After 9-11: Elevating Bioterrorism Preparedness in Hospitals

Jenifer K. Murphy
James Madison University
Health Services Administration Program

Executive Summary
Following the terrorist attacks of September 11, 2001, bioterrorism preparedness became a high priority in hospitals. However, despite significant advancements in preparedness, many hospitals are still unprepared to deal with the impact of bioterrorism. The federal government has provided initial funding to state and local governments for bioterrorism preparedness, however much of this money has yet to reach hospitals. Efforts by hospitals to elevate bioterrorism preparedness should focus on several key areas. These are community involvement, educating hospital staff, improving information technology and disease surveillance, and acquiring additional equipment and staff. Hospitals should also make bioterrorism preparedness planning a regional effort.
After 9-11: Elevating Bioterrorism Preparedness in Hospitals

Introduction
A war exercise conducted in 2001, before the September 11 attacks, simulated the release of smallpox. Within a thirteen-day period, the virus had infected thousands of people and spread across twenty-five states and into fifteen countries (McCarthy 2001). Subsequent to the terrorist attacks of September 11, hospitals in the U.S. had to cope with the threat of anthrax, SARS, and Monkey pox, and emergency preparedness became a high priority focus. Since that time, many hospitals made significant strides in their emergency preparedness (McCarthy 2001), but recently the sense of urgency of preparedness in hospitals appears to have declined somewhat. This is largely due to the perceived belief that an attack is unlikely to occur (Bartlett 2001). As centers of health and medical resources for their communities, hospitals need to remember that even if their locality is not a direct victim of an attack they will still be called upon for regional support and may have to treat victims. Bioterrorism has no boundaries and can happen anywhere and at anytime (Tieman 2002). All hospitals, not just those in high threat areas, should be prepared to combat the catastrophic and widespread effects of a bioterrorism.

This paper addresses the need for hospitals to evaluate their current levels of bioterrorism preparedness and take the necessary actions and precautions to protect their staff, patients and the surrounding communities in the event of an attack. The federal government has provided some initial funding to prepare hospitals, but it is not enough to adequately to be adequately prepared. There are several aspects of bioterrorist preparation that hospitals should have in focus. These priority focus areas are promoting community involvement and communication, educating hospital staff and area primary care physicians, improving information technology, and acquiring additional equipment and staff to deal with a bioterrorist attack. An attack is seemingly inevitable and all hospitals, regardless of location and size, will feel the effects of bioterrorism.

Biological Agents and Current Hospital Preparedness Levels
There are other forms of terrorism and weapons of mass destruction the United States is certainly susceptible to and that hospitals also need to be prepared to handle. Some of these include chemical agents, power outages, radiation, and nuclear weapons. For the purposes of this paper, biological agents are felt to be of the greatest concern to hospitals because of the far-reaching effect a bioterrorist attack would have. The Centers for Disease Control currently list six diseases as Category A biological threats. Category A biological agents are those the "U.S. public health system and primary healthcare providers must be prepared to address" (Centers for Disease Control 2003). They are considered threats to national security, are highly transmittable, and have high mortality rates (CDC 2003). These agents are anthrax, botulism, smallpox, tularemia, viral hemorrhagic fever (VHF), and plague. Are hospitals adequately prepared to deal with the effects of these diseases?
A study of 30 FEMA Region III hospitals completed in 2001 showed a majority of staff felt unprepared to deal with the mass casualties associated with a bioterrorist attack (Treat et al. 2001). None of the hospitals surveyed felt prepared for a bioterrorism attack, 73% only have a single decontamination unit, and 87% said they could only handle from 10-50 patients at a time (Treat et al. 2001). A 2003 study conducted by the American Hospital Association (AHA) shows hospitals are lacking in appropriate medical equipment to deal with mass casualties from bioterrorism. Furthermore, four out of five hospitals in the study did have plans in place to deal with an attack, but did not have policies for involving outside organizations, such as laboratories (Crosse 2003). Much of this lack of preparedness is due to hospitals operating individually and not coordinating their planning efforts with outside organizations (Barbera and Macintyre 2002). The AHA study makes several suggestions to hospitals for improving bioterrorism preparedness. Hospitals need to first develop policies to include local and state health departments in their bioterrorism response scenarios, and test these policies in JCAHO required drills. Staff education, especially in the emergency room, needs to be improved as well. There should also be an increase in critical medical equipment, such as ventilators, decontamination equipment, I.V. infusion pumps, hyperbaric chambers, and external pacemakers (Greene 2002).

What Should Hospitals Do?
It is difficult to prepare for the unknown. The unpredictability of bioterrorism makes planning for it extremely challenging because no one knows when an attack could actually occur. Bioterrorism preparedness plans are also extremely expensive to implement and maintain. Though the importance of bioterrorism preparedness cannot be argued, it is difficult for hospitals to spend money on equipment and systems that may never be used, especially in areas where the threat of an attack is low. While important progress has been made in hospital preparedness levels (McCarthy 2001), there are four main actions hospitals should take to increase their level of bioterrorism preparedness.

Community Involvement
Hospital bioterrorism preparedness needs to be a broad-based community effort coordinated by the hospital. In the event of a bioterrorist attack, local community organizations need to know how to respond in order to avoid and contain mass public panic. These “first responder” organizations include local law enforcement, the fire department, state and local governments, hospitals, HAZMAT teams, emergency medical services, and area public health departments (Crosse 2003). The involvement of and communication among these organizations will be vital to controlling an infectious disease outbreak and to calming the mass public panic that will ensue (Powner 2003).

The emergency room is not the only health provider that will be flooded with victims of bioterrorist attacks. Physician involvement in planning for bioterrorism attacks is severely lacking (Kahn 2003). Primary care physicians will also receive an influx of patients in the event of a bioterrorist attack and have a critical role in any public health emergency (Lane and Fauci 2001). A survey done in 2002 of 1,000 AMA physicians showed only 21% of physicians felt prepared to handle a bioterrorist attack, and only 22% felt hospitals in their practice areas were prepared (Alexander and Wynia 2003). Also, these physicians will be either admitting patients to hospitals or referring patients to hospitals, which are other reasons why planning efforts need to be coordinated with local physicians. The American College of Public Medicine estimates that $22.2 million is needed to adequately train physicians to deal with a mass biological agent attack (Kahn 2003).

Educating Hospital Staff
In June 2002 the Public Health Security and Bioterrorism Preparedness and Response Act was passed, which, among other things, was aimed at improving education for health care professionals (Frist 2002). This bill highlights the need for hospital staff to be able to treat these biological agents, many of which have never been seen by this generation of health care workers. Victims of bioterrorism events are going to go to hospital emergency rooms. Emergency room and infectious disease staff need to be better educated and trained to recognize the signs and symptoms related to biological agents. Several of these biological agents also result in physical signs and symptoms similar to other common illnesses. Anthrax and plague, for example, exhibit signs similar to influenza. Smallpox is also highly communicable, so emergency rooms staff needs to know how and where to isolate possible victims (Powner 2003).

Some of the specific precautions hospital staff need to be alerted to vary depending on how the biological agent is released and what type of agent is released, as shown in Table 1. Standard precautions include washing hands, wearing gloves and masks, and sterilizing equipment. These are all precautions currently taking place in hospitals. Contact precautions include the isolation of patients and equipment likely to be infected, as well as frequent cleaning of equipment (Werner 2002). Droplet precautions require masks to be worn at all times, patient isolation, and maintaining as much distance as possible between health care providers and patients (Werner 2002). Airborne precautions require patients to be put in isolated areas “with negative pressure, a minimum of six air changes per hour, and appropriate filtration of air before discharged” (Werner 2002).

Table 1. Bioterrorism Infection Control Precautions
All Bioterrorism Standard Precautions
Smallpox Standard, Contact, and Airborne
Viral hemorrhagic fever (VHF) Standard, Contact, and Airborne
Brucellosis Standard and Contact
Anthrax Standard and Possibly Airborne
Pneumonic plague Standard and Droplet
Source: Healthcare Purchasing News, December 2002

Hospitals also need to look at vaccinating their essential first responder staff against infectious diseases as well. While the benefits of the anthrax vaccine remain questionable, the smallpox vaccine does pose less of a threat. The CDC Advisory Committee on Immunizations Practice (ACIP) released a statement in June 2003 recommending the formation of “smallpox response teams” to receive small pox vaccinations (DHHS 2003). These 40 person teams include emergency room nurses and physicians, epidemiologists, ICU and PICU staff, infectious disease consultants, respiratory therapists, radiology technicians, engineers, and selected security and facilities management staff (DHHS 2003).

Improving Information Technology and Disease Surveillance
Information technology (IT) is vital to improving communication and the sharing of information in the event of a bioterrorism attack. In November 2002, the Agency for Healthcare Research and Quality (AHRQ) released a report with suggestions for IT improvements. IT can be used in a variety of ways to help contain the effects of a bioterrorist attack. It can be used to gain information from public health departments, which can help to isolate the cases of disease related to a bioterrorist attack from those that may have naturally occurred (Powner 2003).

Information technology can also be used to send information to public health departments for record keeping purposes and surveillance. The CDC is using IT for syndromic surveillance which tracks the number of people visiting emergency rooms with symptoms similar to those presented with certain biological agents (McCarthy 2001). Some of these symptoms are fever, headache, and cough. A rise in the number of patients with these symptoms would cause the CDC to put up a “red flag.” IT is also being used to monitor the number of over-the-counter drugs being purchased, such as Tylenol, which victims of an attack would be likely to purchase to treat initial symptoms (McCarthy 2001). Bioterrorism preparedness does not stop at the emergency room either. The Association of Public Health Laboratories has developed an online education program for clinical laboratories. This program should accompany training already occurring in labs for surveillance of bioterrorist agents (Business Wire 2003). The program highlights the detection of anthrax, tularemia, plague, and brucellosis, which is a Category B infectious agent according to the CDC. The DHHS has also designed a new computer program to aid hospitals in dispensing vaccines and antibiotics in the event of a bioterrorist attack (U.S. Newswire 2003).

Additional Equipment and Staff
To successfully treat the victims of a bioterrorist attack requires large quantities of specialized equipment and medications. Some of the equipment needed by hospitals includes personal protective equipment, mass decontamination shower units, and ventilators, as well as isolation/ quarantine beds and supplies of antibiotics, antidotes, and vaccines. Purchasing all of this equipment is one solution, but another way hospitals can acquire the equipment needed for bioterrorism preparedness is through the sharing of resources with other area hospitals. A study involving 1,482 urban hospitals reported that half currently have resource sharing measures already in place (Crosse 2003).

Resource sharing is also not limited to equipment. Many hospitals also have staff sharing agreements in place in the event of a bioterrorist attack. Hospitals can test how well they have planned for the incorporation of community organizations during their JCAHO required drills. The Joint Commission requires hospitals to complete four drills annually to deal with the outbreak of infectious diseases, which include biological agents.

Evaluation of Bioterrorism Preparedness Measures
With few guidelines currently available for bioterrorism preparedness, hospitals are on their own for planning new policies and implementing new procedures. Hospitals must perform an evaluation of their capacity to address both the direct and indirect effects of a bioterrorism event. Table 2 suggests an approach for hospitals to use to evaluate the action steps discussed above. Hospitals located in areas where the threat of an attack is low (e.g., small urban areas, towns and rural communities) should focus on different measures than hospitals in high threat areas (e.g., metropolitan and large urban areas, and smaller communities having vulnerable military and industry sites).

Hospitals in low threat areas should focus preparedness efforts on staff training and community involvement. By training staff and developing policies with surrounding communities, low threat area hospitals can be called upon for necessary support by hospitals in high threat areas. Hospitals in high threat areas should focus their bioterrorism preparedness measures more on information technology, disease surveillance, and equipment. If an attack occurred, information technology and disease surveillance will help to alert hospitals more quickly and allow them to begin appropriate treatment. Additional equipment to treat bioterrorism victims will also be needed in the event of a direct attack in a high threat area.

Table 2. Evaluation of Bioterrorism Preparedness Measures
Type ofBioterrorism Preparation Cost to Hospital Benefit to Hospital
Community Involvement Low Medium
Educating Hospital Staff Medium High
Improving IT and Disease Surveillance High High
Additional Equipment and Staff High Medium
Source: Compiled from author's review of relevant literature.

Funding Bioterrorism Preparedness Measures
As the current literature suggests, many hospitals are currently ill equipped to successfully handle a bioterrorist attack. A March 2003 statement from the Joint Commission described bioterrorism preparedness as “a brewing cataclysm of underfunding, inexperience and underpreparedness of emergency response capabilities across America’s communities” (PR Newswire 2003). Much of this “underpreparedness” is due to a lack of funding. Bioterrorism preparedness is expensive and most hospitals have trouble investing funds into resources that they may never utilize (Crosse 2003). The federal government has dispersed money in large amounts to deal with bioterrorist attacks, but little of this money has been specifically directed toward hospitals. Money is being given to government agencies and local and state government, but hospitals are finding themselves waiting for the funds to trickle down to them. The financial burden of preparing for bioterrorism has fallen on state and local governments and the federal government needs to continue financial support if they intend to mount a serious defense to bioterrorism. The Department of Health and Human Services (DHHS), along with the CDC, NIH, FDA, EPA, DOE, and the Department of Homeland Security are working together to help better prepare the public for bioterrorism attacks, but efforts have yet to entirely meet the needs of hospitals (Business Wire 2003).

In the wake of the anthrax scares of 2001, $1 billion was distributed to the states for improving information technology (Trembly 2002). In 2002, $125 million was allocated through DHHS's Health Resources and Services Administration (HRSA) to increase hospitals abilities to deal with a bioterrorist attack, however it did require organizations to apply for the funding (Greene 2002). To apply for the funding hospitals had to first conduct a needs assessment for bioterrorism preparedness policies. After initial approval, hospitals then had to submit a second, more detailed plan of implementation addressing the issues of “medications and vaccines; personal protection, quarantine, and decontamination; communications; and biological disaster drills” (Crosse 2003). This initial $125 million from HRSA only works out to $21,000 per hospital, a mere drop in the bucket compared to what hospitals need. The American Hospital Association estimates $1.9 million is needed for each of the 5,800 American hospitals, for a total of $11 billion (Greene 2002).

In March 2003, HRSA again allocated another $498 million to the states, this time through its National Bioterrorism Hospital Preparedness Program. In 2003, President Bush also allocated an additional $300 million to the CDC to increase supplies in the Strategic National Stockpile. The Strategic National Stockpile is a federal government supply of pharmaceuticals, antidotes, and equipment that can be delivered to bioterrorism attack sites (Crosse 2003). Bioterrorist attacks are a threat to national security and should be funded as such. With limited financial resources available to adequately prepare themselves, hospitals should consider preparing regionally rather than individually (Greene 2002).

By sharing resources and planning bioterrorism policies regionally, hospitals focus on preparing an entire region, rather than just individual hospitals. Texas has taken a regional approach in preparing for bioterrorism. Using the money from HRSA, they have developed a bioterrorism guidance manual to assist Texas hospitals and have made their bioterrorism preparedness a regional effort. There are also plans to develop similar manuals to address planning for other types of terrorist attacks (PR Newswire 2003). Texas is also already working with South Dakota to develop their own measures, similar to Texas' (PR Newswire 2003).

Conclusion
It should not have to take a specific event actually occurring on American soil to motivate hospitals to elevate their bioterrorism preparedness. Bioterrorism preparedness needs to be one of the top issues on hospital agendas, especially with the ongoing world conflicts and the proliferation of weapons of mass destruction. Hospitals must continue to do the best they can with what funding they have received to prepare their facilities and to protect their patients and the larger community. By focusing on improving community involvement and information technology, as well as obtaining access to additional equipment and training staff, hospitals can elevate their preparedness for bioterrorism. Hospitals have been the center of care in communities for centuries, and will continue to be the primary source of care for the victims of bioterrorism and other events in the post-9-11 era.

References

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