DISASTER MEDICINE 0733-8627/96 $0.00 + .

20

HAZARDOUS MATERIALS
Disaster Medical Planning and Response

Howard W. Levitin, MD, FACEP,

and Henry J. Siegelson, MD, FACEP

Modern medical disaster planning uses data obtained from an all-hazards

assessment of potential risks and exposures. Hazardous materials, which are
present in every sector of our society, represent a significant threat to local
populations, employees in the workplace, families at home, and medical workers
both in the field and in the hospital emergency department. Disaster planning
typically focuses on the rescue, triage, and immediate treatment of casualties.
The medical management of chemical disasters should incorporate victim decon-
tamination and personal protective equipment into the planning p r o ~ e s s . ~
The United States leads the world with its modern system of medical
technology, prehospital acute care medical and trauma systems, and specializa-
tion of medical care delivery in the hospital emergency department. Currently,
however, very few hospitals are prepared to deliver care to patients exposed to
hazardous materials within the rules and regulations of existing law. Few
hospitals have policies, procedures, and protective gear in place to protect their
employees as care is delivered. In addition, it is rare for hospitals to have
decontamination equipment, training, and protocols that would enable timely
treatment for the exposed patient.
The federal government may assist disaster-affected states at their request.
These resources are organized under the Federal Response Plan (FRP). Some of
these resources offer specific expertise in the care of patients exposed to hazard-
ous materials. This article reviews existing federal regulations, recommendations
from federal agencies, and the medical literature to develop suggestions for

From the Department of Emergency Medicine, St. Francis Hospital and Health Centers
(HWL); the Hazardous Materials Task Force, Section of Disaster Medicine, American
College of Emergency Physicians, Indianapolis, Indiana (HWL); the Division of Erner-
gency Medicine, Department of Surgery, Emory University School of Medicine (HJS);
and the Section of Disaster Medicine, American College of Emergency Physicians,
Atlanta, Georgia (HJS)

EMERGENCY MEDICINE CLINICS OF NORTH AMERICA

-
VOLUME 14 NUMBER 2 * MAY 1996 327
328 LEVITIN & SIEGELSON

hazardous materials (hazmat) planning that can be used by industry, health

care, and government organizations.

THE ENVIRONMENT OF HAZARDOUS MATERIALS

A hazardous material is any substance that is potentially toxic to a biologic

system. This definition not only includes chemicals, but also biologic and dis-
ease-causing agents.16,44, 55 All of these hazards are regulated by the Occupational
Safety and Health Administration (OSHA),which requires employers to imple-
ment safety policies and to provide training and personal protective equipment
to all employees potentially exposed to any of these substances.
The potential for exposure is significant. In the United States we produce
over 60,000 chemicals, many of which are deemed hazardous by the Department
of Transportation (DOT).38,39 OSHA estimates that there are 575,000 chemicals
found in the workplace,4353,000 of which are potentially hazardous.36Over 4
billion tons of chemicals are transported annually by air, surface, and water
from over 100,000 different locations, with over 1 million people involved in the
shipping process.' In 1994, the Chemical Manufacturer's Association emergency
response phone service (CHEMTREC) logged over 200,000 calls, with about 4%
pertaining directly to hazardous materials emergencies.'*
Industrial chemical releases into the community occur through three main
routes: air, water, and food. Exposure from chemical releases occurs through
skin absorption, ingestion, or inhalation. Most chemical releases are due to
single chemical agentsm whose toxicologic properties are often unknown." A
complete health hazard assessment is only available for 7% of the chemicals
used in pesticides, cosmetics, drugs, and food additives. Toxicity information is
available for only about 50% of these substance^.^ The majority of our existing
research concentrates purely on the long-term consequences of the exposure.
Many of these long-term effects may be characteristic of the hazardous chemical
or indistinguishable from illnesses of natural causes, unless epidemiologic stud-
ies are perf~rrned.~
In a major chemical accident, an affected population may be exposed to a
wide range of health hazards. Medical treatment is largely supportive and may
offer minimal benefit. Only a few antidotes are available for the emergency
treatment of a handful of chemicals (Table 1).As a result, preventive measures

Table 1. ANTIDOTES FOR HAZARDOUS MATERIALS EXPOSURES

Antidotes Toxin
Atropine/pralidoxime Organophosphates/carbamates
Sodium thiosulfate (cyanide antidote Cyanide
package)
Calcium Hydrofluoric acid
Oxygen Carbon monoxide
Chelators (BAL, EDTA, DMSA) Heavy metals (arsenic, mercury, lead)
Methylene blue Methemoglobin inducers (aniline,
methylene chloride, nitrates,
nitrites)

Adapted from Kirk MA, Cisek J, Rose SR: Emergency department response to hazardous materials
incidents. Ernerg Med Clin North Am 12:461. 1994.
 HAZARDOUS MATERIALS 329

designed to eliminate the risk of further exposure or reduce the dangers of

secondary contamination become p a r a m ~ u n t . ~
Hazardous materials are used throughout industry, with various forms
found in our hospitals, homes, and businesses. These potentially toxic chemicals
impact every aspect of our lives. We depend on these materials to enhance our
standard of living, to develop new products and technologies, and to feed,
clothe, and house our population. Hazardous materials are economically im-
portant, irreplaceable in most circumstances, and potentially dangerous.
The price of our dependence is realized when either an intentional release
occurs or an accident handling these substances transpires. Accidental releases
of hazardous materials in the United States are a daily occurrence. In Texas, for
example, there is an average of 3.5 hazardous materials releases each day, some
of which result in death, injury, or e v a c ~ a t i o n .This
~ ~ information probably
underestimates the true scope of concern.
Terrorists have the capacity to intimidate large populations by manipulating
readily available hazardous chemicals. A homemade variety of the military
chemical nerve agent Sarin was recently released in a crowded subway station
in Tokyo, Japan, killing 12 and injuring over 5500 (Associated Press). Hundreds
of thousands of tons of this material are currently stored in the United States
and Europe. In Oklahoma City (April 1995), two frequently used hazardous
materials (ammonium nitrate and diesel oil) were combined into an explosive
that destroyed a government office building, killing and injuring numerous
individuals.

THEMANAGEMENTOFEXPOSURE

Federal
Federal agencies work with state agencies and local officials to decrease loss
of property and to reduce morbidity and mortality after a devastating calamity.
Earthquakes, hurricanes, tornadoes, and floods have the capacity to wreak havoc
on a macroscale and overwhelm local resources. A major earthquake in a
densely populated industrialized area has the potential of leading to a release
of hazardous materials.” Warning systems and local response mechanisms could
substantially be compromised. In addition, building collapses, fires, and dis-
placed populations would limit the capabilities of the local emergency manage-
ment and hazmat responses.
When resources at the local and state level are overwhelmed, the governor
contacts the federal government and requests aid. The FWZ4is designed to assist
local communities after a disaster or emergency situation in which there is a
need for federal assistance to augment local and state resources. The FRP
organizes the resources of 27 federal government departments and agencies
whose task is to provide this assistance. The type of assistance is grouped
functionally into 12 emergency support functions (ESF), two of which pertain to
hazardous materials and are summarized below.

ESF #9: Urban Search and Rescue

The Federal Emergency Management Agency (FEMA) has established rigor-
ous standards and training manualss3for the Urban Search and Rescue Teams
(US&R). Under the Task Force Leader and the Technical Teams Manager are
two well-trained and equipped hazmat specialists. Their responsibilities involve
330 LEVITIN & SIEGELSON

assessment, recognition, and identification of chemical hazards with the respon-

sibility of marking these areas with prominent hazmat placards to prevent injury
and morbidity. The hazmat specialists monitor atmospheres (e.g., flammable,
toxic, oxygen deficient) in and around the confined spaces of the collapsed
structures. Currently, the teams have vapor protective (Level A) suits for defen-
sive purposes, but do not have the capability of decontamination or medical
treatment of chemical injuries. In addition, splash protective (Level B) suits are
not currently available for the medical team.

ESF # 10: Hazardous Materials

ESF #10 provides support in response to an actual or potential release of
hazardous materials following a catastrophic man-made or natural disaster, such
as a flood, earthquake, or other event. A declaration of a federal emergency will
not necessarily activate this ESF. FEMA will determine, in consultation with the
Environmental Protection Agency (EPA) and the affected states, whether such
support is indicated.
Federal response to releases of hazardous materials is carried out under the
National Oil and Hazardous Substances Pollution Contingency Plan (NCP) (40
CFR 300). This would include oil discharges and releases of hazardous sub-
stances (e.g., chemical, toxic, pollutant, contaminant).
Currently, FEMA is developing a policy regarding response to hazmat
exposures such that significant resources might be organized by the federal
government from both private and government sources to respond in times of
disaster. Teams from the National Center for Environmental Health of the
Centers for Disease Control (NCEH/CDC) and the Agency for Toxic Substances
Disease Registry (ATSDR) have provided consultative support after chemical
releases in the United States and worldwide. Telephone consultations are avail-
able 24 hours a day at 404-488-7100. Federally sponsored specialized Disaster
Medical Assistance Teams (DMATs) or hazmat teams might be developed for
national use. These federal teams would enable small communities, over-
whelmed by a release of hazardous materials, to have access to federally spon-
sored hazmat experts.

Centers for Disease Control and Prevention

The Centers for Disease Control and Prevention (CDC) has the lead role in
assistance concerning biological, chemical, and radiologic hazards. This agency
will assess health and medical effects on the public and high-risk groups, advise
on protective actions related to human and animal exposures, and provide
technical assistance on medical treatment.
Large quantities of military chemical weapons are stored in eight depots in
the continental United States. During the next 10 years, the Department of the
Army will eliminate these chemical stores by incineration. The chemicals, blis-
tering (mustard) and nerve agents, were designed for lethality and ease of
distribution on the battlefield. Nerve agents, such as Sarin, have been used most
recently by terrorists in Tokyo, Japan (Associated Press), and the use of blistering
agents was documented during the Iran-Iraq War.8
The NCEH/CDC has made recommendations for the minimum standards
of medical preparedness for civilian communities that might be exposed to
chemical warfare agents during the incineration or storage process.z1 These
recommendations are intended for planning purposes for first responders and
primary and tertiary receiving hospitals. Issues addressed include decontamina-
 HAZARDOUS MATERIALS 331

tion, personal protective equipment (PPE), training, triage, security, and medical
transfer. This is the first federal document that has directly addressed these
issues. The standards were prepared in consultation with experts in the fields
of emergency medicine, disaster preparedness, nursing, military chemical pre-
paredness, fire, and emergency medical services (appendix).

Regulations
Federal regulations concerning hazmat preparedness and patient care re-
quirements exist to assist health care providers in their planning processes. These
regulations include OSHA standards that elucidate employer responsibilities for
employee safety; the Superfund Amendment and Reauthorization Act (SARA)
Title 111considers community preparedness and training in the event of a hazmat
release; and the Consolidated Omnibus Budget Reconciliation Act (COBRA),
which mandates the delivery of medical services to individuals seeking care in
an emergency department. The effect of these regulations on hazmat prepared-
ness is discussed in greater detail in this article.

State

States use pertinent federal OSHA regulations in their hazmat planning and
training. In some locales, OSHA has state-level regulating bodies that have the
ability to interpret federal OSHA regulations. Under these circumstances, state
OSHA has the authority to formulate regulations that meet or exceed federal
OSHA statutes.
Federally organized DMATs and US&R teams can be used and activated as
state resources in times of disaster. In this case, the state must assume the
financial and legal burdens of the teams and provide necessary support.

Local

County and city fire and EMS resources follow state and federal OSHA
guidelines, in addition to National Fire Protection Association (NFPA) recom-
mendations. Both of these organizations (OSHA and NFPA) are federally recog-
nized for their development of standards pertaining to hazmat response. In
individual localities, such as communities adjacent to military chemical weapons
depots and large chemical and petroleum facilities, special arrangements with
industry and government resources may provide extra support for hazmat and
disaster response teams. The mayor or senior local official may, after consulta-
tion with local emergency management officials, request aid from the governor
if local resources are overwhelmed after a catastrophe.

HAZARDOUS MATERIALS PREPAREDNESS-PROBLEMS,

CONTROVERSIES, AND REQUIREMENTS

Hazmat Data Collection

Emergency departments become involved with hazardous materials when

an accident occurs during the handling, transportation, or storage phase of these
compounds. The frequency of accidents resulting in victim contamination is
332 LEVITIN & SIEGELSON

difficult to accurately assess because there is a lack of mandatory accident

reporting requirements.6, Previous attempts to quantify victim contamination
from hazmat releases have been limited because a number of the events were
either missed or unreported, and the data collected lacked specific information
about the victims.2’Data collected by commercial entities, such as CHEMTREC,
or public resources, such as regional poison centers, provide facts about emer-
gency calls. This information, however, does not necessarily equate to the true
incidence of hazmat accidents or the number of victims involved. In addition,
many of the commercial organizations have inherent reporting biases that limit
the usefulness of this information.
Evaluations of existing databases may lead to incorrect conclusions. In 1989,
Binder6 evaluated the three largest national databases that record deaths,
injuries, and evacuations secondary to acute chemical releases. In 1986, a total
of 587 chemical releases were found to have occurred that resulted in death,
injury, or evacuation. Only eight of these cases (1%) were found in all three data
bases. These discrepancies resulted from different areas of emphasis among each
of the three databases and failure to report hazmat releases by responsible
parties (reporting biases).
In 1990, the ATSDR implemented a hazmat reporting system whose inten-
tion was to alleviate many of the previous data collection problems. Their
reporting procedure is a state-based hazardous substances emergency events
surveillance (HSEES) system designed to describe the public health conse-
quences associated with hazmat releases (all chemicals except petroleum prod-
ucts)?O Information was collected by state health departments, which included
details of the hazmat release, chemical identification, along with information on
the existence of victims, injuries, or evacuations. Sources of information included
records from state agencies, state environmental protection agencies’ personnel,
police, fire departments, and hospitals. By 1993, 11 state health departments
participated in the study.=
From January 1, 1993, to December 31, 1993, 11 states reported a total of
3945 hazmat releases. Eighty-four percent of the releases occurred at fixed sites
with the rest from transportation events. In 93% of these events, only a single
substance was released. Most of these released chemicals were either liquid
(64%) or vapor emissions (22%), with the most commonly released chemicals
reported during a hazmat incident including the following9,*y, 34:
Corrosives (sulfuric acid, hydrochloric acid, nitric acid, sodium hydroxide,
cleaning liquids)
Pesticides and herbicides
Gases (natural gas, chlorine, ammonia)
Fuels (diesel oil, gasoline)
These events occurred predominantly on weekdays primarily from 6 AM to
6 PM (71%), with only 16.5% of the accidents occurring on ~ e e k e n d s . ~ ~
During ATSDRs 12-month reporting period in 1993, 486 hazmat releases
(12% of all events) resulted in a total of 2269 victims having 4063 injuries.
Approximately 58% of these events involved only one victim and 12% involved
two victims. These accidents occurred most commonly at fixed sites. Respiratory
and eye irritation, along with nausea were the most common injuries reported.
Only 18.5% of all injuries were treated at the scene. Most of the victims (64%)
were transported for care to a hospital and 15% required admission. Sixteen
died as a result of the hazmat release (11employees, 5 from the general public).%
In a similar review of data by ATSDR from January 1990 to December 1992,
 HAZARDOUS MATERIALS 333

75% of the injured employees and 22% of the injured first responders were not
using any personal protective equipment at the scene of the hazmat release.
Only 43% of the first responders wore firefighter protective gear, 19% used
Level B protection, and 12% used Level A protection (see Personal Protective

Hospital Hazmat Preparedness

Every hospital must prepare to treat victims of hazmat accidents before an

incident occurs.18,34 The hospital must provide appropriate hazmat training,
provide personal protective equipment, and develop the policies and procedures
necessary to quickly and efficiently treat contaminated patients.13 A hazmat
(including radiation) policy should be incorporated into the hospital's disaster
plan.
Most hospitals in the United States are ill prepared to treat contaminated
patients.18,20, = Some of these hospitals are located in metropolitan areas, whereas

others are in small communities, which may lack the broad range of medical
specialists recommended for a decontamination facility.= Despite this lack of
preparedness, these institutions will be receiving contaminated patients if an
accident occurs in their community.
Deficiencies in hospital hazmat preparedness are related to a variety of a
factors. For instance, many institutions falsely believe that their emergency
department is prepared to treat victims of a hazmat 25 In 1989, a

study was published that reviewed the level of hazmat preparedness of 45

emergency departments in California. The level of preparedness was based on
the availability of personal protective equipment (i.e., protective clothing and
respirators) in the emergency department. Of those hospitals surveyed, two
thirds thought they had either protective garb or a breathing apparatus. Few of
the respondents actually knew where this equipment was located. Only 2 of
the 45 hospitals actually had protective equipment assigned to the emergency
department, although. in one hospital, the equipment was incomplete and out-
dated, and in the other hospital, the equipment was kept in an ambulance that
was not available on-site at all times.=
Health care institutions are generally not aware of the hazmat threat in their
community, thus preparedness has not been a pressing issue. Many hospitals are
unaware of their responsibilities and the existence of federal standards concern-
ing hazmat Preparedness. Federal law requires employers to furnish a place of
employment free from recognized hazards that are likely to cause death or
serious physical harm to its employee^.'^
A variety of regulatory and certification organizations require emergency
departments to be prepared in the event of a hazmat accident. Many of these
regulations and standards place hospitals in a precarious position when con-
fronted with a Contaminated patient. An emergency department whose staff has
not received appropriate training and personal protective equipment is in direct
violation of OSHA standards (29 CFR 1910.120; 1910.1200; 1910.132). One con-
taminated patient presenting to such an emergency department would be a
"recognized" hazard under this standard. Failure to provide proper training
and personal protective equipment under these circumstances violates federal
law.25Every individual presenting to an emergency department must receive a
medical screening examination according to COBRA. Choosing not to provide
care to a contaminated individual, due to a lack of hazmat training, is a potential
COBRA law violation. Transferring the potentially unstable ( e g , contaminated)
334 LEVlTlN & SIEGELSON

patient without decontamination may be in direct violation of COBRA.17In

addition, the failure to treat may pose broader ethical questions.
In addition to federal and state mandates, certain professional and certifica-
tion organizations have recently recognized the importance of hazmat prepared-
ness for hospitals. For example, the American College of Emergency Physicians
(ACEP), in the publication Clinical Policy for the Initial Approach to Patients with
Acute Toxic Ingestion or Dermal or Inhalation Exposure, warns physicians about the
potential adverse effects that may result from treating a toxic patient. Developed
by a group of toxicologists and emergency physicians, this clinical policy advo-
cates skin decontamination and protection of health care workers in the treat-
ment of contaminated patients. This policy does not, however, take a position
or provide direction on issues such as the hospital’s role in the decontamination
operation, training requirements of emergency department personnel, or level
of PPE requiredJ6Similarly, the Joint Commission of Accreditation of Healthcare
Organizations (JCAHO), which implements standards that must be met for
hospitals to receive accreditation, has also established specific hazmat prepared-
ness guidelines for hospitals’:
Standard EC.1.2.1 Hospitals have a process for providing a physical
environment free of hazards and for managing staff activities to reduce
the risk of human injuries.
Standard EC.1.2.3 Hospitals have a documented management plan, which
includes processes for educating and monitoring personnel who manage
or regularly come into contact with hazardous materials or wastes.
Standard EC.1.2.4 Hospitals’ emergency preparedness plan needs to inte-
grate their role in community-wide emergency preparedness efforts; and
identify, where appropriate, available facilities for radioactive or chemical
isolation and decontamination.
Standard EC.1.3.3 Hospitals have an orientation and education program
that addresses the proper emergency procedures during a hazardous
material and .waste spill or exposure for those personnel who manage or
come in contact with hazardous materials or wastes.
Standard EC.1.4.3 Hospitals’ emergency procedures for hazardous materi-
als and wastes address the specific precautions, procedures, and protective
equipment to be used during a hazardous material or waste spill or
exposure.
Standard EC.1.5.4 Hospitals are required to develop performance stan-
dards for their staff to effectively respond to disasters and emergencies
occurring in the environment of care. This performance standard includes
assessing staff‘s knowledge and skill requirements regarding their role in
the emergency preparedness management program.
These guidelines, however, suffer similar drawbacks as the ACEP Clinical
Policy discussed previously.
Finally, some hospitals may not be prepared to treat contaminated patients
because they believe that other health care facilities in their community have
acquired these skills and are therefore positioned to receive and treat hazmat
accident victims. This assumption fails to consider that most victims of a disaster
seek out the closest hospital for their medical care regardless of the institution’s
capabilities.4,56
It is controversial to require a mandatory level of hazmat preparedness for
all acute care hospitals. Many authors suggest that it is not necessary for every
hospital in a community to have the ability to treat contaminated patients.2,34 In
their opinion, one hospital with tertiary care resources should be designated
 HAZARDOUS MATERIALS 335

as a decontamination facility. In addition, hospitals not designated to receive

contaminated patients should rely on the local fire department for patient
decontamination. Yet despite these recommendations, these same authors agree
that all hospitals should be prepared if a contaminated patient presents to a
facility unannounced or if the designated hospital becomes overwhelmed.
SARA Title 111 (Community Right to Know Act) requires federal, state, and
local governments to provide planning for chemical emergencies, especially
mass casualty events. As a component of this standard, the governor of each
state designates a state and local emergency planning committee (LEPC) to
establish procedures for developing and implementing an emergency response
plan in the case of a hazmat incident. Members of the LEPC include elected
state and local officials; police, fire, and public health professionals; environmen-
tal, health, and transportation officials; and representatives of health care facili-
ties, community groups, and the media. As part of this planning process, specific
hospitals are designated as treatment facilities. By designating specific hospitals,
funding and training resources can be concentrated at these institutions with
prehospital transfer protocols established.'*,36, 40, 52
Identifying hospitals to receive contaminated patients, in theory, alleviates
the hazmat preparedness requirements of the other health care institutions in
the community. Unfortunately, this concept of designating hospitals as decon-
tamination facilities falsely assumes the following:
All contaminated victims will be decontaminated at the scene.
All patients involved in a hazmat incident will only be transported to
designated hospitals.
Contaminated victims arriving by private vehicle will only go to desig-
nated hospitals.
Victims incorrectly presenting to nondesignated hospitals can be safely
transferred to appropriate institutions.
Although decontamination is preferably performed at the scene of exposure,
a variety of factors, such as adverse weather conditions, technologic constraints,
and lack of prehospital training and equipment, may hinder or prohibit this
In addition, most hazmat accidents are small-scale events that occur
at the workplace involving only one or two 30, 36 These contaminated
individuals will often arrive at the hospital by private vehicle before any prehos-
pita1 decontamination?, 25
The hazmat training, personal protective equipment needs, and decontami-
nation requirements do not differ between a designated and nondesignated
decontamination facility. Assigning a hospital in a community to receive contam-
inated patients does not alleviate the preparedness requirements of all institu-
tions that might receive emergency ~atients.4~
It may be impractical to rely on the local fire department to decontaminate
patients at the hospital. Most fire departments in the United States are voluntary,
with financial constraints that may prohibit investing in hazmat emergency
response training and equipment. As a result, many communities do not have
teams that respond to hazmat emergencies, and therefore must rely on the
local hospital to perform decontamination.18,49 Second, hospitals in communities
fortunate enough to have hazardous materials response teams (HMRT) are quick
to realize that HMRTs are contracted to the city and not to the hospital. During
some hazmat accidents, these emergency responders may be occupied at the
scene, thus leaving hospitals to care for contaminated patients who reach their
emergency department without prehospital decontamination. This is especially
336 LEVITIN & SIEGELSON

true in circumstances where victims are unaware of their contamination and

present to the emergency department for related injuries.I8
In a 6-year review of patients presenting to a community hospital emer-
gency department for management of exposure to hazardous chemicals, none of
the 72 patients received prehospital decontamination.MConsequently, hospitals
must incorporate the necessary training, protocols, procedures, and equipment
to become self-sufficient in the care of the contaminated patient. Every hospital
should have the capability at the minimum to treat at least one or two patients,
which is the number of victims in the majority of hazmat accidents.21,28, 3o Larger
scale multiple casualty incidents would make hazmat preparedness difficult for
most hospitals. Such a large-scale hazmat event would overwhelm even the
most prepared institution?

Personal Protective and Decontamination Equipment

Requirements

Personal Protective Clothing

Employers are required to provide PPE to employees who have the potential
of being exposed to a variety of hazards capable of causing injury through
absorption, inhalation, or physical c ~ n t a c t . 'PPE
~ , ~ includes
~ clothing and respira-
tory gear that is used to shield an individual from an assortment of chemical,
biological, and physical hazards that may be encountered during a hazmat
incident. Choosing the proper level of protection depends on a variety of
factors, including the type of chemical hazard, its concentration, and the risk
of inhalation and skin contamination posed by the chemicaLSoAlthough no
combination of PPE protects against all hazards, the equipment chosen should
provide as much protection as possible to the skin, eyes, face, hands, feet,
and body.I3
Personal protective clothing (PPC) is multilayered garments composed of
different materials to provide the broadest protection against a variety of chemi-
cal agents. Traditionally, PPC is divided into four categories based on the level
of protection provided.I3
Level A-provides the maximal amount of vapor and splash protection.
Typically used by specially trained personnel in areas containing highly
toxic concentrations of chemicals. This suit is fully encapsulated and
chemically resistant and requires the use of a self-contained breathing
apparatus along with chemical protective gloves and boots.
Level B-chemically resistant suits that guard against splash exposures and
offer less protection against skin, eye, and mucus membrane exposure
compared with a Level A. This type of suit requires the use of a positive
pressure, full-faced respirator, along with chemically resistant gloves and
boots and is the minimum level of protection required for unknown
contaminants.
Level C-protection is used when the identity of the chemical hazard is
known and its exposure risk is below the concentration that will cause ill
effects. An air-purifying respirator may be required to filter out contami-
nants.
Level D-is only used when there is no danger of chemical exposure. This
ensemble includes work clothes without a respirator.
OSHA requires that the minimum level of protection for emergency person-
 HAZARDOUS MATERIALS 337

nel, if the chemical is unknown, is a Level B suit (splash protective) and a

positive pressure air respirator.7,I3This type of PPE was chosen because inhala-
tion and skin exposure are the most frequent routes of contamination.'8,34, 50
Level B protective gear gives the broadest protection to the chemicals most
commonly encountered, including radiation exposures.1sA higher level of pro-
tection (i.e., Level A or vapor protective clothing) is required in environments
immediately dangerous to life and health (IDLH), which is rarely encountered
in the hospital emergency department.I8,36
Despite OSHA's PPE requirements, a great deal of controversy exists con-
cerning the PPE needs of emergency department personnel. Much of this contro-
versy centers on the following questions: What is the appropriate level of
personal protection required? Is there a true secondary exposure risk to emer-
gency department personnel? Should selection of PPE be on a graded response
or should it be universal?
Some authors suggest that ordinary hospital gowns, plastic goggles, and
plain latex gloves will adequately protect hospital staff when performing patient
decontamination.z,18, 34, 42 These recommendations for a lower level of protective
equipment parallel the PPE requirements for radiation contaminated patients.I8
Although appropriate under these circumstances,applying these same standards
to the chemically contaminated patient may be inadequate and could provide a
false sense of security to emergency department personnel.18
A lower level of personal protection (i.e., Level C or D) is considered
reasonable by these authors for hospital-based decontamination. This type of
equipment requires less training, is universally available, and emergency depart-
ment personnel are already accustomed to its use. Published data are not
available, however, to support the safe use of Level C or D protective gear
for emergency department personnel when treating chemically contaminated
patients. Although a reduced level of protection may provide for easier accept-
ability, such a recommendation falsely assumes that adequate protection will be
provided and secondary contamination of health care workers will not occur.
On the contrary, toxic effects from secondary contamination have been reported
by hospital personnel and rescue and transport workers.I8
A number of highly toxic chemicals, including concentrated acids and bases,
hydrofluoric acid, pesticides, formaldehyde, and a variety of volatile solvents,
are commonly found in hazmat accidents. These substances pose a higher risk
of secondary contamination and require a level of personal protection above a
hospital gown and surgical gloves.I8 For these reasons, the same authors who
recommend Level C or D protective gear advise that if the chemical is known
to be potentially toxic, then a higher level of PPE will be required.',34
Selecting the level of PPE based on the properties of a particular chemical
is ideal (graded response), but often impractical in many situations when there
is not sufficient warning or information available when the untreated, contami-
nated patient presents to the triage desk.34In fact, most hazmat emergencies
involve either unknown substances or chemicals identified as being dangerous
(a threat to life and health of the p o p ~ l a t i o n )In
. ~addition,
~ many of the reference
values (e.g., immediately dangerous to life and health) and resource materials
(e.g., material safety data sheets) used to determine chemical toxicity are not
reliable in this en~ironment.~, 32, 34, Delaying patient care to determine PPE
needs may be disadvantageous since decontamination should be performed as
quickly as possible to prevent absorption of the chemical.'-", 27, 51 Under these
circumstances, an "all-or-nothing" approach may be appropriate in which one
level of protection is selected to provide the most "universal" protection.
The inconsistencies in PPE recommendations reflect that most of the re-
338 LEVITIN 81 SIEGELSON

search used in selecting this equipment is based on hazardous environments

encountered by the fire service or found in industry. Applying these same data
to the hospital environment may not be valid for a variety of reasons: the
contamination load on the patient is less than that found during the initial
release, the fire and explosion risk of the product on the patient is less than at
the accident scene, and decontamination often occurs in an open rather than a
closed environment. Closed environments are used in testing laboratories to
determine exposure limits. In addition, the risk of chemical breakdown of a suit
(penetration, permeation) is less likely because the quantity of pure chemical
available is usually reduced or diluted by the time of patient transfer to the
emergency department.ls
Other hazmat experts contend that the potential risks Level A and B suits
and respirators pose to rescuers may outweigh any advantage this equipment
provides. Level A and B suits are known to pose heat stress-related problems,
and when accompanied with gloves and a respirator, results in limitations in
maneuverability, visibility, and dexterity in performing various tasks.2,13, 33

Respiratory Protective Equipment

Two basic types of respirators are available: air-purifying and atmosphere-
supplying respirators. Both of these respirators have been recommended for
hospital-based decontamination.2, 34 Air-purifying respirators function by in-
haling air through a chemical filter that binds the vapors. These filters are
chemical-specific and require a moderate amount of work to inhale air through
the resistance of the cartridge. As a result, these respirators require a tight fit to
be effective.Is This type of respirator is typically used in industry where the
identity of the agent is known.
Atmosphere-supplying (positive pressure) air respirators are more versatile
for the emergency department because they offer airway protection in all situa-
tions, proper fit is less critical, and they provide a continual source of cool, clean
air.I8 Two types of positive pressure respirators are available: self-contained
breathing apparatus (SCBA) and supplied air respirator (SAR). SCBAs provide
medical air from a tank worn by the rescuer which is expensive, time-limited,
and typically too heavy for most emergency department personnel. In addition,
SCBAs require a great deal of maintenance and training.I8 SARs, on the other
hand, provide air to the rescuer via an air hose from an outside source (air tank
or permanent air supply) and can be used generally for any length of time.Is
OSHA recommends a positive pressure air respirator as the minimum
level of airway protection for unknown chemicals or for those posing potential
inhalation risk.l0Similar to the problems in selecting the proper level of personal
protective clothing, controversies exist concerning the need for and type of
respiratory protection required for health care workers.2, 22, 34, 50 This contro-
versy exists despite the fact that vapors are the most common route of exposure,
causing respiratory and ocular injury.28,30, 47 As a result, most authorities agree
that if an inhalation exposure risks exists, responding personnel should be
trained in the use of respirators (specifically positive pressure air respira-
tors).2, 34
Hazmat responders typically use the worse case scenario when selecting
appropriate PPE.ls Emergency personnel are required to wear the highest level
of protection until the chemical is identified and its properties are known to
require a lower level of protection.13In most situations, there is insufficient time
to adequately assess the secondary exposure risk, thus it is best to err on the
side of caution and protect accordingly.1s,34 Secondary exposure is the process
 HAZARDOUS MATERIALS 339

by which chemicals on a victim or their clothing can be transmitted to others.Is

The risk for secondary exposure in an emergency department is high; thus, a
PPE policy should be implemented at every hospital in which a chance for
secondary contamination exists. The type of PPE selected must provide the
broadest level of protection against the potential hazards encountered.
Two policy options should be considered in order to comply with OSHA
regulations and resolve some of the existing PPE controversies. First, the level
of PPE selected should be based on the known properties of the hazard. For
example, if the contaminant is known to pose negligible skin or inhalation
secondary exposure risks (e.g., radiation or vapor exposure), then a Level C suit
with an air-purifying respirator would be selected. If the chemical was found or
considered to have a secondary exposure risk, then a higher level of protection,
including a Level B suit with positive air respirator, would be chosen.
The second option in selecting PPE would be a universal policy in which
one level of protection is selected for emergency department personnel treating
all exposed and contaminated patients. Because hazmat accidents involving
victims are infrequent, it is much easier and less confusing for responding
personnel to use one universal PPE policy.'8, 36 The equipment selected should
provide the broadest level of protection to the chemicals most commonly en-
countered, require the least amount of training, and be available in multiple
sizes to satisfy the needs of emergency department personnel. Level B suits,
depending on the material and manufacturer, are suitable for these purposes,
especially when coupled with an appropriate respirator (positive pressure),
gloves (nitrile),'* and boots. When information about the chemical has become
known, adjustments in PPE can be made accordingly.
Appropriate planning by emergency department personnel can aid the
PPE selection process by researching the chemicals most commonly stored or
transported in the community (access information through SARA Title 111).
Combining this information with other sources (e.g., ATSDR, MSDS, poison
centers) will assist in the selection of the most appropriate PPE. Whichever level
of protection is chosen, it is essential that personnel are thoroughly trained in
its use.

Decontamination Equipment
Decontamination is the physical process of removing harmful substances
from personnel, equipment, and supplies. It should be performed whenever
there is a risk of secondary exposure from a hazardous substance. A person or
equipment may become contaminated by contacting vapors, gases, mists, solids,
or liquids from the source of contaminant or from others who are already
contaminated.
Various methods for performing decontamination are available (e.g., me-
chanical removal, absorption, degradation, and dilution) with dilution being the
most applicable to the hospital environment. Showering with large quantities of
water dilutes the offending agent, thus reducing the patient's skin contamination
load.36,37 The water is contained in a collection system for future disposal, if
necessary.
Showers may be located either inside (permanent) or outside the emergency
department (portable) in the ambulance bay or near the emergency department
entrance. Choosing the style of decontamination equipment and the proper
location for the decontamination area is based on a variety of factors, which
include space availability, access to water, medical air and electricity, financial
constraints, and patient traffic flow patterns. An additional consideration in
340 LEVITIN & SIEGELSON

choosing between a permanent and portable decontamination facility is the time

required for equipment setup, which should be minimized, to prevent delays in
initiating care.
Traditionally, permanent decontamination facilities have been recom-
mended for hospitals with the design typically modeled after radiation decon-
tamination rooms.7,41 This style of a permanent decontamination facility requires
a designated room that is large enough to hold one victim along with the
responding personnel. A separate air system ventilating to the outside is neces-
sary along with a self-contained water collection system. The floor, including
the point of entry, walls, ceiling, electric outlets, light switches, and cabinetry
are all covered with plastic to limit the spread of contamination. A variety of
markings is placed on the floor to designate clean verses contaminated areas.7,41
Other methods of inside (permanent) decontamination used by hospitals
include use of a showering system in the morgue, in the nurses' locker room, in
the emergency department hallway, or in a separate room built solely for the
purposes of decontamination. Only the latter is the system of choice if a perma-
nent decontamination facility is selected.
The anticipated benefit of a permanent decontamination room is that it
affords patient privacy, provides protection from the weather, and is located
closer to a source of medical air and water. Converting examination space into
a decontamination room, however, is extremely time consuming and is very
labor intensive. Bringing a contaminated patient into the hospital and directing
them through the facility to the decontamination area increases the risk of
spreading the contamination.
Permanent decontamination rooms are costly to build and typically are
nonrevenue-producing square footage. These decontamination rooms are often
designated for other purposes (i.e., storage, splinting, and casting rooms) thereby
delaying the implementation of the decontamination operation. Concerns also
exist that a permanent decontamination room, unless properly ventilated, be-
haves like an enclosed space, increasing the risk of inhalation exposure.18
Hospitals considering a permanent decontamination facility need to desig-
nate one room whose sole purpose is patient decontamination. The room should
have a separate entrance from the outside, be located near the emergency
department, and be large enough to contain one or two victims and two to four
health care workers. A source of medical air and water should be readily
available, and all water from the decontamination operation should be collected
in a holding tank (container).=
Portable decontamination equipment allows for outside decontamination
and offers the advantage of mobility while being less expensive than equipping
an indoor decontamination room.I8 According to OSHA (29 CFR 1910.120),
"Decontamination shall be performed in geographical areas that will minimize
the exposure of uncontaminated employees or equipment to contaminated em-
ployees or eq~ipment."'~ Performing decontamination outside the main hospital
offers the following advantages:
1. Minimizes the potential contamination of other patients, visitors, or
health care providers.
2. Does not contaminate the facility. This potential always exists when
contaminated patients are brought inside the hospital for evaluation and
treatment.Is
3. Maintains normal patient traffic flow through the emergency department.
4. Lowers inhalation exposure risk. Decontamination indoors increases the
 HAZARDOUS MATERIALS 341

risk from vapors in an enclosed space. (Emergency responders should

still use respirators with outside decontamination.)18
5. Allows for handling multiple patients. A variety of commercially avail-
able portable decontamination units are designed to treat multiple pa-
tients simultaneously.
6. Simplifies decontamination area preparation. The time requirement for
setting up a portable decontamination area is less than converting exami-
nation space into a decontamination room.
The disadvantages of outside decontamination (lack of privacy, problems
with inclement weather, water collection, and access to an air supply) can be
easily overcome with simple engineering controls. For example, the shower can
be enclosed with a tarp which provides privacy and wind blockage. The water
entering the shower could be heated (using a mixing valve) with the decontami-
nation runoff contained in a collection pool for future disposal. This collection
pool should be large enough to accommodate a nonambulatory patient on a
backboard. Typical baby pools are too small for this function. A permanent
medical air supply connection could be located near the decontamination area
for easy access because the airline for SARs is able to run up to 300 feet. Finally,
commercially available tents and heating units can be quickly installed.
Whichever style of decontamination system is chosen, it is essential that the
patient is decontaminated before entering the emergency d e ~ a r t m e n t This
.~~
policy needs to be enforced regardless of the patient’s medical status or degree
of inclement weather. The typical ABCs should be performed simultaneously
when possible with decontamination procedures. Seventy percent to 80% of
decontamination is the removal of the patient’s clothing.lS

Training Requirements
Treating patients exposed to or contaminated by hazardous materials re-
quires training of emergency department personnel. Ideally, a minimal level of
training (e.g., awareness, familiarity with policies and procedures) should be
provided to all emergency department staff and support personnel. Because
emergency departments operate 24 hours a day, limiting training to only a few
designated individuals would be disadvantageous.ls,34 Individuals requiring
some degree of training include emergency department nurses, technicians,
physicians, maintenance, security, and other support personnel. The level of
training required depends on an individual’s designated responsibilities during
the decontamination operation.
OSHA, under the Hazardous Waste Operations and Emergency Response
(HAZWOPER) standard, impacts every level of emergency response from pre-
hospital hazmat accidents to hospital-based decontamination. OSHA defines an
emergency response team as an individual or group who responds to a release
of a hazardous material, no matter where the release occurs.13If this release
takes the form of a chemical emitting from a patient’s clothing, the emergency
department personnel responding (providing care) to this patient would, by
definition, be an emergency response team. As a result of this classification, the
training objectives, personal protective equipment needs, and planning provis-
ions required under HAZWOPER would apply to emergency department per-
sonnel in the following circumstance^'^^ 31:
1. A contaminated accident victim presents to the emergency department.
2. A hospital responds as an integral unit of a community-wide emergency
response to a release of a hazardous substance.
342 LEVITIN & SIEGELSON

3. A hospital has an internal release of a hazardous substance (eg., ethylene

oxide, formaldehyde) requiring emergency response.
4. A hospital is designated by the Local Emergency Planning Committee
(LEPC), mandated by the Superfund Amendment and Reauthorization
Act (SARA) to respond to emergencies in the community.
5. A hospital has a Resource Conservation and Recovery Act (RCRA)permit
for an on-site hazardous waste treatment, storage, and disposal facility.
The original target audience of OSHA's HAZWOPER regulation was haz-
ardous waste operators and emergency response personnel at treatment, storage,
and disposal fa~ilities.3~For these reasons, many hazmat experts have questioned
the applicability of HAZWOPER to the hospital e n ~ i r o n m e n tAs
. ~ ~a result, in
1990, after HAZWOPERs final rule was implemented, OSHA began to evaluate
the role of hospitals, particularly emergency department personnel, in the haz-
mat OSHA recognized that emergency department personnel are
integral to the decontamination operation, yet much of the containment and
confinement training of responding emergency personnel are not necessary for
these individuals.&
Hazmat emergency response differs significantly in the prehospital and
hospital environment. Prehospital emergency responders are concerned primar-
ily with containing the spill, thereby limiting the risk of exposure. Gross decon-
tamination of personnel and victims is performed in a multistep process, as a
temporary measure, before hospital transportation. This type of decontamination
requires more support personnel which are often not available in most hospitals.
The main focus of emergency department personnel during a hazmat inci-
dent is protecting themselves and the facility. Treatment is directed toward
patient decontamination. Because the ED is located away from the area of
release, containment procedures take on less importance. Hospitals are con-
cerned with issues unique to their environment, such as staffing constraints,
need and appropriateness of decontamination procedures and antidote therapy,
evacuation procedures, liability issues, risk of emergency department closure
from the potential spread of contamination, and a variety of patient care issues
unique to the emergency department.
HAZWOPER emphasizes the training of all employees who could poten-
tially be exposed to hazardous materials. The level of training varies depending
on the risk of exposure and the specific roles and responsibilities of each
employee during a hazmat event. At a minimum, all emergency department
personnel should be trained to the First Responder Awareness Level (Table 2).
This training provides the staff with the knowledge, skills, and abilities to
recognize hazmat releases, identify spills that require specific equipment and
training for clean-up, and how to notify the proper authorities to initiate emer-
gency res~onse.'~ Personnel actually involved in a decontamination operation
(i.e., donning PPE, decontaminating patients) need to be trained to the First
Responder Operation Level (Table 2).4e46According to OSHA, "Emergency
medical personnel who would decontaminate victims who were involved in a
release of a hazardous substance are to be trained to the First Responder
Operations Level, 29 CFR 1910.120 (4) (6) (ii), which provides instruction on the
selection and use of PPE and on basic decontamination procedure^."^^
In addition to these training requirements, HAZWOPER requires employers
(such as hospitals) to have a written emergency response plan that details all of
the procedures necessary during an emergency response, including the follow-
ing elementsl3:
1. Planning: developing and implementing a plan before a disaster occurs
2. Personnel roles, lines of authority, and communication: developing stan-
 HAZARDOUS MATERIALS 343

Table 2. HAZARDOUS MATERIALS TRAINING LEVELS

Level 1: First-responder Awareness
Witnesses or discovers a release of a hazardous material and is trained to notify the
proper authorities. Training includes recognition and identification of hazardous materials,
proper notification procedures, and employee's role in ERP.
Level 2: First-responder Operations
Responds to release of hazardous substances in a defensive manner, without trying to
actually stop the release. Requires Level 1 competency and 8 hours of additional training
in basic hazard and risk assessment, PPE selection, containment and control procedures,
decontamination, and standard operating procedures.
Level 3: Hazardous Materials Technician
Responds aggressively to stop a release. Requires 24 hours of Level 2 training and
competencies in the following: detailed risk assessment, toxicology, PPE selection,
advanced control, containment, and decontamination procedures, air-monitoring
equipment, and the incident command system (ICS).
Level 4: Hazardous Materials Specialist
Responds with and provides support to hazardous materials technicians, but has
advanced knowledge of hazardous materials. Requires 24 hours of Level 3 training and
proven competencies, along with advanced instruction, on all specific hazardous material
topics.
Level 5: On-site Incident Commander
Assumes control of the incident beyond what is required for Level 1. Requires 24 hours of
training equivalent to Level 2 with competencies in the ICS and ERP, hazard and risk
assessment, and decontamination procedures.

Data from the Code of Federal Regulations, 29, 1910.120, 1989.

dard operating procedures (SOP) describing staff responsibilities during

a hazardous'materials operation
3. Emergency recognition and prevention: recognize potential problems and
develop a plan to resolve them
4. Site security and control: secure the area and keep out unauthorized
personnel
5. Evacuation routes and procedures: a plan to evacuate the emergency
department and hospital if necessary
6. Decontamination procedures
7. Emergency medical treatment
8. Critique of response: a mechanism to evaluate the hazmat incident
9. Personal protective equipment (PPE)

SUMMARY AND RECOMMENDATIONS

Hazardous materials offer a variety of unique challenges to emergency

personnel. These agents have immense economic impact, but when mishandled,
they become notorious for turning contained accidents into disasters involving
the entire During a hazmat accident, the victims often ignore the
rules of the disaster plan by seeking out the nearest hospital for medical care,
regardless of that institution's capabilities. Health care workers rushing to the
aid of contaminated individuals, without taking appropriate precautions (i.e.,
donning PPE), potentially make themselves victims.
344 LEVITIN & SIEGELSON

Disaster preparedness requires planning, policy, and procedure develop-

ment, hazard analysis, training, and the availability of personal protective equip-
ment for all responding personnel. Presently, the level of hazmat preparedness
varies greatly among different hospitals, EMS and fire services, and disaster
response teams. These differences in hazmat preparedness can be linked to a
variety of factors (lack of awareness, funding, and support) and controversies
(types of PPE and level of training required) which have prevented the establish-
ment of a national hazmat policy for most of these organizations.
Despite these difficulties, emergency departments continue to be the pri-
mary provider of care to contaminated individuals. As a result, emergency
physicians must work with their hospital to implement a hazmat decontamina-
tion program in order to appropriately care for these individuals. The appendix
to this article presents a list of recommendations for hospital hazmat prepared-
ness. It is modeled after existing CDC and OSHA guidelines.

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Address reprint requests to

Howard W. Levitin, MD, FACEP
Department of Emergency Medicine
St. Francis Hospital and Health Centers
1600 Albany Street
Beech Grove, IN 46107

Appendix
RECOMMENDATIONS FOR HAZARDOUS MATERIALS
DISASTER PREPAREDNESS*

1. Hospital Disaster Plan

Every hospital disaster plan should include policies and procedures to

handle contaminated patients. Disaster drills should include scenarios in which
patients (ambulatory and nonambulatory) contaminated with hazardous materi-
als present to the hospital without any prior decontamination. These disaster
drills should be evaluated using the hospital’s quality assurance program. The
knowledge, skills, and abilities of all responding personnel should be reviewed
on an annual basis (recertification) to help maintain their professional compe-
tency.

*Data from the Code of Federal Regulations, 29, 1910.120; arid the Department of
Health and Human Services, Centers for Disease Control and Prevention: CDC recommen-
dations for civilian communities near chemical weapons depots: Guidelines for medical
preparedness. Fed Reg 6033308, 1995.
 HAZARDOUS MATERIALS 347

2. Triage Considerations

Any patient suspected of being exposed or contaminated by hazardous

materials should not be permitted entry into the emergency department (ED)
without adequate evaluation and decontamination. Triage personnel should
receive appropriate training in the identification of hazardous materials and the
workings of the hospital’s disaster plan.

3. Security

Topics related to ED security during disasters should be addressed, particu-

larly those issues pertaining to decontamination area access and entry into
the hospital.

4. Decontamination

All persons who may have been contaminated by a hazardous material

should be decontaminated. Proper decontamination prevents secondary contam-
ination of medical and rescue personnel. Hospitals will need to have specific
decontamination solutions (e.g., water, soap, 5% hypochlorite) and antidotes
(e.g., atropine, 2-PAM, cyanide kit, methylene blue, etc.) available, as needed,
along with an ability to contain any decontamination runoff.
At a minimum, every hospital should have the capability to decontaminate
at least one or two ambulatory or nonambulatory patients. Decontamination
should preferably be performed outside the ED. An inside permanent decontam-
ination facility is acceptable if it has an independent entrance from the outside,
large enough to hold at least one nonambulatory patient and two responding
personnel, a separate air system ventilating to the outside, and the ability to
contain the decontamination runoff. Having indoor decontamination facilities
does not alleviate the hospital‘s need for outside decontamination capabilities in
the event of a mass causality incident.

5. Personal Protective Equipment (PPE)

Chemical protective clothing and respirators selected should provide appro-
priate protection (skin, eyes, and respiratory tract) to responding personnel.
These individuals must be familiar with their PPE and trained in its usage
according to OSHA regulations. If the chemical is unknown or poses potential
skin, eye, or inhalation exposure risk, the minimum level of PPE will include a
Level B suit, chemical protective gloves and boots, and a positive air respirator
(SAR or SCBA).
If the chemical is positively identified and its known properties pose negligi-
ble secondary exposure risks, then a Level C suit, surgical gloves and shoe
protection, and an air-purifying respirator would be considered appropriate
PPE .

6. Level of Training

All medical personnel designated under their hospital’s disaster plan to be

members of the decontamination team should receive training appropriate to
348 LEVITIN & SIEGELSON

their level of responsibility. At a minimum, this will include awareness training

consistent with the objectives of OSHA (29 CFR 1910.120 [q]). Medical staff who
are required to wear PPE during a decontamination procedure should receive
training to the First Responder Operations Level as dictated by OSHA (29 CFR
1910.120 [q]).

7. Transportation of Patients to Other Medical Facilities

Patients requiring specialized medical care beyond decontamination may

be transferred to other medical facilities after first notifying the receiving hospi-
tal and having the patient accepted by a physician and the emergency facility at
that institution.