GUIDELINES FOR NEW HAMPSHIRE HOSPITALS* DECONTAMINATION OF PATIENTS

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1





GUIDELINES FOR NEW HAMPSHIRE HOSPITALS*

DECONTAMINATION OF PATIENTS


Presented by the NHHA Hospital Decontamination Committee

J
u
ne 3, 2003

Revised
February, 2006


Committee Members

Neal Boucher, Dartmouth
-
Hitchcock Medical Center

William Brown, Souther
n NH Medical Center

Sharon Cary, VA Medical Center

Richard Cooper, Portsmouth Hospital

Janet Houston, EMS for Children

Mike Melody
, Concord Hospital

Sandra DeMars, Elliot Hospital

Cheryl Pinney, Cheshire Medical Center

Donna Pearce, Monadnock Community Hop
sital

Jim Richardson, DHHS HazMat Liaison

Scott Taylor, Franklin Regional Hospital

Diane Viger, NH Hospital

Gail Wasiewski, Wentworth
-
Douglass Hospital

William Wood, Bureau of EMS


Community
/State

Partners

Andy Anderson, NHFST

Nick Campasano, Manchester Fi
re Department

Curtis Metzger, NH BEM

Roger Hatfield, NH Hazmat Teams

Chris Herrick, Vermont Emergency Management

Dave Jones, NHFST


NH Hospital Association

Kathy Bizarro

Deborah Yeager
* Disclaimer: The recommendations contained in this document are intended to be used as a guide. Hospitals should
consult their own experts when writing plans and procedures regard
ing decontamination of their patients.


2


Executive Summary


The purpose of these guidelines is to establish p
rotection parameters to help New Hampshire
hospitals understand what is required when planning for Hazardous Materials (Hazmat)
situations involving biological, chemical
or radiological contamination of patients
due to an
external
event. In planning
respo
nse actions for this type of event, the
major objective is to protect the facility,
its patients and personnel while attending to the injured. These guidelines are intended as a
baseline or a minimum preparedness standard.



The New Hampshire Hospital Ass
ociation created a group called the Hospital Decontamination
Committee to develop guidelines for hospitals to use in developing, upgrading and evaluating
their decontamination procedures. The committee is comprised of hospital personnel (emergency
departme
nt directors, infection control practitioners, safety officers and medical directors), NH
Regional HazMat Team Coordinator,
Department of Health and Human
Services, Department of Safety
:

Bureau of
Emergency Medical Services
,

the Division
of Fire S
tandards

and Training and the Office of Emergency Management.
T
he committee has

pulled together a variety of national resources which provide
s

a minimum standard that hospitals
in New Hampshire can achieve. Also, it was recognized that there must be a coordinated e
ffort
between hospitals and local and regional hazmat resources.


The Hospital Decontamination Committee recommends New Hampshire hospitals
follow the
principles of
OSHA Best Practices for Hospital
-
Based First Receivers of Victims from Mass
Casualty Inc
idents Involving the Release of Hazardous Substances
, January 2005

. This
describes the protocols to
have

systems in place to have the capacity for decontamination, have
the capability to manage an event on their own until
state and/or federal
resources a
rrive

(approximately 72 hours)
, and be trained and equipped to
OSHA Protection
Level C

.


T
he Hospital Decontamination Committee
is in complete support of recommendations contained
in the OSHA document,
includ
ing for example
:




Conduct a h
azards
vulnerabil
ity a
ssessment

annually

to determine

the need for higher level
of PPE
.



Work with your Local Emergency Preparedness Committee (LEPC) to integrate the hospital
into the community planning process
.



Review and upgrade
your decontamination facilities.



Institute

suggested training
.



Participate in at least 2 drills/exercises a year, one of which should include decon operations
.



Combine d
rills and exercises with local, regional or state resources as much as possible.

The major objective of decontamination
actions is to protect the hospital, its
patients and personnel while attending to
the injured.

These guidelines
are intended as a
baseline or a minimum preparedness
standard.



3


Hospital Role in Decontamination


Hospitals
are critical resources

that
have the potential

to
provide decontamination
response in an
emergency
. The hospita
l

role in decontamination
interconnects

with

other resources in order to
ensure a coordinated approach.
Under

NH law
RSA 154
, fire chiefs have th
e primary
responsibility for response to any hazardous materials incident. This would include
decontamination of contaminated individuals at the scene.

In addition, there are regional hazmat
teams established throughout the state. Mass decontamination tr
ailers are available that
potentially could be used to support hospital decontamination efforts. They are located with the
regional hazmat teams. Industrial locations, such as the paper mills, also have some
decontamination capabilities.
It should be noted

that a fire department and/or hazmat team would
have primary responsibility to operations at the scene of an incident and should not be counted
on as a primary means of decontaminating patients at the hospital.
Access to these resources in
your community
should be determined with the local fire departments and written into hospital
emergency response plans and procedures
, as is reasonable and mutually agreed upon
.


The Hospital Decontamination Committee strongly suggests that each hospital assess the haza
rds
in their community

annually
,
determine

the risk and impact of a disaster and plan accordingly. It
is important that each facility take due diligence for identifying the most likely threats and
provide an appropriate level of protection for
healthcare w
orkers who are involved with
decontamination activities. For planning
purposes, a practical, all hazards approach to
address reasonable scenarios should be followed.


A hospital emergency response team should be able to
quickly secure the facility and
tri
age,
rapidly
decontaminate
and
treat
patients
without endangering
personnel

or contaminating the
facility.
Regardless of the mode of transportation by which a patient arrives, they must be
decontaminated appropriately before entering the facility.

Suffic
ient
staff each shift assigned to
the team should be able to handle decontamination activities and
adequate

numbers should be
trained to allow for rotation.


It is essential that a hospital have the ability to adequately secure the facility to prevent it

from
becoming contaminated. This means ensuring that no contaminated individuals gain access to
any part of the facility. In some cases this may be accomplished by internal lockdown
procedures. However, security procedures should be coordinated with loc
al law enforcement so
that they can provide security reinforcement, if necessary.


Each hospital should assess the
hazards in their community, think
about the risk and impact of a disaster
and plan accordingly.


4


DECONTAMINATION GUIDELINES FOR NEW HAMPSHIRE HOSPITALS


Level C Guideline


A large
-
scale, overwhelming contamination beyond the capability of
an emergency department

is

extremely rare
.

M
ost often, a patient would be decontaminated at the scene of the incident and
perhaps require secondary decontamination at the
hospital. Personal protection equipment (PPE) beyond
universal precautions will be required when
decontaminati
on response is necessary.


OSHA PPE levels go from D, least protective, to A, most
protective. For more information on the OSHA protection
levels, refer to Attachment 1. Ultimately, the level of PPE individual hospitals choose will be
based on the hazar
d assessment and planning considerations in
the

community.


The Hospital Decontamination Committee has made this recommendation based on several
factors:



Analysis of recommendations in other states



Current guidance available from OSHA



Research of current d
ocumentation on the subject



Expertise of committee members and community advisors


Level C Personal Protective Equipment


Level C PPE is recommended when the exposure of a hazard to staff is anticipated to be low and
the hazard is known. It includes liqui
d splash protection and respiratory protection. Refer to
Attachment 1 for the different levels of protection, appropriate PPE and training for each level.


Level C Respiratory Protection


Respiratory protection for Level C would be the use of a
hooded
powered

air
-
purifying respirator
(
P
APR) for known contaminants. This type of respirator filters air instead of supplying air from
another source.
P
APRs filter particulate and chemical vapors.
This system allows for a loose
fitting hood that does not req
uire fit testing of the individual donning the equipment.
Attachment
2 compares the different types of
respirators
available. Respirators with cartridges must meet the
hazard that is presented, necessitating a large stockpile of filters with limited shelf
life in order to
have protection available for any number of hazards. Although hospitals are not providers of
Hazmat response systems, they could be first
receivers
of the patient arriving at the hospital
whether on their own or by ambulance so the level o
f respiratory protection will be a key
decision.


Level C

is the minimum level of prote
ction suggested for New Hampshire
hospitals for two reasons: the possibility of large scale decontamination
event is remote; and the level of contamination will most likely be
secondary, therefore a lower risk to the hospital.

However, hospi t al s may
want

t o consi der

Level B,
i f i ndi cat ed by t hei r HVA.

OSHA Pr ot e ct i on Le v e l s

Le v e l D ( l e ast pr ot e ct i v e )

Le v e l C ( r e comme nde d f or hospi t al s)

Le v e l B ( sce ne r e sponde r s)

Le v e l A ( most pr ot e ct i v e
-

t e chni ci an)



5

Level B Respiratory Protection


Depending on your hazard analysis, you may want to consider the Level B supplied air respirator
which is an inline system that could make use of medical air and/or compress
ed breathing quality
air in tanks on carts. This system
also
allows for a loose fitting hood
.

However, the hood
requires more air and tanks would provide less than 20 minutes of air. A compressor could
provide unlimited air with special manifolds to sup
ply several hoods at a time. Another option is
to use medical air for this purpose,
which is
a recent change in the 2002 NFPA 99 standards.
This supplies a Level B respirator, but may require a manifold retrofit and pressure adjustments.
This is a workab
le solution in some situations, if the hospital decides it is appropriate.
H
ealth
pre
-
qualifications, such as cardiopulmonary health,
will be

necessary for a consistent and safe
respirator program.


Regardless of which level of respiratory protection a hos
pital chooses, each facility must
have a respiratory protection program in place in accordance
with

OSHA standards.


Decontamination Area Sample Layouts & Flow


Decontamination areas should
include
, at a minimum:




A location with strictly controlled acces
s (prevent walk in)



A location within a reasonable proximity to the ED



Sufficient set up to handle both ambulatory and non
-
ambulatory patients



Appropriate PPE



All
-
weather d
econ capability



Indoor/Outdoor facilities that allow for an adequate supply of fr
esh air and minimize
exposure to the elements



Warm water



Easy access from parking to keep other areas of facility free of contamination



Dressing areas for s
taff rotation



Procedures and clearly marked zones to ensure contamination control



Contaminated vs
. clean pathways for entrance through triage, decon and treatment to exit



Containment, classification and bagging of contaminated waste for disposal



A practical method of containing and collecting runoff


Refer to Attachment 3 for a list of equipment to co
nsider and Attachment 4 for sample layouts.


Decontamination of Patients and Environment for Chemical Agents


Patients with chemical contamination are most likely going to be decontaminated by removing
clothing and by showering/washing with soap and water.

Environmental surfaces would be
washed as well. The extent of the decontamination for both victims and environmental surfaces
will be situational. The type of chemical, the extent of injury, and the nature of the
contamination will determine the decontam
ination methodology. Local hazard assessments will
tell you if there are special techniques or procedures required for decontamination of the
particular chemical likely to be encountered in your area.


6


Decontamination of Patients and Environment for Radio
logical Contamination


Patients with external radiological contamination are most likely going to be decontaminated by
removing clothing and by showering with soap and water. Environmental surfaces would be
washed as well. Because you cannot see, smell or

feel radiological contamination, precise
contamination control techniques must be followed. The success of the decontamination efforts
for victims as well as for environmental surfaces would be determined by using radiological
monitoring equipment (survey

meters) to detect the absence or presence of contamination.


Decontamination of Patients and Environment for Biological Agents


In most cases, patient decontamination will not be necessary for biological agents. The
incubation period of biological agents

makes it unlikely that victims of a bioterrorist event will
present immediately following the exposure event. The one exception may be an announced
release of a bioterrorist agent, with gross surface contamination of victims with a confirmed
agent or mat
erial such as raw sewage. In the rare cases where decontamination may be
warranted, simple washing with soap and water is sufficient. If necessary, environmental
surfaces can be decontaminated with an U.S. Environmental Protection Agency (EPA) registered

sporicidal disinfectant or with a 0.5% hypochlorite solution (1 part household bleach added to 9
parts water). Bleach solution should NOT be used to decontaminate patients or pets.


Monitoring Equipment


There is no widely accepted monitoring equipme
nt for chemical or biological contamination
currently in use

in the hospital setting
. There are products under consideration that could be
recommended in the future. The only monitoring equipment that is readily available and in
constant use by competent u
sers are survey meters for radiation detection.


PLANNING & TRAINING


Planning


Hospitals are required under the Superfund Amendment Reauthorization Act (SARA) Title III to
be a participant in their Local Emergency Planning Committee (LEPC). New JCAHO eme
rgency
management standards also include close
coordination with communities. In addition, as
a part of the HRSA grant, NH hospitals are
required to coordinate planning and training
efforts with local and regional emergency management, public health and o
ther resources. It is
important that all responders to an emergency be speaking the same language, working
compatible plans and sharing resources without overlap or gaps. The
Department of Safety,
Bureau of
Emergency Management has a directory of communi
ty emergency management
people on their website. To find contact information for your community, go to
http://www.nhoem.state.nh.us/EmergencyOfficials/EmergencyOfficial
s.asp


Connect with your community
emergency response organizations.



7

When developing or revising your plans for decontamination, contact your fire department to
make sure that your plans coordinate with the community emergency response plan. If your area
is covered by a regional hazmat team, ask the fire department
to include the hospital in the
regional planning process. It is essential that
all entities be aware of the other’s
procedures,
training and equipment

to avoid assumptions that could impact an effective
response. For
informational purposes, a map of New Ha
mpshire Hazmat team coverage

is

located on the
NHHA website,
www.nhha.org

under Emergency Preparedness
. However, in an emergency, all
requests for assistance should be through local channels either through the fire depa
rtment or the
local Emergency Operations Center (EOC), if activated.


The NHHA will also be involved if there is an emergency to help coordinate and facilitate
hospital
-
related activities such as information gathering, resource allocations and coordinati
on of
efforts.


Examine your hospital’s emergency command structure.
According to Presidential Directive 5
of 2003, i
t
must include

an i
ncident
c
ommand
system
, such as Hospital Incident Command
System (HICS) so that response will be coordinated with your
community

in the event that a
unified command structure is needed.


A
ll federal funding for hospitals will be contingent upon
hospital adoption of the HICS management system.


Take every opportunity to exercise plans with the community. If the community

is conducting an
exercise, ask if you can participate. Be a part of the committee that develops the scenario and
make sure that there are situations that will prompt action by the hospital.


Training


The Hospital Decontamination Committee
parnered wit
h Keene State College Safety Center to
develop

a minimum
training curriculum regarding
hazmat and
decontamination
specifically for
hospitals.

through a collaboration with the Department of Safety

and other partners
.
Seventy
-
five trainers from 26 acute car
e hospitals and the
VA have been trained as trainers through this
program based on
the

OSHA Best Practices for
Hospital
-
Based First Receivers of Victims from
Mass Casualty Incidents Involving the Release of
Hazardous Substances
, January 2005.


Recommenda
tions for training broadly call for
a
ll e
mployees who will be part of an emergency
response team should
have

Hospital Decontamination
Hospital Awareness
and those designated
to
have decontamination duties

should
be trained to the

Hospital Decontamination O
perations
level
.

Hospitals should designate at least one person to act as the Decontamination Coordinator.
This individual
should have

more advanced
training and
take the lead in the hospital’s
decontamination program.




Hospital Decontamination
Awarenes
s

includes identification of materials (threat
identification) and safety, notification, discussion of risks, internal spills vs. external events,
response and other general topics.

Depending on level of involvement,
hosp
ital staff should receive
Awareness

and
Hospital
Operations
training.


8




Hospital Decontaminations Operations
will cover basic
HICS
, staffing, a
ssessment &
analysis, suit
-
up, facility set
-
up, containment & control, protective actions, PPE, decon
procedures, waste collection, degowning, clean
-
up and other more specific topics.
Operations training can be conducted in conjunction with drills and exer
cises.




Hospital Decontamination Coordinator

would consist of advanced training for hospital
personnel designated as leaders of decontamination teams.
Further s
pecialized training is
recommended.


Training Category

Target Personnel

Hospital Decon
Awarene
ss
(
4

hours)

All involved hospital staff

Hospital Decon Operations (
8

hours)

(4 class/4 drill)

(can combine Awareness)

Emergency Department and
Decon Team

Hospital Decon Coordinator (24 hours)

At least 1 person per hospital




Many resources exist for
training, such as is
available through the
NH
Fire Academ
y and other
resources
.

It is recommended that training for hospital staff be carefully reviewed for
applicability to the healthcare setting and that appropriate skills for clinicians are considered i
n
the curriculum. According to HRSA, training must be competency
-
based.




Drills and exercises


The committee recommends drills/exercises be held at least
twice
a year
, one of which should include decon
operations. When possible, combine them with local
,
regional and state partners. As a key component of training,
drills and exercises should cover, at a minimum:




activation of hospital incident command center



facility lockdown


doors, ventilations systems, security set
-
up



traffic control


parking lot,
restriction of access, signage, designation of areas for media
& visitors



decon facility setup


according to floor plan, equipment, supplies



donning Level C protection


proper use of respirators, suit up, removal



contamination control procedures


sep
aration of clean/dirty areas, waste handling



triage and other patient management activities



how hospital response interacts with local /regional/state response


Annual refresher training or demonstration of competencies is recommended.
Conduct i
n
-
house
wa
lk
-
throughs of decon procedures periodically to maintain staff proficiency.
Also, utilize pre
-
hospital incidents with potential hazmat situations as an opportunity to initiate activation of
hospital preparedness plans.



Drills and exercises
should be combined
with local, regional or
state resources as
much as possible.



9

REFERENCES

(used in development o
f these guidelines)


American College of Radiology

http://www.acr.org/flash.html


Association for Professionals in Infection Control and Epidemiology, Inc. (APIC)
www.apic.org


California Hospital Bioterrorism Response Planning Guide, California Department

of Health
Services 2002. The plan can be accessed at
http://www.dhs.ca.gov/ps/ddwem/environmental/epo/PDF/ca_hosp_guide.pdf


ECRI Advisory on Selecting PPE, March 2002



For more information, go to
www.ecri.com


Hospital Hazardous Material Emergency Response: The Devil is in the Details, Paul Penn,
Environmental Hazards Management Institute, April 2002, for more information, go to
www.hazmatforhealthcare.com


JCAHO Emergency Preparedness Standards
www.jcaho.org


NFPA 99 Standard for Health Care Facilities, 2002
www.nfpa.org


New Hampshire State Website
www.state.nh.gov



for all state agencies online


OSHA Best Practices for Hospital
-
Based First Receivers of Victims from Mass Casualty
Incidents Involving the Release of

Hazardous Substances
, January 2005


OSHA standards are located on the web at
www.osha.gov




OSHA 29 CFR 1910 addresses various responsibilities of the employer and employee in
dealing with hazardous materials and treati
ng patients contaminated




OSHA 29 CFR 1910.120, App. B, general description and discussion of the levels of
protection and protective gear




OSHA 29 CFR 1910.134 Hospitals and Community Emergency Response


what you
need to know




OSHA 29 CFR 1200 Hazard Com
munication
-

every worker has the right to be protected
from potential work related hazards


Information on SARA Title III, Emergency Planning Community Right to Know Act and Local
Emergency Planning Committees can be found on the is on the web at
www.epa.gov

.


U.S. Department of Transportation
Emergency Response
Guidebook,
http://hazmat.dot.gov/g
ui
debook.htm



10





11

ATTACHMENT 1
-

PERSONAL PROTECTIVE EQUIPMENT (PPE)

OSHA P
rotection Level


PPE Recommended


Training Recommended

Level D (least protective)


These PPE recommendations provide
minimal protection, and act primarily as a
water barrier for the following
conditions:



Minimal contact or exposure is
anticipated



The chem
ical is known
AND

is a
low risk contaminant



This level of PPE is basic for securing,
isolating and denying entry of an
ambulatory
victim.


At this level, decon should be done
outdoors or in a well ventilated area.


The patient must be ambulatory and able

to fully understand self
-

decontamination
instructions.



Liquid splash protection:



Full face shield



Hood or hair covering



Gloves



Water
-
repelling gown



Rubber boots



Work clothes, scrubs



Universal precautions



Respiratory Protection:



No respiratory prote
ction
needed


Recommended




Hospital Decon Orientation


Level C


These intermediate PPE
recommendations provide hazardous
materials protection for the following
conditions:



Potential staff contact or exposure
is anticipated



The chemical is known
AND

is a
l
ow risk contaminant








Liquid splash protection:



Full face shield



Chemical
-
resistant gloves

(inner & outer)



Chemical
-
resistant suit
with hood



Waterproof, chemical
-
resistant boots.

Respiratory protection:



Full face or half
-
mask, air
pu
rifying respirators
(NIOSH approved) such
as powered air purifying
respirator (PAPR),
N95Particulate
Respirator, or Air
-




Hospital Decon Orientation




Hospital Decon Operations






12


Level C (cont’d)

purifying Respirators

(For a comparison, see
Attachment 2).


Level B

These
PPE recommendations provide the
preferred hazardous materials protection
for the following conditions:



Potential or actual staff contact
with patient or contaminate is
anticipated



The agent is unknown AND/OR is
a high risk contaminant



Required protection f
or unknown
substances, high
-
risk
contaminant(s)

For Level B, it is preferable to make
arrangements with your local fire
department for Hazmat team coverage.


Liquid splash protection:




Full face shield



Chemical
-
resistant
gloves



Chemical
-
resistant suit
wit
h hood



Waterproof
-
chemical
resistant boots.


Respiratory protection:



Atmosphere supplying
respirator such as:
supplied air respirator,
Self
-
Contained Breathing
Apparatus (SCBA)



Most Level B respiratory
protection requires fit
testing, training, an
extensi
ve maintenance
program, and medical
evaluation/surveillance.



Hooded supplied air
respirators are considered
Level B and require no fit
test.






Hospital Decon Orientation




Hospital Decon Operations




Hospital Decon
Coordinator Training


Level A (most prote
ctive)


Level A is a Hazmat Technician Level
and is not normally required at a hospital.






13

ATTACHMENT 2


LEVEL C RESPIRATOR COMPARISON



N95 Particulate Respirator

Air
-
purifying Respirators

Powered Air
-
Purifying Respirators

Pros



infectious aerosols



airborne infections



filter ambient air




particulates



HEPA cartridges



battery powered motor & blower




airborne infections



protects against particles



1/2 or full
-
face or loose fitting hood/helmet




such as biological spores,



low likelihood of inwar
d leakage




asbestos fibers, dust, fumes



APF 25
-
50 (as high as 1000)





removes 99.97% of particles w/



lower cardiopulmonary strain and fatigue




0.3 mirons.



greater cooling capacity





fitted w/ chemical
-
specific



hoods highly chemical
-
resi
stant




cartridges to provide protection



easy donning/doffing




against chemicals or mists



can be fitted to airline or supplied air tank





1/2 face & full face



do not require fit testing (with hood)





APF of 10 and 50






are considered neg
ative pressure






enhanced mobility






light weight



less expensive than atmosphere


supplying respirators


Cons




atmospheres
contaminated with



can increase cardiopulmonary strain



cost




volatile organic chemical



cause user fatigue




can increase c
ardiopulmonary strain




easily dislodged



cannot be used in IDHL or oxygen
-



cause user fatigue




easily wetted during
treatment


deficient atmospheres




cannot be used in IDHL or oxygen
-

deficient atmospheres




Fit testing



Only protects against specif
ic
c
hemicals



Only protects against specific chemicals





requires monitoring of contaminant
and oxygen levels



requires monitoring of contaminant

and
oxygen levels





can only be used against known


gas and vapor contaminants



can only be used against

known


gas/vapor contaminants




14

ATTACHMENT 3

DECONTAMINATION EQUIPMENT TO BE CONSIDERED




Ongoing Equipment (will need to be replaced)

One Time Purchase (or infrequent) Equipment



PPE



Sealable plastic bags


f潲 cl潴hi湧 & 灥rs潮al
扥l潮gi湧s Eca
n tri灬e 扡g with clear 灬astic 扡gs).



Paper bags


if there is 灯pential evi摥nce f潲 a⁣rimeⰠ
nee搠t漠灬ace in 灡灥r⁴hen 灬astic if wet.



Soap


mil搬d li步 摩sh 摥tergent/扡批 s潡p



Spray bottles



Labels



Sharpie or other permanent marker



Gowns



Blankets



Tow
els



“Trash Bag” decon sets (optional)



Scissors



Hoses, with gentle flow, controlled nozzles



Containment barrels (55 gal) for belongings, water



“Rubbermaid” totes for equipment storage



Duct tape



Soft, long handled brushes



Buckets



Traffic cones



Barrier tape



S
ponges



Waterproof, disposable cameras



Med Air manifold



Shower
-

Single with flex head
(minimum)/Multiple (recommended)



Tent



Modesty screens



Portable screens



Rope/ tarps



Instructions


laminate搬d 摩ffere湴 langua来s



Decon Table



Gurneys



Back Boards (non
-
por
ous)



Wading Pools


water c潮tainme湴 摥vices
Emi湩m畭 ㌩⁷ith 灬astic 灡llets t漠灲event
sli灰pge



Hand rails or walkers



Megaphone



Signage



*Some of this list excerpted from Paul Penn, the Devil is in the Details


15


ATTACHMENT 4


SAMPLE LAYOUTS

Sample

Indoor Layout

(w/ supplied air)


16