Hospital planning for weapons of mass destruction incidents.
As terrorists attacks increase in frequency, hospital disaster plans need to be scrutinized to ensure that they take into account issues unique to weapons of mass destruction. This paper reports a review of the literature addressing hospital experiences with such incidents and the planning lessons thus learned. Construction of hospital disaster plans is examined as an ongoing process guided by the disaster planning committee. Hospitals are conceived as one of the components of a larger community disaster planning efforts, with specific attention devoted to defining important linkages among response organizations. This includes the public health authorities, political authorities, prehospital care agencies, and emergency management agencies. A review is completed of six special elements of weapons of mass destruction incidents that should be addressed in hospital disaster plans: incident command, hospital security, patient surge, decontamination, mental health consequences, and communications. The paper closes with a discussion of the importance of training and exercises in maintaining and improving the disaster plan. (+info)
Health impact of the Buncefield oil depot fire, December 2005: study of accident and emergency case records.
BACKGROUND: On Sunday 11th of December 2005, an explosion occurred at the Buncefield oil depot, Hertfordshire, resulting in a large fire that blazed for several days. Two Accident and Emergency (A&E) departments were placed on stand-by to receive casualties. A simple surveillance system was put in place during the acute phase of the incident, but this was not adequate to fully examine the health impact of the fire. METHODS: Retrospective study of A&E records at Hemel Hempstead and Watford A&E departments for the period that the fire burnt. RESULTS: Two hundred and forty-four people attended A&E as a result of the fire: 187 were members of the emergency services; 17 were oil depot workers; and 40 were members of the public. The most common presenting complaints were respiratory symptoms (n = 66) and injuries (n = 38). Twenty-five (21%) individuals were referred for medical follow-up. There were no fatalities. CONCLUSION: There was a significant impact on local health services, with many emergency service personnel attending A&E asymptomatically. Alternative health service provision for these individuals, possibly near to the scene of the incident, should be considered. This incident has also highlighted an urgent need to develop surveillance systems that enable real-time monitoring of the acute public health impact of major incidents. (+info)
Panel classification of self-reported exposure histories: a useful exposure index after a mass-casualty event.
OBJECTIVE: Although rapid epidemiologic investigations of toxic exposures require estimates of individual exposure levels, objective measures of exposure are often unavailable. We investigated whether self-reported exposure histories, when reviewed and classified by a panel of raters, provided a useful exposure metric. METHODS: A panel reviewed exposure histories as reported by people who experienced a chlorine release. The panelists received no information about health-care requirements or specific health effects. To each exposure case, each panelist assigned one of five possible exposure severity ratings. When assigned ratings were not in initial agreement, the panelists discussed the case and assigned a consensus rating. Percent agreement and kappa statistics assessed agreement among panelists, Kendall's W measured agreement among panelists in their overall ordering of the exposure histories, and Spearman's rho compared the resultant rankings with individual health outcome. RESULTS: In 48% of the cases, the panelists' initial ratings agreed completely. Overall, initial ratings for a given case matched the consensus rating 69% to 89% of the time. Pair-wise comparisons revealed 85% to 95% agreement among panelists, with weighted kappa statistics between 0.69 and 0.83. In their overall ranking of the exposure histories, the panelists reached significant agreement (W = 0.90, p < 0.0001). Disagreement arose most frequently regarding probable chlorine concentration and duration of exposure. This disagreement was most common when panelists differentiated between adjacent categories of intermediate exposure. Panel-assigned exposure ratings significantly correlated with health outcome (Spearman's rho = 0.56; p < 0.0001). CONCLUSION: Epidemiologists and public health practitioners can elicit and review self-reported exposure histories and assign exposure severity ratings that predict medical outcome. When objective markers of exposure are unavailable, panel-assigned exposure ratings may be useful for rapid epidemiologic investigations. (+info)
Rapid assessment of exposure to chlorine released from a train derailment and resulting health impact.
OBJECTIVES: After a train derailment released approximately 60 tons of chlorine from a ruptured tanker car, a multiagency team performed a rapid assessment of the health impact to determine morbidity caused by the chlorine and evaluate the effect of this mass-casualty event on health-care facilities. METHODS: A case was defined as death or illness related to chlorine exposure. Investigators gathered information on exposure, treatment received, and outcome through patient questionnaires and medical record review. An exposure severity rating was assigned to each patient based on description of exposure, distance from derailment, and duration of exposure. A case involving death or hospitalization > or = 3 nights was classified as a severe medical outcome. Logistic regression was used to examine factors associated with severe medical outcomes. RESULTS: Nine people died, 72 were hospitalized in nine hospitals, and 525 were examined as outpatients. Fifty-one people (8%) had a severe medical outcome. Of 263 emergency department visits within 24 hours of the incident, 146 (56%) were in Augusta, Georgia; at least 95 patients arrived at facilities in privately owned vehicles. Patients with moderate-to-extreme exposure were more likely to experience a severe medical outcome (relative risk: 15.2; 95% confidence interval 4.8, 47.8) than those with a lower rating. CONCLUSIONS: The rapid investigation revealed significant morbidity and mortality associated with an accidental release of chlorine gas. Key findings that should be addressed during facility, community, state, and regional mass-casualty planning include self-transport of symptomatic people for medical care and impact on health-care facilities over a wide geographic area. (+info)
Severe febrile respiratory illnesses as a cause of mass critical care.
Febrile respiratory illnesses with respiratory failure are one of the most common reasons for admission to the intensive care unit. Most causes of febrile respiratory illness are bacterial and viral agents of community-acquired pneumonia. However, a small number of rare and highly contagious agents can initially present as febrile respiratory illnesses, which can lead to an epidemic that can greatly impact the health care system. This impact includes sustained mass critical care, with potential scarcity of critical resources (eg, positive-pressure ventilators), spread of disease to health care workers, sustained spread within the community, and extensive morbidity and mortality. The main agents of febrile respiratory illness that would lead to an epidemic include influenza, the coronavirus that causes severe acute respiratory syndrome, smallpox, viral hemorrhagic fever, plague, tularemia, and anthrax. Recognition of these agents occurs largely based on epidemiological clues, and management consists of antibiotics, antivirals, supportive care, and positive-pressure ventilation. Acute respiratory failure and acute respiratory distress syndrome occur with these agents, so a lung-protective (low tidal volume) ventilation strategy is indicated. Additional respiratory care measures, such as nebulized medications, bronchoscopy, humidified oxygen, and airway suctioning, potentiate aerosolization of the virus or bacteria and increase the risk of transmission to health care workers and patients. Thus, appropriate personal protective equipment, including an N95 mask or powered air-purifying respirator, is indicated. A basic understanding of the epidemiology, clinical findings, diagnosis, and treatment of these agents will provide a foundation for early isolation, evaluation, infection control, and public health involvement and response in cases of a febrile respiratory illness that causes respiratory failure. (+info)
Mass casualty chemical exposure and implications for respiratory failure.
Exposure to chemical agents, both deliberate and accidental, over the past 100 years has resulted in the deaths of thousands and a significant number of casualties requiring hospitalization. The respiratory system is an important portal of entry into the human body for many of these agents, and pulmonary symptoms are a hallmark of many chemical exposures. The 4 major chemical warfare agents are: lung-damaging, blood, blister, and nerve compounds. The review will cover historical exposures, signs and symptoms, treatment, and long-term consequences. There are numerous examples of deliberate (as well as accidental) exposure to harmful chemicals, and each incident requires the provider to understand the signs and symptoms of the particular chemical so that the correct treatment is provided. The respiratory implications of these agents appear to be dose and timing dependent, with full recovery often seen if supportive measures and appropriate antidotes are administered in a timely fashion. (+info)
Modified critical care and treatment space considerations for mass casualty critical illness and injury.
Mass critical care events are increasingly likely, yet the resource challenges to augment everyday, unrestricted critical care for a surge of disaster victims are insurmountable for nearly all communities. In light of these limitations, an expert panel defined a circumscribed set of key critical care interventions that they believed could be offered to many additional people and yet would also continue to offer substantial life-sustaining benefits for nonmoribund critically ill and injured people. They proposed Emergency Mass Critical Care, which is based on the set of key interventions and includes recommendations for necessary surge medical equipment, treatment space characteristics, and staffing competencies for mass critical care response. To date, Emergency Mass Critical Care is untested, and the real benefits of implementation remain uncertain. Nonetheless, Emergency Mass Critical Care currently remains the only comprehensive construct for mass critical care preparedness and response. This paper reviews current concepts to provide life-sustaining care for hundreds or thousands of people outside of traditional critical care sites. (+info)
Surge capacity mechanical ventilation.
Mechanical ventilation in a situation of mass casualty respiratory failure will require a substantial increase in the capacity for mechanical ventilation, to prevent unnecessary mortality. Concern over the difficulties of treating large numbers of patients with respiratory failure is exceeded only by our lack of experience on which to base decisions. This review evaluates the likely scenarios that could lead to mass casualty respiratory failure and the types of respiratory failure anticipated. A literature review was conducted, using the National Library of Medicine Medical Subject Headings terms "mass casualty respiratory failure," "pandemic flu," "disaster preparedness," and "mass casualty care." Papers were reviewed for relevance to the topic. There is little historical or empirical evidence upon which to base decisions regarding mass casualty respiratory failure and augmenting positive-pressure ventilation capacity. Matching the degree of respiratory impairment anticipated from the most likely mass casualty scenarios allows conclusions to be drawn regarding the performance characteristics of ventilators required for these situations. Little is known about the success of mechanical-ventilator stockpiling for mass casualty respiratory failure. Careful planning with an emphasis on matching ventilator performance to patient need and caregiver skill is critical to appropriate stockpile choices. (+info)