Patient Safety Alert: Anthrax outbreak forces closer focus on patient safety

Facilities may have to revisit preparedness plans

The recent anthrax bioterror attacks have been a rude awakening for health care professionals across the country; they now know that what they once considered a dim possibility now is a reality.

And while the threat seems to have died down, it has raised the specter of other, even more serious bioterrorism events involving infectious agents such as smallpox.

What’s more, caring adequately for patients in such emergencies may have ramifications that extend far beyond the health and well-being of those patients. They include the issue of possible malpractice lawsuits, such as the one filed by the son of one of the anthrax victims against the hospital that had treated his father — ostensibly for not diagnosing his disease quickly enough to save him.

Professionals concerned with patient care have redoubled their efforts to ensure their disaster response plans will optimize the well-being of their patients.

Taking another look at disaster planning

"After the events of Sept. 11, we took another look at our disaster response plan, which covers any community or national disaster — chemical exposures, bioterrorism, [or natural disasters] — because of our proximity to [Dallas-Fort Worth] Airport," says Jane Meridith, RN, assistant vice president of nursing for Baylor Medical Center at Grapevine (TX).

The plan, created fairly recently, was rewritten to conform with the Hospital Emergency Incident Command System, used widely by fire depart-ments and emergency medical services across the country. "The Joint Commission [on Accreditation of Healthcare Organizations] says that if we can get the hospitals to use it, we will then all be using the same lingo," she explains.

"Another plus is that, given the transient nature of health care, we wouldn’t have to retrain new staff when people leave," Meridith says.

Subcommittee formed

In the wake of the terrorist attacks, the hosp-ital immediately put together an emergency management subcommittee that meets weekly. It consists of the key people who would be needed to ensure that everything is in place if a bioterrorism event were to occur.

"We started increasing our supply of antibiotics, and we put in place additional security measures, such as being able to lock down the facility, making sure everyone was wearing proper ID badges, and scrutinizing who’s in the building and why," says Meridith. "We limited access in the dock area as well."

Meridith’s team also met with the regional head of emergency management for the Texas Department of Health to identify, among other things, equipment and education needs.

As part of a larger system, the Grapevine facility also has determined which resources can be shared with other facilities, she says.

"We have also met with and have scheduled training for key staff — anyone who could possibly come in contact with someone who has been exposed. That includes security, ED staff, administrative supervisors, front desk receptionists, PBX operators, and volunteers," Meridith observes.

Emergency management staff have identified a core team of individuals who actually would be responsible for decontamination in the event of exposure. "They’ve had extensive training by OSHA [the Occupational Safety and Health Administration], and hands-on training with the equipment that would be used," she notes.

Meridith says the hospital’s efforts fall into three key areas:

  • educating staff;
  • ensuring the appropriate facilities and equipment are available to decontaminate patients;
  • encouraging all employees to be alert to what’s going on in the surrounding environment.

Detailed bioterror component

The response plan at Baylor Grapevine is organized into "annexes," and the bioterrorism annex is extremely detailed.

Aimed at the four diseases most likely to occur as a result of bioterrorism (anthrax, botulism, plague, and smallpox), the annex first outlines procedures, which are subdivided into the following:

  • Reporting Requirements and Contact Information (including phone numbers of internal and external contacts);
  • Detection of Outbreaks Caused by Agents of Bioterrorism;
  • Surveillance;
  • Infection Control Practices for Patient Management (including isolation precautions, patient placement, patient transport and cleaning, disinfection and sterilization of equipment, and environment);
  • Post-Exposure Management.

The annex then goes on to provide detailed information about each of the diseases, outlining etiology, modes of transmission, period of communicability, special planning information, decontamination of exposed patients, isolation precautions for exposed patients, isolation precautions for patients with disease, lab specimen handling/transport, vaccine availability, and post-mortem care.

"This has been a very positive process," says Meridith. "We have a better educated, better prepared staff. We’re better prepared to take care of patients — both inside the facility and out."

While working hard to ensure optimum care for patients, it’s equally important to prevent your staff from becoming patients. Hospital professionals must concern themselves equally with the health and safety of first-responders and others who may come in contact with these patients.

What sort of precautions should be taken? "There are, of course, isolation standards, which we always use," says Jan Schwarz-Miller, MD, MPH, director of occupational medicine for Atlantic Health System in northern New Jersey.

"Most of these were developed in response to HIV. The other concerns are respiratory and droplet and contact," she points out. "Unless it’s cutaneous, anthrax is not passed by any of those routes. There’s a tiny, tiny, tiny risk, so we do use contact precautions. Thank goodness, we do not need to worry about person-to-person spread."

What if we were faced with an outbreak of something more contagious? "That’s a totally different story," Schwarz-Miller says.

"Then, it depends on how it’s transmitted. A worst-case scenario would be something like smallpox, simply because we only have a certain number of negative-pressure rooms," she adds. "The number we have is more than adequate for what we consider to be a standard situation, but in an epidemic, there would have to be huge cohorting."

Don’t forget the basics

No matter how complex your response plan is, it’s critical to keep in mind the basic procedures that will help minimize the risk for all involved, says Bonnie Barnard, MPH, CIC, who heads up the patient safety task force at the national level for the Washington, DC-based Association for Professionals in Infection Control and Epidemiology Inc. (APIC).

"Your first concern is control of the immediate area," she asserts. "The second will be the air-handling system; that will be the route through which terrorists could achieve the greatest impact if they use these small-particle powders than can become aerosolized. If there were only two things that you could do, it would be these two."

Barnard reminds us that things could have been much worse had a more infectious agent than anthrax been used, and that it’s important to be prepared for that eventuality.

"With anthrax, it’s not spread from person to person," she notes. "If you do have something like smallpox, now you’ve opened a real can of worms."

In the case of such an attack, she says, hospital epidemiologists will be very busy, indeed. "Proper isolation procedures must be followed," she explains.

"Right now, you should be making sure there are rooms available in your facility that are truly negative-pressure rooms, because if people are admitted with, say smallpox, they must be very carefully placed in those negative-pressure rooms," she says.

"There has even been talk that if you do see a case and have admitted that individual, the government may have to intercede and shut the hospital down; smallpox is very contagious. One case is an epidemic," Barnard adds.

Resources are available

Fortunately, a number of resources are available to help develop a response plan. APIC has published a bioterrorism readiness plan for health care facilities that can be found at "It’s very comprehensive; it walks you step by step through the components you should have in your plan," Barnard says.

Second, she advises, make sure you’re on the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report notification list. "That’s where the most current information available on bioterrorism is found."

In addition, the Joint Commission on Accreditation of Healthcare Organizations has just published a new issue of Perspectives that focuses on emergency management planning, with a featured emphasis on "The need for a national bioterrorism response." It can be found at

[For more information, contact:

Jane Meridith, RN, Assistant Vice President of Nursing, Baylor Medical Center at Grapevine, 1650 W. College, Grapevine, TX 76501. Telephone: (817) 488-7546. Fax: (817) 424-4700.

Bonnie Barnard, MPH, CIC, 1560 Lexington Road, Helena, MT 59602. Telephone: (406) 443-5288.

Association for Professionals in Infection Control and Epidemiology Inc., 1275 K St. N.W., Suite 1000, Washington, DC 20005-4006. Telephone: (202) 789-1890. Web site:

Jan Schwarz-Miller, MD, MPH, Director of Occupational Medicine, Atlantic Health System, Morristown Memorial Hospital, 100 Madison Ave., P.O. Box 94, Morristown, NJ 07962. Telephone: (973) 971-5440. Fax: (973) 290-7978. E-mail:]