Protecting Your Community Hospitals
© 2007 FrontLine Security (Vol 2, No 1)

Hospitals have a long history of ­participation in emergency preparedness. Historically, it would have two types of emergency plans; one to respond to a mass casualty situation, and a second to evacuate the building in the case of a catastrophic event. Emergency planning for hospitals has evolved in the post 9-11 world, with CBRN (chemical, biological, radiation and nuclear) incident training and preparation becoming more wide spread. Of course, hospitals manage infectious diseases on a routine basis, however, it was not until SARS hit in 2003 that hospitals recognized that being faced with an infectious ­disease could be a ­disastrous event.

The health care sector, and hospitals in particular, are at the forefront of a community’s response to emergencies and, in particular, a pandemic. As a key civic infrastructure element, the hospital capacity must be protected in order to be effective in the response to emergencies.

Hospital capacity has changed dramatically over the past two decades. The overall number of hospitals has decreased as mergers and acquisitions have occurred countrywide – those that remain have closed multiple beds over the years in response to cost cutting efforts and changes in practice. It is striking to note that Canada has lost over 20% of hospital beds that existed in the mid 1980’s, while the population has increased by 18%.

Hospitals make optimum use of available beds – occupancy rates have steadily increased and, depending on the type of hospital and the location, occupancy routinely approaches 95%. At that rate, a hospital bed is typically empty only long enough to clean the room prior to admitting the next patient.

Hospitals themselves have changed, with many facilities, particularly those in multi-hospital cities, consolidating ­services like intensive care units and ­specializing in certain aspects of care. The days of the “general hospital” are indeed disappearing. Specialization has resulted in increased workloads on ambulance ­services as they now find themselves transporting critically ill patients between facilities on a routine basis.

Other matters increase the exposure of hospitals during a disaster. Many hospitals, particularly the larger ones, have moved to “just-in-time” inventory systems. As an example, some of Ontario’s largest hospitals have less than a two-day supply of food in the building, leaving them vulnerable to any disruption in the supply chain.

Hospitals also face substantial difficulties in attracting health care professionals. The majority of health care professionals are from the “baby-boom” generation. Staffing shortages are common, particularly with nurses, and hospitals regularly scramble to maintain a full staff.

A substantial number of Canadians cannot find a family physician. They routinely seek primary care in walk-in clinics and emergency departments. Emergency departments face challenges in attracting enough physicians willing to staff every shift 24/7, particularly in smaller centres. With over 14 million visits annually, emergency department overcrowding is becoming routine. As patients queue up in the emergency department, hospitals scramble to cancel elective surgery in order to free enough beds to care for them.

Hospital security services vary widely, depending on the size and location of the facility. Larger hospitals in metropolitan areas are more likely to have full-time, round-the-clock, on-site security services. In the largest hospitals, this staff may be hospital employees; in others, the service may be contracted out to private security firms. Smaller hospitals are more likely to use remote-monitored camera surveillance in combination with electronic card swipe technologies in place of on-site personnel. In a disaster situation, most hospitals may require physical assistance with perimeter security and crowd control.

These issues combine to restrict hospital capacity at the best of times. Emergency preparedness must take into account these capacity issues as well as the response capability of the local hospital. Hospital officials need to be a part of municipal emergency preparedness committees, and plans should be modified regularly to incorporate changes in hospital capacity. Joint training programs that include both municipal and hospital staff are an excellent way to develop a ­common understanding of emergency procedures, a common language as well as the ever-important key interpersonal networking.

Hospitals are obliged to ­practice their disaster plans annually as part of their accreditation requirements. This provides an excellent opportunity to coordinate and exercise a multi-agency response.

What about a Pandemic?
The oft-mentioned threat of a global avian flu pandemic poses unique challenges that require specialized emergency preparedness plans. At its root, a pandemic will be primarily a health care crisis and hospital capacity will bear substantial strain.

Dr Margaret Chan, the newly elected president of the World Health Organiza­tion, recently reminded the world that pandemic planning must remain at the forefront of organizational thought. As news of avian flu drifts in and out of the popular media, it would be easy to become complacent in developing and maintaining pandemic preparedness. Jurisdictions need to remain vigilant in the planning for critical infrastructure protection during a pandemic outbreak.

The Public Health Agency of Canada (PHAC) has estimated that, in a worst case scenario, the pandemic could result in 70% of the Canadian population becoming ill, with between 15% and 35% ill enough to seek medical treatment. That amounts to 2 to 5 million people who will go to their family physician or hospital emergency department. Of this amount up to 138,000 people will be sick enough to require hospitalization with about 2% of that amount requiring intensive care and mechanical ventilation. The PHAC estimates that up to 58,000 deaths may occur.

Adding this patient care load to a hospital system already functioning at capacity will seriously impact a community’s ability to care for the population.

Challenges of a Pandemic
Experts agree that a pandemic will attack in waves, with each wave lasting between four and six weeks, with six to eight weeks between each wave. The number of waves is completely unpredictable but expectations are that a pandemic could last between 12-18 months. Each successive wave may be shorter as those who have contracted the flu will develop immunity protecting them during further waves.

Paramedics train during a CBRN exercise. (Photo courtesy of Kingston General Hospital)

One of the largest challenges facing all organizations will be the potential loss of employees due to pandemic flu. The PHAC estimates that, at its peak, a pandemic will result in 25% of the workforce being unavailable for 2 weeks during each wave. Given the existing shortage of personnel and the added exposure health care workers face, the impact on hospitals will likely prove significantly larger. This presents a double challenge for hospitals: a substantial increase in patients to be cared for with potentially up to 35% fewer hospital staff.

A hospital’s workforce is predominately female and we know that women carry a disproportionate responsibility for care of children and, increasingly, elderly parents. This will exacerbate the staffing challenge for hospitals during a pandemic. If schools and day care centres are closed as a result of the pandemic, it is more likely that a woman will leave work to watch over the children, a fact that would put further strain on a stretched hospital work force.

 Another area where we know there will be challenges is in the availability and ethical distribution of pandemic pharmaceuticals. During a pandemic, two types of pharmaceuticals will be in demand; anti-virals and ­vaccines. Anti-virals are anti-influenza drugs used to treat and prevent influenza. Taken prophylactically, or within the first 48 hours after onset of symptoms, an antiviral may prevent the user from ­developing full-blown flu.

Debate still reigns among experts as to the effectiveness of anti-virals, but governments and hospitals have developed plans to stockpile enough anti-virals to treat 22% of the population. Availability of anti-virals is limited by the fact that the drug of choice is made by a single European-based pharmaceutical firm.

A vaccine for avian influenza cannot be manufactured prior to an outbreak since the exact strain of influenza must be known before the formula can be created. Although domestic manufacturing capacity has been identified and put on notice, it is generally agreed that a useful vaccine will not be available within the first six months of an outbreak. Unlike many other countries, Canada is fortunate to have the capacity to mass-produce ­vaccine on short notice.

Anytime a product is both in high demand and in short supply, rationing must occur. Jurisdictions need to identify plans for obtaining anti-virals and vaccine and identify a consistent, ethical approach to who should receive prophylactic anti-virals and vaccines and in what order.

In a worst case scenario, if pandemic deaths are mounting and anti-virals and vaccines are being distributed to only a select few, civil unrest could result and security for vaccine and anti-viral stocks will need to be provided. In 2006, when the pandemic was front page news and the issue of potential rationing of anti-virals was first identified, rumours of counterfeit anti-virals being smuggled across the border persisted in eastern Canada.  

Creating Surge Capacity
Given that a pandemic outbreak or even lesser emergencies have the potential to overwhelm local health resources, jurisdictions need to plan and practice how to create surge capacity within their community. In preparing pandemic-specific response plans, hospitals have focussed on identifying which services would be maintained and which curtailed in an effort to make beds available and to maximize their work-force. Staff training programs have been developed to cross train individuals as shortages arise. Lists of volunteers and recent retirees with health care experience have been maintained to enhance fan-out lists. Provincially, the various health care regulatory Colleges have been engaged in discussions to fast track “re-regulation” of personnel who could be helpful in augmenting a pandemic response.

Municipalities need to address how they might assist in creating additional health care surge capacity, specifically for persons with flu symptoms. Possible triage and treatment centres would be located away from the hospital and would need to be staffed with medical and health care personnel who are not affiliated with the local hospital. Municipalities also need to plan for temporary morgue facilities and mass burial scenarios in the event of a worst-case ­scenario.

Key to a pandemic response or major health emergency will be communications. Once surveillance determines that a pandemic response is necessary it will be vital that communications to the general public, to the health care community and to the pandemic response partners be clear and immediate. One of the lessons learned from the 2003 SARS response was that communication with health care professionals can prove challenging. During SARS, the provincial emergency operations centre was able to give directions to hospitals across the province via broadcast fax; however, there was no mechanism, except for the popular media, to communicate directly and quickly with the province’s 26,000 physicians.

The national and provincial governments have produced extensive, evidence-based frameworks for pandemic and emergency health response. While hospitals and municipalities engage in their individual pandemic and emergency plans, there must be coordination of planning at the local level to ensure a successful response. Specifically, there must be a close working relationship between the local public health unit, the hospital, local physicians, first responders and municipal officials. Jurisdictions need to understand the surge capacity, if any, of their local hospital and plan how they might create additional capacity. A pro-active health care committee with representation from the public health unit, hospital, ambulance service, long term care sector and physicians will help to identify potential weaknesses in local response capacity and identify potential multi-agency solutions to these weaknesses.

Emergency planners need to engage local hospital officials on an ongoing basis in order to keep abreast of the ever-changing capacity of this key resource. Even if the emergency is not of itself a medical one, one must integrate the local hospital as a major critical infrastructure in all emergency planning. Continuous dialogue and coordination of emergency training and exercises will create a network of understanding that will ensure a cooperative and collaborative response to any emergency.

Mark Edmonds is an administrator at the Kingston General Hospital and an Assistant Professor with the Faculty of Health Sciences at Queen’s University.
© FrontLine Security 2007