Decontamination Activation

Q: Is there a specific time-limit required by the accreditation organizations for decontamination purposes, from activation of a drill to being able to put victims through a decontamination tent?

A: While there is no specific standard which spells out the amount of time required to set-up a decontamination tent, the time-frame must be evaluated to determine its effectiveness.

The emergency management standards require an effective disaster plan which must be written and educated to the staff of the organization. These same standards require disaster drills that are evaluated by observers for effectiveness. The results of the drill observations must be relayed to the Safety Team which uses the information to improve the hospital’s capacity to respond to disasters. The whole disaster response process includes an on-going evaluation to determine the effectiveness of the organization’s emergency response efforts.

So, while the amount of time to set-up a decontamination tent and run your first patient through is not specified, the catch-all is it must be effective. You may ask who judges whether or not the amount of time is effective? First, the hospital makes that determination but ultimately, the surveyor may make a judgment on that as well. If a surveyor decides that the amount of time to set-up a decontamination tent is too long, then that can lead to a finding.

The bottom line: Run a disaster drill which includes setting up the decontamination tent, and make an evaluation of the time it took from the start of the drill to when a patient can first use the tent. Report that process to your safety committee, and have them decide if it is an adequate amount of time. If the safety committee decides it is adequate, then there is a good chance the surveyor will view it the same.