GHS Pictogram and Hazard Allocation. Pictogram can be downloaded at http://www.unece.org/trans/danger/publi/ghs/pictograms.html.
Various systems have been devised for the actual labeling of hazardous materials. Labels or placards contain information alerting people to the presence of dangerous materials using a pictogram or symbol. The placard may have words such as “flammable liquid” or “toxic gas,” a product identifier, hazard classification number, or an emergency assistance number to call (Figure 34.2). Some identification systems are permanent and cannot be modified once attached to a container. Others can be changed with fitted slots or interchangeable placards. GHS prescribes a standard format and content for labeling of chemicals with product identifier, hazard pictograms, signal words, hazard statements, precautionary statements, and supplier information.
Warning Placard for a Hazardous Material.
In some countries, material safety data sheets (MSDS) containing basic substance information are legally required to accompany each product supplied to an end user. MSDS are not necessarily intended for emergency responders, but they can be used by professional staff to advise such individuals. MSDS have existed for many years in a wide variety of formats, with a broad range of data quality and quantity. Under GHS, MSDS are now termed safety data sheets (SDS) and have sixteen subcategories that include product identification, company information, ingredient information, and hazard identification. A complementary hazard communication information source is found in the International Chemical Safety Cards (ICSC) produced by IPCS and the European community, and these are translated into various languages.41,42
The transport of dangerous goods has a different system of hazard classification under the UN. The first version was issued in 1956 and now the UN has published the seventeenth edition of its Recommendations on the Transport of Dangerous Goods – Model Regulations in 2011.43 Its focus is on the risk associated with transport of the hazard whereas the GHS focus is on the inherent toxicity of the chemicals. The UN groups hazards into nine classes and hazard severity is classified into packing groups. It provides a system of classification in listing, packing, marking, labeling, placarding, and documentation. This is modified by various international aviation, maritime, and rail organizations for adoption into their regulations. There are various forms of hazard communication systems used by transportation industries and fixed facilities in different countries and these are illustrated in the next section. However, these governments are in various stages of implementing and adopting GHS.
Within the European community, regulations require that written emergency instructions be carried in the vehicle cab. The European Chemical Industry Council has produced a series of instructions called TREMCARDS (transport emergency cards). These cards are written using internationally approved standard sentences with appropriate translations. They provide information on immediate actions required as well as first aid advice.42,44
First responders may also encounter other numerical codes such as the Emergency Action Codes and the Hazard Identification Number (also known as the Kemmler Code). Emergency Action Codes (commonly called Hazchem Codes) are designed to assist emergency services providers during the initial contact with a hazmat incident by instructing responders which actions they should perform. They are designed for responding to bulk product incidents. In contrast, the Hazard Identification Number, which is usually found in the United Kingdom on vehicles traveling internationally, gives advice on the nature of the hazard presented by the substance in question, as opposed to the actions required when dealing with the material.45
In the United States, the Department of Transportation (DOT) Pipeline and Hazardous Materials Safety Administration uses the Hazard Classification System in its guidebook.46 This system assigns a chemical to a hazard class based on its most dangerous physical characteristic, such as corrosiveness, flammability, or radioactivity. It is primarily a guide to aid first responders in: 1) quickly identifying the specific or generic classification of the material(s) involved in the incident; and 2) protecting themselves and the general public during the initial response phase of the incident.
In contrast, fixed facilities in the United States use a labeling system that is different from the vehicular placarding system. The National Fire Protection Association (NFPA) 704 system is used at most fixed facilities.47 This system uses a diamond-shaped sign (commonly referred to as the “fire diamond”) that is divided into color-coded quadrants: blue, red, yellow, and the 6 o’clock position which is assigned no special color. The blue color indicates the degree of health hazard, red is used for flammability, yellow for instability, and the last quadrant is reserved for special hazards. These markings assist first responders to quickly and easily identify the risks posed by the hazmat, helping to determine what specialty equipment should be used, procedures followed, or precautions taken during the first moments at the site of the release. They do not identify the substance.
First responders need to rapidly and precisely identify the chemical or the components of a hazmat mixture. They must be familiar with the local labeling systems and know where to seek further information regarding the chemical. One cannot always rely on the presence of a hazmat placard. Many hazmats may not be placarded because their quantity did not exceed a certain weight limit (such as 450 kg). Placards may also be damaged by fire or explosions during the event. Other sources of information that may aid identification include site of the hazmat incident and the type of business, laboratory, or vehicle involved. SDS, order invoices, shipping documents, inventory sheets, and verbal information from front-line employees and management are potential sources of information.38 The Internet provides up-to-date resources related to chemical identification and database information (Table 34.2).
Online Resources Related to Chemical Identification and Database Information
| Name | Description and Internet Address |
|---|---|
| Chemical Abstracts Service (CAS) | A division of the American Chemical Society, this group provides the most comprehensive database of disclosed research in chemistry and related sciences, including the world’s largest collection of substance information, the CAS REGISTRYSM. http://www.cas.org |
| Databases for emergency chemical responses: | |
| CAMEO (Computer-aided Management of Emergency Operations) Chemicals | CAMEO Chemicals is developed jointly by three U.S. federal agencies: National Oceanic and Atmospheric Administration (NOAA), EPA, and Coast Guard. CAMEO Chemicals is an online version of part of the CAMEO A suite of software programs developed by NOAA and EPA. CAMEO supports a number of information management functions, such as retrieval of chemical-specific information to support emergency response activities, threat zone calculation and plotting for risk assessment, organization and management of EPCRA information, and storage and computer display of area maps. http://cameochemicals.noaa.gov |
| CHEMTREC® | Accessible library of over 5 million MSDS, has 24-hour toxicology specialists, language translation services, and chemical industry experts. http://www.chemtrec.com/Chemtrec |
| MSDSOnline® | MSDS online develops on-demand products and services to help environmental health and safety professionals around the globe to access, manage and deploy MSDS and safety information. The database contains millions of original MSDS documents in an indexed electronic format. More than 10,000 new or updated MSDS documents are added to their database each week. http://www.msdsonline.com |
| National Fire Protection Association (NFPA) 704, Standard System for the Identification of the Hazards of Materials for Emergency Response, 2012 Edition | This standard addresses the health, flammability, instability, and related hazards that are presented by short-term, acute exposure to a material under conditions of fire, spill, or similar emergencies. http://www.nfpa.org/aboutthecodes/aboutthecodes.asp?docnum=704 |
| U.S. Department of Transportation (DOT) Pipeline and Hazardous Materials Safety Administration (PHMSA), Emergency Response Guidebook (ERG 2012) | Developed jointly by U.S. DOT, Transport Canada, and the Secretariat of Communications and Transportation of Mexico (SCT) for use by firefighters, police, and other emergency services personnel who may be the first to arrive at the scene of a transportation incident involving a hazmat. http://phmsa.dot.gov/hazmat/library |
| WISER (Wireless Information System for Emergency Responders) | WISER is a system designed to assist first responders in hazardous material incidents. WISER provides a wide range of information on hazardous substances, including substance identification support, physical characteristics, human health information, and containment and suppression advice. http://wiser.nlm.nih.gov |
| Databases for clinical toxicology, risk assessment and emergency preparedness: | |
| Agency for Toxic Substances and Disease Registry (ATSDR) | ATSDR provides comprehensive review of health effects of chemicals. It includes Managing Hazardous Material Incidents (MHMI) series, Medical Management Guidelines (MMGs) for acute chemical exposures and ToxFAQsTM, toxicological profiles and interaction profiles. http://www.atsdr.cdc.gov/substances/indexAZ.asp |
| IPCS InCHEM | InChem is a chemical safety information database produced through cooperation between IPCS and the Canadian Centre for Occupational Health and Safety (CCOHS). It provides rapid access to internationally peer-reviewed information on chemicals commonly used throughout the world. Its databases include references to many others. http://www.inchem.org |
| Occupational Safety and Health Administration (OSHA) Chemical Sampling Information (CSI) | The CSI pages present, in concise form, data on a large number of chemical substances that may be encountered in industrial hygiene investigations. It is intended as a basic reference for OSHA personnel. http://www.osha.gov/dts/chemicalsampling/toc/toc_chemsamp.html |
| Toxicology Data Network (TOXNET) | TOXNET is a group of more than ten databases covering chemicals and drugs, diseases and the environment, environmental health, occupational safety and health, poisoning, risk assessment and regulations, and toxicology. It is managed by the Toxicology and Environmental Health Information Program (TEHIP) in the Division of Specialized Information Services (SIS) of the National Library of Medicine (NLM). http://toxnet.nlm.nih.gov |
Public Health Response Cycle in an Industrial Hazardous Material Incident
Comprehensive emergency management of industrial hazmat incidents involves addressing all the elements of the public health disaster management cycle – prevention, mitigation, preparedness, response, and recovery. A chemical incident management structure is needed to manage and coordinate the widely differing activities undertaken by the many actors involved at the different stages of the disaster cycle. An organizational structure that includes public health professionals is recommended at the various administrative levels (e.g., national, provincial, and/or local levels).1
The aim is to improve prevention of hazmat incidents that might affect the general population and, should an event occur, to minimize adverse effects on human health. Organizations and officials having roles in this management structure include, but may not be limited to, those working in the following areas:48
Ministries of health, labor, industry, and transportation;
Regional and local health authorities and inspectors;
Hospitals and other treatment facilities;
Providers of toxicological/health information, such as poison information centers and chemical emergency centers;
Facilities handling, storing, or producing hazardous materials;
Occupational health centers; and
Suppliers of pharmaceuticals and medical equipment.
On a national level, the main tasks of the organization are to develop:1
A national chemical emergency coordinating structure, including appropriately trained staff with the right knowledge and skills for dealing with each stage of the disaster cycle;
A Chemical Incident Response Plan (including public health involvement);
The necessary policies, legislation, and enforcement strategies for all stages of the disaster cycle;
Databases on chemicals, sites, transport routes, and expertise;
Mechanisms for interagency communication and public communication;
Emergency response guidelines, including environmental protection guidelines;
Incident exercises, training, and audits;
Preventive measures;
National Chemical Incident Surveillance; and
A structure for independent investigation of chemical incidents.
Risk Management, Prevention, and Mitigation
Risk management is part of disaster prevention and mitigation. The main vulnerability factors are political-institutional, economic, and sociocultural.49 They include issues such as fragile infrastructure, absent or poorly developed safety policies, low levels of political and social organization, absence of early warning systems, and an increase in population density, especially around chemical facilities. Table 34.3 contains items to be considered when undertaking a risk assessment in a catchment area.50
|
| Other areas of risk assessment include:49 |
|
For any community, complete prevention of hazmat incidents is unrealistic. There will always be residual risk of events in the presence of hazards. The approach should be that of managing and reducing risks causing disaster. Risks can be assessed by investigating the cause–effect matrix between hazards and vulnerability (hazard vulnerability assessment [HVA]). A four-step risk assessment process that involves hazard identification, dose-response assessment, exposure assessment, and risk characterization may also be used.1
When considering the type of chemical, toxic industrial substances demand extra care and attention. They are defined as industrial chemicals with an LD50 (lethal concentration of a substance in 50% of the population exposed over a specific time) of less than 100,000 mg/m3/min in any mammalian species. In addition, they are produced in quantities exceeding 30 metric tons per year at one production facility.51 These chemicals have the potential for causing a large number of casualties and should be highly regulated by risk management plans. They have a greater potential for harm if deliberately released.
Integrated response plans involving both specialized plant hazmat teams and local community first responders can be devised by following each stage of the chemical life cycle: 1) research and development; 2) site of manufacture; 3) storage at site of manufacture; 4) transportation; 5) storage at site of use; 6) site of use; and 7) disposal of waste products.52 Reducing human error and equipment failure in each stage will yield the highest return. Community awareness and inclusion of emergency responders in planning has increased through implementation of Responsible Care, a global initiative by the chemical industry to embrace chemical safety.53 Implementation of the Global Product Strategy has served to increase public and stakeholder awareness and confidence that chemicals in commerce are appropriately managed throughout their lifecycle.54
In the United States, the Risk Management Program (RMP) is coordinated by EPA. It requires companies to perform hazard analyses and determinations of “vulnerability zones” and put in place preventive and emergency response plans. The program involves about 14,000 facilities using regulated chemicals that exceed a predetermined threshold quantity established by EPA’s RMP.55 In Europe, the European Commission Seveso Directives I, II, and III oblige member states to ensure that operators have a policy in place to prevent major accidents. The regulations provide a tiered approach to the level of controls: the larger the quantities of dangerous substances present within an establishment, the stricter the rules. “Upper-tier” establishments produce larger quantities than “lower-tier” establishments and are, therefore, subject to tighter controls.56
It is much more efficient to implement effective risk-management strategies and avoid the costs of chemical industrial events than to respond to actual incidents. However, one might face reluctance when approaching the topic, due to issues such as cost, poor awareness, resistance to reforms, and minimizing the likelihood of events.49
Plans for mitigation should incorporate an all-hazards approach, be location-specific, and be flexible to circumstances surrounding an event. Mitigation planning commonly includes the following areas, which can be considered in the context of hazmat incidents:49,57
Business continuity plans;
Building design, for example drainage systems for decontamination runoff;
National and local regulation on land use, locating buildings outside hazard zones;
Essential building utilities;
Protection of building contents;
Mechanisms and instruments for spreading risk and/or risk transfer (insurance and safety reserves);
Education, such as training the population and local and national institutions on the causes, impacts, and means of disaster prevention;
Surveillance; and
Warning and evacuation.
Mitigation measures need not duplicate resources. For example, public warning systems for disaster evacuation are all-hazards and are not only used in chemical releases. Special considerations concerning population protection measures arise from chemicals released as vapor or gas. Shelter-in-place contingencies may be useful when there is insufficient time for evacuation following release or when remaining indoors is safer due to the presence of an outdoor chemical plume. To be effective, public awareness, education, and communication are crucial. The process of sustainable hazards mitigation requires: 1) nonjudgmental debate; 2) full public participation; 3) a willingness to experiment, learn, refine, and alter approaches; and 4) a consensus among stakeholders to stand behind their shared commitment to the goal.58
To assist in risk-management planning, emergency exposure limits have been produced by various organizations: 1) the American Industrial Hygiene Association has developed the Emergency Response Planning Guideline; 2) EPA created the Acute Exposure Guideline Level; and 3) the Department of Energy published the Temporary Emergency Exposure Limits. These exposure limits have been used to derive Protective Action Criteria.59 Such criteria represent the concentration of airborne chemicals at which protective actions are required. These exposure limits can help planners institute preventive measures and estimate the consequences of an uncontrolled chemical release. In the event that an incident occurs, they can be used to evaluate the severity of the release and identify potential outcomes. These emergency limits have additional advantages over industrial limits as they can be applied to the general population.
Predictive modeling of a toxic plume cloud can help estimate the rate and spread of an uncontrolled chemical release during an incident. The Area Location of Hazardous Material computer system (among many others) has been developed to generate models that assist in planning and response.60 These models identify areas of exposure and the need to evacuate populations at risk, and can be used for training and actual incident management.
Prevention and mitigation efforts should also focus on the transport of dangerous goods. For example, GPS satellite-based technology that tracks ground transportation vehicles carrying hazardous substances provides their exact locations in the event of an acute release. The system can mitigate damage by reducing response time of emergency services to the scene. It also provides surveillance and early warning of any deviation from predetermined routes, be it accidental or deliberate, as in a hijacking by terrorists. With improved situational awareness by drivers, route planning can be optimized and include consideration of hazards such as the weather. In this way, it also assists with disaster prevention. In the event that the vehicle veers off its allocated route or the drivers become intoxicated, the fuel supply for the vehicle can also be shut off.
Preparedness
A systems approach to seamlessly integrate capability is needed for all-hazards incident planning. The same approach should be undertaken with special considerations to the intricacies of a hazmat incident. The 3-S System (staff, stuff, and structure – see Chapter 3) is a reminder of what plans should include to develop optimized and sustainable capability.61
Planning and Systems
To deal with residual risks, healthcare authorities, local communities, and hospitals need to plan for acute chemical incidents. At any time, hospitals must be ready to safely and rapidly decontaminate, evaluate, and treat a few chemically injured victims. This is the premise for development of further response capabilities for mass casualty incidents involving chemical or radiological weapons of mass destruction. In a study comparing 1996 and 2000 measures of preparedness among hospitals in a major U.S. metropolitan area, the hospitals were poorly prepared to manage chemical emergency incidents, including terrorism. This lack of hospital preparedness did not change significantly between 1996 and 2000, despite increased funds allocated to bioterrorism preparedness at the local level.62
In some countries, such as the United States, extensive legislation, regulation, and standards exist mandating and assisting hospitals to plan for chemical incidents. Examples include:
1. Occupational safety regulations from the Occupational Safety and Health Administration (OSHA) protect healthcare providers during a hazmat response as a worker safety issue.63
2. The Emergency Medical Treatment and Active Labor Act requires hospitals to provide a medical screening examination and stabilization (consistent with their capabilities) to anyone presenting to their location for treatment regardless of citizenship, legal status, or ability to pay.64 It does not make exceptions for contaminated patients.
3. EPCRA is a section of the Superfund Amendments and Reauthorization Act (SARA) Title III.65 It states that facilities manufacturing or storing hazardous chemicals must report inventories and every hazmat release to public officials and emergency health agencies. The act also requires the establishment of state emergency response commissions and local emergency planning committees.
4. Healthcare accreditation organizations such as the Joint Commission have requirements relating to hazmats.66
Planning for toxic incidents involves modification within the framework of existing emergency response plans and incident command systems, rather than creating entirely new protocols. Plans should be established before a hazmat incident occurs. Separate prehospital and hospital plans are needed for first responders and first receivers, respectively, to manage victims. Both plans must be integrated and harmonized.
In addition to areas addressed in general emergency management programs, specific areas to consider when planning for a hospital’s hazmat response include:
Hazards and vulnerabilities identified in an HVA;
Estimated time before arrival based on location of hazard;
Casualty care areas;
Decontamination procedures and protocols;
Secondary contamination and containment of contaminated equipment and runoff water;
Safety: personal protection equipment (PPE);
Communications at decontamination area;
Heating, ventilating, air conditioning, and in-place protec-tion;
Medical management – antidotes;
Interfacility transfers – patients with special needs, burn patients; and
Knowledge resources for hazardous materials.
Local authorities that develop such plans should consider the following:67
Identify local facilities using hazardous substances.
Designate community and industrial coordinators.
Establish mechanisms for emergency notification.
Establish procedures for determining the occurrence of a release and an estimation of the affected population (location and numbers).
Identify community emergency equipment facilities.
Establish evacuation plans.
Establish and schedule training programs for emergency personnel.
Staff
The hospital’s incident command center is responsible for optimal use of staffing resources. It should coordinate medical and auxiliary personnel, direct activities at the various treatment sites, organize equipment and supplies, and maintain contact with outside authorities.68 Standard operating procedures indicating roles and responsibilities of personnel must be established before an event occurs.
Education and training are important aspects of planning because of specialized procedures and equipment used by prehospital providers and hospital personnel. First responders and first receivers must acquire necessary knowledge, skills, and abilities to respond safely to incidents involving hazardous materials. Because of different work environments and PPE requirements, education and training should be tailored to address their specific needs. It should be structured and standardized, locally relevant to hazards and equipment used, continually revised and updated, and delivered multiple times and across all work shifts to enhance retention.
In a study of paramedic students, retention of proper donning and doffing techniques for PPE was poor at 6 months after initial training. Critical errors were common even in individuals with previous hazmat, firefighter, and emergency medical services training.69 It appears unrealistic to retrain hospital decontamination teams composed of staff nurses and allied health personnel every 6 months; however, annual refresher courses are achievable.
The training courses may consist of practical approaches to the management of hazmat casualties, common toxicological agents, triaging contaminated victims, computer searches for information on toxic materials, wearing PPE, and assembling a portable decontamination shower.70 Hospitals can video record and review drills to critique and refresh the knowledge of their participating staff.
Frequently planned drills are essential for effective implementation of disaster plans. Joint training and education are important ingredients in producing a multidisciplinary team functioning optimally under stressful circumstances. Training must include: 1) communication exercises; 2) small-scale (hospital and emergency service) response exercises; and 3) full-scale simulations involving industry, health professionals, emergency services, and others with responsibilities in the area, such as civil defense services and military authorities.71 A cost-effective five-level scale for hospital preparedness in accordance with the existing threat has been suggested (Table 34.4).68
| Level of Preparation* | Action Required |
|---|---|
| I – No Threat | 1. Prepare a hospital deployment plan for a chemical incident (e.g., due to a motor vehicle collision) |
| II – Minimal Threat | 1. Instruction of the hospital plan and principles of chemical agent diagnosis and treatment once a year 2. Assign specific tasks in the deployment plan to hospital personnel 3. Partial practice drill once in 3 years 4. Consider the need for medical equipment, supplies, and communication systems, and examine their maintenance once a year |
| III – Existing Threat | 1. Full practice drill once in 3–5 years, instruction every year 2. Prepare appropriate medical equipment, supplies, and communication systems, and examine their maintenance every half year |
| IV – Increased Threat | 1. Organize appropriate shifts of hospital personnel to increase their availability and an emergency calling system for the staff and auxiliary personnel according to their assigned tasks 2. Full practice drill once in 1–2 years, instruction and smaller scale review drills on receiving the new threat level and as often as possible 3. Examine maintenance of equipment, protective gear, and communication systems every few months. Increase their availability by storage at or near the sites 4. Prepare arrangements for shifting of patients inside the hospital |
| V – Maximal Threat | 1. Be prepared to receive and treat chemical casualties within minutes or hours 2. Organize equipment, protective gear, and communication systems at all sites 3. Arrange patient transfer and discharge when possible 4. Maintain continuous contact with authorities outside the hospital |
* Each level should also include the required actions of the previous levels
Stuff and Structure
Hazmat medical response involves mobilization and utilization of equipment and treatment areas that are rarely encountered in the course of routine hospital work. “Structure” can mean physical infrastructure such as a fixed facility for decontamination, assembly, triage and evaluation, and patient care, all of which must be determined pre-event. Decontamination can be conducted in fixed, semi-fixed, or mobile facilities like tents, inflatable structures, and mass decontamination vehicles.
Some of the challenges facing hospitals on the safe treatment of hazmat exposures may be mitigated by engineering controls. Examples include:62,72
Controlled access points to prevent contaminated patients from entering the facility prior to decontamination;
Designing decontamination shower facilities that can accommodate placement of warm water lines;
Situating shower nozzles on the building exterior;
Collection system to control for contaminated water runoff;
Access fittings for medical gases on the building exterior that will facilitate use by emergency responders when utilizing supplied-air respirators; and
Design of hospital ventilation systems that takes into account the potential need to isolate the internal hospital environment.
Procurement and acquisition of PPE and decontamination items need to complement the hospital’s role and HVA outcomes. Further elaboration on both topics can be found in Chapters 15 and 16. “Stuff” also includes knowledge resources that are needed for medical management of victims. A vast amount of informative resources are web-based, thus underscoring the need for maintenance of Internet access during a crisis. Other resources include poison information centers, ad hoc toxicological advisory teams, in-hospital toxicologists, or textbooks.73
Medical field teams deployed from hospitals to the scene of a hazmat mass casualty incident usually conduct their work in the “cold” zone. Nevertheless, they will need to carry PPE that is commensurate with the hazard’s risk, in case the zone turns suddenly “warm” without the opportunity for timely evacuation. In addition to general items, an inventory of antidotes and burn care supplies should be considered.
Antidote stockpiling is a critical component of comprehensive medical preparedness in chemical emergencies.74 A national program for distribution of antidotes from a central stockpile plays a fundamental role; however, demographic, geographical, and economic factors often obstruct the rapid disbursement of antidotes. Any system of antidote distribution must provide poisoned patients with empirical antidotes based on toxidromic assessment or specific antidotes based on substance identification in appropriate quantities and within the time required for treatment. Local stockpiles of antidotes are limited by factors such as infrequent use, cost, and short shelf life. A push system can be adopted to supplement local stockpiles with antidotes to common poisonings, which can be based on the local HVA. This is important in the initial phase when the substance is unidentified. Larger quantities of specific items or antidotes can follow as the situation becomes clearer. Time-sensitive antidotes such as diazepam, cyanide antidote kits, atropine, and pralidoxime are the most important drugs to stockpile locally for the potential treatment of mass casualties from a chemical emergency (Table 34.5).74–76 In addition to antidote stockpiling, emergency drugs and essential standard drugs should also be stockpiled because these can be rapidly depleted in a mass casualty situation.73
