If you thought handling the nation's first anthrax outbreak was confusing, just try figuring out how to prepare for whatever comes next.
Although just nine hospitals treated patients with inhalation anthrax, the disease's most threatening form, many of the nation's hospitals got their first taste of dealing with a bioterrorism attack. With often-limited guidance from federal agencies, hospitals had to figure out what symptoms to look for, whom to test, whom to treat and whom to bill for whatever services were performed.
For most hospitals this anthrax crisis is over, but it has changed forever what it means for a hospital to be prepared for a disaster. Terrorism experts believe more attacks, possibly including the use of biological or chemical agents, are likely and that the public health system is not prepared to deal with it.
The American Hospital Association said that all hospitals want to upgrade their disaster readiness. Some 77% of hospitals said they have a plan that can be used in chemical or biological attack, according to a Premier survey of 120 of its alliance members done in October. A total of 58% of hospitals said they have conducted a biological or chemical drill.
But Sen. Bill Frist (R-Tenn.), a heart transplant surgeon and leader of an effort to pass bioterrorism preparedness funding legislation, said he is convinced that most hospitals don't have bioterrorism plans. Further, he questioned the need to equip every hospital with resources for every type of disaster.
The response to biological or chemical terrorism raises a number of questions, such as what should hospitals be prepared for, how to prepare and who should pay for it.
State public health leaders said disaster planning should focus on regional strategies, while the AHA argues that every hospital should be prepared, if only at a minimum level, complete with a decontamination unit and medicine stockpile.
The Joint Commission on Accreditation of Healthcare Organization said hospitals' disaster readiness should be based on an assessment of what their needs are going to be, and every hospital may not need its own decontamination capabilities.
Bioterrorism plans developed by two prominent hospitals, 848-bed Johns Hopkins Hospital in Baltimore and 869-bed Washington (D.C.) Hospital Center, differ in their philosophy and the resources they need on hand.
"I think what the challenge is now, for everybody, is to figure out how much readiness we need for chemical and biological (disasters)," said Spencer Johnson, president of the Michigan Health and Hospital Association. "Do you need 20 people in haz-mat suits or can you get by with five or six?"
Finding the dollars
The AHA says it will cost $11.3 billion to increase the nation's 4,900 community hospitals' ability to respond to a nuclear, biological or chemical attack (See editorial, p. 17).
New federal legislation sponsored by Frist and Sen. Edward Kennedy (D-Mass.) would provide at least $375 million for hospitals to spend on bioterrorism preparedness.
Johns Hopkins is spending at least $7 million of its own money on its new bioterrorism plan, which it calls "Operation Orange." Even for a giant like Johns Hopkins, with probably as much expertise on bioterrorism response as any hospital in the country, the financial impact is tough to swallow.
"There is just no wiggle room any longer for unplanned investments," said Judy Reitz, Johns Hopkins' chief operating officer.
The AHA's plan projects spending needs at about $3 million for each metropolitan hospital and $1.4 million for each rural hospital. The estimate is based on a scenario in which 1,000 casualties come to each metro hospital and 200 are received by each rural facility.
The biggest-ticket items in the AHA plan are $750,000 per metro hospital for improvements to disease surveillance, $600,000 for a pharmaceutical stockpile to serve patients and staff for 24 hours, $500,000 for decontamination facilities, and $505,000 for personal protective equipment for staff, including self-contained breathing apparatus and chemical-resistant suits for 50 staff members.
Johns Hopkins is buying 1,000 powered air-purifying respiratory masks, which offer less protection than the breathing apparatus recommended in the AHA plan. It is also spending money to outfit an alternative triage room for its emergency department, so its main triage area can be used for patient overflow. The hospital is maintaining a 14-day supply of linen. It has increased its stock of medicine, critical-care supplies and other equipment, and has made new investments in training and education of its staff.
Washington Hospital Center will spend from $2 million to $5 million this year on all-hazards disaster preparation, including biological and chemical threats, said Michael Covert, the hospital's president. The cost could go as high as $20 million if projects such as upgrading the air-handling system and expanding the lab are undertaken, he said.
Washington Hospital Center is also leading a federally supported initiative to develop a design for an all-risks-ready emergency department. Although design specifications for "Project ER One" won't be completed for another six months, Mark Smith, M.D., the chairman of Washington Hospital Center's department of emergency medicine, said the effort may lead to the design of a facility in which waiting rooms and hallways can be quickly transformed into patient-care units. Smith said the ideal facility design may be capable of being sealed off to protect staff during a crisis, and would have information systems that enable real-time monitoring of patient symptoms related to bioterrorism.
Such a wish list means that the cost for the ultimate terrorism-ready hospital may climb even higher than the AHA's projections, and Johns Hopkins' and Washington Hospital Center's current preparations.
The role of hospitals
Hospitals, many of which have spent much of the last decade downsizing their facilities and staff, are now hearing that they need to upgrade their expertise and find the capacity to handle a surge in patients that a chemical or biological attack might bring.
Hospitals should be considered part of communities' public safety infrastructure and in some cases even part of the national security infrastructure, Smith said. He pointed out that other public safety resources-police, fire department and emergency medical service-are publicly funded, while hospitals generally aren't.
"What we are seeing is that people want to turn to their local community hospital for assistance," Reitz said.
Not only did hospitals across the country report that people came to them for diagnosis and treatment during the anthrax crisis, but in some cases people brought in suspicious substances because they looked to hospitals as the local source of expertise.
The AHA said recently that there is need for a public debate over what role hospitals should be playing in their communities.
Hospitals' current operating mode allows little flexibility in facility, staffing and supplies to suddenly and dramatically increase capacity.
"There is no excess capacity," Smith said. "A moderate-sized event could tip the system over the edge."
The confusion over what role hospitals should be playing in their community has led to an assortment of strategies of how hospitals are preparing themselves. Johns Hopkins' choice to buy 1,000 respiratory devices differs from Washington Hospital Center's approach of keeping about 50 of the systems on hand.
Frist, as well as some state health department officials, encourage a regional approach to hospital disaster planning, which is counter to the AHA's call to at least minimally equip every hospital with decontamination facilities, drug stockpiles and a stash of protective equipment.
"It would not make a lot of sense to spend a lot of money to gear up every single hospital to handle every bioterrorism event," said Louis Rossiter, Virginia's secretary of Health and Human Resources.
A new way of thinking
Johns Hopkins' planning focused on how different bioterrorism is from every disaster the hospital had considered before, while Washington Hospital Center worked to figure out how the responses could be made familiar to staff.
"Because there is not history in dealing with this, we are developing knowledge as we go," Reitz said.
Johns Hopkins developed its Operation Orange plan from scratch, said Jason Farley, the hospital's infection-control epidemiologist. A task force including clinicians, facility engineers, security experts and infection-control specialists studied previous outbreaks, such as one in Germany in 1970 in which smallpox spread from patient to patient through a hospital ventilation system.
The Johns Hopkins team targeted smallpox, which it considered the worst-case scenario, in building its plan. It also considered how to deal with other infectious diseases at the top of the Centers for Disease Control and Prevention's list of biologic diseases, including anthrax, the plague, botulism, tularemia and viral hemorrhagic fever.
For Washington Hospital Center an important consideration is that control of infectious disease, whether it is the flu or smallpox, relies on many of the same infection-control principles.
"One of the important pieces of a bio-incident or bio-agent plan is to demystify the whole thing," Smith said.
In some cases, however, bioterrorism presents new challenges that are rarely considered in other types of disaster planning. For example, in the case of an infectious disease outbreak a quarantine order by state public health officials would require a hospital's security staff to restrict people from entering or leaving the facility. Such an action might result in difficult circumstances.
Because of issues such as this, Johns Hopkins has conducted 30 types of training for staff members since Sept. 11 and now produces a bioterrorism newsletter for staff. The AHA plan calls for metropolitan hospitals to spend $500,000 on training and drills for staff.
Planning and preparation has limits in handling bioterrorism events, however. In addition to training and infrastructure developments, Washington Hospital Center also considers it critical to be able to access "just-in-time knowledge" from a network of experts in the midst of disaster, Smith said.
Inova Fairfax Hospital in Falls Church, Va., treated and later released two inhalation anthrax patients during the recent crisis. The 656-bed hospital attributes much of its success in the cases to its ability to quickly access information from outside experts after an alert physician became suspicious when a patient who worked at the Brentwood post office showed up with flulike symptoms.
The fact that Inova Fairfax saved the lives of anthrax victims because of the sharp thinking of an ER doctor more than the use of its drug stockpiles or protective equipment shows that bioterrorism preparation is far from an exact science.
"People are looking for answers that rapidly give the solutions to a situation that is going to have many solutions, unfortunately," said Russell Massaro, the JCAHO's executive vice president of accreditation operations.