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How far behind?

Some health care experts say that the HRSA money and training, while worthwhile, have been misdirected, still leaving the medical workforce unprepared.

Weaknesses in surge capacity, medical stockpiles, and preventive strategies may place communities and caregivers in peril in the event of a disaster, said Saul Wilen, MD, CEO of San Antonio-based International Horizons Unlimited, a national consultancy specializing in medical problem-solving and disease prevention. He characterizes the readiness of Texas and the nation only as “fair.”

At least half of the federal HRSA money should be spent on prevention instead of a current total of less than 1%, he said. “Of course, any allocation is good, but if you’re only preparing to respond to diseases, it’s an after-the-fact proposition. You know then you are going to have to invest very heavily in treatment and recovery.”

Grimes, of UTHSC-Houston, said the health care environment now “feels a lot like situation in the early ’80s when we started seeing HIV/AIDS. People will begin showing symptoms over time and will be very dispersed. It’s important that nurses know what to look for to alert authorities.”

Issues arising with biological agents, and particularly anthrax, “have brought home the fact that detection systems are not working so well,” said the TNA’s Jordan.

“Nurses realize that they will be the first practitioners to see these people. They are concerned whether they have the knowledge. At the end of an eight-hour shift in ER where they have seen 32 people with abnormal symptoms, they will have to piece this together epidemiologically.”

Wilen cautioned that “unlike bombs or chemical releases, a biological attack could easily go undetected for several days,” he said. “The first seven to 10 days, what does anthrax look like? It looks like the flu. What does SARS look like in the early stages? The flu.”

Blanck of the UNT Health Science Center said the state “is probably doing all it can with the monies we have been given,” but added that the health care community is just not getting enough resources, particularly in surge capacity. “We now have plans for [mass] immunization, but if you’re faced with 10,000 patients, well, you’re in trouble.”

The federal government invested about $4.4 billion in fiscal 2003 for bioterrorism preparedness. But the United States needs to reassess how it is expending its resources and focus more on infectious disease surveillance and other preventive measures, Wilen said. “If you look at reemerging diseases and particularly understand spikes that occur, we can look at detecting [these] problems even before they become clinically manifested,” he said.

Heavy drilling

Although Louisiana doesn’t have continuing education requirements for nurse licensure and relicensure, the state stands out as one of just three CDC-defined geographic areas in the country to earn the top “green” preparedness-level distinction, joining Illinois and New York City, said Doris Brown, RN, MS, APRN, CNS, chief nurse for the Louisiana Department of Health and Hospitals Office of Public Health.

More than a thousand Louisiana nurses have participated in one of three different all-day training programs focusing on the present emergency system and identifying major biological, chemical, and nuclear threats.

Using CDC guidelines, the Louisiana Office of Public Health has developed a competency matrix and a series of voluntary continuing education classes in bioterrorism through the Louisiana State University system. Classes cover disaster scenarios and include hands-on drills, hazardous materials awareness, sample collecting, and establishment of mass immunization clinics.

“We are partnering with the academic arena and hospitals to make sure we are maximizing our resources and dollars,” Brown said.

Rosanne Prats, director of emergency preparedness for the Louisiana Department of Health and Hospitals, said the cooperative nature of the various state regional coalitions “is significant for hospitals, because they are usually in competition with each other. But when it comes to disasters, they’re more than willing to share resources and information.”

Hospitals in the Louisiana regions will continue to conduct regular drills. “It’s like a play,” Prats said. “Everybody knows their lines and their roles. It’s all a matter of coordinating all of it when it is needed most.”

But Prats, like many health officials in Texas, said she sees gaps in saturation points in medication in Louisiana. “Most hospitals are generally stocked up for [medicine] for just one or two days,” she said.

The CDC’s National Pharmaceutical Stockpile program has a national repository of antibiotics, chemical antidotes, life-support medications, IV and airway-maintenance supplies, and surgical items that can be delivered to state and local medical response entities and hospitals on short notice in the event of a biological and/or chemical terrorism incident. Nurses and other hospital personnel will be responsible for collecting evidence suggestive of an infectious disease process to access the stockpile.

“Will there be enough?” Prats said. “Only a disaster can tell us that. It can only be distributed so fast. And there are unknown factors to consider, too, not to mention the fear factor, which will certainly spin things up a notch.”

With biological agents, there may be adequate time to make the initial response and epidemiological investigations because of the incubation period, she said. “In that sense, it will help us with the planning.”

Cooperative efforts

A report released in May by the Agency for Healthcare Research and Quality said that the regional approach “may be the best way for state and local governments to use scarce resources ... to develop teams of trained response personnel and maintain supplies of response equipment.” But the report, Regionalization of Bioterrorism Preparedness and Response, said the shared resources approach will not be adequate in a worst-case scenario.

The anthrax attacks of 2001, SARS, and disaster exercises “have made it clear that no single community can prepare fully, nor respond completely, to a large-scale bioterrorism event 85 [and] there is little consensus about the optimal level of localization or regionalization for each of the resources and services that must be operationalized during a bioterrorism response,” the report said.

A previous report from the Texas Medical Association said that trauma hospitals are better prepared than non-trauma hospitals for bioterrorism response, but Texas hospitals in general are prepared only for an inflow average of 10 patients, instead of a potential surge of hundreds.

“One of the immediate things that stood out in our regional plan is that everybody has to have similar training and similar processes to respond as a whole,” said Julia Henion, RN, MBA, vice president and chief nurse officer of Driscoll Children’s Hospital in Corpus Christi.

To facilitate that, Child Health Corp. of America, parent of Driscoll Children’s, has created its own computer-based preparedness plan “module” and is training key administrators systemwide in its emergency, human resources, engineering, and other departments for disaster scenarios, Henion said.

“The SARS outbreak in Toronto showed that no man is an island,” Henion added. “It was very sobering to the medical community because nurses and physicians died because [SARS] was underestimated. We know that if they don’t understand what they’re doing, they could die.”

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