PHILADELPHIA-November 10, 2002 — Three Philadelphia hospitals run by Tenet are among the company's top facilities nationally in the amount of supplemental money they receive from Medicare.

The for-profit company recently announced it was reviewing its prices in response to the federal government's investigation of whether the company overbilled Medicare. Federal officials said they would begin an audit because Tenet receives above-average amounts of the extra payments.

Tenet executives have said the policy of pricing services higher than some competitors does not violate Medicare regulations.

(Copyright 2002 by The Associated Press. All Rights Reserved.)

Last Updated: Nov 10, 2002

LAKEWOOD, NJ-September 19, 2002 — Kimball Medical Center in Ocean County, New Jersey, has laid off dozens of workers because of funding cuts in both state and federal Medicare reimbursement and charity care, hospital officials said.

About 80 workers lost their jobs last week, but most were not directly involved in patient care. The layoffs were announced Wednesday by Joanne Carrocino, the hospital's executive director .

"This action comes at a time when hospitals throughout the state are facing tremendous challenges to contain costs and improve efficiencies, as they confront unexpected withdrawals of federal and state charity funding, dramatic cuts in Medicare reimbursements and delays in insurance payments," Carrocino said in a prepared statement.

The statement did not specify what departments were affected by the layoffs, and officials with the Ocean County hospital would not comment further. Kimball is an affiliate of the St. Barnabas Health Care System, and Carrocino said she would try to place the affected employees in unfilled positions at other hospitals in the system.

(Copyright 2002 by The Associated Press. All Rights Reserved.)

Last Updated: Sep 19, 2002

NJ Hospital Closer to Becoming For-Profit

TRENTON, NJ-August 19, 2002 — The state Attorney General's office has approved plans for Memorial Hospital of Salem County to become the first for-profit acute-care facility in New Jersey.

The decision, made public on Friday, comes just a few weeks after the state health commissioner also approved the plan. It now goes to a county judge, who is to rule Aug. 27 on the proposal to sell the 140-bed hospital to Brentwood, Tenn.-based Community Health Systems Inc.

The recommendation issued by the attorney general's office calls for $14.6-million to be allocated to a foundation that would cover nonprofit health care at the facility. The state law that regulates the change in the hospital's business status requires that a certain percentage of its assets be set aside for nonprofit care.

Thomas McGoff, the hospital's interim president, said he was pleased to hear of the decision.

"This is a very creative solution to a problem that is everywhere. It goes far beyond Salem County," McGoff told the Gannett State Bureau. "The decision was based on criteria of what is best for the community."

(Copyright 2002 by the Associated Press. All rights reserved.)

Last Updated: Aug 19, 2002

CALN – June 26, 2002 — Brandywine Hospital will not be reopening its trauma center as expected.

That decision followed an earlier announcement by hospital officials that the facility was only closing temporarily. Officials say the region's problems with rising medical malpractice insurance costs will keep the hospital from opening the trauma center again.

That's according to R. Alan Larson, the hospital's chief executive officer. The hospital in Caln was the only trauma center in Chester County. Hospital officials originally said they were closing the trauma center for two weeks.

(Copyright 2002 by WPVI-TV 6. All rights reserved.)

Last Updated: Jun 26, 2002

PHILADELPHIA - June 20, 2002 — Mercy Hospital of Philadelphia will shut down its maternity ward and stop delivering babies Aug. 23, officials said Wednesday.

Administrators at the hospital said the number of babies born there was too small to justify keeping the maternity unit open.

Last year, the hospital delivered about 400 babies.

"It's just not a service you can provide unless you have critical volume," said Bernadette Mangan, the hospital's chief executive officer.

The closing of the maternity ward will save the hospital about $2.5 million a year, officials said. Employees in the unit are being offered other jobs.

Pregnant women will be referred to Mercy Fitzgerald Hospital in Darby.

(Copyright 2002 by the Associated Press. All rights reserved.)

Last Updated: Jun 20, 2002

Jefferson Cutting 270 Jobs at Three Hospitals

PHILADELPHIA: May 21, 2002 — Thomas Jefferson University Hospital said Monday it will lay off 99 employees and eliminate 80 vacant positions to save $30 million.

Last month, Jefferson announced it was closing the maternity ward at Methodist Hospital on June 30, idling 91 workers.

The job cuts announced Monday include managerial, administrative, clerical, information systems and laboratory tech positions. Employees are being notified by their supervisors this week; the cuts take effect June 30.

Hospital administrators blamed the layoffs on skyrocketing malpractice-insurance premiums.

"Our malpractice expense is going up from $16 million in fiscal year 2002 to $32 million in fiscal year 2003, a doubling of our insurance premiums," said Alan L. Brechbill, executive vice president and chief operating officer.

Brechbill said 150 of the total 270 job cuts were being made at Thomas Jefferson University Hospital, 95 jobs would be lost at Methodist Hospital, and 25 positions would be reduced at Jefferson Hospital for Neuroscience.

Copyright 2002 by The Associated Press. All Rights Reserved.

Last Updated: May 21, 2002

NORRISTOWN, PA: May 16, 2002 — A psychiatric nurse at a state mental hospital who said he sensed a workplace conspiracy similar to "the Enron situation" was convicted Wednesday of killing a former supervisor and injuring another in a 46-hour standoff in June 1999.

Montgomery County Judge Paul W. Tressler found Denis Czajkowski, 43, of Perkiomen, guilty of first-degree murder, attempted murder, aggravated assault, kidnapping and related charges.

Czajkowski, a one-time heroin addict who was fired from Norristown State Hospital in April 1999, claimed self-defense in testimony Tuesday.

"I was not a disgruntled employee. I was afraid for my life," said Czajkowski, who blamed his victims for being part of a conspiracy to have him fired.

Czajkowski faced numerous charges in the hostage-taking, in which Carol Kepner, 54, of Lower Merion, died from a gunshot to the head and Maria C. Jordan, 39, was shot several times with Czajkowski's replica antique gun.

The case was put in the hands of Tressler when Czajkowski waived his right to a jury trial in exchange for prosecutors' not seeking the death penalty. Tressler set sentencing for July 30. The murder conviction carries an automatic life sentence.

In closing arguments Wednesday, Montgomery County District Attorney Bruce L. Castor Jr. said that, to Czajkowski, "losing his job was tantamount to his life going down the drain."

Czajkowski, who used a replica of a Civil War-era revolver, shot Jordan twice on the first day. The standoff ended when police broke a window to get a closer look and Czajkowski opened fire on the women, killing Kepner and further injuring Jordan.

The defendant had planned to mount an insanity defense, but dropped the strategy as the trial opened.

Defense lawyer William McElroy argued that his client didn't have the time to form intent in the chaotic moments when police broke the window.

"There was no intent on Mr. Czajkowski's part. He was reacting to the distraction, being confused, basically disoriented and deluded," McElroy said.

Though Czajkowski claims the shooting was unintended, Castor said only the first shot could have been accidental. The antique gun used by Czajkowski requires that the hammer be pulled back before each shot, Castor noted.

"Maybe one shot is an accident or the result of the police breaking the window and him getting scared. But the second shot can't be," Castor said.

Ballistics evidence shows that with the second shot, "he puts the gun against Carol's head and he pulls the trigger and he blows her away," Castor said.

Jordan, who testified her captor refused to let her speak or move without permission during the long ordeal, declined comment after Wednesday's verdict. She has a pending civil lawsuit against the state hospital, state police and other parties.

McElroy said he was left without a strong defense strategy because Czajkowski insisted he not use an insanity defense.

"It's a bizarre system where the defendant is the one to decide whether or not he wants to pursue an insanity defense when everyone around him thought it was the only viable, arguable defense," said another defense attorney, Michael P. Clarke.

Despite Czajkowski's meandering testimony, Castor said he did not believe Czajkowski was insane.

"The defendant here is a filibuster. He just didn't want the case to go forward and it didn't for three years," Castor said.

Czajkowski was hired at the state mental hospital in 1990 from a halfway house. He was arrested for heroin possession in August 1998 and put on medical leave before he was later fired.

Copyright 2002 by The Associated Press. All Rights Reserved.

Last Updated: May 16, 2002

NORRISTOWN, PA: May 14, 2002 — A woman who was held hostage by a disgruntled former employee at a suburban Philadelphia psychiatric hospital described in court Monday the 46-hour ordeal that ended with her shot multiple times and a co-worker dead.

Maria C. Jordan, 39, testified that Denis Czajkowski deliberately shot her in the chest, abdomen, arm, wrist and foot as the standoff began at Norristown State Hospital.

"This was his way of making me pay for terminating him," Jordan said.

The standoff in June 1999 left 54-year-old Carol Kepner, of Lower Merion, dead from a gunshot to the head. Czajkowski is charged with murder, kidnapping and other crimes.

Jordan said Czajkowski restricted his hostages' movement and wouldn't allow them to speak during the standoff. "Even movements as basic as getting rid of a leg cramp had to be cleared with Mr. Czajkowski," Jordan said.

Jordan also described being shot twice more when state police broke an office window to view the hostage scene.

Czajkowski was fired for not following the hospital's attendance and time policies after numerous attempts to help him save his job as a psychiatric nurse, Jordan and a hospital official testified.

Czajkowski fired his initial attorney after being ruled competent to stand trial in October. The attorney had been prepared to argue an insanity defense.

He dropped the insanity defense last week, a day after more than 30 potential jurors had been questioned and four were picked for trial.

He also opted for a non-jury trial. In exchange, prosecutors will not seek the death penalty if he is convicted of murder.

The trial was scheduled to continue Tuesday.

Copyright 2002 by The Associated Press. All Rights Reserved.

Last Updated: May 14, 2002

PHILADELPHIA: April 25, 2002 — Methodist Hospital said Wednesday it will close its maternity ward June 30.

The hospital cited the rising cost of malpractice insurance. Women will be sent 20 blocks north to Thomas Jefferson University Hospital to give birth.

The move will eliminate 91 full-time and part-time positions at Methodist, said James Robinson, Methodist's chief administrative officer.

Jefferson officials said the number of babies delivered at Methodist declined from 1,162 in fiscal year 2000 to 1,053 last year. A total of 1,032 deliveries is expected by the time the current fiscal year ends June 30.

The births at Methodist represent about 5 percent of all births citywide, according to the Pennsylvania Department of Health.

Jefferson acquired Methodist in 1996.

Copyright 2002 by The Associated Press. All Rights Reserved.

Last Updated: Apr 25, 2002

HARRISBURG – October 24, 2001 — The state Department of Health fined a Philadelphia hospital $447,500 Tuesday for a laboratory test error blamed for the deaths of three patients who were given overdoses of a blood thinner.

The fine was imposed more than a month after St. Agnes Medical Center was allowed to resume blood-clotting tests used to prescribe the drug warfarin, a widely prescribed anticoagulant better known by the brand name Coumadin.

The hospital has determined that the patients who died were among dozens of people given overdoses of the drug between June 4 and July 25 after a laboratory error incorrectly interpreted a blood-thickness test. St. Agnes voluntarily stopped testing soon after the errors were discovered.

"The Department of Health has the responsibility to license hospitals and to make sure they consistently provide quality care for their patients," state Health Secretary Robert S. Zimmerman said in a statement. "St. Agnes Medical Center did not provide that care when it failed to give accurate lab test results to some 843 patients over the course of 52 days this summer."

The department could not say how many of the 843 patients were taking Coumadin.

The state is giving St. Agnes the option of using the fine to pay for measures that would improve the oversight and monitoring of its laboratory and pharmacy services. The hospital must notify the state within 10 days of receiving the order and must get state approval for a spending plan if it wishes to do so.

"It's not an option that is used very often, and it's the first time we've used it for hospitals," health department spokesman Richard McGarvey said. "It had to do with the situation. St. Agnes was very up-front about what took place. It wasn't a situation where they tried to hide anything."

Sister Marge Sullivan, St. Agnes' president and CEO, said the hospital may appeal the fine. She said the amount of penalty was "quite disappointing," citing the hospital's cooperation with authorities and its implementation of a plan to correct the problems.

"However, we recognize the state's willingness to be flexible in this matter and we look forward to working with the state to pursue alternative actions to the monetary civil penalty," Sullivan said in a statement.

The lab error involved the prothrombin time (PT) test, which measures blood thickness. Physicians routinely use the test and the International Normalized Ratio to monitor the effect of warfarin on the blood. The INR is a numeric value used to standardize PT results.

Employees at a St. Agnes lab failed to verify the sensitivity of a chemical reagent used in the PT test, leading them to use the wrong INR to calculate the result. The error led some physicians to prescribe a stronger dose of warfarin.

The situation prompted the U.S. Centers for Disease Control and Prevention to call on labs across the country to verify that the correct INR is being used and to give doctors both the PT number and the adjusted INR number.

(Copyright 2001 by The Associated Press. All Rights Reserved.)

Last Updated: Oct 23, 2001

PHILADELPHIA: December 6, 2001 — A Catholic health care provider in the Philadelphia region announced Wednesday that it would eliminate about 400 jobs and reduce services in an attempt to reverse money losses.

As part of the restructuring, Mercy Community Hospital in Havertown, Delaware County, is losing its overnight care, physical therapy, and occupational therapy services, Mercy Health System officials said Wednesday. The hospital will house outpatient surgery facilities, and doctors' and administrative offices.

At Mercy Fitzgerald Hospital just 20 minutes away in Darby, the pediatrics department and other unidentified units are slated to close, but the system will open an inpatient oncology department and expand emergency care.

Mercy Health System expects to lose $8 million this year, most of that from Mercy Community Hospital, said Mark T. O'Neil, Mercy's president and chief executive officer.

The rising cost of medical malpractice insurance and drugs, a nursing shortage, and low reimbursement for health care services were hurting the system, O'Neil said.

Mercy will eliminate 130 jobs from Mercy Fitzgerald Hospital, about 250 jobs from Mercy Community Hospital, and 22 administrative jobs, officials said.

Mercy Community is to become home to the system's administrative offices after Mercy sold its 104,000-square-foot office building in Conshohocken.

In addition, some beds in the medical surgical area and the senior behavioral care unit will move from Mercy Community to Fitzgerald Mercy.

The health system employs 9,000 people and owns seven hospitals, including St. Agnes Medical Center in South Philadelphia.

Copyright 2001 by The Associated Press. All Rights Reserved.

Last Updated: Dec 6, 2001

NEW YORK, NY: October 30, 2001 — A 61-year-old hospital worker was on a respirator in "very serious condition" after becoming what is believed to be the first New Yorker to test positive for the dangerous inhalation anthrax, Mayor Rudolph Giuliani said.

More tests were being conducted to determine how the woman, a stockroom employee of the Manhattan Eye, Ear and Throat Hospital, contracted the potentially deadly bacteria, the mayor said.

Health officials were awaiting tests results to make a final determination Tuesday. The cause of the infection was not immediately known.

"We have to assume on the theory and the assumption that it is anthrax," Giuliani said.

New York City has been a focus of the anthrax investigation since an assistant to NBC anchorman Tom Brokaw was infected earlier this month. The city has had four confirmed skin anthrax cases, all at media outlets, but none of the more-serious inhaled form.

In Florida, New Jersey and Washington, D.C., three people have died from inhaled anthrax, three others have confirmed cases, and one has survived.

The New York woman, whose identity was not released, started showing possible symptoms of anthrax on Thursday, Giuliani said. By Sunday she was in severe respiratory distress and went to the emergency room of Lenox Hill Hospital. "There was a rapid progression from Saturday to Sunday," said city Health Commissioner Neal Cohen.

After the initial tests returned positive showing the woman had contracted inhalation anthrax, a hazardous materials unit was dispatched to the woman's workplace for environmental samples. Nasal swabs were taken from 25 workers and those tested were given antibiotics. About 300 full-time employees work at the hospital, which does not admit patients overnight.

Repeated phone calls to the hospital went unanswered, but employees entering the hospital Tuesday morning said the facility was closed. Giuliani said that as employees came to work they would be taken to a separate area and interviewed as part of the investigation.

The woman worked near a mail room but didn't ordinarily handle mail, which has been a source of anthrax in Washington, D.C., and New York.

Authorities late Monday were tracing mail routes that lead to the hospital. City health officials are also contacting patients who visited the hospital over the past two weeks, the incubation period for anthrax.

Earlier Monday, a postal union filed a lawsuit against the U.S. Postal Service to force the closing of New York's biggest mail-sorting center for testing. "We're simply asking the post office to close the building and make sure it's safe," William Smith, the union president said of the 2-million-square-foot Morgan Processing and Distribution Center. "Test everybody and tell us they haven't been exposed. If that's not done, we shouldn't be in that building."

The Postal Service also announced that absenteeism there had climbed to nearly 30 percent since traces of anthrax were found on sorting machines. But despite the anthrax difficulties, there have been only "minor, minor disruptions" of mail delivery, a Postal Service executive said.

No postal employees in New York have come down with anthrax.

Copyright 2001 by The Associated Press. All Rights Reserved.

Last Updated: Oct 30, 2001

BOSTON - September 30, 2001 — Fewer foreign patients have been visiting the nation's hospitals since the Sept. 11 terrorist attacks, hospital officials say.

The drop-off is significant to hospital finances because international visitors generally are better paying customers than Americans covered by group health care plans.

Spending on food and lodging by those traveling with the patients provides additional economic benefits to cities with major hospitals.

Dr. Jeffrey Gelfand, an internist at Massachusetts General Hospital, is hearing from worried patients overseas.

"People are very anxious about being connected to their doctors over here – they feel cut off," he told the Boston Sunday Globe.

Mass. General treated fewer than 65 foreign patients on Tuesday, down from 350 a month ago, representing more than the normal fall seasonal decline.

Doctors at Mass. General treat up to 3,500 international patients a year; about 60 percent of those come from the Middle East. Last year, Mass. General's international program earned $24 million in revenue, while a similar program at its partner Brigham & Women's Hospital earned $11 million.

At the Cleveland Clinic, the 5,500 annual international patients account for only 4 percent of visits, but they bring in up to 12 percent of revenue.

Foreign patients fly to the United States for complex procedures such as organ transplants and experimental chemotherapy, as well as routine care for diabetes and heart disease.

After the Sept. 11 attacks, some Middle Eastern nations advised patients to quickly return home.

Johns Hopkins Hospital in Baltimore saw 22 percent fewer international patients after the terrorist attacks, compared with the same period in September 2000. Business from the Middle East alone dropped 42 percent.

Similar declines were reported at other prestigious hospitals around the nation, the newspaper said.

(Copyright 2001 by The Associated Press. All Rights Reserved.)

Last Updated: Sep 30, 2001

Mcgreevey Wants Nurses Added to National Registry

McGreevey says a federal law that requires sharing information about doctors engaged in suspicious activity should be expanded to include nurses. He also says the Legislature should adopt a medical errors bill.

Somerset Medical Center never learned that Charles Cullen had been fired from some jobs and left others due to work-related problems and suspicious behavior.

Hospital officials say that's because anything short of a criminal conviction is not reported by a previous employer because of privacy concerns.

Cullen claims he killed dozens of patients in New Jersey and Pennsylvania during his 16-year career.

(Copyright 2003 by The Associated Press. All Rights Reserved.)

Hospital's End

The announcement came on the day MCP nurses were voting on whether to end a strike at the hospital, which employs more than 1,000 people and has 379 beds. The number of patients had fallen to about 70 during the five-week walkout.

Phillip S. Schaengold, vice president of operations of Tenet Pennsylvania, said the decision followed five years of efforts to revive the hospital after years of decline.

"Unfortunately, a tough payor market, the medical malpractice insurance crisis, state budget constraints as well as other factors lead us to this action," Schaengold said.

Local 1199C president Henry Nicholas, whose union represents more than 600 MCP workers, said he was one of a number of union leaders told of the closing Wednesday.

MCP provides general and psychiatric services and is also used by Drexel University to teach medical students.

Councilman Michael Nutter, chairman of Tenet's community board of advisers, said he was told of the closure late Wednesday by Schaengold, who heads the local network of the Santa Barbara, Calif.-based company.

"I am very angry, very disappointed," Nutter said. "This is a significant breach in the nature of my relationship with Tenet." He said he would seek a full investigation of the closure decision.

Nutter said he believed hospital's financial problems predated the Nov. 11 strike. He said Schaengold told him the hospital had projected a loss of more than $20 million both this year and next year. Nutter said a consultant had predicted that the hospital could break even in two years but only if major investments were made.

MCP began in 1850 as the nation's first medical college for women, and started admitting men in 1970. The school and hospital were bought by Pittsburgh-based Allegheny Health Education and Research Foundation in 1988 but entered bankruptcy with most of the Allegheny system in 1998. The medical school was later merged with Hahnemann University, creating the Drexel University College of Medicine, which will continue to operate.

Tenet bought MCP and seven other former Allegheny hospitals in November 1998. Since then, Tenet added Roxborough Memorial hospital but closed Parkview and City Avenue hospitals and sold Elkins Park Hospital.

MCP's closure will leave Tenet Pennsylvania with five hospitals: the 618-bed Hahnemann University Hospital, 248-bed Graduate Hospital, 161-bed St. Christopher's Hospital for Children, 125-bed Roxborough Memorial, and 145-bed Warminster Hospital in Bucks County.

Tenet Healthcare Corp. owns 102 acute care hospitals and many related health care services in 15 states.

(Copyright 2003 by The Associated Press. All Rights Reserved.)

Jeff Rubin is an emergency manager with Tualatin Valley (Oregon) Fire & Rescue and a member of the State of Oregon’s Health Preparedness Advisory Committee. He was a fire, emergency medical services (EMS), and rescue responder for 13 years and served with City of Austin (Texas) EMS for 5 years; his duties there included planning and response for incidents involving hazardous materials and weapons of mass destruction. He has a B.S. in geology and geophysics from Yale University and an M.A. and Ph.D. in geological sciences from the University of Texas at Austin, where he was Assistant Dean for Environmental Health and Safety. He has provided Hospital Emergency Incident Command System (HEICS) and hospital preparedness training across the United States.

Hospitals are an essential component of community preparedness for terrorism and other hazards, both natural and manmade. Despite general preparedness requirements within the industry, hospitals typically are a weak link with respect to community disaster preparedness, particularly for those incidents involving contaminated patients. Significant systemic constraints make most hospitals reluctant partners in preparedness and generate ineffective response; this condition has been highlighted by the antiterrorism training and preparedness programs of the past few years. Results of numerous exercises and actual responses across the United States indicate a predictable list of pitfalls, most of them related to inherent system limitations that continue to hinder effective disaster operations in hospitals:

• Communications
• Hospital security
• Decontamination procedures, equipment, and training
• Hospital staff management
• Exercise realism, content, follow-up

Introduction

Recent events have focused attention on the ability of communities to respond to acts of terrorism. In addition to intentionally generated incidents, most communities have been struggling with preparedness against a range of natural and technological hazards. Public safety and emergency management personnel have developed and tested response plans, and considerable federal resources have been expended toward the same end—albeit with inconsistent results. With some exceptions, community preparedness efforts have faltered at a common, though not exclusive, point: hospitals. Those involved in preparedness and response recognize the quandary: hospitals are essential, irreplaceable resources for planning, response, and recovery associated with disasters, but they carry a unique set of constraints that makes effective participation in such efforts challenging at best.

Hospital Challenges and Constraints

In their article “Ambulances to Nowhere,”¹ Joseph A. Barbera, M.D., Anthony G. Macintyre, M.D., and Craig A. DeAtley, PA-C, cogently discussed the constraints and challenges facing hospitals, along with public expectations. Hospitals as a whole face difficult financial times: approximately 30% of U.S. hospitals are operating at a financial loss, with many more teetering on the financial brink.² Hospitals face increasing operating costs coupled with decreasing reimbursement rates. Emergency departments (EDs) have become primary care intake points for much of the public,³ regardless of their insurance status. Staffing shortages are becoming the rule for most departments across a wide range of skill levels and specialties;⁴ loss of experienced staff exacerbates the problem. High staff turnover rates further burden the remaining staff and add overtime and incentive costs to already strained budgets.⁵

Costs haven’t been the only increasing item. Healthcare facilities are hardly exempt from government regulations (a recent example is the Health Insurance Portability and Accountability Act⁶) and are strongly affected by changes in Medicare reimbursement patterns, but accredited hospitals also deal with the nongovernmental Joint Commission for the Accreditation of Healthcare Organizations (JCAHO). To achieve and maintain accreditation, hospitals must adhere to JCAHO’s consensus standards as demonstrated during periodic onsite and remote surveys. Standards are diverse in scope and generally derived from clinical, ethical, technological, environmental, or occupational indications. Like many government regulations, they tend to add expense and are not accompanied by new revenue streams.

Hospitals rely on public trust as much as on reimbursement revenue. More than most corporations or government agencies, a healthcare facility that suffers a crisis of public confidence stands to lose both funding and patients along with its reputation. Expectations, commonly in the form of blind assumptions, are that hospitals should be able to handle whatever they receive—and do it right the first time. With respect to disasters, this includes

• Managing medical assessment, treatment, and continuing care for acute incidents involving large numbers of patients
• Effectively managing contaminated patients
• Recognizing, identifying, and managing consequences of bioterrorism
• Protecting employees, patients and their families, and anyone else within the facility
• Dealing with all of these while continuing to provide everyday emergency care

Public agencies responsible for preparedness and response have little direct control over public hospitals and none over private facilities (which are not accountable to public officials). There is no suitable alternative to engaged hospitals when trying to plan for or manage a mass-casualty incident or other type of large-scale disaster affecting a community. Should the incident be at the hospital itself (such as a fire or hazardous material release) or involve the hospital (for example, a flood or hurricane), a prepared facility and staff may be the difference between minimal loss of life and a true catastrophe.

Hospital Requirements

Hospitals have been required to have and exercise emergency preparedness plans (also known as “disaster plans”) for many years. As of January 2001, JCAHO required hospitals to have a comprehensive plan in place, covering the four traditional phases of emergency management (mitigation, preparedness, response, and recovery).⁷ A hazard vulnerability analysis, part of the new standards, would not only determine both the most likely and the most catastrophic incidents, but also identify the range of hazards for a given hospital. This all-hazard approach, like municipal emergency operations plans, allows preparedness and a measured and flexible response to a variety of potential incidents. Plans may contain annexes for specific hazards, but an all-hazard plan should obviate a separate plan for each hazard (an “earthquake plan,” a “terrorism plan,” etc.). Plans are supposed to be tested and updated by at least one tabletop or similar exercise and one full-scale exercise or actual activation per year. The standards also establish requirements for staff training and familiarization with the plan.

The wave of training and other preparedness programs, accompanied by requirements and expectations regarding preparedness for acts of terrorism, has not ignored hospitals. The Defense Department’s Domestic Preparedness Program (continued by the Justice Department) in the late 1990s provided basic training on medical management of casualties affected by chemical, biological, and radiological warfare agents. Curriculum and training were limited by design: it was largely military in origin, focused on the response phase, and did not contain much depth in hospital preparedness. The Metropolitan Medical Response System⁸ (initially overseen by the Department of Health and Human Services and now part of the Department of Homeland Security) was the first large-scale federal program to focus on improving the ability of healthcare systems to detect, identify, and manage incidents involving large numbers of casualties, who might be contaminated. The goal of incorporating first responders (public safety agencies), public health agencies, hospitals, and emergency management and linking local, state, and federal agencies was an innovative global approach to a healthcare system that is commonly approached via its components. The challenges faced by Metropolitan Medical Response System participants and administrators have been less a result of the philosophy than of the style and method of administration. Another essential component of hospital disaster preparedness is surge capacity—unused beds that can host unexpected patients. Empty beds do not generate revenue, and surge capacity in American hospitals is near an all-time low.^{9, 10} Even were there significant excess beds, it would be difficult to staff and equip them.

In addition to preparedness requirements, hospitals fall under regulations of the Occupational Safety & Health Administration (OSHA) and the Environmental Protection Agency. As with many detailed federal standards, the requirements for hospitals under OSHA standards are open to interpretation, with a great deal riding on non-standardized sources such as OSHA opinions and interpretations, which are the closest things to a de facto standard. The lack of a clear and consistent application of OSHA regulations has been an obstacle to developing consistency.

Plan development, staff training, and equipment maintenance are unreimbursable costs, but some financial support has developed. In June 2002 the Healthcare Resources and Services Administration issued grants to most states and a few cities focusing on preparedness for bioterrorism in state and local governments and hospitals.^{11, 12} The grants are supposed to assist states in achieving “critical benchmarks for bioterrorism preparedness planning” promulgated by the Department of Health and Human Services. Three of the benchmarks are to designate a bioterrorism preparedness coordinator, establish a hospital preparedness planning committee to advise the state health department, and develop a plan for managing epidemics, regardless of origin.¹³ States have some discretion on disbursement (provided that funds are directed toward fulfillment of primary grant goals), with many aiming for general hospital preparedness as a first step in bioterrorism preparedness. Subsequent and planned grants from the Healthcare Resources and Services Administration allow expansion of preparedness funding from hospitals to health systems and encourage regional and statewide coordination.

Despite requirements, standards, and best intentions, the combination of staff and equipment shortages, lack of surge capacity, and minimal funding have remained significant obstacles. Although there have been (and likely will continue to be) substantial improvements, most hospitals are still unprepared to effectively manage the results of a major incident—whether due to mishap, terrorism, natural disaster, or infectious disease outbreak—requiring treatment of mass casualties, staff protection, or facility evacuation.^{14, 15} An incident contemporaneous with local or regional infrastructure disruption will not only magnify hospital shortcomings, it will further hamper effective hospital response and hospital and community recovery.

Observations

Andrew Milsten, M.D., of the University of Maryland, in his article “Hospital Responses to Acute-Onset Disasters: A Review”¹⁶ surveyed 22 years of incidents in the United States and abroad, identifying a broad list of hospital challenges (communications and power failures, water shortages and contamination, structural damage, hazardous materials exposure, facility evacuation, and resource allocation), accompanied by general suggestions (such as developing plans and procedures for disasters).

The observations on which the discussion and conclusions in this article are based come from multiple sources:

• Direct personal observation (generally as controller or evaluator) of tabletop, functional, and full-scale exercises, along with actual incidents such as tornadoes, ice storms, floods, hazardous materials spills, and multiple-casualty events.
• Personal communications and written after-action reports from local exercises and actual incidents elsewhere.
• Published observations and after-action reports from three large-scale exercises: Topoff (May 2000),¹⁷ Dark Winter (June 2001),¹⁸ and Topoff 2 (May 2003).^{19, 20, 21}

Hospitals consistently encountered challenges in the following areas: communications, security, decontamination, staff training, staff protection, and exercise design and conduct. The most significant aspect of these observations may be their consistency: the challenges and pitfalls encountered by hospitals and the agencies supporting them are definable and reproducible—and thus predictable. As such, there is value in their description, discussion, and analysis.

Communications

Intrafacility communications during exercises and actual events have been described as “difficult,” “inconsistent,” “marginal,” and “nonexistent.” Phones are overloaded, radios—when available—are insufficient in number, range, and frequency options (or a combination of those), and staff commonly lack adequate training in communications procedures or equipment operation. This should come as little surprise, because similar complaints are expressed about everyday operations—that is, a system that doesn’t work well under normal conditions shouldn’t be expected to do so under extreme stress. Few facilities devote planning or resources to external communications. Although most acute-care facilities are able to use the Hospital Emergency Area Radio network, it was designed for short communications between EMS providers and EDs as well as limited interfacility traffic; it was not intended for continuous heavy traffic among multiple parties. Many hospitals host licensed amateur radio operators during disasters; the ham networks provide an important communications resource, allowing voice, data, and even video transmissions among incident scenes, hospitals, emergency operations centers, and other critical facilities.

Security

Security staff in most hospitals that have them are private guards, either hospital or contract employees. Most are unarmed and have no powers of arrest. Although their responsibilities vary considerably, most are there as deterrents and to restrain violent patients or visitors. Hospital security is an important part of JCAHO’s “secure environment,” protecting patients, staff, visitors, information, and the physical infrastructure.^{22, 23} Some hospitals, particularly large ones in urban areas, employ sworn law enforcement officers, either on contract or as employees. Regardless of the type and powers of security staff, the trend of minimal staffing applies across the board, commonly resulting in inadequate coverage for most facilities. Recurrent security-related challenges have internal and external foci: lockdown and the role of local law enforcement.

Lockdown is a common constituent of hospital emergency plans, but there is little consistency to its definition, even between facilities in the same community. In its ideal use, lockdown is an incident management tool that allows hospital staff to assert or regain control of a situation that appears or escalates with little warning. Lockdown is analogous to cardiopulmonary resuscitation (CPR): it is a short-term step intended for use early in the incident to buy time for more definitive measures. In securing all or part of the facility against additional entry, staff implementing lockdown can gain some breathing room while providing short-term protection to themselves and their patients. Also, as with CPR, lockdown can make the difference between success and failure in implementation of an emergency plan but is rarely effective on its own; a plan that ends with lockdown is doomed to fail.

In most exercises simulating a terrorist incident, naturally occurring disease outbreak, or unintentional hazardous material release, the hospital in question has been “overrun,” meaning that a portion (generally the ED) or all of the facility is no longer able to function cohesively, protect its staff, or provide organized care to current and prospective patients. This can be due to contamination of the area, an unmanageable crush of incoming patients, perceived threat of violence, or loss of infrastructure. In many of these exercises, hospital staff recognized impending failure and requested assistance from law enforcement agencies for facility security and crowd control. With few exceptions these requests were unmet (or were met too late), although it eventually became apparent to most participants that these needs were indeed urgent and the loss of hospitals disastrous. Although it is not an exaggeration to say that law enforcement was not an eager player in hospital security, this was not due to laxity on the part of police. As expressed in the Topoff exercise after-action report,²⁴ law enforcement agencies were overrun with urgent requests for multiple types of assistance. As they were given little to no external guidance on how to rank request urgency, they found themselves with too many priorities. This issue offers a compelling example of the need to consider hospital preparedness within the context of community resources.

Decontamination

Mass decontamination has been a common focus since antiterrorism training became a mass-market product in the late 1990s. Considerable sums have been spent on extensive training and equipment designed to decontaminate thousands of people at an incident scene and hundreds at a hospital. Common goals in cities participating in Metropolitan Medical Response System contracts are for hospitals to be able to decontaminate at least 100 ambulatory patients without relying on external assistance (that is, a fire service hazmat team). These are significant expectations, and to date they have proved largely fanciful. Terrorism aside, all acute-care hospitals should be able to successfully manage a single contaminated patient without external resources.²⁵ A 2002 American Hospital Association survey²⁶ reported that a majority of hospitals had plans in place for managing chemical and biological attacks; this is a marked increase relative to surveys taken before 11 September 2001.²⁷ This encouraging report notwithstanding, most hospital plans likely fall into the category of “fantasy documents”²⁸—that is, meeting legal and political requirements but not grounded in realistic capabilities or expectations and not conferring functionality. The great majority still find single-patient decontamination an elusive goal.

Staff Training

As with the public-safety sector, there is no shortage of training and equipment for hospital preparedness; there is also little in the way of functional standards, guidelines, or quality control among programs and their purveyors. Few hospitals have full-time emergency managers or emergency preparedness coordinators: most commonly those responsibilities fall under “other duties as required” for clinical managers, facilities staff, environmental health and safety officers, or administrative staff. Whether the purview of an individual or committee, the decisions are the same. The lack of standardization and the vast range of executive support almost guarantee that each facility or hospital market will go through its own set of decisions, all driven at least as much by financial considerations as by need.

What Type of Training Should Be Provided?

There are many training options, but the most common (and the most applicable) include the HEICS,²⁹ terrorism and weapons of mass destruction, and general and medical management of hazardous materials. HEICS is a standardized incident management system adapted from incident command system variants used by local, state, and federal public-safety and emergency-management personnel. It is specified in the JCAHO emergency management standards and is one of the few consistencies in hospital preparedness training. Beyond HEICS, options are numerous and unregulated, with varying degrees of standardization. How much training should be provided? What are useful and realistic competencies? What will an individual hospital, hospital group, or regional consortium support?

Who Should Be Trained?

Principal distinctions include clinical vs. non-clinical, which departments should be covered, the number of trained staff to provide adequate coverage, frequency of initial and refresher training, and how much effort should be made to include physicians, particularly those who contract with hospitals (a common arrangement, especially in the ED). High turnover rates can quickly deprive a facility of trained employees. Insufficient or ineffective refresher training can produce the same effect as high turnover, as hard-won skills deteriorate due to lack of use. Many preparedness and decontamination training programs are provided in “train-the-trainer” format—that is, a small group of employees is trained and expected to cascade the training down to fellow employees, even though their newly acquired “expertise” is unaccompanied by experience, additional knowledge, or implementation capability. Lack of effective follow-up creates the all-too-common phenomenon of “trainers” who teach few if any classes and soon lose whatever competencies they may have acquired.

Staff Protection

Essential components of staff protection include personal protective equipment (PPE) for common tasks and decontamination, chemoprophylaxis and immunization, and sufficient training, education, and policy development to ensure that they are available and appropriately used. Common PPE pitfalls include inadequate training for existing equipment, inadequate equipment itself, and ineffective policies and procedures governing PPE use. The SARS outbreak of 2003 and the effect it had on hospitals and EMS staff is an excellent example: insufficient and inappropriate PPE contributed to the disruptive effect on health systems and exposure among healthcare workers.^{30, 31} The safety net that chemoprophylaxis (for example, antibiotics for possible anthrax exposures) and immunization (for example, smallpox vaccine for healthcare workers) can provide will fail if it is not made available promptly and to all affected and potentially affected employees. Employees who are not confident that their employer will offer appropriate protection are unlikely to show up for work during a crisis. Likewise, employees who are concerned about the health and safety of their families are unlikely to perform their duties well, if at all, if their concerns are not adequately addressed. This is by no means limited to issues of terrorism, but extends to all potentially catastrophic events.

Exercise Design and Conduct

So far we have examined common pitfalls that relate to staffing, equipment, training, and procedures. One of the mechanisms for determining and evaluating these and other challenges can itself be a challenge: exercises. The purpose of an exercise is to evaluate one or more measurable performance items via objective criteria. Performance items may include use of specific equipment, procedures, emergency plans, communications systems, or a combination of those. Given the longstanding JCAHO requirement of at least two exercises per year, hospitals should house considerable expertise in exercise design, conduct, and evaluation. In fact, a most significant recurring pitfall in hospital exercises is a distorted picture. An exercise, like a written plan, may meet JCAHO standards without conferring significant benefit in terms of actual preparedness or response capability on the hospital(s) in question.

The most common types of exercises (tabletop and functional) do not involve hands-on operations but rather focus on decision making and plan evaluation. Even full-scale exercises, which combine command-level decision making with hands-on tasks, are limited in terms of space, personnel, use of supplies, and the exercise schedule itself. Hospitals must be able to receive and manage actual patients during exercises, requiring either additional staffing to allow exercise operations to go on alongside everyday operations or limiting the scope and duration of play. Additional staffing for exercises means additional cost and staff scheduling challenges.

Because of the need for advance scheduling of personnel and simply having sufficient personnel on hand, two common exercise deficiencies ensue: lack of surprise and preferential testing of the most populated shifts. Lack of surprise may manifest itself in numerous ways, including on-duty staff having recently reviewed emergency procedures (when they otherwise would not have done so), necessary equipment and supplies in unusual states of readiness and/or stocked in unusually high levels, and specialized equipment set up in advance of the exercise, even though there would have been no reason to do so under non-emergency conditions. Examples include ED physicians immediately diagnosing rare conditions that are part of the exercise scenario, with equally rarely used medications being immediately available in the ED or pharmacy and, in more than one exercise, a large ED having a full decontamination station set up, with staff wearing full PPE, before play even began. Any exercise scenario induces a certain degree of artificiality, but effective exercises are designed so that artificiality does not interfere with evaluation of identified objectives. Untoward—artificial—staff preparation for an exercise adds artificiality that directly compromises effective evaluation. In addition, the overwhelming lack of exercises on evening and night shifts tests capabilities only when a hospital is at its highest staffing levels. This not only deprives some staff of exercise experience, but also deprives the facility of evaluating performance during off shifts.

The combination of insufficient training and ineffective exercises deprives staff of experience in improvisation and decision making, thus increasing the likelihood that a single significant obstacle (for example, difficulty setting up decontamination equipment, or even presentation of a contaminated patient) can derail the exercise or actual response.

Suggestions

There are multiple potential solutions for the challenges herein identified. Clearly, fundamental changes are needed, either in the expectations of hospitals (unlikely) or the resources made available to them to further the cause of preparedness (more likely and currently improving). The following suggestions are based largely on operational, intrafacility details (“what works”). There is no question that hospital preparedness must be part of a regional approach to health systems and general preparedness across agency, jurisdictional, and corporate boundaries. Hospitals are part of a greater whole, but each hospital must also have a degree of self-sufficiency to enable independent operations should regional assistance be unavailable. My suggestions focus on making things work better in individual hospitals; in so doing I temporarily de-emphasize larger-scale financial, political, and legal issues, which I will reexamine at the end of this article.

Communications

The first step in designing an internal communications system that works in emergencies is to have one that works on an everyday basis. The second step is to realize that any system can be overtaxed and that there will be some incidents in which even the most durable system will fail. Realistic expectations for communications systems in disasters are essential for effective implementation of an emergency operations plan. Redundancy is an obvious and desirable solution; simple low-tech equipment can be effective. Trunked and repeated radios that allow flexible external communications are important, but if the trunking system and/or repeaters are external to the hospital, the most the hospital can do is buy into the system. This is not meant to de-emphasize the importance of being able to communicate with public safety and other agencies, but rather to focus on what can be done internally. A hospital’s communication system might be improved by use of the following:

• Business radios: inexpensive handheld radios that do not require a license but will work in multistory buildings with reinforced construction and extensive electronic machinery. These are similar to the popular family radios but are intended (and required) for business use.
• Phone/intercom systems: an internal communications system that is powered by emergency generators and does not require functioning external equipment (such as remote switching stations). These systems can be surprisingly robust, even if communications into and out of the facility are disrupted. A facility that owns its own phone switch (that is, switching is done by an internal rather than an external computer) is more likely to retain internal function than one relying on a service provider’s switch. This is even more important for large campuses comprising multiple buildings.
• Status boards: the bane of many a JCAHO survey, further restricted by the Health Insurance Portability and Accountability Act (due to open display of confidential patient information). Simple dry-erase boards in operational areas are an effective way of providing updated information to the staff working there. Most hospitals have such boards in place, but they are not necessarily used during emergency operations. Status boards serve an important function away from patient-care areas as well: information management in hospital emergency operations centers (also known as command centers, coordination centers, and facility command posts). Effective display media in emergency operations centers are essential for managing incoming information, tracking resources and events, and making appropriate resource allocation decisions.
• Runners: when all else fails—and even when it doesn’t—runners are commonly employed to carry information between functional areas or groups. Given the universality of this function, it might as well be part of the plan, to be practiced and tested. Combining runners, status boards, and digital cameras creates the opportunity to receive quick, non-intrusive status reports from various parts of a hospital: literally a snapshot of status that may be delivered to the hospital’s emergency operations center and displayed there.
• Self-initiation: this is more a training than a communications issue, but the point is that the better trained and exercised employees are, the more capable they will be of independent implementation of an emergency operations plan when activation is initiated. If employees can perform critical initial functions without needing centralized communications in place, successful implementation is far more likely.

Security

Of all the issues related to hospital preparedness, security is one of the most important and one of the least directly controllable by most hospitals. Functional security is an everyday issue that is greatly magnified during disasters; it is part of staff protection and allows implementation of emergency plans. Many potential solutions to security issues require hospitals to increase their level of interaction with local emergency management and public safety agencies and may require substantial revision of those agencies’ existing policies, procedures, and mutual aid agreements:

• Meet with local law enforcement agencies: hospitals are essential resources during disasters and may be targets of terrorism. Law enforcement must see protection of hospitals as a high priority. Everyday security resources, where present, are likely to be insufficient during disasters, particularly those involving terrorism. If possible, special units may be identified and preassigned to hospitals; this ideal arrangement removes a decision step during an incident.
• Consider private security to provide or augment protection: although private security guards do not have powers of arrest, they can provide substantial numbers for securing facility access. Some private security companies provide bonded personnel, trained and equipped for use of lethal and nonlethal force, but the presence of a trained, uniformed staff may be the most important. Contrary to popular perception and many exercise scenarios, panicking mobs overrunning hospitals are not a realistic expectation.^{32, 33, 34, 35} If numerous self-referred patients arrive at a hospital and are met with clear information and directions, they will likely comply. Incorporation of private security personnel into emergency plans should include specifications of available staff, call-up procedures, and consultation with local law enforcement regarding policies and procedures for disasters.
• Make lockdown a realistic part of the plan: facilities in a multi-hospital region should reach consensus on a functional definition and share it with local emergency management and public safety providers. All staff should understand the purpose of lockdown and when and how it is to be implemented. Internal training and resources should include readily understandable designation for building entrances and exits. Prepositioned, or readily available, signage and prescripted messages (both for public address systems and local media broadcast as needed) to direct patients and families to appropriate entrances will speed emergency implementation and improve compliance. All doors with outside access should be numbered in a simple, consecutive fashion, so that staff may be sent to secure “door number two” rather than “northwest access 1.4.” Once in place, this numbering system can be added to facility floorplans and shared with public safety agencies for routine, emergency, and disaster response.

Decontamination

Focus on the achievable. The biggest step is to be able to decontaminate a single patient without endangering staff, patients, or visitors and without rendering the ED unavailable to incoming traffic.³⁶ When and if that step is achieved, then is the time to examine multiple-patient scenarios. Industrial incidents can contaminate several patients, making multi-patient capability particularly important for hospitals in industrial areas. Most incidents resulting in contaminated patients occur at fixed facilities or in agricultural applications,³⁷ but they can happen anywhere there is a transportation route; moreover, contaminated patients don’t always go to the closest hospital. The leap from multi-patient to mass decontamination is expensive, requires far more extensive training and drilling, and may be unrealistic (both in capabilities and likelihood) for smaller facilities. For facilities where mass decontamination is considered a legitimate potential need, temporary facilities will likely need to be established; either “dry” decontamination or self-disrobement and decontamination (“strip and shower”)³⁸ should be seriously considered. Whether in the form of trailers, tents, canopies, or large open areas, equipment (and training) must be provided with the foreknowledge that it will be used rarely if at all. This is an important consideration: the greatest likelihood is that employees’ only exposure to the knowledge, skills, abilities, and decision-making processes involved in mass decontamination will be gained and applied only in training and exercises.

Staff Training

Hospital training staff tend to be overloaded with a wide variety of responsibilities, including clinical competencies, continuing education, community education, and non-clinical staff training. Most hospital staff have little expertise in developing and providing training for disaster procedures, particularly patient and facility decontamination. Although “train the trainer” classes are popular and readily available, newly minted trainers commonly find themselves with few resources and little or no experience, with a resultant dearth of cascaded training. The following steps can help compensate:

• Contract for specialized training: Rather than attempting to develop and maintain such expertise, hospitals, hospital groups, or—even better—communities should strongly consider contracting for expertise. As with any contract service, it is essential to select reputable, competent providers. Contracts should include follow-up services (refresher training and assistance with exercise development as needed) and provide the option of developing internal capability for conducting informal training and drills within individual units. This approach requires the same degree of executive commitment as internally derived training, particularly with respect to initial and recurring expenses. John L. Hick et al., in “Establishing and Training Health Care Facility Decontamination Teams,”³⁹ effectively summarized healthcare-specific needs and goals for decontamination training that incorporate recent OSHA interpretations.^{40, 41, 42, 43}
• Let clinicians be clinicians: there are a few positions within a HEICS organization that should be filled by physicians, but in general the most important function for physicians in a disaster is that of a clinician. As many hospitals contract with physician groups, particularly for ED coverage, ensuring training is difficult. Therefore, hospitals should include select staff physicians in HEICS and other disaster training and provide brief orientations to the bulk of physicians, so that they understand the roles, responsibilities, and function of the emergency organization.
• Move some training to the schools: new guidelines from the Association of American Medical Colleges⁴⁴ suggest a curriculum for future physicians in medical schools. Several nursing schools have been offering disaster courses for a year or more.

Staff Protection

No emergency plan can be implemented without staff. The most important provision for staff protection is irrespective of specific issues, procedures, or equipment. Staff protection must be an executive priority, and it must be communicated as such. To enable operations to continue under emergency conditions, staff protection measures must be designed with the intent of demonstrating an institutional commitment to employee safety. This is as much an exercise in trust as in deed; facilities with strained labor-management relations will face greater difficulty in this pursuit than those with smooth partnerships.

• PPE must meet realistic needs: there is no consistent standard for PPE for incidents involving hazmat or weapons of mass destruction. These incidents would send potentially contaminated patients to hospitals. Personal protection standards defined by OSHA⁴⁵ and the National Fire Protection Association⁴⁶ are unrealistic for an acute-care environment—and recent OSHA interpretations support this. Level B ensembles (splash protection with self-contained or supplied-air breathing apparatus) offer substantial respiratory protection, but there is little evidence that it is necessary in this setting, and the additional equipment weight, maintenance, and potential claustrophobic reaction of its wearers may make it deleterious. In addition, regulatory, financial, and training requirements for Level B are likely to render it both prohibitive and ineffective. Self-referring patients arriving at an ED under their own power are likely to have minimal if any contamination (as distinct from exposure) and are well removed from the site of initial contact; effective decontamination training and equipment make Level C (splash protection with air-purifying respirators) appropriate for the great majority of incidents. Clearer guidelines and national consensus standards are essential; the White House’s National Strategy for Homeland Security⁴⁷ tasked the Environmental Protection Agency with developing standards for decontamination equipment and procedures, but the EPA’s Strategic Plan for Homeland Security⁴⁸ does not indicate a focus on hospital activities. John L. Hick et al.⁴⁹ lucidly summarized recent interpretations, considerations, and justifications for Level C PPE in healthcare settings until more definitive standards are promulgated.
• Level C is still a step up: the decision to use Level C protection does not encompass an escape from OSHA standards for respiratory protection;⁵⁰ it requires personnel using respirators to undergo medical screening, fit-testing (not necessary if hooded positive air-purifying respirators are used), training, and refreshers.
• Plan to provide staff with chemoprophylaxis and/or immunizations as indicated: whether chemoprophylaxis and/or immunizations come from internal stocks (most likely for initial use), locally cached supplies, or the contents of a Strategic National Stockpile Push Package,⁵¹ internal and community plans and policies and must specify priority distribution for critical staff and must include procedures for doing so. Cities participating in a Metropolitan Medical Response System contract are required to incorporate caches and Push Package deliveries into their plan, but they must specify priority recipients.
• Consider staff families in plans: it is the unusual healthcare employee who will be satisfied with individual protection that doesn’t cover the family. Plans providing for employee chemoprophylaxis and/or immunizations should include distribution to employee families; this will complicate planning and implementation but will help achieve the goal of having staff available to perform critical functions.

Exercises

Exercises will remain a JCAHO requirement as well as an excellent method of testing plans, training, and equipment—but only if the exercises are designed and conducted with that intent. This requires that hospitals

• Base exercises on realistic plans and models: start at manageable scales and build on demonstrated principles and procedures. An exercise where everything goes great can be just as counterproductive as one where everything fails. Exercises should focus on specific measurable objectives and be conducted realistically. Pre-exercise warning should be minimized, and all shifts should be involved as much as possible. External evaluators will enhance objectivity and help keep employees out of difficult situations (such as evaluating their supervisors). Focused exercise design and competent controllers can prevent or minimize distractions arising from obstacles encountered during play. Local and state emergency management and public safety agencies are excellent resources.
• Use realistic staffing patterns for exercises: in addition to the need for covering all shifts on training and exercises, it is essential to employ staffing patterns that are likely to be in effect when a real incident happens. Task-based drills may not need scenarios, but larger-scale exercises do. Exercises for off-peak shifts should use off-peak staffing; incidents that would require callbacks to provide additional staffing or specialized skills should not assume that those assets are present at the outset.
• Recognize that success has multiple definitions: an exercise that evaluates its intended objectives and yields action items is a success, but only if there is action. “Lessons” are not necessarily “learned.” It is appropriate to determine whether a plan or procedure was successful, particularly regarding specific tasks or functions. Failure requires corrective action, but the objective determination of success or failure has value as well—not everything is relative. Successes should be publicized, internally and externally. An effective preparedness program can use successes and failures as motivators for continued improvement.

Critical Steps

To facilitate hospital and community preparedness, there are some essential needs that require action on the federal level (and in some cases require not just a federal but a national approach):

• Financial incentives and support for hospital preparedness: as long as preparedness is competing with everyday essential needs, it will fail to thrive. Whether by grant, reimbursement, or other means, hospitals must have some type of dedicated (and internally immutable) funding stream to cover not just equipment but planning, initial training, refresher training, and exercises. Preparedness is an ongoing process and must have ongoing support. The current multi-year cycle of Healthcare Resources and Services Administration preparedness grants is an important step in the right direction, but it needs to evolve into a secure funding stream and be tied to measurable, sustainable improvements in broad-spectrum (as opposed to bioterrorism-dominant) preparedness.
• Realistic consensus standards: hospitals and public safety agencies still rely on unproven tenets, many incorporating military models that have little application in the civilian world. In the absence of national standards, states and even localities have been developing their own. In many areas and individual facilities, equipment and training are determined in the absence of standards or even an identified strategy. Such standards are most important with respect to PPE, mass decontamination (including “no decontamination”), and dealing with mass illness.
• Ethics and liability: as discussed by N. Pesik et al.,⁵² triage following use of a weapon of mass destruction on the U.S. civilian population will not fit familiar models. In particular, mass illness related to bioterrorism could create a paradox in which the sickest patients receive palliative care only. Effective, ethical planning is as essential as the legal protection to conduct it. Currently such indemnity from liability does not exist in most states.

Author Contact Information

Jeffrey N. Rubin

Tualatin Valley Fire & Rescue, Aloha, OR

jeff.rubin@tvfr.com

References

Click on an end note number to return to the article.

1. Joseph A. Barbera, M.D.; Anthony G. Macintyre, M.D.; and Craig A. DeAtley, PA-C; “Ambulances to Nowhere: America’s Critical Shortfall in Medical Preparedness for Catastrophic Terrorism,” Journal of Homeland Security, March 2002. This is an excellent treatment not just of the constraints hospitals face, but of the national and local threat the constraints represent.

2. “Hospital Preparedness for Mass Casualties: Summary of an Invitation Forum,” final report, August 2000; summary of an invitational forum convened 8–9 March 2000 by the American Hospital Association with the support of the Office of Emergency Preparedness, U.S. Department of Health and Human Services.

3. S. M. Schneider, M. E. Gallery, R. Schafermeyer, and F. L. Zwemer, “Emergency Department Crowding: A Point in Time,” Annals of Emergency Medicine, vol. 42, no. 2, August 2003, pp. 167–172.

4. “Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis,” Joint Commission on Accreditation of Healthcare Organizations.

5. First Consulting Group, “The Healthcare Workforce Shortage and Its Implications for America’s Hospitals,” 2001.

6. Health Insurance Portability and Accountability Act of 1996.

7. A summary of the new standards, discussion of the underlying philosophy, examples, and resources are available in Joint Commission Perspectives, vol. 21, no. 12, December 2001. Additional information is available at the Joint Commission on Accreditation of Healthcare Organizations website.

8. Metropolitan Medical Response System website.

9. “Hospital Preparedness for Mass Casualties.”

10. R. W. Derlet and J. R. Richards, “Overcrowding in the Nation’s Emergency Departments: Complex Causes and Disturbing Effects,” Annals of Emergency Medicine, vol. 35, no. 1, Jan. 2000, pp. 63–68.

11. “HHS Approves State Bioterrorism Plans so Building Can Begin,” Dept. of Health and Human Services press release, 6 June 2002.

12. “Bioterrorism Preparedness Grants,” Dept. of Health and Human Services press release, 6 June 2002.

13. “17 Critical Benchmarks for Bioterrorism Preparedness Planning,” Dept. of Health and Human Services press release, 6 June 2002.

14. Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but Lack Certain Capacities for Bioterrorism, General Accounting Office Report 03-924, August 2003.

15. Carl H. Schultz, M.D.; Kristi L. Koenig, M.D.; and Roger J. Lewis, M.D.; Ph.D., “Implications of Hospital Evacuation After the Northridge, California Earthquake,” New England Journal of Medicine, vol. 348, no. 13, 3 April 2003, pp. 1349–1355.

16. Andrew Milsten, M.D., “Hospital Responses to Acute-Onset Disasters: A Review,” Prehospital and Disaster Medicine, vol. 15, no. 1 (Jan.–March 2000), pp. 32–45.

17. See Thomas V. Inglesby, Rita Grossman, and Tara O’Toole, “A Plague on Your City: Observations From Topoff,” Clinical Infectious Disease, vol. 32, no. 29, Jan. 2001, pp. 436–445.

18. “Dark Winter,” ANSER Institute for Homeland Security website.

19. “‘Topoff 2’—Week-Long National Combating Terrorism Exercise Begins May 12, 2003,” Federal Emergency Management Agency press release, 5 May 2003.

20. Robert Block, “FEMA Points to Flaws, Flubs in Terror Drill,” Wall Street Journal, 31 Oct. 2003.

21. Martha Frase-Blunt, “‘Operation Topoff 2’ Bioterrorism Exercise Offers Educational Lessons,” AAMC (Association of American Medical Colleges) Reporter, Aug. 2003.

22. Joint Commission on Accreditation of Healthcare Organizations website.

23. NFPA (National Fire Protection Association) Journal, vol. 96 no. 4 (July/Aug 2002), pp. 44–47.

24. Presentation by Mark Quick, epidemiologist with Colorado’s Dept. of Public Health and Environment, at the National Environmental Health Association’s Bioterrorism Conference in Denver, 18–19 June 2000.

25. See Agency for Toxic Substances and Disease Registry, “Managing Hazardous Material Incidents,” 2001—an excellent training and reference resource.

26. “Talking With Your Community About Disaster Readiness,” American Hospital Assn. Disaster Readiness Advisory #7, 28 Aug. 2002.

27. Kimberly N. Treat, M.D.; Janet M. Williams, M.D.; Paul M. Furbee, M.A.; William G. Manley, R.N.; Floyd K. Russell, Ed.D.; and Clarence D. Stamper, Jr.; “Hospital Preparedness for Weapons of Mass Destruction Incidents: An Initial Assessment,” Annals of Emergency Medicine, vol. 38, no. 5, Nov. 2001, pp. 562–565. The low level of preparedness indicated within is typical of small- and large-scale surveys assessing hospital capabilities for events involving weapons of mass destruction as well as ordinary hazmat incidents. A bright side could be that an institution is better off correctly knowing it is not prepared than erroneously believing it is.

28. Lee Clarke, Mission Improbable: Using Fantasy Documents to Tame Disaster (Chicago: Univ. of Chicago Press, 1999).

29. Emergency Incident Command System Update Project website.

30. Damon C. Scales, Karen Green, Adrienne K. Chan, Susan M. Poutanen, Donna Foster, Kylie Nowak, Janet M. Raboud, Refik Saskin, Stephen E. Lapinsky, and Thomas E. Stewart, “Illness in Intensive Care Staff After Brief Exposure to Severe Acute Respiratory Syndrome,” Emerging Infectious Diseases, vol. 9, no. 10, Oct. 2003, pp. 1205–1210.

31. Mark A. Rothstein, M. Gabriela Alcalde, Nanette R. Elster, Mary Anderlik Majumder, Larry I. Palmer, T. Howard Stone, and Richard E. Hoffman, Institute for Bioethics, Health Policy and Law, University of Louisville School of Medicine, “Quarantine and Isolation: Lessons Learned From SARS,” a report to the Centers for Disease Control and Prevention, November 2003.

32. Erik Auf der Heide, Disaster Response: Principles of Preparation and Coordination (St. Louis: Mosby, 1989). Out of print, but available free of charge, through the Center of Excellence in Disaster Management and Humanitarian Assistance.

33. Joseph Barbera, M.D.; Anthony McIntyre, M.D.; Larry Gostin, J.D., Ph.D.; Tom Inglesby, M.D.; Tara O’Toole, M.D.; Craig DeAtley, PA-C; Kevin Tonat, Dr.PH, M.P.H.; and Marci Layton, M.D.; “Large-Scale Quarantine Following Biological Terrorism in the United States,” Journal of the American Medical Association, vol. 286, no. 21, 5 Dec. 2001, pp. 2711–2717.

34. Lee Clarke, “Panic: Myth or Reality?” Contexts, fall 2002, pp. 21–26.

35. Thomas A. Glass and Monica Schoch-Spana, “Bioterrorism and the People: How to Vaccinate a City Against Panic,” Clinical Infectious Diseases, vol. 34, no. 2, 15 Jan. 2002, pp. 271-223.

36. This is not a new concept. ED physicians and consultants Howard Levitin and Henry Siegelson have been emphasizing this for years, as have the George Washington University trio of Joseph Barbera, M.D., Anthony Mcintyre, M.D., and Craig DeAtley, PA-C.

37. Agency for Toxic Substances and Disease Registry, “Hazardous Substances Emergency Events Surveillance,” 1998 annual report.

38. See K. L. Koenig, 2003, “Strip and Shower: The Duck and Cover for the 21st Century” (editorial) Annals of Emergency Medicine, vol. 42, no. 3, Sep. 2003, pp. 391–394.

39. John L. Hick, Paul Penn, Dan Hanfling, Mark A. Lappe, Dan O’Laughlin, and Jonathan L. Burstein, “Establishing and Training Health Care Facility Decontamination Teams,” Annals of Emergency Medicine, vol. 42, no. 3, Sep. 2003, pp. 381–390.

40. “Medical Personnel Exposed to Patients Contaminated With Hazardous Waste,” OSHA standard interpretation, 31 March 1992.

41. “Training Requirements for Hospital Personnel Involved in an Emergency Response of a Hazardous Substance,” OSHA standard interpretation, 27 Oct. 1992.

42. “Emergency Response Training Requirements for Hospital Staff,” OSHA standard interpretation, 25 April 1997.

43. “Emergency Response Training Necessary for Hospital Physicians/Nurses That May Treat Contaminated Patients,” OSHA standard interpretation, 10 March 1999.

44. Association of American Medical Colleges, “Training Future Physicians About Weapons of Mass Destruction: Report of the Expert Panel on Bioterrorism Education for Medical Students,” 2003.

45. “Hazardous Waste Operations and Emergency Response,” 29 CFR 1910.120.

46. National Fire Protection Association standards 471, “Recommended Practice for Responding to Hazardous Materials Incidents”; 472, “Standard for Professional Competence of Responders to Hazardous Materials Incidents”; and 473, “Standard for Competencies for EMS Personnel Responding to Hazardous Materials Incidents.”

47. National Strategy for Homeland Security, July 2002.

48. Environmental Protection Agency Strategic Plan for Homeland Security, Sep. 2002.

49. J. L. Hick, D. Hanfling, J. L. Burstein, J. Markham, A. G. McIntyre, and J. A. Barbera, “Protective Equipment for Health Care Facility Decontamination Personnel: Regulations, Risks, and Recommendations,” Annals of Emergency Medicine, vol. 42, no. 3, Sep. 2003, pp. 370–380.

50. “Respirator Fit-Testing,” 29 CFR 1910.134.

51. Immediate response 12-hour Push Packages “are caches of pharmaceuticals, antidotes, and medical supplies designed to provide rapid delivery of a broad spectrum of assets for an ill defined threat in the early hours of an event,” according to the website of the Centers for Disease Control and Prevention. “These Push Packages are positioned in strategically located, secure warehouses ready for immediate deployment to a designated site within 12 hours.”

52. N. Pesik, M. E. Keim, and K. V. Iserson, “Terrorism and the Ethics of Emergency Medical Care,” Annals of Emergency Medicine, vol. 37, no. 6, Aug. 1999, June 2001, pp. 642–646. Pesik has spoken and written about this topic with great insight; this is one of the major “hidden” issues of preparing for terrorism.

Family in Pa. Suspects Cullen in Father's Death, Charges Hospital with Cover Up

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The man died in 1998, and his daughter says they tried to raise a red flag then, but were ignored. Now they want restitution.

Jen Maxfield talked to the family. She joins us from Bethlehem, Pennsylvania.

The family had always suspected malpractice, but never murder. That is up until last week, when they discovered that Charles Cullen was working as a nurse at Easton Hospital during the time that Ottomar Schramm was given a lethal dose of heart medication.

In an interview the Schramm family accused the hospital of covering up for one of its employees. And they asked the question everyone has been asking; how many lives could have been saved if Cullen had been investigated sooner?

As Ottomar Schramm lay unconscious in his hospital bed, his daughter Christina remembers a male nurse standing by with a syringe in his hand.

Kristina Toth, Daughter: "And he said to me that was in case my father's heart stopped."

She now believes the man holding the needle, the man who gave her father four times the normal dose of digoxin, was Charles Cullen, the former nurse who has confessed to killing as many as 40 patients.

Schramm's widow, Lorraine, filed a wrongful death lawsuit against Easton Hospital in 2001. And today the family blames Easton for failing to fully investigate the lethal dose.

Kristina Toth: "If the job was done a little bit differently, if he could have been stopped then, I mean just look at how many other people would still be alive today."

Cullen left Easton in 1999, and went on to work at two other hospitals before being arrested last week. That a man who had been fired six times, and investigated by two prosecutors could be hired again and again exposes the need for a nationwide database to track nurses, according to New Jersey's two senators.

In a letter the Senate's Health Committee, senators Lautenberg and Corzine blamed the individual hospitals and the system itself for failing to reveal Cullen's troubled past.

A failure that Kristina Toth believes is partially to blame for the death of her father.

Kristina Toth: "When we found out that he had an overdose, that just ... I mean it broke our hearts. That's my father."

There was no comment from Easton Hospital this afternoon. Schramm's death has been ruled a homicide, but Cullen has not been charged. The Northampton District Attorney says he will make a decision on that within the next few weeks.

Meanwhile in New Jersey, the Attorney General met with local prosecutors today to prosecute the case against Cullen. It could include patient deaths in five counties.

Security Scandal At Bellevue Hospital

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On the same floor where patients are being treated, police say a Bellevue Hospital employee was dealing guns and drugs out of his locker. What is even more disturbing, some of his customers were apparently fellow Bellevue workers.

The accused Bellevue gun-dealer has a criminal record which includes car theft and drug convictions. His rap sheet was unknown to his bosses at Bellevue.

Medical assistant Sam Perez worked at the hospital drawing blood. He was arrested last Wednesday night for selling automatic weapons and large amounts of cocaine out of his hospital locker on the second floor. Perez had worked at the hospital since 1999.

Perez was busted after one of his buyers turned out to be an undercover cop. Police say customers had no trouble getting past hospital security and walking right up to Perez's second floor locker.

Today, some employees said they thought such activity was unlikely, but not impossible.

Imran Ahmed, Bellevue Employee: "There are thousands of employees so it is hard to know. But it is surprising."

Security at the sprawling, city-owned hospital is now coming under fire. This arrest is the latest black eye for the hospital.

Just four days ago, police say a 13-year old patient was sexually-assaulted in the pediatric ward last week while she was awaiting eye surgery. Bellevue is now being investigated by the Health and Hospitals Corporation.

Most employees said they feel safe working at Bellevue Hospital, but acknowledged it is difficult to keep track of who is coming and going.

David Hirsch, Employee: "It is pretty much an open-door policy. All you need is a driver's license to go into the emergency room."

Perez pleaded not guilty to gun and drug charges at his arraignment. He is now being held without bail. Meanwhile, Bellevue Hospital is cooperating with investigation, but they say in Perez's four years of working at the hospital, he had a clean employment record. However, officials at the hospital are seeking to terminate Perez's employment.

Hospitals Where Charles Cullen Worked

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Over a 16-year career, Cullen worked at the following facilities:

• St. Barnabas Medical Center in Livingston, N.J., June 1987 to January 1992.
• Warren Hospital in Phillipsburg, N.J., February 1992 to December 1993.
• Hunterdon Medical Center in Flemington, N.J., April 1994 to October 1996.
• Morristown Memorial Hospital in Morristown, N.J., November 1996 to August 1997.
• Liberty Nursing Home in Allentown, Pa., February 1998 to October 1998.
• Easton Hospital in Easton, Pa., November 1998 to March 1999.
• LeHigh Valley Hospital in Bethlehem, Pa., December 1998 to April 2000.
• St. Luke's Hospital in Bethlehem, Pa., June 2000 to June 2002.
• Sacred Heart Hospital in Allentown, Pa., July 8, 2002 to July 24, 2002.
• Somerset Medical Center in Somerset, N.J., Sept. 8, 2002 to Oct. 31, 2003.

Police Investigating Death of Elderly Woman At Bronx Nursing Home

Was it an accident? Was it abuse? Was it something worse? Friday night, Marerro's family says they don't know what to think.

Carmen Rivera, Victim's Granddaughter: "When I heard the autopsy I just said, "Someone killed my grandmother."

Carmen Rivera says it's just too painful to imagine. Her 91-year-old grandmother, was bedridden and after several strokes, practically immobile. A patient at the Hebrew Hospital Home in the Bronx, where her family says she complained of severe pain. Mrs. Marrero was rushed to Jacobi Hospital, where she died five days later. The autopsy revealed that both of her legs had been broken, snapped as if some had twisted them.

Carmen Rivera says she often found her grandmother in the fetal position, and says she may have been roughed up.

Rivera: "Someone probably tried to open her legs to maybe changer her Depends, and fractured her legs that way. It's almost like they ripped your legs apart."
NJ Burkett, Eyewitness News: "You think someone manhandled your grandmother."
Rivera: "Basically."

The Bronx District Attorney and the NYPD say they are treating the case as a homicide. Sources close to the investigation say several staff members at the nursing home had already been interviewed. The administration released a statement saying, "This is a matter that deeply concerns us. We are deeply interested in determining the exact cause of the situation in question."

A recent health department audit of the home alleged a failure to prevent certain infections and pressure sores, failure to provide good nutrition in some cases, and a failure to properly maintain an emergency sprinkler system.

Cynthia Rudder, Nursing Home Watchdog: "One of the biggest issues in nursing homes is what you might call neglect of residents by generally by the facility, and the industry, and not having enough staff in nursing homes to take care of people."

Cynthia Rudder speaking about nursing homes in general, and not the Hebrew Hospital Home in particular. Administrators tell Eyewitness that the home has an excellent record, and insist that they are cooperating with investigators. They also say they are already taking steps to correct the State Health Department's concerns. The department is now investigating this case.

Suspect Charged In Hospital Attack

The nurse is recovering and has been upgraded to stable condition. She has injuries to her face and neck. Police believe this ordeal was a random attack.

Police said the suspect walked into the emergency room at Bronx Lebanon Hospital, demanded thirty-two-year-old Charina Adamos to hand over her wallet, and then brutally beat her. The registered nurse screamed for her life. Police said her attacker either thrust an object or his fingers down her throat to quiet her before running away.

But he didn't get far. Two NYPD officers who just happened to be in the hospital captured him. A hospital spokesperson said hospital security has worked in conjunction with the police, but the whole incident has hospital staffers shook up.

Sherry Arms, Nurse: "She was very sweet. Petite. Mild-mannered. Quiet woman. Really nice, and I really hope all is well with her. We're going to go see her tomorrow."

Adamos was just finishing the night shift when the attack happened. The hospital's spokesperson said he thinks the hospital did everything in their power to help out.

Errol Schneer, Bronx Lebanon Hospital Spokesperson: "150,000 people walk into that emergency center and are treated every year. This has never happened before. Hospital security acted appropriately and helped apprehend the suspect."

But some patients, alarmed by what happened, said security is nonexistent at the hospital.

Francine Silva, Hospital Visitor: "Sometimes they're here...and sometimes they aren't. I visit my baby sometimes late at night and no one is here."

A hospital spokesperson said they don't plan to make any changes with security or their policies because the hospital has been at high-alert since Sept. 11th. The suspect's arraignment will take place late Saturday in the Bronx Criminal Court.

Man Charged With Raping A Brooklyn Hospital Patient

The 37-year-old woman suffers from throat cancer and was hooked up to her respirator. Police say the alleged rapist is a 27-year-old nurse's aide who was working at the hospital just four weeks. It happened at Brooklyn Hospital Center.

The victim was unable to scream or talk. The incident allegedly took place between 10:00 p.m. on Thursday and 8:00 a.m. on Friday. Shortly after, the woman told family and hospital administrators about the attack and they contacted police. Last night, investigators arrested 27-year-old Waseem Rehman, a nurse's aide at the hospital and charged him with two accounts of rape. A hospital spokesman wouldn't comment on the specific incident, but said the matter is under investigation.

People who live in the area, and visit patients in the hospital are shocked by the attack.

Resident: "I am shocked and then I am not. This is the type of neighborhood where stuff like that happens."

Resident: "I am really surprised. I have lived here for over thirty five years and never heard of anything like that happening."

Rehman will be arraigned this afternoon at a Brooklyn Supreme Court. The woman remains a hospital patient here at Brooklyn Hospital.

13-Year-Old Girl Beaten and Raped in Hospital, Police Search For Suspect

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She is recovering from a brutal beating and sexual assault this morning. Her attacker apparently got her to follow him into an empty conference room by impersonating a hospital employee. Police detectives and employees at Bellevue Hospital are tight-lipped about the vicious sex crime that happened on the 8th floor of the hospital early Friday morning.

The 13-year-old victim was admitted to the hospital Thursday night, reportedly for an eye procedure. She was in her hospital bed when police say a man posing as a staff member read her chart and began asking about her health. But he apparently had a more sinister agenda in mind. He told her he was taking her to her next procedure. Instead, he escorted her to a conference room and then beat and raped her. It happened in the pediatric wing where children are not only supposed to be comforted but protected.

Michael Adams, Hospital Employee: "There is security on every floor of the hospital...security patrols the hospital throughout the day. It's just terrible. I think it's terrible. And I'm sure they will get to the bottom of it."

As doctors treat the traumatized young girl, police are searching for her attacker. His description appears below:

• Hispanic male
• 6' tall, medium build
• Brown hair
• Wearing 3/4 length leather jacket
• With a noticeable skin condition from acne or scarring

Bellevue Hospital is not commenting on security procedures, including whether or not they were breeched that day.

This latest attack may bring back memories of another violent crime at Bellevue Hospital that happened 15 years ago. It was when a pregnant doctor was raped and murdered by a homeless man who had gained access to the hospital and impersonated a hospital employee.

Nursing Home Sabotage

 VIDEO: Michele McCormack reports

All six patients at the city-owned Philadelphia Nursing Home survived after the slashed tubes were discovered Wednesday morning. The tubes were reinserted at an area hospital.

Police said they could not name a suspect, but vowed to make a quick arrest.

"For somebody to do this kind of act is extremely barbaric," said police Inspector William Colarulo.

He said investigators were trying to learn who might have had access to the patients. The facility is usually open to visitors for much of the day.

The patients were never in any serious danger because of the act, health officials said. People who rely on food and fluid from a feeding tube can generally live without one for several days before they die of starvation or thirst.

The victims of the incident all had medical conditions that have limited their cognitive abilities and will likely make them unable to identify their attackers. One had dementia. Another was a stroke patient. One had a brain tumor. They ranged in age from their 40s to 80s.

All six victims were in the same 48-patient unit in the nursing home, but were in separate rooms.

Kevin Feeley, a spokesman for Episcopal Long Term Care, the company that operates the home for the city, said the leaking tubes were discovered no longer than 90 minutes after they were cut, and possibly as soon as 15 minutes.

He said all 10 staff people who work in the unit were being questioned by police. Officers were also present in the building Thursday.

"The police have assured us that it is safe for people to be there," Feeley said.

In 1998, the city and Episcopal Long Term Care agreed to improve conditions there to settle a Justice Department complaint that patients there had been subjected to abuse and neglect.

(Copyright 2004 by The Associated Press. All Rights Reserved.)

NJ Nursing Home Reported Unsafe

It don't surprise me at all.

Al Opdyke says his 88-year-old grandmother Esther Carver died at the center in May, weeks after big purple bruises began appearing on the right side of her body.

Opdyke/TRENTON, N.J. :

There was no explanation given. That's what I called for, that's why I wanted an investigation. They told me they don't know what happened. Investigators were never actually inside the facility because they wouldn't tell officials what they were looking for. The county executive is blasting the report.

Bob Prunetti/(R) MERCER CO. EXEC.:

It's unsubstantiated. It's erroneous. It conflicts with other inspection reports that were done by both the state government and the federal government.

In fact the state of New Jersey has given the geriatric center passing grades–rating it as slightly below average. And on their new nursing home website, Medicare officials found conditions satisfactory noting patients are exposed to "minimal harm".

Mark Arnott/PATIENT:

Do you feel unsafe here? No, but I've noticed the overnight shift people sleep on the job.

Jospehine Mitchell says she's in the center 5 days a week to see her husband Stanley–and says she'd know if there were serious problems.

Josephine Mitchell/WIFE: Minimal problems. Nothing's perfect but my experience with him I would say very minimal.

Federal officials won't discuss the report because they say it's an ongoing investigation. In Hamilton I'm Nora Muchanic.

(Copyright 2002 by Action News. All Rights Reserved.)

Police: Nursing Home Resident Dies After Attack

Police said a 46-year-old patient died in the attack at the New Vista Nursing and Rehabilitation Center. Detective Todd McClendon of the Newark Police Department said a security guard found the suspect beating the patient with his fists.

The suspect then turned on the guard.

Police charged the suspect with aggravated assault. McClendon said the charge will be upgraded to homicide because the patient died.

Police did not release the name of the suspect.

(Copyright 2003 by The Associated Press. All Rights Reserved.)

Sixth Patient Diagnosed with Legionnaires' Disease

Nursing Home Under Lockdown

Seven residents of Beverly Manor who were hospitalized for upper respiratory illnesses were being tested for the bacteria that cause Legionnaires' disease. Tests on three of the hospitalized residents came back negative and tests for the other four are not yet complete, Health Department spokeswoman Jessica C. Seiders said Wednesday.

However, urine samples from two other residents have tested positive for legionella bacteria – and one of those residents also had a chest X-ray showing pneumonia, suggesting the likely presence of Legionnaires' disease. Both of those patients were being treated at the nursing home, Seiders said.

Seiders said it could take about two weeks for additional tests to return from the laboratory.

"We cannot say this is an outbreak," Seiders said. "We need to do more testing and more culture sampling."

Beverly Manor, which has 125 residents and 110 staff members, voluntarily went into a lockdown mode last Thursday, meaning it cannot accept new visitors or residents.

Health officials also were investigating whether the weekend deaths of three Beverly Manor residents were linked to any respiratory illnesses, but there was no evidence of any connection so far, Health Department spokesman Richard McGarvey said.

People contract Legionnaires' disease after inhaling mists from a water source contaminated with legionella bacteria, which thrives in warm, stagnant water. Sources can include hot water tanks and evaporative condensers of large air conditioning systems, whirlpool spas and showers.

The nursing home's water sources were being tested and all were being cleaned as a precaution, McGarvey said.

The number of reported cases of Legionnaires' disease on much of the East Coast has risen sharply this year, baffling federal and state health officials. In Pennsylvania, 146 cases have been confirmed so far this year, compared to 68 during the same period last year, McGarvey said.

Symptoms of the disease include fever, chills, cough, body aches, headache and fatigue. The disease can be treated with antibiotics, but between 5 percent and 30 percent of cases are fatal.

While the disease can affect anyone, those at greatest risk include the elderly and people with weakened immune systems.

The bacteria and the disease it causes got their name in 1976, after the disease sickened 221 people and killed 34 at an American Legion convention in Philadelphia.

(Copyright 2003 by The Associated Press. All Rights Reserved.)

Three Wanted For Identity Theft

Sheree Jackson, Damon Wheeler and William Whitlock face a number of charges tonight including criminal conspiracy, forgery and receiving stolen property. police say they along with two other men stole the identity of 92 year old Alexander Simon of Havertown. Police say Jackson works at the nursing home where Simon lives. She allegedly stole his bank account information and sold it to the others.

Montgomery County DA Bruce Castor says the victim is frail and had no idea his information had been stolen.

Castor says it's up to family members of nursing home patients to pay attention to their loved ones finances.

(Copyright 2002 by Action News. All Rights Reserved.)

Blaze Hits Nursing Home

Chopper 6 flew above the Beaumont Nursing Home in the 600 block of North Ithan Avenue in Lower Merion.

A fire broke out in the building about 6am. Firefighters evacuated all the residents and had the fire under control in about 15 minutes.

There were no injuries, and officials say the residents will be allowed back in once crews have finished cleaning up.

(Copyright 2004 by WPVI-TV 6. All rights reserved.)

Ten Dead in Nursing Home Fire

Six others are injured, at least three critically.

Police initially said eleven people had died. They later lowered the number to ten, citing a miscommunication between agencies.

Most of the victims died from smoke inhalation.

At least 40 people were in the RosePark care home just south of Glasgow when the small blaze broke out.

It's one of the worst tragedies to hit a British nursing home since the government began regulating the industry in the 1960s.

Queen Elizabeth has sent a message of sympathy to the families of the victims.

(Copyright 2004 by The Associated Press. All Rights Reserved.)

Alleged Sex Crime in Hospital

In a ruling issued Wednesday, the Department of Health and Senior Services said Kennedy Memorial Hospital did not violate regulations that require hospitals to immediately report cases in which patients are harmed.

The attack occurred around 3 a.m. on Sept. 27, when Frank Norman, 47, of Monroe Township, entered a room occupied by the unidentified woman and Suzanne Marcheski, 40, of Clayton. Authorities say Norman, who was a patient at the hospital, stripped and joined the elderly woman in bed. Marcheski then tried to intervene but was knocked to the floor.

Hospital officials then waited 10 hours before contacting police, and state officials were not notified until Oct. 9. The hospital could have been fined up to $5,000 if officials had determined that the attack should have been reported.

Norman was charged with sexual contact and aggravated assault and was later released on his own recognizance. He has said he does not remember the attack because he was delirious from a combination of anesthesia and medication he was taking.

It was not clear whether the older woman was hurt, but Marcheski sustained hip and shoulder injuries. They plan to file a lawsuit that will seek $5 million in compensatory and punitive damages for each woman.

(© 2003 the Associated Press. All rights reserved.)

Bear Wanders into Hospital

Click Animals & Oddities.

Police shot and killed a full-grown black bear that wandered into a hospital Tuesday. The 300-pound male bear wandered in front of Carilion Franklin Memorial Hospital at about 9:10 p.m. and activated a sensor that opens the hospital's doors, police said.

The bear wandered down a few hallways and into a computer room, said Lt. Karl Martin of the Virginia Department of Game and Inland Fisheries. Two police officers yanked the door shut behind it.

Officers planned to sedate the bear, but because the hospital was nearly full they worried about it getting loose. An officer shot the bear twice and killed it, Martin said.

(Copyright 2004 by the Associated Press. All rights reserved.)

Shots Fired Inside Hospital

(The suspect, 45-year-old Eric Holley)

 VIDEO: John Rawlins reports
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Two Philadelphia corrections officers have been suspended following Thursday morning's shooting at Frankford Hospital. They were supervising a prisoner, 45-year-old Eric Holley, being treated at the hospital. He was apparently only being watched by one corrections officer in a room on the fourth floor.

Authorities say Holley assaulted that officer and grabbed her gun.

He fired three shots before being subdued by the officer and a hospital orderly. No one was injured.

Philadelphia prisons commissioner Leon King says the incident is unacceptable.

The officers will face a disciplinary hearing. They could be dismissed.

From a Previous Report:

The incident happened at Frankford Hospital at 9am.

Officials tell Action News that a guard for the Philadelphia Prison System let an inmate – who was being treated at the hospital – use 4th floor bathroom.

Then, as the inmate left the bathroom, he lunged at the guard and grabbed onto the guard's gun.

While the two were struggling, the inmate got his finger on the trigger and fired 2 shots from the guard's gun.

No one was hit by the bullets and the inmate was then restrained.

Elsa Legesse/deputy corrections commissioner: "This morning when he was being uncuffed to go to the bathroom he assaulted the correctional officer and took her gun and fired a few shots. Luckily, no one was injured. No one was hurt. He was arrested on a gun charge. That's all we have right now. The commissioner will be making a further news statement this afternoon."

Police have identified the suspect as 45-year-old Eric Holley. He was arrested on Wednesday for firearms violations. He has been at the hospital since the time of his arrest.

(Copyright 2004 by WPVI-TV 6. All rights reserved.)

Michele McCormack, Channel 6 Action News. Copyright 2004. All Rights Reserved.

Family Sues Hospital

Verna Kern died on December seventh, 2000 at Sacred Heart Hospital. The suit seeks $7.89-million, the same amount Bethlehem agreed to pay recently to settle a federal suit over the 1997 fatal police shooting of drug suspect John Hirko Junior. The family's lawyer, Joseph Knox says, "With no disrespect to the Hirko family, if the life of a drug dealer in Bethlehem is valued at $7.89-million, the value of Verna Kern's life should not be a penny less."

The suit charges that Kern died because a breathing system wasn't set up properly, putting too much pressure on her lungs and preventing her from exhaling.

The death certificate listed the cause of death as respiratory arrest due to rectal cancer and chronic obstructive pulmonary disease.

Hospital spokesman Chris Sodl says the hospital does not comment on pending litigation.

(Copyright 2004 by The Associated Press. All Rights Reserved.)

Police Nab Sharp-Dressed Hospital Thief

Click Here for More WPVI.com Bizarre News

They say Gregory Hunter, of Orwell, Ohio, would enter hospitals and health care facilities in a suit and tie. Police believe he went unnoticed as he lifted credit cards and cash from locker rooms other places in the hospitals.

Hunter was noticed, however, by Detective Ed Dickens, who has been looking for the Hunter for three years.

Dickens saw Hunter's truck in Erie and arrested him yesterday.

The detective says Hunter gave a phone number once when buying something with a stolen credit card, which led him to a hospital in Willoughby, Ohio.

Dickens learned that Hunter had been arrested there for thefts similar to those in Erie.

(Copyright 2004 by The Associated Press. All Rights Reserved.)

Bullet Bursts Hospital Window

Though there were no injuries, police Chief Stephen White says, "Somebody could easily have been killed."

Hospital spokeswoman Susan Gordon says the bullet hole in the window was discovered about 6am Monday and reported to police.

The bullet went through a double-pane window, traveled 26 feet across an elevator lobby and lodged in a wall 57 inches above the floor.

White says police traced the path of the bullet and found three .40-caliber shell casings from an automatic handgun on the State Street exit ramp off the northbound Route 611 bypass, 600 feet from the hospital.

He says whoever fired the shot probably wasn't aiming at the hospital, because a row of trees separates the hospital property from the highway ramps.

(Copyright 2004 by The Associated Press. All Rights Reserved.)

Cleaning Scare at Local Hospital

 VIDEO: Matt O'Donnell reports

John Michael Whiteman is one of those patients. Last month he underwent a colonoscopy at Grand View Hospital in Sellersville.

The hospital has now sent him and other patients a letter. It informed them that the endoscope used in the procedure "was subjected to only five of the six cleaning and disinfecting procedures."

John Michael Whiteman/patient: "This is particularly concerning to me because I did have surgery not too long ago. Obviously with something that invasive being done beforehand, a number of different complications could arise from that."

(© 2004 WPVI-TV 6. All rights reserved.)

Man Found Dead in Hospital Lounge

Staff Believed He was Sleeping

Robert F. Johnson, 55, who had emphysema, was found Thursday at Southwest General Health Center, police said. It was not clear when he died; an autopsy was planned.

Police Chief John Maddox said Johnson probably had been dead for several hours and most likely died of natural causes.

"It's just unbelievable," his wife, Robin Johnson, said Friday. "Somebody out at the hospital didn't notice that a man was laying there for such a long period of time and not moving? Why didn't anybody check?"

A hospital spokeswoman, Kelly Stanford, declined to comment on the death. "It's an unfortunate situation, but we're cooperating fully with all levels of investigation," Stanford said.

Nurse Lynette Chihil discovered Thursday morning that Johnson was dead. She told police that Johnson, who was fully dressed and curled with his face buried in a cushion, was discolored and cold, and that she had seen him on the same couch 17 hours earlier. Another nurse said she saw a man reclining on the couch late Wednesday.

Robin Johnson said she had not seen her husband since he left home Monday morning after an argument. Police believe he camped out at the hospital rather than return home.

(Copyright 2004 by The Associated Press. All Rights Reserved.)

Patient Escapes Delaware Hospital

 VIDEO: Scott Palmer reports

Forty-five-year-old Jeffrey Modelski walked off the hospital grounds at around 9:30am Saturday.

He was committed in 1994 after being deemed incompetent to face charges that he sexually assaulted a child. Troopers continue their search.

Police say Modelski suffers from uncontrolled shaking of his legs and hands. If you have information on his whereabouts, call 911 immediately.

(Copyright 2004 by WPVI-TV 6. All rights reserved.)

Police: Inmate Escapes from Hospital

Police say Graterford Prison inmate Terrance Brown was undergoing treatment in the hospital when he broke free from a guard, roughed up two hospital staffers and ran from the building.

Officials say he jumped into a car waiting at the light at 11th and Chestnut but was apprehended.

No one was seriously hurt.

(Copyright 2004 by Action News. All Rights Reserved.)

Cooper Hospital Fire

It happened just before 8:30. Smoke from the blaze affected the sixth and seventh floors, but it is not clear whether any patients had to be relocated. The hospital was turning away non-trauma emergency cases as a result of the fire.

(Copyright 2003 by Action News. All Rights Reserved.)

Blaze Burns Trenton Psychiatric Hospital

Food Poisoning at Hospital

Ambulances came rumbling down the windy corridors of Norristown State Hospital. Several patients at building 50, located on the West Norriton Township side of the campus, suddenly complained of having rashes, and of feeling ill.

Chief Robert Adams/West Norriton PD: "All that we really know at this point, is that there are some people, mostly patients, that have had some kind of reaction, maybe an allergic reaction, we don't know."

Chief Robert Adams/West Norriton PD: "There are some security issues. There are some people in this building who are court-committed. And they are not free to leave."

Chief Robert Adams/West Norriton PD: "At this point we are under the belief that this was primarily a food poisoning problem."

David Brown/County Emergency Management: "Can't make a determination on what caused the problem, we'll leave that up to the laboratories and the physicians and the county health department."

(Copyright 2002 by WPVI-TV 6. All rights reserved.)

Fake Doctor Sexually Assaults Patients

Assaults Take Place In Hospital Rooms

HOUSTON -- A man posing as a doctor sexually assaulted three patients at a Medical Center hospital, Houston police told Local 2 Friday.

Video Police Release Information About Sexual Assault Suspect

Investigators said a man victimized three women in separate rooms at Methodist Hospital, 6565 Fannin St., on Sept. 15, 19 and 20. The times varied from 11 a.m. to 10 p.m. In each case, the man entered the room as a medical professional. He then asked several questions, made comments and then assaulted the women under the guise of a pelvic exam. "This is somebody that's role playing, obviously, but as far as the type of person, we're unsure. We don't know if this is a possible employee, ex-employee, someone from another hospital or just someone playing the role," said Sgt. Greg Glenn, with the HPD Sex Crimes Unit. "We are devastated by this. We increased our already stringent security measures. And we also informed all the other hospitals in the Texas Medical Center. We called each hospital to tell them what was going on, so they also would be on high alert," said Stefanie Asin, with Methodist Hospital. Officials released a composite sketch of the culprit, who is described as a white man in his late 20s to early 30s. He is about 6 feet tall, 175 pounds, with a slender or lean build. He has medium to dark short hair and no facial hair. He was professional in his demeanor and appearance. He wore blue scrubs, a white lab coat and a stethoscope. Officials hope the hospital's security camera system may help crack the case. Anyone with information is asked to contact HPD's Sex Crimes Unit at (713) 308-1180 or Crime Stoppers at (713) 222-TIPS.

Copyright 2004 by Click2Houston.com. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Police crack down on hospital crime

WATCHING: PC Andy Harris (left) and PC Dougie Cameron LH0164/1

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POLICE officers are now patrolling the corridors of a Woolwich hospital to crack down on crime.

Queen Elizabeth Hospital now has two bobbies, PC Andy Harris and PC Dougie Cameron, who will be looking after thousands of patients and staff who work there.

They have an office in the busy hospital and "provide a reassuring police presence" for the people there.

This move is part of a new partnership between the hospital and Greenwich Police, called a Hospital Watch Protocol Agreement.

There have been 126 recorded crimes and 22 people charged or cautioned as a result since January, last year, according to Greenwich Police.

Police say there have been a number of minor thefts, particularly in the hospital car park, and an assault in Accident & Emergency in the last year.

The agreement was formalised last week, when Greenwich borough commander Chief Superintendent Sharon Kerr and Queen Elizabeth's chief executive Alan Perkins signed the protocol.

Staff say they are pleased there will be two officers on the hospital site.

One staff nurse in A & E, who did not wish to be named, said: "It is a reassuring for myself and other staff, as well as patients, to know there is extra security to hand if situations become difficult. A familiar face, who understands how the hospital works, will make things much easier."

Inspector Dayne Pearson, of Grreenwich Police, explained there has been an officer at Lewisham Hospital for the last six months which has been a "success".

He said: "The hospital is a community in its own right with up to 3,000 staff.

"They have a right to work in a safe environment. Where you have that many people in one place, it is inevitable you will attract undesirables and there is a potential for crime.

"These officers are walking around the hospital on a regular basis as part of their work in the Riverside beat.

"They are getting to know the staff and have hospital identification."

Hospital Watch is a national police initiative to cut down on crime in hospitals.

11:12am Tuesday 12th March 2002

Police say resident killed supervisor, then self

Thursday, June 29, 2000

By ROBERT L. JAMIESON Jr. and RUTH SCHUBERT
SEATTLE POST-INTELLIGENCER REPORTERS

A University of Washington medical resident who was going to be fired on Saturday walked into the office of his administrator yesterday and fatally shot him before turning the gun on himself.

The gunman, Dr. Jian Chen, a medical resident of one year, had come from medical school in Shanghai to work at the UW Medical Center. But a fellow worker said Chen "was not cutting it" because of language and interpersonal problems, and had known for months that his job was in peril.

	
Police arrive at the UW Medical Center after yesterday's fatal shootings. Authorities said the gunman was Dr. Jian Chen, a pathology resident who "was not cutting it." His victim was Dr. Rodger Haggitt. Jeff Larsen/P-I	

The victim, Dr. Rodger Haggitt, a married father of three grown children, was a pleasant, taciturn and focused researcher. He balanced work as a world-renowned gastrointestinal pathologist with love of teaching, car racing, jazz and the Italian language.

Haggitt was trying to help Chen get work elsewhere.

Yesterday afternoon, Chen entered Haggitt's second-floor office in the UW's Department of Pathology -- and shut the door behind him, locking it.

"There was a loud exchange of words. Then a pop! pop!" said Capt. Steve Robinson of the UW police department.

Dr. Edward Kim, a fellow pathology resident who knew Chen, said: "He was upset with the program. . . . He was upset with Dr. Haggitt.

"And we all heard about the yelling conferences they had with each other, about not being able to find another program for him."

The shootings, at the giant health sciences complex of interlocking buildings, occurred away from the areas where patients are treated.

But the gunfire threw the bucolic UW campus into convulsions of grief, as people clustered around television sets and stood in silent circles of shock.

"It's a tragedy," said Capt. Randy Stegmeier of the UW police. "Two highly educated men, now gone."

Police said Chen's contract was not going to be renewed, and he was going to be released July 1. Authorities said Chen either had an appointment or, at the very least, was expected at Haggitt's office yesterday afternoon.

Chen entered Room BB 210-B and closed the door.

Seconds later, people in nearby offices heard shouting followed by two shots, possibly three.

When police officers arrived they found Haggitt, 57, with at least one gunshot to the chest; Chen had shot himself in the head.

Both men were pronounced dead at the scene. Police recovered a handgun, though it is not immediately clear how Chen got the weapon.

UW personnel said Chen -- who was in his mid 30s and whose family lives in Taiwan -- was very qualified on paper: He held doctorate and medical degrees and had published several papers.

But they believe he may have felt the crushing weight of his pending job loss, compounded by other pressures that medical residents, particularly foreign ones, face.

Those pressures include financial demands and work schedules.

Anita Verna Crofts, executive director of the Foundation for International Understanding Through Students, a group affiliated with the UW, said "there also could potentially have been a cultural chasm as well."

The medical residency in pathology normally takes four to five years to complete. Pathology residencies are considered less rigorous than residencies in other medical disciplines. But the UW's pathology program is hailed as one of the more intense in the country.

Wen Ley Kim, the wife of Edward Kim, said her husband told her that he didn't know what Chen might do.

"They kicked him out of the program," Wen Ley Kim said, "and he couldn't find anything else."

Chen had difficulty speaking English. But that wasn't the only problem, said Wen Ley Kim, who works as a clinical technical at the UW's Medical Center. "He wasn't cutting it," she said.

The residency experience varies from doctor to doctor and from specialty to specialty. Pathologists spend many hours at the microscope, studying biopsy specimens to determine what disease a patient suffers from, or if a clump of cells is tumorous. By most accounts, Haggitt was demanding but honest.

Edward Kim, who was an acquaintance of Chen's, said Chen "had difficulties right from the beginning."

"The faculty basically didn't allow him to practice after I would say about two months into the rotation."

Kim also said Chen had difficulty taking orders from people, which may have stemmed from his language difficulties, his free spirit -- or both.

"It was very difficult for him to understand just about any command you gave him. You really had to sit down and patiently tell him what to do," Edward Kim said. "People would tell him how to handle a certain specimen, and for whatever reason he wanted to do things his own way."

Chen also was having difficulty trying to get into another program, though Haggitt and Rochelle Garcia, an acting assistant professor of pathology, were trying help him. "He was somewhat self-destructive at the end. He wasn't taking any initiative to get into another program.," said Edward Kim, who last saw Chen two months ago.

The scene after the shooting was a surreal tableau.

In the offices near the shooting site, residents and staff scrambled to get out. Meanwhile in offices on other floors, some workers knew nothing about the shooting and even called reporters to get details while they remained hunkered in self-imposed "lock down" at the medical center.

Deanna Braaten and her sister, Jenna Carlson, were sitting in a "quiet room" down the hall from where the shots were fired. Braaten's 3-1/2-year-old son, Caleb, was asleep on the couch.

"It didn't disturb him," said Braaten, who was waiting for her mother to come out of surgery to amputate her foot. "We haven't had any interruption at all. We only heard two staff members outside the door talking about a shooting.

"I thought, 'shooting?' But it didn't occur to us that the shooting was in the hospital."

At 5:30 p.m., a doctor and several other members of hospital staff stood watching TV reports in a lounge just down the hall and around the corner from where the shooting took place. Down the hall, in another waiting room, a dozen people sat waiting for their relatives.

And Steve Chun, joined by his 11-year-old son, Lindsey, waited for Steve's wife, who was having surgery on her knee.

"We knew something was going on, but we didn't know what it was. We never heard any shots," Chun said.

"The hospital probably was trying not to cause panic. Especially here, where people are under stress already, either medically or professionally. They didn't want to cause more anxiety. It's not like the perpetrator was running down the hall."

At the end of a long day, Robinson, of the UW police, weighed the sad events. He said that in the last 28 years, the university -- which swells to a daytime population of 55,000 students, staff, employees and visitors -- has had eight homicides, including the murder of Haggitt.

"Even one homicide is too many," he said wearily.

And yesterday two lives were lost.

Chen -- an ambitious young doctor who crossed an ocean to learn, and Haggitt -- a brilliant scientist who wanted to help.

Haggitt was to speak at a pathologists' convention in November and brush up on his Italian language skills.

P-I reporter Robert L. Jamieson Jr. can be reached at 206-448-8125 or robertjamieson@seattle-pi.com

P-I reporters Vanessa Ho, Hector Castro, Aliya Saperstein, Lise Olsen and Angela Galloway contributed to this

Employee kidnapped at hospital

Woman is burned and her throat is slashed in the attack; suspect is in custody.

By Elizabeth Hume -- Bee Staff Writer
Published 2:15 am PST Sunday, October 31, 2004

By Saturday evening, Daniel J. Harper, a 28-year-old parolee, was in custody after he was found driving the victim's car in Citrus Heights, authorities said.

The woman was attacked in a parking lot of the hospital, in a quiet residential section of Carmichael, as she arrived to work about 6:30 a.m. Police did not release her name.

Her alleged assailant was a young man, smelling of alcohol and wearing a fresh bandage wrapped around his right hand, said Sacramento County sheriff's spokesman Sgt. R.L. Davis.

"We think he was treated at the hospital the night before," Davis said.

According to authorities, a man forced the woman into her car, a gray 2002 Toyota Camry with Betty Boop stickers in the back window, and drove her to the American River Healthpro Credit Union at 5999 Madison Ave. Authorities said she was forced at knifepoint to withdraw money from the ATM.

Somewhere between the hospital and New Hope Road, which runs between Galt and Thornton, the man attacked the woman, brutalizing her and setting fire to her clothes. She was found with more than 20 percent of her body covered in burns, Davis said. Authorities believe she lost consciousness at some point during the attack. They are awaiting test results to determine if she was sexually assaulted.

Detectives suspect the man dumped her in an isolated area, believing she would not survive.

"He left her for dead," said Undersheriff John McGinness. "There's no doubt in my mind."

Sheriff's officials learned of the assault at 9:55 a.m. when a motorist saw a woman wandering down New Hope Road and called 911.

"A witness traveling on New Hope Road saw a female with ripped clothes and a bloody face, running on a bridge screaming," Davis said.

Deputies had difficulty finding the woman. After about 20 minutes of searching, they learned she had made her way to the Thornton Community Center. The woman was taken by helicopter to UC Davis Medical Center, where she remained in critical condition.

By noon, based on the woman's description of her attacker, officers were searching for a 5-foot-5, trim young man with brown hair styled in a short buzz cut and a well-kept brown moustache.

The woman's car was spotted about 3:30 p.m. near Sunrise Boulevard in Citrus Heights. The driver sped away when officers attempted to stop the vehicle. The car crashed into a parked motor home on the 7000 block of Woodmore Oaks Drive.

Harper, a Sacramento resident, was captured at the crash scene and transported to Sutter Roseville Medical Center. His injuries were minor, Davis said.

Harper had been paroled three days earlier after serving time for felony offenses, McGinness said. He would not detail the nature of those offenses, but indicated they involved charges similar to Saturday's attack.

Court records show three felony cases involving Harper between March 1999 and August 2001, but details on those cases were not available Saturday.

Saturday evening, Harper was arrested on suspicion of attempted murder and kidnapping.

"More charges will follow," Davis said.

About the writer:

• The Bee's Elizabeth Hume can be reached at (916) 321-1203 or ehume@sacbee.com.

Medicare bilked for billions in bogus claims
Private watchdogs rife with conflicts make system an easy target for fraud

Reynolds Holding, Chronicle Staff Writer

Sunday, January 12, 2003

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The system of private contractors policing the $250 billion-a-year Medicare program is riddled with conflicts of interest, financial disincentives and regulatory breakdowns so severe that fraud and abuse bleed tens of billions of dollars from the program every year.

Several of the most egregious frauds have involved the watchdogs themselves -- private insurance companies the government hires to examine and pay Medicare claims -- court records show.

But even reputable companies lack incentive to search for fraud. They serve at the behest of medical trade groups and, in some cases, are business partners with doctors and hospitals. They skimp on oversight, checking for the proper completion of claims forms but rarely for deceit.

The result is a variety of billing scams involving nonexistent patients, unnecessary treatments, phony tests, excessive charges, services never rendered or procedures billed more than once.

"It is utterly ridiculous," says Malcolm Sparrow, a health care fraud expert at Harvard University's Kennedy School of Government. "We are trusting insurance companies to do oversight of the medical profession, and they are riddled with corruption themselves."

Sparrow estimates Medicare fraud at $50 billion to $75 billion a year -- about twice the amount of Congress' most expensive proposal for helping senior citizens buy prescription drugs.

Fraud is so costly that it has helped force Medicare into drastic spending limits since 1997. Last year, the program cut doctors' reimbursement rates 5.4 percent, with an additional 12 percent reduction scheduled for the next three years. Lower rates have led many medical providers to drop Medicare patients, leaving millions of Americans without sufficient health care coverage.

The system's failures emerged with disturbing clarity Oct. 30, when FBI agents seized records involving two heart specialists suspected of billing Medicare for unnecessary procedures at Redding Medical Center.

Several days later, the medical center's owner, Tenet Healthcare Corp., announced that a private watchdog -- Mutual of Omaha -- had persuaded the federal Department of Health and Human Services to investigate the company for extracting billions of dollars in possible overcharges through a Medicare loophole.

No charges have been filed in either case.

But other Medicare scams are so brazen that critics say even cursory oversight would reveal wrongdoing.

From 1991 through 1997, Healthcare One, a medical equipment seller in Encinitas (San Diego County), persuaded more than 110 elderly cancer patients to order special pumps for draining excess lymph fluid. Though the pumps didn't meet federal standards, the company forged doctors' letters to certify that the patients could not survive without them.

Failing to check the paperwork, the Medicare watchdog reimbursed the company $5,400 for each pump, a total of more than $500,000 in public funds for bogus medical equipment.

"They jeopardized patients' lives in the name of the almighty buck," says Ray Pettersen, Healthcare One's former national sales manager. "And they weren't ripping off the government, but you and me and every other taxpayer."

CONFLICTS OF INTEREST

Medicare's persistent breakdowns derive in part from its size. The program, created in 1965 to guarantee health care coverage for Americans over 65 or with certain disabilities, covered more than 40 million Americans last year and paid about a billion claims.

But critics say the system's fraud problems stem from a compromise Congress struck with the health care establishment 38 years ago. Fearing socialized medicine, doctors and hospital owners agreed to participate in the program only after being allowed to select the insurance companies that process the claims and serve as the program's watchdogs.

Today, 49 private insurance companies work for the Centers for Medicare and Medicaid Services, the federal agency that runs Medicare.

The insurance companies receive bills from doctors and hospitals that treat Medicare patients, examine the bills for mistakes and then pay them with checks drawn on two federal trust funds. The trust funds are financed through payroll taxes, patient premiums and general tax revenues.

The government reimburses the companies for their costs of processing claims, and grants them a fixed budget for administrative tasks such as controlling fraud and abuse.

Typically, the U.S. government awards contracts through competitive bidding.

But the compromise with Congress allowed the American Hospital Association, an advocacy group for hospitals, to decide which insurance companies should handle hospitals' Medicare bills.

Virtually all the companies turned out to be members of the National Association of Blue Shield Plans, now the Blue Cross Blue Shield Association, a frequent political ally of the American Hospital Association and the American Medical Association.

"'No sooner had the ink dried on that compromise than we began . . . to have horror stories," says Richard Kusserow, inspector general in the Department of Health and Human Services from 1982-1991. For every abuse the government tried to stop, says Kusserow, three would appear in its place.

Bilking Medicare became so lucrative that professional criminals got involved. In 1993, Gabriel Hernandez, a former "logistics coordinator" for the Medellin, Colombia, cocaine cartel, opened a chain of Florida health clinics that billed Medicare and state Medicaid programs for fictitious patients with phony ailments. Over two years, he received checks for more than $1.7 million.

"Everything was easy compared with being in the trafficking business," he says. "All I was doing was picking up checks every week. And I got caught, but I didn't get killed."

Hernandez was convicted in April 1997 of racketeering and spent five years in prison.

Three years ago, the General Accounting Office (GAO) cited "fundamental" conflicts of interest as a factor in the watchdogs' poor performance.

Hospitals and doctors not only help select their overseers, they go into business with them. Many of these companies also run health maintenance organizations. The HMOs funnel business to hospitals and doctors that the insurers may regulate.

Some of the companies even own hospitals. For example, one subsidiary of Cigna Corp. reviews and pays Medicare claims for doctors. Another subsidiary owns Lovelace Health Systems, a hospital and physician group in Albuquerque, N. M. Last month,. Lovelace agreed to pay $24.5 million to settle a whistle- blower suit charging that the company had submitted tens of millions of dollars in false claims to Medicare over 10 years. Cigna did not review the Lovelace claims.

And when a private insurer and Medicare cover the same patient, the insurer is primarily responsible for paying the patient's claims, with Medicare picking up anything left over. But some insurers exploit their Medicare roles by making Medicare the primary payer, a violation that has cost the national Blue Cross Blue Shield Association, Transamerica, Travelers and other insurers more than $100 million in legal settlements.

"Government contractors policing themselves," says Kusserow, "is not a very healthy situation to have."

CORPORATE ABUSE OF SYSTEM

Dozens of these companies have been investigated for abusing the Medicare system, and at least 10 have paid hundreds of millions of dollars in civil penalties and criminal fines:

In July, Blue Cross of California, the company that examined and paid Medicare bills for Northern California hospitals until 2000, agreed to a $9.25 million settlement of charges that it lied to Medicare officials for 10 years about fully auditing claims it had reviewed only superficially. The company admitted no wrongdoing.

In 1997, Blue Shield of California, the company handling Medicare claims for Northern California doctors, settled for $12 million charges that it cheated during Medicare audits and submitted false claims to the program. One supervisor allegedly told an employee to hide a $465,000 overpayment. In 1996, the company paid a $1.5 million fine and pleaded guilty to three felony counts of obstructing a federal audit and destroying documents.

In 1998, Blue Cross Blue Shield of Illinois pleaded guilty to eight felony counts -- and paid $4 million in criminal fines and $140 million in civil settlements -- for fabricating documents, manipulating claims samples and otherwise lying to the government about its poor claims-processing performance.

In 1993, when it discovered that 10,000 claims had been in its mail room for three months, it simply threw them out, according to the government's lawsuit. The company left the Medicare program in 1998.

Prompted in part by a 15 percent to 20 percent cut of whatever the government recovers, whistle-blowers have brought these and an increasing number of cases like them to the public's attention.

"It's clear that whistle-blowers are indispensable," says Stephen Meagher, a San Francisco attorney and former prosecutor who specializes in whistle- blower claims.

FINANCIAL DISINCENTIVES

A major obstacle to effective oversight, say many experts, is the lack of financial incentives to scrutinize claims.

Medicare puts private insurers on a fixed budget to compensate them for the costs of handling claims. The incentive is to process the claims as cheaply as possible.

"We try to do a good job," says an executive responsible for reviewing doctors' claims in California, "but we don't get extra money for doing a good job."

In their private insurance businesses, companies typically spend more than 8 percent of the total cost of paying claims on the review process, the GAO said. But in a 1998 report, the GAO found that 41 companies spent only .007 percent of their cost of handling Medicare bills on ferreting out fraud and abuse.

"There just isn't a whole lot invested in reviewing (Medicare) claims," says William Scanlon, managing director of health care at the GAO.

While researching the 2000 edition of his book on health care fraud, "License to Steal," Sparrow says he posed to several contractors a hypothetical scam: A doctor submits a $1,500 Medicare claim. The insurer pays the claim and thus confirms that the bill was coded correctly. The doctor then submits identical but false claims on the same day for 10,000 other patients.

Virtually every contractor conceded that the scam would work, says Sparrow, and the doctor "would most likely get his or her $15 million check at the end of the week."

A vice president at one contractor told him that the company "probably wouldn't even notice. It's not our money."

The private insurance companies say they perform as best they can within the system's financial constraints. They stress that the huge volume of claims they process would make detailed investigations for fraud prohibitively expensive and time consuming.

"In California, we process over 60 million claims a year," explains Dr. Charlotte Yeh, a medical director for National Heritage Insurance Company, a Medicare watchdog. "We handle over 96,000 providers in California and 3.8 million (Medicare) beneficiaries . . . We do well, but not everything will be perfect."

The review and payment system of insurance watchdogs is almost entirely automatic. Software catches billing errors with checklists developed by Medicare and each private insurer. The software will flag, for example, a claim for a hysterectomy performed on a man. But it cannot tell whether a procedure was actually performed -- or whether a patient even existed.

Company employees review about 2 percent of the claims, says Scanlon, but normally confine their review to supporting documents, which themselves can be fabricated.

The upshot, says Sparrow, is an oversight system almost oblivious to fraud.

In the case involving the two Redding heart specialists suspected of performing unnecessary procedures, Medicare had hired National Heritage to review their bills and those of other doctors in Northern California. But the company didn't report the problem. A whistle-blower did. The company almost never questions whether treatments are necessary, according to Yeh.

"Our job is . . . to try and make sure that claims payment goes smoothly and providers get paid in time," she said.

Still, the federal Department of Health and Human Services touts its record as a fraud buster. Since 1996, the agency has issued annual estimates of "improper Medicare payments." The totals have dropped from $23.2 billion -- or 14 percent of all Medicare payments -- in 1996 to $12.1 billion, or 6.3 percent, in 2001.

The estimates, though, do not include most fraudulent claims, the GAO reported in July 2000.

So how much fraud is there in Medicare?

"Nobody knows," says Sparrow. "But I can't imagine that it would be less than 20 percent, and it's more likely to be 30 (percent) or 35 percent" of annual payments.

REGULATORY BREAKDOWNS

Responsibility for the Medicare system is dispersed across 10 regional offices that critics say treat private insurers inconsistently.

Lacking uniform standards, agents at each office generally decide what to review, when to review it and how to punish substandard insurers, according to the GAO. The agents rely heavily on the companies to evaluate their own performances, a system proven ineffective by recent false-claims cases against companies.

When agents do visit, they give notice, according to the GAO. A recent government lawsuit charged that, in preparation for a government audit, Blue Shield of California deleted references to auto accident injuries for which the insurer rather than Medicare should have paid.

"The superficiality of these reviews is difficult to understand," wrote the GAO in a recent report, "in light of the large number of contractors that have been found to have . . . integrity problems.''

In 1996, Congress attempted to crack down on Medicare abuses by providing more money and prosecutors and by giving the system authority to hire outside companies as claims investigators.

Three years later, Medicare administrators selected 12 such companies through competitive bidding. But rather than independent watchdogs, most of the companies turned out to be private insurers already serving as Medicare watchdogs, or companies related to them.

Tim Hill, the director of program integrity at the Centers for Medicare and Medicaid Services, acknowledges that "we took awhile to figure out how to use" the new companies. But since early last year, he says, they have been assuming an essential role in rooting out Medicare abuses.

Now, when a private insurer suspects fraud, it refers the case to one of the new companies for investigation. The new companies can also unearth fraud themselves by reviewing claims data from all 49 private insurers, detecting suspicious patterns that individual insurers could easily miss.

"(The new companies) have analytic abilities that enable them to identify areas of abuse that we haven't been able to find before," said Hill.

Still, a 37-year head start for health care scam artists has given government officials a lot of ground to make up.

"I admire them for facing up to the problem, but any claims that they have dealt with it are entirely bogus," says Sparrow. "I'm convinced that we can do an awful lot better."

E-mail Reynolds Holding at rholding@sfchronicle.com.