Hospital emergency departments (EDs) differ from other sections of the hospital in that patients are brought in from outside the hospital and often have life-threatening injuries. Because ED patients frequently require rapid treatment, ED personnel must work quickly, even without complete patient information or knowledge about the cause of the illness or injury. Because of this, ED personnel are at risk of injury or illness resulting from secondary contamination. Secondary contamination may occur when a patient is exposed at the scene to a chemical, radiological, or biological agent, which is then inadvertently transferred to attending personnel or equipment in an ED.Reference Ghilarducci, Pirrallo and Hegmann 1 , Reference Okumura, Suzuki and Fukuda 2 Optimally, a patient with chemical exposure would be fully decontaminated before arrival at an ED. However, this often does not occur.Reference Okumura, Suzuki and Fukuda 3 , 4 One reason for this is that patients may be transported by private vehicles to the ED without being treated by the field emergency medical services (EMS) system.Reference Okumura, Suzuki and Fukuda 2 - Reference Trutt and Oster 9 On the other hand, even when transported by EMS, chemical casualties are not always decontaminated in the field.Reference Vogt and Sorensen 5 , Reference Cooper, Souther and Hanlon 10 , Reference Merritt and Anderson 11 Further, EMS responders may be unaware that a toxic exposure has occurred.
In this report, we describe 5 single-patient chemical emergencies involving secondary exposure in which contamination occurred in the ED, the ED was evacuated, or the ED had to be temporarily shut down. Data for this report were obtained from the Hazardous Substances Emergency Events Surveillance (HSEES) system and the National Toxic Substance Incidents Program (NTSIP), which replaced the HSEES in 2010.Reference Duncan and Orr 12 Both systems were or are operated by the Agency for Toxic Substances and Disease Registry (ATSDR) of the US Department of Health and Human Services.
METHODS
HSEES was and NSTIP is a state-based surveillance system for acute hazardous substance releases.Reference Duncan and Orr 12 Participating state health department personnel enter event-specific information into standardized data fields in a common database managed by ATSDR. Searches of HSEES and NTSIP data for hazardous substance releases that resulted in secondary contamination were performed. The search was limited to the period after 2007 because events involving secondary contamination in prior years have already been described.Reference Horton, Orr, Tsongas, Leiker and Kapil 13 - Reference Horton, Burgess, Rossiter and Kaye 15 Event records that contained the key words “ambulance,” “hospital,” “decon,” “responder,” “EMS,” or “fire” in the description of the event were extracted. The resulting records were then reviewed and events not involving ED secondary contamination were excluded.
RESULTS
HSEES/NTSIP data included 33,001 separate events for the years 2007–2013. Of those, 5 incidents (0.02%) involving secondary contamination of an ED were detected. Descriptions of those incidents follow.
Incident 1: Sulfuric Acid
In 2009, a Texas rail yard worker succumbed to various symptoms subsequent to inhalation exposure to sulfuric (and possibly phosphoric) acid. Working inside a railroad tank car used to transport sulfuric acid, he had been removing rust with a phosphoric acid–based product. The worker had used personal protective equipment (PPE) that included a self-contained breathing apparatus (SCBA) while inside the tank car. Upon exiting and doffing the SCBA, he realized he had left personal equipment inside the tank. The worker then re-entered without the SCBA. He immediately lost consciousness and was removed from the tank approximately 2 to 4 minutes later. The worker exhibited respiratory irritation and developed nausea and vomiting. EMS transported the worker to the regional medical center. It was not reported whether EMS alerted the medical center that a contaminated patient would be arriving.
Upon arrival in the ED, the worker was incoherent, had bloody emesis, and emitted a strong odor of sulfuric acid. After ED personnel removed his clothing and performed decontamination procedures, 2 ED nurses (who later reported detecting strong sulfuric acid odors) began to vomit. One of these nurses also experienced unspecified heart problems. Six other ED personnel also developed nausea and vomiting, eye irritation, unspecified respiratory symptoms, headache, dizziness, or other central nervous symptoms. Three other ED personnel with potential exposure due to proximity to the worker did not develop symptoms. Data reported to ATSDR indicated that level “B” PPE (which includes SCBA or an air-hose supplied respirator) was worn by affected ED personnel. It was not reported whether ED personnel donned PPE before arrival of the patient. The exposure-related symptoms experienced by the ED personnel suggests that respirators were not worn properly or were not worn during the entire time the patient was being treated or contaminated clothing was being handled.
All affected ED personnel were decontaminated on site and then released. It was not reported whether the ED was closed as a result of this event. After being decontaminated, the rail yard worker was admitted to the hospital for additional care.
Incident 2: Methamphetamine Production Chemicals
In 2011, a mobile methamphetamine laboratory exploded in a busy parking lot of a Tennessee hospital, resulting in one victim and destroying the victim’s car. The explosion occurred in close proximity to the hospital, and responding firefighters transported the only victim to the hospital’s ED without performing field decontamination. It was not reported whether the first responders had time to alert the ED in advance of patient arrival or if they had time to don appropriate PPE. Although no ED personnel were injured in this event, the ED had to be shut down to be decontaminated. ED staff and the responding firefighters were also decontaminated. The victim of the explosion later died from severe burns.
Incident 3: Methamphetamine Production Chemicals
In 2011, a methamphetamine laboratory fire damaged 6 apartments in Tennessee. One victim of the fire was transported to a nearby ED via a privately owned vehicle. At the ED, the victim claimed to have been burned in a gasoline explosion. Police arrived at the ED to investigate, linked the victim to the apartment explosion, and suggested to ED staff that the victim likely had been exposed to methamphetamine production chemicals. The victim was decontaminated with water and transported to the area burn unit. Part of the emergency room was temporarily shut down for decontamination. The local fire department assisted with the decontamination process. Although none of 35 staff reported illness, 15 were decontaminated as a precaution. The hospital returned to normal operation about 45 minutes later.
Incident 4: Malathion
In 2013, a New York woman intentionally ingested malathion, an organophosphate insecticide, in her home. EMS responded, but it was not reported whether field decontamination of the patient was conducted or whether EMS alerted the local ED about the nature of the patient’s contamination. EMS then transported the patient to the ED, where she gave off a strong chemical odor. ED staff and patients, approximately 75 persons, were subsequently evacuated and a hazardous materials (hazmat) team was called in oversee the situation.
Incident 5: Malathion
In 2013, a Tennessee man ingested malathion and was taken to a nearby ED where he later died. ED staff were unaware of what the man had ingested and quarantined his body within the ED. As a precaution, a portion of the ED was locked down for several hours. A local hazmat team decontaminated more than a dozen ED staff. In this case, the 4-hour decontamination did not interfere with operations. No other patients were affected.
DISCUSSION
Events involving secondary contamination of EDs have been previously reported by use of surveillance data from the HSEES system.Reference Horton, Orr, Tsongas, Leiker and Kapil 13 HSEES was an active, multi-state health department surveillance system for morbidity and mortality from acute releases of hazardous substances and was replaced by the NTSIP in 2010.Reference Duncan and Orr 12 Events involving secondary contamination are rare. Only 5 events, 0.02% of all events captured by HSEES/NTSIP between 2007 and 2013, were detected. By comparison, 22 events involving ED secondary contamination were detected in the HSEES/NTSIP systems during the period of 1995–2006.Reference Horton, Orr, Tsongas, Leiker and Kapil 13 - Reference Horton, Burgess, Rossiter and Kaye 15 Despite being rare, events involving secondary contamination have the potential to harm health care personnel or result in the temporary disruption or closure of an ED. With demand for services outpacing present ED capacity in the United States, 16 even a temporary ED closure can have significant impacts on community health. Furthermore, secondary contamination of an ED may be more likely during a catastrophic event such as a natural disaster or a terroristic act involving a release of a hazardous chemical, biological, or radiological agent, events during which a community can ill afford an ED closure.Reference Reitherman 17 - Reference Lindell and Perry 19
Several best practices for ED response to patients contaminated with chemicals have been advanced. The first practice is to establish hospital-based decontamination protocols and train response teams such that decontamination can commence within minutes of a patient’s arrival at the ED. The response team should be cognizant that ED staff are only likely to become aware of a contamination incident after affected victims arrive at the hospitalReference Auf der Heide 20 and should be prepared to initiate a basic decontamination without full knowledge of the identity of the contaminant. Cibulsky et al note that there is no consensus in the literature regarding a best method to assess a patient’s decontamination needs. 21 However, they provide the following guidance for assessing the need to decontaminate a patient: 21
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∙ Signs and symptoms of exposure displayed by patients;
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∙ Visible evidence of contamination on the patient’s skin or clothing;
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∙ Proximity of the patient to the location of the release;
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∙ Contamination detected on the patient using appropriate detection technology;
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∙ The chemical identity (if known) or physical state, characteristics, and behavior (if unknown);
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∙ Request by the patient for decontamination, even if contamination is unlikely.
Although it is preferable to decontaminate patients before they are transported from the scene, this does not always occur and every ED must be prepared to carry out this task. Basic chemical decontamination, dating back to at least World War II, involves removing the patient’s clothing and rinsing him or her with water.Reference Scanlon 22 Improving on this generic decontamination method, another best practice is to train ED personnel how to quickly access information on decontamination procedures for patients exposed to common chemicals using readily available tools, such as the Wireless Information System for Emergency Responders (WISER; http://wiser.nlm.nih.gov/). Permanent hospital decontamination facilities are regarded as preferable to temporary ones because they can be activated more quickly and generally provide more protection during adverse weather. 23 A decontamination area that is well ventilated and with a ventilation system independent from the hospital is best able to prevent cross-contamination. 23 When this is not possible, decontamination may have to be performed outside the ED to prevent contamination of the ED and the patients within.Reference Macintyre and Barbera 24 In such a case, a source of warm water and protection from the elements should be ensured. While ED personnel are less likely to experience the same exposure levels as responders at the site of a chemical release,Reference Hick, Hanfling and Burstein 25 training the decontamination team in the selection and use of appropriate PPE would be beneficial. Finally, to develop and maintain competency, the decontamination team should undergo regular refresher training and drills.Reference Hick, Penn, Hanfling, Lappe, O’laughlin and Burstein 26 The Occupational Safety and Health Administration has documented mandatory requirements and best practices for ED management of casualties exposed to hazardous substances. 23 Hospitals may also consider developing response practices in the context of local emergency planning committees 27 and health care coalitions.Reference Toner, Waldhorn, Franco, Courtney, Rambhia, Norwood and Inglesby 28 These collaborative groups may be able to provide hospitals with likely incident scenarios, especially in communities with fixed facilities, such as industrial plants or transportation hubs. Conducting incident surveillance, as done with HSEES and NTSIP, allows for evidence-based planning.
It is unclear how many of the above best practices were implemented in the cases presented here. In incident #1, although it is unknown whether the ED was alerted that the patient was contaminated with sulfuric acid vapor, ED staff apparently deployed with appropriate PPE. Ideally, the patient would have had his clothing removed and stored in chemically resistant, vapor-proof sealed containers for later disposal. The ED staff performing the decontamination would have optimally donned PPE prior to contact with the patient, decontaminated the patient, passed the patient into the ED, undergone decontamination themselves, and then doffed their PPE. Incident #3 illustrates how ED staff may be forced to operate with incomplete (or misleading) information when patients are not transported to the ED via EMS. The incidents involving malathion highlight, once again, that victims may be admitted to an ED without apparent need for decontamination but still have potential to contaminate the ED via their vomit.Reference Geller, Singleton and Tarantino 29
CONCLUSIONS
It is encouraging that few events involving ED secondary contamination were detected by the HSEES/NTSIP system. However, the cases presented here demonstrate that secondary contamination continues to be a risk to EDs. This is particularly the case when, as so often happens, patients arrive unannounced by private car or other nonambulance vehicles. Making hospitals aware of the risks associated with secondary contamination and the benefits of proactively training and equipping staff to perform decontamination may reduce the risk of secondary contamination. For situations in which ED secondary contamination occurs despite the implementation of relevant protocols, investigations into these types of occurrences could be conducted to prevent future incidents.
Disclaimer
The conclusions of this article are those of the authors and do not necessarily represent the views of ATSDR, CDC, or the US Department of Health and Human Services.
