Protection And Response To A Chemical, Biological, Radiological And Nuclear (CBRN) Incident
Chemical, biological and radiological (CBR) agents are toxic substances that can harm people and other living organisms. Their release may be deliberate or accidental.
The majority of chemical, biological and radiological substances have been developed for peaceful industrial or medical purposes. Subsequently, there are safeguards in place to prevent their accidental or deliberate release. However, in the event that a release occurs, this directive will articulate the health response.
Some specific substances have been developed for no other application than to kill or harm people, animals or plants. These are usually referred to as chemical, biological or radiological warfare agents. It is predominantly these substances that form weapons of mass destruction that may be used by nation states or non-state organisations, such as terrorists.
HAZARD MANAGEMENT (HAZMAT)
Responsibility for the management of a HAZMAT incident is as follows:
- Fire and Emergency Services Authority (FESA)
- Hazard Management Agency (HMA) for the accidental occurrence of a chemical incident; and
- Combat agency for the consequences of a biological, chemical, radiological or nuclear incident.
- Department of Health WA (DOH)
- HMA and combat agency for the accidental or natural release of a biological or radiological incident; and
- Combat agency for the consequences of a biological, chemical, radiological or nuclear incident.
This Operational Directive describes the mechanisms in place to protect hospitals against contamination by CBR compounds and the use of antidotes for exposure to nerve agents.
Section A of this Operational Directive covers the levels of protection for hospitals and Section B describes the protocols for use of antidotes for exposure to nerve agents.
SECTION A: PROTECTION OF HOSPITALS
In order to protect hospitals, staff, patients and visitors from toxic contamination, it is necessary to secure critical areas within the hospital. As this physical security may potentially breach fire Regulations, the DOH has obtained advice from FESA and legal services regarding this risk. Subsequently, permission has been obtained from the State Health Executive Forum (SHEF) for the implementation of CBRN lockdown perimeter security at hospitals.
The DOH has a statutory duty to provide:
- health care to patients; and
- a safe working environment for staff.
The DOH also has a duty to maintain a standard of care.
Key tertiary and secondary hospitals are designated as critical infrastructure and must be protected from contamination in order to maintain their capability to receive and treat patients, as well as protect staff.
Patients delivered to a hospital by St John Ambulance (SJA) from the site of a CBR incident will have been decontaminated at the incident site. Many patients, however, will use other transport and self-present to nearby hospitals.
Those patients that self-present will include contaminated and the worried well. Self-presenters cannot be permitted to enter a hospital until they have been appropriately triaged and decontaminated. Designated hospitals must therefore have the capability to safely decontaminate all self-presenters.
LEVELS OF PROTECTION
There are 3 levels of protection required by the hospitals:
- perimeter security;
- Personal Protective Equipment (PPE) for staff to conduct triage, decontamination and initial critical treatment external to the hospital; and
- decontamination showers.
The DOH has designated that selected hospitals are to have an automated perimeter lockdown capability. This automated perimeter security system must encompass and secure the critical areas of the hospital when activated. Movement between critical areas must not be impeded. Critical areas are those areas necessary for the treatment of patients. They include, but are not limited to:
- emergency department;
- intensive care unit / high dependency unit;
- diagnostic facilities ( x–ray, CT scan);
- pathology labs;
- wards; and
- central plant.
Activation and deactivation of automated perimeter security is to be from a central control point. All access doors leading to the perimeter, which encompass the critical areas of the hospital, must be programmed to close.
Select doors within the perimeter must be enabled to open and close from the inside, through a control point located adjacent to the door, for the passage of necessary personnel. For example, the entrance door to the Emergency Department should be enabled to allow for the controlled admittance of patients. Activating the internal release of these doors must not result in the deactivation of the entire system.
Emergency exit doors need to be able to be deactivated from the central control point in case of fire. Additionally, staff that work in the clinical areas must have the authority to request deactivation of the security doors in case of fire.
The perimeter security system needs to be supported by a Closed Circuit Television system. The cameras should cover:
- approaches to the Emergency Department; and
- both sides of doors that allow internal egress.
The State Health Coordinator (SHC) must be notified when the automated perimeter security is activated. The SHC is contactable 24 hours a day, seven days a week, via the On-Call Duty Officer Disaster Preparedness on (08) 9328 0553.
PERSONAL PROTECTIVE EQUIPMENT
The PPE to be worn by hospital staff conducting decontamination of patients are the LED 500 CBR suits with push-to-talk (PTT) radios provided by the Disaster Preparedness and Management Unit (DPMU).
All staff need to be trained in the use of PPE prior to their use for operational purposes. The DPMU is responsible for the development of the training package and list of competencies required. DPMU is also responsible for the procurement, distribution and replacement of the suits. Hospitals are responsible for ensuring that hospital staff are trained in the use of the suits and that the suits are mission ready 24 hours a day.
Decontamination stations, consisting of heated fresh water showers, are to be established adjacent to the entrance of all major Emergency Departments. The Guidelines for Decontamination, distributed by DPMU, should be used by the hospitals for the creation and maintenance of this capability.
SECTION B: PROTOCOLS FOR USE OF ANTIDOTES
Combopens and atropine auto-injectors are antidotes for exposure to nerve agents. The protocols within this Operational Directive must be adhered to by all recipients of these antidotes by the DOH.
These goods are exempt from registration on the Australian Register of Therapeutic Goods by virtue of Section 18A of the Therapeutic Goods Act 1989. This section allows the Commonwealth Minister for Health and Ageing to exempt specified medications and medical devices from the rigorous registration or listing procedure normally required under the Act, so that they can be made available immediately for supply in Australia.
This power may only be exercised where it is considered to be in the national interest that:
- medications or medical devices be stockpiled in preparation for a potential threat to public health; or
- medications or medical devices are required in response to an actual threat to public health caused by an emergency (refer to subsection 18A(2)).
The Commonwealth Minister for Health and Ageing has exempted the above goods from the necessity to be registered on the Australian Register of Therapeutic Goods, in order to allow their supply in Australia to combat a potential terrorist threat. This exemption is subject to conditions, specifically in relation to secure storage, supervision and record keeping. Specifically, these conditions are:
- the goods must be stored in secure premises, under the supervision and direction of the SHC or the person who has assumed the role of that position;
- the goods are to be stored at a temperature consistent with that required to maintain their shelf life; and
- records of the goods distribution, supply and administration are to be kept for not less than 10 years.
RESPONSIBILITY FOR RELEASE AND USE
Combopen and atropine auto-injectors are Schedule 4 medications that can only be administered under the direction of specific authorised medical officers. The SHC, or the person who has assumed the role of that position, is the only person who can authorise the release of these medications. If the SHC is not a medical officer, then authority to release these medications can be referred to the Executive Director Public Health Division, Director Disaster Management Planning & Regulation or the On-Call Clinical Toxicologist (after hours).
The SHC is contactable 24 hours a day, seven days a week, via the On-Call Duty Officer Disaster Preparedness on 9328 0553.
The release of a chemical agent may not be recognised until there are multiple casualties and there may be some initial ambiguity and/or delay in determining the chemical involved, however, there is only a narrow time frame in which to administer life saving treatments, including the administration of antidotes (auto-injectors).
Generally, Police and FESA Fire Services will be first to the scene of an incident followed by SJA. If it is determined that a chemical agent has been released, the SHC will be advised and will determine whether auto-injectors should be administered. The SHC will also advise the Hospital Health Coordinators and/or Regional Health Disaster Coordinators, and, if required, approve the administration of antidotes in the hospital(s).
The Hospital Health Coordinators and/or Regional Health Disaster Coordinators will contact
the pharmacy or pharmacies of the hospitals that may have exposed patients being brought to the facility by ambulance or self-presenting, to have their supply of combopen and atropine auto-injectors made available.
If there is a requirement for the auto-injectors to be used elsewhere, the SHC will advise the Chief Pharmacist of the relevant hospitals that the supply they currently hold will be removed.
Monitoring and Review
The Senior Policy Officer, Disaster Preparedness and Management Unit is responsible for the monitoring and review of this document on an annual basis.
The designated hospitals are currently RPH, SCGH, Fremantle, PMH and Rockingham – Kwinana, with funding to be allocated to Bunbury, Nickol Bay and Kalgoorlie hospitals for perimeter security to be installed.
Dr Peter Flet Flett
OFFICE OF THE DIRECTOR'S GENERAL