Findings Hospital One Profile Hospital One is a 40 year-old facility, operated and supported by the county government, that eliminated half its beds two years ago to achieve Critical Access Hospital designation. The hospital provides medical care to a catchment population of approximately 10,000 persons, of which 97 percent are native English speakers. Forty percent of the population is over 65 years of age. The mean annual household income is $33,000. Agriculture is the dominant industry in the community served by Hospital One, which is located within a nexus of roadways supporting heavy cross-continental trucking. Over the past several years there has been a gradual influx of foreign (predominantly Asian) ownership and labor into the local agricultural industry, which houses a portion of the nation’s meatpacking industry and produces soybeans, corn, cattle, pigs, and poultry. Hospital One is also near a nuclear power plant. Nuclear facility representatives engage in required annual drills with the hospital but acknowledged that they have become interested in developing better communication and relationships with the hospital since the events of 9/11. 64 The nuclear facility recently received $10 million to upgrade security measures, including communications and employee background checks. As area residents and birthright farmers, many of the nuclear facility workers?as well as the emergency responders who participated in the study discussions?noted that they are equally concerned about the threat of agroterrorism. As one participant noted, “If they can fly planes into buildings they can come into a feed lot and contaminate the feed.” Aware of the agriculture industry’s severe vulnerability to infectious animal disease outbreaks, another emergency responder noted, “Contaminate one [grain] elevator and you will contaminate all cattle.” A report analyzing the relationship between the health of the county’s citizens and the health of the county’s economy helped support passage of a hospital bond in 2001, resulting in a 10-bed renovation that included a new rehabilitation facility, remodeled operation room (OR), emergency room (ER), and outpatient facilities, and a new business office. Twenty-one visiting medical specialists support a variety of outpatient clinical services. The hospital employs 16 full-time registered nurses and four licensed practical nurses. It has a 24-hour emergency department supported by an ambulance service and the capability to transport patients by helicopter. Hospital One has a one-bed isolation room equipped with negative-pressure airflow capacity. However, hospital administrators do not know whether the isolation room’s negative airflow capacity has been tested, and are not sure the nurses know how to operate the facility. Administrators and staff have considered many critical preparedness questions (“How would we protect the hospital’s resources in the event of a surge in demand? Under what circumstances can the hospital lock its doors? Where would additional trained resources come from? How would we re-supply blood and critical medical equipment?”), but potential solutions have not been determined. Pediatric training and equipment is limited and personnel have little experience in the large-scale triage and tagging procedures necessary during a mass casualty event. In the event of bioterrorism, there is an expectation among law enforcement and safety personnel that the sheriff would institute a “code red” and instruct emergency medical services (EMS) to “suit up.” A flattened decision-making paradigm has been instituted so that individuals on duty during weekends and evenings can act expeditiously during a serious or potentially contagious threat. A large influx of patients presenting with complex medical conditions would quickly overwhelm hospital capacities and capabilities. Terrorism and infectious diseases have been objects of great concern among hospital staff members for three years. The hospital administrator suspects that these and other concerns have not gone unnoticed by the insurance industry, reporting “extreme increases” in the cost of property coverage exceeding 15 percent per year. The nursing staff notes greater sensitivity to unusual events, stating that they now contact the police far more readily if they perceive anything to be out of the ordinary. Since the 2001 anthrax attacks, the hospital has considered the threat of bioterrorism less of a “front burner” issue; it has been replaced by the more recent concerns of SARS, West Nile virus, and influenza. (Hospital staff members recall one episode when all hospital beds were filled to capacity during a large flu outbreak). Hospital One belongs to a statewide consortium of 30 hospitals, most of which are rural and lack JCAHO accreditation. The consortium has initiated multi-hospital agreements for assistance in the event of an emergency. An appraisal of this assistance strategy, along with many other lessons learned, was made after Hospital One participated in a small tabletop exercise with several nearby hospitals. For example, in discussing the generalizability of her skills during an emergency if deployed to assist another hospital one nurse noted, “We don’t know Pyxis at our hospital and we do our meds differently.”65 Hospital One has actively sought to determine how to augment personnel in the event of a large-scale emergency. Currently, maintenance workers function as security guards when needed, although they have had no security training. There has been some work with administrative personnel to supplement mental health services in the event of a crisis. The hospital has agreements with nursing homes to obtain additional surge capacity, but these scenarios have not been practiced. There is agreement that resources are inadequate to independently distribute supplies from the Strategic National Stockpile. 66 In the event of an emergency, the hospital would have limited support from volunteers who are described as being “the same twenty or thirty people who already wear multiple hats.” One participant noted that not all consortia hospitals have been equally convinced of the climate of threats and vulnerabilities. This participant described the following scenario. “…The rail line went through the town [of one dubious hospital administrator] so I got the list of what has been transported on the Union Pacific over the past three months. His eyes opened real wide and he got interested in preparedness real quick.” It was suggested that limited resources and the camaraderie inherent in a small rural hospital negate the need for relatively basic infection control practices. For example, surgical masks are not routinely worn when a patient with an upper respiratory infection presents in the emergency department. Noted one nurse, “We know the patients who come in. They’re our family and friends. They get offended if we put [exam] gloves on.” Training tops the list of needs cited by the majority of participants. One participant noted, “There is a dire need for good training and consistent retraining to maintain skills.” Staff indicated that they need training in bioagents, detection and increased awareness, and incident command. They note the requirement for numerous exercises to test roles and “give the staff the tools to do their job.” Difficulty in releasing staff from work responsibilities to acquire training, should it be available, is a significant obstacle. Communications systems and equipment was another requirement reiterated by the meeting participants over the two-day site visit. Public health funding has supported the installation of fax machines and Internet access within every hospital in the state. This equipment is monitored by a hospital nurse at all times. The staff indicated that the most critical communications necessities included equipment that is reliable and interoperable across sectors and radio capability to communicate with local, state, and federal agencies. One participant noted, “Lots of parts of the state still have dial-up modems.” Hospital Two Profile Hospital Two serves a catchment population of which 70 percent does not speak English as a first language. Forty percent of the population is over the age of 65. The hospital provides care to the indigenous population and many undocumented persons in need of health services. Ties between the hospital and the community are strong. Almost everyone who works at the hospital has a family member employed there, fostering a strong sense of loyalty. A 93-bed hospital in which 76 beds are staffed, the facility has undergone four major renovations since it was built in 1959. The most recent renovation, in 2002, upgraded the emergency and radiology departments, the pharmacy, the lobby and administrative offices, and the outpatient clinics. The hospital is seeking capital to expand to meet a growing demand for service delivery, to upgrade beds and ventilation, and to meet new safety codes, such as a requirement for sprinklers. A not-for-profit independent and JCAHO accredited institution, the hospital is operated and financially supported by a private corporation. The hospital employs a house staff of approximately 200 full- and part-time nurses and 35 physicians. Its remote location makes recruitment of licensed health care professionals difficult and expensive. The hospital provides a wide range of specialty services, including cardiology, nephrology, obstetrics and gynecology, orthopedics, pediatrics, and women’s health. The hospital uses the helipad of the local airport and is designated a level four trauma center. 67 It operates its own ambulance service. Two emergency department physicians are on staff. The hospital is near a military installation that closed its base hospital several years ago. In-patient military medical care is provided at Hospital Two, where military physicians have full privileges. Hospital ambulance services also support the base. Members of the hospital administrative team describe being “more aware of the potential [for acts of bioterrorism and disease outbreaks] but not necessarily more prepared.” They specifically cited the experiences of Toronto hospitals during the recent SARS epidemic as a sobering reminder of the vulnerabilities of hospitals to infectious disease outbreaks. One meeting participant noted, “I don’t know if there is enough of anything [human or other resources] to handle bioterrorism.” Hospital staff identified their specific vulnerabilities as including remote location, agricultural center, 10 minutes walking distance to a border, proximity to a military installation, and the major trucking and rail lines through the city that transport millions of tons of freight annually. Despite a significant investment in the purchase and installation of security cameras, only one security guard is on duty at all times. It was acknowledged that this guard is unable to monitor the cameras, patrol the 16 unlocked doorways and multiple other entrances in and out of the hospital, and respond to requests for assistance. Visitors have full access to the hospital without badging or routing at a central entrance. Hospital staff indicated that a suspicious individual would be stopped. Recently, an unfamiliar panel truck parked next to the hospital caused immediate concern. However, as one meeting participant noted, “The hospital is very diverse. We just think everyone is the relative of a patient.” Janitors and maintenance staff might be able to backfill security during an emergency, but they have received no training. The hospital would look to the sheriff’s office and the border patrol?both of which participate in preparedness planning efforts?to augment security functions in the event of a large-scale emergency. The hospital communications system is supported by a limited number of T1 lines and an antiquated 911 system. 68 One hospital representative noted, “when we send ambulances to certain areas, they are on their own because we can’t communicate with them.” Another recalled a recent situation when a Medevac helicopter could not be contacted for 45 minutes, and then only through a convoluted series of telephone calls. Although the border patrol is an important source of security backup, there is “no way to talk to them.” Various community responder sectors are purchasing communications equipment, but participants were concerned that “some [devices] are analog and some are digital.” Significant mention was made of the need for a communications infrastructure supported by repeaters and switches. The CDC’s Health Alert Network is being developed and satellite phones are a planned purchase. The hospital believes it would be overwhelmed “in minutes” by more than 30 patients, probably far fewer if the emergency involved a communicable disease. The hospital is the “go to” place: “During a mass infection or disease outbreak, people will want to come to your doors,” noted one hospital employee. However, the hospital has only two negative-pressure isolation rooms which would fill up quickly. The hospital has five ambulances, one of which is old, and none of which can be kept locked and secured. Hospital Two has a memorandum of understanding to share resources with 23 hospitals over a 22 county area. A plan has been developed by the city and county to close the nearby international border, if necessary. None of these plans have been tested through a drill or tabletop exercise. The regional responders have conducted one drill testing their response to a chemical spill. There is a five-day supply of food and three emergency generators that could run for 72 hours. Alerting the community during an emergency was reported as a serious problem. The literacy levels are low, and fewer than 10 percent of the population uses the Internet, though most people have phones. The use of police bullhorns was mentioned as a possible alerting method. The hospital’s administrative staff also raised concerns about how they would be alerted to a threat, describing a situation in which there are no formal channels of information or specific guidance to hospital officials. “Every time [the Federal government] changes the threat level we don’t know how or what to do differently,” stated a hospital employee. “The EMS person might hear about a threat, but he knows only because a higher-level EMS person mentioned it,” stated one of the meeting participants. “We might get some bulletins from the state public health agency,” noted another participant, “but that is usually after the fact.” Many obstacles to preparedness—a level hospital leadership calculated as two on a scale of one to ten (ten being the most prepared)—were articulated. “The thinking part is easy, but the resources are difficult,” stated the hospital COO. In addition to money, hospital preparedness will require significantly more and ongoing staff training, exercises, community education, and technical assistance. A portable tent in which to triage patients was cited as essential to mitigate the spread of an infectious agent into the hospital that could potentially expose patients and staff. The hospital expressed a need for more trained professionals, especially nurses. There are no extra staff or nurse banks. School nurses might be able to provide assistance to the hospital, but this had never been discussed with them. Additionally, as one participant noted, “In the event of a bioattack or disease outbreak, everyone would want to respond, but we don’t have enough protective equipment for them.” Hospital volunteers are mostly senior citizens and would provide little staff backup during an emergency. Area nursing homes are filled to capacity and could not service an overflow of patients. “The city could open a facility, ” noted the Mayor, “but how could it be manned?” Acknowledging limited capabilities for and training in biological agents, the hospital would look to the expertise and hands-on support from the nearby military base. Hospital Three Profile Hospital Three serves a population that is 85 percent African American
and 97 percent English speaking. The average household income is $22,000;
33 percent of the county’s residents are below the federal poverty
level. Hospital Three is located in an agricultural area transected by
an expanding major highway designed to support an increased volume of
truck and tourist traffic. A port also exposes the area to shipping and
barge traffic. The community is near a nuclear facility. The hospital employs 25 full- and part-time nurses and offers several outpatient services, such as radiology, EKG, and ultrasound. As one participant noted, “We don’t offer [the community] a whole lot, but what we offer they need.” Participants from Hospital Three expressed many concerns about terrorism-related issues and their lack of preparedness. When posed with the hypothetical situation of a possible case of smallpox one individual noted, “People would be exposed before we knew what was going on.” Another participant stated, “A communicable disease would be tough to handle and tough to contain.” There are no formal isolation procedures or supplies in place. The hospital has one (makeshift) negative pressure room, but staff has not been trained in true isolation procedures. Surge capacity is extremely limited at this facility, which has no more
than one day’s worth of extra patient care supplies. There are no
lists of trained personnel in or near the surrounding community, or retired
staff who might be available to augment the limited number of hospital
staff. A nearby nursing home is full and could not provide extra capacity
for non-acute hospital patients who might have to be quickly moved from
their acute-care hospital setting. The local elementary school has one
licensed practical nurse to serve 1000 pupils. The area’s federally
qualified health center (FQHC)69
and the three to four local home health agencies that might have homemakers
and aides who could provide assistance to the hospital during a large-scale
event, have not been involved in any bioevent or disaster planning. A
subsidized private ambulance service, which staffs only one of its two
ambulances at a time, also covers hospitals in many other nearby counties.
The hospital has no security staff to monitor and protect its nine entrances.
Security support from the Highway Patrol reportedly would require “hours
to respond.” The hospital contains a few outdated personal computers supported by dial-up Internet access, but for the most part, communication equipment is old and lacks interoperability across responder sectors. One participant noted, “We can’t talk with each other. The road manager can’t talk to the Director of Civil Defense. [We need to be able to reach] the EOC, the sheriff and the county administrator…. Someone needs to work a radio to coordinate a response.” In the event of a biological attack or a mass-casualty situation, the hospital and the community anticipate assistance from the state health department. The state is in the process of writing and formulating response plans, but is currently experiencing “the greatest shortage of nurses in its history.” Multiple, simultaneous events would severely tax state resources and thereby would limit the timeliness and number of deployable personnel to this and other hospitals. Hospital Four Profile Hospital Four is the only source of health care for an hour’s drive in any direction. It serves a population of over 7,000 that is 75 percent Caucasian and 18 percent Native American. Local industry includes mining, lumber and agriculture. The hospital is located a short drive from an international border, which is routinely and regularly traversed by local residents seeking opportunities for recreation, sports, and dining. Hospital Four was moved to its present location in 1974. The facility contains 25 beds, of which 14 are used for long-term care. Both long-term and acute-care beds occupy the same wing of the hospital building and receive care from a shared nursing staff. Nurses cover the units as well as the emergency department. The emergency department in Hospital Four is telemedicine capable, but there are no ventilators or specialized equipment anywhere in the hospital. There is one room that is designated, but not approved as a true negative-pressure isolation facility. Without immediate transportation of seriously ill patients, “survivability would be low,” noted one of the participants. However, winter fog routinely prevents helicopter transport, and fixed wing planes can land only during the daylight. During winter months, cold temperatures would prohibit appropriate pre-hospital triage of potentially communicable patients. The hospital has one 32-year-old generator that does not cover the entire hospital’s power needs. “A loss of emergent power [during winter months] would require complete evacuation of the hospital within one hour,” noted a hospital official. Members of the hospital’s staff have begun to develop new policies to address the threat of bioterrorism. They recently participated in a state-sponsored bioterrorism tabletop exercise and realized the complexity of such issues as isolation, exposure screening, incident command, and adequate telecommunications (broadband Internet availability and cell phone service area) outside the township. The hospital is part of a regional response plan that includes 19 hospitals. Staff of all levels of skills and expertise are at a premium in this community, where “everyone wears multiple hats.” Hospital officials are beginning to assemble lists of emergency personnel and phone numbers. Training is considered to be a critical need in all areas of preparedness, including triage, decontamination, bioagents, and disease management and detection. However, it is difficult to release staff for training, as there are no positions to backfill for trainees. None of the hospital’s staff received smallpox vaccinations during the Phase I vaccination program, because the vaccinations were administered at only one state site, three hours distant. Decontamination equipment and protective suits for law enforcement personnel are an expected state purchase in 2005. But, as one participant noted, “Throwing equipment at us doesn’t matter if you don’t have people. We could have lots of decontamination [equipment], but who would handle it?” Hospital Four is accessible through six entrances, all of which could be manually locked during an emergency. The master lock has not been changed since 1974, and there reportedly are “a lot of keys out there.” But, as a hospital official noted, “Open doors are important in a small community for a hospital.” The hospital does not have 24-hour security. All doors to treatment rooms, medical storage, files, and sensitive equipment are key or keypad locked. Community alerts from the hospital have, in the past, included use of a cable TV station, postings on local public buildings, and the use of educational videos in pizza parlors. In the event of an emergency, however, the most effective strategy for getting the word out to this close-knit community is, as one participant noted, “to just tell two people.” Limited communication systems were noted repeatedly as a serious problem.
“There are lots of dead spots because of the mountains,” noted
one participant. “Cell phones are good for less than 10 percent
of the time I drive and work,” noted another participant. “Hospitals
can’t talk with each other,” a third individual reported.
As one participant described, “The government is throwing equipment
at us (the Sheriff’s department finally received two more repeaters),
but it’s not compatible with the other equipment, and the government
is not funding installation or operation.” The Sheriff’s department
also received hand-held radios, which have not been programmed and for
which no training has been provided. “The equipment came and that
was that,” noted one participant. Communication strategies, as well
as improved technology, were noted as another important requirement. One
participant noted that the EOC gets overrun in the first hour of an incident,
such as a fire, and comes to a standstill because of the huge influx of
calls and use of multiple frequencies. Hospital Five Profile Hospital Five serves a population of 30,000 people, 92 percent of whom are native English speakers. The median household income is $35,000. Hospital Five is a short distance from an international border described by one participant as a conduit for “smuggling drugs, cigarettes, booze, and people.” At certain periods of the year the number of tourists exceeds by four times the number of indigenous residents. Hospital Five is a JCAHO accredited, 49-bed hospital built in 1972. It provides a wide array of inpatient and outpatient specialty services supported by 75 registered nurse and 10 licensed practical nurse full-time equivalents. Filled bed census averages 19 patients. The hospital has recently entered into a service delivery agreement with a medical school that will make more specialized services available. The emergency room is staffed by full-time physicians and specialized nurses who are trained in many aspects of acute medical care. Emergency department staff provide local educational programs, continuing medical education and quality assurance and offer support and training to pre-hospital providers. Hospital Five has one negative pressure room and the capability of creating a negative pressure environment in the emergency room through the use of a portable high-efficiency particulate air (HEPA) filters and ductwork that vents outside. The fire department has a fully equipped HAZMAT trailer and a portable decontamination unit. The hospital has a 5,000 sq ft parking lot, which it would designate as a triage area during warmer weather months. Hospital Five is a member of a 16-hospital compact overseen by the state hospital association to provide mutual aid for staff, equipment, and triage in the event of a bioterrorism attack or large-scale disaster. Collegiality and partnership is the rule, not the exception, across a community of industry, academia (state college), emergency responders, and the hospital and health care providers, all of which have engaged in some level of preparedness and response discussions since Y2K. In recent years hospital staff and other participants indicated far greater awareness of the potential of a bio or chemical terror incident. A recent prank that threatened to compromise the community’s water system catalyzed the hospital’s digging of its own well with a 40-gallon-per-minute capacity. The hospital has an 80-hour capacity for power from its backup generator and on-site fuel. Following September 11, 2001, the hospital immediately began to consider the impact of airline shut downs on the delivery of medical supplies and the resulting ramifications to the ongoing hospital functions. As one hospital official noted, [In the event of an emergency] “there is no coordinated plan to bring in materiel.” Having moved from a “just-in-time” inventory system, the hospital now has a 30-day cache of routine medical supplies. Acquiring replacement staff was a problem identified when considering the potential for a mass patient event. As one participant noted, “Everyone wears multiple hats.” The use of retired and home health nurses has been considered a plausible strategy to augment hospital surge capacity, but these individuals have not been included on rosters, nor have they participated in drills. The state is in the process of writing plans, including assigning the National Guard the role of protecting hospitals in the event of bioterrorism and a surge in demand for medical services, as well as to assist in the distribution of materials from the Strategic National Stockpile. The Border Patrol 71 has been considered an important component of any bioterrorism response, but agreements for their participation have not been formalized. Several members of the hospital staff have volunteered to receive smallpox vaccinations. Of the three ambulance companies designated to transport smallpox patients, two do not require respiratory protection for employees and none have vaccinated them. The hospital recently participated in a SARS tabletop. One participant noted, “Drills help, but you never know until it happens.” Another participant indicated that it is difficult to envision a large-scale event, and that certain response procedures will depend on the season, implying the important role of weather and environmental conditions, adding, “[We] don’t have a plan to transport non-critical patients out [because] where would they go?” The hospital has 18 entrances, most of which are locked after 6 PM; after 8 PM, only the admitting entrance is open to the general public. There is no security staff, the hospital incorporates a “security presence” of untrained but alert employees. There are 34 security cameras that record on tapes that are reviewed in the event of a problem. Communication systems and technologies were reported to be critical concerns. The hospital has discussed strategies for sharing information and augmenting capacity with local governments across the nearby international border. Power grids are vulnerable to the weather, and phone communication is limited by the mountainous terrain. Communication with ambulances is difficult in some places. The amount of cell towers is inadequate. One participant noted, “At three o’clock, when the college gets out, all the cell coverage is jammed.” EMS, fire and police radios were upgraded recently, but the lack of local repeaters prevents seamless regional radio access. Additionally, the strategies underlying cross-sector communication activities are problematic. In the words of one participant, “This talking with everybody is relatively new. [We] have to understand who talks when.”
Hospital participants indicated numerous requirements for improving preparedness
capacity and capabilities, including a respiratory protection program
that would include the purchase of more equipment (N95 as well as self-contained
breathing apparatus), fit-testing, and training programs. The hospital
needs a continuing staff-training program to improve and maintain skills,
assure compliance, and provide appropriate record keeping. Participants
noted the importance of building uniform plans across all hospitals statewide
to assure consistency of training and equipment, especially at a regional
level. HAZMAT and EMS recently provided incident command training for
the hospital. Hospital participants indicated that it was difficult to
integrate the hospital response. More drills and exercises—especially
cross border—are considered essential. As one participant noted,
“The state is on a learning curve for bio-preparedness.” 64. Following the accident at Three Mile Island in
1979, the Nuclear Regulatory Commission (NRC) reexamined the role of emergency
planning for protection of the public in the vicinity of nuclear power
plants. The Commission issued regulations requiring that before a plant
could be licensed to operate, the NRC must have "reasonable assurance
that adequate protective measures can and will be taken in the event of
a radiological emergency." NRC regulations require that comprehensive
emergency plans be prepared and periodically exercised to assure that
actions can and will be taken to notify and protect citizens in the vicinity
of a nuclear facility. Typically the emergency preparedness plan for a
nuclear power plant includes an area within about a 10-mile radius around
the plant. The facility's emergency response plan must be discussed and
agreed upon by the organization operating the power plant, by local and
county emergency response officials, and by state emergency management
officials. Source: http://www.nrc.gov.
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