Hazardous Materials Emergencies in Surgery
by Jack Donaldson, RN, CNOR, CSPDM
From the beginning, professional nursing has concerned itself with the health and hazards of the environment of the healthcare system. For example, Florence Nightingale influenced the advancement of healthcare by advocating for a safe healthcare environment and applying statistical analysis to support her recommendations for change.1 Over the last 150 years, this process has led to the introduction of advanced engineering and work practice controls into the healthcare environment for the patient's and worker's benefit. These advances have not come without some risk. Levitan notes that "there are 575,000 chemicals found in the workplace, 53,000 of which are potentially hazardous."2 The National Institute for Occupational Safety and Health (NIOSH)3 lists over 200 hazardous materials found in hospitals. Potentially hazardous materials and environments are part of the modern healthcare setting.
Definition of Hazardous Materials
There are many definitions for hazardous materials. For the purposes of this article, the definition of hazardous materials is best summarized by Seibert who writes, "Generally, a substance is considered hazardous if it could affect a person's health, cause injury or death, or damage or pollute air, water, or land. If the product's label contains a warning such as 'caution,' 'danger,' 'warning,' or refers to characteristics such as 'toxic,' 'flammable,' 'reactive,' or 'corrosive,' then the product would most likely be considered hazardous and would be covered by the standard."4 Two types of chemicals are exempted from the Hazardous Communication Standard's inventory requirements. "Any consumer product...as defined in the Consumer Product Safety Act...where the employer can demonstrate it is used in the workplace in the same manner as normal consumer use..." and "Any drug...when it is in solid final form for direct administration to the patient (i.e., tablets or pills)."4
When assessing the existence of potentially hazardous materials in work settings, it is important to understand that a potentially hazardous material can be created secondary to the combination of what appears to be non-hazardous products. Also, hazardous materials in storage that are no longer used in the work setting are still considered hazardous.
Sources of Hazardous Materials
Hazardous materials risks can arise from two fundamental sources--external and internal. External sources are hazardous material incidents that result in individuals receiving injuries requiring hospitalization, surgical intervention, or result in environmental contamination that impacts the work setting negatively. Their occurrence is uncontrolled by the healthcare provider. However, the provider must be able to respond to the potential exposure from external sources posed to the workers caring for the injured or in the case of an environmental incident, the ability of the healthcare facility to function.
The probability of OR departments being exposed to hazardous materials from an external source is small. However, Cox argues that "Even though patients contaminated with hazardous materials are uncommon...Failure to provide employees with adequate training and protective gear can result in unnecessary exposures to toxic agents and violations of OSHA regulations and could result in potential litigation...Secondary contamination with a hazardous substance can result in toxic insult to health care workers or costly contamination to medical equipment or facilities. Contamination...can necessitate closure, depriving the public of a much needed service."5
Cox recommends that until a patient is decontaminated, only basic life-support measures and life saving procedures be performed. Aside from the risk to healthcare workers and the care environments, he further notes that an invasive procedure performed on a contaminated victim may expose the patient to increased amounts of hazardous substances. He also notes that the traditional scrub attire used in the surgical setting is inadequate for the care of a non-decontaminated patient. The recommended attire for hospital workers who must care for non-decontaminated patients is full-face air purification devices and nonencapsulating chemical-resistant suits with nitrile gloves and chemical resistant boots. ATSDR recommends that "Depending on the concentration of the chemical and its potential for secondary contamination, victims with serious trauma or medical complications (e.g., seizures) may have to wait for advanced medical care until gross contamination is removed. Rescuers wearing respirators and heavy gloves will find it difficult to provide advanced medical care such as inserting an intravenous line or performing endotracheal intubation; therefore, this care is not administered until the victim is transferred to the Support Zone. Generally, electronic equipment, such as cardiac monitors, are not taken into the Decontamination Zone because the equipment may not be safe to operate and may be difficult to decontaminate."6
If necessary, emergency surgery performed on a contaminated patient should take place in a suite in the Emergency Department. This would reduce the opportunities for the spread of contamination. In the absence of this capability, and if a decision is made that surgery must be performed on a contaminated patient, the following protocols should be considered.
Personnel: A hazmat safety officer should be in attendance to assist with technical advice and to advise on cleanup and disposal after the procedure, and a security officer should be present to coordinate such aspects as public access to potentially hazardous care sites and transportation sites. The room should have a dedicated outside circulator/triage nurse and should be staffed by non-pregnant personnel. A rapidly developing fetus is much more susceptible to low dose exposure from hazardous materials than an adult.
Containment: The patient's clothes must be removed in the ER. Cox notes that 70% to 85% of most contaminants are contained in the clothing. Additionally, the patient should be transported to the OR by the least public route on a gurney covered with disposable linen. It is important to contain the hazardous material and not put others at risk. The linen from the transport gurney should be placed in containment containers located in the OR that are appropriate for the hazardous materials. The surgical suite used should be the most under-utilized and remote suite away from the general traffic patterns in the OR. All unnecessary equipment should be removed from the room to avoid contamination, and all linens and drapes should be disposable and placed in containment containers, located in the operating room, that are appropriate for the hazardous materials. Surgical gowns should be disposable and should be worn over appropriate level C personal protective equipment as defined by the EPA. All surgical attire should be left in the OR following the procedure. Boots should be decontaminated at the surgical suite door before a team member leaves at the end of the case, and all fluids used during the case should be contained in storage containers in the OR suite.
Instruments should be decontaminated in the OR suite. No instruments should be sent to the SPD immersed in fluids used during the case. In the case of radioactive contamination, instruments should be tested by the radiation safety officer for absence of unsafe levels of radiation before being released to central/sterile decontamination. Ingested chemicals and products formed by their reaction with stomach acid may be hazardous through direct contact with vomitus or by inhalation of the gases liberated from the vomitus. Measures must be taken to isolate vomitus or gastric washings. This can be accomplished by attaching a lovage tube to isolated wall suction or other closed systems.5,7
While the probability of a contaminated patient reaching the OR is low, Cox notes that "The most important mechanism for preventing chaos and hysteria in the event of receiving a contaminated patient is to have a well-conceived protocol describing the procedures that are to be followed. The...staff must be familiar with the protocol."5
When establishing your protocols for the surgical services response to an external hazmat incident, it would be prudent to examine the surrounding community. For example, a hospital located in a heavily industrialized petro-chemical area may be expected to have a more developed protocol than a hospital located in a rural non-agricultural region. At a minimum, the surgery division management should review the emergency response program with their staff and meet with key members of the hazmat response team each year. Lastly, there are occasions when external hazardous materials incidents do not produce victims. Rather, they pose such a potential environmental exposure risk that a hospital may have to be evacuated.
Such was the case in 1998 when a chemical spill at a milk-processing plant forced the evacuation of a hospital in Arcadia, Wisconsin.8 In June, 1998, 50 patients were evacuated from the Royal Melbourne Hospital when chemical fumes from photographic fluid by-products were circulated throughout the hospital by the air-conditioning system.9 In May 1997, patients and staff of Helena regional Medical Center (West Helena, Ark) were evacuated when a chemical packaging plant exploded and burned, releasing a cloud of toxic gas.10 In another incident following a new construction project, contractors testing a new emergency generator failed to identify that the exhaust was vented less then 10 feet from an existing fresh air intake port for a portion of the operating suites. The entire surgical team was overcome with exhaust gases and were preparing to abandon the surgery before they discovered the source of the fumes. Levitin reports that hazmat incidents in a one year long study of 11 states "occurred on weekdays primarily from 6 AM to 6 PM (71%), with only 16.5% of the accidents occurring on weekends."2 The hours of these incidents correlate with the typical surgical hours in an OR. It would be prudent for hospitals located in heavily industrialized petro-chemical regions to have an evacuation plan that addresses emergency protocols for termination of surgical procedures and evacuation of surgical patients. Also, a workable evacuation plan is expected by JCAHO.11
While external sources of hazmat risks are acute but rare, internal risks can be characterized as frequent and insidious. It is not uncommon for workers to become comfortable with their work surroundings and overlook work practices, technological changes, and environmental changes that bring new hazardous risks to the work setting. This is no more apparent than in the ORs of modern hospitals. Changing surgical techniques and healthcare practices are introducing new sources of high energy risks (lasers), radioactive risks (brachytherapy), chemical risks (AbTox), biological risks (VRE, VRSA, MSRA, TB, Prion Diseases), physical risks, and sophisticated but difficult to disinfect and sterilize instrumentation. To ensure that no harm comes to the patient and staff, today's OR staff are experiencing an increasing need for educational and technical training. These training programs should have at their core the goal of dispelling complacency in the workplace. OSHA, through the Hazard Communication Standard, and JCAHO, through Standard EC 1.5, outline their expectations for healthcare facilities as how to address the hazardous materials issues in the workplace. The remainder of this article will focus on the internal sources of hazardous risks and how to respond to them.
Types of Hazardous Materials
Hazardous materials are broken broadly into four categories, physical, chemical, biological, and radioactive. Exposure to these hazards can be acute or chronic. Injuries associated with them can include cardiovascular, dermal, electrolyte, gastrointestinal, hematologic, hepatic, immunologic, musculoskeletal, ocular, peripheral neurologic, renal, respiratory, thermal injury, blunt trauma, acute toxicity, allergic sensitivity, reproductive effects, developmental effects, carcinogenicity, neurotoxicity, infection, and death.6 A properly designed hazmat orientation and training program should educate staff as to the purpose, function, storage considerations, degree of risk, types of risks, proper handling, disposal, containment, and exposure response with regards to potentially hazardous materials in the work setting. A yearly systems review should take place to see if new, less toxic, products have been designed that can be substituted for current products or if engineering and work re-design can reduce the exposure to potential hazards.
Although physical hazards are not generally identified in hazardous materials literature, within the context of Seibert's definition of hazardous materials discussed earlier, steam autoclaves, secondary to scalding steam and heated exterior surfaces, do pose a potentially serious risk of injury to OR staff. Appropriate training, addressing the operation and safe practice of handling heated instrumentation, trays, and autoclave surfaces should be a part of any OR personnel orientation and safety programs. Internal surface temperatures of an idle autoclave can be as high as 240ºC. Thus, loading instruments manually into an empty autoclave poses a risk for thermal injury. Instruments and trays being removed from flash sterilizers can have extremely hot water, capable of scalding unsuspecting staff, pooled on their surfaces.
A facility's design should address the thermal hazard of an autoclave. The design of a new facility should create appropriate traffic patterns around autoclaves. There should be adequate room to pass by the autoclave when the door is open. Another source of physical hazards is the high-pressure gases used in the OR to run air- driven surgical equipment. Healthcare workers have experienced dental, facial, and blunt trauma injuries when pressurized apparatus were handled incorrectly or inattentively.
Chemical hazards represent the broadest category of potential risk to OR personnel. Chemical hazards come in solid, liquid, and gas/vapor forms. Potential exposure can be acute or chronic. Injuries associated with chemical hazards can include thermal injury, blunt trauma, acute toxicity, allergic sensitivity, mutagenic changes, cancer, birth defects, loss of vision, neurotoxicity, and death. Solid chemical hazards are found primarily in the form of chemical disinfectants, which must be premixed with water before they can be used as cleansers in the OR. Liquid chemical hazards are used primarily in disinfection, sterilization, medication, and tissue preservation in the OR. Gas/vapor chemicals are primarily associated with anesthesia, disinfection, sterilization, and surgical equipment in the OR.
Biological hazards are responsible for some of the greatest changes in current healthcare practice. Potential exposure can be acute or chronic. Illness resulting from exposure can lead to autoimmune disease, liver disease, respiratory disease, neurological disease, and death. The emergence of AIDS in the mid 1980s led to the recommendation by the CDC in 1985 and implementation by OSHA in 1991 of the practice of universal precautions for protection from fluid and bloodborne pathogens. The implementation of these standards has impacted no area of the healthcare industry as broadly as the OR divisions of hospitals. However, fluid and bloodborne pathogens are not the only biological concerns of OR personnel.
Strong evidence exist that the pappaloma virus is carried in the smoky plum of laser and electrocautery smoke. New strains of tuberculosis, vancomycin resistant bacteria, and methycillin resistant bacteria are presenting surgical divisions with new challenges ranging from case scheduling to protecting staff with appropriate PPE. The current findings regarding the resistance of prion disease proteins to standard sterilization protocols issues a new challenge to OR personnel.8
Potential radiological hazards may be organized into three categories, thermo (lasers), radioactive isotopes (brachytherapy and radioimmunoscintigraphy procedures), and electromagnetic radiation (x-ray, gamma, and ultraviolet radiation). OR personnel are exposed to all three radiological hazards. Lasers pose potentially significant thermo radiological hazards in the OR for staff and patients. Of primary concern are the risks they represent as a potential ignition source for surgical fires and ocular damage. Radioactive isotopes are used in brachytherapy and radioimmunoscintigraphy. In addition to OR personnel, they also represent a significant potential risk to patients, family, and the public at large.
Another EM source of radiation commonly encountered in orthopedic surgery is ultraviolet (UV) irradiation, used to decrease environmental bacterial counts during orthopedic total joint surgery. UV irradiation poses a risk to ocular and dermal tissue. All surgical suite personnel and the patient must be shielded from the effects of the UV irradiation. This is accomplished simply by covering all body surfaces with clothing or drapes and shielding the eyes and face of perioperative staff with UV resistant face shields.
Hazardous materials are a part of our daily private and working lives. Today's OR professionals must be ready to respond to external and internal HASMAT incidents. Well-designed plans and staff education will prepare healthcare personnel to reduce the probability of such incidents and respond appropriately.
Jack Donaldson, RN, CNOR, CSPDM, is the Nurse Manager of Sterile Processing at Sutter Medical Center (Sacramento, Calif). He is also the editor of the Internet Nursing Education Site NurseCEU.com.
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