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On the morning of Sept. 11, Kim Jones, RN, was teaching a class on the 1995 terrorist attack in Tokyo that killed 11 people and injured more than 5,500 after sarin nerve gas was released in the subway system.

Almost immediately after the second plane hit the World Trade Center, Jones remembers thinking that "terrorism is now a reality in America. We've seen weapons of mass destruction in action."

In speaking with 11 hospitals around the country, NurseWeek found that three-quarters still are working on their bioterrorism preparedness plans. Jones estimates about 10 percent of hospitals nationwide are effectively prepared. Also, once a hospital has a plan in place, it has to spend time and money training its nursing staff.

"Nurses are our emphasis now," said Carol Gunter, MPA, RN, assistant director of the Los Angeles County Emergency Medical Services Agency, a division of the County Department of Health Services. "That's really our weakest area."

Before Sept. 11, some hospital disaster preparations were in place. But financial support for equipment and training programs was lacking, said Jones, director of critical care services at the Chino Valley Medical Center in California and an adjunct instructor with the Texas A&M University system.

"To be frank, I don't think there was that much community or fire agency support either," she said.

As an instructor at Texas A&M, Jones teaches the Hospital Emergency Incident Command System in which hospital staff, police officers and firefighters learn to speak the same language in managing a large-scale emergency such as bioterrorist attacks.

Bioterrorism preparedness plans call for decontamination facilities (showers accessible from the outside of the hospital to wash off contaminants). However, in some hospitals, Jones said, showers were constructed without the collection tank for the contaminated fluids because the cost of the tank is significantly higher than the shower. Under pressure to reduce costs, hospitals did not spend funds on protective equipment or increased stocks of antibiotics.

Staff training in disaster response is as important as a good plan and adequate equipment stocks. Acute care hospitals are required to hold disaster drills at least every six months. But in reality, Jones said, "Prior to Sept. 11, most hospital administrators saw the disaster committee as just another annoying activity."

Jim Fenn, RN, EMTP, adult study coordinator and outreach educator for the department of trauma services at The Toledo Hospital in Ohio, agrees with Jones' assessment.

Fenn planned and conducted a communitywide response drill in Fostoria, Ohio, in May. The drill simulated a covert release of anthrax at a factory.

According to Fenn, a lot of federal money has gone into metropolitan response teams, which are focused on the pre-hospital arena.

"That's left very little money directed to hospitals for preparedness," Fenn said. "And I think that's influenced the decisions by many hospitals to make preparedness a low priority until now."

In May, Fenn led a communitywide drill called "Bioterry," a concise guide for hospitals and patient care providers to detect and respond to bioterrorism.

The drill tested the efficacy of the manual and emergency deployment of hospital staff, firefighters, EMS, law enforcement, county EMA (Emergency Management Agency), Red Cross and the CDC if a covert incident was to occur in one location.

The toughest biological attack to identify is the covert attack, Fenn said. Because hospitals are where covert bioterrorist attacks are initially identified and reported, they are the frontline of defense.

"And in our drill, nurses did recognize, respond and report," Fenn said.

"The ER nurse must maintain a high level of suspicion all the time. She must not be afraid to suggest to the physician some differential diagnoses that could indicate a biological attack so at least they could rule that out," he said.

One outcome of effective preparation is effective patient teaching, Fenn said. Nurse teaching can allay a person's anxiety and fears.

Patient teaching should include signs and symptoms of high-priority bioterrorist agents, simple infection control and how to prevent exposure to an agent, he said.

But Fenn said he finds the ICU and floor nurses have received little education.

"Hospitals need to start at home," he said. "We need to educate our own people so we don't give multiple or conflicting messages to the public. And that goes down to the nursing assistants. Nurses can make a big impact that way. Nurses can be a voice of reason."

Ahead of the curve
In Houston, home to a huge petrochemical industry, Memorial Hermann Hospital has had an NBC (Nuclear, Biological and Chemical) hazardous decontamination plan in place for 10 years, said Cristy Perches, RN, an emergency center clinical manager.

Beginning last year, hospital staff participated in two citywide drills during which mass NBC contamination was simulated.

The outcome: ER nurses drilled to handle the hundreds or possibly thousands of people who might descend on a hospital following a bioterrorist attack.

"We drilled in how to handle the large volume of people who show up at the hospital after a covert biological attack," Perches said.

Tom Flanagan, MA, RN, a licensed paramedic and certified medical transport executive, is the administrative director of emergency services at Memorial Hermann.

One of the most important areas a hospital needs to handle is public concern, he said. If a gas or nerve agent is released in a large public place, those closest to it will be affected by the release of the gas.

People in the periphery will panic, get into their cars, leave the scene and drive to their place of comfort, Flanagan said. From there, they will go to their local hospital.

"If they truly had some kind of exposure, you don't want them walking into your hospital because you'll have a secondary contamination to the staff and facility," he said.

Staying connected
In Los Angeles County, home to 10 million people, a single, unified response protocol was completed Oct. 18.

The plan details how all county hospitals, law enforcement agencies, fire departments and the FBI will respond to mail-communicated threats and overt chemical, biological, radiological, nuclear and explosive incidents.

The response protocols now will move into the distribution and training phase, Gunter said.

"Over the last five years, first responders [public safety, fire and law] have been training to respond to threats of weapons of mass destruction. So they are highly prepared," Gunter said. "Hospitals are now the area where we need to focus."

The good news, Gunter said, is that federal funds for hospital training appear to be coming out of Washington. As of this writing, proposals by Sen. Edward Kennedy, D-Mass., and Sen. Bill Frist, R-Tenn., would provide as much as $5 billion in block grants to states for preparedness programs for hospitals and public health.

In Los Angeles County, that means hospital training and equipment, Gunter said.

Two weeks ago, the Department of Health surveyed all 911 receiving hospitals in Los Angeles County. Now, the county has a complete hospital list of everything from pharmaceuticals on hand to protective equipment and decontamination capabilities.

"It will help us identify where we're going to focus," Gunter said. "It will give us a complete picture of hospital preparedness. We need to connect the dots. That's something that needs to be corrected immediately."