DISASTER-RESPONSE ISSUES

Your facility disaster-response plan is vital to the safety and well-being of special-needs residents and staff during and following any emergency or disaster. How you organize and assign responsibility for these functions depends on your staffing pattern, the number of residents under your care, their level of physical mobility, and the size of your facility.

Be sure to address and assign responsibility for each function in terms of a staffing schedule. Adapt procedures to fit your needs—daytime, evening, and nighttime coverage or by alternative shift schedules, according to your facility. When a disaster response is activated, each shift should plan at least six hours ahead so the next shift will be able to continue the work already underway and have the benefit of the information posted on the walls to provide a picture of the most current situation (e.g., number of residents injured, locations of damage, availability of drinking water, etc). It is important to remember that the situation will be changing, and planning must be flexible to adjust to and reflect these changes.

Command Center

The command center should be located in a secure area and have sufficient space to accommodate necessary staff. An alternate site should also be selected as a backup. Communications equipment should include telephones, fax machines, cellular phones, and two-way or ham radios, if available. A status board—white board, flip chart, bulletin board—must be available to track response actions, decisions made, staff schedules, status of facility/resident needs, and other disaster- and facility-specific information. Laptop computers and printers are helpful tools, as long as power is available to operate them. A conference room can easily be converted into a command center with the equipment and supplies prepositioned and stored until needed.

Staffing Priorities

If adequate staff are available, disaster-response activities should be undertaken simultaneously, as appropriate depending on the incident, with staff preassigned their primary responsibility. You may wish to establish a preparedness committee of residents, if their physical condition allows, and include members of this committee in both preparedness and response planning for the facility. Involving interested and capable residents and assigning them responsibilities in planning efforts and organized response functions can greatly enhance your overall capability.

If adequate staff members are not available to undertake response functions simultaneously, those functions should be carried out in the following order:

1. Direction and control Determine who is in charge of the emergency response at the time of the disaster. Evaluate the situation and activate response staff as needed. Activate the command center to coordinate emergency activities.

2. Site security. Check and turn off gas and/or electricity. Make sure the emergency generator is functioning and emergency power is on. Turn off the water supply if pipes are broken or leaking.

3. Fire suppression. Check for fires and suppress small fires. Notify the fire department.

4. Search and rescue. Quickly search the facility for people who may be trapped or injured. Assist if possible. Note and record the situation for other responders, including name and location of those trapped.

5. First aid. Administer first aid to injured persons. Note and record injury for assistance from other responders, including name and location.

6. Damage assessment. Inspect facility. Record damage and report to the command center. Request barricades, off-limits signs, and additional support from security or law enforcement as needed.

Community resources will be overwhelmed in a major disaster, and you could be on your own for a long time. Self-sufficiency is required.

Considerations for Handling Special Populations During a Catastrophic Event

Regardless of the size and type of facility, a catastrophic event that requires an evacuation of clients will challenge facility staff in many ways. By thinking of the worst-case scenarios, safeguards and redundancies can be included in your planning that will make the experience much easier for you, your staff, your clients, and the receiving facility. The following are provided for consideration as you plan to manage clients and provide necessary resources and supplies when evacuating from special-care environments.

Planning should ensure

• proper identification and monitoring of patients or clients once they are relocated;

• mechanisms for patient data transfer to continue regularly scheduled treatments and medications after relocation;

• sufficient number of caregivers to ensure proper care of relocated patients/clients at the receiving facility; and

• sufficient support of staff in stressful conditions with time off for proper rest and time with families. Remember: staff at both the receiving and sending facility may be victims of the disaster, too.

Be aware and plan for lack of services and other problems, such as

• water, sewer, gas, and electrical services;

• supplies such as linens, food, medicine, and water for days;

• creative planning for proper nutrition in lieu of hot meals for several days;

• delivery of meals and provision of services in multistory facilities if elevator not operational;

• assistance for patients who need help with activities of daily living;

• fluid loss in patients and staff due to lack of power, air conditioning and/or heating; and

• communication within the facility and to the outside if phones lines or cell connections are down.

Needs of Pediatric Patients

HRSA reiterates that a host of special anatomical, physiological, and psychological considerations leave children more susceptible to the effects of disasters and acts of terrorism. Planning must consider, but not be limited to, special treatment areas for mass pediatric casualties in hospitals, triage areas, and health centers; development of pediatric response protocols, paying special attention to appropriate medications and dosages; pediatric-specific training and exercise procedures; and provision of psychological support to children and families, including methods to ensure reunification of children with family members, as needed (HRSA 2003).

MITIGATION ISSUES

An all-hazards approach for the domestic and international emergency management framework applies to the threat of terrorism. Better plans, more training, and greater awareness enhance capabilities to manage natural and technological disasters, day-to-day emergencies that may occur, as well as terrorist incidents. A course recently developed for the Federal Emergency Management Agency’s Higher Education Project, “Social Vulnerability Approach to Disasters,” is an excellent tool to help in understanding our vulnerability while suggesting strategies and actions (Enarson et al. 2003).

The course describes structural and nonstructural mitigation strategies. Both provide security measures that may be taken to prevent or reduce loss of life and property from terrorist events and acts of violence. The distinction between structural mitigation techiques and nonstructural mitigation techniques is often made in terms of reducing potential loss (nonstructural) rather than in terms of reducing hazards (structural).

It is relatively easy to provide physical or structural mitigation measures to secure a facility or person by providing guards, iron bars, eleo trified fences, surveillance cameras, and other physical security measures. But these measures are often consuming and are most effective in controlled-access areas; they may be less effective in areas where large numbers of people have access (Enarson et al. 2003).

Nonstructural mitigation measures include training to reduce vulnerability and implementing measures into response plans to reduce the likelihood of losses and to speed recovery. These measures may be easier for public agencies to fund and implement than are physical or structural changes to a building (Enarson et al. 2003). For example, facility staff members who are keenly aware and trained to alert their supervisor or shift leader to anything out of the ordinary—a suspicious package or vehicle, someone in the building without a visitor’s badge—enhance your facility’s safety factor.

Staff skilled in the tools necessary to handle emergency and disaster situations are valuable assets and increase your chances of responding to and recovering from any disaster in a more expedient and timely manner. Training reduces your vulnerability while building capacity and confidence among your facility team players. If residents are competent and willing to help with disaster management and facility security, they can be trained as well. This type of cooperative effort and vested interest in the mutual safety and security of your facility is wise and cost effective. Its benefits are immeasurable in terms of your facility’s greatest asset—human resources—and personal self-sufficiency and pride.

In keeping with all-hazards, or “dual purpose,” emergency management planning, it is significant to note that terrorism is not the only form of violence common to institutions, workplaces, and all aspects of American society. The primary justification for preparedness is to ensure the readiness of your facility for the potential unknown that may be faced at any time. In addition to terrorism, Americans daily face threats of criminal (physical and sexual), domestic (spouse, family, or other intimates), and other common types of violence (Enarson et al. 2003).

These same threats of violence are present in healthcare facilities and patient care environments. The size and nature of the facility, number of residents and staff, physical location, population and demographics of the area, and many other factors may determine the amount of security measures implemented. Many mitigation actions that reduce vulnerability to all types of violence can be accomplished at little or no cost.

EVACUATION CONSIDERATIONS

Evacuations of hospitals and other healthcare facilities can be lengthy and complex events. A 1990 study examined the evacuation of 34 hospitals and 46 nursing homes (Vogt 1990). In the 34 hospital evacuations at facilities that ranged from 99 to 310 beds, the largest facility took 5 hours to evacuate 127 patients, whereas the smallest hospital took 2 hours to evacuate 27 patients. The most rapid evacuation involved the movement of 57 patients in 1.5 hours (Vogt 1990). In addition to results of nursing home evacuations, it was found that the time to evacuate was not related to the number of patients evacuating. The strongest predictors of evacuation time were the nature of the threat (weather versus nonweather events), the ratio of staff to patients, and whether the facility was in an urban area (Vogt 1991). A more recent study documents the evacuation of 575 patients from a hospital prior to a hurricane (Cocanour et al. 2002). In this case, completing the evacuation took almost 28 hours. Of the 575 patients, 169 were discharged and 406 were taken to 29 other facilities.

Both Vogt (1990) and McGlown (2001) examine factors influencing the evacuation process in healthcare facilities. Although Vogt focuses on the implementation of an evacuation at an organizational level whereas McGlown focuses on individual decision making, the two studies have similar findings. Processes are shaped by factors such as threat, risk, time, resources, infrastructure impediments, internal and external environment, organizational characteristics, social linkages, and social climate.

In terrorist events, both patients and workers in healthcare facilities are vulnerable groups. Patients are at risk because they lack the ability to protect themselves. Workers are at risk because of the nature of their roles as caregivers and because of the extra burden that an emergency creates. Despite such difficulties, responding to an emergency can be successful with careful planning, training, and exercising.

Case Example: Hospital Evacuations in Arkansas

Shortly after 1:00 p.m. on Thursday, May 8, 1997, clouds of foul-smelling smoke began pouring from a herbicide and pesticide packaging plant in West Helena, Arkansas. The incident began when smoke was emitted from a 1,500-pound bulk container of azinphos-methyl, a commercial brand of parathion, which is a chemical with toxicity levels similar to sarin (Vogt and Sorensen 1999). An alert was sounded, employees were evacuated, and the West Helena fire department was called. As the smoky, malodorous cloud drifted away from the plant, authorities ordered residents in a two-mile area downwind of the plant to evacuate and those in the two- to three-mile zone downwind to shelter-in-place.

Phillips County Regional Medical Center was the one medical facility evacuated following the release. Located across the highway from the fields surrounding the industrial park, the complete service hospital, providing care for residents in a 50-mile radius, employs about 330 people and has 155 beds.

The evacuation of the medical center was facilitated by efforts taken six months earlier to update the hospital’s evacuation plan and reconfirm support agreements for relocation sites and supplies. When the plan was updated, the entire staff had also participated in a mock drill. At the time of the incident, the safety officer observed the buildings across the highway being evacuated and questioned officials on the possibility of also being evacuated. When the director of nursing gave the “code white” alert (the signal that an evacuation to an off-site facility would follow), an evacuation plan that was familiar to staff was in place and had been practiced, and staff were amply prepared to move patients.

All patients who could be discharged were sent home with a physician’s nurse. Another four or five patients (the most seriously ill) were transferred to a hospital about one-half hour away. Approximately 17 patients in the rehabilitation unit were transferred to a vacant wing of the Crestpark Nursing Home accompanied by hospital support staff. One maternity patient evacuated to the nearby Phillips Community College, where the hospital staff had evacuated and opened emergency room services.

The evacuation of patients began at 1:40 p.m., and all but three patients (two on ventilators and one being stabilized in the emergency room) were out 55 minutes later. The remaining three patients were evacuated 15 minutes later. As per the evacuation plan, a variety of vehicles transported patients—vans, school buses, ambulances, private cars, and mortuary services vehicles. As a precaution, National Guard personnel provided security at the evacuated hospital.

Until the hospital could be reopened, hospital personnel operated a triage area, an emergency room, and a laboratory at the recently completed fine arts building at the community college. The space provided by the college suited the hospital’s needs. In addition to the space, dressing rooms with showers and toilets were readily available. The college also has an emergency medical technician program and a school of nursing. One of the rooms used for training nurses was used to house maternity patients until stabilized, but no other patients were kept overnight. Ambulance operators rerouted patients to other medical facilities as needed. Staff maintained records using a notebook computer. The college also provided a separate extension phone line for hospital staff use.

Although monitors indicated no contamination in the facility, the state health department required a thorough cleanup of the hospital before patients could be admitted. This meant that all hard services had to be scrubbed and all soft materials (drapes, etc.) had to be removed. The health department also required that all filters in the building be replaced before the interior cleanup was started. Staff were unable to locate the filters because of the special design and the fact the company making them did not operate on weekends. Recognizing the urgency of having the regional hospital operational, state officials exerted pressure to convince the company to alter its policy to aid in the recovery from this incident. The filter company extended its hours and worked through the night, delivering the replacement filters to the hospital on the following Saturday. The hospital staff began cleaning on Sunday in shifts, starting with the rooms where filters were replaced. The emergency room was considered the highest priority and cleaned first. The hospital was reopened on May 13, six days after the initial evacuation.

Source: Vogt, B.M., and J.H.Sorensen. 1999. Description of Survey Data Regarding the Chemical Repackaging Plant Accident, West Helena, Arkansas. ORNL/TM-13722. Oak Ridge, TN: Oak Ridge National Laboratory.