Patient Safety / Quality

Preparing for disaster

The severe acute respiratory syndrome (SARS) epidemic of 2003 and 2004…the tsunami that devastated Southeast Asia in 2004…the London transit bombings and Hurricane Katrina in 2005 

Major disasters can kill, injure, and displace tens of thousands of people. As healthcare providers, we play a central role in dealing with disasters. With so much at stake, nurses need to learn as much as we can about preparing for and managing emergencies. To increase your confidence in working through a disaster, here’s advice I’ve collected from colleagues who’ve “been there, done that.” 

Know how to communicate
Imagine this scenario: You’re working your shift at the hospital when the telephones suddenly go dead. A few moments later, the electronic displays and overhead lights flicker, and you hear the emergency generator kick in. What’s going through your mind? You may wonder whether the outage is affecting just your area, the entire building, or the whole community. You may worry about loved ones. Are they safe? How will you reach them? 
Of course, you’d be concerned for your patients. Did they notice the lights flicker? Do they know the phones aren’t working? If so, are they panicking or staying fairly calm? More important—is critical patient care equipment still running? How will you be able to communicate with the resource personnel you need to provide safe care?

Prompt, clear, reliable communication is vital to healthcare facilities at all times—but it’s absolutely critical during an emergency. The Joint Commission on Accreditation of Healthcare Organizations requires healthcare facilities to have backup internal and external communication systems in case the primary system fails. Before an emergency occurs, learn about your facility’s backup system. Are backup telephones available on a different telephone switch? If so, where are they located? Do you know how to use them? Or maybe your facility has purchased portable radios or satellite phones to use in case of emergency. Do you know where to find them and how to use them? Even if the telephones are down, you might still be able to use the Internet and e-mail, depending on the type of connection your facility has. In the first few days after Hurricane Katrina, e-mail proved to be one of the most reliable communication methods. 

Protect yourself
If you’re not safe, your patients won’t be safe. The SARS experience taught us many hard lessons. Nurses and other healthcare providers became infected with the coronavirus that causes SARS, and died before they recognized the need to use appropriate protection—particularly during high-risk respiratory procedures. Would you know how to protect yourself if your facility received SARS patients or victims of chemical or radiation contamination? Front-line workers—including “first receivers” and the staffs of emergency departments, trauma centers, and operating rooms—may face especially significant risk in these situations.

If you’re a front-line worker or if you’re on your unit awaiting patients from a mass casualty incident, first find out if you’re at risk from contact with victims. If the answer is “yes”—or if no one seems to know—assume the worst and don appropriate personal protective equipment (PPE), according to facility policy. Depending on the situation, for instance, you may need to wear an N-95 mask or full protective gear with powered air-purifying respirators. Better yet—don’t wait until a disaster occurs to get up to speed. Before disaster strikes, find out what precautions to take by asking people in your organization who’ve worked on these issues. Get answers to the following questions:


•     How would we transport contagious or contaminated patients to the operating room, diagnostic imaging area, or other key areas?
•     How would we handle patient waste and potentially contaminated linens?
•     How would we send patient specimens to the lab?
•     What would we do if an infected patient “codes”?
•     What actions, if any, would we perform differently than usual for these patients?

Recognizing that these situations put healthcare workers at risk, the U.S. Occupational Safety and Health Administration (OSHA) has published guidelines titled “OSHA Best Practices for Hospital-Based First Receivers from Mass Casualty Incidents Involving the Release of Hazardous Substances.” To view this document, visit www.osha.gov/dts/osta/bestpractices/html/hospital_firstreceivers.html.

Another resource for healthcare workers is the ER One Institute in —a national test-bed for responding to both conventional and nonconventional medical threats. 

Protect your patients
Learn about the basic steps you need to take to ensure patient safety. For instance, how would you evacuate your part of the hospital, if required? If you’re not sure, read up on your facility’s evacuation plan. Chances are, you don’t need to know the full scope of the plan. But at least find out where you and your patients should go if you need to move from your location immediately. Many facilities have equipment to assist in evacuation, especially for nonambulatory patients. Know what equipment is available and how to get it—at any hour and any day of the week. If the disaster doesn’t require evacuation and you’re preparing to receive victims, here are some steps you can take to safeguard your patients, no matter which department you work in:

•     Prepare for a rapid surge in patient influx. Initially, expect large numbers of victims to arrive at the  hospital rapidly. To estimate the total number of victims who are likely to come to the facility, disaster planners typically double the number of victims received during the first hour. However, if you’ve obtained statistics from the scene itself, from media reports, or from the local , use these instead of the general “doubling” rule.
•     While wearing appropriate PPE, assess arriving patients and focus on the actions you and your team members must take to move previously admitted patients to other destinations, if needed. In case you need to accept new victims, collect patients’ laboratory results, administer ordered medications, complete ordered treatments, and organize medical equipment and personal belongings so you can transfer these patients rapidly.
•     Help your facility collect the information it needs to obtain a bed count, capacity count, and staff count. These numbers will help officials determine what resources are available to respond to the emergency. 

Know who’s in charge
Although consensus decision-making can be a wonderful tool for nurses, a disaster isn’t the right time to use it. Time and again, those who’ve worked through disasters emphasize that a single person (preferably predesignated) must take charge, assuming the role of formal leader and guiding the staff accordingly. This person should be your most experienced and competent nurse. In your organization, it could be a charge nurse or nurse-manager. This person organizes efforts within the department (such as promoting patient flow and providing bed, staff, and equipment counts) and interfaces with the system. Be aware that all hospitals are required to have an incident command structure or system to respond to emergency events. A common command structure is the Hospital Emergency Incident Command System, which organizes hospital personnel into leadership and functional roles that facilitate the response to an emergency. Know the system your organization uses, and learn with whom you should interface during an emergency. 

Cooperate and collaborate
In a disaster, all staff members must cooperate and collaborate with other departments to ensure that the facility responds rapidly and effectively. Ideally, the facility’s response should be integrated with the response of the community as a whole. During a disaster, you may be designated to report to a labor or personnel pool. Most likely, you’ll stay in your department or be asked to respond from home to assist in patient care. Do your best to ensure that patients are tracked in the system carefully so that family and friends know their location and status. As requested, provide accurate information to your facility’s public relations department so it can send an accurate, consistent message to the community—which, in turn, reduces undue stress caused by misinformation. 

Care for the caregivers
Like everyone else, healthcare providers need care during an emergency. Your facility should have plans in place to meet staff members’ basic needs. Unfortunately, “just-in-time” inventories and space crunches have gradually whittled away many hospitals’ stockpiles of emergency supplies. Hurricane Katrina showed all too clearly what can happen when dedicated emergency supplies are in short supply. Caregivers frequently were unable to bathe; lacked nutritious food, clean linens, and hygiene products; and were forced to conserve water.

Conventional wisdom and emergency planners may recommend keeping on hand enough essential supplies—including food, water, electrical power sources, patient supplies, and waste systems—to last 3 days. But Katrina showed us that a 3-day supply may not be adequate. You may need enough to last for 5 or even 7 days.
Sometimes, caregivers’ need for emotional support is overlooked. Nurses should have access to outlets for sharing and discussing their experiences. Debriefing sessions from events such as the nightclub fire of 2003, which killed 99 people and sent 200 more to hospitals, pointed to the impact on caregivers both immediately after the event and months later. Each healthcare organization’s emergency plan should provide for both individual counseling services and formal groups facilitated by mental health professionals. 

Plan for disasters at home
Effective planning also helps you and your family prepare for disasters. Here are some important steps you can take at home:

•     Establish an emergency plan for you and your loved ones. Make sure everyone understands the plan.
•     Gather basic emergency supplies in your home.
•     Write down important contact information and distribute it to all family members.
•     Designate specific meeting points outside the home where family members can reunite if separated. 

It can happen to you
Few people expect—and no one wants—to be involved in a disaster. But you may find yourself in the middle of one at any time. Emergency planners emphasize that to stay prepared, you should assume it’s not a matter of if but when a disaster will strike.
As a nurse, your role in providing care is even more crucial during an emergency. You’ll be called on to use all your skills under stressful circumstances. But isn’t that what nurses do every day? Nurses are extraordinarily resourceful and creative. Adding emergency preparedness to your knowledge base can greatly enhance the power of your practice—and can help you save lives when the unimaginable happens. 

Selected references
Agency for Healthcare Research and Quality. www.ahrq.gov/prep. Accessed July 21, 2006.

Emergency Nurses Association. www.ena.org/EmergencyPrepared. Accessed July 21, 2006.

Federal Emergency Preparedness Agency. www.fema.gov. Accessed June 29, 2006.

Joint Commission on Accreditation of Healthcare Organizations. www.jointcommission.org/PublicPolicy/ep_home.htm. Accessed June 29, 2006.

Koenig KL. Strip and shower: the duck and cover for the 21st century. Ann Emerg Med. 2003:42(3):391-394.

Loeb M, McGeer A, Henry B, et al. SARS among critical care nurses, Toronto. Emerg Infect Dis. 2004;10(2):251-257.

Occupational Safety and Health Agency. www.osha.gov. Accessed June 29, 2006.

Susan Eckert RN, , is Director of the Institute for Innovations in Nursing Readiness at the ER One Institute, Washington Hospital Center, Washington, D.C.

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