Many healthcare organizations confuse emergency operations planning with preparedness. In fact, developing an emergency operations plan (EOP) is but one component of an effective emergency management program to ensure preparedness. Healthcare organizations must develop plans for two different scenarios: one in which they serve as response agencies and one in which they are also victims of the incident. If one plan alone is developed, it must address both of these circumstances. An EOP can be thought of as an executive-level or leadership guidebook to manage the consequences of a disaster. It is a concept document that describes in general terms what response operations and functions will be performed or accomplished by what department, agency, or organization and under what circumstances. It is not a detailed reference tome to be used as a standard operating procedures manual by all response personnel during actual disaster operations.
In addition to EOPs, many organizations develop adjunctive standard operating procedures or job aids. These are more detailed, job-specific or department-specific checklists that delineate duties and responsibilities of each individual or position that is part of the organization response plan. Many of the details usually seen in EOPs should rightfully be placed in these documents, which provide instructions on how to do what is necessary in support of the EOP.
Of paramount importance in EOP development for incidents involving CBRNE are 15 basic issues. These areas are described in the following sections.
Notification. It is imperative that hospitals and emergency departments be included in a notification system that a disaster event has occurred that may affect healthcare services. In CBRNE events, the risk to the facility multiplies. Less than 20 percent of those contaminated by industrial chemicals are subsequently decontaminated on the scene (Levitin and Siegelson 1996); thus, the potential for arrival of contaminated victims at the healthcare facility must be considered and planned for.
Decontamination. Who will perform decontamination, where it is to be performed, how the disposition of victims and their belongings will be handled, and how contaminated wastewater will be handled should be addressed early in the planning process. If outside resources will be required, their availability and timeliness of response must be verified. Appropriate supplies and equipment, PPE, and a process for patient flow from contaminated to clean areas must be addressed.
Facility physical protection. In addition to actual victims, a large number of asymptomatic, possibly exposed individuals (often referred to as “worried well”) may also present for care, and this additional workload must be anticipated. As was seen in the Tokyo sarin event, these individuals may rapidly overrun the facility and may indeed pose a threat to continued operations (Matsui, Ohbu, and Yamashina 1996).
Evacuation. Released agents may remain airborne for a significant period of time. If the facility is downwind from the site of release, provisions must be established to rapidly decide if evacuation of patients, staff, and visitors is necessary. Transportation assets and receiving facilities must be identified. The establishment of alternate treatment facilities, until such time as environmental surety has been established, should also be included.
Shelter-in-place. When sufficient time to evacuate the facility is not available, expedient shelter-in-place provisions must be developed. Policies concerning securing of ventilation systems, internal movement of patients, and provision of PPE to critical facility personnel must be addressed. Sheltering-in-place can be accomplished horizontally (movement along the same level or floor into an area of the facility away from risk) or vertically (movement to higher or lower floors to escape threats where damage has occurred or where height is an issue, such as in flooding, fire, or high winds).
Detection. Detection is one of the weak links in the chain of emergency management and response. Most biological agents will not produce immediate symptoms, many chemical agents have delayed presentations, and, short of massive radiation doses, weeks may pass before those exposed may feel ill. Detection may occur through trend analysis if done in a near-real-time fashion through syndromic surveillance. Syndromic surveillance is a public health epidemiological process of collecting and analyzing patient data based on predetermined signs and symptoms, referred to as a syndrome. The goal of this analysis is to identify abnormal changes or trends in the numbers of patients presenting at portals of entry to the healthcare system. However, this must occur prior to the diseases that cause these syndromes progressing to the point of fatalities or severe morbidity, so that preventive and treatment measures may be instituted early in the course of the outbreak. Detection may also occur clinically or through laboratory analysis. The EOP should identify detection methods used and the procedures to be followed should an event be suspected.
Identification. Separate from detection, identification of agents that produce similar clinical syndromes or effects but have different treatment and protection regimens is a critical capability. Because most hospital laboratories do not have these sophisticated testing capabilities, methods of linking to CDCs Laboratory Response Network must be included in EOPs.
Triage. Triage of victims of a CBRNE event differs from that for other mass-casualty events because many more victims are likely. In the event of a biological-agent attack, two different victims with identical physiological measurements may have significantly different survival probabilities. Specific life-saving procedures, such as the administration of antidotes, may exist that would alter traditional triage algorithms predicated on the ability of the community healthcare network to absorb all casualties in short order—a situation unlikely to occur if the entire community is affected (Burkle 2002).
Treatment options. Just as triage of CBRNE victims is different, so are treatment concerns. The nature of traumatic disasters is such that the majority of victims who will eventually die do so at the scene or during the first 24 to 48 hours, and most do not require isolation to protect other patients and staff. Victims of chemical, biological, or radiological events may require sophisticated support (including burn therapy, isolation rooms, invasive monitoring, and mechanical ventilation) and may require these modalities for prolonged periods of time.
Surge capacity. The ability to increase facility capacity to accept more victims while facing resource constraints, especially during the initial hours and days after the event, is a huge challenge. Other patients not affected by the disaster may continue to present with emergencies that will require treatment. It is unacceptable to assume that only victims of the disaster will be ministered to during response operations. Early discharges, transfers, and use of home health care services may functionally expand facilities, while cancellation of elective procedures and same-day surgery may free more beds and staff. Extending shift times for staff from 8 hours to 12 hours for a short period (less than one week) effectively increases staff by 50 percent (Schultz, Mothershead, and Field 2002).
Surge capacity also applies to material resources. A facility may elect to increase caches of materials and supplies, but storage capabilities and costs of procurement may be a hindrance. Service-level or backup agreements or even memoranda of understanding with local pharmacies and hospital-supply distributors may provide a functional supply surge capacity at a fraction of the cost. This also obviates the need to dedicate space and personnel to store and maintain these goods.
Prophylaxis. Determining who will receive prophylaxis, and at what priority, in the event of a biological release and methods for distributing and dispensing these pharmaceuticals must be included in an EOP. Keep in mind that unprotected staff will most likely not work, nor will staff who are concerned about their families. The facility’s role in providing or dispensing prophylactic antibiotics to the community must also be ascertained.
Fatality management. A large event may produce a significant number of casualties who die after arrival at a hospital, overwhelming hospital morgues. If surge facilities for temporary interment cannot be identified through traditional services (e.g., city morgues, funeral homes), alternate sites must be established and appropriately equipped, staffed, and secured. It is unwise to presume that other response organizations will assume this responsibility. This issue, as others, should be addressed at the community-planning level, with all providers informed of the plan for mass-fatality management.
Counseling services. As seen after the World Trade Center and Murrah Federal Building attacks, responders may suffer both acute and long-term stress reactions, including delayed development of post-traumatic stress disorder (North et al. 2002). It is the responsibility of the healthcare organization to take care of its employees, and the provision of counseling services cannot be ignored. The healthcare system will also most likely be called on to provide these services for victims, victims’ families, and the community at large. Depending on the nature of the disaster, counseling requirements may far outstrip other medical needs of survivors and the community.
Horizontal and vertical integration. Integrating health services with other local or regional response organizations is essential for successful emergency operations. The prolonged phases of emergency response require that healthcare networks operate together and that various actions by other response organizations be interdependent. Organizations must not plan in a vacuum. Federal law requires the use of an incidentmanagement system in such operations (U.S. Congress 1996). A terrorist event involving CBRNE agents also mandates activation of the Federal Response Plan, which is soon to be replaced with the National Response Plan being developed by the Department of Homeland Security. (See Chapter 7 for more information on organized emergency management systems and the Federal Response Plan.)
Law enforcement and incident forensics. Any terrorist event is a criminal act, and law enforcement investigators will be intimately involved throughout all phases of response. Additional requirements for maintaining a legal chain of custody while handling and transporting samples, patient information sharing, and other cooperative ventures will require new approaches to incident management by all response organizations.
