Elsevier

Annals of Emergency Medicine

Volume 48, Issue 2, August 2006, Pages 194-199.e2
Annals of Emergency Medicine

Disaster medicine/original research
Lessons Learned From Clinical Anthrax Drills: Evaluation of Knowledge and Preparedness for a Bioterrorist Threat in Israeli Emergency Departments

Presented orally at the 14th World Congress for Disaster and Emergency Medicine, May 2005, Edinburgh, Scotland.
https://doi.org/10.1016/j.annemergmed.2005.12.006Get rights and content

Study objective

Emergency department (ED) physicians and nurses are considered critical sentinels of a bioterrorist attack. We designed a special hospital drill to test EDs’ response to inhalational anthrax and assess the level of preparedness for anthrax bioterrorism. We hypothesized that the occurrence of such a drill in an ED would improve the knowledge of its physicians, even those who had not actually participated in the drill.

Methods

We conducted 23 drills at all Israeli general hospitals’ EDs. An actor entered the walk-in triage area, simulating a febrile patient with lower respiratory complaints. A chest radiograph with mediastinal widening, as can be seen in early anthrax disease, was planted in the hospital’s imaging results system. Patients were instructed to give additional epidemiologic clues, such as having a few friends with a similar syndrome. Either before or after the drills, we distributed multiple choice tests about diagnosis and management of anthrax to the 115 senior emergency physicians at these hospitals.

Results

In 91% of EDs, a decision to admit the patient was made. Sixty-one percent included anthrax in the differential diagnosis and activated the appropriate protocols. Only 43% contacted all relevant officials. Average score on the anthrax tests was 58 (of 100). Physicians who were tested before the drill (in their institution) achieved a mean score of 54.5, whereas those who were tested after their ED had been exercised achieved a mean score of 59.3.

Conclusion

A national framework of drills on bioterrorism can help estimate and potentially augment national preparedness for bioterrorist threats. It is not, on its own, an effective educational tool. More emphasis should be given to formal accredited continuing medical education programs on bioterrorism, especially for emergency physicians and ED nurses, who will be in the front line of a bioterrorist attack.

Introduction

The postal anthrax attack of September and October 2001 has reminded us that inhalational or cutaneous anthrax can be a result of a deliberate spread of Bacillus anthracis spores.1 These recent events also emphasized the importance of emergency department (ED) physicians and nurses as sentinels, whose early recognition of and response to the first cases of inhalational anthrax can be crucial in limiting morbidity and mortality.2

A bioterrorist attack can be detected either by a public health surveillance system or by astute local health care providers. Surveillance systems’ alerts would probably miss the first wave of patients. In a recent survey of infection control practitioners in the United States, fewer than 10% reported confidence in the public health system’s surveillance efficacy.3 The first suspicion of a bioterrorist attack might therefore be by clinical sentinels: primary care physicians, emergency physicians or nurses, veterinarians, or laboratory workers. In the case of inhalational anthrax, because diagnosis depends on clinical data, laboratory results, and imaging studies, EDs’ health care providers would likely be the first to suspect the diagnosis.4

Diagnosis of early cases of anthrax is, however, difficult because the symptoms are similar to “influenzalike illness,” and making the diagnosis requires integration of accurate clinical knowledge, high index of suspicion, and accurate interpretation of laboratory results and chest imaging.5

Biological drills with actors simulating a clinical syndrome have been carried out successfully.6 We designed a clinical anthrax drill for emergency physicians and nurses. Our objectives were (a) to exercise all Israeli general hospitals, (b) to assess the national and the local level of preparedness for anthrax bioterrorism, (c) to evaluate emergency physicians’ knowledge about anthrax disease, and (d) to examine whether a biological attack drill of the ED is by itself an educational tool, improving the relevant knowledge of emergency physicians. We hypothesized that such an intriguing drill in an ED would result in a spread of knowledge, either formally or informally, to all of the hospital’s emergency physicians, not only those who participated in the drill.

Section snippets

Study Design

The study was designed and executed by military physicians and nurses of the Hospital Preparedness Branch, a military medical branch of the Home Front Command. The Hospital Preparedness Branch is integrated with the Emergency and Disaster Management Division of the Ministry of Health and is the national Israeli organization responsible for drilling hospitals for all emergency scenarios, especially unconventional nuclear, biological, or chemical drills.7 The study was planned and approved by an

Results

Patients were treated by a senior emergency physician in all 23 EDs, either as the first physician or after consultation with a resident. Ninety-one percent of hospitals (21 of 23) decided to admit the patient. Sixty-one percent of hospitals included anthrax in the differential diagnosis, activated the appropriate protocols, and admitted the patient for evaluation of that suspicion. Thirty percent of hospitals admitted the patient because of suspected “lymphoma” or “a mediastinal space

Discussion

These anthrax sentinel drills helped us to estimate the current preparedness and alert level of Israeli EDs for anthrax bioterrorism. The high level of admission (91%), even without suspicion of anthrax, is encouraging, although optimally anthrax should already be suspected in the ED before the patient is admitted to the medical ward. Still, taking into account the benign clinical picture of our actor-patient, who was neither hypoxemic nor septic, this high rate of admissions gives us some

References (14)

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Supervising editor: Jonathan L. Burstein, MD

Author contributions: AL, AG, AA, and YY planned the study. AL and AG conducted the study. AL planned drills, wrote the anthrax test, and wrote the article. AH participated in primary planning of the study as former Home Front Command chief medical officer. AL, AG, YA, AA, and YB-D were members in the expert committee of the study and participated in some of the drills. YA and AA evaluated the manuscript. GW and AG supervised the conduct of the study. YA, AA, and GW evaluated study results. RL was responsible for statistical analysis. RL and YB-D were responsible for quality control. YY was an expert consultant in CBRN medicine. YY and AG revised the manuscript. YL was chairman of the supervising committee of the study (Supreme Health Authority). YB-D revised the study plan and article. Y-BD was the research group leader and takes responsibility for the paper as a whole.

Funding and support: The authors report this study did not receive any outside funding or support.

Publication dates: Available online February 2, 2006.

Reprints not available from the authors.

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