An all-hazards approach for the domestic and international emergency management framework applies to the threat of terrorism. Better plans, more training, and greater awareness enhance capabilities to manage natural and technological disasters, day-to-day emergencies that may occur, as well as terrorist incidents. A course recently developed for the Federal Emergency Management Agency’s Higher Education Project, “Social Vulnerability Approach to Disasters,” is an excellent tool to help in understanding our vulnerability while suggesting strategies and actions (Enarson et al. 2003).

The course describes structural and nonstructural mitigation strategies. Both provide security measures that may be taken to prevent or reduce loss of life and property from terrorist events and acts of violence. The distinction between structural mitigation techiques and nonstructural mitigation techniques is often made in terms of reducing potential loss (nonstructural) rather than in terms of reducing hazards (structural).

It is relatively easy to provide physical or structural mitigation measures to secure a facility or person by providing guards, iron bars, eleo trified fences, surveillance cameras, and other physical security measures. But these measures are often consuming and are most effective in controlled-access areas; they may be less effective in areas where large numbers of people have access (Enarson et al. 2003).

Nonstructural mitigation measures include training to reduce vulnerability and implementing measures into response plans to reduce the likelihood of losses and to speed recovery. These measures may be easier for public agencies to fund and implement than are physical or structural changes to a building (Enarson et al. 2003). For example, facility staff members who are keenly aware and trained to alert their supervisor or shift leader to anything out of the ordinary—a suspicious package or vehicle, someone in the building without a visitor’s badge—enhance your facility’s safety factor.

Staff skilled in the tools necessary to handle emergency and disaster situations are valuable assets and increase your chances of responding to and recovering from any disaster in a more expedient and timely manner. Training reduces your vulnerability while building capacity and confidence among your facility team players. If residents are competent and willing to help with disaster management and facility security, they can be trained as well. This type of cooperative effort and vested interest in the mutual safety and security of your facility is wise and cost effective. Its benefits are immeasurable in terms of your facility’s greatest asset—human resources—and personal self-sufficiency and pride.

In keeping with all-hazards, or “dual purpose,” emergency management planning, it is significant to note that terrorism is not the only form of violence common to institutions, workplaces, and all aspects of American society. The primary justification for preparedness is to ensure the readiness of your facility for the potential unknown that may be faced at any time. In addition to terrorism, Americans daily face threats of criminal (physical and sexual), domestic (spouse, family, or other intimates), and other common types of violence (Enarson et al. 2003).

These same threats of violence are present in healthcare facilities and patient care environments. The size and nature of the facility, number of residents and staff, physical location, population and demographics of the area, and many other factors may determine the amount of security measures implemented. Many mitigation actions that reduce vulnerability to all types of violence can be accomplished at little or no cost.


Evacuations of hospitals and other healthcare facilities can be lengthy and complex events. A 1990 study examined the evacuation of 34 hospitals and 46 nursing homes (Vogt 1990). In the 34 hospital evacuations at facilities that ranged from 99 to 310 beds, the largest facility took 5 hours to evacuate 127 patients, whereas the smallest hospital took 2 hours to evacuate 27 patients. The most rapid evacuation involved the movement of 57 patients in 1.5 hours (Vogt 1990). In addition to results of nursing home evacuations, it was found that the time to evacuate was not related to the number of patients evacuating. The strongest predictors of evacuation time were the nature of the threat (weather versus nonweather events), the ratio of staff to patients, and whether the facility was in an urban area (Vogt 1991). A more recent study documents the evacuation of 575 patients from a hospital prior to a hurricane (Cocanour et al. 2002). In this case, completing the evacuation took almost 28 hours. Of the 575 patients, 169 were discharged and 406 were taken to 29 other facilities.

Both Vogt (1990) and McGlown (2001) examine factors influencing the evacuation process in healthcare facilities. Although Vogt focuses on the implementation of an evacuation at an organizational level whereas McGlown focuses on individual decision making, the two studies have similar findings. Processes are shaped by factors such as threat, risk, time, resources, infrastructure impediments, internal and external environment, organizational characteristics, social linkages, and social climate.

In terrorist events, both patients and workers in healthcare facilities are vulnerable groups. Patients are at risk because they lack the ability to protect themselves. Workers are at risk because of the nature of their roles as caregivers and because of the extra burden that an emergency creates. Despite such difficulties, responding to an emergency can be successful with careful planning, training, and exercising.

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