Disaster Management: Healthcare Professionals Working Together
A Conversation With David Vukich, MD, Chairman of the Department
of Emergency Medicine at the University of Florida
By Kelly M. Pyrek
The first in a series examining disaster management and bioterrorism as related to infectious diseases.
Q: In your opinion, is the average US hospital prepared for a mass disaster like the Sept. 11 terrorism attacks?
A: US hospitals are doing a good job with what they've got. However, the average hospital is prepared for a disaster of only modest scope and complexity, such as 30-50 casualties at most and those better not all be critical, as many hospitals could not take that many patients. The average hospital has only modest resources before any disaster and, with personnel and resource reductions, they operate at or near capacity most of the time. My own emergency department (ED) continuously holds admitted patients because we do not have in-patient beds available. Now, imagine loading another 20, 30, or 50% critical on top of this. That being said, the New York and DC hospitals did very well with the tragedies of Sept 11. They did a terrific job and clearly could have handled many more patients. But what would have happened if the numbers were reversed, if there were 6,500 critically injured and 1,000 dead? If we suffer a bioterrorism attack, these may be more like the numbers we see.
Q: Do you think the average hospital's emergency plan adequately addresses potentially infectious agents being introduced into the facility's ED in a disaster scenario?
A: I think most disaster plans address this issue. My institution has a great plan and an incredible external de-con facility and personnel protection capability. The problem is that talking about it and recognizing it are two different things. We may not recognize a mass contamination until it's too late. We see a lot of viral illness, particularly during the winter. Who can tell an influenza outbreak from anthrax during the first 72 hours? Not me. We have trained as part of the Metropolitan Medical Strike Team (federally sponsored training) but this is still frightening. Again, I think we're doing the best we can with what we've got but it will take many more resources than the current EDs have in place to treat the mass of number of patients we already see and look for suspicious trends and react to them timely.
Q: What do you believe are the areas in a hospital's emergency plan that need the most attention?
A: I'm sure every hospital will be different. We have a regional poison control center here and toxicologists on faculty, so we're pretty sensitive to chemical agents and de-con. Others may not be so prepared for these agents. The only answer I can offer is planning, training, and resource management. I am most concerned about our recognizing the threat and avoiding high casualties among ED staff. This would be priority No. 1. Next would be training provided to combat agents and operating in ways foreign to most ED staff.
Q: What did Y2K teach hospitals that might be of use in a disaster scenario? Obviously there's a difference between an event that can be planned for and something like bioterrorism or a terrorist attack.
A: I don't have a good answer for this one. I know that a great deal of money was poured into Y2K. We better start pouring...
Q: Do you believe most hospital EDs' approach to triage requires further standardization and quality control?
A: I think the problem will be in field triage, getting the patient delivered to the best location for the needs of the patient. In New York they were all delivered to the closest hospital regardless of need. We all know better but we want to prevent that if this happens again.
Q: What would be the protocol in the average ED if a victim presents with a likely infectious disease or a wound that has the capacity to become infectious?
A: Of course, this happens several times per day. It's only something like TB that causes us to behave differently. Then there are protocols and in some cases, negative-flow isolation rooms. We have those, but only two in the ED. We would certainly use them but it sounds like they would rapidly be overcome, turning the entire ED into an isolation ward. We would then behave more like we were facing a chemical agent with hot and warm zones, etc.
Q: How can infection control practitioners support and assist members of the ED in a disaster situation?
A: Probably by serving as the infectious disease "conscience" of the staff, including reminding us of precautions, hot zones, de-con, and setting up the physical space in a disaster situation.
Q: Are ED staff well versed in disaster management with only twice-yearly drills as mandated by the Joint Commission?
A: Considering what happened on Sept. 11, there is no way we could prepare adequately. Even if we lived like the Israelis, whose civilians carry gas masks, we would not be prepared for the dissemination of anthrax or smallpox. This will be a balance between paranoid preparation and expenditures, and reasonable training and preparation. To me, it is clear that we need much, much more preparation. It's not that we don't work at this, but when you've already got sick people in front of you and you're routinely overwhelmed, it's difficult to justify spending precious resources training for what might be. Hospital EDs are working at or over capacity already. They need many more resources to do justice to this horrible topic. I am optimistic about our country's ability to further prepare. We are not unarmed in this battle; but, with current capability, we're taking a knife into a gunfight.
Industry Addresses Disaster Scenarios
While healthcare agencies couldn't have predicted the Sept. 11 terrorist attacks, they address key components of preparedness that infection control practitioners should keep in mind. Both the Health Care Financing Administration (HCFA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandate that US hospitals have sufficient numbers of personnel to meet patient needs in emergency/disaster care, that services are appropriate to patient needs, and that emergency services are integrated with other departments within the hospital.
JCAHO standards require hospitals to conduct two emergency management drills annually, designed to both provide training exercises as well as to identify unanticipated shortcomings in the current plan-especially as related to infectious agents. According to the AHA's report, "Biological terrorism will pose additional challenges of both uncertainty and fear. Reactions to unknown infectious agents can perhaps best be gauged by the reaction of healthcare workers to HIV/AIDS in the early 1980s, when some workers were reluctant to care for infected patients. Staff concerns can be reduced through appropriate education and the use of universal precautions until the nature of the disease agent is understood."
The Association for Professionals in Infection Control and Epidemiology (APIC) will present on Nov. 8 a bioterrorism audioconference with expert Michael Osterhelm, PhD.
Osterholm is author of the book "Living Terror," and will deliver the 75-minute audioconference. Public health and safety preparations and professional responses will be discussed. For registration information, log onto www.apic.org/bioterror/bioterrorproducts.cfm.