SAMHSA: Synthetic Marijuana linked to thousands of Emergency Department Visits

First report on Synthetic Marijuana use highlights dangers, healthcare impact

The Substance Abuse and mental Health Services Administration (SAMHSA) has released a study highlighting the impact of synthetic marijuana use. Drug Related Emergency Department Visits Involving Synthetic Cannabinoids appears in the December, 2012 issue of The Drug Awareness Warning Network (DAWN) Report.

Synthetic drugs are generally considered to include synthetic Bath Salts (sBS) and synthetic marijuana (sM). Both sBS and sM are sold under a variety of names and are made up of any number of chemical compositions. Both classifications of drugs have been linked to thousands of emergency department visits and hospital admissions as well as a variety of medical and psychiatric outcomes. The exact composition of synthetic cannabis and bath salts may change with manufacturer. For more on chemical composition and effects on the body, see Bath Salts: Stronger than dirt!.

According to the DAWN report, 11,406 emergency department visits involved a synthetic cannabiod product. Ages 12 to 29 years made up three quarters of those visits with an overwhelming majority of users being male.

The DAWN report also notes that:

"They [synthetic marijuana] have been reported to cause agitation, anxiety, nausea, vomiting, tachycardia, elevated blood pressure, tremor, seizures, hallucinations, paranoid behavior, and nonresponsiveness."

Polypharmacy use is often seen with synthetic bath salts, it may not be a large issue among synthetic marijuana usesers. Fifty-nine percent of those reporting to ED after synthetic marijuana use (12 to 29 age group) had no other substances involved. When polypharmacy was present, alcohol was found in 13% of cases and other pharmaceuticals used in 17%.

Synthetic drugs including bath salts and synthetic marijuana have captured the attention of public health officials, hospital staff and the media. The use of these materials continues to climb as does the awareness to the consequences. The CDC published its first article on the subject of bath salts in the May, 2011 edition of Morbidity and Mortality Weekly Report (MMWR) [Emergency Department Visits After Use of a Drug Sold as "Bath Salts"]. Since that report nearly two years ago, the use of synthetic drugs continues to rise.

A recent high profile case involving a young woman from Texas and a new CDC finding have added to the list of dangers from synthetic drugs use. A CNN news story indicates that a teenage girl from Cypress, Texas had been diagnosed with vasculitis after smoking synthetic marijuana that may have contributed to a stroke and resulting in two weeks ICU care. The CDC is reporting in its February 15, 2013 MMWR cases of unexplained acute kidney injury associatied with synthetic cannabinoid use. MMWR report indicates:

"AKI has not been reported previously in users of SCs and might be associated with 1) a previously unrecognized toxicity, 2) a contaminant or a known nephrotoxin present in a single batch of drug, or 3) a new SC compound entering the market."

Also, according to the CDC; "Synthetic cannabinoids (SCs) are psychoactive chemicals dissolved in solvent, applied to plant material, and smoked as a drug of abuse. They are sold in "head shops" and tobacco and convenience stores under labels such as "synthetic marijuana," "herbal incense," "potpourri," and "spice." Most reports of adverse events related to SCs have been neurologic, cardiovascular, or sympathomimetic."

 References.
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (December 4, 2012). The DAWN Report: Drug-Related Emergency Department Visits Involving Synthetic Cannabinoids. Rockville, MD.

Acute Kidney Injury Associated with Synthetic Cannabinoid Use - Multiple States, 2012. Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report. February 15, 2013 / 62 (06); 93-98

Teen narrowly escapes death after smoking synthetic marijuana CNN and affiliate news reporting.

Synthetic cannabis, Wikipedia

CDC Defines the Biological Threat

CDC Categorizes Bioterrorism Agents and Diseases

Events involving naturally occurring  pathogens and weaponized biological agents share many features.  The intentional release of smallpox would make world-wide front page news and would be a devastating global public health crisis. Naturally occurring biological events are no different, albeit much less glamorous. Naturally occurring biological events can be as devastating as any intentional biological event, but we rarely consider seasonal flu as a "major event". The fact is that any biologic event can have a profound physical and psychological impact on society and culture. The 2012/2013 Influenza season is a good example of how a naturally occurring event can impact public health. Solid biologic event planning is the key to successful operation during a natural or intentional event. You need know how to write your biologic plan and should avoid common pitfalls in bio-event planning.

The Centers for Disease Control and Prevention list biological agents into categories according to potential harm and ability to be manipulated. Category A biologic agents are those pathogen (bacteria, toxins, and virus) that are rarely seen in the United States and have potential to be enhanced or engineered in order to increase the likelihood of harm. Pathogens in Category A include:

• Anthrax
• Botulism
• Plague
• Smallpox
• Tularemia
• Viral  hemorrhagic fevers

According to the CDC Bioterrorism Agents/Diseases page, Category A biologic agents  pose a risk to national security because they can be easily transmitted person to person, have high mortality rates/major public health impact, could cause panic and social disruption, and require special public health preparedness.

Category B pathogens are defined as those that are moderately easy to disseminate, result in moderate mobility rates and low mortality rates, and need specific enhancements of CDC diagnostic capacity and surveillance. 

Visit the CDC Bioterrorism agents/diseases page for further details on category B pathogens.

Category C pathogens are defined by the Centers for Disease Control and Prevention as those emerging pathogens that could be engineered for mass dissemination in the future. Factors in this making this determination include availability, ease of production and dissemination, and potential for high morbidity/mortality rates with major public health impact.

 Visit the CDC Bioterrorism agents/diseases page for further details on category C pathogens.

What could we do to a virus, toxin, or bacteria to enhance its effects? The first step in answering that question is to understand the target potential (hard or soft) and dissemination. Understand also that intentional biological events may utilize indirect means of dissemination. Person to person spread of disease is possible in both natural and intentional events.

Additional Media
How to write your biologic plan

Four pitfalls to avoid in biologic planning

What good plans have that bad ones don't

The Bioterrorist Next Door

Clinton Warns of Bioweapon threat

Black Death DNA

Alarm Dutch lab creates killer flu

Biologic Exercises provide valuable information

Recommendations show promise for future biological event success

Terrorist attacks using biological agents are potentially deadly beyond imagination. In 2001, the dissemination of engineered Anthrax struck panic with American civilians and emergency service responders resulting in exaggerated responses and near-ridiculous actions. Inhalation anthrax is fatal if not treated appropriately, but there is treatment. How would be as population fair if the biological agent was something more devastating than anthrax; an agent with no cure or treatment? Let’s use smallpox as an example.

In June of 2001, the Johns Hopkins Center for Civilian Biodefense Strategies along with the Center for Strategic and International Studies, the Analytic Services Institute for Homeland Defense held a senior-level tabletop exercise that simulated the effects of a covert biological attack on the United States. The dissemination of highly contagious smallpox as an act of terrorism became know as the “Dark Winter” scenario. This one-of-a-kind TTx examined the ability of senior-level policy makers to face the challenges of a bio terrorist attack with outbreaks of highly contagious diseases.

A similar event took place in January, 2005, this time among the international leadership community. Known as Atlantic Storm, this TTx continued on a larger scale from Dark Winter. Atlantic Storm simulated the heads of state and senior international governmental leaders attempting to manage a simultaneous smallpox bio terror attack on Istanbul, Frankfurt, Warsaw, Rotterdam, New York, and Los Angeles.

Both Dark Winter and Atlantic Storm focused on government leadership and ability to manage issues in public health, medical services, diplomacy, domestic response, and critical infrastructure. Both exercises were well developed and planned...they did, however, reached differing results. What follows is a comparison of the tabletop exercises Dark Winter (2001) and Atlantic Storm (2005). Despite commonalities in scenario and biological agent, glaring differences have emerged that leave those studying such material wondering and concerned. The opinions and concerns addressed herein are based upon study of documents, video where available, objective analysis of the scenarios themselves, of course, smallpox.

Comparison of Assumptions
 Dark Winter focused on the United States as the only target in a “worst-case” scenario; Atlantic Storm targeted the international community with “best-case” circumstances. This primary difference may prove to be a single most perturbing factor when comparing the two exercises.

Although both scenarios simulated the use of smallpox as the agent with similar methods of dissemination, there were concerning differences in the projected infection rates, death rates, and person-to-person transmission potential. Dark Winter assumed a thirty percent fatality rate while deaths from smallpox were projected at twenty-five percent in Atlantic Storm. Atlantic Storm also assumed that there was residual immunity among the affected population with 300 million doses of vaccine available. Dark Winter was somewhat less optimistic; simulating a CDC stockpile of 15.4 million doses of vaccine and allowing for up to twenty percent of stockpile loss due to contamination or improper use.

Dark Winter hypothesized that 1g of smallpox could generate 100 infections when aerosolized resulting in 3000 first generation cases from 30gms of virus. There is no mention of virus quantity in Atlantic Storm; however, both scenarios disseminate the virus via an aerosolizing device under similar conditions. Dark Winter used 1:10 transmission rate (every one person with smallpox could infect ten others) as compared to Atlantic Storms rate of 1:3. Atlantic Storm also anticipated 1: 0.25 for second to third generation while no mention was made in the Dark Winter scenario of second to third generation transmission. Dark Winter planners integrated herd immunity of twenty percent into the scenario which was not accounted for in Atlantic Storm. I found the following excerpt from the Dark Winter scenario an interesting commentary on person-to-person transmission rate. A sidebar reads:

“…Given the low level of herd immunity to smallpox and the high likelihood of delayed diagnosis and public health intervention, the authors of this exercise used a 1:10 transmission rate for Dark Winter and judged that an exercise that used a lower rate of transmission would be unreasonably optimistic, might result in false planning assumptions, and, therefore, would be irresponsible. The authors of this exercise believe that a 1:10 transmission rate for a smallpox outbreak prior to public-health intervention may, in fact, be a conservative estimate, given that factors that continue to precipitate the emergence and reemergence of naturally occurring infectious diseases (e.g., the globalization of travel and trade, urban crowding, and deteriorating public health infrastructure) [26, 27] can be expected to exacerbate the transmission rate for smallpox in a bioterrorism event…”

In contrast, the Atlantic Storm best-case scenario planned for adequate disease control, compliance with public health “social distancing” (a.k.a. quarantine), available vaccine, higher herd immunity, residual protection granted by prior vaccination, and lower transmission rates. The wide range of transmission rates between the two exercises may account for the differences in total number of smallpox cases and deaths. Dark Winters worst-case predicted 1,000,000 deaths with 3,000,000 infections while the Atlantic Storm exercise predicted 660,000 cases and approximately 495,000 deaths.

Summary: Lessons/RecommendationsDark Winter summarized the exercise with a list of lessons and Atlantic Storm used the term recommendations to summarize. Below is a list of lessons from Dark Winter or recommendations from Atlantic Storm that seem to be common to both events despite being conducted years apart. Various excerpts from the text have been added to aid explanation.

• Leaders are unfamiliar with the character of bioterrorist attacks, available policy options, and their consequences.
• After a bioterrorist attack, leaders’ decisions would depend on data and expertise from the medical and public health sectors.
• …they were given more information on locations and numbers of infected people than would likely be available in reality.” Statement concerning the amount of infromation given out in both TTx's.
• …lack of information, critical for leaders’ situational awareness in Dark Winter, reflects the fact that few systems exist that can provide a rapid flow of the medical and public health information needed in a public health emergency.”
• …it was difficult to quickly identify the locations of the original attacks…”
• The lack of sufficient vaccine or drugs to prevent the spread of disease severely limited management options.
• After a bioterrorist attack, leaders’ decisions would depend on data and expertise from the medical and public health sectors.
  
  

  … [This] reflects the fact that few systems exist that can provide a rapid flow of the medical and public health information needed in a public health emergency.”
  “What’s the worst case? To make decisions on how much risk to take…whether to use vaccines, whether to isolate people, whether to quarantine people…I’ve got to know what the worst case is” (Sam Nunn).

• The lack of sufficient vaccine or drugs to prevent the spread of disease severely limited management options.
• The US health care system lacks the surge capacity to deal with mass casualties.
• The numbers of people flooding into hospitals across the country included people with common illnesses who feared they had smallpox and people who were well but worried.”

“…[the challenges]of distinguishing the sick from the well and rationing scarce resources, combined with shortages of health care staff, who were themselves worried about becoming infected or bringing infection home to their families, imposed a huge burden on the health care system.”

• To end a disease outbreak after a bioterrorist attack, decision makers will require ongoing expert advice from senior public health and medical leaders. 

• “…the imposition of geographic quarantines around affected areas, but the implications of these measures (e.g., interruption of the normal flow of medicines, food and energy supplies, and other critical needs) were not clearly understood at first. In the end, it is not clear whether such draconian measures would have led to a more effective interruption of disease spread.”

  “A complete quarantine would isolate people so that they would not be able to be fed, and they would not have medical [care].…So we can’t have a complete quarantine. We are, in effect, asking the governors to restrict travel from their states that would be nonessential. We can’t slam down the entire society” (Sam Nunn).

• Federal and state priorities may be unclear, differ, or conflict; authorities may be uncertain; and constitutional issues may arise.
  
  

  “My fellow governors are not going to permit you to make our states leper colonies. We’ll determine the nature and extent of the isolation of our citizens…You’re going to say that people can’t gather. That’s not your [the federal government’s] function. (Frank Keating).

  
  

  “…worried that it would not be possible to forcibly impose vaccination or travel restrictions on large groups of the population without their general cooperation."

  
  

  “The federal government has to have the cooperation from the American people. There is no federal force out there that can require 300,000,000 people to take steps they don’t want to take” (Sam Nunn).

  
  

  “…Atlantic Storm showed that even experienced politicians have unrealistic notions of what WHO would be able to deliver in a crisis, given its current budgetary, political, and organizational limits.”

  
  

  “In Atlantic Storm, leaders viewed border closings and travel bans as an unattractive option for controlling the spread of disease, but, given the lack of vaccine or any other mechanism to control disease, they were forced to consider these measures.

“…leaders were provided with far more situational awareness than they would have had in a real crisis. They were given the locations and numbers of reported smallpox cases in almost real time, and they were constantly updated as information changed. If this had been a real bioattack or epidemic affecting cities in multiple countries, leaders would have had a great deal of trouble getting even this level of basic information.”

Questions:In the end it would appear that we are not much closer to answering (or instituting) the questions posed by these two exercises. The results of the two events, despite being years apart, have come to similar end points…without resolution. Since Dark Winter, we have seen the 9-11 attacks, dealt with WNV, witnessed SARS, and begun preparing for H5N1. Yet, these questions continue to be re-invented.

Given the time frame of the two exercises, one being pre-9-11 and the other post-9-11, is there any expectation change in the “post-9-11 mindset”?

Can any correlation be drawn between the expectations of national leaders towards international cooperation and state/local leaders towards cooperation with the Federal government?

Will the American public respond differently to a biological attack that threatens only the United States in contrast to an attack threatening the U.S. as well as other nations?

How will we approach issues of evacuation, quarantine, mandatory vaccination, and loss of freedoms? Will compliance be better or worse based on the events of Katrina?

Can we compare the expectations of FEMA during Katrina to the expectations of the CDC during a biological terrorist attack?

Why are we not closer to resolving the issues mentioned in these exercises?

So many of the Atlantic Storm recommendations are strikingly similar to the lessons of Dark Winter that one has to ask if the organizers have even read the Dark Winter scenario!

Lessons from Dark Winter and Atlantic Storm applied to seasonal Influenza

Biologic Tabletop Exercises can help Influenza preparedness

Everyone remembers Hurricane Katrina. Did you know that about a year before Katrina there was another devastating hurricane? Just about a year before Katrina hit the Gulf Coast, Hurricane Pam ripped through causing the levee system to fail, flooding New Orleans, and causing destruction on nearly a life for life, dollar for dollar par with Katrina. The storm was Hurricane Pam and you didn’t read about this storm in the paper or see it on television. Why doesn't anyone remember Hurricane Pam? You don’t remember Pam because it never actually happened...Hurricane Pam was a tabletop exercise (TTX) that predicted with eerie accuracy what would happen if a major hurricane scored a direct hit on the Gulf Coast. The point is that we can learn a lot from our own exercises if we listen. In this post I’m suggesting we learn the lessons from two biologic event tabletop exercises...

In the setting of a naturally occurring or intentional biologic attack how will countries manage shortages of medicine, vaccines, and medical supplies? What mechanisms will be used to control or halt the spread of disease? How will local and national leaders balance their responsibilities to their own citizens with their responsibilities to the international community?

These are the questions we should be asking ourselves and these are the issues addressed by two tabletop exercises Dark Winter and Atlantic Storm.

Click the player below for staged media footage used in Dark Winter.

Watch Dark Winter Pretext for TOPOFF/CCMRF/CBRNE Martial Law Drills in Educational & How-To | View More Free Videos Online at Veoh.com

In June of 2001, the Johns Hopkins Center for Civilian Biodefense Strategies along with the Center for Strategic and International Studies, the Analytic Services Institute for Homeland Defense held a senior-level tabletop exercise that simulated the effects of a covert biological attack on the United States. The dissemination of highly contagious smallpox as an act of terrorism became known as the “Dark Winter” scenario. This one-of-a-kind TTx examined the ability of senior-level policy makers to face the challenges of a bioterrorist attack with outbreaks of highly contagious diseases.



A few years later, in January, 2005, a similar exercise took place. This time among the international leadership community, known as Atlantic Storm, this TTx continued on a larger scale from the Dark Winter exercise. Atlantic Storm simulated the heads of state and senior international governmental leaders attempting to manage a simultaneous bioterror attack. The attack was centered on Istanbul, Frankfurt, Warsaw, Rotterdam, New York, and Los Angeles with Smallpox as the weapon.

Already know it all? Think again. Atlantic Storm verbalizes many of the issues discussed in recent studies as well as historic preparedness problems. An excellent real-life example, Atlantic Storm is also a high quality tabletop exercise, complete with PDF user guides and downloadable documents, Atlantic Storm provides an outstanding example of power a tabletop exercise (TTX) can bring to the planning and training process.

A review of Dark Winter and Atlantic Storm is a useful tool for traditional and non-traditional responders. Take an hour and view the presentation, review the documentation. To view Atlantic Storm; go to: http://www.atlantic-storm.org/flash/index-b.html and turn up you speakers!

Will your POD work when you need it?

Planning essential for Points of Distribution success

Points of Distribution, or POD, is a site designated for the distribution of medications or supplies in the event of a crisis or emergency. The pubic gathers at a give location or locations and materials are handed out.are the hub of pandemic planning in some communities. The POD system can be a viable option for medication distribution but is dependent on a number of factors for success.

The current points of distribution model is based on an earlier process used to receive, break down, repackage, and distribute materials/supplies from the National Pharmaceutical Stockpile (NPS). The idea was further refined for the use after experiences with SARS, H5N1 Highly Pathological Avian Flu and 2009 H1N1.

There are four basic assumptions to be considered in points of distribution planning. We assume that:

• the pathogen will be known 
• the appropriate medication/vaccine will be available
• staffing will be adequate
• civil order will be maintained

The assumption that the pathogen will be known or reliably predictable is key. Without this vital information there is little benefit to mass vaccination or prophylactic medication. We may also have to predict when a given pathogen is threatening and plan time to medicate/vaccinate our public. Many assumptions were based on a disease coming from a certain known area and estimating how long it may take for that disease to reach a given population. Many so called pandemic plans assume a disease like SARS or Avian Influenza will take weeks or months to reach us and we'll have sufficient time to put plans into action. Our experience with SARS and predictions of H5N1 and is rendered totally dysfunctional after experience with 2009 Swine Flu. To assume there will be a "lead-time" when we know a pathogen is coming is a mistake. As we have seen with H1N1 in 2009, the disease was present in various states with little or no lead-in. In that situation, we have to plan for the disease spreading beyond any given boundary by virtue of our modes of modern travel and limited surveillance ability. Without clear definition of the pathogen in question, bringing otherwise healthy people together into a central location for medication distribution may actually increase exposure. The key to success is to provide as much information as possible to the public and institute non pharmacological interventions to prevent disease spread during your distribution.  

Points of distribution planning must consider vaccine or medication availability. Vaccine or medication may not be available in quantities needed to meed the demand at a given POD site while others may be overstocked. One of the worst possible situations would be to run out of medication. Running out of medication leaves people standing in line and not getting protected, perhaps being exposed and certainly not meeting expectations. In the extreme situation, there is a risk of civil unrest (imagine being next in line and told "sorry, we just ran out) and certainly a blow to your public image.

Adequate staffing is major planning point. Staffing must be able to meet demand for service. Conducting you point of distribution under the NIMS model will be helpful. Incident Action Planning and Operation Period Planning are vital to determine staffing requirements. Managing the que and providing sanitation services, shelter from the environment, food, and medical care at POD locations are additional logistics that must be considered but may not be part of your points of distribution planning.  The people in line are y our concern and their needs must be addressed. Utilization of Federal Medical Stations as a model may be beneficial for points of distribution planning. Federal Medical Stations are part of the Centers for Disease Control and Preventions Strategic National Stockpile program and is designed to fill a gap that exists between disaster shelters and temporary hospitals. According to the CDC Works For You 24/7 Blog, Federal Medical Stations are non-emergency medical installations used during disaster situations to care for people with special medical needs and  chronic health conditions. They also include services for those with mental health issues. The CDC notes that FMS can be operational within 48 hours. See Federal Medical Stations, Mitigation Journal (December, 2012)

 Civil unrest and disobedience is a real problem that could threaten all aspects of points of distribution operation. Dealing with uncooperative persons, people with special needs, and those intent on causing problems is often beyond the scope of those working in a POD. Understand that the unrest can turn into a riot and become violent quickly especially if you run out of medication and needs are not met. Sufficient law enforcement resources must be in place to prevent or counter any disruptive situation. Law enforcement must also be able to manage traffic flow and parking.

In isolated situation  points of distribution were overwhelmed with people and had delays of several hours while other locations remained nearly silent. This may be due, in part, because  people did not know where to go, under what conditions to go, or did not understand direction. Plan for people not following direction. We can expect that once the media announces that site "A" is running with a ten-hour delay, many people will flood site "B".

Points of Distribution sites are difficult to manage and plan for. They are a part of pandemic planning, but only a part.

Additional resources:
Four pitfalls to avoid in biologic planning Mitigation Journal July, 2012
How to write you biologic plan Mitigation Journal October, 2010

Commonn Sense Influenza

Prevention of transmission of flu sometimes takes on a life of its own. The media hype and hysteria can easily overwhelm the facts. We need to remember that the flu virus is one of the most infectious pathogens we know of and that Type A influenza is prone to subtle changes in its structure that make it a challenge to our immune systems year after year. It's also important to remember that droplets aerosols and direct contact can spread influenza. Knowledge and common sense can keep us safe.

The first thing in the need to know about influenza is the terminology… and we've come to recognize quite a bit of terminology surrounding the flu. Seasonal flu (sometimes called the common flu) is exactly what it sounds like; that strain of flu that circulates a given area every year. Avian flu (highly pathologic avian influenza) is the name given to a strain of flu that mainly circulates in Asia impacting various bird species with limited transmission to humans. Swine flu on the other hand, is the name given to a strain of influenza that emerged from South America–Mexico–in late 2008. This strain of influenza was particularly troublesome because it seemed to impact otherwise healthy people in a very dramatic way. And lastly, the term pandemic. A pandemic has been seen by the media as a term that indicates large numbers of deaths from disease. Although throughout history this is often the case, a pandemic is not an automatic term for mass fatalities. The term pandemic simply means the disease has spread around the globe and impacted many areas of population.

There are several types of influenza viruses and  influenza virus belongs to the category of diseases known as Orthomyxoviruses.   The three types of flu are Type  A, Type B,  and Type C. Type A influenza is known as a multi-host pathogen infecting both humans, swine, and birds. This is the most virulent  group and is classified by its surface antigens into subtypes. It is these subtypes that make up the H and N that we hear so much about on the news. H stands for hemagglutinin and N indicates neurominidase.  Both of these are surface proteins on the virus that allow the virus to get into a host cell, reproduce, and then escape. Remember, viruses are parasites and need to have a host to survive. There are 15 different types of H's and nine types of N's giving us a total of 135 potential combinations of type A influenza. Type B influenza is seen mostly in humans and although it's very common it is much less severe than Type A influenza. Epidemics involving type B influenza occur much less often than those involving Type A. It's important to note here that human seasonal flu vaccine includes two strains of Type a and one strain of Type B protection. Given that there are 135 potential type a influenza combinations and only two are included in the seasonal flu vaccine, indicates why we have years when the seasonal flu vaccine is less effective than others… that is, scientists have to guess which two strains of influenza should be included in the vaccine. Type C influenza infects humans and swine and has a completely different pattern of surface proteins. Normally Type C presents with rare occurrences and has mild or no symptoms. In fact, by age 15 most people have antibodies against Type C influenza.

During an average flu season in the United States there are 35,000 to 45,000 deaths attributed to seasonal flu. The hardest hit by seasonal flu include those with severe medical conditions,  impaired immune systems, or extremes of age… young or old. Epidemics tend to occur in the winter months with peaks of hospitalization and death related influenza during this time.

DHS Fires Back with Active Shooter Preparedness

The Department of Homeland Security is hosting an Active Shooter Preparedness site loaded with a variety of interactive, web-based tools and instructional aids.

Poster from DHS Active Shooter Preparedness

The Active Shooter Preparedness site offers the following resources 

• Active Shooter: What Can You Do Course
• Active Shooter Webinar
• Active Shooter Workshop Series
• Active Shooter: How to Respond Resource Materials
• Options for Consideration Active Shooter Training Video
• U.S. Secret Service (USSS) Active Shooter Related Research
• Active Shooter Resources for Law Enforcement and Trainers: Request for Access to Joint Countering Violent Extremism (CVE) Portal
 

Most of the material hosted by DHS is ready-to-use or self-study format. This site is ideal for in-service training. According to the DHS Active Shooter Preparedness site:

The Department of Homeland Security (DHS) aims to enhance preparedness through a ”whole community” approach by providing training, products, and resources to a broad range of stakeholders on issues such as active shooter awareness, incident response, and workplace violence. In many cases, there is no pattern or method to the selection of victims by an active shooter, and these situations are by their very nature are unpredictable and evolve quickly. DHS offers free courses, materials, and workshops to better prepare you to deal with an active shooter situation and to raise awareness of behaviors that represent pre-incident indicators and characteristics of active shooters.

For more, see prior MJ postings Soft Targets Attractive to Active Shooter Events and MJ Podcast #187: Inside Look at Net Talon. Also recommended: Net Talon

 

Highlights

Active Shooter: How to Respond Resource Materials provides quick and easy reading materials for businesses, offices and schools in preparing for an active shooter event. Print materials available include: active shooter booklet, active shooter poster and active shooter pocket card.

The Active Shooter Training Video gives simple and easy to follow recommendations for personal safety during a shooter event. This video is crisp and to the point and would be ideal for introducing the topic to a workforce and supporting training already in progress.

For those interested in case study, the United States Secret Service has provided several research papers related to active shooter events.

• Campus Attacks: Targeted Violence Affecting Institutions of Higher Education
• Prior Knowledge of Potential School-Based Violence: Information Students Learn May Prevent a Targeted Attack
• Assassination in the United States: An Operational Study of Recent Assassins, Attackers, and Near Lethal Approaches
• Protective Intelligence & Threat Assessment Investigations: A Guide for State and Local Law Enforcement Officials
• Threat Assessment: An Approach to Prevent Targeted Violence
• Threat Assessment: Defining an Approach for Evaluating Risk of Targeted Violence

The Best Disease Prevention is Action

More than vaccine, personal protection requires personal action

Personal protection equipment (PPE) can protect us from everything from anthrax to influenza but use of such equipment is unrealized as is the value of a good infection control program until someone gets sick.  Our personal protection is more than  a “thing” we put on, our best personal protection is our action.

No matter which side of the mandated vaccine debate you happen to be on, vaccine is a top preventive measure. Vaccines are proven to be safe and effective. Not only do they provide the individual with protection from specific diseases, vaccination also provides herd immunity to a given population. A community that is vaccinated and protected against disease also protects those who have not developed immunity. Herd immunity is vital to those with compromised immune systems and even to some healthy groups such as schoolchildren.

CDC photo

Pharmacological measures such as vaccine are fantastic at preventing disease. However, the downfall is that they are not always readily available and pharmaceutical shortages have become frequent. Deployment of vaccine and oral medications can be challenging. It's important to understand the role of non-pharmaceutical interventions in disease spread control. The non- pharmaceutical interventions include; hand washing, respiratory etiquette, appropriate social isolation.

Hand hygiene, the simple act of washing your hands, is rated as the number one means for preventing the spread of disease. The use of warm water and soap for washing hands for between 15 and 30 seconds is a major component in effectively stopping disease spread in any population.

Respiratory etiquette means covering your cough and your sneeze and limiting other secretions you discharge from your mouth or nose. Covering your cough and sneeze is a mainstay of respiratory etiquette and helps prevent droplet transmission of disease. Droplet transmission is a major mode of transmission for Type A influenza. Don't be afraid to put a mask on yourself or patients exhibiting signs of influenza-like illness. Placing a mask on the patient goes a long way to containing the source of the droplets and respiratory secretions at the source and placing a mask on you significantly decreases your intake potential of those droplets and respiratory secretions. The Centers for Disease Control and Prevention noted that standard surgical masks were sufficient to prevent droplet transmission in the setting of many respiratory illnesses including Type A influenza.

Social distancing means staying home when you're sick and includes staying out of public areas when you're ill. It does us no good to have someone stay home from work and/or school only to go to the local shopping mall or otherwise be out in public. I realize this is not a popular topic with many employers but the fact remains that people who are ill with gastrointestinal problems or respiratory illness should not be in a position to spread that disease whenever possible.

Simply wiping down flat surfaces in your work environment will go a long way to preventing your exposure to disease and the spread of many illnesses. Many commercial products are available for this purpose and a quick wipe on telephones and computer keyboards will help prevent disease spread.

Flu Emergency. How prepared are we?

NYS, Boston declare public health emergency as widespread flu remains "intense"

New York State joined Boston, MA by declaring a public health emergency as a result of seasonal influenza. Boston Mayor Thomas Menino made the emergency declaration on January 9, 2013, New York followed with its own emergency declaration at the direction Governor Cuomo on January 12.

The NYS declaration includes an Executive Order that allows pharmacists to administer flu vaccination to people six-months and older. Governor Cuomo strongly urged all New Yorkers to get a flu shot and directed the NYS Health Department to "to marshal all needed resources to address this public health emergency and remove all barriers to ensure that all New Yorkers - children and adults alike - have access to critically needed flu vaccines." Mayor Menino included statements urging people to remain home when sick in addition to getting a flu vaccine. Mayor Menino further stated that "This is not only a health concern, but also an economic concern for families..."

Could we see flu coming?
The public health emergencies in Boston and New York State were issued during week 2 (January) 2013 while influenza had been identified as "high" or "widespread" in some states since week 46 (November) 2012. According to the Centers for Disease Control and Prevention,  Mississippi was experiencing high or widespread flu activity in November (week 46) and by week 47, flu was identified as high or widespread in Tennessee, Alabama, Louisiana, and Texas. By week 52 there were 30 states, including New York and Boston, that made the list of states experiencing high or widespread flu.

By comparison, Google Flu Trends identified NY and Massachusetts as having "high" flu activity on December 12, 2012. Flu activity was identified as "intense" in  NY and in Boston on December 23, 2012.

Both the NY and Boston public health officials encourage vaccination and have opened flu vaccine clinics and since the declarations of emergencies, mainstream media attention has expanded. Looking back, we haven't seen the flu awareness campaign as we did in response to the 2009 Swine flu situation.

Are public health and local health care systems prepared to deal with unexpected biologic situations? The answer is not reassuring.  According to Trust for Americas Health 10th annual Ready or Not? Protecting the Public from Diseases, Disasters, and Bioterrorism report, 35 states and Washington, D.C. scored a six or lower on 10 key indicators of public health preparedness. See also States Lagging in Emergency Preparedness by Healthday News.

While the 2012/2013 Flu Season continues, the question on the minds of many is: why is flu so bad this year?  While this question will be studied and debated, an easy answer may be that people simply did not get vaccinated and were unprepared for an early start to the flu season. The CDC states that its too early to define peak of flu season. However, the Washington Post is reporting that over 60% of Americans have not been vaccinated as of November 2012. Meanwhile, an interesting side story is developing...despite low vaccination rates, retail and healthcare systems are reporting dwindling vaccine supply. If vaccine supply is drying up when 60% of the population didn't get the shot, how ready were we in the first place?

No vaccine, no mask? No job

Healthcare providers fired over flu vaccine mandate

ABC is reporting the firing of eight hospital Indiana hospital employees, three of them nurses, for failure to comply with influenza vaccination program. USA Today is running a story about a registered nurse who has been fired for not wearing a mask after declining flu vaccine. These reports indicate a growing trend in healthcare: comply with flu vaccine mandates or risk loosing your job.

Mandate the shot or not? We may have an answer to that question.
There are indications that mandated participation in flu vaccine programs have become normal. Notice the term flu vaccination program, meaning that there is more than just vaccine involved. Flu programs typically give the healthcare employee a choice to be vaccinated or, decline the vaccine and wear a mask while at work. Having reviewed a number of policies, we've noticed a growing number of healthcare agencies (including non-hospital facilities) have begun to require "participation" in a flu program. The meaning of the word "participation" changes frequently between facilities and can indicate a vaccine requirement, receipt of vaccine or signed declination, or vaccine/decline and wear a mask.

As noted in the USA Today piece, some healthcare providers feel stigmatized by being requiered to wear a mask. Some may consider their privacy has been eroded as they feel compelled to explain why they have to wear a mask.

No shelter for you! In case of emergency, go some place else

Identifying where not to shelter is becoming popular. 

The reason should be no surprise.

People may evacuate or shelter in place during a disaster situation. Evacuees often find themselves seeking refuge in an established shelter of one type or another. Shelters are typically preplanned and established within the framework of a disaster plan that includes a system of public information. Those who don't evacuate to a shelter, didn't receive shelter information, or are unfamiliar with their current location, may find themselves seeking safe haven at locations of perceived safety. Public locations such as schools and libraries may be thought of as "places to go" during a crisis. Similarly, other installations may represent a location of service or place to go for help. Fire stations and healthcare facilities are often understood to be locations were the public can go for help in times of crisis. But are these locations suitable and prepared to become shelters during disaster or crisis situations?


What happens when public expectation is not met?

Photo credit: Michael Ehrman

We discussed this topic in the aftermath of hurricane Katrina and the Tenet health decision. Tenet Health, owners of  a New Orleans hospital, were sued by the people who sought shelter at the hospital during and after hurricane Katrina. The suit alleged that the hospital was not prepared to deal with the disaster situation and provide for the needs of those who sought shelter at the hospital. It'd be important to to note that those who came to the hospital during Katrina were not patients. Since the public had never been told not to shelter there, it was a reasonable expectation that the hospital was a shelter and, therefore, liable. At the time of publication, we called the Tenet decision the biggest healthcare preparedness ruling that no one is talking about. While the monetary impact of the suit may not have been impressive, the implications of the outcome were president setting. More and more we're seeing signs posted telling the public that this place "is not a shelter". It seems a little creepy to find a sign on the door of your local school or hospital or Moose Lodge reminding you to go someplace else in the event of an emergency.

Michael Ehrman, retired emergency manager and long time MJ follower, sent in the above photo taken at a school in his area. What locations in your ares might be considered to be a safe haven or shelter by the public? Is your agency prepared to take in refugees during a disaster? Finally, are you aware of public perceptions concerning sheltering in your area? In the wake of natural disasters like Hurricane Katrina and more recently, Super Storm Sandy, this would be a good time to explore those questions and include the proper information in your public education and preparedness efforts.

Related posts:
Forward thinking: Bringing the Katrina Healthcare Decision Home
Message from Katrina: Hospitals, be ready

Thirteen years after Columbine, what have we learned about school shootings?

 Are we any further ahead at preventing school shootings today than we were in 1999?

Our prayers are with the victims, survivors, and rescuers...

Newtown CT joined the ranks of the those communities devistated by a school shooting event  on December 14, 2012 when a 20-year-old carries out shooting event at an elementary school. The lone attacker is reportedly to have fatally shot his mother as she slept, stealing two pistols and one rifle, prior to going to the Sandy Hook Elementary School.


According to media reports, he forced entry, easily defeating school security systems, by shooting out a window and proceeded to shoot two school administrative staff and children in a first grade class. All the children were between six and seven-years-old. Authorities are reporting a total of 20 children and 7 adults murdered.

It’s sad to say it and hard to hear it. It's even harder to understand. Sadly, it is a topic we've visited many times in this blog and podcast. We've discussed active shooter events and civilian soft targets as much as we've talked about chemical and biological weapons.

We most recently spoke on this topic after the Aurora Colorado movie theater shootings. Our opinions are the same today as they were after that tragedy. The liberal left and conservative right have it all wrong when it comes to finding causes and preventing similar active shooter events. (listen to MJ 238 Aurora CO Movie Shootings - Why we’ve got it all wrong) Stricter gun control will not solve this issue. More people with guns will not prevent future attacks.

Commonalities in active shooter events

• Civilian soft target remain the location of choice. Hospitals also remain at risk with once such active shooter event taking place almost simultaneously at a hospital in Birmingham, Alabama. The Sandy Hook School did have some level of security but it was circumvented. Why was it so easy to breach?

• Gunshot wounds inflicted at close range. The rate of fire and physical confines produce a rapid attack with high fatality rate. There is little opportunity for protective action because of the speed of the event (possibly also because of the age of majority of the victims and the situation they are in).

• Ancillary event - some other related occurrence, prior to main event, that would herald the main attack - shooting his mother, in this case. Use of explosives in other situations to draw attention away form the intended target or as a secondary event to create further casualties.

• History - in many of the cases the alleged perpetrator has had a mental illness diagnosis

Shooting events at high profile soft targets are difficult to prevent and have significant, long-lasting effects. They also have numerous commonalities that can be used to aid planning efforts.

"Locations of critical infrastructure such as hospitals, will need to be protected from attack as will other civilian locations. Hotels, coffee shops, and shopping centers lack the deterrents necessary to prevent attacks. The psychological impact of an attack on any of these soft targets will nearly as devastating as the loss of life."

How ready are we for active shooter events? A question asked too many times over the last seven years.

Active shooter situation may be the most difficult to domestic terrorism situation to deal with. Many of the active shooter situations take place in a work environment or in a public venue with little or no warning. Firearms of all varieties have been noted in active shooter case studies from the United States. According to the Department of Homeland Security:

"An Active Shooter is an individual actively engaged in killing or attempting to kill people in a confined and populated area; in most cases, active shooters use firearms(s) and there is no pattern or method to their selection of victims..."

These events are unpredictable in nature and timing, but the outcomes and be generically predicted.  If we follow the basic principles of Life Safety, Incident Stabilization, and Property Conservation, we'll be able to keep personnel safety and response priorities in balance.

Key to remember that soft targets continue to be chosen by active shooters and present significant threats. Preplanning and inter-agency cooperation is paramount to reducing the loss of life.

Active shooter situations in a soft target location - a mall, school, hospital/health care environment, or sporting events are disastrous. The answer may be someplace between the left and right...

Screen savers and call bells offer hand hygiene reminders

Two studies look at infection control prompts

Non-pharmaceutical interventions for preventing and controlling infection often take a back seat to vaccination programs. This is especially true during flu season. While vaccination is a vital cornerstone of preventing disease spread, limited access to vaccine and reluctance of staff to get vaccinated can cripple your vaccination program. Non-pharmaceutical interventions are easily taught and integrated within your daily routine. The typical non-pharmaceutical interventions include hand hygiene, respiratory etiquette, and appropriate social distancing, and should be readily available at all times. Hand hygiene is historically considered the most important of these interventions for controlling the spread of disease.

How do we increase voluntary compliance with such an important intervention?

Two studies published in the American Journal of Infection Control looked specifically at ways to improve hand hygiene compliance.

Sample screen saver message

Computer screen saver hand hygiene information curbs a negative trend in hand hygiene behavior.
Can your screen saver change hand hygiene habits? Apparently so, according to the authors of this study. They concluded that by placing gain-framed messages highlighting the benefits of hand hygiene on computer screen savers that compliance was increased.

Evidenced based or not, this seems like a good idea. Screen savers are a venue for delivering a message to your target audience. Rather than displaying some random graphic or blank screen, use the screen saver to reinforce important information on relevant topics.

Positive deviance: Using a nurse call system to evaluate hand hygiene practices evaluated the use of staff alerting system (referred to in the study as a nurse call system) to improve compliance with hand hygiene when entering and leaving a patient care area.
This study monitored the use of alcohol based hand sanitizers using electronic counters. They found that the use of hand sanitizer increased after linking the call system and sanitizer use data - using the call system as a reminder to use hand sanitizer - with higher utilization rates remaining for 2 years. They also noted a trend toward lower device-related infections, including urinary catheter-associated infections.

The study concluded: “The PD [positive deviance] approach to hand hygiene produced increased compliance, as measured by increased consumption of alcohol hand sanitizer, an improved ratio of alcohol hand rub uses to nurse visits, and a reduced rate of device-related infections, with results sustained over 2 years.”

Federal Medical Stations

Providing special needs care in less than 48 hours

What do you get when you add 24 hours and 40,000 square feet of
 medical equipment? You get a Federal Medical Station or FMS.

The FMS is part of the Centers for Disease Control and Preventions Strategic National Stockpile program and is designed to fill a gap that exists between disaster shelters and temporary hospitals. According to the CDC Works For You 24/7 Blog, Federal Medical Stations are non-emergency medical installations used during disaster situations to care for people with special medical needs and  chronic health conditions. They also include services for those with mental health issues. The CDC notes that FMS can be operational within 48 hours and their operational period is open-ended.

 It’s vitally important that basic medical needs are met during disaster situations and meeting those needs becomes an extraordinary challenge when hospitals are compromised or destroyed. While the FMS’s are not hospitals, they provide an invaluable resource and example for the disaster and emergency management community. Federal Medical Stations become a force multiplier by providing routine medical care for those with routine medical conditions, including the provision of routine medications, by sheltering those people, and keeping them out of an already stressed healthcare system during disaster. The FMS has the extra dimension of meeting mental health needs.

The FMS system relies on the asset management and logistics of the Strategic National Stockpile (SNS) for deployment. The SNS is a combination of warehoused supplies and vendor managed inventories of critical medications and equipment that can be shipped in bulk to areas in need. Each city or jurisdiction should have a plan in place (and tested) to receive assets from the SNS.

Photo Credit: CDC - Federal Medical Station

Creation of civilian, locally-based medical stations (in addition to disaster shelters) would be a major improvement to local and regional preparedness. Systems like the FMS should be reproduced by local jurisdictions to meet the expected needs of a community during crisis. We’re not suggesting reinvention of the entire system or duplication of existing programs. A smaller scale version of the FMS that is readily available to local governments with minimal lag-time would improve local response to crisis and disaster situations.

Influenza Vaccine Overrated?

Study reignites vaccine, antiviral controversy

Debate to mandate the (flu) shot or not for healthcare workers in the United States continues as additional data suggests seasonal influenza vaccine may not be all its cracked up to be.

Canadian healthcare workers are getting two differing opinions on mandated flu vaccine according to a report published by Public Health Ontario/Canadian Medical Association. Some Canadian researches continue to endorse the mandated flu vaccine policy for healthcare workers citing an 86% effectiveness when the vaccine is well matched to circulating virus. Researchers also claim that flu vaccination of healthcare workers in long-term care facilities (LTCF) may decrease resident flu mortality by 5-20%. The Canadian report, published in CIDRAP, the Public Health Ontario editorial indicates that flu strains that may produce Guillian-Barre Syndrome (GBS) are avoided in vaccine production. Its not clear how, exactly, GBS causing strains of influenza are kept out of vaccine production.

In the United States many healthcare systems and some sates are mandating participation in a flu vaccination program, according to the Centers for Disease Control and Prevention (CDC). “Participation” may include mandated vaccine, vaccine or singing a declination form, or mandated to don a mask.

Adding to the vaccine mandate controversy is a report from the Center for Infectious Disease Research and Policy at the University of Minnesota. This report proposes that seasonal influenza vaccine offers little protection to otherwise healthy young and middle-age individuals. They also believe that the benefit may be even less for those greater than 65 years of age. The New York Times recently printed an editorial on this topic.

While the vaccine debate continues, use of the antiviral drug Tamiflu is drawing concern. You may recall that Tamiflu (oseltamivir), and a class of medications known as Neuraminidase (NA) inhibitors, has been used to treat influenza. These medications are also on the CDC list for the treatment of seasonal influenza. However, reports have suggested that influenza has become (or is becoming) resistant to Tamiflu. One report from the CDC (9 Jan 09) states early data from a limited number of states indicating that a high proportion of influenza A (H1N1) viruses are resistant to the influenza antiviral medication oseltamivir (Tamiflu®). An article in Medscape highlights Tamiflu concerns brought on by researchers in the British Medical Journal. If you'd like to read in scientific detail about Tamiflu resistance, check out this post from the Virology Blog.

What’s the answer?
We have to remember that season influenza A continues to change every year. Some years the vaccine is well matched to the circulating strain, while other years it may not be. Its important to have an understanding of the terminology, types and impact of influenza (see 3 things to know about seasonal flu MJ 11/10). You should also brush up on the non-pharmaceutical interventions of hand hygiene, respiratory etiquette, and (appropriate) social distancing.

Selling the Preparedness Mindset

A recent comment got my attention; it should get yours, too. 

 

Aaron Marks posted a comment in response to No surprises in Sandy's wake that will hit home for many in emergency management as we struggle to make a successful pitch for preparedness. Although his comment specific to business and commercial preparedness, I think the spirit of the post can be applied to the public/civilian.

Aaron Marks writes:


For most of the people who follow MJ you're preaching to the choir here. The million dollar question is how do we fix it? 

I spend most of my time these days trying to convince business owners to invest in preparedness - with extremely limited success. Most of the decision-makers and so-called leaders out there just don't want to acknowledge that there is an issue because once they acknowledge it there may be liability associated with failing to do something about it. How do we convince 'the massess' that preparedness is an INVESTMENT and not a cost?

Why is preparedness such a hard topic to sell?

We should put the word sell in parenthesis. We can be selling the idea of preparedness or selling a product or service related to preparedness, or both. In there may be the problem. We’re trying to convince people in the community, business owners, public officials, or civilians that a certain action needs to be taken when most of those we’re selling to haven’t ever experienced any kind of serious event. And they don’t think they ever will. Many individuals and business owners have used phrases like “that’s what I have insurance for” when rationalizing their lack of preparedness.

What we’re “selling” is the preparedness mindset.

Persuading anyone to buy or do something they don’t think they need is an extraordinary uphill trek. After terrorist attacks and natural disasters woke us from the slumber of complacency, we’re eager to hit the snooze alarm and get back to business as usual. Or at least back to business of the new normal...whatever that may be.

The sad and unrelenting fact is that in the face terrorism, pandemics, and devastating natural disasters, many continue to believe that “its not going to happen to me.” In June, 2008, we wrote about this in the posting In search of preparedness in America. That post generated considerable discussion. As I wrote then “governments seem to have lacked the stamina to keep up with preparedness...” and I continue to believe that today. The response to and recovery from Hurricane Sandy continue to make my point here in 2012. You’d think that with Sandy fresh in our minds that preparedness would sell itself.

The liability of acknowledgment.

We also described an interesting, yet disturbing trend in October, 2010 (see Cassandra Paradox)  - We’ll call it the Theory of Successful Blame.

“Emergency planners, managers, and responders are responsible for actions taken (or not) before, during, and after disaster situations. While emergency planners, managers and responder should be held accountable for their performance during crisis or the performance of their planning or training preparedness, it seems that the need to have a scapegoat overpowers the reality that many of the disaster situations are fluid and may not evolve as predicted. Unreasonable expectations need to hold someone accountable when an unpredictable situation goes astray.”

The point is that acknowledged or not, someone is going to be held accountable. The preparedness liability exists and will remain on someones shoulders. A review of of the Hurricane Katrina/Tenent Health decision is a good reminder of this.

How do we convince the masses?

What we should be doing is informing and keeping it simple. Informing that preparedness is a cost effective in financial and life safety terms. We can provide information and rationale that may be helpful in bringing awareness to the forefront.

E. L. Quarantelli (University of Delaware Disaster Research Center) is my most cherished resource on emergency management teaching. In his paper More and Worse Disasters in the Future (1991); Quarantelli provides us with decent talking points, if not ammunition, to get people thinking about their need to embrace preparedness (click here for PDF).

For example, Quarantelli suggests that:

• Natural disasters will increasingly generate technological disasters
• Old kinds of natural disaster agents will simply have more hit and along some lines more vulnerable populations to impact
• There are technological advances that add complexity to old threats
• Many of the future threats or risks have high catastrophic potentials by way of the casualties or kinds of injuries they may generate
• Some of the future disasters while occasioning relatively few casualties or physical damage will be very economically costly or socially disruptive

Perhaps the most poignant statement in his paper is this:

Better disaster planning can mitigate the impact of these future kinds of disaster but will not prevent their occurrence.

 On a more individual note, you might consider advocating a preparedness program that focuses on the home and the family. Doing as much as possible towards making individuals and family groups will go a long way in making communities as a whole more resilient in times of crisis.

Healthcare realities you can't ignore...anymore

Healthcare facilities: part domestic preparedness and part public safety.

Simply meeting building and fire codes do not equate to resiliency and checking off the Joint Commission preparedness requirements does not mean you're prepared.

Healthcare facilities will need to function before, during and after an event. The goal is to maintain operation as independently as possible for any foreseeable threat in your hazard vulnerability assessment. Those that can’t do that will need to evacuate or move their operations to another facility. Sheltering in place or evacuation are clearly realities each facility must face. They’re big decisions. Both options require substantial pre-planning and functionality between facilities.

Sheltering in place.

Deciding to remain in your facility during an event (sheltering in place) is not an easy choice. On the surface it may appear that staying put is a simple thing to do but, sheltering in place (making the decision not to evacuate ahead of a threat) comes with its own set of risks. Hopefully you have a robust 96-hour plan that you’ve trained on and tested. Hopefully it’ll see you through the situation. Even with solid planing, we have to has how long can you remain in your facility without outside support? Of course you have memorandums of understanding (MOU) with a variety of vendors as required by the Joint Commission. So, you're set. Right? The interesting thing about MOU's is that your vendor has an MOU with  all their clients, not just you. Will they be able to deliver their goods or services when demand is maxed out by all clients? Consider that infrastructure damage, such as damage to roads and bridges, will prevent shipments from making it to your supplier and further, prevent them from making delivery to you.

Part of sheltering in place is having a series of decision points or triggers that will tell you when its time to change tactics. Trigger events are situations that cause you reconsider your current position and may indicate the need for evacuation.

If you haven’t got a functional 96-hour plan or if your plans are questionable, you may want to consider evacuation ahead of a threat if possible.

Evacuation.

Evacuation of a healthcare facility is a major event. There are risks to go along with the benefits. Before you give the order to begin the evacuation process you need to consider the following:

• Will this be a full or partial evacuation?

• What is the available capacity of receiving facilities? Can they absorb the number of patients we wish to send?

• Have the receiving facilities damaged by the current event or are they in danger of being evacuated themselves?

• What resources are available to move people and equipment?

• What are the risks of going out into the environment?

Keep in mind that surge capacity may exist before an event, but not during or after. Evacuations must be done early or pre-event whenever possible. Ideally, your evacuation plans and triggers have been shared and tested with other facilities.