Hospital Preparedness Plans

Disaster preparedness can be defined as planning, infrastructure, knowledge, capabilities, and education comprising the main elements of maintaining preparedness. ^{Reference Adini, Goldberg, Laor, Cohen, Zadok and Bar-Dayan30} Appropriate preparedness can only be obtained through hospital preparedness plans. ^{Reference Kaji, Koenig and Lewis31} Lack of preparedness plans in hospital negatively impacts the response activities of hospitals, such as managing victims and patients exposed to biological agents. ^{Reference Bennett32} Plans must also establish orientation and training programs for staff who participate in response operations that address roles and responsibilities, information and skills required, monitoring of staff knowledge, skills, competencies, participation, incident reporting, and program evaluation. ^{Reference Schultz, Mothershead and Field33} The plan should address the physical infrastructure needs of the biological hazards response plan, such as biocontainment areas in the emergency department, or the hot zones and isolation units. ^{Reference Shaikh34} The hot zone is the area in which the incident occurred and in which contamination exists. All individuals entering the hot zone must wear the appropriate levels of PPE and be decontaminated before leaving. ^{Reference McIsaac35} Components of hospital preparedness plans for biological hazards include procedures for activation, notification, structure of the command and response communications and media relations, evacuation and establishment of alternate care sites, personnel and facility protection, and recovery issues. ^{Reference Schultz, Mothershead and Field33,Reference White36}

Risk Assessments

Risk assessments include evaluation of hazards or potential threats, profiling of hazards maps, capacity assessment and estimation of potential human and economic losses based on the exposure and vulnerability of community or hospital to the threats and incidents. ^{Reference Jonidi Jafari, Baba and Dowlati37} Assessments should be conducted in structural, nonstructural, and functional aspects. ^{38,Reference Ippolito, Puro and Heptonstall39}

Vulnerabilities of hospital should be forecasted, and the risk assessment should include the entire service area of the hospital. ^{Reference Schultz, Mothershead and Field33} Hospitals and laboratories are recommended to consider biosafety and biosecurity issues and to prepare their response plans based on the most likely risks and categorization of biological agent groups. Risk assessment identifies the severity of infection, the potential for transmission to exposed people and to the wider community or environment, the possibility of patient admissions, and availability of effective prophylaxes and treatments. ^{Reference Ippolito, Puro and Heptonstall39}

Hospital Incident Command System (HICS)

A biological hazards will need a developed incident management and command system to integrate the different response functions. ^{Reference Schultz, Mothershead and Field33} An important strategy for organizing hospital staff for mass casualties resulting from exposure to a biological agent is to implement a Hospital Incident Command System (HICS). HICS provides a common disaster language, a representative authority or a commander, and a flexible infrastructure framework for the disaster response that can expand as needed, depending on the size and complexity of the incident. ^{Reference Koenig, Kahn and Schultz40} According to the situation and the type of hazards, the commander may choose to activate a medical-technical specialist officer unit with an infectious disease physician on staff. In situations involving a hazardous material (HazMat), such as internal or external biological agent release, the commander activates the HazMat branch subgroup of the operations section. The HazMat branch will have the personnel and equipment to address agent recognition, monitoring, and victim decontamination. ^{41,Reference Vastag42}

Hospital Collaboration

Biological hazards pose unique challenges to hospitals because they may go unrecognized for days, with the possibility of victims and patients admitting to different hospitals. Collaboration and information sharing with other hospitals and community physicians could provide the possibility of identifying suspected exposure to the biological agent. The local health department would obtain information from hospitals as part of the laboratory or syndromic surveillance system. Mutually, the hospitals would benefit from the health department’s information regarding a suspected case of biologic hazards or bioterrorist agent, in a timely manner. ^{Reference Shaikh34,Reference Vastag42} Hospitals were required to collaborate with the following:

• Local public health system and the medical system

• Law enforcement

• Emergency medical services (EMS)

• HazMat teams

• Centers for Disease Control (CDC) and the local health department

• Environment agency

• Water authority

• Military medicine experts

• Physicians and fire departments^{Reference Kao, Ko, Guo, Chen and Chou43-Reference Niska45}

During disasters and emergencies, hospitals must collaborate about surge capacity in equipment and supplies, deployment of physicians and other hospital staff, and use of spaces. ^{Reference Gursky46}

Health Risk Communications

Risk communication encompasses provision of exact, timely, complete, and easily understood information to the community about the following:

• The incident

• Control and mitigation effort

• Safety self-protection

• Provision of information to hospital staff about diagnosis

• Interventions after and post exposure

• Communication with families and others close to those affected by the emergency

• Communication with the news media

• Communication within and between all those involved in emergency management^{Reference Ippolito, Puro and Heptonstall39}

Internal hospital communications involve the need to communicate with the following parties:

• Staff concerning the nature of the event

• Implement the hospital disaster plan

• Activate the staff “call back” and rotation system to ensure adequate manpower

• Provide critical incident stress debriefing for both personnel and their families^{Reference Rinnert47}

During biological incidents, effective risk communication will play an important role in providing essential information to the public and hospital staff. ^{Reference Koenig, Kahn and Schultz40} Inappropriate communication could result in rumors and incorrect information spreading, which may result in overwhelming the hospital, especially emergency rooms, because of surge of patients and inappropriate induced demand. ^{Reference Scharoun, van Caulil and Liberman48}

Early Detection and Surveillance System

The aim of a syndromic surveillance system is to provide an early warning for the onset of an epidemic, as well as tracking and quick recognition of epidemics, which allow more effective health care responses, especially in the event of a bioterrorist attack. ^{Reference Buehler, Whitney, Smith, Prietula, Stanton and Isakov49} Early detection is essential for preparedness against a biological hazard, including the provision of chemoprophylaxis, early proper medical therapy and vaccination to improve the chance of survival, and also public health measures such as quarantine and isolation. ^{50,Reference Lepler and Lucci51} It is critical to recognize the symptoms of a bioterrorist agent and differentiate it from symptoms common to other disease. ^{Reference Scharoun, van Caulil and Liberman48} Specifically, surveillance systems can reduce the infection with a pathogen in order to detect the disease or an outbreak caused by a biological agent and improve its early detection. ^{Reference Buehler, Berkelman, Hartley and Peters52} Patients infected with a biological agent may initially appear to have a routine medical illness. ^{Reference Koenig, Kahn and Schultz40} Syndromic surveillance uses health-related data that precede diagnosis and signal a sufficient probability of a case or an outbreak to warrant hospital response. ^{Reference Romao, Martins, Germano, Cardoso, Cardoso and Freitas53}

Diagnostic Laboratories

During biological hazards, hospitals should strengthen their diagnostic laboratory capability for rapid detection and identification of biological agents. For example, blood culture bottles and possibly continuous-monitoring blood culture instruments should be stockpiled. In the case of a surge of patients’ specimens, hospital laboratories should have a limited number of level II Biological Safety Cabinets (BSC), with isolation and negative pressure rooms. ^{Reference Gilchrist54} Therefore, assigning additional space to diagnostic laboratories and modifying the existing airflow in rooms are essential. ^{Reference Shapiro55} Laboratory experts and technicians should be trained in bioterrorism, because they are one of the first responders to detect the presence of an unusual biological agent or disease process. Procedures need to be in place for the safe handling and transport of specimens to specialized laboratories. ^{Reference White36}

Personnel and Facilities Protection

Most of the time, infected patients and victims exposed to biological agents are not decontaminated upon their arrival to the hospitals. Therefore, the staff and facilities may be exposed to the biological agents. ^{Reference Chan, Yeung and Tang56} Hospital staff involved in direct handling of infectious patients should be protected by appropriate PPE. Also, hospital personnel should be trained and adapted to the use of PPE. ^{Reference Mortelmans, Gaakeer, Dieltiens, Anseeuw and Sabbe23,Reference Chan, Yeung and Tang56,Reference Loutfy, Wallington and Rutledge57} PPE includes masks, gloves, protective clothing, eye shields, face shields, shoe covers, and also powered air purifying respirator (PAPR) devices. ^{Reference Wetter, Daniell and Treser24,Reference Luther, Lenson and Reed58} Ideally, for agents transmitted by respiratory droplets, an N-95 mask would theoretically be adequate. In an ideal situation, a high-efficiency particulate air (HEPA) filter mask might be more appropriate. ^{Reference Koenig, Kahn and Schultz40}

Mass Prophylaxis and Vaccination

Some diseases caused by biological agents, such as anthrax, tularemia, and plague, can be prevented through adequate antibiotic prophylaxis. The aim of any hospital prophylaxis plan is to provide a unit in order to maintain staff such as emergency department and laboratory personnel who may have early exposure to the biological agent during and after a bioterrorism event. Staff and their family would get prophylaxis only if they were considered to have likely been exposed to biological agents. ^{Reference Sharp, Brennan, Keim, Williams, Eitzen and Lillibridge59} Hospital staff may not want to come to the hospital, particularly without some prophylaxes. ^{Reference Katona44,Reference Coelho and García Díez60} Thus, pharmaceuticals and vaccines must be distributed quickly and efficiently to first responders before disease transmission to others. ^{Reference Katona44} Post-exposure vaccination and prophylaxes are essential measures to reduce morbidity and mortality after biological hazards. ^{Reference Koenig, Kahn and Schultz40}

Patients and Facility Decontamination

With biological hazards, such as overt release of a biological weapon, decontamination will play a role in patient management. The presence of decontamination facilities outside and downwind of a hospital is necessary. ^{Reference Macintyre, Christopher and Eitzen61} For biological agents such as anthrax spores, which can survive in the environment for decades, decontamination has been recommended. ^{Reference Inglesby, O’Toole and Henderson62,Reference Lepler and Lucci51} Specific hospital personnel who perform triage and stabilizing should be trained to perform decontamination activities. ^{Reference Rinnert47} Decontamination facilities should consider shelter, warm water, and clothing for operations in winter. ^{Reference Case, West and McHugh22} Use of external decontamination facilities that can be activated quickly, barriers to provide patient privacy, and the use of warm water and soap should be sufficient to remove most biological agents. ^{Reference Schultz, Mothershead and Field33} Internal decontamination stations protect against warm and cold weather but have the disadvantage of permitting contaminated patients and victims to enter the hospital. ^{Reference Cole63}

Education and Exercise

All hospital staff should be trained and educated on all aspects of biological hazards. ^{Reference Torani, Majd, Maroufi, Dowlati and Sheikhi64} The main components of an education plan include agent detection and recognition, hospital incident command structure, response support, personnel safety and protection, decontamination, isolation and quarantine, infection-control policies and procedures, triage, prophylaxis activities, psychological effect management, risk communication, treatment, and fatality management. ^{Reference Luther, Lenson and Reed58} Hospitals should begin by testing their preparedness plan with regular exercises to assess performance and to ensure correct staff response. ^{Reference Chan, Yeung and Tang56} Exercises should be performed to recognize weakness; enhance teamwork; improve coordination; and promote skills, knowledge, and competencies. ^{Reference Shaikh34,Reference Klein, Brandenburg, Atas and Maher65} Hospital exercises might be crafted to reflect the hospital preparedness status for biological attacks and those for severe epidemics and pandemics, thus encouraging the hospital to review its status. ^{Reference Niska and Burt66}

Psychological Effects Management

A key component of any biological hazards preparedness plan will be providing psychological care to exposed victims, involved hospital personnel, and affected communities. ^{Reference Koenig, Kahn and Schultz40} Psychological and psychosocial support for both patients and the hospital staff are necessary during the biological hazards. Staff are affected by the fear of contracting infectious disease and the anxiety caused by their families’, friends’, and colleagues’ disease. Patients experience stress because of their quarantine and isolation, fear for their lives, guilt, anger, anxiety, and depression. Psychological teams in hospitals (including social workers, security personnel, psychiatric nurses, psychiatrists, and infectious disease specialists) can developed a plan for biological hazards in relationship with hospitals’ psychiatry departments to manage and care for the psychological impact on patients and hospital staff. ^{Reference Loutfy, Wallington and Rutledge57}

Biological Hazard Specialized Team

One unique approach to biological hazards is developing special teams. ^{Reference Loutfy, Wallington and Rutledge57} In general, multidisciplinary teams developed and organized for response should include disaster management experts, physical plant/engineering, facilities maintenance, bioengineering, occupational physicians, emergency physicians, emergency nurses, toxicologists, infectious disease physicians, epidemiologists, infection-control experts, security personals, safety officers, hospital administrators, facility engineers, mental health practitioners, volunteer services coordinators, pharmacists, and health educators. ^{Reference Shaikh34,Reference White36,Reference Rinnert47}

Infection Control Services and Isolation

Effective infection control services are important in biological agent control and may operationalize victim and patient isolation needs. ^{Reference Rinnert47,Reference Rebmann, Carrico and English67} During a biological hazard, the safety officer should collaborate with medical-technical specialists (biological/infectious disease) to determine what information and protective measures are required. ^{41,Reference Loutfy, Wallington and Rutledge57} Major infection control practices for biological hazards include checking the availability of PPE, hand hygiene, sharps safety and disposal arrangements, removing and disposing of the PPE, arrangements for cleaning, and ensuring environmental hygiene. Also, infection control planning for biological hazards should identify and consider the extra space, such as negative airflow rooms suitable for airborne infection and respiratory systems of available isolation or single rooms. ^{Reference Case, West and McHugh22} Isolation rooms and rooms under negative pressure should be established in a suitable location and in sufficient numbers, as it should be the case for a plan to increase this capacity through portable high efficiency particulate air devices. ^{Reference White36}

Increase Capability

An ability to increase capability is a major issue for hospitals in disaster and overcrowding conditions. ^{Reference Rebmann, Carrico and English67} Increasing capability, or the ability to rapidly respond to a sudden and dramatic increase in needs, has been addressed as one of the components of preparedness so hospitals can effectively respond to disasters. ^{Reference Shapiro55} Increasing capability comprises 3 components: staff, stuff, and structure. Structure consists of both the management infrastructure as well as the physical space required to provide for infectious patients’ care. ^{Reference Koenig, Kahn and Schultz40,Reference Koenig, Cone, Burstein and Camargo68} Hospitals must have a preparedness plan to increase capability for response to biological hazards, as the potential large number of victims requiring medical care would soon overwhelm hospital facilities. Plans to expand the hospital capability internally and then to alternate care sites can help mitigate the impact. Expansion requirements include personnel, supplies and equipment, and space. ^{Reference Bennett32,Reference White36}

Hospital Personnel and Volunteer Forces

Developing hospital personnel to meet the rapidly increasing demand for services and staff in the aftermath of a biological hazard may be one of the most challenging aspects of preparedness to respond to biological hazards. Some staff members may themselves be infected by exposure to the biological agents or may fail to come to work for a variety of reasons, such as caring for their families. A list of alternate personnel should be prepared and a recall system for mobilizing adequate on-call personnel should be developed. Sufficient numbers of hospital staff include infectious disease physicians, emergency medicine, surgeons, intensivists, nurses, pharmacists, radiology technicians, infection control, clinical laboratory experts, and respiratory therapy. These types of staff will be most useful in addressing an infectious disease outbreak. ^{Reference Rebmann20,Reference Rinnert47} Possible sources of extra personnel could include staff from other hospitals, closed clinics, or outpatient surgery departments; hospital retirees; medical, nursing, and allied healthcare students; and volunteer forces. ^{Reference White36} One solution for the shortage of specialized hospital staff could be pre-identified health care volunteers within or outside the affected community. ^{Reference Salmani, Seyedin, Ardalan and Farajkhoda69} These individuals will require proper education and orientation and may be asked to perform beyond their levels of competency under supervision. Because it is possible that terrorists may seek to volunteer, these persons must be selected cautiously. ^{Reference White36}

Supplies and Equipment

A main consideration in the preparedness for biologic hazards is stockpiling of necessary medications, supplies, and equipment. ^{Reference Koenig, Kahn and Schultz40,Reference Hui, Jian-Shi, Xiong, Peng and Da-Long70} Even if hospitals usually have proper and sufficient treatments and pharmaceutical procedures, during biological disasters their supplies (prophylaxis/medications) would be limited. ^{Reference Bennett32,Reference White36} In the case of a biological hazard, casualties are likely to be widespread and medications may be in demand from multiple sources. ^{Reference Koenig, Kahn and Schultz40,Reference Barbisch71} Hospitals must seek other possible sources of equipment, including neighboring medical facilities, pharmacies, medical suppliers, and veterinarians. ^{Reference Schultz, Mothershead and Field33} These plans include increasing the ability of the hospital to quickly prepare large quantities of antibiotics, vaccines, and antitoxins; equipment to provide standard precautions; PPE; disposable clothing for decontaminated patients; ventilators and biohazard bags; HEPA filters, supplies routinely required for all patients, such as bed pans, linens, and other materials in excess of anticipated demand. ^{Reference Schultz, Mothershead and Field33,Reference Katona44,Reference Shapiro55} Ventilators are one of type of equipment that is likely to be in short supply after a biological hazard, so purchasing portable, disposable ventilators is critical. ^{Reference White36}

Hospital Security

Hospitals may become terrorist targets especially during disasters and when the hospitals are overcrowded. ^{Reference White36} Hence, hospital officials must improve their security personnel in an effort to provide crowd control and protection for staff and patients. ^{Reference Bennett32} Patients should be isolated or quarantined for prevention of spread of infection. Patients must be restricted exit from isolation by security personnel. Reserve security personnel are needed at hospital entrances, triage points, emergency departments, and isolation units to prevent unauthorized access. Reporting the suspected terrorist events should begin with local law enforcement, police, and local health departments. ^{Reference White36} During biological hazards, security personnel must be in place to control the flow of human gathering inside and around the hospital. In addition, security must monitor all vehicular traffic and assure that ambulances are able to transport patients rapidly. ^{Reference Scharoun, van Caulil and Liberman48}