Bioterror drills show need to revise emergency preparedness plans
Whatever you did to satisfy the Joint Commission probably isn’t enough
Many quality and peer review professionals started wondering about the real-life effectiveness of their emergency preparedness plans after the Sept. 11 terrorist attacks, and a recent bioterrorism drill confirms the need to revamp a plan that has been on the shelf for a while. Bioterrorism threats pose unique challenges that probably weren’t included in your plan, even if the Joint Commission on Accreditation of Healthcare Organizations gave it an A-plus.
When McAlester (OK) Regional Health Center participated in a communitywide bioterrorism drill, hospital leaders found that previous plans for disasters were inadequate. So many aspects of a bioterrorism attack are different from a tornado, earthquake, or plane crash, that you probably will need to revamp your plan, says Jackie Turnbull, FNP, a family nurse practitioner and the hospital’s director of emergency preparedness.
McAlester’s disaster plans have always received high marks from the Joint Commission, she says, but that’s not enough for today’s challenges.
"We’re taking another look at our plan, and the drill showed us lots of ways we could improve it," she says. "Most hospitals are just not set up to treat bioterrorism, so it’s not really covered in the plans. A bioterror attack is so different from the usual scenarios we plan for, partly because you have to keep people away as much as you take patients in for treatment."
Turnbull’s hospital participated as part of a three-day bioterrorism drill in the community, one of the most complex drills of its type ever undertaken.
The drill began with an airplane buzzing the city to simulate spraying a biological agent over the town of 18,000. About 10,000 people participated in the drill — including the hospital, local military and municipal authorities, and many members of the public. The drill was planned months in advance, and the entire community was urged to play along.
According to the scenario, 95% of the population was infected with the pneumonic plague, and 120 people had died by the second day. Boy Scouts were recruited to play patients and taken to the hospital for treatment. In addition to treating patients at the hospital, McAlester had to aid the local health department in providing prophylactic antibiotics to everyone in the community. Nearly 700 volunteers handed out 10,000 packets of jelly beans and 1,000 pediatric juice doses, simulating the medication, to members of the public. In addition, the hospital had to administer preventive medicine to its own staff and to public safety officers to keep them healthy and able to continue in the drill.
Bioterror very different from tornado disaster
The drill went well, Turnbull says, though it highlighted some important problems that the hospital will address. McAlester treated 77 patients in 1½ hours, representing infected soldiers from a nearby military base. She says some of the most important lessons that will be incorporated into a revised emergency preparedness plan include:
• Your emergency department (ED) may not be the best place to start.
Most emergency preparedness plans focus on the ability to treat a large influx of patients in the ED, but bioterrorism turns that scenario upside down. If there is an infectious agent in the community, you will want to keep most people away from your main facility so that it can be a "safe" area for patients and workers alike.
McAlester used an ambulatory surgery center as its intake center, where patients could be triaged and (in theory) decontaminated before moving them on to the hospital proper. The ambulatory surgery center is on the hospital campus but physically separate, making it the ideal location for a bioterror intake center.
• Bioterrorism creates huge security concerns for your facility.
In a bioterror event, people may flock to your facility for preventive medications and for treatment once they are infected. This also is very unlike a typical disaster scenario. And if the entire community is in crisis, you may be on your own for security needs.
"If something really happened, the police and fire department are going to be busy, so we had to plan to be on our own for anything we were doing," she says. "We brought in our maintenance people for added security and put up barriers around the campus. That was all new to us. We’ve never had to shut down the hospital, but you can’t let contaminated people into your hospital."
• Decontamination is a new concern.
Decontamination of people exposed to the bioterror agent may be necessary before you can allow people into the hospital. Some emergency preparedness plans may call for the local fire department to decontaminate people in hazardous materials incidents, but the fire department may be too busy in a bioterror attack. Turnbull says McAlester is planning to buy its own decontamination equipment.
• Dispensing medication may strain your resources.
For a communitywide bioterror attack, your hospital may be called on to dispense prophylactic medications to the public — something else that you probably haven’t planned for if a tornado is the more likely disaster in your area. McAlester also had to dispense 7,000 doses of simulated medicine to its own employees and family members the night before treating the public.
• Morgue preparations might be inadequate.
The number of dead in a bioterror attack could far exceed casualties expected from a natural disaster or other type of emergency. It might be necessary to make additional preparations for the storage of bodies.
"In rural Oklahoma, we have a tiny little morgue. If you had 50 dead bodies, they would fill up our morgue and every funeral home in town," Turnbull says. "Do you have a plan for what to do with 500 bodies?"
McAlester has an agreement with a local food supplier to send refrigerated trucks to the hospital in any disaster for the possible storage of bodies.
• You might have to transfer patients from the hospital.
If you end up treating a large number of bioterrorism patients, you may have to transfer other patients to open up bed space. McAlester phoned other institutions to arrange transfers and simulated moving patients out.
At least one staff person should be dedicated solely to the task of arranging transfers and keeping records of moved patients, Turnbull says.
• Coordination of staff is key.
McAlester found that it had plenty of physicians and nurses at the intake center to triage and treat patients, but too often, the physician’s instructions were not carried out promptly. The problem was that the nurses were moving about too much and no one was directly responsible for the physician’s orders.
"Next time, we will have nurses dedicated to each treatment station, not moving around wherever they think they’re needed," Turnbull says. "And we’ll have a nurse partnered with each physician, going wherever he or she goes."
Some expense, but drill worth the effort
The McAlester drill was very realistic and worth all the effort put into it, Turnbull says. The drill cost the hospital a considerable amount of money, mostly for the 70 extra employees called in for the "disaster" and paid overtime. After the drill in McAlester, similar exercises were held in Tulsa, OK; Lawton, OK; and Detroit.
Even more realistic tests took place at the Uni-versity of Utah during the period encompassing the 2002 Olympic and Paralympic Winter Games. One night during the Olympics, University of Utah physician Per Gesteland, MD, received an automatic alarm signal through his pager. He rushed to his home computer, worried about the possibility that a disease outbreak was under way or that terrorists had released biological weapons.
After using a secure computer connection to check graphs and maps depicting where disease symptoms were being reported by county and by zip code, Gesteland knew within minutes that the incident was a false alarm.
The alarm was triggered when the number of daily viral infections seen at acute-care clinics reached seven, just slightly above the alarm threshold of 6.69 expected cases per day.
Another alarm was traced to the number of patients seeking treatment for bleeding. The number of bleeding patients — whether bloody noses or rectal or vaginal bleeding — reached 33 in the seven counties within a 24-hour period. That triggered the alarm because it was somewhat above the expected level of 29.34 cases. At its worst, a sudden jump in bleeding cases might reflect a bioterrorism attack using the deadly Ebola virus.
Gesteland says the sporting events provided a good test of the system he monitored — a system named Real-Time Outbreak and Disease Surveil-lance (RODS).
"If you’ve got a lot of people in the community getting sick at the same time with the same thing, this system will see it," says Gesteland, who is a National Library of Medicine fellow and graduate student in medical informatics at the University of Utah.
Reed Gardner, PhD, the university’s medical informatics chair, explains that RODS automatically collected data in real time on about three-fourths of all patients visiting acute-care facilities in Salt Lake, Summit, Utah, Davis, Weber, Morgan, and Wasatch counties.
The facilities included nine EDs and 19 acute-care clinics run by Intermountain Health Care, plus the ED at University Hospital and the polyclinic that served athletes and their families staying at Olympic Village on the university campus.
RODS tracked the total number of acute-care visits, plus seven types of symptoms: viral (such as sore throat, muscle aches, and fever without other symptoms), respiratory (such as coughing and shortness of breath), encephalitic (headaches, dizziness, and delirium), diarrhea, rash, bleeding, and botulinal symptoms (drooping eyelids, difficulty speaking, and other neurological symptoms that could indicate botulin toxin poisoning).
As usual, staff members at the acute-care facilities recorded each patient’s name, account number, age, sex, birth date, and primary complaint or symptom. But instead of staying solely within each facility’s computer system, the data also were sent automatically to the University of Pittsburgh Medical Center, where physician Michael Wagner and colleagues developed RODS. There, the data were processed, triggering an alarm if the number of cases of any symptom exceeded what normally would be expected.
Negotiations required
Each time an alarm went off, Gesteland’s role was to examine computerized details, then consult by e-mail and phone with the RODS Technical Advisory Group, which included Gesteland, Rolfs, or another Utah Department of Health official, a Pittsburgh researcher, and a local health department official from the county where the alarm was triggered.
If there had been a real disease outbreak or bio-weapons attack, the Technical Advisory Group would have reported within two hours to a Policy Advisory Group — a team of officials who would have decided how best to respond.
It took only a week to set up computer and communications equipment and software so the various acute-care facilities could share the data they normally collected anyway, Gesteland says.
According to Gardner, a good deal of negotiating was required to discuss privacy and other issues before the University of Utah, Intermountain Health Care, and state officials agreed to share patient information.
"We dealt with this by having secure communications, legal agreements between institutions, and having secure access to databases and only authorized access," he says.
[For more information, contact:
- Jackie Turnbull, FNP, McAlester Regional Health Center, One Clark Bass Blvd., McAlester, OK 74501. Telephone: (918) 426-8166.
- Per Gesteland, MD; Reed Gardner, PhD, Department of Informatics, University of Utah, Salt Lake City, UT 84112 (801) 581-7200.]
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