Hospital Preparation for Bioterror (eBook)

Front Cover 1
Title Page 4
Copyright Page 5
Table of Contents 8
Contributor list 10
Preface 14
Acknowledgments 16
1. Recurring Pitfalls in Hospital Preparedness and Response 18
1.1 Introduction 18
1.2 Hospital Challenges and Constraints 18
1.3 Hospital Requirements 19
1.4 Observations 21
1.5 Communications 21
1.6 Security 21
1.7 Decontamination 22
1.8 Staff Training 22
1.9 Staff Protection 23
1.10 Exercise Design and Conduct 23
1.11 Suggestions 24
1.12 Communications 24
1.13 Security 25
1.14 Decontamination 26
1.15 Staff Training 27
1.16 Staff Protection 27
1.17 Exercises 28
1.18 Critical Steps 29
References 29
2. The History and Threat of Biological Weapons and Bioterrorism 34
2.1 Introduction 34
2.2 Biological Weapons in the Ancient World 34
2.3 Battlefield Use of Infectious Diseases, or "Giving The Gift That Keeps On Giving” 34
2.4 Biological Contamination of Water Supplies 36
2.5 Biological Contamination of Food 36
2.6 Toxin Weapons 36
2.7 World War I—German Saboteurs 37
2.8 World War I—US Research 38
2.9 World War II—Japan 38
2.10 World War II—Germany 39
2.11 World War II—United States 39
2.12 Post-WWII to Modern Era 40
2.13 Soviet Biological Weapons Program 40
2.14 US Biological Weapons Program 41
2.15 Aum Shinrikyo 42
2.16 Rajneeshees 42
2.17 St. Paul Medical Center, Dallas 43
2.18 Other Recent Bioterrorism Incidents 43
2.19 Biological Weapons and Countries Thought to Possess Them 44
References 48
3. Hospital Syndromic Surveillance 54
3.1 Hospital Inpatient Data 55
3.2 Hospital Emergency Department Data 57
3.3 Other Data Streams 58
3.4 Confirmatory Clinical Data 58
3.5 Pre-Diagnostic Clinical Data 58
3.6 Non-Traditional Health Indicator Data 59
3.7 Selection of Data Elements 59
3.8 Data Acquisition and Presentation 60
3.9 Data Analysis: Algorithms for Aberration Detection 60
3.10 Control Chart Usage 60
3.11 Issues in Aberration Detection 62
3.12 Upcoming Challenges in Hospital-Based Aberration Detection 62
3.13 Summary 62
References 63
4. Biological Agents, Effects, Treatment, and Differential Diagnosis 66
4.1 Disease: Anthrax 66
4.2 Disease: Botulism Intoxication 67
4.3 Disease: Plague 68
4.4 Disease: Smallpox 69
4.5 Disease: Tularemia 70
4.6 Disease: Viral Hemorrhagic Fever 71
4.7 Disease: Brucellosis 72
4.8 Disease: Glanders 72
4.9 Disease: Q Fever 73
4.10 Disease: Ricin Intoxication 74
4.11 Disease: Staphylococcal Enterotoxin B Intoxication 75
4.12 Disease: Trichothecene Mycotoxin (T2) Intoxication 76
References 76
5. Medical Considerations for Radiological Terrorism 78
Disclaimer 78
5.1 Introduction 78
5.2 Physics 80
5.3 Decontamination, Diagnosis, and Management 81
References 86
Radiological Casualty Related Websites 86
Appendix: Terrorism with Ionizing Radiation General Guidance Pocket Guide 86
6. Nerve and Chemical Agents 90
Disclaimer 90
6.1 Introduction 90
6.2 Nerve Agents 90
6.3 Cyanide 96
6.4 Vesicants 99
References 104
Suggested Comprehensive Resources 105
7. Decontamination and Personal Protection 106
7.1 Removal of Clothing 106
7.2 Skin Contamination 106
7.3 Training 108
7.4 Surgical Wound Decontamination 108
7.5 Site Security 109
7.6 Site Layout 109
7.7 Patient Identification 109
7.8 Certification of Decontamination 111
7.9 Personal Protection Equipment 112
7.10 Skin Protection 114
7.11 Conclusion 116
Appendix 7.1 117
Example 1. Vital Signs and PPE Checklist 117
Example 2. Vital Signs Monitoring Checklist 118
Appendix 7.2 Example of Patient Decontamination Procedure 119
Appendix 7.3 PPE Donning and Doffing Sequence 122
Appendix 7.4 Example of Technical Decontamination Process for Hospital Personnel 123
Appendix 7.5 Example of Integrated Procedures for First Receivers 123
References 133
8. EMS Preparation for Terrorist Events 136
8.1 Introduction 136
8.2 Preparation 136
8.3 Urban vs. Rural Preparation 136
8.4 Personnel and Training 137
8.5 Treatment Protocols 139
8.6 Patient Decontamination 139
8.7 Planning 141
8.8 Patient Transportation 142
8.9 Return to Service 143
Department of EMS Education, Hartford Hospital — Terrorism Protocols 144
References 150
9. Emergency Department Preparation 152
9.1 Introduction 152
9.2 Preparation 152
9.3 Planning 153
9.4 Patient Flow 153
9.5 Security 154
9.6 Notification of an Incident and Preparation to Receive Patients 155
9.7 Additional Preparation 156
9.8 Decontamination 157
9.9 Staff Needs 157
9.10 Post Incident Return to Normal Operations 158
References 159
10. Pediatrics: Special Considerations for Children 160
10.1 Introduction 160
10.2 Children: Special Vulnerabilities 160
10.3 Children and Agent-specific Vulnerabilities 165
10.4 Mental Health Considerations in Pediatric Victims of Terrorism 171
References 171
11. The Role of Psychiatry and Social Services in the Hospital Response to Bioterrorism 174
11.1 Introduction The Psychological Dimension of "Terror” in Bioterrorism 174
11.2 Management of Acute Traumatic Stress and Grief Reactions in Patients and Staff 178
11.3 Longterm Psychiatric Services in the Wake of Bioterrorism: After the Heroic/Honeymoon Phases 187
11.4 Conclusion 188
Acknowledgments 189
References 189
Appendix 11.1 For the Healthcare Professional: When Disaster Strikes 190
Appendix 11.2 Coping Effectively with Extreme Stress: Focusing 192
12. Bioterrorism and Obstetrics The Exposed Pregnant Patient 194
12.1 Introduction 194
12.2 Obstetrics Staff Training 194
12.3 Management of the Exposed Pregnant Woman 195
13. Operating Room Preparation for Mass Casualties 200
13.1 Introduction 200
13.2 Individual Preparation 200
13.3 Departmental Plan 201
13.4 Expansion of Capacity 204
13.5 Patient Flow and Infectious Considerations 204
13.6 Training Drills 206
13.7 Communications 207
13.8 Security/Crowd Control 207
13.9 Conclusion 207
References 207
14. Bioterrorism and Implications for Nurses and Nursing 210
14.1 Vulnerable Groups 211
14.2 Triage 212
14.3 Hospital Expansion 213
14.4 Summary 215
References 216
15. The Role of Pharmacy in Emergency Preparedness 218
15.1 Strategic National Stockpile 220
15.2 Staffing Concerns in a Crisis 221
15.3 Training and Participation of the Pharmacy Staff in Community Preparedness Efforts 222
15.4 Conclusion 222
References 222
16. The Clinical Engineering Department Role in Emergency Preparedness 224
16.1 Lessons Learned 225
16.2 Priorities 226
16.3 Incident Command System 226
16.4 Communications 226
16.5 Departmental Staff Care 227
16.6 Individual Preparedness 228
16.7 Departmental Preparedness 228
16.8 Vendor Preparedness 231
16.9 Business Resumption Planning 232
16.10 Departmental Response 232
16.11 Putting it all Together 234
Appendix: Disaster Action Sheet Normal Work Hours Hospital Clinical Engineering 234
References 235
17. Amateur Radio Support for Hospitals 236
Executive Summary 236
17.1 What is Amateur Radio? 236
17.2 What Motivates “hams” to Volunteer their Time, Skills, and Equipment? 237
17.3 External Hospital Communications 237
17.4 Redundant Systems and Pathways 239
17.5 Where can a Hospital or Healthcare System Find Amateur Radio Resources? 240
17.6 Hospital Disaster Plan 241
17.7 Summary and Conclusions 241
References 244
Additional Resources 244
18. Hospital Power: Critical Care 246
18.1 Code Required Systems 246
18.2 Recommended Systems 247
18.3 HVAC System Impact on Generator Size 247
18.4 What can Happen during the Loss of Normal Power 248
18.5 Alternate Cooling Strategies 248
18.6 Emergency Generator Coordination 249
18.7 Commissioning 249
18.8 Conclusion 249
19. Electromagnetic Interference 250
19.1 Overview of EMI 250
19.2 Intentional EMI 252
19.3 Mitigation 252
19.4 Summary 255
References 256
20. Chapter for Simulation for Bioterrorism 258
20.1 Introduction to Simulation 258
20.2 History of Simulation 258
20.3 Adaptation of Simulation to Medicine 260
20.4 Basic Elements of Simulation Education 261
20.5 Post-Simulation Period: Debriefing and Reflection 263
20.6 Crew Resource Management 264
20.7 Moulage vs. Mannequin Training 266
20.8 Medical Professionals: Little Things Mean a Lot 266
20.9 Simulation Drills for Bioterrorism 267
20.10 Conclusion 268
References 268
21. Simulation II: Preparing for Biodisasters 272
Disclaimer 272
Objectives for the Reader 272
Key Words 272
21.1 Audience 272
21.2 Premise 272
21.3 Unique Contribution of Simulation 272
21.4 Scenario Resources 273
21.5 Scenario Creation 275
21.6 Scenario Examples 275
21.7 Example 1: Clinical Students 276
21.8 Example 2: Non-clinical Students 278
21.9 Example 3: Clinical and Non-clinical Students 280
21.10 Summary 282
Reference 282
Resources 282
22. Hospital Large-Scale Drills 284
22.1 Introduction 284
22.2 Hospital Drill Planning 285
22.3 Decontamination 291
22.4 Drills 293
22.5 Conclusion 294
References 296
23. Response to SARS as a prototype for bioterrorism: Lessons in a Regional Hospital in Hong Kong 298
23.1 Introduction 298
23.2 Recognition of an Impending Outbreak in Hong Kong 298
23.3 Recognition of the Outbreak in PYNEH 299
23.4 Response at the Emergency Room Level 300
23.5 Response at Ward and Department Levels 300
23.6 Response at Hospital Management Level 306
23.7 Further Response at Hospital Authority Head Office (HAHO) Level With Direct Impact on the Department 308
23.8 Outbreak Resolution 309
23.9 Aftermath 309
23.10 Conclusion 309
References 309
Appendix A: Emergency Preparedness, Response & Recovery Checklist Beyond the Emergency Management Plan
I. Introduction 312
II. Incident Command (Orange) 315
III. Operations (Red) 320
IV. Planning (Blue) 331
V. Logistics (Yellow) 335
VI. Finance (Green) 338
VII. Recovery: Ending Emergency Operations 342
VIII. Selected Resources 343
Appendix A.A Application of EMTALA During a Major Public Health Emergency 343
Appendix A.B Risk-Management Considerations 345
Appendix A.C Securing Disaster Funding 346
Appendix A.D Directories of State and Territorial Public Health Directors, State Public Health Legal Counsel, and CDC Emergency-Preparedness Contacts 348
Appendix A.E Selected Public Health Emergency-Preparedness Standards and Plans 348
Appendix B: Model Hospital Mutual Aid Memorandum of Understanding 350
I. Introduction and Background 350
II. Purpose of Mutual Aid Memorandum of Understanding 350
III. Definition of Terms 351
IV. General Principles of Understanding 352
V. General Principles Governing Medical Operations, the Transfer of Pharmaceuticals, Supplies or Equipment, or the Evacuation of Patients 353
VI. Specific Principles of Understanding 354
Appendix B.1: Primary Data Collection Form 358
Appendix B.2a: Secondary Data Collection Form 359
Appendix B.2b: Secondary Data Collection Form 360
Appendix C: Protecting Building Environments from Airborne Chemical, Biological, or Radiological Attacks 362
Scope 362
Background 363
Preparatory Recommendation—Know Your Building 363
Specific Recommendations 364
Conclusions 372
For Additional Information 372
Appendix C.A Interagency Workgroup on Building Air Protection 375
Appendix C.B Research Team on Building Vulnerabilities 375
Appendix D: Develop a Mitigation Plan (FEMA) 376
Overview 376
Step 1: Develop Mitigation Goals and Objectives 376
Step 2: Identify and Prioritize Mitigation Actions 377
Step 3: Prepare an Implementation Strategy 383
Step 4: Document the Mitigation Planning Process 383
Appendix E: Medical Examiner/Coroner Guide for Mass Fatality Management of Chemically Contaminated Remains 386
Managing the Incident Site 386
Resource Management 387
Remains Processing 388
Additional Coordination 390
Websites 390
Appendix F: Systems and Communications Security During Recovery and Repair 392
Security and Recovery Basics 392
Security During Backup 395
Prevention During Recovery 395
Security During Recovery 395
Security During Repair and Correction 397
Recommended Course of Action 398
Appendix G: Altered Standards of Care in Mass-Casualty Events 400
Executive Summary 400
Chapter G.1 Introduction 403
Overview 403
Chapter G.2 Health and Medical Care Delivery in a Mass-Casualty Event 405
Health and Medical Care Standards in the Context of a Mass-Casualty Event 405
Hypothetical Scenarios Illustrating Changes in the Delivery of Care in Response to a Mass Casualty Event 406
Changes in Care Delivery Common to Two Scenarios 406
Chapter G.3 Framework and Guiding Principles When Planning for Health and Medical Care in a Mass Casualty Event 410
Framework 410
Guiding Principles for Developing Altered Standards of Care to Respond to a Mass Casualty Event 410
Chapter G.4 The Larger Context: Important Related Issues 413
The Authority to Activate the Use of Altered Standards of Health and Medical Care 413
Legal and Regulatory Issues 413
Financial Issues 417
Communicating with the Public 417
Ensuring an Adequate Supply of Health Care Providers 418
Provider Training and Education Programs 418
Protection of Health Care Providers and Facilities 419
Caring for Populations with Special Needs 420
Transportation of Patients 421
Chapter G.5 Recommended Action Steps 422
Step 1: Develop general and event-specific guidance for allocating scarce health and medical care resources during a mass casualty event 422
Step 2: Develop and implement a process to address nonclinical issues related to the delivery of health and medical care during a mass-casualty event 422
Step 3: Develop a comprehensive strategy for risk communication with the public before, during, and after a mass casualty event 422
Step 4: Identify, analyze, and consider modification of Federal, State, and local laws and regulations that may affect the delivery of health and medical care during a mass casualty event 423
Step 5: Develop means for verifying credentials of medical and other health personnel prior to and on-site during a mass casualty event 423
Step 6: Create strategies to ensure health and medical leadership and coordination for the health and medical aspects of system response during a mass casualty event 423
Step 7: Continue and expand efforts to train providers and others to respond effectively in a mass casualty event 424
Step 8: Develop and support a research agenda specific to health and medical care standards for mass casualty events 424
Step 9: Develop a community-based planning guide for mass casualty care 425
Step 10: Identify and support states, health systems, and regions to develop mass casualty and health and medical care response plans based on the Planning Guide and to share their results widely 425
Appendix G.A Final Participant List: Expert Meeting on Mass Casualty Medical Care 425
Appendix G.B Preliminary Review of Selected Emergency Response Protocols and Models 428
Modular Emergency Medical System 428
References 429
Appendix H: Surge Hospitals: Providing Safe Care in Emergencies 430
Executive Summary 430
Introduction 430
Using surge hospitals to respond to emergencies 431
Planning for, establishing, and operating surge hospitals 433
Other issues to consider 437
Ensuring that long-term surge hospitals offer safe care 439
Possible development of Joint Commission standards for surge hospitals 440
Case studies 441
Closing Comment 447
References 448
Appendix I: Medical-Surgical Supply Formulary by Disaster Scenario 450
Background 450
Medical/Surgical Supply Formularies 450
Considerations for Materials Management Professionals 450
Index 454