Out-of-hospital provider participation and support needs for chemical, biological, radiological, or nuclear events

Abstract

Study objectives: Emergency medical services (EMS) plays a key part in management of any mass casualty disaster; the role of out-of-hospital providers would be especially crucial in a protracted chemical, biological, radiologic, or nuclear (CBRN) accident or terrorist act. Hospital and EMS disaster response plans are mutually dependent, and preparation for CBRN events requires an evaluation of staff availability in all capacities. Results of our previous study of emergency department (ED) personnel demonstrated a minimum of 17% reduction in staff participation for these scenarios primarily because of conflicts between personal and professional obligations. An assessment of out-of-hospital provider availability and support needs may provide further insight to aid in disaster preparedness. The purpose of the study is to determine the anticipated participation of out-of-hospital providers during CBRN and other disaster scenarios, as well as the importance of support factors, including dependent care. An additional objective is to compare the responses of out-of-hospital providers to those of ED personnel. Methods: Approval of the institutional review board, EMS medical director, and EMS coordinator were obtained. A survey and cover letter were distributed by mail to each out-of-hospital provider working at least half time in our EMS system, which includes 32 municipal departments and 4 private ambulance companies. Survey completion was voluntary and anonymous. Respondents indicated whether they would be willing and able to work during various mass casualty disaster scenarios if the event occurred while they were at work or at home. Sixteen support services were rated on a scale of 0 (no importance) to 4 (essential) with respect to their importance in enabling the providers to work during an extended disaster event. Specific questions were included about dependent care needs. Results: The response rate was 44% (446 of 1,022) in contrast to a 72% response from the ED. For a chemical event, 74% of providers indicated that they would stay at work; 67% would come in from home. For a biologic event, 72% would stay and 64% would come in. For a nuclear event, 67% would stay and 60% would come in. Fourteen percent were "unable to answer" about their perceived ability to participate in a CBRN event. Anticipated EMS personnel participation in a CBRN event did not differ from that of ED staff, whether at work or home. Eighty-six percent of out-of-hospital providers indicated that they would commit to work in a disaster occurring as a result of multiple trauma or weather. Thus, EMS personnel were much less likely to participate in CBRN disasters than in multiple trauma or weather disasters, whether at work or at home (<i>P</i><.0000001, for both at work and at home comparisons). The 8 support factors rated most important are listed in descending order of priority: shelter for family and training, medical care, security at home, security at work and shelter for self, and clarification of role and food. The most common limitation given for an inability to work was family commitments. Only 3 providers listed concern about personal safety as an impediment; 3 others noted lack of training and personal protective equipment. Thirty percent of out-of-hospital providers versus 34% of ED staff thought that they would rely on their employer for dependent care. For these respondents, care or accommodations for an average of 2.3 (versus 2.6) dependents per provider would be necessary. Conclusion: This study indicates that a minimum 16% reduction in the EMS workforce should be anticipated during CBRN events because of providers being unwilling to remain on the job. An even greater proportion of providers (20%) would not be willing to come in from home during these scenarios. The participation rate may be even less, depending on the ultimate choice of those undecided. These findings are consistent with the results from the ED personnel. A nuclear event caused the most apprehension for out-of-hospital providers, again consistent with ED personnel. Policies ensuring adequate training, shelter and security for families, and medical care may have an impact on promoting EMS staff participation; however, hospitals and EMS systems need to anticipate significant out-of-hospital provider unavailability during a CBRN mass casualty disaster.