CBRNE - Chemical Warfare Mass Casualty Management

Introduction

This article is for managers who prepare hospital operational plans, for leaders responsible for response activities within a hospital, and for hospital healthcare providers. It is intended to provide credible source material on how to accomplish numerous concurrent tasks required during a chemical event involving a large number of casualties. More specifically, the intent is to offer possible solutions to a number of tasks comprising the intimidating mission of caring for overwhelming numbers of chemically contaminated casualties.

Although no one article can contain everything a medical treatment facility will require to complete this mission, a number of practical solutions to critical tasks are presented. This information is the product of expertise acquired during the 1991 Persian Gulf War assisting hospitals to prepare, train, and exercise to receive chemical warfare agent casualties; during many years of preparing a hospital response capability for a disaster; and during actual hospital disaster response. It is a work in progress and will be regularly updated.

These recommended actions will be most useful in planning the early response phase of a chemical event but also have relevance for other public health events. It is not meant to supplant other works from either private or governmental sources but rather to provide a complementary perspective on how to approach several key tasks. A number of additional resources are identified to facilitate preparation of plans and procedures; these are identified as references or as web sites in the text.

While the measures discussed are possible actions for an individual healthcare facility, the inherent nature of a weapon of mass destruction (WMD) demands a community or regional approach (The Joint Commission). Each healthcare organization within the community must define its role and understand the roles and limitations of other treatment facilities to develop viable comprehensive plans to address overwhelming numbers of casualties. Through collaborative planning, community healthcare institutions capabilities and limitations will be recognized.

The joint community planning extends beyond healthcare facilities. An event that produces large numbers of casualties will transcend all aspects of emergency response and local government. Police, fire, emergency medical services (EMS), and other emergency operations groups must plan together to identify overlapping capabilities and, more importantly, to recognize limitations and develop interagency communications capability. Many areas have local emergency planning committees (LEPC). These committees would provide an excellent forum to begin or continue planning to protect public health, safety, and the environment from chemical hazards.

A hazard vulnerability analysis (HVA) is a necessary first approach. Defining potential hazards within the local geographic area is essential to prepare comprehensive, all-inclusive, realistic plans. The Occupational Safety and Health Administration (OSHA) included examples of HVAs in their publication "Best Practices for Hospital-Based First Receivers." ^[1] Developing an HVA in concert with other medical and nonmedical authorities will provide a basis for decision-making and development of coordinated plans. Identification of appropriate staff, development of specialized teams, selection of personal protective clothing, other specific equipment and materials, and necessary pharmaceuticals can only be determined once specific local hazards are recognized.

Environmental conditions will present risks to both casualties and hospital first receivers. Practical solutions are required for cold weather to protect patients during decontamination. Hospital personnel working outside in hot conditions, particularly those in personal protective equipment (PPE), are at risk for heat injury. Environmental factors are particularly important when large numbers of personnel are being triaged and held for treatment. Persons who are chronically ill, elderly, and very young are especially susceptible to heat or cold; an area must be identified to protect them from extreme conditions.

Procedures for a chemical weapon response

Specific measures to handle an incident involving a chemical WMD should be integrated into existing hospital emergency preparedness plans. Although some of these measures are common to disaster response of any nature, the demands that may result from a chemical WMD crisis may require expanding existing hospital emergency preparedness plans, personnel, equipment, and training, including the protection of employees and the physical plant.

First, a recognized chain of command to direct the hospital staff and to manage critical assets during a mass casualty event will be required to provide an orderly response. The designated leader is responsible for coordinating the activities of the departments and hospital staff in accordance with the emergency preparedness plan. In addition, the leader is responsible for communicating and coordinating activities with outside agencies. This chain of command may be delineated in the healthcare facility incident command system (see Hospital Incident Command System [HICS]) or in the emergency operations plan.

One strategy to promote such planning is to have department or clinic chiefs prepare a sequence of objectives for their staff to achieve during response to a chemical incident that is in accordance with the overarching hospital response plan. Include peripheral activities that are interdependent to the response such as housekeeping, facility engineers, maintenance, administrative, pharmacy, and security staffs. To support the hospital plan, each department or unit must develop a standard operating procedure (SOP) that defines how each task is to be accomplished. The unit's SOP must be simple but all-inclusive; each task must be defined. Cue cards or checklists to address specific tasks or the sequence of tasks can be prepared as appendices to the SOP. The cue cards, distributed at the outset of an event, list essential tasks to be performed and prevent them from being overlooked. Laminated wallet cards can be issued pre-event. The SOPs must be consolidated and reviewed closely to identify shortcomings and to ensure a coordinated response.

Staff members must practice frequently to maintain their competency. Also, take into consideration the staffing differences by shift or day of the week. Special attention to training is needed by part-time weekend personnel.

A chemically hazardous environment requires additional safeguards to protect hospital workers and patients. Designate a qualified safety officer. This officer ensures work/rest cycles of employees working in PPE are tracked and followed, ensures accountability of personnel, ensures contamination control, and identifies safety hazards that occur during the hospital response. In addition, the safety officer ensures that patients are decontaminated thoroughly before entering the hospital; therefore, the safety officer is the last line of defense for clinical personnel and the facility. Even with the urgent needs of many victims of a chemical attack, the hospital, staff, and patients must not be compromised by chemical contamination.

Establish a plan to handle decontaminated and contaminated victims of a chemical WMD incident. ^[2] Ideally, Fire and Emergency Services first responders or hazardous materials (HAZMAT) teams decontaminate people at the incident site before evacuating them to a medical facility, but this cannot be relied upon. However, planners should anticipate that less-injured patients may self-transport to the nearest medical facilities and may contaminate these facilities. The plan must include ways of diverting these people to a holding and/or treatment area that does not compromise the healthcare facility. The requirement to remove all chemical contamination from patients delays their entry into the healthcare facility but should not delay lifesaving treatment by staff in appropriate PPE. Finally, do not rely on hasty decontamination done by others outside the hospital. Put patients through a thorough decontamination procedure at the hospital when indicated.

The Joint Commission's Environment of Care (EC) standards require organizations to participate with the community in establishing priorities among potential emergencies, defining the organization's role in the community's emergency medicine (EM) program, and linking with the community's command structure (EC.4.10)

Detection, diagnosis, and mitigation of illness and injury caused by biological and chemical terrorism constitute a complex process that involves numerous stakeholders and activities. A large-scale chemical event is not solely a medical issue. Many local and community resources will be called upon to assist in resolving the incident. Whenever or whatever disaster or mass casualty event occurs, community and local response will be key to survival; communities must look to themselves and adjoining communities for answers. ^[3]

Implementation of a plan requires collaboration with state and local public health agencies and groups, including the following:

• Public health organizations

• Poison control centers

• Medical research centers

• Healthcare providers and their professional networks

• Professional societies

• Medical examiners

• Emergency response units and first responder organizations

• Safety and medical equipment manufacturers

• Federal agencies

• Federal Bureau of Investigation (FBI)

• Local law enforcement

• Emergency management agencies and local emergency planning committees

Establish an early notification process with emergency response units and first responder agencies to notify hospitals when a chemical WMD incident occurs. Preparing a medical facility to receive casualties who may arrive without having been decontaminated requires considerable effort. Early warning permits initiation of specific procedures and assembly of appropriate staff to receive casualties.

Prepare formal agreements with vendors (ie, hospital suppliers, pharmacies), health departments, EMS, fire and police departments, other local hospitals, laboratories, city officials (eg, transportation and emergency planners), the American Red Cross, and ambulance services to provide the best possible response. Review these agreements annually and practice procedures frequently to maintain proficiency.

Steps to prepare public health agencies for chemical attacks include the following ^[4] :

1. Enhance epidemiologic capacity for detecting and responding to chemical attacks.

2. Enhance awareness of chemical terrorism among EMS personnel, police officers, firefighters, physicians, and nurses.

3. Stockpile chemical antidotes.

4. Develop and provide bioassays for detection and diagnosis of chemical injuries.

5. Prepare educational materials to inform the public during and after a chemical attack.

While these steps are intended primarily for public health agencies, key hospital staff must be aware of the total response environment. Understanding the overall community response is critical to becoming an active and successful member of the community response team.

An effective communications network is essential to a coordinated and efficient incident response. Communication equipment and expertise are likely to be among the weakest links in any response to a terrorist incident. During conventional incidents involving only a few casualties, information frequently is inadequate, incorrect, or nonexistent. Backup systems with built-in redundancy inside the hospital are necessary to ensure that communication equipment is available at critical moments. Consider continuous open channels to maintain a flow of information. Communication plans should identify departments, units, or positions rather than individuals because of varying work shifts and rotation of personnel in key positions. Designated channels should be available for law enforcement and other essential contacts.

Method of communication

Select an effective method of communication. Mobile telephone systems may be overwhelmed and become ineffective as the first responders, members of the ICS and healthcare system, and citizens attempt to keep abreast of the situation. Handheld radios within the hospital are effective and frequently are the communication method of choice. The radios' short range is effective within the medical facility but does not interfere with similar devices a short distance away. Care must be taken with portable communication equipment to avoid interference with patient monitoring devices and other electronic equipment within the hospital.

Coordinate communication plans with external agencies early in the planning phase to avoid conflicts with local regulations and outside requirements. Tailor the methods of communication for each hospital's needs; the methods must also meet the requirements of the surrounding community. Anticipate communication needs that may occur during a crisis and plan for those needs. As a last resort, plan a runner system. Print a supply of messages and request forms for the department's use.

Hospitals should coordinate and practice communication systems to be prepared during a chaotic situation. Anticipate having to shift personnel and move supplies to meet rapidly changing demands. Moving patients within the healthcare system requires effective communication between the receiving area, clinics, wards, radiology, and expedient patient holding areas so that patients are tracked effectively. Maintain a written log to monitor patients to ensure that they reach the appropriate area for definitive care. If available, a bar code system is a rapid and effective means to accomplish patient tracking. Members of the American Red Cross or another volunteer group may be able to operate a patient locator system and permit hospital staff to be assigned to more critical or complex positions.

Establish procedures to receive calls from family members and friends to keep telephone lines free for operational purposes. Hospitals must be prepared to help families and friends when they inquire about patients' whereabouts and medical status. Plan a family waiting area. Finding and identifying patients is a major undertaking. Patient confidentiality must be maintained during this process.

Information dissemination

Controlling sensitive information may be a priority among law enforcement officials. Police and the ICS supervisor are more willing to communicate with healthcare facilities if outsiders cannot access the communication system. The ICS and Unified Command System (UCS) are methods for command, control, and coordination of a response and provide a means to coordinate the efforts of individual agencies as they work toward the common goal of stabilizing the incident and protecting life, property, and the environment.

An emergency communication plan that ensures rapid dissemination of health information to the public during actual, threatened, or suspected acts of chemical terrorism will be a valuable asset. Announcements to the news media must be coordinated, open, reliable, and current. During a terrorist event, all public communication should be through the designated community or regional spokesperson, even though large medical centers may have communication procedures and a media spokesperson. Gaining public cooperation requires that consistent information from all sources is related by one spokesperson. Effective communication with the public through the news media is essential to limit the terrorist's ability to induce public panic and disrupt daily life. Gaining and retaining public confidence and cooperation is extremely important during a WMD incident.

Address what information to release and by which method. Prepare sample public health advisories and develop repositories of information on anticipated chemical warfare agents and industrial chemicals for use in a crisis. Specific information is available on traditional chemical warfare agents and toxic industrial chemicals at one or more of the web sites identified in this article. ^[5] Provide the community spokesperson with a fact sheet prepared specifically for the public. In some instances, the hospital spokesperson may be called upon to comment on the situation. Reliable information from a known and respected community resource can dismiss rumors and inaccurate predictions from self-proclaimed experts. To achieve a more rapid response to warnings, provide the public with enough information to allow everyone to understand the instructions from local officials.

In the hospital's emergency preparedness plans include plans for communicating with the media. The designated spokesperson or security person should assist the reporters and camerapersons but not allow them to interfere with hospital activities. During decontamination and treatment, consider the privacy of patients and prohibit filming of patient areas. Staff members who come into contact with media personnel should refer the reporters to the appropriate hospital spokesperson. The designated spokesperson responds to the media according to hospital policy after coordinating with the regional or community spokesperson.

Improving the plan

Prepare a formal critique of the event response as an important step in improving the emergency plan. Afford the entire staff the opportunity to present comments through the chain of command. Presenting these comments during the first 24 hours after the event is resolved or an exercise is completed is critical to capture the lessons learned. Follow with review, consolidation, and consideration for how changes affect other departments and integrate into the department plan as well as changing the overall plan.

Personnel considerations

Develop a recall roster adapted to local needs. Prioritize and update the sequence of notification of personnel (see the table below). Clinics or support departments may have their own recall roster in addition to maintaining one for key hospital staff. Because actual terrorist incidents are likely to be unannounced, the treatment facility may have little or no time to prepare for receiving casualties. Adding as many key staff members as quickly as possible will facilitate the hospital response. Although the presence of clinical staff members is generally the first priority, support staff members also are necessary. Security, logistics, pharmacy, housekeeping, and patient decontamination personnel are other essential staff in a chemical incident scenario.

Table. Recall Roster (Open Table in a new window)

Those individuals identified as essential in the event of a mass casualty incident must be aware that they are required to respond with little or no notice. Family considerations and support require advance planning and preparation. Many of today's workers are single parents, and, in many families, both spouses are employed. Essential personnel need to make prior arrangements for family support, child care, and pet care in case the operation continues for hours or up to days. Planning strategies should be developed that account for medication prophylaxis of essential personnel and their families. Training nonmedical support personnel is essential to build confidence, dispel fears, and promote their participation during crises.

Prepare a format to provide critical information to the local poison control center, public health department, and other agencies. Distribute the format to key personnel in the hospital and those agencies. Provide the following information in accordance with local community procedures as it becomes available:

• Number and types of casualties

• Substances involved

• Estimated time of arrival at the hospital

• Time of incident

• Incident site

• Method of contamination (vapor or liquid)

• Necessary decontamination (and extent)

• Hazards to healthcare providers

• Role of the healthcare facility in the incident

• Frequently updated information as it becomes available

Enlisting the support of healthcare providers who usually work outside the hospital is important during an influx of casualties. Physicians and nurses in family practice clinics and urgent care centers may be available to augment the hospital staff. Have a list readily available of community healthcare providers who are trained and prepared to assist in emergencies. These providers are essential during sustained operations. Consider approving credentials and hospital privileges for these physicians and nurses for emergency situations. Address liability and reimbursement for services. Volunteers may be available to help with specific tasks. Identify in advance people from outside the usual hospital staff who can help in a severe situation and use these people when appropriate. These individuals require an orientation to the disaster plan and should be included in training and exercises to be most effective.

The hospital incident commander must know what staff is available at all times; therefore, maintain a roster of when staff members and volunteers arrive and depart. When they report to work, have key and essential personnel pass through the hospital entry control point. The cue cards discussed earlier can be handed out as staff supervisors enter the facility. This procedure allows the hospital incident commander to identify personnel shortfalls and tasks that need to be reassigned.

A healthcare facility must develop an area, preferably outside the hospital, for decontamination, and personnel must be trained in patient decontamination. This special area is crucial for the protection of the facility. After the Tokyo sarin attack, local hospitals were overwhelmed immediately with chemical agent casualties; many of whom transported themselves to the hospital. No effort was made to decontaminate them; as a result, healthcare providers were exposed to sarin vapor that off-gassed from clothing.

Protection of personnel

The first rule for personnel assigned to decontamination must be that they protect themselves. (Information concerning PPE is presented in CBRNE - Personal Protective Equipment.) OSHA has identified the minimum PPE for hospital-based first receivers. ^[1] Failure to use appropriate procedures or protective equipment places the individual, healthcare workers, and the medical treatment facility at risk. The respirators commonly used in hospitals for infectious materials are not protective in a chemical environment. During a mass casualty incident, many people require medical care; neither healthcare personnel nor healthcare facilities can be compromised. ^[6]

Risk to hospital receivers

In the Tokyo sarin attack, many patients were not decontaminated on-scene or seen by EMS prior to arrival at hospitals. Tokuda et al reported 35% of the injured walked to a hospital, 24% were transported by taxi, and only 7% were transported by ambulances. In the Graniteville, South Carolina chlorine gas rail care accident, it was found that of 57% of patients in the data collection, 63% self-transported in an automobile and only 35% were transported by ambulance and 2% by police.

These statistics should highlight to hospital first receivers that many incident patients arrive at the emergency department without decontamination. Additionally, while not all patients will necessarily need decontamination from an incident, it does emphasize the potential danger to hospital personnel caring for them, the need for the facility to have a rehearsed procedure, and the necessary personal protective equipment (PPE) for their personnel. In the case of the Tokyo incident, the vapor from the sarin became trapped in the patients’ winter clothing. When the clothing was removed in the hospital, these patients off-gassed and sickened physicians, nurses, and other care providers.

OSHA best practices, as well as the literature promulgated by other responsible agencies, should be followed at all times to protect hospital staff. Hospitals need to have available a quantity of various-sized protective garments rated for the likely hazards to be encountered, as well as NIOSH-certified breathing protection for various chemicals. Owing to the heat load from PPE, fresh replacements must be suited and ready to relieve tired personnel.

Decontamination area

The ambulance garage or parking area may be used as a decontamination area. Since the ambulance area frequently is located near the ED entrance, casualties may be sent to the ED or other designated area after they are clean. The garage also may provide adequate storage for decontamination equipment and supplies. This area can be heated for patient protection or cooled to reduce the heat load of PPE worn by the workers; however, even sites with overhead cover only can provide protection from radiant heat. A water source generally used for washing vehicles can be used to decontaminate casualties. Firefighters or facilities engineers can be consulted on how to modify the existing plumbing so that it is conducive to washing both ambulatory casualties and nonambulatory casualties.

Consider the traffic pattern for both ambulatory patients and litter patients. In addition, plan for and prepare sites for the separation of males and females for undressing, washing, and dressing; a heating source for water; and drainage and capture of potentially contaminated water when possible. An effective decontamination site can be erected with limited expenditures by using available structures and equipment. Litters are now available with open mesh fabric that permits effective decontamination, which is not possible with a standard gurney. Conveyor roller units also can make handling nonambulatory patients easier as they are moved through the decontamination lane.

Since much of the United States experiences very cold winter temperatures, special consideration must be given by first responders and hospital first receivers regarding decontamination. Water flowing from a fire department hose in the winter could result in hypothermia, adding additional stress to already compromised casualties. This may particularly profound in children, elderly persons, and debilitated individuals. Stripping off outer garments down to under garments aids greatly in removing decontamination. Aluminum foil blankets are inexpensive and hundreds can be carried in a small chest or bag. These could aid in temporarily preventing hypothermia as well as protecting modesty, reducing the logistical burden of having gowns of various sizes to distribute. An additional essential item is slippers or booties to protect the feet.

While water is usually available quickly, consideration must be given to other decontaminants that can be used if water is not available or in the presence of extreme cold weather issues, among other situations. Fuller’s earth is an adsorbent clay that is used by many NATO countries. It can be sprinkled on affected body parts and then physically removed. Other dry decontaminants include soil, spill pads, oil-dry, and kitty litter.

Adding liquid body soap to the decontaminating water can increase the efficacy, especially when chemicals of an oily nature are encountered. Do not use detergent and take care to not abrade the skin with vigorous scrubbing of the skin.

Hospitals can expect to receive a number of casualties from an incident, including contaminated and uncontaminated, worried well, and traumatic injuries. While many hospitals use special tents to accomplish decontamination, they take time to set up and have a low through-output. Hospitals can arrange a piping system with spray nozzles and attach these to the undersides of building canopies, or in a vehicle parking garage, as is done in Israel. Often, the building hot water supply can be tapped into to provide lukewarm water during incidents, which reduces cold injuries and increases compliance. Liquid body soaps, often in 55-gallon drums for intuitional use, can be obtained and a proportioning pump can meter an amount into the water supplies of the decontamination setup. The use of a fixed decontamination system such as described and with shower nozzles emitting water and soap can save setup time and hospital personnel and can be very effective.

Personnel designated to decontaminate patients require initial training and periodic practice. Specific procedures that may be suitable to civilian needs are detailed in the Guidelines for Mass Casualty Decontamination During a Terrorist Chemical Agent Incident prepared by the US Army Soldier and Biological Chemical Command. ^[7]

A decontamination site has 3 areas, as follows:

• Hot zone: Incoming traffic, personnel, and casualties potentially contaminate this area.

• Warm zone: Decontamination takes place in this area.

• Cold zone: In this clean area, casualties are triaged again and then moved into the healthcare facility.

Managing a chemical casualty is a continuum from triage to discharge from the hospital. Only the management principles required to get a chemical casualty safely into a medical treatment facility are discussed.

Triage

The first task is to triage casualties before decontamination and again as they enter the hospital. ^[8] The purpose of triage is to sort the injured by priority and determine the best use of available resources (eg, personnel, equipment, medications, ambulances, hospital beds). The emphasis is on saving as many people as possible. Triage must occur at each site because of changes in patient status. In a chemical incident, victims are triaged for 3 purposes at the incident site: decontamination, treatment, and evacuation. Triage at the hospital primarily is for decontamination and treatment. Evacuation to other medical facilities may be necessary to provide specialty care or to distribute the patients throughout the regional healthcare system.

Triage terminology and methods to identify the different categories vary and are a matter of preference. Military terminology is presented below, but civilian methods such as the Simple Triage and Rapid Treatment/Transport (START) are both rapid and effective methods of separating casualties. To avoid confusion or delays in care, standardize terminology and methods throughout the region. Four triage categories for treatment are described as follows:

• Immediate: Casualties need lifesaving measures performed without delay if they are to survive.

• Delayed: Casualties can wait for definitive treatment without causing additional harm.

• Expectant: Casualties will not survive or will require extensive resources and time if they are to be saved.

• Minor: Casualties are generally ambulatory and are only slightly injured.

Triaging for decontamination is necessary to move the casualties quickly and safely into the healthcare system. Divide casualties into ambulatory and nonambulatory groups. Ambulatory casualties most often are classified as minor or delayed. However, observe people triaged as minor or delayed for worsening signs and symptoms. Immediately decontaminate casualties who were closest to the point of chemical release, those with liquid contamination, and those who have severe signs or symptoms of chemical injury or severe conventional injuries. Victims may be classified as expectant when they have serious signs and symptoms after initial therapy or are unresponsive to antidotes.

Move deceased casualties to a site that is not observed readily by the public or other casualties. Keep the deceased at this site until law enforcement officers have acquired any available evidence and living casualties have been moved into the healthcare facility. Deceased casualties require a thorough decontamination before they are moved to the morgue or they are ready for release.

Effective triage requires the presence of a triage officer who is trained to identify the type of casualties that will be sorted. For instance, a person contaminated with a liquid nerve agent who arrives as an ambulatory casualty may deteriorate rapidly once the agent is absorbed. Triage officers are in a key position, and the individual must be capable of making quick and frequently difficult decisions. Also, triage officers must be very familiar with the medical staff and the hospital's capabilities and limitations.

Admission procedures

Following a chemical event with many casualties, normal patient admission procedures are not effective. A system that initially captures essential information is sufficient. Additional patient information can be captured when time permits. Ambulatory patients and many nonambulatory casualties are able to provide appropriate information. However, identify unconscious casualties before their personal belongings are removed. A plastic driver's license with a photo may be decontaminated and used to accompany the patient. Photo identification is particularly useful for unconscious and deceased casualties.

Additionally, a number can be assigned to each patient; the number then can be placed on the patient and on 2 bags. The first bag contains clothing; the second holds the patient's valuables. Clear bags facilitate identification at a later date. Consider these bags contaminated, keep in a secured location, and preserve as potential evidence as in any criminal investigation. A meticulous practical method of cataloging belongings helps ensure proper return and possibly helps in forensic investigations.

A bar code system is an excellent approach to tracking multiple casualties evacuated from an incident scene to multiple healthcare facilities. The EMS and hospitals in St Louis use an impressive system on a daily basis that has the capability to expand to meet the patient identification needs for a large-scale event. A comprehensive system that meets routine daily needs is essential. Attempting to institute an unfamiliar system during the confusion of a mass casualty event is difficult.

A secondary triage following decontamination further identifies casualties who require immediate attention and those who can wait for treatment. Move casualties who can wait for treatment to a clean holding area. A nurse, paramedic, or emergency medical technician assigned to the clean holding area can observe these individuals and provide reassurance if necessary. Additional clean holding areas can be established in dining rooms, physical therapy departments, and meeting rooms.

Emergency treatment

Emergency treatment for immediate casualties depends on the chemical agent(s) used and on the availability of definitive treatment measures. For many toxic agents, no antidotes are available, and treatment is supportive. Administer antidotes judiciously to ensure that they are not wasted on minor casualties who arrive early or on those with no chance of survival.

The requirement for ventilators may exceed availability. Spreading the serious casualties among community hospitals or consolidating ventilators to 1 or 2 major medical treatment facilities are local options. The Strategic National Stockpile (SNS) has ventilators in their inventory and can provide them within a few hours. The specific types that are in the SNS should be identified to train respiratory therapists on the use of the particular models that will arrive. Also, the model information will be important to acquire repair parts and consumables when needed.

Take measures to protect hospital personnel and maintain the integrity of the healthcare facility. Have emergency procedures for exposure of staff members in place. If the decontamination procedure fails and staff members become contaminated, decontaminate and treat them. Until the cause of the contamination is determined, do not use the treatment facility or the contaminated area of the facility if that can be determined. If decontamination procedures fail, correct them immediately. Place exhaust fans to ventilate contaminated air. Keep doors between clean and contaminated areas closed, except when moving a casualty into a treatment area. Do not let chemical vapor contamination into an area with unprotected healthcare providers and casualties. Consult with the hospital facilities engineer for heating, ventilating, and air conditioning (HVAC) guidance. Include physical plant personnel in the planning process.

Human remains may provide essential evidence and are important to law enforcement personnel. Unconventional methods may be required to hold the bodies until they can be decontaminated and released. Refrigerated vans may be used to store the remains temporarily. Morticians and funeral directors may need to be given specific directions for handling the remains. Bodies exposed to classic chemical warfare agents can be decontaminated and released to funeral homes. Bodies contaminated by other chemicals require individual evaluation for safety in handling. The National Disaster Medical System has Disaster Mortuary Operational Response Teams (DMORT) to provide victim identification and mortuary services. State authorities may request assistance from these teams.

An important part of the medical response to a chemical terrorism event is dealing with the psychological reactions among healthcare workers, first responders, and the public. The death of family members, coworkers, and particularly children is traumatic. Plan to provide critical incident stress management support early in a chemical event.

Transportation issues

Transportation and evacuation of patients are major tasks during a WMD event. Have a community-wide plan, enforced by the local police department, to identify and mark areas of contamination so that hazardous areas can be avoided and traffic does not become congested. Healthcare providers must be able to identify themselves and use the routes identified by the police to travel to the hospitals. Although many of the victims may arrive early at the medical facilities by various modes of transportation, the more severely injured may be among the last to arrive. Contact the US Environmental Protection Agency for specific guidance on contamination identification and control.

Plan for the movement of equipment, supplies, and pharmaceuticals to support the influx of casualties. Access to critical areas must remain open, and traffic must not be permitted to become congested. A circular movement of traffic in the critical areas facilitates unloading casualties and rapid departure of vehicles. To ensure that vehicles follow the plan, assign a security guard wearing PPE to direct traffic flow. Security personnel in PPE must have training and medical clearance, required by the Occupational Safety and Health Administration (OSHA), when wearing respirators and protective clothing. During warm weather, security personnel must be rotated frequently to avoid heat injury.

A sufficient number of ambulances may not be available to transport hundreds of casualties in a short time. Consider city bus systems or school buses as alternatives. Methods of moving large numbers of victims may vary for different communities. As a general rule, do not mix resources used to move contaminated or potentially contaminated casualties with those used for moving uncontaminated patients.

When the number of patients exceeds the treatment capability of a medical treatment facility, resource management becomes crucial. Planning for the availability of essential supplies, equipment, and PPE at critical times requires close coordination between clinical and support personnel.

Maintain a list of the location and quantity of ventilators and establish agreements between vendors and hospitals prior to an incident. These agreements must be reviewed and agreed upon by all healthcare facilities in the community and not limited solely to agreements between one hospital and a supplier. Develop a respiratory therapy mutual aid plan among multiple hospitals to share equipment, supplies, and respiratory therapists, and include ventilator vendors. Other important equipment requires the same coordination and written agreements.

List vital pharmaceuticals and supplies and prepare them for rapid distribution. An integral part of an emergency plan includes listing specific antidotes and supporting pharmaceuticals for the most likely emergency situations. Such lists permit pharmacists to prepare preplanned push packages to send to the emergency treatment area and save valuable time in meeting the treatment demands of many casualties. Awareness of the stockpile of antidotes maintained by the Metropolitan Medical Response Systems (MMRS) and the Strategic National Stockpile (SNS) of the Centers for Disease Control and Prevention (CDC) as well as the antidotes' expected time of arrival may alleviate the need for large quantities of antidotes to be stockpiled locally. A regional pharmaceutical mutual aid plan can be developed among hospitals and can include pharmaceutical suppliers.

Floor plans of the hospital and diagrams of the immediate area surrounding the hospital are useful in planning for a WMD event. Floor plans help determine the most appropriate routes for patient flow and vehicle movement. The identification of an area for decontamination with ready access to an emergency treatment area may be much more apparent when looking at a diagram. A large dining facility or waiting area may be prepared quickly to receive decontaminated casualties. Warehouses may provide alternate facilities for initial triage, decontamination, and emergency treatment or serve as a holding area for minor casualties. Alternatives to the usual ways of conducting business and areas allowing for overflow of patients are important components of a comprehensive plan.

Alternate or back-up utilities may be required if the chemical incident site includes the local electrical plant or if electrical power is disrupted. Water systems also may be affected. A medical treatment facility must be self-sufficient for at least 24 hours following a terrorist event or natural disaster.

The influx of both patients and staff requires food service support. If the chemical event continues for hours or days, food service personnel need to provide food and water to meet the increased demands. Additional housekeeping service to remove excess trash, provide linens, and replace expendable items is required. Maintenance workers are needed to keep equipment functioning in treatment areas. Identify areas for the temporary storage of potentially contaminated clothing and other personal belongings that must be identified and stored until final disposition is determined.

The normal hospital security plan requires modification to satisfy requirements of the emergency situation and to conform to community plans. Hospital lock-down should be implemented when a mass casualty incident happens. To avoid the risk of the healthcare facility becoming contaminated and unusable, it must be secured and access limited. At the hospital staff entry point, guards check to ensure that people arriving are listed on the hospital disaster response roster, log those people in, and note their time of arrival. The same procedures apply to personnel leaving the hospital. Identification (ID) badges can be issued at the entry control point. The ID badges may be issued to employees before an event, but invariably, some will not have their ID badges when they arrive. Badges can be color coded to identify a particular unit or service.

Security is necessary at the decontamination point. Guards need to wear PPE; rotate staff frequently in warm weather. Crowd control, casualty flow, and traffic control are critical at the healthcare facility. Vehicles must not linger in the area, or others may be slowed or denied access. Crowds and media must be kept at a safe distance so that they are not harmed and do not impede the emergency process. Develop a plan to address any breach of security.

A terrorist may plant more than one device. Additional devices may not be the same type as the initial one and may not be at the same site. Investigate and secure the area where casualties or onlookers congregate during an emergency to exclude the presence of additional devices. For example, a terrorist in Northern Ireland exploded a bomb that caused several casualties. Knowing a crowd would form to unload and assist the casualties, the terrorist exploded a second bomb outside the busy emergency treatment area.

Have a safety plan that addresses specific issues in chemical safety and augments the existing emergency preparedness safety plan for other disasters. An existing safety plan may not include contamination control and casualty decontamination requirements.

At least one safety officer who is knowledgeable in the operations being implemented should be at the medical treatment facility. The safety officer has specific responsibility for identifying and evaluating hazards and provides direction with respect to the safety of operations. The safety officer's primary function is contamination control to ensure the safety and welfare of the hospital personnel and to prevent the contamination of the facility. To avoid contaminating treatment areas, constant vigilance is required to ensure that contaminated casualties, staff, and equipment are not permitted to enter the hospital area prior to decontamination. When positioned at a critical location, the safety officer can help prevent the spread of contamination. Safety officers need to work closely with security staff and police to enforce measures to protect personnel and healthcare facilities.

In addition to preventing contaminated people and objects from entering the healthcare facility, the safety officer can observe workers while they are performing decontamination. The officer is able to ensure that work and/or rest cycles are implemented and enforced and that PPE is worn appropriately in hazardous areas. Also, safety officers may be appointed as the final approving authority for decontaminated casualties to enter the hospital.

Training

OSHA cites specific training requirements for first responders and others who participate at the incident site. Additional information on training requirements may be available at the National Institute for Occupational Safety and Health. Hospital personnel who are designated as safety officers or who are involved in decontamination also should be trained to the appropriate level as specified in the OSHA Hazardous Waste Operations and Emergency Response regulation.

Everyone who participates at an incident site or in receiving contaminated casualties must know the basic hazards, signs, and symptoms of exposure to chemical agents. OSHA has a document titled "Best Practices for Hospital-Based First Receivers" that also addresses training for hospital-based personnel to receive victims from mass casualty incidents involving the release of hazardous substances. ^[1]

An effective mass casualty plan relies on all staff members knowing their tasks and responsibilities. Most employees are involved in a specific task in one area of the hospital. Becoming familiar with a particular task may require minimal training. Individual training and small team training are appropriate before integrating multiple teams into a training exercise.

Decontamination is not a routine task, and employees require extensive training. Each specific task is not complex; however, the ability to perform the tasks while wearing PPE requires hours of practice. In addition, cross-train the decontamination team in various tasks because they must be capable of changing tasks to assist other team members. Building from single tasks to multiple tasks, learning to function in PPE, and learning to work as a team takes time, but rehearsal can produce an effective team. Physicians, physician assistants, and nurse clinicians designated to provide treatment to chemically contaminated casualties require specific training. A cadre of well-trained healthcare and public health workers should be available at each healthcare facility. Local poison control centers should be consulted immediately to acquire the latest information on specific treatment of patients. A detailed description of patient decontamination is beyond the scope of this article but specific procedures are well described in reference 5.

A national decontamination planning guidance became available from DHS and DHHS in December 2014. ^[9] This document is divided into functional areas and succinct, specific guidance statements that are well described. Guidance statement 2.11 addresses an alternative to wet decontamination: a much-needed substitute for patient decontamination during cold weather. Saturating casualties in a cold environment, particularly at-risk members of the population, would degrade their already compromised medical status. This is not a new approach; many NATO countries have used absorbent materials for chemical decontamination for their military for many years. Guidance is also provided for using a risk-based approach to guide the response level, strategies, and tactics. A clear understanding of this approach assists providers enforce health protection and determine appropriate medical intervention, as well as aiding in deciding who requires triage versus who does not.

The US Army requires that physicians assigned to depots storing chemical warfare agents attend courses in the management of chemical agent casualties in addition to attending advanced cardiac life support (ACLS) and advanced trauma life support (ATLS) courses. The Medical Response to Chemical Warfare and Terrorism teleconference course is available to civilian healthcare providers via the Internet and is offered biannually at many videoconference sites throughout the country. Information on these broadcasts and additional training courses such as the "Medical Management of Chemical and Biological Casualties Course," jointly sponsored by the US Army Medical Research Institute of Infectious Diseases (USAMRIID) and its sister organization, the Institute of Chemical Defense (USAMRICD), can be found at http://www.usamriid.army.mil/education/ .

Rapid turnover of personnel requires ongoing training programs. Reviewing the appropriate portion of a written plan and viewing a videotape of a previous exercise can facilitate the training process. Videotaping exercises is an excellent method to capture department activities, and videotapes can be produced inexpensively. In addition to being used as training aids, tapes can be observed and critiqued to improve response.

Hospital preparedness for mass casualty incidents increases if hospitals engage in regular ongoing inservice training programs and in readiness drills. Some of the cost for such training can be defrayed through the use of videotapes, CD ROMs, and web-based technologies. In addition to being cost effective, these resources are updated frequently and provide new and revised lists of resources. The American College of Emergency Physicians is preparing a standardized 2-phase curriculum and a set of training materials for mass casualty preparedness. Such initiatives to standardize training reduce individual hospital costs and provide acceptable procedures and educational material.

Components of the educational curricula and course outlines have been developed by several agencies. The typical curriculum is divided into multiple levels. The first level, a brief awareness program, is designed for all workers and describes the threat and basics of how to respond while protecting personal safety. A decontamination procedures course is more extensive and is intended for workers designated as members of the decontamination team. The decontamination course includes presentations on PPE, safety issues, required medical screening, stations in the decontamination line, and physical characteristics of chemical agents. Healthcare providers are presented a course on the recognition and management of chemical agent casualties. The clinician's course may use the Medical Response to Chemical Warfare and Terrorism teleconference.

To supplement training, some hospitals have developed cue cards that identify a set of tasks for a department or unit. Using a checklist facilitates accomplishing all tasks that are necessary for the operation. In the absence of a trained primary member, another member of the unit can ensure that each task is assigned and completed.

Drills

Following individual and unit training, the hospital should integrate a WMD response into 1 of the 2 annual drills required by the JCAHO. An ideal hospital exercise requires rehearsals through tabletop exercises for supervisors and small unit drills. Both require time and personnel, but, in some cases, they can be as simple as a clinic or unit staff meeting designed for a discussion and walk-through of each portion of the emergency preparedness plan. Hospitals should endeavor to hold more than the 2 annual drills in consideration of their 3 shifts and separate weekend crews to better prepare their staff.

A tabletop exercise for leadership provides an opportunity for senior personnel to coordinate their activities during a mock exercise. An exercise that involves each department chief and requires synchronization of major activities reveals deficiencies in the emergency preparedness plan at the management level. In addition to the overall plan, the communications component can be tested during the tabletop exercise. Internal hospital communications and contacts with designated agencies within the community are both critical to the response. Once the unit training and the tabletop exercise are completed, schedule an exercise to test the overall system and to meet JCAHO requirements.

Biannual (or more frequent) hospital exercises can be videotaped for review, analysis, and future training. The exercises can be extremely valuable in identifying flaws in and minor adjustments to the response plan. A person who happened to be videotaping in a Tokyo hospital recorded the 1995 sarin incident. That videotape has been used many times as an example in training classes and as a tool to improve hospital response.

Patient Education

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education articles Chemical Warfare and Personal Protective Equipment.

Once the event has ended and the patients are within the healthcare system, the process of returning to normal function begins. Scientifically and logistically, this can be the most difficult aspect of the incident. Numerous areas, equipment, vehicles, and other items may be left contaminated. Identifying the contaminating chemical or chemicals, the preferred methods for decontamination, the chemical's persistency on various surfaces, and the chemical's effect on water and food sources requires considerable review and expertise.

The decontamination area must be cleaned, and contaminated clothing and equipment used during the decontamination process must be cleaned or disposed of appropriately. Final disposition of contaminated articles is in accordance with previously established arrangements and the overall community hazardous waste plan.

Patients' valuables are an important issue. During the patient decontamination process, rings, watches, wallets, purses, and other items such as hearing aids are removed and placed in marked plastic bags.

A security person may be the most appropriate person to ensure that these items are stored in a secure manner. To avoid legal difficulties, follow chain-of-custody procedures to ensure that these valuables are not disturbed. As soon as it is practical, check these items for contamination and clean them as necessary for return to their owners. The agency responsible for declaring items safe for return to their owner may be a city, state, or federal organization, depending on local and state capability. Law enforcement approval must be obtained to return personal clothing and items that may be considered evidence in a terrorism incident.

Capture lessons learned early in the recovery phase. An exercise critique must include each participant at the clinic or unit level. Individual workers and unit supervisors can contribute important comments on specific procedures to improve their respective operations. The activities at this basic level are crucial to the overall plan and must be included to refine and improve the complete plan. Department chiefs then must meet to discuss their consolidated recommendations. The incident leader and hospital administrator can incorporate the needed changes.

Lessons learned must be captured within hours after an exercise or incident. Otherwise, hospital staff returns to normal responsibilities, and important information is lost. Allocate a time at the termination of each exercise to obtain these comments and recommendations. The department chiefs can consolidate the comments and recommendations and meet with other chiefs and administrators within 24 hours to discuss their suggestions.