Critical Path Network: Bioterror response requires targeted disaster plan

Stanford initiative draws nationwide attention

It’s not enough merely to update the bioterrorism component of your current disaster preparedness plan, experts say; you must create a detailed bioterrorism response plan that stands on its own.

That’s precisely the philosophy behind the Bioterrorism Response Preparedness Plan for Stanford (CA) Hospital and Clinics and Lucile Packard Children’s Hospital in Palo Alto, CA, which is gaining widespread recognition as a model for such plans. In fact, several Kaiser Permanente facilities in California already have adopted the plan.

"You need a separate [bioterrorism] plan," asserts Eric A. Weiss, MD, assistant professor of emergency medicine at Stanford, associate director of trauma at Stanford Hospital, and chairman of the disaster committee and bioterrorism task force. (See guidelines and clinical pathway.)

"During most disasters, for instance, you don’t rely on the microbiology lab to identify pathogens," he points out. "Also, infectious disease and infection control staff take on a major, heightened role."

In disasters such as an earthquake, Weiss notes, you don’t have to worry about the quarantine of patients or the spread of infectious agents, you do not have to put on protective clothing, or worry about cross-contamination of existing patients who may be immunosuppressed.

The plan, which is available on the Stanford web site (www.stanfordhospital.com), is incredibly detailed, including sections such as:

• Bioterrorism Response Preparedness Plan;
• Emergency Department Triage Guideline;
• Suspected Exposure to Bioterrorism Agent Clinic Triage Guideline;
• Specimen Collection for Suspected Bioterrorism Agent Diseases;
• Bioterrorism Agent Exposure Epidemiology Tracking Form;
• Anthrax Information Sheet;
• Summary of Laboratory Resources Related to Bioterrorism Agents;
• Infection Control Precautions for Suspected Bioterrorism Agent Disease;
• Clinical Pathways for Cutaneous Anthrax, Inhalational Anthrax, and Smallpox.

Revisiting a skeleton’ plan

A bioterrorism plan had been in place prior to 2001, Weiss says, "but it was really just a skeleton plan — not very comprehensive. It was part of a larger disaster preparedness plan, but a plan to deal with mass casualties from bioterrorism is very different."

When you have a major disaster such as the collapse of the World Trade Center, Weiss notes, local health care providers are likely to come to the hospital and offer to chip in and help wherever they can. "But what happens when the word goes out that patients are walking around with smallpox?" he poses. "Are providers going to want to stream down to the hospital and potentially infect themselves and their families? You need a response plan to address the safety of health care providers, so they will feel comfortable and want to show up for work."

To create such a plan, the Bioterrorism Planning Task Force was formed about 18 months ago, incorporating personnel from 30 or more different departments at both facilities, including infectious diseases, infection control, emergency medicine, pediatrics, critical care, ICUs, nursing and hospital administration, dermatology, psychology, social services, environmental health and safety, and so forth.

"We began putting the plan together when we identified the fact that the current plan was not adequate," Weiss notes. "We accelerated our activities after Sept. 11. After Sept. 11, everybody wanted to be part of it."

Weiss and his task force set out three major goals:

• Develop a comprehensive plan that would protect both the staff and its patients.
• Develop a plan to provide appropriate care for the people in the surrounding community.
• Develop a plan that potentially would mitigate the spread of infectious diseases related to the event.

The entire committee had input into the structure of the plan — i.e., which clinical pathways should be included and what guidelines and tracking forms were needed. "Then, we developed subcommittees to deal with the specific pathways," Weiss says.

"We brought their recommendations back to the task force for approval," he adds.

While anthrax was a logical choice for inclusion, it also was determined that smallpox should be addressed. "Anthrax is a good example of a pathogen that is not contagious, but we also wanted to address one that is," Weiss explains.

"The two are markedly different, and each is a quintessential example. When we have a mechanism in place to deal with both, we have all the bases covered."

Looking to the future

Weiss anticipates additions to the plan in the near future. "We are now dealing with nuances with other diseases like plague and tularemia," he notes. "But having addressed two of the major components [anthrax and smallpox], we’ll just have to tweak the existing plan."

The task force also is planning to hold a drill soon. "We’re trying to coordinate with representatives from the [Centers for Disease Control and Prevention], which we hope will come out and participate, as well as with state and local officials," Weiss says. "To test the plan, you have to test the response of state and federal agencies in conjunction with the hospital."

Weiss suggests this would be a good model for hospitals throughout the United States. "Every hospital will require input from these organizations," he notes.

He said it was not originally his plan to share the task force’s work with other facilities. "Originally, that was not our mission," he says, "but once we got pretty far into it, we started to receive calls, word had gotten out, and people asked if they could use it or see it." Now, he says, the plan is not only available on the web site, but in a printed, bound version as well.

[For more information, contact:

• Lou Saksen, Vice President of General Services, Stanford University Medical Center, 300 Pasteur Drive, Room H3205D, M/C 5230, Stanford, CA 94305. Telephone: (650) 723-7108.]