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VHF Protocol Considerations

Before your group adopts VHF protocols for your SOP, consider our recent issues with treatment in the USA. No matter how advanced the medical system is frequent practice is how skills are refined. A protocol is only a set of rules. “Skill” with that protocol is what succeeds.

All the appropriate amendments have been updated to the Training Protocol from the CDC/WHO field manual involving a response to VHF (Viral Hemorrhagic Fever) otherwise known as the category that contains the Ebola virus. Power-Points should follow the exact procedure for disinfection/decontamination for workers treating, transporting, or otherwise dealing with infected patients from this work. While Training guidelines are important to have for your EAP (Emergency Action Plan) there are a few concepts that need to be taken into consideration and FREQUENTLY practiced at your facility. Having a set of rules/protocols does not mean YOU will be able to perform them when an incident occurs if your practical evolutions are infrequent.

We shall discuss the following concepts allowing your organization to put this protocol in practice so your workers will be properly protected. The following “Rules of Engagement” must be the cornerstone upon which you build your Training Foundation for these procedures. If this is not done, or practiced often, you still end up with great guidelines but also contaminated workers. It is up to your health and safety managers to decide which it will be.

Rule #1 all contamination stays in the Hot Zone

Rule #2 Do Not Violate Rule #1

Rule #3 VHF is a “Splash” contamination exposure

Rule #4-Decontamination is a way of thinking, more than a process (15:1 Rule)

Rule #5 One exposure = contamination, the perfect Haz-Mat, you cannot see, hear, or smell it

Rule #6 there will always be cross-contamination, (the line process reduces this)

1] Whichever protocol your organization chooses, they should all agree that the basic principle of confining the contamination to no other location apart from the Hot Zone is universal. Every time contaminated/exposures are found, it is because this rule has been violated. When dealing with non-professional responders, this rule takes on new dimensions. The general public/infected individuals are driven by fear and anxiety not training, “IF” they have ever had any. This equates to HCW’s (Health Care Workers) and Security forces as a monumental issue to deal with. While aid to these “exposed” is our primary rescue task, we cannot sacrifice the spread of this contamination to the “unexposed.” This will cause more injured/sick/death than the original exposure. The challenge shall be to reassure these “victims” that the time consuming activities they face are not only in their best interest, but critical to providing them health care. If they violate your procedures due to personal fear or anxiety, they risk losing their health care givers to exposure and sickness. If HCW’s become ill, they cannot help you. When this happens, many more people are exposed. This is the reassurance logic that you can offer them. The question of a fearful affected person must be considered and compensated for. In the advent of an unmanageable person, there must be some way/plan for securing them and the subsequent spreading of their contamination. This is always a difficult decision, but your organizations security system must subdue these persons before your operational system is compromised and can no longer function. Therefore, in the WHO/CDC manual is a detailed EAP (Emergency Action Plan) for your sites Security operatives. They too, can effectively be protected while performing the patient “holding” tasks decided upon by your facility.

2] “IF” this rule is compromised, the “Hot Zone” has immediately been expanded. This cannot overwhelm your operational system, so you must have a back-up plan to implement. Obviously some facilities may not allow for this due to their physical structure and the maximum load of patients they can physically handle. Therefore, if this is the case, security precautions must be more restrictive and adhered to without exemption. Again, the result will be a system shut-down and failure to treat or rescue. While these are hard discussions to make, you must be able to look at the bigger picture. What is your goal? Humanity or functionality? These decisions need reflection by the EM (Emergency Manager) in charge of a response treatment facility and will not be easily reached.

3] VHF contaminants are spread and contaminate through the “contact” of infected liquids. Therefore, all contamination procedures must center on level “B” or greater PPE (Personal Protective Equipment) protection for physical contact with these infected. While respiratory protection is the prime element for choosing between these levels, some adaptation can be made in this particular case. Remember, CPC is an “ensemble”” and this quite exactly means “a combination of elements to provide the proper chemical protection.” So while the “purist” may object from past training, the actual definition defends the position of adaptation for the “specific hazard” involved. These issues also must be handled at the facility level long before operations commence. It is critical for all operational personnel to understand why they do what they are doing. This insures confidence and allows your Team of HCW’s to continue in the knowledge that they are properly protected for their work function during this “emergency.”

4] The decontamination process really is a “way-of-thinking” as opposed to a simple technique. One of the examples we use in the Emergency Rescue venue is the 15:1 rule. This too is a conceptual way of thinking about safety. Regardless of the contaminant or hazard, we build into our systems/plans a 15 to 1 safety margin for all tasks that we possibly can. A good example is rope rescue; a 9000 lb. static rope for holding a life/person/rescuer from an elevated position from which, they could fall and perish must be 15 times stronger than the weight it will be holding. In the case of a 350lb individual, at 15 times would be 5,250lbs. This means that a 9,000lb rope is a one (1) person rescue line. At two (2) individuals you would only be holding 700lbs, BUT you also would violate the 15:1 rope safety margin by 1,500lbs. This same principle is used for decontamination. The bottom line is, when hazardous materials teams operate, this is exactly WHY you do not see them crowding the emergency rooms with injuries. Applying this “concept” to decontamination/infection control will yield your operations and workers the same results.

5] Since the exposure of only one (1) spore could possibly infect a HCW, this means there is no room for ANY error. One exposure immediately downgrades the HCW from rescuer and patient treatment specialist, to victim in quarantine for an extended period of time. Not to mention the issue of “replacements” for this HCW now that he/she is permanently “out-of-service.” The care and precision of the decontamination/disinfection system needs frequent practical training to be successful. Simply put, the more frequently you use a tool, the better you will work with it, and the less injuries will you have. Due to the intensity of this training and the lethal exposure of its failure, scheduling quarterly session(s) should be the minimal rate throughout the calendar year.

6] Cross-contamination is prevalent in ALL decontamination systems. It is the EM goal to minimize the “amount” of cross-contamination. Every system cannot be implemented in a perfect style. It is not feasible to create the perfect decontamination room or facility and rarely use it. Proper decontamination systems for this hazard can be effective and safe for your facility regardless of its location or resources. However, just be aware that when systems have to be minimized, you move closer and closer towards a 1:1 safety system and away from a 15:1 system. The end result is that the chance of exposure becomes greater for the HCW the closer your system moves to 1:1. The “line” system of decontamination does increase this ratio in the positive direction, but quite simply, modern hospitals are just not designed to handle these types of infrequent emergencies. Working with your system restraints and devising a “system” for decontamination/disinfection is the best way to minimize any exposure to this deadly family of viruses known as VHF.

                                        Haz Mat Mike

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