Title: Mole Hills with Mountainous Potential: Facing the Challenges of Health Care Institutions
1Mole Hills with Mountainous Potential Facing the
Challenges of Health Care Institutions
- Churton Budd
- Paul Rega
- Kelly Burkholder-Allen
2In 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
3State 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
4Ten 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
5Systemic 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
6Predictable 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
7Financial 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
8Hospital 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
9Staffing
- 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
10Mr. 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
11Un-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
12Communications
- 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
13Security
- 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
14Management 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
15JIT 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
16Behavioral 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
17Family 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!
18Special Needs Population
- The disabled
- Mobility impaired
- Hearing impaired
- Visually impaired
- Cognitively impaired
- Elderly
- Pediatric
- Pregnant females
- Non-English speaking
19The 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
20People 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
21Planning 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
22Service 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
-
23Mobility 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?
24Hearing 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
25Visually 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
26Cognitively 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
27Assisting 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
28The 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
29Defining the Elderly
- Elderly gt65
- Young Old 65-74
- Aged 75-84
- Oldest Old gt85
30The 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
31Children Are Not Little Adults
32Pediatric 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
33Pediatrics
- 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
34Pediatrics
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36Pregnant 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
37The 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
38Underestimating 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
39Exercise 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
40The 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
41Using 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
42Keeping 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
43Maintaining 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.
44E.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
45Analyzing 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
46Mitigation, 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
47Processes 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
48Processes 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
49Decontamination 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)
50Mass 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
51- 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)
52Points 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
53Hospital 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?
54Management 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
55HRSA 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?
561995Tokyo, 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
571987Goiania, 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
582001Alliance, 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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60Lacking 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
61What 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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632003Singapore
- 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
64Tan 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
65TTSH 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
66Tan 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
67Singapore 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
-
68National 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
69Protecting 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
70Screening 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
71Establishing 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
72Establish 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
73Isolation 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?
74Backfill 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?
75Keeping 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
76References
- 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
Administration. FEMA FA-235/August 2002. - Family Survival Guide Preparing Your Family For
Times of Emergency. American Red Cross,
Washington, D.C., 2000. - Census Brief Disabilities Affect One-Fifth of
All Americans. U.S. Department of Commerce,
Bureau of The Census, Washington, D.C.,
CENBR/97-5, December, 1997
77References
- Public Health Preparedness Response Capacity
Improving, but Much Remains to Be Accomplished. - McGlown, JCoordinating Roles at the Community
and State Levels, presented at When Disaster
Strikes The Role of the Hospital, ACHE,
Washington, DC, February, 2002. - Lanzilotti, S, et al Hawaii Medical
Professionals Assessment A study of the
availability of doctors and nurses to staff
non-hospital, field medical facilities for mass
casualty incidents resulting from use of weapons
of mass destruction and the level of knowledge
and skills of these medical professionals as
related to the treatment of victims of such
incidents. Study conducted through contract No.
282-97-0049 with DHHS.
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80References
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Bombings Epidemiological Outcomes, Resource
Utilization, and Time Course of Emergency Needs
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- Burkle, F Measures of Effectiveness in
Large-Scale Bioterrorism Events. Prehosp Disaster
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Assessment A Framework for Integrated
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Emergency Department Crowding. Annals Emerg Med
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Epidemiological Outcomes, Resource Utilization,
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Prehosp Disaster Med 200318(3)193-198 - Per, E Educational and Training Systems in
Sweden for Prehospital Response to Acts of
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CasualtieRe-evaluating Existing Dogma. Prehosp
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Med 200318(3)242-247.
81References
- Gopalakrishna, G SARS Transmission and Hospital
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200410(3)395-400. - Barbera, J, et al Ambulances to Nowhere
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