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RMH Emergency Operations Preparedness Plan

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PURPOSE:
The purpose of the Emergency Operations Plan is to manage emergencies involving “all hazards.” All-hazards Preparedness is the comprehensive preparedness required to manage the casualties that result from the plethora of possible hazards.

The Code Yellow Plan addresses the procedures designed to respond to those situations most likely to disrupt the normal operations of the hospital and return the hospital to a normal status. The Code Yellow Plan response is designed to assure availability of resources for the continuation of patient care during the emergency, and to meet the needs of victims of a hospital or community based incident. Riverton Memorial Hospital (RMH) uses the Hospital Emergency Incident Command System (HEICS) structure to effectively manage these events.

SCOPE:
The Emergency Operations Plan is designed to assure appropriate, effective response to a variety of emergency situations that could affect the safety of patients, staff, and visitors, or the environment of RMH, or adversely impact upon the hospital's ability to provide healthcare services to the community. The program is also designed to assure compliance with applicable codes and regulations. Should any of these hazards pose a threat to the environment follow the Hospital Lockdown Policy or the Airborne Hazard Policy.

FUNDAMENTALS:
A. All-Hazards include natural and accidental man-made events, with the destructive capability of causing multiple or mass casualties. Each All-Hazard event can create a Public Health Emergency. Table 1 is representative of All-Hazard events.

All-Hazard Events

Earthquakes

Emergency infectious diseases

Explosive devices

Firearms

Industrial accidents

Landslides

Meteors

Oil field events

Structure collapses

Structure fires

Terrorism events

Tornadoes

Transportation events

Volcanoes

Wildfires

WMD events

B. Any of the above hazard events can lead to a disaster situation. A disaster is an event that exceeds the capabilities of the response in other words NEED EXCEEDS RESOURCES.

The D-I-S-A-S-T-E-R paradigm is an organizational tool for responders to utilize resources, assess needs, and enhance communication consistency for all individuals and agencies. The DISASTER paradigm is a standardized method to recognize and manage the event and to care for the victims at RMH.

The D-I-S-A-S-T-E-R paradigm is as follows:

Detect - (Does need exceed resources? Activate Code Yellow.)

Incident Command - (Report to commander)

Safety/Security - (Violence Threat? Activate Lockdown Protocol)

Assess Hazards - (Fire? Hazmat? Infections? Radiation? Terrorism?)

Support - (Call for agencies needed: police,fire,EMS,Government)

Triage/Treatment - (See Below Section C)

Evacuation - (Are enough transport units available?)

Recovery - (Patient Safety/Healthcare needs are priority)

ABC of safety and hazard assessment:

A - Assess hazards - (situational awareness of all hazards.)

B - Barrier needed? - (Use PPE, keep distance.)

C - Communicate - (Provide information to incident commander.)

C. A Mass Casualty Incident (MCI) is any incident that exceeds the capabilities of the hospital and would be considered a disaster. A code Yellow is called when healthcare needs exceeds resources. The goal of the MCI is to do the greatest good for the greatest number of survivors. The triage system used to manage any MCI event is the MASS triage system. The M-A-S-S Triage system sorts groups of multiple victims in order to determine the ID-me treatment categories.

M-A-S-S Triage system

MOVE:
Anyone who can walk, Move to the Green collection area.

ASSESS:
Assess the remaining patients using the START Priority system

SORT:
Categorize individual patients according to “ID-ME”

Immediate (Red)

Delayed (Yellow)

Minor (Green)

Expired (Black)

SEND:

Immediate (Red) patient assess A-B-C, for life threatening injuries or illnesses address during decontamination, if indicated, prior to moving to the ER

Delayed (Yellow) should be taken to temp assessment area IE: OSTS, ICU, OB.

Triage Categories:

IMMEDIATE:
Obvious threat to life or limb; usually alteration I vital functions (ABCs.)

DELAYED:
Need definitive medical care, but should be stable if care is delayed initially.

MINIMAL:
“Walking wounded”: abrasions, contusions, minor lacerations; stable vital signs.

EXPIRED:
Little or no survival chance, resources not used initially, unless available

The S-T-A-R-T system categorizes patients into the appropriate ID-ME treatment priorities.

PREPARATIONS FOR MASS CASUALTY INCIDENT

POLICY:
The following are recommendations for adequate preparedness in the event of a Mass Casualty Incident.

PROCEDURE:
Essential supplies, equipment, food, water and utilities must be provided to meet shelter needs for up to 72 hours.

Efficient traffic flow must be established. Prepare floor plans that designate areas for specific patient care functions and ensure that the staff is familiar with these plans.

Provide for essential utilities for an emergency source of electrical power capable of operating all essential electrical equipment. Plan for failure of the emergency generators.

Establish an alternate source of safe water.

Provide an alternate means of waste disposable in the event of sewage system failure.

Provide for sufficient fuel to last for 72 hours of expanded operation.

Arrange for disaster supporting services to be performed by local businesses, utility companies, government agencies and individuals.

DISASTER SUPPORTING SERVICES WOULD INCLUDE:

TRANSPORTATION

COMMUNICATIONS

TRAFFIC CONTROL

FOOD SUPPLY

UTILITY MAINTENANCE

The hospital must test its plan and operational readiness at least semiannually. This is accomplished through either exercises in which many planned disaster functions are performed as realistically as possible under simulated disaster conditions, or in the event of a real disaster.

COMMITTEE FOR (MCI)

The meetings of the hospital Environment of Care Committee will be devoted to a review of the situation to establish a basis for planning and to set criteria.

This review will include studying the community civil defense plan, and make a general assessment of the hospital's present key resources:

PHYSICIANS.

NURSES.

BEDS.

CRITICAL SUPPLY AND EQUIPMENT ITEMS.

AVAILABLE SPACE.

Determine the hospital's maximum expansion capability in terms of beds and services, assuming that resources are used with optimum efficiency.

Weigh resources on hand against estimated requirements to determine the extent of resource deficiencies or surpluses.

FUNCTION OF COMMITTEE:
The function of the committee is to designate and oversee the following.

To inform and teach the plan to all employees.

to coordinate the hospital plan with the overall community plan.

To supervise frequent drills to practice the hospital's (MCI) plan under various simulated situations

To review and revise the plan at regular intervals and as indicated by periodic drills.

Coordinate drills with City, County, and Civil Defense agencies.

The Hospital Mass Casualty Incident Plan will be submitted to the Environment of Care Committee, Governing Body, Local Emergency Health Services for recommendations.

The hospital Mass Casualty Incident Plan will be reviewed annually by the committee.

COMMUNICATIONS DURING (MCI)

Communications must be efficient, reliable and properly maintained to handle a disaster.

The hospital telephone system must be safeguarded from overloading during an emergency.

Two-way radio equipment (i.e. Walkie-talkies) and operators familiar with equipment.

In the absence of a radio system, arrangements must be made with the Fremont County Emergency Preparedness Director for the assignment of a two-way radio unit to the hospital.

Volunteers will be assigned to the hospital to provide both internal and external messenger service to supplement and support all other means of communication as per the HEICS alga rhythm.

Communication will be limited to messages essential to the emergency operation.

External communications will be chiefly with the Liaison officer and Public information officer in the HEICS plan.

Other incoming calls will be accepted only from County Emergency Services, Fire, Police or other officials with disaster responsibilities.

When telephone extensions to the Incident Commander's office are tied up, incoming calls will be switched to a messenger personnel who will copy the messages and route them to the Incident Commander.

SECURITY:

The following provisions have been made for the security of the physical plant, patients, and employees of the hospital during disaster situations.

Employees of the hospital are required to wear name badges identifying them as employees. Only persons with proper identification shall be admitted to the hospital during an emergency. All employees, regardless of department are to enter the hospital at the fire door between the front lobby and radiology.

At the time the Mass Casualty Incident plan is activated; the nursing supervisor or maintenance personnel on duty will be responsible for locking all exits and entrances throughout the hospital.

All relatives will be directed around the outside of the building to the front lobby entrance and be asked to wait in the lobby entrance until further instructions can be given.

No visitors for inpatients will be allowed unless the patient is critical and permission is received from the nursing unit.

There will be at least one person assigned by the Safety and Security Officer outside the hospital to direct vehicles delivering patients. Police, Fire or Civil Defense may be called for assistance.

All disaster patients will be unloaded at the Ambulance entrance. And entranceway cleared immediately.

As soon as treatment areas have been prepared, employees will be stationed at all entrances and exits to act as security guards. The Safety and security officer will be in charge of assigning these duties.

EMERGENCY WATER SUPPLY:

DRINKING WATER:

In the event that the hospitals drinking water supply is contaminated and or unavailable, bottled water is available from...

Rocky Mountain Bottled Spring Water
671 Lincoln St. Lander, Wy
(307) 332-7310 or 1-800-967-1790

The logistics Chief shall be responsible for contacting alternative water supply companies.

NON-STERILIZED WATER:

Non-sterilized water is defined as a large base supply of water requiring sterilization if used for human consumption, i.e. drinking water.

The Riverton Fire Dept. will provide a pumper truck if possible. Water may also be utilized from Fremont County Emergency Management or see emergency contact list located in the maintenance department, for possible other suppliers.

SUPPLIES, UTILITIES AND EQUIPMENT:

Procedures shall be established and followed to ensure the availability of supplies, utilities and equipment needed during a disaster.

Preparations must be made to provide adequate essential hospital supplies, utilities and equipment to ensure the most efficient use of these resources.

PREPARATIONS MUST INCLUDE THE FOLLOWING:

Standardized disaster treatment techniques to ensure the most economical use of medical supplies.

Assess available resources

Estimate emergency material needs

perform an inventory of essential items on hand.

Determine probable shortages allowing for improvisation and substitution whenever possible.

Offset shortages by increasing current inventories of essential items to the degree possible.

Establish lists of supplies and equipment to be sent to treatment areas upon activation of the plan.

Rotate supplies that are subject to deterioration.

Assemble disaster supplies into sets and locate the sets for easy accessibility to the using area.

Disaster cart kept in the Emergency Dept. with additional supplies, updated and checked monthly by Materials Management.

Materials Management is to have procedures for emergency procurement of additional supplies.

Materials Management is to maintain current lists of health supply sources in the community.

REQUIREMENTS FOR DIESEL FUEL ON HAND IN AN EMERGENCY:

1,000 gallons of diesel fuel in the storage tank for emergency generator and 2,000 gallons of dieses fuel in the storage tank for the boilers.

Levels are to be checked quarterly and filled as appropriate.

Located at North East corner of hospital grounds.

EMERGENCY WATER SUPPLY:

During an emergency, a water rationing plan shall be instituted.

FOOD SUPPLIES STORAGE:

Food supplies are stored in the main kitchen.

A three day supply of perishable food is maintained.

Non-perishable foods sufficient to last two weeks is maintained.

DRUG SUPPLIES STORAGE:

Non-perishable drug supplies are stored in the pharmacy, perishable drugs are kept in the pharmacy in separate refrigerators.

Drugs are rotated and expiration dates carefully noted.

MATERIALS MANAGEMENT:

Upon activation of a code yellow materials management will fall under the Materials Supply Unit Leader. Their responsibilities are first to organize and supply medical and non-medical care equipment and supplies to appropriate triage and treatment areas.

Materials have several accounts throughout the town to obtain supplies such as linens, minor bandages food building supplies ect.

DELEGATION OF RESPONSIBILITY:

PROCEDURES:

notification is received via the County Defense Coordinator of a disaster if external or if internal, the house supervisor or person reporting.

If the situation arises internal then the house supervisor will assess the emergency and either designate or take it upon themselves to call what help is indicated.(i.e. fire department, law enforcement, administrator on call.)

During an external disaster the house supervisor will receive the information needed and use the DISASTER algorithm at the beginning of this policy to determine if need exceeds resources.

The house supervisor or person designated will contact the administrator on call and determine if the Code Yellow should be called.

when the Code Yellow is activated the Incident Command Center will be opened up depending on size of disaster, or the supervisor may assign help the emergency area as needed.

Once a Code Yellow is activated the house supervisor will follow the call algorithm located in the blue Disaster Plan Book. This book is to be located in the supervisors office and one in the administration office and one in the emergency department.

D.  An influx of Patients with a potentially infectious disease should be managed using the following procedures.

1.  The staff should notify the House Supervisor and implement the Airborne Hazard Plan and The Facility Lockdown Plan as indicated by the infectious agent. In the event of an unknown agent the same procedure applies.

In small-scale events, routine patient placement and infection control practices should be followed.
When the number of patients presenting to RMH are too large to allow routine triage and isolation strategies it may be necessary to apply practical alternatives. These may include cohorting patients who present with similar syndromes, IE, grouping affected patients into a designated section of the facility or in the emergency department.
Designated cohorting sites should be determined by the CEO or his designee, in consultation with the safety officer, operations staff and infection control based on patterns of airflow and ventilation, availability of adequate plumbing and waste disposal, and capacity to safely hold potentially large numbers of patients.

The HEICS response center should be set up to monitor and manage the event. If an alternate triage or cohort site is required the operations chief needs to aquire separate triage areas as needed.

Controlled entry should be maintained according to the lockdown plan to minimize the possibility for transmission of infections to other patients at the facility and to staff members not directly involved in managing the outbreak.

At the same time, reasonable access to vital diagnostic services, EG; radiography departments should be maintained.

E. Weapons of Mass Destruction (WMD) Comprise those events or agents that injure or kill large numbers of victims. These can be divided into several categories and are as follows.

1. CHEMICAL AGENTS

2. BIOLOGICAL AGENTS

3. RADIOLOGICAL AGENTS

4. NUCLEAR AGENTS

5. EXPLOSIVE AGENTS

The hospital shall make every attempt to be prepared for hostile acts of Bioterrorism.  While at the same, producing a calm atmosphere for patients and visitors while in the hospital and for the community as well as maintaining a safe environment for patients in the hospital.

BACKGROUND:
The threat of Bioterrorism and biological warfare is increasing. Many microorganisms and toxins are easily acquired and mass-produced as aerosolized biological weapons.  Acts of Bioterrorism can range from hoaxes to the release of agents that could cause mass casualties that may overwhelm the public health system, and the threat is a concern both globally and locally.  Examples include Anthrax, Sarin, botulinum toxins, smallpox and other virus's associates with hemorrhagic fever, brucellosis, plague, Q fever, and tularemia. It is critical that Riverton Memorial Hospital increase its preparedness for such attacks. Pharmacologic antidotes are available to treat many biological warfare agents (see attached chart [Appendix A]). However, hospital pharmacies may have an insufficient supply of necessary medications if many people are exposed.

Every employee in the hospital need procedures for handling biological agent threats, protecting themselves and other from occurrences that happen in the hospital, and how to treat a person that may have come in contact with one of these agents.

This protocol includes information on how to handle threats and who to contact when one is received or detected. Recommendations for the medical management of each specific biological organism or toxin are contained in  (Appendix A), and a policy for obtaining pharmacologic antidotes is established (Appendix B). The hospital and other pharmacies have pledged to work together and to contact each other for additional medications if necessary.  Appendix C lists some sources of information on Bioterrorism preparedness.

Epidemiologic principles must be used to assess whether a patients presentation is typical of an epidemic disease or an unusual event and should raise concern.   Features that should alert health care providers include:

1.  A rapidly increasing incidence (within hours of days) in a normally healthy population;

2.  An epidemic curve that rises and falls in a short period of time;

3.  An unusual increase in the number of people seeking care, especially with a fever, respiratory or gastrointestinal complaints;

4.  An epidemic disease rapidly emerging at an uncharacteristic time or in an unusual pattern;

5.  Lower attach rates among people who have been indoors especially in areas with filtered air or closed ventilation systems compared to people who have been outdoors;

6.  Clusters of patients arriving from a single locale.

7.  Large numbers of fatal cases;

8.  Any patient presenting with a disease that is relatively uncommon and has Bioterrorism potential (e.g. pulmonary anthrax, tularemia, or plague).

PROCEDURE:
How to handle Anthrax and other biological agent threats.  Use these guidelines for handling the following incidents

I. Prevention of Infection:

A. All patients shall be managed using Standard Universal Precautions

B. After handling the mail or packages all hospital personnel will wash there hands and all other exposed skin with soap and water.

C. Patient Placement in the event of a Bioterrorism event should follow the preexisting patient placement as detailed in the Emergency Preparedness Plan:

1.  Treatment Area #1:  Emergency Department for patients who need immediate treatment for emergent conditions such as respiratory failure.

2.  Treatment Area #2:  ICU for cardiac and respiratory distress that is stabilized.

3.  Treatment Area #3:  Medical/surgical patients with serious problems but in stabilized condition.

4.  Treatment Area #4:  OSTS hallway and rooms, all contaminated victims without serious or life threatening conditions after proper decontamination procedures are finished.

If victims are infected with diseases that requires respiratory precautions mask these victims and place them in the Cast Room of the Emergency Department, notify public health, and place the portable HEPA Filtration unit in the room.  IF SMALLPOX IS SUSPECTED THE ED NEEDS TO BE ISOLATED AND PUBLIC HEALTH NOTIFIED.  OUR FACILITY WILL THEN BECOME THE SMALL POX FACILITY AND ALLOTHER PATIENTS WIL BE DIVERTED TO LANDER HOSPITAL.  THE AIR HANDLING SYSTEM WILL NEED TO BE SHUT DOWN AND ISOLATION PROCEDURES FOLLOWED.  LET NO ONE GO HOME THAT CAME WITH THE PATIENT OR WAS IN TRIAGE WITH THEM.

II. How to Report Bioterrorism Incidents:

A.  Report all incidents to the NURSING SUPERVISOR, administration, pharmacy, and infection control nurse.  They will in turn notify the local authorities.  The authorities to notify are:

1. Public Health at either there office number or after hours beeper; RIVERTON:  1-800-478-0422 or LANDER 1-800-482-3250

2. The local police department and sheriff's office.  (Use the 911 numbers).

3. Fremont County Risk and Emergency Manager, Richard Klouda  [856-2374 or 856-7200]

4. Wyoming Bioterrorism Response Program 1-888-996-9104 (24 hour hotline) or Web site: http://wdhfs.state.wy.us.ahrp or http://wdhfs.state.wy.us/bioterrorism

5. The Center for Disease Control (CDC)  (770-488-7100) Web site:  http://www.bt.cdc.gov

III.  Suspicious unopened letters or packages marked with threatening message such as “Anthrax”:

A. Do not shake or empty the contents of any suspicious envelope or package.

B. Place the envelope or package in a plastic bag or some other container to prevent leakage of the contents.

C. If you do not have any container, then cover the envelope or package with anything (e.g. clothing, paper, trashcan, etc.) and do not remove this cover.

D. Then leave the room and close the door, or section of the area to prevent others form entering (i.e. keep others away).

E. Wash your hands with soap and water to prevent spreading of any powder to your face.

IV. Envelope or package with suspicious powder that spills out onto surface:

A. Do not try to clean up the powder.  Cover the spilled contents immediately with anything (i.e. clothing, paper trashcan, etc) and do not remove this cover!

B. Then leave the room and close the door or section off the area to prevent others form entering (i.e. keep others away)

C. Wash your hands with soap and water to prevent spreading of any powder to your face.

D.  Remove heavily contaminated clothing as soon as possible and place them in a plastic bag, of some other container that can be sealed.  This clothing bag should be given to emergency responders for proper handling.

E. Shower with soap and water as soon as possible.  Do not use bleach or other disinfectants on your skin.

V. Aerosols:  For example: small device triggered, warning that air-handling system is contaminated, or warning that biological agent was released in a public space.

A. Turn off local fans or ventilation units in the area (leave biological and horizontal airflow hoods on).

B. Close the door, or section off the area to prevent others from entering (keep others away).

C. Report the incident to administration, the pharmacy, or the nursing supervisor.  They will in turn notify the local authorities.

D. Shut down air handling system in the building.

E. If possible, list all the people who were in the room or area, especially those who had actual contact with the suspicious powder.  Give this list to whomever you reported the incident to for follow-up investigations.

VI. How to identify suspicious packages or letters:  Some characteristics;

A.  Excessive postage
B.  Handwritten or poorly typed address
C.  Incorrect Titles
D.  Title, but no name.
E.  Misspellings of common words.
F.  Oily stain, discolorations or order.
G.  No return address
H.  Excessive weight
I.  Lopsided or uneven envelope.
J.  Protruding wires or aluminum foil.
K.  Excessive security material such as masking tape, string, etc.
L.  Visual distractions.
M.  Ticking sound.
N.  Marked with restrictive endorsements, such as “personal” or “Confidential”
O.  Shows a city or state in the postmark that does not match the return address
P.  Package is from a vendor that we do not order from.

Appendix A

Recommended antidotes for Bioterrorism agents See table 1.  Medications Stocked for Treatment and Prophylaxis of Infection by Bioterrorism Agents on the last page of this appendix.

Anthrax

Onset of symptoms:
1-5 days.

Treatment (symptomatic):
For first-line treatment, Levofloxacin 500 milligrams I.V. every 24 hours. For second-line treatment, Doxycycline 200 milligrams I.V. followed by 100 milligrams I.V. every 12 hours, OR Penicillin 2 million units I.V. every 4 hours plus Streptomycin 30 mg/kg I.M. or I.V. daily (or Gentamicin). Supportive therapy for shock, fluid volume deficit, and airway adequacy may be indicated.

Post exposure prophylaxis:
In adults (including pregnant women), provide for 4 weeks until 3 doses of vaccine are given or for 8 weeks if vaccine is unavailable. For first-line prophylaxis, Levofloxacin 500 milligrams by mouth daily. For second-line prophylaxis in adults, Doxycycline 100 milligrams by mouth twice a day OR Amoxicillin 500 milligrams by mouth every 8 hours (if susceptibility is confirmed).  In children, for first-line prophylaxis, Ciprofloxacin 20-30 mg/kg/day by mouth, in divided doses every 12 hours (maximum dosage, 1 gram/ day). For second-line prophylaxis in children, Doxycycline 2.5 mg/kg by mouth every 12 hours OR Amoxicillin adult dosage in children [3] 20 kg and 40 mg/ kg/day in divided doses every 8 hours in children greater than 20 kg.

Isolation precautions:
Standard precautions.

1.  Patient placement in a private room is not necessary.  Decontamination of patients should include the following:

2.  Remove all contaminated clothing and store in labeled plastic bags.

3.  Have patient shower thoroughly with soap and water

4.  Use standard precautions when handling contaminated clothing.

5.  Decontaminate surfaces with facility approved sporicidal/germicidal agent or with 0.5% hydrochloride solution (1 part household bleach to 9 parts water).

Comments:
Vaccinate when antidote is given if the vaccine (obtainable from CDC) is available (for Bioport Corporation vaccine, give 0.5 mL s.c. as soon as possible after exposure, then at 2 and 4 weeks.  Once symptoms appear, treatment is almost always ineffective.  Other therapeutic alternatives include erythromycin and chloramphenicol.

A.  Anthrax is caused by infection with Bacillus anthracis, a gram-positive spore-forming bacterium. The spore form of this organism, which can survive in the environment for many decades, is not virulent, doesn't aerosolize well, and, in natural concentrations, is very hard to transmit through touch.

B.  Anthrax acquired by inhalation generally occurs after an incubation period of one to six days. After incubation, a nonspecific flu-like illness ensues, characterized by fever, myalgia, headache, a nonproductive cough, and mild chest discomfort. The second phase is marked by high fever, dyspnea, stridor, cyanosis, and shock

C.  Penicillin can be an effective treatment of certain forms of anthrax. However, since the anthrax form that might be used in Bioterrorism attacks (inhalational anthrax) is likely to be antibiotic-resistant, ciprofloxacin (Ciproโ) is the drug of choice

F.   Important points for the public to keep in mind:

1.  Inhalation anthrax has little potential for person-to-person transmission. It also is very difficult to disperse effectively across large populations.

2.  The U.S. health care system has effective treatment protocols for individuals who have contracted anthrax. However, early diagnosis and treatment is critical. If therapy is begun more than 48 hours after the onset of symptoms, the probability of death is high.

3.  Vaccines for anthrax are currently only available for military personnel, are for pre-exposure prophylaxis, and require multiple injections and yearly boosters.

4.  Consumer stockpiling of medications such as ciprofloxacin (Ciproโ) can lead to national shortages when a real need arises. Self-diagnosis and self-treatment is never a good idea. Medicines, in general, also have a limited shelf life, can have significant side effects and drug interactions, and may not be the right therapeutic agent for the condition you have.

5.  Moreover, health care providers must ensure they have a clear diagnosis or strong indication of anthrax infection in immature pediatric patients as ciprofloxacin (Ciproโ) can stunt cartilage growth in this patient population.

For more information, check out the CDC's Web site: www.cdc.gov/ncidod/dbmd/diseaseinfo/anthrax.

Botulinum toxins

Onset of symptoms:
1-5 days.

Treatment (symptomatic):
Trivalent equine antitoxin for serotypes A, B, and E (available from CDC).

Post exposure prophylaxis:
None.

Isolation precautions:
Standard precautions.

Comments:
Risk of anaphylaxis; perform skin test for horse serum sensitivity before administering equine antitoxin. May also cause serum sickness.

Brucellosis

Onset of symptoms:
5-60 days (occasionally, months).

Treatment (symptomatic):
Doxycycline 200 milligrams/day by mouth plus Rifampin 600-900 milligrams/day by mouth times 6 weeks 8 OR Doxycycline 200 milligrams/day by mouth times 6 weeks plus Streptomycin 15 milligrams/kg twice a day OR Gentamicin 1.5 milligrams/kg every 8 hours I.M. for first 10 days.

Postexposure prophylaxis:
Doxycyeline and Rifampin x 3 weeks.

Isolation precautions:
Standard; contact isolation if draining lesions present.

Plague

Onset of symptoms:
2-3 days.

Treatment (symptomatic):
For pneumonic plague, Streptomycin 15 milligrams/kg I.M. twice a day for 10 days, or Gentamycin 1.5 mg/kg every 8 hr I.M. for 10 days, OR Doxycycline 200 milligrams I.V. once, then 100 mg I.V. every 12 hours for 10-14 days.  For plague meningitis, Chloramphenicol 25 mg/kg IV, then 60 mg/kg/day in 4 divided doses.

Post exposure prophylaxis:
For first-line pro-phylaxis in adults (including pregnant women) and children, Ciprofloxacin 500 milligrams by mouth twice a day. OR Doxycycline 100 milligrams by mouth every 12 hours for 7 days [6,8] OR (except in children and pregnant women) Tetracycline 500 milligrams by mouth four times a day for 7 days.  Alternative: Chloramphenicol 25 mg/kg by mouth four times a day.

Isolation precautions:
For pneumonic plague, droplet precautions until patient have been treated for 3 days.

Comments:
Greer inactivated vaccine: 1 mL, then 0.2 mL at 1-3 and 3-6 months (not protective against pneumonic plague).  Currently no vaccines are commercially available to the general public.

Q Fever

Onset of symptoms:
10-40 days.

Treatment (symptomatic):
Doxycycline 100 milligrams by mouth every 12 hours for 5-7 days OR Tetracycline 500 milligrams by mouth every 6 hours for 5-7 days.

Post exposure prophylaxis:
Start Doxycycline 8-12 days after exposure for 5 days; start tetracycline 8-12 days after exposure for 5 days.

Isolation precautions:
Standard precautions.

Smallpox

Onset of symptoms:
7-17 days.

Treatment (symptomatic):
Cidofovir I.V. effective in vitro; dosage not known. Also Ribavirin I.V. (however, only by mouth and aerosolized formulations are available).

Post exposure prophylaxis:
Vaccinia immune globulin 0.6 mL/kg I.M. (give within 3 days of exposure; best if given within 24 hr).

Isolation precautions:
Airborne precautions.

Comments:
If >3 yr since last vaccination, preexposure and post exposure vaccinations are recommended. Currently there are no vaccines commercially available to the general public.

Staphylococcal enterotoxin B

Onset of symptoms:
1-6 hr.

Treatment (symptomatic):
Ventilatory support and other supportive care.

Post exposure prophylaxis:
None.

Isolation precautions:
Standard precautions.

Comments:
Vomiting and diarrhea may occur if toxin is ingested.

Tularemia

Onset of symptoms:
2-10 days.

Treatment (symptomatic):
Streptomycin 15 milligrams/kg twice a day I.M. for 10-14 days OR Gentamycin 3- 5 mg/kg/day I.M. for 10-14 days.

Post exposure prophylaxis:
Doxycycline 100 milligrams by mouth every 12 hours for 14 days OR Tetracycline 2 grams/day by mouth for 14 days.

Isolation precautions:
Standard precautions.

Comments:
There is a live attenuated vaccine, but currently no vaccines are commercially available to the general public.

Viral Encephalities

Onset of symptoms:
Venezuelan equine encephalitis (VEE), 2-6 days; Eastern equine encephalitis (EEE) and Western equine encephalitis (WEE), 7-14 days.

Treatment (symptomatic):
Supportive therapy (analgesics and anticonvulsants p.r.n.).

Post exposure prophylaxis:
None.

Isolation precautions:
Standard precautions.

Comments:
There are vaccines for VEE, EEE, and WEE, but currently no vaccines are commercially available to the general public.

Viral hemorrhagic fevers (Congo-Crimean hemorrhagic fever, fevers caused by arenaviruses)

Onset of symptoms:
4-21 days.

Treatment (symptomatic):
Ribavirin 30 mg/ kg I.V. initially, then 15 mg/kg I.V. every 6 hours for 4 days, then 7.5 mg/kg I.V. every 8 hours for 6 days (however, I.V. ribavirin not commercially available).

Post exposure prophylaxis:
None.

Isolation precautions:
Contact precautions; additional precautions in cases of massive bleeding.

Comments: Aggressively manage secondary infections and hypotension.

Organophosphorous nerve agents having anticholinesterase activity:

Onset of symptoms:
Immediately to exposure

Symptoms:
Strange or confused behavior, increased wheezing and increased difficulty in breathing, severely pinpointed pupils, red eyes with tearing, vomiting, severe muscular twitching and general weakness, involuntary urination and defecation, convulsions, unconsciousness, respiratory failure, Bradycardia

Treatment:
Mark I nerve agent, auto-injector provides Atropine 2.1 milligrams in 0.7 ml of sterile, pyrogen-free solution AND Pralidoxime Chloride 600 milligrams in 2 ml of a sterile, pyrogen-free solution   The auto-injector is stored in self-contained unit designed for automatic self or medical personnel I.M. administration.  May be repeated up to three times by medical personnel.

POISONING DUE TO ORGANOPHOSPHATE COMPOUNDS SUCH AS MALATHION, PARATHION, FENTHION, TEPP, DICHLOROS ETC:
1-2 grams of pralidoxime along with 2-4 milligrams of 1-2 grams of pralidoxme along with 2-4 milligrams of Atropine give I.M. OR I.V. as 5% solution in atropine given I.M. or I.V. as 5% solution in water over 5-10 minutes or infuse in 100 ml normal saline over 15-30 minutes.  Repeat after 1 hour and then hourly with care if muscle weakness persists.  Children: Pralidoxime 20-40 milligrams/kg and Atropine 0.05-0/1 milligram/kg.  In both adults and children, atropine might have to be injected frequently to relieve respiratory depression.  Full resuscitative measures should be always utilized.

IMPORTANT:  PHYSICIANS AND/OR MEDICAL PERSONNEL ASISTING IN THE CARE OF VITIMS OF NERVE AGENTS SHOULD AVOID EXPOSING THEMSELVES TO CONTAMINATION BY THE VICTIM'S CLOTHING.

Medications Stocked for Treatment and Prophylaxis of Infection by Bioterrorism Agents

A = anthrax, PEP = post exposure prophylaxis, P = plague, treat = treatment, T = tularemia, B = brucellosis, Q = Q fever.

Appendix B

Policy on obtaining pharmacologic antidotes for Bioterrorism exposures

Background
The threat of Bioterrorism and biological warfare is increasing. Many microorganisms and toxins are easily acquired and mass-produced as aerosolized biological weapons. Contact of populations with these microorganisms has the potential to produce mass casualties that may overwhelm the public health system. It is critical that Riverton Memorial Hospital increase its preparedness for such attacks. Pharmacologic antidotes are available to treat many biological warfare agents (see attached chart [Appendix A]). However, hospital pharmacies may have an insufficient supply of necessary medications if many people are exposed. The attached chart includes information about treatment of confirmed cases, post exposure prophylaxis, isolation precautions, and local availability of agents.

The protocol below outlines the procedures for obtaining medications that may not be available or that may be stocked in insufficient quantities in the pharmacy.

Implementation
The pharmacy will be notified as soon as an exposure is known and will be given an estimate of how many patients may have been exposed.

The pharmacy will refer to the attached chart to determine which hospitals stock the necessary medications.

The pharmacy will call nearby hospitals and try to obtain the items. [Lander Valley Medical Center, 307-332-4420: Wyoming Medical Center, 800-822-7201; Hot Springs Memorial Hospital, 800-788-9459]

The pharmacy will attempt to obtain the items from the wholesaler. [1-877-425-6242 account number 028249]
The pharmacy will obtain assistance from resources outside the local area:

Risk and Emergency Manager
Richard Klouda
[856-2374 or 856-7200]

Emergency Coordinator
U.S. Public Health Service
206-615-2469

Centers for Disease Control and Prevention Emergency      Response
(see CDC: National Pharmaceutical Stockpile Program (NPS at the end to this appendix)
770-488-7100

Poison Control Center
[1-800-955-9119]

Domestic Preparedness (partnership of federal agencies)
800-424-8802 (emergency)
800-368-6498 (nonemergency/information/ planning)

Centers for Disease Control and Prevention Office of Bioterrorism, Preparedness, and Response
404-639-0385

CDC: National Pharmaceutical Stockpile Program (NPS)
The CDC has established the NPS program as a national repository of antibiotics, chemical antidotes, life support medications, IV administration and airway maintenance supplies, and medical/surgical items. (In California Department of Health Services coordinates access to the NPS). The NPS is designed to re-supply state and local public health and medical response entities in the event of a biological and/or chemical terrorism incident anywhere, at anytime within the United States. The NPS will back up first response efforts with a general re-supply package followed by larger quantities of the medical materiel specific to the health consequences associated with the agent used.

There are 2 phases within the NPS program. First, there are 8 separate, yet identical pre-packaged caches of medical materiel called 12-hour Push Packages that are fully stocked, positioned in environmentally controlled and secured warehouses, and ready for immediate deployment to reach any affected area within 12 hours of the federal decision to release the assets.  These Push Packages have been pre-positioned regionally throughout the

United States. Each Push Package includes: oral and intravenous drugs to therapeutically and prophylactically treat persons exposed to anthrax, plague, or tularemia. Each package also contains chemical antidotes and additional medical material necessary to treat victims of chemical agents and trauma. Beyond these medications, each Push Package includes: catheters, administration sets, antiseptics, and other supplies needed to provide IV therapy, emergency medications to treat anaphylactic reactions; and certain medical/surgical supplies to care for those with other emergency medical needs (i.e. ventilators). Second, if the incident requires a larger or multi-phased response, Vendor Managed Inventories known as VMI packages will be shipped to arrive within 24 to 36 hours after the initial Push package.  The VMI packages will be comprised of pharmaceuticals and supplies that can be "tailored" to provide pharmaceuticals, supplies and/or products specific to the type of suspected or confirmed agent or combination of agents. CDC has contractual agreements with manufacturers and vendors, throughout the United States, for each of the items in the VMI formulary. Should an event occur which exceeds the demands of any one or all eight of the 12-hour Push Packages; CDC will immediately notify its designated contract manufacturers to begin pulling stock and stand ready to transport VMI re-supply packages.

Currently, the NPS is activated through the normal Medical and Health Mutual Aid system. Initially, the NPS Push Package is received by CDHS and OES at an air terminal near an affected community. Distribution of the Push Package to affected communities involves coordination with local, state and federal agencies. CDHS and OES are charged with developing an NPS response plan to deliver NPS assets to local operational area, staging facilities. Local government is responsible to coordinate the distribution of NPS resources to clinical sites.

Appendix C - Sources of information on Bioterrorism preparedness

National Domestic Preparedness Office (partnership of federal agencies)
Telephone: 800-368-6498
Fax: 410-612-0715
E-mail: cbhelp@sbccom.apgea.army.mil
Web: http://dp.sbccom.army.mil

United States Army Medical Department, Medical NBC Information Server
(www.nbc-med. org)

Johns Hopkins University Center for Civilian Biodefense Studies
(www.hopkins-biodefense.org)

Centers for Disease Control and Prevention (publisher of MMWR Morbidity and Mortality Weekly Reports and Emerging/Infectious Diseases)
(www.cdc.gov)

Centers for Disease Control and Prevention (Bioterrorism Preparedness and Response)
(www.bt.cdc.gov)

American Society of Health-System Pharmacists Emergency Preparedness-Counter terrorism Resource Center
(www.ashp.org/public/ proad/emergency/em_prep.html)

Wyoming All Hazard Response Program
1-888-966-9140

Public Health Nursing
332-1072

856-6979

US Patent Numbers 7,720,998 B2, 7,836,207