Communication breakdown plagues bioterrorism drill

But follow-up drill shows improvement

Communication between hospitals and public health departments was a major problem among Chicago-area facilities participating in a federal bioterrorism drill, says Connie Cutler, RN, MS, CIC, director of clinical excellence for Advocate Healthcare.

As the coordinator for infection control activities in the eight-hospital system, Cutler also was particularly aghast that in some of the hospitals, the infection control department was not contacted during the exercise.

"My colleagues said they were waiting by the phone for the call from the emergency department," she says. "It never came."

During the May 2003 exercise held by the U.S. Department of Homeland Security, there was inadequate communication between hospitals in health departments.

"Part of the problem was that we have eight hospitals that report to four different heath jurisdictions," she says. "They use different reporting forms and different mechanisms of notifying the health department. Some departments want a simple one-page form faxed to them, and others wanted a three-page form on every patient."

While some health departments worked well with their area hospitals, others were overwhelmed by the number of patient reports they received. The scenario was a release of pneumonic plague at a large indoor sports arena and at the metropolitan airport.

The hospitals were not aware of the venues, but had been advised by drill planners that the agent would be pneumonic plague.

"To me, it would be a better drill had we not known it was pneumonic plague," Cutler says. "That kind of made it a slam-dunk for our ED [emergency department] docs to know what these patients had when they came in. I think [planners] did it to allay panic and allow us to better triage the patients and not disrupt patient care. But it might have been hard for them [to make the diagnosis] because pneumonic plague is fairly nonspecific."

As it was, surges of incoming "patients" were played by drill participants and represented by incoming faxes. The surge of patients seriously challenged the capacities of the hospitals, she adds. More than 300 patients — human and paper — were sent to the eight EDs during the drill.

Approximately one-third of the patients had symptoms consistent with pneumonic plague. A number of patients were dead on arrival or expired soon after.

While communication was lacking, all hospitals initiated appropriate isolation precautions, Cutler reports. Symptomatic patients were placed on airborne precautions in negative-pressure rooms, and personnel wore N95 particulate respirators. Most hospitals switched to surgical masks once the health departments identified the agent. One site recorded an inadequate supply of personal protective equipment. Infection control or employee health gave prophylaxis to exposed patients and personnel. However, one hospital did not take the drill seriously enough, simply setting the patients aside, designating them for isolation and — as previously mentioned — not contacting the infection control department.

"They didn’t go through the exercise of trying to move people around — at least on paper — and they did not contact infection control," she says. "They did a postmortem on the drill, and the observers who were sent from the federal government said, in this particular hospital, you would have had infections spread all over the hospital."

However, a follow-up, unannounced exercise held a few months ago yielded much better results. "In the year since [the drill], we have made major improvements, especially at the hospitals that were not reacting the right way," Cutler adds. "We had another bioterrorism drill on a smaller scale that was unannounced. It happened on a Saturday, when we [ICPs] don’t normally come in, but every infection control professional was called at home. It was very impressive how much we had learned in a year."