In today's world of domestic and global terrorism, local hospitals and other healthcare facilities are at an ever increasing risk. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has called for all healthcare facilities to include policies and procedures on dealing with mass casualty scenarios. This includes emergency procedures involving terrorist acts which could include the presence of hazardous materials. Every hospital has a right to refuse any patient that is or could be contaminated with a hazardous material. However, it is very difficult and rare to plan on refusing care to contaminated victims. The probability that injured and contaminated victims inundate the emergency room is great, no matter what the written policies and procedures of the hospital are. This is exactly why every hospital should provide effective training for all emergency room employees (first receivers). Once a hospital decides to provide aid and/or admit patients involved in any emergency involving hazardous materials, they fall underneath OSHA’s HAZWOPER standard. This means that every first receiver needs to be trained, at a minimum, to the Awareness level of HAZWOPER. Additionally, if the hospital plans to offer emergency decontamination or even handle potentially contaminated patients, those employees need to be trained to the Operations level of HAZWOPER (the next higher level).

Many hospitals, emergency room directors, and ambulance department heads, believe that their first receivers aren’t required to be trained to the HAZWOPER standards. Even though that this standard is initially meant for first responders of hazardous materials incidents, OSHA has made it very clear that first receivers who plan to admit patients that have been contaminated fall under OSHA’s HAZWOPER standard.

“OSHA BEST PRACTICES for HOSPITAL-BASED FIRST RECEIVERS OF VICTIMS from Mass Casualty Incidents Involving the Release of Hazardous Substances” provides the standards for how hospitals should prepare and train their first receivers.

The training indicated for first receivers depends on the individuals' roles and functions, the zones in which they work, and the likelihood that they will encounter contaminated patients.⁴¹ OSHA recognizes that hospital staff who decontaminate victims at the hospital are removed from the site of the emergency (OSHA, 2002a, 2002b, 19992b). However, letters of interpretation provide that HAZWOPER First Responder Operations Level and First Responder Awareness Level training meet the requirements for first receivers in certain roles and positions. For other employees, a briefing at the time of the incident will be appropriate. In each case, the training must be effective, that is, be provided in a manner the employee is capable of understanding.⁴²

The following sections discuss HAZWOPER training provisions and contemplate levels of training commensurate with the employees' designated role within the EMP. 

OPERATIONS LEVEL TRAINING

OSHA letters of interpretation specify that hospitals must provide HAZWOPER First Responder Operations Level training to first receivers who are expected to decontaminate victims or handle victims before they are thoroughly decontaminated (OSHA, 2003, 2002b, 1999, 1992c, 1991a). This level of training is appropriate for anyone with a designated role in the Hospital Decontamination Zone.

Training requirements for First Responder Operations Level appear under 29 CFR 1910.120 (q)(6)(ii), which indicates a minimum training duration of 8 hours and outlines topics to be covered (competencies the employee must acquire). Both the required competencies and training time were recently confirmed in an interpretive letter (OSHA, 2003). OSHA, however, allows these topics (but not the minimum training time) to be tailored to better meet the needs of first responders. For example, the training might omit topics that are not directly relevant to the employee's role (e.g., recognition of Department of Transportation placards), but instead should include alternative training on hazard recognition (e.g., signs and symptoms of contamination or exposure), on decontamination procedures provided by the hospital, and on the selection and use of PPE (OSHA, 1992c). Training that is relevant to the required competencies counts toward the 8-hour requirement, even if the training is provided as a separate course. For example, training on PPE that will be used during victim decontamination activities may be applied towards the 8-hour minimum Operations Level training requirement, regardless of whether the PPE training is conducted as part of a specific HAZWOPER training course or as part of another training program (OSHA, 1992c).

First Responder Awareness Level training also counts towards the 8-hour requirement for Operations Level training. This point is clarified in a recent letter of interpretation issued by OSHA: "...if you spend two hours training employees in the required competencies for First Responder Awareness Level as described in 29 CFR 1910.120(q)(6)(i)(A)-(F), then you would need to spend at least six additional hours training employees in the required competencies for First Responder Operations Level as described in 29 CFR 1910.120(q)(6)(ii)(A)-(F). Depending on the employees' job duties and prior education and experience, more than eight hours of training may be needed" (OSHA, 2003).

As an alternative to the 8-hour training requirement, the HAZWOPER Standard allows employees to demonstrate competence in specific areas, presented in 29 CFR 1910.120(q)(6)(ii) and reproduced in Section 1.2.3.1 of Appendix A. OSHA reaffirmed this point in a letter of interpretation, stating "...employees with sufficient experience may objectively demonstrate the required competencies instead of completing eight hours of training" (OSHA, 2003). However, it is important to note that in most hospital settings it might be difficult to ensure that employees have sufficient experience to waive the training requirement. Most hospital employees do not have extensive experience with hazardous materials or PAPRs, and decontamination activities are performed infrequently.

Hospitals must document how training requirements are met. This is particularly important whenever hospitals allow employees to satisfy any portion of the training requirement through other related training or through demonstration of competence. The HAZWOPER Standard requires and an OSHA letter of interpretation confirms that "the employer must certify in writing the comparable training or demonstrated competencies" (OSHA, 2003).

Annual refresher training is specified under 1910.120(q)(8)(i), or the parallel State Plan standards; however, the length of the refresher training is not specified. Instead, the standard requires that employees trained at the First Responder Operations Level "shall receive annual refresher training of sufficient content and duration to maintain their competencies, or shall demonstrate competency in those areas at least yearly." Additionally, the hospital must document that refresher training was performed, or alternatively, keep a record of how the employee demonstrated competency.

The initial and annual refresher training to the HAZWOPER First Responder Operations Level must be provided to all hospital personnel who have been designated to provide treatment, triage, decontamination, or other services to contaminated individuals or who may reasonably be expected to come in contact with those individuals arriving at the hospital. Training core elements must include:

• Understanding the hospital emergency operations plan and their roles in the response.
• Site safety, including risks to receiving personnel.
• Appropriate selection and use of PPE.
• Decontamination procedures.

The Operations Level training related to the use of PPE must include topics such as those specified by OSHA's Personal Protective Equipment Standard (29 CFR 1910.132). Under that standard, training must be provided to each employee who is required to use PPE. At a minimum, that training must cover the following:

• When PPE is necessary.
• What PPE is necessary.
• How to properly put on, remove, adjust, and wear PPE.
• Limitations of PPE.
• Proper care, maintenance, useful life, and disposal of PPE.

Employees must demonstrate their understanding of the training by showing they can use the PPE properly, prior to using the protective equipment in the workplace. Refresher training is warranted when the employee cannot demonstrate proficiency in the proper care and use of the PPE, when changes in the workplace render the previous training obsolete, or when changes in the type of PPE to be used render the previous training obsolete. OSHA specifies that the hospital must maintain a written record of employee PPE training.

Operations Level training also must include training required by OSHA's Respiratory Protection Standard (29 CFR 1910.134), or the parallel State Plan standards. Specifically, any employee who must wear a respirator must be trained in the proper use and limitations of that device prior to its use in the workplace. The training must be comprehensive enough that the employee is able to demonstrate knowledge of the seven training topics specified in the standard and outlined below. The employee also must be able to demonstrate competence in wearing the complete PPE ensemble, including respirator, protective garment, gloves, boots, and other safety equipment required for the employee's role. Refresher training is required at least annually, or sooner if changes in the workplace or type of respirator render previous training inadequate. Refresher training is also required if the employee does not demonstrate proficiency in the proper care and use of the respirator, or any other time when retraining appears necessary to ensure safe respirator use.

At a minimum, training under OSHA's Respiratory Protection Standard must cover the following topic areas:

• The nature of the respiratory hazard, and why a respirator is needed.
• Respirator capabilities, limitations, and consequences, if the respirator is not used correctly.
• How to handle respirator malfunctions and other emergencies.
• How to inspect, put on, remove, use, and check seals on the respirator.
• Maintenance and storage procedures.
• When to change cartridges on APRs.
• How to recognize medical signs and symptoms that may limit or prevent effective use of a respirator.
• General requirements of the respiratory protection program.

Note that first receivers who wear respiratory protection must be deemed medically qualified to do so, following the process required by 29 CFR 1910.134(e)(1) through (e)(6) of OSHA's Respiratory Protection Standard. Employees who wear tight-fitting respirators also must be properly fit tested as required in 29 CFR 1910.134(f) (Respiratory Protection), or the parallel State Plan standards.
 

AWARENESS LEVEL TRAINING 

First Responder Awareness Level training is required for those employees who work in the contaminant-free Hospital Post-decontamination Zone, but might be in a position to identify a contaminated victim who arrived unannounced. This group includes ED clinicians, ED clerks, and ED triage staff who would be responsible for notifying hospital authorities of the arrival, but would not reasonably be anticipated to have contact with the contaminated victims, their belongings, equipment, or waste. The group also includes decontamination system set-up crew members and patient tracking clerks, if their roles do not put them in contact with contaminated victims, their belongings, equipment, or waste (e.g., setting up the decontamination system before victims arrive, or tracking patients from a location outside of the decontamination zone).

First Responder Awareness Level training also is required for hospital security guards who work away from the Hospital Decontamination Zone, but who may be involved tangentially in a mass casualty event (specifically, those security personnel who would not reasonably be anticipated to come in contact with contaminated victims, their belongings, equipment, or waste) (OSHA 1991b). Security staff assigned to roles in the Hospital Decontamination Zone would require a higher level of training (e.g., First Responder Operations Level).

Training requirements for First Responder Awareness Level appear under 29 CFR 1910.120 (q)(6)(i), which does not require a specific minimum training duration, but outlines topics to be covered (competencies the employee must acquire). As with Operations Level training, the HAZWOPER Standard allows an alternative to the Awareness Level training requirement. Training can be waived if the employee has had sufficient experience to objectively demonstrate competency in specific areas. These areas are listed in 29 CFR 1910.120(q)(6)(i), or the parallel State Plan standards, and reproduced in Appendix A, Section 1.2.3.2.

Annual refresher training is required for employees trained at the Awareness Level. As with Operations Level refresher training, the class content must be adequate to maintain the employees' competence, and the hospital must document the training or the method used to demonstrate the employees' competence.
 

AUXILIARY/EXPANDED FUNCTION TRAINING

A member of the staff who has not been designated, but is unexpectedly called on to minister to a contaminated victim, or perform other work in the Hospital Decontamination Zone, is considered "skilled support personnel." Examples include a medical specialist or a trade person, such as an electrician. These individuals must receive expedient orientation to site operations, immediately prior to providing such services (OSHA, 1997). The orientation must include:

• Nature of the hazard (if known).
• Expected duties.
• Appropriate use of PPE.
• Other appropriate safety and health precautions (e.g., decontamination procedures).

As part of the briefing, these personnel also must be medically cleared for respirator use and properly fit tested (if wearing a tight-fitting respirator), as required by 29 CFR 1910.134 (Respiratory Protection), or the parallel State Plan standards. See Section 1.2.3.3 in Appendix A for additional information on briefing content.

While a "just in time" briefing during the response is the only required training for these personnel, time and resource limitations inherent in a crisis likely will diminish the effectiveness of such training. Thus, hospitals should diligently consider the broad range of skills/capabilities that may be required within the Decontamination Zone during a mass casualty event and attempt to identify, and train, all persons who may be called to work in the Decontamination Zone prior to a mass casualty event. 

HAZARD COMMUNICATION TRAINING

Hospitals should consider offering a basic level of training for other employees in the ED, such as housekeeping staff. This group could include those personnel who do not have a role in the decontamination process, reasonably would not be expected to encounter self-referred contaminated patients, and reasonably would not be expected to come in contact with contaminated victims, their belongings, equipment, or waste. OSHA's Hazard Communication Standard offers a useful model for appropriate training, which could include general information on the hospital's emergency procedures and plans for mass casualty incidents involving contaminated victims, steps the employees can take to protect themselves (usually by leaving the area), and the measures the hospital has implemented to protect employees in the ED. While not required under the OSH Act, such training could help to ensure that all staff in the ED understand what precautions and actions would (and would not) be expected of them if an incident occurred.

What Can Casper Safety Do For Your Hospital?

Casper Safety can provide all your hospital consulting, training, and Hazardous Materials needs. Since JCAHO and OSHA require hazardous materials training for hospital first receivers it is crucial that you choose the most effective training possible. Here, at Casper Safety, we provide high quality first receiver training that is guaranteed to be the most effective training you have ever received.

Our hospital training program has been developed and refined to create an atmosphere that is effective and challenging to every student. We believe that conducting extremely challenging and interesting training builds a solid foundation for every student. By providing quality & exhaustive training students will be pushed to their maximum potential. Conducting hands-on training, involving situations that are more difficult than the “average” hazmat incident, will develop confidence and effectiveness. Not only is mass decontamination training very affordable, it is required.

Our hospital training programs include three major areas of expertise (required for all hospital training programs): Hazmat Awareness, Hazmat Operations, & hospital HEICS training.

We tailor the training that you need specifically for your facility. We understand that annual training requirements create a “burn-out” environment for employees. That is why we assure a dynamic and interactive training environment, in which employees learn but also have fun.

Casper Safety also provides different, new, & continually updated training to reduce the familiarization and “burn-out” of annual training/refreshers. Our hazmat training prepares your first receivers to properly handle multiple self referred contaminated victims as well as incoming contaminated ambulance units. Your first receivers can’t afford not to have this dynamic, fun, & challenging training.

It is our commitment to “change” training as you, your employees, & your facility have come to know it. It is also our commitment to provide our training at the lowest price possible. We not only would appreciate repeat business, but we understand that funding is always an issue. Our training costs are all-inclusive and will never increase. It includes all student materials, snacks, off-site research & development, and much more!

What do we offer that others don’t?

Casper Safety’s chief trainer and consultant, Steve Dacus, has extensive experience with JCAHO’s WMD, terrorism, and mass casualty issues. He was a vital asset in developing a hospital training program for all Oklahoma hospital first receivers involving mass decontamination for WMD, terrorist, and mass casualty incidents. Not only do we offer unique experience in hospital training, but Casper Safety offers high quality classroom instruction and focuses on hands-on training.

Our hands on portion of the courses depend on specific facility needs and are relevant and specific to your facility. Our hands-on training consists of scenarios that challenge students mentally and physically. We strive to make each student comfortable to responding to large scale incidents and/or smaller and more complex incidents. We believe that our training pushes the class as a team in extreme situations. Thus resulting in a hazardous materials response team that is confident, efficient, and can quickly handle contaminated patients properly. We guarantee to meet and exceed your specific needs and expectations.

Awareness Level training

Our awareness level training includes a comprehensive approach to all the issues involved during a mass casualty incident involving hazardous materials. Although this level of training does not allow students to work with or handle patients, they will gain an intimate knowledge in the tasks and jobs that are critical to the command system. They will understand what is within their scope and they will also better understand how the whole operation and incident command system work. This class is designed for all first receivers in the Emergency Room or any first receiver who would be involved in any support or more involved roles during an incident.

Operations Level training

Our Operations level training is based around a three (3) day course schedule in which aspects such as hazardous materials, emergency response, the first receiver’s’ role in a mass casualty incident, and proper decontamination techniques. This is a very in depth look at how mass casualty incidents involving hazardous materials can be effectively controlled, managed, and stabilized. Our operations course is very intense and every student gets many hours of quality hands on training. The first two days of the course are classroom lecture. Here tactics, hazard recognition, tactical objectives, and much more are taught and discussed. The third day is all hands on training. Students start the third day out with friendly competitions using props, and then it progresses to the last scenario of the day which consists of a full blown mass casualty incident where some kind of WMD was used. Due to a high probability that the next large mass casualty incident could contain a weapon of mass destruction, our Hospital Operations Level Course includes a very in depth look into terrorism, chemical and biological weapons, as well as nuclear hazards and dirty bombs.  We guarantee proficiency far beyond any training they have had before. Every student gets quality student – teacher time and each course helps the student class come together as a cohesive unit. You can’t afford not to have this type of training. Not only will your ER/Ambulance first receivers be comfortable to deal with any situation they encounter, but they will work more effectively and quicker as a team. Please call us to schedule your required Operations level training for Emergency Room first receivers.

NIMS, ICS, & HICS Training

Command and control at an emergency scene is something that is mandatory to manage a scene effectively and in an organized manner. This is something that emergency response personnel already know, however those involved at the hospital and/or within the emergency room usually are not trained to a level that properly equips them with the knowledge and confidence to be thrust into an involved command structure.

Our incident command courses create the confidence required to effectively manage an emergency scene. Through the use of table top exercises, full scale scenarios, and discussion forums; every student gains understanding on exactly how the command structure works, when to expand/shrink the structure, and how to use incident command as a tool to better manage all resources at their disposal.

We guarantee that every student that graduates from our course will be fully equipped to deal with whatever emergency that could be thrust upon them. How you handle your emergency within the first 10 minutes will dictate how the entire incident will go. Can you afford not to have fully qualified and capable first receivers?