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With the increase in worldwide terrorism incidents, hospital disaster plans need to be scrutinized to ensure they include preparedness elements that are unique to weapons of mass destruction (WMD) incidents. The practice of emergency planning varies considerably among hospital facilities. The nature of the hospital planning process reflects a facility’s size, functions, and resources. Larger health care facilities have more resources and personnel and greater organizational complexity in medical specialization. Such hospitals tend to create formalized processes and rely more heavily on written plans and inter-agency agreements. Smaller facilities may adopt an informal process based on personal relationships and produce few written documents. Communities with a high frequency of hazard impacts—hurricanes along the Gulf Coast or earthquakes in California— are also likely to have a formalized planning process, even in smaller jurisdictions. The threat of WMD transcends these patterns because of the difficulty in predicting such events and the lack of geographic or seasonal focus. Even standard planning practices need modification to account for WMD threats. For example,
- the hospital itself or its staff may be targets;
- patients will arrive at the hospital with little or no warning (patients also converge on facilities closest to the scene, if there is a scene);
- many patients will be self-referred without treatment by emergency medical personnel at a scene;
- patients may need to be decontaminated at the hospital;
- the hospital building, equipment, and personnel can become contaminated;
- information regarding the nature and hazard of the agent will not be immediately available to hospital staff; and
- many patients will be present as “worried well,” having little or no exposure to the agent.
These and other circumstances dictate that conventional planning may not be adequate to meet the demands posed by a WMD incident.
Using examples of hospital experiences with such incidents, this research-paper reports on planning lessons learned. A foundation for good planning is examined by acknowledging that planning is an ongoing process that requires linkages to the wider community including public health authorities, political authorities, and emergency responders. The importance of realistic assumptions about how people react to disasters is also discussed. This research-paper reviews special elements of WMD incidents that need to be addressed in hospital disaster plans, such as, incident command, patient surge, communications, universal precautions, personal protective equipment, decontamination, and hospital security. This research-paper closes with a discussion of the importance of training and exercising in preparing hospitals to respond to WMD events.
Establishing A Foundation For Good Planning
The foundation of good emergency planning is rooted in applicable standards and regulations, the establishment of regional planning efforts, and an understanding of how citizens respond to crisis.
Standards and Regulations Pertaining to Hospital Planning
Complying with codes, standards, and regulations is a significant aspect of managing hospital operations. The Joint Commission for Accreditation of Healthcare Organizations (JCAHO) has created standards that require hospitals to develop (Standard EC 1.4) and regularly exercise (Standard EC 2.9.1) an emergency response plan. Standards generally do not have the force of law, unless a local government body adopts them. Regardless of whether the jurisdiction having authority has adopted standards as code, standards are frequently cited in court cases. In contrast, hospitals must adhere to federal and state rules and standards, which are promulgated and enforced by a regulatory agency. Some regulations relevant to WMD preparedness are found in the Code of Federal Regulations (CFR) and include HAZWOPER (29 CFR 1910.120(q)), personal protective equipment (29 CFR 1910.132), eye and face protection (29 CFR 1910.133), and respiratory protection (29 CFR 1910.134). The Superfund Amendments and Re-authorization Act (SARA) Title I was enacted to require the Occupational Safety and Health Administration (OSHA) to enforce regulations for health and safety. OSHA 1910.120 describes the minimum level of knowledge, skills, and abilities that must be met by first responders. While not directly related to health care facilities, the National Fire Protection Association (NFPA) publishes standards for the fire service that define competencies for personnel responding to hazardous materials incidents. These documents can be useful in designing training programs for hospital preparedness. Finally, the National Institute for Occupational Safety and Health (NIOSH) works closely with the Center for Disease Control and Prevention (CDC) in developing regulations related to protecting health care workers from infectious diseases. Hospital planners must keep abreast of applicable codes, standards, and regulations to ensure that emergency plans and training programs meet minimum standards.
Establishing Regional Relationships
Hospitals are critical parts of the system that forms a community. As such, they are immersed with government, suppliers, law enforcement, emergency medical services, and the public health system—crossing the public, private, and nonprofit sectors. Effective emergency preparedness requires that hospitals create linkages across these sectors with the goal of insuring readiness for chemical, biological, radiological, nuclear, and explosive agents. For hospitals, the specific objective is to minimize the negative health consequences of an event while preserving the integrity and resiliency of the health care system. Preparedness takes place through a system of emergency planning, acquisition of support equipment and supplies, and training personnel in their response roles. There is a tendency to think of planning as an isolated task undertaken independently by each type of organization. Historically, hospitals have individually addressed issues such as mass casualty response, disease surveillance, patient tracking, and medication and immunization availability in an effort to achieve adequate facility preparedness. WMD incidents demand fuller participation in collective planning.
Fuller participation demands adopting a regional view of the plan process, the definition of the threat, and the determination of resources. Regional planning can help address capability deficiencies by establishing prearranged agreements for sharing of resources that—while adequate for everyday needs—may be in short supply during a terrorist event. Plans also need to be in place for internal and external communication. This communication is not just for emergency response; staff needs to be able to recognize diagnostic cues and understand how to report illness patterns to the public health system to identify disease patterns potentially caused by a terrorist action.
Local government fire and law enforcement organizations have long entered into voluntary mutual aid agreements to facilitate a rapid, coordinated, and effective response to large-scale incidents. Such agreements forestall situations that may overwhelm the resources of any single jurisdiction by establishing a formal relationship among signatories that set guidelines for sharing personnel, resources, and equipment. Regional imbalances are easily created by victim self-referrals to hospitals nearest the incident site, quickly overloading some institutions while others receive few patients. Hospital mutual aid systems allow for the systematic redistribution of patients and the sharing of medical or support staff, supplies and equipment, and pharmaceuticals. Regional preparedness through mutual aid should be considered a standard of care in the health care community.
Local governments and emergency management authorities have been engaging in intensive efforts to develop community wide terrorism response plans. After the 9-11 attack, hospitals were recognized as an integral component in local planning and response to terrorist events (General Accounting Office, 2003). Through participation in planning efforts, hospitals learn the expectations authorities have of them, while also educating officials on the capabilities and limitations of the regional health care system. Participation also creates linkages with local agencies that can support hospital operations during crises. The community planning process enhances hospital contacts with prehospital care providers and guides treatment protocols, enhances triage practices, and shapes patient load by identifying priorities for receiving hospitals. Additionally, planning committees are the place for dialogue about the need for specialized expertise and equipment such as patient decontamination and off-site treatment locations.
Finally, the ability of hospitals to respond effectively to a WMD event depends on establishing linkages to the public health system. Public health authorities serve as both a source of funding and information to address needs such as isolation, quarantine, evacuation, medications, treatment protocols, and long-term patient care. There are thousands of local health departments involved in disease outbreak investigations, vaccination campaigns, and environmental testing. Public health authorities possess legal power to order mass evacuation and immediately commandeer appropriate space to address patient surge capacity, receive and distribute federal medical assets, and conduct mass immunization. At the national level, the CDC maintains a stockpile of pharmaceuticals and provides assistance to public health departments for WMD incidents. Dialogue among hospitals, public health agencies, and other concerned organizations is an important path for addressing the long-term rehabilitation and health care needs of victims of WMD agents. Tracking of victims of the Bhopal chemical release, for example, required years of follow-up care. Given the special treatment needs of various agents, hospitals, rather than private physicians, will have to assume a significant role in long-term patient care.
Understanding Citizen Response to Terrorism
In the wake of a disaster, press coverage commonly focuses on stories of personal psychological incapacitation or isolated examples of social deviance. Such stories have given rise to a number of common myths regarding citizen responses to disasters, despite evidence to the contrary. Misconceptions about individual and group behavior during and immediately after the impact of a disaster lead many administrators to expect widespread panic, passive obedience to authority, or inaction due to emotional shock. Social science research has repeatedly shown that maladaptive behaviors rarely materialize. Individual behavior during the disaster period tends to be prosocial as well as rational. Myths of irrational and antisocial behaviors in disaster are not inconsequential; they hamper the effectiveness of planning efforts, lead to misallocation of resources, and cause officials to withhold critical information from the public. Research on human behavior provides a basis to predict and prepare appropriately for response to the immediate postterrorist incident period.
First, hospital emergency planners should expect patients to exhibit anxiety, not panic. Technically, panic is an acute fear reaction accompanied by a loss of self-control and analytic ability, often associated with flight behavior. Yet, past terrorist incidents have demonstrated that such reactions are extremely rare. Aguirre, Wenger, and Vigo (1998) studied the evacuation of the World Trade Center after the bombing in 1993 and found no documented incidents of panic flight. Similarly, after the terrorist attacks on September 11, 2001, thousands exited the burning towers in an orderly manner, with many examples of altruistic responses. In one instance, two men carried a wheelchair-bound woman to safety from the 68th floor of Tower 1 (Murphy & Levy, 2001). Although not common, panic flight in disaster situations is not entirely unheard of. When panic flight is observed, it appears to occur in only a small percentage of the affected population, lasts for a short period of time, and is a reaction to a number of simultaneously existing conditions. These include
(a) a perception of an immediate threat of entrapment;
(b) a belief in a lack of escape options, except through flight;
(c) a sense of complete social isolation, that is, there is no one else that can be depended on to help in a situation; and
(d) ineffective crisis management and a lack of communication. Providing direct, relevant information about the hazard and any actions people can take to protect themselves is the key to addressing anxiety. Withholding information only increases anxiety; it does not prevent panic.
While one can reasonably anticipate victim cooperation and action in the short run, the disaster syndrome can be extended, and traumatic responses are possible. Even posttraumatic stress syndrome and other difficulties can be manifest in psychological responses, particularly depression and sometimes “survivor syndrome.” The research literature shows that such long-term consequences are more likely to arise among: (a) people who have witnessed death or handled the dead; (b) people who have been exposed to large-scale property destruction; (c) people whose relatives, neighbors, or friends have been seriously injured or lost their lives. Particularly in terrorist events where victims often bear no obvious relationship to perpetrators, individuals experience long-term anxiety, guilt, and depression. Even in the absence of death of significant others or direct contact with death, loss of property and other negative economic consequences associated with it can produce depression. Hospital authorities need to plan for crisis-counseling capabilities for both victims and their families, as well as for nonvictim self-referrals (psychological casualties). Also, long-term postevent plans should include provisions for therapeutic contact as a means of reducing long-term negative consequences for citizens.
A second important observation for planners is to expect people to take action for their own protection. There have been documented cases of postdisaster shock behavior characterized by docility, disorientation, and disbelief. Termed the disaster syndrome, this reaction that immediately follows the disaster impact period has lead to the myth that victims will engage in irrational behavior and are unable to care for themselves. Three important conclusions have emerged from research on this issue. First, the disaster syndrome appears to occur most frequently in events that have little forewarning and result in severe damage, injury, or death. Second, only a relatively small percentage of the affected population will exhibit symptoms of disaster syndrome. Third, symptoms of disaster syndrome typically last only a few hours and do not extend beyond the immediate postimpact period. In general, researchers have found that people will take action to protect themselves during and following a disaster. Studies of individual actions following California earthquakes have documented the self-protective actions residents take as recommended by authorities (Bourque, Russell, & Goltz, 1993). It is therefore important that information provided by authorities include appropriate actions people can take to protect themselves. In the absence of such information, people will take action anyway—devising creative solutions that may turn out to be harmful. A well-developed public information strategy can enable positive adaptive behaviors and reduce anxiety.
Finally, it is appropriate for planners to expect victim compliance with direction and guidance. When dealing with unfamiliar situations or while under extreme stress, citizens often look to public authorities and experts—such as physicians, nurses, and emergency medical personnel—for protection and guidance. In the height of a crisis, citizens can be expected to carefully follow the direction of hospital staff. In March 1999, a collection agency received an envelope reportedly containing anthrax. While news helicopters hovered above, 10 women stood nude in an open-top corridor to be decontaminated by an all-male hazardous materials team. While one person brought up the issue of modesty, none of the women refused to comply with the instruction of emergency responders (Perry & Lindell, 2003). This incident illustrates the level of trust people have in authorities in times of crisis and the degree to which they will comply with instruction. It is important for hospital planners to remember that the demands created by terrorist incidents are dynamic, requiring an emphasis on response flexibility. Planning should focus on principles, not an elaborate process. Citizens will comply with the direction of authorities but they expect consideration, discretion, and competence, and they will hold authorities responsible through the political and legal process.
Important Planning Considerations
A terrorist attack is likely to involve a multiagency response and could involve mass casualties. Hospitals will need to coordinate planning efforts to maximize treatment capacity and capability. At a minimum, hospital planning for WMD events must promote effective communication and information sharing, coordination with other agencies, and distribution of resources.
Interoperable Communications and Information Management
External communications capabilities and effective information management are staples of a coordinated response to disasters, especially WMD incidents. Regional planning efforts should focus on establishing reliable, multimodal communication links with prehospital providers, assisting medical facilities, public health officials, and other relevant organizations. Hospital communications and data systems must also link with local and regional emergency operations centers. Individual modes of communication have all experienced problems in disasters, including overloaded cell phone systems, a lack of mobility and scalability of intercom systems, poor interoperability of radio communications and lack of availability of frequencies, and insufficient access to laptop computers with Internet connection for data exchange (Kenar & Karayilanoglu, 2004). Well-prepared regions employ a combination of systems with which to share data including e-mail, the Internet, radio, telephone, and fax machines. Such systems may be developed through regional planning efforts or purchased through commercially available systems.
Interoperability refers to the ability of emergency responders to communicate and work seamlessly via a myriad of voice and data systems. “Communications problems and the inability to coordinate with other disciplines and jurisdictions have been recognized as major operational limitations in every major incident, from the shootings at Columbine High School to the terrorist attack on the World Trade Center” (Pessemier, 2006, p. 2). Implementation of a unified command structure at the WTC was hampered due to a lack of interoperable communications between the FDNY, the New York Police Department, and the Port Authority of New York (National Commission on Terrorist Attacks, 2004). In 2004, 50% of local jurisdictions had no interoperable communications between their police, fire, emergency medical services, and public works departments, while 88% of cities were not interoperable with the U.S. Department of Homeland Security (U.S. Conference of Mayors, 2004). Yet, the “ability of an agency to execute its essential functions . . . is dependent upon the identification, availability, and redundancy of critical communications and information technology systems to support key government leadership, internal elements, other agencies, critical customers, and the public” (Federal Emergency Management Agency, 2004, p. 6). Preparedness plans must identify communications systems that directly support an agency’s essential functions, provide protection from disruption to primary channels of communication, and ensure sufficient redundant backup systems are in place.
Voice communications are one component of a comprehensive data communications system. Attention must also be paid to designing and using secure, standards-based Internet protocol architecture to ensure interoperability with data transferring information technology systems. Hospitals need to share data on the nature of the hazard and patient conditions, as well as the availability of beds, specially trained personnel, pharmaceuticals, and medical supplies. Many areas have established regional clearinghouses that fill a critical role as information management systems and serve as a point of contact for health care facilities for collecting and disseminating real-time information. An application of the regional clearinghouse concept is the St. Louis Area Regional Response System (STARRS). STARRS structures coordinated planning and response for large-scale critical incidents in the St. Louis metropolitan area. Components of the system include a Hospital Emergency Administrative Radio (HEAR) network (a VHF radio system), EMSystem (an Internet-based hospital status system), the Emergency Patient Tracking System, and routine communications (phone and fax). The concept and practice of STARRS are clearly important models for export to other areas.
Detection of a terrorist attack, especially one involving biological agents, is likely to be uncovered as unusual illness patterns appear in local hospitals. The CDC has developed two Internet-based communication tools for information exchange among public health entities (Masci & Bass, 2005). The Health Alert Network (HAN) was launched in 1999 in partnership with the National Associa-tion of County and City Health Officials, the Association of State and Territorial Health Officials, and others. HAN links a myriad of health service organizations critical to national health care preparedness and response through a high-speed, continuous, secure Internet connection. The system allows for distance learning through satellite- and Web-based technologies; provides an early warning system for broadcast of urgent health threats; allows local health authorities access to shared disease reports, response plans, and diagnostic and treatment guidelines; and allows for rapid communication and coordination of local, state, and federal health authorities during an incident (CDC, 2007b). Similarly, the Epidemic Information Exchange (EPI-X) is a secure communications network for public health authorities designed for surveillance and notification of urgent health care events. Since the network’s inception in 2000, approximately 6,700 reports have been posted to the site related to SARS, West Nile virus, influenza pandemic preparation, food-borne outbreaks, and natural disaster health-related issues (CDC, 2007a).
Clearly, the connection between hospitals and other critical disaster response organizations has yet to be optimized. The important principle here is to be aware that terrorist events require a highly coordinated response. The demands imposed by WMD incidents are immense and affect virtually all community institutions. No hospital can effectively operate independently during such an event; demands created by the complexities of the incident quickly outstrip capacity and capabilities.
Adopting a System for Managing the Incident
Management of emergency operations during a WMD incident demands a nontraditional linking of agencies. Following the terrorist attacks in New York City in 2001, the World Trade Center became not only a mass casualty incident but it was also a large fire, a crime scene, a public health hazard, and a national security event. Incidents involving WMD agents create confusion and chaos in the hospital setting that lacks an efficient and effective system for managing operations and coordinating the efforts of the various response agencies. A study of hospital management after an earthquake in Gujarat, India found that hospitals that utilized an Incident Command System (ICS) were better able to sustain medical service delivery both during and after the crisis (Bremer, 2003). JCAHO requires facilities that it accredits to adopt a command structure in coordination with local responders.
Hospitals differ from other critical community response entities in that they are autonomous facilities that lack a defined command structure or paramilitary-style hierarchy. Organizing and coordinating interfacility operations can be difficult using the traditional command model since these facilities may lack personnel with the organizational roles, functional responsibilities, or legal authority necessary for seamless integration into the ICS. Many health care facilities therefore are adopting a version of ICS that is tailored specifically to medical operations. The Medical and Health Incident Management System (MaHIM) is one such variation of the ICS and is intended to facilitate regional coordination of health care facilities. MaHIM was designed to be used as a toolkit providing broad-based management strategies and actionable items that can be used during a crisis. In addition to being an incident management system, MaHIM addresses specific operations problems presented by mass casualty incidents such as casualty distribution, patient tracking, and coordination and information sharing among facilities.
Perhaps the most common ICS system designed specifically for internal hospital use is the Hospital Emergency Incident Command System (HEICS). HIECS was built upon the principles of ICS and designed as an operational framework for hospital response to a variety of hazards. HEICS includes a core set of response concepts, procedures, and terminology that enables medical staff to fully integrate their activities with those of supporting agencies, such as the fire department, hazardous materials teams, and emergency medical services, as well as better manage the influx of self-referred patients, family members, and others who converge on medical facilities after an incident (Macintyre et al., 2000). The U.S. Occupational Safety and Health Administration (2004) considers HEICS a best practice for emergency preparedness. Fundamental elements of the system include a predictable chain of command with a flexible organizational structure, accountability of position and team function, and common terminology for promoting interagency communication.
Version IV of HEICS was published in August 2006 with support from the American Hospital Association, the U.S. Department of Homeland Security (DHS), and JCAHO. HEICS has evolved into the Hospital Incident Command System (HICS) and can play a major role in advancing institutional preparedness while integrating health care facilities into the local response system. This latest version is also consistent with many of the components of the National Incident Management System, mandated by DHS to promote national standardization in command and management structures, as well as place an emphasis on preparedness, mutual aid agreements, and resources management. HICS incorporates new operational tools to support hospital planning activities for a multitude of realistic events including epidemic, natural disasters, civil unrest, and acts of terrorism.
HICS includes the Job Action Sheet (JAS), a customizable incident management tool that is designed to familiarize users with critical aspects of their command position. Each of the 78 JAS forms include information regarding the name of the command position, graphic depictions of reporting relationships, a brief statement summarizing the mission and basic purpose of each job, and documents and tools to facilitate the completion of roles and responsibilities. The JAS forms provide a prescribed format and standardized terminology that ensure compliance with the National Incident Command System utilized by federal, state, and local responders.
Homeland Security Presidential Directive 5 (HSPD-5) created the National Incident Management System (NIMS). NIMS is intended to be an all-hazards system for coordinating public, private, and nonprofit assets during incidents of national significance. It is based on the established management characteristics of ICS, but also stresses multiagency coordination, public information systems, and elements generally associated with mitigation. HSPD-5 requires hospitals to comply with NIMS by August 2008 as a condition of receiving federal grants or contracts. The NIMS Integration Center in cooperation with the U.S. Department of Health and Human Services developed detailed guidance in the NIMS Implementation Activities for Hospitals and Health Care Systems to assist hospitals with implementation of NIMS.
Dealing With Patient Surge
A hospital’s capacity to manage a large influx of patients following any disaster is a critical element of preparedness planning. Surge capacity is the ability to mobilize, for a time-limited period, the availability of space and resources to provide medical care in response to sudden or prolonged demand (JCAHO, 2003). Planning for the sudden increase in demand for medical services also involves surge capability, the ability of the health care system to acquire specialized resources to manage patients with special needs, such as decontamination, treatment of burn injuries, or medical quarantine (Hick et al., 2004). Past natural and technological disasters have illustrated the need for surge capacity and capability. The worst chemical disaster on record occurred in Bhopal, India resulting in 150,000 casualties that needed treatment for exposure (Srivatsa, 1987). The sarin nerve gas attack on the Tokyo subway in 1995 produced 6,000 injured, many of whom bypassed emergency medical services and self-referred to local hospitals (Perry & Lindell, 2003).
Addressing an acute surge in health care needs is complicated by a trend toward decreasing inpatient care capacity and the nationwide shortage of skilled medical professionals. The expansion of managed care coupled with increasingly stringent Medicare and Medicaid reimbursement policies, has resulted in the closure or consolidation of hospitals. In 2002, there were 900 fewer hospitals than there were in 1980 (JCAHO). This has resulted in the loss of 38,000 hospital beds, including a 20% decline in ICU capacity (Hick et al., 2004). Furthermore, high numbers of uninsured people and a lack of availability of primary health care physicians have forced many to seek treatment of minor medical ailments in already overcrowded emergency departments. Biological and chemical agents also require more intensive treatment and observation of patients, which necessitates still more capacity and trained medical personnel. A severe nursing shortage, estimated to be 400,000 by 2020 (Buerhaus, 2000), jeopardizes the availability of critical, specialized medical treatment after a WMD event.
Unfortunately, no single framework exists to adequately prepare health care facilities for the inevitable patient surge that would accompany a nuclear, biological, or chemical attack. Hospital administrators must work with local disaster planning groups to develop surge plans based on the community’s Hazard Vulnerability Assessment and on the capabilities of the regional health care system. Fundamental components of such plans include the immediate deployment of additional health care personnel, patient decontamination, isolation capacity, medical surveillance, compatibility of equipment throughout the regional health care institution, adequate short-term pharmaceutical reserves, staff training and personal protective equipment, and interoperable communication and information-sharing technologies. Planning for surge capacity and capability requires a systems-based approach that builds from the individual hospital facility plan to integration into a local health care coalition, ultimately with the support of state and federal medical assets.
Establishing Facility Surge Capacity
JCAHO defines surge in place as the ability to expand capacity in an existing health care facility in order to meet the increased demand on a facility. This requires explicit planning in order to quickly expand patient capacity through restructuring of existing bed space and incorporating alternative on-site treatment areas. Strategies for increasing hospital bed availability include canceling elective procedures, adding more stringent triage and admission standards, and discharging inpatients early and providing follow-up home health care by professionals. Within 3 hours of the 2001 attack on the Pentagon, Inova Health System’s four hospitals in northern Virginia freed up 343 beds (nearly 25% of their capacity) and 43 operating rooms for immediate use (Hick et al., 2004). Another example of surge in place involves expanding operations into a closed ward of an existing facility; the Earl K. Long Medical Center in Baton Rouge effectively doubled its 200-bed capacity to treat victims of Hurricane Katrina by opening several closed wards within the hospital (JCAHO, 2006). Other accommodations can be made by incorporating “hasty treatment space” such as hallways, sheltered parking, meeting rooms, and office space. Under some circumstances where risk of contagion is low or patients are asymptomatic, quarantine of patients at home may be an option for increasing capacity.
Of course, expanding capacity requires adequate staffing with qualified personnel. The surge component of the hospital emergency operations plan should examine measures to effectively utilize hospital personnel for disaster duty, such as expanding work shift hours, calling back off-duty employees, adapting nonclinical staff to include clinical roles where appropriate, and developing rosters of private physicians with hospital privileges to call in during an emergency. On March 20, 1995, the St. Luke’s Hospital Emergency Department in Tokyo, Japan received 640 patients within two hours of the sarin gas attack on the city subway system. Buck (2002) found that 541 of those patients were self-referred having never been treated by emergency medical services workers at the scene. The hospital had previously conducted extensive disaster planning that included a contingency plan to address the needs of patient surge capacity and capability. St. Luke’s plan was implemented postponing routine surgical and outpatient procedures. This freed up over 100 physicians and 300 registered nurses and volunteers to handle the influx of patients from the terrorist attack.
Establishing Regional Surge Capacity
Planning for surge capacity and capability must extend beyond individual medical facilities to include an inter-organizational, multijurisdictional, and multidisciplinary work plan to adequately meet the health care needs and provide a safe environment for WMD victims. This process begins with taking an inventory of community assets and other resources, including alternate sites that can be quickly converted to treatment space. It is important to calculate expansion capacity based on accepted patient standards of care. Target surge capabilities established by the National Preparedness Goal call for 500 beds per 1 million patients with acute symptoms of exposure to infectious disease and 50 beds for patients with noninfectious diseases and injury. Effective joint preplanning can help identify alternative sites for adding capacity. JCAHO (2006) guidelines on surge hospitals identify some nonmedical buildings that can be used as “facilities of opportunity” such as warehouses, veterinary hospitals, convention centers, airport hangars, sports arenas, and hotels. Mobile medical facilities and portable “hospitals in a box” trailers are “fully equipped, self-contained, turnkey systems designed to be set up near mass casualty events to treat the most severely wounded as soon as possible” (p. 3). When traditional medical facilities become overloaded, nontraditional sites, often referred to as casualty collection points (CCP) or patient staging areas (PSA), may be designated to collect, triage, and begin initial prehospital treatment of victims (Buck, 2002). CCP and PSA sites aid in the control of patient flow to emergency departments and can be used to cohort patients with similar symptoms to the same medical facility as well as triage patients to facilities with appropriate specializations such as trauma centers, burn centers, or poison control hospitals.
The Center for Disease Control maintains a national repository of pharmaceuticals and medical materiel that includes antidotes, antitoxins, IV equipment, airway maintenance supplies, and medical and surgical items. The Strategic National Stockpile (SNS) program works with governmental and nongovernmental agencies to rapidly supplement local public health capabilities by delivering caches of medications and supplies to affected areas with 12-hour Push Packages that can be delivered anywhere in the United States within 12 hours of an event. As an incident progresses, Vender Managed Inventory packages begin to arrive within 24 to 36 hours brining in agent-specific medications and supplies. Once materiel has arrived at the designated receiving site, responsibility for logistical support for the collection, security, and distribution of the Strategic National Stockpile is the responsibility of state and local authorities. Plans for providing adequate staging space, trained personnel, and transportation of materiel must be prepared and exercised in advance of an incident to ensure prompt and effective use of SNS assets.
Surge capacity planning must also take into consideration the fact that WMD events involving NBC agents have the potential to create a high mortality rate. Deceased victims may continue to pose a significant public health threat due to an infectious disease or contamination hazard (Morgan, 2004). This requires that planners work with public health authorities and medical examiners to address the need to expand morgue facilities or establish temporary morgue space. Additional capacity will be needed to facilitate postmortem examinations, victim identification, and disposition of remains. Such procedures are needed to confirm the pathogen involved and inform treatments. Disaster mortuary response teams (DMORT) may be used to augment local medical examiners or establish field mortuary operations. The Federal Emergency Management Agency maintains two disaster portable morgue units in support of DMORT operations—one located in San Jose, California and a second in Rockville, Maryland. These units contain a fully equipped and stocked morgue and are capable of supporting autopsies with x-ray equipment, forensic dental pathology examinations, forensic anthropology studies, and finger print processing.
Protecting Staff, Patients, And Visitors
Emergency management plans must include procedures for preventing the spread of infectious disease, chemical residue, or radiological exposure to medical personnel, patients, and the community at large. Protective actions include universal precautions, decontamination, personal protective equipment, and hospital security.
The anthrax outbreak that occurred in the United States in the latter part of 2001 raised the specter of bioterrorism. Dissemination of the disease was through letters containing anthrax spores sent through the postal system resulting in 5 deaths and sickening as many as 22 others. Health care workers are particularly vulnerable to contagious diseases given that those infected will seek treatment in the emergency department and clinics. An illustration of this susceptibility is the SARS outbreak in China and Canada in 2003 where primary care physicians, nurses, and other health care professionals were among those who became ill along with civilian patients. To help prevent the spread of disease, hospitals need to establish policy that ensures that employees understand and follow appropriate infection control practices at all times.
Universal precautions and the higher level of protection, body substance isolation, are designed to protect health care workers from infectious diseases. Standard universal precautions generally involve the use of barrier devices such as disposable gloves, masks, goggles, and disposable garments. Increased levels of respiratory protection, such as the N95 mask, may require fit testing to ensure proper sizing, otherwise adequate protection may be lacking. Contract employees and janitorial services should also utilize disposable garments and follow proper contamination avoidance procedures to reduce exposure. Other elements of an effective infection control program include immunizations, patient isolation policies, decontamination procedures, proper waste handling and disposal practices, and continuous training. Hospitals must learn all they can about the risks brought on by a biological terrorism threat. This means working closely with prehospital providers, epidemiologists, public health officials, and emergency managers to develop standards and guidelines for the treatment and control of infectious disease outbreaks.
Decontamination is the process of removing potentially harmful or dangerous substances from people, equipment, or supplies in order to prevent the spread of contaminants beyond the already contaminated area and to avoid adverse health effects to unexposed persons and health care providers. It is extremely important that victims of WMD incidents, particularly those involving radiological or chemical materials, be decontaminated prior to treatment. Generally, hazardous materials responders will conduct decontamination procedures on scene before transporting patients to the emergency department. However, in some instances it may be necessary for EMS to quickly treat victims with life-threatening injuries while simultaneously conducting emergency decontamination procedures. “Gross” or “emergency” decontamination efforts are used to remove large quantities of contaminants from a surface. While this process significantly reduces the hazard of cross contamination, a more thorough decontamination of a victim may have to be done at the hospital. Furthermore, self-referred patients may carry residue of dangerous substances and need to be isolated and decontaminated before being seen in the emergency department.
Consequently, it is necessary for hospitals to establish procedures, train personnel, and acquire the equipment necessary to decontaminate patients. Both JCAHO and OSHA mandate that hospitals develop and maintain emergency response plans for dealing with hazardous materials incidents. These standards require that emergency departments maintain current toxicological reference materials and antidote information, a list of referral and consulting contacts, and equipment for handling hazardous materials. OSHA requirements under 29 CFR 1910.120[q] identify the need for training staff in the duties in which they are expected to perform.
Establishing decontamination capability requires the availability of special solutions, showers or spray nozzles with water containment, monitoring instruments, facilities to provide modesty, bags for the collection of personal items, and accommodations for both ambulatory and non-ambulatory patients. The specific measures required for decontamination will depend on the physical state of the agent involved, the water solubility or vapor pressure of the substance, and the level of contamination. Under IMS, the decontamination officer is responsible for determining the most appropriate decontamination procedure and managing the decontamination process. Assessing decontamination needs will require that medical staff contact field personnel for information about the degree and type of exposure encountered. A local poison control center may also be consulted about potential treatment protocols. Hospitals can contact the Chemical Manufacturers Association for information on exposure and treatments of specific chemicals. The National Response Center operates the Domestic Preparedness Chem/Bio Hotline for technical advice for dealing with WMD agents.
Personal Protective Equipment
Medical practitioners and hospital staff must be adequately protected from potential exposure to hazardous materials. Personal protective equipment (PPE) and garments are designed to shield individuals from the harmful effects of chemical, biological, and radiological residue as well as the physical hazards that might be encountered during a WMD event. The Department of Justice publication Guide for the Selection of Personal Protective Equipment for First Responders provides information to aid in the selection and purchase of respiratory and percutaneous PPE. While not held to the same standards as emergency services personnel, OSHA standards state that the hospital staff’s PPE be “sufficient for the type and exposure levels an employee can reasonably anticipate from such incidents” (Fairfax, 2002). An important consideration for planning is the selection of PPE based on the hospital’s role in response to WMD events and equipping employees for the worst-case scenario—exposure to NBC agents.
Providing for Hospital Security
Security not only directly protects the hospital facility, personnel, and patients, but also serves to define and separate functions, and forms an intelligence link with local law enforcement. Since few hospitals require a large security force, considerable planning is required with local law enforcement agencies to function during WMD incidents. In cities with metropolitan medical response systems, local police assist hospitals with crowd control and all security needs for off-site operations. Numerous law enforcement agencies may need to be represented in security planning, which needs to be done on a regional basis. Hospital security must be extended to all external activities (outside triage or decontamination) as well as to the institution itself. Coordination with local law enforcement is important both for ensuring adequate personnel levels, but also because the hospital becomes a link in the “chain of evidence” associated with the incident. This includes movement of patients between hospitals and movement of bodies to the county medical examiner’s office and morgue and any satellite or temporary morgue facilities.
The Importance Of Training And Exercising
Once a plan is established, its implementation revolves around the logistics and protocol required to execute the specified series of tasks. Implementation usually begins with a detailed assessment of the hospital’s capacity, defined in terms of its mutual aid support from the full range of regional organizations and governments. Agencies that provide different functions under the plan must be evaluated for their ability to comply. Personnel compliments and equipment need to be brought to plan specifications. In connection with or as a product of this assessment, a variety of training needs may be identified. These include both training and education of personnel regarding the threat, the response processes and procedures, as well as the use of the equipment called for under the plan. In this context, training is the activity that translates information defined as needed by the plan into a coherent program that can be imparted to responders.
Broadly speaking, exercises represent constructed opportunities to test the protocols and equipment specified under a plan and taught in the training phase. Exercises may be seen as a form of training in the sense that individuals are rehearsing response measures. Ultimately, however, exercises provide the forum to test the effectiveness of both the training program and the plan, as well as the ability of personnel to execute the plan. The creation of meaningful disaster exercises demands that the event test personnel, protocol, and equipment. Thus, developing an exercise requires the elaboration of milestones designed to simulate an event or incident that approximates the threat addressed in the planning and training phases. A critical initial exercise milestone is to set the objectives for the exercise. These may be broad or narrow, depending on the scope of testing that is desired. For example, in exercising a biological response plan for a smallpox agent, one might choose to devise an exercise built solely around testing the warning phase activity. Such an exercise scenario might involve tasks associated with evaluation of medical surveillance data by public health and hospital emergency department physicians, making a decision to evacuate or quarantine private homes and businesses, constructing a warning message, and notifying and mobilizing the agencies involved in disseminating the message to the public. Once testing or exercise objectives have been set, one must devise an event scenario. Such a scenario must posit an event or series of events that offer an opportunity for plan specifications to be implemented. In some exercises, the creation of the scenario is particularly intricate involving not only simulation of an event, but also including simulated victims and physical damage. The management of an exercise is somewhat similar to a major stage production in that there must be realistic actors and props and detailed stage direction (training). Often the utility of the exercise depends in part upon the extent that participants find the activity believable or compatible with their knowledge of potential events. Exercises are usually generated with specific goals and objectives that are carefully related to the vulnerability profile and planning activity of a given jurisdiction.
It is important to emphasize that no disaster management for any threat plan should be considered final. The planning process emphasizes that plans change as the threat environment changes, as changes occur in the state of technology relative to hazard agents, and as a function of experience with the response system (Perry & Lindell, 2007). The experience dimension is among the most important. Experience comes from exercises and from incidents. In every case, an exercise critique or after-action report becomes a document to guide change in the plan. In an even more critical sense, disaster responses are tests of the plan, and the operational system and like exercises should be followed by an after-action report. While exercises simulate response operations, when the system responds to a disaster incident, one sees the critical tasks and relationships tested in the stressful conditions under which the system was designed to perform. Thus, after-action reports associated with a disaster response become not only bases for adjusting and improving the local jurisdictional emergency system, but also valuable information that can be shared with other jurisdictions to communicate lessons learned.
Preparedness leads to successful management and it flows from effective planning, training, and exercising. This research-paper has assumed that the broader emergency functions such as vulnerability analysis, technical analysis of structural and nonstructural mitigation options, and organizational and technical feasibility reviews have been completed. Furthermore, we assume that a specific threat agent has been identified and a constellation of response measures have been taken. In this context, hospital emergency planning involves the construction and codification of strategy and tactics into an executable series of actions or tasks. Plans address all aspects of the response, including personnel, equipment, contingency issues, policy issues, and inter-organizational and intergovernmental relations. The plan represents, then, a blueprint for addressing all aspects of multiple WMD threats. Of course, this blueprint is created within the limitations of knowledge and technology regarding the threat agents and remains subject to situational contingencies.
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