Positive-pressure filtration systems draw contaminated air into the building through special filters that remove the contaminants. This creates a slight positive pressure in the building, which in turn prevents the nonfiltered, contaminated air from leaking into the building. Experience suggests that such systems, however, are expensive and difficult to properly engineer. A less expensive but less protective measure is to engineer the building controls so that the HVAC system could be completely shut down. Little outside air would be drawn into the structure if all doors and windows were closed.

The ability of an action to adequately protect people in a healthcare facility depends on the characteristics of the toxic agent(s) involved, the size and nature of the release, meteorological conditions, the characteristics of the population affected, and the ability of the threatened structures to provide protection from outdoor agent concentrations. Deciding to shelter-in-place requires a prediction of the outdoor plume concentration of the toxic agent that will occur in the risk area, an estimation of the concentration that will occur inside the buildings at risk, and a calculation of the indoor estimated level of exposure. Deciding to evacuate requires an estimation of how long it will take to move patients and staff out of the building and when they will reach a safe distance compared to the outside concentration that people will experience while evacuating; that is, calculating exposures to those who evacuate in the plume will be considered against exposures to those who have not left (Sorensen, Shumpert, and Vogt 2002).

The indoor concentration of a contaminant is determined by infiltration rates into a building and the inside circulation of air. The inside environment will have a lower peak concentration of a contaminant than the outside air. The lower the air exchange, the lower the peak concentration. Infiltration is measured by air changes per hour (acph) between the outside and the inside or the number of times each hour that an enclosure’s total volume of air is exchanged with outside air. An average air exchange rate for office buildings is estimated to be 0.66 acph and an industrial building to be 0.31 acph with the HVAC system(s) off and doors and windows closed (Engelmann 1990). Little is known about the movement of contaminants inside buildings, especially large and complex structures such as hospitals.

Overall exposure to contaminants in a closed indoor environment will be similar to the overall outdoor exposure because contaminants remain in the building after the plume has passed. If reducing total exposure is the goal, as opposed to reducing peak concentration, then the facility needs to be evacuated or ventilated after the plume has passed or the outdoor concentration is less than the indoor concentration (Rogers et al. 1990).

Sheltering for a biological hazard is slightly different from that for a chemical vapor in that hospital HVAC systems are designed to filter out most aerosols in the size range of biological agents (0.5 to 10 microns) (Weik and Weik 2001). Thus, leaving the HVAC system on would be warranted if the hospital is not under positive pressure.

Sheltering for a radiological hazard is somewhat different from that for chemical hazards in that a building will provide some protection against radiation from inhalation exposure as well as exposure from atmospheric clouds and ground deposition. The amount of protection against radiation is determined by the type of structure and location in the structure. Interior rooms and basements in buildings such as hospitals would typically reduce exposure from a cloud source by 70 percent to 90 percent and from a ground source by 98 percent to 99 percent (Schleien 1983).


The National Research Council (NRC 1999) defines decontamination as the process of removing or neutralizing a hazard from the environment, property, or life form. However, no consensus nationally or among agencies has been reached on standard operating definitions of decontamination, and existing procedures may contradict best healthcare practices for protecting potentially exposed victims as well as healthcare providers.

For decontamination to be effective, the following three elements must be in place:

  1. The contaminants are correctly identified.

  2. The procedures and equipment are available and properly employed to neutralize (or remove) the contaminant.

  3. The reduction of risk is defensible by scientific or regulatory standards (which is not always possible).

Furthermore, most current decontamination systems are labor intensive and require excessive quantities of water. As Macintyre et al. (2000) note, most decontamination guidelines for treatment of exposed victims were created following military models and are inappropriate in today’s civilian healthcare settings.

This discussion is not intended as an all-inclusive treatment on decontamination dos and don’ts but is meant to alert managers to the potential difficulties and pitfalls in planning procedures for decontaminating victims exposed to hazardous substances.

Types of Decontamination

To protect the healthcare facility, it is important to understand where and how (or if) decontamination is performed outside the medical facility, because the problems associated with decontamination of victims (including secondary contamination) in the ED can often be attributed directly to those factors. The degree to which a patient is decontaminated in the prehospital setting depends on the medical decontamination plan, available resources and medically trained personnel, the weather, and characteristics of the contaminant.

General protocols suggest that patients exposed to a hazardous chemical or biological substance should receive, at a minimum, gross decontamination before transport and treatment. Gross decontamination involves showering clothed patients with copious amounts of water, often conducted by a HAZMAT team with a fire hose or by having victims move through a HAZMAT decon tent or other treatment facility. Patients requiring additional medical attention, antidotes, or other emergency care should receive that care depending on the substance’s effects and the ability of staff to protect themselves during treatment. For some situations, such as a patient exposed to a radiological or nonvolatile chemical substance, use of barrier nursing clothing is ample protection. However, if the chemical is highly volatile or persistent, staff should never attempt care or bring potentially contaminated patients into the hospital without appropriate respiratory protection. This includes admitting patients to ED waiting areas where the possibility of secondary contamination could shut down operations.

Hazardous-materials teams traditionally handle decontamination of the environment and persons exposed to hazardous substances, generally relying on a conservative model that advocates precautionary decontamination of potentially exposed victims. The HAZMAT definition of medical decon or patient decon is what most healthcare providers would consider gross decontamination. The procedures, however, are not much different from those proscribed in hospital settings. The first step is removal and disposal (i.e., bagging and sealing) of patients’ clothing and personal belongings. (Cox [1994] estimates that this simple process removes 70 percent to 80 percent of the contaminant, but little scientific data support that assertion.) Victims are then given a quick overall rinse with water.

Secondary decontamination involves washing rapidly with a decontamination solution—usually a diluted bleach or soap and water—and rinsing again. At this point, victims can be dried, given clean clothes, and sent home or transported to a medical facility. The degree of proficiency will vary depending on equipment, resources, and training. One problem is providing privacy to victims, as not all HAZMAT teams are equipped with individual decontamination units or trailers.

Alternatively, mass decontamination processes victims in one or more groups. Chemical warfare agents can cause large numbers of casualties if dispersed in a vapor or aerosol, as manifested in the sarin incident in the Tokyo subway. Such a situation could also occur in a high-profile event at a stadium, a concert, or an airport. The process requires cordoning off several exits where a decontamination corridor can be set up with fire department aerials and/or deluge guns in close proximity. The nozzles are set at low volume so as not to inflict damage but to maximize the amount of water to which each victim is exposed. Ambulatory victims progress through the deluge so that they may be grossly decontaminated. In conjunction with removal of clothing, this will likely suffice to decontaminate those victims not exhibiting signs or symptoms of chemical agent exposure.

A second method is to set up a sprinkler head near the exit point as a rudimentary decontamination shower. In this scenario, water delivered at 500 gallons per minute will produce 8 gallons per second. If the victim remains in the shower for 3 seconds on average, he or she is exposed to 12 gallons, or the amount used in a normal shower.

In either scenario some clothing is left on, which reduces the effectiveness if vapor has penetrated to the skin. Also at issue is the runoff of wastewater with possible contaminants, the disposal of which must comply with local or state environmental regulations.

Self- and buddy-decontamination techniques can also be employed by first responders, workers in hazardous situations, and groups trained in self-help for emergencies. Such techniques may be needed in situations in which immediate removal of contaminants is essential and no time is available to set up a decontamination operation.

Water temperature is a comfort issue that can affect the time spent showering. Normal fire hydrant water temperature is 55 to 65 degrees Fahrenheit. Discomfort during showering is a particular issue with children and the elderly who may suffer additional distress, especially if the ambient air temperature is much cooler or the weather is windy and cloudy. The outside decontamination process is more traumatic than that conducted in an enclosed environment, especially if victims feel a lack of privacy during the process.

Understanding and Implementing Standards and Guidelines for Emergency Management

Several regulations, guidelines, and standards have improved the management of emergencies and disasters in the United States over the last two decades. Such publications have been developed and released by organizations and government agencies such as ASTM International (formerly the American Society for Testing and Materials), the Occupational Safety and Health Administration (OSHA), the Environmental Protection Agency (EPA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Department of Veterans Affairs (VA), and the National Fire Protection Association (NFPA).

The principles within these standards and guidelines regarding

  • mass-casualty incidents,

  • hazardous materials,

  • decontamination, and

  • emergency management program development.

Multiple- and Mass-Casualty Incident Standards

ASTM standard F-1288, Standard Guide for Planning for and Responding to a Multiple Casualty Incident, covers planning, needs assessment, training, interagency coordination, mutual aid, and other important issues as they relate to multiple-casualty incidents. It identifies key terms and activities and explains how the incident management process is organized at the scene (ASTM 1990).

In addition to that standard, George Washington University recently developed a peer-reviewed model for mass-casualty response that integrates the functional requirements of medical, public health, and emergency management agencies in the Medical and Health Incident Management System (MaHIM) (available online at The model was based on the definition of a mass-casualty incident involving 5,000 casualties, 10 percent of which would be considered significant (Barbera and Macintyre 2002). Casualty refers to any human accessing health or medical services, including mental health services and fatality care, as a result of a hazard impact. The MaHIM model clarifies the types of activities that may become necessary at the community-health-system level and how they would be organized in a mass-casualty incident.

It is a useful tool for jurisdictional and regional system development, education, and planning. The Department of Health and Human Services (U.S. DHHS 2002) and the Department of Homeland Security (U.S. DHS 2003) promote this type of management-system framework and are considering applying MaHIM to support current public health and hospital bioterrorism preparedness (CDC 2003). MaHIM is entirely consistent with broader efforts to create a national incident-management system (The White House 2003).

Hazardous-Materials Legislation

A sentinel event occurred in 1985 in Bhopal, India, in which thousands were killed and injured as a result of the release of a toxic gas from a nearby industrial facility. Congress responded to the concerns of such a disaster occurring in the United States by enacting the Superfund Amendments and Reauthorization Act (SARA) of 1986, amending the Comprehensive Environmental Response, Compensation and Liability Act of 1980.


The basic purpose of SARA Title III, also known as the Emergency Planning and Community Right-to-Know Act, was to promote emergency planning to respond to chemical releases and to ensure that information regarding chemicals in the community is available to the public and emergency response agencies. These goals are accomplished by

  • establishing state emergency response commissions and local emergency planning committees (LEPCs) with responsibility to develop emergency plans to be followed in the event of a chemical release and

  • implementing a series of notification and reporting requirements to state and local emergency planning activities with respect to type and quantities of specific chemicals.

Environmental Protection Agency

As part of SARA Title III, the EPA will not enforce HAZWOPER for environmental consequences stemming from necessary and appropriate actions such as decontamination during the phase of an emergency response where an imminent threat to human health and life is present. However, once this phase passes, every attempt should be made to contain the runoff and dispose of it properly (Makris 1999).

Beyond industrial or transportation accidents involving hazardous materials, recent events have directed major emphasis on preparedness for occurrences involving weapons of mass destruction. Because of this threat, hospitals and health departments have become much more involved in communitywide emergency preparedness efforts.

One question that has been hotly debated is how SARA Title III, or more specifically HAZWOPER, applies to healthcare facility preparedness for these types of hazardous materials. OSHAs position until lately had been that if the contaminating substance was unknown, staff performing decontamination at a hospital who were not in the immediate area of the release were required to wear Level B personal protective equipment (PPE), including a mask supplied by an external air source.

Many experts disputed the necessity of this elevated measure of pro tection, contending that Level C PPE using a full face mask with powered or nonpowered canister filtration systems was adequate for hospital decontamination (Macintyre et al. 2000). In September 2002, OSHA took the position that as long as the choice of PPE was based on a risk assessment conducted by the employer, the agency would not require any particular level of PPE and respiratory protection (Fairfax 2002).


Healthcare facilities that do not prepare for the potential arrival of contaminated patients face a dilemma. Refusing to assess and, if necessary, stabilize a contaminated patient is a violation of the Emergency Medical Treatment and Active Labor Act (U.S. GAO 2001). Employees who have not been adequately trained or equipped to deal with the situation can refuse to participate, leaving the facility only one choice: to dial 911 and request support from the local public safety system. These same resources, however, may already be fully involved at the site of the release.

Department of Vetemns Affairs

The VA developed a mass-casualty decontamination program that is based on a site-specific hazards vulnerability and capability analysis of the facility and surrounding community. Permanent or semipermanent showering facilities (in smoking shelters, along an external wall, etc.) are seen as advantageous over temporary tent-type facilities because of the speed of setup and lower expense (VA 2002a). Macintyre et al. (2000) believe that the following aspects are key to an effective decontamination protocol:

  1. Event recognition

  2. Activation

  3. Primary triage

  4. Patient registry

  5. Collection of clothing and personal property

  6. Decontamination

  7. Secondary triage

  8. Treatment and post-incident activities (e.g., media and family relations, medical surveillance, critique, etc.)

Healthcare-facility-decontamination training programs should follow NFPA standard 473, Standard for Competencies for EMS Personnel Responding to Hazardous Materials Incidents (Beatty 2003). NFPA 473 (this standard may be reviewed at identifies the levels of competence required of emergency medical services personnel who respond to hazardous-materials incidents (NFPA 2002a). It specifically covers requirements for basic (Level I) and advanced (Level II) life-support personnel in the prehospital setting. This standard also provides information on training, recommended support resources, medical treatment considerations, patient decontamination, and hazardous-materials characteristics and references.

Emergency Management Standards

Joint Commission on Accreditation of Healthcare Organizations

In January 2001, JCAHO updated its emergency preparedness standards (standards EC.1.4, EC.2.4, and EC.2.9.1[1.] found in the Environment of Care, or EC, section), adopting the four phases of comprehensive emergency management: mitigation, preparedness, response, and recovery. Other key additions to the emergency management standards were requirements for a hazards vulnerability analysis (HVA), the requirement that healthcare organizations implement an incident command system (ICS) consistent with that used by their community, and the acceptance of tabletop exercises for one of two required annual drills. Specific requirements for drills include the following:

  • A facility designated as business occupancy must execute one drill annually.

  • Hospitals, long-term-care organizations, ambulatory care facilities, and behavioral health facilities not classified as business occupancy must conduct drills twice a year at least four months, but not more than eight months, apart.

  • Facilities offering emergency services or designated as disaster receiving stations must base one exercise on an external disaster, and it must include volunteer/simulated patients who must be triaged, put on stretchers or in wheelchairs, and transported through the system as if they were actual patients.

  • An organization must participate in a community drill that is relevant to its priority emergencies and that will assess communications, coordination, and the effectiveness of the organization’s and the community’s command structures.

The events of terrorism that took place in the United States in fall 2001 brought several more changes to the overall 2002 standards, including clarification on the process and products of the HVA (in particular, that procedures should be developed for each priority hazard identified), a requirement for cooperative planning with other healthcare facilities in the geographic area, and procedures for emergency credentialing. In 2003, components of the hospital emergency management standards were extended to long-term care, ambulatory care, behavioral health care, and home health care settings (Environment of Care News 2002). For 2004, the EC standards have been renumbered and reformatted but have not undergone any substantive changes in requirements.

National Fire Protection Association

NFPA emergency management Standard 99, entitled “Healthcare Facilities,” contains very similar requirements to JCAHO (NFPA 2002b). One big difference between the standards is the additional material in the annexes of the NFPA standard: explanatory material, references, and additional planning considerations (NFPA 2002a).

NFPA Standard 1600, Emergency Management and Business Continuity Programs, has gained international recognition and consensus among the public and private sectors. This standard articulates the generic elements of these programs and serves as the basis for an emergency management program evaluation and accreditation system by state, local, and tribal governments (NEMA 2001). Thus, NFPA 1600 represents a standard for communitywide emergency management programs (NFPA 2002c).


No emergency preparedness program is complete without a continuous quality improvement (CQI) program. The optimal way to ensure that programs and plans are updated and effective is through the use of a sound CQI program that evaluates the various parts of the emergency management program, identifies deficiencies and issues for action, and develops and tracks solutions for those identified problems. Plans will need to be changed or modified as resources, requirements, threats, and vulnerabilities fluctuate.

CQI programs should include prospective, concurrent, and retrospective review. Prospective review may evaluate resource inventory control and tracking, personnel training, or currency of memoranda of understanding. Concurrent review usually occurs as drills, exercises, or response operations are conducted and evaluated. Retrospective review often involves identifying specific events (such as a motor vehicle accident involving multiple casualties) and performing a retrospective record review to determine areas of difficulty in operations that may translate to further problems in the event of an even larger disaster.

A periodic review of the facility plan is advisable every six months to one year. The plan should also be reviewed after any exercise to accommodate shortfalls or better ways to accomplish certain disaster tasks. However, the best and most critical time to review your facility plan is after a real disaster that tests every part of your plan. A critique of the disaster from impact to recovery should indicate areas of the plan that worked well and areas that did not work as planned.

After objectively reviewing the findings from your disaster critique, the plan is ready for revision, addressing any gaps and shortfalls discovered. Action to be taken should be fully documented, with time frames for completion or implementation. Those you cannot act on at the present time should be noted and carried forward for future action. A substitute or other means of remedying the situation or problem should be found.

After the plan has been revised, approved, and shared with all involved, it must be tested and reviewed once again, implementing suggestions for improvement at each opportunity. A good planning and quality improvement process never ends.

Exercises | Disaster Planning

The Federal Emergency Management Agency defines an exercise as “a controlled, scenario-driven, simulated experience designed to demonstrate and evaluate an organization’s capability to execute one or more assigned or implicit operational tasks or procedures as outlined in its contingency plan” (FEMA 1997).

Disaster preparedness can be tested through the response to and recovery from an actual event or through drills or exercises. An effective exercise

  • includes all staff, on all shifts, for every day of the week;

  • reveals existing vulnerabilities; and

  • ingrains the emergency plan into the minds of the medical facility’s staff.

Although actual disasters cannot be planned, several variations of planned exercises are available. These are described below.

Orientation or information exercises. The goal of such exercises or meetings is to provide newly hired staff with an overview of the organization’s responsibilities in the event of a disaster, the methods by which these responsibilities will be discharged, and general responsibilities that they will be expected to fulfill.

Tabletop exercises. These leadership-level exercises are designed to work through interdepartmental or interorganizational issues. Typically, a scenario is presented and, at various stages, an opportunity is provided for leaders of the various functional or organizational response elements to present their concept of operation. This exercise clears up misunderstandings of responsibilities, capabilities, and methodologies and allows personnel involved to become acquainted and to collaborate prospectively—opportunities that are invaluable if an actual event were to occur.

Functional exercises. These operational-level exercises are designed to test specific functional elements of response, such as communications, decontamination procedures, and patient flow. They may involve one or more departments and typically require test actions, as opposed to discussions. Because they may interfere with normal organization operations, they are done less frequently.

Full-scale exercises. Although expensive, labor intensive, and likely to interfere with normal operations, full-scale exercises provide leaders an unequaled opportunity to see how all elements function together as well as provide valuable, realistic training for all participants. Interactions between functional elements under real-world conditions can be more easily identified in full-scale deployment than through individual functional exercises.

Exercises should be assessed against measurable information or qualitative and quantitative data gathered during the event. If your exercise reveals nothing wrong, something is wrong with your exercise. Your goal should be to stress your system to identify weaknesses. An exercise that results in no recommendations is a waste of precious time. Identified and documented deficiencies and efficiencies should highlight those plans, policies, or procedures that should be changed and the training required.

JCAHO Environment of Care standards require each accredited healthcare organization to regularly test the plan, either through actual disaster response and plan activation or in planned drills. The plan must be executed at least twice yearly. In most healthcare facilities, drills must be performed at least every four months and no more than eight months apart. This critical element of the emergency preparedness program is more than just an exercise. The more realistic the scenario, the better are the opportunities for learning and improvement.

Emergency Operations Planning | Disaster Planning

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.


Mitigation activities or controls are any actions taken to permanently eliminate or reduce the risk of hazards to human life, property, and function. The four basic mitigation activities are as follows:

  1. Deterrent controls reduce the likelihood of a deliberate attack and/or dissuade would-be attackers by making a facility less desirable as a target.

  2. Preventive controls protect vulnerabilities by making an attack unsuccessful or reducing its impact.

  3. Corrective controls reduce the effect of an attack.

  4. Detective controls discover attacks and may trigger preventive or corrective controls.

Combining Risk Assessments and Mitigation Initiatives

A more sophisticated method of conducting risk analysis and assessing mitigation initiatives is a failure modes and effects analysis (FMEA) (Electronic Industries Association 1971). Developed by the U.S. military in 1949 as a reliable evaluation technique to determine the effect of system and equipment failures (U.S. Armed Services 1984), FMEA systematically identifies potential system failures, their causes, and the effects on the system’s operation. It is most often used to proactively assess the safety of system components and to identify design modifications and corrective actions needed to mitigate the effects of a failure on the system.

The FMEA process can be a valuable tool in improving internal preparedness for response to emergencies or disasters of any sort and has been endorsed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). When the analysis is extended to include an assessment of the failure mode’s severity and probability of occurrence, the analysis is called a failure mode, effects, and criticality analysis (FMECA).

An example of the FMECA process applied to routine hospital operations might be patient admissions through the emergency department. To admit a patient, a number of functions must occur: an accepting physician must be identified and contacted, initial orders must be provided to the accepting floor or ward, administrative and clerical work accompanying the admission must be completed, a bed and the nursing staff must be prepared to accept the patient, and the patient must be delivered to the floor or ward. A defined failure might be the inability to admit the patient within one hour of the determination that admission is warranted. By analyzing the processes involved with getting the patient admitted, failure modes can be identified (e.g., inordinate delay in preparing the patient’s room), and the root cause of these failure modes can be further elucidated. If the cost of the failure mode is sufficient (e.g., patient or staff dissatisfaction), procedures may be modified, additional staff may be hired, or other actions may be taken to improve this process.


Many chapters of this book outline an approach to preparedness and planning for a terrorist event involving WME in more detail; however, three overarching principles for optimal preparedness of the healthcare sector cannot be overemphasized: integration, testing, and resources.


Planning and preparedness for any disaster cannot be done in isolation, nor can hospitals develop plans based on untested assumptions of what other response agencies (fire services, law enforcement, etc.) will or will not do in a disaster response. Similar agencies must plan as a unit. In the event of a large-scale catastrophe, all hospitals will be involved, and thus area facilities must plan as though they are part of a regional network.

The healthcare sector encompasses much more than hospitals. Primary care clinics and private physicians, emergency medical services, private ambulance companies, community and state public health agencies, pharmacies, veterinary clinics, urgent care centers, long-term-care facilities and hospices, funeral homes, medical vendors and warehouses, and many other business concerns have both potential roles and a stake in the success of response operations. These potential sources of staffing and material resources must be included in planning and preparation. Integration and interoperability are discussed in further detail in other chapters of this book.


Modeling and simulation for terrorist events have historically been based on large-scale events that would rapidly overwhelm the local response system’s capacity, requiring the utilization of state and federal resources. Although this may be a valid test of vertical integration (the ability to incorporate regional, state, and federal resources into local disaster operations), another rarely used approach is to determine the system’s actual time-phased functional capability and capacity.

This methodology seeks to determine the resources actually required from all response sectors at a given period of time after the incident and may be of particular value because it could be used to establish the trigger required to activate and release these higher-level resources. Prospective determination of a system’s capacity allows a “high-water line” with which to compare an actual event as it unfolds, allowing more accurate needs assessments and requests for assistance that drive the state and federal responses.


It is unreasonable to expect the healthcare sector to expend resources they do not have or to amass large quantities of excess expirable supplies based on a low-probability event. Unlike the majority of emergency response organizations, the healthcare sector has historically received little or no funding from the public coffers for disaster preparedness and mitigation. The December 2003 Homeland Security Presidential Directive/HSPD-8 includes “clinical care” among its defined “first responders,” and healthcare is a first-responder discipline listed in budgets for fiscal year 2004 Office of Domestic Preparedness grant monies. This will allow the healthcare sector to use the grant money for planning, organizing, equipping, training, and exercising (The White House 2003).

Recent legislation has allotted some funding to improvements in state and community public health agencies, and a small percentage of this funding is designated for traditional healthcare operations. Businesses involved with healthcare operations should gain the support of local and state governments for a share of disaster preparedness funding if the communities can reasonably expect full participation in planning for these events.

Weapons of mass effect pose a challenge that the healthcare sector has not seen in the history of this country. Federal resources are necessary; however, these events would be first and foremost local calamities, and the local healthcare system will be part of the vanguard of response. Mitigation, planning, resource procurement, education, and training are required if this critical partner in response is to be prepared for these events.


Weapons of mass effect pose a particular challenge to healthcare operations not normally seen in the response to technological or natural disasters. Most American disasters have been distinguished by significant property destruction, with relatively low levels of death or significant injuries. There have been only 7 disasters in U.S. history (excluding the events of 9/11) resulting in more than 1,000 deaths (Auf der Heide 1989). The single bloodiest non-war-related day in American history occurred when the Galveston Island (Texas) hurricane of 1900 claimed between 6,000 and 8,000 lives (Galveston County Daily News staff 2003). The terrorist attacks against the World Trade Center and the Pentagon on 9/11 resulted in nearly 3,000 lives lost.

These are extreme, and rare, events. Most disasters in the United States have resulted in fewer than 50 deaths, with injuries on that same order of magnitude. Healthcare operations in disasters typically were marked more by a temporary mismatch between supply and demand than absolute shortages: less than 5 percent of hospitals involved in disaster response suffer either personnel or material shortages, and few healthcare facilities are directly affected by those events.

On the contrary, a widespread disaster resulting from a terrorist attack using WME could, at a time when the demand for healthcare would be at a sustained high level,

  • damage, destroy, or contaminate healthcare facilities;

  • produce significant healthcare personnel losses through contamination, illness (among themselves or their families), or fear; or

  • result in significant and prolonged material-resource deficits in critically needed items (e.g., ventilators, negative pressure isolation rooms, antibiotics).

One need look no further than recent history to understand the potential magnitude of these gaps. Two examples that easily come to mind are the effects of Tropical Storm Allison on healthcare operations in Houston in 2000 and the consequences of the terrorist posting of anthraxladen letters in New York; Washington, DC; and Florida in 2001. (See the case examples)

Hospital capacity to handle even relatively small surges in patient loads under more routine circumstances is a cause for concern. In a study commissioned by the American Hospital Association (The Lewin Group 2002), 62 percent of all hospital emergency departments and 79 percent of urban hospitals reported that they were functioning at or over capacity, and more than half of urban hospitals reported significant time on diversion (time during which patients had to be diverted to other hospitals) because of lack of available critical care beds in the hospitals. These hospitals report an increase in demand as high as 12 percent from 2001 to 2003.

Even if a hospital were not directly affected by a terrorist event, it could indirectly become a casualty. As was clearly demonstrated in the Tokyo sarin incident, chemically contaminated but ambulatory victims might not wait for the arrival of hazardous-materials and decontamination units at the scene. Entrance of these victims into emergency departments would threaten existing patients and staff and might force closure of the department itself.

In one 2001 study conducted in the northwest United States, only 6 percent of hospitals surveyed had the capability to manage a hypothetical sarin incident. Although 75 percent of facilities responding had some decontamination capabilities, these were minimal and certainly would not be able to handle even a moderate number of contaminated casualties. Few hospitals had personal protective equipment appropriate for responding to a chemical incident, and in those that did, the equipment was minimal (one or two respirators or masks). Only about half of the hospitals polled had antibiotic supplies sufficient to provide prophylaxis to even 50 individuals for two days (Wetter, Daniell, and Treser 2001).

Improvements may have occurred since this study was published; however, it is unlikely that funding has sufficiently improved to produce a dramatic turnaround in these results in such a short period of time. Hospitals designated as receiving facilities for accidents at nuclear power facilities are required to have appropriate equipment, training, and testing to manage small numbers of casualties from incidents at these locations, but most hospitals in the United States do not.

RISK MANAGEMENT AND Weapons of Mass Effect

The actual risks from the use of such horrific weapons by terrorists against the American population are difficult to determine. Most communities face a much greater threat from unintentional anthrogenic or natural disasters. Traditional events—those due to accident, nature, or human error—can be predicted or at least anticipated based on historical records, and the magnitude of the consequences can be estimated. For instance, the existence and location of floodplains are known, as are areas prone to tornadoes or hurricanes, and local emergency planning committees are aware of the locations and quantities of highly toxic materials. Armed with such information, engineering and administrative controls instituted as an outcome of previous disasters have greatly lessened the consequences of these events.

The key elements of effective risk management are threat and vulnerability assessments. These processes, discussed in greater detail in Chapter 3, form the backbone for risk assessment. Risk assessment drives mitigation initiatives to prioritize actions to reduce either the probability that an event will occur or lessen the consequences should it happen. Modeling and simulation are powerful tools to identify community or facility vulnerabilities to a wide range of potential threats but do little to determine the actual threat.

The WME threat is based on terrorist motive, opportunity, and availability of the weapons or agents. Little need be said concerning terrorist motivation to do harm against the United States and its citizens. Although the United States is the most open society in the world, difficulties in gaining entrance to the nation while harboring significant caches of these weapons lessen, but do not eliminate, the opportunity. It is only the lack of the availability of such weapons, or the skills and resources by which to produce them, that keeps the overall threat low. Advances in science may work against these odds in the future, however. It is generally presumed that terrorists will have the greatest difficulty in obtaining or fielding those weapons that produce the greatest threat: nuclear or biological weapons. Chemical-warfare attacks and the use of radiological dispersal devices are considered to pose an intermediate threat, and the use of conventional explosives or the intentional release of toxic industrial materials poses the greatest threat.

It is equally difficult to measure the threat against a specific community or organization. Most terrorist attacks historically were targeted against governments, the military, or industry. Although these organizations and entities remain high on terrorist lists, a trend has developed over the last decade toward attacks against the civilian population. This shift is in keeping with the prime motivation of terrorists to create terror. Although the random sniper attacks near Washington, DC, in fall 2002 did not use WME, the effect was the same: a population significantly affected by fear. Finally, extremist organizations within our borders, such as religious cults or single-issue terrorists, may target organizations traditionally not prone to such attacks. One can only imagine the overall effect on its citizens if hospitals in small towns across the United States were targeted for explosions in a random fashion over several weeks or months.

Preparing Your Healthcare Facility for Disaster


Checklist 1.1. A successful Emergency Planning Process

  • Image from book Commitment and leadership from the top of the organization: The CEO, or equivalent, must be the champion for preparedness, setting an example for all employees and being the purveyor of the growth of a “disaster culture” in the organization.

  • Image from book An organizational need and desire to “do the right things”: A mandated plan, for the sake of meeting mandated requirements, is a useless tool. It will not be followed, is rarely developed as a facilityspecific entity, and will fail to meet the needs of the facility. The desire for preparedness must be inherent within the organization.

  • Image from book A facility-specific disaster plan: Plans that address appropriate responses to the needs of your facility are not transferable to your neighbor’s facility, nor to other types of healthcare facilities.

  • Image from book Input from the organization as a whole: Management and staff must participate to create staff ownership and pride in the plan and to ensure that all areas of concern and need are appropriately addressed.

  • Image from book Integration with the community: Coordination with and understanding of community resources and assistance are critical.

  • Image from book Delineated support functions: Authority and coordination, roles and responsibilities, and the ability to find and access needed resources must be addressed in detail.

Source: Adapted from Anderson, B., J.Dilling, P.Mann, A.Moore. 1996. Emergency Planning for Assisted Living Facilities. Silverdale, WA: Emergency Training & Consulting, International. Used with permission.

Checklist 1.2. Facility Preparedness for Terrorism

I. Emergency Management Team and Planning

  1. Designate an emergency management or disaster planning team in each facility and the community that

    • Image from book Consists of all disciplines that will respond to the disaster

    • Image from book Is represented by all standard and support departments (create an internal call list of team members, with all contact numbers)

    • Image from book Designates and understands the healthcare facility’s role in the community emergency management team and response

    • Image from book Understands the medical functions and their interconnectivity in a federalized response

  1. Define the work of the emergency management team and the work to be accomplished.

    • Image from book Conduct an internal hazards vulnerability analysis (HVA)

    • Image from book Prioritize threats and risks, and establish a plan to address each

    • Image from book Conduct a community and area HVA

    • Image from book Develop production time lines for each HVA issue addressed

    • Image from book Assess community programs and processes for current disaster response, and identify weaknesses and gaps in service

    • Image from book Plan for alternative delivery methods and routes for delivery of supplies, personnel, or other needs

    • Image from book Review all relevant disaster-response plans, and ensure that appropriately designated staff are familiar with their content and strategies

    • Image from book Know the community’s local or regional emergency management plans, command structures, and contacts in each organization

    • Image from book Determine secondary and backup processes and programs, and identify need for redundant systems

  1. Assess and test power and backup systems.

    • Image from book Identify all patient care needs in a power failure; prepare to use manual systems for a prolonged time

    • Image from book Develop a staffing support system for critical tasks during power or infrastructure failures

    • Image from book Understand the capabilities of the area emergency operations center (EOC) for communication and service should the area be without power for extended lengths of time

    • Image from book Preidentify special needs and services that the healthcare facility will require from the community or area services in a power failure; have a clear understanding of capabilities and limitations available in the local area

    • Image from book Assess strengths and vulnerabilities of internal technology, communications, information, and data systems

    • Image from book Ensure manual access to automated systems (e.g., medication dispensing) in power failures

  1. Establish an internal command center in each healthcare facility.

    • Image from book Prepare staff and volunteers via incident command system standards and protocols for seamless response

    • Image from book Practice setting up and operating the center frequently

    • Image from book Involve ham or volunteer radio operators in EOC operations; you may elect to have an on-site HAM operator to ensure continual communications

II. Communications Systems

  • Image from book Establish internal and external lines of communications (to medical staff, personnel, responding agencies, and public health authorities) with appropriate and redundant technology; develop a call list of external team members and contact numbers.

  • Image from book Establish collaborative strategies for communicating with neighboring hospitals, civic leaders, law enforcement, public health authorities, and emergency response agencies.

  • Image from book Assess routine staffing and emergency call-up plans, and ensure they are supported with communication and transportation strategies.

  • Image from book Maintain ongoing primary and redundant communication systems.

  • Image from book Inform staff of how you will communicate with them when off duty and what is expected of them in disasters; if a call chain is to be used for staff activation from home, make certain that alternate means of reaching each person are available.

  • Image from book Communications systems for influx of large volumes of calls must be predetermined, tested often, and designed to meet the needs of all Emergency Support Functions of the National Response Plan.

  • Image from book Ensure adequate internal communication systems and prepare for failures of vital equipment (e.g., cell phones and pagers); develop alternative delivery systems, including runners.

III. Communications, Alerts, and Warnings

  • Image from book Coordinate all activities through the area command center, emergency management agency, or EOC.

  • Image from book Know the alert systems and sources for alert information in your area.

  • Image from book Incorporate the community warning system into your facility disaster planning.

  • Image from book Link the community command center or EOC to each healthcare provider in your area.

IV. Community Integration

  • Image from book Develop strong relationships with other healthcare organizations and providers.

  • Image from book Develop personal and professional relationships with providers through a continual planning process.

  • Image from book Plan and conduct communitywide drills often, taking into account input from all sectors of the community.

  • Image from book Establish formal memoranda of understanding and agreements with critical providers of services.

  • Image from book Establish ties with counterparts at other healthcare organizations (e.g., incident commanders, pharmacists, laboratory directors, administrators) to better know each other and understand the plans of respective facilities.

  • Image from book Quantify pharmaceutical and antibiotic supplies, both at central and satellite facilities; routinely update this list.

  • Image from book Participate in the development of a coalition of hospitals that are geographically close to share supplies, pharmaceuticals, and staff under a clear chain of command.

  • Image from book Assess strengths and vulnerabilities of the community’s internal technology, communications, and information and data systems, and know how these interact with healthcare facility systems or providers.

  • Image from book Ensure that appropriate healthcare professionals from all agencies are aware of the importance of reporting unusual disease presentations, clusters, and atypical patterns of hospital use, and know the mechanisms for reporting.

V. Disaster Preparedness

  • Image from book Ensure preparedness to operate independently and be self-sufficient for up to 72 hours minimum.

  • Image from book Assess routine staffing and emergency call-up plans, and ensure that these are supported with communication and transportation strategies; update the roster of essential personnel.

  • Image from book Develop work-arounds or substitutions for any services and supplies you anticipate may not be available or may be inaccessible for delivery.

  • Image from book Consider developing a volunteer safety service team to assist with safety, security, and crowd control if professional help is not available.

  • Image from book Coordinate the preestablishment of an areawide licensure or certification approval system for local physicians, nurses, and other professional staff; establish a system to quickly evaluate essential credentials for temporary or volunteer professional staff; establish a community or area database to track and verify certification of medical personnel.

  • Image from book Develop a community or area volunteer service (e.g., Citizens Corp), and provide training and education and determine tasks for these teams in disasters to strengthen the overall response.

  • Image from book Ensure that the community is prepared to receive the Strategic National Stockpile in the event of a massive medical emergency; personnel needed for unloading, warehousing, security, and medication distribution should be preidentified; personnel should be trained and prepared in their roles and the processes tested in every drill event.

  • Image from book Prepare for mass-fatality management of deaths occurring inside the facility and in the community; bodies or body parts must be identified, cataloged, and refrigerated, and contaminated remains must be identified and secured for proper disposal.

VI. Drills and Exercises

  • Image from book Conduct both internal and external drills and exercises.

  • Image from book Participate in all communitywide disaster drills and exercises when requested.

  • Image from book Focus external drills on the role of the facility to respond to community needs in concert with emergency medical services and other emergency responders.

  • Image from book Clearly define the roles of first-responder agencies in various types of disaster events (e.g., Which department takes the lead in decontamination of victims? Will this be done in the field or at the hospital only? Will there be assistance from outside agencies if decontamination capability is established outside the emergency department?).

  • Image from book Conduct a communitywide tabletop exercise to include the most difficult tasks such as lockdown or quarantine of the town, a facility, or an area.

  • Image from book Drill multiple aspects of the plan at a time to provide an opportunity for the healthcare facility to realistically test interoperability with other community responders.

  • Image from book Include the establishment and operation of various shelters to provide care in a community; test medical overflow shelters or temporary structures.

  • Image from book Plan with community providers to treat a large number of patients (hundreds to thousands).

  • Image from book Test evacuation plans for the area, including the evacuation of the healthcare facilities.

  • Image from book Test shelter-in-place provisions throughout the healthcare delivery system.

  • Image from book Assess mutual-aid pacts and cooperative agreements for mass-casualty treatment capability.

Sources: This checklist was developed by K.J.McGlown, with additional information from the following: JCAHO. 2001. “The Power of Preparation.” Special issue, entitled “Emergency Management in the New Millennium.” Joint Commission Perspectives 21 (12):13–15; JCAHO. 2001. “Responding Effectively in the Midst of a Natural Emergency.” Special issue, entitled “Emergency Management in the New Millennium.” Joint Commission Perspectives 21 (12):22–23.

Checklist 1.3. Successful Drills and Exercises

  • Image from book Involve employees from all departments in planning an exercise; incorporate their suggestions and ideas for specific actions to be tested and examined.

  • Image from book Exercise emergency plans a minimum of twice a year, with a variety of internal and external events; various types of exercises can keep preparedness issues before staff year-round.

  • Image from book Fully integrate exercises to involve all area healthcare facilities and providers.

  • Image from book Test the communication and notification links within the organization and those from the organization to the external community at large.

  • Image from book Test internal systems.

    1. Notifying key personnel

    2. Setting up the command post

    3. Assessing internal damage to the physical plant and the impact on patient care delivery

    4. Preparing the emergency department (ED) to identify, process, and care for large groups of patients (establish alternate emergenct care locations in case the ED is destroyed or contaminated)

    5. Testing capacity and ability to clear beds as needed

    6. Implementing victim tracking and documentation

    7. Determining equipment and supplies available for activation (test delivery of items to ED or central care points)

    8. Establishing a triage center outside the ED

    9. Securing all ED operations and access points into the department

    10. Securing all entrances to the facility

    11. Establishing media control and public relations procedures

    12. Activating secondary call and standby for patient care services (e.g., surgery, burn unit, pediatrics, etc.)

    13. Testing communications with the area emergency operations center and other external responding agencies; testing backup systems of various types

  • Image from book Practice the stand-down of the exercise, testing the return to normalcy. These actions include adjustment of staff schedules and call coverage, communications required, and reporting processes.

  • Image from book Critique the exercise. Have outside experts evaluate your effectiveness; request comments from all participating organizations.

  • Image from book Conduct a “results oriented” evaluation process, and address (among others) the following major aspects of disaster preparedness:

    1. Alert systems

    2. Mobilization

    3. Direction and control

    4. Facilities

    5. Communications

    6. Exposure of responders

    7. Monitoring of environment

    8. Public information

    9. Media information and rumor control

    10. Special populations/schools

    11. Reception or mass-casualty receiving centers

    12. Traffic and access

    13. Medical services, transportation, facilities, and equipment

  • Image from book Develop corrective action plans from the gaps between performance and expectations.

  • Image from book Provide timely feedback to staff to reinforce lessons learned.

  • Image from book Take corrective actions on gaps identified from the exercise; document all actions taken.

  • Image from book Write the final “after action” report of the exercise, including findings and corrective action taken; share results with decision makers and those with a need to know.

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