Running head: DISASTER PREPAREDNESS FOR NURSES 1

Disaster Preparedness for Nurses

Janie Rigsby

Mt. San Jacinto College

Advanced Medical Surgical Nursing

Nursing 244

Cheri Levy, RN, BSN

September 07, 2010

 Disaster Preparedness for Nurses

Healthcare regulating agencies have recently enacted many changes regarding disaster

preparedness and emergency management standards. This paper will discuss what constitutes a

disaster, the components of disaster preparedness, and hospital regulations that pertain to

emergency management. Bioterrorism and disaster will be compared and contrasted in an effort

to clarify their impact on the healthcare community.

Disaster Preparedness

A disaster is an event wherein forces overwhelm a community in such a way that services

are compromised (Veenema, 2006). Disaster situations usually require outside assistance due to

the fact that resources close to the event are negatively impacted. Disasters can be natural such as

an earthquake or man-made which would include transportation accidents, nuclear events or

bioterrorism (Veenema, 2006). Prior to a disaster occurring, efforts to anticipate problems can

proactively put policies in place to manage emergencies. Some disasters trigger warning signals

wherein the public may be made aware of the ensuing event. After the emergency occurs, the

affected area must be isolated and a remedy should be enacted. Beyond that, recovery may take

years and at times, full recovery may not be possible.

The components of emergency management are preparedness, mitigation, response, and

recovery (Koenig, 2007). Preparedness is the key component for disaster management. Hospitals

must be in compliance with many regulating agencies such as the Joint Commission and Center

for Medicare and Medicaid Services (Koenig, 2007). The hospital must perform a hazard

vulnerability analysis to determine whether the hospital is located near a nuclear power plant or

if there is a hurricane risk (Koenig, 2007). Comprehensive Emergency Programs (CEM) have

been adopted in an effort to standardize the nomenclature for Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) standards (Koenig, 2007). Preparedness also entails staff

orientation, rehearsal and training regarding each member’s role in the emergency. A call-in line

or website should be set-up to communicate with staff. Resources must be contracted prior to the

event and agreements made ahead of time. The importance of managing resources was

experienced during Hurricane Katrina where a sole busing company was contracted to evacuate

nursing homes. That company was unable to provide this service so several companies are now

in charge of that task (Veenema, 2006). Emergency operation plans allow hospitals to identify

their ability to provide services for 96 hours should that hospital fail to be supported by the

community (Veenema, 2006). Alternate sites for care should be pre-arranged.

Mitigation is the second component of disaster preparedness. Hazards must be evaluated

as well as vulnerability. Events that threaten the hospital environment must be mitigated

(Veenema, 2006). Actions must be taken to ensure that systems will be functional should an

event occur. Logistics must be managed such as how to replenish medications and supplies as

well as how to maintain utilities. Security must manage access to the hospital and coordinate

traffic control measures (Veenema, 2006). Hospitals must coordinate disaster drills in response

to an actual emergency or to a simulated drill. These exercises allow organizations to test their

procedures and discover and deficiencies (Ignatavicius & Workman, 2010)

Response is the third component of disaster preparedness. Staff must be prepared to be

activated in the event of an emergency. The staff must also prepare their families in the event

that the emergency requires the staff members’ presence for an extended period of time

(Ignatavicius & Workman, 2010). On-call lists should be maintained and be current, command

structures and personnel assignments should be in the form of a facility organizational chart

(Berman, Erb, Kosier, & Snyder, 2008). Critical staff should be trained in organization and
operation of triage situations. Nurses must be adept with situation assessment, management of

care, infection control and safety. Sanitation, nutritional, and mental health needs must be

coordinated in conjunction with social services (Koenig, 2007). Use of personal protective

equipment should be mandatory.

Response is necessary for the hospital as a facility as well. Warnings and notifications

require communication with the news media. The emergency preparedness plan will be activated

which may send a cascade of events into play. Waiver authority can be utilized to modify

Medicare and Medicaid requirements (“Authority to waive requirements during national

emergencies“, 2005). JCAHO has also approved Disaster Privileging requirements so that in the

event of a disaster, hospitals may grant disaster privileges to volunteer practitioners (“Disaster

Privileging Requirements“, 2006). In Nevada, Universal Badging Systems (UBS) was created to

provide a means of reliable and secure form of identification (Universal Badging Systems, n.d.).

Recovery includes all programs and actions that attempt to return the environment to pre-

disaster status. Nurses should adjust patient care and set priorities and objectives according to the

present level of care. The hospital should offer stress relief for clients and staff (Berman et al.,

2008). A committee should be implemented to critique the response and make recommendations

to the emergency plan (Ignatavicius & Workman, 2010).

Bioterrorism and Disaster

Ignativicius (2010), states that bioterrorism is the use of biologic agents to terrorize.

Veeneme (2006) defines bioterrorism as “the intentional release, or threatened release, of

disease-producing living organisms or biologically active substances derived from organisms for

the purpose of causing death, illness, incapacity, economic damage, or fear”. Nurses are very

much in the center of disaster situations and bioterrorism could be the reason for the disaster.
Biological agents can be used for biological warfare but infectious diseases that are found in

nature also present challenges to nurses. The incidence of several infectious diseases, such as

“severe acute respiratory syndrome (SARS), bovine spongiform encephalopathy (BSE), avian

influenza, and monkeypox, and the re-emergence of mutated diseases, such as tuberculosis, have

increased” (Veeneme, 2006, para. 4). Rebmann (2005), states that nurses must have adequate

education and training in order to deal with a stressful situation such as a bioterrorism attack.

Nursing curriculum has recently embraced disaster and emergency preparedness (Rebmann,

2005).

Disaster can be defined as a calamitous event, especially one occurring suddenly and

causing great loss (Berman et al., 2008). Bioterrorism and disaster are very much alike in that

any terrorist attack has the potential to be a disaster. Early recognition and detection are essential

to isolating the offending organism as well as affording enough time to seek medical treatment

(Veeneme, 2006). One example of a bioterrorist act occurred during the aftermath of the tragedy

on September 11, 2001. Anthrax was used as a vehicle to kill five people and infect 17 others

(Greenemeier, 2008). This was an unprecedented national disaster.

Bioterrorism and disaster are somewhat different as well. Disaster defined could include

bioterrorism but is not mutually exclusive. One can have a disaster without terrorism being the

cause. Many disasters are natural disasters such as Hurricane Katrina or the tsunami that flooded

Haiti. Recent man-made disasters include the oil spill off the coast of Louisana, and the nuclear

accidents at the Marshall Islands, Three Mile Island and Chernobyl (“Man-made Disasters“,

2008). Bioterrorism and disaster differ in that bioterrorism is an intentional act and a disaster

may not be intentional.

 Southwest Health System Policy and Procedures

Southwest Healthcare System (SWHS), in coordination with the Joint Commission, has

developed an Emergency Preparedness Management Plan. The compilation can be found on the

Intranet within the Southwest computer system. The actual manual is within the SWHS Policy

and Procedure Manual under Environment of Care (EOC) (Southwest Healthcare System Policy

and Procedure website, 2002). The goal of this plan is to identify team roles in the event of an

emergency and moreover, the responsibility of the hospital to the public.

Administration is the nucleus for the administration of this plan. According to Daub

(2002) the most obvious goal is to meet low-probability, high consequence events such

as bioterrorism can also elevate day-to-day healthcare operations and services.

Understanding how to accomplish this, as well as identifying what capacities are needed

for development or enhancement, depends on a structured approach to needs assessment.

Integrating and automating hospital and other response agency preparedness assessment

activities assures that necessary capacities are identified and that coordinated response

systems are developed (p. 7).

Preparedness in Common with Local Agencies

Administration is responsible for coordinating local agencies in the implementation of the

disaster plan. Disaster drills must be completed in-house as well as within the community. The

following are just a few examples from Daub (2002, p.3) of the many considerations

administration may have:

• Recognition of a bioterrorist-related condition

• Potential epidemic involving at least 500 patients

• Critical partner relationships

 • Personnel and care provider notification

• Increase bed capacity to accommodate at least 500 patients

• Isolation and quarantine for casualties

• Hospital diversion and rapid communication with Emergency Medical Services

• Special need so children, pregnant women, the elderly and those with disabilities

• Provision for increases in staffing

• Facility evacuation and patient transfer

• Alternate site designation

• Communication (internal/external)

• Back up utilities

• Receipt of the National Pharmaceutical Stockpile

• Media response

• Triage of the ill and worried well

• Laboratory capacity and referral

• Hospital security

• Protection of staff and their families

Disaster Command Center

The Command Center may include the Administrator that is on-call, Medical Chief of

Staff, Runners, Walkie-Talkie Operator, Documentation Recorder and House Supervisor. These

people will “Maintain an overview of emergency needs and hospital resources (Southwest

Healthcare System Policy and Procedure website, 2002, para. 2). The Command Center will also

keep records, serve as a communication center, assess for supplies, equipment and staffing

during the disaster and coordinates bed availability with other facilities (Southwest Healthcare
System Policy and Procedure website, 2002). Walkie-Talkie operators will be assigned to Triage

and the Emergency Department; Medical and non-medical labor pools will send a representative

to the Command Center for instructions and updates (Southwest Healthcare System Policy and

Procedure website, 2002). Each department will keep a list of on-duty and off-duty staff

available for assignment, maintain records of assignments and makes calls as required to obtain

necessary staff (Southwest Healthcare System Policy and Procedure website, 2002).

The triage area is established by the Emergency Department nurse and physician on duty.

Staffing should include a physician, nurse, admitting clerk, medical records clerk, Walkie-Talkie

operator and a runner. Triage victims are based on acuity such as emergent (care within one

hour), urgent (care within 4 hours), and the walking wounded (care within 8 hours), and minor

care (Southwest Healthcare System Policy and Procedure website, 2002). Victims will be

identified by a disaster tag number, names placed on a Casualty Flow list which will be tracked

as the disaster progresses (Southwest Healthcare System Policy and Procedure website, 2002).

There will be a family waiting/discharge area staffed by a Risk Manager, Chaplain, runner,

Social Worker and volunteers. This area will provide food to families and serve as a type of

command center for information about treatment and care (Southwest Healthcare System Policy

and Procedure website, 2002).

Staff Responsibilities in the Disaster Plan

Staff has responsibilities to the community, hospital, and clients. The Joint Commission

on Accreditation of Healthcare Organizations (2003) acknowledges the risks that healthcare

workers face when they respond to a crisis. “Staff members need to be trained and be provided

proper equipment to reduce the risk of an unsafe response… staff must also have the highest

priority for prophylactic antibiotics, chemical antidotes, and other practical therapeutic measures
(The Joint Commission on Accreditation of Healthcare Organizations [JCAHO], 2003, p. 24).

The hospital should provide decontamination areas for employees. Vaccinations, mental health,

communications support, provision of transportation, and attention to child-care needs are

necessary to facilitate meeting the needs of staff members (JCAHO, 2003).

Specific responsibilities of the staff are included in the SWHS Policy and Procedure

website (Southwest Healthcare System Policy and Procedure website, 2002). Staff must accept

training in the safety features of the work environment, know evacuation routes, and be willing

to implement their assigned duty in the event of a disaster or bioterrorism attack (Southwest

Healthcare System Policy and Procedure website, 2002). Staff should provide treatment areas

and site management in the event of a mass casualty situation. Coordination of care and plans to

recruit other medical professionals should also be initiated (Southwest Healthcare System Policy

and Procedure website, 2002). Individual clinical staff responsibilities can be department specific

as well as part of a general “pool” of healthcare providers. An example of department specific

would be phlebotomists that stay with immediate blood draws while other phlebotomists may

report to the Emergency Department (Southwest Healthcare System Policy and Procedure

website, 2002).

Non-medical staff has alternate responsibilities in the event of a disaster or bioterrorism

attack. Electrical, heating, ventilation, plumbing, gas, vacuum, and data exchange report to the

Labor Pool in anticipation to perform the stated duties within the SWHS Policy and Procedure

Manual (Southwest Healthcare System Policy and Procedure website, 2002). The SWHS (2002)

website states that in the event of a bioterrorist event, the emergency response system is activated

and notification should include:

• Hospital Administration
 • Safety Officer

• Infection Control personnel

• Local emergency medical systems

• Police and Fire Departments

• Local and state health departments

• Federal Bureau of Investigation field office

• Center for Disease Control

The Infection Control team would be asked to designate an area for the media, for

decontamination and for labor assignments. Specimen packaging, handling and documentation

must be done with the chain of command in place (Southwest Healthcare System Policy and

Procedure website, 2002). Security personnel will lock all exits except for the ambulance

entrance (Southwest Healthcare System Policy and Procedure website, 2002). Medical staff and

employees will have to carry an identification badge in order to gain access to the hospital

(Southwest Healthcare System Policy and Procedure website, 2002). Cohorting of patients with

the same symptoms may be necessary. Environmental cleaning will be performed according to

Standard Precautions (Southwest Healthcare System Policy and Procedure website, 2002). As of

the writing of this paper, materials were not available to document on the specifics of all staff

responsibilities.
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