Case study: ED acts quickly after anthrax

[Editor’s note: This is an ongoing series profiling EDs that have updated their disaster plans in response to the Sept. 11 terrorist attacks. If you’d like to share the changes that you’ve made to your disaster plan, contact Staci Kusterbeck, Editor, ED Management, 280 Nassau Road, Huntington, NY 11743. Telephone: (631) 425-9760. Fax: (631) 271-1603. E-mail:]

When anthrax attacks occurred last fall, EDs nationwide were forced to revamp disaster plans to manage scores of patients who feared exposure. But for EDs in communities with documented cases of anthrax exposure, the situation was even more urgent.

"Trenton was essentially the epicenter of the first known bioterrorism incident in the U.S.," says David Schreck, MD, FACEP, chairman of the department of emergency medicine at Capital Health System in Trenton, NJ, which includes the Helene Fuld Medical Center and Mercer Medical Center — Trenton. "We had to revise our policy for an incident that had never occurred before, so certain modifications were needed," he says. "But if this should ever happen again, we’re ready."

Here are some changes that were made to the ED’s disaster plan:

• Notification procedures were streamlined. Contacting various individuals and agencies became of the utmost importance, according to Schreck. "There were so many people involved in the notification process, it was incredible," he says. These included hospital administration, the state department of health, law enforcement, hazardous materials agencies, patients’ families, infectious disease experts, and private physicians, he notes.

Notifications were made in a particular order and documented in a specially created log book, says Deborah Cioffi, RN, BSN, director of emergency services. "The information was clearly documented and shared between the infectious disease department, corporate health, and the ED," she explains.

• "Contingency" plans were developed. Because the situation was constantly changing, the disaster plan was evaluated on a daily basis, says Cioffi. "The ED spent [more than] 60 days on high alert status," she reports. "Every day, staff geared up for what if’ scenarios to prepare for the worst."

Contingency plans included updating phone lists so staff could be contacted at a moment’s notice and putting vendors on alert in case additional medications or decontamination supplies were needed. "Our plan clearly looked at how we could accommodate 30 patients, 300 patients, or even more patients," says Cioffi. To increase the number of patients that could be managed simultaneously, an $8,000 decontamination tent was purchased for one of the EDs, she adds.

• A scanner was used to communicate directly with EMS. Schreck now carries a portable scanner for direct communication with EMS, police, and HazMat response teams. This scanner allowed him to find out if patients are being taken to his ED or another facility, he explains. "You are used to mobilizing your resources whenever you get calls from the dispatch unit. But in this case, there were a lot of false alarms when patients were actually sent to other hospitals," he says. In this scenario, having direct communication with first responders ensures that you’re aware of last-minute decisions, Schreck says. "It’s vitally important to know exactly who is coming to your ED," he explains. "You can provide much more efficient care that way."

• Some patients were diverted to employee health. In many cases, patients who were worried about exposure but didn’t require decontamination bypassed the ED and instead were managed at the hospital’s employee health facility. "This was extremely helpful, because it reduced the numbers of nonurgent cases in our EDs," says Cioffi.

In total, the ED managed a total of 167 patients with suspected anthrax exposure, and employee health handled about 490 suspected anthrax exposures. "We are fortunate that they are only a block away and could handle patients who were sent by their employer for routine screening, and also the walking worried’ who presented to the ED," says Schreck.

If patients were symptomatic, they were always seen in the ED, but they usually went to employee health otherwise, he explains. Even so, the ED treated about eight patients with suspected anthrax exposure each day for 20 straight days, and the ED decontaminated about 30 patients, Schreck reports.

• Staff members were trained in the decontamination process. In addition to ongoing inservices given by the clinical nurse specialist, staff received training in the entire decontamination process from paramedics who volunteered their time, says Cioffi. "If you don’t actually use the equipment, you don’t know what you’re doing," she says. "Staff became familiar with setting up the decontamination tents by doing this all hours of the day and night and weekends."


For more information on the response to the anthrax attacks, contact:

• Deborah Cioffi, RN, BSN, Director, Emergency Department, Capital Health System, 750 Brunswick Ave., Trenton, NJ 08638. Telephone: (609) 815-7568. Fax: (609) 394-4001. E-mail:

• David Schreck, MD, FACP, FACEP, Chairman, Department of Emergency Medicine, Capital Health System, 750 Brunswick Ave., Trenton, NJ 08638. Telephone: (609) 394-4413. Fax: (609) 394-4001. E-mail: