Don’t ignore biological, terrorist threats in your emergency plan

A flexible plan that can adapt to all situations works best

(Editor’s note: This is the second of a two-part series that takes a look at why health agencies should address the threat of bioterrorist events. Last month, we looked at the most recent information from the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices in relation to vaccination for smallpox and first-response teams. This month, Hospital Home Health examines how home health agencies should incorporate bioterrorism into their emergency-response plans.)

What would you do if a field nurse reported an unusual rash on several of her patients? What would you do if a bomb caused the closure of major roads usually traveled to reach your agency’s patients? How would you stay in touch with field staff and patients if cell phones no longer worked?

These are just a few of the questions home health managers should be answering in their emergency plans. Other time-consuming, immediate concerns such as new federal regulations, staffing shortages, and financial pressures, however, have kept many agencies from reevaluating their emergency plans, says Barbara B. Citarella, BSN, MS, CHCE, president of RBC Limited, a home care management consulting firm in Staatsburg, NY. "Agencies in some areas, such as New York City, have been at the forefront of putting plans into place, but we are still educating most agencies about the need for planning," she adds.

Although all agencies have some sort of emergency plan to address specific events, what is needed now is an overall, comprehensive plan that takes into account myriad communications, infection control, and coordination issues, says Cynthia Muller, RN, BSN, CIC, vice president of operations for RBC Limited. "In general, home health agencies are not prepared for a catastrophe that goes beyond natural events with which we are familiar," she says. "Agencies need to be able to address emergencies with a biological, radiological, or chemical threat as well as emergencies that hinder travel and communication," she adds.

"We have always had a basic emergency plan, but on Sept. 11, 2001, we realized that it did not adequately address some of our needs," says Orael M. Keenan, RN, MSN, chief executive officer of Visiting Nurse Association of Long Island in Garden City, NY. "Communication was our biggest obstacle," she says. The combination of damaged transmission towers and the volume of calls people tried to make made cell phones and beepers useless, she says.

Because the agency staff had to rely upon telephone land lines, they realized that many of the family contact numbers included on the medical records of priority one patients were cell phones.

"Nurses would arrive at the homes of patients to find them gone. With no way to contact the patient or family members, nurses had to leave notes on the doors, asking someone to call the agency to let them know where the patient was," she says. In all cases, concerned family members had taken the patients to their homes, but did not know how to alert the home care agency, she adds.

The number of roads closed during the days following Sept. 11 also created problems because direct routes to patients’ homes sometimes weren’t available, and staff members didn’t always know direct routes, Keenan says. "We now require all nurses to have up-to-date maps in their cars," she says.

Security concerns following any type of attack also make it necessary for home care workers to have proper identification, Keenan says. "Not only did we make sure our employees have their VNA identification badge, but we also made up VNA of Long Island signs for them to place in their cars," she adds.

Although home care agencies won’t be the recipients of patients directly involved in biological or other terrorist attacks, they must be ready to take mass admissions as hospitals clear out their beds to take new patients, Citarella points out. "The emergency plan should address mass admissions from every aspect," she says.

The policy should limit calls for admissions to emergency calls from hospitals involved in the disaster, and multiple referrals should be handled in one call, she suggests. Also, a supply of 100 admission packets with streamlined documentation should be on hand, she adds.

When you are updating your emergency plans, don’t forget patient education, suggests Rita Lapham, RN, director of patients services and owner of Golden Age Home Health in Oklahoma City. "We have looked carefully at our admission packet to make sure it contains information that patients and their families need in an emergency," she says. 

Because some staff members may not be able to get to the office during an emergency, it’s important to make sure all information related to the patient is in a central place that can be accessed by any employee, Lapham says.

"We have one place on the patient’s chart that includes all emergency numbers for that patient," she says. The telephone numbers collected are for the next of kin, an alternate for the next of kin, any equipment companies that provide services to the patient, and the patient’s physician.

"We make sure we get land-line telephone numbers, and we keep it on the paper chart because a power failure doesn’t affect your ability to read a chart," she adds.

It’s also important to set up alternate sites for employees to meet in case the office is not accessible, Citarella says. Make sure all employees know where to meet and that they have directions to the site as well as alternate telephone numbers, she adds.

Notifying staff during an emergency can be tricky, Citarella admits. While it is important to designate a radio station for employees to monitor for information on reporting to work, the best way to make sure your employees are notified is by telephone. 

Be sure your plan also spells out how you are going to go back and pick up patients whose visits you delayed, Muller says. "It’s important to make sure that you don’t let any patients fall through the cracks."

Biological, chemical, and radiological emergencies carry their own set of needs that home care agencies typically have not addressed, she says. Dealing with the infection control issues of these types of emergencies can be cumbersome. "Rapid response is essential, so it is important to designate one nurse who knows what to report, to whom to report, and how to handle the patient," Muller says.

Not only do home care staff members need to know whether or not to use standard precautions or universal precautions, they also need access to respirator masks, gowns, and gloves, she adds. The nurse also needs to know who has push packs, or large-volume shipments of vaccines, medications, and other related supplies for biological emergencies, she says.

"I don’t think most home care agencies can do their biological emergency planning by themselves," Keenan says. "I think it’s important to talk with experts, such as consultants in emergency planning, infection control, and biological threats, to make sure your plans are reasonable and effective."

As the events of 9/11 have demonstrated, not all emergencies are handled by only one or two community agencies, so it is important to make sure you’re involved in any communitywide planning effort, she says.

Although many communitywide emergency planning committees include hospitals, they may not include home care agencies, so it’s up to the agencies to find out what is going on and how they can get involved, Lapham says.

Most importantly, keep in mind that your employees may be victims of the emergency, Muller says.

"Be prepared to offer child care to employees whose normal child care is disrupted, and make sure your plans address your employees’ safety as well." Also be prepared with names of part-time employees or independent contractors who can fill in the gaps if your employees cannot work due to their own family situations, she adds.

Protecting employees doesn’t just refer to field staff either, Keenan points out. As a result of the anthrax attacks, her agency developed a policy that all mail was to be opened in an enclosed area using gloves. "We’ve relaxed the enclosed area rule now, but our employees still use gloves, and everyone knows to look at all pieces of the mail closely to determine if they appear suspicious," she says. All employees who handle mail also have a list of people and agencies to call if they are suspicious of any mail items, she adds.

While most home health emergency plans will need to be enhanced to reflect today’s needs, don’t automatically throw out your old plan, Muller says.

"First, evaluate your current plan and perform drills to identify strengths and weaknesses," she advises. "Focus on your needs; make sure infection control is included; keep it flexible; and be sure you can implement it with less than a full staff."

[For more information about emergency planning in the home health setting, contact:

Barbara B. Citarella, BSN, MS, CHCE, President, RBC Limited, 48 W. Pine Road, Staatsburg, NY 12580. Telephone: (845) 889-8128. Fax: (845) 889-4147. E-mail: Web site:

Orael M. Keenan, RN, MSN, Chief Executive Officer, Visiting Nurse Association of Long Island, 100 Garden City Plaza, Garden City, NY 11530. Telephone: (516) 739-1270. E-mail:

Rita Lapham, RN, Director of Patient Services/ Owner, Golden Age Home Health, 2228 Shadowlake Drive, Oklahoma City, OK 73159. Telephone: (405) 878-8775. E-mail:]

Emergency Planning Resources

Guide to Emergency Management Planning in Health Care.

Published by the Oakbrook Terrace, Ill-based Joint Commission Resources, a subsidiary of the Joint Commission on Accreditation of Health Organizations, the book provides practical advice on revising and implementing an emergency management plan that is flexible enough for a variety of disasters. Information on collaboration with other agencies, creation of communications channels, and training and management of staff during an emergency are addressed. The publication is available for $60. Orders can be made by telephone at (630) 792-5800 or on-line at Use the order code EMPHC-01 when placing an order.

California Hospital Bioterrorism Response Planning Guide 2002.

This guide, published by the California Department of Health Services, Licensing and Certification Program in Sacramento, CA, is geared to hospitals but contains information that home care agencies can incorporate. A variety of biologic agents such as smallpox, anthrax, brucellosis, botulism, tularemia, viral hemorrhagic fever, Q fever, and plague are described. Symptoms, treatments, and incubation periods for each are described as well as proper precautions to use for each suspected disease. Screening forms also are included. The plan can be found at