Ready for the Worst
Hospitals devote increased attention and training to prepare for bioterrorism threats and disease outbreaks

By Steve McLinden
June 7, 2004

Nurses in a post-Sept. 11 world are filled with the same fears of bioterrorism attacks and mysterious illness outbreaks as the general population, but they are more prepared than ever to deal with the potential consequences.

Behind the scenes, nurses are being educated to deal with disasters that are not as hypothetical as once imagined. Nurses are considered part of the frontline of defense for hospitals and governments teaming up on strategies to combat these new, grave threats to communities.

“Preparedness” is the new keyword, and many states — including Texas and Louisiana — are taking the initiative to best support their nurses for the challenge. Although the defenses are far from fortified, the recognition of the danger is fully realized.

“Nurses are at the forefront of bioterrorism preparedness,” said Ronald Blanck, DO, president of the University of North Texas Health Science Center and chair of the Texas Medical Association’s Task Force on Bioterrorism. “They will play such a critical role in early recognition ... and will put themselves in harm’s way to do the right thing for the patient, no matter what. We need to help them be armed for that role.”

Disaster preparedness training now is in the curriculum of nursing schools, and federal grants are supporting continuing education programs. Hospitals also are conducting drills with local emergency responders to determine the impact a major event could have on health care staff and services.

M. Teresa Verklan, RN, CCNS, teaches bioterrorism classes at the University of Texas Health Science Center at Houston. She is concerned that health care workers “aren’t really prepared to handle anything of magnitude. I can’t even visualize how we would handle major casualties, get supplies out, and coordinate operations.”

If primary hospitals are hit in an attack on an urban area, the care will shift to tertiary centers in outlying areas.

“We are really looking at community hospitals delivering the majority of care in this event,” said Verklan, an associate professor at the UTHSC-Houston School of Nursing and director of clinical research and advanced practice at Memorial Hermann. “This is something that most people don’t know anything about.

“With the world getting smaller and smaller and the risk of something happening in this country getting greater, the prospect of people trying to handle mass casualties is a disturbing one.”

Should power be knocked out, for example, nurses may have difficulty manually calibrating dosages in specialized IV infusions and performing other functions traditionally reliant on computerization, Verklan said.

Time of need

In preparation for the worst, nurses throughout Texas, Louisiana, and the rest of the United States have been busy engaging in drills and continuing education, volunteering for “reserve” nurse units, and helping their own hospitals link with other institutions.

In the event of a disaster, a “nurse reserves” unit of at least 1,200 nurses has been formed to combat anticipated care shortfalls in Texas.

The Ready Texas Nurses Emergency Response System, initiated in early 2002 by the Texas Nurses Association, taps into a nurse population that may not be active in a hospital or clinic setting, but has the skills and active licenses to assist in time of need.

Nurses from a vast spectrum of practices have signed on (at www.texasnurses.org) for service, TNA Executive Director Clair Jordan said. Many are semiretired or not practicing. Volunteer applicants answer brief questions about their practice expertise and willingness to volunteer, she said.

The TNA also has a bank of 15 phones that can be converted to toll-free numbers to enable the organization to process calls from would-be volunteers from out of state who want to cross state lines to help in a time of crisis. The organization will help them quickly convert their licenses so they can work in Texas. “We learned that from New York,” Jordan said. “They had so many spontaneous volunteers after Sept. 11.”

Health officials also have learned other lessons from previous incidents, including the 1995 sarin gas attack on the Tokyo subway system that left 12 people dead and sent more than 5,000 in search of medical care. “When we looked at Tokyo, a lot of these people were simply going to the nearest hospital,” said Ron Hilliard, RN, coordinator of the Texas Department of Health Bioterrorism Hospital Preparedness Program. “They were pretty scattered.”

Texas and Louisiana are using a regional approach as the basis for their disaster planning, with Texas forming 22 cooperative “regional” hospital planning groups and Louisiana forming nine. The groups were created during the first year of bioterrorism-training funding.

Hilliard said the TDH has looked at every licensed hospital facility in Texas, whether it was acute care, specialty, military, VA, or psychiatric. “Every hospital is going to be a resource and is going to have some level of preparedness,” he said. “People will go to what is most familiar to them.”

The groups, which use a national Centers for Disease Control and Prevention model for guidance, are asked to meet at least once a quarter to develop and maintain plans and coordinate preparedness activities.

“Every hospital is set up to handle contagious disease outbreak,” Hilliard said. “The question is, can they handle one? For crowd control involving hundreds of people, we even thought in terms of a lockdown. But one hospital in Texas didn’t even have locks on its doors.”

In preparation, Memorial Hermann Hospital in Houston has installed a standing decontamination unit with three showerheads, which drains into an independent holding tank, said Richard Bradley, MD, medical director of the Emergency Center at Memorial Hermann and an associate professor of emergency medicine at UTHSC-Houston.

The unit, which has already been used for petrochemical decontamination, has a mask plugged into the wall so caregivers can breathe clean air while they are decontaminating.

Some hospitals, such as Parkland Health & Hospital System in Dallas, also have outdoor showerheads for decontamination.

In part as an offshoot of the Canadian SARS outbreak, Memorial Hermann and other hospitals throughout the state are stressing “cough etiquette,” where patients are asked to cough into tissues and dispose of them in no-touch containers, Bradley said.

Another adjunct concern, Bradley said, is the Occupational Safety and Health Administration’s Hazardous Waste Operations and Emergency Response standard, which requires that hospital workers be trained at first-responder level if they are expected to provide even limited decontamination. Such training determinations should be based on worst-case scenarios, according to OSHA.

“Every hospital has to have a team available to comply with this unfunded federal mandate,” Bradley said.

New training

To meet qualifications for licensure, RNs and LVNs in Texas must complete at least two hours of bioterrorism training. The classes are required by all Texas nurses seeking licensure after June 1 and for all nurses who will seek licensing renewal in the state after that.

“We have 200,000 RNs and LVNs in the state of Texas and this whole issue of bioterrorism has come about since most have graduated,” said Deanna Grimes, RN, DRPH, FAAN, an associate nursing professor at the UTHSC-Houston School of Nursing.

UTHSC-Houston leads an alliance of five UT system schools that are training nurses for disasters through the Texas Statewide Bioterrorism Continuing Education program, which was funded by a two-year, $3.6 million federal grant awarded late last year.

UT officials say they hope to train 20,000 health care workers in the next two years at five campus locales statewide. Some training also will take place at remote sites, including hospitals.

The mandatory two-hour courses, which cost just $15, cover identification of patients infected by biological agents and viral agents such as inhalation/subcutaneous anthrax, botulism, smallpox, monkey pox, ricin, and SARS, as well as decontamination, personal protective equipment, and reporting protocol.

“For example, each facility has a contact person who, if she runs into botulism, should contact the epidemiologist who will contact the TDH and then the CDC,” said Candiance Duplessis, site coordinator for continuing education classes for the UTHSC-Houston School of Nursing.

More than $60 million is filtering down from the U.S. Health Resources and Services Administration to the Texas Department of Health over three years, in addition to other smaller state and federal grants. Louisiana received about $10 million from HRSA for its first two years and is awaiting word of its third-year grant denomination.

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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