Deliberate process for recommending personal protective equipment

Health care facilities war on terrorism:
a deliberate process for recommending personal
protective equipment
Kristi L. Koenig MDa
, Connie J. Boatright RN, MSNb
, John A. Hancock MS, CSPc
Frank J. Dennyc
, David S. Teeter PharmD, RPhd
Christopher A. Kahn MDa,
*, Carl H. Schultz MDa
Department of Emergency Medicine, University of California, Irvine, Orange, CA 92868, USA
Indiana Primary Health Care Association, Indianapolis, IN 46202, USA
Department of Veterans Affairs, Washington, DC 20420, USA
Wishard Hospital, Indianapolis, IN 46202, USA
Received 1 May 2006; revised 15 June 2006; accepted 26 June 2006
Abstract The protection of health care facility (HCF) staff from the effects of weapons of mass
destruction has gained heightened attention since the 9-11 terrorist attacks. One critical component of
protection is personal protective equipment (PPE). No universal standard exists for an bessentialQ level
of PPE for HCF staff. The absence of such a standard raises the need for development of national policy
for PPE levels, particularly in HCFs. We describe a process used by the Veterans Health Administration
for recommending policy for bessentialQ PPE levels. Although the recommendations are specific for
Veterans Health Administration, the process, findings, and applications may be useful to other
institutions as they attempt to resolve this critical issue. This descriptive account will serve to generate
practical scientific debate in the academic community and lead to definitive public policy
recommendations for the Nations HCFs in executing their roles in the event of a terrorist attack.
D 2007 Elsevier Inc. All rights reserved.
1. Introduction
Until the terrorist attacks of September 11, 2001, most
people working in the emergency management and health
care communities based plans and operations on the
assumption that use of weapons of mass destruction
(WMD) was little more than a theoretical concern. A
theoretical threat no more, WMD are a valid concern and
have prompted expedited planning that ensures in-place
programs for defending people and facilities against the
harmful effects of chemical, biologic, and radiological
agents and high-explosive devices. In the January 2000
issue of JAMA, Macintyre et al [1] described health care
facilities (HCFs) as ban integral, yet often overlooked
component of overall community response.Q In the recent
past, personnel at HCFs could expect to treat the occasional
0735-6757/$ see front matter D 2007 Elsevier Inc. All rights reserved.
Disclaimer: the views expressed in this article do not necessarily
represent the view of the Department of Veterans Affairs or of the United
States Government.
* Corresponding author. Tel.: +1 714 456 5239; fax: +1 714 456 5390.
E-mail address: [email protected] (C.A. Kahn).
American Journal of Emergency Medicine (2007) 25, 185 195
patient contaminated with hazardous agents but often after
prehospital personnel performed on-scene decontamination.
Now, the scene may be at or near the HCF [1]. Previous
studies show that patients will converge on hospitals and
may bypass prehospital evaluation. In a mass casualty
situation, it is likely that large numbers of patients will leave
the scene and present themselves to hospitals. Health care
facility personnel may find themselves on the front lines,
being the first to assess victims contaminated with WMD
agents [2]. Health care facility personnel are attempting to
embrace this new role but are finding that existing standards
for personal protection and decontamination were developed
for traditional bfirst respondersQ going to the scene of an
incident. They do not take into consideration the scenario of
patients who present to an HCF after exposure to an
unknown concentration of an unidentified chemical, biologic, or radiological terrorism agent. Personnel in fixed
facilities become the bfirst respondersQ or bfirst contact
personnelQ in the case of biologic terrorism or for patients
exposed to chemical terrorism who bypass the prehospital
system. This role as front-line community responders is
expanding and receiving new emphasis.
Many HCF leaders and practitioners are compelled to bdo
somethingQ to prepare staff and facilities for terrorist use of
WMD, lest they find themselves vulnerable and unprepared.
Because national scientifically validated standards and
guidance on issues such as personal protective equipment
(PPE) levels and decontamination procedures for hospitalbased personnel are lacking, HCF decision makers are
applying a variety of approaches in preparing those who may
receive large numbers of contaminated victims. The Veterans
Health Administration (VHA) of the Department of Veterans
Affairs (VA), the largest and most comprehensive health care
system in the United States, is taking deliberate steps in
preparing its HCFs for response to WMD incidents. The
process described here for recommending selection of PPE
levels may assist others as they begin to address the
complexities associated with the novel challenges facing
HCFs in this unfamiliar environment. Clinicians, planners,
administrators, and managers at all levels and with a variety
of experiences have presented diametrically opposing views
on appropriate PPE levels for providers at HCFs.
Our purpose in writing this article is to present the
approach by VHAs Emergency Management Strategic
Healthcare Group (EMSHG) (TAC), a group that focused specifically on preparedness
issues for VHA personnel at its 163 medical centers. One of
the initial tasks of the EMSHG TAC was to determine
bessentialQ levels of PPE for all VHA HCFs. The term
essential was used in place of minimum as a modifier for
PPE standards to avoid any potential negative connotation.
Although this approach may or may not be appropriate for
other environments, our intent is to provide sufficient detail,
so as to encourage broader consideration, scientific evaluation, and academic debate of appropriate PPE levels at
HCFs confronting these new threats.
1.1. Veterans Affairs EMSHG TAC
In 2000, the EMSHG Director formed the EMSHG
TAC, a group of approximately 20 expert advisors, to
review emergency management issues and recommend
policies relevant to VHA internal emergency management
practices [3,4]. The TAC is advisory to the EMSHG
Director, who is the principal advisor to the VHA Under
Secretary for Health on emergency management issues.
Technical Advisory Committee membership includes VA
internal advisors as well as expert representatives from the
US Army Medical Research Institute of Chemical Defense,
US Army Medical Research Institute of Infectious Disease,
Centers for Disease Control and Prevention (CDC), US
Public Health Service, Federal Bureau of Investigation,
Federal Emergency Management Agency, and the former
National Domestic Preparedness Office. The mission and
function of the EMSHG TAC has been previously
described elsewhere [3,4].
The EMSHG TAC conducted its work through 10 task
forces (Box 1). The PPE and Decontamination Task Force,
chaired by VAs Director of the Office of Occupational
Safety and Health, was divided into 2 focus groups: one to
address PPE, the other to address decontamination. Task
Force membership included VA safety managers, emergency managers and trainers, industrial hygienists, hazardous
materials team members and an occupational health
physician, as well as experts from US Army Medical
Research Institute of Chemical Defense and academia. Over
a several-month period, the group met by conference calls
and frequent email communications. The primary goal of
the PPE and Decontamination Task Force was to bprovide
guidance to the EMSHG TAC Chair (and ultimately VHA
leadership) on policy for level(s) of dessentialT PPE
necessary for the national network of VA HCFs.Q The task
force proceeded to: (1) conduct a background review of the
scientific and administrative foundations of PPE regulations
and guidelines and examine significant issues, including
those specific to VA HCFs; (2) assess current practices
regarding PPE levels in other (non-VA) HCFs; (3) define
possible essential PPE options and determine bprosQ and
bconsQ of selecting each option; and (4) Arrive at a
Box 1: EMSHG TAC Task Forces
PPE and Decontamination
Basic Training
VAs Role in the Community
Pharmaceutical Caches
Organizational Support
Emergency Management Academy
186 K.L. Koenig et al.
recommended option of essential PPE and present results to
the EMSHG TAC for concurrence/consensus. The process
included review of the literature and many discussions with
representatives of regulatory bodies, HCFs, and acknowledged experts.
2. Background
The threat of nuclear, biologic, and chemical terrorism
against the United States civilian population is now more
real than ever. The willingness of political and other
factions to implement terrorist plans, along with the
increasing availability of WMD, are recognized as
prominent factors in the increasing risk of terrorism in
America [5]. Weapons of mass destruction such as nerve
agents (sarin, soman, VX); blister agents (sulfur mustard,
lewisite); blood agents (hydrogen cyanide, arsine); and
biologic agents such as bacteria (anthrax, plague, tularemia), viruses (hemorrhagic fevers, smallpox), and toxins
(botulinum, ricin, staphylococcal enterotoxin B, T-2
mycotoxin) comprise a lethal arsenal for terrorist organizations and their sponsors [6]. In addition to chemical and
biologic warfare agents, more than 60 000 chemicals are
produced in the United States, 2000 of which the US
Department of Transportation considers hazardous [7].
Although not as lethal as the highly toxic nerve agents,
industrial chemicals are potential terrorist weapons because
they are readily accessible, poorly defended and can be
deployed over a widespread area. Accidental releases of
toxic industrial materials may also occur in communities
near HCFs. Such events may be more likely to occur than
WMD incidents and would have similar effects.
Other terrorist weapons include radioactive material
involving a-, b-, or c-radiation. The type of emitter and
delivery mechanism (eg, explosives, water contamination,
or physical contact resulting from hidden emitters) will have
a significant impact on the type of PPE and the time of
exposure permitted during decontamination activities.
Although HCFs are an important part of community
emergency management plans and Local Emergency Preparedness Committees, many HCF directors and managers
indicate that they are not currently prepared for WMD agent
releases or mass casualty incidents. The recommendations
for PPE selection reported in this manuscript will assist HCF
managers in fulfilling essential PPE requirements and
participating in a fully implemented national WMD PPE
program for HCFs. Table 1 describes the PPE levels (A, B,
C, and D) that were assessed by the task force [3].
2.1. Significant issues
Expectations of HCF personnel, care of victims exposed to
WMD agents, and the levels of respiratory and protective
clothing are obvious concerns. As with other contemporary
health care systems, VA is engaged in bbusiness continuity
planning,Q that is, implementing measures that ensure
continuous patient care with minimal disruption. The task
forces focus was on internal VA concerns and procedures that
contribute to patient and staff health and safety. Its processes,
however, relied heavily on input from a wide range of experts
representing a variety of settings; therefore, recommendations may be generalizable to other HCF settings.
Many factors must be considered and will influence
selection of essential levels of PPE. The task force examined
the following:
2.1.1. Health care facility staff
! May be called on to accept Emergency Medical
Services (EMS)delivered or self-reporting victims
of a WMD agent exposure (health care facilities
employees involved in WMD events may include
police and security personnel; firefighters and
hazardous materials response organizations; receptionists; and nurses, physicians, and other clinical
and administrative support staff);
! May be exposed to unknown toxic chemical or
biologic agents at unknown concentrations and are
at risk for developing harmful effects from secondary contamination [8];
! Have an obligation to protect their patients, guests,
employees, and the facility from exposure to
Table 1 Personal protective equipment levels
Level bAQ (fully encapsulates the body so that no vapor
penetrates the suit): respiratory protection is SCBA or
supplied air. Other features include inner/outer chemical
gloves and boots, and PAS device. This is typically worn
by responders into IDLH incidents or unknown
atmospheres for the purpose of rescue, assessing, or
mitigating the hazardous materials event.
Level bBQ (full-body chemical suit that may not protect
against vapor in an IDLH environment): respiratory
protection and other protection features are normally the
same as used in level A. This is typically worn by
responders who have identified the material or agent, have
determined expected exposure levels, and may conduct
rescue or further incident assessment and initiate recovery,
even in IDLH environments.
Level bCQ (full-body chemical suit): respiratory protection is
air purifying. this normally consists of inner/outer gloves
along with chemical resistive boots. This is typically worn
by responders or others who have assessed exposures either
by reviewing plans or by monitoring of chemical
agents. Cartridges must be specific for the types of
agents expected and must not exceed exposure limitations.
Level bDQ (no respiratory protection required; minimal skin
protection): In an HCF, it is recommended that anytime
persons may be in contact with chemicals,
chemical-resistive clothing including gloves, boots, and
face and eye protection be worn.
SCBA, ; PAS, personal alert system;
IDLH, immediately dangerous to life and health.
Health care facility PPE 187
internal and community hazardous material spills
and WMD agent exposure;
! Are obligated to respond to community emergencies
when called upon under community emergency
response plans;
! May not be able to readily identify the nuclear,
chemical, or biologic agent, the concentration of that
agent, the duration of the exposure, or the extent of
population exposure (furthermore, it would be
entirely possible for a terrorist to combine any of
the above agents or incorporate them into a high yield
explosive device to enhance dispersal or to create a
more confusing clinical picture or syndrome).
2.1.2. Regulatory and compliance factors
(internal and external)
! Occupational Safety and Health Administration
(OSHA) regulation 29 CFR Part 1910.134(d),
Selection of Respirators, requires that civilian
employers bprovide an appropriate respirator based
on the respiratory hazard to which the worker is
exposed and workplace and user factors that affect
respirator performance and reliabilityQ [9]. Furthermore, OSHA requires that employers bshall select a
NIOSH-certified respiratorQ and that bthe respirator
shall be used in compliance with the conditions of
its certificationQ [10]. The OSHA Hazardous Waste
Operations and Emergency Response regulation 29
CFR Part 1910.120 also has PPE requirements [11].
! OSHA specifies level A protection for workers in
environments that are known to be bimmediately
dangerous to life and healthQ (IDLH) and
specifies level B as the minimum protection for
workers in danger of exposure to unknown
chemical hazards [12]. Air-purifying respirators
may be used only when monitoring equipment
assures that the concentration of the chemical
does not exceed the respirator protection factor
assigned by National Institute of Occupational
Safety and Health (NIOSH).
! NIOSH currently certifies air-purifying respirators
for general civilian protection from chemical agents
when the chemical and concentration can be
detected and measured by the wearer [13].
! At the time of this writing, the Joint Commission on
Accreditation of Healthcare Organizations is revising
its emergency management standards but does not
currently specify the level of protection required in
HCF hazardous material plans and training [14].
Joint Commission on Accreditation of Healthcare
Organizations does require, however, that HCFs
must have documented plans to maintain employee
safety [15].
! Many HCFs have established written policies in
support of community emergency management and
response plans. In some cases, the procedure is to
block downQ the facility in an attempt to allow
staff time to identify the WMD agent before accepting victims.
Emergency care regulations under 42 U.S.C. 1395 dd (13)
(commonly known as the Emergency Medical Treatment and
Active Labor Act [EMTALA]) [16] require HCFs to provide
a medical screening exam and stabilization up to the level of
their capability for all persons presenting to facility grounds.
Patients must be stabilized before transfer to another HCF or
alternate treatment location. If an HCF establishes a
decontamination unit with level B PPE capability and has
current capacity to accept victims, it would be obligated to
provide service to victims who arrive at the facility and
require this level of service. If the capability and capacity to
decontaminate victims were not established, the facility
would not be obligated to accept contaminated victims under
this code. Although the regulations are undergoing review
and new interpretive guidelines were recently published, at
the time of this writing, unless a waiver specific to the current
event were issued, the facility would still be obligated to
perform a medical screening exam and stabilization to the
extent resources permit. EMTALA allows an exception for
handling certain biologic exposure cases. A community or
region may designate facilities to handle specific bioterrorism
patients. Health care facility staff may transfer or refer these
patients to designated sites, thereby fulfilling their obligations
under EMTALA [17]. A corporate legal opinion may be
necessary to ensure appropriate interpretation of this issue.
2.1.3. Unique PPE and equipment issues
! NIOSH has certified an air purifying cartridge for
chemical, biologic, and radiological/nuclear (CBRN)
environments with the use of a full face mask, once
conditions are understood and exposures are determined to be at appropriate levels for use with this
respirator. In addition, NIOSH has developed a
concept standard for a powered air-purifying respirator (PAPR), but a standard for this more popular
type of respirator for CBRN has not been certified for
civilian use. However, on July 27, 1994, OSHA, in
conjunction with the Army Chemical Stockpile
Emergency Preparedness Program (CSEPP), issued
a notice approving the use of specially equipped
PAPRs, under certain circumstances, for responders
in communities near chemical warfare weapon
depots where known chemical agents are stored [18].
! Level C respiratory protection incorporates a highefficiency particulate air filter or P-100 cartridge.
Level C protective clothing provides effective
protection against nearly all radiological and biological agents. Level C particulate filters do not,
however, provide protection against T-2 mycotoxins, a biologic agent that requires an approach
188 K.L. Koenig et al.
similar to chemical agents. c-Radiation permeates
all levels of protection. All victims treated in HCFs,
including symptomatic victims with suspected or
confirmed bioterrorism-related illnesses, should be
managed using current established CDC Guidelines
for Protection [19,20]. bStandard precautions,Q such
as those used in the care of pneumonia patients,
provide protection against most biologic agents.
! Air-purifying respirators may be used only when the
monitoring process determines that the chemical agent
has been identified and that its concentration does not
exceed the respirator protection factor assigned by
NIOSH for that respirator system. Chemical agent
detection equipment can detect the presence of
multiple chemical agents; however, for many highly
toxic industrial and chemical warfare agents, current
detectors do not have the sensitivity to measure
concentrations at the level where physical effects
occur. Current equipment with real-time detection
capability is limited, expensive, and often unreliable
[21]. Furthermore, anecdotal reports from users
indicate that many detection devices cannot be
effectively operated while the user is wearing protective gloves and with level A PPE, in particular [22].
2.1.4. Experience with past chemical terrorism
agent exposure
An assumption often made in chemical agent assessments
is that persons who are able to escape the target area and who
are alive and ambulatory when they arrive for treatment at a
HCF are not bcarryingQ fatal levels of contaminant. This
assumption and the assessment of the protective value of
btime and distanceQ factors have not been scientifically
validated. The following 2 incidents demonstrate the
necessity for high levels of caution in HCF workers.
In 2000, an individual ingesting industrial strength
organophosphate in a suicide attempt was transported to
the hospital by a friend. During initial treatment, 3 emergency department (ED) personnel developed symptoms, and
1 required intubation. All exposed individuals survived,
including the suicidal patient [8].
During the receipt and treatment of 640 sarin-exposed
victims of the 1995 Tokyo subway attack, Tokyos St Luke
Hospitals ED medical staff did not wear PPE or conduct
decontamination procedures. Once a chemical exposure was
suspected, the ED staff removed the clothing of the victims
to limit the ongoing toxicity and secondary contamination of
the medical staff [23]. There was secondary sarin exposure
of the St Luke medical staff from affected victims. Atropine
and, in one case, pralidoxime were administered to several
health care workers during the incident (the hospital staff,
however, did not show decreased plasma cholinesterase
activity) [24]. Other more viscous agents, such as VX and
HD, would present a lesser vapor hazard because of their
lower volatility. Chemical agents of lower toxicity than sarin
would also be expected to present a lower hazard threat.
It is expected that immediate decontamination efforts
would reduce employee exposure. Nine percent of EMS
workers and a significant number of hospital workers at
other hospitals in Tokyo experienced acute symptoms. This
was presumably because of the staffs failure to remove
victim clothing (a cultural issue in Japan) or otherwise,
perform decontamination before placing victims in unventilated ambulances and hospital treatment rooms [25].
Some experts believe that terrorists will learn from and
perpetrate acts more sophisticated than the Tokyo attack.
These acts may generate higher WMD agent concentrations
and present a greater likelihood of high secondary WMD
exposures to health care personnel. Further, hospitals with
experience in the management of mass-casualty, high-stress
events have reported that EMS responders often do not
decontaminate victims before hospital delivery and that
hospitals must expect to receive self-presenting contaminated victims from WMD target areas [26].
2.1.5. Timely warning of a WMD event
To maximize the effectiveness of an HCFs protective
response, notice of a WMD event must be received before
victim receipt. Unfortunately, HCFs may learn of an event
only as victims are presenting at the reception area, lobby, or
front gate. Health care facilities should be prepared to isolate
entrance areas and establish bfall backQ decontamination,
treatment, and victim relocation areas to maintain the safety
of patients, guests, and staff in the facility. Law enforcement
personnel closely involved in contaminated victim management (eg, guiding, restraining, decontaminating) will require
chemical detection equipment and levels of protection as
part of the decontamination team.
2.1.6. Mitigating factors and discussion points
! NIOSH has approved air-purifying cartridges for
use when working with a large number of chemicals
below IDLH concentrations [13]. Risk assessments
may consider acquisition of cartridges to cover the
most likely agent exposures. Additional study of
this concept is necessary.
! Emergency response is initiated at the local community level. Communities will not receive additional
state or federal assistance until it can be mobilized and,
theoretically, only if local resources are exhausted.
! Emergency care clinicians may have different
cultural perspectives from EMS personnel in
responding to victims. Emergency Medical Service
personnel, as field-based first responders, have been
trained to be more cautious in evaluating the nature of
a hazard before handling victims. Emergency care
clinicians may be more open than EMS personnel to
receiving victims and providing care without having
exercised caution over the circumstances associated
with victim exposure. Health care facilitybased
personnel may, by nature, be more vulnerable to the
unannounced presentation of contaminated victims.
Health care facility PPE 189
! Quantities of PPE units purchased will depend in
some measure on the degree of decontamination
procedures selected and developed by each HCF.
The greater the number of victims that can be
decontaminated at a HCF, the greater number of
PPE units that will be required. Other rate-limiting
steps, such as time to disrobe, may limit decontamination capacity. Furthermore, it may be difficult to
determine at what point a patient is decontaminated,
that is, the bhow clean is clean?Q dilemma [27,28].
! Another related factor involves the percentage of
contaminated victims that are nonambulatory after
exposure to a WMD agent. A greater number of
nonambulatory victims increases the likelihood of
secondary contamination levels and the need for
higher levels of protection.
! The use of high-powered fans around the decontamination site may allow for a lower level of PPE selection
by establishing a relative airflow behind which
employees may find enhanced protection. Additional research is necessary to validate this premise.
3. Non-VA HCF PPE postures
The EMSHG TAC members contacted representatives of
several respected health care organizations to ascertain their
PPE posture and to establish the current, generally accepted
industry response to victim decontamination in WMD
events. Table 2 represents accepted PPE levels at a sample
of HCFs or organizations. Most of these health care
organizations currently use level C based on:
! Isolation from the exposure incident (nonfirst
responder status);
! Advanced notice of victim receipt;
! Detection levels within OSHA/CSEPP parameters;
! Low level of contaminant aerosol around victim
(based on either a high contaminant evaporation rate
for victim exposed to vapor only, in which case
most of the contaminant will evaporate by the time
victim is received at the decontamination location,
or contamination with a substance with a low
evaporation rate, resulting in little or no airborne
contaminant around the victim);
! The effectiveness of acid gas/organic vapor highefficiency particulate air filter cartridges for powered PAPRs for probable exposure to WMD; and
! Economic impact of providing higher PPE levels.
The Montgomery County Fire and Rescue Service,
Bureau of Life Safety Services, in cooperation with the
US Army Soldier and Biological Chemical Command
National Protection Center, conducted testing of PAPRs,
cartridges, and high-efficiency filters for use during WMD
exposures. This protective equipment evaluation resulted in
the approval by the State of Marylands Department of
Labor, Licensing, and Regulation of level C PPE clothing
with a PAPR system with protective capability from dust,
fumes, and mist, acid gases, and organic vapors [29].
Military PPE has been tested for protection against
chemical weapons, but NIOSH has not certified military
PPE for civilian purchase or use for any purpose (Table 3)
[18,30]. In an attempt to resolve the impasse for civilian
first responders in communities near chemical weapons
stockpiles, CDC and CSEPP sponsored nerve and mustard
agent testing of commercial respirators and chemical suits
[31]. Testing resulted in the approval of several levels A
and C PPE units for purchase by Metropolitan Medical
Response Systems. Because of the testing by CSEPP,
several specific filter canisters for PAPRs were shown to
provide protection against exposure to specific chemical
agents [32]. However, NIOSH certifies entire PPE units,
not individual filter canisters. The NIOSH has developed a
draft concept standard for evaluating WMD-capable PAPRs
for use bby first receivers and others in atmospheres where
the levels of CBRN contamination will be at low
concentrations due to prior victim decontamination, minimal secondary contamination emitted from ambulatory
victims or because of the extreme distance from the eventQ
[33]. Once this standard is finalized, manufacturers may
have their PAPRs certified by NIOSH as meeting this
performance standard. Before finalization of NIOSHs
performance standard, manufacturers can be asked to what
degree their PAPRs meet this standard.
Decisions surrounding PPE level selection depend on
factors well beyond those deemed bsimply financial.Q For
example, levels A and B PPE have important limitations
with respect to mobility, donning time, length of use (wearer
heat exhaustion and dehydration potentials), weight, dexterity, response time, and cost. Providing mass casualty care
while exclusively wearing level A PPE may present
Table 2 Accepted PPE levels at sample HCFs
Inova Fairfax Hospital (Falls Church, VA) Level C
with PAPR
University of California,
Irvine Medical Center
(Orange, CA)
Level C with
George Washington
University Hospital
(Washington, DC)
Level C with
Kaiser Permanente
(California, Statewide)
Level A, level B
with air line and
rescue tank
Harbor-UCLA Medical Center
(Los Angeles, CA)
Level A
Johns Hopkins University Hospital
(Baltimore, MD)
Level D
Maimonides Medical Center
(Brooklyn, NY)
Level B
Mount Sinai (New York, NY) Level B
190 K.L. Koenig et al.
insurmountable challenges for health care providers [22].
Potential advances in PPE and collaboration with NIOSH to
resolve certification issues are under development.
When HCF staff are able to identify the hazardous
material and its concentration (eg, via community coordination or from on-site detector readings), and if the result is
below IDLH level, the decontamination team may, based on
its own risk assessment, elect to use level C with appropriate
filter cartridges.
In support of PPE selection, decontamination station staff
should also use monitors and materials for detecting
radioactive, organic, and inorganic agents and, if possible,
their concentrations, and communications equipment that
allows contact with the local incident commander, other local
health care providers, the community public health system,
and other emergency response organizations. Additionally,
staff may consider using high capacity fans to establish
airflow away from team members, the decontamination
station, and facility intake vents, thereby lowering possible
concentrations of contaminant vapor, mist, or gas; however,
this modality has not been validated, and may present a risk
of hypothermia to victims being decontaminated.
4. Proposed essential PPE options:
pros and cons
The third step of the PPE and Decontamination Task
Force was to consider all aforementioned factors, including
the myriad of regulatory compliance issues, impact of PPE
selection on the health and welfare of patients, staff and
others, and VA HCFs role in community WMD response.
The task force was instructed to recommend an bessentialQ
rather than a bminimumQ standard. Those VA HCFs that
have the resources and quality improvement programs in
place to move to a higher level would be permitted to do so,
but the goal would be for VA HCFs to have a basic
capability across the entire system. Table 4 represents the
pros and cons of each PPE option that the Task Force
recommended for consideration.
5. Recommended essential PPE option for
The PPE and Decontamination Task Force briefed the
full TAC membership on the process used to arrive at a
recommendation and presented its findings and conclusions.
The task force recommended that the EMSHG TAC endorse
option 6:
bVA HCFs use a combination of PPE levels A through
D, based on a risk assessment before and during a WMD
! Each decontamination station must have at least 2
personnel capable of performing victim screening
and decontamination while in level B PPE, with
ready backup of 2 additional personnel in a stand-by
and swap-out capacity.
! The remainder of the decontamination team must be
equipped with level C PPE. Level C PPE should be
used in cases when: (1) casualties present after
exposure to chemical agents and the contaminant
and concentration can be determined and are below
IDLH levels or (2) casualties present after exposure to
biologic agents, with the exception of T-2 mycotoxins.
! As part of a comprehensive emergency management approach, each HCF would conduct a hazard
vulnerability analysis. This process will demonstrate the range of potential/likely hazards for the
facility and community. An unexpected hazardous
substance could impact the HCF through a
transportation accident or terrorist incident. In an
ideal situation, a responder at a HCF would
initially have accurate information regarding the
hazards and could apply PPE specifically for that
Disadvantages of option 6 include the requirement for
rapid, accurate identification of the agent and its concentration at each HCF, and its vulnerability to incorrect decision
making during the initial response. Additionally, it is likely
to be less cost effective, as sites must purchase multiple
levels of PPE and equipment for agent identification. Health
care facilities would have to conduct training specific for
each piece of equipment and level of PPE.
Table 3 Distinctions between military and civilian PPE
Civilian Military
Termed personal protective
Termed Mission-Oriented
Protective Posture
Four levels
(A is most protective,
D is least protective)
Five levels
(4 is most protective,
0 is least protective)
Worn by personnel
specifically trained to enter
bhot zonesQ; intended for
bhot zoneQ entry
Worn by combat personnel
in or close to zones where
potential for chemical,
biologic, radiological/
nuclear, or explosive threat
exists; not intended for
bhot zoneQ entrya
Protective mask
(in higher levels) includes
a self-contained air supply.
Protective mask filters
environmental agents while
providing respiratory, eye,
and face protection but
does not include a
self-contained air supply.
Regulated by OSHA and
Not regulated by OSHA or
a The military deploys specialized teams when bhot zoneQ entry is
required. These teams are trained in and wear PPE similar, and
sometimes identical, to that worn by civilian responders.
Health care facility PPE 191
Table 4 Pros and cons of recommended PPE options
Options Arguments for Arguments against
Option 1:
No action; VHA provides no national
guidance for the selection of PPE for
emergency victim decontamination.
!Autonomy of local facilities. !Less than essential protection
!HCFs would not spend money on !Inappropriate protection
low-probability incidents !No HCF preparedness
!Possible OSHA violations
!Threat assessments not always accurate
Option 2:
Use level A PPE !Complies with OSHA regulations !Degrades functional capabilities
!Eliminates concerns re: type and !Time required to don
concentration !Restricts work
!One size fits all !Requires fit testing
!Requires medical surveillance
!Limits operational time to 30-60
minutes maximum
!Unreasonable cost / benefit ratio
!Extensive training required
!Requires high level of fitness
Option 3:
Use level B PPE !Protects employee !Requires fit testing
!OSHA compliant !Medical requirements
!Easier to don than Level A !Limited operational time
!Easier to work in !Extensive training requirements
!Cooled air to wearer !Requires high level of fitness
!Offers protection with less movement
restrictions than with level A
Option 4:
Use level C PPE !Provides protection in non-IDLH
!Not certified by NIOSH for IDLH
!Less donning time !Respirator cartridge may not filter
!No fit testing for hooded system chemicals used in terrorism
!Physical stress levels lower than with !Terrorism agents are extremely toxic
level A !Terrorism agents have low warning
!Dexterity superior to level A properties
!Protects against wide range of hazards
if levels below IDLH
!Respirator must meet OSHA requirement
Option 5:
Use level D PPE !Avoids employee exposure to many
biologic agents
!Does not protect employee sufficiently
to allow assistance to nonambulatory
!Not OSHA-compliant
!Patients may not adequately selfdecontaminate
Option 6:
Use a combination of levels A through D,
based on risk assessment before
!Provides range of protection based on
the threat
!Need to have staff that can determine
type and concentration of agents
and during a WMD event !Allows HCF to establish requirement
based on risk analysis
!Requires complex decision making
in potentially stressful and
time-sensitive situations
!Complies with OSHA !Must purchase more than one PPE level
!Offers initial protection, and employee can
reduce to lower PPE level when medically
!Some of decontamination team must
meet requirements for levels A and B
192 K.L. Koenig et al.
Additional issues that must be addressed by hospital
administrators in their final decisions on essential PPE for
HCFs include:
Legal considerations
! Under what circumstances may HCF providers
refuse to treat victims who may present a danger
to the health and safety of patients or the employees themselves? May HCFs, in cooperation with
emergency response partners, establish, in advance,
a level of victim decontamination that will be
accommodated? Applying EMTALA in a situation
involving the presentation of contaminated patients
is most likely dependent on the HCFs decontamination capabilities. Assuming that the HCF has the
appropriate capability (including equipment, trained
staff, and policy), and that decontamination is
advisable as part of the stabilization process
(particularly is the patients health and safety would
otherwise be compromised), it seems likely that the
HCF staff should decontaminate the patient or
arrange transport to an HCF that does have the
appropriate capabilities. Following Hurricane
Katrina, during which some hospitals were forced
to turn away patients, many discussions arose
regarding EMTALA and its applicability to disaster
or mass casualty situations. The following conclusion was cited on bEMTALA is
a requirement that applies to normal situationsQ
[34]. The site further implies that the requirements
do not necessarily apply to disaster situations.
! Legal concerns also surround the question of HCF
staff safety. The OSHA has clear regulatory guidelines regarding HCFs use of PPE levels, decontamination, and training [11]. Furthermore, many
hospitals have unionized staff, which may be
protected by contractual obligations regarding these
issues. Hospital and other HCF leaders must ensure
compliance with EMTALA and OSHA or risk
violation of regulations and potential legal actions.
! Budget and financial considerations
! The purchase of PPE (and necessary decontamination equipment) for any system, whether as vast as
the VA and its HCFs or as compact as a single HCF,
will be no small undertaking. Implementation of a
standard program extends beyond buying equipment
and a must factor in issues such as initial and
sustainment training, equipment maintenance and
monitoring, fit testing and medical surveillance,
record keeping, and logistics. Recent approximate
costs for a high-end, level A ensemble (including
overgarment, boots, gloves, self-contained breathing
apparatus, and canisters) range from $4000 to
$5000. In addition, training costs may be $300 to
$400 per responder per year. The total cost per
facility will depend on the facilitys mission, as well
as its role in local emergency plans as cited by the
Local Emergency Planning Committee or other
local/regional bodies and will be dependent on the
results of assessments mandated by OSHA. Personal
protective equipment must be available for primary
and backup team members simultaneously. In
addition, once a particular set of PPE is used in a
bhot zoneQ response, it is considered compromised
and must be replaced. It is possible that a particular
facility may be able to access funds administered by
the Health Resources and Services Administration,
CSEPP site programs, Local Emergency Preparedness Committees, states, or other entities to assist
with PPE purchases and training.
! Labor issues
! Health care facility employees may be entitled to
hazardous duty pay if they are required to don
PPE. A decision will need to be made as to whether
using PPE is an bessential dutyQ and, if so, how to
manage employees who are unwilling or physically
unable to participate. This could be particularly
problematic for some shortage specialty areas such
as nursing.
! Non-HCF employees, such as rotating residents or
moonlighting physicians, may cover emergency
services in some HCFs. A single provider may be
present on a night shift.
! Any PPE policy will need to be coordinated with
the HCFs employee labor unions.
5.1. Conclusion
The terrorist use of WMD agents against the United
States and its citizens is a real and new challenge to HCFs.
Victims who survive initial exposure will rely on HCFs to
provide timely decontamination and treatment. Unprepared
HCFs may not only be unable to render appropriate
interventions but may also risk compromising care of the
existing HCF patient population and the ability of the HCF
to continue operations.
No national standard exists that assists HCFs in
determining essential levels of PPE for staff. There are
also no scientific or empirical assessments to validate the
most effective air-purifying respirator and PPE ensemble
for HCF providers and other staff. Some authors have
suggested that an HCF-specific type of PPE, level H,
should be designed [35]. The need for an HCF-specific
type of PPE stems from the fact that PPE for bfirst
respondersQ was initially developed for the scenario in
which providers went to the scene of an incident rather than
one in which patients present to a distant site. Although the
assumptions for the original scenario would hold true if an
incident occurred on the grounds of the HCF, the more
common situation would be that health care workers are
Health care facility PPE 193
functioning as bfirst receiversQ and managing patients who
have been exposed at a remote site. Patients who live to
make it to an HCF may represent a different secondary
exposure threat than those evaluated immediately after an
exposure. Further, the risk from continued exposure to the
original threat is minimized at a distant site.
Veterans Affairs, as the largest integrated health care
system in the nation with 163 medical centers located
throughout the United States and its territories, has elected
not to wait until standards are established. Rather, it has
devoted careful and deliberate attention to arriving at the
best solution for essential PPE selection for its HCF staff.
The EMSHG TAC and its PPE and Decontamination Task
Force, drawing on input of the experts, coupled with
careful examination of current principles and practices,
have recommended an option of PPE that is based on local
hazards vulnerability analyses and will provide the initial
step toward HCF preparedness for WMD events.
Carefully designed studies and scientific inquiry on
effectiveness, appropriateness, and safety of PPE selection
are axiomatic to an effective system with resultant protection of patients and staff. There is no national consensus on
definitive PPE levels in HCFs, as evidenced from the cited
sample reviews of and interviews with non-VA HCFs and
organizations. There is, however, a tremendous need for
applied research and other studies on the bbestQ approach to
PPE selection and many other protective and interventional
measures inherent in this age of domestic terrorism. The
EMSHG TAC recommendation on essential PPE levels
provides one option for consideration. It is the hope of the
authors that, by sharing the process used by VA in
addressing this very complex issue, the opportunity for
scientific, academic, and practical debate and discussion is
generated and encouraged.
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destruction events with contaminated casualties: effective planning for
health care facilities. JAMA 2000;283(2):242 – 9.
[2] Auf der Heide E. Disaster response: principles of preparedness and
coordination. St. Louis, ; 1989.
[3] Boatright CJ, Koenig KL. The Emergency Management Strategic
Healthcare Group Technical Advisory Committee: expert guidance for
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[4] Koenig KL. VA capability to enhance the medical response to a
domestic biological threat. Paper presented at: Institute of Medicine
Forum on Biological Threats and Terrorism: How Prepared Are We?
Assessing the Science and our Response Capabilities, 2002.
[5] U.S. Congress Office of Technology Assessment. U.S. Government
Printing Office. Proliferation of weapons of mass destruction:
assessing the risks. Publication OTA-ISC-559, 1993.
[6] Sidell FR, Takafuji ET, Franz DR, editors. Textbook of military
medicine: medical aspects of chemical and biological warfare.
Washington (DC)7 Department of the Army, Office of the Surgeon
General, Borden Institute; 1997.
[7] Cox RD. Hazmat. eMedicine. Last updated 13 April 2006. Available
at: [Accessed 19
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associated with emergency department treatment of organophosphate
toxicityGeorgia, 2000. MMWR Morb Mortal Wkly Rep 2001;
49(51-52):1156 – 8.
[9] U.S. Department of Labor, occupational safety and health administration standards. Respiratory protection. 29 CFR Part 1910.134
section (d)(1)(i), 63 FR 1152. Enacted 8 April 1998.
[10] U.S. Department of Labor, occupational safety and health administration standards. Respiratory protection. 29 CFR Part 1910.134
section (d)(1)(ii), 63 FR 1152. Enacted 8 April 1998.
[11] U.S. Department of Labor, occupational safety and health administration standards. Hazardous waste operations and emergency
response. 29 CFR Part 1910.120.
[12] Personal Protective Equipment. In: Institute of Medicine, editor.
Chemical and biological terrorism: research and development to
improve civilian medical response. Washington (DC)7 National
Academies Press; 1999. p. 34 – 42.
[13] National Institute for Occupational Safety and Health. Certified
equipment list. Publication #2001-139. 2001.
[14] Wise R to Koenig KL on 1 May 2006.
[15] Accreditation standards for hospitals, 2000. Oakbrook Terrace,
Illinois: Joint Commission on Accreditation of Healthcare Organizations; 2000.
[16] Emergency Medical Treatment and Active Labor Act. 42 USC 1395
section dd (13).
[17] Department of Health and Human Services HCFA, letter from
Director of Survey and Certification Group to Regional Administrator
for State Survey Agencies: question and answer relating to bioterrorism and EMTALA. Reference S&C-02-04. 8 November 2001.
[18] OToole T, Lillibridge SR. CDC recommendations for civilian
communities near chemical weapons depots: guidelines for medical
preparedness. Fed Regist 1994;59(143):38191 – 6.
[19] Garner JS. Guideline for isolation precautions in hospitals. 1 April
2005. [Accessed
20 April 2006].
[20] Dower JM, Metzler RW, Palya FM, et al. Department of Health and
Human Services. and
biological respiratory protection workshop report. Publication 2000-
122. February 2000.
[21] Detection and Measurement of Chemical Agents. In: Institute of
Medicine, editor. Chemical and biological terrorism: research and
development to improve civilian medical response. Washington, DC7
National Academies Press; 1999. p. 43 – 64.
[22] Garner A, Laurence H, Lee A. Practicality of performing medical
procedures in chemical protective ensembles. Emerg Med Australas
2004;16(2):108 – 13.
[23] Okumura T, Takasu N, Ishimatsu S, et al. Report on 640 victims
of the Tokyo subway sarin attack. Ann Emerg Med 1996;28(2):
129 – 35.
[24] Kulling P. The terrorist attack with sarin in Tokyo on 20th March
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[25] Okumura T, Suzuki K, Fukuda A, et al. The Tokyo subway sarin
attack: disaster management, part 2: hospital response. Acad Emerg
Med 1998;5(6):618 – 24.
[26] Watson RD, Multi-casualty mass decontamination plan, County of Los
Angeles, CA: Interagency Board of Equipment Standardization and
Interoperability, Standards Coordination Committee; August 2000.
[27] Raber E, Carlsen T, Folks K, et al. How clean is clean enough? Recent
developments in response to threats posed by chemical and biological
warfare agents. Int J Environ Health Res 2004;14(1):31 – 41.
[28] Raber E, Jin A, Noonan K, et al. Decontamination issues for chemical
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Environ Health Res 2001;11(2):128 – 48.
[29] Maryland State Department of Labor, Licensing, and Regulation,
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