An Approach to Terrorism Preparedness:
Parkland Health and Hospital System

Background

In response to growing concerns regarding domestic terrorism, the 104th Congress passed Public Law 104-201, the National Defense Authorization Act for fiscal year 1997. In addition to providing training regarding emergency response to weapons of mass effect for the nation's first responders (law enforcement agencies, fire departments, emergency medical services, emergency planners, and healthcare personnel), this legislation required that the Secretary of Defense develop and carry out a program for testing and improving the responses of federal, state, and local agencies to emergencies involving nuclear, biological, or chemical weapons. Federal officials determined that the first phase of this ambitious nationwide effort, known as the Domestic Preparedness Program, should be concentrated in the most highly populated metropolitan areas in the United States. As such, the 120 most populated cities in the country were initially identified to receive the planning, training, and evaluative efforts of the Domestic Preparedness Program .

As the eighth-largest population center in the United States, the City of Dallas received the Domestic Preparedness Program's community-wide analysis in the fall of 1997; it examined the resources, strengths, and shortfalls in the existing municipal services and medical community. A multidisciplinary team with representation from the areas of law enforcement (the Dallas Police Department and the Dallas Division of the Federal Bureau of Investigation), fire suppression and emergency medical services (the Dallas Fire Department), City Administration (the Office of Emergency Preparedness and the Department of Water and Streets), and the medical community (Dallas City Environmental and Health Services, Dallas County Medical Examiner, Dallas County Health and Human Services, the University of Texas Southwestern Medical Center, and the Parkland Health and Hospital System) were assembled to plan, develop, and test a city-wide preparedness plan.

Over 48 months, from July 1997 to July 2001, the development of the Dallas Metropolitan Medical Response System involved the cooperation and planning of over a dozen government and community agencies. Throughout this period, the Parkland Health and Hospital System, in concert with the Dallas-Fort Worth Hospital Council, has actively participated in the development and implementation of medical community education and hospital facility preparations specific to these events. Despite the absence of a dedicated funding stream to defray the costs of personnel, education, medical supplies, and pharmaceuticals, the Parkland Health and Hospital System has been recognized as a national model for hospital preparedness efforts. A comprehensive document entitled “NBC Readiness Guidelines,” published in September 2000, details the hospital's efforts.

Defining the Problem

First, Parkland officials sought to redefine and reevaluate the catchment area of its patient population and communities of interest. This evaluation focused on the unique threats of terrorism and led to the realization that there are vulnerabilities and potential targets within the Parkland Health and Hospital System catchment area: North Central Texas is a significant population center (5.1 million people, 20% of the population of Texas); Dallas County (880 square miles, 2 million people) is a geographically large and complex, containing the City of Dallas and 22 suburban cities; Dallas-Fort Worth is an extensive transportation hub (rail, air, and motor freight); Comanche Peak nuclear power facility is within the region; Interstate 20, also within the region, serves as the major east-west corridor for the Waste Isolation Pilot Project; and multiple federal, state, and city offices and large attractions (amusement parks, sports facilities, and convention complexes) are located here.

Next, the Parkland Health and Hospital System evaluated the medical community and acknowledged both its role as a significant medical resource and its obligation to protect and preserve the health and well-being of the community in the event of a terrorist incident. Resources unique to Parkland that may assist in mitigating a terrorist event include a 940-bed county hospital; seven community-based health clinics in addition to school-based and mobile clinics; a Level I trauma and burn center; BioTel, a unified emergency medical services command and hospital notification center; the North Texas Poison Control Center; and affiliation with the University of Texas Southwestern Medical Center and the University of Texas Allied Health Sciences School.

Following this vulnerability and resource assessment, Parkland officials elected to devote personnel, time, and resources to develop, train, and periodically test and revise the hospital's response plan during a terrorist event. Representatives from the departments of Safety Management, Emergency Services, Infection Control, Pharmacy, Facilities Maintenance, Bioengineering, and Education formed a multidisciplinary team to lead this effort. The group's first task was to modify the hospital's existing disaster plan to address the unique nuances of a response to chemical, biological, or nuclear agent exposure. Professionals from a variety of departments within Parkland Health and Hospital System and University of Texas Southwestern reviewed and revised disaster plans relative to these specific agents. The departments of Radiology and Environmental Health and Safety revised plans involving radiological agents; the departments of Infection Control and Infectious Diseases revised response protocols for biological agent exposure; and Emergency Services, Emergency Medicine, and the North Texas Poison Control Center revised chemical agent exposure protocols. Key contacts, lines of communication, and treatment and isolation protocols were developed to expedite the identification, treatment, and surveillance of exposed individuals.

Defining Critical Functions

In addition to updating Parkland Health and Hospital System's disaster plans, Parkland officials identified five functions critical to event mitigation: safety and security, decontamination, acute and definitive medical care, communications, and resource procurement and management. These functions may be applicable in whole or in part, depending upon the agent used in the terrorist attack.

Safety and Security

Since terrorists may identify health care facilities as primary or secondary targets, safety and security issues are important. Among the civilian population, confusion and fear will be prominent, irrespective of their actual involvement in the incident. This will bring unprecedented numbers of victims, concerned family members, and the "worried well" to hospitals. In an incident involving weapons of mass effect, safety personnel should establish a secure perimeter around the hospital campus, controlling access by vehicle and foot traffic. This will simultaneously limit access by criminal elements and prevent contamination caused by the uncontrolled arrival of victims. Separate patient and employee entrances should be secured and maintained throughout the event, and a system of identification should be in place, allowing hospital access to “critical need” employees only.

Since the use of a weapon of mass effect is a criminal act, key information should be collected from victims. Scripted interrogation should include the time and location of the event, an estimate of the number of people involved, any unusual activities or people noticed just prior to the event, and any unusual sights, sounds, or smells just after the incident. Documentation of the prominent signs and symptoms experienced by those who have been exposed may aid in the early identification of the agent involved. Evidence collection (such as bagging of clothing samples) from victims before decontamination may yield clues to the nature of the agent. Interrogation and evidence collection should be coordinated with local police and FBI officials. Regular security sweeps of the hospital facility should be performed to look for secondary devices, the presence of unauthorized personnel, or breaches in building access.

Decontamination

To prevent contamination and subsequent closure of the hospital facility, and to ensure the safety of personnel and currently hospitalized patients, victims of nuclear or chemical attacks will usually be triaged and undergo decontamination at a central location external to the facility. (Decontamination is rarely if ever necessary for biological agent exposure.) While decontamination activities do not require medically trained personnel, the process is overseen by medical providers to perform triage (assess patient acuity) and provide stabilizing, rudimentary care as needed. Specific hospital personnel should be trained to perform decontamination activities while in appropriate personal protective equipment.

The use of specific decontamination techniques as they relate to individual nuclear or chemical agents should be based on information from law enforcement or on-scene intelligence as well as medical expertise. Personnel should be able to perform gross decontamination on non-ambulatory and ambulatory patients. Decontamination solutions and containment of runoff should be consistent with the community response plan and acceptable to the local water and sewer officials. Specific logistical issues should be clearly defined in the hospital response plan, which should include a system to identify and bag personal effects (valuables), tag and bag clothing (potential evidence in an event involving weapons of mass effect), provide gender-specific changing and decontamination corridors, and provide modesty garb. These issues should be addressed before patients enter the health care facility for medical treatment. A unified, strong presence from the Security and Public Safety department will promote cooperation and efficiency in accomplishing mass decontamination.

Acute and Definitive Medical Care

Hospital personnel should be available to respond to a mass-casualty incident as needed. As established in the response plan, a roster system should be used for mobilizing adequate numbers and types of workers. Acute-care physicians and nurses (emergency medicine, surgeons, and intensivists) will be most useful in addressing anticipated injuries and illnesses (traumatic injury, respiratory extremis, toxidromes). Infectious disease physicians should be consulted for any infection suspected to be related to a biological attack. Allied health staffing should include operating room support staff, radiology, clinical laboratory services, pharmacology, infection control, and respiratory therapy. The results of laboratory assays and foreign material removed from victims may become evidence during the investigation and prosecution of a terrorist act. Medical personnel should understand that cooperation with local law enforcement and FBI officials is critical for evidence collection and for eventual prosecution of the perpetrators of these incidents.

Hospitals may develop a defined treatment posture (for victims and currently hospitalized patients) based on their resources. Facilities should decide whether they will perform both acute and definitive victim care or acute care only with the transfer of victims to specialized facilities distant from the local incident. Hospitals may choose to accept no acute victims and instead accept transfers of stable, hospitalized patients from other facilities to free up bed capacity for victims. Patient treatment and mobilization agreements must be clearly defined by contract and response plans between hospital agencies. Planned access to ancillary, offsite facilities (schools, hotels, public halls, etc.) may expand the capacity of a hospital and may be used to perform short-term observation for masses of asymptomatic victims.

Communications

An organized and regimented system for external and internal communication is an important component of any disaster plan. External communications issues deal with the need to exchange information with local emergency management agencies and other heath care facilities; disseminate standardized, non-sensational information sound bites for the local news media; act as a clearinghouse for victim identification and acuity; and act as a public information source (providing public service announcements) about event-related issues (signs and symptoms, where to obtain medical care, etc.). Internal communications involve the need to communicate with employees concerning the nature of the event, implement the hospital disaster plan, activate the staff callback and rotation system to ensure adequate personnel, and provide critical incident stress debriefing for personnel and their families.

Resource Procurement and Management

Knowing the particular agent (chemical, biological, or nuclear) and route of exposure (inhalation, ingestion, contact), hospitals may anticipate an increased need for specific facilities, supplies, equipment, and medical expertise. The hospital response plan should include prearranged agreements with local industries and agencies, vendors, and other heath care facilities for resupply and exchange of resources in the event of an incident involving weapons of mass effect.

Hospital resources may be conveniently divided into the following groups: facilities, supplies and pharmaceuticals (single-use items), equipment (multiple-use items), and personnel.

Facilities for the treatment and/or observation of victims may include traditional hospital settings or offsite ancillary settings. Nontraditional settings may include schools, meeting halls, and hotels. Specific areas of the hospital or external, contiguous locations should be designated for activities such as triage, decontamination, biological isolation, and short-term observation. Current physical plant facilities or rapidly deployable temporary facilities may be useful in the management of large numbers of victims.

Medical supplies (single-use items such as personal protective equipment, pharmaceuticals, antiseptics, and cleaners) will be in high demand; therefore preemptive stockpiling of frequently used items may be useful. Pharmaceutical companies, medical supply vendors, and hospital exchange contracts may allow for emergency reordering when increased demand is realized. Bulk reconstitution of specific pharmaceuticals and access to military stockpiles are other options that can prevent pharmaceutical shortfalls when large numbers of victims require treatment. Prearranged contracts and agreements with vendors and nearby military facilities may allow for an uninterrupted supply of medical care items.

Equipment (multiple-use items) may be needed in increased numbers: mechanical ventilators or respiratory assist devices (for constant positive airway pressure and biphasic positive airway pressure), cardiac monitors, portable radiography units, etc. Hospitals must choose between prearranged contracts for shipping in additional equipment and transferring victims to other hospital locations within nearby states or regions with surplus equipment.

Medical personnel within the hospital may be trained and designated to respond to events involving weapons of mass effect. Personnel with key roles include physicians, nurses, respiratory and radiology technicians, safety and security officers, administrators, and public relations officers.

Ensuring the safety and security of their families may assume a high priority, preventing hospital personnel from reporting for duty. Conservatively, it may be expected that 30% to 60% of hospital personnel may not report for work during an event. This loss of personnel may be experienced in the face of overload situations and extended operations.

Staffing shortfalls should be anticipated, and a callback or rotating roster system may be devised to ensure adequate numbers of personnel. Mechanisms to preemptively credential staff from the community (retired healthcare workers, students within the medical and allied healthcare fields, etc.), service agencies (the American Red Cross, the Salvation Army, visiting nurse agencies, etc.), other hospitals (those within geographic proximity or a multi-facility healthcare network), and government agencies (National Disaster Medical Services) should be developed and operationalized.

Developing Procedures for Weapons of Mass Effect and Department-Specific Responses

Parkland Health and Hospital System has tasked key departments-Emergency Services, Infection Control, Security and Public Safety, Public Relations and Media, and Pharmacy-with specific roles and responsibilities relative to these five critical functions.

Emergency Services personnel will likely make the first determination that a terrorist use of an agent has occurred. Knowledge of the general classes of agents-including specific toxidromes, unusual clinical signs and symptoms, and unusual clusters of patients exhibiting similar signs and symptoms-should serve to alert clinicians to a potential event. Notification of hospital administration and a determination of the potential for disease spread must be made expeditiously. Triage and the need for decontamination or isolation are important early considerations. Emergency services personnel must maintain current knowledge of the initial stabilization and treatment for the most likely chemical, biological, or radiological agents. Data gathering on countywide hospital capacity, emergency transportation resources, hospital destination, hospital pre-arrival notification, and medical direction is an extremely important role fulfilled by BioTel within the Department of Emergency Services. Communications relative to area hospital capacity, patient destinations, and transport needs will be performed in cooperation with the joint information center in the City of Dallas Emergency Operations Center.

Infection Control personnel are important in biological agent identification and may define and operationalize patient isolation needs. The use of epidemiological principles to detect the attack rate, source, and likely agent should be done in cooperation with public health officials. Expansion of hospital isolation capacity, cohorting, and offsite observation facilities may be used. The facilitation of laboratory surveillance and testing is another key function. Specific identification, isolation, and treatment protocols have been developed for the four most likely biological agents known to be used by terrorist elements.

Security and Public Safety personnel may secure the hospital perimeter and limit facility access during an event. The maintenance of internal order and periodic security sweeps may be necessary to prevent unauthorized personnel from accessing the facility. Ongoing interfacing with local and federal law enforcement agencies will promote complementary activities involving intelligence gathering, evidence collection, and investigative activities. The external decontamination facility is operated through the Security and Public Safety Department with specially trained personnel. Members of the decontamination team drill periodically to maintain the requisite cognitive and psychomotor skills.

Public Relations and Media personnel may preemptively develop communications networks with local officials. Knowledgeable, predesignated spokespersons will schedule the delivery of timely, simple, accurate sound bites. As much as possible, the nature and detail of such media releases will be determined in advance. Communications will be performed in cooperation with the joint information center in the City of Dallas Emergency Operations Center. Public-service announcements may report what has happened, signs and symptoms of exposure, viable self-care options, medical care options, and assistance in locating victims. Specific instructions on where victims should go to obtain triage and treatment, perhaps at novel locations, may lessen the hospital burden. Coordination of the specific public-service announcements from all medical facilities is a critical component to ensure that a uniform message is delivered to the public.

Pharmacy personnel have preemptively determined the potential agents of exposure; determined the most efficient, effective treatment option; determined the duration of therapy; determined prophylaxis and vaccination needs; and anticipated the potential numbers of victims. Review of the current treatment standards and available generic equivalents will determine the most cost-effective manner for treating large numbers of exposed or infected individuals. The Pharmacy and Therapeutics Committee will regularly review these policies to ensure medical validity and currency with the standard of care. A cache of pharmaceuticals and pars (amounts) will be kept on hand for immediate use. Purchasing plans, funding streams, and inventory maintenance and control have been determined in advance. Additionally, a use and distribution plan, storage location, and restock mechanism are the responsibility of pharmacy personnel. Preemptive external agreements with drug wholesalers and companies will allow rapid resupply and will limit pharmaceutical shortfall when large numbers of individuals require expedient treatment.

Summary

In Dallas, as in most metropolitan areas, the medical community is exceedingly complex. The healthcare community is fractionated into a bewildering array of providers, including physician offices, clinics, urgent care centers, public health agencies, nursing agencies, and hospitals. In addition, the hospital community comprises a multitude of private and public facilities providing a range of services including basic medical and surgical care, acute and tertiary care, or services to special populations (children, veterans, etc.). Such diversity and fractionation may act as a barrier in efforts to unify and organize the medical community's approach to events involving weapons of mass effect. The absence of a single controlling healthcare authority, tenuous economics, and competitive postures further dilute the medical community's sense of ownership and responsibility as it pertains to the management and mitigation of an event involving weapons of mass effect.

An analysis of the Dallas medical community revealed that there are 25 acute-care hospitals with approximately 6,300 beds (1999 AHA Guide, Hospital Listings). Fewer than 15% of the hospitals within the Dallas-Fort Worth area have incorporated specific planning, training, and treatment policies for weapons of mass effect into their facility disaster plans (Dallas-Fort Worth Hospital Council hospital survey, 1999). City planners, public health officials, and healthcare administrators have not developed a comprehensive, community-wide medical response plan. Such a plan should incorporate the resources of all facilities within the medical community. The entire medical community must commit to organized, widespread preparative efforts. As a public service and health resource, hospitals should acknowledge their responsibility to minimize morbidity and mortality within their communities. Hospital administrators and decision makers must prepare their facilities for the pivotal role they will play in the stabilization and treatment of victims who may number in the thousands. Individual hospital characteristics, such as bed capacity, complexity of medical services, workforce sophistication, and mutual aid and contractual agreements may be used to define the roles and responsibilities of specific facilities within the context of an event involving weapons of mass effect. If preparative efforts are not widespread and comprehensive, in the event of an incident involving weapons of mass effect, a single institution working in isolation will not significantly reduce community morbidity and mortality.