PREPARING FOR TERRORISM
Being prepared for terrorism as a health care provider includes awareness of the potential for covert use of WMDs, self-protection, and early detection, containment, or decontamination of sub-stances and agents that may affect others by secondary exposure. The strength of many toxins, today’s mobile society, and long in-cubation periods for some substances can result in an epidemic that can quickly and silently spread across the entire country. For example, there must be awareness that the healthy person with a rapid onset of flu-like symptoms can have an ominous illness, as occurred with the anthrax exposures in 2001.
Health care personnel should have a heightened awareness for trends that may suggest deliberate dispersal of toxic or infectious agents (Howard, 2001). The following are some general princi-ples of awareness that should raise suspicion:
· Beware of an unusual increase in the number of people seeking care for fever or respiratory or gastrointestinal com-plaints.
· Take note of an unusual illness for the time of year. Clusters of patients from a single location should raise suspicion. Clusters can be from a specific geographical location, such as a city, or from a single sporting or entertainment event.
· A large number of rapidly fatal cases should raise suspicion, especially when death occurs within 72 hours after hospital admission.
· Any increase in disease incidence in a normally healthy pop-ulation should also raise suspicion. These cases should be re-ported to the state health department and to the CDC (Chettle, 2001).
An extensive patient history is taken in an attempt to identify the agent involved. This history includes an occupational, work, and environmental assessment in addition to the regular admis-sion history. An exposure history contains, at a minimum, infor-mation about current and past exposures to possible hazards and an assessment of the patient’s typical day and any deviations in routines. The work history includes, at a minimum, a description of all previous jobs, including short-term, seasonal, and part-time employment and any military service. The environmental history includes assessment of present and previous home locations, water supply, and any hobbies, to name a few factors. The admis-sion history should include such information as recent travel and contact with others who have been ill or have recently died of a fatal illness. This is just a brief review of the extensive history that may need to be obtained to identify an exposure agent. This type of history should become a universal part of admission processes at all health care facilities (Agency for Toxic Substances and Disease Registry, 2000).
Suspicions or findings are reported to the appropriate re-sources in the facility and to proper authorities in the commu-nity. Resources can include the Infection Control Department, material safety data sheets (MSDS), the state Health Depart-ment, the Centers for Disease Control and Prevention, the local poison control center, and many Internet sites (Chettle, 2001). Reporting furnishes data elements to those agencies responsible for epidemiology and response. Reporting also allows for sharing of information among facilities and jurisdictions and can help de-termine the source of infections or exposure and prevent further exposures and even deaths.
Another component of preparedness and response involves the protection of the health care provider by additional personalprotective equipment (PPE). Chemical or biological agents andradiation are silent killers and are generally colorless and odorless. The purpose of PPE is to shield individuals from the chemical, physical, and biological hazards that may exist when caring for contaminated patients. The U.S. Environmental Protection Agency (EPA) has divided protective clothing and respiratory protection into four categories, level A through level D:
· Level A protection is worn when the highest level of respi-ratory, skin, eye, and mucous membrane protection is re-quired. Briefly, this includes a self-contained breathing apparatus (SCBA) available in the prehospital arena. This also includes a fully encapsulating, vapor-tight, chemical-resistant suit with chemical-resistant gloves and boots.
· Level B is similar to level A and is selected when the situa-tion requires the highest level of respiratory protection but a lesser level of skin and eye protection. This level of pro-tection includes the SCBA and a chemical-resistant suit (Currance & Bronstein,1999).
· Level C protection requires the air-purified respirator (APR), which uses filters or sorbent materials to remove harmful substances from the air. A chemical-resistant coverall with splash hood, chemical-resistant gloves, and boots are included in level C protection.
· Level D protection is basically the work uniform.
Level C and Level D PPE are the levels most often used in hos-pital facilities (Currance & Bronstein, 1999).
Protective equipment must be donned before contact with a contaminated patient. The acute care facility’s standard precaution PPE (levels D or C) generally is not adequate for protection from a contaminated patient. The health care provider must use equip-ment that is capable of providing protection against the agent in-volved. This may mean using a splash suit along with a full-face positive- or negative-pressure respirator (a filter-type gas mask) or even an SCBA for medical personnel in the field (Burgess et al., 1999; Currance & Bronstein, 1999; JCAHO, 2000).
No single combination of PPE is capable of protecting against all hazards. Under no circumstances should responders wear any PPE without proper training, practice, and fit testing of respira-tor masks as necessary.
Decontamination, the process of removing accumulated contam-inants, is critical to the health and safety of health care providers by preventing secondary contamination. The decontamination plan should establish procedures and educate employees about decontamination procedures, identify the equipment needed and methods to be used, and establish methods for disposal of contam-inated materials (Currance & Bronstein, 1999).
Although many principles and theories surround decontami-nation of a patient, authorities agree that, to be effective, decon-tamination must include a minimum of two steps. The first step is removal of the patient’s clothing and jewelry and then rins-ing the patient with water. Depending on the type of exposure, this step alone can remove a large amount of the contamination and decrease secondary contamination (Burgess et al., 1999). The second step consists of a thorough soap-and-water wash and rinse. When patients arrive at the facility from a prehospital provider, it should not be assumed that they have been thoroughly decontaminated.
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