Survey: Most hospitals are unprepared to protect their staffs in case of an attack

Equipment, policies, training needed, experts say

Hospitals are ill-prepared to cope with a biological or chemical terrorist attack and lack the policies, training, and equipment to protect health care workers, experts in emergency preparedness say.

That failing is coming under increased scrutiny in light of the Sept. 11 attack on the World Trade Center and the Pentagon. While individual hospitals reassess their community’s risk of attack, the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, is considering how to assure compliance with a new standard on emergency preparedness. Keeping employees safe is a critical aspect, which means employee health should be active in the planning process, experts say.

The Joint Commission standard requires hospitals to conduct a "hazard vulnerability analysis." That analysis may be fundamentally different after Sept. 11.

"We now clearly have an enemy who is capable and interested in doing repeated and large-scale activities in this country that would produce a large number of casualties," says Robert Wise, MD, vice president of the division of research standards for the Joint Commission. "They’ve already shown their ability, and they’ve been clear about their interests. When a hospital looks at its environment, should these types of possibilities be on the radar screen?"

The answer isn’t simple in a time when hospitals are financially stressed. Wise advises that planning for potential terrorist events should occur as a part of a communitywide effort. Meanwhile, Joint Commission officials are meeting with representatives of other health care organizations and federal agencies to discuss what resources hospitals should have and what outside support they might receive.

Wise stresses that preparedness begins with the basic ability to cope with hazardous materials and major disasters, including a provision to support staff and their families. That may include providing temporary housing, transportation, and counseling, he says. Employee health should be involved in planning, awareness training, and policy development, he says. "If staff do not feel their families are being taken care of, they’re not going to come to work," he says. "If they don’t come to work, you’ve basically brought your hospital down. We would expect the hospital is giving consideration to these issues."

Before Sept. 11, few hospitals took seriously the threat of biological or chemical terrorism — despite recommendations by the Centers for Disease Control and Prevention that hospitals create a "bioterrorism readiness plan."1

In a 1998 survey of 186 hospital emergency departments (EDs) in four northwestern states, only about half (48%) of respondents agreed that "biological and/or chemical weapons are a real enough threat to [the] community that [the] hospital should make specific plans in preparation to treat victims of such weapons."2

One-quarter of hospitals reported having no isolation or decontamination resources of any kind in the ED — either internal decontamination units or portable, outdoor units — that could be used in the case of a chemical event. Most hospitals reported having no respiratory protective equipment that would be appropriate against chemical agents, such as respirators with supplied air, the researchers reported in the American Journal of Public Health.

Based on a hypothetical incident involving 50 victims of sarin gas poisoning, only 6.5% of hospitals had a "minimum recommended" level of preparedness, the researchers concluded. Only 9% of hospitals had a written plan for handling victims of bioterrorism as well as a sufficient antibiotic inventory.

"It’s possible the survey has underestimated [the situation]," says Bill Daniell, MD, MPH, associate professor in the department of environmental health at the University of Washington in Seattle, who conducted the research with lead author Donald Wetter, who is now with the Office of Emergency Preparedness of the U.S. Public Health Service in Atlanta. "Even if you allow for that, there’s a striking degree of lack of preparedness for these types of incidents," says Daniell. "Up until the recent terrorist attack in New York City, this was pretty low priority on people’s radar screens."

Daniell and others point to the sarin gas incident in Tokyo in 1995 as an example of what could happen. Thousands of people flooded area hospitals after members of a cult poisoned the subway system with sarin gas. Patients ranging from the exposed to the "worried well" came to the hospital on their own, without previous decontamination, and hospital workers developed symptoms of secondary poisoning.

Being able to safely assess and decontaminate even one victim of chemical exposure is the minimum level of preparedness, says Henry Siegelson, MD, FACEP, an emergency physician based in Atlanta and an expert on hospital disaster preparedness. While that may seem basic, many hospitals don’t have that capability, he says. Secondary poisonings have been reported after victims of chemical poisoning came to an ED.3 (For more information, see "Terrorism plans can be cost-effective," in this issue.) "Very, very few hospitals have policies and procedures and equipment that will enable them to protect their employees from potential exposure to chemical hazards," he says.

Hospitals often rely too much on the preparedness of "first responders," the emergency teams that treat victims at the site of an incident, says Susan McLaughlin, MBA, CHSP, MT(ASCP)SC, president of SBM Consulting Ltd., in Barrington, IL, and an expert on hospital preparedness. "People have written into their plan that the fire department will decontaminate people in the field, but we can’t count on that any longer."

The need for preparedness may give employee health professionals a strong argument for additional resources, notes Michael Bell, MD, medical epidemiologist at the Centers for Disease Control and Prevention in Atlanta and lead author of CDC’s guidance paper on bioterrorism.

Respirators require medical evaluations and fit-testing, preparedness plans call for frequent staff training, and employee health may be involved in organizing periodic drills, experts say.

"You might be able to make the case for an additional person or expanded resources to meet an expanded job description. [Employee health] can be an important part of preparedness," Bell says. In fact, by working with infection control professionals, employee health can help boost everyday protections. The rigorous adherence to standard precautions would provide protection against biological terrorism agents, he notes.

It’s important to use "any mechanisms by which we can make sure routine practices are a little more disaster-proof," Bell says. "We don’t have a warning saying, Now’s the time to be careful.’ We’re always at risk for complacency." But now is the opportunity for employee health professionals and others to use the heightened awareness to improve our ability to respond, he says.


1. Association for Professionals in Infection Control and Epidemiology; Centers for Disease Control and Prevention. Bioterrorism Readiness Plan: A Template for Healthcare Facilities.

2. Wetter DC, Daniell WE, Treser CD. Hospital preparedness for victims of chemical or biological terrorism. Am J Public Health 2001; 91:710-716.

3. Geller RJ, Singleton KL, Tarantino ML, et al. Nosocomial poisoning associated with emergency department treatment of organophosphate toxicity — Georgia, 2000. MMWR 2001; 49:1,156-1,158.