General Hospital Psyc

Hospital preparedness for possible nonconventional casualties:

an Israeli experience

Shaul Schreiber, M.D.*, Naomi Yoeli, M.A., M.Ed., Gedalia Paz, Ph.D.,

Gabriel I. Barbash, M.D., M.P.H., David Varssano, M.D., Nurit Fertel, R.N.,

Avi Hassner, M.D., Margalit Drory, M.S.W., Pinchas Halpern, M.D.Department of Psychiatry, Tel Aviv Sourasky Medical Center, Weizmann Street 6, Tel Aviv, Israel

Tel Aviv Sackler School of Medicine, Tel Aviv, Israel

Received 26 September 2003; accepted 25 May 2004

Abstract

Since 9/11, hospitals and health authorities have been preparing medical response in case of various mass terror attacks. The experience of

Tel Aviv Sourasky Medical Center in treating suicide-bombing mass casualties served, in the time leading up to the war in Iraq, as a platform

for launching a preparedness program for possible attacks with biological and chemical agents of mass destruction. Adapting Quarantelli’s

criteria on disaster mitigation to the bmicroinfrastructureQ of the hospital, and including human behavior experts, we attempted to foster an

interactive emergency management process that would deal with contingencies stemming from the potential hazards of chemical and

biological (CB) weapons. The main objective of our work was to encourage an organization-wide communication network that could

effectively address the contingent hazards unique to this unprecedented situation. A stratified assessment of needs, identification of unique

dangers to first responders, and assignment of team-training sessions paved the way for program development. Empowerment through

leadership and resilience training was introduced to emergency team leaders of all disciplines. Focal subject matters included proactive

planning, problem-solving, informal horizontal and vertical communication, and coping through stress-management techniques. The

outcome of this process was manifested in an boperation and peopleQ orientation supporting a more effective and compatible emergency

management. The aim of article is to describe this process and to point toward the need for a broad-spectrum view in such circumstances.

Unlike military units, the civilian hospital staff at risk, expected to deal with CB casualties, requires adequate personal consideration to enable

effective functioning. Issues remain to be addressed in the future. We believe that collaboration and sharing of knowledge, information, and

expertise beyond the medical realm is imperative in assisting hospitals to expedite appropriate preparedness programs.

D 2004 Elsevier Inc. All rights reserved.

Keywords: Chemical and biological casualties; Disaster management; Hardiness; Nonconventional war; Preparedness; Resilience; Terrorism

1. Introduction

Preparing to respond to the threat of chemical and

biological (CB) casualties, either from terrorism or war, is

one of the fundamental realities for hospitals in Israel, as it

has become for hospitals all over the world recently [1–3].

Tel Aviv Sourasky Medical Center (TASMC) has standing

protocols and drills that correspond to various threats.

However, after the events of September 11, 2001, and the

0163-8343/$ – see front matter D 2004 Elsevier Inc. All rights reserved.

doi:10.1016/j.genhosppsych.2004.05.003

* Corresponding author. Tel.: +972 3 697 4707; fax: +972 3 697 4586.

E-mail address: shaulsch@tasmc.health.gov.il (S. Schreiber).

subsequent spread of deadly anthrax by mail in the United

States, the possibility of the use of nonconventional

weapons of mass destruction against civilian populations

has become an even more tangible reality. Increased

awareness of the possibility of changing scenarios called

for updating of protocols and training.

The international political arena of late 2002 suggested

an imminent second Gulf War, with the possible use of

nonconventional weapons [4]. Based on the 1991 (first)

Gulf War experience (when Israel was the target of 39 Iraqi

SCUD missiles, most of them on the Tel Aviv area) and its

intracity location, our tertiary-referral 1100-bed hospital was

declared a bfront-line responder Q for treatment of CB

hiatry 26 (2004) 359–366

Table 2

Details of security forces and Israeli civilians killed between 9/2000 and

3/2003

Total Security forces Israeli civilians Type of attack

2 0 2 Rocks

6 0 6 Stabbing

8 7 1 Running over

19 2 17 Lynching

197 104 93 Shooting

37 9 28 Driveby shooting

71 11 62 Shootings at vehicle

from an ambush

21 6 15 Shootings at towns

and villages

26 26 0 Shootings at military

installations

60 36 24 Bombings

449 47 402 Suicide bombing

38 23 15 Car bomb

1 1 0 Mortar bombs

5 4 1 Other

942 276 666 Total

S. Schreiber et al. / General Hospital Psychiatry 26 (2004) 359–366360

casualties. The transition from isolated, frequent, mass

casualty, suicide-bombing terrorist attacks characterizing

the present wave that began on September 29, 2000 (Tables

1 and 2) [5–7], to preparing for massive CB casualties, in

which hospital staff and their families at home might be

exposed to chemical or biological hazards, called for a

contingency plan that would evolve from the existing

emergency program and relate to large-scale multidimen-

sional emergency management. The possible presentation of

new agents (CB) required an integrated comprehensive

response process that may apply to an array of yet unknown

variables, such as effective medical response, sufficient

training for mass CB casualty treatment, availability of

effective protective measures, duration of the events

(responding after a sporadic incident varies greatly from

an ongoing situation), the need for first respondents to care

for themselves, minimizing first-responder fatalities and

casualties, morale aspects of staff, safety of personnel family

members, threat of role abandonment [8], caring for mass

psychological casualties (as evident in the Sarin nerve agent

attack in Tokyo) and a multitude of possible unprecedented

problems. Hospital executive management identified the

need for an integrated preparedness program, while the

existing plan focused mainly on agent-generated needs (i.e.,

medical treatment protocols of anthrax casualties) and for

developing a response plan that would address the possible

psychological impact on personnel and on casualties.

The issue of psychological impact of nonconventional

weapons on the victims has, to some extent, been addressed

[9] and stress reactions of rescue and medical personnel

dealing with casualties of bconventionalQ terrorism, ac-

cidents, and disasters have been investigated [10,11]. We

found no reference to the issue of psychological effects on

staff members who have never before been exposed to actual

treatment of CB casualties. Moreover, the need to resolve the

role conflicts over caring for family members at risk while

performing one’s duties, demanded attention to personal

safety, psychological needs, morale and leadership issues, in

order to enhance personal resilience, and performance.

The aim of this article is to describe the endeavor of

TASMC to improve hospital preparedness and response to

CB mass casualties by adapting emergency-management

concepts and enhancing resilience trough training of staff,

attention to staff safety and personal needs, and to present

the results, conclusions, and issues that remain to be

addressed in the future. It is unlikely that we embraced all

Table 1

Casualties since September 29, 2000 (updated March 30, 2003)a

Total no. of

Israeli casualties

Security forces Civilians Casualties

6286 1842 4444 Injured

942 276 666 Killed

a Total number of casualties during the present wave of terrorism in

Israel, characterized by vast use of suicide bombing. This wave began on

September 2000 and data is updated to the beginning of the war in Iraq

(March 19, 2003).

possible areas. A realistic approach to good emergency

management involves awareness of the limitations in

preparing for a scope of unknown variables. We believe

that the introduction of these principles contributes to

greater awareness of unexamined venues when preparing a

response plan.

2. Methods

CB preparedness is not part of the daily routine of a

civilian general hospital: its complexity requires a major

management effort. In order to achieve results, appointment

of a senior executive is of paramount importance. And

indeed, at TASMC, a top executive officer (deputy CEO)

was appointed to coordinate and expedite the process. He

possessed high decision-making responsibilities, wide-

spectrum vision, vertical and horizontal negotiation

capabilities, and personal commitment to the success of

the preparedness plan. He was personally acquainted with

the staff and situation, and was constantly available and

present bin the field.Q A task force headed by the director of

the Emergency Medicine department, a person with great

expertise in hospital emergency response, was set up in

order to assess staff needs, identify bottlenecks, prioritize

emergencies, plan team training sessions, and recommend

management policies. The task force initiated a dynamic

assessment process and meetings with the hospital

management, including the support unit leaders and the

central emergency headquarters members. An array of

exterior issues was addressed: collaboration with key

agencies such as public health authorities, Israel Defense

Forces Home Front Command medical units, military

hospital support units, city administration, local police,

and civil volunteer organizations. It also bolstered dialogue

between management and staff, surfaced problems, miti-

S. Schreiber et al. / General Hospital Psychiatry 26 (2004) 359–366 361

gated organization conflicts, shed light on unresolved

personnel issues, etc. The main objective focused on

evolving from a top-down process to an interactive

orientation that would encourage effective problem-solving,

directly addressing upcoming hazards through an organiza-

tion-wide communication network (the process is summa-

rized in Table 3).

The inclusion of experts on human behavior under

extreme stress in the emergency task force as well as

their participation in executive management meetings

fostered greater awareness and readiness to deal with

issues of personnel safety, impasses relating to personal

hazards, psychological resilience, and to attempt to

improve coping skills of staff in all echelons. Consulta-

tion got underway through individual assessment meet-

ings with the hospital management personnel including

the support unit leaders and the central emergency

headquarters members. Use of available communication

technology, information flow, discrepancies between needs

and resources were deliberated. During individual meeting

with chief executives and emergency team leaders, goals,

needs, gaps, difficulties, and expectations were assessed. This

Table 3

Emergency management developmental process

Phase Action items

Pre-emergency–management

phase—up to 11/2002

Appointment of assistant

Planning preparedness

bTop downQ process

I: 12/2002–01/2003 Appointment of advisory

Executive management assumes central role in

introduction of emergency management

Appointment of Deputy C

program implementation

Introduction of emergency

management process

II: 02/2003–03/2003 Human behavior experts

(emerging from the Task

Emergency management plan becomes

focal in the process

Implementation of emergency Deputy CEO and team

management criteria

III: 3/19–4/10 (2003) Integrated action (fusion)

executive management em

Operation center and hum

behavior experts

24 days of semi-emergency state (war in Iraq )

Unified hospital emergency headquarters

served also as a catalyst for accelerating preparedness action

on their part.

Quarantelli makes the distinction between disaster

planning and disaster management, viewing planning as

strategy and management as tactics. Principles of good

planning include a continuing planning process rather than

an introduction of an end product, adoption of a multihazard

view that focuses on coordination of emergent resources

rather than imposing command and control, emphasizes an

inter- and intraorganizational integration, anticipates likely

problems and possible solutions, and relates to all phases of

planning process (mitigation, preparedness, response, and

recovery). Quarantelli asserts that although it is impossible

to anticipate the specific tactics to be used in an actual crisis

(because they will be tailored to the actual emergency that

develops), disaster preparedness should highlight tactical

considerations involved in efficient and effective disaster

management [12].

Adapting Quarantelli’s approach to disaster mitigation

[12] to the bmicroinfrastructureQ of the hospital, we

attempted to foster an interactive management process that

would deal with the various contingencies stemming from

Activity and results

for BC response Writing protocols based on military policy

Teaching medical procedures

Logistic requisites

Interface with Ministry of Health

and Military Home-Front Command

task force Task force evaluates needs of executive

management and emergency response teams

EO in charge of Deputy CEO maps comprehensive

organization needs, impasses, and networking

Force)

Resilience training for management of

sections and of emergency team leaders

Liaison for establishment of vertical

and horizontal communication channels

Paving way for nonformal communication channels

Troubleshooting

Upgrading available services according to needs

Mediation of all participating units

Assimilation of government policy

of Deputy CEO,

ergency

an

Multidirectional (nonhierarchy) communication

according to task/problem/need

Emergency management drills, and debriefings

Functional problem-solving process

S. Schreiber et al. / General Hospital Psychiatry 26 (2004) 359–366362

the new hazard of CB [13]. Quarantelli’s 10 criteria for good

disaster management are:

1. Recognize correctly the difference between agent- and

response-generated needs and demands.

2. Carry out generic functions in an adequate way.

3. Mobilize personnel and resources effectively.

4. Involve proper task delegation and division of labor.

5. Allow adequate processing of information.

6. Permit the proper exercise of decision-making.

7. Focus on development of overall coordination.

8. Blend emergent aspects with established ones.

9. Provide the mass communication system with appro-

priate information.

10. Have a well-functioning Emergency Operations Cen-

ter [12].

Emergency preparedness was expanded to include two-

facet consultation/training: (a) increasing awareness of

hospital management to psychological needs of staff under

hazardous conditions and (b) training the staff team leaders

to use leadership in order to enhance resilience, respond to

personal needs, and promote cohesiveness and coping skills.

2.1. Management consulting

Management consultation focused on the following

topics:

1. Initiating problem-solving sessions with external

agencies in order to form informal links and establish

clear communication channels.

2. Harnessing existing communication technologies such

as public announcement system, telephone lines,

emergency overload-resistant telephone network, mail,

fliers, staff meetings, and public address by manage-

ment in order to process and dispense crucial

information. These functions were coordinated by

the hospital’s spokesperson, information center, com-

mand headquarters, and executive management who

decided on the content and method of information

dispensing.

3. Determining information content: periodic emergency

situation assessment, personal information, shift

changes, policy adaptations, recreational activity dur-

ing long shifts, assistance availability, and preparing in

advance scripts announcements for various emergency

states to be read by designated command headquarters

members.

4. Building an alliance and establishing trust between

management and staff on shared goals through public

sharing of information, team meetings, feedback

channels, setting up a forum for deliberating and

solving personal and professional problems and

assuring that staff will not be exposed to CB hazards

unnecessarily or without protective garb.

5. Setting up protective childcare centers for children of

personnel was a unique achievement. Under the

management of nursing school staff, these facilities

can accommodate up to 1200 children, distributed by

age groups and family affiliation. Resolving role

conflict of parents was targeted through manage-

ment–staff assessment dialogue, sharing information

and parental involvement through Q and A sessions.

Nursing school staff was also trained in stress-

management techniques with children.

6. Performing simulations and drills involved team

leaders, emergency headquarters members, hospital

executive management, and all external agencies. The

drills aimed to improve emergency management and

included interdisciplinary ad-hoc problem-solving,

interorganization communication, mass media in-

volvement on the scene, and updating medical

treatment procedures.

7. Reevaluating placement of first-responders involved

assessment of previous experience, hardiness (a

personality construct with dimensions of commitment,

control, and challenge) [14–16] and was conducted

with flexibility.

8. Focusing on the first-responding teams (triage, decon-

tamination, first aid) enabled quick resolution of

specific issues (e.g., the protocols called for decon-

tamination in showers outside hospital grounds.

Walking casualties were to dispose of clothing articles,

shower for 6 min, and proceed to triage station at

hospital entrance. The actual written protocol did not

consider privacy and aesthetics of this essential

procedure. The issue was raised by the decontamina-

tion team leader and resolved through installation of

curtains and provision of disposable garments).

9. Incorporating defusing techniques for tension and

stress relief and monitoring compassion fatigue or

exhaustion of team members [17,18] was addressed

through group leaders who routinely conduct group

meetings in the wards (made up of social workers and

nurses).

10. Establishing horizontal and vertical communication

channels (rather than traditional hierarchic ones)

provided support and flexibility for emergency teams

through constant adaptation to changing situations,

dealing with personnel overload resulting from triple

shifts.

2.2. Staff training program

Performance under extreme psychological stress varies

among individuals. Much research has been devoted to the

study and improvement of performance under stress and to

the hazardous long-term impact of exposure. Hardiness is a

personality quality manifested in a positive approach to

stressful situations and characterized by three main

dimensions: control, commitment, and challenge. Other

factors known to improve performance under stress are:

training, social support, various stress-coping techniques,

S. Schreiber et al. / General Hospital Psychiatry 26 (2004) 359–366 363

self-esteem, trust in leadership, and fulfillment of basic

needs.

Considering the anticipated situation of exposure to

unfamiliar danger, extreme stress, and only partially

experienced civilian medical staff, the role of team leaders

became crucial in promoting coping behavior and enhancing

resilience of their team members. Our initial step aimed at

empowering leaders and expanding their responsibility

through establishing direct dialogue with management. We

based the training program on two assumptions: (a) team

members expected to work under extreme stress, hazardous

conditions, and a great deal of uncertainty are in a mental

state of increased suggestibility and dependence and (b)

emergency teams may be expected to react and perform well

when team leaders provide appropriate guidance, monitor

emotional needs, and are familiar with the use of coping

skills under stress. Psychological means of managing the

negative effects of stress were adapted from the work of

Mechenbaum on stress inoculation (conceptualization of the

problem, skills training and rehearsal for dealing with the

stressors identified, and application of the strategies

developed into day-to-day life) [19] and from the work of

Kobasa on increasing hardiness (focusing on the physical

signs of stress, reconstructing stress situations and thinking

of ways in which it could have been better versus ways in

which it could have been worse, and compensating for

unavoidable stressors through self-improvement by doing

things one is good at) [20–22].

We designed and implemented hospital-wide training

sessions for effective emergency team leadership of all

disciplines. Instruction was modular and adapted to each

professional group. Focal teams were triage, decontamina-

tion, mental health providers, hospital management depart-

ments, childcare facilities employees, and teams identified

for high-risk of burnout, exhaustion, or extreme stress (i.e.,

forensic photographers).

An assessment period preceded each session. Team

leaders (a senior physician, a head nurse, and an adminis-

trator) were encouraged to bring up issues of concern;

verbalize conflicts; assess duties; examine discrepancies;

define special needs of their teams; and establish commu-

nications channels with other relevant team leaders, central

emergency headquarters members, and hospital manage-

ment. The role of team leaders was redefined to include

caring for well-being of their staff, serving as role models

for team members, and attending to both operational tasks

and human needs while fostering group cohesion.

A teaching session aimed at stress inoculation [19]

included information about the sources of stress, physical,

emotional, behavioral and cognitive reactions, coping

methods, and expectations. Participants were taught princi-

ples of emotional first aid, leadership skills in emergency,

identifying and responding to normal stress reactions,

maintaining long-term team performance, the importance

of efficacy and seeking professional aid on the premises.

Our personal acquaintance with hospital human behavior

agents served to remove stigma and normalize expected

behavior modes. The lack of evaluation tools for prepared-

ness without an actual emergency taking place prevents us

from evaluating the degree of readiness to respond from the

human and management perspectives. Nevertheless, infor-

mal feedback and reactions pointed to greater self-efficacy,

an improved sense of besprit de corps,Q and a sense of

alliance between management and emergency staff.

2.3. Maintenance during the days of war

When the war in Iraq began, the Israeli government

declared a semi-emergency state that lasted for 24 days. The

general population was instructed to prepare appropriate

shelter, have gas masks handy for use, and carry on with

their routine life. All hospital’s emergency teams mem-

bers—about 1000 people (one out of five employees)

switched to operate on triple daily shifts at all times during

these 24 days. The anticipatory period required emergency

team members to change their familiar daily routine in order

to work on shifts, resolve home versus work conflicts on a

daily basis, improvise childcare arrangements at home (the

semi-alert state did not call for operating the hospital

childcare centers yet), keep alert and vigilant, maintain a

high-yet-not-too-high level of anxiety while holding-on to

the esprit de corps. At the same time, the general population

was gradually restoring routine life and the rest of hospital

staff carried out the hospital’s routine work without

interruption, while physicians, nurses, lab technicians, and

secretaries on the emergency teams were missing on the

wards albeit spending much more time in the hospital. This

created yet another conflict between emergency teams and

nonemergency staff. During this period, we availed our-

selves to team leaders for ongoing consultation and

problem-solving. We also served as consultants between

management and teams to help foster and maintain an

ongoing dialogue, mutual continuous assessments, flexibil-

ity, and attention to staff needs and a logical and right

division of burden.

This state of balert without actionQ may easily yield

complacency, rumors, frustration, and eventually loss of

commitment to the task. In order to combat it,

management, human behavior experts, and emergency

headquarters personnel made daily (and nightly) rounds at

the sites, recreational activities were available, pep talks

where held, and intermediate practice sessions took place.

It should be emphasized that complacency, in general, is

preparedness planning’s worse rival. Maintaining a steady

level of competency is a challenge to any preparedness

program.

3. Discussion

An ever-growing literature is available as far as

medical, technical, financing, and logistic preparedness

of public health facilities (hospitals and other authorities

S. Schreiber et al. / General Hospital Psychiatry 26 (2004) 359–366364

or agencies) for dealing with natural disasters [23,24] and

with chemical and biological terrorism [25,26]. Further-

more, some researchers addressed the issue of the

psychological and sociological effects of actual [27–29]

or threatened [30–32] chemical and biological warfare on

the general population or on mental patients [33], and also

that of a nuclear accident [34]. A recent survey in Israel

measured the psychological impact of continuous expo-

sure to terrorism on the general population and found it to

be considerably moderate [35]. Although survey partic-

ipants showed distress and a lowered sense of safety, they

did not present high levels of psychiatric distress, which

may be related to habituation process and to coping

mechanisms [35]. The mental patients treated at TASMC,

much like most of the civilian population in Israel, went

on with routine life and did not seem to be otherwise

affected by the semi-emergency state declared. (It seems

that whenever possible, denial served as a rather effective

coping mechanism). However, the sociopsychological

aspects of preparing a hospital staff to cope with such

stressful and own-life–threatening situations have not been

studied yet.

Current literature suggests relying on disaster expertise in

preparing for CB, but considerations focus mainly on

economic issues (budgeting and financing, the need for

government aid, etc.), medical issues, technical-logistic

issues [36–39] and an information-communication model

highlighting the need to share information in order to

facilitate adequate patients distribution among the hospitals

responding to a disaster. All of these are vital for

maintaining the capability to respond in case of a CB

emergency. However, lack of an integrated management

model based on research inhibits the development of a solid

management preparedness model. Both disaster expertise-

based hospital management and the issue of training staff for

prolonged functioning under extreme stress conditions have

so far been neglected entities.

Toward the end of 2002 when the war in Iraq became

imminent, a training program was developed at TASMC,

based on previous experience of two of the authors (N.Y.

and G.I.B.) in a comparable situation [40] and on theoretical

concepts [12,19,22]. A careful step-by-step evaluation of the

emerging needs as the program evolved, led to modular

training sessions for the emergency medical teams, the

directors of the diverse support units, and the executive

management.

One research-based sociological model of disaster

mitigation stresses the need to view disasters in terms of

huge operations that require the development of an

ongoing dialogue among responding agencies, along with

a contingency plan [12]. This global view of megasystems,

however, needs redeeming in order to activate a large-scale

emergency medical center response. We implemented

operative tools in order to substantiate an already existing

biomedical and logistic response program at TASMC. Our

multi-focal outlook stresses: (a) task orientation (the

primary need of each professional leader to be well-trained

and competent in his/hers own particular emergency role);

(b) the recognition of the significance of a people-

orientation approach (tending to staff special needs and

promoting coping skills under stress to enable effective

functioning); (c) a broad-spectrum vision of the expansive

scene and of all participants or emergency responders, their

roles, resources, and needs (bawareness of the greater

pictureQ); and (d) active participation in developing vertical

and horizontal communication channels, and problem-

solving mechanisms.

We approached each subunit individually, fragmentizing

and analyzing the needs of each team separately in order to

subsequently integrate a comprehensive program under the

leadership of the executive management. We assumed that

each team was a bmicrocommunityQ with common and

individual goals and needs that must be tended to if staff is

expected to function extensively under risky, harsh,

unfamiliar circumstances. Consequently, each of the

various medical facilities (decontamination and triage units,

emergency room teams, childcare facilities, transportation

unit, food facilities, administration and registration, pho-

tography unit) was addressed separately. The importance of

leadership cannot be underestimated in any approach.

Relying on the well-based assumption that people under

stress tend to respond with greater dependence and look for

guidance and reassurance, the training of team leaders

aimed at three major objectives: (a) defining their teams’

specific goals and expectations; (b) assuming overall

responsibility for their units; (c) tending to team members

safety, personal needs, and special skills. Training also

aimed at improving emotional communication skills.

Executive management was consulted along the same lines

of empowering team leaders, inviting greater responsibility,

allowing direct communication, and addressing relevant

emotional issues. Communication at all levels is another

major domain dealt with. Leaders were encouraged to

communicate personally and frequently, convey relevant

information, and provide necessary feedback on problem-

solving processes.

Some of the main impasses during this period involved

the virtual situation of btwo parallel subhospitalsQ operatingsimultaneously and impinging on each other’s functioning:

CB alert teams alongside existing wards carrying on

routine work with 1100 hospitalized patients, all drawing

on the same human resources. Conflicts evolved around

staff placement, shifts, etc. Increased transportation needs

required augmenting and funding driving fleet and

vehicles. The poorly defined bemergency stateQ declared

at the beginning of the war in Iraq posed further enduring

problems of operation. Keeping an alert state around-the-

clock required extra staff on duty (much more than the

usual on-call evening and night shifts of the hospital) and

personal consideration of special needs in order to

minimize burnout and exhaustion resulting from the

multiple extra shifts, weekly readjustments of familiar

S. Schreiber et al. / General Hospital Psychiatry 26 (2004) 359–366 365

routine, and difficulty maintaining an anticipatory alert

state. Concurrent maintenance of routine hospital operation

multiplied the difficulty. Fortunately, preparedness was not

examined under actual impact. Yet, the 3-month period of

preparation and training program followed by 24 days

functioning under bsemi-emergency state,Q served as an

unprecedented massive exercise from which many lessons

may be drawn.

1. Upscaling hospital preparedness program to meet the

complex circumstances of CB attacks requires

serious consideration of expert models of emergency

management. Multidisciplinary research-based disas-

ter-management models have much to offer in this

field.

2. The introduction of human behavior aspects contributed

to hospital policy-makers’ integrative view of prepared-

ness. Task and operation orientation must be supple-

mented by careful attention to personal adeptness and

emotional resilience of civilian hospital staff. The

possible harsh effects on responders under CB hazards

should not be disregarded. It is our view that mental

health professionals (psychiatry, psychology, social

work) in a general hospital should be called to the

mission as experts on human behavior. They have at

their disposal both basic knowledge and familiarity with

hospital management and staff necessary to pave their

natural path for playing a significant role. In this

situation, further emergency orientation and proficiency

is mandatory.

3. Reactions to this program indicate that it helped

cultivate trust and build an alliance between manage-

ment and staff. The feeling among staff members that

management listened and cared for their needs was

essential for an identification and commitment process.

Similar to combat conditions, team members must

develop trust and cohesion within their units. This may

promote long-term resilience and improve functioning.

Staff must trust that hospital management will back

them up, protect them from unnecessary dangers,

expose them only to duties they are capable of

performing, and attend to their special needs.

4. Implementation of an effective preparedness program is

a dynamic, ongoing process that requires investment of

resources, a profound and intensive assessment of

emerging needs, continuous improvement of commu-

nication-collaboration-coordination, intensified training

of all team leaders, and an integrated view by all

participants: inter- and intraagencies. This developmen-

tal process leans heavily on continuous sustenance.

5. Specific attention should be paid to emergency teams

through: (a) meticulous selection of personnel per

specific roles focusing on proficiency and leadership

aptitude; (b) implementation of appropriate selection

tools; and (c) intensified and continuous training for

team leaders.

6. The introduction and use of stress defusing techniques

may help team members achieve a better sense of self-

control and improved self-efficacy [41].

4. Limitations of our work

Our work was confined to hospital boundaries and aimed

at catalyzing an ongoing process between management and

various departments and disciplines. We are aware of the

need to promote better linkage and dialogue among all

participants responding in emergencies. Further improve-

ment of collaboration among multiple agencies over

numerous problems in such acute states of emergency is

mandatory (i.e., a programmed discharge and aftercare of

casualties into the community, treatment of bsecond waveQof CB casualties, population evacuation, hospital contam-

ination, mass casualty). The issue of collaboration with the

military medical unit allocated within the hospital and

responsible for the initial triage stage performed on the

street outside the hospital’s boundaries was addressed

intermittently as well. (In case of CB, military medical

units will be stationed at civilian hospitals to aid in

processing the mass casualties. Triage and decontamination

will be performed prior to admission. Incorporating exterior

medical units under the hospital management and coordi-

nation is essential).

Lack of evaluation tools applicable to assessment of

preparedness program is another deterrent. A comprehen-

sive program, integrative as it may appear, is a

cumbersome endeavor that may not qualify for cost-

effectiveness, but should be effective when implemented.

However, at present, assessment criteria for effective

hospital emergency preparedness are ambiguous when

applied prospectively.

Another limitation derives from the adaptation of a

sociological model of bcommunity disaster,Q exclusively to

a hospital community detached from the greater area.

Hospitals need to adopt a multidisciplinary attitude that

will enable development of a truly comprehensive program.

Yet, the validity of generic disaster-management criteria

makes it a sensible basis for further investigation and

development of hospital preparedness. Resource investment

priority should be evidence-based. Data on massive hospital

treatment of CB casualties is insufficient and, unfortunately,

may be available only after future incidents. While

addressing these issues requires tremendous additional

resources, mitigation cannot be complete without the

process described above. Further studies are needed to help

hospitals orient themselves in preparing toward noncon-

ventional (CB) casualties.

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