Hospital Preparedness Plan Requirements

Hospitals should plan to be self-sufficient for at least 24-48 h when faced with chemical incidents and disasters. ^{Reference White25 - Reference Okumura, Ninomiya and Ohta29} Eventually, extensive governmental disaster resources are used in disasters, but not immediately; therefore, the role of local hospitals in incidents and disasters (especially chemical disasters) is crucial. ^{Reference White25} For this reason, hospitals should be prepared to respond to chemical incidents and perform medical management of contaminated victims. ^{Reference Nitrite28 , Reference Okumura, Ninomiya and Ohta29}

Hospital preparedness may include administrative and structured preparedness. Administrative preparedness variables include training; use of information resources, such as CHEMTREC, hotlines, chemical companies, governmental agencies, and industry contacts; and the existence and practice of internal and external disaster plans for chemical incidents and disasters. Structured preparedness variables include modifications or sketching space to widen the physical plant of the hospital, such as designating a decontamination area, separate entry or special entrances; isolated air circulation and air conditioner system; receptacles and disposal for waste-water and contaminated materials; and available medicine and clinical equipment, such as protective gear, detectors, antidotes, and clinical laboratory. ^{Reference Candiotti, Kamat and Barach30} One important issues that usually is neglected is water supply for washing and drinking in this situation. ^{Reference Candiotti, Kamat and Barach30 , Reference Williams, Nocera and Casteel31}

Prerequisites for chemical plan development include assessment of risk and vulnerability, resources and capabilities and staff competency; the definitions of chemical disasters, events, catastrophes; features of a hospital emergency management plan, ^{Reference White25 , Reference Williams, Nocera and Casteel31 , Reference Landesman, Markowitz and Rosenberg32} plan activation notification (early warning system) communication, personal identification, chain of command, hospital command center, support staff, reporting center, traffic flow, triage, decontamination, treatment areas, patient care-transportation-tracking, logistics and supplies; specialized areas for family, volunteer, media, morgue, evacuation; establishment of alternate care sites; education and training; testing and evaluating plans, including ambulatory sites; and recovery. ^{Reference White25}

Preparedness Team Member (Multidisciplinary Team)

In different countries, the members of the hospital team are different in chemical incidents and disasters. In general, a multidisciplinary team includes emergency physicians, emergency nurses, toxicologists, infectious disease physicians, epidemiologists, infection-control practitioners, security, safety officers, pharmacists, hospital administrators, public relations officials, facility engineers, mental health practitioners, volunteer services coordinators, and health educators. ^{Reference White25}

In addition, there should be a specialist team for hospital planning in chemical incidents including personnel with responsibility for emergency planning, emergency services, senior emergency department medical and nursing staff, British Association for Immediate Care (BASICs) doctors, specialist units, public health, occupational health, environment agency, water authority, and military. ^{Reference Taebi, Sourosh and Modirian14 , Reference Chan, Yeung and Tang33 , Reference Veenema35}

Psychologists are considered as highly important members in chemical team, based on past chemical events in the world because many victims need counseling after chemical disasters. The victims of hazardous materials or terrorist incidents, including chemical events, may experience posttraumatic stress disorders, which were estimated to occur in 25% of victims. In this regard, early psychological debriefing and interviews with patients and personnel should be prioritized among the psychologists. ^{Reference White25}

Decontamination

Equipment, training, and preparedness are required for decontamination of chemically contaminated victims. ^{Reference Burgess, Kirk and Borron26} Based on past chemical events, most victims of disasters arrive at hospitals on their own. ^{Reference Burgess, Kirk and Borron26 - Reference Okumura, Ninomiya and Ohta29} For example, after releasing a nerve agent into the subway system in Tokyo, Japan in 1995, 640 patients who were chemically contaminated arrived by private conveyance at a single health-care facility within the first few hours. Accordingly, 23% of emergency department staff became secondarily contaminated. ^{Reference White25}

Planning for the chemical decontamination of victims in hospitals include management of hospitalized patients, triage and decontamination of victims, medical treatment, and protection of the community from secondary contamination. ^{Reference White25 , Reference Burgess, Kirk and Borron26} Accordingly, planning for outdoor decontamination of patients, designation of personnel responsibilities, the types and location of personal protective equipment (PPE) and decontamination equipment, medical treatment guidelines, and reference lists of information resources are essential for decontamination in the hospital. ^{Reference Okumura, Ninomiya and Ohta29 - Reference Williams, Nocera and Casteel31}

PPE

The personal protection levels are labeled A-D. Level A provides the highest, while level D has the lowest protection. PPE is needed for all staff in emergency departments. ^{Reference Tan and Fitzgerald6 , Reference Burgess, Kirk and Borron26} Paramedics and emergency department staff may be on the front line in a major chemical warfare incident. ^{Reference Okumura, Ninomiya and Ohta29} According to reports, most hospitals in the world only have level C PPE for employees. ^{Reference White25} Ideally, those persons who are responsible for selecting PPE and the decontamination process should be trained for the first-responder operation level. ^{Reference Tan and Fitzgerald6} The most important issue about PPE is that almost all of the emergency departments have suitable PPE but not enough knowledge is available for using this equipment. Furthermore, improper use of PPE may injure personnel. Therefore, learning to use PPE should be considered for the training program. ^{Reference White25 , Reference Nitrite28 , Reference Okumura, Ninomiya and Ohta29}

Education and Training

It is claimed that that education, training, and practice before a disaster are considered the key elements for an effective response. ^{Reference White25} Although based on a systematic review, the available evidence is insufficient to determine whether training interventions for health-care providers are effective in improving knowledge and skills in disaster response. ^{Reference Candiotti, Kamat and Barach30} Some of the prioritized educational topics for chemical disasters include nuclear/biological/chemical (NBC) agent and terrorism awareness, early recognition of chemical emergencies, incident command system, triage of massive numbers of victims, proper use of PPE, decontamination procedures for chemically exposed patients, use of backup communication systems, and methods for preparing backup supplies. ^{Reference Williams, Nocera and Casteel31 , Reference Landesman, Markowitz and Rosenberg32} Training programs and levels are different for the staff in emergency departments. ^{Reference White25} Training and education should be based on the duties of staff and their roles. ^{Reference Candiotti, Kamat and Barach30 , Reference Williams, Nocera and Casteel31}

Based on the evidence from many training programs, it is necessary to repeat technical training periodically, usually within 6-9 months to maintain competency. ^{Reference Okumura, Ninomiya and Ohta29} Regarding hospital preparedness, proper training and orientation are essential for the safe and effective use of protective equipment, decontamination, and triage. ^{Reference Candiotti, Kamat and Barach30} Drills are regarded as the best method for assessing preparedness and response in chemical incidents. ^{Reference Tan and Fitzgerald6 , Reference Burgess, Kirk and Borron26} In addition, drills should involve participants from diverse areas, including public health, fire department, emergency management team, law enforcement, disaster medical assistance teams (DMATs), corporations, and media and public information. ^{Reference Chan, Yeung and Tang33 - Reference Veenema35} Hospital disaster drills are mandated twice a year by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for the organizations related to chemical disasters. ³⁶

Job Descriptions and Roles

After identifying the team, it is important to determine the responsibilities of each member that should be considered in planning the hospital preparation. In addition, role cards may be useful. ^{Reference White25} Based on the lessons learned from past events, many people fail to do their role properly during the incident. ^{Reference White25 - Reference Nitrite28} Furthermore, many roles are mixed, and some of team members may perform the duty of other staff, leading to agitation and anarchy, and slower service to the victims. ^{Reference Candiotti, Kamat and Barach30 , Reference Landesman, Markowitz and Rosenberg32} The use of a hanging necklace that includes information about each person’s job description, can solve this problem. ^{Reference White25 , Reference Williams, Nocera and Casteel31 , Reference Chan, Yeung and Tang33}

Communication

Effective communication is the biggest challenge for hospitals during chemical incidents and disasters. ^{Reference Nitrite28 , Reference Candiotti, Kamat and Barach30} In addition, hospital communication may collapse both internally and externally. ^{Reference White25} Based on the studies conducted in most countries, there is a lack of reliable networks for disaster communication between hospitals and other key external agencies, especially in chemical disasters. ^{Reference White25 , Reference Nitrite28 , Reference Candiotti, Kamat and Barach30} Furthermore, meaningful information may not be received from the scene before the arrival of the first victims. ^{Reference Tan and Fitzgerald6 , Reference Burgess, Kirk and Borron26} A disconnected Internet network causes staff to become unaware of important issues regarding facilities and resources. Thus, the information about resource availability and victim status is not shared successfully, which results in weakening of the overall response against chemical disasters. ^{Reference White25 , Reference Williams, Walter and Challen37}

The creation of additional and off-line applications in internal and external communication systems for sharing critical information is considered as one of the important solutions for solving this problem. ^{36 , Reference Williams, Walter and Challen37}

Database for the Chemical Events

Specific chemicals, along with the form of the material and the route and duration of the exposure should be identified to evaluate the chemical toxicity and determine appropriate treatment in chemical incidents. ^{Reference White25 , Reference Veenema35 , Reference Williams, Walter and Challen37} A chemical database is a database that is specifically designed for storing information about chemicals’ chemical and crystal structures, spectra, reactions and syntheses, and thermo physical data. ^{13 , Reference Nilsson21}

The database includes some features such as having a simple, easy-to-use, and accessible system; using everyday language that is easy to understand and act upon; providing accurate and reliable information with high quality; and providing integrated multi-device platforms available for PC, laptop, mobile data terminals (MDTs), command and control systems, tablets, and mobile phones. ³⁸

Based on the results, the medical management guidelines for acute chemical exposures from the Agency for Toxic Substances and Disease Registry (ATSDR) (http://www.atsdr.cdc.gov/mhmi.html) is regarded as an excellent resource for designing such procedures. ^{Reference White25} Furthermore, the European Chemicals Agency (ECHA) website is a unique source of information for the chemicals manufactured and imported in Europe, which provides their hazardous properties, classification and labeling, and information on the way for using them safely. ^{38 , Reference Molander and Rudén39} Material Safety Data Sheets (MSDS) can play a role in identifying the chemicals, although they may not have correct treatment information. ^{Reference White25} Also, Chemical Hazardous Emergency Medical Management (CHEMM) Produced by the US Department of Health and Human Services is good source of information about procedures in chemical incidents. ^{Reference Nitrite28}

Mutual Aid Agreement

Mutual aid agreements may contribute to the sharing of personnel and equipment among hospitals and the evacuation of advanced patients during chemical incidents. ^{Reference Veenema35 - 38} Additionally, using mutual aid agreements can provide alternate care sites such as hotels, long-term care facilities, hospice, surgical and procedure centers, psychiatric hospitals, schools, churches, mosques, football fields, stadiums, and community centers. ^{Reference White25 , Reference Nitrite28}

Staff and Volunteers

Hospitals may not have the additional staff that is necessary to cope with the significant surge in influx of patients during a chemical disaster. ^{Reference White25} Although government disaster teams are responsible for helping hospitals, they usually arrive later. Access to a cadre of supplemental reserve staff or volunteers is necessary, especially during the early phases of a disaster. ^{Reference Chan, Yeung and Tang33 - 38} To provide the expert staff for such situations, designing a plan involving the effective use and training of local volunteers is a high priority. ^{Reference White25 , Reference Okumura, Ninomiya and Ohta29} Volunteers should be oriented to the emergency management plan of the hospital and the command structure of the incident. ^{Reference Landesman, Markowitz and Rosenberg32 , Reference Chan, Yeung and Tang33} Potential sources of reserve staff include outpatient clinic personnel, retirees, trainees, and former health-care professionals. Call-up (also termed recall) and back-fill mechanisms for each department are regarded as critical features of the emergency management plan in chemical disasters. ^{Reference Burgess, Kirk and Borron26 , Reference Nitrite28}