Canadian emergency department preparedness for a nuclear, biological or chemical event
Daniel Kollek, MD
Associate Professor, Emergency Medicine, McMaster University, Hamilton, Ont.; Director of Continuing Medical Education, Emergency Program, Hamilton Health Sciences Centre, Hamilton, Ont.
Since the terror attacks of September 11th, emergency departments across North America have become more aware of the need to be prepared to deal with a mass casualty terror event, particularly one involving nuclear, biological or chemical contaminants. The effects of such an attack could also be mimicked by accidental release of toxic chemicals, radioactive substances or biological agents unrelated to terrorist activity.
The purpose of this study was to review the risks and characteristics of these events and to assess the preparedness of Canadian emergency departments to respond. This was done by means of a survey, which showed a significant risk of a mass casualty event (most likely chemical) coupled with a deficiency in preparedness -- most notably in the availability of appropriate equipment, antidotal therapy and decontamination capability. There were also significant deficiencies in the ability to respond to a major biologic or nuclear event.
Depuis les attaques terroristes du 11 septembre, les départements d'urgence à travers l'Amérique du Nord ont été sensibilisés davantage à l'importance de se préparer en prévision d'une catastrophe à victimes multiples, en particulier lorsque des polluants nucléaires, biologiques ou chimiques sont en cause. Les effets d'une telle attaque pourraient aussi se manifester dans le contexte d'une libération accidentelle de produits chimiques toxiques, de substances radioactives ou d'agents biologiques non reliés à des activités terroristes.
La présente étude avait comme objectif de passer en revue les risques et caractéristiques de ces événements et d'évaluer l'état de préparation des départements d'urgence canadiens en cas de désastre. L'étude prit la forme d'un sondage qui révéla un risque important de catastrophe à victimes multiples (très probablement d'origine chimique) associé à un état de préparation inadéquat, plus particulièrement au niveau de la disponibilité de l'équipement approprié, des antidotes et des capacités de décontamination. On notait également des lacunes importantes dans la capacité à répondre à une catastrophe majeure d'origine biologique ou nucléaire.
Introduction | Methods | Results | Discussion | General disaster preparedness in Canada
Chemical and radiological preparedness in Canada | Biological preparedness in Canada
Limitations | Conclusion | References
Terrorism can be defined as an attack that targets non-combatants in a civilian location.1 Since the terrorist attacks of September 11th there has been an increased awareness of the need to be able to respond to disasters and specifically the need to consider terrorist events in the possible disaster scenarios. In addition, the subsequent anthrax alert in the United States highlighted North America's vulnerability to non-conventional weapons of mass destruction. Traditionally these have been categorized as Chemical, Biological, Radioactive and Nuclear (CBRN) weapons, with each category having its unique response requirements.
In addition to the threat of CBRN terrorism, there is a much greater risk of a CBRN accident, and Canada has experienced many such events, most often involving chemical agents. Reviews from the US, Australia and England have highlighted emergency department (ED) lack of preparedness for such situations.2-7 Despite this, there has been no formal review of Canadian ED preparedness for CBRN events. The objective of this paper was to review Canadian ED disaster readiness, specifically for events involving biological, chemical or radioactive materials.
This was a cross-sectional online survey of Canadian EDs. The survey was addressed to the chief of each ED.
Survey questions were developed based on a search of relevant literature. The survey (see Appendix 1, p. 26) included 24 questions divided into 4 categories: risk assessment, general disaster preparedness, preparedness for a biological event, and preparedness for a chemical or nuclear event. Prior to distribution, the draft questionnaire was reviewed for face validity and comprehensibility.
When the survey was finalized, a Web-based form was designed and, on Nov. 2, 2001, it was posted on a dedicated Web page located on the Hamilton Health Sciences Corporation, Hamilton, Ont., server. The system allowed responders to click only 1 response for each of the survey questions, and automatically collated the responses into a spreadsheet. The system was tested with dummy data to ensure that it functioned accurately. After pilot testing, all dummy data was erased.
The Canadian Association of Emergency Physicians provided a list of ED chiefs and their email addresses. All department chiefs were contacted by email, invited to fill in the questionnaire, and given the appropriate URL (Web address). Chiefs responsible for multiple sites were asked to submit a separate questionnaire for each site. A total of 3 emailings were made, to maximize response rate. To avoid the possibility of duplicate responses (a potential hazard of online questionnaires) the questionnaire included a postal code identifier. To avoid unwanted responders, there were no links to this page from any other locations.
The last response was received on Dec. 3, 2001, one month after the questionnaire was posted. Questionnaires with inappropriate responses were flagged for manual review. In cases where there were conflicting entries from a single postal code and it was unclear which response was correct, a "null" value was input. If it was clear that the newer entry corrected a previous internal data conflict and the newer data set was internally consistent, the newer data was used. This only applied to the same 1 question in 2 separate submissions. The "null" field was also used in cases where a question was left unanswered. The data set was locked on Mar. 7, 2002.
Of 206 emails sent to ED chiefs, 26 email addresses were determined to be incorrect. Of the remaining 180 eligible respondents, 59 (30%) completed the survey. Based on postal code identifiers, there were 5 duplicate and 1 triplicate entries.
Most respondents indicated that their ED is at risk of a CBRN event, with 47 (80%) EDs being close to a hazardous material transport route, 25 (42%) close to a chemical factory or manufacturing site, and 7 (12%) close to nuclear facilities (Table 1). Only 1 ED was defined as definitely not at risk. Table 1 also shows that general disaster preparedness was inadequate. Although 56 (95%) EDs had a disaster plan, only 28 (47%) had reviewed it, only 22 (37%) had run a paper trial and only 11 (18%) had run a disaster exercise during the 12 months prior to Nov. 2, 2001, the date the questionnaire was first posted.
Despite respondents categorizing their ED as being "at risk," most of these EDs were ill prepared for a CBRN event. Only 37 (63%) had a protocol to report sentinel bio-events, 24 (41%) respondents were aware of their local pandemic plan, and 22 (37%) reported being able to obtain the necessary supplies in a biological crisis. The highest CBRN risk was chemical, yet only 18 (30%) respondents stated that their ED had a decontamination area and only 3 EDs (5%) had respiratory equipment for their staff. There were 8 EDs (14%) with respiratory equipment and no plan.
Table 1 shows that 23 EDs (39%) had sufficient benzodiazepines to deal with more than 10 patients and that 8 EDs (14%) had enough atropine to treat 5 patients. Only 20 EDs (33%) had pralidoxime, and 17 more (29%) could obtain pralidoxime if necessary. Slightly more than half of the EDs (55%) stocked cyanide kits, with another 22% able to obtain them if required.
The key finding of this study is that Canadian EDs -- and by inference Canadian hospitals -- are unprepared for a CBRN event, this despite their chiefs identifying the ED as being at risk. Many lack an updated plan, and those that have one have rarely tested it. Most respondents reported their ED as having inadequate equipment and medications. While this study focused on CBRN readiness, it would appear from the data that general disaster readiness is also inadequate. Most respondents to this survey were aware of significant hazards in their region and needed to achieve a higher level of preparedness at their ED for a CBRN event -- particularly a chemical event.
CBRN events are unavoidable because systems cannot be made foolproof. In fact, during the past 10 years, the most common cause of biologic, chemical and nuclear contamination has been human error or mechanical failure of a containment system.8 North America produces 60 000 different chemicals (of which 57 500 are in the workplace), and 53 000 are potentially hazardous. Every year 4 billion tons of these are transported between 100 000 North American locations. In 1994 CHEMTREC (Chemical Transportation Emergency Center, a public phone service of the Chemical Manufacturers' Association) logged over 200 000 calls,8 4% of which were directly related to Hazmat (hazardous materials) (www.hazmat.dot.gov/) emergencies. In 1993 there were 3945 Hazmat releases in the US, with 1.6 events every day that caused death, injury or evacuation.9
Major chemical incidents involved cyclohexane (Flixborough, UK, 1974), chlorine (Missisauga, Canada, 1976), dioxins (Seveso, Italy, 1976), PCBs (polychlorinated biphenyl waste) (Saint-Basile-le-Grand, Canada, 1988), benzene, toluene and xylene (Hagersville, Canada, 1990) and, most tragically, methyl isocyanate gas (Bhopal, India, 1984). Biological incidents range from the accidental release of anthrax from a Soviet facility in 1979 (causing 79 cases and 68 deaths)10 to the recent E. coli (Escherichia coli) incident in Walkerton, Canada. Radiation events range from the occasional steam releases from reactors to full-fledged disasters like the one in Tokaimura, Japan in 1999. Of concern, since 1958 more than 1.8 million radioactive consumer devices have been distributed in the US, with minimal regulatory oversight.11 Given the penetration of these agents in society and the scope of their use, it is clear that accidental CBRN events are both likely and potentially far-reaching. Nuclear, biological and chemical events differ in the emergent and ongoing response they require (Table 2),10-12 but this does not rule out the possibility of a combined event.
The September 11th attacks sensitized North Americans to the devastating impact terrorism can have. It is clear now that when developing disaster response plans we must consider the possibility of terror events. Recognizing this, the US Center for Disease Control and Prevention (CDC) has prepared lists of major biologic and chemical terror agents (Table 3) and categorized them by lethality, transmissibility and resource requirements. To date, most terror events have been characterized by large numbers of patients with blunt and penetrating trauma.13 As such, these events did not differ much from other mass casualty events. Updated risk analysis suggests a worrisome change in this pattern. In addition to the capability of inducing trauma there is evidence that terror organizations and nations who support them are developing nuclear, biologic and chemical capability.10,14-16 Documents seized from the al-Qaeda network in Afghanistan reveal their attempts to obtain CBRN weapons. Recently, Hamas, the Islamic Resistance Movement, has selectively used hepatitis B carriers as suicide bombers (Dr. Nathan Gottehrer, Director, Emergency Department, Shaare Zedek Hospital, Jerusalem: personal communication, 2002). The anthrax mailings through the US postal service are another example of operational deployment of bioterrorist methodology.
The US is the most powerful nation on earth and the prime target of terror movements dedicated to destabilizing global power structures. Because of our proximity and our large shared border, terrorists may use Canada as a staging ground for attacks on the US, and this raises the possibility of an accidental CBRN event on Canadian soil. In addition, our role as a US ally could provoke terror attacks directed at Canadian citizens.
Not all terror events are carried out by foreign nationals. In 1984 a religious commune in The Dalles, Oregon, used a biological agent (salmonella) to contaminate restaurant salad bars, demonstrating ease of access and use.17 In 1995, a fanatic religious group, Aum Shinrikyo, carried out a sarin nerve gas attack on the Tokyo subway. As the information on how to prepare and deliver weapons of mass destruction, particularly biological10,17-19 and chemical agents,16 becomes more widely available, and as the ideology of terror movements disseminates, it becomes only a matter of time before internal extremist groups combine the two.
Radiological events may be nuclear or radioactive. A nuclear event is the detonation of a nuclear device with the subsequent explosive and radioactive effects. A radioactive event is the dissemination of radioactive materials by conventional means, either accidental (e.g., a leak of radioactive steam from a reactor) or malicious. One disturbing but possible scenario is a "dirty bomb,"12 which is an explosive device that spreads radioactive waste over a large area.
Victims of radiological events can be divided into 2 categories: irradiated and contaminated. Patients who have been irradiated are not a risk to others, while those who have been contaminated, by virtue of ingesting or being covered by radioactive substances, can irradiate others nearby. Contaminated patients must be decontaminated as soon as possible to minimize the injury they sustain and the risk they pose to others. Ideally, decontamination should take place before entry to a treatment facility, unless the facility and staff are equipped to function in a radioactive environment. Protection and monitoring of the decontamination crew or the hospital staff will depend on the type of radiation because different forms of particulate radiation have different penetration.12 Those who have ingested radioactive material rarely put caregivers at risk by virtue of proximity and do not need external decontamination, but their body waste does pose a radiation hazard. The treatment of radiation-induced illness is beyond the scope of this paper.
Chemical agents are like radioactive particles in that they may adhere to skin and clothing and mandate decontamination. Table 2 shows that they have significant variability in terms of onset, volatility, vapour density, lethality and method of action. ED caregivers cannot wait to identify the specific agent and must instead focus on self-protection, identifying the class of agent and toxidrome management. The characteristics of the agents, particularly the volatility and vapour density,15,16 will determine the degree of risk to caregivers from their patients "off-gassing."
The argument that the patients can be decontaminated on site prior to transport, making decontamination in the ED redundant, is a common fallacy.2,8 The Tokyo experience shows that, regardless of existing disaster plans, patients will make their way independently to the nearest ED prior to decontamination.
Biological events differ from chemical and nuclear events in speed of onset and resources required.10 Biological agents are characterized by high potency, easy delivery, substantial accessibility, low visibility, and latency of onset. The latency of biological agents makes them hard to detect, and epidemiologic data verifying the nature of an outbreak are typically slow in coming. As a result, biological events may be ongoing for significant periods of time before they are recognized by health authorities. Rapid identification of index cases to regional health authorities allows for pattern recognition and is critical to an organized early response.
The disaster plans of most institutions are designed for the intake of multiple patients with conventional problems over a short time span. Thus, they should be able to deal with a mass casualty event, be it accidental or a "conventional" terror attack. This assumes that the disaster plan of the institution is functional, has been updated and has been practised. Unfortunately, in this survey at least half of the respondents had not reviewed their plan within the past year, and 10% had not reviewed it for over 3 years. Less than half the EDs had run any kind of exercise within the past year, increasing to two-thirds within the last 3 years. The vast majority of EDs ran only paper exercises, not requiring the actual moving of patients and resources. These exercises are of questionable value. Only 4 EDs (6.7%) had run any live exercise within the past year, 30% within the past 3 years.
In view of the significant recent administrative and manpower changes within the health care system, it is possible that at many EDs the disaster plan may no longer be applicable and that the ED staff may not be adequately trained. Thus, we cannot assume that our hospital disaster plans are functional. Computer simulation and planning tools may be useful to help bridge this preparation and training gap.20,21
Decontamination of chemically or radiologically contaminated patients, ideally prior to entering the health care facility, is a critical step in the delivery of care.8,12,15,16 In the review of decontamination capability, only 18 of 59 respondents (30%) stated that their ED had a decontamination area or a plan to establish one. Of these, there was an almost even split between those EDs with an internal or external decontamination site.
In order to assess the functionality of the decontamination plan, we asked respondents whether their ED had a hot/cold zone system in place. The system defines 2 areas: one where contaminated patients arrive for decontamination (the "hot" zone) and one where decontaminated patients receive definitive care (the "cold" zone). Decontamination occurs at the border between the zones.22 The hot zone should include an intubation station for the resuscitation of critically ill patients, and the resuscitation team must be able to perform techniques such as intubation while wearing protective equipment (see Fig. 1).16,22 Absence of this kind of system indicates a potentially ineffective plan.16,23
In our survey only 5 EDs (8% of respondents) with a decontamination plan had a hot/cold system in place. This raises the concern that, even among hospitals with decontamination plans, the systems may not be sufficient to manage large events involving contaminated patients. Similar US surveys done prior to September 11th reported that only 44% to 63% of facilities could receive chemically- exposed patient and 41% to 47% did not have decontamination facilities.2,8,24
In the absence of an external decontamination protocol, there should be a contingency plan in the event that incoming patients contaminate the ED.8,25 In an ideal situation, particularly if the ED is near the site of the event, there would be the option of shutting down the department partially or completely to isolate it from the contaminated area. Positive pressure ventilation (PPV) and an airlock system would provide safe access. This usually requires a purpose-built department because it is costly to retrofit an existing structure. Only 13% of EDs covered by this survey have PPV capability, and the same number of respondents stated that their ED could manage contaminated run-off fluids.
EDs that have no decontamination plan, and that cannot keep contaminated patients and equipment outside the ED, must provide protective equipment so staff can function at relatively low risk. This may involve having staff and patients wear gas masks and protective gear while in the hospital.8,9,22 But in this survey, only 41% of the EDs were stocked with protective coveralls (list price, $5.18; Lawlor Safety) and only 19% had either gas masks or positive pressure ventilation masks. This is inadequate, given the fact that 85% of EDs could not decontaminate patients without bringing them in to the building. A recent US survey reported that 63% of EDs had access to protective equipment (i.e., gowns, masks and gloves) but only 30% had any respiratory equipment whatsoever.2,24
Preparedness for chemical agents requires a readily available stock of antidotes. In this survey, we asked specifically about atropine, cyanide kits, and benzodiazepines and pralidoxime (for nerve agents). Assuming that patients requiring maximal support would consume 20 mg of atropine and 30 mg of diazepam or equivalent,16,25,26 most sites surveyed had inadequate supplies on hand. This data is worrisome because, terrorism aside, these antidotes are useful for managing patients with a variety of with toxic ingestions (e.g., insecticides and industrial agents). While atropine and benzodiazepines are routine ED items, the amount available in most surveyed EDs was insufficient to deal with a mass casualty chemical disaster. Health regions often plan to store drugs in a central repository and deliver them rapidly to EDs when requested. This process may not work in a true event, where transport and delivery systems are slow or disrupted (as has occurred in past Canadian disasters).
In this survey, only 63% of sites had a protocol for reporting suspected index cases -- an extremely worrisome finding in view of the key role reporting plays in the early response to a bio-event. This is also surprising in view of the fact that having a reporting protocol costs the hospital nothing and can save the health care system significant cost by minimizing the spread of disease. To address this concern, Edmonton has developed the innovative concept of using Telehealth and other telephone triage lines for syndromic surveillance. The information systems supporting these triage and advice services can be used to detect and flag clusters of disease in a given area or presumptive index cases.
Readiness for an influenza pandemic can be considered a surrogate marker of preparedness for bio-terror. Unfortunately, in this survey only 41% of EDs were aware of a regional pandemic plan and only 37% had a protocol to access supplies if required.
This study enrolled a convenience sample of respondents and had a small sample size. In addition, although it assessed the presence of disaster response components, it did not address the quality of the disaster plans described. Nevertheless, the data suggest a worrisome lack of preparedness, particularly a lack of tested disaster plans and decontamination facilities that could handle large numbers of patients without putting EDs at risk.
Hospitals across Canada need to revise their disaster readiness plans, with CBRN events in mind. Canadian hospitals need realistic and verifiable standards for CBRN and general disaster readiness that can be applied and tested regularly as part of the accreditation process.
- International Convention for the Suppression of Terrorist Bombing (United Nations General Assembly Resolution, New York: 12 January 1998) [modified]; United Nations Office for Drug Control and Crime Prevention proposed definitions of terrorism. Available: www.undcp.org/odccp/terrorism_convention_terrorist_bombing.html
(accessed 2002 Dec 4).
- Cone DC, Davidson SJ. Hazardous materials preparedness in the emergency department. Prehosp Emerg Care 1997;1:85-90.
- Rodgers JC. Chemical incident planning: a review of the literature. Accid Emerg Nurs 1998;6:155-9.
- Rodgers J. A chemical gas incident in London: How well prepared are London A & E departments to deal effectively with such an event? Accid Emerg Nurs 1998;6(2):82-6.
- Edgell M, James MR. Contaminated casualties: Are we prepared to receive them? J Accid Emerg Med 1994;11:172-7.
- Totenhofer RI, Kierce M. It's a disaster: emergency departments' preparation for a chemical incident or disaster. Accid Emerg Nurs 1999;7:141-7.
- Wetter DC, Daniell WE, Treser CD. Hospital preparedness for victims of chemical or biological terrorism. Am J Publ Health 2001;91:710-6.
- Levitin HW, Siegelson HJ. Hazardous materials -- disaster medical planning and response. Emerg Med Clin N Am 1996;14:327-48.
- Cox RD. Decontamination and management of hazardous materials exposure victims in the emergency department. Ann Emerg Med 1994;23:761-70.
- Grafstein E, Innes G. Bioterrorism: an emerging threat. CJEM 1999;1(3):205-9.
- Lubenau JO. Unwanted radioactive sources in the public domain: a historical perspective. Health Phys 1999;76(2 suppl): S16-22.
- Mettler FA, Voelz GL. Major radiation exposure -- what to expect and how to respond. N Engl J Med 2002;346:1554-61.
- United Nations Office on Drugs and Crime. Conventional terrorist weapons. Available www.23.odccp.org/odccp/terrorism_weapons_conventional.html (accessed 2002 Dec 4).
- Stephanson J. Pentagon funded research takes aim at agents of biological warfare. JAMA 1997; 278:373-5.
- Sidell FR. Chemical agent terrorism. Ann Emerg Med 1996;28:223-4.
- Holstege CP, Kirk M, Sidell FR. Chemical warfare, nerve agent poisoning. Crit Care Clin 1997;13:923-42.
- Torok TJ, Tauxe RV, Wise RP, Livengood JR, Sokolow R, Mauvais S, et al. A large community outbreak of Salmonellosis caused by intentional contamination of restaurant salad bars. JAMA 1996;278(5):389-95.
- Kolavic SA, Kimura A, Simons SL, Slutsker L, Barth S, Haley CE. An outbreak of Shigella dysenteriae type 2 among laboratory workers due to intentional food contamination. JAMA 1997;278(5):396-8.
- Zilinskas RA. Iraq's biological weapons. The past as future? JAMA 1997;278(5):418-24.
- Hirshberg A, Stein M, Walden R. Surgical resource utilization in urban terrorist bombing: a computer simulation. J Trauma 1999;47:545-0.
- Levi L, Bregman D, Geva H, Revach M. Hospital disaster management simulation system. Prehospital Disaster Med 1998;13:29-34.
- Israel Ministry of Health. [Prepared - a journal for emergency situations.] Prepared 1999;April.
- Plante DM, Walker JS. EMS response at a hazardous materials incident: some basic guidelines. J Emerg Med 1989;7:55-64.
- Burgess JL, Blackmon GM, Brodkin CA, Robertson WO. Hospital preparedness for hazardous materials incidents and treatment of contaminated patients. West J Med 1997;167:387-91.
- Sidell FR. What to do in the case of an unthinkable chemical warfare attack or accident. Postgrad Med 1990;88:70-84.
- Treatment of nerve gas poisoning. Med Lett Drugs Ther 1995;37(948):43-4.
Dr. Daniel Kollek, Department of Emergency Medicine, Hamilton General Hospital, 237 Barton St. E, Hamilton ON L8L 2X2; 905 527-4322 x46368, fax 905 527-7051, firstname.lastname@example.org