Terror alert: Are you ready for any possibility?
Hospitals move beyond smallpox in hazard analysis
As Americans encountered an elevated terror alert and braced for war with Iraq, Tom Ridge, Homeland Security chief, announced a "Ready Campaign," saying, "Terror forces us to make a choice. We can be afraid, or we can be ready."
For homeowners, that meant stocking up on duct tape and bottled water. But how ready are hospitals to respond to an act of terrorism that results in contaminated patients and mass casualties? Preparedness experts worry that the smallpox vaccination program may be diverting resources from other types of emergency capability. Many hospitals have not done enough to coordinate with other hospitals and agencies in their community or to maintain effective equipment and training — even though that is required by the Joint Commission on Accreditation of Healthcare Organizations’ standard on emergency management.
More importantly, many hospitals lack the "big picture" perspective that is essential to preparedness, says Paul Penn, MS, CHEM, CHSP, western director/vice president of the Environmental Hazards Management Institute in Diamond Springs, CA.
Terrorism should be integrated into other disaster preparedness plans, he says. For example, a nerve agent that could be used in chemical terrorism is not much different from organophosphate poisoning due to a pesticide spill.
"Let me put this into perspective. Terrorism is a menace with malice.’ In health care, we are more concerned with the menace component. A chemical terrorism event is a hazardous materials incident. A bioterrorism event is an infectious disease outbreak. Instead of focusing entirely on the chemical terrorism or the bioterrorism event, let us prepare organizations to handle the broader and more likely event so they can handle the other ones," Penn explains.
At a minimum, every hospital should have the capability to decontaminate one or two patients, and determine if a larger capacity is appropriate, he says. That sounds simple, but actually entails the ability to assess risk, identify hazards, conduct safe decontamination, provide protective equipment to select employees, and keep up skills through training.
"Ideally, everybody should attain a level of preparedness that is appropriate for their own unique situations and make sure that what they are doing supplements what their nearest neighbors are doing," says Luke Petosa, MSc, HEM, director of the Center for Healthcare Environmental Management at ECRI in Plymouth Meeting, PA. Petosa developed an advisory on selecting personal protective equipment for chemical and biological terrorism events (available at www.ecri.org).
As of January 2003, the Joint Commission added a new requirement to its emergency management standard: Hospitals must plan cooperatively with other health care organizations in their geographic area. That includes identifying resources that could be shared during an event.
The occupational health nurse plays a key role in both planning and response, as someone who will help identify hazards, protect health care workers, and possibly coordinate a hospital’s emergency response, according to the American Association of Occupational Health Nurses in Atlanta.
Here are some major steps that hospitals must take in their emergency management:
• Conduct a hazard vulnerability analysis. Think of every imaginable hazardous event, either inside or outside your hospital: sewage backup, HVAC failure, a massive chemical spill, an act of terrorism.
To evaluate the risk of those and numerous other events, Mitch Saruwatari, MPH, national threat assessment manager at Kaiser Permanente in Pasadena, CA, developed an Excel-based spreadsheet. Hospitals can identify their highest priorities and focus their resources on training and preparedness. (The form is available free of charge at www.hazmatforhealthcare.org.)
"Since Sept. 11, we’ve asked all of our hospitals to reconfigure their hazard vulnerability analysis," Saruwatari says. "If you’re next to a stadium, you may not have thought that was a big risk. But under today’s standard [of a terrorism alert], that adds a greater risk to your facility."
Saruwatari advises meeting with community response agencies, such as fire department officials or law enforcement, to gain additional perspective on risks. Then you can make your planning and resources flexible. "Any preparation that you do in a hospital will have overlap for preparing for any other event," he says.
For some incidents, you may be able to take mitigating action. For example, earthquake damage can be minimized through structural reinforcements of a building. "Those mitigation activities reduce the severity, which ultimately reduces the risk," says Saruwatari.
You also should understand your internal capabilities for containing a hazard, such as the HVAC system.
"You need to understand how your ventilation system works," says Petosa. "What happens if an individual walks into your facility and you don’t know that he has smallpox, but three weeks later you do? Can you quarantine an area?"
• Create an incident command center (or emergency operations center). The Joint Commission requires hospitals to have an "all-hazards" command structure that links with a community command structure. The key is to make this something more than just a policy placed on a shelf. "It’s only good if you truly incorporate it into the organization and you practice it," says Penn.
During a disaster, you want to be able to use a common nomenclature and organizational structure such as the hospital emergency incident command system, which is patterned after the systems used by first responders. (For more information, go to: www.emsa.ca.gov/dms2/heics3.htm.) You want to be able to communicate readily not just with first-responder agencies but with other hospitals in the community, he notes.
Hazmat for Healthcare offers training that enables hospitals to practice using their incident command center. (For more information, see editor’s note.) "The things that occur the least frequently are the things you need to practice the most," Penn says. "Doing an unusual process has to be practiced so if they need to do it, they can do it competently."
• Select appropriate personal protective equipment (PPE). What contaminants are you likely to encounter? Who will be wearing the respirators, and for how long? How much time will be required for training and fit-testing related to the respirators?
Those are questions you must consider when selecting respirators and other equipment, such as protective clothing. (An advisory on PPE is available at www.ecri.org.)
At Johns Hopkins University in Baltimore, John Schaefer, CIH, HEM, CPEA, associate director for health care, safety, and environment for the university and hospital, has chosen not to use N95 respirators — even for protection against tuberculosis. Schaefer notes that by definition, N95s allow penetration of 5% of any substance. Even with a good fit, another 10% of contaminated air will penetrate. Moreover, N95s will not provide protection against a chemical contaminant.
"The best protection you can get from an N95 is 85% reduction of the exposure," says Schaefer, who is an assistant professor of medicine and environmental health sciences. "That’s a big concern. That’s why we don’t use the N95s for bioterrorism."
Instead, Schaefer favors powered air-purifying respirators, which blow HEPA filtered air and don’t require a tight fit. The air-purifying respirators are costly — $300 to $500 each — but the hospital saves money on training and fit-testing, he says. "Once [hospitals] use N95s for anything other than TB, they have to comply with the full respirator protection program."
On the other end of the spectrum, self-contained breathing apparatus (SCBAs) can be too difficult and unwieldy for health care workers, he says. "A lot of people want to grab air tanks to handle chemicals," says Schaefer. "It’s very easy to say that until you take a physician or a nurse and put a 60-pound air tank on that person that’s good for 30 minutes and watch this person try to maneuver. It’s very heavy. If you’re not ready for it, you can wind up with some back injuries."
• Be prepared to recognize a potential hazard. As with an infectious disease, swift identification is the single most important factor in protecting staff and other patients from chemical and other hazards. "You’re looking for physical signs," says Penn. "Their body is twitching, as they might if they were exposed to a nerve agent. They’re sweating profusely, as if they were exposed to some contagion or pathogen. These should be immediate signs. Unfortunately, many hazards of concern cause flu-like symptoms. It is often a challenge to differentiate between the traditional and the extraordinary illnesses."
Your emergency department (ED) and health care workers may be contaminated in the first moments of contact with a patient if they haven’t taken protective measures, notes Petosa.
"If you do not have the training and background in assessing a hazard, then everything else is for naught," he says. "You might know how to put the suit on and a respirator, if you don’t recognize when you need that and when you do not, it doesn’t matter."
Penn teaches hospitals to direct patients who are ambulatory and can follow directions to self-decontaminate before they enter the ED. When they remove their clothes, they will have reduced the contamination by 85% to 90%, he says. "You want to protect the victim, the other patients, the facility, your employees, the community, and the environment," he says. "For the more common one to five patients with contamination, you get them outside, put them in a shower with soap and tepid water. You do that without touching them. For nonambulatory patients and mass decontamination, a greater level of training and equipment is necessary."
Indoor decontamination raises a host of issues, notes Petosa. Do you have a space with separate ventilation, so the contaminated air doesn’t seep into other parts of the hospital? Do you have explosion-proof lights? "When you’re outside and you’re doing your decontamination, now you’re using God’s good outside air to provide you with an enormous amount of free ventilation," he says.
Your hazard vulnerability analysis will tell you which substances you are most likely to encounter in a disaster scenario. At Detroit Medical Center, a multidisciplinary task force met with local emergency planning teams to identify potential dangers as part of a two-year effort.
"We now have a map of which [hazardous] sites are near us and what hazardous chemicals are used at those facilities," says Tammy Lundstrom, MD, the hospital’s vice president/chief quality and safety officer. Those chemicals represent a risk of both accidental and intentional release. "Anything in the immediate vicinity is something that has potential [for use by terrorists]."
Failure to swiftly identify a contaminant can cripple your hospital. Schaefer recalls a night more than a decade ago when he was awoken by a phone call from the ED. A contaminated patient had carried a tear gas grenade into the ED. Schaefer ordered part of that area shut down.
Now, security guards encounter patients as they walk in. "If they’re reeking of a chemical, they are isolated," he says.
• Maintain regular training of staff. The Joint Commission requires disaster drills to maintain emergency preparedness. But your ability to respond to an incident will only be as good as your ongoing training in every area of response, from hazard communications to PPE uses.
"No matter what you buy, unless you train right initially and keep your skills up, you’re fooling yourself," says Petosa. "You’re actually doing yourself more harm. You’re lulling yourself into a false sense of security. You think you’re prepared, and you’re really not. You’ve got to remember what we’re doing here," he says.
"We’re buying, assessing, selecting, and training for an event or events that are highly unlikely to ever occur. Unless you properly train and continue to train and stay on top of things, you won’t be ready." Petosa adds.
[Editor’s note: An advisory on PPE, as well as other information and consulting services, is available from ECRI. For more information, call (610) 825-6000, ext. 5326, or e-mail [email protected]. For more information on Hazmat for Healthcare training programs, contact Paul Penn, Western Director/VP, Environmental Hazards Management Institute, P.O. Box 280, Diamond Springs, CA 95619. Telephone: (530) 622-5964. E-mail: [email protected]. Web site: www.ehmi.org or www.hazmatforhealthcare.org. Information sheets on chemical and radiologic terrorism are available on the CDC web site at www.bt.cdc.gov/index.asp.]
How ready are hospitals to respond to an act of terrorism that results in contaminated patients and mass casualties? Preparedness experts worry that the smallpox vaccination program may be diverting resources from other types of emergency capability.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content