Ever since September 11, 2001, there has been an increased emphasis on emergency preparedness in nursing homes. The New York State Department of Health recently issued an advisory (Dear Administrator Letter) for long term care facilities to guide them in emergency preparedness. They also have published guidelines to assist nursing homes with emergency preparedness planning. These efforts intensified after the poor emergency response to nursing home facilities during and immediately after Katrina in 2005. The Office of Inspector General (OIG) released a study of nursing home emergency preparedness in the hurricane disasters in August, 2006.
Traditionally, disaster plans for nursing homes have focused on fires and weather events such as floods, storms, etc. In this era, disaster planning needs to be expanded to include new potential threats. These include disruption of multiple services to the facility, such as power, telephone, etc.; disruption of mass transit or closure of highways used by staff to commute to work; release of bioterrorism agents in surrounding community with potential impact on residents, staff, and neighbors; and the possible role of triage and emergency care provider in a mass casualty event. The State of Louisiana has a very well developed framework for a nursing home emergency and evacuation plan. The template for this, and other plans for various care delivery settings, can be found on the web page for the Louisiana Department of Emergency Managerment.
Lessons Learned on September 11, 2001
Traditional disaster planning did not anticipate the kind of city-wide failure of systems experienced
Communication with other hospitals in the area had to be done by runner due to phone failure
The only means of communication with outside world was by email with cable connection
Some staff became victims, not knowing whereabouts of loved ones or having last cell phone conversations with them before building collapse
Usual routes of commuting for staff--bridges, tunnels, subway,etc.-- were unavailable for days
In the event of a very large disaster when access to acute care hospitals is restricted by lack of transportation or overcrowding, long term care facilities may be pressed into service as temporary acute care settings. It is more likely that this would happen informally, as victims would seek out care in whatever setting they could access that is identifiable as a health care provider. For this reason, facility disaster plans should include the following:
Identification of an area for triage and immediate care
Identification of an area for caring for acutely ill until they can be transferred to higher level ofcare
Identification of an area where victims already cared for can be discharged from
Identification of a cool, remote area that can be used as a temporary morgue
Development of a system for victim registration and responding to inquiries from concerned family members
Supplies and equipment normally used for long term care purposes will need to be adapted for acute care. The following chart offers examples of such adaptations, but it is not meant to be an exhaustive list:
Equipment or Supplies
Decubitus ulcer dressings
Dressings and bandages for trauma
Duoderm, Opsite, or similar wound dressings
Occlusive dressing for sucking chest wounds
Orthotic splints for contracture prevention
Splints for fractures
Intravenous fluids for dehydration and sepsis treatment
Intravenous fluid for treatment of volume depletion or shock
Have you considered?
Consider these questions about your facility…
Is your facility near a major highway or railroad transporting hazardous materials?
Is your facility in a concentrated urban environment that may be the target of airborne bio-terrorism?
Is your facility in an area where insects such as mosquitoes may transmit diseases such as West Nile Disease?
If the answer to one or more of these is yes, then check that your facility disaster plan has a procedure for quickly alerting staff to close doors and windows and to keep residents indoors in response to a potential emergency.
Evacuation plans should be included in the facility disaster plan. According to Eric S. Weinstein, MD, Chair of the ACEP Disaster Medicine Section and Medical Director of Emergency Services at Colleton Medical Center at the Medical University of South Carolina, these evacuation plans should include the actual physical evacuation process, arrangement of ambulances, vehicles or family member vehicles; creation of Memorandum of Understandings (MOUs) with accepting similar facilities; patient tracking and then the process to accept patients back into the facility; transportation of medication, equipment and resident records with the evacuated patients; physician to physician contact to promote continuity of care; account services to track all costs associated with the evacuation; education and training for an evacuation; personnel assignments in all phases of evacuation; and the process to determine when the facility is able to return to function, structural or otherwise. Also consider the process to accept residents from another facility that had to evacuate. The plan for internal evacuation, in that areas of a facility evacuate to another area or areas, should also be outlined.
With plans to shelter-in-place, it is a must for all facilities to be able to turn off their HVAC system if a toxic cloud has suddenly appeared from a fire or other event, like the recent Atlanta suburb pool chemical fire, or for an ice storm or other loss of infrastructure. Facilities may be asked to become special needs shelters, formally or informally in a pinch. The more prepared, the better they will be able to manage their own patients, as well as those that arrive.
Evaluation of Nursing Home Emergency Response to Katrina
In 2006, the Office of Inspector General of HHS issued a report evaluating the emergency preparedness and the response of nursing homes in the area of the country affected by Hurricane Katrina. This report highlights not only weaknesses in planning, but also weaknesses in implementing what plans there were. It also speaks to issues regarding sheltering in place, as well as concerns about coordination of emergency response with government agencies. Click on the icon to the right to download the report.