Assessing levels of hospital emergency preparedness

INTRODUCTION: Emergency preparedness can be defined by the preparedness pyramid, which identifies planning, infrastructure, knowledge and capabilities, and training as the major components of maintaining a high level of preparedness. The aim of this article is to review the characteristics of contingency plans for mass-casualty incidents (MCIs) and models for assessing the emergency preparedness of hospitals. CHARACTERISTICS OF CONTINGENCY PLANS: Emergency preparedness should focus on community preparedness, a personnel augmentation plan, and communications and public policies for funding the emergency preparedness. The capability to cope with a MCI serves as a basis for preparedness for non-conventional events. Coping with chemical casualties necessitates decontamination of casualties, treating victims with acute stress reactions, expanding surge capacities of hospitals, and integrating knowledge through drills. Risk communication also is important. ASSESSMENT OF EMERGENCY PREPAREDNESS: An annual assessment of the emergency plan is required in order to assure emergency preparedness. Preparedness assessments should include: (1) elements of disaster planning; (2) emergency coordination; (3) communication; (4) training; (5) expansion of hospital surge capacity; (6) personnel; (7) availability of equipment; (8) stockpiles of medical supplies; and (9) expansion of laboratory capacities. The assessment program must be based on valid criteria that are measurable, reliable, and enable conclusions to be drawn. There are several assessment tools that can be used, including surveys, parameters, capabilities evaluation, and self-assessment tools. SUMMARY: Healthcare systems are required to prepare an effective response model to cope with MCIs. Planning should be envisioned as a process rather than a production of a tangible product. Assuring emergency preparedness requires a structured methodology that will enable an objective assessment of the level of readiness.     

Critical assessment of statewide hospital pharmaceutical surge capabilities for chemical, biological, radiological, nuclear, and explosive incidents

INTRODUCTION: In recent years, government and hospital disaster planners have recognized the increasing importance of pharmaceutical preparedness for chemical, biological, radiological, nuclear, and explosive (CBRNE) events, as well as other public health emergencies. The development of pharmaceutical surge capacity for immediate use before support from the (US) Strategic National Stockpile (SNS) becomes available is integral to strengthening the preparedness of local healthcare networks. METHODS: The Pharmaceutical Response Project served as an independent, multidisciplinary collaboration to assess statewide hospital pharmaceutical response capabilities. Surveys of hospital pharmacy directors were conducted to determine pharmaceutical response preparedness to CBRNE threats. RESULTS: All 45 acute care hospitals in Maryland were surveyed, and responses were collected from 80% (36/45). Ninety-two percent (33/36) of hospitals had assessed pharmaceutical inventory with respect to biological agents, 92% (33/36) for chemical agents, and 67% (24/36) for radiological agents. However, only 64% (23/36) of hospitals reported an additional dedicated reserve supply for biological events, 67% (24/36) for chemical events, and 50% (18/36) for radiological events. More than 60% of the hospitals expected to receive assistance from the SNS within < or = 48 hours. CONCLUSIONS: From a pharmaceutical perspective, hospitals generally remain under-prepared for CBRNE threats and many expect SNS support before it realistically would be available. Collectively, limited antibiotics and other supplies are available to offer prophylaxis or treatment, suggesting that hospitals may have insufficient pharmaceutical surge supplies for a large-scale event. Although most state hospitals are improving pharmaceutical surge capabilities, further efforts are needed.     

Ability of regional hospitals to meet projected avian flu pandemic surge capacity requirements

INTRODUCTION: Hospital surge capacity is a crucial part of community disaster preparedness planning, which focuses on the requirements for additional beds, equipment, personnel, and special capabilities. The scope and urgency of these requirements must be balanced with a practical approach addressing cost and space concerns. Renewed concerns for infectious disease threats, particularly from a potential avian flu pandemic perspective, have emphasized the need to be prepared for a prolonged surge that could last six to eight weeks. NULL HYPOTHESIS: The surge capacity that realistically would be generated by the cumulative Greater Dayton Area Hospital Association (GDAHA) plan is sufficient to meet the demands of an avian influenza pandemic as predicted by the [US] Centers for Disease Control and Prevention (CDC) models. METHODS: Using a standardized data form, surge response plans for each hospital in the GDAHA were assessed. The cumulative results were compared to the demand projected for an avian influenza pandemic using the CDC's FluAid and FluSurge models. RESULTS: The cumulative GDAHA capacity is sufficient to meet the projected demand for bed space, intensive care unit beds, ventilators, morgue space, and initial personal protective equipment (PPE) use. There is a shortage of negative pressure rooms, some basic equipment, and neuraminidase inhibitors. Many facilities lack a complete set of written surge policies, including screening plans to segregate contaminated patients and staff prior to entering the hospital. Few hospitals have agreements with nursing homes or home healthcare agencies to provide care for patients discharged in order to clear surge beds. If some of the assumptions in the CDC's models are changed to match the morbidity and mortality rates reported from the 1918 pandemic, the surge capacity of GDAHA facilities would not meet the projected demand. CONCLUSIONS: The GDAHA hospitals should test their regional distributors' ability to resupply PPE for multiple facilities simultaneously. Facilities should retrofit current air exchange systems to increase the number of potential negative pressure rooms and include such designs in all future construction. Neuraminidase inhibitor supplies should be increased to provide treatment for healthcare workers exposed in the course of their duties. Each hospital should have a complete set of policies to address the special considerations for a prolonged surge. Additional capacity is required to meet the predicted demands of a threat similar to the 1918 pandemic.     

医院灾害应急准备的国内外文献分析

目的系统检索报告／介绍应对国内外重大灾害的医院应急准备相关文献并加以总结与分析，为我国医院建立应对突发事件的应急准备提供参考。方法系统检索MEDLINE（1950～2008．6）、CNKI（1980～2008．6）和相关网站，对符合纳入标准的文献的主要结果进行描述性分析。结果共纳入85篇文献，其研究类型以专家意见和现况调查居多，分别占43．53％和29．41％。应对突发事件的医院应急准备是一个减灾、准备、反应和恢复的动态过程。应急准备可考虑以下内容：短期内成批接纳伤员能力、防灾减灾预案、合作与协调、培训与演习、人力资源、物资设备、实验室能力、伤员分检分类、诊断和治疗、消毒、经费保障、员工安全、后勤保障和心理支持等。医院应急准备可采用调查、清单或专用评估工具进行评价。结论医院应急准备是灾害救援的重要环节，医院应针对不同灾害和本地实情及各类灾害风险作好切实可行的灾害救援应急预案。     

Financing hospital disaster preparedness

Disaster preparedness and response have gained increased attention in the United States as a result of terrorism and disaster threats. However, funding of hospital preparedness, especially surge capacity, has lagged behind other preparedness priorities. Only a small portion of the money allocated for national preparedness is directed toward health care, and hospitals receive very little of that. Under current policy, virtually the entire funding stream for hospital preparedness comes from general tax revenues. Medical payers (e.g., Medicare, Medicaid, and private insurance) directly fund little, if any, of the current bill. Funding options to improve preparedness include increasing the current federal grants allocated to hospitals, using payer fees or a tax to subsidize preparedness, and financing other forms of expansion capability, such as mobile hospitals. Alternatively, the status quo of marginal preparedness can be maintained. In any event, achieving higher levels of preparedness likely will take the combined commitment of the hospital industry, public and private payers, and federal, state, and local governments. Ultimately, the costs of preparedness will be borne by the public in the form of taxes, higher healthcare costs, or through the acceptance of greater risk.     

Preparing hospitals for toxicological mass casualties events.

OBJECTIVE: For most hospital staffs, treatment of chemical casualties presents an obscure and even frightening situation. We report our unique experience from hospital drills in order to improve hospital preparedness for patient management under mass casualty conditions involving hazardous chemicals. SETTING: Twenty-one major hospitals in Israel. INTERVENTIONS: A unique hospital deployment plan for the management of chemical casualties was developed, and hospitals were required to have a full chemical practice drill every 3 to 5 yrs. These drills were designed as realistically as possible, and all included the use of personal protective equipment, decontamination, and treatment of simulated patients. Twenty-five percent of these patients, simulating children and adults, required intensive care and ventilation support. Hospitals were inspected and reviewed on the quality of treatment given and the overall continuity of care as well as on their administrative performance. RESULTS: Between 1986 to 1994, 30 full chemical practice drills were conducted in 21 major hospitals. Each drill included treatment of 100 to 400 simulated patients. The lessons from the hospital drills are described and were incorporated in the proposed revised hospital deployment plan. All hospitals significantly improved their ability to respond appropriately to these incidents. CONCLUSIONS: The level of preparedness for a chemical mass casualty scenario should be established according to the existing threat and the available resources. The proposed plan can serve as a basis for hospital planning and staff training worldwide, thus facilitating optimal care in the event of an incident involving toxic chemicals. A cost-effective scale for hospital preparation levels according to the existing threat is suggested.     

Jordanian nurses' perceptions of their preparedness for disaster management

AimTo assess Jordanian RNs’ perceptions regarding their knowledge, skills, and preparedness for disaster management.BackgroundCurrent disaster knowledge, skills, and preparedness levels need to be evaluated to guide plans for effective educational programs. There is also a need to know where RNs received their knowledge, skills, and preparation, to enhance or improve future educational opportunities.MethodsCross-sectional survey where the Disaster Preparedness Evaluation Tool (DPET®) was distributed to Jordanian RNs who work in three randomly selected Ministry of Health hospitals and two university hospitals.ResultsFour hundred and seventy-four participants completed the survey. Sixty-five per cent of respondents described their current disaster preparedness as weak: 18% medium: 12% good; and 5% felt their preparation was very good. Thirty-one per cent received disaster education in undergraduate programs; 8% in graduate nursing programs; 31% in facility drills, and 22% in continuing education courses. Eleven per cent had participated in a real disaster. Four hundred and thirty RNs wanted to learn more about RNs role in disasters, including knowledge and skills.ConclusionKnowledge, skills, and disaster preparedness need continual reinforcement to improve self efficacy for disaster management.RecommendationsThere is a need for a consistent national nursing curriculum for disaster preparedness and nationwide drills to increase disaster knowledge, skills, preparedness, and confidence.     

Emergency department preparedness for the evaluation and treatment of victims of biological or chemical terrorist attack

This study evaluated the preparedness of Emergency Departments (EDs) in the greater Philadelphia area to evaluate and treat victims of a terrorist biological or chemical agent release. All hospitals with EDs in the survey target area were included. A survey instrument consisting of 38 questions was mailed to the physician director of each ED. Fifty-four of 62 directors returned usable surveys. This represented an overall response rate of 88.5%. Deficiencies in preparedness were identified involving physician training and education, antidote stocking, written policies, interagency agreements, and decontamination facilities. The overall level of preparedness for hospital EDs responding to this survey was low based on a set of predetermined, implicit criteria. Comprehensive plans should be developed and implemented to remedy the identified deficiencies.     

State of Research in High-consequence Hospital Surge Capacity

High‐consequence surge research involves a systems approach that includes elements such as healthcare facilities, out‐of‐hospital systems, mortuary services, public health, and sheltering. This article focuses on one aspect of this research, hospital surge capacity, and discusses a definition for such capacity, its components, and future considerations. While conceptual definitions of surge capacity exist, evidence‐based practical guidelines for hospitals require enhancement. The Health Resources and Services Administration's (HRSA) definition and benchmarks are extrapolated from those of other countries and rely mainly on trauma data. The most significant part of the HRSA target, the need to care for 500 victims stricken with an infectious disease per one million population in 24 hours, was not developed using a biological model. If HRSA's recommendation is applied to a sample metropolitan area such as Orange County, California, this translates to a goal of expanding hospital capacity by 20%–25% in the first 24 hours. Literature supporting this target is largely consensus based or anecdotal. There are no current objective measures defining hospital surge capacity. The literature identifying the components of surge capacity is fairly consistent and lists them as personnel, supplies and equipment, facilities, and a management system. Studies identifying strategies for hospitals to enhance these components and estimates of how long it will take are lacking. One system for augmenting hospital staff, the Emergency System for Advance Registration of Volunteer Health Professionals, is a consensus‐derived plan that has never been tested. Future challenges include developing strategies to handle the two different types of high‐consequence surge events: 1) a focal, time‐limited event (such as an earthquake) where outside resources exist and can be mobilized to assist those in need and 2) a widespread, prolonged event (such as pandemic influenza) where all resources will be in use and rationing or triage is needed.     

Response of Thai hospitals to the tsunami disaster

The disaster caused by the tsunami of 26 December 2004 was one of the worst that medical systems have faced. The aim of this study was to learn about the medical response of the Thai hospitals to this disaster and to establish guidelines that will help hospitals prepare for future disasters. The Israeli Defense Forces (IDF) Home Front Command (HFC) Medical Department sent a research delegation to Thai hospitals to study: (1) pre-event hospital preparedness; (2) patient evacuation and triage; (3) personnel and equipment reinforcement; (4) modes used for alarm and recruitment of hospital personnel; (5) internal reorganization of hospitals; and (6) admission, discharge, and secondary transfer (forward management) of patients. Thai hospitals were prepared for and drilled for a general mass casualty incident (MCI) involving up to 50 casualties. However, a control system to measure the success of these drills was not identified, and Thai hospitals were not prepared to deal with the unique aspects of a tsunami or to receive thousands of victims. Modes of operation differed between provinces. In Phang Nga and Krabi, many patients were treated in the field. In Phuket, most patients were evacuated early to secondary (district) and tertiary (provincial) hospitals. Hospitals recalled staff rapidly and organized the emergency department for patient triage, treatment, and transfer if needed. Although preparedness was deficient, hospital systems performed well. Disaster management should focus on field-based first aid and triage, and rapid evacuation to secondary hospitals. Additionally, disaster management should reinforce and rely on the existing and well-trusted medical system.     

Hospital disaster preparedness in Osaka, Japan

PURPOSE: To investigate the adequacy of hospital disaster preparedness in the Osaka, Japan area. METHODS: Questionnaires were constructed to elicit information from hospital administrators, pharmacists, and safety personnel about self-sufficiency in electrical, gas, water, food, and medical supplies in the event of a disaster. Questionnaires were mailed to 553 hospitals. RESULTS: A total of 265 were completed and returned (Recovery rate; 48%). Of the respondents, 16% of hospitals that returned the completed surveys had an external disaster plan, 93% did not have back-up plans to accept casualties during a disaster if all beds were occupied, 8% had drugs and 6% had medical supplies stockpiled for disasters. In 78% of hospitals, independent electric power generating plants had been installed. However, despite a high proportion of power-plant equipment available, 57% of hospitals responding estimated that emergency power generation would not exceed six hours due to a shortage of reserve fuel. Of the hospitals responding, 71% had reserve water supply, 15% of hospitals responding had stockpiles of food for emergency use, and 83% reported that it would be impossible to provide meals for patients and staff with no main gas supply. CONCLUSIONS: No hospitals fulfilled the criteria for adequate disaster preparedness based on the categories queried. Areas of greatest concern requiring improvement were: 1) lack of an external disaster plan; and 2) self-sufficiency in back-up energy, water, and food supply. It is recommended that hospitals in Japan be required to develop plans for emergency operations in case of an external disaster. This should be linked with hospital accreditation as is done for internal disaster plans.     

Factors associated with willingness to respond to a disaster: a study of healthcare workers in a tertiary setting

Introduction: Due to recent disasters, disaster planners increasingly are focusing on healthcare worker preparedness and response in the event of a disaster. In this study, factors associated with pediatric healthcare workers' willingness to respond are identified.Hypothesis: It was hypothesized that personal factors may affect a pediatric healthcare worker's willingness to respond to work in the event of a disaster.Methods: Employees of a tertiary, pediatric care hospital in Los Angeles were asked to complete a brief, 24-question online survey to determine their willingness to respond in the event of a disaster. Information on demographics, employment, disaster-related training, personal preparedness, and necessary resources was collected. A logistic regression model was performed to derive adjusted odds ratios (OR) and their corresponding 95% confidence intervals (95% CI).Results: Eight hundred seventy-seven pediatric healthcare employees completed the survey (22% response rate). Almost 50% (n = 318) expressed willingness to respond in the event of a disaster. Men were more likely to be willing to respond to a disaster than were women (OR = 2.4; 95%CI = 1.6-3.6), and single/divorced/widowed employees were more willing to respond than married or partnered employees (OR = 1.5; 95%CI = 1.1-2.1). An inverse relationship was observed between number of dependents and willingness to respond (OR = 0.45; 95%CI = 0.25-0.80, ≥3 dependents compared to 0). An inverse dose response relationship between commuting distance and number of necessary resources (ptrend = 0.0485 and 0.0001, respectively) was observed. There was no association between previous disaster experience, disaster training, or personal preparedness and willingness to respond.Conclusions: Number of dependents and resources were major factors in willingness to respond. Healthcare facilities must clearly communicate their disaster plans as well as any provisions they may make for their employees' families in order to improve willingness among hospital employees.     

Public health preparedness for mass-casualty events: a 2002 state-by-state assessment

INTRODUCTION: The ongoing threat of a terrorist attack places public agencies under increasing pressure to ensure readiness in the event of a disaster. Yet, little published information exists regarding the current state of readiness, which would allow local and regional organizations to develop disaster preparedness plans that would function seamlessly across service areas. The objective of this study is to characterize state-level disaster readiness soon after September 2001 and correlate readiness with existing programs providing an organized response to medical emergencies. METHODS: During the first quarter of 2002, a cross-sectional survey assessing five components of disaster readiness was administered in all 50 states. The five components of disaster readiness included: (1) statewide disaster planning; (2) coordination; (3) training; (4) resource capacity; and (5) preparedness for biological/chemical terrorism. RESULTS: Most states reported the presence of a statewide disaster plan (94%), but few are tested by activation (48%), and still fewer contain a bioterrorism component (38%). All states have designated disaster operations centers (100%), but few states have an operating communications system linking health and medical resources (36%). Approximately half of states offer disaster training to medical professionals; about 10% of states require the training. Between 22-48% of states have various contingency plans to treat victims when service capacity is exceeded. Biochemical protective equipment for health professionals is lacking in all but one state, and only 10% of states indicate that all hospitals have decontamination capabilities. States with a functioning statewide trauma system were significantly more likely to possess key attributes of a functioning disaster readiness plan. CONCLUSION: These findings suggest that disaster plans are prevalent among states. However, key programs and policies were noticeably absent. Communication systems remain fragmented and adequate training programs and protective equipment for health personnel are markedly lacking. Statewide trauma systems may provide a framework upon which to build future medical disaster readiness capacity.     

浙江省三级甲等医院护士在疫情下的灾害准备度现状及影响因素分析

目的 了解护士在新型冠状病毒肺炎疫情下的灾害准备度水平及影响因素.方法 采用便利抽样法,使用护士灾害准备度量表,对浙江省杭州地区5家三级甲等医院护士开展问卷调查.结果 回收有效问卷1999份,护士灾害准备度得分为(179.87±36.76)分,处于中等水平.多元线性回归分析结果显示:护士工作年限、工作科室、灾害知识培训...     

Strategies to improve pediatric disaster surge response: potential mortality reduction and tradeoffs

OBJECTIVE: To estimate the potential for disaster mortality reduction with two surge response strategies: 1) control distribution of disaster victims to avoid hospital overcrowding near the scene, and 2) expand capacity by altering standards of care to only "essential" interventions. DESIGN: Quantitative model of hospital mortality. SETTING: New York City pediatric intensive care unit and non-intensive care unit pediatric hospital capacity and population. MEASUREMENTS AND MAIN RESULTS: Mortality was calculated for a hypothetical sudden disaster, of unspecified mechanism, assuming 500 children per million population need hospitalization, including 30% severely ill/injured warranting pediatric intensive care unit care, with high (76%) predisaster hospital occupancy. Triage rules accommodated patients at lower levels of care if capacity was exhausted. Specified higher relative mortality risks were assumed with reduced levels of care. In a pessimistic baseline scenario, hospitals near the disaster scene, considered to have 20% of regional capacity, were overcrowded with 80% of the surge patients. Exhausted capacity at overcrowded hospitals near the scene would account for most of the 45 deaths. Unused capacity would remain at remote facilities. If regional surge distribution were controlled to avoid overcrowding near the scene, then mortality would be reduced by 11%. However, limited pediatric intensive care unit capacity would still require triage of many severe patients to non-intensive care unit care. Instead, if altered standards of care quadrupled pediatric intensive care unit and non-intensive care unit capacity, then mortality would fall 24% below baseline. Strategies 1 and 2 in combination would improve mortality 47% below baseline. If standards of care were altered prematurely, preventable deaths would occur. However, additional simulations varying surge size, patient severity, and predisaster occupancy numbers found that mortality tradeoffs would generally favor altering care for individuals to improve population outcomes within the range of federal planning targets (500 new patients/million population). CONCLUSION: Quantitative simulations suggest that response strategies controlling patient distribution and expanding capacity by altering standards of care may lower mortality rates in large disasters.     

Lack of hospital preparedness for chemical terrorism in a major US city: 1996-2000

INTRODUCTION: The [US] Nunn-Lugar-Domenici Defense Against Weapons of Mass Destruction (WMD) Act (the WMD Act of 1996) heralded a new wave of spending by the federal government on counter-terrorism efforts. Between 1996 and 2000, the United States of America (US) federal government allocated large sums of funding to the States for bioterrorism preparedness. Distribution of these funds between institutions involved in first-responder care (e.g., fire and safety departments) and hospitals was uneven. It is unknown whether these additional funds had an impact on the level of hospital preparedness for managing mass casualties involving hazardous materials at the local level, including potential terrorist attacks with chemical agents. OBJECTIVES: (1) To compare 1996 and 2000 measures of preparedness among hospitals of a major US metropolitan area for dealing with hazardous material casualties, including terrorism that involved the use of weapons of mass destruction; and (2) To provide guidance for the improvement of emergency preparedness and response in US hospitals. METHODS: In July 1996 and again in July 2000,21 hospitals in one major US city were surveyed by questionnaire. A survey was used to assess the amounts of antidote stocks held available for treatment of casualties caused by toxic chemical agents and institutional response capabilities including the number of showers for decontaminating patients, the level of worker protection, and the number of staff trained to decontaminate patients. RESULTS: Hospital preparedness for treating and decontaminating patients exposed to toxic chemical agents was inadequate in 1996 and in 2000. From 1996 to 2000, there was no statistically significant change in the lack of hospital preparedness for stocking of nerve agent and cyanide antidotes. Capacity for decontamination of patients, which included appropriate hazardous material infrastructure and trained staff, generally was unimproved from 1996 to 2000 with the exception of an increase of nearly 30% in hospitals with at least one decontamination shower facility. CONCLUSION: Hospitals surveyed in this study were poorly prepared to manage chemical emergency incidents, including terrorism. This lack of hospital preparedness did not change significantly between 1996 and 2000 despite increased funds allocated to bioterrorism preparedness at the local level.