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    A readied response: The emergency management plan


    RN/MCPHU Home Study Program

    A readied response: The emergency management plan

    CE credit is no longer available for this article. (Expired June 2004)

    Originally posted June 2002

    A readied response: The emergency management plan


    RENÉ STEINHAUER is a nurse at Northbay Medical Center in Fairfield, Calif., a paramedic with Medic Ambulance in Vallejo, Calif., and the author of International Medicine: Your Passport for Adventure ( www.internationalmedicineonline.com ). JEFF BAUER is a senior editor at RN.

    KEY WORDS: emergency management plan, mitigation, preparedness, response, recovery, decontamination, communications, personal protective equipment

    Is your hospital prepared to treat mass casualties from a terrorist attack with biological, chemical, or nuclear weapons? The answer lies in its emergency management plan. In this fourth and final installment of our series we describe how you can tell if your hospital's plan covers all that it should.

    Jump to:

    René, do you have any suggestions for our disaster plan?" That question was directed at me during a hospital disaster planning committee meeting in the spring of 1995.

    Given my experience with disaster planning and response as a nurse in the military, I was interested in offering my insight to the committee. Although the administrators of the hospital, a 550-bed facility in Saudi Arabia, knew that its existing disaster plan was inadequate, they hadn't been aggressive about disaster planning and were looking to implement only minimal revisions.

    During our meeting, I asked the group, composed of administrators, doctors, nurses, and paramedics (in Saudi Arabia, paramedics are part of the ED), a question of my own. What expectations did they have for disasters, including terrorist attacks?

    Members of the committee chuckled and said, "Those sorts of things don't happen here." Given their mindset, it was an uphill battle to create an emergency management plan that took into account a wide range of potential disasters. But in the end, the committee succeeded.

    And thankfully so. In November of that year, there was a massive explosion downtown—an apparent terrorist attack with early estimates of 250 casualties. The hospital's emergency plan went into effect.

    Though the actual number of casualties was much smaller—six dead and 63 injured—rapid implementation of the emergency management plan significantly enhanced our hospital's ability to care for a sudden influx of patients. In fact, we could have handled far more patients, had they arrived.

    As this story shows, no facility can afford to harbor the illusion that "those sorts of things don't happen here." All hospitals must have a comprehensive emergency management plan that, among other things, details how to respond to a terrorist attack.

    But how does your facility's emergency management plan stack up? Does it comply with the latest standards from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)? Does it cover all the important bases? And do you understand your role in it?

    The review that follows will help you answer these questions and guide your efforts to call attention to any deficiencies you might find.

    Four phases all plans must address

    JCAHO-accredited hospitals are required to have a comprehensive plan in place to ensure an effective response to any emergency—including a terrorist attack—that would disrupt the hospital's ability to treat patients or significantly increase the demand for its services.1

    In January 2001, JCAHO introduced new emergency management standards, adding to its existing disaster preparedness requirements.2 (JCAHO discourages organizations from developing separate plans for different types of emergencies, such as floods, fires, transportation accidents, or warfare.3)

    According to JCAHO standards, a hospital's plan must specifically address four phases of emergency management. They are: mitigation, preparedness, response, and recovery. While these phases apply to any type of emergency, here's how they would apply to a terrorist attack.

    Mitigation is an assessment phase of sorts. JCAHO requires hospitals to perform a hazard vulnerability analysis to identify the kinds of emergency situations that are most likely to occur and their probable impact.

    Preparedness involves taking steps to increase a hospital's ability to manage the effects of an attack. This includes creating an inventory of resources—from staff to supplies—that may be needed and establishing agreements with vendors and other healthcare facilities to provide increased resources in the event of an attack. Establishing primary and backup communications systems, training staff, and conducting organization-wide drills are all part of preparedness.

    Response is a phase that encompasses the actions all staff must take in the event of an attack, like reporting to predetermined locations and utilizing specific triage strategies. It also includes management activities, such as initiating the emergency management plan and issuing warnings and notifications. Decontamination procedures and disease surveillance and reporting are other examples of response activities every plan should address.

    Recovery involves the steps taken to restore essential services and resume normal operations. This phase needs to begin almost as soon as the response phase does.

    As part of the JCAHO requirements, hospitals must regularly test their emergency plans.1 Specifically, the response phase of the plan has to be tested twice a year, with at least four months (but not more than eight months) between tests. The plan must be tested in planned drills that include an influx of volunteers or simulated (on paper) patients. An actual emergency that involves the plan also qualifies.

    JCAHO recommends—but does not yet require—that, as part of the planning process, hospitals consider cooperative planning with other healthcare organizations that together serve a geographic area.1 The goal is to make it quicker and easier to share essential information and resources that would be used in an emergency. This recommendation is based on the experiences of healthcare organizations that responded to terrorist attacks in New York City and Washington, D.C., on September 11.

    The plan must define a chain of command

    A well-defined chain of command and provisions for establishing a central control location are essential components of any emergency management plan.

    A number of facilities rely on a tool called the Hospital Emergency Incident Command System (HEICS) to establish this chain of command. HEICS provides a flexible template of common titles and roles used by all agencies in response to an emergency. This template allows hospitals to efficiently divide tasks among their staffs and customize their response to the specific crisis at hand. (For more information about HEICS, point your browser to www.emsa.cahwnet.gov/dms2/heics3.htm .)

    Whether or not your hospital's plan includes HEICS, it should nevertheless spell out a command structure—including a description of the roles and responsibilities of each and every staff member.

    It's also essential that the plan outline the workings of a central command center—or nerve center, if you will—from which the emergency can be managed. Such a command center should be established as soon as possible to avoid confusion or conflicting information and orders. Your facility's plan should designate both a location for, and the responsibilities of, all command center personnel.4 The role of each member assigned to the command center must be practiced until it's second nature.

    So much depends on communications

    Clearly, in a public emergency, hospitals need ongoing open channels of external and internal communication. External lines of communication will need to extend to other hospitals; fire, EMS, hazardous materials (HAZMAT), and state and local public health departments; and local, state, and federal law enforcement agencies. Phone numbers for both external and internal contacts should be posted in the command center.

    "Interoperability"—the ability of various public safety organizations to communicate with each other on demand—is one of the most important factors of a hospital's plan of action.5 Currently, pagers, cellular phones, mobile data terminals (small computer terminals typically mounted in emergency vehicles), and mobile laptop computers are being used for this purpose. However, common problems include equipment failure in "dead spots," interference, and channel congestion.

    For all of these reasons, your facility needs to have a plan for a backup communication system. Some alternatives include two-way radio, amateur ("ham") radio, fax, e-mail, video conferencing, or even a courier system. All staff members need training in the proper use of whatever communication systems are to be used, and all equipment needs to be tested and updated regularly.

    Your hospital also needs to anticipate that the news media will be urgently asking for information. One person from the organization should be designated as the media contact. Regularly scheduled press briefings should be held at a location away from patient care areas like the ED.5

    Processes and methods for internal communication can't be overlooked either. In the event of a terrorist attack, staff members need to know what happened, how many patients to expect, and when patients will begin to arrive so they can prepare both themselves and the facility. Staff members will also need to know how they can communicate with their own families, who may have been affected by an attack. Establishing a call tree, where a few designated individuals outside of the hospital are called and they in turn telephone the families of all other staff members, is an efficient way to accomplish this without overwhelming the hospital's phone system.6

    The plan must also address equipment

    Besides addressing key communication issues, an emergency management plan should also describe the steps that will be necessary to ensure that there are adequate supplies of personal protective equipment (PPE) in the event of a large-scale attack. If such an attack were to occur, most, if not all, of the staff may need PPE for universal precautions—that is gloves, gowns, masks, goggles, shoe covers, and high efficiency particle air (HEPA) filtration masks. Such equipment will generally provide protection from the biological agents that may be used in an attack.5

    Other PPE can provide more extensive protection for use in the event of a chemical or nuclear attack, but it can be extremely costly to purchase and train staff members to use. Each hospital has to make its own determination as to which level of protection is appropriate by evaluating potential hazards, consulting local emergency response agencies, and complying with Occupational Safety and Health Administration (OSHA) regulations.5

    OSHA regulations for respiratory protection and PPE define three levels of protection.5 Level A provides the highest level of respiratory and skin protection. This entails a chemical-resistant suit, including gloves and boots, that provides a fully enclosed environment and is impervious to gases or vapors. It's used with either an internal self-contained breathing apparatus (SCBA) or a supplied-air respirator, which provides air to a hood or face piece from an external compressor, cylinder, or tank.

    A Level B suit provides a high level of respiratory protection but not a fully enclosed environment. It's chemical-resistant but doesn't fully protect against vapors.

    A Level C suit is chemical-resistant and would be used with a full- or half-face air-purifying respirator, like a HEPA mask fitted with cartridges to filter out the specific agent involved.

    It's important to check that your hospital's plan spells out which level of protection should be used under what circumstances, where the equipment is located, and when you'll be trained to use it. No nurse should wear Level A or B equipment without first getting comprehensive training, which should include learning how to work while wearing the equipment.

    Have enough supplies for at least 24 hours

    JCAHO requires your facility's plan to address how critical supplies would be obtained and allocated during an emergency. Hospitals need to maintain an adequate inventory of antibiotics, antitoxins, antidotes, and other supplies to treat victims of an attack. (Recommended pharmaceuticals and supplies are listed in the "Essential supplies" box.)

    The Centers for Disease Control and Prevention (CDC) has a National Pharmaceutical Stockpile (NPS) designed to provide lifesaving pharmaceuticals, antidotes, and other medical supplies and equipment necessary to any location, including hospitals, to counter the effects of nerve agents, biological pathogens, and chemical agents.7 The NPS offers, among other things, something called "push-packages," which are caches of pharmaceutical agents and medical supplies needed to respond to a variety of terrorist agents. Push-packages are secured in regional warehouses across the United States for immediate deployment.

    The American Hospital Association (AHA) estimates that such external supplies would be available within 24 hours of a biological or chemical agent being detected.5 Therefore, hospitals need to maintain a 24-hour supply of pharmaceutical products in the most common dosages for the projected number of patients and staff.

    In addition to such special supplies, your hospital also needs to have adequate inventories of routinely used drugs and supplies in the event that local transportation is disrupted or warehouses destroyed. The need may be especially great for high-use medications, such as insulin, that are taken by many people with chronic conditions. For drugs and supplies rarely used in routine hospital care, a plan for pooling resources through mutual aid agreements among area healthcare facilities may be needed.

    Decontamination needs to be part of the plan, too

    Whenever possible, decontamination should be performed by specially trained HAZMAT personnel at the site of contamination.8 This is mostly an issue with chemical and nuclear attacks since it's unlikely that victims of a biological attack will still be carrying the agent on their skin or clothing by the time they come to the ED. (That's because of the incubation period of these agents.)

    In the event that your facility must handle decontamination, your hospital's plan should include measures for creating and equipping a decontamination area—preferably one outdoors, though one within you facility can work as well. In cold weather, tents or other temporary structures can be equipped with temporary showers, lighting, and heat as needed.

    The decontamination area should be in a location where hospital security can strictly control access. It should have PPE and medical equipment that's specifically dedicated for use with contaminated victims. There should also be an appropriate means for handling and storing contaminated clothing and other material until HAZMAT personnel order its removal.8

    Finally, training is an essential element of any decontamination plan. OSHA requires training for those who perform the actual decontamination.8 But at a minimum, all staff in the ED should be trained to have a basic understanding of what decontamination entails.

    If the attack is biological, proper reporting is key

    Of the three types of attacks with weapons of mass destruction, a biological attack is the one most likely to occur covertly, with increasing numbers of patients presenting to EDs over a period of days or weeks. Patients' symptoms may be similar to those of a number of diseases and conditions.5 That puts you and your colleagues on the front lines of recognition and response.

    As described in the first installment of this series, you'll need to be alert to patterns such as an unusual temporal or geographic clustering of illnesses, or a sudden influx of patients with illnesses that are out of season or not endemic to your local area.9

    Your hospital's plan must establish procedures for alerting public health authorities when a biological attack is suspected. Notification procedures will likely require that your facility first notify the local or state health department. They, in turn, will notify the CDC and/or law enforcement agencies. (For more information, see the CDC's recommended notification protocols at www.bt.cdc.gov/EmContact/Protocols.asp .)

    When it comes to preparedness, the bottom line is that "attitude is everything"—hope for the best, but plan for the worst. Obtain a copy of your hospital's plan, which is typically kept at each nurses station. Study the plan closely, make sure it covers all the right bases, and key in on your role in it.

    If you find shortcomings—if you discover, for example, that your hospital hasn't reviewed its plan or conducted drills recently—be proactive and ask that these issues be addressed. In training meetings, find out how your facility is working with local or federal health departments and local emergency services to ensure that its plan is integrated into the community's plan for emergency management.

    Having an in-depth knowledge of your facility's emergency management plan, and your role in it, will enable you to respond appropriately should an act of terrorism occur in your community. If recent events have taught us anything, it's that no community is immune to terrorism.


    1. Joint Commission Resources, Joint Commission on Accreditation of Healthcare Organizations. "Using JCAHO standards as a starting point to prepare for an emergency." Joint Commission Perspectives. 2001. www.jcrinc.com/subscribers/perspectives.asp?durki=1004& site=10&return=1122 (20 March 2002).

    2. Joint Commission Resources, Joint Commission on Accreditation of Healthcare Organizations. "Mobilizing America's health care reservoir." Joint Commission Perspectives. 2001. www.jcrinc.com/subscribers/perspectives.asp?durki=1002&site=10&return=1122 (14 March 2002).

    3. Joint Commission on Accreditation of Healthcare Organizations. "Standards—frequently asked questions—hospitals." 2000. www.jcaho.org/standard/faq/hos.html#ec3 (20 March 2002).

    4. Joint Commission Resources, Joint Commission on Accreditation of Healthcare Organizations. "The power of preparation." Joint Commission Perspectives. 2001. www.jcrinc.com/subscribers/perspectives.asp?durki=1012&site=10&return=1122 (20 March 2002).

    5. American Hospital Association. "Hospital resources for disaster readiness." 2002. www.aha.org/Emergency/Readiness/ReadyAssessmentB1101.asp (14 March 2002).

    6. Joint Commission Resources, Joint Commission on Accreditation of Healthcare Organizations. "Talking to each other in a crisis." Joint Commission Perspectives. 2001. www.jcrinc.com/subscribers/perspectives.asp?durki=1013&site=10&return=1122 (15 March 2002).

    7. Centers for Disease Control and Prevention, National Pharmaceutical Stockpile Program. "National Pharmaceutical Stockpile Program." 2002. www.cdc.gov/nceh/nps/default.htm (20 March 2002).

    8. Joint Commission Resources, Joint Commission on Accreditation of Healthcare Organizations. "Nuclear, biological, and chemical decontamination." Joint Commission Perspectives. 2001. www.jcrinc.com/subscribers/perspectives.asp?durki=1015&site=10&return=1122 (20 March 2002).

    9. Centers for Disease Control and Prevention. (2001). Recognition of illness associated with the intentional release of a biological agent. MMWR, 50(41), 893.

    Essential supplies

    For hospitals to effectively treat mass casualties from a terrorist attack using biological or chemical agents, the American Hospital Association recommends that they maintain a 24-hour supply of the drugs and related supplies listed below. After that, resources from the Centers for Disease Control and Prevention's National Pharmaceutical Stockpile would become available. (For details on the use of these items, see the previous three installments of this series.)


    Terrorist weapon Required drugs/supplies
    Biological agents
    Bacteria Ciprofloxacin HCl (Cipro), doxycycline (Vibramycin, Monodox, others), penicillin, chloramphenicol (Chloromycetin), rifampin (Rifadin, Rifamate, others), streptomycin sulfate, gentamicin sulfate (Garamycin, Cidomycin, others)
    Chemical agents
    Cyanide Cyanide antidote kits containing amyl nitrite, sodium nitrite, and sodium thiosulfate
    (a vesicant agent)
    Dimercaprol (British Anti-Lewisite, BAL in Oil)
    Nerve agents Atropine sulfate, pralidoxime chloride (Protopam chloride), diazepam (Valium)
    Pulmonary agents Oxygen delivery devices and respiratory care supplies
    Any biological or chemical agent

    Vasopressors and resuscitation equipment and supplies. There is also a need for miscellaneous equipment and supplies that include: mechanical ventilators (adult, pediatric, neonate); IV pumps, poles, fluids, indwelling catheters, and sets for 1,000 patients; suction machines; stretchers; wheelchairs; linens; bandages and dressings

    Adapted from: American Hospital Association. "Hospital resources for disaster readiness." 2001. www.aha.org/Emergency/Readiness/Ready AssessmentB1101.asp (15 March 2002).

    Resources for evaluating your hospital's plan

    In response to the events of September 11, many organizations have published updated information and recommendations for hospital emergency management. RN's sister company, Thomson American Health Consultants, for one, recently published Preparing for mass casualties: A sourcebook for health care professionals (800-688-2421). A number of other offerings from several key organizations are listed below.

    American Hospital Association (AHA)
    The AHA has extensive information on emergency planning in the disaster readiness section of its Web site, at www.aha.org/Emergency/EmIndex.asp . Its "Chemical and Bioterrorism Preparedness Checklist," available at www.aha.org/Emergency/Content/MaAtChecklistB1003.doc , can be used to evaluate your facility's plan.

    Association for Professionals in Infection Control and Epidemiology (APIC)
    In cooperation with the Centers for Disease Control and Prevention, APIC has created "Bioterrorism Readiness Plan: A Template for Healthcare Facilities." The document is available online at www.cdc.gov/ncidod/hip/Bio/13apr99APIC-CDCBioterrorism.PDF .

    Centers for Disease Control and Prevention (CDC)
    The CDC Strategic Planning Workgroup published "Biological and Chemical Terrorism: Strategic Plan for Preparedness and Response" in the April 21, 2000 issue of the Morbidity and Mortality Weekly Report, which is available online at www.cdc.gov/mmwr/preview/mmwrhtml/rr4904a1.htm . The CDC provides further preparation and planning information on its bioterrorism Web site at www.bt.cdc.gov/Planning/index.asp .

    Federal Emergency Management Agency (FEMA)
    In April 2001, FEMA published guidelines for state and local emergency planners to use in developing a response to a terrorist attack with weapons of mass destruction. The guidelines are available online at www.fema.gov/library/allhzpln.htm .

    Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
    In January 2001, JCAHO released new emergency management standards, which are available online at www.jcaho.org/standard/pharmfaq_mpfrm.html . In addition, JCAHO's Joint Commission Resources offers a free special issue of its Joint Commission Perspectives newsletter containing comprehensive information on hospital emergency management plans, with special emphasis on biological, chemical, and nuclear attacks. It's available at www.jcrinc.com/subscribers/perspectives.asp?durki=1122.


    Emil Vernarec, ed. Rene Steinhauer III, Jeffrey Bauer. A readied response: The emergency management plan. RN 2002;6:40.

    Published in RN Magazine.
    Rene Steinhauer, III, RN, EMT-P
    Rene Steinhauer is a nurse at Northbay Medical Center in Fairfield, CA, a paramedic with Medic Ambulance in Vallejo, CA, and the author ...