Bioterrorism threat is new health care challenge

Does our health system lack capacity to respond?

By all accounts, New York City medical and public health personnel responded admirably in the face of the Sept. 11 attack on the World Trade Center. But since the number of deaths dwarfed the number of injuries, the strain created by that disaster may pale in comparison to the stress that would result from a major bioterrorist event.

While some people believe that the health care delivery system will be able to cope in the event of a large-scale bioterrorist attack, Dennis O’Leary, president of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently warned Congress that the health care delivery system currently lacks that capacity.

"All health care is local," O’Leary said, and that maxim ultimately applies to emergency management. He said local readiness planning will have to be scaled and tailored to fit the characteristics and capabilities of individual communities.

For some time, the Joint Commission has required accredited health care organizations to meet established emergency preparedness standards. Recently, however, the Joint Commission’s accreditation standards were modified in three respects. First, JCAHO shifted the focus of the standards from emergency preparedness to emergency management, with health care organizations expected to address four specific phases of disaster planning: mitigation, preparedness, response, and recovery.

The new emergency preparedness standards, which became effective in January 2001, also require accredited organizations to take an "all-hazards approach" to planning, which means that organizations must develop emergency management plans that contain a chain-of-command approach that is common to all hazards.

The last new requirement is involvement in at least one annual communitywide practice drill by those health care organizations whose all-hazard risk assessment identifies credible community threats. "Drills also can be extremely instructive," O’Leary said. Even though hospitals will be considered the first place to go when people are severely ill, in the face of a biological disaster, it may not pay to admit everyone who arrives at the hospital’s doors.

For example, if individuals are infected with a virulent pathogen, they risk infecting physicians, nurses, and other staff and curtailing the availability of critical medical personnel, he added. It may be preferable to keep the hospital free from contamination by setting up off-campus isolation units and treatment modalities that are overseen by properly protected staff.

Moreover, in the face of a biological threat, if everyone were accepted into the hospital for evaluation, there is a real risk of overwhelming facility capabilities. "Experience with drills has shown us that even the largest hospitals would be unable to handle the onslaught of people who are concerned that they may have the dreaded agent," O’Leary explained. "This raises the real potential need for off-site evaluation and triage of individuals in a fashion different from the usual conduct of emergency services."