance). This step should

include copious rinsing. [See discussion below.]

10) Inspect victims to evaluate the effectiveness of

decontamination and guide decontaminated victims to the medical treatment area (Hospital

Post-decontamination Zone). Return inadequately decontaminated victims to the shower area

and repeat cleansing.

11) Decontaminate equipment and the decontamination system (if not disposable). 

12) Staff remove PPE and decontaminate themselves.

See Appendix J for an additional example of victim

decontamination procedures.

All of the steps above can influence the extent of

healthcare workers’ exposure to the contaminant.

However, certain steps should be highlighted for their

direct impact on the concentrations of contaminant

first receivers will encounter. For example, disrobing

might remove as much as 75 to 90 percent of the contaminant arriving on a victim (Macintyre et al., 2000;

Vogt, 2002; USACHPPM, 2003a). 69 By isolating (in an

approved hazardous waste container) the contaminated clothing, staff prevent these materials from offgassing into the work area. To minimize first receiver

exposure levels, these steps should be implemented

immediately as victims arrive.

Non-ambulatory victims can require a substantial

proportion of first receivers time and efforts. First

receivers are likely to experience the greatest exposures while assisting these victims. Staff should take

steps to identify possible sources of contamination

and limit their exposure to those sources. For example, Hospital A uses specific procedures for removing

victims clothing to minimize first receiver and victim

exposures. Assistants use blunt-nose scissors to cut

away clothing, rather than pulling it off. Tugging on

clothing can produce a wringing action that might distribute contaminant on the victim, healthcare workers,

69 The percentage of contaminant reduction depends on the

type of clothing the victim was wearing when exposed. The

estimates may be somewhat lower (down to 50 percent) for

victims wearing short pants or skirts and higher (up to 94 percent) for victims exposed to biological warfare agents while

wearing protective military uniforms (USACHPPM, 2003a).

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 43
and the surrounding area. Once removed, the clothing

is immediately placed into a sealed container.

Unless a hospital uses detection equipment with

demonstrated accuracy and reliability, victim washing

procedures and visual inspection offer the only practical way healthcare workers can conclude that victims

are definitively decontaminated. Staff in the ED might

become exposed if contaminated victims are permitted to enter the Hospital Post-decontamination Zone.

All the hospitals interviewed for this project indicated

that they currently require victims to soap and shampoo completely and spend 5 to 6 minutes under a

flow of running water. Some hospitals time the individual victims’ total wash periods, while others

observe the victims to ensure that they wash thoroughly. It may be advantageous to start the victim

cleansing process with a full minute under a drenching shower to rinse away as much contaminant as

possible, followed by subsequent soaping and rinsing

steps, repeated as necessary (USACHPPM, 2003a).

Hospital G has a progressive shower, in which each

victim spends one minute at each of several wash stations. 

Most of the hospitals interviewed also provide victims with written or pictorial instructions. In addition,

tepid water, security of personal effects, single-gender

facilities, shelter, and replacement clothing influence

how quickly and completely victims comply with

requirements to undress, shower appropriately, and

wait for medical treatment until they are completely

decontaminated. In cold climates, heated spaces and

blankets might be necessary. Victim inspection provides a final check to ensure contaminant is not carried into the ED. 

Victims from some incidents may arrive at the hospital after having been decontaminated at the incident

site (Release Zone) or elsewhere. Before admitting a

victim to the ED, first receivers should evaluate each

individual to ensure the patient was adequately

cleansed.

The methods staff use to decontaminate themselves and doff PPE also impact their own exposure.

ATSDR, 2000 and Appendices K and L offer examples

of procedures used by some hospitals. While there is

little definitive published information available regarding optimal shower procedures (for victims or staff),

the following sections summarize information provided by organizations with some expertise in this area.

These procedures apply to a wide variety of contaminants and are appropriate for unknown contaminants

that could arise from a release of toxic chemicals, biological agents, or radiological particulates. Decontamination procedures, like PPE use, can be modified once

the contaminant is identified; hospitals that are

cleansing victims to remove known contaminants can

tailor procedures as appropriate. For example, a

longer rinse might be beneficial for corrosive substances or contamination in the eyes. Organizations

such as the Center for Disease Control and Prevention

(CDC) and the Department of Homeland Security offer

specific recommendations for decontaminating victims exposed to individual hazards, such as ionizing

radiation (CDC, 2003; Department of Homeland

Put victim’s personal items in a labeled plastic zip bag.

Use blunt scissors to cut away clothing. Avoid stretching or wringing cloth.

44

Occupational Safety and 

Health Administration
Security, 2003). 70 After cleansing with soap and water,

certain residual chemical warfare agents (sarin, mustard gas, and others) can be neutralized on the skin

using a substance such as the reactive skin decontamination lotion (RSDL), used by the U.S. Army and

other military organizations. 71

Shower Flush Time and Practices

Numerous agencies and organizations recommend a

shower time of approximately five minutes for contaminated victims brought to a hospital. Despite the

fact that there is no empirical data, operational procedures deem this time as adequate. 

• The U.S. Army Center for Health Promotion and

Preventive Medicine (USACHPPM) recommends

one-minute rinsing from head to toe with tepid

water (slightly warm, not hot) after removal of

contaminated clothing, followed by a more thorough decontamination of washing with a soap

with good surfactant properties (e.g., hand dishwashing detergent), tepid water, and soft sponges.

Avoid stiff brushes and vigorous scrubbing,

which can damage the skin and increase the

chance the contaminant would be absorbed by

the victim. USACHPPM recommends these procedures for most classes of contaminants, except

certain reactive metal dusts (USACHPPM, 2003a).

• The U.S. Army Soldier and Biological Chemical

Command’s (SBCCOM) Mass Casualty Decontamination Research Team (MCDRT) states that

actual showering time will be an incident-specific

decision but might be as long as 2 to 3 minutes

per individual under ideal circumstances (SBCCOM, 2000b).

• The Agency for Toxic Substances and Disease

Registry (ATSDR) recommends that patients contaminated with an unidentified chemical should

flush exposed or irritated skin and hair with plain

water for 3 to 5 minutes. For oily or otherwise

adherent chemicals, mild soap on the skin and

hair followed by a thorough rinse with water is

also recommended (ATSDR, 2003).

• A technical expert for Hospital A’s Emergency

Mass-Casualty Decontamination Program stated

that research regarding how long it takes to

decontaminate an individual is scarce. This

organization recommends a 5-minute shower

time, based on operational experience. However,

in some cases the total decontamination period

could last longer than five minutes, depending

on the agent, its viscosity, the quantity on the

victim, and the amount of clothing removed.

Soap

Numerous agencies and programs recommend the

use of water and a liquid soap with good surfactant

properties (such as hand dishwashing detergent) to

decontaminate victims during emergencies and mass

casualties involving hazardous substances. Their recommendations are summarized here.

• SBCCOM’s MCDRT recommends the rapid use of

water, with or without soap, for decontamination.

Using soap can marginally improve the results

by ionic degradation of the chemical agent. Soap

helps dissolve oily substances like mustard or

blister agent. Liquid soaps are quicker to use

than solids. However, the decontamination

process should never be delayed to add soap

(SBCCOM, 2000b).

• A multi-service effort of the U.S. Army, U.S.

Marine Corps, U.S. Navy, and U.S. Air Force recommends that a contaminated individual use

generous amounts of soap and water and scrub

downward from head to toe. However, the

decontamination process should not be delayed

to due to a lack of soap (U.S. Army, 2001).

• A technical expert with Hospital A’s Emergency

Mass-Casualty Decontamination Program stated

that this organization uses mild liquid (hand)

dishwashing soap to avoid irritating the skin

while still allowing, with enough water and friction, removal of the contaminant. He stated that

the Department of Defense (DOD) has also suggested using mild soap for chemical warfare

agents. USACHPPM suggests using mild (hand)

dishwashing soap for removing a wide range of

possible contaminants, including industrial

chemicals, chemical warfare agents, biological

agents, and radiological particles (USACHPPM,

2003a).

70 The International Commission on Radiological Protection

(ICRP) and the National Council on Radiation Protection and

Measurement (NCRP) also offer guidance for radiological incidents.

71 Neutralizing agents reduce toxic effects of agent already

absorbed into the skin. RSDL won Food and Drug Administration (FDA) approval in 2003.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 45
Security

Site security helps maintain order and control traffic

around the decontamination facility and the hospital

entrances. Security officers might need to control a

contaminated individual to prevent other staff from

becoming exposed and to protect equipment. Security

officers also ensure contaminated victims do not

bypass the decontamination hospital or enter the ED

without passing inspection. In cases of civil disturbance, properly identified security officers protect the

decontamination facility and staff so normal operations can continue.

Personal Protective Equipment

Hospitals should select PPE (e.g., respirators, suits,

gloves, face and eye protection) based on a hazard

assessment that identifies the hazards to which

employees might be exposed. Under OSHA’s

Personal Protective Equipment standard (29 CFR

1910.132) or the parallel State Plan standards, all

employers, including hospitals, must certify in writing

that the hazard assessment has been performed. For

first receiver PPE, hospitals may base the hazard

assessment on the Personal Protective Equipment

section of this best practices document, then use the

PPE listed in Table 3. Hospitals likely to respond to

incidents involving a specific hazard should adjust the

PPE accordingly.

OSHA’s Personal Protective Equipment standard

also requires that employees be provided with equipment that fits appropriately. Some hospitals assign a

set of protective equipment (except the PAPR respirator) to a specific individual. The equipment is stored

in a container marked with the individual’s name.

Other hospitals maintain general supplies of PPE, storing sets of equipment by size (one set includes a large

suit, large gloves, and large boots). In this case, the

packages are clearly marked only with the size. Each

first receiver tries on equipment to determine what

size group fits best, then, during an emergency, the

employee can quickly locate an appropriate PPE set.

One hospital reported that boot size serves as the

basis for its PPE sets. It is sometimes necessary to

include two sizes of each type of glove in the set to

ensure proper fit for everyone who wears the PPE set.

Suits do not need to fit as closely and excess fabric

can be taped or rolled to fit. To prevent protective

suits from tearing at the crotch, hospitals should order

over-sized suits (larger than the individuals normal

size) (SBCCOM, 2003). Loose-fitting PAPR respirator

hoods offer a universal fit, thus are not included in

individual or size-based PPE sets; however, tight fitting facepieces do require fit testing.

Hospitals must include first receivers’ respirators

in a respiratory protection program, as specified by

OSHA’s Respiratory Protection standard (29 CFR

1910.134), or the parallel State Plan standards. These

respirators can be integrated into the hospitals existing respiratory protection program, which should

include the following elements (listed in

1910.134(c)(1)):

• Procedures for selecting respirators for use in the

workplace.

• Medical evaluations of employees required to

use respirators.

• Fit testing procedures for tight-fitting respirators.

• Procedures for proper use of respirators in routine and reasonably foreseeable emergency situations.

• Procedures and schedules for cleaning, disinfecting, storing, inspecting, repairing, discarding,

and otherwise maintaining respirators.

• Procedures to ensure adequate air quality, quantity, and flow of breathing air for atmospheresupplying respirators.

• Training of employees in the respiratory hazards

to which they are potentially exposed during routine and emergency situations.

• Training of employees in the proper use of respirators, including putting on and removing them,

any limitations on their use, and their maintenance.

• Establishing and implementing respirator chemical cartridge change schedules.

• Procedures for regularly evaluating the effectiveness of the program.

Most of the hospitals interviewed for this project

had previously developed respiratory protection programs covering the use of respirators by other

employees. The hospitals were able to expand the

program to include the use, cleaning, storage, and

maintenance of the PAPRs worn by first receivers.

Certain materials absorb or are damaged by

some chemical agents. As they become available,

hospitals should select respirators that have been

specifically tested for performance in the presence of

chemical, biological, radiological, and nuclear hazards (CBRN). The National Institute for Occupational

Safety and Health (NIOSH) is responsible for devel46

Occupational Safety and 

Health Administration
oping certification standards for approving various

styles of CBRN respirators. When the HVA reveals a

potential WMD threat and until NIOSH completes its

CBRN certification process for PAPRs, use PAPRs that

have been tested by the manufacturer for a CBRN

environment.

NIOSH maintains a list of respirator makes 

and models certified for use against specific 

hazards or types of environments. Hospitals can

search the list by contaminant type (e.g., organic

vapors), facepiece style (e.g., hood) and other 

criteria. CBRN-approved respirators will appear 

on this list as they are certified. To access the list,

see www.cdc.gov/niosh/nppt/topics/respirators/cel.

Protective equipment deteriorates with use and

time. To minimize the amount of costly equipment

expended during frequent drills, the interviewed hospitals typically maintain sets of PPE that are designated for drills. These “reusable” items are marked

accordingly and repackaged after each training session. In differently marked containers, the hospitals

store identical PPE (still in the original or comparable

packaging) that would be used during a real incident.

Protective equipment storage can present challenges. The hospitals that were interviewed typically

use one of two methods: cabinets or plastic storage

boxes on shelves. Hospital A uses large stainless steel

rolling cabinets that can be pushed to the ED entrance

for easy equipment access when the decontamination

facility is activated. Other hospitals use clear (easy to

see contents) or colored (for coding) plastic storage containers to hold PPE sets and other supplies. To ensure

that equipment is convenient during an emergency, the

hospitals store equipment on shelves or cabinets near

the ED door or in an adjacent room. One small hospital

keeps equipment in locking cabinets along one wall of

the small ED entry vestibule.

Long-term maintenance of battery-powered respirators, such as PAPRs, creates a special challenge. The

batteries should be kept fully charged and should be

maintained according to the manufacturer’s directions. The respirator manufacturer’s specific recommendations for charging, testing, and expected battery service life should be considered in any effort to

maintain future readiness. Lithium-based batteries

might offer more reliable long-term service. However,

hospitals should discuss the relative merits and maintenance of the available batteries with the respirator

manufacturer.

Detection Equipment

Hospitals face a significant challenge in identifying

contaminated individuals when they arrive unannounced as well as after decontamination procedures.

All the hospitals interviewed depend on triage personnel or clerical staff to identify self-referred patients

who have been in contact with hazardous substances.

The first indication of the need to activate the hospital’s EMP and decontamination team might come

from staff who identify these individuals through an

initial interview, by visual observation, by the presence of indicative odors, and through signs that a

substance appears to be affecting health. After a victim has been through the decontamination system,

hospitals rely on visual inspection and the extent to

which the victim followed prescribed showering proStaff can quickly move wheeled equipment

carts from storage to the staging area.

A storage room near the ED door offers convenient access for first receivers’ supplies.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 47
cedures. A few hospitals have access to commercially

available detection equipment that can help with the

identification. Although published selection criteria

are available (see NIJ, 2000), the interviewed hospitals

agree that the available practical detection equipment

only evaluates specific hazards (e.g., ionizing radiation

and traditional chemical weapon nerve and blister

agents). 72

Ionizing Radiation Meters

Experts suggest that alpha or beta emitting particles

may be the more likely contaminants in mass casualty

events involving the release of radiological particles

(CDC, 2003). Relatively reliable and easy to use

instruments are available for measuring ionizing radiation. Hospitals that offer patients nuclear medicine

services generally have access to specific types of

radiation meters used in that department. For example, the Radiation Safety Office for Hospital F indicated

that such meters would be available for post-decontamination evaluation of victims, staff, and hospitals, as

deemed appropriate. It is important that meters used

by first receivers be selected based on the types of

radiological particles with which victims could be contaminated. 73 To ensure more immediate access to

appropriate equipment, Hospital B has obtained

micro-roentgen per hour (μR/h) survey meters for the

dedicated use of the decontamination team. In the

event of a radiological emergency, the team will use

the meters as they evaluate the effectiveness of victim

decontamination. 

To evaluate the effectiveness of decontamination

procedures and also to help identify possible embedded fragments of radioactive materials, Hospital G

obtained a pair of radiological monitoring devices

(Ludlum Model 3 Survey Meters, with Model 44-7 End

Window G-M Detectors and headphones). This choice

was based on reports of good experiences with the

instrument, price, and versatility (the equipment can

be used for estimating exposure rate as well as

detecting contamination). The hospital also acquired

Radiagem-4 Personal Portable Radiometers, which are

small hand-held gamma source meters that will

potentially serve the dual purpose of screening victims for contamination and simultaneously recording

the accumulated exposure of the employee using the

equipment. These user-friendly detectors integrate the

reading and will alarm after reaching a preset threshold. 74

Ionizing radiation detection equipment could also

be useful for identifying contaminated individuals that

might enter the ED unannounced. Hospital G is in the

process of obtaining and testing radiation detection

meters (Syrena Gamma Source Finder) that will be

located at patient entrances to the hospital. These

portable devices—about the size of an attaché case—

will be tested at an entrance to determine whether

they are useful for detecting radioactivity. The hospital hopes to use this type of equipment to avoid the

spread of contamination by identifying contaminated

individuals as they enter the hospital. 75 The hospital

also plans to evaluate equipment that could be used

to screen victims by moving them past an instrument

(e.g., at the entrance and exit of a shower system)

eliminating the need for an employee in this position. 

Chemical and Biological Agent Detection Equipment

User-friendly equipment of adequate sensitivity is also

becoming available for specific agents typically used

as chemical weapons (Environmental Technologies,

undated). For example, two of the interviewed hospitals (Hospitals B and C) obtained the same make and

model (“APD 2000” from Environmental Technologies)

of hand-held detection meters designed to detect

parts per billion levels of specific chemical “nerve and

blister agents” used as chemical weapons (e.g.,

organophosphates, and mustard agent).76,77 However, a third hospital (Hospital A) felt that this type of

equipment might be more useful for evaluating an

incident site than for declaring victims to be thoroughly clean after decontamination efforts.

Equivalent equipment for detecting industrial

chemicals and biological agents remains problematic.

Although the interviewed hospitals indicated that they

are interested in obtaining comparable detection

72 Traditional chemical weapon nerve agents are commonly in

the organophosphate chemical class.

73 The U.S. Department of Homeland Security has adopted

several standards for the design and performance criteria of

radiation and nuclear detection equipment (see

http://www.dhs.gov/dhspublic/display?content=3307).

74 Hospital G also obtained a more costly portable spectrum

analyzer that can also be used to measure ionizing radiation

exposure rates. This instrument, which requires a skilled operator, might also be used to identify radioactive isotopes. 

75 In general, gamma source detectors are more useful for

detecting a source of radiation, rather than for detecting contamination on an individual.

76 The meter detects some agents at lower levels than others.

77 The U.S. Armed Forces have also developed colorimetric

contact paper to screen skin and equipment surfaces for these

agents. However, the papers do not indicate potential for airborne exposures.

48

Occupational Safety and 

Health Administration
equipment that would identify and measure low levels

of industrial chemicals or biological agents, none of

the hospitals feel that the instruments currently available are practical for this purpose. Experts do agree,

however, that some of the current broad-spectrum

detection devices are capable of detecting classes of

agents (although not the individual agent) with reasonable sensitivity and accuracy. Hospitals should

determine the availability and utility of these instruments for the specific categories of substances identified in the hospital’s HVA. 

Hospital A indicated that optimal detection instruments would be (1) sensitive at low concentrations to

a wide range of substances, (2) have a rapid response

time (preferably a few seconds), (3) be easy to operate, (4) be rugged and portable enough to function

outdoors under emergency conditions, (5) require

only occasional routine maintenance, and (6) be reasonably priced. Macintyre et al., 2000, point out that

the currently available detectors and monitors “would

only complicate and lengthen the decontamination

process,” without providing substantial value. 

TRIAGE CONSIDERATIONS

Hospital A notes that pre-decontamination triage

serves three purposes:

• Distinguish contaminated individuals from other

patients arriving at the hospital (e.g., by identifying symptoms and victim’s proximity to a known

chemical release).

• Identify victims who require immediate stabilization before they enter the decontamination system (e.g., shock and respiratory arrest).

• Identify injuries or critical pre-hospital treatment

materials that will require special handling inside

the decontamination system (e.g., a tourniquet

that must be replaced with an uncontaminated

compression device).

A plan for pre-decontamination triage should be

included in the EMP.

Post-decontamination triage for medical treatment

should occur in the Hospital Post-decontamination

Zone, after victims are inspected and found to be free

of contamination. Some hospitals combine decontamination and initial medical treatment (such as antidotes), which means either the healthcare worker

attempts medical triage while wearing PPE (preferred)

or the worker is at risk of exposure from victims that

have not been adequately decontaminated.

EXTERNAL COMMUNICATION

Obtaining Timely Information

Experience has shown that hospitals cannot count on

receiving immediate and complete information

regarding an incident. However, hospitals can take

steps to maximize their opportunities to receive useful

and timely information. Hospitals D and F have found

that the quality and timeliness of the received information improved as a result of strong working relationships with community organizations, coordinated

EMPs, and drills conducted with other groups that

respond to emergency situations.

Coordinating Activities

Coordinated response activities allow individual

organizations to respond appropriately, when needed.

Hospitals that work with the community to identify

their roles can encourage coordinated responses.

Hospital A (which maintains its own HAZMAT team in

addition to a decontamination team) is located in a

large urban area near other hospitals and fire departments, also with HAZMAT teams. As in many cities,

the community’s emergency management organization activates the appropriate HAZMAT team for 

each incident. This practice reduces the chance that

response will be duplicated needlessly, thus protecting community resources that might otherwise be

wasted. In the event that a large-scale emergency produced contaminated victims, Hospital A’s two facilities

(across a river from each other) would coordinate with

the community to determine which one of its two decontamination locations to activate (based on number

and location of victims)—or whether both systems

would be required. 

Hospitals should also activate two-way communication with the incident site. The more information a

hospital can obtain regarding the hazard, the better

first receivers will be able to protect themselves and

treat the victims. Additionally, while treating victims,

hospital staff might obtain valuable information regarding the nature of the contaminant, the route of

entry, and symptoms of exposure. By passing these

details back to the Release Zone, hospitals provide

first responders at the site with information that could

help those workers recognize possible signs of exposure, initiate life-stabilizing medical treatment, or

adjust their PPE to provide better protection. 

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 49
RECOVERY

HOSPITAL DECONTAMINATION

Solid Waste Management

All hospitals consulted indicate that solid waste generated during victim decontamination activities will be treated as hazardous waste following the hospitals’ existing

hazardous waste management procedures. These hospitals plan to work with contract hazardous waste management companies to test and dispose of waste that is

considered hazardous (except for any items required by

law enforcement as evidence). Anticipating that the

need might arise, several of the hospitals have made

advance arrangements with private companies that specialize in hazardous waste removal.

For emergencies involving only a few contaminated victims, hospitals typically plan to use plastic bags

to collect individual’s contaminated clothing for disposal. The bags will be sealed and double-bagged or

put in hazardous waste containers, then stored in

existing secure hazardous waste storage areas until

disposal. Hospitals that anticipate that they might

receive a large number of contaminated victims maintain a supply of hazardous waste barrels (with airtight

lids) into which decontamination team members will

place contaminated materials. Hospital representatives stress that sealing the bags or closing the containers is important to eliminate contaminated materials as possible continuing sources of victim or health

care worker exposure.

In response to some incidents, Federal authorities

might request that certain types of waste be retained

as evidence. In that case, the agency will provide instructions on handling the waste.

Wastewater Management

During an emergency, first receivers should take all

necessary steps to save lives, protect the public, and

protect themselves. 78 Once imminent threats to

human health and life are addressed, first receivers

should make all reasonable efforts to contain contamination and avoid or mitigate environmental consequences (U.S. EPA, 2000).

Wastewater from decontamination showers can

contain low-level concentrations of the substance(s)

with which victims are contaminated. Given the opportunity to plan for decontamination activities (by

designing and installing or purchasing decontamination facilities, developing procedures, and preparing

staff), hospitals should consider the management of

decontamination shower water as part of the plan. To

determine appropriate wastewater management practices, hospitals should consult with LEPCs, whose

members “can work together creatively using available resources to minimize the environmental impact

of [hazardous materials] incidents” (U.S. EPA, 2000).

The hospitals interviewed follow several strategies

for handling decontamination shower wastewater.

Management methods range from complete water

retention in a storage unit to uncontrolled release

(e.g., into a parking lot or storm drain). The choice is

usually based on the circumstances under which the

individual decontamination system will be used. For

example, these hospitals have generally arranged for

some level of treatment or containment of wastewater

generated by their primary decontamination systems

(i.e., the systems that would be used most frequently).

However, the same hospitals do not typically apply

specific controls to wastewater from additional, openair showerheads intended for use only as backup

shower capacity (in the event that an unexpectedly

large number of victims overwhelms the hospital’s

primary decontamination system). 

Hospital B has a memorandum of understanding

with the municipal wastewater treatment facility,

which allows the hospital to drain water from its large,

permanent, indoor decontamination system to the

sanitary sewer. The agreement specifies that the hospital notify the treatment facility immediately when

the shower is used to treat contaminated victims.

Hospital B includes this notification in the EMP protocol for activating the shower.

Hospital A and Hospital C incorporate large (1,000

or more gallons) underground storage tanks into the

design of their permanent, enclosed decontamination

systems. When necessary, the water can be held until

tested. After consultation with local environmental

authorities, the hospital can either treat the wastewater, pump it out, or drain the water to the sanitary

sewer or storm drain.

78 According to an EPA Alert (EPA, 2000), first responders’ liability under the Comprehensive Environmental Response,

Compensation, and Liability Act (CERCLA) for environmental

damages occurring during hazardous materials incidents is

limited (when public health or welfare are in danger) by the

“Good Samaritan” provision contained in Section 107(d)(1) of

CERCLA. This provision applies to emergencies involving hazardous materials release, including acts of terrorism.

However, first responders also may be subject to liability

based on applicable state statutes and regulations. Thus, first

responders may consider consulting with local legal counsel to

ascertain the scope of their potential liability. To access a copy

of the EPA alert, see http://yosemite.epa.gov/oswer/Ceppoweb.

nsf/vwResourcesByFilename/onepage.pdf/$File/onepage.pdf.

50

Occupational Safety and 

Health Administration
Among the hospitals interviewed, those that have

obtained portable decontamination systems typically

use a wastewater-containment device built into the

base of the system enclosure. These containment

devices usually include a low supportive wall (a few

inches high) around the perimeter of the shower and

a plastic lining to catch and hold wastewater. The hospitals often pump water from the shower base containment into a separate bladder to limit the volume

in the shower base and to increase water storage

capacity. 79 As with underground tanks, wastewater

stored in bladders is held for subsequent testing and

treatment or release, as deemed appropriate by

authorities based on sample results. 

An important consideration for positioning wastewater storage receptacles is the eventual need to

drain or transport them (once filled, these containers

are heavy and can only be shifted using special equipment). Hospital D noted that its hazardous waste

management contractor provided useful advice about

locating the wastewater receptacle where it could be

easily accessed by the contractor’s equipment, or

could be drained with little assistance if water treatment was not required. This advice influenced the

ultimate decontamination area design. 

Decontaminating Surfaces and Equipment

The hospital EMP should include procedures for

cleaning equipment and surfaces during and after an

incident. Cleaning should be performed by properly

protected and trained employees. Items that cannot

be decontaminated safely should be processed for

appropriate disposal. It is unlikely that portable gear

could be adequately decontaminated after an incident

involving a persistent or highly toxic agent.

The hospitals interviewed assign specifically

trained individuals to be responsible for decontaminating and cleaning surfaces and equipment. These

individuals are usually members of the decontamination team, but at least one of the hospitals uses specially trained housekeeping or facilities management

staff (hospital employees) to fill this role. It is important to note, however, that hospitals are increasingly

concerned about delegating this role to housekeeping

staff. According to the hospitals interviewed, the current industry trend is toward using contract services

rather than hospital employees for general housekeeping activities. Hospital E acknowledged that for

contracted employees, protection and liability issues

can be complicated when contractual arrangements

do not specifically address these matters. Additionally, rapid personnel turnover among contract housekeepers often hinders the hospital’s ability to ensure

workers receive specialized training. 

Hospital D is considering a different contractual

option. The hospital anticipates that large, time-consuming decontamination and associated recoveryphase cleaning tasks will be performed under contract

by the hospital’s hazardous waste service provider.

This arrangement will include cleaning and/or disposal of the portable decontamination facility and equipment, and any areas of the ED that might become

contaminated.

Employees of the contract hazardous waste service

provider should be trained as required under 29 CFR

1910.120(b) through (o). If hospital employees perform the cleaning, appropriate training would either

be that specified under 29 CFR 1910.120(q)(11), or 120

(b) through (o), depending on the situation (this matter is currently under consideration by OSHA).

MAINTAINING FUTURE READINESS

To sustain a functional level of emergency preparedness, hospitals need to maintain equipment, supplies,

and employee training. They should devote time and

attention to evaluating and updating the HVA and

EMP and coordinating these activities with the community. These efforts all require resources that will

not be available without support at all levels of management. Hospitals D and F note that emergency

planners can take active steps to help hospital management recognize the need for continuing effort.

These steps might include providing management

with after-action reports following drills and updated

information regarding the community’s expectations

of the hospital.

Administrators need to be aware that all aspects of

the EMP should be maintained equally. Continued

79 To transfer water, hospitals use a portable electric pump

(approximately 2.5 gallons per minute, or a rate similar to the

standard combined water flow rate of the most consistently

used showerheads; approved for submersion and on a

ground-fault interrupt circuit). The pump sits in the shower

base containment and pumps the accumulating wastewater

into a portable rubber bladder or barrel. Wastewater storage

barrels and bladders used by these hospitals range in size

from 50 to 2,500 gallons capacity, and are selected based on

the size of the decontamination system, anticipated average

total water flow rate, and the number of victims the hospital is

prepared to treat. While larger portable decontamination systems with multiple showerheads can generate wastewater

more quickly than smaller systems, the large systems also

tend to have larger floor-level water-containment enclosures.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 51
employee training alone will not provide adequate

protection if protective equipment (including respirator cartridges) is not replaced after use or when its

shelf life expires. Some equipment, such as PAPR batteries, requires routine maintenance (e.g., charging

and battery-life evaluation) for the life of the equipment. In addition, a well-maintained decontamination

facility will not function well if employees do not have

the experience of active, recent drills.

Hospitals in more mature stages of emergency

management planning might require less concentrated efforts than during start-up, but continue to dedicate full- or part-time staff to ensure the hospital

retains a full level of preparation. Emergency managers use creative methods to obtain additional help

when needed. Hospital D uses an energetic emergency manager to direct the activities of employees

from other departments who temporarily require

light-duty work due to medical restrictions (after an illness or injury). These individuals provide some of the

labor needed to update and improve the alreadymature HVA and EMP.

52

Occupational Safety and 

Health Administration
Atmosphere supplying respirator (ASR):

A respirator that provides clean air from an uncontaminated source to the facepiece. Examples include

supplied-air (airline) respirators, SCBA, and combination supplied-air/SCBA.

Assigned protection factor (APF):

A rating assigned to a respirator style by OSHA or

NIOSH. This rating indicates the level of protection

most workers can expect from the properly worn,

maintained, and fitted respirator used under actual

workplace conditions. An APF of 1,000 indicates that

the concentration of contaminant inside the facepiece

would be 1,000 times lower than the concentration in

the surrounding air. A respirator with an APF of 1,000

will provide greater protection than a respirator with

an APF of 100. (Note: The APF should not be confused

with a similar measure, the “fit factor,” obtained during quantitative fit testing. Fit factors, which tend to be

higher numbers, provide a relative indication of how

well a respirator fits an individual, but do not represent the level of protection the respirator would provide in the workplace.)

Awareness Level:

See First Responder Awareness Level.

CBRN:

Chemical, biological, radiological, or nuclear [agent or

substance].

Clinicians:

Physicians, nurses, nurse practitioners, physicians’

assistants, and others.

Doff:

To take off or remove (e.g., PPE).

Don:

To put on, in order to wear (e.g., PPE).

ED:

Emergency Department.

EMP:

Emergency Management Plan.

First Receiver:

Employees at a hospital engaged in decontamination

and treatment of victims who have been contaminated by a hazardous substance(s) during an emergency

incident. The incident occurs at a site other than the

hospital. These employees are a subset of first

responders .

First Responder:

Personnel who have responsibility to initially respond

to emergencies. Some examples are firefighters, HAZMAT team members, law enforcement officers, lifeguards, forestry personnel, ambulance attendants,

and other public service personnel. In the case of hazardous materials incidents, these personnel typically

respond at the site where the incident occurred.

First Responder Awareness Level:

Individuals who might reasonably be anticipated to

witness or discover a hazardous substance release

and who have been trained to initiate an emergency

response sequence by notifying the proper authorities

of the release. They would take no further action

beyond notifying the authorities. [OSHA HAZWOPER

standard 29 CFR 1910.120(q)(6)(i)].

First Responder Operations Level:

Individuals who respond to releases or potential

releases of hazardous substances as part of the initial

response to the site for the purpose of protecting

nearby persons, property, or the environment from

the effects of the release. These individuals shall have

received at least 8 hours of training or have sufficient

experience to objectively demonstrate competency in

specific critical areas. [OSHA HAZWOPER standard 29

CFR 1910.120(q)(6)(ii)].

HAZCOM:

OSHA’s Hazard Communication standard [29 CFR

1910.1200].

HAZMAT: 

Hazardous Material.

HAZWOPER:

OSHA’s standard on Hazardous Waste Operations and

Emergency Response, 29 CFR 1910.120. In particular,

paragraph (q) of this standard covers employers

whose employees are engaged in emergency response to hazardous substance releases.

Hazard Vulnerability Analysis (HVA):

The identification of potential emergencies and direct

and indirect effects these emergencies may have on

the healthcare organization’s operations and the

demand for its services.

Hazardous Substance:

Any substance to which exposure may result in adverse

effects on the health or safety of employees. This

includes substances defined under Section 101(14) of

CERCLA (Superfund); biological or disease-causing

agents that may reasonably be anticipated to cause

death, disease, or other health problems; any substance

listed by the U.S. Department of Transportation as hazardous material under 49 CFR 172.101 and appendices;

and substances classified as hazardous waste.

Appendix B: 

Acronyms and Definitions

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 53
Hospital Emergency Incident Command System

(HEICS):

An example of an optional NIMS-based ICS tailored

specifically for use by hospitals and designed to function in conjunction with other common ICSs used by

emergency response organizations (e.g., Fire Service

Incident Command System). 

Hospital Decontamination Zone:

This zone includes any areas where the type and

quantity of hazardous substance is unknown and

where contaminated victims, contaminated equipment, or contaminated waste may be present. It is

reasonably anticipated that employees in this zone

might have exposure to contaminated victims, their

belongings, equipment, or waste. This zone includes,

but is not limited to, places where initial triage and/or

medical stabilization of possibly contaminated victims

occur, pre-decontamination waiting (staging) areas for

victims, the actual decontamination area, and the

post-decontamination victim inspection area. This

area will typically end at the emergency department

door. In other documents, this zone is sometimes

called the “Warm Zone,” “contamination reduction

zone,” “yellow zone,” or “limited access zone.”

Hospital Post-decontamination Zone:

The Hospital Post-decontamination Zone is an area

considered uncontaminated. Equipment and personnel

are not expected to become contaminated in this area.

At a hospital receiving contaminated victims, the

Hospital Post-decontamination Zone includes the emergency department (unless contaminated). This zone is

sometimes called the “Cold Zone” or “Clean Area.”

IDLH:

Or Immediately dangerous to life or health, means an

atmospheric concentration of any toxic, corrosive or

asphyxiant substance that poses an immediate threat

to life or would interfere with an individual's ability to

escape from a dangerous atmosphere.

Incident Command System (ICS):

A flexible organizational structure which provides a

basic expandable system developed by Fire Services

to mitigate an emergency situation of any size. 

Incident Commander (IC):

The individual who holds overall responsibility for

incident response and management.

JCAHO:

Joint Commission on Accreditation of Healthcare

Organizations.

LEPC:

Local Emergency Planning Committee.

Mass Casualty:

“A combination of patient numbers and patient care

requirements that challenge or exceed a community’s

ability to provide adequate patient care using day-today operations.” (Barbera and MacIntyre, 2003).

NIMS:

The National Incident Management System, established by the U.S. Department of Homeland Security

as a standardized management approach to incident

response that all responders will use to coordinate

and conduct response actions. 

NFPA:

National Fire Protection Association.

Operations Level:

See First Responder Operations Level.

Personal Protective Equipment (PPE):

Examples include protective suits, gloves, foot covering, respiratory protection, hoods, safety glasses, goggles, and face shields.

Powered Air-Purifying Respirator (PAPR):

A respirator that uses a battery-powered blower to

force air through a filter or purifying cartridge before

blowing the cleaned air into the respirator facepiece.

Release Zone:

An area in and immediately surrounding a hazardous

substance release. It is assumed to pose an immediate health risk to all persons, including first responders. For the purposes of this document, the Release

Zone is always REMOTE from the hospital. This zone

is also referred to as the “exclusion zone,” the “red

zone,” and the “restricted zone” in other documents.

Self-contained Breathing Apparatus (SCBA):

A respirator that provides fresh air to the facepiece

from a compressed air tank (usually worn on the

worker’s back).

Supplied-air Respirator (SAR):

A respirator that provides breathing air through an

airline hose from an uncontaminated compressed air

source to the facepiece. The facepiece can be a hood,

helmet, or tight fitting facepiece.

Triage:

The process of screening and classifying sick, wounded, or injured persons to determine priority needs in

order to ensure the efficient use of medical personnel,

equipment, and hospitals.

WMD:

Weapon of Mass Destruction.

54

Occupational Safety and 

Health Administration
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of Threshold Limit Values and Biological Exposure

Indices. American Conference of Governmental

Industrial Hygienists (ACGIH), Cincinnati, OH.

ATSDR. 2000. Managing Hazardous Materials

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patients, Volume II (revised). Agency for Toxic

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Health and Human Services. Last accessed April 21,

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ATSDR. 2003. Managing Hazardous Materials

Incidents: Medical Management Guidelines (MMGs)

for Unidentified Chemical, Volume III. Agency for Toxic

Substances and Disease Registry, U.S. Department of

Health and Human Services. Last accessed April 21,

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Auf der Heide, E. 2002. Principles of hospital disaster

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Barbera, J.A., Anthony G. Macintyre. 2003. Mass

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Preparedness and Response, First ed. Jane's

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Beatty, J. 2003. Decontamination procedures (personal e-mail correspondence). Central Arkansas Veterans

Healthcare System, Little Rock, AR. October 23.

BNA. 2003. Hospitals low on protective suits in event

of bioterrorist attack, report says. Daily Labor Report

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Burgess, J.L. 1999. Hospital Evacuations Due to

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Cheryl Starling of the California Emergency Medical

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July 21.

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Chemical Decontamination, Staff Protection, Chemical

Decontamination Equipment and Medication List,

Evidence Collection. Hospital and Healthcare System

Disaster Interest Group (DIG). California Emergency

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Centers for Disease Control and Prevention (CDC),

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December.

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Georgopoulos, P.G., P. Fedele, P. Shade, P.J. Lioy, M.

Hodgson, A. Longmire, M. Sands, and M.A. Brown.

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Personnel Handling Casualties from Weapons of Mass

Destruction and Terrorism Events (Technical Guide

275). U.S. Army Center for Health Promotion and

Preventive Medicine. August. http://chppm-www.apgea.

army.mil/documents/TG/TECHGUID/TG275new.pdf

USACHPPM. 2003b. Chemical Risk Assessment and

Exposure Guidelines (and how AEGLs fit in). U.S.

Army Center for Health Promotion and Preventive

Medicine, Directorate of Health Risk Management.

March. http://www.osha.gov/SLTC/emergencypreparedness/chemical/ppt/csepp-aegl_march_2003.ppt.

U.S. Army, U.S. Marine Corps, U.S. Navy, and U.S. Air

Force. 2001. Multiservice Tactics, Techniques, and

Procedures for Nuclear, Biological, and Chemical

Aspects of Consequence Management. AFTTP (I) 3-

2.37. December.

VA. 2003. VHA Decontamination Training Program –

Train the Trainer Participant Manual. Little Rock

Employee Education Resource Center, Employee

Education System, Department of Veterans Affairs

(VA), Little Rock, AR. April.

Vogt, B.M. and J.H. Sorrensen. 2002. How clean is

safe? Improving the effectiveness of decontamination

of structures and people following chemical and biological incidents – Final Report (ORNL/TM-2002/178).

Prepared by Oakridge National Laboratory for the U.S.

Department of Energy. October. Accessed September

2004 at http://emc.ornl.gov/EMCWeb/EMC/PDF/

How_Clean_is_Safe.pdf

Walter, F. G., Bates, G., Criss, E. A. et al. 2003.

Hazardous materials responses in a mid-sized metropolitan area. Prehosp Emerg Care 7:214-218. Apr-Jun.

Young, Bruce H., Ford, Julian D., Rusek, Josef I. et al.

Disaster Mental Health Services: A Guidebook for

Clinicians and Administrators. National Center for

PTSD. Last Accessed: 2002. Available from:

http://www.ncptsd.org/treatment/disaster/index.html.

58

Occupational Safety and 

Health Administration
Agency for Toxic Substances and Disease Registry

www.atsdr.cdc.gov

Agency for Toxic Substances and Disease Registry,

Division of Regional Operations

http://www.atsdr.cdc.gov/DRO

California Emergency Medical Services Authority

www.emsa.ca.gov

Centers for Disease Control and Prevention (CDC)

http://www.cdc.gov/

Department of Veterans Affairs

http://www1.va.gov/vasafety/page.cfm?pg=528 

Healthcare Association of Hawaii

www.hah-emergency.net

Homeland Security

http://www.whitehouse.gov/homeland/

The InterAgency Board

http://www.iab.gov/

Joint Commission on Accreditation of Healthcare

Organizations

www.jcaho.org

Local Emergency Planning Committee (LEPC)

Locations

www.epa.gov/swercepp/lepclist.htm

DisasterHelp (U.S. Office of Management and Budget

– Disaster Management Initiative)

https://disasterhelp.gov/portal/jhtml/index.jhtml

National Institute of Justice

www.ojp.usdoj.gov/nij

National Institute for Occupational Safety and Health

(NIOSH) 

http://www.cdc.gov/niosh/homepage.html 

Occupational Safety and Health Administration

(OSHA) [includes contact information for OSHAapproved State Plans]

www.osha.gov

Office for Domestic Preparedness

http://www.ojp.usdoj.gov/odp/welcome.html 

U.S. Army Center for Health Promotion and Preventive

Medicine (USACHPPM) 

http://chppm-www.apgea.army.mil/ 

U.S. Army Medical Institute for Chemical Defense,

Chemical Casualty Care Division

https://ccc.apgea.army.mil/ 

U.S. Army Soldier and Biological Chemical Command

(Effective 9 October 2003, SBCCOM has been redesignated). See sites below:

Research, Development and Engineering

Command (RDECOM)

http://www.rdecom.army.mil/ 

Chemical Materials Agency (CMA)

http://www.cma.army.mil/ 

PM Nuclear, Biological and Chemical Defense 

(PM NBC)

http://www.pmnbc.army.mil/ 

Soldiers System Center (SSC)

http://www.natick.army.mil/ 

Appendix D: 

Additional Resources (Web Links)

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 59
FACEPIECE STYLE ADVANTAGES DISADVANTAGES

Half facepiece • Employee may wear any appropriate • If there is a break in the seal between 

eyewear that does not interfere with the mask and the face, contaminated 

the respirator seal. air can enter. Fit testing must be performed prior to use and user seal 

checks must be done by the user 

every time the respirator is used.

• Does not provide eye protection.

Full facepiece • When used with a powered air- • If there is a break in the seal between

purifying respirator (PAPR), a tight the mask and the face, contaminated

fitting facepiece might allow a worker air can enter. Fit testing must be perto pull filtered air into the facepiece formed prior to use and user seal

if the battery fails. checks must be done by the user

• Provides eye protection. every time the respirator is used.

• Workers who wear glasses may require 

spectacle kits to be used inside the 

facepiece.

Loose fitting • Provides eye protection. • When used with a PAPR, the hood will

helmet/hood • Provides skin protection for the head provide little or no protection if the

and (certain models) neck. battery fails.

• Fit testing is not required.

• Some workers find loose fitting 

respirators more comfortable than 

tight fitting models.

• Can be worn by employees with facial 

hair and facial scars/deformities.

• Employees may wear their own glasses 

under the helmet/hood.

Adapted from Personal Protective Equipment Guide for Military Medical Treatment Facility Personnel

Handling Casualties from Weapons of Mass Destruction and Terrorism Events (Technical Guide 275). 

U.S. Army Center for Health Promotion and Preventive Medicine (USACHPPM), August 2003.

Appendix E: 

Advantages and Disadvantages of 

Various Respirator Facepiece Styles

60

Occupational Safety and 

Health Administration
Example 1. 

Kaiser Permanente Hazard Vulnerability Analysis

This document is a sample Hazard Vulnerability

Analysis tool. It is not a substitute for a comprehensive emergency preparedness program. Individuals or

organizations using this tool are solely responsible for

any hazard assessment and compliance with applicable laws and regulations.

Instructions

Evaluate potential for event and response among the

following categories using the hazard specific scale.

Assume each event/incident occurs at the worst possible time (e.g., during peak patient loads). Please note

specific score criteria on each worksheet to ensure

accurate recording.

Issues to consider for probability include, but are not

limited to:

1. Known risk

2. Historical data

3. Manufacturer/vendor statistics

Issues to consider for response include, but are not

limited to:

1. Time to marshal an on-scene response

2. Scope of response capability

3. Historical evaluation of response success

Issues to consider for human impact include, but are

not limited to:

1. Potential for staff death or injury

2. Potential for patient death or injury

Issues to consider for property impact include, but are

not limited to:

1. Cost to replace

2. Cost to set up temporary replacement

3. Cost to repair

4. Time to recover

Issues to consider for business impact include, but are

not limited to:

1. Business interruption

2. Employees unable to report to work

3. Customers unable to reach facility

4. Company in violation of contractual agreements

5. Imposition of fines and penalties or legal costs

6. Interruption of critical supplies

7. Interruption of product distribution

8. Reputation and public image

9. Financial impact/burden

Issues to consider for preparedness include, but 

are not limited to:

1. Status of current plans

2. Frequency of drills

3. Training status

4. Insurance

5. Availability of alternate sources for critical 

supplies/services

Issues to consider for internal resources include, but

are not limited to:

1. Types of supplies on hand/will they meet need?

2. Volume of supplies on hand/will they meet need?

3. Staff availability

4. Coordination with any medical office buildings 

(e.g., doctors’ offices and clinics) included in the 

EMP

5. Availability of back-up systems

6. Internal resources ability to withstand 

disasters/survivability

Issues to consider for external resources include, but

are not limited to:

1. Types of agreements with community 

agencies/drills

2. Coordination with local and state agencies

3. Coordination with proximal (close by) healthcare 

facilities

4. Coordination with treatment-specific facilities

5. Community resources

Complete all worksheets including Natural,

Technological, Human and Hazmat. The summary section will automatically provide your specific and overall relative threat.

Appendix F: 

Hazard Vulnerability Analysis Examples

Sources:

Kaiser Permanente.

American Society for Healthcare Engineering (ASHE, 2000).

Note: This appendix provides a brief look at the general format two healthcare organizations use as the basis for

their HVAs. Contact the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for more information, including additional format examples, instructions for completing HVAs, and lists of the types of events

that might be included in an HVA.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 61
EXAMPLE 1. KAISER PERMANENTE HAZARD VUNUERABILITY ANALYSIS

HAZARD AND VULNERABILITY ASSESSMENT TOOL

(example of format used with a complete threat list)

TECHNOLOGIC EVENTS

SEVERITY = (MAGNITUDE - MITIGATION)

EVENT PROBABILITY HUMAN PROPERTY BUSINESS PREPARED- INTERNAL EXTERNAL RISK

IMPACT IMPACT IMPACT NESS RESPONSE RESPONSE

Likelihood this Possibility Physical Interruption Preplanning Time, Community/ Relative

will occur of death losses and of services effectivness, mutual aid threat§

or injury damages resources staff and

supplies

SCORE

Mass Casualty Incident 

(trauma)

Terrorism, Biological

Mass Casualty Incident 

(medical/infectious)

Fuel Shortage

Natural Gas Failure

Water Failure

Sewer Failure

Steam Failure

Fire Alarm Failure

Communications Failure

Medical Vacuum Failure

HVAC Failure

Information Systems 

Failure

Fire, Internal

Hazmat Exposure, 

Internal

AVERAGE SCORE

§Threat increases with percentage.

0 = N/A 

1 = Low 

2 = Moderate 

3 = High

0 = N/A 

1 = Low 

2 = Moderate 

3 = High

0 = N/A 

1 = Low 

2 = Moderate 

3 = High

0 = N/A 

1 = Low 

2 = Moderate 

3 = High

0 = N/A 

1 = High 

2 = Moderate 

3 = Low-none

0 = N/A 

1 = High 

2 = Moderate 

3 = Low-none

0 = N/A 

1 = High 

2 = Moderate 

3 = Low-none

0 - 100%

RISK = PROBABILITY * SEVERITY

62

Occupational Safety and 

Health Administration
Instructions

Evaluate each potential event with respect to the probability, risk, and the perceived level of preparedness.

Add additional events as needed.

Issues to consider for probability include, but are not

limited to:

1. Known Risk

2. Historical Data

3. Manufacturer/Vendor Statistics

4. Intelligence Information from Law Enforcement

Issues to consider for risk include, but are not limited

to:

1. Immediate Danger (Threat) to Life or Health (IDLH)

2. Disruption of Services

3. Damage/Failure Potential

4. Loss of Community Trust

5. Financial Impact

6. Legal Issues

Issues to consider for preparedness include, but are

not limited to:

1. Status of Current Plans

2. Training Status

3. Insurance

4. Availability of Back-up Systems

5. Community Resources

Computation

The event score is arrived at by multiplying each of

the ratings (Probability * Risk * Preparedness). The

total values in descending order represent the event

in need of organization focus and resources for emergency planning. The organization needs to determine

a value below which no action is required.

EXAMPLE 2. NEW YORK UNIVERSITY MEDICAL CENTER

HAZARD VUNERABILITY ANALYSIS

Version date: August 2003

(Example of format used with a threat list)

(Version date: August 2003)

PROBABILITY RISK PREPAREDNESS

EVENT TOTAL

Score 3 2 1 0 5 4 3 2 1 3 2 1

Mass Casualty 

Incident (MCI)

(Trauma)

MCI (Medical)

MCI (HazMat)

Small Scale HazMat

Terrorism Chemical

Terrorism Biological

Terrorism Nuclear

H

I

G

H

M

E

D

L

O

W

N

O

N

E

P

O

O

R

F

A

I

R

G

O

O

D

Life Health/ High Moderate Low

Threat Safety Disruption Disruption Disruption

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 63
ABOUT THE HEICS III PROJECT

In 1992, a generic disaster response plan was released

to hospitals based upon the Incident Command System.

The Hospital Emergency Incident Command System,

modeled after the FIRESCOPE management system,

was first tested by six hospitals in Orange County,

California. A second edition was developed by a statewide task force and tested again by Orange and Los

Angeles County hospitals. In May 1992, the Second

Edition of the Hospital Emergency Incident Command

System (HEICS) was made available with copies having

been sent throughout the United States, Canada, and

across the globe. 

HEICS features a flexible management which allows

for a customized hospital response to the crisis at hand.

There is an organizational chart with forty-nine positions

grouped into one of four sections. This all results in an

organized division of tasks and a realistic span of control for each manager. This organizational structure provides a platform for common terminology to enhance

communication and improve documentation. 

Following the 1993 Northridge Earthquake, HEICS

was used successfully by some hospitals damaged in

the quake. The plan has also been used in single hospital emergencies and in many disaster exercises. From

these repeated uses of the HEICS program, much

insight has been gained. It is the goal of San Mateo

County Emergency Medical Services that the Hospital

Emergency Incident Command System Update Project

recreate a HEICS plan which is more useful and relevant

to the medical community. And, a plan which is more

accessible, as is found in this website (www.emsa.ca.

gov). You are invited to access and download the

Second Edition of the HEICS plan. You are encouraged

to take a critical look at this document and return your

comments to the San Mateo County Emergency

Medical Services team who are working on this exciting

update.

For More Information...

about the Hospital Emergency Incident Command

System, contact the California Emergency Medical

Services Authority at (916) 322-4336; or visit the website

at www.emsa.ca.gov. Electronic copies of the materials

contained in this appendix are available from the EMSA

website.

Appendix G: 

Introduction to HEICS

64

Occupational Safety and 

Health Administration

Source:

California Emergency Medical Services Authority,

Sacramento.
HOSPITAL EMERGENCY INCIDENT 

COMMAND SYSTEM

Third Edition

EXECUTIVE SUMMARY

January 1998

Confusion and chaos are commonly experienced by the

hospital at the onset of a medical disaster. However,

these negative effects can be minimized if management

responds quickly with structure and a focused direction

of activities. The Hospital Emergency Incident

Command System (HEICS) is an emergency management system which employs a logical management

structure, defined responsibilities, clear reporting channels, and a common nomenclature to help unify hospitals with other emergency responders. There are clear

advantages to all hospitals using this particular emergency management system.

Based upon public safety’s Incident Command

System, HEICS has already proved valuable in helping

hospitals serve the community during a crisis and

resume normal operations as soon as possible. A

survey of California hospitals in the Spring of 1997,

revealed that a significant number of hospitals have, or

will be incorporating HEICS within their emergency

plans. HEICS is fast becoming the standard for health

care disaster response and offers the following features:

• predictable chain of management 

• flexible organizational chart allows flexible

response to specific emergencies 

• prioritized response checklists

• accountability of position function 

• improved documentation for improved accountability and cost recovery 

• common language to promote communication

and facilitate outside assistance 

• cost-effective emergency planning within health

care organizations 

The 1996 Edition of the National Fire Protection

Association, Health Care Facilities Handbook states in

chapter 11-4.3, “The disaster planning committee shall

model the disaster plan on the incident command system (ICS).” The American Society for Healthcare

Engineering of the American Hospital Association in an

August 1997 Healthcare Facilities Management Series

states “One of the best examples of emergency preparedness through checklists can be found in The

Hospital Emergency Incident Command System...” In

California, public hospitals seeking financial recovery

following a declared disaster are required to implement

the 1993 mandates of the Standardized Emergency

Management System. The utilization of the HEICS plan

is recognized as partial compliance with this state law.

HEICS and all of its support material is offered without charge. Implementation templates and instructional

materials are free and make the cost of converting to

the HEICS system minimal. HEICS is financially prudent

as it assists the medical facility in staying open following a disaster and promotes the restoration of day-today hospital functions. It is an efficient method for managing emergencies of disastrous proportions, as well as

those of a lesser degree.

ORGANIZATIONAL CHART

• Positions may or may not be activated.

Each emergency must be evaluated as to the specific positions which will need activation in order to

address challenges of the emergency. The disaster’s nature, proximity, and other factors may mandate all or very few of the positions to be staffed. 

• Positions may be filled immediately or later based

upon needs and staffing.

A particular disaster may require that a certain

number of positions need to be filled. However, if

there are only a few managers available for the

next 12 hours, then each manager must take more

than one position. If this is not acceptable, then the

top priority positions must be identified and carried out in the best manner possible. 

• More than one position may be assigned to an

individual.

Many managers are capable of carrying out more

than one function at a time. Situations of a critical

nature may require an individual to perform multiple tasks until additional support can be obtained.

The use of checklists should facilitate the task of

multiple position assignment. 

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 65

Note: HEICS does not formally incorporate a decontamination team; however, “decontamination team leader” might

be included under “treatment area supervisor” or other

operational subgroup. If the hospital actually has a HAZMAT release response team, this may be a separate operational subunit.
66

Occupational Safety and 

Health Administration

Hospital Emergency Incident Command System Organization Chart

Incident Commander

Public 

Information

Officer

Safety and

Security Officer

Medical

Officer

Liaison

Logistics Chief Planning Chief Finance Chief Operations Chief

Medical Care

Director

Human Services

Director

Ancillary 

Services

Director

Staff Support

Unit Leader

Dependent Care

Unit Leader

Psychological 

Support

Unit Leader

Laboratory

Unit Leader

Radiology

Unit Leader

Pharmacy

Unit Leader

Cardiopulmonary

Unit Leader

Treatment Areas

Supervisor

In-Patient Areas

Supervisor

Delayed Treatment

Immediate 

Treatment

Unit Leader

Unit Leader

Minor Treatment

Unit Leader

Discharge

Unit Leader

Morgue

Unit Leader

Triage Unit Leader Surgical Services Unit Leader

Maternal Child

Unit Leader

Critical Care

Unit Leader

General 

Nursing Care

Unit Leader

Out-Patient 

Services

Unit Leader

Communications

Unit Leader

Transportation

Unit Leader

Materials Supply

Unit Leader

Nutritional Supply

Unit Leader

Facility

Unit Leader

Damage

Assessment and

Control Officer

Sanitation

Systems Officer

Situation Status

Unit Leader

Labor Pool

Unit Leader

Medical Staff

Unit Leader

Nursing

Unit Leader

Patient Tracking

Officer

Patient

Information Officer

Time

Unit Leader

Procurement

Unit Leader

Claims 

Unit Leader

Cost Unit

Leader
Example 1. NVERC Medical Monitoring of

Response Staff

Northern Virginia Emergency Response Coalition

It is important to determine that personnel who are

being asked to wear personal protective equipment (PPE)

during a hazmat/weapon of mass destruction (WMD)

incident have no preexisting medical conditions that

might put them at increased risk for illness or injury. The

following medical monitoring procedure is to be used

from the outset of an incident to accomplish this objective.

At the Outset of the Incident

• The medical monitoring equipment (blood pressure [BP] cuffs, stethoscopes, scales, thermometers, medical monitoring sheets) should be

brought from the PPE storage area and placed in

the PPE dress out area.

• 1–2 staff persons should be assigned responsibility

to perform medical monitoring of all response personnel.

• Time permitting (ex. advance incident information

and arrival notice has been given by emergency

medical services [EMS]), each person intending to

dress in PPE is to have the following pre-entry

medical monitoring assessment completed and

recorded on their Medical Monitoring Incident

Response Record: 

- BP

- Pulse

- Respirations 

- Weight 

- Temperature

- Listing of current medications 

- Confirmation of no current, upper respiratory 

tract infection, chronic obstructive pulmonary 

disease, sinusitis, or gastrointestinal illness.

• If there is inadequate time to perform pre-entry

medical monitoring it will be important that each

staff member exercises good judgment and dress

out only if they know there is no preexisting condition that should preclude their use of PPE.

• The clinical data obtained from medical monitoring

done on each person must fall within the participation criteria listed. Persons whose vital signs

exceed the requirements should either be sent to

rest for 15–30 minutes and then re-examined or

given a responsibility not requiring the use of PPE.

Staff are NOT to dress out until they meet the prerequisite criteria.

During the Incident

• After the completion of each work rotation requiring PPE use, the staff member is to have post-entry

medical monitoring done. The elements of this

exam are the same as the pre-entry exam. They

are to be recorded on the staff member’s Medical

Monitoring Incident Response record. If significant

changes in the clinical data are found or subjectively offered information indicates the need 

for more comprehensive evaluation or medical

treatment, the staff member is to be sent to 

the Emergency Department. The Emergency

Department should be given a pre-alert ASAP

about the staff member’s pending arrival.

• Staff dressing out in PPE for a second work rotation are to have another pre-entry medical monitoring evaluation before donning PPE if the last

exam performed was: (a) abnormal or (b) greater

than 2 hours old.

After the Incident is Over

• Once the incident is declared over, the Medical

Monitoring Incident Response Records for all staff

are to be reviewed by the charge Emergency

Department MD or Occupational Health MD to

determine if any further short- or long-term clinical

evaluation is necessary. If the decision is made

that additional evaluation is needed, the staff

member involved is to be immediately notified by

the evaluating MD and arrangements made for the

exam ASAP.

• The costs associated with any follow-up evaluation

or treatment associated with the incident will be

the responsibility of the hospital.

• Each staff member’s Medical Monitoring Incident

Response record is to be put into their personnel

file and kept secure and retrievable for a period not

less than 30 years following their retirement or resignation.

Appendix H: 

Examples of Medical Monitoring for First Receivers, 

Including Information on Heat Stress

Sources:

Northern Virginia Emergency Response Coalition. Available at:

http://www.hazmatforhealthcare.org/download/doc/misc

Patient_Decontamination_Procedure-complete.doc (Accessed

September 2, 2003).

NIOSH Publication No. 86-112 “Working in Hot Environments.”

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 67
Example 2. U.S. Coast Guard National 

Strike Force

1. Medical Monitoring

• Medical monitoring shall be conducted on all

entry, backup, and decon personnel prior to

Exclusion Zone entries. Follow-up medical monitoring shall also be conducted on all entry, backup,

and decon personnel at the conclusion of each

work shift. For workers wearing impermeable

chemical protective clothing, workers shall also be

monitored when the temperature in the work area

exceeds 70oF (21o C). Medical monitoring shall be

conducted during the rest period following each

work cycle in accordance with chapter 8 of reference 1. If the work cycle specified in Table 8-10 of

Reference 1 is less than 30 minutes, the supervisor

may consult the Commanding Officer for authorization to extend the work cycle up to 30 minutes.

• Recommended values from the American Heart

Association are to be used as guidance for preentry medical monitoring:

Blood Pressure (Max): 140 bpm Systolic/100 

Diastolic* 

Pulse Rate (Max): 100 bpm

Temperature: 98.0o F (Min), 99.2o F (Max) 

(or +/- 0.6o F from normal)

• When a medical value is found to be outside the

accepted guidance, the supervisor should be

informed immediately. Anomalous readings

require medical advice prior to continued entries

by an individual.

• Use appropriate forms to record field medical

monitoring.

• When questions regarding medical monitoring

arise, the unit Safety and Occupational Health

Coordinator (SOHC) shall be contacted.

* Note: At the onset of an incident, fear and anxiety may

cause employees’ blood pressure to be elevated.

2. Heat Stress (adapted from NIOSH Publication No. 86-

112 “Working in Hot Environments”)

HEAT STROKE 

Heat stroke is the most serious of health problems associated with working in hot environments. It occurs when

the body’s temperature regulatory system fails and

sweating becomes inadequate. The body’s only effective means of removing excess heat is compromised

with little warning to the victim that a crisis stage has

been reached.

A heat stroke victim’s skin is hot, usually dry, red or

spotted. Body temperature is usually 105° F or higher,

and the victim is mentally confused, delirious, perhaps

in convulsions, or unconscious. Unless the victim

receives quick and appropriate treatment, death can

occur.

Any person with signs of symptoms of heat stroke

requires immediate hospitalization. However, first aid

should be immediately administered. This includes

removing the victim to a cool area, thoroughly soaking

the clothing with water, and vigorously fanning the

body to increase cooling. Further treatment, at a medical facility, should be directed to the continuation of the

cooling process and the monitoring of complications

which often accompany the heat stroke. Early recognition and treatment of heat stroke is the only means of

preventing permanent brain damage or death.

HEAT EXHAUSTION 

Heat exhaustion includes several clinical disorders having symptoms which may resemble the early symptoms

of heat stroke. Heat exhaustion is caused by the loss of

large amounts of fluid by sweating, sometimes with

excessive loss of salt. A worker suffering from heat

exhaustion still sweats but experiences extreme weakness or fatigue, giddiness, nausea, or headache. In more

serious cases, the victim may vomit or lose consciousness. The skin is clammy and moist, the complexion is

pale or flushed, and the body temperature is normal or

only slightly elevated. In most cases, treatment involves

having the victim rest in a cool place and drink plenty of

liquids. Victims with mild cases of heat exhaustion usually recover spontaneously with this treatment. Those

with severe cases may require extended care for several

days. There are no known permanent effects.

68

Occupational Safety and 

Health Administration
HEAT CRAMPS 

Heat cramps are painful spasms of the muscles that

occur among those who sweat profusely in heat, drink

large quantities of water, but do not adequately replace

the body’s salt loss. The drinking of large quantities of

water tends to dilute the body’s fluids, while the body

continues to lose salt. Shortly thereafter, the low salt

level in the muscles causes painful cramps. The affected

muscles may be part of the arms, legs, or abdomen; but

tired muscles (those used in performing the work) are

usually the ones most susceptible to cramps. Cramps

may occur during or after work hours and may be

relieved by taking salted liquids by mouth.

FAINTING

A worker who is not accustomed to hot environments

and who stands erect and immobile in the heat may

faint. With enlarged blood vessels in the skin and in the

lower part of the body due to the body’s attempts to

control internal temperature, blood may pool there

rather than return to the heart to be pumped to the

brain. Upon lying down, the worker should soon recover. By moving around, and thereby preventing blood

from pooling, the patient can prevent further fainting.

HEAT RASH 

Heat rash, also known as prickly heat, is likely to occur

in hot, humid environments where heat is not easily

removed from the surface of the skin by evaporation

and the skin remains wet most of the time. The sweat

ducts become plugged, and a skin rash soon appears.

When the rash is extensive or when it is complicated by

infection, prickly heat can be very uncomfortable and

may reduce a worker’s performance. The worker can

prevent this condition by resting in a cool place part of

each day and by regularly bathing and drying the skin.

TRANSIENT HEAT FATIGUE

Transient heat fatigue refers to the temporary state of

discomfort and mental or psychological strain arising

from prolonged heat exposure. Workers unaccustomed

to the heat are particularly susceptible and can suffer, to

varying degrees, a decline in task performance, coordination, alertness, and vigilance. The severity of transient

heat fatigue will be lessened by a period of gradual

adjustment to the hot environment (heat acclimatization).

PREPARING FOR WORK IN THE HEAT

Adjustment to heat, under normal circumstances, takes

about a week, during which time the body will undergo

a series of changes that will make continued exposure

to heat more endurable. With each succeeding daily

exposure, hazardous physiological responses will gradually decrease, while the sweat rate will increase. When

the body becomes acclimated to the heat, the worker

will find it possible to perform work with less strain and

distress.

Gradual exposure to heat gives the body time to

become accustomed to higher environmental temperatures. Heat disorders in general are more likely to occur

among workers who have not been given time to adjust

to working in the heat or among workers who have

been away from hot environments and who have gotten accustomed to lower temperatures. Hot weather

conditions of the summer are likely to affect the worker

who is not acclimatized to heat. Likewise, workers who

return to work after a leisurely vacation or extended illness may be affected by the heat in the work environment. Whenever such circumstances occur, the worker

should be gradually reacclimatized to the hot environment.

Heat stress depends, in part, on the amount of heat

the worker’s body produces while a job is being performed. The amount of heat produced during hard,

steady work is much higher than that produced during

intermittent or light work. Therefore, one way of reducing the potential for heat stress is to make the job easier

or lessen its duration by providing adequate rest. Rather

than be exposed to heat for extended periods of time

during the course of a job, workers should, wherever

possible, be permitted to distribute the workload evenly

over the day and incorporate work-rest cycles. Workrest cycles give the body an opportunity to get rid of

excess heat, slow down the production of internal body

heat, and provide greater blood flow to the skin.

REST AREAS

Providing cool rest areas in hot work environments considerably reduces the stress of working in those environments. There is no conclusive information available

on the ideal temperature for a rest area. Rest areas

should be as close to the work area as possible, and

provide shade. Individual work periods should not be

lengthened in favor of prolonged rest periods. Shorter

but frequent work-rest cycles are the greatest benefit to

the worker.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 69
DRINKING WATER

In the course of a day’s work in the heat, a worker may

produce as much as 2 to 3 gallons of sweat. Because so

many heat disorders involve excessive dehydration of

the body, it is essential that water intake during the

workday be about equal to the amount of sweat produced. Most workers exposed to hot conditions drink

less fluids than needed because of an insufficient thirst

drive. A worker, therefore, should not depend on thirst

to signal when and how much to drink. Instead, the

worker should drink 5 to 7 ounces of fluids every 15 to

20 minutes to replenish the necessary fluids in the body.

There is no optimum temperature of drinking water, but

most people tend not to drink warm or very cold fluids

as readily as they will cool ones. Whatever the temperature of the water, it must be palatable and readily available. Individual drinking cups should be provided—

never use a common drinking cup.

Heat acclimatized workers lose much less salt in

their sweat than do workers who are not adjusted to the

heat. The average American diet contains sufficient salt

for acclimatized workers even when sweat production is

high. If for some reason, salt replacement is required,

the best way to compensate for the loss is to add a little

extra salt to the food. Salt tablets SHOULD NOT be

used.

CAUTION—PERSONS WITH HEART PROBLEMS OR

THOSE ON A “LOW SODIUM” DIET WHO WORK IN HOT

ENVIRONMENTS SHOULD CONSULT A PHYSICIAN

ABOUT WHAT TO DO UNDER THESE CONDITIONS.

PROTECTIVE CLOTHING 

Clothing inhibits the transfer of heat between the body

and the surrounding environment. Therefore, in hot

jobs where the air temperature is lower than skin temperature, wearing clothing reduces the body’s ability to

lose heat into the air. When air temperature is higher

than skin temperature, clothing helps to prevent the

transfer of heat from the air to the body. The advantage

of wearing additional clothes, however, may be nullified

if the clothes interfere with the evaporation of sweat

(such as rain slickers or chemical protective clothing). 

70

Occupational Safety and 

Health Administration
Example 3. NIOSH Publication No. 86-112

Working in Hot Environments

HEAT STRESS CONSIDERATIONS

The Site Safety Officer or Site Safety Supervisor for the

entire response should make heat stress determinations

throughout the day. If it is determined that a heat stress

hazard exists, an alert should be passed to all teams to

implement mandatory rest periods. The Site Safety

Officer/Supervisor should generally be guided by the

American Conference of Governmental Industrial

Hygienists (ACGIH) guidelines in determining work/rest

periods. Fluids should be available at all times and

encouraged during mandatory rest periods.

SAFETY CONCERNS

Certain safety problems are common to hot environments. The frequency of accidents, in general, appears

to be higher in hot environments than in more moderate environmental conditions. One reason is that working in a hot environment lowers the mental alertness

and physical performance of an individual. Increased

body temperature and physical discomfort promote irritability, anger, and other emotional states which sometimes cause workers to overlook safety procedures or to

divert attention from hazardous tasks.

HEALTH CONCERNS

Excessive exposure to a hot work environment can

bring about a variety of heat-induced disorders. 

Heat Stroke

SIGNS AND SYMPTOMS. Heat stroke is the most serious of health problems associated with working in hot

environments. It occurs when the body’s temperature

regulatory system fails and sweating becomes inadequate. The body’s only effective means of removing

excess heat is compromised with little warning to the

victim that a crisis stage has been reached. 

• A heat stroke victim’s skin is hot, usually dry, red or

spotted.

• Body temperature is usually 105° F or higher. 

• The victim is mentally confused, delirious, perhaps

in convulsions, or unconscious. 

MEDICAL ATTENTION. Unless the heat stroke victim

receives quick and appropriate treatment, DEATH CAN

OCCUR. 

Any person with signs or symptoms of heat stroke

requires immediate hospitalization.

SEND SOMEONE TO GET MEDICAL ASSISTANCE/EMT

IMMEDIATELY!!!

While waiting for medical assistance, first aid should

be immediately administered. 

This includes:

• removing the victim to a cool area, 

• thoroughly soaking the clothing with water, and 

• vigorously fanning the body to increase cooling. 

Heat Exhaustion 

Heat exhaustion includes several clinical disorders having symptoms which may resemble the early symptoms

of heat stroke. Heat exhaustion is caused by the loss of

large amounts of fluid by sweating, sometimes with

excessive loss of salt. 

SIGNS AND SYMPTOMS. A worker suffering from heat

exhaustion: 

• still sweats, but 

• experiences extreme weakness or fatigue, giddiness, nausea, or headache. 

In more serious cases:

• the victim may vomit or lose consciousness, 

• the skin is clammy and moist, 

• the complexion is pale or flushed, and 

• the body temperature is normal or only slightly

elevated.

MEDICAL ATTENTION. General treatment:

• notify the site EMT, 

• have the victim rest in a cool place, and 

• have the victim drink plenty of liquids.

Victims with mild cases of heat exhaustion usually

recover spontaneously with this treatment. Those with

severe cases may require extended care for several

days. There are no known permanent effects.

Heat Cramps

SIGNS AND SYMPTOMS. Heat cramps are painful

spasms of the muscles that occur among those who

sweat profusely in heat, drink large quantities of water,

but do not adequately replace the body’s salt loss. 

MEDICAL ATTENTION. Cramps may occur during or

after work hours and may be relieved by taking salted

liquids by mouth. 

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 71
Fainting 

A worker who is not accustomed to hot environments

and who stands erect and immobile in the heat may

faint. 

SIGNS AND SYMPTOMS. With enlarged blood vessels

in the skin and in the lower part of the body due to the

body’s attempts to control internal temperature, blood

may pool there rather than return to the heart to be

pumped to the brain. 

MEDICAL ATTENTION. Upon lying down, the worker

should soon recover. By moving around, and thereby

preventing blood from pooling, the patient can prevent

further fainting. 

Heat Rash 

Heat rash, also known as prickly heat, is likely to occur

in hot, humid environments where heat is not easily

removed from the surface of the skin by evaporation

and the skin remains wet most of the time.

SIGNS AND SYMPTOMS. The sweat ducts become

plugged, and a skin rash soon appears. When the rash

is extensive or when it is complicated by infection, prickly heat can be very uncomfortable and may reduce a

worker’s performance.

MEDICAL ATTENTION. Workers can prevent this by

resting in a cool place part of each day and by regularly

bathing and drying the skin.

Transient Heat Fatigue

Transient heat fatigue refers to the temporary state of

discomfort and mental or psychological strain arising

from prolonged heat exposure. Workers unaccustomed

to the heat are particularly susceptible and can suffer, to

varying degrees, a decline in task performance, coordination, alertness, and vigilance. 

PREPARING FOR WORK IN THE HEAT

One of the best ways to reduce the heat stress of workers is to minimize heat in the workplace. However, heat

is difficult to control while working outdoors and exposed to various weather conditions. 

Humans are, to a large extent, capable of adjusting

to the heat. This adjustment to heat, under normal circumstances, usually takes about 5 to 7 days, during

which time the body will undergo a series of changes

that will make continued exposure to heat more endurable. 

Workers who return to work after vacation or extended illness may be affected by the heat in the work

environment. Whenever such circumstances occur, the

worker should be gradually reacclimatized to the hot

environment. 

MECHANIZATION

Heat stress depends, in part, on the amount of heat the

worker’s body produces while a job is being performed.

The amount of heat produced during hard, steady work

is much higher than that produced during intermittent

or light work. Therefore, one way of reducing the potential for heat stress is to make the job easier or lessen its

duration by providing adequate rest time. Mechanization of work procedures can often make it possible to

isolate workers from the heat source and increase overall productivity by decreasing the time needed for rest. 

WORK/REST PERIODS

Rather than be exposed to heat for extended periods of

time during the course of a job, workers should, wherever possible, be permitted to distribute the workload

evenly over the day and incorporate work-rest cycles or

regular (and enforced) breaks. Work-rest cycles give the

body an opportunity to get rid of excess heat, slow

down the production of internal body heat, and provide

greater blood flow to the skin. 

Providing cool rest areas in hot work environments

considerably reduces the stress of working in those

environments. Rest areas should be as close to the work

area as possible, and provide shade. Shorter but frequent work-rest cycles are the greatest benefit to the

worker. 

DRINKING FLUIDS 

In the course of a day’s work in the heat, a worker may

produce as much as 2 to 3 gallons of sweat. Because so

many heat disorders involve excessive dehydration of

the body, it is essential that water intake during the

workday be about equal to the amount of sweat produced. 

Most workers exposed to hot conditions drink less

fluids than needed because of an insufficient thirst

drive. A worker, therefore, should not depend on thirst

to signal when and how much to drink. 

Five to 7 ounces of fluids should be consumed every

15 to 20 minutes to replenish the necessary fluids in the

body. 

There is no optimum temperature of drinking water,

but most people tend not to drink warm or very cold fluids as readily as they will cool ones. 

72

Occupational Safety and 

Health Administration
Heat acclimatized workers lose much less salt in their

sweat than do workers who are not adjusted to the heat.

The average American diet contains sufficient salt for

acclimatized workers even when sweat production is

high. If for some reason, salt replacement is required,

the best way to compensate for the loss is to add a little

extra salt to the food. 

Salt tablets SHOULD NOT be used. 

CAUTION—PERSONS WITH HEART PROBLEMS OR

THOSE ON A “LOW SODIUM” DIET WHO WORK IN HOT

ENVIRONMENTS SHOULD CONSULT A PHYSICIAN

ABOUT WHAT TO DO UNDER THESE CONDITIONS. 

PROTECTIVE CLOTHING AND HEAT STRESS

Clothing inhibits the transfer of heat between the body

and the surrounding environment. Therefore, in hot

jobs where the air temperature is lower than skin temperature, wearing clothing reduces the body’s ability to

lose heat into the air. When air temperature is higher

than skin temperature, clothing helps to prevent the

transfer of heat from the air to the body. The advantage

of wearing additional clothes, however, may be nullified

if the chemical protective clothes interfere with the

evaporation of sweat.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 73
Example 1. Vital Signs and PPE Checklist

(Central Arkansas Veterans Healthcare System)

NAME

DATE

>> INSPECT condition of ALL PPE prior to use <<

*Medical Exclusion

Employee ID#:_______________________

PRE POST

BLOOD PRESSURE:

*Diastolic > 105 

HEART RATE:

* > [70% (220 – Age)]

*Any irregular rate or rhythm

RESPIRATION:

* > 24 / min

TEMPERATURE:

* > 99.5 deg F oral

WEIGHT:

SKIN:

*Open sore, large rash or 

sunburn

HYDRATION:

MENTAL STATUS:

Alert; oriented to time & place;

clear speech; normal gait

MEDICAL HISTORY:

*Any meds last 72 hours ___________________

*Alcohol past 24 hours_____________________

*New meds Rx / diagnosis last 2 weeks______

*Symptoms fever, NV, diarrhea, 

cough in past 72 hours__________________

*Pregnant _____________________________

*Prior heat stress or exhaustion_____________

NOTES:

CHECKED BY:_______________________

Appendix I: 

Vital Signs and PPE Donning Checklists

PAPR–COMBINATION CARTRIDGES..... 

PAPR FLOW CHECKED......................... 

REMOVED SHOES, JEWELRY, ETC....... 

INNER NITRILE GLOVES..................... 

INNER SUIT...................................... 

GLOVES & NECK TAPED.................... 

OUTER SUIT..................................... 

BUTYL HOOD................................... 

INNER SHROUD TUCKED INSIDE

GLOVES & NECK TAPED..................... 

OUTER GLOVES...................................... 

BOOTS............................................. 

SUIT TAPED OVER BOOTS ................. 

CHECKED BY:_________________________

TIME IN SUIT:_________________________

TIME OUT: ____________________________

74

Occupational Safety and 

Health Administration

Source:

Central Arkansas Veterans Healthcare System
Example 2. Vital Signs Monitoring Checklist

(U.S. Coast Guard National Strike Force)

ON-SITE MEDICAL MONITORING (ENTRY TEAM) 

NAME:______________________________________________________________________________

CASE:__________________________________ CASE NO.:___________________________________

DATE:__________________________________ EXPOSURE RISK: HIGH / MED / LOW

PROTECTIVE EQUIPMENT:____________________________________________________________

_____________________________________________________________________________________

SUBSTANCE(S) INVOLVED:___________________________________________________________

_____________________________________________________________________________________

CONCENTRATION/LENGTH OF EXPOSURE:_____________________________________________

_____________________________________________________________________________________

MEDICAL TESTING:__________________________________________________________________

COMMENTS:

*************************************************************************************

PRE-ENTRY MEDICAL MONITORING:

WEIGHT:______________TEMPERATURE:_______________ METHOD:______________________

PULSE:___________ BP: SYSTOLIC_________/DIASTOLIC_________ METHOD:_______________

MONITORING CONDUCTED BY:_______________________________________________________

*************************************************************************************

POST-ENTRY MEDICAL MONITORING:

WEIGHT:______________TEMPERATURE:_______________ METHOD:______________________

PULSE:___________ BP: SYSTOLIC_________/DIASTOLIC_________ METHOD:_______________

MONITORING CONDUCTED BY:_______________________________________________________

*************************************************************************************

SUPERVISOR (RO/RS) VERIFICATION:

NAME:______________________________________________________________________________

COMMENTS:

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 75

Source:

U.S. Coast Guard National Strike Force
Patient Decontamination Procedure

(Northern Virginia Emergency Response Coalition)

AMBULATORY PATIENTS 

1. Direct patient to Decon Sector.

2. Children should be kept with their parents if at all

possible; if no parent or older sibling is available

then a Decon Team member should provide needed

assistance to a child.

3. Patient should be given Personal Decon set as soon

as it is available and be given rapid instructions on

its use – PLAY THE TAPE recorded set of instructions, if available.

• The kit stays with you as you proceed through

the process.

• Open up the bag – it has three parts.

• Take out the plastic bags now.

4. Patient should quickly remove all clothing, putting

valuables into the clear plastic bag and clothing into

the large bag, then put both bags into the 3rd bag

and cinch tight w/ tag number in pack. Patient should

put numbered tag around their neck and wear it

through decon and treatment.

5. The clothing bag should be set aside in a secure

area.

6. If staff is available, patient’s name and number

should be recorded on the Patient Decon Record.

7. Patient should continue forward into the Decon

Sector with remaining part of Personal Decon Kit.

8. Patient should quickly rinse themselves from head to

toe with water using either the hand held sprayer,

garden hose, or showerhead.

9. Patient should next wash with soap and wash cloth

or brush from the kit in a systematic fashion, cleaning open wounds first and then in a head-to-toe

fashion for 5 minutes when the agent is non-persistent and 8 minutes when a persistent or unknown

agent is involved. Discourage the patient from rubbing too vigorously while washing. Eye irritation

may require the use of a topical anesthetic first

before irrigating.

10. The Decon Team should closely observe each victim

to ensure they are thorough in washing themselves.

Particular attention should be made to ensure they

wash the axilla, creases, folds, and hair. Help should

be offered as necessary.

11. Once the washing is completed, each patient should

thoroughly rinse themselves (this should require

about a minute to complete).

12. Decon soap, wash cloths, brushes, and sponges

should be put into a nearby trash can and NOT carried into the Cold Zone.

13. After the rinse/wash/rinse cycle is complete the

patient should next proceed to the towel off area

and complete drying off and leave the towel in the

trash can.

14. Following drying off, the patient should put on the

patient gown and proceed to the Triage Officer for

rapid assessment and assignment to a Treatment

Sector.

15. Additional treatment will be limited only to those

interventions deemed life saving by the Decon

Officer. Antidote administration should be done via

the intramuscular (IM) route after cleaning the affected area first.

16. Decon Team members should be alert to the possibility that an ambulatory patient may clinically deteriorate and require immediate removal to the NonAmbulatory Sector via backboard, stretcher, or

wheelchair.

NON-AMBULATORY PATIENTS

1. Patient should be brought to the Decon Sector and

tended to by a minimum of 4 decon personnel.

2. Each patient should be put onto a backboard or EMS

stretcher w/ the pad removed.

Appendix J: 

Example of Patient Decontamination Procedure

Source:

Northern Virginia Emergency Response Coalition. Available

at: http://www.hazmatforhealthcare.org/download/doc/misc/

Patient_Decontamination_Procedure-complete.doc

(Accessed September 2, 2003).

76

Occupational Safety and 

Health Administration
3. All patient clothing should be removed and valuables put into the clear plastic bag and clothing into

the large bag, then put both bags into the 3rd bag

and cinch tight w/ tag number in pack. Clothing

should be cut away where necessary.

4. Attention should be paid to minimizing the aerosolization spread of particulate matter by folding

clothing inside out as removal is being done and

dabbing the skin with sticky tape and/or vacuuming.

5. Patient should have their clothing bag tag around

their neck and wear it through decon and treatment.

6. The clothing bag should be set aside in a secure

area. If staff is available, the patient’s name and

number should be recorded on the Patient Decon

Record.

7. While resting the backboard on saw horses or other

device or with the patient on an EMS stretcher, the

patient should quickly be rinsed from head to toe

with water using either the hand held sprayer, garden hose, or showerhead; protection from aspiration

of the rinse water should be ensured.

8. Next the patient should be washed with soap and

either a brush or wash cloth in a systematic fashion,

cleaning airway first followed by open wounds then

in a head to toe fashion for 5 minutes when the

agent is non-persistent and 8 minutes when a persistent or unknown agent is involved. Avoid rubbing

too vigorously.

9. The patient should be rolled on their side for washing of the posterior head, neck, back, buttocks and

lower extremities by 2–4 personnel; attention to a

possible neck injury should be given.

10. Careful attention should be given to washing the

voids and creases such as the ears, eyes, axilla, and

groin.

11. Topical eye anesthetic may be required for effective

eye irrigation to be done.

12. The patient should then be rinsed in a head to toe

fashion that minimizes contamination spread for

about one minute. Overspray or holding the rinsing

device too close so as to irritate the skin should be

avoided.

13. Decon Team members should be alert to the probability that the non-ambulatory patient may require

ABC’s support (airway positioning, suctioning, O2

administration, spinal stabilization, etc.) and administration of life saving antidote administration by IM

injection. If IV therapy is needed the extremity site

for the IV should be deconned quickly before the IV

is started. If IV therapy is needed the patient should

be pulled out of line in the Decon Corridor but

remain in the Decon Sector. 

14. The patient should be dried off, put into a hospital

gown, and transferred to a clean backboard (or clean

off and dry the board they are on if additional

boards are not available). Patients on an EMS

stretcher should be transferred to a clean backboard.

15. Decon soap, brushes and sponges should be put

into a trash can and not carried into the Cold Zone.

O2 material should remain in the Decon Sector.

16. The patient should be taken to the Triage Officer for

rapid assessment and assignment to area in the

Treatment Sector. 

PATIENTS WITH SPECIAL NEEDS

Glasses/Contact Lenses 

1. Patients with glasses should keep them if they cannot see without them. They must be washed and

rinsed thoroughly during the decon process before

being worn. Otherwise, the glasses should be placed

in the valuables portion of the clothing bag.

2. Contact lenses should be removed and placed in the

valuables portion of the clothing bag.

Canes/Walkers

1. Patients who use walking assist devices may retain

them, but the device must be washed with soap and

water during the decon process before being allowed into the Treatment Sector.

2. Patients who are unsteady standing and/or walking

should be given a walker upon entry into the Decon

Corridor. The walker should be used to assist with

ambulation until they get to the end of the line when

it should be retrieved, deconned, and returned to the

front of the Decon Corridor for the next patient who

needs it. 

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 77
Percutaneous Lines/Saline Locks 

1. Unless contaminated, percutaneous lines and saline

locks should be covered with Tegoderm or Saran

wrap before the area is decontaminated. 

2. Contaminated percutaneous lines or saline locks

should be removed before being decontaminated.

After the area is cleaned, a dressing should be

applied until in the Treatment Sector where antibiotic

ointment and a new bandage should be applied.

Hearing Aids 

1. Hearing aids CANNOT be immersed or otherwise be

soaked with water. Thus, they should either be

removed and placed in the valuables portion of the

patient’s clothing bag or if they must be used by the

patient because there is no hearing without them,

they should be carefully wiped off with a slightly

saline moistened 4x4 gauze, dried off, put into a

clear plastic bag, and handed to the patient. The

cleaned hearing aid is NOT to be worn until the

patient has completed the decon process (including

washing the ears) and is in the Treatment Sector. 

Dentures

1. Unless the oral cavity is contaminated, dentures

should remain in place and no decontamination is

necessary. 

2. If the oral cavity is contaminated, then the dentures

should be removed, placed in a clear plastic bag

with the patient’s name or clothing identification

number placed on it. The dentures should later be

decontaminated in accordance with instructions

received from the Poison Center and/or a dentist.

The patient’s mouth should be decontaminated with

mouthwash or saline that is gargled and safely spit

out into a bio-hazard bag. Note that, depending on

the contaminant, it may not be possible to decontaminate plastic items, such as dentures.

Law Enforcement Officers with Weapons

1. In most cases, law enforcement personnel who have

been injured on the scene will have had their gun(s)

removed before arrival and given to a fellow officer.

However, if that is not the case, the weapon should

be left in the holster and the gun belt removed by a

Decon Team member and placed in a clear plastic

bag labeled with the patient’s name and/or clothing

number. The bag should then be passed to the

Treatment Sector where it should be given to a fellow officer or hospital Security Officer for safe keeping until it can be given to a representative of the

injured officers department. THE GUN SHOULD BE

LEFT IN THE HOLSTER IF AT ALL POSSIBLE. If the

gun must be removed, it should be handled by a

Decon Team member familiar with firearms, rendered safe, placed in a clear plastic bag marked with

the patient’s name and/or clothing identification

number, and given to a fellow officer or hospital

Security Officer in the Treatment Sector. 

2. Decon Team personnel should be aware that oftentimes an officer may have a backup weapon usually

found in a holster near the ankle, in their pocket, in a

ballistic vest, or near an armpit. The holster with the

weapon in place should be removed and secured as

described above. 

3. An officer’s gun belt may also contain items that

could prove dangerous if allowed to get in the

wrong hands. Thus, the belt should be collected and

separately bagged ASAP and passed to a fellow officer or hospital Security Officer in the Treatment

Sector. DECONNING OF AN OFFICER’S WEAPON

AND/OR GUN BELT WILL BE THE RESPONSIBILITY

OF THE POLICE DEPARTMENT.

4. If the officer is wearing a ballistic vest it must be

removed prior to undergoing decon. The vest is usually easily removed by loosening the Velcro® straps

and then pulling the vest apart and off the patient. It

should then be placed in a large plastic bag identified with the patient’s name and/or clothing number

on it and passed to a fellow officer or Hospital

Security Officer in the Treatment Sector. 

Prepared by: 

Northern Virginia Emergency Response Coalition

78

Occupational Safety and 

Health Administration
PPE Donning Sequence

(NOTE: The following sequence outlines the order in

which one hospital’s employees find it efficient to put on

their specific first receiver PPE. The list is not intended

to provide detailed step-by-step instructions for putting

on the PPE.)

1. Test PAPR flow rate to be sure it meets rate specified

by the manufacturer.

2. Remove jewelry & clothing.

3. Put on inner nitrile gloves.

4. In COLD WEATHER: Put on inner suit. Tape gloves

at wrist & zipper at neck.

5. In WARM WEATHER: Put on scrubs.

6. Put on outer chemical protective suit to waist. Put on

boots & outer chemical protective gloves.

7. Connect PAPR to hood with hose; turn airflow on.

Put on butyl hood (position the inside shroud

between suits). Pull chemical protective suit up

and on.

8. Ensure zipper is covered & secured, put tape on top. 

9. Belt PAPR to waist.

10. Put outer butyl hood shroud over suit.

11. Stretch arms, pull suit sleeves OVER gloves, tape in

place.

12. Pull suit cuff over boot top, tape in place.

13. Place a piece of tape on the hood exterior and label

with the employee’s name & time that employee is

entering Hospital Decontamination Zone.

PPE Decontamination and Doffing Sequence

(NOTE: The following sequence outlines the order in

which one hospital’s employees find it effective to

decontaminate themselves and their PPE as one procedure, to minimize the chance of contaminating their skin

while removing their first receiver PPE. The list is not

intended to provide detailed step-by-step instructions.)

1. Wash hands thoroughly. 

2. Still wearing PPE, wash self, starting at the top of the

head and working down to the bottom of the boots.

Have a partner wash your back.

3. Untape boots and gloves, but do not remove them.

4. Unlock PAPR and place it on chair/gurney/floor, etc.

5. Remove the outer suit—roll the suit away from you,

inside out (with help from a partner). Remove outer

gloves along with the outer suit.

6. Remove PAPR hood, place in waste.

7. Step out of boots and suit into final rinse area (keep

inner gloves and clothing on). Wash and rinse thoroughly (with partner’s help).

8. In COLD WEATHER: Remove (inner) suit, place in

waste.

9. Remove nitrile gloves: first pinch one glove and roll

it down partially, then place thumb in other glove &

remove both gloves simultaneously.

10. Wash again, removing inner clothing, then step out

of decontamination shower and into towels/blankets.

Appendix K: 

PPE Donning and Doffing Sequence

Source:

Adapted from Central Arkansas Veterans Healthcare System.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 79
Technical Decontamination Process 

for Hospital Personnel

Personnel should remove protective clothing in the following sequence.

1. Remove tape (if used), securing gloves and boots to

suit.

2. Remove outer gloves, turning them inside out as

they are removed.

3. Remove suit, turning it inside out and folding downward (first loosen and secure PAPR belt). Avoid shaking.

4. Remove boot/shoe cover from one foot and step

over the clean line. Remove other boot/shoe cover

and put that foot over the clean line.

5. Remove respirator. The last person removing his/her

respirator may first wash all other respirator hoods

or facepieces with soapy water and thoroughly wipe

PAPR fan housing, then clean his/her own equipment before removing his/her suit and gloves. Place

the masks in plastic bag and hand the bag over the

clean line for placement in second bag held by

another staff member. Send bag for decontamination. Discard items that cannot be effectively cleaned

(e.g., it may not be possible to completely remove

persistent contaminants from PAPR belts).

6. Remove inner gloves and discard them in a drum

inside the dirty area.

7. Secure the dirty area until the level of contamination

is established and the area is properly cleaned.

8. Personnel should then move to a shower area,

remove undergarments and place them in a plastic

bag. Double-bag all clothing and label bags appropriately.

9. Personnel should shower and redress in normal

working attire and then report for medical surveillance.

Appendix L: 

Example of Technical Decontamination Process for 

Hospital Personnel

Source:

Adapted from Managing Hazardous Materials Incidents.

Hospital Emergency Departments: A Planning Guide for the

Management of Contaminated Patients. Volume II. U.S.

Department of Health and Human Services. Public Health

Service. Agency for Toxic Substances and Disease Registry

(Revised 2000). www.atsdr.cdc.gov

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Policy #: Disaster Plan, 2002 Rev, Envir of Care Safety Manual

Emergency Management Plan

INOVA HEALTH SYSTEM

Emergency Management & Disaster Preparedness Plan 

Subject: ANNEX C- Chemically Contaminated

Patient Care Protocol 

___________________________________________________________________________________________________________ 

Written: August 5, 2002 Revision:

Emergency Management and Disaster Preparedness Task Force

PURPOSE: To establish a policy for providing care to victims of hazardous materials and/or

chemical terrorism incidents while ensuring the safety of the emergency department

(ED) personnel and hospital environment. 

BACKGROUND: The potential for hazardous materials exposure requires specific procedures for the

protection of the patient, staff, and the environment. It differs from the other emergency situations because of that added risk of contamination to staff and facility.

Worker safety and training are key factors in the management of these medical

emergencies. Often these patients may arrive at the hospital unannounced. Patients

being transported by EMS may not have been fully decontaminated prior to their

arrival to the hospital. 

TOXICOLOGICAL

PRINCIPLES: Exposure to hazardous materials may produce a wide range of adverse health

effects. The likelihood of an adverse health effect occurring, and the severity of the

effects, are dependent upon:

• The toxicity of the agent or pathogen 

• Route of exposure 

• The nature and extent of exposure to that substance

Appendix M: 

Example of Integrated Procedures for First Receivers

Note: The Emergency Management and Disaster Preparedness Plan—Chemically contaminated patient care protocol

included in this appendix was developed by the INOVA Health System (Virginia) for use in INOVA facilities. The

INOVA Health System uses powered air-purifying respirators (PAPRs). However, in cases where information is adequate to determine that an air-purifying respirator (APR) would provide adequate protection against the hazard, APRs

might be used in place of PAPRs. At INOVA facilities, a specific, designated individual (the Charge MD) is responsible

for determining the appropriate PPE for the decontamination team and for making appropriate adjustments as the situation evolves. 

This example plan represents a portion of the emergency management plan used by one healthcare organization.

Based on their individual circumstances, other organizations will have different procedures, terminology, and division

of responsibilities.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 81
Toxic chemical effects may be localized at the site of exposure, or may result in systemic symptomatology after absorption into the blood stream. 

The three main routes of exposure are:

• Inhalation resulting in the introduction of toxic chemicals, radioisotopes, or

pathogens via the respiratory tract. Most of the compounds that are inhaled are

gases or vapors of volatile liquids. However, solids and liquids can be inhaled as

dusts or aerosols. Inhalation of chemical agents generally result in a rapid absorption into the bloodstream because of the large surface and vascularity of the

lungs. The signs and symptoms of pathologic exposure will usually occur 1–10

days after exposure. 

• Skin contact or absorption via mucous membranes is usually not as rapid as

inhalation. Exposure can be through the mucus membranes (including conjunctiva)

and open wounds. 

• Ingestion is a less common route of exposure. It can be the result of unintentional

hand to mouth contamination or swallowing of saliva with trapped airborne particles. Or it may also be intentional, such as an oral ingestion for a suicide attempt. 

In addition to the route of exposure, the amount of compound absorbed by the body

depends upon the:

• Duration of exposure 

• Concentration of contaminant 

• Time of exposure 

• Environmental factors

Response to toxic chemicals, radiological agents and pathogens may differ among

individuals because of the physiological variability present in the population. 

• Age

• Preexisting medical conditions 

• Prior exposure 

• Medications 

• Concurrent injury 

• Pregnancy 

NOTIFICATION: Unannounced Arrival refers to a patient(s) that presents to the ED Triage Nurse or

other healthcare provider. Once the healthcare provider determines a hazardous

materials incident has occurred and contamination may be present he/she should:

• Direct the patient outside the ED lobby entrance and proceed to the entryway of

the decon room. Confine the patient in this location and remain with them. 

• Notify the charge nurse.

• Notify security at Triage to secure the area.

• Any persons the victim came in contact with, including the initial healthcare

provider contact, should also be directed to the decon room until the extent of

contact and the need for care can be determined. 

• If there are multiple patients affected, prepare to implement the mass decontamination procedure utilizing identified areas outside of the hospital facility but contiguous to the ED.

Announced Arrival is a patient already entered into the EMS system that arrives by

ambulance. The major advantage created by pre-hospital notification is the provision

of preparatory time and available clinical data and incident information from the field

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as well as initial intervention by EMS personnel. The arriving patient should be kept

with the pre-hospital EMS personnel outside of the ED until the “decontamination

team” is prepared to assume patient care. 

Consultation with the referring agency as to the decontamination, if any, performed

at the incident scene must occur prior to admitting these patients directly into the

ED. This should depend upon the nature of the agent, degree of decontamination

provided in the field, and suspicion of potential contamination upon visual inspection

of the patient. If in doubt, have the patient go through decontamination at the hospital. 

EMERGENCY DEPARTMENT RESPONSIBILITIES

Communication Nurse

• Determine caller’s ID and telephone number. 

- Type and nature of incident 

- Number of victims 

- Signs and symptoms being experienced by victim 

- Nature of injuries 

- Prior medical history of victim – meds and allergies 

- Name of chemical involved and what information is readily available 

on product container if present

- Name of facility involved and/or type of contaminants found at facility 

- Extent of victim decontamination in field 

- Other medical interventions completed 

- Estimated time of arrival (ETA) 

• Notify charge nurse.

• Notify EMS Public Safety Communications Center (PSCC) of incident and request

redirection of other ambulance traffic to ED lobby entrance. 

• If incident involves multiple patients, request that ED be placed on “reroute” status. 

Charge Nurse

• Consult with charge MD and assess the present patient capacity and acuity. If incident involves multiple patients, implement “Disaster Plan – Annex C.”

• Expedite movement of “admitted” patients to assigned beds. 

• Notify the ED Patient Care Director and Administrative Director as to the status

of incoming contaminated patients. Consider the need for additional staff and

resources and initiate response, if warranted. 

• Initially assign 2 nurses and 2 techs to the decontamination team. 

• Notify ED registration, triage nurse, and security. 

• Notify respiratory therapy and determine the number of adult/pediatric ventilators.

• Determine number of available adult/pediatric beds.

Administrative Director 

• Notify security officers to redirect ED traffic and ambulances. 

• Notify physical plant staff. 

• Notify environmental services. 

• Notify Personal Health for follow-up on staff involved. 

• Notify Media Relations to be available for purpose of public information if needed.

• Notify Administrator-on-call that “Disaster Plan – Annex C” is being implemented. 

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 83
Charge MD

• Confer with ED Charge Nurse regarding the immediate need to implement the

“Disaster Plan – Annex C” and assess the disposition status of existing patients in

the ED. 

• Notify ED Chairman. 

• Notify Poison Control–obtaining available product info to decontaminate and care

for patient(s), when available.

• Notify critical care pharmacist with product info for anticipated antidote. Obtain

inventory of available antidotes. 

• Determine appropriate level of Personal Protective Equipment (PPE) for Decon

Team.

• Assign MD and/or PA to Decon Team. 

• Direct 1–2 personnel to set up decon area and 1–2 persons to assist decon team

with dress out procedures. 

Security

• Secure entrances and exits to the ED.

• Assist with traffic and crowd control around the ED.

• Will be responsible for maintaining “chain of custody” of personal belongings of

patients undergoing decontamination. These items will NOT be individually catalogued, but rather placed in red biohazard plastic bags that will be tagged, numbered, and recorded.

DECONTAMINATION

PURPOSE: To remove or neutralize harmful materials that have gathered on personnel and/or

equipment and to prevent secondary contamination to healthcare workers and the

facility. Decontamination is a systematic process that is determined by the nature and

degree of contamination. Effective decontamination consists of making the patient as

clean as possible, meaning that the contamination has been reduced to a level that is

no longer a threat to the patient or healthcare provider. 

DECON SETUP: In a “traditional” HAZMAT incident involving known exposure to chemical agents

involving less than 3 patients simultaneously, consideration can be given to using the

existing Emergency Department Decontamination Room, if available.

Decon room preparation tech shall be assigned to:

• Remove all non-essential and nondisposable equipment and items from established Hazmat/Decon wash room. 

• Activate drain switch to contain runoff, if available. 

• Obtain decon cart with necessary stocked items.

• Obtain crash cart and place contiguous to Decon wash room.

• Place D or E size O2 tank with regulator. 

• Place clean stretcher in Hazmat/Decon wash room with additional O2 tank, BVM,

and non-rebreather mask. 

• Place stretcher outside of decon room on plastic ground cloth to receive nonambulatory patient from ambulance. 

• Place bucket for soiled items used in wash room for technical decon. 

• Place lined trash baskets in decon area for Biowaste. 

• Place Personal Decon Kits (PDK) in decon area.

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Mass Decontamination Setup 

In the event that the chemical exposure incident involves more than 3 people requiring decontamination simultaneously, or incident information suggests the arrival of

large numbers of patients requiring decontamination as a result of a mass exposure,

preparation for mass decontamination should commence.

The following materials have been identified as basic prerequisites for Mass

Decontamination set up and preparation:

• A hose bib splitter for each bib within 100 feet (within range) of the proposed

decontamination area.

• Two 100-foot hoses for each hose bib within range of the proposed decontamination area.

• Four (2 sets) sawhorses to hold litter bound patients within the decontamination

area and set of C-clamps.

• Two backpack sprayers per facility.

• Two baby pools per facility.

• Four buckets for each hose bib within range of the proposed decontamination

area.

• Four scrub brushes for each hose bib within range of the decontamination area. 

• Duct tape, flashlights, permanent markers, soap, large trash cans, red biohazard

bags, and towels.

• One blood pressure cuff, stethoscope, and set of trauma scissors per litter decontamination station.

• Towels and redress kits.

• Two Geiger counters per facility (Reference “Disaster Plan – Annex R”).

• Two Bull horns per facility.

• Polaroid camera with film or digital camera for later use in identification of moribund patients.

• A locked, centrally located storage mechanism (cart, closet, etc.) for storage of the

aforementioned items.

Included in this Annex is a schematic diagram for use in establishing a Mass

Decontamination procedure that details the process flow of patients. This should

be adapted to each individual healthcare facility.

LEVEL C PERSONAL PROTECTIVE EQUIPMENT

Decon team preparation

1. Obtain appropriate personal protective equipment (PPE) as recommended by ED

charge physician.

2. A minimum of 4 persons should don PPE. 

3. Decon team personnel should undergo pre-entry medical monitoring as soon as

possible. Only personnel meeting inclusion criteria, and having met the required

training standards will be allowed to dress in PPE. 

4. The Inova Health System has elected to use LEVEL C respiratory protection and

chemical protective clothing as the highest level of protection available. LEVEL C respiratory protection is comprised of:

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 85
• Powered Air Purifying Respirator (PAPR): This provides air that is drawn through

organic/HEPA filter cartridges affixed to a battery powered unit worn by the decon

team personnel on a belt around their waist. It is worn as a hood placed over the

head, with the inner sleeve tucked into the chemical protective clothing suit.

• Air Purifying Respirator (APR): This provides air that is filtered through organic/

HEPA filter cartridges dependent on the negative inspiration created by the work of

breathing. This is worn as a full-face mask with the cartridges affixed to the mask.

Caution: These respiratory protective equipment contain LATEX products and are

not to be worn by LATEX-allergic individuals.

LEVEL C chemical protective clothing is contained in the Tri-con PPE packs that

include:

• 2 layers of gloves

• chemical resistant suit (check for appropriate sizing)

• chemical resistant boots

Note: Some Tri–Con PPE packs will also contain an APR mask. Consult with the ED

physician in charge with regards to selection of APR or PAPR. Persons needing to use

glasses, or those with beards or full moustaches, are NOT to use a face mask device.

A Decon team member should double check to assure all personnel have donned

their PPE properly. Special attention should be paid to proper seal of mask/face and

proper occlusion at wrists and ankles. Particular attention must be made to ensure all

“pull tabs” are removed from respiratory cartridge filters prior to use. 

Immediately evaluate the available information and confirm/re-confirm (as more

information becomes available) that your key operational planning assumptions for

Level C PPE are valid:

• Incident location (including area of significant downwind contamination) does not

include your facility.

• Agent characteristics: Known or suspected agent doesn’t require higher level of

PPE (example: high-grade plutonium or other very rare agents).

• Event characteristics: Your facility is not being “overrun” by casualties.

Adjust the planned operations as indicated by the evolving circumstances. Possible

adjustments include:

• Upgrading plan: more personnel protected, shorter rotation periods for PPE personnel, longer soap & wash cycles for victims, obtaining assistance from other

hospitals or from emergency response resources.

• Evacuating or closing the facility to “shelter in place” if the hospital is in the zone

of contamination.

• “Lock-down” of facility if agent, agent concentration, or the number of patients

exceeds the safe operation of the plan or compromises the hospital integrity.

• Any need to isolate the decontamination wastewater (notify authorities to remove

it per prior arrangement). Otherwise, notify “downstream” water authorities that

decontamination wastewater is entering the sewer system.

• Downgrade the plan (lesser protective clothing and/or respiratory protection if

agent is identified as non-threatening). This should be a high priority if possible,

since safely downgrading the level of PPE will enhance the efficiency of the decontamination process.

Donning Procedures: Staff medical monitoring to be completed by assigned

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Registered Nurse (RN) or MD (use designated medical monitoring form included in

this Annex). Use a room with privacy and plenty of sitting space to facilitate donning

of PPE.

1. It is preferable that a scrub suit be worn in lieu of regular street clothes. Clothing

should be suitable for preserving comfortable body temperature.

2. Remove all jewelry and leather material and place in plastic bag with your name

on it—place in secure location for Security to maintain. Persons needing to wear

glasses or with beards or mustaches are NOT to use a face mask device.

3. Persons with long hair should apply a hairnet or place up in a braid.

4. Hydrate with 8–16 ounces of fluid. 

5. If time allows have blood pressure (BP), pulse, respiration rate, and temperature

taken and recorded on Medical Surveillance form.

6. Obtain appropriate sized PPE ensemble pack or individual pieces, APR/PAPR, battery, and appropriate cartridges (2–3 depending on APR/PAPR being used).

7. Layout PPE pieces and confirm they are right size and in working order. 

8. Apply appropriate type of cartridges (most incidents will require HEPA/organic

vapor cartridge set) and remove all pull-tabs. DO NOT OVERTIGHTEN the cartridges

on the mask.

9. Put on latex or plastic inner glove—consider placing light circular band around top

of glove to lessen chance of premature removal during doffing.

10. While sitting, remove shoes and place on foot covers (foot protection should not

present tear risk to the suit nor be heelless).

11. Pull on chemical/biological protective suit to waist.

12. Place outer booties/boots on over the foot portion of the suit.

13. Using duct tape, seal top of booties to protective coverall (use a flap of tape at the 

end and place facing front to ease removal).

14. For chemical incident, place one set of nitrile gloves and one set of butyl rubber

gloves on hands. For biological incident, use double plastic/latex gloves or plastic/

latex and nitrile gloves.

15. Seal seam of protective suit and gloves with duct tape (use a flap of tape at the

end and on the front of the wrist area to ease removal of tape).

16. Zip up protective suit to neck and close zipper securing and covering zipper seal.

17. If using PAPR, put on vest. Cinch up vest to snug fitting around with motor unit

riding above the buttocks. Secure battery to the belt (side of the dominant hand is

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 87
suggested) and plug in the PAPR. The air hose should come over the shoulder not

under the arm.

18. Position APR/PAPR facepiece to ensure full visibility and comfortable fit. Tighten

all bands in pairs by pulling them backwards and not up. Confirm tight seal by covering cartridge opening with hand and taking deep breaths—face shield should pull

tight against face. If faulty seal is found, then retighten all bands and repeat seal test.

If tight seal cannot be obtained, then seek second provider assistance or use hooded

device. 

19. Pull suit hood up and over the head maximizing the coverage of the head, neck,

and ears and covering the APR/PAPR seal edge around the face–ensure the suit is

pulled up and fully under the chin and zipper is closed and covered. There should be

NO EXPOSED SKIN.

20. Turn PAPR on, also making sure that all cartridge tabs are removed to allow airflow.

21. Have someone place a 3 in. piece of Velcro® or tape across shoulders with staff

member’s last name and function (e.g., Jones RN) written with magic marker.

22. Have second person perform safety check before proceeding to assigned work

area.

23. Note time personnel left the dress out area.

Ambulatory Patient Decontamination 

• Children should be kept with their parents if at all possible; if no parent or older

sibling is available then a Decon Team member should provide needed assistance

to a child.

• Patient should be given Personal Decon kit as soon as it is available and be given

rapid instructions on its use. 

The ambulatory patient may be directed by the decon nurse and tech to self-decon in

the Emergency Department Decontamination Room thereby sparing additional staff

from involvement (though the full decon team should remain dressed and ready in

an adjacent room if intervention is needed). If the situation involves multiple patients

requiring simultaneous decontamination, this process will occur using the Mass

Decontamination set up.

1. If dry contaminant, remove first by using tape or dust off clothing or skin before

wetting.

2. Have patient remove all valuables and place in the small plastic bag.

3. Clothing is removed and placed in the larger plastic bag. Place both bags into the

red biohazard plastic bag. Place identifying tag with unique patient number on bag

and seal off top. Place outside on ramp area for future disposition by Safety and

Security.

4. Patient will do head-to-toe gross decontamination wash using mild soap and

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water. Have patient place ID band around wrist. This ID band will have the same

identifying number that has been placed on the red biohazard plastic bag holding the

patient’s personal effects.

5. Special attention should be paid in the washing process to hair and all body

crevices. Wash time cycle should be 5 (five) minutes per person under a single

stream of water. 

6. Water temperature should be tepid.

7. Washing should be gentle to avoid abrading skin. 

8. Open wounds should be washed first with sterile water and covered with occlusive

dressing prior to remainder of body decontamination.

9. Upon completion of wash cycle, patient should step away from the immediate

wash area, towel dry, and put on a supplied Tyvek® gown from the Patient Redress

Kit.

10. All ED towels and wash cloths used by patients in the showering process should

be placed in a marked contaminated container for later clean up and decontamination. 

11. Patient may then enter the ED, where the receiving RN can obtain vital signs,

complete secondary triage, complete decon paperwork, and transport to an assigned

bed in ED. 

12. Decon team personnel should be decontaminated prior to entering the ED as

described in Personnel (Technical) Decon section. 

13. Soap should be changed out every five patients or whenever needed.

Non-Ambulatory Patients 

In a mass exposure to chemical agents, non-ambulatory patients will most likely

arrive after the initial arrival of ambulatory patients exposed in the same geographic

location. Because of the trimodal distribution of injuries, non-ambulatory patients are

likely to be more significantly exposed to the contaminating agent. Those who are

most severely affected will be in the expectant category at the incident scene, and

those who are least affected or only “potentially exposed” will arrive as ambulatory

patients.

The non-ambulatory patient decontamination should be performed simultaneously

with patient stabilization. Basic life support (ABC’s) will be maintained, but definitive

intervention should be delayed until the patient is decontaminated to a degree that

ensures staff safety and that invasive procedures will not increase the patient’s risk of

systemic toxic absorption. If large numbers of non-ambulatory patients are delivered

for decontamination and treatment simultaneously, the ED Charge Physician will be

required to make urgent triage decisions.

1. Patient should be received on a backboard and stretcher by EMS staff. If incident

involves a single non-ambulatory patient, utilization of the Emergency Department

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 89
Decon Room may be considered. If multiple patients are expected, set up of the nonambulatory mass decontamination corridor should commence. 

• Placement of saw horses with available C-clamps in order to secure backboards to

the sawhorses.

• Availability of water source for adequate decontamination, including use of backpack sprayers.

2. The Decon team for non-ambulatory patients must include a minimum of four (4)

providers, two of whom will be responsible for turning the patient on the backboard

and one who will be responsible for maintaining cervical spine precautions.

3. If the patient has not had a primary gross decon in the field (defined as the

removal of clothing and first wash), visible particulate matter should be removed by

gently brushing or dusting, and clothing should be cut and rolled away from the center of body, in order to contain the contaminants on the clothing.

4. Follow procedure for removal and bagging of personal valuables. 

5. Follow procedure for head-to-toe decontamination wash cycle.

6. Irrigate open wounds with irrigation syringe and copious amounts of saline and

cover with occlusive dressings. Any existing dressing must be removed and placed in

bio-hazard trash container.

7. Eye irrigation may be done with Morgans lens and NS and/or IV tubing alone, if

gross contaminants on the face are suspected. Otherwise, perform manual irrigation

with copious fluids.

8. Gentle ear and nasal irrigation with frequent suctioning from portable suction may

be done if such contamination is suspected. 

9. C-collars as well as backboards must be washed or changed if they are still

required for patient immobilization.

10. Patient should be transferred to a clean stretcher for entry into the ED.

Personnel (Technical) Decon

Prior to leaving the decon room the decontamination team must undergo decontamination.

1. All equipment used by the decon staff must be placed in appropriate receptacles or

in bins designated for equipment which can be cleaned and reused. Refer to clean-up

and recovery protocol for direction on rehabilitation of used equipment. 

2. Decon staff will undergo a technical decontamination wash from head-to-toe

involving the outer garments, gloves, and boots.

3. After the wash is complete, personnel should remove protective clothing in the

following sequence:

• Remove outer gloves, turning them inside out as they are removed and place in

bio-hazard trash container.

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• Remove tape from wrist and boot tops. 

• Remove boots.

• Remove suit, turning inside out and avoid shaking. 

• Remove APR mask or PAPR hood. The last member removing his/her respiratory

protective equipment may take responsibility for washing all masks in soapy

water. Refer to clean-up and recovery protocol. 

• Remove inner glove and discard into bio-hazard trash container. 

• Isolate all potentially contaminated materials until level of contamination is established and arrangements for cleaning and handling of trash and equipment can be

determined. 

• Post-exposure medical monitoring should be initiated and new data recorded on

the primary form. 

• Personnel should then remove scrub wear and shower and dress in replacement

scrubs. 

Emergency Decon 

• Staff member distress is recognized. 

• Staff member PPE immediately decontaminated with soap and water. 

• PPE removed quickly in head to toe fashion in cold zone area. Medical care rendered as warranted. 

KEY RESOURCES/POINTS OF CONTACT

Notifications of appropriate authorities:

Law EnforcementLocal Police Department

Federal Bureau of Investigation/DC [202-324-3000]

Fire/Rescue Department

Local Health Department

State Health Department 

Emergency Epidemiology After Hours [1-866-820-9611]

National Capital Region Poison Control Center [202-625-3333]

Agency for Toxic Substances and Disease Registry (ATSDR) [1-404-498-0120]

National Response Center [1-800-424-8802]

IN-HOSPITAL HAZMAT INCIDENT

• Contain victims in area of incident until contamination is confirmed.

• Administrative Director to be notified by area supervisor of incident site and

specifics.

• Hospital operator, notified by area supervisor, shall page ED charge nurse with

HAZMAT location.

• Hospital operator shall page Safety and Security to restrict access to the site.

• ED charge nurse and ED charge physician assign HAZMAT team for response to

site ONLY if patients are identified to be immediately in danger of exposure. 

• If Emergency Department HAZMAT team required to respond within facility have

the communication nurse call PSCC to request ED “reroute” status and request

Fire Department HAZMAT response per facility protocol. 

• The HAZMAT team should then dress in appropriate level of PPE for the given

response. If unknown contaminant, dress in highest level of protection available.

• The HAZMAT team responds to site bringing portable decontamination equipment

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 91
for decontamination at a safe area closest to the site of incident.

- Single patient – non-ambulatory bring 2 stretchers, one with containment cover 

and hose and container for runoff collection.

- Ambulatory – bring kiddy pools (2) and backpack sprayers or large irrigation 

bottles for decon wash.

• Decon shall be completed at site (as in previously described manner) until patient

is clean enough for transport to ED for more definitive decon. 

• Transport to ED shall be on the clean stretcher with a clean transport team. 

• ED HAZMAT team to complete personal decon at the incident site prior to return

to ED. 

MEDICAL MONITORING

The need to perform ongoing medical monitoring of those healthcare personnel participating in the decontamination procedure is MANDATORY. This entails a systematic evaluation of all participants, focusing particular attention to the risk of suffering

adverse reactions from heat, stress or hazardous materials exposure. This is performed for the purpose of prevention or early recognition of such symptoms, and in

compliance with federal regulations. 

Medical monitoring is performed prior to donning PPE in order to:

• Ascertain baseline vital signs. 

• Identify staff who will be disqualified from donning PPE and participating in the

decontamination process due to pre-existing medical conditions. 

• Identify staff who may be at a higher risk for potential adverse effects while working in this environment.

Pre-entry physicals are required on all individuals in protective clothing and performing hazardous material operations. This is to be completed within one hour prior to

entry, when possible.

PRE-ENTRANCE EXAM COMPONENTS

• Vital Signs 

- Blood pressure, pulse, respiration rate, temperature 

- Weight (estimated)

• Skin evaluation for presence of:

- Rashes

- Lesions 

- Open wounds 

• Mental Status evaluation, including assessment of psychological stressors. 

• Medical History 

- Chronic illnesses 

- Recent illnesses 

- Medications, including OTC taken within the past 72 hours 

- Current symptoms of fever, nausea, diarrhea, vomiting, coughing, wheezing, 

or recent alcohol consumption.

• Exclusion Criteria 

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- Blood pressure: diastolic over 95 

- Pulse: greater than 70% maximum heart rate (220 - age) x 0.7

irregular rhythm not previously documented 

- Respiratory rate: greater than 24 per minute 

- Temperature: less than 97 or greater than 99.5

- Weight or Size: inability to fit in available suit without causing undue 

strain on seams 

- Skin evaluation: open sores, large areas of rash, or significant sunburn 

- Mental status: any alteration 

- Recent medical history: nausea, vomiting, diarrhea within the past 72 hours, 

recent heat related injury, new prescriptions started 

within the past 72 hours.

- Pregnancy

ALL STAFF MUST BE CLEARED FOR PARTICIPATION BY THE ED CHARGE

PHYSICIAN PRIOR TO PARTICIPATION.

• ENTRY Medical Monitoring 

- Performed before donning PPE.

- Based on buddy evaluation by team member. 

- Observe for changes in gait, speech or behavior. 

- Any complaints of chest pain, dizziness, SOB, weakness, headache, nausea or 

vomiting should be reported. 

- Reporting of symptoms requires immediate personnel decon and removal from 

the decon site. 

- Personnel data should be recorded on HAZMAT Medical Monitor form (see 

attached).

• POST-ENTRY Medical Monitoring 

- Vital signs repeated every 10 minutes until return to less than 85% of maximum 

pulse rate.

- Oral rehydration started immediately upon completion of personal decon. 

- IV hydration and more aggressive medical evaluation shall be initiated for 

victims displaying medical illness and/or unstable vital signs. 

• The completed Hazmat Medical Monitoring form shall be forwarded to Employee

Health for review and decision, if further evaluation is needed. The assessment

form is to become part of the individual’s occupational health file. 

EQUIPMENT/SUPPLY ACQUISITION 

If needed equipment and supplies are not available in the ED, the ED charge physician should be notified immediately. This information should then be immediately

forwarded to the DISASTER SUPPORT CENTER, which can help procure needed

materials. If all on-site resources have been exhausted, the Inova Health System 

DISASTER COMMAND CENTER will be contacted by the hospital Disaster Support

Center in order to identify location of needed supplies and additional logistical support.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 93
CLEAN-UP AND RECOVERY

Upon completion of the decontamination process, consideration must be given

immediately to the following issues:

• Personal belongings and valuables of patients

These items will be in tagged, sealed red biohazard bags kept outside of the healthcare facility under the direct supervision of the hospital Safety and Security staff, or

local law enforcement personnel. These items may not be returned until they are

deemed safe for handling and their evidentiary content has been evaluated.

• Bio-hazard trash can contents

These trash cans will contain soaps, sponges, scrub brushes, towels, and other items

used by patients during the decontamination process. These bags must be sealed

and segregated for later removal by contract waste haulers.

• Towel discard bins

These bins will hold the towels discarded by patients who have completed the

decontamination process just prior to their entry into the healthcare facility. These

bags must be segregated for possible laundering or later removal by contract waste

haulers.

• Wastewater effluent

In the event that mass decontamination efforts are required, the importance of life

safety concerns supercedes the potential environmental impact of contaminated

effluent. Every attempt should be made to direct this effluent into the sanitary sewer,

with immediate notification of the proper municipal agencies. In those cases in which

only limited numbers of patients are involved, every attempt should be made to contain this effluent using “baby pools” or similar methods. Such collected water must

then be properly disposed of under the direction and supervision of the appropriate

municipal agencies and contract waste haulers.

Any area outside of the healthcare facility that was used in the mass decontamination process and was inside of the WARM or HOT ZONES must be cordoned off until

such time as it is verified by hazardous materials experts that no risk of contamination exists.

94

Occupational Safety and 

Health Administration
OSHA Assistance

OSHA can provide extensive help through a variety

of programs, including technical assistance about

effective safety and health programs, state plans,

workplace consultations, voluntary protection programs, strategic partnerships, training and education,

and more. An overall commitment to workplace safety

and health can add value to your business, to your

workplace and to your life.

Safety and Health Program Management Guidelines

Effective management of worker safety and health

protection is a decisive factor in reducing the extent

and severity of work-related injuries and illnesses and

their related costs. In fact, an effective safety and

health program forms the basis of good worker protection and can save time and money (about $4 for

every dollar spent) and increase productivity and

reduce worker injuries, illnesses and related workers’

compensation costs.

To assist employers and employees in developing

effective safety and health programs, OSHA published

recommended Safety and Health Program Management Guidelines (54 Federal Register (16): 3904-3916,

January 26, 1989). These voluntary guidelines apply to

all places of employment covered by OSHA.

The guidelines identify four general elements critical to the development of a successful safety and

health management program:

■ Management leadership and employee involvement.

■ Work analysis.

■ Hazard prevention and control.

■ Safety and health training.

The guidelines recommend specific actions, under

each of these general elements, to achieve an effective

safety and health program. The Federal Register notice

is available online at www.osha.gov 

State Programs

The Occupational Safety and Health Act of 1970

(OSH Act) encourages states to develop and operate

their own job safety and health plans. OSHA approves

and monitors these plans. Twenty-four states, Puerto

Rico and the Virgin Islands currently operate approved

state plans: 23 cover both private and public (state and

local government) employment; 3 states, Connecticut,

New Jersey and New York, cover the public sector

only. States and territories with their own OSHAapproved occupational safety and health plans must

adopt standards identical to, or at least as effective as,

the Federal standards. 

Consultation Services

Consultation assistance is available on request to

employers who want help in establishing and maintaining a safe and healthful workplace. Largely funded

by OSHA, the service is provided at no cost to the

employer. Primarily developed for smaller employers

with more hazardous operations, the consultation

service is delivered by state governments employing

professional safety and health consultants. Comprehensive assistance includes an appraisal of all

mechanical systems, work practices and occupational

safety and health hazards of the workplace and all

aspects of the employer’s present job safety and

health program. In addition, the service offers assistance to employers in developing and implementing

an effective safety and health program. No penalties

are proposed or citations issued for hazards identified

by the consultant. OSHA provides consultation assistance to the employer with the assurance that his or

her name and firm and any information about the

workplace will not be routinely reported to OSHA

enforcement staff.

Under the consultation program, certain exemplary

employers may request participation in OSHA’s Safety

and Health Achievement Recognition Program (SHARP).

Eligibility for participation in SHARP includes receiving

a comprehensive consultation visit, demonstrating

exemplary achievements in workplace safety and

health by abating all identified hazards and developing

an excellent safety and health program.

Employers accepted into SHARP may receive an

exemption from programmed inspections (not complaint or accident investigation inspections) for a period of one year. For more information concerning consultation assistance, see the OSHA website at

www.osha.gov

Voluntary Protection Programs (VPP)

Voluntary Protection Programs and on-site consultation services, when coupled with an effective

enforcement program, expand worker protection to

help meet the goals of the OSH Act. The three levels

of VPP are Star, Merit, and Demonstration designed to

recognize outstanding achievements by companies

that have successfully incorporated comprehensive

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 95
safety and health programs into their total management system. The VPPs motivate others to achieve

excellent safety and health results in the same outstanding way as they establish a cooperative relationship between employers, employees and OSHA.

For additional information on VPP and how to

apply, contact the OSHA regional offices listed at the

end of this publication.

Strategic Partnership Program

OSHA’s Strategic Partnership Program, the newest

member of OSHA’s cooperative programs, helps encourage, assist and recognize the efforts of partners to

eliminate serious workplace hazards and achieve a

high level of worker safety and health. Whereas

OSHA’s Consultation Program and VPP entail one-onone relationships between OSHA and individual worksites, most strategic partnerships seek to have a broader impact by building cooperative relationships with

groups of employers and employees. These partnerships are voluntary, cooperative relationships between

OSHA, employers, employee representatives and others (e.g., trade unions, trade and professional associations, universities and other government agencies). 

For more information on this and other cooperative

programs, contact your nearest OSHA office, or visit

OSHA’s website at www.osha.gov

Alliance Programs

The Alliances Program enables organizations

committed to workplace safety and health to collaborate with OSHA to prevent injuries and illnesses in

the workplace. OSHA and the Alliance participants

work together to reach out to, educate and lead the

nation’s employers and their employees in improving and advancing workplace safety and health. 

Groups that can form an Alliance with OSHA include employers, labor unions, trade or professional

groups, educational institutions and government agencies. In some cases, organizations may be building on

existing relationships with OSHA that were developed

through other cooperative programs. 

There are few formal program requirements for

Alliances and the agreements do not include an enforcement component. However, OSHA and the participating organizations must define, implement and meet

a set of short- and long-term goals that fall into three

categories: training and education; outreach and communication; and promoting the national dialogue on

workplace safety and health. 

OSHA Training and Education

OSHA area offices offer a variety of information

services, such as compliance assistance, technical

advice, publications, audiovisual aids and speakers for

special engagements. OSHA’s Training Institute in

Arlington Heights, IL, provides basic and advanced

courses in safety and health for Federal and state compliance officers, state consultants, Federal agency personnel, and private sector employers, employees and

their representatives.

The OSHA Training Institute also has established

OSHA Training Institute Education Centers to address

the increased demand for its courses from the private

sector and from other Federal agencies. These centers

are nonprofit colleges, universities and other organizations that have been selected after a competition for

participation in the program.

OSHA also provides funds to nonprofit organizations, through grants, to conduct workplace training

and education in subjects where OSHA believes there

is a lack of workplace training. Grants are awarded

annually. Grant recipients are expected to contribute

20 percent of the total grant cost.

For more information on grants, training and education, contact the OSHA Training Institute, Office of

Training and Education, 2020 South Arlington Heights

Road, Arlington Heights, IL 60005, (847) 297-4810 or

see “Outreach” on OSHA’s website at www.osha.gov.

For further information on any OSHA program, contact

your nearest OSHA area or regional office listed at the

end of this publication.

Information Available Electronically

OSHA has a variety of materials and tools available

on its website at www.osha.gov. These include e-Tools

such as Expert Advisors, Electronic Compliance

Assistance Tools (e-cats), Technical Links; regulations,

directives and publications; videos and other information for employers and employees. OSHA’s software

programs and compliance assistance tools walk you

through challenging safety and health issues and common problems to find the best solutions for your workplace.

A wide variety of OSHA materials, including standards, interpretations, directives, and more, can be

purchased on CD-ROM from the U.S. Government

Printing Office, Superintendent of Documents, phone

toll-free (866) 512-1800.

96

Occupational Safety and 

Health Administration
OSHA Publications

OSHA has an extensive publications program. For

a listing of free or sales items, visit OSHA’s website at

www.osha.gov or contact the OSHA Publications

Office, U.S. Department of Labor, 200 Constitution

Avenue, NW, N-3101, Washington, DC 20210. Telephone

(202) 693-1888 or fax to (202) 693-2498. 

Contacting OSHA

To report an emergency, file a complaint or seek

OSHA advice, assistance or products, call (800) 321-

OSHA or contact your nearest OSHA regional or area

office listed below. The teletypewriter (TTY) number is

(877) 889-5627.

You can also file a complaint online and obtain

more information on OSHA Federal and state programs by visiting OSHA’s website at www.osha.gov

OSHA Regional Offices

Region I

(CT,* ME, MA, NH, RI, VT*) 

JFK Federal Building, Room E340

Boston, MA 02203

(617) 565-9860

Region II

(NJ,* NY,* PR,* VI*)

201 Varick Street, Room 670

New York, NY 10014

(212) 337-2378

Region III

(DE, DC, MD,* PA, VA,* WV)

The Curtis Center

170 S. Independence Mall West

Suite 740 West

Philadelphia, PA 19106-3309

(215) 861-4900

Region IV 

(AL, FL, GA, KY,* MS, NC,* SC,* TN*)

61 Forsyth Street, SW

Atlanta, GA 30303

(404) 562-2300

Region V

(IL, IN,* MI,* MN,* OH, WI)

230 South Dearborn Street 

Room 3244

Chicago, IL 60604

(312) 353-2220

Region VI

(AR, LA, NM,* OK, TX)

525 Griffin Street, Room 602

Dallas, TX 75202

(214) 767-4731 or 4736 x224

Region VII

(IA,* KS, MO, NE)

City Center Square

1100 Main Street, Suite 800

Kansas City, MO 64105

(816) 426-5861

Region VIII

(CO, MT, ND, SD, UT,* WY*)

1999 Broadway, Suite 1690

PO Box 46550

Denver, CO 80202-5716

(720) 264-6550

Region IX 

(American Samoa, AZ,* CA,* HI,* NV,* Northern

Mariana Islands)

71 Stevenson Street, Room 420

San Francisco, CA 94105

(415) 975-4310

Region X

(AK,* ID, OR,* WA*)

1111 Third Avenue, Suite 715

Seattle, WA 98101-3212

(206) 553-5930

* These states and territories operate their own OSHAapproved job safety and health programs (Connecticut,

New Jersey and New York plans cover public employees

only). States with approved programs must have a standard that is identical to, or at least as effective as, the

Federal standard.

Note: To get contact information for OSHA Area

Offices, OSHA-approved State Plans and OSHA

Consultation Projects, please visit us online at

www.osha.gov or call us at 1-800-321-OSHA.

OSHA BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS 97
www.osha.gov