|Year : 2015 | Volume
| Issue : 4 | Page : 195-199
From investigation of hospital protocols and guidelines to designing a generic protocol for responding to chemical, biological, radiological, and nuclear incidents
Elham Anbari1, Mohammad Hossein Yarmohammadian2, Mehdi Nasr Isfahani3
1 Department of Health management, School of Health Management and Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
2 Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Emergency Medicine, Isfahan University of Medical Science, Isfahan, Iran
|Date of Web Publication||11-Aug-2015|
Department of Health Management, School of Health Management and Information Sciences, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
Introduction: The awareness of using chemical, biological, and nuclear agents in everyday industrial and nonindustrial incidents has increased recently; release of these materials can be accidental or intentional. Since hospitals are the forefronts of confronting chemical, biological, radiological, and nuclear (CBRN) incidents, the goal of the present research was to provide a generic protocol for CBRN incidents through a comparative review of CBRN protocols and guidelines of different countries and reviewing various books, handbooks, and papers. Methods: The integrative approach or research synthesis was adopted in this study. First a simple narrative review of programs, books, handbooks, and papers about response to CBRN incidents in different countries was carried out. Then the most important and functional information was discussed in the form of a generic protocol in focus group sessions and subsequently confirmed. Results: Findings indicated that most of the countries had various protocols, guidelines, and handbooks for hazardous materials or CBRN incidents. The final outcome of the research synthesis was a 50 page generic protocol whose main topics included introduction, definition and classification of CBRN agents, four major phases of incident and disaster management cycle, hospital response management plan, equipment, and recommended supplies and antidotes for decontamination (radiological/nuclear, chemical, biological); each of these also had subtopics. Conclusion: In the majority of international protocols, guidelines, handbooks and also international and Iranian books and papers, there is an emphasis on the importance of incident command system, determining the safety degree of decontamination zones, maps of decontamination zones, decontamination process, triage classifications, personal protective equipment, and supplies and antidotes for decontamination; these are the least requirements for such incidents and also consistent with the provided generic protocol.
Keywords: Biological incidents, chemical incidents, decontamination, generic protocol, hospital protocols, nuclear incidents, radiological incidents
|How to cite this article:|
Anbari E, Yarmohammadian MH, Isfahani MN. From investigation of hospital protocols and guidelines to designing a generic protocol for responding to chemical, biological, radiological, and nuclear incidents. Int J Health Syst Disaster Manage 2015;3:195-9
|How to cite this URL:|
Anbari E, Yarmohammadian MH, Isfahani MN. From investigation of hospital protocols and guidelines to designing a generic protocol for responding to chemical, biological, radiological, and nuclear incidents. Int J Health Syst Disaster Manage [serial online] 2015 [cited 2018 Aug 17];3:195-9. Available from: http://www.ijhsdm.org/text.asp?2015/3/4/195/162553
| Introduction|| |
The awareness of using chemical, biological, and nuclear agents in everyday industrial and nonindustrial incidents has increased recently.  These agents are toxic materials which may do harm to people and living organisms. Release of these materials may be due to accidental or intentional incidents.  These are incidents of generally low possibility, but may have significant impacts on citizens and the society. Whenever and wherever these incidents happen, they require a multidimensional and stepwise (regional, national, and international) approach because these incidents will bring about severe unexpected physical, mental, social, economic, and political impacts which can easily go beyond national borders.  Each day, huge amounts of hazardous chemical materials are produced, transferred, stored and used for home and industrial purposes. Moreover, formula and instructions for producing many of chemical materials which may have military or terrorist applications are available to public on the internet and social networks without safety supervisions. The worst industrial disaster of the world is the Bhopal incident happened in December 3, 1984 with 150,000 injured and 2500 dead.  Sarin attack in Japan in 1994 is among chemical terrorist incidents which injured 5000 and killed 11 people; more than 300 of injured people were responsive emergency staff (police, firefighters, doctors, and ambulance services).  Nuclear energy and radioactive materials also have numerous applications in medicine, industry, agriculture, energy supply, and scientific research. With the extended use of this technology in various fields, the possibility of incidents resulting in exposure of environment and human communities to impermissible radiations is inevitable. Therefore, despite the observance of safety measures and compliance with international standards, numerous cases of nuclear incidents cause severe human exposure each year along with many unreported cases which also must be taken into account. Other scenarios such as terrorist attacks with radioactive materials, suitcase nuke, the possibility of being used in international conflicts, and accidental or intentional incidents in nuclear power plants must be added to the list.  Among the unintentional incidents is the earthquake and tsunami in March 11, 2011 in Japan which led to release of radioactive materials from Fukushima Daiichi nuclear power plant to its surrounding.  Casualties were reported to be over 14,000. 
Chernobyl disaster is another instance of unintentional incidents in which, because of dispersion of radioactive materials from nuclear fuel rod (despite the small scale of the incident), expected health risks were quite noticeable. Among intentional nuclear incidents is the US atomic attack to Japan which dropped the first atomic bomb on Hiroshima in August 6, 1945; more than 60,000 people were killed and 120,000 people injured at the very time of bombing. Three days later, a larger atomic attack on Nagasaki claimed the lives of 74,000 people with the same number of injuries.  A biological incident, either intentional or accidental explicit or implicit, also can be described as a biological agent such as the probability of a pandemic flu or terrorist groups' threats to use biological weapons against civilians.  Among the intentional biological incidents, the most recent one goes back to late 2001 after September 11 attacks where anthrax spores were dispersed through US Mail and contaminated several people.  The issue of bioterrorism is so important and serious that in 2002, World Health Assembly called for proper policies in order to provide safe and out of bioterrorists' reach food;  ; in its 2007 report, WHO also underscored the threat of bioterrorism through intentional food contamination and provided warnings and guidelines accordingly.  Iranian authorities have also repeatedly emphasized the battle against terrorist acts of extremist groups, and policies to eliminate terrorist groups across the world.  Therefore, since release of CBRN agents may occur anywhere and anytime, hospitals need to be prepared to respond to chemical, biological, and nuclear incidents because when a crisis or emergency occurs in society, most people will go to hospital because it gives them a sense of safety and they presume that it has necessary antidotes, medications, or therapies.  Moreover, since the biggest challenge for healthcare services would be the sudden rush of contaminated people, protection and decontamination against chemical, biological, radiological, and nuclear (CBRN) agents which are potentially very harmful will be of critical importance.  For example, secondary contamination might shut down emergency centers which could endanger the staff and cause the loss of a social capital. In an incident occurred in a healthcare center in Australia, a patient was not decontaminated before treatment in emergency ward; therefore, the ward was quarantined for 20 h.  Since hospitals are the forefronts of confronting CBRN incidents and given the importance of decontamination and prevention of secondary contamination, hospitals must have a comprehensive plan to confront CBRN incidents. The goal of the present research is to provide a generic protocol for CBRN incidents through a comparative review of CBRN protocols and guidelines of different countries and also reviewing various Iranian and international books, handbooks and papers.
| Methods|| |
The integrative approach or research synthesis was adopted in this study. First a simple narrative review, both library and online, of programs, books, handbooks, and papers about response to CBRN incidents in Iran and other countries was carried out. Then the most important and functional information was put together in the form of a generic protocol. This protocol was discussed by experts and specialists in the field and subsequently confirmed in order to be used for healthcare staff at the time of incidents.
| Results|| |
Review of international protocols, guidelines, and papers revealed that since the late 19 th century, most countries have developed protocols, national guidelines, handbooks, and papers about preparedness and response of hospitals and especially emergency ward to CBRN incidents, incidents containing hazardous materials, and weapons of mass destruction and terrorism-related incidents.
Medical response, personal protective equipment, decontamination of contaminated patients, and even secondary contamination of emergency staff and psychological recommendations were topics covered in the reviewed guidelines and papers. In Iran, however, except for books written on preparedness in incidents and disasters and preparedness and response to radiological incidents, no protocol or guidelines existed for hospital preparedness, and response to CBRN incidents. On the other hand, papers on radiological/nuclear incidents focused more on awareness and attitudes of medical and nursing personnel toward about the subject. However, several papers were written on topics such as necessities of establishing nuclear emergency centers, providing a model for emergency wards' preparedness and response to nuclear incidents, external nuclear decontamination, and health-related impacts of nuclear explosion. In addition, there were numerous Iranian review and research papers on bioterrorism. Other papers focused on crisis management and hospital preparedness for disasters.
The final outcome of the research synthesis was a 50 page generic protocol whose main topics included introduction, definition and classification of CBRN agents, four major phases of incident and disaster management cycle, hospital response management plan, equipment, and recommended supplies and antidotes for decontamination (radiological/nuclear, chemical, biological); each of these also had subtopics. Personal protective equipment (A, B, C, and D) discussed in the plans and papers had the same basis so that weakness of one piece of equipment would be covered by the strength of the other and each level was explained more systematically and comprehensively. Moreover, the same held true for incident command chart, which also was expressed more systematically and comprehensively especially in terms of CBRN incidents. Activation process of hospital incident management plan, notions of contamination and decontamination, A to D levels of personal protective equipment, and necessary equipment, supplies, antidote and medications for CBRN decontamination were stated systematically and comprehensively in this protocol. Despite some of the reviewed protocols and guidelines, however, the activation process of hospital response management and early warning system were explained exhaustively in the present protocol. The [Figure 1],[Figure 2],[Figure 3] and [Figure 4] depicts a schematic view of the protocol.
|Figure 2: Equipment, supplies and antidotes for chemical decontamination|
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|Figure 3: Equipment, supplies and antidotes for biological decontamination|
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|Figure 4: Equipment, supplies and antidotes for radiological/nuclear decontamination|
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| Discussion|| |
According to the present research, most countries have various protocols, guidelines, and handbooks for hazardous materials or CBRN incidents as well as handbooks and articles on hospital preparedness for intentional incidents such as terrorism. In the majority of international protocols, guidelines, handbooks and also international and Iranian books and papers, there is an emphasis on the importance of incident command system, determining the safety degree of decontamination zones, maps of decontamination zones, decontamination process, triage classifications, personal protective equipment, and supplies and antidotes for decontamination; these are the least requirements for such incidents and also consistent with the provided generic protocol. ,,,,,,,,,,,,,,,,,
| Conclusion|| |
Therefore, given the fact that most countries have several protocols, national guidelines, and handbooks for responding to intentional and unintentional CBRN incidents and that such incidents are unexpected and daunting for people, it is necessary that Iranian health centers especially hospitals have protocols and guidelines for confronting industrial and nonindustrial CBRN incidents.
Finally, it is suggested that more research be carried out on hospital management and medical response to industrial and nonindustrial chemical incidents.
This paper is part of the Master's thesis entitled "The survey of Generic response management to CBRN incidents in teaching hospitals affiliated with Isfahan University of Medical Sciences" in (2013-2014) with the registration code 393328 supported by Isfahan University of Medical Sciences.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]