Emergency preparedness planning: Biological and chemical response
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February 2, 2017
Emergencies that introduce contamination into a hospital require a special type of planning
Editor’s note: This is the third of a series of stories that will address common planning concerns when it comes to certain types of emergencies that can strike a hospital facility.
For the most part, hospitals are ready for just about anything. When a disaster strikes, patients need to know that their local hospital is open and ready, and that they can expect the best care.
But a hospital also needs to protect itself—in most cases, when a disaster strikes, it stays outside the confines of a hospital’s doors, and at least theoretically, the hospital is a safe zone that is outside the confines of what is going on out there to make people hurt or sick.
There are a few types of emergencies, however, where the effects of the emergency can be brought right into the hospital, and if not prepared for, it can make hospital staff part of the problem.
Take a biological or chemical incident, for instance. These incidents tend to occur in situations that seem relatively commonplace, until the secondary situation makes people realize it’s not. When one or two people get sick, hospitals can handle it, but when those people are followed by another 200 that may have been exposed to an unknown illness, it may be too late—many of those people may already be sitting in your waiting room.
On May 12, 2016, when an Amtrak train derailed on the major Washington-New York rail corridor running through Philadelphia, at least seven hospitals in the greater Philly area had only minutes to get ready to receive hundreds of patients, from busloads of “walking wounded” to critically injured patients coming in via ambulance.
Officials didn’t not know at first if it was a terrorist attack or if the crash involved hazardous materials that could affect the safety of the hospital.
“I needed to know about bomb residue, chemicals, or radiation,” says Herbert Cushing, MD, FACP, chief medical officer of Temple University Hospital. “We were about 40 minutes in and I couldn’t let [staff] keep treating people if there was an issue. We were able to get information from the scene about whether or not there were [weapons of mass destruction] involved.”
These unknowns that can occur before patients even walk in the front door are the reason emergency preparedness officials and accreditation experts expect hospitals to have a plan in place and practice ahead of time. So take a lesson, and learn about some of the things you can do to prepare.
Prepare for what can happen in your neighborhood. Ideally, you already have a good idea of the hazards that lurk around your hospital, and that drives much of your emergency planning. In emergency planning circles, this is called conducting a Hazard Vulnerability Analysis (HVA), the base document that hospitals should develop to help guide their emergency response plans. It’s a document that is required by The Joint Commission as part of its Emergency Management standards (EM.01.01.01, EP 2), and CMS requires it as part of its increasingly stringent survey standards requiring an “all hazards” approach to emergency planning.
By design, the HVA is a flexible document; it should be reviewed annually and revised as needed, used as a planning document for your drills, and improved as you discover weaknesses (or strengths) in your facility’s response plans.
In this document, start with a clear assessment of the hazards that are present in your community. Is there, for instance, a research facility for hazardous diseases, or a huge chemical plant in the middle of town that could cause a large-scale evacuation or contamination in the event of an explosion (ask the folks in West, Texas about that one)? Does a rail line with frequent freight trains rolling through go through the center of town? Are you the only major facility for miles around? These are all factors that could make you the first and only place where victims of a biological or chemical incident look for help.
Know where the money is. It’s been said many times that you need to have a plan in place, and you need to drill to practice those plans; we won’t overemphasize the point. But many hospitals still say one of the reasons they don’t do it enough is because of a lack of money or resources for knowing where to start.
That’s no longer an excuse. If you do the homework, you’ll discover that there are lots of places—private and public—where you can find funding to help you out.
“There is a lot of money that’s going toward that coalition development, coalition exercises, coalition training,” says Christopher Sonne, CHEC, assistant director of the Emergency Management Solutions Program at HSS, Inc., in Denver. It is the company that provides emergency management training, facilitation, and subject matter expertise for hospitals and healthcare providers throughout the United States. “Depending on what regions of the country you’re from, what state, what city, what municipality or healthcare coalition, you may have different capabilities that you’re looking to pursue, to foster with your community partners.”
Consider the following resources as a starting point:
- Public Health Emergency Preparedness (PHEP) Cooperative Agreements—A CDC-backed program, since 2002 it has provided nearly $9 billion to public health departments across the nation to upgrade their ability to effectively respond to a range of public health threats, including infectious diseases, natural disasters, and biological, chemical, nuclear, and radiological events.
- Hospital Preparedness Program—A program from the U.S. Department of Health and Human Services (HHS) that has granted more than $4 billion to help “improve surge capacity and enhance community and hospital preparedness for public health emergencies.”
- Homeland Security Exercise and Evaluation Program (HSEEP)—This won’t necessarily pay for your drill, but it will help you get the biggest bang for your buck. Designed by the Homeland Security Department in 2002, HSEEP provides a set of guiding principles for exercise programs, as well as a common approach to exercise program management, design and development, conduct, evaluation, and improvement planning. Check it out for lots of ideas on how to plan and execute your exercises.
If you can share money, that’s even better. A lot of public agencies—your police and fire departments, for example—are also looking for this grant money to help them prepare. If your hospital can partner with them and become part of their own exercises, you could benefit from that.
Train your staff to be a SWAT team. If someone walked into your hospital with symptoms of Ebola or acute radiation poisoning—or if several did, would your ER staff know what to do?
After the Philadelphia train crash, a number of hospitals in the area created SWAT teams of staff members who are specially trained to respond immediately.
“It’s been nothing but training and they are very motivated,” says John Ward, director of safety and materials management for Einstein Healthcare Network in Philadelphia.
Einstein formed what it calls an SIDRT (Special Infectious Disease Response Team) that would be first on the scene as soon as the symptoms are identified. The team consists of seven ER physicians, 22 critical care nurses, four respiratory therapy assistants, and a radiological team that would swing into action with their specialized skills. A response plan has been mapped out that involves blocking off certain areas of the hospital, designating certain rooms as off limits, and pre-stocked carts that can be wheeled into place at a moment’s notice.
Get ready to lock everyone out. That being said, you’ll need to be ready to cut off the source of contamination coming into your facility, and that may mean keeping everyone outside until the problem can be contained. That goes against everything a hospital stands for. But you may be dealing with mass hysteria, media coverage, concerned family members, and keeping your staff healthy. And your security staff will be the ones front and center handling the lockdown and the anxious crowd.
Figure out your protocols now: You may have lockdown procedures in place, but when is the last time you went over them and practiced them? And at what point do you shut all the doors and let no one else inside? Do you have the proper facility locks and barricades in place? Are there protocols in place to limit facility access to only a few entrance points so that you can control the movement of people who are potentially infectious through your doors?
Buy and stock plenty of PPE. The moment that you get scores of patients with smallpox lesions or evidence of radiation poisoning is not the time to realize that you don’t have enough respirators available for your entire team; nor is it the time to discover that the only full-body suits your hospital owns are in a closet or trailer somewhere off-site. By now, you should have purchased at least the very least you will need to deal with the very intricate PPE your staff will need to wear when dealing with very infectious organisms, especially since the Ebola outbreak of 2014 taught healthcare workers what can happen. Many hospitals also have begun stocking the equipment in easy-to-access cabinets outside patient safety rooms.
Make sure everyone knows how to use it. Just because you have equipment available doesn’t always mean staff know how to use it. One of the biggest revelations to come out of the Ebola outbreak of 2014 was how little nurses and other staff members responsible for patient care knew about donning full-body suits and other PPE such as respirators. The result was new training programs and funding from the CDC and other agencies to help get hospitals ready.
It’s also why you need to drill. A realistic drill with local emergency officials can make for lots of teachable moments. There’s nothing quite as encouraging as watching your local fire chief give an impromptu lesson to your ER staff during a HazMat disaster simulation when he realizes that not everyone knows how to operate the decontamination tent. Should they know how to do this? Yes? Will you need to test them on it later? Of course. But letting educational needs unveil themselves during a drill is when it should happen; it saves you effort, and it’s also a great time to create permanent relationships with your local emergency response officials.
Drilling can be a fun way to practice. A well-planned drill can be a great way to test your staff’s response to a patient surge that would inevitably occur after a biological or chemical incident—and The Joint Commission requires it.
At Longmont (Colorado) United Hospital, a drill was planned on Halloween 2014 that simulated a zombie invasion, which coincidentally, was a perfect simulation of a surge of patients.
The ER staff was tested with more than 50 “zombie” patients with a disease called Zombthrax to descend upon the hospital looking for treatment.
“We had people here who did moulage, and they looked great,” says Mary M. Pancheri, CHEP, HEM, manager of safety, security, and emergency preparedness at Longmont. “Everyone had a great learning experience. We flowed them into the hospital units and everyone had to deal with them.”
Triage protocols went into place, and decontamination tents were set up in the parking lot of the hospital, just like it would happen if there was a real life chemical or biohazard emergency. Extra help was called in from the public health department and first responders in the community. High school students from the local EMS explorers unit were used as victims and also helped out with the triage process. The best part? The prophylactic “pills” that were handed out to everyone who was potentially contaminated were really M&Ms® candies.