Critical Care / Emergency / Trauma

Care during crisis

Nursing has always been about responding to emergencies and meeting the needs of vulnerable populations. It’s a huge responsibility under normal circumstances, but during times of disaster, the challenges grow exponentially.

One only has to think back to 2005, when hurricanes Katrina and Rita hit the Gulf Coast. Despite the heroic achievements of numerous health care professionals, many people called into question the effectiveness of the disaster response system.

With that in mind, the American Nurses Association (ANA) is pursuing two major initiatives.
The first involves gathering an expert working group of RNs, other health care professionals, government representatives, and disaster planning strategists to create a comprehensive document that can help guide and protect RNs working under extreme conditions.

The group, which first met in December 2006, specifically is examining disaster planning, response, and care in conjunction with three long-standing ANA documents that define nursing standards of care and ethical practice. The documents are Nursing’s Social Policy Statement, Nursing: Scope and Standards of Practice, and the Code of Ethics for Nurses with Interpretive Statements. (For more information, go to ANA’s website at www.NursingWorld.org.)

The other major initiative is an ANA conference, “Policy by the People: Nursing Care in Life, Death and Disaster,” which will be held June 20–22 in Atlanta, Georgia to further discuss and shape the profession’s disaster-response policy. Among the attendees will be RNs, including staff nurses, nurse managers and educators; regulators; disaster planners and responders; and policymakers at the national, state, local, and institutional levels. (To register, go to www.nursingworld.org/meetings/.)

Overall conference goals include examining how current nursing standards of care might be altered during a disaster to save as many lives as possible, describing institutional and individual actions that can reduce risks to patients when care must be altered for emergency purposes, and directing individual RNs to sources for planning emergency and disaster response preparedness.

A change in plans
Originally, ANA planned to focus on strategies to address one major threat—a pandemic—which was getting increased national attention.

“We were thinking about national planning for a pandemic, when up to a third of the RN workforce could be ill themselves or unable to respond because they were providing care to their families,” says Kristine Gebbie, DrPH, RN, FAAN, co-chairperson of the ANA policy work group and director of the emergency preparedness subspecialty program at Columbia University School of Nursing in New York City. “Given a reduced and reconfigured health care workforce, we knew we had to think through in advance how we could ensure the provision of quality care.”

Then came the 2005 hurricanes, criticism of response efforts, and the specter of criminal prosecution of a physician and two nurses who provided care at a flooded New Orleans hospital. The health care professionals, who worked under deplorable conditions and with few resources, are accused of killing four severely ill patients by allegedly injecting them with lethal doses of medications. Although the New Orleans coroner recently said he couldn’t classify the deaths as homicides, the case was expected to go to an Orleans Parish grand jury, as of press time.

“I don’t feel the public has lost confidence in nurses and health care professionals,” says Gebbie, a New York State Nurses Association member. “In general, and as was the case with hurricanes Katrina and Rita, many people do extraordinary things to help those at risk.”
However, ANA, Gebbie, and others soon realized that the nursing community needed to come together to address nursing standards of care during all kinds of major events.

The federal Agency for Healthcare Research and Quality (AHRQ) published its own document addressing disaster response in April 2005 called Bioterrorism and Other Public Health Emergencies—Altered Standards of Care in Mass Casualty Events. Its authors note that, to save as many lives as possible, “health and medical care will have to be delivered in a manner that differs from the standards of care that apply under normal circumstances.” They also note that the issue of what they refer to as “altered standards” has not been included in many disaster preparedness plans.

“I don’t think alteration means lowering of standards, but rather it means having different standards or processes,” says Martha Turner, PhD, RN, assistant director of the ANA Center for Ethics and Human Rights and a member of the work group. “We do things differently all the time based on circumstances. And in some cases, we don’t have to change things at all.”
For example, certain standards, such as providing comfort and maintaining patient confidentiality, can remain intact no matter what the circumstances, according to Turner.
Other circumstances require nurses and other health care professionals to change the way they provide care.

“We’ve been learning about managing patients during disasters in bits and pieces over many years, and over that time, technology has changed the way we communicate and organize tasks,” Turner says. “But what do you do when the technology we’ve become dependent on crashes? If we can’t access medical records electronically, we need to determine the best way to provide care with perhaps limited information.”

Gebbie adds that major disasters force nurses to think differently about how they provide care. It becomes a matter of battlefield triage and how best to use limited resources.

The conference, meeting special needs
Like the breadth of the issue itself, the June conference is designed to cover a range of topics, from understanding the role of federal agencies in emergencies, to the legal and regulatory implications of providing “altered” standards of care during certain circumstances, to creating a family and professional emergency plan.

Also on the agenda is a discussion about the needs of vulnerable or special populations—a demographic that includes pediatric patients, elderly persons, and patients with mental health or behavioral issues. And given the nature of major disasters, the number of people who may be considered “vulnerable” can increase greatly as they are forced to cope with a lack of medication, equipment, or ongoing care.

“During Hurricane Katrina, everybody was negatively affected,” says Roberta Carlin, JD, MS, executive director of the American Association on Health and Disability and a work group member. “But for people with disabilities, the issues they had to deal with were heightened.”

For example, people with chemical sensitivities could no longer control their environment, some shelters didn’t have wheelchair-accessible bathrooms, and people didn’t have access to needed medications.

“Many of the challenges that people with disabilities face can be averted with proper planning,” Carlin maintains. That means that persons with disabilities have to develop their own emergency plans, and they have to be at the table when communities are developing their strategies.

Patricia La Brosse, APRN, CNAA, BC, president of the Louisiana Chapter of the American Psychiatric Nurses Association and a work group member, adds, “We need a seamless health care system so we can ensure a better level of care during emergencies. My experience during the aftermath of Hurricane Katrina is that people needed ways to access more medication, safe environments, and in some cases, hospitalization.”

She recalls that when she first got to the shelter at the Cajun Dome in Lafayette, Louisiana, health care professionals were ill-prepared to address the needs of persons with mental illnesses.

“I immediately began to help a group of local mental health professionals set up a psychiatric unit, where people with mental illnesses could be triaged,” says La Brosse, president-elect of the Louisiana State Nurses Association. “We created our own patient charts and arranged times for people to meet with psychiatrists or other health care professionals.”

La Brosse also saw how her efforts sometimes were in vain. She recalls arranging transportation for four patients who needed methadone. The vehicle, however, was commandeered by the sheriff’s department, and the patients were left in the street.
Florida Nurses Association member and public health nurse Deborah Hogan, RN, has helped plan shelter care several times, including when her state was hit repeatedly by severe hurricanes in 2004 and 2005.

“One of our main challenges with the special needs shelters is space limitations,” Hogan says. “We only have cots for the child with special needs and a guardian, who must provide the required care, such as suctioning or tube feedings. If parents have other children, they are put in the position of having to split up their family during frightening conditions.”

Hogan also witnessed the hardships of nurses who had to provide care to others while wondering how their own families were faring because communication systems were down.

Gebbie urges nurses who wish to respond to disasters to join an organized response team, system, or state volunteer registry, and to take seriously the need for regular training and practice to be effective team members.

Susan Trossman, RN, is the senior reporter in ANA’s Communications Department.

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