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A Review of federal Bioterrorism Preparedness Programs from a Public Health Perspective.
Subcommittee on Oversight and Investigations
Mr. Ron Petersen
Mr. Chairman, I am Ron
Peterson, President of The Johns Hopkins Hospital and Health System in
Baltimore, Maryland. I am here
today representing the American Hospital Association (AHA) and it's nearly
5,000 hospitals, health systems, networks, and other providers of care.
We appreciate this opportunity to present our views on an issue that is
dramatically affecting hospitals and communities across America: readiness for a
potential terrorist attack utilizing chemical, biological or radiological (CBR)
weapons. September 11 introduced a new consciousness to the collective American mind. We find ourselves faced with the task of preparing for new threats that once seemed unimaginable. Among those threats is the potential use of CBR against our citizens. HOSPITAL DISASTER PLANS To answer these and other
threats, hospitals nationwide, like those that directly responded to the
September 11 tragedies, have disaster plans in place that have been carefully
developed and tested. The plans are
multi-purpose and flexible in nature
because the number of potential disaster scenarios is large.
As a result, hospitals maintain an "all-hazards" plan that
provides the framework for managing the consequences of a range of events.
Hospitals conduct at least two drills a year: one may be focused on an
internal event, such as a complete power failure.
Another must be focused on an external event, such as a major highway
crash, a hurricane or an earthquake. A
hospital near an airport, for example, might focus on responding to an airplane
crash, while a hospital near a nuclear plant or an oil refinery would focus on
responding to the consequences of incidents at those sites.
It is important to remember that all incidents are local, and that local
agencies and organizations must work together so that response mechanisms are
tailored to the needs of their community. A good example of how hospitals worked with their communities to prepare for a wide range of possibilities was the change of the calendar to the year 2000. Throughout 1999, hospitals across the nation engaged in a major preparedness effort: Y2K readiness. While Y2K was easier to address than mass casualty readiness, because it had a known time . midnight of December 31 . and place . the hospital . the consequences were unknown. Hospitals were ready. Mass casualty preparedness is similar, because the possibilities are many.
But it is also different because of its uncertainty.
No one can accurately predict when an incident will occur, where it will
occur, or what will be its cause and consequences.
That is why the all-hazards plan,
tailored to suit the needs of each individual hospital and its community, has
provided an excellent framework for doctors and nurses forced into action by a
wide range of events. Nowhere was
this better reinforced than on September 11. SEPTEMBER 11: HOSPITAL REACTIONWhen
hospitals in New York received the call to expect thousands of injured patients,
triage teams were immediately set up, rehabilitation centers were transformed
into auxiliary emergency rooms, and hundreds of off-duty nurses and doctors
swarmed the hospital to offer assistance. Hospitals
in New Jersey and Connecticut were also at the ready. In Washington, readiness paid off as regional hospitals in
Virginia, the District of Columbia and Maryland launched into their disaster
modes. And in Pennsylvania,
facilities in the southwest part of the state were ready to provide care for
victims of the airplane crash there. When
the emergency plan went into effect, everyone was in their place, doing their
jobs. Nurses, doctors, and others,
working side by side, communicating effectively, relying on teamwork and
training to assist the incoming wounded. Different
cities, different hospitals, hundreds of miles away from each other, each
responding efficiently to a direct hit of terrorism.
Each reacted in a positive, planned manner that not only saved lives, but
also proved that America's health care heroes are dedicated, caring
professionals who are ready for the worst of circumstances.
The health care professionals and volunteers at all the sites were
prepared to treat far more patients than actually came to them.
Death tolls were simply too high, and health care workers grieved that
they couldn't do more. LEARNING TOOLSIt
is important to realize each incident is used to improve our preparedness. Disaster managers use the term "after action
analysis" to describe the types of activities that are conducted to study
what happened, what worked and what did not.
The AHA and its state, regional and metropolitan associations work with
our member hospitals to share throughout the field critical information that can
be derived from responses to events. The
following are important facts that we already know: ·
By definition, a mass casualty incident would overwhelm the resources of
most individual hospitals. Equally
important, a mass casualty incident is likely to impose a sustained demand for
health care services rather than the short, intense peak customary with many
smaller scale disasters. This adds
a new dimension and many new issues to readiness planning for hospitals.
BIOTERRORISM
The threat of chemical,
biological and radiological agents has become a focus of counterterrorism
efforts because these weapons have a number of characteristics that make them
attractive to terrorists. Specifically,
biological agents pose perhaps the greatest threat.
Dispersed via the air handling system of a large public building, for
example, a very small quantity may produce as many casualties as a large
truckful of conventional explosives, making acquisition, storage and transport
of a powerful weapon much more feasible. Some
CBR agents may be delivered as "invisible killers," colorless, odorless and
tasteless aerosols or gases. The
distinguishing feature of some biological agents-such as plague or
smallpox--is their ability to spread. The
victim may even become a source of infection to additional victims.
The effects of viruses, bacteria and fungi may not become apparent until
days or weeks after initial exposure, so there will be no concentration of
victims in time and locale to help medical personnel arrive at a diagnosis.
Exposure to biological agents may cause a variety of symptoms, including
high fever, skin blisters, muscle paralysis, severe pneumonia, or death, if
untreated.
HOSPITAL READINESSBecause
September 11 redefined the meaning of disaster, hospitals are now upgrading
their existing readiness plans to meet the new needs of their communities.
Since the risk of chemical and biological attacks is now an obvious
concern, hospitals are reassessing their current plans.
The AHA so far has sent two Disaster Readiness Advisories to all of
America's hospitals with information and resources to help them in this effort.
The
following are among the key items that we believe need to be addressed to help
hospitals as they update their disaster plans to meet the challenges of a threat
that, until recently, seemed hypothetical: an attack using chemical, biological
or radiological agents. Medical
and pharmaceutical supplies -
Hospitals must be properly
stocked with antibiotics, antitoxins, antidotes, ventilators, respirators, and
other supplies and equipment needed to treat patients in a mass casualty event.
Communication
and notification - There is a need for greater coordination of
public safety and hospital communications, the ability of different entities to
communicate with each other on demand. In
addition, alternative and redundant systems will be required in case existing
systems fail in an emergency. Surveillance
and detection - Improving
hospital laboratory surveillance and the epidemiology infrastructure will be
critical to determining whether a cluster of disease is related to the release
of a biological or chemical agent. The
ability to rapidly identify the agent involved is vital. Personal
protection - Hospital supplies
of gloves, gowns, masks, etc. would quickly be used up during an attack, and
equipment like canister masks is rarely kept in adequate numbers to meet demands
of a large casualty attack. Hospital
facility - Among the
capabilities hospitals will need in the event of an attack: lockdown ability;
auxiliary power; extra security; increased fuel storage capacity; and large
volume water purification equipment. Dedicated
decontamination facilities -
Hospitals need a minimal capability for small events and the ability to ramp-up
quickly for a larger event. Training
and drills - Staff training is
needed at all levels for all types of potential disasters.
Additional disaster drills beyond the two per year required by JCAHO,
particularly community-wide drills, would enhance the level of hospital
readiness. Mental
health resources - Mass casualty
events trigger escalated emotional responses.
Hospitals must be ready to treat not only patients exhibiting these
symptoms, but others, such as family members, emergency personnel and staff.
COMMUNICATION
/ TRANSPORTATION ISSUES
To
truly solidify response readiness, the federal government should help establish
an emergency communication and transportation strategy.
During the recent attacks, street closings and clogged roads impeded EMS
workers as they tried to reach the affected areas, and hindered quick access to
hospitals. No-fly zones were
implemented to prevent other air attacks, but those zones hindered med-evac
helicopters and other air transports that shipped blood and bandages to
hospitals in dire need. Hospitals
need assistance from Federal Aviation Administration officials to keep the skies
open to critical medical aircraft. In
addition, any biochemical attack will require the coordination of local, state
and federal agencies. In response,
the Centers for Disease Control and Prevention have invested in and upgraded
state-of-the-art labs to identify and monitor reports of suspicious cases of
illness across the country. Working
in conjunction with state and local epidemiologists, they will communicate their
findings to government agencies.
READINESS RESOURCESRealistically,
America can never afford to prepare every hospital in the country for every
possibility of attack. However, the
federal government can provide assistance to help ensure that hospitals and
their local agencies are best able to respond to potential attacks.
These funds would be earmarked to meet the challenges outlined above,
including inventories of the necessary drugs and equipment needed to help
victims of terrorist attacks. Communities
need the funding to assist their hospitals and expand their emergency relief
teams, as well as to establish or implement new systems of readiness.
HOSPITAL CHALLENGESThere
is no more important strategy in this domestic war on terrorism than to help our
hospitals reach a state of readiness. But
if America's hospitals are to enhance their readiness for a new world
of possibilities, they must have in place the people they need to do the job.
However, America's hospitals are experiencing a workforce shortage that
will worsen as "baby boomers" retire. Currently,
our health systems have 126,000 open positions for registered nurses, for
example. The United
States Department of Health and Human Services predicts a nationwide shortage of
400,000 nurses by 2020. There
also are shortages of other key personnel, such as pharmacists.
This shortage cuts to the core of America's health care system,
because dedicated, caring people are the heart of health care. Fortunately,
Congress has recognized the importance of this issue.
Legislation has been introduced that can help hospitals attract
and maintain the health care workforce that is needed to ensure that our
patients receive the right care, at the right time, in the right place.
For example, the Nurse Reinvestment Act (S.706/H.R. 1436) offers the
right step to ensure health care professionals avert the collision course we
face with lack of hospital staff. CONCLUSIONThe
United States has been thrust into a new era.
Our hospitals have always been ready for the foreseeable.
Now we must plan for the previously inconceivable.
Hospitals are upgrading existing disaster plans, and continue to tailor
their disaster plans to suit the individual needs of the community in the face
of new threats. America
can be comforted that, as we have witnessed over the last few weeks of our
national tragedy, highly trained, caring doctors, nurses and other professionals
are the heart of our health care system. They
perform heroic, lifesaving acts every day.
And, in the face of the unexpected, they can be depended on to rise to
the needs of their communities. The AHA has worked closely with the administration on this important issue, especially with Sec. Thompson. We look forward to working with Congress as we help ensure that the people we serve get the care they need in any and all circumstances.
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