Bioterrorism and home health care: Develop your emergency plan now

Reacting and overreacting: A fine line

In 1999, the Centers for Disease Control and Prevention (CDC) in Atlanta felt there was a credible-enough chance of germ warfare that it earmarked $121 million for bioterrorism activities. Of that, $51 million has gone into stockpiling vaccines and other drugs to combat such diseases as anthrax and smallpox. Other funds were poured into laboratory support, enhanced communications systems with state and local health departments, and improved surveillance and epidemiology activities.

As part of this, the CDC also designed a four-tier system of labs designed to detect and identify bioterrorist agents. While the average home health care agency is unlikely to face an epidemic of anthrax among its patients, it is important that it develop at least a basic emergency plan to deal with the potential threat.

Bioterrorism: Are you ready?

Rose Williamson, RN, QI coordinator with Wilson (NC) County Home Health, has been putting together an inservice for her agency’s staff on biological and chemical agents, symptoms of exposure, appropriate responses, and reporting procedures. (See fact sheet, below.) Yet she has stopped and asked herself a question that is on a lot of peoples’ minds: Am I overreacting?

"I want my folks to feel knowledgeable and as prepared for disaster as is possible to be without making things worse," Williamson explains.

As a health care provider, it is of paramount importance that all health-related incidences be taken into account when planning for disaster-related situations. But when the actual chance of exposure is still relatively low, you have to wonder if preparing for the worst is a waste of time.

Not necessarily, say many in the field. Even though the odds are low that any one of us will be infected with anthrax or another bioterrorism agent, it is considerably more likely than it was a year ago. Further, were such a disaster to occur, having a plan in place would save considerable time that could mean the difference between life and death.

Bioterrorism "should be an integral part of any organization’s disaster plan. The Sept. 11 event [should] serve as a reminder to us all to update and attend to our disaster response plans," says Loretta Schlachta-Fairchild, RN, PhD, president and CEO of iTelehealth Inc. in Frederick, MD. "The bioterrorism part is but one element that should be addressed."

Schlachta-Fairchild says to focus solely on bioterrorism would be an overreaction, but that creating a disaster plan response is something to be strongly considered by every home care agency.

Diane Henry, RN, program compliance advisor for Oklahoma City-based Professional Providers Solutions and author of Health and Safety Compliance For Home Health Care, shares that opinion.

"I feel very strongly that the health care infrastructure should be providing mass training on these [bioterrorism] measures and any others that we have identified since Sept. 11th," she says.

Henry’s advice is being taken to heart by home care agencies across the country.

Susan Ezell, RN, RN-QI, AAA, SEA, quality improvement coordinator with the Area Agency on Aging of Southeast Arkansas in Pine Bluff, has also been hard at work putting together information for her agency’s family disaster plan. In it, she is including information on a supplies kit and an emergency preparedness checklist.

But she admits to having her doubts about the project, not from a practical standpoint but because, "I don’t want to cause undue panic. We’ve had enough of that for awhile."

Education through inservices

Alice Fritz-Warren, RN, BSN, MS, regional performance improvement director, Sun Plus Home Health in San Leandro, CA, says that developing an inservice on bioterrorism is a great project.

"As a matter of fact, we were asked if we had a bioterrorism response protocol when we were surveyed by the Joint Commission," she says. "We weren’t dinged for not having a protocol specifically for bioterrorism, but I guess pretty soon we will all be expected to have one. I actually started a reference notebook at the time and got some good information from the CDC."

Although the tendency has been, at least within the home care field, to focus on natural disasters such as hurricanes or earthquakes, Denise (Dee) McCarraher, RN, audit nurse/ case manager with IVNA of Richmond, VA, says it’s time to enlarge the focus.

"I think it’s time for all of us to review and update our policies and ourselves," she says. "Bio incidents are not what we have generally looked at in the past nor are terrorists acts. And while I agree we should not take this education to our elderly patients and frighten them, we must prepare ourselves to provide the care they need under these circumstances."

Creating a plan: What you should do?

The first step in developing an emergency plan for bioterrorism or any type of emergency is to clearly define what measures must be taken and rank them in order of importance. (See "Enhancing bioterrorism preparedness and response," in this issue.)

Which patients, for example, must be seen or taken to the hospital in the event home care aides or nurses cannot get to their homes?

From there, it’s solid advice to assign specific tasks to your staff with the understanding that they will be responsible for implementing them once the go-ahead has been given.

These procedures should be reviewed and updated regularly so that all staff remain clear on their given tasks and any changes that might have been made to the plan since the last review. For example, staff turnover may necessitate changing staff responsibilities — something you don’t want to decide in the throes of a crisis.

A good idea is to set up a phone tree to make certain that everyone involved is notified as quickly as possible, and have the last person on the phone tree contact the first as a means of double-checking its effectiveness.

Don’t overlook background material, says Henry. "In developing or reviewing their emergency management plans, home health agencies should include emergency management and bioterrorist information."

Consider creating fact sheets for your patients and their families to inform them of what they should do in case of emergency and a basic outline of how your agency plans to deal with the crisis — will staff visits be reduced? (See box, below.) Will only certain patients receive home care visits? Such a fact sheet should include a list of supplies that should be kept on hand and a list of emergency phone numbers including the local hospital’s emergency department.

If you are looking to develop a plan specifically to deal with bioterrorism, consider talking with your local Federal Emergency Management Agency representative.

If you are near a military base, "try contacting the medical folks [there]. It is the medics and corpsmen who teach biohazard-related things," says Dean Smith, BSHS, RN, C, PHN, clinical application specialist for San Diego-based UCSD Home Care. Maybe they will share, as most of the stuff is unclassified. Besides, many servicemen and women have spouses in the medical fields as well. You should be able to find someone to chat with easily."

While having an emergency plan in place is certainly a good thing from a patient perspective, it is also required by law, Henry says. "All businesses are required by [Occupational Safety and Health Administration] regulation to provide a safe work environment for employees. This includes training in specific areas like exposure control, bloodborne pathogens, and emergency management. You should have an emergency management plan in place along with exposure control plan, respiratory protection program, hazard communication plan, just to name a few.

"I personally think it would be a good time for your safety committee, human resources department or administrator to review your emergency management plan to ensure the plan provides procedures to follow in all emergency situations," she adds. "If we have these required programs and plans in place, and staff are instructed and trained on the procedures provided, then that would be sufficient. It may be a good time to provide an inservice and review the emergency management plan and procedures with the staff. It may help relieve some of the fears employees are experiencing and give a sense of security in knowing the agency is concerned with the safety and welfare of their employees."

[For more information, contact:

  • Susan Ezell, Quality Improvement Coordinator, Area Agency on Aging of Southeast Arkansas, 709 E. Eighth St., P.O. Box 8569, Pine Bluff, AR 71611. Telephone: (870) 543-6300.
  • Alice Fritz-Warren, Regional Performance Improvement Director, Sun Plus Home Health, 303 W. Joaquin Ave., Suite 110, San Leandro, CA 94577. Telephone: (510) 895-1604.
  • Diane Henry, Program Compliance Advisor, Professional Providers Solutions, 8265 S. Walker Ave., Oklahoma City, OK 73139. Telephone: (405) 634-1428.
  • Dee McCarraher, Audit Nurse/Case Manager, IVNA, 1004 N. Thompson St., No. 300, Richmond, VA 23230-4927. Telephone: (804) 358-0200.
  • Loretta Schlachta-Fairchild, President and CEO, iTelehealth Inc., 6935 N. Clifton Road, Frederick, MD 21702. Telephone: (301) 371-8495.
  • Dean Smith, Clinical Application Specialist, UCSD Home Care, 6711 Convoy Court, San Diego, CA 92111-1000. Telephone: (619) 543-8255.
  • Rose Williamson, QI Coordinator, Wilson County Home Health, 1801 Glendale Drive S.W., Wilson, NC 27893-4401. Telephone: (252) 237-4335.]

Broad Generalizations of Safety Measures to Follow

  • Protection of airways is the single most important factor in aerosolization of chemical or biological agents.
  • Many agents are heavier than air and stay close to the ground. Find an upward safe haven, such as an upstairs room.
  • Once indoors, close all windows and exterior doors and shut down air conditioning and/or heating systems.
  • Cover your mouth and nose. Use surgical masks, pollen masks, or gas masks if available. If these are not available, an improvised mask can be made by soaking a clean cloth in a solution of 1 tablespoon of baking soda in a cup of water. This will provide minimal protection and some relief.
  • If you know you or someone has been exposed to a biological or chemical agent, decontaminate as soon as possible.
  • Thorough scrubbing with large amounts of warm soapy water or a mixture of 10 parts water to one part bleach will greatly reduce the possibility of absorbing an agent through the skin.
  • If water is not available, use talcum powder or flour. Sprinkle the flour or powder liberally over the affected skin area, wait 30 seconds, and brush off with a wash cloth, or gauze pad. (Note: powder absorbs the agent so it must be brushed off thoroughly.) If available, rubber gloves should be used.
  • Biological agents are generally not transmitted from person to person. Exception: smallpox and pneumonic plague.
  • Health care facilities should follow universal or standard precautions.
  • Have your state emergency contact information and numbers listed in your emergency management plan (i.e., surveillance and epidemiologist, state public health department, state emergency management agency, and bioterrorism contact person).
  • Include federal emergency information: Federal Emergency Management Agency — (940) 898-5399 — and the FBI office in your area.

Source: Bureau of Diplomatic Security, Washington, DC.