SHELTERING ISSUES | Population

In some incidents, it may be wiser and safer to remain inside. To “shelter-in-place” means to make a shelter out of the place you are in. It is a way to make the building, or a portion of it, as safe as possible to protect your residents and your staff (CDC 2003). The decision to shelter-in-place or evacuate may be mandated or may be determined by the nature of the threat and the amount of time predicted before disaster strikes.

Public Shelters

It is unlikely that patients with special needs can be adequately cared for and monitored in hastily prepared shelters, randomly located and with untrained personnel, in the aftermath of a natural disaster. The best care for the frail elderly during such a crisis would be provided by a facility such as a long-term-care facility that already has in place the resources necessary for all aspects of proper care.

For the frail elderly to be sheltered successfully, their logistical, dietary, communications, staffing, and patient physical and psychiatric care needs must be addressed. None of these areas can be dismissed as trivial or unimportant. Whether concerned with the capacity to maintain climate control, nutritional requirements, adequate hydration, or communications in-house and outside, appropriate staffing is crucial in all areas when the safety and health status of the facility’s residents are at stake. This can be applied to other special populations when planning for any large-scale disaster situation.

To ensure adequate staffing to handle the regular population in addition to an influx of new patients, facilities must provide a host of services and benefits for employees as well as for families; everything from food and bedding to legal assistance should be available (Silverman et al. 1995). During crises that overwhelm resources, staffing will fall below desirable levels. To prepare for these contingencies, train all employees and equip them to aid in the basic care (such as feeding) of individuals who require assistance in their activities of daily living (Silverman et al. 1995).

Shelter-in-Place

Sheltering-in-place may be the only choice when there is little or no time to warn or evacuate residents and staff. Furthermore, it is the only proper protective action in situations such as a hazardous-materials spill or a tornado warning. Sheltering-in-place can have many advantages, including the following:

§  Immediate protection. Sheltering-in-place involves little time required after the warning, and it is less disruptive to residents.

§  Ideal life-support systems. The facility has food, water, sanitation, medicines, bedding, clean air, communications, and medically prepared surroundings.

§  Less staff burden. Sheltering-in-place requires considerably less emergency staff support than evacuation, without the transportation problems or need for additional security personnel.

MAAs for Evacuation

Establishing mutual-aid agreements, or informal arrangements when appropriate, for the staffing, equipment, and other resources you may need in a disaster will expedite facility response and recovery when disaster strikes.

If you are in a small community, an informal agreement to use a building as a temporary shelter for your facility residents may be sufficient. However, once moved, it is imperative that the residents are not disrupted unnecessarily or forced to encounter multiple moves. Transportation of residents during an evacuation may also be an informal arrangement with staff members, family or friends of residents, or other persons willing to help. It is a good idea to recruit more people and vehicles than you will actually need to ensure a sufficient number when the circumstances require evacuation of residents.

Formal agreements for the deployment or utilization of another jurisdiction’s or political subdivision’s staffing or equipment in an emergency or disaster situation, or MAAs.

To be effective, MAAs should

§  be in writing,

§  be reviewed by legal counsel,

§  be signed by responsible parties from all agencies involved,

§  define liability, and

§  detail the cost involved.

Other Contractual Agreements

Contracts and agreements can be used to ensure the provision of resources or services that go beyond immediate disaster-relief provisions. Contracted agreements should include the costs, estimated time to provide the service, and duration of the service contract. Examples of contracted services include emergency generators, cleanup and debris removal, food and water services, pharmaceutical supplies, medical and surgical supplies, and oxygen and special gases.

A projection of potential disaster resources should include a roster of specific resource providers or vendors, with current telephone numbers and multiple methods of emergency communication with suppliers. To expedite requests, the roster should also include the business name; location; contact name and title; phone, fax, and cell or beeper numbers; order number or item number of supplies most likely to be requested; and other pertinent information. 

SHELTERING CONSIDERATIONS

Positive-pressure filtration systems draw contaminated air into the building through special filters that remove the contaminants. This creates a slight positive pressure in the building, which in turn prevents the nonfiltered, contaminated air from leaking into the building. Experience suggests that such systems, however, are expensive and difficult to properly engineer. A less expensive but less protective measure is to engineer the building controls so that the HVAC system could be completely shut down. Little outside air would be drawn into the structure if all doors and windows were closed.

The ability of an action to adequately protect people in a healthcare facility depends on the characteristics of the toxic agent(s) involved, the size and nature of the release, meteorological conditions, the characteristics of the population affected, and the ability of the threatened structures to provide protection from outdoor agent concentrations. Deciding to shelter-in-place requires a prediction of the outdoor plume concentration of the toxic agent that will occur in the risk area, an estimation of the concentration that will occur inside the buildings at risk, and a calculation of the indoor estimated level of exposure. Deciding to evacuate requires an estimation of how long it will take to move patients and staff out of the building and when they will reach a safe distance compared to the outside concentration that people will experience while evacuating; that is, calculating exposures to those who evacuate in the plume will be considered against exposures to those who have not left (Sorensen, Shumpert, and Vogt 2002).

The indoor concentration of a contaminant is determined by infiltration rates into a building and the inside circulation of air. The inside environment will have a lower peak concentration of a contaminant than the outside air. The lower the air exchange, the lower the peak concentration. Infiltration is measured by air changes per hour (acph) between the outside and the inside or the number of times each hour that an enclosure’s total volume of air is exchanged with outside air. An average air exchange rate for office buildings is estimated to be 0.66 acph and an industrial building to be 0.31 acph with the HVAC system(s) off and doors and windows closed (Engelmann 1990). Little is known about the movement of contaminants inside buildings, especially large and complex structures such as hospitals.

Overall exposure to contaminants in a closed indoor environment will be similar to the overall outdoor exposure because contaminants remain in the building after the plume has passed. If reducing total exposure is the goal, as opposed to reducing peak concentration, then the facility needs to be evacuated or ventilated after the plume has passed or the outdoor concentration is less than the indoor concentration (Rogers et al. 1990).

Sheltering for a biological hazard is slightly different from that for a chemical vapor in that hospital HVAC systems are designed to filter out most aerosols in the size range of biological agents (0.5 to 10 microns) (Weik and Weik 2001). Thus, leaving the HVAC system on would be warranted if the hospital is not under positive pressure.

Sheltering for a radiological hazard is somewhat different from that for chemical hazards in that a building will provide some protection against radiation from inhalation exposure as well as exposure from atmospheric clouds and ground deposition. The amount of protection against radiation is determined by the type of structure and location in the structure. Interior rooms and basements in buildings such as hospitals would typically reduce exposure from a cloud source by 70 percent to 90 percent and from a ground source by 98 percent to 99 percent (Schleien 1983).