How would you handle a terrorist act involving weapons of mass destruction?
How would you handle a terrorist act involving weapons of mass destruction?
Your ED needs a solid plan to confront everybody’s worst nightmare’
Add this to your long list of things to do to prepare for an accreditation survey: Surveyors from the Joint Commission on Accreditation of Healthcare Organizations are asking what EDs are doing to prepare for domestic terrorism, says Robert Suter, DO, MHA, FACEP, regional medical director for the North Texas region at Questcare Emergency Services in Plano.
"Seven hospitals that I consult for got Joint Commission visits this summer, and every single one was asked about domestic terrorism preparedness," Suter says. "This is very clearly on their question sheet."
From a Joint Commission standpoint, preparation for domestic terrorism is going to be as important as "conscious sedation" policies have been in previous years, Suter says. "Due to public awareness, there is a strong emphasis on this."
The Central Intelligence Agency recently looked into rumors that an encephalitis outbreak in the New York area was the work of terrorists and concluded it was not. In a 1995 incident in Toyko, Japan, cultists released the nerve gas sarin into the subway system. The attack affected 5,000 people, Suter says.
The threat of encountering a domestic terrorism incident involving nuclear, biologic, or chemical (NBC) agents in your ED is real, Suter says. And if an incident occurs in your community, the eyes of the world will be on your ED.
"When CNN broadcasts the first story, every hospital staff member within 200 miles is going to panic. You and your hospital better be prepared to offer them some evidence that you have thought about this," says Christopher Richards, MD, chairman of the disaster committee and an attending physician at the department of emergency medicine at Brigham and Women’s Hospital in Boston. "If you don’t have enough gowns and run out of doxycycline before the end of the broadcast, the staff are going to be a problem, not to mention the patients."
Those types of weapons are difficult to defend against, so they probably constitute the greatest threat, Suter says. "It’s very realistic to think that even a small group of terrorists could kill large groups using these means." (See story defining NBCs, p. 123.)
A nuclear or chemical terrorism incident combines the problem of treating mass casualties with the problem of decontaminating patients, says Suter. "In the past, these have been looked at as separate problems. These scenarios are a combination of the two, which is everybody’s worst nightmare," he says.
Joint Commission wants to know your plan
For some time, the Joint Commission has required EDs only to be able to decontaminate a single patient. "So theoretically, everybody’s disaster plan currently includes the ability to take care of at least one patient exposed to hazardous materials," says Suter.
But that will change, he explains. "This is the same principle but on a larger scale."
Right now, the Joint Commission’s expectations are fairly low, he notes. "They don’t introduce a new concept and flunk people right away. They will start asking questions about it and make everybody aware of this. Over the next few years, they will apply tougher standards."
Although the Joint Commission was unable to confirm exactly how the standards will change, there is no doubt they will become more stringent, says a spokes person. "The Joint Commission is aware of bioterrorism concerns, and we are looking at how to best address that in our standards," the spokesperson says.
Right now, surveyors will ask what you have done to prepare. "They will want to know if you have plans for this and what your policies are," Suter says. "Most hospitals do have some sort of [hazardous materials] policy, but they will want to know how you are integrating preparation for domestic terrorism into that policy."
Acceptable answers include sending medical and nursing directors to domestic preparation training courses and integrating what they learn into your hazardous materials (HazMat) plans, Suter says.
However, over the next few years, expectations will be higher, Suter predicts. "They will expect to see either a separate policy or a section of the hospital disaster plan to address weapons of mass destruction," he says.
The Joint Commission also probably will want to see specific drills addressing this issue, says Suter. "I expect that a hospital that has not had a separate disaster drill for large-scale decontamination will get at least slapped on the wrist."
Also, EDs won’t be able to pass the buck, he stresses. "While it will be acceptable to say, We will be working with the fire department,’ to say, We will have the fire department do this’ will not be acceptable. Everybody will recognize that will not work," he says.
To prepare physicians for a terrorist attack, the Chicago-based American Medical Association’s house of delegates voted to sponsor a bioterrorism conference before next December. The Dallas-based American College of Emergency Physicians (ACEP) also is developing strategies to ensure EDs are ready for bioterrorism, Suter says. ACEP formed a task force last year to develop special training courses to prepare EDs for terrorism.
"We have defined what emergency physicians, nurses, and paramedics need to know to respond appropriately to terrorism," says Joseph Waeckerle, MD, FACEP, chairman of the ACEP task force.
The courses will teach ED personnel how to recognize a biological attack, notes Waeckerle. "There is currently no way available to detect and identify a biological agent quickly. So the early identification through clinical presentation is critical," he says.
The task force is advocating a national public health surveillance system in which the ED would play a key role, he reports. "If you have a chemical attack, the first responders are the fire department or HazMat people, and the scene is the site where the attack occurred. With a biologic attack, the scene becomes your ED, and the first responders are your staff."
The task force is now developing the actual curriculum. "These will not be traditional course offerings," Waeckerle notes. "Within 18 months, we will be offering a number of educational interventional strategies, including CD-ROM, self-learning texts, and courses with experts." Separate courses will be developed for physicians, nurses, and paramedics, he explains.
Your ED already may have a protocol for an everyday HazMat incident, but you also need one for NBC agents, stresses Suter. "Your current policy on hazardous materials is an excellent start to preparedness for nuclear and chemical incidents," he says. (See stories on creating a protocol for bioterrorism, p. 124, stockpiling supplies, p. 126, and triage strategies for patients after a terrorist attack, p. 126.)
Essentially, you need to expand that policy with an eye toward treating hundreds if not thousands of patients, says Suter. "Additionally, while bioterrorism could generate even more patients, preparing for victims of a biologic attack presents you with an entirely different set of issues," he notes. (See story on recognizing a biologic attack, p. 127.)
If you look at disaster preparedness as a pyramid, NBC incidents are at the top of the pyramid, he says. "That means that what everybody has done historically to be prepared for regular disasters forms the basis for everything. This preparedness is a little more specialized, but it’s a manageable amount of things to learn and do."
Preparing for weapons of mass destruction can enable you to save lives if an incident occurs, Suter stresses. "You cannot throw up your hands and say, Everybody’s going to die anyway, so what is the point?’"
You already have the basic skills and problem-solving approach, he says. "With a reasonable amount of education about these threats, you can be prepared for these incidents as well."
Sources
Christopher Richards, MD, Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115. Telephone: (617) 732-5640. Fax: (617) 264-6848. E-mail: [email protected].
• Robert Suter, MD, FACEP, QuestCare,101 E. Park Blvd., Suite 921, Plano, TX 75074. Telephone: (972) 881-8353. Fax: (972) 422-2208. E-mail: r.suter@ questcare.com.
• Joseph Waeckerle, MD, FACEP, 4601 W. 143rd St., Leewood, KS 66224. Telephone: (816) 276-7665. Fax: (913) 402-9001. E-mail: [email protected].
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