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VOLUME
II NUMBER
II April, 2004
"Hospital
Security News" is SAI’s quarterly newsletter dedicated to helping
hospitals identify and manage their security risks, recognize organizational
strengths and weaknesses in physical protection and improve the personal
security of patients, staff and individuals that use their facilities. This special edition features an article on
hospital bioterrorism preparedness written by SAI for Larry Anderson, Editor of
‘Access Control & Security Systems’ magazine.
To receive a free copy of Hospital Security News, please write to:
newsletter@saione.com. If you would like to contribute your personal
experiences, please write to Pam Carter, RN,
“Bioterrorism:
Are Hospitals Our Weakest Link?”
Hospitals play an essential role in community preparedness for terrorism and other hazards, both natural and manmade. Even prior to 9-11 hospitals were judged to be a weak link in community disaster preparedness, especially for incidents involving patients contaminated with nuclear, chemical or biological agents. Terrorism preparedness efforts of the past two years have identified significant obstacles that have made hospitals reluctant to partner with communities thus creating ineffective response. With the expenditure of considerable federal resources to develop and test community-wide mass casualty response plans, many of these obstacles are being addressed. The hospital’s link in terrorism preparedness chain is getting stronger, but many obstacles remain.
Hospitals have developed and exercised Emergency Preparedness Plans (also called “disaster plans”) for as far back as anyone can remember. Early plans covered a range of natural and manmade disasters, but did not include preparation for mass casualties due to terrorism. In the mid-1990’s hospital preparedness plans followed the broad, national requirements imposed by FEMA, HHS, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) with more than 100 other government agencies sharing various levels of preparedness responsibility. Hospitals were given a broad preparedness mandate summarized by this general statement of expectations:
“The hospital must have an emergency
preparedness system for managing the consequences of power failures, natural
disasters or other emergencies that disrupt the hospital's ability to provide
care.”
JCAHO requirements applied specifically to accredited hospitals ranging in size from small rural facilities to large urban medical centers. JCAHO pre-9/11 preparedness standards focused on four areas:
·
Emergency
preparedness management plan
·
Security
management plan
·
Hazardous
materials and waste management plan
·
Emergency
preparedness drills
Hospital disaster planning, included planning for nuclear accidents and incidents, has been on going for decades at all levels of government. This planning was done without provision for mass casualties due to acts of chemical or biological terrorism. But even before 9/11 this was beginning to change.
In January 2001, the Joint
Commission revised their existing standard to require an “all-hazards” approach
to disaster preparedness that embodied the four traditional phases of emergency
management (mitigation, preparedness, response and recovery). Acts of chemical and biological terrorism
certainly qualified for preparedness planning under the new “all-hazards”
approach. However, only a small
percentage of the nation’s 6,000 hospitals had worked to achieve a reasonable
state of readiness prior to 9/11. The
reason is understandable. Acts of
terrorism in the
Immediately after 9/11 hospitals scrambled to include terrorism in their vulnerability analysis. They contacted community organizations, public health departments, and emergency services to help them incorporate a terrorism element into their “Emergency Management Plan”. Tabletop drills and planning for full-scale, community-wide mass casualty exercises began in earnest.
Federal, State
and local governments mobilized to fight terrorism on all fronts. The “Office of Homeland Security” was
established within White House to provide a unified homeland security
structure. Legislation to create the
Department of Homeland Security (DHS) was singed into law on
In February of 2002 the American Hospital Association (AHA) sent surveys to approximately 5000 hospitals asking them to assess their readiness to handle a terrorist attack. Out of the 1,700 hospitals that responded; 69% had already incorporated a bioterrorism response into their disaster plans, 28% expected to do so within the next 12 months, 77% had established a terrorism component and 20% anticipated adding a terrorism component within the year. Over three quarters (78%) indicated that financial resources limited their ability to establish additional safeguards.
Government responded. By June 2002 – HRSA (Health Resource and Services Administration), a branch of the Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) had issued grants totaling $182 million to the 50 states and several cities. The goal of this grant funding was to achieve “17 critical benchmarks for bioterrorism preparedness planning.” Fourteen benchmarks were overseen by the CDC and related to public health preparedness. The three benchmarks under HRSA purview related to hospital preparedness.
- Designate a Coordinator for
- Establish a Hospital Preparedness Planning
Committee to provide guidance, direction and oversight to the State health
department in planning for bioterrorism response.
- Devise a plan for a potential epidemic in each
state or region. Recognizing that many of these patients may come from
rural areas served by centers in metropolitan areas, planning must include
the surrounding counties likely to impact the resources of these cities.
In total, the DHS and HHS spent $3.01 billion in FY 2002 to fund all of the various components for bioterrorism terrorism preparedness nationwide. This was a 10-fold increase over $305 million spent in FY 2001. Total bioterrorism funding was $4.4 billion in FY 2003, and FY 2004 is projected to be $5.2 billion. (See: Graph #1)
As related to hospital preparedness, these expenditures have been used to:
·
upgrade infectious
disease surveillance and investigation
·
enhance the
readiness of hospitals and the health care system to deal with large numbers of
casualties
·
expand public
health laboratory and communications capacities
·
improve
connectivity between hospitals, and city, local and state health departments to
enhance disease reporting
·
strengthening
public health preparedness to address bioterrorism, outbreaks of infectious
diseases and public health emergencies
·
conduct readiness
assessment
·
dissemination
health information, provide education and training, and smallpox preparedness
planning
·
develop surge
capacity to deal with mass casualty events, including the expansion of hospital
beds, development of isolation capacity, identifying additional health care
personnel, establishing hospital-based pharmaceutical caches, and providing
mental health services, trauma and burn care, communications and personal
protective equipment
Have these funds been used effectively? In the middle of 2002 a General Accounting Office survey of more than 2,000 urban hospitals found that four out of five of the hospitals surveyed had a written emergency response plan that addressed bioterrorism, but most plans omitted key information such as contact number for local laboratories. Also evident was the lack of regional and statewide coordination in major disaster drills and exercises. Fewer than 50% of the hospitals surveyed had conducted drills or exercises simulating a response to a bioterrorism incident. The majority of hospitals surveyed from May to September 2002, revealed that they also lacked medical equipment that would be essential for an influx of mass casualties. Oral comments by representatives of the American Hospital Association (AHA) show they generally agreed with the GAO findings.
Several notable exceptions to
the general lack of county-wide terrorism exercises took place in 2002 with
large-scale simulations taking place in
- Participate in a Community-wide Disaster Drill
- Receive and Track Mass Casualties
- Decontaminate and process victims
- Provide Personal Protective Equipment
- Provide facility and staff with Safety &
Security
- Provide equipment and training for hospital &
staff
Post exercise findings and
follow up were extremely helpful in identifying strengths and weaknesses in
Even today, as vital as these
exercises are to effective preparation, a large percentage of hospitals are
still only in the planning stage. They
have yet to participate in a community-wide or regional major disaster
exercises. Recently completed disaster
exercises as well as the actual responses to disaster events across the
Recurring problem areas are:
- Communications
- Hospital security
- Decontamination procedures, equipment, and
training
- Exercise realism, content and follow-up
- Lack of specific benchmarks for hospitals to use
in planning
- Specific directives from State Hospital
Bioterrorism Preparedness Planners
Systemic obstacles within the healthcare industry itself also limit a hospital’s ability to prepare effectively in some of the critical ways necessary to fully meet terrorism threats.
Systemic obstacles that affect the majority of hospitals:
·
Enormous
downsizing as a result of “Managed Care”
·
Competitive
pressures to cut cost
·
Just-in-time
pharmaceutical supplies and staffing practices
·
Limited capacity
of certain specialty services
·
Approximately 30%
of
·
Staffing
shortages across a wide range of skill levels and specialties
By definition, mass casualty incidents will overwhelm the resources of individual hospitals. The ability to mount an effective response will depend on the nature and magnitude of the event. Multiple events that may also disrupt communications and utility services or require evacuation of hospital facilities must also be considered. To be effective any response will require a high level of coordination among first responders and emergency personnel. Depending upon circumstances, a coordinated local response may be sufficient for community recovery. In worst case scenarios, the coordinated response would be statewide, regional or even national.
From an individual hospital’s perspective the staff and equipment required to respond effectively to a terrorist attack generating mass casualties are far greater than what are needed for everyday performance. Equally important, a mass casualty incident is likely to impose a high sustained demand on health services rather than the customary short, intense peak associated with smaller scale disasters. Hospital staff themselves must also be protected from chemical or biological agent(s). This adds another dimension of complexity for hospital preparedness planners.
Terrorism preparedness is expensive and hospitals are reluctant to create capacity that is not needed on a routine basis and may never be used. In addition, along with a hospital's ability to meet the routine needs of the community, the need for additional capacity to respond to bioterrorism emergencies must be balanced with the need to be prepared for all types of emergencies. Terrorism events still earn a low priority rank in most hospital vulnerability assessments (HVA). None-the-less, hospital officials recognize that their facilities are an essential component of our nation's terrorism preparedness, and they are planning and training to increase their response capacity.
Most hospitals, however, still lack equipment, medical stockpiles, and quarantine and isolation facilities for even a small-scale response. Respirator isolation beds and burn units could very easily become critical should a biological /chemical terrorist attack occur. Not only is availability of equipment a problem, hospitals have to take into consideration the potential cost that would be incurred, as well as the need for preparatory investments, which may not be reimbursed after a crisis is over.
None-the-less, hospitals are expected to have an adequate supply of personal protective equipment (PPE) and clothing on-hand that includes:
·
Gloves, gowns,
HEPA masks (OSHA/NIOSH – approved high efficiency particulate
·
Goggles, shoe
covers (available in all sizes), enough inventory for frequent changes.
·
Fit-Testing for
all employees
·
Level B
protection (for front-line employees and custodial staff
·
Self-contained
breathing apparatus w/ positive mode
·
Hooded, 2-piece
chemical resistant suits
·
Chemical
resistant gloves and boots
Healthcare facilities must also comply with myriad government regulations related to patient safety standards promulgated by OSHA and the EPA as well as track and follow mandates, guidelines and directives from the FDA, CDC, HIPPA and others. Accredited hospitals must also demonstrate adherence to a diverse set of non-governmental standards during periodic surveys by the Joint Commission.
Hospitals are also required to provide regular “in-service” training programs and readiness drills for their terrorism preparedness plan. All these practices are expensive and hospitals can end up losing money preparing for an event that may or may not occur. Cash-strapped hospitals faced with the choice between purchasing a piece of much needed medical equipment, or having to buy bioterrorism preparedness equipment for an event that may never happen, are faced with a difficult dilemma.
Summary:
Many obstacles
and challenges facing American’s hospitals have been identified as preparation
continues for possible catastrophic acts of terrorism. Solutions to overcome them are being studied,
tested and implemented at an increasing rate.
States have completed the 3 critical benchmarks for hospital bioterrorism
preparedness mandated by HRSA in their hospital preparedness grant
program.
Total
government terrorism preparedness funding continues to increase. Funds for hospital preparedness are being
directed towards overcoming the obstacles of communications, security,
decontamination procedures, equipment, and training and realistic exercises
with follow-up.
HSS Secretary
Tommy Thompson stated the following on
“The contrasts between what we were doing a few years ago and what we’re
doing today is absolutely striking. The
amount that HHS spends on bioterrorism preparedness is absolutely 12 times as
much as three years ago. We’ve gone from
$300 million in 2001 to $3.9 billion, which was requested for this year. And I’m happy to say that we are better prepared
to prevent and respond to any public health emergency in
Bibliography:
“17 Critical
Benchmarks for Bioterrorism Preparedness Planning,” Department of Health
and Human Services press release,
Hospital
Preparedness: Most Urban Hospitals Have Emergency Plans but Lack Certain
Capacities for Bioterrorism, General
Accounting Office Report 03-924, August, 2003
“Hospital
Preparedness for Mass Casualties: Summary of an Invitation Forum,” final
report, August, 2000; Invitational forum convened 8-9 March, 2000 by the
American Hospital Association, with support from OEP and HSS
NBC Terrorism Preparedness Conference – How Well is Your Hospital Prepared for
Terrorism & Mass Emergencies?
Audio Conference hosted by Security Assessments International, Inc.,
Audio Conference Documents supplied by
- Emergency
Preparedness Management
- Hazard
Vulnerability Assessment
- Hazard
Vulnerability Analysis
- Major Disaster
Plan
- Terrorism
Response Plan - NBC Preparedness Response Plan - response to Nuclear,
Chemical and Biological terrorism
Fact Sheet: “Public
Health Emergency Preparedness – Transforming America’s Capacity to Respond”
-
Recurring
Pitfalls in Hospital Preparedness and Response, by Jeffrey N. Rubin, Homeland Security Journal,
January, 2004
Bio-Surveillance
Program Initiative Remarks, DHS/HSS
Joint Press Conference,
On-line resources
Bioterrorism Preparedness and
Response
http://www.healthpolicyinstitute.org/projects/disaster_response/guidance_document.pdf
http://www.hrsa.gov/bioterrorism/preparationandplanning/healthcare_hospitals.htm
Hospital Preparedness Program
Documents
Security Assessments International
Future Newsletter Topics
Hospital
Liability “When to hire a Security Expert”
Components of a
“Self-Assessment”
Educating
Employees and Staff
How
to select an infant security system
State-of-the-art
protection for Emergency Departments
Violence
in the workplace
Access
control / lockdown
Parking
deck and parking lot lighting
Note from SAI: Twenty plus years
of experience as hospital security professionals has taught us that each
facility is unique. Many factors have to be taken into consideration
when assessing the vulnerability of a particular hospital. This can only
be accomplished through an on-site visit.
The preceding article written by Jeff Aldridge appeared in Access
Control & Security Systems Integration magazine.
Disclaimer
Advice given in this
"Newsletter" is general in nature, and subscribers (readers of this
material) should consult with professional counsel for specific legal, ethical,
or clinical advice. The information provided in the SAI
Newsletters is for educational purposes only and should not be
considered 'legal' advice. Websites listed are for reference only
and are provided for subscribers (readers of the material) to have an
opportunity to read the original documents in total. Please consult your
legal counsel or Compliance Officer for clarification of laws and rules related
to your State when applicable.
SAI is not affiliated with the Joint
Commission on Accreditation of Healthcare Organizations.
SAI -
©April, 2004
