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CANUS Corporation Safety Emergency Preparedness This Emergency preparedness Web site is dedicated to our public health, hospital, and
community safety partners. We have all come to recognize that they stand ready to serve.
Healthcare facilities and their staff play a key role in emergency preparedness efforts for all
types of events, including natural or man made disasters, pandemic influenza outbreaks, or
terrorist attacks. The availability of healthcare is essential to accommodate the surge in demand
for providing care related to a public health emergency.
The September 11, 2001 terrorist attacks, recent hurricanes in the Gulf region, and the threat of a
pandemic influenza outbreak have prompted healthcare facilities to reassess and upgrade their
existing emergency preparedness plans. These emergency plans need to be coordinated at the
local community level based on the individual needs of the community.
This Web site is intended to assist healthcare facilities in with all aspects of emergency planning,
including mitigation, preparedness, response, and recovery. Comprehensive tools and resources
are provided from federal governmental agencies, professional organizations, universities, and
state and local public health agencies. These include resources for education and training, key
documents, products and equipment and sample procedures and lessons learned.
In addition to general preparedness resources, targeted tools and downloadable resources are
provided for:
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Influenza seasonal and pandemic
Public health updates
Hurricane relief
Premier carefully monitors and provides input into related legislative issues and continues to
share lessons learned from its members who have experienced disaster first-hand.
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Level of readiness
General elements of emergency management for healthcare facilities include mitigation,
preparedness, response, and recovery. These include specific issues such as:
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Hospitals’ incident command system and integration with community emergency
planning groups
Decontamination
Evacuation
Disaster recovery
CANUS Corporation Safety Although hospitals have general emergency management plans in place, they may not have
planned for a large-scale chemical or biological terrorism incident until federal and state public
health groups developed communication plans and networks to address such incidents. Such
planning better prepares staff to manage smaller hazardous materials situations, such as
industrial accidents – in which both staff and facility may be contaminated unless such incidents
are anticipated beforehand. Planning should address the concerns of caregivers and the potential
for distribution of a contaminant throughout the emergency department or even the hospital.
Local emergency planning committees (LEPC) or state public health departments may have
information available to facilitate planning for the physical facility as well as equipment and
communications. The American Institute of Architects (AIA) provides some guidelines for the
planning and design of decontamination facilities in its Guidelines for Design and Construction
of Hospitals and Healthcare Facilities 2001. Ordering information is available from the AIA.
Other issues that may require rethinking include staffing levels and training time. Training for
decontamination processes involves more than a single annual inservice; for example, it also
requires identifying the various types of personal protective equipment necessary (including
respiratory protection) as well as training and practice in the use of the equipment.
Some plans that consider all of these issues in response to an act of chemical or biological
terrorism include Michigan’s Public Health Response to Bioterrorism & Public Health
Emergencies and APIC/CDC’s Bioterrorism Readiness Plan: A Template for Healthcare
Facilities.
An example of a healthcare system's Major Communicable Disease Response (MCDR) Plan is
available as an example of how one system interfaced the biological agent issues with the overall
Emergency Disaster Plan.
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Elements of risk assessment
Facility risk assessment: The facility risk assessment should be a multidisciplinary process,
with representatives from all services involved in an emergency situation. This includes
infectious disease, infection control and safety staff to assist in differentiating biological from
chemical agent exposures and in follow-up management.
Hazard vulnerability analysis: The facility should initiate a hazard vulnerability analysis –
considering the impact of a hazardous materials incident, a chemical incident, or bioterrorism.
This process includes assessing the probability of each type of event, the risk it would pose, and
the organization’s current level of preparedness. The pattern of response in New York and how
individuals sought help are causing many organizations to reevaluate their current plans. This
assessment should also take into account nearby community resources likely to be affected or
called upon for assistance – including schools, churches, public transportation, news media,
telephone and communication systems, voluntary organizations (such as the Red Cross and the
Salvation Army), restaurants, and food suppliers. A sample checklist for conducting hazard
CANUS Corporation Safety vulnerability analysis is available as well as an Excel™ sheet that permits ease of calculation of
the HVA score.
Chemical incidents: Local industries and traffic patterns may be more important than size or
urban/rural location in assessing impact on the facility. Weather conditions may redirect
contaminants into the facility’s vicinity. A transportation accident may be the initiating event;
agricultural, industrial, and even home garage accidents are not infrequent. In the aftermath of
such accidents, contaminated victims may be transported to the nearest facility, rather than to a
major trauma center. Chemicals used in the healthcare facility should be considered as potential
sources of accidental spills.
The VA Office of Public Health and Environmental Hazards has published a rapid contingency
plan for responding to victims of an chemical attack. This very practical document includes
management suggestions for handling of casualties and decontamination.
Biological agents: Bioterrorism is quite different from a chemical incident. An incident of
bioterrorism may be recognized as such only after a number of victims displaying similar
symptoms arrive at the emergency department, following an incubation period of unknown
length. Diagnosis may be difficult: it may be hard to distinguish biological from chemical
exposures (or the possibility of both, immediately after an event like an explosion). Deployment
of a biological agent in a public place would impact everyone and everything in the area,
including the healthcare facility. Rapid assessment and infection control management are critical.
Guidelines for managing infected individuals once the causative agent is tentatively identified
may be found in the table "Bioterrorism Infection Control: Guidelines for Patient Management"
(see Sample Procedures and Tools) or on the Web site of the Center for the Study of
Bioterrorism and Emerging Infections.
Community-based first responders: Many hospitals base their emergency management plans
on local fire departments, counting on them to carry out decontamination activities. In New
York, firefighters were totally occupied at the scene of the incident, with multiple demands on
their human and material resources; moreover, they were exposed to the "agent" (in this case,
dust containing asbestos and possibly other hazardous substances). In the event of an incident,
victims who are able to move may not wait to be decontaminated, but seek help wherever
possible. Following an incident in Tokyo, 80 percent of the victims treated at hospitals were
privately transported, self-referrals, or walk-ins. Healthcare facilities may need to consider
training more first responders.
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Other planning issues
Identification of chemical or biological agents: When a recognized incident occurs in a
community, the key to treating the exposed individuals is identification of the agent. In the case
of an industrial, agricultural or transportation accident, that identification may be made early in
the event. In the case of a covert action, the hospital must rely on detection equipment used by
emergency responders at the site in response to presentation of symptoms. Understanding the
CANUS Corporation Safety decontamination process becomes critical in these "unknown" exposures. Some chemical and
biological agents of greatest concern in a terrorist attack are listed on the CDC Web site.
Clinical assessment: The hospital depends on clinicians in the emergency department to make
the initial diagnosis until other information becomes available. Clinicians must remain alert for
unusual diseases that could result from an act of bioterrorism. As an event progresses, the public
health department will work closely with healthcare organizations to identify patterns and
exposed victims. See resources for training programs on learning to identify and treat critical
agents. CDC notes in the MMWR, April 21, 2000 / 49(RR04) that "…early detection and
control of biological and chemical attacks depends on a strong and flexible public health system
at the local, state and federal levels. In addition, primary health-care providers throughout the
United States must be vigilant because they will probably be the first to observe and report
unusual illness or injuries."
Security issues: Facility security needs include planning for facility lockdown to prevent access
by unauthorized individuals. As the event progresses, the procedure must also consider traffic
and crowd control as more individuals are identified as victims. Family members, the "worried
well," and the media are likely to converge on the facility. Panic may ensue even if the biological
agent is not contagious (that is, spread by person-to-person contact). Planning should include
determining staff resources that can be deployed to support hospital security staff.
Communication: Local news media may gather at the hospital. Communication between news
media and hospital media relations can support the healthcare organization by conveying
important and realistic information to the public, such as recognition of symptoms and initial
treatment steps to take, as well as realistic clinical information about the outcome based on the
agent identified. Many Internet resources provide downloadable fact sheets on chemical and
biological agents that can be duplicated and shared; these are described below.
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Biological and chemical agents
Lists of agents: CDC provides disease/agent-specific information pertaining to two basic
categories: biological agents/diseases and chemical agents.
Biological agents: CDC provides detailed information on the agents most likely to be used in
biological or chemical attacks, including pathogens rarely seen in the United States. These are
summarized in Table 1 below.
The biological agents are classified in three categories:
Category A: Top-priority agents include organisms that pose a risk to national security because
they:
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can be easily disseminated or transmitted person-to-person;
cause high mortality, with potential for major public health impact;
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might cause public panic and social disruption; and
require special action for public health preparedness.
Category B: Second-priority agents include those that:
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are moderately easy to disseminate;
cause moderate morbidity and low mortality; and
require specific enhancements of CDC's diagnostic capacity and enhanced disease
surveillance.
Category C: Third-priority agents include emerging pathogens that could be engineered for
mass dissemination in the future because of:
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availability;
ease of production and dissemination; and
potential for high morbidity and mortality and major health impact.
Table 1: Biological agents by category
Category A
Category B
Category C
Anthrax (Bacillus anthracis)
Q fever (Coxiella burnetti)
Nipah virus
Botulism (Clostridium botulinum)
Glanders (Burkholderia
mallei)
Hantavirus
Plague (Yersinia pestis)
Ricin toxin from (Ricinus
communis)
Tickborne
hemorrhagic fever
Smallpox (Variola major)
Epsilon toxin (Clostridium
perfringens)
Tickborne
encephalitis
Tularemia (Francisella tularensis)
SEB Staphylococcus
enterotoxin B
Yellow fever
Viral hemorrhagic fever (Ebola,
Marburg, Lassa, Junin, Machupo)
Multi-drug resistant
TB
Fact sheets on Smallpox, Plague, Anthrax, and Botulism can be downloaded. Other sources such
as the Association for Professional in Infection Control and Epidemiology (APIC) provides
additional resources and fact sheets.
Complete information on each of these agents may be reviewed from the consensus documents
published by the Journal of the American Medical Association. Each article may be downloaded
from Key documents | Consensus documents.
Clinical Laboratories: CDC issued revised anthrax guidelines for state and local health officials
and intended to assist clinical laboratories. The basic guidelines can be downloaded here or may
CANUS Corporation Safety be downloaded from several Web sites. In early 2006 the CDC has provided an algorithm for the
laboratory diagnosis of anthrax.
Chemical agents: CDC provides detailed information on treating exposure to representative
chemical agents (for example, mustard gas) on its Web site. Chemical categories and an
example of each are listed in Table 2 below.
Table 2: Chemical agent categories and examples
System affect/use
Example
Blister/vesicants
Mustard Gas
Blood
Arsine
Choking/lung/pulmonary damaging
Chlorine
Incapacitating
Fentanyl
Nerve
Sarin
Riot control/Tear gas
Chloroacetophenone
Vomiting
Adamsite
Other industrial chemicals
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Treatment and strategic national stockpiles
Strategic national stockpiles (SNS) formerly National Pharmaceutical Stockpile: CDC and
other federal agencies have developed stockpiles that have been pre-configured and identified as
"push packages." These are stored regionally and can be flown to the scene of an incident in
approximately 12 hours. They contain both therapeutic and prophylactic medications, and would
be supplemented by additional supplies specific to the suspected or confirmed agent, which
would arrive in 24-36 hours. For more information, visit the Web site of the CDC NPS program.
Federal plan for SNS distribution: These stockpiles have been established and maintained by a
number of federal departments and agencies. A presidential directive designates the following
responsibilities:
The Department of Health and Human Services (DHHS) is the federal agency which takes the
lead in planning and preparing for a national response to medical emergencies in the event of an
attack using "weapons of mass destruction" (WMD). The Office of Emergency Preparedness
(OEP) in the National Disaster Medical System takes the lead in these activities within DHHS.
The Federal Emergency Management Agency (FEMA) has the authority to release medical
resources and other supplies in the event of a disaster or emergency declared by the president.
CANUS Corporation Safety FEMA coordinates the federal response through the Federal Response Plan (FRP), which details
the roles and responsibilities of federal agencies during national emergencies.
If a terrorist event overwhelms the capacities of local and state authorities and requires a
presidential disaster declaration, FEMA will implement the FRP and coordinate not only its own
response activities, including the dispatching of federal pharmaceutical stockpiles, but also those
of as many as 28 other federal agencies that may provide assistance.
Local governments (with support from state and federal agencies when appropriate) shoulder
much of the initial responsibility for providing effective medical response to a terrorist attack.
Local public health systems will be called upon to provide protective and responsive medical
measures such as patient care, immunizations or prophylactic drug treatments for exposed
populations, and decontamination of the environment. For more information, visit the National
Association of County and City Health Officials.
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Disinfection and sterilization
Environmental decontamination - Anthrax: Increased media attention to Anthrax
contamination following incidents around the nation raises questions about managing potentially
contaminated personnel and the environment. The chapter on Anthrax in the Control of
Communicable Diseases Manual from the American Public Health Association recommends
basic skin cleansing with soap and water. Effective disinfection of potentially contaminated
surfaces can be accomplished with diluted (1:10) bleach.
Medical equipment: Other tuberculocidal and sporicidal agents may be appropriate for certain
circumstances and general guidance may be found in the comprehensive APIC guideline for
selection and use of disinfectants or APIC.
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Mail handling
Suspicious packages: Issues will continue to surface, such as the anthrax exposures related to
mail handling that have occurred on the east coast. Viewers are urged to check the CDC site on a
regular basic for new information, such as the CDC October 12th, 2001 advisory on handling
suspicious packages, and laboratory information for transporting specimens, and the October
27th update on handling mail. CDC has also published Interim Recommendations for Protecting
Workers from Exposure to B. anthracis in Works Sites Where Mail is Handled or Processed on
November 2,2001.
Gloves: The CDC comprehensive recommendations address engineering, administrative, and
housekeeping controls as well as personal protective equipment. The recommendations suggest
CANUS Corporation Safety mail workers avoid latex gloves because of the risk of latex allergy. The choice (e.g., vinyl or
nitrile) should be based on fit, durability, and comfort; sterile gloves are not needed.
OSHA: The Occupational Safety and Health Agency has provided an assessment tool for
determining levels of risk for exposure to anthrax spores and protective measures for each. See
OSHA’s Workplace Risk Pyramid.
Updating readiness
Staying current: Facilities should continue reassessing their emergency readiness plans in light
of the events of September 11. All facets of planning must be re-examined; most importantly,
coordination with local emergency planning agencies in surrounding communities as well as
communications with local and state public health should be enhanced. The American Hospital
Association has provided several documents that may be timely and useful in the current
assessment. You may download the AHA’s 2001 document on Hospital Preparedness for Mass
Casualties as well as an Emergency Preparedness Checklist or visit the AHA Web site on
emergency readiness.
Products and equipment: Disaster preparedness planning requires a wide variety of supplies,
equipment and resources, including personal protective equipment (PPE), decontamination
equipment, and training. Visit the products and equipment section of the Safety Web for details
about various safety equipment resources.