Chemical,Biological,Radiological,or Nuclear Response in Queensland Emergency Services: A Multisite Study

Abstract

A disaster overwhelms the normal operating capacity of a health service. Minimal research exists regarding Australian hospitals' capacity to respond to chemical, biological, radiological, or nuclear (CBRN) disasters. This article, and the research supporting it, begins to fill that research gap. We conducted a descriptive quantitative study with 5 tertiary hospitals and 1 rural hospital in Queensland, Australia. The study population was the hospitals' clinical leaders for disaster preparedness. The 25-item survey consisted of questions relating to each hospital's current response capacity, physical surge capacity, and human surge capacity in response to a CBRN disaster. Data were analyzed using descriptive statistics. The survey data indicated that over the previous 12 months, each site reached operational capacity on average 66 times and that capacity to respond and create additional emergency, intensive care, or surgical beds varied greatly across the sites. In the previous 12 months, only 2 sites reported undertaking specific hospital-wide training to manage a CBRN disaster, and 3 sites reported having suitable personal protective equipment required for hazardous materials. There was a noted shortfall in all the hospitals' capacity to respond to a radiological disaster in particular. Queensland hospitals are crucial to CBRN disaster response, and they have areas for improvement in their response and capacity to surge when compared with international preparedness benchmarks. CBRN-focused education and training must be prioritized using evidence-based training approaches to better prepare hospitals to respond following a disaster event.

Background

Disasters are costly in human and economic terms.¹ The United Nations defines disasters as “a serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses which exceed the ability of the affected community or society to cope using its own resources.”² From a healthcare perspective, disasters generate a patient casualty profile that threatens to overwhelm existing hospital resources.³ Disasters are generally considered in 2 broad forms: conventional (eg, bushfires, floods, cyclones) and nonconventional (eg, chemical, biological, radiological, nuclear).

Chemical, biological, radiological, and nuclear (CBRN) disasters typically occur without notice⁴ and create unique challenges, uncertainties, and obstacles for health delivery. Further, deliberate acts of harm using CBRN agents are growing in complexity and pose increasing concern for health services.⁵ As such, hospitals must be prepared for a sudden increase in patient presentation following a CBRN disaster and plan to manage the associated surge. Hospital surge capacity is the ability to provide acute care to both critical and noncritical casualties simultaneously following a disaster, extending beyond a hospital's normal day-to-day operational capacity.⁶ The key goal of the health response following a disaster, such as a CBRN incident, is to do the greatest good for the greatest number of people. In a hospital, this response is optimized if emergency care services—care provided by emergency department (ED), intensive care unit (ICU), operation theater, and trauma services—can provide an adequate surge response.⁷ In 2007, Traub et al⁸ reported that the physical assets, such as ED, ICU, and surgical beds, in Australasian public hospitals were insufficient to surge following a disaster when compared with international hospital benchmarks. Fifteen years and several disasters later, it is unclear whether this remains the case.

CBRN disasters not only result in many patient presentations within a short period,^9-11 they create added challenges for emergency care staff if patient decontamination or specialized personal protective equipment (PPE) is required.¹² The origin of CBRN-related patient symptoms can be complex because they can also be seen as a result of other causes, such as exotic toxins, poisons, or severe radiation poisoning, making the causative agent difficult to ascertain.¹³ These challenges can be magnified in areas where geography is vast and the population is dispersed, as it can delay the triage and specialist treatment of patients.¹⁴

The potential for future CBRN disasters is real.¹⁵ It is therefore imperative to investigate how hospitals and their staff are currently prepared to provide care to a surge in patient presentations should a CBRN disaster occur. Understanding the current situation allows for potential deficits to be highlighted, providing an opportunity to strengthen health service disaster planning. Globally, CBRN events occur that require a healthcare response. As such, lessons from 1 country or jurisdiction may help inform the health response of another jurisdiction. This study aims to describe how emergency care services in Queensland are prepared in their response to a CBRN disaster and to use international benchmarks to estimate the capacity of key hospitals to provide a surge response.

Methods

We conducted a descriptive quantitative study from November 2020 through May 2021, using a paper-based survey.

Population

This research was set in the state of Queensland, Australia, which covers 1.7 million square kilometers and has the third-largest population of any Australian state or territory,¹⁶ with about 5.28 million people (as of May 5, 2022).¹⁷ Queensland is the most disaster-prone state/territory in Australia, with perennial floods, cyclones, and fires. However, to date, few CBRN events have resulted in multiple casualties.

There are 106 hospitals in Queensland that provide reportable data, and these hospitals are managed within 16 hospital and health services. Each health service has its own distinct governance and disaster capability ethos and preparedness plan. Within Queensland's reportable hospitals in 2019-2020, there were 313 presentations per 1,000 people.¹⁸

Sample

Seven hospital sites were invited to participate in this study; however, only 6 are included in the analysis: 5 public tertiary hospitals and 1 rural hospital. The tertiary sites were selected as they are pivotal to state-led disaster responses and contain specialist emergency care-related services required to treat adult and/or pediatric patients. The rural hospital is located near several major facilities of strategic significance for Queensland and provides surge capacity to treat patients if a disaster occurs at the nearby military base, airport, coal mine, or power station.

Given the focused nature of this study, purposive sampling was used. A research team member (the site contact) contacted each hospital's clinical lead for disaster preparedness/response (ie, disaster manager) via telephone and invited them to participate. Respondents were informed of the project aims and time commitment. If they expressed interest, we sent them an email that included the respondent information and consent form and survey tool. If the disaster manager indicated they were unable to participate (ie, complete the survey), we asked if they could recommend a colleague with equivalent knowledge of the hospital's emergency and disaster capacity, who was then invited to participate.

Survey Tool

The research team developed a 25-item, paper-based survey (Supplementary Material, www.liebertpub.com/doi/suppl/10.1089/hs.2021.0214) to collect data related to hospital surge capacity in the event of a CBRN disaster that was informed by the literature.^19,20 We pilot tested the survey using both a hospital and a university disaster educator to refine it for content validity and clarity; the final version was predicted to take approximately 40 minutes to complete. The survey items include (1) current capacity (the number of patients on average who present to each ED daily); (2) physical surge capacity (the maximum number of additional staffed beds that each ED, ICU, and operation theater can create in 1, 6, and 12 hours' notice); and (3) human surge capacity (each hospital's expanding staff availability).

Data Collection

The survey was emailed to the hospital's disaster manager (or delegate) for completion, with the option to have questions asked by a study investigator over the telephone to optimize response rate and reduce transcription time, particularly for respondents in busy clinical roles.

Data Analysis

Survey data were entered into Microsoft Excel for analysis, and descriptive statistics were used to summarize the hospital study data and compare it against US Centers for Disease Control and Prevention²¹ and US Agency for Healthcare Research Quality (AHRQ) benchmarks²⁰ for CBRN disasters. In 2004, AHRQ set a critical benchmark for all US states to establish a system that allows for the triage, treatment, and disposition of 500 adult and pediatric patients per 1 million people who suffer from acute illness or trauma requiring hospitalization following a CBRN disaster. Health service catchment populations for each site were obtained from the state health service to calculate ratios per 100,000 population of ED, ICU, and surgical beds, as well as surge populations (500 patients per million people).

Ethics

Griffith University and a multisite Human Research and Ethics Committee gave approval for this study (Ref No: 2020/562). No names were recorded, and confidentiality was assured. We sought written informed consent from hospital disaster managers before survey data collection, advising respondents that anonymity could not be guaranteed due to the nature of the survey responses, which could potentially identify the site. To provide as much anonymity as possible, responding sites were given a pseudonym and any site-identifying information was removed.

Results

The catchment population and total number of ED, ICU, surgical beds, and X-ray machines by hospital site are outlined in Table 1, together with the calculated ratio of beds and X-ray machines per 100,000 people. The number of ED, ICU, and surgical beds per 100,000 people was highest in hospital 4 (tertiary, regional facility). Hospitals 1, 2 and 3 (tertiary, metropolitan facilities) had a similar capacity. While hospitals 3, 4, and 5 had pediatric capacity, only hospital 5 was a specialist children's hospital. Hospital 6 had no ICU bed capacity because it was a rural community facility, and critically ill patients would have to be transferred to the nearby regional referral hospital. The number of fixed or mobile X-ray machines per 100,000 people ranged from 1 to 21. While point-of-care ultrasound has a leading role in trauma patient assessment, access to X-ray (particularly mobile) is still deemed a key capability within a health services response in Australia.

Table 1.

ED, ICU, and Surgical Beds and X-Ray Machines Available at Each Site^a

Hospital Site	Site Type	Health Service Catchment Population	ED Beds		ICU Beds		Surgical Beds		X-Ray Machines (Fixed and Mobile)
Hospital Site	Site Type	Health Service Catchment Population	n	Ratio	n	Ratio	n	Ratio	n	Ratio
1	Tertiary metro	1,163,335	55	4:7	24	2:1	262	22:5	21	1:8
2	Tertiary metro	1,024,627	50	4:9	22	2:1	220	21:5	8	0:1
3	Tertiary metro	622,048	89	14:3	23 + 4^b	3:7/0:1	176	28:3	12	1:9
4	Tertiary regional	240,883	74	30:7	21 + 8^b	8:7/3:3	97	40:3	13	5:4
5	Tertiary metro	1,002,243	68^b	6:8	23^b	2:3	225^b	0:1	6	0:6
6	Rural	557,876	2	0:4	0	0	8	1:4	1	0:2

Total number and ratio per 100,000 people.

Pediatric.

Abbreviations: ED, emergency department; ICU, intensive care unit.

All sites had implemented an incident command or management system facility-wide (eg, Australasian Inter-Service Incident Management System) or followed the Hospital Major Incident Medical Management and Support principles. Further, they all reported having a memorandum of understanding with a nearby acute care facility to accept in-patients who required acute nursing care during a declared disaster.

The hospital sites reported reaching operational capacity (ie, staffed/funded beds) on average 66 times over the previous 12 months. The ability to surge and create additional ED, ICU, or surgical beds varied greatly among hospitals, with 3 hospital managers reporting that business as usual reflected operating at maximum bed capacity in these 3 areas (Table 2). In the 3 hospitals that did have capacity to surge bed numbers, the more preparation time they had the greater their ability to add capacity. All sites reported an adaptive approach to creating additional ED, ICU, or surgical beds during a disaster, such as canceling elective surgery, increasing inpatient discharge, or using nonclinical areas (eg, waiting rooms, corridors) as overflow. In 12 hours postdisaster, 2 hospitals could increase ED bed capacity by 70% or more (relative to operational capacity); 3 hospitals could increase ICU bed capacity by 42% or more; and 1 hospital could increase surgical bed capacity by 9%. Surgical beds were consistently more difficult to upsurge in all 6 hospitals, and immediate pediatric bed surge capacity was lacking.

Table 2.

Hospital Surge Capacity for ED, ICU, and Surgical Beds at 1, 6, and 12 Hours Following a Disaster

Hospital	Surge Population^a	ED Beds			ICU Beds			Surgical Beds
Hospital	Surge Population^a	1 hrs n (%)^b	6 hrs n (%)^b	12 hrs n (%)^b	1 hrs n (%)^b	6 hrs n (%)^b	12 hrs n (%)^b	1 hrs n (%)^b	6 hrs n (%)^b	12 hrs n (%)^b
1	582	16^c (29)	-	-	3 (12.5)	8 (33)	10 (42)	3 (1)	25^c (10)	-
2	512	5 (10)	20 (40)	40 (80)	4 (18)	8 (36)	12 (55)	4 (2)	10 (5)	20 (9)
3	311	-	-	17^c (74)	-	-	17^c (74)	-	8^c (5)	-
4	120	No capacity to surge bed numbers
5	501	No capacity to surge bed numbers
6	279	No capacity to surge bed numbers

Catchment population (Table 1) x 500 patients per million people.²²

Percentage increase relative to operational capacity (Table 1).

Maximum capacity achieved.

Abbreviations: ED, emergency department; ICU, intensive care unit.

We also surveyed strategies for supporting hospital staff in responding and presenting for duty following a CBRN disaster. To access additional staff during an emergency, options in all 6 sites included the use of on-call staff, local providers (ie, agency), extending rosters (8 to 12 hours), or changing nurse–patient ratios. Two sites had capacity to support staff if they were required to remain onsite following a disaster event. Noted challenges in these sites included staff's ability to commute to work due to communication or transportation problems, accessing self-care activities, and support for their family unit. To overcome these challenges, site respondents noted that the hospital should provide extended services to staff (eg, babysitting, laundry, meals, accommodation). Both hospitals were located within a large metropolitan city, and it was assumed likely that, following a CBRN disaster, key roads, bridges, and public transport to the hospital would be impacted.

Only 2 respondents reported that, in the previous 12 months, the hospital site in which they worked had delivered specific training to manage a hazardous material (HAZMAT) incident. For example, the disaster manager at hospital 5 described a tabletop exercise that tested the emergency and trauma services' capacity to manage a nearby fertilizer truck explosion that resulted in mixed (ie, adult and pediatric) patient presentations to their hospital. The disaster manager at hospital 6 (rural) indicated challenges in the site's ability to perform comprehensive decontamination management (ie, irrigation system, water/shower, setup crew, cleanup crew, security staff, patient tracking clerks). Further, only half of the respondents surveyed reported having appropriate HAZMAT PPE for emergency staff use (ie, level C air-purifying respirator, chemical-resistant suit or similar waterproof coveralls, double-layer gloves, eye protection, P2/N95 mask, hair/shoe covers).

There was a notable shortfall in the site hospitals' capacity to respond to a radiological disaster compared with a chemical or biological disaster. Several respondents (n = 4) were unsure of their internal radiological disaster governance processes or the capacity to detect radiological contamination. Further, the majority of respondents reported that their hospital site could not establish adequate control lines or provide emergency care clinicians with personal dosimeters if radiological contamination occurred. Some respondents (n = 3) did indicate that Queensland had an overarching coordinated approach to managing HAZMAT and CBRN disasters. For instance, they commented that the Queensland Fire and Emergency Services has a specialized scientific branch that contains flexible storage and specialist equipment, such as detectors that can find and identify liquids, solids, gases, or radiation, as well as specialist mitigation equipment.²³

Respondents from hospitals 1 through 5 reported that the embedded use of electronic medical records provided them with a CBRN surveillance capacity, which afforded them on-demand ability to track ED visits, hospital admissions, influenza-like illness, and increased antibiotic prescription rates. Most respondents (n = 5) reported that they did not routinely practice how to manage patients following a CBRN disaster and had no recent history of responding to a disaster (ie, in the past 3 years). Hospital emergency disaster plans (termed a CODE BROWN) had been activated at 3 sites in the past 5 years and were mostly caused by tropical weather events (eg, cyclone) or COVID-19. Four respondents reported having a dedicated medical or nursing director at their site who was solely responsible for coordinating hospital disaster training and preparedness, while the remaining 2 sites incorporated disaster preparedness into existing management positions.

Discussion

CBRN disasters are distinct from natural disasters because they often result in a large number of patients within a short period.^24,25 For instance, when a cyclone or flood disaster occurs, communities are often provided with preemptive warnings, and emergency care services can prepare and plan their surge response—this is not the case with CBRN disasters. Our study was, to our knowledge, the first to explore how Queensland hospital acute care services could provide a surge response and care for the unique needs of patients following a CBRN disaster. The results suggest that many of the sites surveyed have insufficient capacity to surge their emergency services and optimize patient care. Further, in Queensland, pediatric emergency care capability would be critically affected following a CBRN disaster, with limited capacity to surge. In the current environmental and political climate, it is not a matter of if a CBRN disaster will occur, but when. It is thus timely and necessary to examine our hospitals' capacities to respond and to better prepare our emergency care services for a CBRN disaster.

The Queensland Health multiagency CBRN plan²³ applies to all Queensland Health services and provides for the effective and timely management of natural, accidental, criminal, or terrorist-related releases of CBRN agents into the community. The Queensland Fire and Emergency Services is the lead agency for chemical emergencies and provides decontamination support to state hospitals for all CBRN incidents. Queensland's disaster response is based on the 4 internationally recognized tenets of “Prevent, Prepare, Respond, and Recover.”¹³ When a disaster occurs, the initial decisions on how best to respond are devolved to the local level (closest to the people affected); hence, the emergency care clinical leaders within hospitals make first-response decisions on what needs to be done,²⁶ thus making it imperative that these initial responders have the knowledge and equipment they need to best protect the community. In the current study, 4 respondents reported having a dedicated medical or nursing director at their site who was solely responsible for coordinating hospital disaster training and preparedness. The importance of disaster managers and incident controllers as a distinct leadership structure (apart from clinical leadership) has previously been highlighted, as they have been provided with adequate disaster training.²⁷ In 2014, Australia adopted a standardized Hospital Major Incident Medical Management and Support course that provides a framework to guide a hospital response following a disaster.²⁸ Several responding sites used Hospital Major Incident Medical Management and Support or Emergo train,²⁹ but an overall consistent approach to training, education, and response was not apparent. In Australia, COVID-19 has impacted hospital-wide education and training,³⁰ which may account for limited CBRN disaster training during the study period. However, 1 respondent reported using a tabletop exercise to test how the hospital could surge following a disaster. Immersive simulation is useful in testing hospital disaster protocols and detecting shortcomings before such gaps become apparent, and there is value for enhanced uptake of healthcare simulation to prepare emergency services to respond following a CBRN disaster.^31,32

During and after a disaster event, hospital emergency staff are often confronted with challenges that affect their ability to report for work and perform effectively. Further, adequate hospital staffing during and after a disaster is critical to meet increased healthcare demands and to ensure continuity of care and patient safety.³³ However, when a disaster occurs, staff may become both victim and responder, decreasing their ability and willingness to report for work.^34-36 In the current study, only 2 respondents stated their hospital offered additional services to support staff to remain onsite during and following a disaster. Both of these disaster managers acknowledged that following a CBRN disaster, staff may have challenges in commuting to work due to communication or transportation problems, accessing self-care activities, or supporting their family unit, and so hospitals should provide extended services to staff (eg, babysitting, laundry, meals, accommodation).

The study identified a shortfall in the site hospitals' capacity to detect, diagnose, and treat a radiological injury despite the fact that radioactive sources are familiar in daily life.³⁷ The medical response to radiation—whether the result of radiological warfare, terrorist deployment of improvised radiation dispersal weapons, political assassination, or occupational and industrial accidents—remains one of the least-taught disciplines within medical education.¹³ Radiation and radioactive contamination are readily detectable with the right equipment, and hospital emergency services (or their nuclear medicine departments) have equipment for detecting beta and gamma radiation.³⁸ Knowing the type of radioactive material involved is important because it can guide clinical treatment decisions. If a patient is contaminated, internally or externally, they will continue to be irradiated by that radioactive material until it is removed. External contamination—usually dust or particulate matter—should be removed by wet decontamination.³⁸ Interestingly, half of the respondents in our study reported that their sites had limited capability to perform wet (or dry) decontamination and had limited HAZMAT PPE. This suggests that there is a potential risk of contaminated walking casualties and well survivors self-referring to the hospitals and contaminating existing patients and staff within the ED.³⁹

A growing concern emerging in the CBRN literature considers how chemical warfare agents such as asphyxiants (eg, cyanide), opioids (eg, carfentanyl), and nerve agents (eg, ricin) could be used in a terrorism-related CBRN attack.^5,15 For over a decade, studies have recommended that Australian health services use US Centers for Disease Control and Prevention guidelines as a benchmark for the physical and human capacity for a hospital response following a CBRN disaster.^8,40 In 2004, the AHRQ²⁰ set a critical measure for all US states to establish a system that allows for the triage, treatment, and disposition of 500 adult and pediatric patients per 1 million people who suffer from acute illness or trauma requiring hospitalization following a CBRN disaster. The extent to which the Australian healthcare system meets this benchmark is unclear; however, this current study highlights challenges in Queensland hospitals' capacity to surge following a CBRN disaster. Our study also highlights that the pediatric emergency care response should be at the forefront of Queensland disaster planners' minds because this population is particularly vulnerable in a mass casualty event. ⁴¹

Study Strengths and Limitations

A strength of this study is the success of the purposive sampling strategy that involved clinicians responsible for the site hospitals' disaster preparedness/response. These clinical managers possessed unique knowledge of the hospital's emergency and disaster capacity, which is not readily available or reported in the literature. However, the current study is limited by being confined to 6 sites in 1 Australian state, which reduces the transferability of the findings. One site, a regional (mixed adult/pediatric) tertiary hospital, was invited to participate in the study, but clinical managers reported they had no capacity to complete the survey tool. Data collection also occurred during the COVID-19 pandemic, which could have influenced the preparedness and surge capacity of the sites surveyed.⁴² For the site that did not respond, it was evident that COVID-19 had strained hospital clinical research capacity, an impact not isolated to our study. Collecting data from self-report surveys is a pragmatic approach to gathering descriptive information⁴³; however, this approach can lead to response bias.⁴⁴ To address this, we followed a systematic approach to enhance the internal validity of the survey tool and control for potential bias. For example, we drew the survey questions from the broader literature and pilot tested them, then refined them to enhance validity; telephone interviews supported more in-depth explanations of each survey item. We have provided detailed descriptions of the Queensland population and our study sample, which strengthens our study, enabling researchers to judge the applicability of our recommendations to their hospital.

Conclusion

While Queensland's hospital emergency care services have demonstrated their ability to surge and provide patient care following a natural disaster, our study indicates that hospitals crucial to a state-led CBRN disaster response have areas for improvement when compared with international preparedness benchmarks. CBRN disasters have been uncommon in Australia, but our hospitals and clinical leaders must anticipate and be prepared for a surge response to future disasters. Consequently, education, training, and policies must support effective hospital-wide disaster response and account for the unique challenges presented by CBRN threats. Further opportunities to engage in progressing local, national, and international best practice for CBRN disaster response are warranted.

Footnotes

Acknowledgments

The authors thank all the respondents for their time completing the study survey. This study was supported by funding awarded from the Emergency Medicine Foundation. The funder had no input into any phase of the project or publication decisions.

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