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Abstract

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 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine
SPECIAL REPORT
Introduction
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.
1-9
From
1996 to 2000, the National Response
Abstract
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
2003;18(3):193–199.
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
Correspondence:
Mark E. Keim, MD
141 Chantilly Lane
Lawrenceville, GA 30043 USA
E-mail: mkeim@disastercare.net
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
Abbreviations:
COBRA = US Consolidated Omnibus
Reconciliation Act
HazMat = hazardous materials
HAZWOPER = Hazardous Waste
Operations for Emergency Response
JCAHO = Joint Commission on
Accreditation of Healthcare
Organizations
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;
1
Nicki Pesik,MD;
2
Nana A.Y.Twum-Danso,MD,MPH
3
194 Hospital Preparedness for Chemical Terrorism
Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol.18,No.3
treat at least one HazMat-contaminated patient.
27
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.
29
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.
33
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.
33,41-47
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
patients.
33
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.
3
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.
48
The commercially
available cyanide antidote kit includes triple drug therapy
(amyl nitrate, sodium nitrite, sodium thiosulfite).
Methods
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
materials.
10
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.
11,12
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
risk.
13
The US population is at significant risk for HazMat
emergencies involving both intentional and unintentional
exposures to toxic chemicals.
14-18
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.
14
During the
1996 to 2000 period, the National Response Center docu-
mented 120,076 events involving release of HazMat in the
United States.
10
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.
19-25
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.
26
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
27,28
Unfortunately, hos-
pital preparedness for chemical emergencies and disasters is
often reported as inadequate.
29-37
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;
34-37
or (2) the ability to treat mass casual-
ties.
29,33
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
accidents.
38-40
The JCAHO accreditation also is based
upon the requirement of hospital preparedness to be able to
July – September 2003 http://pdm.medicine.wisc.edu 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.
Results
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
Atropine
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
(6mg/adult)
Hospitals with at least 300mg (%) 0 4.8 NS
2-Pralidoxime
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
(2g/adult)
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
applicable)
Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu 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”.
28
Personnel who
actually are likely to be involved in a decontamination
operation, must be trained to the First-Responder:
“Operation Level”.
28
Such certification of capabilities
should be linked to specialty training, board examination,
hospital privileges, and continuing medical education
requirements.
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
1910.134(c).
49,50
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
shown).
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).
Discussion
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.
49
In one six-year review of 72 chemically exposed
patients presenting to a community hospital emergency
department, none had received prehospital decontamina-
tion.
43
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
applicable)
July – September 2003 http://pdm.medicine.wisc.edu 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.
52
The
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.
43,53
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.”
52
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.
38-40
Large-scale, multi-
casualty incidents would make HazMat preparedness diffi-
cult for most hospitals.
54
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.
27
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
incidents.
45
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-
sures.
51
One may expect that federal legislation relative to
Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu 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.
14,31–37
Conclusions
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.
Contributors
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.
Acknowledgements
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 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine
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