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The [US] Nunn-Lugar-Domenici Defense Against Weapons of Mass Destruction (WMD) Act (the WMD Act of 1996) heralded a new wave of spending by the federal government on counter-terrorism efforts. Between 1996 and 2000, the United States of America (US) federal government allocated large sums of funding to the States for bioterrorism preparedness. Distribution of these funds between institutions involved in first-responder care (e.g., fire and safety departments) and hospitals was uneven. It is unknown whether these additional funds had an impact on the level of hospital preparedness for managing mass casualties involving hazardous materials at the local level, including potential terrorist attacks with chemical agents. (1) To compare 1996 and 2000 measures of preparedness among hospitals of a major US metropolitan area for dealing with hazardous material casualties, including terrorism that involved the use of weapons of mass destruction; and (2) To provide guidance for the improvement of emergency preparedness and response in US hospitals. In July 1996 and again in July 2000,21 hospitals in one major US city were surveyed by questionnaire. A survey was used to assess the amounts of antidote stocks held available for treatment of casualties caused by toxic chemical agents and institutional response capabilities including the number of showers for decontaminating patients, the level of worker protection, and the number of staff trained to decontaminate patients. Hospital preparedness for treating and decontaminating patients exposed to toxic chemical agents was inadequate in 1996 and in 2000. From 1996 to 2000, there was no statistically significant change in the lack of hospital preparedness for stocking of nerve agent and cyanide antidotes. Capacity for decontamination of patients, which included appropriate hazardous material infrastructure and trained staff, generally was unimproved from 1996 to 2000 with the exception of an increase of nearly 30% in hospitals with at least one decontamination shower facility. Hospitals surveyed in this study were poorly prepared to manage chemical emergency incidents, including terrorism. This lack of hospital preparedness did not change significantly between 1996 and 2000 despite increased funds allocated to bioterrorism preparedness at the local level.
July – September 2003 Prehospital and Disaster Medicine
Hazardous materials (HazMat)
Emergencies and Chemical Terrorism
The public health threat of terrorism
using weapons of mass destruction
(WMD-T), involving nuclear, bio-
logical or chemical weapons has
become increasingly real.
1996 to 2000, the National Response
Introduction:The [US] Nunn-Lugar-Domenici Defense Against Weapons
of Mass Destruction (WMD) Act (the WMD Act of 1996) heralded a new
wave of spending by the federal government on counter-terrorism efforts.
Between 1996 and 2000, the United States of America (US) federal gov-
ernment allocated large sums of funding to the States for bioterrorism pre-
paredness. Distribution of these funds between institutions involved in
first-responder care (e.g., fire and safety departments) and hospitals was
uneven. It is unknown whether these additional funds had an impact on the
level of hospital preparedness for managing mass casualties involving haz-
ardous materials at the local level, including potential terrorist attacks with
chemical agents.
Objectives:(1) To compare 1996 and 2000 measures of preparedness among
hospitals of a major US metropolitan area for dealing with hazardous mate-
rial casualties, including terrorism that involved the use of weapons of mass
destruction; and (2) To provide guidance for the improvement of emergency
preparedness and response in US hospitals.
Methods:In July 1996 and again in July 2000, 21 hospitals in one major US
city were surveyed by questionnaire.A survey was used to assess the amounts
of antidote stocks held available for treatment of casualties caused by toxic
chemical agents and institutional response capabilities including the number
of showers for decontaminating patients, the level of worker protection, and
the number of staff trained to decontaminate patients.
Results:Hospital preparedness for treating and decontaminating patients
exposed to toxic chemical agents was inadequate in 1996 and in 2000. From
1996 to 2000,there was no statistically significant change in the lack of hos-
pital preparedness for stocking of nerve agent and cyanide antidotes.
Capacity for decontamination of patients, which included appropriate haz-
ardous material infrastructure and trained staff, generally was unimproved
from 1996 to 2000 with the exception of an increase of nearly 30% in hos-
pitals with at least one decontamination shower facility.
Conclusion: Hospitals surveyed in this study were poorly prepared to man-
age chemical emergency incidents, including terrorism. This lack of hospi-
tal preparedness did not change significantly between 1996 and 2000 despite
increased funds allocated to bioterrorism preparedness at the local level.
Keim ME,Pesik N,Twum-Danso NAY:Lack of hospital preparedness for
chemical terrorism in a major US city: 1996–2000. Prehosp Disast Med
1.Department of Emergency Medicine,
Emory University of Medicine, Atlanta,
Georgia USA,Tulane University School of
Public Health and Tropical Medicine, New
Orleans, Louisiana USA; Johns Hopkins
University School of Medicine, Baltimore,
Maryland USA
2.Department of Emergency Medicine,
Emory University School of Medicine,
Atlanta, Georgia USA
3.Department of Family and Preventive
Medicine, Emory University School of
Medicine, Atlanta, Georgia USA
Mark E. Keim, MD
141 Chantilly Lane
Lawrenceville, GA 30043 USA
Keywords: antidotes; decontamination;
disaster medicine; emergency depart-
ment; hazardous materials; hospital
preparedness; mass casualties; personal
protection equipment; public health
preparedness; terrorism; weapons of
mass destruction
COBRA = US Consolidated Omnibus
Reconciliation Act
HazMat = hazardous materials
HAZWOPER = Hazardous Waste
Operations for Emergency Response
JCAHO = Joint Commission on
Accreditation of Healthcare
OSHA = Occupational Safety and
Health Administration
PPE = personal protective equipment
US = United States of America
WMD = weapons of mass destruction
WMD-T = terrorism using weapons of
mass destruction
Web publication: 15 March 2004
Lack of Hospital Preparedness for Chemical
Terrorism in a Major US City: 1996–2000
Mark E.Keim, MD;
Nicki Pesik,MD;
Nana A.Y.Twum-Danso,MD,MPH
194 Hospital Preparedness for Chemical Terrorism
Prehospital and Disaster Medicine Vol.18,No.3
treat at least one HazMat-contaminated patient.
However, WMD-T, by definition, has the potential to
create mass casualties that are likely to exceed the capacity
of any one-hospital service area. Therefore, hospital pre-
paredness for chemical emergencies resulting from WMD-
T also must include a contingency for mass casualties.
Effective preparedness and response also must employ a
more comprehensive approach to include community-wide
coordination among healthcare facilities and the public
safety community.
Preparedness efforts must match emergency needs on
the basis of realistic expectations of hospital inventories
and surge capacity. Surge capacity may include the need for
stockpiling drugs and medical supplies.
Wetter and col-
leagues defined hospital preparedness within the context of
a WMD-T scenario involving 50 casualties. Indicators of
preparedness were based upon stocking drug supplies that
include nerve-agent antidotes, as well as “resource pre-
paredness”.Resource preparedness includes the presence of
a HazMat plan and the availability of at least one HazMat
shower, one OSHA Level-B breathing apparatus, and one
chemical protective garment.
Emergency treatment of chemical casualties involves two
primary interventions: (1) patient decontamination; and (2)
antidote therapy. Both have been reported as critical for a
hospital response to chemical emergencies.
In the
present study, these same two interventions were defined as
measures of hospital preparedness. For comparison, hospital
preparedness was quantified in terms similar to those of
Wetter and colleagues, i.e., capacity to manage at least 50
However, both intentional and unintentional
chemical releases have the potential to create many more
casualties than the conservative thresholds selected for this
study. For example, the methyl-iso-cyanate poisonings in
Bhopal injured an estimated 30,000 persons.
The purpose of this study was to determine if there was
any change in hospital preparedness for WMD-T in a
major US metropolitan area after the enactment of the
WMD Act of 1996, which enabled an increase in federal
spending on bioterrorism preparedness in the US.
Decontamination preparedness was defined for each hospi-
tal as the collective presence of: (1) at least one on-site
decontamination shower facility; (2) at least one set of per-
sonal protective equipment (PPE) to include OSHA Level-
B protection or higher; and (3) hospital staff training in the
tenets of HazMat emergency response to afford staffing
availability of at least three trained workers per any given
eight-hour shift (approximated >10 trained workers per hos-
pital for the purposes of this study). Antidote preparedness
was defined as the stocking of at least 300 mg of atropine,
100 g of 2-pralidoxime (2-PAM), and 50 cyanide antidote
kits, based upon current recommendations for the treatment
of 50 moderately intoxicated patients.
The commercially
available cyanide antidote kit includes triple drug therapy
(amyl nitrate, sodium nitrite, sodium thiosulfite).
In July 1996, before passage of the WMD Act of 1996,and
again in July 2000, a one-page, seven-question survey was
distributed by mail to hospital emergency department
Center, a United States of America (US) Coast Guard
clearinghouse for federal interagency monitoring of haz-
ardous materials (HazMat) release events, reported 102
incidents involving terrorist events associated with
HazMat that did not result in an environmental release of
HazMat is defined as substances dangerous to
life and health. The US Nunn-Lugar-Domenici Defense
Against Weapons of Mass Destruction Act (the WMD
Act of 1996) galvanized federal efforts to combat terror-
ism.Since then,federal spending to counter terrorism from
1996 to 2000 amounted to more than US$36 billion,divid-
ed among 23 major federal departments and agencies.
In 2001, the US Congress allocated US$1.1 billion to state
public health departments for bioterrorism preparedness
for the fiscal year 2002. However, federal programs for
countering terrorism have been criticized for being based
upon a less-than-complete analysis of credible threats or
The US population is at significant risk for HazMat
emergencies involving both intentional and unintentional
exposures to toxic chemicals.
One survey of hospital
safety officers revealed that 47% of responding hospitals
had received at least one chemically contaminated patient
during 1994; the median was two patients.
During the
1996 to 2000 period, the National Response Center docu-
mented 120,076 events involving release of HazMat in the
United States.
The character of HazMat risk also has
changed in the wake of recent acts of terrorism.Emergency
responders, including both law enforcement and emer-
gency medical services care providers, not only are poten-
tial victims, but also potential targets.
Hospital Preparedness for HazMat Emergencies and
Chemical Terrorism
Preparedness to reduce loss of life from any HazMat inci-
dent, including those involving a biological or chemical
weapon, depends upon the availability of local resources.
Therefore, prevention of mortality is critically dependent
on hospital preparedness at the local level.The standards of
the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) and the regulations of the
Occupational Safety and Health Administration (OSHA)
for participation in HazMat incident emergency response
plans, require hospital emergency departments to have
emergency procedures that describe the specific precau-
tions, procedures, and protective equipment used during
HazMat waste spills or exposures
Unfortunately, hos-
pital preparedness for chemical emergencies and disasters is
often reported as inadequate.
Indicators of Hospital Preparedness for Chemical Disasters
Prior studies have defined preparedness according to two
basic criteria: (1) the ability to treat one chemically conta-
minated patient;
or (2) the ability to treat mass casual-
Criteria for the former scenario are based upon
the premise that every hospital should have the minimum
capability to treat at least one or two contaminated
patients, which is the number of victims in most HazMat
The JCAHO accreditation also is based
upon the requirement of hospital preparedness to be able to
July – September 2003 Prehospital and Disaster Medicine
Keim et al 195
Hospital preparedness was insufficient for nerve-agent
emergencies during both 1996 and 2000 (Table 1).
Although hospital atropine stocks were adequate on a city-
wide basis, no single hospital had at least 300 mg of
atropine in stock in 1996, whereas in 2000, only one hos-
pital met this criterion (4.8%). Citywide inventories of the
co-therapeutic 2-PAM were insufficient to match the
atropine stocks in both 1996 and 2000; thus limiting the
total number of treatments citywide to 662 in 1996 and
313 in 2000. Only 23.8% of hospitals had at least 100 mg
of 2-PAM in 1996 compared to 4.8% in 2000. Of note, no
single hospital had at least 300 mg of atropine and 100 g of
2-PAM. There were no statistically significant changes in
2000 from the 1996 mean inventories of nerve-agent anti-
dotes: atropine (p = 0.74) and 2-PAM (p = 0.18).
There also was inadequate hospital preparedness for
cyanide emergencies. There were a total of 276 cyanide
antidote kits in the city in 1996 compared to 35 in 2000. In
1996, two hospitals met the minimum criterion of 50 or
more cyanide-antidote kits in inventory, whereas by 2000,
the inventory of cyanide antidote kits in the 21 hospitals
ranged from zero to four.
To perform HazMat decontamination safely and effec-
tively, it first is necessary that each hospital have all three
components of one complete system in place: PPE, train-
ing,and showers.In 1996, 10 of the 21 hospitals (47%) had
a complete system. By 2000,this had only increased by one,
to 11 out of the 21 hospitals (52%). During both 1996 and
2000, a minority (20% and 24% respectively) of hospitals
provided adequate PPE for hospital staff to wear during
HazMat decontamination. However, a majority (67% and
91%) of these same hospitals reported offering some staff
training involving emergency decontamination (Table 2).
There was a statistically significant increase of 28.6% in
directors of 21 hospitals in the greater metropolitan area of
one major US city with a population of approximately 4
million people. Respondents were emergency department
directors and hospital pharmacy directors. Follow-up
reminders were made using telephone calls and facsimile
10 to 14 days after the initial contact.
Results of the survey were analyzed using SAS System
for Windows Version 8.2 (SAS Institute, Cary, North
Carolina USA). The 1996 data were compared with the
2000 data using a paired analysis. In addition, university
affiliation and the annual census of the emergency depart-
ment were evaluated as possible predictors of the level of
hospital preparedness. The continuous data (atropine and
2-PAM) were found to be non-parametric, even after log
transformation, and thus, were compared using the
Wilcoxon signed rank test for paired data and the
Wilcoxon rank sum test for independent samples. The
remaining variables (cyanide kits, HazMat showers,
HazMat PPE, trained staff, and isolation plan) were cate-
gorized and analyzed using the McNemar’s test when the
data were paired, and the Fishers Exact test when inde-
pendent samples were compared.
All 21 questionnaires distributed were returned by mail,
fax, or e-mail. The response rate for every question was
100% in 2000,but varied from 71% to 96% for 1996 except
for the question related to hospital isolation plans, which
had a response rate of 52% in 1996.
The mean and median values for the 1996 annual emer-
gency department census for all 21 hospitals were 39,290
and 34,518 patients, respectively. The range of emergency
department censuses was 13,050 to 105,315. Nine of the
21 hospitals were affiliated with universities.
Antidote 1996 2000 p-value
Amount (g)
Total 584.298 1,213.237 NS
Average 30.753 57.773 NS
Median 0.5 0.25 NS
Range 0–261.4 0.02–1,116 NS
Total number of emergency treatments 97,383 202,206 NS
Hospitals with at least 300mg (%) 0 4.8 NS
Amount (g)
Total 1,323 625 NS
Average 66.15 29.762 NS
Median 6 6 NS
Range 0–600 0–384 NS
Total number of emergency treatments 662 313 NS
Hospitals with at least 100g (%) 23.8 4.8 NS
Cyanide antidote kits
Total number 276 9.5 NA
Hospitals with at least 50 (%) 35 0 NA
Prehospital and Disaster Medicine © 2003 Keim
Table 1—Comparison of citywide antidote stocks between 1996 and 2000 (NS = not significant statistically; NA = not
Prehospital and Disaster Medicine Vol.18,No.3
196 Hospital Preparedness for Chemical Terrorism
care for patients that arrive to the hospital in a contami-
nated state.
A coordinated national strategy likely would improve
community-based hospital capabilities to meet the chal-
lenges of modern chemical emergencies. This strategy
should include: (1) education of hospital administrators
and care providers; (2) enforcement of existing HazMat
laws and regulations;(3) engineering controls that facilitate
safe and effective hospital-based HazMat responses; (4)
economic incentives for development of hospital prepared-
ness; and (5) enhancement of community coordination,
planning, and communication.
1. Education
The need for continuing medical education on clinical tox-
icology is obvious. However, HazMat decontamination is
not commonly taught to hospital-based emergency care
providers. Training is needed to familiarize and train hos-
pital-based care providers in the basic principles and pro-
cedures of HazMat decontamination, along with the
important associated principles of occupational health and
personal protection. At a minimum, all hospital emergency
department staff should be trained and assisted in main-
taining up-to-date certification to the Hazardous Waste
Operations for Emergency Response (HAZWOPER)
First Responder: Awareness Level”.
Personnel who
actually are likely to be involved in a decontamination
operation, must be trained to the First-Responder:
“Operation Level”.
Such certification of capabilities
should be linked to specialty training, board examination,
hospital privileges, and continuing medical education
Hospitals also would benefit from public health educa-
tion regarding the selection and maintenance of a local
stockpile of pharmaceutical antidotes based upon an
assessment of the vulnerability of the hospital and the haz-
ard profile of the community.
2. Enforcement
Both the US OSHA and the Environmental Protection
Agency have established regulations to help protect work-
ers dealing with hazardous waste and emergency opera-
tions. Title III of the US Superfund Amendments and
Reauthorization Act of 1986 (SARA Title III) directed
OSHA to establish a comprehensive rule to protect
employee health and safety during emergency responses to
the release of hazardous substances. Accordingly, OSHA
published the HAZWOPER standard (Title 29 Code of
Federal Regulations (CFR) 1910.120), which requires
employers, including hospitals, to plan for emergencies
involving hazardous substances that they expect their
employees to handle. An emergency department whose
staff has not received appropriate training and personal
protective equipment would be in violation of OSHA stan-
dards 29 CFR 1910.120, 1910.1200, 1910.132, and
The US Consolidated Omnibus Reconciliation Act
(COBRA), 42 U.S.C., Section 1395(d) requires that every
individual presenting to an emergency department must
receive a medical screening examination. Choosing not to
the number of HazMat showers available from 1996 (n =
16) to 2000 (n = 27), but there were no statistically signif-
icant changes in the other decontamination capacities of
availability of sufficient numbers of PPE and adequately
trained staff.
To minimize the potential for exposure of hospitalized
patients to an airborne chemical terrorist attack that may
occur outside of the hospital, but close enough to represent
a threat, hospitals must have the ability to comply with
population protection measures. One common element of
population protection involves shelter-in-place measures in
which persons are recommended to stay inside their build-
ings with the air inputs from external air sources shut
down. In 1996, none of the 11 respondents had an emer-
gency plan for isolation of external air sources. By 2000,
five of 21 respondents (24%) had developed such a plan.
In 1996, but not in 2000, there were statistically signifi-
cant differences between the five university-affiliated and
the 16 non-university-affiliated hospitals for stocks of
atropine,2-PAM, and cyanide antidote kits.University affil-
iation did appear to be associated with a better institutional
capability for decontamination compared to non-university-
affiliated hospitals.This appeared to be true during 1996 and
2000 for both PPE availability and staff training (data not
The nine hospitals with an annual emergency depart-
ment census of >40,000 were compared with the 12 hospi-
tals with 40,000 visits per year. There were no statistically
significant differences between these groups with respect to
both antidote preparedness and decontamination prepared-
ness for both 1996 and 2000 (data not shown).
Many US hospitals depend upon their local Metropolitan
Medical Response System team or fire departments to pro-
vide patient decontamination; however, most contaminated
victims receive decontamination at the hospital, and not in
the field.
In one six-year review of 72 chemically exposed
patients presenting to a community hospital emergency
department, none had received prehospital decontamina-
Hospitals must be prepared to receive, triage, and
Decontamination Capacity 1996 2000 p-value
Showers available
% hospitals with 1 57.1 85.7 0.01
Personal Protective Equipment
% hospitals with
Level-A or B protection 20.0 23.8 NS
Staff Training
% hospitals with some
training 66.7 90.5 NS
% hospitals with >10
trained staff 30.0 47.6 NS
Isolation Plan
% hospitals with plan 0 23.8 NA
Prehospital and Disaster Medicine © 2003 Keim
Table 2—Comparison of HazMat infrastructare between
1996 and 2000 (NS = not significant statistically; NA= not
July – September 2003 Prehospital and Disaster Medicine
Keim et al 197
hospital preparedness for chemical emergencies and terror-
ism also could have a positive impact.
Federal legislation also should address compensation for
hospitals that experience mass-casualty incident. The
Stafford Act, which provides the authorization and frame-
work for federal assistance by the Federal Emergency
Management Agency, has proven to be an unreliable source
for hospitals in communities experiencing disasters.
Stafford Act is more attuned to providing funds for proper-
ty damage than for the added costs or lost revenues, accom-
panying the delivery of disaster-related health services.
Federal and state governments may consider providing eco-
nomic incentives for hospitals that implement engineering
controls, as described above, that would be effective during
chemical emergencies.
5. Enhancement of Community-based Coordination
Some authors suggest that it is not necessary for every
hospital in a community to have the ability to treat conta-
minated patients.
In their opinions, one hospital with
tertiary-care resources should be designated as a deconta-
mination facility. Unfortunately,this concept may be based
on the following false assumptions:
1. All (or even a majority) of the contaminated patients
will be decontaminated at the scene of exposure;
2. All of the patients involved in a HazMat incident only
will go to certain designated hospitals (and not the clos-
est one);
3. Contaminated victims presenting to non-designated
hospitals can be transferred safely to appropriate insti-
tutions without endangering patients or ambulance
staff; and/or
4. The non-designated hospitals would not incur a viola-
tion of the COBRA laws for not offering medical
screening of contaminated victims.
Instead, all hospitals in a community should plan
together for mass casualty contingencies. Hospital pre-
paredness should expand from planning within the context
of a single hospital organization to planning by the hospi-
tal to become part of a community-wide initiative to
address mass casualties.”
Every hospital should have the
capability at the minimum to treat at least one or two con-
taminated patients, which is the number of victims in the
majority of HazMat incidents.
Large-scale, multi-
casualty incidents would make HazMat preparedness diffi-
cult for most hospitals.
In this event, it would be in the
best interest of the community to coordinate the varying
levels of hospital HazMat capabilities in a manner similar
to current trauma-care systems.
Study Limitations
The study design of comparing data from two cross-sec-
tional surveys has one important, inherent limitation;
namely, it was not possible to measure variations in antidote
stock during the calendar year, which may or may not have
been significant. However, since successful terrorist attacks
by definition are unpredictable, one could argue that it is
just as important to be prepared on any given day as it is in
a given month. Thus, a cross-sectional design, as employed
in the present study, may provide valuable insight.
provide care to a contaminated individual, due to a lack of
HazMat preparedness, is a potential COBRA law violation.
Finally, the Joint Commission on Accreditation of
Healthcare Organization (JCAHO), which develops hos-
pital accreditation standards for more than 17,000 US hos-
pitals, also has established specific HazMat preparedness
guidelines for hospitals.
Enforcement of already existing legislation and guide-
lines likely would contribute to improving hospital pre-
paredness for HazMat decontamination, PPE, and training.
3. Engineering Controls
Some of the challenges facing hospitals on the safe treat-
ment of HazMat exposures may be mitigated by engineer-
ing controls.Hospitals should have controlled access points
to prevent contaminated patients from entering prior to
decontamination. Design and construction of decontami-
nation shower facilities can accommodate placement of
warm water lines and shower nozzles on the building exte-
rior. Controls for dirty water run-off may be installed using
exterior collection drains. Access fittings for medical gases
on the building exterior also would facilitate use by emer-
gency responders when utilizing supplied-air respirators.
Design of hospital ventilation systems should consider the
potential need to isolate the internal hospital environment
from a contaminated outdoor plume or toxic cloud.
Hospitals also could design emergency departments to bet-
ter serve the surge in demand common to mass-casualty
4. Economic Incentives
Hospitals currently have few incentives for maintaining a
complete system for safe treatment of chemical casualties.
For example, there is no code in the International
Statistical Classification of Diseases and Related Health
Problems (ICD-9) that allows a hospital to bill for the
decontamination of a patient with HazMat exposure.This
lack of reimbursement exists in spite of the highly techni-
cal equipment and procedures needed to detect and treat
HazMat exposures. This appears inconsistent when com-
pared to other highly technical procedures performed at
the hospital (i.e., surgery) For example, both surgical and
HazMat procedures require a highly trained and coordi-
nated group of health professionals that must work as a
team to perform time-critical, life-saving interventions;
both procedures require specialized facilities and PPE for
worker safety; and both may be associated with significant
medico-legal and occupational liability.
Even though chemical releases may be relatively com-
mon throughout the US as a whole, the probability of a
mass-casualty event occurring at any one hospital is low.
However,this low probability event also may have an enor-
mous societal impact. Federal assistance should promote
hospital preparedness for the sake of national public health,
especially in consideration of the individual institutional
burden of preparing for these low-probability, high-impact
events. Federal environmental legislation (SARA Title III)
has been reported to improve planning by the healthcare sec-
tor for emergencies caused by environmental chemical expo-
One may expect that federal legislation relative to
Prehospital and Disaster Medicine Vol.18,No.3
198 Hospital Preparedness for Chemical Terrorism
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With regard to HazMat infrastructure and staff train-
ing, it is unlikely that this study design would have made
similar assumptions, since these factors require substantial
financial investment from the hospital, and thus, may not
be as subject to monthly variations.
Another potential limitation of this study is that the
results may not be able to be generalized to the entire US
population,since this study involved only one metropolitan
area. However, descriptive studies of antidote and HazMat
preparedness also have reported similar findings in numer-
ous cities throughout the US during the same time period
under investigation.
The hospitals surveyed in this study were poorly prepared to
manage chemical, mass-casualty events, including terrorism.
This lack of hospital preparedness for chemical emergencies
did not appear to change significantly between 1996 and
2000 in spite of an increasing threat for chemical terrorism
and increased funding for bioterrorism preparedness at the
local level. A coordinated national strategy for development
of community-based hospital capabilities is suggested to
meet the challenges of modern chemical emergencies. This
strategy would include: (1) education of hospital administra-
tors and care providers;(2) enforcement of existing HazMat
laws and regulations; (3) engineering controls that facilitate
safe and effective hospital-based HazMat response; (4) eco-
nomic incentives for development of hospital preparedness;
and (5) enhancement of community coordination, planning
and communication.
In 2001, after the terrorist events in the US in which
hijacked aircrafts and aerosolized anthrax were used as
weapons of mass destruction, the US Congress allocated
US$1.1 billion to state public health departments for
bioterrorism preparedness in fiscal year 2002. It is hoped
that, in light of the heightened awareness and real threat
generated by these events, hospital preparedness would
have improved since then. The authors currently are
preparing a follow-up study to measure any changes in pre-
paredness that may have occurred since then.
M. Keim planned this study and was responsible for man-
uscript preparation and data interpretation. N. Pesik was
responsible for data collection. N. Twum-Danso was
responsible for data analysis and data interpretation.
The authors express a sincere debt of gratitude to the fol-
lowing for assistance rendered: Erik Auf der Heide, MD,
MPH; Richard Brennan, MD, MPH; Miguel Cruz,
MPH, USPHS; and Scott Lillibridge, MD, USPHS.
July – September 2003 Prehospital and Disaster Medicine
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... Keim et al found that hospitals in a major city in the United States were insu ciently prepared to address emergencies that involve nerve agents and cyanide poisoning. (26) Similar to the present ndings, the availability of adequate amounts of antidotes like atropine, pralidoxime, and diazepam in hospitals have also been reported by studies that have been conducted in the United States and Belgium. (10,27) However, Eliseo et al found that these compounds were unavailable in hospitals. ...
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Objectives Chemical, biological, radiological, and nuclear (CBRN) incidents are those that involve chemical or biological warfare agents or toxic radiological or nuclear materials. These agents can cause disasters intentionally or accidentally. Hospitals play a crucial role in handling CBRN disasters. This study aimed to assess the CBRN preparedness of government hospitals in Riyadh.MethodsA descriptive cross-sectional study was conducted across government hospitals in Riyadh, all government hospitals in Riyadh with more than 100 inpatient beds and an emergency department met the inclusion criteria. Hospital preparedness was assessed using an adaptation of the CBRNE Plan Checklist. Results were described in frequencies across several domains such as foundational considerations, planning, training and awareness, procedures, and modules for preparing for a biological incident, a chemical incident, and a radiological or nuclear incident.ResultsOf the 11 eligible hospitals, 10 participated in the study. Further, CBRN considerations were included in the disaster plans of 7 hospitals. Drills had been conducted in collaboration with local agencies in only 2 hospitals. The staff had been trained to recognize the signs and symptoms of exposure to class (A) biological agents in less than half of the hospitals. A majority of the hospitals had antidotes and prophylactics to manage chemical incidents, but only half of them had radiation detection instruments. Personal protective equipment was available in all hospitals, but rapid access to stockpiles of medications was available in only half of them.Conclusion Government hospitals in Riyadh demonstrated insufficient CBRN preparedness. Therefore, their staffs should be trained to manage CBRN emergencies, and local drills should be conducted to improve their preparedness.
... Many pieces of research on chemical terrorism have been carried out on chemical weapon types [3,8], emergency response [9,10] and countermeasures [11][12][13]. Different approaches to analyze patterns and relationships of terrorist activity has been conducted by [14][15][16][17][18][19]. ...
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The chemical terrorist attack is a type of unconventional terrorism that threatens the safety of cities. This kind of terrorist attack is highly concealed and difficult to be detected. Once the attack is successful, the consequences will be severe and the scope of impact will be enormous. Therefore, public security and emergency departments need to perform risk analysis and dynamic knowledge update to reduce risk or mitigate the effects of accidents. In order to quickly and effectively analyze the risk of chemical terrorist attacks, this article proposed a hybrid approach (B-R model) to analyze the risk of chemical terrorist attacks. First, a modular and customizable Bayesian network (BN) model library was built, which can satisfy users to select multi-dimensional risk factors. Based on the personalized BN, a risk knowledge graph (RKG) is constructed with multi-source data to realize the combination of risk analysis and knowledge acquisition. Then the threat degree of terrorist organizations, the strength of defensive forces, and the risk value of targets is calculated and displayed. The BN-RKG method provides data and theoretical support for defenders’ resource allocation and emergency decision-making. Finally, a case study was conducted for a hypothetical scenario analysis. The result shows that the hybrid method can help with risk control and have the potential to support practical policymaking.
... Another reason for the low proportion was the lack of equipment, funds, staff and techniques. Unlike the detection of bacteria, which has been widely carried out in HCLs 23,24 , viral detection was not common in HCLs, especially for emerging viral infectious diseases as pH1N1 influenza 25,26 . The WHO Global Influenza Surveillance Network, one of the biggest infectious disease surveillance systems in the detection also obtained its data from PHLs rather than HCLs (the National Influenza Center and sentinel laboratories in each country) 27, 28 . ...
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Most hospital clinical laboratories (HCLs) in China are unable to perform influenza virus detection. It remains unclear whether the influenza detection ability of HCLs influences the early identification and mortality rate of influenza. A total of 739 hospitalized patients with 2009 influenza A (H1N1) virus treated at 65 hospitals between May and December, 2009, in Zhejiang, China, were included based on identifications by HCLs and by public health laboratories (PHLs) of the Centers for Disease Control and Prevention. Of the patients, 407 (55.1%) were male, 17 died, resulting in an in-hospital mortality rate of 2.3%, and 297 patients were identified by HCLs and 442 by PHLs. The results indicated that a 24-hour delay in identification led to a 13% increase in the odds of death (OR = 1.13, P < 0.05). The time between onset and identification (3.9 days) of the HCL cohort was significantly shorter than that of the PHL cohort (4.8 days). The in-hospital mortality rate of the HCL group was significantly lower than that of the PHL group (1.0% vs. 3.2%, P < 0.05). HCL-based detection decreased the in-hospital mortality rate by 68.8%. HCL-based influenza virus detection facilitated early identification and reduced influenza mortality, and influenza detection ability of HCLs should be strengthened.
Introduction Physicians’ management of hazardous material (HAZMAT) incidents requires personal protective equipment (PPE) utilization to ensure the safety of victims, facilities, and providers; therefore, providing effective and accessible training in its use is crucial. While an emphasis has been placed on the importance of PPE, there is debate about the most effective training methods. Circumstances may not allow for a traditional in-person demonstration; an accessible video training may provide a useful alternative. Hypothesis Video training of Emergency Medicine (EM) residents in the donning and doffing of Level C PPE is more effective than in-person training. Null Hypothesis Video training of EM residents in the donning and doffing of Level C PPE is equally effective compared with in-person training. Methods A randomized, controlled pilot trial was performed with 20 EM residents as part of their annual Emergency Preparedness training. Residents were divided into four groups, with Group 1 and Group 2 viewing a demonstration video developed by the Emergency Preparedness Team (EPT) and Group 3 and Group 4 receiving the standard in-person demonstration training by an EPT member. The groups then separately performed a donning and doffing simulation while blinded evaluators assessed critical tasks utilizing a prepared evaluation tool. At the drill’s conclusion, all participants also completed a self-evaluation survey about their subjective interpretations of their respective trainings. Results Both video and in-person training modalities showed significant overall improvement in participants’ confidence in doffing and donning PPE equipment (P <.05). However, no statistically significant difference was found in the number of failed critical tasks in donning or doffing between the training modalities (P >.05). Based on these results, the null hypothesis cannot be rejected. However, these results were limited by the small sample size and the study was not sufficiently powered to show a difference between training modalities. Conclusion In this pilot study, video and in-person training were equally effective in training for donning and doffing Level C PPE, with similar error rates in both modalities. Further research into this subject with an appropriately powered study is warranted to determine whether this equivalence persists using a larger sample size.
Methods: A descriptive, cross-sectional study was performed. All 93 Dutch hospitals with an emergency department (ED) were sent a link to an online survey on different aspects of CBRN preparedness. Besides specific hospital information, information was obtained on the hospital's disaster planning; risk perception; and availability of decontamination units, personal protective equipment (PPE), antidotes, radiation detection, infectiologists, isolation measures, and staff training. Results: Response rate was 67%. Sixty-two percent of participating hospitals were estimated to be at-risk for CBRN incidents. Only 40% had decontamination facilities and 32% had appropriate PPE available for triage and decontamination teams. Atropine was available in high doses in all hospitals, but specific antidotes that could be used for treating victims of CBRN incidents, such as hydroxycobolamine, thiosulphate, Prussian blue, Diethylenetriaminepentaacetic acid (DTPA), or pralidoxime, were less frequently available (74%, 65%, 18%, 14%, and 42%, respectively). Six percent of hospitals had radioactive detection equipment with an alarm function and 22.5% had a nuclear specialist available 24/7 in case of disasters. Infectiologists were continuously available in 60% of the hospitals. Collective isolation facilities were present in 15% of the hospitals. Conclusion: There is a serious lack of hospital preparedness for CBRN incidents in The Netherlands. Mortelmans LJM , Gaakeer MI , Dieltiens G , Anseeuw K , Sabbe MB . Are Dutch hospitals prepared for chemical, biological, or radionuclear incidents? A survey study. Prehosp Disaster Med. 2017;32(5):1-9.
Occupational exposure to cyanide may occur during acrylonitrile production, in response to aviation fires, and in processes involving extraction of gold from ores. Occupational exposure to cyanide presents two distinct problems related to different outcomes: the prevention of acute lethal exposure and the prevention of chronic effects that are primarily manifestations of mucosal irritation, together with varying degrees of low-level neurotoxicity. Cyanide salts are relatively more common in industrial use but are only found in certain industries and processes such as electroplating, as described in this chapter. Toxicity from cyanide among firefighters is likely to occur in the context of a mixed exposure with combined and possibly interactive effects. Cyanide exposure is possible in the setting of hazardous materials (hazmat) response, including intentional use of toxic agents in terrorist acts. The cyanide is readily available through illegal mining activities and appears to have been an improvised substitution for illegal dynamiting.
We have developed an integrated pipeline for countermeasure discovery that, under the auspices of the National Institutes of Health Countermeasures Against Chemical Threats network, is one of the few efforts within academia that by design spans the spectrum from discovery to phase I. The successful implementation of this approach for cyanide would enable efficient proof-of-concept studies that would lay the foundation for a generalizable strategy for parallel mechanistic studies and accelerated countermeasure development in the face of new and emerging chemical threats.
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Introduction: Hospitals are often considered to be the forefront of countering incidents, some of which result from a wide range of incidents including industrial accidents, natural outbreaks of disease, and regional accidents called chemical, biological, radiological, and nuclear (CBRN) accidents. This study was conducted to assess the level of preparedness, capacity, and capability of responding to CBRN incidents in teaching hospitals of Isfahan, Iran. Methods: This descriptive study was conducted in 2013-2014. The statistical population consisted of 43 managers, matrons, educational supervisors, emergency supervisors, and head-nurses in teaching hospitals (12 hospitals) of Isfahan. The participants were selected through census sampling. The data collection tool was a checklist translated by the researcher and its content validity was verified by facts and concepts provided in valid sources and by university professors and experts. Results: Except hospital A, which had a specialized emergency room for CBRN accidents, no other hospital was prepared to deal with CBRN incidents. Using the checklist, hospital A obtained the a good score in terms of preparedness and planning, employing decontamination team, warm decontamination zone, warm decontamination system, decontamination triage, and patient decontamination. It obtained a relatively good score in terms of security and access control, and medical monitoring of staff. It also acquired an average score in in hazard declaration and recovery. However, it did not obtain a good score in training and exercise, and personal protective equipment. Conclusion: None of the studied hospitals had the necessary capacity and capability to counter CBRN incidents. The emergency ward of hospital A, however, was assessed to perform well in terms of preparedness and response (score: 67%).
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Purpose: To examine hospital hazardous-materials preparedness. Methods: The safety officers of all acute-care hospitals in the five-county Philadelphia metropolitan region received surveys. Questions addressed the ability of EDs to safely decontaminate and treat chemically contaminated patients. Results: Thirty-six of 58 hospitals (62.1%) returned usable surveys. Of these, 25 (69.4%) have a written ED hazmat plan, and 11 (30.6%) conducted a drill of the plan in 1994. Nineteen (52.8%) EDs have a specific treatment area for chemically contaminated patients. A stock of supplies for protecting the ED from secondary contamination is maintained by 16 (44.4%). While 23 (63.9%) EDs store personal protective equipment, most of these involve only gowns, gloves, and surgical masks; only 12 provide any type of respiratory protection. Seven respondents were certain that patients brought in by local EMS would have been decontaminated adequately in the field, eight stated that they believed or felt decontamination would be adequate, and 12 were concerned that field decontamination might not be adequate. Seventeen hospitals (47.2%) reported treating one or more (mean = 2.4) chemically contaminated patients in 1994. We believe the return rate reflects reluctance to commit hospital policies to paper. This was confirmed during telephone follow-up of nonrespondents; for example, one safety officer discussed hazmat principles for 40 minutes, but refused to complete the survey. Conclusions: Hospital hazmat preparedness in this area varies tremendously. A significant proportion of EDs lack a written plan and equipment to allow the ED to safely and effectively handle the chemically contaminated patient. There is reluctance to discuss this topic.
The problem of protection and sheltering of hospitalized patients in wars and other national emergencies has been reviewed by many countries in recent years. Presently, there are wide differences in policies that range from full underground sheltering of hospitals as adopted by the Swiss, partially protected to almost fully protected facilities in hospitals as adopted by the Israelis, to no protection at all as in most other countries.
Since the early 1980s several disasters involving mass release of toxic substances have focused the attention of different administrations and the fire services into producing protocols and guidelines for action in civilian situations. The bomb attack in the Tokyo subway, in March 1995, made it clear that a terrorist attack using highly toxic agents is now feasible. Management of disasters in the civil sector in France is based upon two interlinked plans: the Red Plan, which covers on-site organisation, and the White Plan, which concerns the interface with hospital services. Special procedures have been developed to adapt the Red and White Plans for use in the event of toxic attack and concern the deployment of emergency responding personnel, the provision of life support and antidotes in the contaminated zone, the prevention of secondary contamination and the transport and reception of victims at the hospital. Based on the established principle of pre-hospital resuscitation and well-tried assistance plans, this doctrine allows a safe and effective response to terrorist attacks as well as to other toxic release incidents.
The potential use of chemical and biological weapons, while being banned by international treaties, has never been higher than now. The current Persian Gulf crisis, and the easy availability of these weapons by "terrorist nations," makes the danger all too real. The experience derived from the Iraqi attack on Majnoon Island demonstrates the devastating effects of these weapons when used during modern warfare. Exposure to the agents used during the 8 years of the Iran-Iraq War results in a triad of injuries: skin burns, ocular damage, and pulmonary distress. Specific antidotes are available for some agents used in warfare; however, the clinical presentation following exposure to the different toxins is extremely similar, making a bedside diagnosis of the specific agent involved almost impossible. The Majnoon Island experience has shown the value of prevention, when possible, and decontamination, of both casualties and equipment. The prompt implementation of general treatment strategies, as well as specific antidotes, are paramount for the successful management of patients after a chemical weapons attack.
A great many laws, at federal, state, and local levels, deal with hazardous materials and protective measures against them. They are not yet specific to emergency departments but many surely include the emergency workplace. For a variety of reasons (cost, concentration on AIDS, too few nurses), too many departments may not be fulfilling their legal duties to protect their personnel. Every emergency department, regardless of size, should have immediately at hand appropriate sets of toxin-protective personal equipment in sizes to suit its staff and in numbers suitable to the population it serves. The unexpected is to be expected in emergency practice. To be sure, no garments, respiratory devices, or means of disposal exist that will be fully effective against everything, but that does not excuse the legal duty to take reasonable measures, such as providing appropriate training, equipment reasonably calculated to offer protection, clear and accessible procedures, and clear avenues to further resources, including posted phone numbers for the regional poison control center and for CHEM-TREC, the 24-hour response center of the chemical industry, which can provide indispensable assistance and information (800-424-9300).
Problem/condition: A review of existing reporting systems indicated that not enough information was being collected to determine the public health consequences of emergency events involving hazardous substances. Reporting period covered: January 1990 through December 1992. Description of system: State health departments in selected states collect and each quarter transmit information about the events, substances released, and the public health consequences of hazardous substance releases (i.e., morbidity, mortality, and evacuations) to the Agency for Toxic Substances and Disease Registry (ATSDR). Five state health departments (Colorado, Iowa, Michigan, New Hampshire, and Wisconsin) began data collection on January 1, 1990. On January 1, 1992, the reporting state health departments included those from Colorado, Iowa, New Hampshire, New York, North Carolina, Oregon, Rhode Island, Washington, and Wisconsin. Results and interpretation: During 1990-1992, 3,125 events were reported from participating states to ATSDR's Hazardous Substances Emergency Events Surveillance (HSEES) system. Of these events, 2,391 (77%) were fixed-facility events (i.e., occurred at stationary facilities), and 723 (23%) were transportation related. In 88% of events, a single chemical was released. The most frequently released hazardous substances were volatile organic compounds (18% of the total 4,034 substances released), herbicides (15%), acids (14%), and ammonias (11%). In 467 events (15% of all events), 1,446 persons were injured; 11 persons died as a result of these injuries. Respiratory irritation (37%) and eye irritation (23%) were the most frequently reported health effects. A total of 457 (15%) events resulted in evacuations; of these, 400 (88%) were ordered by an official (e.g., a police officer or firefighter).(ABSTRACT TRUNCATED AT 250 WORDS)
Emergency physicians must stay alert to situations that involve toxic chemical exposures. An appropriate response to victims of chemical contamination is important for the victim's outcome and the safety of hospital personnel. Successful management of such a situation requires managing information, resources, and patients with complex medical conditions. Chemical contamination may affect one or hundreds of victims. Community planning is essential for an effective response to toxic chemical accidents (Haz-Mat).