OSHA Best Practices for Hospital Based First Receivers Involving the Release of Hazardous Substances

Healthcare workers risk occupational exposures to chemical, biological, or radiological materials when a hospital receives contaminated patients, particularly during mass casualty incidents. These hospital employees, who may be termed first receivers, work at a site remote from the location where the hazardous substance release occurred.¹ This means that their exposures are limited to the substances transported to the hospital on victims' skin, hair, clothing, or personal effects (Horton et al., 2003). The location and limited source of contaminant distinguishes first receivers from other first responders (e.g., firefighters, law enforcement, and ambulance service personnel), who typically respond to the incident site (i.e., the Release Zone).

In order to protect their employees, hospitals benefit from information to assist them in emergency planning for incidents involving hazardous substances (BNA, 2003; Barbera and Macintyre, 2003). Emergency first responders, at the site of the release, are covered under OSHA's Standard on Hazardous Waste Operations and Emergency Response (HAZWOPER), or the parallel OSHA-approved State Plan standards, and depending on their roles, some hospital employees also are covered by the standard.^2,3 However, OSHA recognizes that first receivers have somewhat different training and personal protective equipment (PPE) needs than workers in the hazardous substance Release Zone, a point clarified through letters of interpretation (OSHA, 2002a).

In this best practices document, OSHA provides practical information to help hospitals address employee protection and training as part of emergency planning for mass casualty incidents involving hazardous substances. OSHA considers sound planning the first line of defense in all types of emergencies (including emergencies involving chemical, biological, or radiological substances). By tailoring emergency plans to reflect the reasonably predictable "worst-case" scenario under which first receivers might work, the hospital can rely on these plans to guide decisions regarding personnel training and PPE (OSHA, 2003, 2002b, 1999). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires an all-hazard approach to allow organizations to be flexible enough to respond to emergencies of all types, whether natural or manmade (unintentional or intentional).⁴

Worst-case scenarios take into account challenges associated with communication, resources, and victims. During mass casualty emergencies, hospitals can anticipate little or no warning before victims begin arriving.⁵ Additionally, first receivers can anticipate that information regarding the hazardous agent(s) would not be available immediately. Hospitals also can anticipate a large number of self-referred victims (as many as 80 percent of the total number of victims) and assume victims will not have been decontaminated prior to arriving at the hospital (Auf der Heide, 2002; Barbera and Macintyre, 2003; Vogt, 2002; Okumura et al., 1996).

The appropriate employee training and PPE selection processes are defined in applicable OSHA standards.⁶ An employee's role and the hazards that an employee might encounter dictate the level of training that must be provided to any individual first receiver. PPE selection must be based on a hazard assessment that carefully considers both of these factors, along with the steps taken to minimize the extent of the employee's contact with hazardous substances.

Despite many hospitals' strong interest in powered air-purifying respirators (PAPRs) as a practical form of respiratory protection for first receivers in the Hospital Decontamination Zone, many knowledgeable sources avoid making specific PPE recommendations, but rather point out the advantages and disadvantages of the various options, or recommend appropriate PPE (JCAHO, 2001; Lehmann, 2002; Penn, 2002). Others offer stronger opinions. CA EMSA (2003a) promotes the use of a multi-tiered approach to PPE. Burgess (1999) indicates, in an article published prior to more recent letters of interpretation specific to healthcare workers, that OSHA requires Level B protection or self-contained breathing apparatus (SCBA) for unknown hazards, but points out there are substantial difficulties for healthcare workers who attempt to care for patients while wearing this type of equipment and also addresses the hazards of wearing SCBAs (e.g., slips, trips, falls, and overexertion, particularly for infrequent users of this equipment). These sources demonstrate appropriate caution in the face of unknown contaminants of unknown concentration. However, OSHA believes that the substantial body of recent information on first receivers' actual experiences and probable exposure levels now allows more definitive guidance.

In this best practices document, OSHA specifies PPE that hospitals could use to effectively protect first receivers assisting victims contaminated with unknown substances, provided the hospital meets certain prerequisite conditions designed to minimize the quantity of substance to which first receivers might be exposed. This PPE for first receivers includes: a PAPR with an assigned protection factor of 1,000, a chemical-resistant protective garment, head covering if it is not already included in the respirator, a double layer of protective gloves, and chemical-protective boots (see Table 3, Section B.3). As part of OSHA's required hazard assessment process, each hospital also must consider the specific hazards first receivers might reasonably be expected to encounter.⁷ The hospital must then augment OSHA's PPE selection when necessary to provide adequate protection against those specific identified hazards.

The specified PPE is appropriate when the hazardous substance is unknown and the concentration is strictly limited by 1) the quantity of material associated with living victims and 2) the conditions, policies, equipment, and procedures that are in place and that will reduce employee exposure. Tables 1 and 2 of the best practices document list those specific prerequisites that OSHA believes are necessary to adequately limit first receiver exposures and to assure the adequacy of the PPE presented in Table 3. Such conditions include a current Hazard Vulnerability Analysis (HVA) and emergency management plan (EMP), as well as procedures to ensure that contaminated materials are removed from the area and contained so they do not present a continuing source of exposure.

The first receiver PPE listed in Table 3 is not the only option for first receivers. Employees at hospitals that do not meet the criteria shown in Tables 1 and 2 must determine whether more protective equipment is required (e.g., HAZWOPER Level B). A higher level of protection also may be necessary for any hospital that anticipates providing specialized services (such as Hazardous Materials Response Team at the incident site). Additionally, if a hospital is responding to a known hazard, the hospital must ensure that the selected PPE adequately protects the employees from the identified hazard. Thus, hospitals must augment or modify the PPE in Table 3 if the specified PPE is not sufficient to protect employees from the identified hazard. Alternatively, if a hazard assessment demonstrates that the specified PPE is not necessary to effectively protect workers from the identified hazard, a hospital would be justified in selecting less protective PPE, as long as the PPE actually selected by the hospital provides effective protection against the hazard.

This best practices document provides hospitals and other health care providers with information to assist in the provision of PPE and training for first receivers. Section A introduces the subject, while section B provides a detailed analysis of potential hazards, as well as a comprehensive discussion of the PPE currently available to protect workers from these hazards. In Section B.3, OSHA provides three tables designed to assist employers in selecting PPE adequate to protect healthcare workers and to comply with relevant OSHA PPE standards. Employers who meet the prerequisites in Table 1 and 2 may use this best practices document as the OSHA-required generalized hazard assessment. Such employers may choose to rely on the PPE specified in Table 3 to comply with relevant OSHA standards and to provide effective protection for first receivers against a wide range of hazardous substances. However, such employers also must conduct a hazard assessment that considers hazards unique to the community in which they are located. In rare situations, these employers will need to augment or modify the PPE specified in Table 3 to provide adequate protection against unique hazards identified in the community-specific hazard analysis. Of course, employers are not obligated to follow the guidance in Table 3; any employer can choose instead to perform an independent hazard assessment that is sufficient to identify the hazards that its employees are reasonably anticipated to encounter, and then select PPE adequate to protect its employees against such hazards. Section C of this best practices document contains a discussion of training required for first receivers and concludes with Table 4, which matches required training levels to employee roles and work areas.

Appendix A of this best practices document provides background information on how various aspects of a hospital's preparation, response, and recovery impact employee protection during hazardous substance emergencies. Appendices B, C, and D list additional information sources, while Appendices E through M offer examples of procedures and equipment used in some hospitals. OSHA offers these examples for informational purposes only and does not recommend one option over the many effective alternatives that exist. Emergency managers might find these resources helpful in developing or updating existing EMPs.  Click here to see the complete article.