Caller Name

Caller Phone Number

What are the patient symptoms?

What is the suspected contaminate?

Is this a Patient transfer from another facility?

Is this a Burn Unit patient transfer?

Have you notified the ER Team Leader?

Remind staff:
1) When ED receives the 5 minute out call from EMS, the ED Team Leader calls the Burn Unit Team Leader to come to ED and prepare for the arrival of the patient.
2) once patient arrives and is accessed, the ED, Burn and Safety On Call will agree upon a Decon plan.
3) If patient is to be deconned, an ABLS certified staff member shall be present in the Decon Room and participate throughout the procedure.
4) if no decon, proceed with standard admissions process.

Was the patient deconned prior to transport to ACH?

How confident are you that the patient was previously deconned?

Patient must be screened at ambulance bay checking for any signs of contamination.

Prepare staff and Decon Room for a decon event. Screen patient at ambulance bay for any signs of contamination.

Do you have an SDS?
Available from Team ACH, MSDS Online or provided by another facility

Do you have PPE recommended in the SDS?

PPE is located in the supply room. Follow the instructions on the wall to see how to don PPE.

Is the Decon Room shower(s) working?

Pick a shower. Pull down on handle.
Open the correct control panel.
1) Flip power switch marked #1 to ON.
2) Flip the switch up for the appropriate shower

Is the water temperature okay?

Has water been running for longer than 5 minutes?

There is a problem with the plumbing. DO NOT RUN SHOWERS FOR LONGER THAN 30 MINUTES. Collection tank could overflow into the parking lot and to a storm drain leading to the Arkansas River.

Let the shower run for 3-5 minutes or until water is warm.

Do you have the soap, brush, sponge and bucket ready?

These supplies are located above or below the sinks. Prepare a bucket of soap and water.

Do you need an EHS representative to come in?

Call Director of Safety at 501-680-9262

Arrival time

Enter additional response details here:

Add media here:

REMIND STAFF: You never know when you next decon event will occur.
1) Turn off showers
2) Place contaminated items such as clothing in a bag and place in the corner of decon room.
3) Dispose of trash in the trash receptacle.
4) Personal items may be returned to the patient once cleaned and bagged.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.