Patient decontamination is a multi-step process of removing and containing harmful substances in order to minimize the risk of further absorption and inhalation of the offending agent, and to reduce the likelihood of secondary contamination.  It starts with identifying potentially exposed and contaminated individuals (through history taking, patient observation, and interpretation of presenting signs and symptoms), isolating them in a safe location (typically outside the emergency department), removing gross contaminants (via clothing removal and showering), performing agent identification (through fact finding), and performing post-decontamination care.  Success of the process relies heavily on the free flow of information.  In a hectic, demanding environment, any breakdown in communication between staff and patients makes the decon process more arduous and hazardous.  Despite best intentions, there are a number of barriers to effective communication that must be considered and addressed in order to enhance the outcome of an emergency decontamination operation and increase victim compliance.  Examples of these barriers include language, disability and culture.

Barriers to Effective Communication

According to the U.S. English Foundation, the number of languages that are spoken in the US ranges from 207 in California to 59 in Wyoming.  Los Angeles County leads the nation with 135 languages spoken at home.  Of the 322 languages spoken in the United States, 93 had more than 10,000 speakers and 38 had more than 100,000 speakers.

Although English is the most common language spoken in every state, there is significant variation in the other major languages used in a particular area.   In one US county, for example, Spanish, Navaho and Yupik were the most common languages spoken after English.  In a Midwestern city, Hakha Chin, a language spoken primarily in eastern India and Burma, was the third most common language used in the area.  In addition to spoken language barriers, nearly 10,000,000 persons are hard of hearing and close to 1,000,000 are functionally deaf in this country.

Planning initiatives focusing on communication barriers should also consider the various visual inputs inherent in the decon process and how they may impact its effectiveness for the estimated 8.6 million people in the US with visual impairment and the 580,000 who are legally blind.  Lastly, decontamination planning needs to address local cultural sensitivities as it relates to clothing removal, modesty, male/female interactions, and other expected norms.

Advancing effective communication, cultural competence and patient-centered care in hospitals is a growing focus for The Joint Commission (TJC) in the coming year.  Although current emergency management standards by TJC provide planning guidance, they do not explicitly address effective communication, cultural competence, and patient/family-centered communication.  Nonetheless, it is necessary to consider the diverse needs of the patient and community population so that emergency response efforts provide for the safety of all who require hospital services. The Joint Commission offers the decontamination process as an example where communications can be improved. According to TJC, decontamination instructions provided to patients by staff should not only be verbal, but should also be in the form of posters or other visual aids for patients who are deaf or have limited English proficiency.

Steps to Better Communication

A number of steps can be taken to better improve communication and address cultural sensitivities during decontamination. For example, clearly demarcating each stage of the decon process with signage that uses pictograms to illustrate the expected activity (e.g., clothing removal and use of privacy gown; showering; post-decon drying off and donning gown; etc.), theatrical-like demonstration of the activity expected at each station, strategic placement of interpreters, and the distribution of pre-printed, multi-lingual information sheets can improve communication. Recognizing the inherent need for modesty through adequate use of privacy screens, separate showers for men, women, and children, and gender segregation of staff is also important to consider. Understanding that personal space varies among cultures and that eye contact is not always appropriate should be stressed in training.  Staff should be attuned to a patient’s apparent comfort level when making direct eye and physical contact. 

For many patients, allowing a friend, relative, or support person to accompany them through the decontamination process may enhance their calmness and cooperation. Allow wheelchair patients to perform their own transfers as appropriate. In many cases wheelchair, walker, and cane dependent patients may need to be guided through the decon process on a chair or other mobility device. Proper positioning of Occupational and Physical Therapists will prove very valuable.  Service animals should be decontaminated with the patient. Finally, don’t rush patients through decon. Hurrying a patient may promote feelings of anxiety and confusion. This is especially true with pediatric and elderly patients.  

Enhancing communication with patients during decontamination or any other encounter will enhance the healthcare experience for all involved. Success requires planning, training, practice, patience and consistency. The single biggest problem in communication, as noted by the Nobel Laureate and Oscar winner, George Bernard Shaw, is the illusion that it has taken place. Unless we become proactive in improving how we communicate with patients, we will never completely fulfill the axiom – Primum non nocere - do no harm.