When a suspicious package prompts an ER lockdown

How prepping for Ebola helped empower a Maryland hospital to handle hazmat scare

When two men opened a piece of mail at home in Frederick, Maryland, in May, they found a mysterious substance lurking inside. One man soon developed a small burn on his forearm. Both began suffering respiratory symptoms. So the two decided to seek medical treatment about a mile down the road at Frederick Memorial Hospital. And they brought the suspicious package with them. 

Once hospital staff realized the patients had brought a potentially hazardous material into the ED, they initiated a multi-agency emergency response, calling upon police, firefighters, public health officials, and others to contain a situation that seemed poised to rapidly deteriorate into chaos. The hospital evacuated its ED and relied on a segregated HVAC system to minimize the threat of cross-contamination. A hazmat team established a decontamination tent on-site, and ambulances carrying incoming patients were diverted to other hospitals.

Phil Giuliano, director of public safety and security for Frederick Memorial, says medical staff believed they were dealing with an unknown white powder delivered in an envelope to the two patients from an unknown source. The big fear was that the contents of the envelope, which were mailed to a residence on Military Road, might have something to do with the U.S. Army installation across the street. 

While single-family homes line the south side of Military Road, a barbed-wire fence along the north marks the outer boundary of Fort Detrick, a garrison that serves not only as the top employer in the county but also as a hub for biodefense research. It was the heart of the U.S. biological weapons program (until the program was discontinued in 1969), and today it facilitates an array of military agencies and private research groups within the National Interagency Biodefense Campus. This is not the sort of place where mysterious white powders are given the benefit of the doubt.

Hospital staff and law enforcement worried that one of the men might work in one of the laboratories at the installation, Giuliano says. A spokesperson for Fort Detrick confirmed, however, that the men were neither service members nor civilian employees of the military. Initial testing revealed that the suspicious package did not contain a biological or viral agent, Giuliano says; a second round confirmed the result, suggesting that the substance was instead a common household chemical. A third round is expected to tell investigators precisely what that chemical was.

While the three-hour hazmat scare proved far less dire than it could have—the patients’ condition never worsened, and the nurse who worked with them never showed symptoms—the incident offered real-world practice to the various local, state, and federal officials involved in this sort of emergency response.

“Honestly, I think it went as smooth and as seamless as it could,” says Lt. Clark Pennington, commander of the Frederick Police Department (FPD) Criminal Investigation Division. “This is something we plan and we train for.”

That being said, there are always areas for potential improvement, which is why FPD committed to joining with the hospital and other local agencies for an after-action review of the response, Pennington says.

At this point, it seems the overarching lesson is that emergency responders need each other, and they need to build strong bonds in anticipation of emergencies large and small, Giuliano says.

“When events like this take place, I think it’s a reminder for hospital staff, hospital leaders, and community members as a whole how important it is to have strong relationships, to maintain strong relationships with those other partners you have in your county, in your jurisdiction, in your area of operations,” Giuliano says.

That level of refined collaboration requires that agencies have confidence not only in their own members but in each other as well, says Michael G. McLane Jr., MBA, BSN, RN, assistant vice president of support services and behavioral health for Frederick Memorial.

“You don’t get that trust just by saying, ‘Well, I trust you,’ ” McLane says. It takes extensive collaboration, meeting, pre-planning, training together, frequent communication, and more.

Prepped for Ebola

The ED team at Frederick Memorial didn’t have an emergency response guide labeled “How to handle envelopes of unknown white powder.” But they did have detailed plans on how to respond to a different type of emergency: suspected cases of Ebola.

As the deadly Ebola virus ravaged West Africa in mid-2014, the CDC launched an initiative to prepare U.S. hospital systems to respond quickly to patients with symptoms. A man in Texas who had recently traveled to Liberia died after his Ebola symptoms were first diagnosed as sinusitis, then two nurses who cared for him also contracted the virus, spurring fears that U.S. facilities might be underprepared to spot and deal with the highly contagious infection, according to a report published by the CDC last year.

Since certain hospitals faced a higher likelihood than others of having a patient with Ebola show up in the ED entryway, the CDC and the HHS Office of the Assistant Secretary for Preparedness and Response rolled out an approach with three tiers: frontline healthcare facilities (which would quickly identify and isolate patients with possible infections), Ebola assessment hospitals (which would receive patients with possible infections and coordinate laboratory testing for the virus), and Ebola treatment centers (which would care for patients with confirmed cases as long as needed).

Frederick Memorial was designated an Ebola-assessment hospital, one of only five in Maryland, Giuliano says. That means his team has spent the past few years developing and practicing plans around how clinical staff would safely care for patients with Ebola symptoms while minimizing the threat to fellow patients and staff. These plans came in handy when hospital staff were faced with the threat of the suspicious envelope.

“It provided good guidance up front for us and the right steps to take in getting the right partners in place quickly,” Giuliano says.

Since there was concern that the nurse who initially cared for the two men might also have been exposed to hazardous material, she was treated alongside the patients and underwent a decontamination shower.

“There was no break in her care,” Giuliano says, “and it was done in tandem prophylactically just to make sure that, if there was any opportunity for any exposure, she received the same treatment.”

Praise for training

Credit for the smooth response to May’s hazmat scare should be assigned to the extensive and collaborative practice undertaken by hospital staff and other agencies, Giuliano says. He advises other healthcare safety professionals to similarly prioritize training, even for unlikely scenarios, because the lessons learned focusing on one particular issue can come in handy responding to a number of real-world situations. At least one staff member who was working through an active-assailant training program, for instance, said the practice on how to keep clearheaded in the event of an attack made it easier for that person to keep everyone in the hospital calm as the hazmat incident was unfolding.

“Train and educate every opportunity you have. The plans are only as good as the exercises that you put behind them,” Giuliano says. “There are always going to be gaps in any plan that you’ve created, and to close those gaps, they have to be living documents.”

Giuliano adds that repeatedly putting a plan into practice is the best way to ensure your team knows how to respond in high-stress situations.

“A policy, again, is only as good as the understanding of the individual who is trying to utilize it, and that understanding has to come from a basis of knowledge that is already in place,” he says. “So I think emergency managers have a responsibility to be educators as one of their top priorities, because a hospital [requires] an all-hazards approach. There are so many things that can walk through those doors. There are so many things that can impact a hospital system. Without having an all-hazards approach that’s understood at a line-staff level, you’ve really lost an opportunity.”

In the wake of any emergency response—even a false alarm or pre-planned exercise—a thorough after-action assessment is indispensable.

“If you’re not looking for those opportunities on how to enhance the program after an event like this, or a smaller event, then you’re missing the mark,” Giuliano says. “We’re always ironing out wrinkles. With an event like this, it’s an opportunity to take pause.”

Emergency preparedness rule

Under the new CMS Emergency Preparedness Rule implemented last fall, Frederick Memorial and other hospitals must conduct two annual exercises by November 16, 2017. When a real-world incident prompts a hospital to activate its Emergency Operations Plan, however, that can count as an exercise, as The Joint Commission acknowledges in element of performance 1 under EM.03.01.03.

Giuliano says the May hazmat scare was one of four separate real responses, all within a 10-month time span, that could count toward the CMS/Joint Commission requirement. These are in addition to two pre-planned exercises. Although the hospital does not plan to use the real responses as substitutes for any exercises, the team keeps documentation of each response anyway—digital and hard copies—for regulators to review, Giuliano says.

“I like having a separate binder for each event that’s categorized the same way, completed with an after-action report that follows the six subcategories [of the Emergency Preparedness Rule] so that it’s apples-to-apples and you can do comparisons on the event,” Giuliano says.

Most inspectors have really wanted to see those hard copies, he adds, so keep them printed out and stored in a logical order.