Vol. 21 No.

February 2002

IN FOCUS

Emergency Response and Preparedness

In 1993, Karol Murov was the director of risk management at St. Vincents Hospital in New York City, the trauma center closest to the World Trade Center site. When a bomb exploded in the World Trade Center in 1993, killing six and injuring many more, St. Vincents immediately activated its emergency response plan to care for the injured. When the crisis passed, Murov and others at the hospital evaluated their response and made changes to the plan, hoping to ensure that they would respond even better in the face of another attack. Eight years later, the tragedy of September 11, 2001, gave Murov, now the corporate director of risk management for St. Vincents Catholic Medical Centers of New York, and the rest of the staff an unimaginable repeat emergency response challenge. On the front lines in response to that days terrorist attacks, St. Vincents emergency response plan was implemented again, as staff sought once more to treat as many patients as possible. Since then, St. Vincents and the rest of the nation have been taking a long, hard look at emergency preparedness and response plans and finding more room for improvement, still hoping never to have to implement them again. In an October 2001 survey of Healthcare Risk Control (HRC) Weekly News readers, 98.2% of respondents stated that their institutions are reevaluating their emergency preparedness plans in light of the attacks, and 89.5% said that risk management staff is involved in that evaluation. As many hospitals have discovered in their emergency preparedness evaluations since September 11, there is more work to be done in upgrading their role in the community than there is as an individual entity. Some of the main gaps that HRC Weekly News survey respondents have identified in their emergency preparedness plans are listed in Figure 1 on page 3. Indeed, Murov says, St. Vincents review of the first phase of its emergency response after September 11
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yielded no major recommendations for how the hospital could have responded better to the immediate emergency. The second phase of the behavioral health crisis intervention for the traumatized victims, rescue workers, families, and caregivers, however, was enormous. The hospital responded by setting up a center to provide psychological counseling to those affected by the tragedy. Space for the center was donated by a neighborhood school, and local restaurants generously provided food for the patients and caregivers around the clock. The availability of these community resources was extremely beneficial to provide the care required for our patients, Murov says. Knowing which community resources are available in times of disaster, she says, should be part of the preplanning for disaster response. Following that lead, this article will discuss the response of several facilities, addressing first the hospitals role in the community and as an emergency medical service provider and then its role as a separate organization dealing with its own response to an emergency.

Three-Tiered Response
Hospitals will have a three-tiered response to emergencies, said James Bentley, Ph.D., senior vice president for strategic policy planning for the American Hospital Association (AHA), in a special session at the October 2001 American Society for Healthcare Risk Managements annual conference in Boston, Massachusetts. First, the hospital must respond as a unit unto itself, handling issues such as staffing and ensuring its own security. The hospital must then react as part of the emergency medical service, caring for incoming patients (continued on page 3)

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Figure 1. What are the main gaps you have identified in your review of your emergency preparedness plans?

Source: HRC Weekly News survey, conducted October 2001.

(continued from page 1) and arranging to have patients sent to other facilities as necessary. Finally, hospitals must react as part of the overall community, taking a lead in education efforts and offering posttraumatic stress counseling for patients, staff, and their families. That model breaks down somewhat, Bentley acknowledges, in situations like the ongoing bioterrorism concern. Unlike mass-casualty incidents, where emergency situations tend to be confined to a known population and for a predictable duration, bioterrorism emergency situations are prolonged, and heightened levels of alertness must be maintained. Almost every disaster or incident weve ever had to deal with is an incident that comes to a rapid peak and generally has a rapid decline, Bentley says. One of the things, as we look at chemical, biological, and terrorism incidents, is that they will involve a sustained level of effort or demand that requires us to be continuously prepared and responding. This can create an additional challenge for healthcare risk managers, who must simultaneously ensure an

appropriate response to a new, ongoing emergency and prepare their facilities for a response to a more traditional emergency.

Working with the Community

It is no anomaly that for many people, the first reaction following the September 11 attacks was to reach for the telephone and call loved ones, even if they were nowhere near the attack sites. That need for communication is instinctive and, for hospitals, it can be instructive. The best kind of planning you can do is opening lines of communication, says Charles Magazine, risk manager for the city of Boynton Beach, Florida, and a member of the HRC editorial advisory board. When something happens that you cant plan for, you have to have a network of people to help deal with it. In Boynton Beach, Magazine says, the primary emphasis of emergency preparedness has been related to hurricanes and other weather problems common in the area. As such, Boynton Beachs main hospital has a long-standing relationship with the city, emergency services providers, and county and state public health agencies.

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The relationship goes beyond merely arming someone at each facility with a list of phone numbers for other organizations, Magazine says. The greatest need is for face time, so that when an emergency does occur and someone at the hospital needs to contact someone at the county health agency, the people on both ends know who they will be speaking to personally. Hospitals must also communicate with each other to ensure that two or more hospitals are not counting on the same resource, potentially overwhelming the system. Before he worked in Boynton Beach, Magazine was the risk manager for a mid-Atlantic hospital. Together with a host of local, regional, and state organizations, his hospital assigned senior staff to an emergency operations center, where representatives of each organization had near- instant access to all pertinent information that the emergency response coordinators needed. Hospital representatives could provide the numbers of beds they had available, police and firefighters could determine what staff they had available in a given area, government representatives could coordinate their response, and so on. One of the most important things about that forum, Magazine says, is that it forced healthcare risk managers to expand beyond healthcare. Understandably, healthcare risk managers can sometimes become enveloped in their own world. A situation requiring a coordinated response, however, forces risk managers into relationships with school districts, media outlets, large corporations, and all the public agencies listed above. AHAs Bentley emphasizes that all communications (and other resources, such as command systems and oxygen delivery systems) should have built-in redundancies in case one or more of the systems fails. In New York City on September 11, for instance, both land-line and cellular telephone service were largely interrupted due to the flood of calls and collateral damage from the attacks. At times, messages had to be carried by people on bicycles or simply on foot. Hospitals should have contingency plans in place for even these dramatic situations, Bentley says, echoing Magazines emphasis on the importance of communication. As a model, AHA suggests that hospitals follow the Hospital Emergency Incident Command System (HEICS), a project of the San Mateo County, California, Department of Health Services Emergency Medical Services Agency and the California Emergency Medical Services Authority. AHA says that hospitals can use HEICS to define responsibilities, establish reporting channels, set up a logical management structure, and define common nomenclature. AHAs recommendations came in a disaster readiness advisory issued on November 7, 2001, and are available from the Internet at http:// www.aha.org/ Emergency/Readiness/MaIncidentB1107. asp. The full HEICS plan is available from the Internet at http:// www.emsa.cahwnet.gov/dms2/heics3.htm. Healthcare facilities seem to be taking Magazines message to heart. Nearly all respondents (91.2%) to the HRC Weekly News survey are coordinating their efforts with local or state public health agencies and police, firefighters, and emergency service providers. Many (63.2%) are also working with neighboring hospitals. For a complete summary of survey responses, see Figure 2 on page 5. Murov adds that working with healthcare and emergency agencies is not enough hospitals need to know what they can count on from local businesses as well. In the hours and days following the September 11 attacks, Murov says, local restaurants and businesses opened their doors to rescue workers, in some cases sending as much coffee and sandwiches as the workers needed. The outpouring was spontaneous and welcomed, but it would help in disaster planning if facilities knew ahead of time what they could count on. The same can be said of working with local school districts, for instance, to determine whether auditoriums or other large spaces can be used to house patients or volunteers. In the end, Magazine says, hospitals are caught in the unpleasant position of trying to prepare for situations that really cannot be prepared for. No matter how much planning is done, a situation will occur that hospitals have not planned for, and risk managers must be able to adjust quickly within their organizations and the community. Youre going to be reacting, he says. Its important to know who your partners are.

Keeping the Public Informed Both in preparing for and during emergencies, keeping the public informed is a significant task for healthcare facilities. Murov says that on September 11, her hospitals emergency preparedness plan allowed appropriate access control for the media and allowed staff to give accurate information about patients who had been to the hospital.* What the plan could not do, Murov says, was allow information to be given about patients who were at other hospitals. To control both public and media access to the facility, the hospital immediately closed all entrances except for one, says Murov. When it was deemed appropriate, the hospital designated an escort to accompany media members wherever they went in the hospital. This allowed the
* In a member advisory released on November 8, 2001, AHA stated that hospitals are permitted to give information on a patients presence and condition in response to inquiries about specific, named patients. The advisory is available from the Internet at http://www.aha.org/ Emergency/Readiness/MaGuideInfoPatientB1108.asp.

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Figure 2. With what other organizations are you coordinating your emergency preparedness plans?

Other groups listed included the local hospital council, poison control center, coroners, morticians, clergy, charitable agencies, zoonotic experts, and community business leaders.
Source: HRC Weekly News survey, conducted October 2001.

hospital to send out a consistent message through a single spokesperson to the public, avoiding confusing (and potentially dangerous) contradictions if two or more spokespersons gave out conflicting information. Hospitals should also encourage their physicians and other experts to be generous with their availability to the media and other professionals once the initial crisis has calmed down, Murov says. In addition to keeping the message consistent and accurate, sharing information among professionals may allow others to benefit from the lessons learned at each facility. Because of the large number of missing persons in the New York attacks, St. Vincents and other New York hospitals were flooded not only with patients, but also with family members and friends looking for loved ones. We were able to tell people quite accurately about patients who came through our emergency department, Murov says. If a patient had not come through St. Vincents, however, the best their staff could do was recommend that loved ones visit other hospitals and keep looking. As a result, thousands of people walked from hospital to hospital in long, draining searches for loved ones.

Eventually the hospitals, in coordination with the Greater New York Hospital Association, were able to set up a centralized database of patients so that friends and relatives could get answers more quickly. Murov and Bentley recommend that hospitals develop the capabilities for similar databases on a regional level so that they can react more immediately in case of an emergency. One potential roadblock to such information sharing is the privacy rule issued under the Health Insurance Portability and Accountability Act (HIPAA), which limits the ways healthcare facilities can use patient information. Some have suggested that Congress amend HIPAA and other laws to grant temporary waivers in emergency situations. For more on this discussion, see the box on page 6. For Kenneth C. Johnson, Jr., risk manager for the 26-bed Hillsboro Community Medical Center in Hillsboro, Kansas, the response has necessarily been different from that of St. Vincents in New York. Hillsboros primary role since the attacks has been as an educator for the 3,000 to 4,000 residents of the small farming community located about an hour from Wichita.

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Federal Law Waivers?

Many have argued that in mass-casualty incidents, hospitals have no hope of complying with many federal laws and regulations, including the Emergency Medical Treatment and Active Labor Act (EMTALA) and regulations issued under the Health Insurance Portability and Accountability Act (HIPAA). These advocates have suggested that Congress and the U.S. Department of Health and Human Services make amendments to grant waivers to hospitals in certain emergencies. EMTALA requires, among other things, that hospitals screen and stabilize patients who come to the facility with an emergency medical condition and follow certain requirements if patients must be transferred to another facility for care. In mass-casualty incidents, this may not be possible or even desirable, as, for instance, burn patients may need to be sent immediately to burn treatment centers or less seriously injured patients may need to be sent to fartheraway hospitals to allow treatment of more seriously injured patients. In November 2001, the Centers for Medicare & Medicaid Services (CMS) prepared guidance for state survey agencies on EMTALA requirements in the Collaborating with the entire medical community, Johnson says, the facility has planned a series of townhall-type meetings. While the community is generally familiar with bovine and ovine anthrax, questions still abound about the current situation and the medical communitys ability to respond. Of particular concern to Hillsboro residents is the fact that they are in a community that uses crop dusters, which have been cited as a potential means of distribution for biological or chemical weapons. Johnson also says that Hillsboro Medical Center has been working with the local media to make staff members available to allay the publics fears. As Boynton Beachs Magazine notes, The media is in a frenzy, and all we can do is deal with the aftermath of that. Johnson has found that it is important to keep representatives of the medical center available to make sure that the public has access to accurate, noninflammatory information. Jeannie Lusby, risk manager for the Shore Health System of Maryland, Inc., which runs two hospitals on the eastern shore of Maryland, attended similar county meetings. In addition, the health systems corporate communications staff placed an ad in local newspapers, met with local legislators, and attended town and event of a bioterrorist attack. CMS said in the guidance that hospitals following established community emergency response plans would not be in violation of EMTALA, even if they might otherwise be. In addition, privacy rules issued under HIPAA sharply limit the ways that personally identifiable healthcare information can be shared without prior written consent. Some members of the public health community have argued that these limitations could complicate infectious disease surveillance programs designed to detect early outbreaks. The rules could also hamper attempts to alert family members to a loved ones status. As of this writing, no HIPAA waivers have been granted or even formally proposed. However, healthcare risk managers should add this topic to their list of congressional and regulatory activities to watch. If waivers are passed, risk managers should be aware of conditions in which the emergency waivers will apply, exactly what provisions of what laws will be waived, and to what extent. Risk managers should also ensure that policies are in place to educate healthcare workers about waivers and to avoid abuse of waivers when they may not apply. county meetings with the infection control manager to help ensure that all members of the community had access to valid information. One emergency department (ED) physician wrote a commentary on bioterrorism that was published in local newspapers for community information. Because Easton is located only about 70 miles from Washington, D.C., there is concern that the towns residents could be exposed to anthrax sent through the mail system. Lusby says that this concern has prompted the health system to encourage patients who believe they may have been exposed to anthrax or any other biological or chemical contaminant to first contact 911 before coming to the ED. Magazine echoes the sentiment: All we can do is react, try to calm people down, and be supportive until positive information is available. Bentley also speaks of risk managers responsibility to gradually and carefully educate the community about what to expect in times of crisis. For instance, if quarantines need to be instituted, people will likely be deprived of some civil liberties they usually take for granted, including their freedom of movement. In addition, Bentley

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says, the community may also need to be prepared for a reverse triage (sometimes referred to as battlefield triage) system that will likely be uncomfortable for many patients. Traditionally, more critically ill patients are treated first, and most patients in the ED understand this. However, Bentley says, in times of emergency, severely ill patients may be treated only with comfort medication, with healthcare workers focusing their efforts on the most survivable patients on the theory that the time spent on 1 critically ill patient could cost 10 otherwise treatable patients their lives. Both quarantines and reverse triage situations are likely to be met with some resistance from the community, but if hospitals do their part to tell patients what to expect, they may be able to mitigate the resistance and give more effective care. the time and money spent preparing them could have been saved if the hospital staff had waited until it was confirmed that patients were on their way to the hospital.

Staffing
During an emergency, hospitals are likely to face several forms of staffing crises. On one hand, hospitals have to counter potential shortages as their staff deal with how the emergency is affecting their own families; on the other hand, facilities may have staffing surpluses as volunteers flood affected hospitals to donate their expertise. The two situations are likely to occur at the same time in a given facility. According to Bentley, up to 85% of most hospitals staff are female, many of whom are single parents or have responsibility for at least one dependent. Some hospitals, Bentley says, tend to adopt an attitude during an emergency that encourages workers to go home, take care of their families, and then return to work. While this may allow workers to focus on their job knowing their families are safe, there is the danger that some workers will not be able to or will refuse to return to work. It also leaves a hospital dangerously short-staffed in the immediate aftermath of an emergency. Other facilities have urged workers merely to go home, pick up their loved ones, and bring them to the hospital with them. In a bioterrorism incident, however, this may expose more people to the biocontaminant. Communities need to begin planning together to say that if the hospital staff is going to be able to remain on duty and probably remain on duty for long shifts, [this is] whats going to be done on the community level to make sure that at an elementary school, a church or synagogue, or a community building, there is a safe haven to which children and dependents can go and know they can go, and parents on [the hospital] staff can know their children went there and got treated safely, Bentley says. Hospitals must also be prepared to handle physicians or other healthcare workers who volunteer during an emergency. Most states have provisions allowing hospitals to grant temporary credentials to physicians in emergency situations. Those credentials must be terminated when the hospital is no longer operating under its emergency management plan. Others have noted that physicians can obtain federal credentials through the National Disaster Medical System to practice anywhere in the nation in emergency situations. However, because that process can be cumbersome, few physicians take part and have obtained the credentials. To ameliorate this, many advocates have called for more streamlined federal or state emergency credentialing programs. Even after physicians have been cleared to practice in a facility, however, their sheer number can make assigning

Internal Hospital Systems

As Shore Health Systems Lusby notes, the rapid change of circumstances as the situation evolves has made staff education somewhat of a moving target. Whereas complying with a standard like the Occupational Safety and Health Administrations hearing or respiratory protection standard requires educating staff about specific, known, quantifiable risks and mitigation measures, educating staff about emerging bioterrorism risks and responses is proving to be a more fluid effort. To help combat this, Lusby says, the medical and management personnel in Shore Health Systems ED and infection control department have taken over the role of information gatherers and storers. There is a central repository of all information received daily that is specific to bioterrorism and patient care updates from the Centers for Disease Control and Prevention, AHA advisories, Federal Bureau of Investigation warnings, and so on. Lusby adds that it is important to keep all physicians practicing at the hospital updated. For Shore Health System, this means including independent practitioners credentialed to practice at the system hospitals, hospitalists employed by the system, staff and pool nurses, temporary staff, and so on. We have started with the ED and are expanding the educational effort to include all clinical and nonclinical healthcare providers, Lusby says. It doesnt matter what the point of access [for the healthcare provider] is, we want to get timely, consistent information out. The need for consistent information is underscored by what happened at some hospitals in New York City and the surrounding area after the September 11 attacks. In some cases, hospitals prepared for an influx of patients who never came by opening consumables and preparing intravenous medications that were not needed, setting up all operating rooms, and lending equipment that was never returned. Those wasted products not to mention

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them work difficult. To help combat this, St. Vincents Murov says that her facility employed a system that paired a volunteer with a member of the facilitys regular staff within the same specialty for the duration of the emergency. Thus, a volunteer orthopedic surgeon was assigned to work with a St. Vincents orthopedic surgeon. This system accomplished several goals: it ensured that volunteer physicians were not expected to perform procedures out of their normal scope of practice, allowed staff familiar with the hospital and the area to guide newcomers while still utilizing their skills, and ensured that St. Vincents staff could be present at a greater number of procedures. Facilities also need to be prepared for the possibility that some of their staff who serve in the military reserves or National Guard may be called to active duty. According to the Department of Defense, there are more than 4,600 physicians nationwide in the reserves or National Guard; nonphysician staff, including nurses, maintenance personnel, administrative staff, and others, are also enrolled. Lusby notes that her health systems human resources staff maintains an updated list of which staff serve in the reserves. Knowing who was a potential call-up some staff have already been called to active duty, Lusby says allowed the system to plan to deal with potential staffing shortfalls. As several authorities have noted, this is another area in which it is critical that hospitals maintain open communication with each other. Hospitals must ensure that two or more hospitals are not depending on the same physicians to cover staffing shortfalls; physicians, obviously, cannot be in two places at once, and hospitals will face significant crises if they are depending on physicians already answering the call at another facility. what we needed to do to respond to such a disaster. But I dont think we realized the extent of the need for mental health services; it was a major priority we didnt expect. Bentley echoes this finding: As Ive listened to the people in New York, if theres any underappreciated or underdeveloped part of a lot of disaster plans, its the mental health resources for staff, for patients, and for patient families. Bentley notes that hospitals are often seen as refuges in times of disasters, drawing people even when they do not need healthcare services. Those people are generally hoping to find only three things, he says: They want a drink, they want to go to the bathroom, and they want to make a phone call. In times of large-scale emergencies, hospitals may be among the only buildings with electricity and are seen as safe havens by the entire community. Often, he says, people may just need someone to talk to. Although they will likely restrict access to the facility during an emergency, hospitals need to be prepared to handle this onslaught of survivors, caring for their needs without letting them interfere with the provision of medical care to patients who need it. The need for mental health services is likely to extend beyond patients and their families to include caregivers and their families as well. Murov talks of humanizing the tragedy, and staff or volunteers who are forced to tell family member after family member that their loved one has not yet been found are certain to understand the human toll of a disaster all too well. The unique nature of the terrorist attacks (as opposed to a natural disaster like an earthquake or a hurricane) has also unsettled many people, prompting them to seek counseling. While they can never accurately predict which or how many staff or patients will need or seek counseling following a disaster, hospitals should be prepared for a significant influx of patients and should have processes in place to alert interested parties to the available resources.

Counseling
Nearly three-quarters of the respondents to the HRC Weekly News survey say that their emergency preparedness plans include provisions for grief and posttraumatic stress counseling for patients, staff, and their families. The 26% who do not have such provisions and even the 74% who do should note that St. Vincents experience following the September 11 attacks revealed that behavioral health crisis intervention became a high priority and required a large number of trained behavioral health counselors to deal with the numbers of people experiencing stress symptoms. This specialty group plays a major part in a disaster of such magnitude, and its role should be clearly defined in the disaster plan. Provisions for long-term as well as immediate short-term counseling became an important healthcare intervention. We went through the first World Trade Center bombing [in 1993], Murov says, and that told us a lot about

Drills
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires facilities to develop an emergency management plan and to test it through planned drills executed at least twice a year. In light of the recent terrorist attacks, JCAHO recommends that facilities drill for multiple elements of an emergency at one time, such as a large influx of patients combined with a loss of power and other internal and external disasters. JCAHO is considering only minor changes to its standards for emergency management after the September 11 attacks and provided detailed guidance to healthcare facilities about lessons learned from the terrorist attacks in the December 2001 issue of Joint Commission Perspectives. Some of these findings are summarized in the box on page 9.

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JCAHOs Perspective
Like healthcare facilities, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is reevaluating emergency preparedness and response plans in light of the September 11 tragedies. In the December 2001 issue of its Joint Commission Perspectives newsletter, JCAHO described the changes it is proposing for its emergency preparedness standards and outlined some lessons learned by hospitals who responded to the September 11 attacks. Standard Changes Standard EC.1.4 of the Comprehensive Accreditation Manual for Hospitals requires facilities to have emergency management plans (other accreditation programs have similar standards). JCAHO has proposed adding a statement to the intent of the standard that would require hospitals to plan with other healthcare facilities in the geographic area to share information about the following:
G G

discusses in detail how JCAHO surveyors will evaluate emergency preparedness plans, including many of the questions hospital staff members are likely to face. Lessons Learned Some lessons learned by hospitals in the wake of the September 11 attacks include the following:
G

Anticipate transportation needs, especially when it comes to getting employees to the hospital or to an external disaster site, each of which may be cordoned off by police. Create a staging area for clinical staff, to keep them both organized and away from potential decontamination, as well as to keep them separated from nonclinical volunteers. Create a special triage area large enough to accommodate the potential influx of patients. Know how to handle and request additional help and resources, including cross-training nonclinical staff within your institution to perform other nonclinical services as needed, such as using medical records staff to assist with admissions and discharges. Be prepared, with an appropriate triage system, to handle the increased demand for mental health services following an attack. Maintain two-way radios and other communications systems independent of land-line and cellular phone systems.

Essential elements of their command structures and control centers for emergency response Names, roles, and telephone numbers of individuals in their command structures Resources and assets that could potentially be shared or pooled in an emergency response Names of patients and deceased individuals brought to their organization to facilitate identification and location of victims of the emergency
G

Other sections of the intent of standards EC.1.4 and EC.2.9.1 (which requires drills to test emergency management plans) have been clarified, but no other new requirements have been proposed as of this writing. The December 2001 Perspectives also

The December 2001 issue of Joint Commission Perspectives is available from the Internet at http://www. jcrinc.com/subscribers/perspectives.asp?durki=1 87.

Paying for It All

As Murov points out, the financial cost of responding to an emergency is almost impossible to predict. For St. Vincents, costs in the wake of the September 11 attacks included the foreseeable, like staff overtime and increased supply use, and the unforeseeable, like ambulances lost in the collapse of the World Trade Center and the increased demand for mental health services. These costs can be compounded by lost income if patients are forced to stay away from an area where a hospital is located, as was the case in parts of New York City, or if elective procedures must be delayed following an emergency. Nonetheless, healthcare facilities need to be prepared for an increase in spending after an emergency and must

know which agencies are available to provide emergency funds. Facilities should set up systems to ensure accurate and timely reimbursement from Medicare, Medicaid, and private insurance companies. If charitable donations will be accepted, organizations should also have systems in place to facilitate that process. While these costs may be limited to facilities responding to actual incidents, all healthcare facilities are now in the midst of increased spending to prepare for future incidents. AHA has estimated that the national cost for preparedness will be more than $11.3 billion and has asked Congress to fund the effort, at least in part. That estimate takes into account costs for communication and notification; disease surveillance and reporting; personal

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protective equipment; decontamination facilities; medical, surgical, and pharmaceutical supplies; training and drills; and mental health resources. AHAs full assessment is available from the Internet at http://www.aha.org/ Emergency/Readiness/ReadyAssessmentB1101.asp. As of this writing, no funds have yet been set aside by the federal government to absorb this cost, although the U.S. House of Representatives has passed a preliminary measure. Risk managers should continue to monitor congressional activity and ensure that their facilities act to access their share of whatever funds are eventually made available. Risk managers should also contribute to their facilitys budget process by recommending that budgets include appropriate provisions for personal protective equipment, medical supplies, and other items deemed necessary during the emergency preparedness plan review.

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