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Emergency preparedness for healthcare facilities

Introduction Emergency preparedness

Healthcare facilities and their staff play a key role in emergency preparedness efforts for all types of events, including natural or man made disasters, pandemic influenza outbreaks, or terrorist attacks. The availability of healthcare is essential to accommodate the surge in demand for providing care related to a public health emergency.

The September 11, 2001 terrorist attacks, recent hurricanes in the Gulf region, and the threat of a pandemic influenza outbreak have prompted healthcare facilities to reassess and upgrade their existing emergency preparedness plans. These emergency plans need to be coordinated at the local community level based on the individual needs of the community.

This Web site is intended to assist healthcare facilities in with all aspects of emergency planning, including mitigation, preparedness, response, and recovery. Comprehensive tools and resources are provided from federal governmental agencies, professional organizations, universities, and state and local public health agencies. These include resources for education and training, key documents, products and equipment and sample procedures and lessons learned.

In addition to general preparedness resources, targeted tools and downloadable resources are provided for:

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Level of readiness

General elements of emergency management for healthcare facilities include mitigation, preparedness, response, and recovery. These include specific issues such as:

Although hospitals have general emergency management plans in place, they may not have planned for a large-scale chemical or biological terrorism incident until federal and state public health groups developed communication plans and networks to address such incidents. Such planning better prepares staff to manage smaller hazardous materials situations, such as industrial accidents – in which both staff and facility may be contaminated unless such incidents are anticipated beforehand. Planning should address the concerns of caregivers and the potential for distribution of a contaminant throughout the emergency department or even the hospital.

Local emergency planning committees (LEPC) or state public health departments may have information available to facilitate planning for the physical facility as well as equipment and communications. The American Institute of Architects (AIA) provides some guidelines for the planning and design of decontamination facilities in its Guidelines for Design and Construction of Hospitals and Healthcare Facilities 2001. Ordering information is available from the AIA.

Other issues that may require rethinking include staffing levels and training time. Training for decontamination processes involves more than a single annual inservice; for example, it also requires identifying the various types of personal protective equipment necessary (including respiratory protection) as well as training and practice in the use of the equipment.

Some plans that consider all of these issues in response to an act of chemical or biological terrorism include Michigan's Public Health Response to Bioterrorism & Public Health Emergencies and APIC/CDC's Bioterrorism Readiness Plan: A Template for Healthcare Facilities.

An example of a healthcare system's Major Communicable Disease Response (MCDR) Plan is available as an example of how one system interfaced the biological agent issues with the overall Emergency Disaster Plan.

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Elements of risk assessment

Facility risk assessment: The facility risk assessment should be a multidisciplinary process, with representatives from all services involved in an emergency situation. This includes infectious disease, infection control and safety staff to assist in differentiating biological from chemical agent exposures and in follow-up management.

Hazard vulnerability analysis: The facility should initiate a hazard vulnerability analysis – considering the impact of a hazardous materials incident, a chemical incident, or bioterrorism. This process includes assessing the probability of each type of event, the risk it would pose, and the organization's current level of preparedness. The pattern of response in New York and how individuals sought help are causing many organizations to reevaluate their current plans. This assessment should also take into account nearby community resources likely to be affected or called upon for assistance – including schools, churches, public transportation, news media, telephone and communication systems, voluntary organizations (such as the Red Cross and the Salvation Army), restaurants, and food suppliers.  A sample checklist for conducting hazard vulnerability analysis is available as well as an Excelâ„¢ sheet that permits ease of calculation of the HVA score.

Chemical incidents: Local industries and traffic patterns may be more important than size or urban/rural location in assessing impact on the facility. Weather conditions may redirect contaminants into the facility's vicinity. A transportation accident may be the initiating event; agricultural, industrial, and even home garage accidents are not infrequent. In the aftermath of such accidents, contaminated victims may be transported to the nearest facility, rather than to a major trauma center. Chemicals used in the healthcare facility should be considered as potential sources of accidental spills.

The VA Office of Public Health and Environmental Hazards has published a rapid contingency plan for responding to victims of an chemical attack. This very practical document includes management suggestions for handling of casualties and decontamination.

Biological agents: Bioterrorism is quite different from a chemical incident. An incident of bioterrorism may be recognized as such only after a number of victims displaying similar symptoms arrive at the emergency department, following an incubation period of unknown length. Diagnosis may be difficult: it may be hard to distinguish biological from chemical exposures (or the possibility of both, immediately after an event like an explosion). Deployment of a biological agent in a public place would impact everyone and everything in the area, including the healthcare facility. Rapid assessment and infection control management are critical. Guidelines for managing infected individuals once the causative agent is tentatively identified may be found in the table "Bioterrorism Infection Control: Guidelines for Patient Management" (see Sample Procedures and Tools) or on the Web site of the Center for the Study of Bioterrorism and Emerging Infections

Community-based first responders: Many hospitals base their emergency management plans on local fire departments, counting on them to carry out decontamination activities. In New York, firefighters were totally occupied at the scene of the incident, with multiple demands on their human and material resources; moreover, they were exposed to the "agent" (in this case, dust containing asbestos and possibly other hazardous substances). In the event of an incident, victims who are able to move may not wait to be decontaminated, but seek help wherever possible. Following an incident in Tokyo, 80 percent of the victims treated at hospitals were privately transported, self-referrals, or walk-ins. Healthcare facilities may need to consider training more first responders.

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Other planning issues

Identification of chemical or biological agents: When a recognized incident occurs in a community, the key to treating the exposed individuals is identification of the agent. In the case of an industrial, agricultural or transportation accident, that identification may be made early in the event. In the case of a covert action, the hospital must rely on detection equipment used by emergency responders at the site in response to presentation of symptoms. Understanding the decontamination process becomes critical in these "unknown" exposures. Some chemical and biological agents of greatest concern in a terrorist attack are listed on the CDC Web site.

Clinical assessment: The hospital depends on clinicians in the emergency department to make the initial diagnosis until other information becomes available. Clinicians must remain alert for unusual diseases that could result from an act of bioterrorism. As an event progresses, the public health department will work closely with healthcare organizations to identify patterns and exposed victims. See resources for training programs on learning to identify and treat critical agents.  CDC notes in the MMWR, April 21, 2000 / 49(RR04) that "…early detection and control of biological and chemical attacks depends on a strong and flexible public health system at the local, state and federal levels. In addition, primary health-care providers throughout the United States must be vigilant because they will probably be the first to observe and report unusual illness or injuries."

Security issues: Facility security needs include planning for facility lockdown to prevent access by unauthorized individuals. As the event progresses, the procedure must also consider traffic and crowd control as more individuals are identified as victims. Family members, the "worried well," and the media are likely to converge on the facility. Panic may ensue even if the biological agent is not contagious (that is, spread by person-to-person contact). Planning should include determining staff resources that can be deployed to support hospital security staff.

Communication: Local news media may gather at the hospital. Communication between news media and hospital media relations can support the healthcare organization by conveying important and realistic information to the public, such as recognition of symptoms and initial treatment steps to take, as well as realistic clinical information about the outcome based on the agent identified. Many Internet resources provide downloadable fact sheets on chemical and biological agents that can be duplicated and shared; these are described below.

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Biological and chemical agents

Lists of agents: CDC provides disease/agent-specific information pertaining to two basic categories: biological agents/diseases and chemical agents.

Biological agents: CDC provides detailed information on the agents most likely to be used in biological or chemical attacks, including pathogens rarely seen in the United States. These are summarized in Table 1 below.

The biological agents are classified in three categories:

Category A: Top-priority agents include organisms that pose a risk to national security because they:

Category B: Second-priority agents include those that:

Category C: Third-priority agents include emerging pathogens that could be engineered for mass dissemination in the future because of:

Table 1: Biological agents by category
Category A Category B Category C
Anthrax (Bacillus anthracis) Q fever (Coxiella burnetti) Nipah virus
Botulism (Clostridium botulinum) Glanders (Burkholderia mallei) Hantavirus
Plague (Yersinia pestis) Ricin toxin from (Ricinus communis) Tickborne hemorrhagic fever
Smallpox (Variola major) Epsilon toxin (Clostridium perfringens) Tickborne encephalitis
Tularemia (Francisella tularensis) SEB Staphylococcus enterotoxin B Yellow fever
Viral hemorrhagic fever (Ebola, Marburg, Lassa, Junin, Machupo)   Multi-drug resistant TB

Fact sheets on Smallpox, Plague, Anthrax, and Botulism can be downloaded. Other sources such as the Association for Professional in Infection Control and Epidemiology (APIC) provides additional resources and fact sheets.

Complete information on each of these agents may be reviewed from the consensus documents published by the Journal of the American Medical Association. Each article may be downloaded from Key documents | Consensus documents.

Clinical Laboratories: CDC issued revised anthrax guidelines for state and local health officials and intended to assist clinical laboratories. The basic guidelines can be downloaded here or may be downloaded from several Web sites. In early 2006 the CDC has provided an algorithm for the laboratory diagnosis of anthrax.

Chemical agents: CDC provides detailed information on treating exposure to representative chemical agents (for example, mustard gas) on its Web site.  Chemical categories and an example of each are listed in Table 2 below.

Table 2: Chemical agent categories and examples
System affect/use Example
Blister/vesicants Mustard Gas
Blood Arsine
Choking/lung/pulmonary damaging Chlorine
Incapacitating Fentanyl
Nerve Sarin
Riot control/Tear gas Chloroacetophenone
Vomiting Adamsite
Other industrial chemicals  

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Treatment and strategic national stockpiles

Strategic national stockpiles (SNS) formerly National Pharmaceutical Stockpile: CDC and other federal agencies have developed stockpiles that have been pre-configured and identified as "push packages." These are stored regionally and can be flown to the scene of an incident in approximately 12 hours. They contain both therapeutic and prophylactic medications, and would be supplemented by additional supplies specific to the suspected or confirmed agent, which would arrive in 24-36 hours. For more information, visit the Web site of the CDC NPS program.

Federal plan for SNS distribution: These stockpiles have been established and maintained by a number of federal departments and agencies. A presidential directive designates the following responsibilities:

The Department of Health and Human Services (DHHS) is the federal agency which takes the lead in planning and preparing for a national response to medical emergencies in the event of an attack using "weapons of mass destruction" (WMD). The Office of Emergency Preparedness (OEP) in the National Disaster Medical System takes the lead in these activities within DHHS.

The Federal Emergency Management Agency (FEMA) has the authority to release medical resources and other supplies in the event of a disaster or emergency declared by the president. FEMA coordinates the federal response through the Federal Response Plan (FRP), which details the roles and responsibilities of federal agencies during national emergencies.

If a terrorist event overwhelms the capacities of local and state authorities and requires a presidential disaster declaration, FEMA will implement the FRP and coordinate not only its own response activities, including the dispatching of federal pharmaceutical stockpiles, but also those of as many as 28 other federal agencies that may provide assistance.

Local governments (with support from state and federal agencies when appropriate) shoulder much of the initial responsibility for providing effective medical response to a terrorist attack. Local public health systems will be called upon to provide protective and responsive medical measures such as patient care, immunizations or prophylactic drug treatments for exposed populations, and decontamination of the environment. For more information, visit the National Association of County and City Health Officials.

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Disinfection and sterilization

Environmental decontamination - Anthrax: Increased media attention to Anthrax contamination following incidents around the nation raises questions about managing potentially contaminated personnel and the environment. The chapter on Anthrax in the Control of Communicable Diseases Manual from the American Public Health Association recommends basic skin cleansing with soap and water. Effective disinfection of potentially contaminated surfaces can be accomplished with diluted (1:10) bleach.

Medical equipment: Other tuberculocidal and sporicidal agents may be appropriate for certain circumstances and general guidance may be found in the comprehensive APIC guideline for selection and use of disinfectants or APIC.

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Mail handling

Suspicious packages: Issues will continue to surface, such as the anthrax exposures related to mail handling that have occurred on the east coast. Viewers are urged to check the CDC site on a regular basic for new information, such as the CDC October 12th, 2001 advisory on handling suspicious packages, and laboratory information for transporting specimens, and the October 27th update on handling mail.  CDC has also published Interim Recommendations for Protecting Workers from Exposure to B. anthracis in Works Sites Where Mail is Handled or Processed on November 2,2001.

Gloves: The CDC comprehensive recommendations address engineering, administrative, and housekeeping controls as well as personal protective equipment. The recommendations suggest mail workers avoid latex gloves because of the risk of latex allergy. The choice (e.g., vinyl or nitrile) should be based on fit, durability, and comfort; sterile gloves are not needed.

OSHA: The Occupational Safety and Health Agency has provided an assessment tool for determining levels of risk for exposure to anthrax spores and protective measures for each. See OSHA's Workplace Risk Pyramid.

Updating readiness

Staying current: Facilities should continue reassessing their emergency readiness plans in light of the events of September 11. All facets of planning must be re-examined; most importantly, coordination with local emergency planning agencies in surrounding communities as well as communications with local and state public health should be enhanced. The American Hospital Association has provided several documents that may be timely and useful in the current assessment. You may download the AHA's 2001 document on Hospital Preparedness for Mass Casualties as well as an Emergency Preparedness Checklist or visit the AHA Web site on emergency readiness.

Products and equipment: Disaster preparedness planning requires a wide variety of supplies, equipment and resources, including personal protective equipment (PPE), decontamination equipment, and training. Visit the products and equipment section of the Safety Web for details about various safety equipment resources.

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