Mole Hills with Mountainous Potential: Facing the Challenges of Health Care Institutions

1
Mole Hills with Mountainous Potential Facing the
Challenges of Health Care Institutions

• Churton Budd
• Paul Rega
• Kelly Burkholder-Allen

2
In every country, we should hit their
organizations, institutions, clubs, and
hospitals, it reads. The targets must be
identified, carefully chosen and include their
largest gatherings so that any strike should
cause thousands of deathsFrom the Manual of
Afghan JihadHamza Hendawi, The Associated Press
Feb. 2, 2002
3
State of Health Hospital Preparedness

• In spite of preparedness requirements within the
  industry, hospitals typically are the weakest
  link with respect to community preparedness
• Systemic constraints are the major cause
• Analysis of numerous exercises conducted
  throughout the U.S. have yielded a predictable
  list of pitfalls that continue to hinder
  hospitals in effective preparedness

4
Ten Commandments of State and Local Emergency
Management for Health Care Administrators

• Thou shall respect that all disasters are local
• Thou shall recognize FEMAs influence on the
  Health Care Industry
• Thou shall know the terms Pre-hospital,
  EMAs, EOCs, and recognize that they are
  different
• Thou shall participate WILLINGLY in local
  emergency preparedness activities
• Thou shall drill and exercise internally and
  externally, and play well with others
• Thou shall forget the misguided notion that you
  may know everything there is to know about
  emergency management
• Thou shall meet and greet.forming mutual aid
  agreements and addressing contract issues before
  they are needed
• Thou shall make up for lost time as soon as
  possible
• Thou shall lead responsibly those in your charge
• Thou shall be prepared to deliver medical care
  for at least 72 hours.ALONE

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Systemic ConstraintsMinimal Surge Capacity

• 30 operating at a financial loss
• Increasing costs, decreasing reimbursement
• EDs have become PCPs for many
• Staffing shortages are becoming a norm
• Loss of experienced and mature staff
• Increasing governmental regulations and un-funded
  mandates
• Accreditation Requirements

6
Predictable Pitfallsinherent system limitations

• Communications
• Security
• Management of Staff
• Decontamination equipment, procedures, and
  training
• JIT inventory management
• Management of Behavioral Casualties
• Management of Special Needs population
• Underestimating the media response
• Exercise realism, content, and corrective actions

7
Financial Resources

• Profit margins are declining
• From 5.8 to 4.2 from 2002-2003 (AHA)
• Plan development, staff training, equipment
  maintenance are not reimbursable
• HRSA funding just recently began to trickle
  down498 million to states, territories, and
  freely associated states (OH 1/17 states to
  receive double digit figure)
• Empty beds do not generate revenue

8
Hospital Surge Capacity EDs

• Surge capacity is a significant issue
• 900 hospital closures since 1980
• ED visits rose to 95 million in 1997 to 108
  million in 2000
• Less than 10 of all ED visits are classified as
  non-urgent by CDC standards (ACEP)
• Many of the nations EDs are operating at/above
  capacity---crowding is the most severe in major
  metropolitan area EDs
• A GAO report revealed that two thirds of our EDs
  are diverting ambulance patients
• 20 of the time (4 hours/day)
• Diversion has a cascade affect on hospitals in
  the surrounding area

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Staffing

• Hospitals are experiencing shortages of a variety
  of health care providers
• Nursing shortages continue and will get worse
• More care delivered by physician extenders and
  nursing assistants
• GAO Report revealing that large numbers of
  hospital staff working overtime and taking call
• Numerous published studies highlighting the
  selectivity that staff may exhibit in their
  willingness to report for duty in a variety of
  disasters/WMD events, and their perception of
  barriers that would impact the ability of staff
  to report for duty in such events

10
Mr. Administrator----TEAR DOWN THOSE BARRIERS!!!

• Fear for safety (self and family)
• Transportation issues
• Conflicting emergency response obligations
• Military reserves
• Volunteer firefighting
• Affiliation with DMATs
• Issues
• Long distance phone service
• Ability to utilize email
• Pet care
• Child care
• Elder care

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Un-Funded Mandates and Accreditation Requirements

• Clarification for HIPPA, EMATALA, OSH, and EPA
  regulatory requirements and their applications in
  emergency situations is vital
• JCAHO adaptation to a post-September 11, 2001
  world
• Mandates imposed by other accrediting agencies

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Communications

• Redundant communications are essential
• Both internal and external
• Interoperability of communication equipment
  within a community is a must
• The PIO managing both internal and external
  communications must be in sync with hospital
  policy and community activities

13
Security

• Hospital Security forces to maintain
• daily operations are stretched at present
• Local law enforcement will not be able to assist
  in the event of a large scale event
• Instituting a Lock Down will require additional
  security challenges
• In the event of an epidemic such as SARS,
  securing the quarantined and limiting entry will
  create additional issues

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Management of Staff

• Even staff with specific roles and defined tasks
  must have an understanding of the roles of other
  participants
• HEICS clearly delineates lines of authority, yet
  provides flexibility to adapt to evolving events
• Frequent training is the key to success by
  promoting standardization and interoperability

15
JIT Inventory Management

• Hospitals have transitioned to JIT inventory
  management strategies raising concerns about
  surge capacity for essential suppliesthe 24-48
  hour Stand Alone is jeopardized
• Pharmaceuticals
• Soft medical supplies
• Hard medical supplies
• Other resources necessary to maintain a sudden
  increase in daily operations

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Behavioral Casualty Management

• Few hospital plans address the needs that the
  behavioral casualties will bring with them
• It is estimated that for every physical casualty
  caused by a terrorism, there will be 4-20
  psychological victims
• In the first two weeks following 9/11, St.
  Vincents Hospital in NYC provided counseling and
  support to more than 7,000 people and received
  more than 10,000 calls to its help line

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Family Information

• In large scale events hospitals will receive an
  influx of family members seeking information
  regarding loved ones. They will have needs as
  well
• Clerical and Social Service
• Food and possibly Shelter
• Information about and location of loved one
• Space away from Media
• If your EMP has not planned for the management
  of families---take action immediately!

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Special Needs Population

• The disabled
• Mobility impaired
• Hearing impaired
• Visually impaired
• Cognitively impaired
• Elderly
• Pediatric
• Pregnant females
• Non-English speaking

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The Disabled

• One out of every five Americans has a disability
• One out of ten has a severe disability
• Approximately 9 million have disabilities so
  severe that they require personal assistance with
  ADLs---many of these individuals receive this
  assistance from family
• 54 million US citizens have a disability
• 58 have NO PLANS for safe and expedient
  evacuation from their homes
• 50 of the employed disabled report that there
  are no plans in their workplace for safe and
  expedient evacuation
• Nearly 800,000 disabled persons live in assisted
  living facilities

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People with Disabilities

• Prior to the 1993 WTC attack, people with
  disabilities opted not to be identified as
  disabled---that changed!
• A December 2001 survey released by the National
  Organization on Disability yielded the following
• 58 of people with disabilities said that they
  did not know who to contact about emergency plans
  for their community
• 61 said that they had not made plans to evacuate
  their homes quickly and safely
• Among the employed, 50 said that no plans have
  been made to evacuate their workplace safely

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Planning for Management of Disabled Individuals

• Persons with a disability have unique limitations
  and abilities
• Include outside agencies in your hospital
  planning activities and exercisestheir input and
  feedback is essential to success
• Practice evacuation plans by having the planners
  simulate disabilities---much can be learned on
  either end

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Service or Assistance Animals

• There are many types of specially trained dogs
  providing assistance to disabled individuals have
  you factored these animals into your planning
• Hearing dogs for the deaf
• Seeing-eye-dogs
• Motor or mobility assistance dogs

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Mobility Impaired

• People who use wheelchairs or other assistance
  devices may have a wide variety of abilities and
  limitationsit is difficult to generalize their
  needs
• 1.5 million Americans use a wheelchair
• How would you evacuate wheelchair dependent and
  other mobility impaired individuals in
  stairwells?
• Does your facility have evacuation devices that
  can be used?

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Hearing Impaired

• Hearing impairments range from a mild loss of
  hearing to profound deafness
• 28 million Americans have a hearing deficit
• 500,000 are completely deaf
• Communication in times of an emergency can be
  aided by
• Establishing eye contact and facing the light
• Speaking slowly and clearly
• Using facial expressions and hand gestures
• Providing written instructions or other written
  communication
• Providing flashlights for signaling to health
  care providers
• Using pictographs and communication boards

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Visually Impaired

• 8 million Americans live with limited vision
• 130,000 are legally blind
• The visually impaired may vary in degree from
  having limited to no vision, planning for the
  safe management and care of these individuals
  cannot be overlooked
• Even those who are independent, cannot be left in
  unfamiliar surroundings without assistance
• In an emergency situation, provide clear and
  simple instructions---practice evacuation
  simulating visual impairment
• Braille

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Cognitively Impaired

• 7 million Americans have mental retardation
• People with developmental disabilities may
  experience limitations with cognitive abilities,
  motor abilities, and social abilities---they may
  have difficulty recognizing rescuers or being
  motivated to act in an emergency
• Visual perception of written instructions or
  signs may be confused
• Sense of direction may be limited
• Ability to understand is often more developed
  than the individuals vocabulary
• The individual should be treated as an adult who
  happens to have a cognitive or learning
  disability

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Assisting the Cognitively Disabled

• Be patient
• Break down information into simple steps
• Use signs and symbols
• Read information to them
• Do not talk down to or treat as if they are a
  child

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The Elderly

• By 2020 California and Florida will double their
  1993 elderly population
• By 2030, older adults will account for 20 of our
  population in the U.S.an increase from 13 in
  2001
• 1994-1995, 1.86 million individuals gt65 reported
  difficulties with 2 or more ADLs
• Between 1960 and 1994, the oldest old increased
  by 274

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Defining the Elderly

• Elderly gt65
• Young Old 65-74
• Aged 75-84
• Oldest Old gt85

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The Elderly

• Many of the services traditionally provided at
  hospitals are now being delivered in the home
  setting
• More elderly are living independently longer
• Greater dependency upon health care
  infrastructure to provide life-sustaining
  equipment, treatments, and medication
• ? age ? vulnerabilities
• ?sensory perception
• ? strength
• Poor exercise tolerance
• Poor thermoregulation
• Pre-existing conditions
• Socio-economic hardships

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Children Are Not Little Adults
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Pediatric Patients

• Pediatric patients differ from adults
  physiologically, psychologically, anatomically,
  cognitively, and mentally
• They have immature motor and cognitive skills
  which predispose them to remain in harms way
• Triaging Pediatric patients presents
  challengesespecially if your facility does not
  have a pediatric department
• JUMP-Start Triage captures the subtle nuances of
  the pediatric population
• Pediatric patients are at risk for emotional
  trauma---assessment of emotional trauma should be
  included in the triage process
• Work with staff from the Pediatrics Department to
  establish Mass Casualty management of pediatric
  patients

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Pediatrics

• Greater number of respirations
• ? risk for inhalation aerosolized agent or toxic
  substance
• Short in stature
• ? risk of inhaling more concentrated dose of
  substance that is heavier than air
• Inadequate skin keratinization
• ? capacity to protect skin from dermal injury
• ? capacity to absorb toxins thru skin
• Greater Body Surface Area
• ? potential to lose body heat
• ? potential to absorb toxins thru skin
• Less Internal Fluid Reserves
• Prone to dehydration and shock---making timely
  fluid replacement a priority

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Pediatrics
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Pregnant Females

• Performing triage on pregnant females can be
  present challenges
• Involve OB/Gyn staff in the planning for
  reception of pregnant females
• Pre-position ultrasound equipment in ED, or work
  with OB department to set up and staff a
  secondary Triage area

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The Non-English Speaking

• The use of pictographs can be used to replace
  spoken language
• Does your facility have large pictographs that
  can be used with traditional signage to direct
  individuals?
• In the absence of an interpreter, communication
  boards can bridge many of the language barrier
  gaps in emergency situations

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Underestimating the Media

• If it happens.they will come
• Preparation is a must
• Review and define the roles and responsibilities
  of the PIO
• Your PIO should be planning today for tomorrows
  events

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Exercise Planning and Realism

• Large plans ? preparedness.in fact, they
  frequently invoke a false sense of preparedness
• Preparedness is more of a process than a
  product---exercising the plans is a vital part of
  the process
• As with plans, exercises should be flexible yet
  have pre-determined objectives
• Whether conducting a full functional or a
  tabletop exercise---an After Action Report and a
  hot wash should be the beginning point for plan
  revisions

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The only thing harder than explaining why you
need to prepare for a disaster is to explain why
you didnt Leslie Stein-SpencerChief of
EMSIllinois Department of Public Health
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Using JCAHO Standards!

• E.C.1.4. requires development of an EMP that
  ensures an effective response to emergencies
  affecting the environment of care
• E.C.2.4. requires implementation of the EMP
• E.C.2.9. requires execution by conducting drills

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Keeping the mole hills mole hills

• E.C.1.4---The organization has an Emergency
  Management Plan
• Intent The EMP comprehensively describes the
  organizations approach to responding to
  emergencies within the organization or in its
  community that would suddenly and significantly
  affect the need for the organizations services,
  or its ability to provide those services. The
  plan addresses the following
• Mitigation actions taken in attempt to lessen
  the severity and impact of a potential
  emergency
• Preparedness actions taken to build capacity and
  identify resources that may be used in an
  emergency
• Response
• Recovery

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Maintaining the mole hills

• E.C.2.9.1. Drills are conducted regularly to
  test emergency management
• Intent The response phase of the EMP is tested
  twice a year, either in response to an actual
  emergency or in planned drills. Drills are
  conducted at least four months apart and no more
  than eight months apart.

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E.C.1.4 and E.C.2.4 Requirements

• Execute Hazard and Vulnerability Analysis
• Identify all of the hazards that could occur in
  your community, their likelihood, and their
  probable impact
• Security
• Utility Failures
• Natural Events, Technological Events, Human
  Events
• Structural Implications
• Other
• Your local EMA already has already performed a
  HVA for your community----use it as a springboard
• www.ashe.org for Hazard Vulnerability Assessment
  Tool

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Analyzing and Integrating the HVA

• Organize the analysis so that it integrates into
  the overall EMP
• Assess each risk according to your organizations
  ability to
• prepare for
• respond to
• mitigate against
• recover from

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Mitigation, Preparedness, Response, and Recovery
Identification and Processes for

• Coordination with Community Emergency Planners in
  establishing priorities among the potential
  emergencies
• Identification of procedures to mitigate, prepare
  for, respond to, and recover from the priority
  emergencies
• Defining the role that your institution will play
  and integrate it into your communitys EMP
• Delineating lines of authority

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Processes for

• Activation of the EMP
• Notification of outside agencies
• Notification of personnel
• Back-up communication systems
• Management of all resources
• personnel, materiels

• Management of patient care activities
• Evacuation
• Transportation and transfer of patients
• Establishment of alternate care sites
• Back-up utility services
• Re-establishment of continuous operations

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Processes for

• Identification of isolation and decontamination
  sites and practices
• Orientation and education programs for the staff
• Ongoing monitoring of performance in drills and
  actual emergencies

• Annual review of the EMP
• Post exercise corrective action planning post
• Staff Needs
• housing
• transportation
• incident stress debriefing
• family support activities

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Decontamination Issues

• Little attention has actually been paid to the
  decontamination process
• Even experienced HazMat teams have limited
  experience
• Protocols to meet the needs of the chemical and
  vapor decontaminated are necessary
• Critical assessment of
• Inherent delays in mass decon at a scene
• Decision-making process to provide water decon
  (ambient temperature, type of agent exposure,
  symptomatology, liquid vs. vapor vs. radiological
  vs. biological)

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Mass Decontamination

• Identify the agent
• Evacuate from the source
• Decontaminate--timely
• Treat the symptomatic
• Observe the asymptomatic for delayed onset of
  symptoms
• The reality is that those who survive to rescue
  will survive

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• Decontamination is the process of removing or
  reducing the concentration of harmful substances.
  It should be performed whenever there is a
  likelihood of contamination or risk of secondary
  exposure. The most important step in
  decontamination is the speed of the removal of
  the agent. (Levitan et. al)

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Points to Ponder

• Vapor exposure does not require decontamination,
  removal from the source and possibly removal of
  clothing is sufficient---
• Removal of clothing eliminates 80-90 of
  contaminants and minimizes the risk of spreadbut
  is dependent upon the amount of clothing warn at
  time of exposure
• Removal of clothing is the minimal acceptable
  level of decontamination after a hazardous
  chemical, radioactive contamination, or terrorist
  event
• Nothing has been proven to be more effective than
  soap and water, bleach is contraindicated
• Decontamination of known radiological agents
  parallels that for chemicals, with the exception
  that life-threatening injuries are managed prior
  to decontamination
• The Radiation Safety Officer should oversee the
  monitoring of the victims and make determination
  of adequate decontamination
• Decontamination after known exposure to
  biological agents is controversial---these agents
  are non-volatile and do not off-gas
• T2-Mycotoxins and Sarin are exceptions
• Weaponized Anthrax can act as a vapor

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Hospital Decontamination Considerations

• Will the victims remove their clothing? How will
  you manage these items?
• How long will they remain cooperative pending the
  decon process?
• What impact does modesty or inclement weather
  play in the decision-making process?
• Have you taken cultural and religious issues into
  consideration?
• Will the ambulatory willingly proceed thru a
  decon corridor?
• How long will they need to remain in the line?
• How will inclement weather Impact the decisions
  made?
• Is triage feasible? How will it be performed?
• What level of PPE is necessary for the staff?
• What ratio of trained staff to victims is
  necessary?
• Is removal of clothing only a suitable form of
  decon? What criteria determines this?
• Gender separation? Family separation?

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Management of the Contaminated Patient

• The most important step in decontamination is the
  speed of the removal of the agent!
• Equipment, staffing, and training all require
  funding and maintenancefrequent drills as well
• What are your facilitys capabilities?
• Can your facilitys plan be rapidly expanded?
• Nearly 70 of hospitals can provide 5 minute
  decontamination for up to 10 victims per hour per
  100 staffed beds (GAO-2003)
• 50 of these hospitals could handle lt6 per hour

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HRSA Recommendations

• Portable or fixed decontamination systems for
  managing 500 adult and pediatric victims and
  health care workers per 1,000,00 population---
  our RMRS is already working to accomplish this!
• Where does your facility factor into providing
  these capacities?

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1995Tokyo, Japan

• Sarin gas release in subway system
• 12 exposed victims died, thirty-seven were
  critically ill, and several hundred were
  symptomatic and sought treatment
• Over 30 of the first responders and hospital
  staff developed symptoms related to exposure to
  the Sarin that remained in their clothing
• gt5,500 sought evaluation in already burdened
  hospitals

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1987Goiania, Brazil

• 1987 accidental release of cesium-137 from a
  medical device in an abandoned clinic
• yielded 4 deaths from ARS and 249 with internal
  or external contamination
• 125,000 people sought screening for radiological
  contamination (10 of population)
• Of the first 60,000 screened, 5,000 complained of
  actual sx of ARS

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2001Alliance, OH

• Meningococcal Meningitis outbreak
• Two deaths of teenage high school students
• One teenager was hospitalized after attending
  funeral service for friend who died from
  meningitis
• gt10,000 presented to medication dispensing sites

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Lacking resources to manage infectious diseases

• A recent GAO Report revealed the following
• Less than 10 PPE suits per 100 staffed beds
• 40 had fewer than 2 suits
• Less than 10 isolation beds per 100 staffed beds
• 50 had fewer than 4 isolation beds
• Most hospitals have lt10 ventilators per 100
  staffed beds

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What if we applied the Regionalized Trauma Care
Model to Bioterrorism and EIDs?

• Formalized protocols for pre-hospital and
  hospital care contribute to improved patient
  outcomes
• Established communication networks have been
  essential to coordinated regionalization of
  trauma
• Outreach activities
• High quality, cost-effective specialty care in
  specifically designated hospitals

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2003Singapore

• SARS Outbreak initiated by a traveler to Hong
  Kong, in February, 2003 (Pt. A)
• Tan Tock Seng Hospital admitted traveler on March
  1, 2003 (dx atypical pneumonia)
• Removed from 6 bed ward and placed into isolation
  on March 6th
• 24 of this patients primary contacts were
  diagnosed with probable SARS
• 9 health care workers (8 nurses), five patients,
  and 10 visitors
• EID.www.cdc.gov/eid Vol. 10, No. 3, March, 2004

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Tan Tock Seng Hospital Singapore

• Pt. AA (a nurse caring for Pt.A) was admitted on
  March 10 to an open ward
• Pt. AA was isolated on March 13, but by this
  time, 25 persons had been infected 12 health
  care workers, 4 patients, 8 visitors, 1 household
  contact
• Pt. AAA from the above population of exposed
  contacts was admitted to CCU from March 12-19 for
  what appeared to be a non-SARS admission (Pt. AAA
  with an extensive medical history)
• Pt. AAA then spread the infection to 27 5
  physicians, 13 nurses, 1 ultrasonographer, 1
  attendant, 2 cardiac techs, and 5 visitors

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TTSH Spread

• On March 15, probable SARS was diagnosed in 13
  persons all of whom were admitted to TTSH
• 6 were family and friends of Pt. A
• 6 were health care workers who attended to Pt. A
  while in open ward
• 1 was a health care worker who attended to Pt.
  AAA in CCU
• There were additional employees at home ill with
  fever who had worked on the open wards
• The spread of SARS continued until March 22, 2003
  when all normal operations were suspended at TTSH
  and it functioned as a dedicated SARS facility

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Tan Tock Seng Hospital

• It took 3 weeks to stem the spread at TTSH
• In addition to the SARS spread within TTSH, the
  infection was spread outside by infected
  visitors, healthcare workers, and household
  contacts to other hospitals
• Singapore was removed from WHOs list of areas
  with local SARS transmission until May 31, 2003
• At that time, 206 probable SARS cases had been
  diagnosed 40.8 in health care workers, 39.8 in
  family, friends, or visitors to hospital, and
  12.2 were in inpatients

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Singapore General Hospital

• Index case Pt. B who did not exhibit typical
  SARS symptoms, was admitted to an open ward on
  March 24 for GI bleeding
• Fever was attributed to a UTI which developed on
  March 26
• Was transferred to another open ward on March 29
  and remained there until April 2
• On April 4, a cluster of 13 health care workers
  developed fevers 1 physician, 11 nurses, and an
  x-ray tech---all had attended to Pt. B---probable
  SARS developed in all 13
• The SGH outbreak totaled 60 24 health care
  workers, 11 inpatients, two outpatients, 12
  visitors, and 11 household contacts
• Because SGH was the largest hospital, closing it
  was not an option---all SARS patients and those
  exposed were taken to TTS, followed up by phone,
  or quarantined for ten days
• Containment measures worked within 10 days

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National University Hospital

• Pt. C was treated in the ED on April 8, remaining
  for approx. 4 hours
• Was transported to an open ward and remained
  there for approx. 8 hours prior to requiring
  intubation and transfer to isolation in an ICU
• The next morning Pt. C was transported to TTSH
• Within two days, a physician who had attended Pt.
  C spiked a fever---at that point, all exposed
  persons were isolated (no new admissions or
  discharges for 10 days), staff members were
  quarantined after work
• The inpatients who developed fever were
  transferred to TTSH and two nurses were isolated
  at NUH after developing fevers

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Protecting Your Staff

• During a biological event or a naturally
  occurring disease outbreak, strategies to protect
  your staff and their families is an essential
  component of maintaining a robust workforce
• Communications and cooperation with your facility
  and local public health cannot be overestimated

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Screening is just the beginning!

• All screened contacts must be logged
• Information must be carefully managed
• Information must be shared
• Follow-up is essential
• Screening efforts are part of overall
  surveillance activities
• Where will the personnel come from?
• What forms will they use?
• How will the information be managed?
• Working with local Public Health officials

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Establishing the Screening Process for Disease
Outbreaks

• Determine all portals of entry
• Delivery entrances, public access entrances,
  ambulatory department entrances, ED entrance
• Provide for mandatory temperature screening of
  every individual who enters (name should be
  logged as well)
• Provide appropriate PPE for all staff and
  visitors
• Screen all staff at beginning and end of every
  shift
• Implement algorithms for movement of visitors and
  patients

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Establish a Logging/Tracking Process for Disease
Outbreaks

• Everyone who enters the facility should be logged
  as well as their travels throughout the facility
• Minimize movement of staff from respective units
• EVERY patients contact history must be thorough

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Isolation and Quarantine of Staff

• Where will you isolate staff who are ill?
• How many of your staff are immunosupressed?
  Pregnant?
• What if they have family members who are
  immunosuppressed or pregnant?
• If an entire unit is in isolation, who will
  enforce the no admissionno discharge policy?
• Where will the extra security come from?

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Backfill to cover Staff

• Quarantined staff coverage
• Exposed to probable SARS or another contagious
  disease at work
• Exposed as household contacts
• Many health care workers are employed at several
  hospitals in one community---how will you stop
  the spread?
• Will quarantined staff members be able to work if
  they are asymptomatic?

• Ill staff member coverage
• If one hospital becomes the designated
  contaminated hospital will staff be able to
  work or make rounds in other hospitals?
• Who will choose which hospital physicians will
  practice at during EID or bioterrorism-related
  outbreak?

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Keeping the bad in and the good out?

• Enforcement of isolation and quarantine?
• Cancellation of visitation for patients
• Restriction of movement of staff?
• Intra-facility employment yields intra-facility
  spread of infectious diseases

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References

• Regionalization of Bioterrorism Preparedness and
  Response. AHRQ, Evidence/Technology Report No.
  96. available at
• www.ahrq.gov
• Mobilizing Americas Health Care Reservoir.
  Joint Commission Perspective 200121(12)1-23.
  available at
• www.jcrinc.com
• Hazard Vulnerability Analysis. 2000, American
  Society of Engineering. Available at
  www.ashe.org
• Health Care at the Crossroads Strategies for
  Creating and Sustaining Community-wide Emergency
  Preparedness Systems. Joint Commission on
  Accreditation of Healthcaer Organizations, 2003.
• Orientation Manual for First Responders on the
  Evacuation of People with Disabilities. U.S. Fire
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