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Mr. Chairman, I am Ron Peterson, President of The Johns Hopkins Hospital and Health System in Baltimore, Maryland. I am here today representing the American Hospital Association (AHA) and its nearly 5,000 hospitals, health systems, networks, and other providers of care. We appreciate this opportunity to present our views on an issue that is dramatically affecting hospitals and communities across America: readiness for a potential terrorist attack utilizing chemical, biological or radiological (CBR) weapons.
September 11 introduced a new consciousness to the collective American mind. We find ourselves faced with the task of preparing for new threats that once seemed unimaginable. Among those threats is the potential use of CBR against our citizens.
To answer these and other threats, hospitals nationwide, like those that directly responded to the September 11 tragedies, have disaster plans in place that have been carefully developed and tested. The plans are multi-purpose and flexible in nature because the number of potential disaster scenarios is large. As a result, hospitals maintain an "all-hazards" plan that provides the framework for managing the consequences of a range of events. Hospitals conduct at least two drills a year: one may be focused on an internal event, such as a complete power failure. Another must be focused on an external event, such as a major highway crash, a hurricane or an earthquake. A hospital near an airport, for example, might focus on responding to an airplane crash, while a hospital near a nuclear plant or an oil refinery would focus on responding to the consequences of incidents at those sites. It is important to remember that all incidents are local, and that local agencies and organizations must work together so that response mechanisms are tailored to the needs of their community.
A good example of how hospitals worked with their communities to prepare for a wide range of possibilities was the change of the calendar to the year 2000. Throughout 1999, hospitals across the nation engaged in a major preparedness effort: Y2K readiness. While Y2K was easier to address than mass casualty readiness, because it had a known time midnight of December 31 and place the hospital the consequences were unknown. Hospitals were ready.
Mass casualty preparedness is similar, because the possibilities are many. But it is also different because of its uncertainty. No one can accurately predict when an incident will occur, where it will occur, or what will be its cause and consequences. That is why the all-hazards plan, tailored to suit the needs of each individual hospital and its community, has provided an excellent framework for doctors and nurses forced into action by a wide range of events. Nowhere was this better reinforced than on September 11.
When hospitals in New York received the call to expect thousands of injured patients, triage teams were immediately set up, rehabilitation centers were transformed into auxiliary emergency rooms, and hundreds of off-duty nurses and doctors swarmed the hospital to offer assistance. Hospitals in New Jersey and Connecticut were also at the ready. In Washington, readiness paid off as regional hospitals in Virginia, the District of Columbia and Maryland launched into their disaster modes. And in Pennsylvania, facilities in the southwest part of the state were ready to provide care for victims of the airplane crash there. When the emergency plan went into effect, everyone was in their place, doing their jobs. Nurses, doctors, and others, working side by side, communicating effectively, relying on teamwork and training to assist the incoming wounded.
Different cities, different hospitals, hundreds of miles away from each other, each responding efficiently to a direct hit of terrorism. Each reacted in a positive, planned manner that not only saved lives, but also proved that Americas health care heroes are dedicated, caring professionals who are ready for the worst of circumstances. The health care professionals and volunteers at all the sites were prepared to treat far more patients than actually came to them. Death tolls were simply too high, and health care workers grieved that they couldnt do more.
It is important to realize each incident is used to improve our preparedness. Disaster managers use the term "after action analysis" to describe the types of activities that are conducted to study what happened, what worked and what did not. The AHA and its state, regional and metropolitan associations work with our member hospitals to share throughout the field critical information that can be derived from responses to events. The following are important facts that we already know:
By definition, a mass casualty incident would overwhelm the resources of most individual hospitals. Equally important, a mass casualty incident is likely to impose a sustained demand for health care services rather than the short, intense peak customary with many smaller scale disasters. This adds a new dimension and many new issues to readiness planning for hospitals.
Hospitals, because of their emergency services and 24-hour a day operation, will be seen by the public as a vital resource for diagnosis, treatment, and follow up for both physical and psychological care.
To increase readiness for mass casualties, hospitals have to expand their focus to include planning within the institution, planning with other hospitals and providers, and planning with other community agencies.
Traditional planning has not included the scenario in which the hospital may be the victim of a disaster and may not be able to continue to provide care. Hospital planners should consider the possibility that a hospital might need to evacuate, quarantine or divert incoming patients.
Readiness could benefit from exploring the concept of reserve staff that identifies physicians, nurses and hospital workers who are retired, have changed careers to work outside of health care, or now work in areas other than direct patient care (e.g., risk management, utilization review). The development of a list of candidates for a community-wide reserve staff will require that we regularly train and update the reserves so that they can immediately step into various roles in the hospital, thereby allowing regular hospital staff to focus on taking care of incident casualties.
Hospital readiness can be increased if state licensure bodies, working through the Federation of State Medical Boards, develop procedures allowing physicians licensed in one jurisdiction to practice in another under defined emergency conditions. Nursing licensure bodies could increase preparedness by adopting similar procedures or by adopting the Nursing Compact presently being implemented by several states.
The threat of chemical, biological and radiological agents has become a focus of counterterrorism efforts because these weapons have a number of characteristics that make them attractive to terrorists. Specifically, biological agents pose perhaps the greatest threat. Dispersed via the air handling system of a large public building, for example, a very small quantity may produce as many casualties as a large truckful of conventional explosives, making acquisition, storage and transport of a powerful weapon much more feasible. Some CBR agents may be delivered as invisible killers, colorless, odorless and tasteless aerosols or gases.
The distinguishing feature of some biological agentssuch as plague or smallpox--is their ability to spread. The victim may even become a source of infection to additional victims. The effects of viruses, bacteria and fungi may not become apparent until days or weeks after initial exposure, so there will be no concentration of victims in time and locale to help medical personnel arrive at a diagnosis. Exposure to biological agents may cause a variety of symptoms, including high fever, skin blisters, muscle paralysis, severe pneumonia, or death, if untreated.
Because September 11 redefined the meaning of disaster, hospitals are now upgrading their existing readiness plans to meet the new needs of their communities. Since the risk of chemical and biological attacks is now an obvious concern, hospitals are reassessing their current plans. The AHA so far has sent two Disaster Readiness Advisories to all of America's hospitals with information and resources to help them in this effort.
The following are among the key items that we believe need to be addressed to help hospitals as they update their disaster plans to meet the challenges of a threat that, until recently, seemed hypothetical: an attack using chemical, biological or radiological agents.
Medical and pharmaceutical supplies Hospitals must be properly stocked with antibiotics, antitoxins, antidotes, ventilators, respirators, and other supplies and equipment needed to treat patients in a mass casualty event.
Communication and notification There is a need for greater coordination of public safety and hospital communications, the ability of different entities to communicate with each other on demand. In addition, alternative and redundant systems will be required in case existing systems fail in an emergency.
Surveillance and detection Improving hospital laboratory surveillance and the epidemiology infrastructure will be critical to determining whether a cluster of disease is related to the release of a biological or chemical agent. The ability to rapidly identify the agent involved is vital.
Personal protection Hospital supplies of gloves, gowns, masks, etc. would quickly be used up during an attack, and equipment like canister masks is rarely kept in adequate numbers to meet demands of a large casualty attack.
Hospital facility Among the capabilities hospitals will need in the event of an attack: lockdown ability; auxiliary power; extra security; increased fuel storage capacity; and large volume water purification equipment.
Dedicated decontamination facilities Hospitals need a minimal capability for small events and the ability to ramp-up quickly for a larger event.
Training and drills Staff training is needed at all levels for all types of potential disasters. Additional disaster drills beyond the two per year required by JCAHO, particularly community-wide drills, would enhance the level of hospital readiness.
Mental health resources Mass casualty events trigger escalated emotional responses. Hospitals must be ready to treat not only patients exhibiting these symptoms, but others, such as family members, emergency personnel and staff.
To truly solidify response readiness, the federal government should help establish an emergency communication and transportation strategy. During the recent attacks, street closings and clogged roads impeded EMS workers as they tried to reach the affected areas, and hindered quick access to hospitals. No-fly zones were implemented to prevent other air attacks, but those zones hindered med-evac helicopters and other air transports that shipped blood and bandages to hospitals in dire need. Hospitals need assistance from Federal Aviation Administration officials to keep the skies open to critical medical aircraft.
In addition, any biochemical attack will require the coordination of local, state and federal agencies. In response, the Centers for Disease Control and Prevention have invested in and upgraded state-of-the-art labs to identify and monitor reports of suspicious cases of illness across the country. Working in conjunction with state and local epidemiologists, they will communicate their findings to government agencies.
Realistically, America can never afford to prepare every hospital in the country for every possibility of attack. However, the federal government can provide assistance to help ensure that hospitals and their local agencies are best able to respond to potential attacks. These funds would be earmarked to meet the challenges outlined above, including inventories of the necessary drugs and equipment needed to help victims of terrorist attacks. Communities need the funding to assist their hospitals and expand their emergency relief teams, as well as to establish or implement new systems of readiness.
There is no more important strategy in this domestic war on terrorism than to help our hospitals reach a state of readiness. But if Americas hospitals are to enhance their readiness for a new world of possibilities, they must have in place the people they need to do the job. However, Americas hospitals are experiencing a workforce shortage that will worsen as baby boomers retire. Currently, our health systems have 126,000 open positions for registered nurses, for example. The United States Department of Health and Human Services predicts a nationwide shortage of 400,000 nurses by 2020. There also are shortages of other key personnel, such as pharmacists. This shortage cuts to the core of Americas health care system, because dedicated, caring people are the heart of health care.
Fortunately, Congress has recognized the importance of this issue. Legislation has been introduced that can help hospitals attract and maintain the health care workforce that is needed to ensure that our patients receive the right care, at the right time, in the right place. For example, the Nurse Reinvestment Act (S.706/H.R. 1436) offers the right step to ensure health care professionals avert the collision course we face with lack of hospital staff.
The United States has been thrust into a new era. Our hospitals have always been ready for the foreseeable. Now we must plan for the previously inconceivable. Hospitals are upgrading existing disaster plans, and continue to tailor their disaster plans to suit the individual needs of the community in the face of new threats.
America can be comforted that, as we have witnessed over the last few weeks of our national tragedy, highly trained, caring doctors, nurses and other professionals are the heart of our health care system. They perform heroic, lifesaving acts every day. And, in the face of the unexpected, they can be depended on to rise to the needs of their communities.
The AHA has worked closely with the administration on this important issue, especially with Sec. Thompson. We look forward to working with Congress as we help ensure that the people we serve get the care they need in any and all circumstances.
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