This article is a brief synopsis of an NHS England paper looking at how it relates to nuclear licensed sites. Please refer to the original paper rather than this article if preparing plans. Katmal Limited can provide advice on planning should you require it.
“Members of the public who may be contaminated, especially following large incidents, may leave the scene and subsequently seek assistance at a nearby healthcare facility. All healthcare facilities are required to have arrangements in place to manage self-presenting patients. These plans need to recognise that people concerned about the health impacts of a HazMat/CBRNE contamination incident, but not necessarily affected by it, may also attend healthcare facilities and other NHS sites even though they do not require treatment.”
Timely alerting – are all NHS facilities alerted to a local incident?
Planning risk assessment
“The risk assessment should also take account of the need to protect healthcare facilities, staff members and uncontaminated patients and the provision of timely and appropriate care to people self-presenting from a HazMat/CBRNE incident”. This risk assessment is likely to conclude that anyone self-presenting following an accident at a nuclear reactor site may be contaminated with fission products (other licensed sites have their own specific hazards – for example plutonium, uranium or tritium for AWE) but, actually this remains unlikely and the levels of contamination if they were to be contaminated would not be sufficient to affect the health of staff members, uncontaminated patients or other persons on site. What remains is a presentational issue. How do we assess and reassure the self-presenter and how do we maintain confidence that the facility is fit for purpose against rumour that it is badly contaminated?
The paper does not mention it but for those NHS facilities near a licensed site it would be sensible to understand the type of contamination that is possible and how it could be identified and measured on people. This is easier for sites that might release beta/gamma active materials rather than sites that might release pure alpha emitters. But either way, an understanding of how to detect and measure plausible local contaminants should be pursued and suitable instruments maintained.
“Organisations may wish to identify areas of their premises where IOR [Initial Operational Response] activities can take place. This would include access to clean running water and be considerate of patient modesty. Such areas could be marked with zones for patients to disrobe and then move to, making communication easier”.
Ideally the facility would be able to move the self-presenters to a remote area where they can be processed without the potential to contaminate busy areas of the facility. Initial screening might be by questioning where the person was and what they were doing during plume transit.
“An incident of this nature has the potential to be disruptive and may result in the affected premises being compromised for a period of time. The plan will need to link to the organisation’s business continuity arrangements to mitigate this.”
Section 3.6 of the paper reviews the potential psycho-social impacts of the event stating that the public are likely to be orderly, will respond better in a well planned and executed response with clear information, efficient, polite and caring handling of self-presenters including respected the need for privacy and modesty during decontamination. It is important to plan and train to get this aspect of the response right.
“Available evidence suggests public behaviour will be orderly and there will be no panic.”
“These arrangements and the Remove, Remove, Remove model do not require staff members to wear specialist protective equipment[1] nor does it require specialist decontamination equipment for the patient to use. Instead the model utilises any absorbent material such as blue roll or paper towels which can be retrieved from most building’s toilets or kitchen facilities”.
Lock-down procedures might be required to control access and egress to the facility to minimise confusion and the spread of contamination. “It should be noted, however, that healthcare organisations cannot physically prevent people from leaving their premises (even if the hazard or threat is outside the building which is locked down)”.
The NHS has a STEPS 1-2-3 protocol:
“The Emergency Services use the STEPS 1-2-3 plus process as a recognition and risk assessment tool. If one incapacitated patient is encountered with unexplained symptoms then they are treated using NHS universal precautions. If two incapacitated patients are encountered together with unexplained symptoms they are treated with caution and a high index of suspicion of contamination using NHS universal precautions. When three or more incapacitated patients are encountered together with unexplained symptoms the staff withdraw to a safe distance and call for specialist resources and advice. At the same time the plus element indicates the instigation of IOR.”
This is very unlikely to be triggered for a nuclear accident at a licensed site as the dose rates are likely to be too low to trigger symptoms. It could be triggered if a powerful source is left in a public space (See Cochabamba bus incident 2002) or if a powerful source is dismantled and distributed among a population (See Goiania orphan source incident 1985).
The remove, remove, remove Initial Operational Response then comes into play.
Tell those affected to:
- Remove themselves … from the immediate area to avoid exposing others. Fresh air is important.
- Remove outer clothing …
- Avoiding pulling clothes over head if possible;
- Do not eat, drink or smoke
- Do not pull off clothing stuck to skin
- Remove the substance …. from the skin using a dry absorbent material to either soak up or brush it off.
Again, it is unlikely that skin will be itchy or painful as a result of radioactive contamination. Care should be taken not to break the skin and allow contaminants a route into the body.
Under the remove themselves banner it is suggested that the self-presenters should be isolated from other patients and staff members in a safe area, preferably outside. Continuous clear communication would be key so that the worried person does not feel abandoned.
The advice for removing outer clothing (which is expected to remove most of the contamination) suggests that “Undressing should be systematic to avoid transferring any contamination from clothing to the skin”. It recommends cutting clothes off rather than pulling them over the head. The important thing is to avoid touching the outer surface, particularly avoiding the outer surface coming into contact with the mouth, nose or eyes.
Modesty and warmth may become an issue when asking members of the public to disrobe outside.
Removed clothing should be bagged and labelled but this process should not be allowed to slow the undressing process unduly.
Dry decontamination, blotting and lightly rubbing skin with any dry absorbent material such as paper tissue, clean cloth etc is the preferred for of decontamination.
Hair may need careful wet decontamination. In the meantime potentially contaminated hair should be covered and away from the face.
If there is an incident a dynamic risk assessment would be expected from those in charge.
“When conducting a dynamic risk assessment there are five principal stages to be followed:
Stage 1 – Identify the hazard
The first step is to look for hazards. Consider the location that the activity or process is carried out and check for potential dangers. Concentrate on anything with the potential to cause serious harm to employees, members of the public and the patient(s).
Stage 2 – Decide who might be harmed and how
Decide who and how many might be at risk
Stage 3 – Evaluate the risks and identify suitable and sufficient control measures
Implement the Remove Remove Remove procedures
Stage 4 – Record and implement findings
The findings of the risk assessment must be brought to the attention of those at risk to harm and appropriate training and instruction given on the implementation of the control measures.
Decide who and how many may be at risk; is it those undertaking the activity or may it also affect members of the public and staff.
Stage 5 – Review the assessment
All risk assessments should be reviewed at a frequency proportional to the risk.”
Section 5 states that there might ne a requirement to seek specialist advice. This may come from UKHSA or the operator of the facility that is the source of the issue.
There is more discussion about PPE (Section 6) and Quarantine (Section 7) and a larger section on Recovery (Section 8).
This is a refreshingly short and focused advice sheet with sensible sounding advice.
[1] Direct physical contact with the patient(s) should be avoided.