Hospital Preparedness for Victims of Chemical or Biological Terrorism Essay

Hospital Preparedness for Victims of Chemical or Biological Terrorism Essay ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Hospital Preparedness for Victims of Chemical or Biological Terrorism Essay Read the attached article and address the bullet items listed below: Hospital Preparedness for Victims of Chemical or Biological Terrorism Essay What is the objective of this study? Describe the methods used. What are the results? What is your impression of the results? Were there any statistics in this paper that stuck out to you? Requirements: 400 Words Total APA hospital_preparedness_for_victims_of_chemical_or_biological_terrorism.pdf Hospital Preparedness for Victims of Chemical or Biological Terrorism A B S T R A C T Objectives. This study examined hospital preparedness for incidents involving chemical or biological weapons. Methods. By using a questionnaire survey of 224 hospital emergency departments in 4 northwestern states, we examined administrative plans, training, physical resources, and representative medication inventories. Results. Responses were received from 186 emergency departments (83%). Fewer than 20% of respondent hospitals had plans for biological or chemical weapons incidents. About half (45%) had an indoor or outdoor decontamination unit with isolated ventilation, shower, and water containment systems, but only 12% had 1 or more self-contained breathing apparatuses or supplied air-line respirators. Only 6% had the minimum recommended physical resources for a hypothetical sarin incident. Of the hospitals providing quantitative answers about medication inventories, 64% reported sufficient ciprofloxacin or doxycycline for 50 hypothetical anthrax victims, and only 29% reported sufficient atropine for 50 hypothetical sarin victims (none had enough pralidoxime). Conclusions. Hospital emergency departments generally are not prepared in an organized fashion to treat victims of chemical or biological terrorism. The planned federal efforts to improve domestic preparedness will require substantial additional resources at the local level to be truly effective. (Am J Public Health. 2001;91:710–716) 710 American Journal of Public Health LCDR Donald Clark Wetter, PA-C, MPH, USPHS, William Edward Daniell, MD, MPH, and Charles David Treser, MPH There is growing concern about possible terrorist use of chemical or biological weapons against civilian populations. Although such incidents have occurred rarely to date, the need for concern is illustrated graphically by the sarin nerve gas attack in a Tokyo subway by the Aum Shinrikyo cult in 1995, causing 11 deaths and sending thousands of people to hospitals.1,2 The United States is not immune from terrorist attacks within its borders, as evidenced by the bombings of the World Trade Center in New York and the Murrah Federal Building in Oklahoma and by a 1984 incident in Oregon, where members of a religious commune deliberately contaminated restaurant salad bars with Salmonella typhimurium, causing 751 cases of gastroenteritis.Hospital Preparedness for Victims of Chemical or Biological Terrorism Essay 3 One theoretical model predicted that a terrorist attack releasing Bacillus anthracis spores in prevailing winds toward the suburb of a major city could cause up to 50000 cases of anthrax, with more than 32000 deaths, in an exposed population of 100000 people.4 The US government is taking seriously the need to prepare for terrorist attacks involving weapons of mass destruction. Presidential Decision Directive 39 in 1995 triggered actions among many national agencies.5 Congress enacted the Defense Against Weapons of Mass Destruction Act of 1996, requiring development of a Domestic Preparedness Program, including efforts to improve the capabilities of local emergency response agencies.5,6 The program developed training course materials for local responders, and it will train local responder-trainers in 120 cities by fiscal year 2001.7 True preparedness to reduce loss of life from an incident involving a biological or chemical weapon is critically dependent on the availability of resources at the local level.8 Federal response teams and resources probably would not reach the scene of an unanticipated terrorist attack in time to substantially reduce mortality from a chemical weapon or until after a population exposed to a biological weapon had dispersed.5 The Domestic Preparedness Program, however, has included no systematic efforts to integrate hospitals into response plans, and it has provided only limited funds to acquire resources for state and local responders and none for hospitals.7,9 A large proportion of hospitals probably are poorly prepared to handle victims of chemical or biological terrorism. Commonly, hospitals are not fully prepared to respond to massive casualty disasters of any kind, either in their capacity to care for large numbers of victims or in their ability to provide care in coordination with a regional or federal incident command structure.10 Surveys of hospital emergency departments (EDs) have found broadly prevalent deficiencies in knowledge, plans, or resources for responding to hazardous materials or radiation incidents.11–14 Even relatively small-scale hazardous materials incidents have overwhelmed the response capacities at some hospitals, producing symptoms in secondarily exposed ED staff or necessitating ED evacuations.15–17 However, although the state of preparedness for hazardous materials incidents provides some indication of the level of preparedness for chemical weapons inciAt the time of this study, Donald Clark Wetter was with the Extended Degree Program, School of Public Health and Community Medicine, University of Washington, Seattle. He is now with the Office of Emergency Preparedness, US Public Health Service Region II, New York, NY. William Edward Daniell and Charles David Treser are with the Department of Environmental Health, School of Public Health and Community Medicine, University of Washington, Seattle. Hospital Preparedness for Victims of Chemical or Biological Terrorism Essay Requests for reprints should be sent to LCDR Donald Clark Wetter, PA-C, MPH, Office of Emergency Preparedness, US Public Health Service Region II, 26 Federal Plaza, Room 3835, New York, NY 10278 (e-mail: dwetter@hrsa.gov). This article was accepted August 10, 2000. Note. The opinions and findings in this article are those of the authors and should not be construed as official policies or positions of the US Public Health Service. May 2001, Vol. 91, No. 5 dents, the hazardous materials model may have limited applicability to the potential types and scale of problems associated with a chemical weapons incident, and it probably has little or no relevance for biological weapons incidents.18 In this context, an increasing number of authors writing in major journals have advocated the need for health care providers and hospitals to make specific plans for response to incidents involving chemical or biological weapons, and they have put forth principles and guidelines for such plans.18–24 Other reviewers, however, have expressed concern that the magnitude of government support for domestic terrorism initiatives may be disproportionate to the probability of such incidents occurring, particularly compared with government support for initiatives to address existent public health problems that affect large segments of the population.25 A substantial need for additional expenditures at the local level to ensure true preparedness for managing victims of terrorist incidents, particularly without the commitment of additional federal funds, could reduce the availability of limited state and local funds for other health care and public health problems. There is a clear need for information about current hospital preparedness for terrorist attacks, to provide a foundation for systematic planning and broader discussion about relative costs, probable effectiveness, and overall societal priorities. To address this need, the present study examined existing administrative, physical, and medication resources at hospitals in 4 northwestern states for managing the victims of incidents involving chemical or biological weapons. Methods This study was a cross-sectional questionnaire survey of all hospital EDs in US Public Health Service Region X (Alaska, Idaho, Oregon, and Washington). A subsample of respondent hospitals was visited to verify selected questionnaire responses. Study procedures were approved in advance by the University of Washington Human Subjects Review Committee. Questionnaire Survey We used the American Hospital Association directory26 to identify all hospitals in Region X for potential inclusion in the study.Hospital Preparedness for Victims of Chemical or Biological Terrorism Essay Pediatric, urgent care, psychiatric, and rehabilitation facilities were excluded. A selfadministered questionnaire, cover letter, and postage-paid return envelope were mailed to 224 eligible hospitals, addressed to the “manMay 2001, Vol. 91, No. 5 ager” of the ED. Surveys were mailed up to 3 times (in June–July 1998) if there was no response to initial mailings, with the third mailing addressed to a specific person identified by a telephone call to the hospital. The questionnaire requested information about (1) hospital and ED demographics; (2) respondents’ awareness and opinions; (3) planning, training, and drills within the last 24 months; (4) patient isolation and decontamination resources; (5) personal protective equipment; and (6) inventory of selected antidotes. Questions about hazardous materials incidents assessed readiness for presentations similar to those that would arise after a chemical weapons incident. The questionnaire asked whether the ED had (1) an indoor decontamination area (a) with or without ventilation isolated from the rest of the hospital and (b) including or adjoining a shower, with or without a separate water containment system; (2) portable outdoor decontamination equipment; or (3) other relevant resources. Atropine and pralidoxime were selected to represent antidotes for nerve agents and ciprofloxacin and doxycycline for anthrax and other biological agents. Data Analysis Data were examined for possible associations between selected preparedness variables and 3 primary independent variables: hospital location (rural or urban),27 ED annual census, and proximity to the US Army chemical weapons depot in Umatilla, Ore. The ED annual census was categorized post hoc according to sample-distribution tertiles (low, <5000 visits/year; medium, 5000–15 000; high, >15 000). The low and medium census categories were combined for some analyses, because there were only 2 low-census urban hospitals. On the basis of the probable transport distance for patients immediately after an accidental chemical release and computer-generated plume estimates, proximity to the Umatilla depot was defined as 35 miles or less.28 Responses of “aware” and “somewhat aware” were combined into 1 category. Comparisons used ?2 or Fisher exact tests to assess statistical significance. Relative risks and Taylor series 95% confidence intervals were calculated with Epi Info.29 All other analyses used SPSS for Windows.30 Preparedness for Hypothetical Incident The analysis examined the preparedness of individual hospitals to initiate treatment in 2 hypothetical incidents involving 50 individuals exposed to either a chemical weapon (sarin) or a biological weapon (anthrax). For the hypothetical sarin incident, medication preparedness was defined by the reported inventory of atropine and pralidoxime. Hospital Preparedness for Victims of Chemical or Biological Terrorism Essay Using the Tokyo incident as a model, we projected treatment to require 160 mg of atropine (2 mg each for 40 patients and 8 mg each for 10 patients) and 96 g of pralidoxime (2 g each for 48 patients).31,32 The present study defined “minimum recommended” physical resource preparedness by the following criteria: (1) a hazardous materials or chemical weapons plan; (2) either (a) an ED indoor area with isolated ventilation and a shower with water containment (“integral decontamination unit”) or (b) an outdoor portable decontamination unit; (3) at least 1 self-contained breathing apparatus or supplied air-line respirator; and (4) at least 1 chemical-protective garment. Less stringent definitions for “questionably effective” levels of physical resource preparedness included (1) access to a conventional shower in lieu of criteria 2a and 2b, given that wastewater containment may be a low priority in a mass casualty situation,24 or (2) a chemical cartridge air-purifying respirator in lieu of criterion 3. A chemical cartridge respirator, particularly in combination with a high-efficiency particulate air filter, could provide protection against some chemical agents.24 For the hypothetical anthrax incident, medication preparedness was defined by the reported availability of ciprofloxacin or doxycycline sufficient to provide prophylaxis for 2 days, with the assumption that replacement stocks would become available thereafter.33–35 The risks of secondary aerosolization and person-to-person transmission of anthrax are negligible36,37; therefore, scenario preparedness was defined only by having a biological weapons plan and the necessary antibiotic supply, without any requirement for specific physical resources. Results Survey Participants Responses were received from 186 of 224 contacted hospitals (83%; Table 1). Most respondents were registered nurses (n = 162; 87%). The others were physicians (n=10; 5%), physician assistants or nurse practitioners (n= 4; 2%), and other professionals (n = 9; 5%). The response rate was highest in Idaho and Washington (90% and 86%), lowest in Alaska (67%), and intermediate in Oregon (80%). Hospital Preparedness for Victims of Chemical or Biological Terrorism Essay The response rate was similar for rural hospitals (n = 114; 84%) and urban hospitals (n = 72; 81%). Most respondent hospitals (61%) were in rural locations. There were proportionally American Journal of Public Health 711 TABLE 1—Hospital Emergency Departments Participating in Survey of Hospital Preparedness for Incidents Involving Chemical or Biological Weapons Alaska No. of hospitals contacted No. of hospitals responded Hospital locationa Rural, n (%)b Urban, n (%)b No. located ?35 miles from US Army chemical depot c Idaho Oregon Washington Total 24 16 42 38 64 51 94 81 224 186 14 (87.5) 2 (12.5) 0 34 (89.5) 4 (10.5) 0 27 (52.9) 24 (47.1) 2 (3.9) 39 (48.1) 42 (51.9) 3 (3.7) 114 (61.3) 72 (38.7) 5 (2.7) a Urban = within a standard metropolitan statistical area; rural = all other locations. Values in parentheses represent percentages of respondent emergency departments in each state (total n = 186). c Army chemical weapons depot at Umatilla, Ore. b more rural hospitals in Alaska and Idaho than in Oregon and Washington (Table 1). Overall, median ED size was 8 beds (range = 1–58) and median hospital size was 64.5 beds (range=7–697).26 Median ED census for 1997 was 10900 patient visits (range=739–80000). Most urban hospitals (65%) reported more than 15000 ED patient visits per year, whereas most rural hospitals (75%) reported fewer annual visits. Conversely, 42% of rural hospitals reported fewer than 5000 visits per year, but only 2 urban hospitals fell into this low-census category. Responses were received from 5 of 7 eligible hospitals located within 35 miles of the US Army chemical weapons depot at Umatilla, Ore (Table 1). Respondent Awareness and Opinions Slightly more than half of the respondents were aware (or slightly aware) of local or state preparedness plans, and about one third were aware of plans or resources at the national level (Table 2). Only 14% reported any familiarity with applicable federal legislation. In general, respondents from urban hospitals reported levels of awareness equal to or higher than those reported by respondents from rural hospitals, and respondents from larger urban hospitals reported the greatest awareness. Nearly half of the respondents (48%; n= 90) answered yes to a final question asking whether “biological and/or chemical weapons are a real enough threat to your community that your hospital should make specific plans in preparation to treat victims of such weapons.” The other respondents answered no (41%; n= 76) or gave no answer (11%; n=20) to this question. Twenty-one cited location in a rural area as the reason for no concern. Sixteen cited concern because of proximity to a military facility and 3 because of closeness to militia groups. Hospital Preparedness for Victims of Chemical or Biological Terrorism Essay Administrative Plans and Training About 80% of the hospitals reported having a plan for response to hazardous materials 712 American Journal of Public Health incidents, whereas fewer than 20% had response plans for incidents involving biological or chemical weapons (each, P < .001; Table 2). Urban hospitals were 3 times as likely as rural hospitals to have response plans for incidents involving chemical weapons (relative risk [RR]=3.4; 95% confidence interval [CI]= 1.7, 6.8) or biological weapons (RR=3.4; 95% CI = 1.5, 8.0), with no significant difference relative to urban ED census. The number of hospitals that reported training for response to incidents involving hazardous materials was less than the number reporting the existence of plans for such a response (Table 2). However, the opposite was seen for weapons incidents, where training was reported more often than hospital plans. Ten hospitals reported conducting 1 practice drill within the preceding 24 months for a chemical weapons incident, and 5 reported 2 or more drills. A smaller number of hospitals reported practice drills for response to a biological weapons incident (n=5). Isolation and Decontamination Resources Only 21% of hospitals reported having an ED indoor area with isolated ventilation, shower, and water containment systems (indoor “integral decontamination unit”; Table 3). About a third of these same hospitals (14 of 39) additionally had outdoor portable decontamination units, and 45 other hospitals (24%) had an outdoor decontamination unit but less than a fully integral indoor unit. Another 27% of EDs at least had access to a conventional shower, without separate water containment, and in most cases without isolated ventilation (46 of 51). There were no isolation or decontamination resources of any type, fixed or portable, at 25% of the hospitals. Urban hospitals were more likely to have integrated indoor or portable decontamination units (urban, 58%; rural, 37%; RR = 1.7; 95% CI = 1.2, 2.5). Among urban hospitals, however, there was no sig- nificant difference between those with relatively busy and those with less busy EDs (RR = 1.1; 95% CI = 0.8, 1.6). Personal Protective Equipment Most hospitals reported having no respiratory protective equipment that would be appropriate against chemical agents (Table4). Only 23 (12%) reported at least 1 self-contained breathing apparatus (2–4 per hospital) or at least 1 air-line respirator (1–6 per hospital), or both. Nine of these hospitals also had at least 1 chemical cartridge mask.Another 20 hospitals (11%) had only chemical cartridge masks. Of all hospitals with chemical cartridge masks, most had only 1 or 2 masks (48%). Urban hospitals were more likely than rural hospitals to report having any such form of respiratory protective equipment (urban, 40%; rural, 14%; RR=2.9; 95% CI=1.9, 9.0).Hospital Preparedness for Victims of Chemical or Biological Terrorism Essay The availability of chemicalprotective garments had a similar distribution. In addition to the limited available self-contained breathing apparatus and air-line respirators, most hospitals had respiratory-protective equipment that would provide at least partial protection against biological agents and particulate chemical agents, including high-efficiency particulate air masks and surgical masks. Preparedness for Hypothetical Incident Eighty percent of respondents provided quantitative information about hospital medication inventories (“central pharmacy and emergency department” supply). The remainder gave only qualitative or no information. Of respondents with quantitative answers, 29% (41 of 143) reported an atropine supply sufficient to treat 50 patients in the hypothetical sarin incident (see “Methods” section), although another 22% (n=32) reported at least half the necessary amount. The median reported amount of atropine was 103 mg at urban hospitals and 60 mg at rural hospitals. Urban hospitals were almost twice as likely as rural May 2001, Vol. 91, No. 5 TABLE 2—Respondent Awareness of and Hospital Administrative Preparedness for Terrorist Incidents Involving Chemical or Biological Weapons Urban Hospitals,b No. (%) ?15000 >15000 Visits/Year Visits/Year (n = 22) (n = 47) a Hospital Location, No. (%) Total No. (%) Rural (n = 186) (n = 114) Respondent aware … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10