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UWHC,

Policies,Clinical,UWHC Clinical,Department Specific,Emergency Department

Decontamination-Biohazardous Materials or Radiation (9.0)

Decontamination-Biohazardous Materials or Radiation (9.0) - Policies, Clinical, UWHC Clinical, Department Specific, Emergency Department

9.0

POLICY & PROCEDURE





Effective Date:
June 30, 2014

 Administrative Manual
 Nursing Manual
 Emergency Department

Policy #:9.0

 Original
 Revision

Page 1
of 7

Decontamination- Biohazardous materials
and/or radioactive materials


I. PURPOSE

To provide a safe procedure in the Emergency Department for the decontamination of patients
exposed to biohazardous materials and/ or radioactive materials.

II. POLICY

In the event an individual or individuals present to the Emergency Department (ED) after being
exposed to biohazardous materials, the ED Care Team Leader and Administrative Attending MD will
evaluate the situation and decontaminate all exposed individuals prior to their entry into the ED. If
time permits, an evaluation of the situation should also be rapidly performed by the Director of Life
Safety. The decontamination suite is designed for Level C decontamination.

In the event an individual or individuals present to the Emergency Department (ED) after being
exposed to radioactive materials, the ED Care Team Leader and Administrative Attending MD will
determine if there was an irradiation vs. contamination exposure. . A person is irradiated when he/ she
is “exposed” to ionizing radiation. In the case of an irradiation there is no material transferred. This
means that an irradiated patient has no radioactive material on him/ her and poses no radiological
hazard to the treatment team. If a patient has radioactive material on/in him/ her, he/ she, is said to
be contaminated. Entry will be restricted and other possible contaminated patients will be brought
through the same location. Life threats will be treated prior to decontamination of patients who are
said to have only contamination from radioactive material. If time permits, an evaluation of the
situation should also be rapidly performed by the UWHC Health Physicist (HP).).


III. EMERGENCY DEPARTMENT PREPARATION

A. Notification
1. The CTL will notify the Safety Officer and the Director of Environmental Services that the
Decontamination Suite will be utilized.
a. Include the number of victims expected and the contaminant if known.
b. The UWHC Health Physicist (pager 2783) and UWHC Radiation Health Physicist, (Pager:
3747, Work cell 608-235-7049) will be notified in the event of radioactive material
contamination.

2. The ED will notify the Paging & Message Center to activate the Hazmat/contaminated
patient page list if > 5 individuals are expected or the exposure is related to radioactive
material.
a. The Paging & Message Center will notify the following:
a. Safety Manager
b. UWHC Health Physicist, pager 2783 (radiation exposure only)
c. Environmental Services Director
d. Administrator on call
e. RN Coordinator

POLICY & PROCEDURE





Effective Date:
June 30, 2014

 Administrative Manual
 Nursing Manual
 Emergency Department

Policy #:9.0

 Original
 Revision

Page 2
of 7

Decontamination- Biohazardous materials
and/or radioactive materials


f. ED Clinical RN manager
g. Public Affairs
h. For radioactive contamination: U.S Department of Energy-Oak Ridge
Associated Universities phone # 865-576-1005.
i. On call Hematologist/ Bone Marrow Transplant MD.

B. Evacuation
1. All non-essential staff and non-contaminated ED patients and visitors will be moved to the
North side of the ED.
a. In the event of an external disaster, patients will be placed, based on acuity, according
to policy 12.17.
3. All pregnant or possibly pregnant women move to the North side of the ED or other
contamination-free area.

C. Preparation
1. Decontamination Suite- Biohazardous Material

a. Non-essential equipment will be removed from the Decontamination Suite and hall
leading from the Decontamination Suite to the ED.
b. Decontamination personal protective equipment (PPE) cart will be moved into the
hallway outside the Decontamination Suite.
c. If > 30 individuals are expected, and decontamination has not been performed at the
scene, Madison Fire Department Hazmat Unit may be consulted.
d. A registration station will be set up in the ambulance hallway outside the
Decontamination Suite.
e. CS will be notified if additional supplies are needed.
f. Red biohazard bags will be placed in all Decontamination Suite trash cans.
g. Verify supplies of soap and sponges for contaminated individuals
h. Verify supplies of belongings bags and markers for personal belongings

2. Decontamination Suite- Radioactive Material Contamination only

a. Obtain personal radiation dosimeters for each Decontamination Team member.
b. Verify that the portable survey meters are functioning appropriately.
- Personal radiation dosimeters and portable survey meters are located in the ED.
c. Take note of the background radiation level.
d. Obtain radiation labels to place on trash cans and/or bags.
e. Request CS send baby wipes and fenestrated towels.
f. Housekeeping will tape brown paper to floor from ambulance entrance to treatment
area. Treatment rooms will also have brown paper taped to floor and all non essential
equipment removed from room.
g. For non- ambulatory patients, brown paper will be taped to slide boards as well as on
patient carts under the sheet.


POLICY & PROCEDURE





Effective Date:
June 30, 2014

 Administrative Manual
 Nursing Manual
 Emergency Department

Policy #:9.0

 Original
 Revision

Page 3
of 7

Decontamination- Biohazardous materials
and/or radioactive materials


3. The ED CTL will make staff assignments in the Decontamination Suite.

D. Decontamination Team
1. Triage- If multiple individuals are expected, an ED MD, RN and/ or ED Technician (EDT)
will be assigned to triage.
2. EDT/ Primary Nurse(s)
a. Conduct/ assist with decontamination procedure
b. Monitors patient needs/ status
c. Set up eye irrigation sets if appropriate
3. EDT/ Circulating Nurse(s)
a. Assist with belonging collection and bagging
b. Assist with removal of clothing
c. Provide direction to ambulatory patients
4. Exit Nurse or EDT
a. Assist with preparation/ needs prior to exiting Decontamination Suite and entering the
ED.
5. Recorder Nurse
a. Record decontamination team vital signs prior to entering and after exiting the
Decontamination Suite
b. Record and monitor entry and exit times of Decontamination Team members
c. Record radiation dosimeter readings for each Decontamination Team member and
background reading from survey meter pre and post incident.
d. Communicate with Decontamination Team members regarding equipment/ supply
needs.
e. Document events in Decontamination Suite
E. Decontamination Team Preparation
1. Use restroom
2. Record vital signs prior to donning PPE
3. Consult with Safety Officer/Health Physicist regarding effectiveness of PPE against
contaminant
4. Change into disposable scrubs
5. Obtain assistance in donning PPE
6. Assemble PPE in appropriate size
7. Remove jewelry
8. Tuck pants into socks
9. Radioative Material only – radiation safety in-service will be conducted
F. Donning PPE
1. In the hallway between the Decontamination Suite and the ED
a. Provide chairs
b. For unknown radioactive material wear personal dosimeter underneath your coverall;
uniquely identify your personal dosimeter, i.e. write name with marker.
b. Put on yellow coverall/ Tyvex suit and zip half way up
c. Put on boots
d. Put coverall legs over outside of boots

POLICY & PROCEDURE





Effective Date:
June 30, 2014

 Administrative Manual
 Nursing Manual
 Emergency Department

Policy #:9.0

 Original
 Revision

Page 4
of 7

Decontamination- Biohazardous materials
and/or radioactive materials


e. Tape coveralls to boots, making certain to tab the tape for easy removal.
f. Put on thin nitrile gloves.
g. Put on Silver Shield gloves – Put sleeves over gloves and tape.
h. Put on thick nitrile gloves –Put sleeves over gloves and tape to coveralls, remembering
to tab the tape.


G.
Radiation contamination:
Check with Health Physicist if PAPR required.
1. Check all air supply connections
a. Utilize a PAPR if there are any concerns with the air supply
i. Check PAPR system
ii. Make sure there are three unopened canisters that are not expired
iii. 1 PAPR
iv. 1 Hood
v. 1 Rubber tube
vi. 1 Flow meter
vii. 1 Battery
viii. Attach rubber tube to PAPR if not attached
ix. Open canister packages ,remove caps and attach all three canisters to PAPR unit
x. Attach battery to PAPR
xi. Check air flow of PAPR to manufacturing specifications
2. Size respiratory head band and then put on hood.
3. Tuck hood into neck opening of the coverall
4. Zip the coverall
5. Make the connection to the air supply if used
6. Put on yellow over-hood and secure the Velcro belt. (if used)

IV. PATIENT ARRIVAL

A. Processing Patient
1. A minimum of 2 dressed personnel is required to be in the room.
2. Patients with radiation exposure should be treated for life threatening injuries first,
limiting the amount of time any one person spends with the patient and the geographical
location.
B. Ambulance arrivals
1. Remove clothing and prosthetic devices in the ambulance if possible
a. Provide a gown or sheet to cover the patient
2. Ambulatory patients will walk to the Decontamination Suite entrance
3. Non-ambulatory patients will be placed on a backboard and moved from the ambulance
cot to the non-ambulatory decontamination line.
4. Ambulance personnel are instructed to stay by the ambulance until they and the
ambulance

POLICY & PROCEDURE





Effective Date:
June 30, 2014

 Administrative Manual
 Nursing Manual
 Emergency Department

Policy #:9.0

 Original
 Revision

Page 5
of 7

Decontamination- Biohazardous materials
and/or radioactive materials


are monitored for contamination.
a. If not contaminated, released for duty
b. If contaminated, decontaminate in shower after processing the patient.
C. Arrivals by self/ family/ friend
1. Individual will be directed to the Decontamination Suite entrance from the parking ramp.

V. DECONTAMINATION OF PATIENT -Biohazardous material

A. Ambulatory Patients
1. Patients will enter the Decontamination Suite directly from the parking ramp
2. Valuables will be bagged, labeled and placed in the tall storage cabinet in the entrance to
the
Decontamination Suite
3. Clothing will be cut off, minimizing stretching and flapping of contaminated clothing, and
placed in trash cans with red biohazard liner
4. Prosthetic devices will be removed, bagged, labeled and placed in tall storage cabinet
5. Patient will be proceed to the automatic showers and instructed on decontamination
procedure
a. Series of 5- 1 minute showers
b. Use sponge and soap, focusing on hair, creases, folds and wounds
B. Non-ambulatory Patients
1. Patients will enter the Decontamination Suite directly from the parking ramp
2. Valuables will be bagged, labeled and placed in the tall storage cabinet in the entrance to
the
Decontamination Suite
3. Clothing will be cut off, minimizing stretching and flapping of contaminated clothing, and
placed in trash cans with red biohazard liner
4. Prosthetic devices will be removed, bagged, labeled and placed in tall storage cabinet
5. Patient will be placed on a backboard and moved the non-ambulatory line
6. The primary RN(s) will decontaminate the patient with a series of 3- 2 minute showers,
using the soap and sponge and focusing on hair, creases, folds and wounds
C. In case of an emergency, exit out of the Decontamination Suite into the hallway toward the ED
(the warm zone). Personnel should NEVER exit toward the parking area (the hot zone). This
would increase the possibility of contamination.
D. Radioactive material decontamination- Follow same procedures as above to decontaminate
individual.
1. To verify the removal of contamination, use the portable survey meter as follows:
a. Verify survey meter is working properly;
b. Take note of the background radiation level;
c. Place survey meter probe approximately ¼” from individual and “scan” entire body
surface;
d. Survey readings above the background radiation level indicate the presence of
radioactive material; contact UWHC Health Physicist or UW Radiation Safety Officer.
2. Areas of contamination to be cleaned in the following manner

POLICY & PROCEDURE





Effective Date:
June 30, 2014

 Administrative Manual
 Nursing Manual
 Emergency Department

Policy #:9.0

 Original
 Revision

Page 6
of 7

Decontamination- Biohazardous materials
and/or radioactive materials


a.) For non-ambulatory patients utilize multiple sheets underneath of patient to change
out
after removal of clothing
b.) Priorities of decon are to follow; Wounds first, Body orifices around the face second,
intact skin there after.
c.) Wound dressing should be saved after removal for further radiological evaluation
d.) Drape chux around the area of contamination to prevent spreading of radiation
e. ) Initially irrigate the wound using sterile saline, allowing run off to go directly into a
basin or trash can, avoid splashing or spreading to other areas
f. ) Decontaminate intact skin and hair by washing with soap and water.
g. ) Baby wipes may also be used to decontaminate intact skin by placing over area of
contamination and from there pinching the baby wipe together as to pull the
contaminant into the wipe and from there dispensing that wipe
h.) Baby wipes may also be used by wiping from out side the area of contamination
working your way into the center of the area of contamination and from there
dispensing that wipe
i.) After cleaning each area of contamination, re measure level of radiation with survey
meter, continue to clean area until you obtain a level of zero or background on the
survey meter. - if background readings not achieved, contact UWHC HP or UW RSO
j.). All waste should be collected and contained to one area for proper disposal




VI. REMOVAL OF PATIENT FROM DECONTAMINATION AREA

A. Post decontamination, ambulatory patients will be instructed to dry off and don a gown and
robe
B. Non-ambulatory patients will be transferred on the backboard from the non-ambulatory line
to an ED stretcher. They will be dried off and covered with a clean sheet.
C. The patient will exit the Decontamination Suite into the hallway between Decon and the
ED. An ED MD will assess the patient.
D. The patient will be registered, roomed in the ED and evaluated for medical needs.




VII. POST- PATIENT DECONTAMINATION

A. Team decontamination and doffing PPE
1. The decontamination team will proceed through the ambulatory decontamination line
while
still in the decontamination suit.
2. After 5- 1 minute showers, Decon team members will dry off with towels. Discard towels

POLICY & PROCEDURE





Effective Date:
June 30, 2014

 Administrative Manual
 Nursing Manual
 Emergency Department

Policy #:9.0

 Original
 Revision

Page 7
of 7

Decontamination- Biohazardous materials
and/or radioactive materials


in receptacles in room.
3. Doff the yellow hood and place in large container.
4. Remove tape from outside gloves and boots.
5. Remove regulator belt while still on air.
6. Remove outer turquoise nitrile gloves.
7. Remove tape from Silver Shield gloves.
8. Unzip yellow suit.
9. Pull arms through the suit leaving the Silver Shield gloves on the outside. A partner may
help to get the suit over your shoulder.
10. When suit is off your shoulders roll it down your body to your boots. Make sure to only
touch the inner white part of the suit.
11. Step out of the suit and boots onto a clean and dry area.
12. With blue inner gloves remove your air hood.
13. Disconnect your airline at the regulator to stop the airflow.
14. Dispose of your blue inner gloves in waste container.
15. For radioactive material contamination, prior to leaving the Decontamination Suite, verify
that you were not contaminated. If contaminated, contact UWHC Health Physicist or UW
Radiation Safety.
16. Exit the Decontamination Suite
17. Take off your ear mike walkie-talkie and turn off. (if used)
18. Recorder to document post–decon vital signs
19. Proceed to employee dressing room to shower.
20. Proceed to ER for medical evaluation.
21. Recorder to document information on Decon Room Log.

IX. OTHER CONSIDERATIONS FOR RADIATION EXPOSURE

A. UW Radiation Safety Officer (RSO) or UWHC Health Physicist
1. Monitoring
a. Ambulance and attendants
b. Route from ambulance to decontamination area
c. Decontamination room (patient and personnel)
2. Decontamination of areas if found in (A) above
3. Proper disposal of any contaminated items or water
4. Examine all dosimeters and proper follow up as needed
5. FOR 24 HOUR ASSISTANCE IN DEALING WITH RADIATION
ACCIDENTS, CALL REACTS (615) 482-2441.








POLICY & PROCEDURE





Effective Date:
June 30, 2014

 Administrative Manual
 Nursing Manual
 Emergency Department

Policy #:9.0

 Original
 Revision

Page 8
of 7

Decontamination- Biohazardous materials
and/or radioactive materials



X. REFERENCE
ξ See Policy 12.17 External Disaster Plan,
ξ U.S Department of Energy and Oak Ridge Associated Universities. ( 2011). The Medical Aspects
of Radiation Incidents(2nd ed.) Canada:Sugarman, S.L., Goans, R. E.,A.s.,&Livingston, G.K.


XI. COORDINATION

Reviewed and approved by:
Nursing Supervisor-Emergency Department
ED Clinical Operations Committee

SIGNED BY

Jeff Pothof, MD Tami Morin, RN, MS
Vice Chair of Quality and Operations Director
Department of Emergency Medicine Emergency Services