Are you ready for anthrax, or worse? You must revamp your bioterrorism plan

Bioterrorism is a reality: You can’t afford weak spots in your plan

Patients coming to your ED thinking they have the symptoms of anthrax. Large numbers of people panicking and calling 911, fearing they’ve been exposed to a biological agent. Decontaminating patients who report possible exposure as a routine part of your staff’s daily practice.

Until recently, these scenarios were only part of your disaster drills, but they have become a reality for most EDs. It’s imperative that your disaster plan be "simple and doable" to address bioterrorism effectively, urges Neill S. Oster, MD, FACEP, director of disaster emergency medical services at Mount Sinai School of Medicine — Elmhurst Hospital Center in New York. "You need to be ready for mass numbers of patients who may show up," he underscores. "You must exercise the plan, practice real scenarios, critique them immediately, and do it again. That is the way disaster preparedness gets better."

A recent study of 22 rural and eight urban hospitals suggests that EDs are not prepared for mass casualties caused by bioterrorism. Only one hospital had stockpiled any medications, and 26 of the hospitals said they could only handle between 10 and 50 casualties at once.1

When an employee of Manhattan Eye, Ear, and Throat Hospital died on Oct. 31 from inhalation anthrax, it was a wake-up call for many hospitals that there was no time to waste. However, no sources of anthrax or additional contamination were found in the facility or among the staff. With disaster plans and decontamination procedures under the microscope, ED managers are "much better prepared now than a month ago," according to Oster. "It’s not all doom and gloom, I think we are getting there," he says. "Previously, most of us thought the risk of a biological or chemical event was zero, or near zero. Now people are out there getting educated." (See "10 steps to handle a bioterrorism attack" in this issue.)

Here are areas your bioterrorism plan must address:

• Alternate places to care for patients.

Alternate care and triage sites often are overlooked in disaster plans, according to Robert Suter, DO, FACEP, president of Texas Emergency Physicians, an ED physician practice group based in Dallas. "These sites should be identified or created in advance," he says. "Very few EDs are physically set up to absorb and process contaminated patients, let alone return to business as usual quickly."

Suter recommends selecting sites with clean-up in mind. "You do not want to contaminate an area that is critical to the future function of the hospital," he says. Choose areas that you can "abandon" for prolonged clean-up, as you return to caring for your usual patient population, Suter explains. He points to the following locations as potential care sites for contaminated patients: breezeways, tents in the parking lot, and connecting hallways between buildings. "These can be torn down and taken to a hazardous landfill afterward," he points out.

You need alternate areas for triage and treatment inside and outside your hospital, Oster advises. He recommends acquiring halogen lamps for external nighttime triage. "That way, contaminated patients don’t have to come into the hospital if they’re not sick," he says. "They can be seen outside." However, patients treated outside need to be given the same quality of care that they would get inside the ED, Oster cautions. Your external triage facility also must provide protection from rain or snow, he adds.

When considering alternate care sites, you should brainstorm with community organizations, says Sue C. Felt, RN, MS, MPH, CIC, associate hospital epidemiologist and infection control coordinator at San Francisco General Hospital. "Due to the high probability that the ED will be overwhelmed, your plans may need to include gymnasiums and churches," she explains. Your plan also must address significant numbers of deceased, says Felt. "In some mock disaster drills, refrigerated trucks have been used," she notes.

• Mass casualties.

"Look at your plan and see if it really addresses the issue of 300 to 500 people showing up all at once," Oster advises. Ask yourself, can my facility handle that? "If not, assess how many you can handle safely," Oster says. "Then make arrangements to get up to those kinds of numbers." In most hospitals, there are shortages of beds for critical patients, says Oster. "To be ready for 500 patients requiring care, some thinking outside the box has to be done," he says. Oster recommends asking the following questions:

  • How can you safely discharge patients from the hospital sooner than planned?
  • How should follow-up be handled so these patients don’t fall through the cracks?
  • How can you ensure that patients who have been discharged early get home safely?

• Stockpile of medications.

Consider stockpiling certain antidotes and medications, with the goal of being able to treat your entire hospital population for several days, Oster suggests. "My institution has 5,000 people around the clock. You better believe that if something happens on the first floor, everyone on the 10th floor is going to want treatment, too," he says. "We just saw that happen at NBC — people who weren’t even close to the event got treated." After an envelope containing anthrax was sent to NBC News headquarters in New York City, more than 600 employees were tested and given preventive medical treatment.

First, determine your current supply of major antidotes for chemical agents and atropine stores for biological agents, says Oster. (Editor’s note: For a Chemical/Biological Agent Checklist, go to the web site: "You need to find out how much you have on hand, and develop a plan to acquire more as needed," he explains. For rural EDs, have the department of health buy and stockpile medications for several hospitals within the county, Oster suggests.

He also recommends taking an inventory of ventilators, including how many more units can be obtained if needed. "The federal government can help, but they’ll be there 12 hours later. Can you make a call and get them sent from another facility?" he asks. "If it’s a statewide event, that is not likely, and you may have to go outside the state."

• Personal protective equipment (PPE).

All ED staff must be trained in PPE, urges Suter. That includes awareness, threat recognition, assessment of the level of the threat, and response needed, he adds. "PPE needs to be worn by all personnel, at the level relevant for their job," he says. "The current situation has not really changed things. The basics are the same."

For biological agents, universal precautions are sufficient, says Oster. "If it’s something spread by droplet, you need some type of face shield with eye protection," he says. "It is the recommendation of CDC from 20 years ago with HIV, and there is no reason we can’t deal with anthrax the same exact way."

But when it comes to chemical agents, the situation is completely different, says Oster. He points to the 1991 Tokyo incident when 5,500 people came to EDs, some of them contaminated with sarin gas. "Had they done external decontamination of these people, the first responders would have been OK," he says. "They got contaminated because the patients were off-gassing inside the institution, and they never should have entered the building with clothing on. We should learn from that event."

Viral hemorrhagic fevers require contact precautions, pneumonic plague and tularemia require droplet precautions, and smallpox mandates immediate isolation and airborne precautions, summarizes Felt. Training of staff should include reminders of the importance of hand washing, and staff should be provided with gloves, gowns, masks, and eye/face coverings, says Felt. "Standard precautions, should, of course, be used for all patients at all times," she underscores.


1. Treat KN, Williams JM, Furbee PM, et al. Hospital preparedness for weapons of mass destruction incidents: An initial assessment. Ann Emerg Med 2001; 38:562-565. n


For more information about bioterrorism preparation, contact:

Sue C. Felt, RN, MS, MPH, CIC, Infection Control, San Francisco General Hospital, 1001 Potrero Ave., Building 100, Room 301, San Francisco, CA 94110. Telephone: (415) 206-5466. E-mail:  

Neill S. Oster, MD, Mount Sinai School of Medicine/Elmhurst Hospital Center, Department of Emergency Medicine, 79-01 Broadway, Elmhurst, NY 11373. Telephone: (718) 334-3050. Fax: (718) 334-3015. E-mail:   

Robert Suter, DO, FACEP, Texas Emergency Physicians, 5926 Saint Marks Circle, Dallas, TX 75230-4048. Telephone: (214) 306-2029. Fax: (214) 739-0658. E-mail:

The Association for Professionals in Infection Control and the Centers for Disease Control and Prevention have developed a free sample bioterrorism plan: Bioterrorism Readiness Plan: A Template for Healthcare Facilities. The document can be downloaded at

The American Hospital Association has several resources for disaster preparation on its web site ( Resources include a chemical and bioterrorism preparedness checklist and a report on Hospital Preparedness for Mass Casualties. To access either document, click on "Disaster Readiness." Under "Readiness Resources," click on "Hospital Readiness Response and Recovery Resources." To access Readiness Bulletin: What to Tell Your Community About Anthrax, click on "Disaster Readiness" then scroll down in the "What’s New" section.